Professional Psychology: Research and Practice 1995, Vol. 26, No. 5,499-506 Copyright 1995 by the American Psychological Association, Inc. 0735-7028/95/S3.00 Patient-Therapist Boundary Issues: An Integrative Review of Theory and Research David Smith and Marilyn Fitzpatrick McGill University Boundary issues, which regularly arise in therapy, can present difficult dilemmas for clinicians. The purpose of this article is to help clinicians resolve these dilemmas by integrating some of the theoret- ical positions with empirical evidence reported in the literature on boundary issues in counseling and psychotherapy. The authors review the concept of treatment boundaries and the ethical princi- ples that underpin them. They also review common boundary violations and provide recommenda- tions to attenuate harm done to clients when such boundary violations occur in therapy. It has long been recognized that boundary violations by health care professionals pose a potential for serious harm to their clients. The Hippocratic Oath, which appeared about 2,200 years ago, obliges physicians to "[keep] far from all inten- tional ill-doing and all seduction, and especially from the plea- sures of love with women and men" (Borland's Medical Dictio- nary, 1974, p. 715), Early this century, Sigmund Freud made a number of strong statements on this issue. Perhaps most sig- nificant, he clearly distinguished the clinical phenomenon of transference from the nonclinical experience of "falling in love": "The patient's falling in love is induced by the analytic situation and is not to be ascribed to the charms of [the ana- lyst's] person" (Freud, 1963, as cited in Pope & Bouhoutsos, 1986). Furthermore, he believed that a sexual relationship be- tween therapist and patient was antithetical to a positive thera- peutic outcome: "The love-relationship actually destroys the in- fluence of the analytic treatment on the patient: a combination of the two would be an inconceivable thing" (Freud, 1963, as cited in Pope & Bouhoutsos, 1986). After Freud, public discus- sion of the issue diminished—and in some contexts was even discouraged (see Pope & Bouhoutsos, 1986, pp. 25-32)—until the 1960s when significant political and social changes in North America led to renewed interest in the topic. The issue of boundary violations in counseling and psychotherapy is now a serious matter of scientific research, legislation, and litigation. One specific kind of violation, the sexual misconduct of men- DAVID SMITH, MEo, is a doctoral candidate in Counselling Psychology at McGill University in Montreal, Canada, and is currently completing an American Psychological Association (APA)-accredited internship at Camp Hill Medical Centre in Halifax, Nova Scotia. MARILYN FITZPATRICK, MED, is a doctoral candidate in Counselling Psychology at McGill University in Montreal and is currently complet- ing an APA-accredited internship at the Montreal General Hospital. She also has a part-time private practice. THE AUTHORS ARE GRATEFUL to Frank Dumont for providing helpful comments on an earlier version of the manuscript. CORRESPONDENCE CONCERNING THIS ARTICLE should be addressed to David Smith, c/o Diane Bernier, Department of Educational and Coun- selling Psychology, McGill University, 3700 McTavish, Montreal, Que- bec, Canada, H3 A 1Y2. tal health professionals, has received the most intense scrutiny, a scrutiny that is understandable given its potential for severe and enduring consequences. Yet, there are many other kinds of boundary issues that present troubling dilemmas to clinicians on a daily basis. Our review attempts to draw together some of the major issues in the discussion and to propose some avenues of prevention for clinicians facing dilemmas in everyday practice. The Concept of Treatment Boundaries One wayin which treatment boundaries have been conceptu- alized is as a therapeutic frame which defines a set of roles for the participants in the therapeutic process. The frame has been described in several ways, including as ground rules of psycho- therapy (Langs, 1982) and as unchanging basic elements that define psychotherapy and distinguish it from other kinds of so- cial events (Spruiell, 1983). The therapeutic frame includes both the structural elements (e.g., time, place, and money) and the content (what actually transpires between therapist and cli- ent) of therapy. Although therapists are largely responsible for constructing and maintaining the therapeutic frame, it is gener- ally accepted that patients also contribute to its development (Gutheil&Gabbard, 1993; Langs, 1982; Spruiell, 1983). The growth of managed care in the United States as an al- ternative to the more traditional fee-for-service delivery systems has significantly altered this conceptualization of the therapeu- tic frame. In managed care settings, the therapeutic relationship is no longer a "private contractual world of the provider and consumer" (Haas & Cummings, 1991). Rather, health mainte- nance organizations (HMOs), in their efforts to contain costs, have expanded the therapeutic frame to include themselves. HMOs exert substantial influence over treatment decisions— such as the length of treatment, the number of sessions, and even the content of therapy—through their directives and fi- nancial incentives to clinicians. This relatively recent develop- ment in health care delivery has raised new ethical questions. Unfortunately, ethical guidelines bear only obliquely on prac- tice within managed care settings, providing less than adequate guidance to clinicians attempting to negotiate their divided loy- alties (Newman & Bricklin, 1991). 499