Psychotherapy

Review of "Boundaries and Boundary Violations in Psychoanalysis"

By Glen O. Gabbard and Eva P. Lester
American Psychiatric Publishing, 2002
Review by Marilyn Graves, Ph.D. on Nov 7th 2003
Boundaries and Boundary Violations in Psychoanalysis

This is a book that would primarily be read by mental health professionals.  It has been used as a text in classes and it is a clearly written, excellent resource.  The authors are well known in their field and have extensive experience in dealing with these issues.

Gabbard and Lester are talking about boundary violations in therapy from a dynamic and treatment oriented perspective.  Thus, the focus is on internal representations, transference and countertransference rather than specifics of ethical codes or laws.  They look at both nonsexual and sexual boundary violations. 

The authors begin with an explanation of how mental representations of self and others are developed and how people experience psychological boundaries.  When a patient begins psychoanalytic therapy, a set of parameters of treatment are instituted:  the analytic frame.  The authors say, "The analytic frame is an envelope within which the treatment itself takes place." (p. 39) and "the analytic frame creates an atmosphere if safety." (p. 41).   Within this frame patients are then safe to explore thoughts and feelings from the past. They establish a transference to the therapist.  The authors talk about the responsibility the analyst has in the professional role:  that it is not to gratify libidinal needs but to help the patient make sense of the past and to preserve the analytic space so that the treatment can continue.  

This book contains an extensive chapter on the history or the analytic movement and how an understanding of transference and countertransference developed over time. It also contains some unfortunate examples of boundary violations on the part of some early and well known analysts. The authors appear to feel the need to provide historical context as "blind spots in one analytic generation may well become blind spots in the next." (p. 86). 

In the chapter on sexual boundary violations Gabbard and Lester say "although discussions of sexual boundary transgressions generally imply that interpersonal boundaries are being crossed, earlier in the progression down the 'slippery slope,' inner boundaries between self and object representation are eroded." (p. 88).  They look at how this progression can develop.  In looking at extensive case studies they suggest there are four categories of therapists who have sex with patients.  The first, psychotic disorders, is rare and more likely to be a therapist in a manic phase of bipolar disorder.  A group they call "predatory psychopathy and paraphilias" (p. 92) they see as possibly incapable of rehabilitation.  The majority of the therapists who have sex with patients they categorize as lovesick. These therapists mistake the transference love of the patient for real love and believe they feel real love for the patient while being unable to see the harmful effects of their actions on the patient.  The last group of therapist they categorize as engaging in a masochistic surrender to the patient.  They list some commonalities of the therapists in boundary violation cases: narcissistic issues, grandiosity, sadomasochistic core issues, tendency toward action over reflection, thick inner boundaries, superego disturbance, and perception of the patient as having a deficit which requires enactment.  They also discuss the idea that these therapists overvalue love and concretely expect it to heal the patient rather than insight or analytic work. 

In the chapter on nonsexual boundary violations the authors discuss things like receiving or giving inappropriate gifts.  They talk about role of projective identification in confusing boundaries and about countertransference enactments.  There is an extensive case analysis. They also discuss instances where the therapist acts inappropriately and concretely in a mothering role.

It is rare to see discussions of post-termination issues and this book has a chapter on boundaries and post-termination. Looking at follow-up studies, the authors suggest that the transference continues as a latent structure after the termination of therapy  and that a significant number of patients may ask for consultation of their former analysts after termination.   They suggest there may be value in former therapists maintaining sufficient distance to allow the patient to resume therapy if needed.  This is more difficult where the patient is a mental health professional and may well subsequently work or supervise at the same workplace as their former analyst. Gabbard and Lester suggest that allowing hope of gratifying the patient's wish for a relationship after the analysis is done may make a full working through of grief and loss issues impossible.

There are chapters on boundaries in supervision and a look at the history of institutions responses to the boundary questions.

While this book is written about psychoanalysis, it is applicable to psychodynamically-oriented psychotherapy and may be useful to therapists of other orientations as well.   All in all, this book is highly recommended for all clinicians practicing psychotherapy.  

© 2003 Marilyn Graves



Marilyn Graves, Ph. D. is a clinical psychologist and topic editor of Psychology and Fiction at suite101.com.

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