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At workshops, I regularly field questions from experienced therapists who agonize about issues that ought to be far less fraught with ominous implications. Should they accept a gift of home-baked cookies from a client at Christmas? Should they ever give a small gift to a client that they think might serve a therapeutic purpose—a blank-paged book for journaling, for example? Should they go to the recital of a child whom they've coached through paralyzing stage fright? Should they acknowledge a client in a grocery store or at synagogue or at the town's one health club, or slink away at first sighting? 

This isn't to deny that most interactions between therapist and client—including touch, self-disclosure, gifts, dual relationships, boundary crossings—require from the clinician solid judgment, sensitivity, awareness of the context, critical thinking, and a certain tolerance for uncertainty, but resources are available to help therapists make decisions about unusual situations. To turn Leslie's advice on its head, "If you have to ask, consult!" Good therapists should and do consult with experts on ambiguous and complex questions of boundaries, confidentiality, and dual relationships all the time, but therapists in today's climate often seem driven by fear that's out of all proportion to the actual risk.

Even more disturbing, therapists sometimes seem on the brink of not doing what they know and feel is good therapy, in the interest of practicing hyperdefensive therapy. Always looking over their shoulders, as it were, fear leads them to commit what Arnold Lazarus called, "the worst professional or ethical violations"—taking care of themselves at the expense of their clients' care.

This extreme self-watchfulness and rigid avoidance of anything resembling a "boundary violation" by a psychoanalytic or risk-management yardstick can do clients real harm. A patient of mine lost her infant son in a drunk-driving accident. Devastated by grief, unable to stop crying, she'd seemed to her terrified family to be on the verge of committing suicide. They insisted on an emergency appointment for her with a psychiatrist. Barely able to walk, she entered the psychiatrist's office and sobbed uncontrollably. In her desperation and isolation, she begged him to hold her. He firmly instructed her to sit down, calmly explained that therapy was about talking—not touching—and cited the importance of maintaining professional boundaries. At the end of the session, he prescribed Valium for her and scheduled a second appointment a few days later.

She never kept the appointment. Instead, she became addicted to alcohol and Valium, divorced, and entered (and failed) two rehab programs. Eight years after seeing the psychiatrist, she began therapy with me. After an intense few months of sessions, we went to her son's grave—the first time she'd ever visited it. We stood there, holding each other and weeping. In the long time we stayed, as she cried, she could finally begin truly mourning her child and grieving for the years lost in drugged denial.

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stephen144  - Appreciative of clear thinking   |Registered |2011-02-25 13:19:06
I appreciated this article and your presentation on Digital Ethics. You made a
convincing argument and a clear distinction between standard of care and risk
management... very useful.

Thank you.
ivkennedy  - LCSW   |Registered |2011-02-24 10:22:07
Dr. Zur, Your presentation on digital ethics has been so helpful. The
information is good. Your emphasis on the importance of therapeutic competence
rather than fear and risk management offers more possibilities for solutions to
these dilemmas. Your ideas are refreshing and show you are a curious and
creative clinician. Thank you.
ggro@comcast.net  - The ethical eye   |Registered |2011-02-24 09:08:15
This is the clearest article on ethics that I've ever read. It is a much needed
rebuttal to the fear mongering that is so prevalent today. My thanks to the
author for both his learned and common sense thinking.
snordquist  - Thanks for clarity   |Registered |2011-01-23 00:22:30
For a new PsychoSocial Rehabilitation Practicianer working with children and
adolescents, I found freedom and wisdom in learning the ethical boundaries,
learning the importance of good records, and consulting with trusted colleagues
for advice. I'll be reading more of your articles at your website.
mitelpunkt   |2011-01-05 20:58:11
I don't remember who said that "there are patients that we build a set to
treat them, and patients that we treat them to build a set".
The most
impressive change in a psychotic patient acurred once that a made an "acting
out" inviting him to a drink. After this event, very significant in
repairing his (and mine) relation with his father, he never again felt inot
psychotic states!!!
I was then affraid of bringing it to supervision, I never
did it, but it was a truely therapeutic act.

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