Which therapists are most likely to violate professional boundaries?
Ned Dickeson, conducted this study for his Master of Clinical Psychology research report at University of Adelaide, co-supervised by Associate Professor Rachel Roberts and me. Across his studies he has been interested in therapists’ propensity to make unethical decisions and deviate from norms for professional conduct. Despite its obvious importance, there is little research in this area and contemporary papers continue to quote prevalence statistics obtained by Kenneth Pope and his colleagues from the late 1980s and early 1990s, so it’s commendable that Ned has made this area his focus. His study looking at factors that predict propensity to violate boundaries has just been published in Clinical Psychology and Psychotherapy, so it seemed timely to feed back its results.
Ned invited 6,163 mental health professionals from Australia and New Zealand to participate in the study, of which 358 began, and 275 completed. Of course, there is no obligation for busy professionals to take part in any study by an unknown student, but it was a disappointing response rate for a project targeting scientist practitioners! The majority of completers were female (74%), married or in a relationship (76%), non-rural (92%) practitioners of Master’s level qualification (52%). 47% were psychologists, 24% counsellors or psychotherapists, 15% social workers and 14% other professions. 42% worked as solo private practitioners, 23% in non-government organisations, 20% in private non-solo practices, 11% in government, with 4% in other settings. Clinicians from ages 21-74 participated (M = 50, SD = 12.4).
Propensity to violate boundaries was ascertained by three self-report measures of varying directness. Arguably, the most indirect measure was the Boundaries In Practice (BIP) scale Ethical Decision subscale which presented a range of vignettes and asked practitioners how ethical the character’s behaviour (never; ethical under some conditions; ethical under most conditions; always). For example, “you have been under a lot of personal stress and the client asks you what is wrong. You find yourself telling the client about your problems. How ethical is this decision?” Ned developed the second measure – Boundaries Violation Propensity Questionnaire – during his Honours project. It too contains vignettes but asks the participant how likely they would be to make the same decision as the character. The Sexual Boundary Violation Index (SBVI) was the most direct and asked people how frequently they have actually engaged in behaviours such as “I have thought that my client’s problem would be helped if he/she had a romantic involvement with me” or “I have used language other than clinical language to discuss my client’s physical appearance or behaviours I may consider seductive”. Each of these scales was only moderately correlated with the others. Predictably (and thankfully), there were low levels of endorsement of most items and median responses were close to scale minima. Nevertheless, Ned also included a few items measuring actual past boundary violations and these data support the need to maintain research in this area: 51 disclosed having initiated a hug with clients; 12 had formed a social friendship; 15 had flirted or consumed alcohol with a client and 2 admitted to having had sexual intercourse with a client.
Ned investigated a number of possible predictors of propensity to violate boundaries. Propensity did not seem to relate to age, being divorced, operating in solo private practice or distress associated with sympathy for the client. Overall, being male, more experientially avoidant, being more narcissistic (both grandiose and vulnerable types) and impulsive were all correlated with greater propensity. When looking at personality traits, the relationships with boundary violation propensity differed by gender. Male boundary violation propensity was associated with higher tendencies to be “intrusive”, “domineering” and “self-centred”, whereas female boundary violation propensity was associated with greater “non-assertiveness”, “self-sacrificing” and “exploitable” tendencies. When controlling for other predictors, vulnerable narcissistic tendencies remained a consistent predictor of boundary violation propensity for both genders. Male boundary violation propensity was also somewhat uniquely predicted by self-centredness, low empathic concern, and grandiose narcissism. Female boundary violation propensity was also somewhat uniquely predicted by self-sacrificing tendencies, childhood adversity and impulsivity.
Take home: Clinical Implications
A basic essential competency for psychotherapists is good self-awareness. If you recognise these tendencies in yourself:
Men: self-centredness - narcissism (vulnerable or grandiose), or challenges with empathy
Women: vulnerable narcissism, self-sacrificing, impulsivity
Have a plan to manage their impact. The frequency of harm to clients may be low, but the severity of harm is potentially devastating. The cost of managing the risk is relatively low.
Ideally, find a supervisor with whom you can trust to form a relationship in which you can discuss these tendencies and meet with them regularly. Choose someone who will neither minimise these concerns nor condemn you for them, but who will help you be accountable for managing them. None of us necessarily choose our tendencies, and we need not be defined by them. As Paul Gilbert, father of Compassion-Focused Therapy says, “these are not your fault, but they are your responsibility”.
Be alert but not alarmed. If you are mindful and willing to acknowledge their potential, the risk of problematic personality traits driving your behaviour is lessened. If you try not to think about them (experientially avoid), the risk of these driving your behaviour is increased.
Help your colleagues. Create workplace cultures that maintain professional boundaries. Create peer and hierarchical supervision relationships that make it safe for supervisees to explore automatic thoughts and emotions that might be associated with problematic personality traits and schemas. Create the expectation that supervisees will watch for thoughts and feelings that influence them to veer from well-established professional and ethical practice, watch for what triggers these thoughts and feelings, and develop strategies to mitigate them.
If these tendencies pervade your life outside of work, consider psychotherapy for yourself. Or, if these tendencies pervade the life of a supervisee or colleague, consider recommending they seek help.
Go to https://onlinelibrary.wiley.com/doi/abs/10.1002/cpp.2465 for the original article