VANCOUVER: Boundaries and Boundary Violations in the Child and Adult Therapeutic Settings | September 2020

The Western Branch CPS Course Committee (Vancouver) is pleased to offer a series of four seminars designed to investigate the topic of “Boundaries and Boundary Violations in the Therapeutic Setting”. This course will highlight the work of various psychoanalysts who have written on this subject.

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_{Photo credit: Carolyn Steinberg | “Reflections on Boundaries” 2020}

This course has two primary objectives:
1) To review a range of psychoanalytic perspectives on boundaries and boundary violations in the therapeutic setting.
2) To provide examples of various psychoanalytic views of the issues such as how and why these violations happen, the impact on the patient, other patients, candidates, the larger community and profession as well as the analysts and other health care professionals who commit the offences.

Learning Objectives: 

1. Describe components and functions of the therapeutic frame.
2. Differentiate boundary crossings from boundary violations.
3. Appreciate the inherent power imbalance in the therapeutic relationship.
4. Discuss risk factors/vulnerabilities that could lead to boundary violations, sexual and non-sexual.
5. Consider ways to work within our organizations to prevent boundary violations and assist vulnerable practitioners.

Course Outline:

CLASS #1
Boundaries, Sexual Boundary Violations, and Collateral Damage
Faculty: Elizabeth Wallace, MD, FRCPC, FIPA
Date: Tuesday September 15, 2020

Description:
The concepts of boundaries and therapeutic frame are central to ethical clinical practice, and education plays an important part in preventing and arresting the “slippery slope” to serious transgressions. As practitioners, we are all vulnerable. The first part of this seminar will include a review of boundary theory, the distinction between boundary crossings and violations, and what we have learned about the precursors to and anatomy of sexual boundary violations, and the practitioners who commit them. Guidelines for evaluating contemplated deviations from the frame will be highlighted.

The second part of the seminar will include a discussion of two papers written by Dr. Wallace regarding the short-term and long-term effects of a sexual boundary violation by her training analyst, with another patient, which resulted in his expulsion from practice. The collateral damage to herself, her colleagues, the psychoanalytic society and institute, and community will be explored. One of the constructive impacts has been her determination to teach about boundaries to trainees and professionals in workshops such as this for the past decade, as well gaining experience in assessing and treating professionals with boundary violations through their regulatory colleges in Alberta.

Readings: Wallace, E.M. (2007). Losing a Training Analyst for Ethical Violations: A Candidate’s Perspective. Int. J. Psycho-Anal. 88(5): 1275 – 1288.
Wallace, E.M. (2010). Collateral Damage: Long-Term Effects of Losing a Training Analyst for Ethical Violations. Canadian J. Psychoanal. 18(2): 248 – 254.

Optional: Ruskin, R. (2011) Sexual Boundary Violations in a Senior Training Analyst: Impact on the Individual and Psychoanalytic Soceity. Canadian J. of Psychoanal. 19(1): 87 – 106.

Learning objectives:

1. Describe components and functions of the therapeutic frame.
2. Differentiate boundary crossings from boundary violations.
3. Describe risk factors for sexual boundary violations as well as elements in prevention.
4. Discuss collateral damage to patients, colleagues, and professional communities when sexual boundary violations occur.

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CLASS #2
Sexual Boundary Violations in the Therapeutic Setting
Faculty: Judith Setton Markus M.Ed., R.Psych., FIPA and Darren Thompson, MD, FRCPC, FIPA, DABP
Date: October 13, 2020

Description:
It is not uncommon for a patient to develop an oedipal love transference toward his or her therapist, not unlike the one a child experiences toward a parent during childhood. As occurs with parents toward their oedipal child, when an oedipal transference love develops in the treatment, therapists will experience reciprocal oedipal feelings toward their patient (Searles,1959). It is often part of a successful analytic and psychotherapeutic treatment to reciprocally experience and work through such oedipal strivings. The paradox underlying healthy oedipal love is that, in both childhood and in the transference-countertransference, the wished-for ‘marriage’ is treated simultaneously as a real and as an imaginary marriage (Searles, 1959). In successful therapies oedipal transferences can be held in this paradoxical transitional space and not enacted in a sexual boundary violation. The inherent power imbalance between patient and therapist, not unlike the power imbalance between parent and child, places the responsibility on the therapist to maintain an ethical boundary so that the imaginary aspect of oedipal love does not collapse into a concrete erotic enactment.

In the preceding workshop, aspects of practitioners that make them more vulnerable to committing a sexual boundary violation were addressed. In this seminar we will explore these aspects more deeply: the various characteristics and vulnerabilities of practitioners, and signs to look for that make them more susceptible to committing sexual boundary violations. We will also consider ways in which to assist vulnerable practitioners so as to prevent the collapse of the imaginary aspect of oedipal love.

Readings:

1. Margolis, M. (2012). Analysts Who Have Sexual Relationships with Their Patients: The Central Role of Masochism. In: The Clinical Problem Of Masochism. pp. 186-195
2. Celenza, A. (1991). The Misuse of Counter-transference Love in Sexual Intimacies Between Patients and Therapists. Psychoanalytic Psychol., 8(4): 501-509.

Optional readings:

1. Ogden, T.H. (2007). Reading Harold Searles. Int. J. Psycho-Anal. 88(2) 353-369.
2. Searles, H.F. (1959). Oedipal Love in the Counter-Transference. Int. J. Psycho-Anal., 40:180-190.

Learning Objectives:

• Explore and discuss with more depth the common characteristics of practitioners who commit sexual boundary violations.
• Discuss the various risk factors/vulnerabilities that could lead to sexual boundary violations with attention to recognizing early signs.
• Appreciate the inherent power imbalance in the therapeutic relationship.
• Consider ways in which we can work within our organizations to assist vulnerable practitioners so as to help prevent boundary violations.

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CLASS #3
Non-Sexual Boundary Crossings and Violations
Faculty: Paul Steinberg, MD, FRCPC, FIPA
Date: November 3, 2020

Description:
In this seminar various types of non-sexual boundary crossings and violations will be discussed, including treating individuals with a connection to the therapist, such as friend of friend, friend of relative, or relative of a friend: having a business transaction with a patient, for example receiving or giving practical advice from him or to a patient, be it stock market tips or where to buy something cheap, or suggestions for reading or cultural events; personal advice, such as whether to marry or divorce; social interactions between patients and therapists, including professional interactions, happenstance meetings, and social interactions which are planned, potentially leading to the “slippery slope”. We will explore the potential effects of these enactments, and ways to prevent or interrupt them.

In the first part of the seminar I will present some scenarios involving boundary crossings and violations to discuss. In the second part the participants are invited to bring vignettes of their own experiences with boundary and violations.

Reading:
Gabbard GO & Lester P (1995). Boundaries and Boundary Violations in Psychoanalysis. Chapter 7: Nonsexual Boundary Violations. Washington, DC & London: American Psychiatric Publishing.
Learning Objectives:

1. Recognize and distinguish between non-sexual boundary crossings and violations in psychotherapy.
2. Understand both the potential damage and interference in psychotherapy that nonsexual boundary crossings and violations may result in, and the potential benefit in boundary crossings.
3. Be able to identify boundary crossings and use them constructively in psychotherapy, and prevent boundary violations.

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CLASS #4
Boundaries at the Intersection of Child Work
Faculty: Clifford Ridley, PhD, R.Psych., FIPA and Carolyn Steinberg, MSc, MD, FRCPC, FIPA
Date: December 1, 2020

Description:
In contrast to adult work, working psychoanalytically with children requires equipment beyond the couch or chair. A space conducive to play is essential. In addition, contemporary child analysis also involves working, sometimes intensely, with the parents as well as with the child.

Therapists face professional standards of care often set exclusively with adult patients in mind. Child work requires the careful consideration of the complex environment of the family where the treatment can flourish in the safety of adequate boundaries. This adds a unique layer to explorative child work where creating a protective space for inner psychic and developmental change is required.

This seminar provides readings and discussion whereby those working with children may think about the clinical situations they encounter.

References:

• Schmuckler AG, Atkeson PG, Keable H, & Dahl EK (2012). Ethical Practice in Child and Adolescent Analysis and Psychotherapy: Protecting Safety in a Therapeutic Environment. UK: Jason Aronson.
• Chapter 1 (pages 9 – 18). Clinical Models of Child Psychotherapy and Ethical Issues.
• Chapter 2 (pages 19 – 22). Ethical Dilemmas Shaped by Transference and Countertransference.
• Chapter 3 (pages 23 – 45). Ethical Considerations in Our Work with Parents.
• Joseph B (1998). Thinking about a playroom. J. Child Psychother., 24(3): 359-366.

Learning Objectives: we would like participants to come away from our seminar with an enhanced appreciation of the child’s inner world and the delicate membrane which forms to protect that world. We will learn:

1. By honing our analytic skills in the understanding of unconscious process, developmental lines, conflict, defense, transference and countertransference we become freer and more confident to engage the child in a way that respects the child’s boundaries and in turn the growth of their internal world.
2. To strive to help parents become better parents in nurturing a space for the child’s inner world, one which respects the boundaries.
3. Space can also mean physical space and how we respect the child by setting up our offices to enhance the work.
4. The delicate membrane of boundary can engender a great sense of responsibility and even anxiety in us, as well as the parents. The paradox of analytic work with children is being able to create a forum for play in an arena where unconscious enactment of conflict informs the therapeutic action but can also initiate boundary violation in the unprepared.