by Thomas G. Gutheil and Archie Brodsky; New York, Guilford Press, 2007, 340 pages, $38
Dr. Bolton is clinical assistant professor of psychiatry, Center for Health and Wellbeing, University of Vermont, Addison.
This book is a well-written, well-referenced, comprehensive guide to boundaries in clinical practice for therapists of all stripes. Thomas G. Gutheil, M.D., the preeminent expert on the topic, and Archie Brodsky, who has written in this area and collaborated with Dr. Gutheil in the past, are uniquely qualified to write on this subject.
What makes this work valuable and refreshing is the focus on the dynamic principles that shape the relationship between therapist and patient. The authors recognize a broad array of therapies and different norms that characterize each, while teaching sound clinical practice that is informed by basic psychodynamic principles. Frequent clinical vignettes underscore teaching points, and chapters often end with "key reminders" that summarize these points.
The book is logically organized, starting with definitions that differentiate boundary violations from boundary crossings. These distinctions set the tone for exploring this complex topic in a down-to-earth and knowledgeable manner. Dilemmas are explored and advice is given on various situations, including but not limited to meeting patients in social situations, nonpayment of fees, bartering, gifts, self-disclosure, physical contact, e-mail, and out-of-office contacts. There are even examples of suggested dialogue with a patient. Much appreciated by this writer, who practices in a small community, is the attention given to practitioners who work in remote areas or communities of shared interest, where roles often intertwine.
Sexual misconduct and the typologies of offenders are well discussed. Attention is devoted to the identification of patients who are susceptible to boundary incursions or who are prone to test boundaries. Likewise, guidance is offered for therapists to recognize vulnerabilities in themselves. Another important topic covered is the potential harm to patients and the ramifications of the legal processes patients may use to complain. Prevention, as noted in the title, sums up the main work.
As the authors note, no book can provide all the answers to the multitude of questions and scenarios possible in regard to boundary problems. They express hope that the book is a reference to be used in conjunction with supervision and consultation and as a way of conceptualizing a situation. The work meets and exceeds this expectation. This book provides sound, clinically focused principles for thinking about our responsibility to our patients, the underpinnings of the relational dynamics with our patients, and our responsibility for maintaining our own health and healthy boundaries.
Particular strengths of the work are the egalitarian tone in which the differing work of clinicians of various theoretical backgrounds and work settings are recognized, the combination of clinical and forensic expertise that inform the book, the level of detail in discussing each area covered, and the time taken to explain the underlying psychodynamic principles and clinical rationale. Experienced therapists and psychoanalysts may experience the book as rudimentary and at times repetitious, but this book is a must-read for clinicians in training and is a solid reference for even the most experienced clinicians—especially for those who think "this won't happen to me."