Preventing Boundary Violations in Clinical Practice. By Thomas G. Gutheil & Archie Brodsky, Guilford Press, 2011, £16.99, pb, 340 pp. ISBN: 9781462504435

This is the paperback edition of a book first published in 2008. My impression then was that it appeared as almost anthropological, as stories from another world. It is not that clinical ‘boundary violations’ (most usually those of a sexual nature) may be any fewer in Britain, although data are hard to come by; rather, it is that accusations and litigation are more frequent in the USA. Apparently, insurance companies will not cover physicians for compensation in the case of professional misconduct or criminal offences, but may do so for ‘clinical negligence’. As a result, physicians (even non-psychiatrists) have been found to have been neglectful of the handling of transference phenomena, even when their specialty might make it unlikely that they had even come across the concept. ‘Warning signs’ or steps in the ‘slippery slope’ have also been taken very literally by some jurisdictions, as evidence of neglect or abuse. The situation of ‘multiple jeopardy’ is even worse than in the UK, with lawyers advising in which order and how to use the various systems. Gutheil & Brodsky point out that ‘just as a flexible rule invites manipulation and exploitation, an absolute rule risks abusive enforcement’, and that ‘you cannot count on an ethics committee or licensing board to respond reasonably’.

The result, understandably, is that clinicians have to be extremely cautious about, for instance, what they reveal about themselves or if it is ever safe to touch a patient. Advice is given on when it might be appropriate to give a lift to a patient, what to do if you find yourself in the same reading group and what physical manoeuvre to perform if a patient repeatedly tries to hug you. Considerable effort, not entirely successful, is made to reflect on what would be appropriate in therapeutic modalities other than the primarily psychoanalytic, acknowledging the somewhat obvious, for instance that it may then be all right to have lunch with a patient as part of a treatment programme.

Nevertheless, Gutheil & Brodsky have great expertise, and also write clearly and humanely. After the initial culture shock is overcome, there is plenty to learn and reflect on. I would recommend this book primarily as a teaching aid within the areas of communication skills, risk and ethics; the vignettes lend themselves well to discussion, and just by being from elsewhere highlight the possibilities of different cultural expectations and assumptions which are such an important part of clinical practice in the UK today.