



































Professional Boundaries and Psychotherapy : A Review


Bangladesh Journal of Bioethics 2012; 3(2):16-26 

 16 

PROFESSIONAL BOUNDARIES AND PSYCHOTHERAPY: A REVIEW   
 
Dr Avinash De Sousa 
Consultant Psychiatrist and Psychotherapist 
Private Practice 
Mumbai 
E-mail: avinashdes999@yahoo.co.uk  
 
  
ABSTRACT: Psychotherapy is a vital component of any treatment programme in the management of 

psychiatric disorders. It is very essential that the therapist receives adequate training prior to 

embarking on therapy with patients. There are various ethical issues and boundaries that the therapist 

must be aware of when dealing with psychiatric patients. Both experienced and novice therapist may 

experience confusion and dilemma when it comes across certain boundaries for the benefit of the 

patients. The present article introduces the readers the various boundaries that need to be maintained 

in psychotherapy and how the boundary is crossing or violations can lead to serious problems. The 

issue of gifts, fees, transference, physical contact between therapist and patient and sexual boundary 

violations are discussed. The need for focusing on boundaries in psychotherapy training is stressed. 

Key words – professional boundaries, psychotherapy. 

 

INTRODUCTION: Psychotherapy is defined as a form of psychological treatment where a trained 

therapist enters into a professional relationship with the patient, with the aim of reducing certain 

symptoms, removing certain symptoms and bringing about overall growth and development of the 

personality of the patient
1
.  Psychotherapy is a professional relationship that helps patients in solving 

their own problems with their own efforts as well as that of the therapist. Psychotherapy treatments 

occur within a construct that has been termed as the therapeutic frame. A simple definition of 

professional boundaries is that they are the parameters defining the limits of a relationship in which 

one person (a patient or client) entrusts his or her welfare to another (a psychotherapist), and where 

fees or payments are made for the provision of a therapeutic service
2
. These boundaries suggest 

professional distance and respect which is a prerequisite of ethical professional behavior.  

In the last decade, a renewed interest in psychotherapy has been seen in India. A larger number of 

psychiatric patients seek psychological interventions rather than medication as a cure for their 

problems. Hence psychotherapy today has found a permanent place in all treatment programs of 

psychiatric disorders. Psychotherapy pertains have not only had major psychiatric problems but also 

have various areas like school counseling in handling behavioral and parenting issues. Many couples 

seek psychotherapy to find a solution to their marital problems. Psychotherapists specialize in various 

forms of psychotherapy like cognitive therapy, rational emotive therapy and family therapy have 

increased in the last few years with more and more people realizing the long term value of 

psychotherapy in the treatment of psychological problems.    

mailto:avinashdes999@yahoo.co.uk


Bangladesh Journal of Bioethics 2012; 3(2):16-26 

 17 

Professional boundaries is a concept in psychotherapy which is essential, largely out of concern for 

the growing number of cases of sexual misconduct by therapists, which led to malpractice litigation 

and severe damage the reputation of mental health professionals
3
. There is a growing amount of 

cases of sexual misconduct being reported year after year where unqualified and untrained 

psychotherapists engage in both sexual and non-sexual boundary violations with their clients or 

patients
4
. This is more relevant in India, where patients present herself/himself whole heartedly to the 

therapist thinking him or her a knowledgeable and responsible for providing a cure for their problems. 

Therapists in some quarters are known to take advantage of such vulnerable patients.  

  

THE CONCEPT OF BOUNDARY VIOLATION IN PSYCHOTHERAPY: There are namely two types 

of boundary violations noted in psychotherapy viz. the non-sexual boundary violations which is milder 

and the graver sexual boundary violations. Boundary crossings are benign phenomena that do not 

occur repetitively and are discussable between the therapist and the patient, while being non 

exploitative. Psychotherapy is a process where both the patent and therapist observe each other and 

share emotions. In Indian culture, the psychotherapist or doctor is often viewed as a demi-god who 

cures the patient. In such cases it is not unusual for patients to talk and enquire about the therapist’s 

likes and dislikes or ask certain questions that may be personal during the course of therapy. Falling 

at the feet or touching the feet or sometimes kissing the hand of a doctor (who is perceived to be a 

healer) and cannot be viewed as a personal boundary crossing
5
. Many patients in therapy often 

enquire about the therapist, his native place, his family, what they do and whether he has children and 

how old they are. This is normal social enquiry that is rampant in our culture and must not be viewed 

as with a boundary crossing mindset.  

It is normally seen that rigidity with respect to boundary crossings does no good for therapy. A good 

psychotherapist adjusts the treatment to the patient rather than expecting the patient to adjust to the 

treatment.  Novice psychotherapists are trained and taught so much about boundaries in courses, that 

they show great concern about maintaining proper boundaries thereby becoming cold, rigid, formal 

and inapproachable in their way of dealing with the patients or clients.  Some patients reject such 

therapists who behave more professional than human and do not generally follow up for therapy. 

Rigidity about boundaries serves as hindrance in developing a good rapport with the patient in 

therapy
6
. This is a common reason why novice therapists complain of a lack of follow up amongst 

their patients. Patients in India want a therapist who is friendly, homely and yet a guide and an 

advisor. In such cases the therapist has greater responsibility bestowed on him where he serves as 

an elder, friend, philosopher and guide for his patients. He may be looked upon in this role not only by 

the patients but also by the entire family of the patients. Rigidity and unfriendliness by the therapist in 

such cases will result in the patients seeking therapy elsewhere where he finds a therapist with the 

qualities he desires.      

In psychotherapy, the beginning phase involves a period of adjustment where a sensitive 

psychotherapist needs to develop a comfort level of closeness or distance so that an appropriate 



Bangladesh Journal of Bioethics 2012; 3(2):16-26 

 18 

therapeutic frame and environment conducive for therapy is created. This phase needs joint efforts by 

both the patients and the therapists. Some patients need a more talkative therapist, whereas others 

prefer a quiet and good listener. Some patients may appreciate the use of laughter, jokes and 

metaphors while some may feel ridiculed by the therapist when this is done. Good psychotherapists 

need an individualized approach with each patient throughout therapy. They vary their therapeutic 

style depending on the particular patient’s need
7
.  

Indian patients may be shy and reserved when it comes to opening up and discussing intense 

emotional issues with a new member in their circle i.e. the therapist. In such cases a slow, friendly 

and steady approach by the therapist shall boost the confidence of the patient in the therapist and 

shall improve their relationship in therapy. A therapist who shall hurry his patients to open up shall end 

up losing such a patient who may feel that the therapist does not understand the gravity and nature of 

the problem.     

Many life events that occur with patient may need professional as well as a personal outlook. 

Sometimes there may be death of a figure to who he patient was extremely attached and the patient 

may expect a little extra sympathy or a patient listening from the therapist. Lack of sensitivity at such 

points of time may destroy any rapport that has been established and affect therapy as well. 

Sometimes therapy may seem to be going nowhere and therapists may get bored of their patients. At 

such times it may be seen that the therapist may seem disinterested in sessions and may look 

forward to hurry up sessions or prolong the time between consecutive appointments. All these 

phenomena may affect the patient who too observes therapist behavior just as the therapist observes 

patient behavior
8
. Many of our patients in India need someone who would listen to them so that they 

may express their emotions. Female patients coming from conservative and orthodox backgrounds 

often have problems expressing delicate issues and need a patience listening. At such times attitude 

like those mentioned above may be detrimental to the patients.    

Boundary violations on the other hand, represent events or phenomena that are usually repetitive, 

harmful to the patient, and exploitative of the patient’s dependent position in therapy. Sexual activity 

with the patient or engaging in a sexual relationship with a patient would be the gravest example. 

Other examples would be exploiting the patient financially or emotionally
9
. The psychotherapeutic 

relationship is by definition a relationship where there must be equal power with both the therapist and 

patient
10

. The psychotherapist is trained and paid to deliver a service based on skills acquired by 

specialized training. The patients may assume that whatever the therapist says or does is designed to 

help of the patient.  As a result, many patients innocently succumb to boundary violations under the 

feeling that it is for their own good
11

.  

A boundary transgression is used as an umbrella term that encompasses both boundary crossings 

and boundary violations
12

. Another term of note is boundary blurring which is used to describe 

instances in which the boundaries are confused but not enacted in the form of a boundary violation
13

.
 



Bangladesh Journal of Bioethics 2012; 3(2):16-26 

 19 

THE SETTING OF PSYCHOTHERAPY: In any consideration of psychotherapeutic boundaries one 

must take into account the setting in which therapy takes place. Therapy usually takes place in an 

office, clinic or hospital that is sufficiently private so that the patients feel comfortable to  disclose 

embarrassing, sexual and shameful content
14

. Some patients prefer to sit on a comfortable chair or 

couch and talk while some prefer to walk while talking. Water, tea or coffee may be offered to the 

patients in the therapy room. A medically or terminally ill patients in a general hospital may require 

therapy at the bedside. The psychotherapy setting may change if some form of behavior therapy such 

as an exposure therapy is being applied in case of phobias and panic attacks. This may be the case 

in animal phobia, bus phobia or fear of the dark
15

. The setting may also change in case of a behavior 

therapy termed flooding used in obsessive compulsive disorder where dirt may be used.  

In India, the doctor or therapist visiting the home of the patient is a common occurrence. The therapist 

as far as possible must conduct psychotherapy sessions in a clinic setting and must avoid visiting the 

house of the patient too often as chances of boundary violations occur. It happens many a time that a 

visit to the patient’s house results in the therapist being offered lunch or dinner and a session that 

should last 30-45 mins may extend to a few hours building the chances for boundary violations and 

relationships other than that in a therapeutic frame. The therapist should refrain from becoming 

associated with various family members and relatives of the patients and must focus on the patients 

concerned. Even getting a rakhi tied by the patient though sacred as a relationship must be avoided   

as the therapist must maintain his frame of reference. Even traveling on a vacation with the patients 

and his or her family for counseling sessions there must be avoided.      

 

THE ISSUE OF CONFIDENTIALITY IN PSYCHOTHERAPY: The fundamental principle in 

psychotherapy is one of confidentiality regarding what is spoken to the therapist. Patients may speak 

out content that they may associate with shame, guilt, remorse, self-loathing, fears of disapproval, and 

a host of other anxieties.  The confidentiality reassurance allows them to open up in a manner that 

they probably would not even to their family members. Hence, confidentiality is regarded as the most 

important professional boundary
16

. The principle of confidentiality extends beyond not repeating what 

the patients say. Numerous cases exist in which a third party realized that the only source of specific 

information could have been from  the patient, and there were justifiable feelings of violation or breach 

of privacy.  A breach of confidentiality can make one vulnerable to litigation or to action from 

professional bodies that govern therapists
17

. 

Sometimes in order to protect confidentiality, the therapist may have to lie to others outside the 

consulting room. He may have to pretend that he does not know information which has learned of 

solely through a patient. Over time, psychotherapists develop the capacity to compartmentalize 

certain information so as to keep it sequestered in a private sector of the psyche belonging to 

information heard during psychotherapy
18

. Confidentiality is not an absolute boundary. One is required 

to break confidentiality to report child abuse or any form of sexual abuse. A threat of imminent 

violence or suicide to an individual requires a ‘duty to warn’ exception to confidentiality
19

.   



Bangladesh Journal of Bioethics 2012; 3(2):16-26 

 20 

Psychotherapists may meet and speak about a patient when there is a secret pleasure of treating a 

celebrity or a public figure. However, the notion of confidentiality should be construed as meaning that 

one cannot even reveal whether a specific patient is in treatment or not.  However, when one presents 

a psychotherapy case for educational purpose or research and publication, one must be careful to 

disguise the identity of the patients. Moreover, even if consent is offered by the patient, identifying 

features must still be disguised so that an audience or reader does not recognize the patients
20

.  

In India, confidentiality becomes a difficult issue because there are relatives and family members who 

often believe that nothing should be hidden from them and thus want to know whatever the patient 

has mentioned in therapy. Sometimes in cases of children and adolescents, the parents feel they 

have brought the child for therapy and actually pay the therapist his fees, hence they have a right to 

know what their child has disclosed. The same may be the case with the husband wife relationship in 

India. The therapist is sometimes in a quandary in such situations whether he must answer or not. 

The therapist must at such times not hurt anyone and keep in mind the sensitivity of both the patients 

and the relatives. The patients however, must be asked before disclosing anything to the relatives or 

family members.    

 

THERAPIST SELF –DISCLOSURE IN PSYCHOTHERAPY: Therapists cannot be anonymous to the 

patient, no matter how hard they may try.  The way they dress, the way they decorate their clinics, 

their facial expressions and the issues they choose to address when they speak all reveal a great deal 

about the therapist. The issue for the psychotherapist is not whether to self-disclose. The actual 

boundary concern is how much should one self-disclose. Feelings that the therapist may experience 

provides useful feedback for the patient. It would be far better to be an honest therapist that 

expresses what he feels than to be deliberately deceptive. Therapists often communicate feelings so 

that the patients may know what the therapist feels before the patients asks him or her
21

. One way of 

implementing a boundary on self-disclosure is to deliberately avoid sharing with the patients any 

details about one’s personal life or family.  Superficial elements like views on a political issue, a sport, 

a cricket match or studies may be needed at times. This may help in the rapport building process.  

Self-disclosures about personal problems must be avoided. Some personal disclosures may be 

initially received well by the patients and therefore may mislead the therapists into thinking that such 

information is productive and useful. Small personal disclosures may often lead to greater intimacy 

and lead to the patients and therapists getting involved with each other either emotionally or 

sexually
22

. In India, the therapist is viewed as a learned person and hence certain insights from the 

personal life of the therapist may actually give strength and confidence in certain areas to the patients. 

Thus therapists disclosure may be beneficial and must be used judiciously by the therapist.   

 

THE PROFESSIONAL ATTITUDE AND PSYCHOTHERAPY: The concept of being a professional is 

fundamental to boundaries. The therapist is not a mother, father, priest, brother, son, lover or friend.  



Bangladesh Journal of Bioethics 2012; 3(2):16-26 

 21 

In the first session and initial therapist-patient meetings, it is prudent to clarify what therapy is and 

what therapy is not. The therapist’s professional role does not require that the therapist be excessively 

formal or inordinately depriving. The most important aspect is that psychotherapy is a scientific form of 

psychological treatment and this entails the professional aspect of the therapists, though in doing so 

therapy must not lose its humane touch
23

.  

Another limit imposed on the professional therapist-patient relationship involves the duration of 

sessions.  The time of the session is often 45-50 minutes but can be as brief as 15 minutes or as long 

as 90 minutes.  In any case, the time parameters must be clear to the patient, and it is useful for the 

patient to understand from the beginning of the therapy that time constraints will always apply.  

Patients generally understand if the therapist explains that the session cannot be extended because 

there are other patients waiting to be seen. Sometimes one cannot be totally rigid, however, and 

occasionally may need to extend the time of sessions if the patient has just started to open out 

towards the end of a session or express an important facet of his or her problem or to accommodate 

an emotional reaction by a patient
24

. One must always have office assistants around when the patient 

is called as calling patients at odd hours may communicate to the patients that there is a potential for 

something other than a professional relationship. One must avoiding scheduling sessions on holidays 

or late at night and unless and emergent problems demands the same.  

Therapy is hard work, and the therapist deserves to be paid. Fees are another aspect that conveys 

the professional aspect of therapy. The fact of being paid further differentiates the therapist from 

parent, lover, friend, and so on.    In any case, therapists should carefully monitor their attitude about 

the patient’s payment and the fee they are charging as a way of examining counter transference 

wishes to give the patient something for nothing. Novice or beginner therapists are typically conflicted 

about deserving a fee or how much to charge and this may be resolved after consulting a senior 

colleague
25

. 

 

GIFTS AND TOKENS OF APPRECIATION GIVEN BY THE PATIENT: Grateful patients may wish to 

express their appreciation by bringing gifts to their therapists. This may happen after they have had 

success at work which may be attributed to the therapy, found a new job or just returned from a 

vacation. Some wealthy patients may wish to make a donation to the institution where a therapist 

works. Patients may consciously or unconsciously feel that they are entitled to special dispensation 

because they have given money or other material gifts to a therapist.  There are concerns about the 

potential of gifts to corrupt the therapeutic process and it is advisable to refuse all gifts. When a 

patient brings something handmade, a recommended book, a pen or a small memento, many 

therapists simply thank the patient for the gift and talk about the particular meaning or symbolism of 

gift.  Patients who may not be able to afford a gift or feel that gifts are inappropriate will sometimes 

offer to provide service for the therapist like painting the clinic, bringing something from a shop the 

patient owns or some other service.  In general, services from patients blend into the area of business 

transactions and dual relationships, which are almost always problematic in psychotherapy
26

. 



Bangladesh Journal of Bioethics 2012; 3(2):16-26 

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THE USE OF APPROPRIATE DRESSING AND LANGUAGE: Both dressing sense and language 

are aspects of the psychotherapist role that are often not studied as part of professional boundaries.  

Dressing in a professional manner conveys that the therapist is a professional.  Patients sometimes 

quit after an initial session of a therapist as he does not appear like a seasoned professional therapist 

to them. Informal or crude language can also work against professionalism. The use of slangs may be 

problematic for some patients and one must exercise caution when using the same
27

.  

 

PHYSICAL CONTACT ISSUES IN PSYCHOTHERAPY: In general, psychotherapy avoids physical 

contact. There is generally a handshake when a therapist and patient first meet. There are 

exceptions, of course, often based on cultural practices, so that some patients will initiate a 

handshake at the beginning and end of each session. Psychotherapists can return the handshake 

without concern about boundaries in most cases. Some therapists argue that a hug is sometimes 

needed by a patient, but people’s capacity for self-deception is extraordinary. What a therapist may 

think is best for the patient may actually be a way of fulfilling the therapist’s own needs
28

. The concept 

of a non- sexual hug is usually in the mind of the therapist but not necessarily in the mind of the 

patients.  

 

PROFESSIONAL BOUNDARIES AFTER THE TERMINATION OF PSYCHOTHERAPY: Although 

there is a broad consensus that sexual contact between the psychotherapist and a patient is always 

unethical, the idea of post termination sexual relations has been somewhat more controversial
29

 The 

American Psychiatric Association determined in 1993 that any sexual relationship between a 

psychiatrist and former patient is unethical
30

. The American Psychological Association, on the other 

hand, allows for the possibility of a 2 year cooling-off period, after which it probably might be ethical 

for a therapist and a patient to begin a romantic or sexual relationship. Psychotherapy may often be 

terminated for the specific purpose of embarking on a romantic relationship
31

.  

 

OTHER CRITICAL ISSUES IN PSYCHOTHERAPY: Transference involves the re-experiencing of the 

therapist and attributing emotions to the therapist  was a powerful and authoritative figure from the 

past
32

. Neurobiological studies demonstrate that representation of parents are laid down in neural 

networks that represent self and other from early in childhood, and then activated again and again by 

specific characteristics of current figures in one’s life
33

. Transference may persist for a long time after 

therapy has been terminated
34

. In other words, the patient’s dependency and vulnerability to 

exploitation does not disappear at termination of therapy.  

As all experienced therapists know, patients who terminate psychotherapy frequently return for further 

therapeutic work in the midst of a life crisis or a struggle with a new developmental phase that must 

be mastered. Hence, an argument for an absolute prohibition against romantic involvement following 



Bangladesh Journal of Bioethics 2012; 3(2):16-26 

 23 

termination is that the therapist may be needed again in the professional role of psychotherapist 

rather than as a friend, business partner, or lover. There may be areas of common interest that bring 

them together periodically as well. For example patients and mental health professionals may serve 

on committees together or be involved in organizing a conference or with social causes or non 

governmental organizations
35

.  

 

PREVENTION AND EDUCATION REGARDING BOUNDARY VIOLATIONS: Education about 

professional boundaries is essential in the training of psychotherapists. By its very, nature, 

psychotherapy involves a radical form of privacy. Two people are meeting each other regularly behind 

closed doors, and one of them is confessing his or her darkest and most shameful secrets to the 

other. The atmosphere of emotional confession and acceptance fosters a rate kind of intimacy not 

often available outside of therapy. Boundaries cannot be taught simply as a list of rules. They need to 

be taught as part of clinical wisdom, integrating boundary notions into discussions of technique and 

the choices a therapist must make. This can be done by an effective mentor or trainer who is there to 

guide and support the therapist. In any case, prevention depends to a large extent on what the 

therapist does in pivotal moments.  In the final analysis, therapists must be their own watchdogs to 

avoid professional boundary violations
36

. 

 

CONCLUSIONS: In this review, professional boundaries in psychotherapy have been dissected as 

issues that every psychotherapist must be aware of. Different forms of psychotherapy are going to 

require different emphases on the way that the boundaries are implemented. Within different 

techniques, whether one uses gestalt therapy or cognitive therapy or psychodynamic methods 

coupled with behavior therapy, one adjusts the boundaries to make the patient more capable of 

collaborating with the therapist. One of the most difficult aspects of psychotherapeutic practice is our 

incapacity to know the ultimate impact of departing from boundaries. Nevertheless whenever 

boundary issues thwart psychotherapeutic practice they must be addressed.   

 

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CONFLICT OF INTEREST: There is no Conflict of interest.  

 

 

 

 

 

 

  


