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Electronic Letters to:

Articles: Sameer P. Sarkar Life after therapy: post-termination boundary violations in psychiatry and psychotherapy Adv Psychiatr Treat 2009; 15: 82-87 [Abstract] [Full text] [PDF]

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Electronic letters published:

There is more to post-termination boundary violations than sex

Larkin J Feeney   (16 March 2009)

boundary violations and attachment

Daniel McQueen   (23 March 2009)

There is more to post-termination boundary violations than sex 16 March 2009
Larkin J Feeney, Consultant Psychiatrist Send letter to journal: Re: There is more to post-termination boundary violations than sex larkinfeeney{at}gmail.com Larkin J Feeney	I enjoyed the article and the accompanying commentary. I would simply like to add that there are situations other than sexual ones in which such boundary violations can occur. Some of these can be relatively innocent, such as a former patient doing a few odd jobs around the house. Others can be more sinister, such as the recruitment of former patients into religious groups. Sometimes it is impossible to avoid having an ongoing relationship with a former patient. Nonetheless, in all such situations it is incumbent on the doctor in question to make certain that there is nothing exploitative in that relationship.
boundary violations and attachment 23 March 2009
Daniel McQueen, SpR Psychotherapy Cassel Hospital, West London Mental Health Trust Send letter to journal: Re: boundary violations and attachment daniel.mcqueen{at}virgin.net Daniel McQueen	Sarkar argues that transference is the crucial ethical obstacle to sexual relationships between psychiatrists, psychotherapists and patients, present and past. However as he rightly points out, transference and power inequalities are ubiquitous. In the invited commentary Sheather highlights the purpose of the doctor patient relationship to allow the divulgence of intimate details required for treatment, and that it is the intrinsic emotional vulnerability of psychiatric patients that underpins the prohibition on relationships with psychiatric patients although Sarkar has already argued this may be patronising and stigmatising and in any case emotional vulnerability per se is no obstacle to relationships in other contexts. Attachment theory describes how mammals are instinctually driven, via the attachment system of behaviours, to seek proximity to a caregiver or “secure base” who provides the security which is a precondition for exploration (1). Psychotherapeutic encounters differ from other medical encounters in the degree to which clinicians set out to purposefully cultivate an attachment relationship with patients (2). As Bowlby writes: the first task of psychotherapy is to “provide the patient with a secure base from which he can explore the various unhappy and painful aspects of his life” (3). It is the existence of this attachment relationship, deliberately pursued as a psychotherapeutic means and end, beyond either transference or vulnerability which sets apart the relationship between psychiatrist or psychotherapist and patient. A romantic relationship after a psychotherapeutic relationship inevitably exploits the (psychotherapeutic) attachment relationship. (1) Ma, K. Attachment theory in adult psychiatry. Part 1: Conceptualisations, measurement and clinical research findings. Advan. Psychiatr. Treat., Nov 2006; 12: 440 - 449. (2) Ma, K. Attachment theory in adult psychiatry. Part 2: Importance to the therapeutic relationship. Advan. Psychiatr. Treat., Jan 2007; 13: 10 - 16 (3) Bowlby, J. (1988) A secure base: Clinical applications of attachment theory. London & New York: Routledge.