A minimum of  3 scholarly peered reviewed article  must be sited using APA format 400 words for each topic 5 and 6 

  

Topic 5 

Discuss why it is important to maintain professional boundaries when working within the field of psychology?

Topic 6

What are some potential consequences if a professional has loose or poor professional boundaries? What are some factors that may make it difficult to maintain professional boundaries?

Counselling Psychology Quarterly
Vol. 25, No. 3, September 2012, 277–287

‘‘We’re people who don’t touch’’: Exploring clinical psychologists’

perspectives on their use of touch in therapy

Carmel Harrison
a*, Robert S.P. Jones

b
and Jaci C. Huws

c

a
Betsi Cadwaladr University Health Board, Flintshire Community Learning
Disability Team, Mold, UK;

b
School of Psychology, Bangor University,

Gwynedd, UK;
c
School of Healthcare Sciences, Bangor University,

Gwynedd, UK

(Received 16 May 2011; final version received 24 February 2012)

There is a paucity of research that explores the use of touch within
psychotherapy from therapists’ perspectives. This qualitative study
explored clinical psychologists’ accounts of offering or excluding touch
within therapeutic practice. Semi-structured interviews were conducted
with six clinical psychologists working within adult mental health services.
The interview transcripts were analysed using interpretative phenomeno-
logical analysis (IPA). Five superordinate themes emerged from the data:
(1) the touch instinct; (2) touch and professional boundaries; (3) individual
clients and contexts; (4) the value of touch in therapy and (5) the cost of
touch in therapy. It is suggested that the perspectives of professionals and
clients be given greater consideration in the future as such open discussion
may serve to challenge the taboo status often surrounding the issue of
touch, and highlight its potential roles in therapy.

Keywords: touch; boundaries; clinical psychologists; interpretative phe-
nomenological analysis (IPA)

The use of touch has long been associated with healing (Frank, 1957; Hunter &
Struve, 1998), yet little is known about why some professionals use touch while
others do not (Durana, 1998). Freud (cited in Galton, 2006) suggested that
therapeutic transference would be exacerbated through touch; thus its exclusion was
considered necessary to ensure psychoanalytical, boundaried and effective interven-
tions. Although adherence to a psychodynamic model may be considered
particularly incompatible with touch (Bonitz, 2008), many professionals hold fast
to this legacy of touch exclusion for a myriad of reasons: potentially as their beliefs
genuinely fit these models; perhaps to fulfil the criteria deemed necessary to retain
group membership; or, to maintain the special or unique nature of their approach.
Consequently, touch exclusion can be perpetuated, irrespective of practitioners’
therapeutic approaches.

Others deem touch to be appropriate and even beneficial within therapy. Hunter
and Struve (1998) suggest that touch has the propensity to establish, maintain or
deepen therapy relationships; to assist clients to overcome distractions and be

*Corresponding author. Email: carmel_harrison@flintshire.gov.uk

ISSN 0951–5070 print/ISSN 1469–3674 online

� 2012 Taylor & Francis
http://dx.doi.org/10.1080/09515070.2012.671595

http://www.tandfonline.com

present; to provide nurturance and reassurance; to facilitate the access, exploration

and resolution of emotional experiences; to provide containment and safety and to

promote touch as a healthy component of relationships outside therapy. Those

advocating the use of touch suggest that its prohibition is as unacceptable as touch

itself when this could exclude the opportunity for therapeutic progression (Sponitz,

1972).
Pope, Tabachnick, and Keith-Spiegel (1987) found that 41% of their sample of

456 psychologists within the Psychotherapy Division of the American Psychological

Association reported that they hugged their clients somewhat frequently. In this

questionnaire study, 30% of humanistic therapists believed that touch might be

beneficial in terms of clients’ progress, while only 6% of psychodynamic therapists

held this view. In addition, the psychodynamic therapists deemed the risk of

misinterpretation as being high enough to warrant touch exclusion. However, Stake,

and Oliver’s (1991) survey of over 200 psychologists indicated that some forms of

touch within therapy (e.g. hugging; touching the shoulder, arm or hand of the client)

were rarely thought to constitute misconduct, nor were they typically seen as overtly

sexual or suggestive.
Stenzel and Rupert (2004) found that approximately 80% of 470 psychologists

practicing in adult psychotherapy sometimes shook hands with clients. This form of

touch was most likely to occur at session beginnings or endings. Close to 90% of

these respondents claimed that they never or rarely offered other forms of touch to

clients during sessions. This suggests that handshakes and touch within sessions were

appraised quite differently possibly due to social norms, theoretical considerations or

training experiences.
Milakovich (1992) used a telephone questionnaire to explore the differences

between 84 therapists who used touch and those who did not. Therapists who used

touch were more likely to be female and had received more training on its use.

Therapists who used touch positively valued touch in therapy; believed in the touch

need/deficit; and considered the gratification of the touch need as therapeutic.

Participants who did not utilise touch were inclined to negatively view touch within

therapy, typically as gratifying need was considered detrimental to the process. The

therapists who employed touch tended to trust their own instinct in relation to its

appropriateness and appeared less concerned about potential risks.
Clance and Petras (1998) used questionnaires to explore psychotherapists’

decision-making in relation to touch in psychotherapy. Therapists who used touch

did so in an effort to help clients access feelings; to comfort and support; to model

safe touch; to respond to clients’ requests for touch; to address histories of touch

deprivation; or, to say goodbye. Decisions not to touch were made when there was a

possibility of misinterpretation; when touch would be invasive; because the client was

able to access feelings without touch; because of the clients’ needs for clear

boundaries; or, if touch would be unbearable for the client.
In the last two decades, a shift in focus towards risk management and ethical

practice within therapy has impacted on the use of touch. Physical contact may be

viewed as risky with: clients who use therapy to fulfil relational needs; those with

poor attachment histories, poor boundary control or who display ‘borderline

functioning’; or, those who act seductively (Glickauf-Hughes & Chance, 1998).

By associating touch with risk, even those who typically avoid touch may be

278 C. Harrison et al.

reluctant to discuss rare use of touch for fear of the suspicion of misconduct (Stenzel
& Rupert, 2004).

The present qualitative study aimed to investigate the views of clinical
psychologists in relation to touch in therapy by focussing on the reasons why
participants chose to incorporate or avoid touch. There appears to be no existing
qualitative research on touch in therapy solely within a sample of clinical
psychologists in the United Kingdom. Studies that focus on touch have typically
utilised survey or questionnaire measures, and although there have been some
opportunities for elaboration within certain studies (Clance & Petras, 1998;
Milakovich, 1992), the use of questionnaires may have restricted participants’
accounts.

Method

Qualitative perspective

Interpretative phenomenological analysis (IPA: Smith, Flowers, & Larkin, 2009) was
utilised in this study as its emphasis is on exploring the meaning that participants
assign to their experiences. Two stages of interpretation, or a double hermeneutic,
are involved in the dynamic exploration of experiences: participants attempt to make
sense of their experiences (as they recall and verbalise their thoughts); and the
researcher attempts to analyse and make sense of participants making sense of these
experiences. These interpretations are not free from bias and, in accordance with IPA
methodology, these biases are embraced and deemed necessary by the researcher in
order to make sense of the participants’ lived experiences (Smith & Osborn, 2004).

Participants

The aim of IPA studies is to understand frames of reference for small groups of
individuals who are selected according to aspects of homogeneity (Smith et al., 2009).
Following national and local research ethics approval, three female and three male
clinical psychologists were purposively selected on the basis that they were employed
by the NHS and delivered one-to-one therapy within adult mental health services in a
rural area of Wales, UK. They were aged between 35 and 55 years, and had
a minimum of five years post-qualification experience (range 8–25 years, mean
15 years). They all described their therapeutic orientation as ‘‘eclectic’’ or
‘‘integrative.’’

Data collection

Six potential participants were sent an information sheet relating to the study. Then
the first author (CH) met with individuals to discuss the research in more detail.
Each individual was informed that they could take up to a week to decide if they
would like to take part and all subsequently participated in the study.

Each participant was met at their place of work by the first author on a
convenient, pre-arranged date. Individuals were informed that participation was
voluntary, that they had the right to withdraw from the study at any time, and they

Counselling Psychology Quarterly 279

were assured of anonymity and confidentiality. Participants were asked whether
direct quotes from their interviews could be included in the reporting of the study.
They were informed that some details relating to clinical practice (such as issues that
were previously known to co-workers) might compromise their anonymity; however,
all participants agreed that direct quotes could be included in the reporting of the
study following the application of pseudonyms.

After obtaining informed, written consent, participants were asked to provide
basic demographic and professional information. In accordance with the guidelines
for IPA studies (Smith et al., 2009), a semi-structured interview was utilised to guide
the interview and further questions were asked based on the answers given. This
ensured that responses reflected individuals’ experiences and beliefs. Participants
were aware that each interview would be recorded and later transcribed for the
purposes of analyses. The interviews ranged in duration from 35 to 60 min and upon
completion, participants were given the opportunity to ask further questions about
the research.

Analysis

An idiographic method of analysis (Smith et al., 2009) was adopted. First, each
transcript was read in detail and the left-hand margin was used to write initial ideas,
to highlight specific points, to summarise and make connections within the data.
Then each transcript was re-read and the right-hand margin was used to note
emerging themes and more abstract terms. These themes were listed and clustered
prior to returning to the transcript to confirm that the analysis was firmly grounded
in the accounts. This process was repeated for each transcript, and the analysis led to
the creation of a master list of themes representative of the experiences of all
participants. Consistent with the IPA approach, themes were not necessarily selected
due to prevalence, but rather in relation to the richness of participants’ accounts.

To ensure the validity of the analysis, issues of transparency and credibility were
addressed. Prior to embarking on the research, the first author (CH) recorded her
own thoughts and perceptions about the topic, and reflected upon these with the
second author (RSPJ) within a supervisory context. This fostered a self-awareness of
researcher-bias. The third author (JCH) carried out credibility checks of the analysis
by reading the transcripts and theme lists to ensure that the interpretations were
identifiable within the data.

Results

Participant accounts clustered around five superordinate themes: the touch instinct;
touch and professional boundaries; individual clients and contexts; the value of
touch and the cost of touch. The importance of the topic of touch to the participants
was confirmed by the fact that all agreed that direct quotes could be included in the
reporting of the study following the application of pseudonyms.

The touch instinct

Participants considered touch an instinctual response and appropriateness was not
thoughtfully considered, but inherently experienced as a sense of being ‘‘right’’ in

280 C. Harrison et al.

context. Despite this, all participants emphasised the rarity and cautious use of touch
in their practice.

For example:

I’m just responding to non-verbals from the client and sort of sensing, I’m not sure I’m
thinking (James).

. . . it’s something that has to be used very, very carefully. It’s not my first response
(Elsie).

As advocates for the cautious use of touch, James and Lydia used terminology
such as ‘‘light touch’’ and spoke of a need for considered restraint. Even though its
use was viewed as being instinctual, Elsie and Lydia believed that obtaining clients’
consent was central if touch was to be used to meet clients’ needs:

I would definitely ask her before I did it. I’d say ‘‘would you like a hug?’’ (Elsie).

. . . you have to get somebody’s permission to do it, but they don’t have to give it
verbally (Lydia).

Although Elsie outlined a direct approach to gaining consent, Lydia discussed
how client need and acceptance of touch was sensed intuitively without the exchange
of words. Irrespective of whether clients were asked directly or not, Sylvia raised an
additional issue in relation to the use of touch and consent:

Do we ever know that they are ever consenting to it? (Sylvia).

Therefore issues relating to informed consideration, decision-making and client
consent regarding the use of touch remained, however, the three female participants
all recommended the promotion of client choice, irrespective of the different ways
that assent and need were assessed.

Touch and professional boundaries

Clive, Sylvia, John and Elsie discussed how clinical psychologists were generally
perceived as not offering touch:

. . . there is a sense that we’re people that don’t touch (Clive).

Expectations and the non-touching identity appeared to be strengthened from
within the profession through an absence of actual touch, a dialogue on touch or
specific training, thus perpetuating and retaining the taboo status of the topic. The
belief that touching was something clinical psychologists should not do was
discussed by the three male participants. For example:

I think the therapist’s role is to help the person to find the people who will do the
touching. We’re not the person in people’s lives, we’re not their friend, we’re certainly
not the person they are having a physical relationship with, we’re simply someone who
is trying to help (James).

Whilst acknowledging the need for touch, James suggested that this was outside
the remit of clinicians who instead endeavoured to empower clients to establish such
interactions outside therapy.

Clive, Sylvia and Lydia spoke of the unique, intimate nature of therapeutic
relationships yet all the participants (except for Clive) spoke of how professionals
working within the confines of certain therapeutic approaches are destined to
practice without touch, as particular models seemingly dissuade its inclusion.

Counselling Psychology Quarterly 281

Irrespective of approach, all participants spoke of professional boundaries within
therapy relationships. In this sense, the therapeutic model and boundaries of
individuals define who and how professionals are as clinicians.

Individual clients and contexts

. . . it has to be taken in the particular situation with the knowledge of that client
(Sylvia).

Sylvia’s recommendation that professionals appreciate client individuality and
context was also emphasised by Clive, Elsie and James. Participants referred to the

lack of a clear sense of right or wrong in relation to touch and recommended a stance
within which absolute rules were questioned. The participants (except James) descri-
bed how client distress could evoke or necessitate a touch response. Lydia suggested:

When it’s touch, I’m seeing that they need some kind of acknowledgement, because
they’re so distressed, it’s a grounding type thing. I’m saying, ‘‘I’m here’’ when they are
just so away with the emotion (Lydia).

Lydia reported that extreme distress can ‘‘remove’’ the client from the therapy
and touch is used to bring the client back. By enabling therapy to continue, touch is

utilised as a therapeutic tool to illustrate recognition of experience and to facilitate
progression.

Certain client diagnoses or presentations were described as necessitating touch
avoidance and John, Elsie and Lydia specified that the exclusion or careful
consideration of touch was required with clients presenting with specific issues in line
with a personality disorder diagnosis:

I’ve had clients who would fall in the borderline personality disorder realm whereby
touching could quite easily be misinterpreted and/or used in quite a negative or difficult
way (Elsie).

Clients’ life circumstances were also viewed as impacting on the use of touch.

Two of the male participants considered loneliness:

. . . if I had a patient who was very lonely, wanting to have someone and then I give them
a hug, that’s not a very good thing to do (John).

I’m painfully conscious of my clients’ isolation and I’m sure that makes me feel like I’d
like to give someone a hug, or a pat on the back (James).

John felt that physical contact with an isolated client would be inappropriate,
while James focused on his urge to touch lonely clients, although he identified his
tendency to notice, rather than act upon the feeling. In both instances, client

isolation impacted on touch.
Participants also spoke of the use of touch with clients who had been abused:

I can remember just holding the client’s two hands in mine, she was very, very
distressed, just disclosed abuse, I think for the first time (Elsie).

. . . for many of our clients, touch in terms of physical/sexual abuse has been present, so
that probably leads to the feeling of a need to be very careful, and yet, in my experiences
with some of those clients who have felt so abhorrent, so repulsive, that’s made it all the
more powerful (Sylvia).

282 C. Harrison et al.

Sylvia not only reported how these clients were perceived as a group with whom

touch needed to be tentative, but also suggested that touch was appropriate and most

effective when working with such clients.
All participants referred to the impact of client gender on touch. Elsie

stated:

I certainly would not offer touch to a male client. If a male client asked me to hold them
I would instantly go into quite a different mode. I hope that I would stay empathic and
tuned in, but I would not respond in that way because of the different interpretations
that can be put on that (Elsie).

The male participants discussed the potential complexity of touching a female

client and described their reservations. The female participants were more definitive,

and stated that touching male clients, beyond a handshake, had not and would not

occur. It is apparent that client–therapist gender difference influenced professional

decisions.
The majority of the participants had experienced client-led touch, for example:

. . . it’s very much dependent on client initiated behaviour, there’s no way that I would
touch somebody, unless, well when the hugs are involved I don’t hug them, they hug me
and I just don’t reject them (Lydia).

Hence, this touch may be more permissible as the desire is located with the client.

However, Sylvia stated that on occasions, she felt she had ‘‘no choice’’ in such

interactions. Elsie described client ‘‘signals’’ such as details of their abhorrence of

touch, which she interpreted as an instruction not to touch. The behaviours and

presentations of clients appear to influence professional responses and decisions

around future physical contact.

The value of touch in therapy

The majority of participants commented that touch could provide support. James

stated:

. . . perhaps the best thing we could do would just be to say ‘‘look, let’s leave all that for a
minute’’ and just do something [gestures reaching out] just to be very supportive or
empathic if someone is very upset (James).

It seems touch may support and simultaneously demonstrate empathy in a way

that words might not. Participants also referenced other benefits, such as its

acknowledging and validating impact:

. . . they have seen it as a further extension of acknowledging they are having a difficult
time and that I’m here (Clive).

Touch was also viewed as being of benefit for the professional:

. . . I think it has helped in that moment to just calm things down, enable the client to
come back, to being able to contain their distress (Elsie).

Lydia, James and Clive also believed that touch could assist the professional,

particularly in the communication of their feelings, but John did not agree:

. . . touching has a meaning in those situations, it means empathy: they are showing
empathy by touching the patient when they are distressed during the session. I don’t
think that. I don’t see any therapeutic value in touching (John).

Counselling Psychology Quarterly 283

John acknowledged that touch has a meaning, and perhaps therefore a value for

some professionals, but disagreed with the other participants such as Sylvia who

described touch as having the potential to be a ‘‘pivotal moment’’ in therapy.
All participants referred to the use of touch at session or intervention endings.

For example:

. . . shaking the hand at the end in kind of a sealing the deal way, if you strike a bargain
with somebody or an agreement you shake hands, and often by the end of a session,
there’s that sense that’s what you’re doing (James).

James described the handshake as a signification of the therapeutic contract that

communicated an agreement to what had passed. This is expanded upon by Lydia in

her account of touch at endings:

They haven’t hugged me after each session for the year or two that they’ve seen me, but
it’s an end point when they are not going to see me anymore (Lydia).

As touch was deemed prevalent at therapy endings by all participants, one value

of touch may be its propensity to signify farewell to the client. Alternatively, at the

end of therapy, professionals may no longer feel bound by the nature of the

relationship and consequently touch occurs.

The cost of touch in therapy

Issues of misinterpretation, confusion and dependency were common in a number of

the accounts, and James’s reflections encapsulated these:

. . . you don’t want to hug your clients because you might create all kinds of strange
ideas for them, you might make them dependent, it might be misinterpreted, blah blah
blah. . .. What is the risk that they are going to think this is sexual or that they are going
to get dependent on me? You have to weigh it all up, then you give them a big hug
[laughter] (James).

Whilst acknowledging a variety of potential negatives, James somewhat

minimised the impact of these costs by implying that there are an infinite number

of possible consequences with his remark and laughter. Clive spoke of the capacity

touch has to ‘‘destroy’’ the therapy relationship if misapplied, which necessitates

careful thought. It is apparent that clinicians can reflect on these issues in different

ways: James insinuated that in practice, touch is led by feeling, while Clive

appreciated the need for a more cautious approach due to associated risks.
The most frequently considered negative consequence of touch was the possibility

that it could be misconstrued by the client:

. . . if they misinterpret my intentions then that muddies the waters in a way that isn’t
going to be helpful (Elsie).

Elsie suggested that misinterpretation could negatively impact on the effective-

ness of the therapy process. Clive sensed that costs may be less when the perceived

probability of misinterpretation was reduced.
The group identified consequences for the professional following touch. Sylvia

described an incident of client-initiated touch after a therapy session:

. . . there was almost a slight feeling of shame. I can remember thinking maybe my
colleagues around me think this is what happens with all my clients (Sylvia).

284 C. Harrison et al.

Sylvia may be referencing the aforementioned theme that professionals are not
expected to touch and as a result, shame is experienced when colleagues witness this
interaction. When asked to elaborate on the impact of using touch, Clive added:

. . . there is always the no smoke without fire type things, damage to your reputation
amongst your peers and I think, for the added advantage that maybe a reassuring touch
would have given over comforting words, I don’t know whether the benefit outweighs
the risk.

Clive believed that lasting damage to the professional’s reputation could occur
without malpractice or sanction. Reflecting on the benefit-risk ratio, he felt uncertain
whether the value of touch was greater than the cost, implying that the prospect of
negative outcomes may be enough to deter professionals.

Discussion

By adopting an IPA approach, insights into touch from the perspectives of clinical
psychologists were captured, and meaning was dynamically explored. The existence
of the double hermeneutic and the inherent embracing of researcher biases fostered a
‘‘making sense’’ of participants’ lived experiences and allowed an insider perspective
on the issue to be obtained. Only one participant (John) reported that he did not
believe touch had any value within therapy, although he could appreciate the
meaning of touch for some. The other participants suggested that touch could be
both helpful, and harmful, depending on a myriad of client, contextual and
professional variations.

Clance and Petras (1998) reported that psychotherapists put a great deal of
thought into their decisions regarding touch. Although participants considered issues
relating to touch within the current study, it was apparent that decisions in therapy
were typically guided by instinct or a ‘‘feeling’’ without extensive ‘‘thinking.’’

All participants emphasised the rarity of touch within their practice and a number
described contact as ‘‘careful’’ or ‘‘light.’’ Participants discussed touch as being outside
the remit of clinicians, and considered how limited discussion and training perpetuated
this belief. These findings support the theories of Stenzel and Rupert (2004) that
discussion on touch within professional groups is limited due to the focus on risk
relating to accusations of misconduct. This results in a vicious cycle whereby
professionals are not expected to touch, therefore they avoid talking about it due to the
perceived risks. This reaffirms the belief that touch does not occur, thus maintaining
assumptions regarding touch-free, good practice. Moreover, therapeutic orientation
was discussed in relation to professional boundaries, and psychodynamic practice was
considered the least compatible with touch due to the neutrality necessitated within this
approach. This finding was consistent with Sinason’s (2006) belief that psychoanalyt-
ically informed professionals adopt a philosophy of ‘‘no touch.’’

Glickauf-Hughes and Chance (1998) suggested that clients with unfulfilled
relational needs and those who displayed so-called borderline functioning might
warrant the exclusion of touch in therapy. The results of the current qualitative study
supplement these findings as participants made the distinction that client isolation
increased a desire to touch, but not necessarily actual contact. Although touch with
clients who had experienced abuse necessitated a need to be careful, participants
reported that touch had been most helpful for these clients. This supports the
findings of Horton, Clance, Sterk-Elifson, and Emshoff (1995) that clients who had

Counselling Psychology Quarterly 285

experienced abuse found touch beneficial. While some participants in this study
would grant touch following client requests, Mintz (1969) believed that clients who
were assertive enough to request touch were likely to have this need met outside
therapy and consequently, touch was deemed less of a necessity. Milakovich (1992)
found that therapists who offered touch were more frequently female, however,
within the current qualitative study both male and female participants offered touch
and it appeared that the female participants more vehemently excluded the
possibility of touch with clients of the opposite gender.

The values of touch included the ideas that touch could offer clients support,
acknowledgement and containment, and that it had the propensity to ground or
bring the client back to the reality of the therapy. These findings support the
suggestions of Hunter and Struve (1998) that touch can enable clients to be present in
the therapy by overcoming distractions. In this study, the potential for touch to lead
to change and its description as a ‘‘pivotal moment’’ were findings consistent with
those of Durana (1998) and Llewelyn and Gardner (2009) who reported that specific
boundary violations might be appropriate in treatment.

Although all participants discussed the risks associated with touch, reluctance at
therapy endings seemed to disappear. In line with the findings of Stenzel and Rupert
(2004), the results of this study suggest that touch at endings is perceived as
symbolically different from touch within therapy. This may be because such touch is
more consistent with societal norms or, as the relationship ceases to exist, perhaps
professionals are freed from the shackles of the therapeutic relationship and can
more clearly show their humanity to clients.

In reaching our conclusions, we are mindful that the accounts provided by the
participants may have been censored due to the perception that touch within therapy
is a taboo. This potential limitation will be a factor within all studies that endeavour
to focus on controversial issues; however, this is not to imply that these topics should
not be addressed, rather that they should obtain further recognition so as to
challenge the taboo status.

Future research on client views on touch and the perspectives of other
professional groups may be particularly useful. The findings of this study implied
that gender differences between therapists may influence the use of touch in therapy
and this warrants further attention. The primary recommendation in terms of future
research is for more exploration to occur to ensure that this topic becomes
recognisable as an issue for therapists and that in turn, professionals feel more able
to be open about the issue in both theory and practice.

It is hoped that this study will communicate that professionals are not alone in
their ethical dilemmas, that it will encourage discussion of the topic and potentially
promote training on touch as this was typically deemed to be lacking by the
participants. In addition, this and future studies that demonstrate the potential value
of touch in therapy have the propensity to challenge ingrained ideas and to change
the perceived parameters of therapeutic relationships to incorporate touch within
best ethical practice.

Notes on contributors

Carmel Harrison (D. Clin. Psy.) is a Senior Clinical Psychologist in Betsi Cadwaladr
University Health Board. She currently works in the Adult Learning Disability Team in
Flintshire.

286 C. Harrison et al.

Prof. Robert S.P. Jones (PhD) is Head of Learning Disability Clinical Psychology in Betsi
Cadwaladr University Heath Board and Deputy Programme Director of the North Wales
Clinical Psychology Training Programme. He is an Honorary Professor of Psychology at the
School of Psychology, Bangor University.

Jaci C. Huws (PhD) is a Lecturer at the School of Healthcare Sciences, Bangor University. She
is also a registered nurse (adult; child).

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Can boundary crossings in clinical supervision be beneficial?

JoEllen M. Kozlowskia,b, Nathan T. Pruitta,c*, Theresa A. DeWalta,d and Sarah Knoxa,d

aDepartment of Counselor Education and Counseling Psychology, Marquette University,
Milwaukee, WI, USA; bHennepin County Medical Center Whittier Clinic, Minneapolis, MN, USA;

cCenter for Counseling and Student Development, Siena College, Loudonville, NY, USA;
dCounseling Services, University of Wisconsin-Whitewater, Whitewater, WI, USA

(Received 1 August 2013; accepted 25 November 2013)

Published studies have addressed boundary violations by clinical supervisors,
but boundary crossings, particularly those deemed positive by supervisees,
have not received much attention. Eleven trainees in APA-accredited doctoral
programs in clinical and counseling psychology were interviewed regarding
positive boundary crossings (PBCs) they experienced with clinical supervisors.
Interview data were analyzed using Consensual Qualitative Research.
Examples of PBCs included socializing with supervisors outside the office,
sharing car rides, and supervisor self-disclosure. Typically, supervisees did not
discuss the PBC with their supervisors because they were uncomfortable
doing so, felt that the PBC was normal, or felt that processing such issues
was not part of the supervisor’s style. Most supervisees viewed the PBCs as
enhancing the supervisory relationship and their clinical training; however,
some participants reported that the PBCs created role confusion. The results
suggest that there are legitimate reasons for supervisors to be scrupulous about
their boundaries with supervisees; however, supervisors who hold rigid
boundaries can deprive supervisees of deeper mentoring relationships or a
more authentic emotional relationship that can be valuable to supervisees
learning how to provide psychotherapy.

Keywords: supervision; boundary crossing; ethics, supervisees; CQR; positive;
training

Many trainees have identified the supervisory relationship as the most important
component of their clinical training experience (Ramos-Sanchez et al., 2002). Bernard
and Goodyear (2009) refer to supervision as the “signature pedagogy” of psychotherapy
that is essential to a supervisee’s professional development and to ensure client welfare.
Part of a strong supervision alliance originates from the supervisor setting healthy
boundaries (Heru, Strong, Price, & Recupero, 2004) and modeling ethical supervisory
practice (Gottlieb, Robinson, Younggren, 2007; Vasquez, 1992). Boundaries have been
defined for both psychotherapy and psychotherapy supervision as “rules of the
professional relationship that set it apart from other relationships” (Knapp & VandeCreek,
2006, p. 75). Gutheil and Gabbard (1993) posited that rules about boundaries tend to
focus on a few selected issues: “role; time; place and space; money; gifts, services, and
related matters; clothing; language; self-disclosure and related matters; and physical

*Corresponding author. Email: npruitt@siena.edu

© 2013 Taylor & Francis

Counselling Psychology Quarterly, 2014
Vol. 27, No. 2, 109–126, http://dx.doi.org/10.1080/09515070.2013.870123

mailto:npruitt@siena.edu

http://dx.doi.org/10.1080/09515070.2013.870123

contact” (p. 190). Pearson and Piazza (1997) argue that relationships in psychotherapy
and supervision are dynamic and require readjusting boundaries depending on the circum-
stances of the relationship, suggesting that universal rules about boundaries in supervision
are not practical. Despite the potentially complex nature of such boundaries, Heru et al.
(2004) found strong agreement from both supervisors and supervisees on appropriate and
inappropriate topics of discussion during clinical supervision. If supervisors and supervi-
sees agree on supervision boundaries, these findings would also suggest they might
implicitly agree on when these boundaries were being crossed.

Boundary crossings, as described by Gottlieb et al. (2007), are supervision events
where “a professional deviates from the strictest professional role but is not unethical
per se” (p. 241). Boundary crossings can be initiated by either the supervisor or super-
visee and can include a variety of situations: gift-giving, self-disclosure about issues not
related to work, having multiple roles, or socializing outside of work. In psychotherapy,
boundary crossings are often commonplace and not avoidable, especially for
practitioners in small communities or the military (Syme, 2003). In fact, some psycho-
therapeutic treatments, such exposure for anxiety disorders outside the office, require
crossing traditional psychotherapeutic boundaries (Abramowitz, 2013). Similarly, super-
visors cannot always avoid boundary crossings due to their own multiple roles (teacher
and professor), working in a small community, or simple happenstance (singing in the
same choir; being members of the same club) (Bernard & Goodyear, 2009).

Boundary crossings are frequently confused with boundary violations, which “reflect
exploitation of the supervisee, a supervisor’s loss of objectivity, disruption of the super-
visory relationship, or the reasonable foreseeability of harm” (Gottlieb et al., 2007,
p. 241). Boundary violations, such as having a sexual relationship with a supervisee,
are prohibited in all situations (American Psychological Association [APA], 2002). A
2012 study reported that one-third of graduate-level supervisees had experienced a
boundary violation in supervision which resulted in “profoundly negative effects on
themselves, the supervisory relations, work with subsequent supervisors, and patient
care” (Hardy, 2012, p. 4967). Some researchers have argued there can be a “slippery
slope,” that can result in some boundary crossings leading to a boundary violation
(Lamb & Catanzaro, 1998). In support of this argument, Lamb, Catanzaro, and Moor-
man (2004) reported that a surprising 45% of psychologists in their sample had thought
about initiating a sexual relationship with a supervisee, though very few follow-through
with the action. For supervisors unsure about whether a boundary crossing would be
appropriate, some researchers have generated recommendations (Gottlieb et al., 2007)
and decision-making models (Burian & Slimp, 2000).

An understanding of the power dynamics in supervision seems essential to maintain-
ing appropriate supervision boundaries. Supervisors can be oblivious to the power they
have over supervisees, as “the person with greater power often is able to remain less
consciously aware of [her authority] than is the person with less power” (Bernard &
Goodyear, 2009, p. 185). Thus, a supervisor might initiate a boundary crossing with the
best of intentions (e.g. taking predoctoral interns to lunch as a group) without realizing
that the supervisees might feel they cannot decline the invitation. Thus, although
boundary crossings are not always unethical (APA, 2002; DeJulio & Berkman, 2003)
and not always harmful (Barnett, Lazarus, Vasquez, Moorehead-Slaughter, & Johnson,
2007; Glass, 2003; Gutheil & Gabbard, 1993), the issue of supervisees ability to
consent to crossings and their relative lack of power is a concern.

110 J.M. Kozlowski et al.

Though many authors have argued that boundary crossings in supervision are “not
bad,” few studies have focused on how boundary crossings can be positive for
supervisees. Several studies have reported positive supervisory relationship outcomes as
a function of supervisor self-disclosure (e.g. Higdon, 2001; Ladany & Lehrman-Water-
man, 1999). Ladany and Walker (2003) argued that one of the most important factors
in determining the helpfulness of supervisor self-disclosure was whether the disclosure
was made “in the service of the supervisor versus the trainee” (p. 613). Consistent with
that assessment, Matazzoni (2008) found that supervisees perceived an improvement in
the working alliance when their supervisors disclosed relevant past clinical experiences,
but they felt the supervision relationship was damaged by irrelevant disclosures.
Similarly, a qualitative study of supervisees found that supervisor self-disclosure usually
normalized clinical struggles or enhanced the supervision relationship, but also found
that a few supervisees felt their supervisors’ disclosures were surprising or inappropriate
(Knox, Edwards, Hess, & Hill, 2011). These studies of supervisees stand in contrast to
reports from supervisors, who typically felt their self-disclosures only helped their
supervision relationships (Knox, Burkard, Edwards, Smith, & Schlosser, 2008).

Though many authors have written that boundary crossings can be beneficial so
long as they are undertaken in an ethical manner (e.g. Burian & Slimp, 2000; Gottlieb
et al., 2007), there has been little study of the positive effects of boundary crossings for
supervisees. Supervision theoretical orientations, however, do not appear to explicitly
address how to use boundary crossings to benefit supervision. Consequently, both
supervisors and supervisees are left with little guidance as to what is appropriate when
navigating the ground between extremely strict boundaries (e.g. conversations only
focus on work; only meet at defined times in a work setting; never meet outside of
work) and their feelings that a more flexible relationship might be helpful. Understand-
ing the positive effect of boundary crossings for supervisees is essential, since if there
is little benefit for such crossings, there would be no sense in risking problems with a
legal system that sees any boundary crossing as “bad, wrong, and harmful” (Gutheil &
Gabbard, 1993, p. 188). We wondered what types of events supervisees would see as a
positive boundary crossing (PBC), whether such a crossing was entirely positive or also
had negative effects, and how these crossings were handled in the supervision relation-
ship. We defined boundary crossings as instances in which a supervisor steps outside
the expected limits of the supervisory relationship when intervening with the supervisee.
The identification of the boundary crossing as “positive” was made solely by the super-
visee. We elected to use a qualitative design since boundary crossings and the associ-
ated consequences are highly contextual, and because there has been little research on
PBCs.

Method

Participants

The participants in this study included nine advanced practica (completion of at least
four semesters of practica) and two pre-doctoral internship students who were
geographically dispersed across all regions of the USA. Ten of the eleven participants
were female, and all participants were enrolled in APA-approved doctoral programs. Of
the nine advanced practica students, five came from clinical psychology programs, three
from counseling psychology programs, and one from a school/child clinical combined

Counselling Psychology Quarterly 111

program. The two pre-doctoral interns were from a clinical psychology program and a
child and family psychology program. Seven participants identified as Caucasian, one
as Caucasian-Pakistani, one as Russian-Jewish, one as White Middle Eastern, and one
as Filipino-American. Participants ranged in age from 25 to 32 years old (M = 28.1,
Mdn = 27, SD = 2.32). Participants’ theoretical orientations were Cognitive Behavioral
(n = 4), Psychodynamic (n = 3), Interpersonal (n = 2), and Integrative (n = 2), and they
saw between 3 and 9 clients per week (M = 5.5, Mdn = 5, SD = 2.0). To protect the
identity of the one male participant, all references in the

Results

and

Discussion

sections will use female pronouns.

In discussing supervision training, six participants reported having had neither
supervision coursework nor experience providing supervision; three reported having
coursework only; and two participants were providing supervision but had no
coursework in this area. As supervisees, participants reported working with between 3
and 13 (n = 70, M = 6.4, Mdn = 5.5, SD = 2.97) supervisors throughout their training,
most of whom were Caucasian. Participants reported they experienced boundary
crossings (whether negative, neutral, or positive) with the supervisor discussed in the
critical event (i.e. the PBC) between one and 17 times. Participants rated the quality of
their relationship with the PBC supervisor highly (between 5 and 7 on a scale where 1
= very negative; 7 = very positive; M = 6.6, Mdn = 7, SD = .69).

Measures

Participants completed a demographic form that asked about essential characteristics of
themselves, their supervisors, and the relationship with their supervisor. Additionally, the
participants completed a semi-structured, audiotaped phone interview (see Appendix 1).
The initial interview protocol consisted of three parts. The opening questions asked
participants to define “boundaries” and to describe any boundary crossings that had
happened while they were supervisees. The protocol also asked participants to report their
own and their supervisor’s cultural backgrounds, and how, if at all, any similarities and
differences between themselves and their supervisor influenced the supervision
relationship. The second part of the interview asked about a specific PBC event and its
associated details (e.g. description of event, relationship with supervisor at the time, when
the PBC occurred, why it was positive, whether the PBC was discussed in supervision
afterward). The final part of the protocol asked why the supervisees agreed to participate
in the research, the effects of the interview, and whether there was any additional infor-
mation that they wished to share. The follow-up interview, which occurred one to two
weeks after the first interview, offered an opportunity for the researcher to clarify the
information from the first interview. Similarly, the participant was given the opportunity
to add or clarify anything that was said in the previous interview.

Procedures

Pilot interviews

Two pilot interviews were conducted by the lead author before any of the participants
were interviewed. One of the interviewees was a recent graduate from an APA-accred-
ited counseling psychology program in the Midwest, and the other was a doctoral
student at the same university as the authors of this study. The pilot interviews were

112 J.M. Kozlowski et al.

conducted with the initial protocol developed from the literature by the primary
researcher and the auditor. Based on feedback from the pilot interviews, the protocol
was revised (e.g. to clarify wording).

Participant recruitment

Participants were recruited by posting an email notice on the Association of Psychology
Postdoctoral and Internship Centers listserv and the Division 17 (Counseling Psychol-
ogy) Clinical Training and Supervision listserv. Once an individual agreed to join the
study, the participant was asked for a home address so that a study packet could be sent
(i.e. cover letter, informed consent forms, demographic form, initial interview protocol,
and postcard to request a copy of the study’s results). Participants were compensated
with a long-distance phone card valued at $10.

Twenty-three students responded to requests for participation. Of those, seven
dropped out of participation after being contacted by the primary investigator (e.g. did
not return paperwork, stopped returning emails, and scheduled an interview time but
then did not participate), and four participants did not meet the study criteria (e.g. too
early in training or had already graduated), leaving 12 total participants. During data
analysis, the primary team and the auditor determined that one participant’s experience
did not meet criteria for the study, as her PBC was actually a boundary violation that
was almost entirely a negative experience. This participant reported that the supervisor
was insistent on having a personal, non-sexual friendship with the supervisee and con-
tinued to press the issue even though the supervisee made it clear she was not interested
in such a relationship. The participant initially was flattered by the attention and took it
to mean she was a good therapist, but she changed her mind as the advances persisted.
The interviewer discussed with the participant whether she would report the harassment,
but the participant was adamantly opposed. She was, however, appreciative of the
opportunity to clarify her thinking about her experiences with the supervisor during the
study interview, and she was getting support from friends in her program. Unfortu-
nately, the participant’s situation highlights Lamb and Catanzaro’s (1998) caution about
the “slippery slope” that can lead from boundary crossing to boundary violation. After
this individual was dropped, eleven people comprised the final sample for the study.

Interviews

All interviews were audiotaped and conducted over the telephone by the primary
researcher, and lasted from 31 to 51 min (M = 42.4, Mdn = 43.5, SD = 6.2). At the end of
the initial interview, a follow-up interview (Range = 3.25 to 7.75 min, M = 5.1, Mdn = 4.8,
SD = 1.4 min) was scheduled with each participant. All interviews were transcribed
verbatim, with the exceptions of stuttering, minimal encouragers, pauses, and silence; all
identifying information was removed; and participants were referred to by code number.

Author biases

Prior to conducting the interviews, all team members openly discussed their biases with
regard to supervision boundaries, supervisors crossing boundaries, and any boundary
crossings that they had experienced in their professional training as a supervisee. All

Counselling Psychology Quarterly 113

three principal investigators had experienced PBCs with their supervisors (e.g. going to
lunch, visiting a supervisor’s home); however, all three were cautious as to whether to
engage in a boundary crossing with their own supervisees. One author had experienced
boundary crossings that disrupted a supervision relationship. Two authors expressed
concern about boundary crossings between male supervisors and female supervisees (or
vice versa) being perceived as romantic or sexual by people outside the relationship.

Data analysis

Data were analyzed using Consensual Qualitative Research (CQR) (Hill et al., 2005;
Hill, Thompson, & Williams, 1997). All of the researchers had engaged in several
previous research projects using this method, and the auditor of the study had published
numerous studies in this area. CQR requires three steps to analyze data: domaining (the
coding of the interview transcripts into topic areas), core ideas (reducing domained data
to their essential elements by paraphrasing participants’ words), and cross-analysis
(identifying common themes that emerged across cases within a domain). Throughout
all of these steps, the team members must come to consensus on all decisions about the
data, as “a variety of viewpoints and experiences among the team members may help
unravel the complexities and ambiguities of the data” (Hill et al., 2005, p.197). Of
course, all team members needed to feel they could express their opinions openly,
which Hill et al. (2005) suggested was facilitated by the members having “strong inter-
personal skills as well as [liking and respecting] each other” (p.197). With regard to this
study, all of the team members were well-acquainted with each other from previous
work, and all had either completed or were nearing the completion of a doctorate in
psychology (hopefully suggesting at least an acceptable level of interpersonal skills).
All members seemed to enjoy working together and were confident they were active
participants in the decision-making process.

The initial domain list was developed by the primary researchers meeting together
to identify topics that were emerging in each transcript, and was revised as data analysis
proceeded (e.g. new domains were identified, other domains were collapsed). After the
team agreed on the domained and cored version of each transcript, the auditor reviewed
the document to assess whether the data were coded correctly and summarized
accurately. During the cross-analysis, the auditor reviewed each core idea’s fit within
the categories developed by the primary team as well as the overall logic of the cross
analysis (Hill et al., 1997, 2005). The auditor offered her feedback to the research team,
who considered the feedback and came to consensus regarding how to integrate the
auditor’s comments into the cross analysis.

Results

Categories were labeled “general” if they applied to all or all but one case; “typical” if
they represented at least half the cases; and “variant” if they applied to at least two
cases (Hill et al., 2005). Thus, for this study, general categories were composed of
10–11 cases, typical categories were 6–9 cases, and variant categories 2–5 cases. In
such cases where core ideas emerged from only one participant’s transcript, the data
were placed in the “other” category under their respective domain and are not reported
here. The findings are summarized in Table 1.

114 J.M. Kozlowski et al.

Contextual findings

Definition of boundaries

Participants typically defined boundaries as professional behavior that is expected of
individuals in a particular role. For example, one participant defined boundaries as
“what areas are off limits and what areas are within the limits,” whereas another
described boundaries as “maintaining appropriate professional behavior.” A variant
definition of boundaries was the idea that supervisees should behave in accordance with

Table 1. Domains, categories, and frequencies of contextual and specific PBC questions.

Domain Category Frequency

Contextual findings
1. Definition of boundaries Behaving within expected role

Typical

Behaving according to internal ethical
limits

Variant

2. Boundary crossings experienced in
previous supervision

Supervisor shared personal information Typical
Eating lunch or socializing with supervisee Typical
Going to supervisor’s home Variant
Receiving a gift from supervisor Variant
Supervisor provided extra supervision Variant
Supervisor was a professor in supervisee’s
graduate program

Variant

Supervisee perceived supervisor was
sexually attracted to her

Variant

Sexist comments or behavior by supervisor Variant

PBC critical incident findings

3. Rapport in PBC supervisory

relationship before PBC
Supervisee felt close to and/or supported
by SR

General

Neutral or superficial rapport Variant
4. Description of PBC Eating/Socializing with supervisor Typical

Supervisor shared personal information Typical
Sharing car rides Variant

5.

Discussion

of PBC in supervision PBC not addressed in supervision Typical
PBC was addressed in supervision Variant

6. Why PBC was not discussed Supervisee felt intimidated/anxious Typical
PBC perceived as normal, so discussion
not needed

Typical

Discussion did not fit supervisor’s style Variant
Supervisee unsure why PBC not addressed Variant

7.

Effects of PBC

A. Strengthened supervision
relationship

General
Supervisee discussed feelings and personal
concerns more openly

Typical

Supervisee grew personally Variant
Supervisor became mentor/role model to
supervisee

Variant

Others benefited from PBC Variant
Supervisee thought relationship would
continue after supervision

Variant

B. Enhanced supervisee’s training Typical
C. Created role confusion Typical

Notes: 11 cases total. General = 10–11, Typical = 6–9, Variant = 2–5.

Counselling Psychology Quarterly 115

their own personally circumscribed limits. “Everyone has their own set of these internal
rules that they view as acceptable” explained a participant.

Boundary crossings experienced in previous supervision

In prior supervision experiences, participants typically reported the supervisor shared
personal information. For instance, one participant stated that her supervisor discussed
the supervisor’s impending wedding and asked the supervisee what she thought of her
engagement ring. Another participant reported that the supervisor discussed his own
reaction to difficult clients. Supervisees also typically reported socializing with
supervisors, such as going to lunch with a supervisor or going out for alcoholic drinks.
Participants variantly reported visiting a supervisor’s home, variantly reported receiving
a gift from a supervisor, and variantly received extra supervision (e.g. while sharing car
rides on the way to co-lead a group). Participants were variantly engaged in dual roles
with supervisors. For instance, some supervisors were also instructors of courses in
which supervises were students. Participants variantly reported the supervisor seemed
sexually attracted to the supervisee. Finally, participants also variantly reported
boundary crossings in which supervisors used sexist language or behavior. As an
example, one participant explained that her male supervisor “saddled up next to [her],”
which the supervisee felt was inappropriate and upsetting.

The contextual findings demonstrate the difficulties the supervisees had in defining
boundaries. There appeared to be a tension in some participants whether boundaries
should be set by the supervisee (internal boundaries), by an authority (external bound-
aries), or some combination of the two. Also, the fact that all participants experienced
boundary crossings in previous supervisions (most listed multiple events) illustrates the
ubiquity of these occurrences.

PBC critical incident findings

Rapport in PBC supervisory relationship before PBC

A general category emerged as the participants described the supervisory relationship
prior to the PBC as supportive. For example, participants reported that their PBC
supervisor was genuine, understanding, warm, empowering, reinforcing, and caring.
Participants variantly described the supervision relationship as being neutral or
superficial. In all of these variant cases, the supervisee had been in supervision only a
short amount of time before the PBC.

Description of PBC

Participants typically reported a PBC in which the supervisor and supervisee went out
to eat with each other or socialized outside the work environment. One supervisee went
out in a group and drank alcohol with her supervisor. Other supervisees met the
supervisor’s family or had supervision at the supervisor’s house. Participants typically
reported supervisors discussing personal topics, ranging from the health of one supervi-
sor’s pets to the status of one of the supervisee’s friend’s application to the graduate
program where the supervisor was also a professor. In a final variant category,
supervisees shared car rides with supervisors.

116 J.M. Kozlowski et al.

Discussion of PBC in supervision

Participants typically reported that the PBC was not discussed in supervision. In fact,
only two of the eleven participants discussed the PBC in supervision. One participant
whose PBC was not addressed reported that she felt that if the supervisor thought it
was common practice to go out to lunch, then the supervisee was “fine with that
assessment.” She also felt, however, that “a good supervisor would have pursued it
[discussing PBC] further.” Variantly, supervisees did report that a discussion with the
supervisor about the PBC occurred, with one stating that she brought up the PBC in
supervision and that the supervisor was surprised but open to discussion.

Why PBC was not discussed

Typically, participants felt too intimidated or anxious to bring up the PBC. One partici-
pant was afraid of the supervisor getting angry (“backlash”), and another felt that, “as a
clinician-in-training it seems a little difficult to [bring-up the boundary crossing].”
Participants also typically indicated that they considered the PBC normal, with one
saying that she “just wanted to enjoy it” and not “process it to death.” Another partici-
pant just “assumed it was ok.” Participants also variantly felt that discussion of the PBC
did not fit their supervisors’ style. As an example, one participant stated that her supervi-
sor was “hands off” and did not “micromanage” issues in the supervisory relationship.
Lastly, participants variantly did not know why the PBC was not addressed in supervi-
sion. For instance, one participant attempted to talk about the PBC, but stated that her
supervisor did not seem interested in pursuing it, so she dropped the discussion.

Effects of PBC

Generally, participants stated that the PBC enhanced the supervisory relationship. Partic-
ipants here reported increased feelings of comfort, camaraderie, being “really under-
stood” by the supervisor, and feeling cared for. Five subcategories emerged under this
general category. First, participants typically felt that the PBC allowed them to share
their feelings and personal concerns more openly with the supervisor. As an example,
one participant reported that the PBC allowed her to feel more comfortable telling her
supervisor she often felt “stressed out” and “incompetent” when doing therapy. She felt
she could make this disclosure because she knew the supervisor would be supportive.
Supervisees also variantly reported that they grew personally from the PBC, such as the
supervisee who felt the PBC helped her begin to bridge the cultural divide she per-
ceived between herself and the other staff at the practicum site. Participants variantly
reported that the supervisor became a mentor or role model to the supervisee, with one
saying she viewed her supervisor as a “true expert and professional.” Participants vari-
antly reported that others benefited from the PBC. As an example, one participant and
her supervisor worked together to assist a student in getting into a graduate program.
Another participant, who co-led a therapy group with her supervisor, acknowledged that
the extra supervision the participant received during their shared car rides benefited the
therapy group members.

In a second typical finding, participants reported the PBC enhanced their training.
As an example, one supervisee explained that being vulnerable and working through

Counselling Psychology Quarterly 117

her feelings helped her connect with her clients. Another supervisee reported that she
was “much more motivated to do my work and apply myself” for her supervisor after
the PBC. Finally, the PBCs, while remaining an overall positive experience, also
typically created role confusion for the supervisees. One participant explained that the
supervisor “pushed the limit” on self-disclosure, but the supervisee did not feel comfort-
able telling the supervisor to stop, even though it was taking away from time to discuss
cases. Another supervisee wondered if the supervisor was still her friend after car rides
and going out to eat early in the year became focused mostly on clinical issues later in
the year.

Illustrative examples of a PBC. Included here are two participants’ experiences of a
PBC. These examples were chosen to represent common themes that occurred for many
participants. Though both boundary crossings had a positive effect on the supervisees
involved, they differ in that the first participant experienced role confusion and did not
discuss the crossing in supervision. In contrast, the second participant did not
experience role confusion and did discuss the crossing in supervision (i.e. the opposite
situation of the first participant). In order to maintain the participants’ confidentiality,
slight changes have been made to demographic information and to the reported
experiences.

In the first situation, the participant was a 27-year-old single Caucasian doctoral
student in clinical psychology receiving supervision from a married Caucasian female
in her early 40s. They did not have a prior relationship before the practicum. The super-
visee and supervisor became acquainted through shared car rides to sites where they
would administer neuropsychological assessments. Eventually, they started to get
snacks, eat lunch together, and engage in mutual self-disclosure. They discussed work
and personal matters, and the supervisor eventually invited the supervisee to her house
to meet her husband and two sons. The supervisee felt supported by the supervisor and
consequently felt she could discuss her clinical insecurities openly with less fear that
she would be perceived as incompetent. After the supervision was over, she asked the
supervisor to be on her dissertation committee, and they still keep in touch through
phone, email, and occasional lunch outings. Neither the supervisee nor the supervisor
labeled any of these incidents as “boundary crossings,” and they did not discuss them
as such during supervision. The participant thought the crossings were “not a big deal”
and not worth discussing. As was typical for participants in this study, the PBC did
cause the participant some initial role confusion. She worried early in the relationship
the supervisor was evaluating her constantly and she was not sure how much of herself
she could share with the supervisor. Despite this initial confusion, the experience was a
growth-enhancing experience that helped her develop as a clinician and resulted in a
friendship.

In the second situation, the participant was a 32-year-old Caucasian woman in a
clinical psychology doctoral program who had returned to school after some years in
the workforce as a social worker. The supervisor was a 38-year-old Asian-American
female psychologist. They developed a strong rapport quickly due to similarities in per-
sonality, age, gender, and because they were both single. “I wouldn’t have felt as close
with a male supervisor,” as she had a previous male supervisor had made sexist
comments and flirted with her. The boundary crossings began after a few all-staff
outings where they socialized outside of the office for the first time. After four months

118 J.M. Kozlowski et al.

of supervision, the participant and supervisor started getting lunch together and sharing
more personal information. When that went well, they went out for alcoholic drinks on
a few occasions after work.

The participant reported she enjoyed the supervisor’s company and did not think
much of the boundary crossings; so, she was surprised when the supervisor brought it
up for discussion during a supervision session. The supervisor said she asked colleagues
about the extra outings with the supervisee, and the colleagues reportedly said it was
acceptable so long as the participant consented, and that there was still a “trainer/trainee
relationship.” The supervisee responded, “I feel totally comfortable with this. It’s not a
problem for me at all.” The supervisee estimated it was “a two-minute conversation.”

The participant reported many positive outcomes from the boundary crossings. She
felt she learned “more from this supervisor than any other supervisor in my career.”
Because she and the supervisor were close, she felt she did not have to “play a role”
with the supervisor to please her. She also felt like she could ask questions about
sensitive issues, like sexism in the workplace, which she had avoided with other super-
visors. Overall, the participant said she “wouldn’t change anything about the situation”
and views the supervisor as a mentor.

Discussion

This study sought to examine supervisees’ experiences of a PBC by a supervisor in
clinical supervision. The findings demonstrated that PBCs usually occurred in the con-
text of an already supportive supervision relationship. The types of PBCs included
socializing with the supervisor outside the office, the supervisor sharing personal infor-
mation, and sharing car rides with a supervisee. The most notable positive effects for
the supervisees included a strengthened supervision relationship and a perception their
training was enhanced. The findings also demonstrated that while PBCs might appear
mundane to some supervisors (e.g. sharing a car with a supervisee), the supervisees
clearly experienced role confusion after such crossings. This role confusion would seem
to highlight the importance of talking about the boundary crossings; however, in most
situations, this did not occur.

Contextual findings

Participants seemed to define boundaries fairly generically, suggesting they had diffi-
culty coming up with an exact definition. Consistent with this, Gutheil and Gabbard
noted that, “clinicians tend to feel that they understand the concept of boundaries
instinctively, but using it in practice or explaining it to others is often challenging”
(1993, p. 188). Interestingly, participants seemed unclear whether they should look
toward themselves or some external source for how to act. Their confusion reinforces
the need for supervisors to continually discuss the parameters of their supervision rela-
tionships. In other words, even if supervisors are well-intentioned about boundary cross-
ings (i.e. “going to lunch will help my supervisees feel comfortable with me”), they
cannot simply assume their supervisees will feel the same way. Burian and Slimp
(2000), in arguing against rigid supervision boundaries, stated that the close mentoring
pre-doctoral interns receive in order to help them transition into being full professionals
“cannot occur without some degree of social interaction resulting in the potential for

Counselling Psychology Quarterly 119

the development of social relationships” (p. 333). Since all of the participants had previ-
ous experiences with boundary crossings, it seems reasonable to conclude that many
supervisors have adopted boundary crossings as part of their supervision practice,
whether they acknowledge it or not. While the results of this study support how
boundary crossings can be helpful, the vagaries of boundaries in any relationship make
discussion and consultation with colleagues imperative. As one author noted when writ-
ing about boundaries between physicians and patients, “it takes only a moment to step
over the line, especially when no one knows exactly where the line is” (Zuger, 2013).

PBC critical incident findings

Most participants reported positive relationships and good rapport with their supervisors
before the boundary crossings. This finding echoes Slimp and Burian’s study (1994)
that found that strong alliances influenced the development of boundary crossings.
Thus, PBCs appeared to strengthen a good existing supervision relationship. These find-
ing also again demonstrated that supervisor self-disclosure can be beneficial which is
consistent with previous research (e.g. Higdon, 2001; Ladany & Lehrman-Waterman,
1999; Matazzoni, 2008). Additionally, these findings lend support the Ladany and
Walker’s (2003) contention that a boundary crossing, such as self-disclosure, enhances
the relationship when it is done for the benefit of supervisees not supervisors.

Though participants reported that the PBC was a positive experience, many partici-
pants also experienced role confusion after the boundary crossing, particularly with
regards to how much the supervisor was their friend versus an authority figure. While
the role confusion never reached the threshold for a boundary violation as defined by
Gottlieb et al. (2007), the supervisees’ confusion should give pause to supervisors con-
sidering a boundary crossing. Specifically, supervisors need to insure, as Ladany and
Walker (2003) cautioned, that they are not trying to meet their own needs by crossing a
boundary. Supervisors also need to be aware that different supervisees may experience
the same boundary crossing quite differently.

A seemingly easy way to clear-up any role-confusion would be to discuss the
boundary crossings in supervision. Such a discussion, unfortunately, occurred for only
two out of the 11 participants in this study. There seem to be several possibilities for
why a discussion did not occur in most situations. First, as previously discussed, su-
pervisees have less power than their supervisors, and might feel awkward about raising
the boundary crossing as a topic of conversation. Supervisees might also worry about
negatively affecting a practicum or internship evaluation by making their supervisors
uncomfortable (Holloway, 1997). Consistent with this interpretation, supervisees in this
study usually felt either that the crossings were normal or that they were too anxious
about how the supervisor would react to discuss the crossing.

While these explanations show why the supervisees did not discuss the issue, why
did not the supervisors bring it up? One possibility is that since some supervisors lack
of awareness of their own authority (Bernard & Goodyear, 2009), they might have
decided that if supervisees did not bring-up the issue, then the supervisees were giving
their unspoken consent. Similarly, previous research has also shown that sensitive “pro-
cess” topics, like race and gender, are often not addressed in supervision (Bauer &
Mills, 1989; Gatmon et al., 2001). Another possibility is that the supervisors themselves
dismiss the significance of boundary crossings. While discussing seemingly low-risk

120 J.M. Kozlowski et al.

boundary crossings (e.g. supervisor self-disclosure, sharing a meal, and being in the
same extra-curricular activity) might be awkward, the results of this study suggest that
not discussing boundary crossings is a mistake. Such a discussion potentially benefits
both the supervisor and the supervisee. The supervisee would learn that boundary cross-
ings are acceptable to discuss in supervision; that the supervisee’s opinions about the
boundary crossings are important to the supervisor; and that the supervisor wants to
maintain healthy boundaries. The supervisors would know they are modeling ethical
supervision practice and guard against charges that the crossings are harmful for superv-
isees. After all, if the crossings are truly positive, there should not be much risk in a
discussion. If the supervisor would not be comfortable discussing the crossings, perhaps
that in itself is a sign the supervisor should seek further consultation before proceeding.

Limitations

This study was limited in that it only examined positive supervision boundary crossings
from the point of view of the supervisee. It may be that the supervisors to whom the
participants were referring would have had a different perspective on these events. Also,
participants were recruited by agreeing to talk about a PBC. So, simply by joining the
study, the participants were acknowledging that they experienced such an event. Under-
standably, there might be concern that this recruitment strategy primed participants to
tell the researchers what the participants thought the researchers wanted to hear (i.e.
only positive results of a boundary crossing). This appears unlikely, however, given the
participant who was excluded after her report of negative consequences of a boundary
crossing. Instead, it appeared that participants were genuinely feeling the boundary
crossings were positive. Furthermore, directly informing the participants about the focus
of the study on PBCs enhanced informed consent.

A third potential limitation is that the participants were not asked about negative
boundary crossings in the same supervision relationship where the positive crossing
occurred. It seems unlikely there were such negative crossings for most participants,
given that they described their supervision relationships in positive terms both before
and after the PBCs; however, the possible interaction of positive and negative crossings
would have been interesting to study. Another limitation of this study was the possibil-
ity of retrospective recall errors since the participants were discussing a past event.
Finally, the sample was not diverse in terms of gender (all but one were female) or race
(majority were Caucasian). Thus, the results may not generalize as well to male supervi-
sees and supervisees of color.

Implications

Clearly, PBCs can have a significant positive effect on a supervisee’s development as a
clinician and a professional. In fact, these results fit well Gottlieb et al.’s (2007, p. 243)
statement:

We contend that it is seldom problematic, for example, to have lunch with a supervisee,
discuss current events, or travel to a professional meeting together. In fact, a sound argu-
ment can be made that such informal contacts with supervisees are beneficial, provide good
opportunities for mentoring and modeling, and that there may be no slippery slope at all.

Counselling Psychology Quarterly 121

Unfortunately, “seldom problematic” does not mean “never,” and some supervisees in
this study had some lingering worries and unresolved feelings about the PBCs,
highlighted by the majority not discussing the PBCs in supervision and concerns about
role confusion. Discussion of the PBCs is essential to avoid this role confusion as well as
too avoid the “slippery slope” that has been shown in some cases to lead to boundary vio-
lations (Lamb & Catanzaro, 1998). This caution was apparent even in this study, where
one participant was dropped after discussing how an initially PBC turned into a boundary
violation. Consequently, if supervisors are unsure whether to engage in a boundary cross-
ing, consultation with objective colleagues or using ethical decision-making models (e.g.
Burian & Slimp, 2000) is essential to avoid harming supervisees. Lamb et al. (2004), in
fact, reported that many psychologists engage in such consultation with colleagues when
faced with questions about boundaries in supervision. With these cautions in mind, the
results of this study show that boundary crossings can enhance the supervision
relationship and improve the training experience for supervisees.

Future research

Ideally, a future study would compare the reports of boundary crossings from pairs of
supervisors and supervisees, thus highlighting the potential different interpretations of
the same boundary crossing. Future research on PBCs should include more male
participants and participants of color, as it is possible that these groups would have a
different perspective on boundary crossings. Third, supervision theoretical models
should explicitly discuss PBCs to help guide supervisors in their work, especially
seeing as the results of this and other studies have shown such crossings might be
relatively common. Finally, supervision in general is an understudied area, resulting in
“a relative dearth of research articles [that] is somewhat disquieting” (Bernard &
Goodyear, 2009, p. 298). With this conclusion in mind, we join with other supervision
researchers in encouraging more academics and clinicians to research and publish their
findings on this important aspect of clinical training.

Conclusion

This study demonstrated the potential benefits to supervisees of crossing traditional
boundaries in supervision. Despite these benefits, caution is still warranted. The supervi-
sees in this study seemed unsure about how to define boundaries, meaning they were
somewhat unsure about what is and is not acceptable in a supervision relationship.
Given this, it was somewhat troubling to see so few supervisors in this study discussing
these issues with their supervisees. A discussion would allow clarification of bound-
aries, show respect for the supervisee, and possibly allow supervisors to avoid crossing
a boundaries they might not be aware of. Supervisors must ensure that they discuss
boundaries with their supervisees and with colleagues, ideally before any crossing
occurs. There also is a responsibility for supervision literature and training programs to
discuss some of these more mundane boundary crossings (e.g. supervisor self-disclosure
about personal matters, eating with supervisees, etc.) in a forthright manner with
students. Such a discussion would be more likely to provoke mixed feelings amongst
practitioners, making them more difficult to discuss than boundary violations, where
there is broad agreement about the probable damage to supervisees.

122 J.M. Kozlowski et al.

If appropriate precautions are taken, boundary crossings can have benefits to
supervisees in the form of an improved relationship with the supervisor, more honesty
from a supervisee about her clinical struggles, or a mentoring relationship. Given these
benefits, maintaining traditional and strict supervision boundaries may lead to missed
opportunities for supervisee growth.

Acknowledgements

No grant funding was used for this research. We thank Dr. Alan Burkard, Dr. Tim Melchert, and
Dr. Pat Bradway for their comments on earlier drafts of this article. We thank the participants for
volunteering for this research.

Notes on contributors

JoEllen M. Kozlowski completed her doctorate in counseling psychology in the Department of
Counselor Education and Counseling Psychology at Marquette University. She is a senior licensed
clinical psychologist at Hennepin County Medical Center Whittier Clinic. Her clinical interests
include health psychology in primary care environments, clinical supervision, and medical
education.

Nathan T. Pruitt completed his doctorate in counseling psychology in the Department of
Counselor Education and Counseling Psychology at Marquette University. He currently works as
a licensed psychologist in the Center for Counseling and Student Development at Siena College
near Albany, NY. His clinical interests include college student mental health, clinical supervision,
grief, and mindfulness.

Theresa DeWalt completed her doctorate in counseling psychology in the Department of Counseling
Education and Counseling Psychology at Marquette University. She currently works as a licensed
psychologist and training director at the University of Wisconsin – Whitewater Counseling Services
Center. Her clinical interests include sexual assault treatment and prevention.

Sarah Knox completed her doctorate in counseling psychology at the University of Maryland.
She is a full professor in the Department of Counselor Education and Counseling Psychology at
Marquette University and is the author of numerous research articles on the qualitative research,
the psychotherapy relationship, and clinical training and supervision.

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Appendix 1. Interview protocol

Thank you for agreeing to participate in this project. Your willingness to share your
experiences is greatly appreciated.

Today we will be talking about boundary issues in supervision. Specifically, I will
be asking you about your experiences with boundary crossings in supervision that you
experienced as initially positive, or that in retrospect you now view as positively
influencing your growth. For this study, we are defining a PBC as a supervision
intervention that falls outside the expected supervision activities and is viewed by the
supervisee as beneficial. We note however, that boundary crossings may first be viewed
as distressing, but if a discussion ensues between supervisor and supervisee and the
resolution of that discussion enhances the supervisory relationship or the supervisee’s
professional development, such a boundary crossing is defined as positive. Several
examples of boundary crossings that may deemed positive (either initially or later) are
eating lunch with a supervisor, difficult discussion of sensitive clinical issues, (e.g.
sexual attraction), and supervisor self-disclosure of a personal nature. Do you have any
questions before we begin?

Opening questions:

(1) People define boundaries in many ways … how do you define boundaries?
(2) Please describe some of the boundary crossings that you have experienced in

supervision.
(3) What is your cultural background and your supervisor’s cultural background?

(a) How, if at all, did these similarities or differences influence
boundaries in the supervisory relationship?

Counselling Psychology Quarterly 125

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http://dx.doi.org/10.1037/0735-7028.35.3.248

http://dx.doi.org/10.1037/0735-7028.33.2.197

http://dx.doi.org/10.1037/0735-7028.33.2.197

http://dx.doi.org/10.1037/0735-7028.25.1.39

http://dx.doi.org/10.4135/9781446218624

http://dx.doi.org/10.1037/0735-7028.23.3.196

http://www.nytimes.com

PBC questions:

(4) Please tell me about a specific experience you had involving a supervisor’s
boundary crossing that you experienced as initially positive, or that ended
positively, in supervision.

(a) What was the PBC?
(b) How long had you been in supervision with this supervisor at the time of

the event?
(c) What level of rapport had been established between you and your

supervisor at the time of the event?
(d) What were the antecedent events leading up to the boundary crossing?
(e) What made this event positive for you?
(f) How, if at all, was the PBC addressed in supervision?

(i) What may have facilitated this discussion?
(ii) What may have inhibited this discussion?

(g) Why was not it discussed (if that is the case)?
(h) How did the PBC affect your supervision? (e.g. you, the supervision

process, the relationship)
(i) What are your current thoughts about this event as you reflect back (i.e.

would you do anything different, if so, what and why, if not, why not)?

Closing questions:

(5) How has this interview affected you?
(6) Why did you participate in this study?
(7) Is there anything else you would like to add?

126 J.M. Kozlowski et al.

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Abstract
• Method

Participants
Measures
Procedures
Pilot interviews
Participant recruitment
Interviews
Author biases
Data analysis
Results
Contextual findings
Definition of boundaries
Boundary crossings experienced in previous supervision
PBC critical incident findings
Rapport in PBC supervisory relationship before PBC
Description of PBC
Discussion of PBC in supervision
Why PBC was not discussed
Effects of PBC

Discussion
Contextual findings
PBC critical incident findings
Limitations
Implications
Future research

• Conclusion
• Acknowledgements

Notes on contributors
References

• Appendix 1. Interview protocol