Quality and therapeutic relationships have been of great concern in the medical field. In therapeutic relationships, boundary creation between the therapist and the patients is vital. The boundaries are accompanied by legal and ethical concerns, which both parties must observe. Therapeutic relationships and attachment to the service provided are said to measure something distinct that the users of the service experience about the care. If the care services keep on changing, the patients find it hard to form attachments that are positive to the service being provided. Therefore, for a good therapeutic relationship to exist, the patient should be used to one therapist, who is to give the therapy until the desired results are achieved.Physicians and nurses are striving to develop therapeutic relationships with their patients, especially those who are vulnerable. These efforts result to a relationship that is effective, enabling them to fully understand the needs of the patients. The result is well targeted care that achieves more positive results. This paper aims at exploring the therapeutic boundaries as portrayed in the movie ‘what About Bob?’, the legal and ethical issues related to the boundaries, sound clinical judgment in ethical decision making, the code of ethics and the violations that occur, and the issues of culture and human diversity, among others.

Plot summary of the movie: ‘What About Bob?’

This is a movie about doctor to patient relationship, which extended beyond office. Bob, the main character, is a patient who has multiple phobias, like travelling alone. He is directed to a psychotherapist, Dr. Leo Marvin, with whom he goes through therapy sessions. Bob likes the sessions and become attached to Dr. Leo, who later leaves for vacation. He leaves Bob with a book ‘Baby steps’ to be reading. The book talks about emotional disorder theories, and his philosophy of how he treats patients with phobia. Dr. Leo is egotistical, and gets annoyed by Bob’s attachment to him. When he leaves for vacation, Bob searches for his contacts and gains courage to follow him to his vocational home at New Hampshire lakeside. Dr. Leo is quite annoyed to see Bob, whom he had thought that he won’t bother him for some time.

Bob gains popularity to Leo’s family because of his good sense of humor, his witty personality, and his well planned ways of manipulating other people. Fay, Anna, and Siggy come to like him because of his fun, while Leo is quite dull. Leo fears that bob is taking over and tries to eliminate him from his family by making him go back to New York, but it becomes hard. Leo kidnaps bob by gunpoint in the dark, and ties explosives around him, and calls it a death therapy. Bob manages to escape b applying Leo’s ‘Baby steps’ approach which he has read for a long time. He goes back to Leo’s family with the explosives, which destroys the house. Leo is hit by catatonia because of the shock. When he is later brought to Bob’s and Lily’s wedding, he regains consciousness as he wants to dispute the union between Bob and his sister. The family becomes joyous.At the end, Bob becomes a psychologist, writing a novel ‘Death Therapy’ which becomes very famous. Leo tries to sue Bob for the rights (Ziskin & Oz, 1991).

Therapeutic boundaries and relationship issues

According to Mikulincer, Shaver & Berant (2013), it has raised great interest in the past decade to apply attachment theory in the clinical applications. A therapist-client relationship should be composed of trust, empathy, respect, power and professional intimacy. In their article, Mikulincer, Shaver & Berant (2013) have explored the therapeutic relationship and the role that the therapist plays in emotional healing. This has also been shown in the movie ‘What About Bob’. The relationship that resulted between Bob and Leo was purely therapeutic, and Leo had a great role to play in Bob’s recovery from his phobias.

For the healing process to take place quickly, the patient should feel secure when under the care of the therapist. Just like any other performance, a sense of security is essential to the client. The therapist should also feel secure during the process, in order for the therapeutic outcomes to be more positive. If there are any attachment insecurities from either side, the desired results could not be achieved, and this should be reduced as much as possible (Mikulincer, Shaver &Berant, 2013). In order to achieve great therapeutic attachment, security can not be ruled out. Bob felt good under the care of Dr. Leo, and that’s why he followed him to his vocational home because he could not feel secure being treated by another therapist.The therapist is supposed to have a non-stigmatizing attitude towards the client, because it can delay the healing process (Denhov & Topor, 2012). Once the therapist stigmatizes the patient, he sees his problem being beyond repair and can respond very slowly to the therapy. It is important for the therapist to act as a source of encouragement to the patient, and be willing to do much more beyond their routine. Like the case of Bob, if Leo had been a bit soft to him, his healing could have been facilitated. Had Leo been willing to push himself beyond what the office expected him to do, he would have taken Bob in cheerfully and establish a good relationship with him outside office. Instead of this, Leo sought all means to push bob away and stigmatize him, although bob overcame through his sense of humor.

In order for the client to feel more secure, the therapist owes the client confidentiality, which is an ethical obligation. There is also a legal concept which protects the client from their information being disclosed, which is privileged communication. The promise to the client that what is discovered during the therapy will not be disclosed to people who are not authorized becomes a legal matter if it is violated.In order to maintain the right therapeutic boundaries, staff has to be well and carefully selected. Therapists should have an open type of intimacy with their patients. It should be healing and safe, not abusive or frightening to the patient (Haigh, 2013). Therapists should have a limit to the extent in which they establish openness with their clients. This helps in maintain confidentiality and self disclosure. Expected attendance to therapy should also be maintained at a boundary between the patient and the therapist.

The boundaries also have it that there should not be friendship that is out of therapist-patient relationship, and no romantic relationship should be established between the two. They should also maintain the same boundary with the client’s family and friends, since a deep relationship can lead to disclosure of unintended information about the client (Ghuloum, Bener, Commons, Miller, Bulgut, & Bhugra, 2013). The greeting behavior between the therapist and client should not defy ethics to suggest inappropriate relationship between the two. The member of staff is not allowed to dress differently when seeing a specific client, or think about the client while away from work. The therapists should also not spend off-duty sessions with the client. Dr. Leo was behaving in the expected code of ethics by not allowing Bob, his client, to be incorporated into the family.

The relationship should not be sexually exploitative, or non- sexually exploitative like verbal abuse or bartering. It is also important for the therapist to be aware of the dual relationship that can exist; if the patient belongs to someone they know, like a friend. They should ensure that the already existing relationship do not interfere with objectives or the judgment between the therapist and the client (Ghuloum et al., 2013). Dr. Leo was subjected to the dual relationship since the patient, Bob, was directed to him by a colleague. They could be tempted to share Bob’s therapeutic results but it seems that they were guide by a code of ethics.

Some relationships are accepted between the clients and the therapists, like giving and receiving gifts from the clients, as it boosts the safe intimacy between the patient and the therapist, accelerating the healing processes. Allowing the patient to talk about themselves is advisable in the clinical practice, but how far it goes should be carefully monitored. Since it is sometimes hard to manage the professional boundaries, physicians are advised to identify and differentiate personal relationship boundaries and the professional boundaries.

Ethical decision making in therapeutic relationships

Since boundary issues that exist in therapy have raised a dilemma to many clinicians, it is important to think critically when making any decision concerning the ethical issues. For example a patient may become very pleased for the good care given by the therapist and feel the need to meet them outside the therapy. According to Ghuloum et al (2013), the encounter between therapists and clients outside therapy was a boundary violation admitted by participants. A therapist should decide whether o cross this boundary because of a certain reason, by considering the context of the therapy. It is true that Leo’s interaction with bob while on vacation as away of defying ethical codes, but Bob’s show of wits acted as a challenge to Dr. Leo and other psychotherapists, that it is important to step out of the rules sometimes.

Therapists should know that awareness of ethical codes and the legal standards can never be an aspect of critical thinking when making ethical decisions or about ethics in general. They should neither determine the ethical decisions that they make, nor should they be a substitute for making them feel or think their way through the dilemmas faced. The ethical decisions that they make, therefore, should put into considerations that all patients are unique in their own ways; the situations that need therapy are unique and evolves with time, and that the therapists are different. In addition, the community from which the client comes from is different from the one that the therapist comes from (Haigh, 2013). A patient could be from a community where they are used to soft touching as a way of comforting, and could expect the therapist to do the same to them. Although this is a violation of therapy ethical codes, the therapist ought to think critically what desirable effect the touch could bring to the patient.It is important to consider that almost every psychotherapist makes mistakes concerning the boundary decisions, can overlook something important and sometimes reach wrong conclusions. They can also take a misguided belief and believe so much in it. It is good, therefore, to put that into consideration when making critical decisions(Haigh, 2013). In the movie ‘What About Bob’, Dr. Leo was supposed to think critically of the consequences that could follow after attempting to kill Bob, and as a result consider violating some of the ethical codes that were set. He could have tried to empathize with Bob and find a way of speeding his recovery process.

It is important for a therapist to consult trusted colleagues because they may not fully rely on their own decisions. The colleagues should not be people involved in the issue, in order to enhance and strengthen ethical decision making. The colleague could view the situation in a different way and bring out the bias about it. This could broaden the therapist’s mind and help them to think more critically. If the therapist makes decision in a stressed state, it could not be the best; hence, they are required to consult at this time. The decisions that the therapists make could affect their lives, for example, a certain violation of a rule could lead to being fired with many other problems resulting. Consulting, therefore, could help the therapist know the consequences of the decision which they might have overlooked.

Therapists should understand that the needs of their clients come first, and that their clients have so much trust in them, like in the case of Bob in the movie ‘What About Bob?’ Bob trusted Leo so much that he used all means to find out where he went for vacation, and gained courage to travel and meet him. The therapist is not expected to involve himself in the client’s personal relationships in away that can bring a negative impact on the client, according toGhuloum et al, (2013). Therefore, in this context, Dr. Leo had no right to scold Bob and treat him as badly as he did just because he established friendship with his family members, because the code of ethics justified bob to lead his personal life without interference.

Supervision also has its ethical dangers. Supervisors and those being supervised like the therapists have to follow certain set code of ethics. Some of the ethical violations that occur in therapeutic relationships can also be seen in supervisory relationships. The supervisors evaluate the performance and look at the dual relationship that occurs between the therapists and the clients. The supervisory relationships can be accompanied by uncomfortable feelings from those being supervised, as they might feel that the supervisors are confining them to set guidelines, denying them freedom to be themselves and explore their ideas (Catty, Cowan, Poole, Ellis, Geyer, Lissouba, White& Burns, 2012). The supervisors should help the staff recognize any therapeutic boundaries that they violate, and try to solve the problem as early as possible in order to avoid further complications.Supervisors are expected to face issues about the employees on critical thinking and encourage them to make decisions based on critical thinking, not solely being guided by the outlined code of ethics. The ethical dilemmas sometimes facilitate the process of supervision, and can be a chance for the therapists to increase insight and grow professionally. Supervisors also have an important role in preventing poor judgment which can be caused by stress in the therapists.

In order to manage the boundaries of therapeutic relationships, the therapist should establish and follow a comprehensive plan of care. The client should establish this with the client, the family and his members of staff. The plan gives guidance on the strategies that the therapist is going to use in order to meet the therapeutic needs of the client (Porr, Drummond, & Olson, 2012). If a strategy is incorporated as part of the care plan, the therapist is saved from the accusations of crossing or violating the boundaries. After the health team agrees with the treatment plan, it should be documented and kept in the records for future referencing, in case the therapist is questioned about the strategy used.

Code of ethics and violations of the ethics

There are lot codes of ethics that exist in the therapeutic relationships, some of which are violated. Therapeutic code of ethics requires that the therapist should not have disclosure of their personal lives to the clients, or greet the client in a manner that suggests another relationship between the two other than the therapist-client relationship (Ghuloum et al, 2013). Violation of this code of ethics occurs when the therapists discloses themselves too much to the client. The therapists’ professionalism might not be respected by the client in this case.Therapists must not engage in behaviors that are viewed as sexually suggesting, seductive or exploitative. They should not touch the client in a sexual nature. By so doing, they violate the ethical code boundaries.

Culture and human diversity.

According to Haigh (2013), a culture of safety is esteemed in most communities. Continued involvement in issues and challenges causes a regressive force on members, and cause them to act with range on the undesirable actions subjected to them. Other communities encouraged the culture of openness through communalism. Open communication and intimate relationships are encouraged in such communities, and when patients from those communities seek therapy, they expect to be treated in a similar manner (Haigh, 2013). Humanity is also diverse, divided into classes. Those from lower classes are not able to go for good quality therapy, and they should be considered by the therapists. When dealing with patients, it is good for the therapists to understand that we are all different and we all require different attentions.

Conclusion

It is evident that therapeutic relationships are associated with the client’s ability to form a relationship, and their attachment to the service being provided. In the movie ‘What About Bob’, Bob had the ability to form a relationship easily and he became attached to Leo. Some boundaries have to be kept in therapeutic relationships like observing the personal space between the client and the therapist, which should not be violated. However, some crossing of the boundaries can be crossed by subjecting them to critical thinking, in order to meet the needs of the client, since everyone is unique in their own way, through culture and human diversity. Dr. Leo was trying to keep ethical boundaries with the Bob, but he was supposed to make decisions critically, by empathizing with Bob.

References

Catty, J., Cowan, N., Poole, Z., Ellis, G., Geyer, C., Lissouba, P., White, S., & Burns, T. (2012). Attachment to the clinical team and its association with therapeutic relationships, social net-works, and clinical well-being. Psychology and Psychotherapy: Theory, Research and Practice, 85(1), 17-35.

Denhov, a., & Topor, A. (2012). The components of helping relationships with professionals in psychiatry: user’s perspective. International Journal of social Psychiatry, 58(40), 417-424.

Ghuloum, S., Bener, A., Commons, M., L., Miller, P., M., Burgut, F., T., Bhugra, D. (2013). Perceptions of boundaries and cultural influences in Qatar. International Journal of Social Psychiatry, 31(1), 68-79.

Haigh, R. (2013). The quintessence of therapeutic environment. Therapeutic Communities: The International Journal of Therapeutic Communities, 34(1), 6-15.

Mikulincer, M., Shaver, P., R., & Berant, E. (2013). An attachment perspective on therapeutic processes and outcomes. Journal of Personality, 81(6), 606-616.

Porr, C., Drummond, J., Olson, K. (2012). Establishing therapeutic relationships with vulnerable and potentially stigmatized patients. Quality Health Research, 22(3), 384-396.

Ziskin, L. (Producer), & Oz, F. (Director). (1991). What About Bob? [Motion picture]. United States: Touchstone Pictures& Touchwood Pacific Partners.

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