Picture this. You’re sat in the waiting room of your therapist’s office. Your appointment was due to start fifteen minutes ago. Just as you’re beginning to bore of the housekeeping magazines on the coffee table, and your anxiety about some upcoming emotional disclosure is reaching an undeniable peak, your therapist calls you in.
As you settle nervously into your usual seat, Mr Therapist hastily stashes away a McDonalds burger wrapper and wipes some remnants of chocolate donut off his shirt collar. Irritably, he looks as his watch and announces he needs to make a phone call. After hanging up from an argument with his wife, he tells you that unfortunately your session has been cut short. But you’re still paying the full fee – that won’t be a problem, will it?
So I’ve just described the most irritating man in the world. Thankfully this scenario is fictional. I hope and pray that nobody has a therapist like that. (Though if you do, it might be time to check out my guide to finding the right therapist.)
Which brings me onto the topic of (you guessed it) therapeutic boundaries. This is a term that will be familiar to many, but for those new to the experience of psychotherapy, I would like to talk a little bit about boundaries and their purpose.
I will warn you that I am a little biased when it comes to this topic. That’s because my ex therapist violated boundaries with me. Not the blatant donut-eating, wife-calling kind, but something much more sinister (you can read about it here). I can attest to the psychological damage caused by poor boundary setting. Even the smallest of infractions can add up to a create a concoction of confusion for the client, or in the very least, an anxiety about the competency of the clinician and an undoing of all the hard work you’ve done together so far.
What are boundaries?
Boundaries are agreed limits, within which psychological safety is provided. They may also be seen as implicit and explicit ‘rules’ which are part of the formal nature of all therapy. They protect both clients and therapists. There is a consensus of ethical standards of practice in the counselling/psychotherapy profession, which includes the principle ‘doing no harm’.
Boundaries enable clients to feel safe and able to discuss topics that may seem taboo, frightening or embarrassing.
Who is responsible for therapeutic boundaries?
The therapist is responsible for maintaining boundaries. By the very nature of the therapist’s expertise, and the vulnerability of some (if not all) clients, it is expected that the therapist is in a position of power. It is sometimes helpful to compare this to a parent / child relationship, where the parent is the one with superior experience and knowledge. It is always the job of the parent to have an overall awareness of any issues and to act accordingly. This responsibility does not fall to the child. It is the same in therapy with the therapist / patient relationship.
Some clients may have difficulties with boundary setting – particularly if they have experienced this in their early lives. Abuse and trauma victims, or simply victims of bad parenting, can have challenges when it comes to attachment and appropriate responses. This can be emphasised for anyone when faced with emotionally charged subjects in therapy. It is the therapist’s role to keep this in check, and they should have had extensive training in order to facilitate this.
Some examples of boundaries
Some general boundaries are not usually discussed within each client/ therapist relationship, but are taken for granted by therapists as being part of the professional ‘ethos’ of all therapists. This applies, for example, to the boundary which forbids therapists from having a sexual relationship with their clients.
Other specific boundaries may be negotiated at the start of therapy, and are part of the ‘terms and conditions’ of the therapy contract. For instance, as well as arranging fees, times and frequency of appointments, therapists might discuss whether it is acceptable or desirable for you to have telephone conversations between therapy sessions, and under what circumstances, so that you both have clear expectations.
The following are just a few more examples of healthy boundaries:
- Consistency and predictability of therapy sessions – in the same location, at the same time, unless otherwise agreed
- A calm, non-distracting environment where the focus is on the client
- Maintaining confidentiality
- Maintaining neutrality rather than imposing the therapist’s values
- Avoiding dual relationships with clients, e.g. student/teacher or supervisee /supervisor relationship
- Ensuring that contact between therapist and client is limited to pre-arranged appointments (unless phone calls etc are previously agreed as part of treatment)
- Appropriately and ethically managed physical attraction between therapist and client, if it occurs, rather than it being acted on
- Avoiding giving, receiving or exchanging gifts
- Managing the end of therapy to ensure formal boundaries are maintained once the therapy relationship has been concluded and/or during a break in therapy sessions
Boundary breaking and boundary violations
Boundary issues are disruptions of the expected and accepted social, physical, and psychological boundaries that separate physicians from patients. There are two types of boundary issues, as identified by Gutheil and Gabhard: Boundary crossings and boundary violations.
As the above table demonstrates, not all boundary issues are equal. Boundary crossings may even be helpful to therapy, and provide useful discussion points that benefit the relationship.
Violations are usually much more concerning. This is something I will be discussing in my next post: Signs of Bad or Questionable Therapy.
Feel free to leave a comment on my blog if you’d like to share your experience of therapeutic boundaries. (If you are unable to access comments via the WordPress reader, you can access the comment box on the main site at this link.)