Drawing Boundaries – recognizing structure and boundaries in patient-therapist interactions
Deborah A. Lott
Forget sex. It’s the smaller intimacies, sometimes even commonplace courtesies, that present the biggest dilemmas between clients and therapists.
Lana was in her five o’clock therapy session when the Seattle temperature took a nosedive. Clad in a light cotton blouse, Lana complained to her therapist, Ruth, that she was “freezing.” In response, Ruth turned up the heat and then offered Lana the green cable knit sweater that always hung on the inside door of her office. Lana hesitated, uncomfortable with the offer for reasons she didn’t quite understand. After a brief pause, she declined the sweater.
After years of media scrutiny, we have all gotten the message that sex between client and therapist is wrong. Not only is an affair an ethical transgression on the part of the counselor, it is also often a psychological disaster for the patient. But there are countless subtler–and no less consequential–boundary dilemmas that confound clients and therapists. These dilemmas center around the smaller intimacies, even the commonplace courtesies, that normally mark people’s everyday behavior. In a psychotherapeutic setting, however, they often take on deeper, symbolic meanings.
To Ruth, offering her sweater seemed well within the limits of her professional role, demonstrating concern for Lana’s welfare and making sure that therapy wouldn’t come to a standstill because of her client’s discomfort. But for Lana, the sweater wasn’t just any sweater. Lana associated the garment with Ruth. Indeed, during therapy sessions, Lana sometimes found it easier to look at the sweater and think about Ruth in the abstract than to look Ruth in the eye.
One of the issues Lana was dealing with in therapy was her tendency in close relationships to “lose herself” in the other person. Then she would get angry at herself for her own malleability, and withdraw. Lana imagined that, unlike her, Ruth was impervious to the influence of others, totally self-contained. Lana admired and feared this self-containment. The prospect of putting on Ruth’s sweater made Lana nervous because it brought up complicated feelings about closeness and distance. Moreover, if the sweater did not fit, Lana might have to confront the differences between herself and her therapist in too visceral a way.
Boundaries are a crucial element in patient-therapist interaction. First and foremost, they recognize the inherent power inequity of the relationship and set limits for the therapist’s expression of power. Second, they set a structure for the relationship, providing a consistent, reliable, predictable, knowable frame for a process that remains somewhat mysterious.
Most therapists agree about the broad basics. For example, a client should be able to count on a particular appointment time, which is not changed frequently or capriciously, and a set fee for sessions. Therapy should take place in the office, not in exotic locales. Practitioners should not engage in ongoing secondary relationships with clients.
Beyond these fundamental limits, however, there are a host of situations where the delineation of a boundary is less clear, situations that fall outside the formal ethics codes and lie instead on the cusp of principles and technique. Should a therapist who runs into a client at a restaurant, party or at the local gym engage in social chitchat or cut and run? Can a client and therapist both serve on the same school board or charity committee without distorting their therapeutic alliance? Should a client who has worked for years in her sessions to be able to sustain a romantic relationship expect her therapist to attend her wedding? Can a therapist give a compassionate hug to a patient after a particularly painful session?
How a therapist answers these questions may depend on theoretical persuasion and even personal bent. The individual therapist, in the sanctity of his office, often decides them alone. That is why some therapists drink tea with their clients during sessions and others do not; some have family photos in view and others banish them; some will attend an occasional social function where a client is present, and others will leave a party if they spot a client across the room; some will hug routinely, some will hug only if asked, and some will flinch at even a handshake with a client.
For therapists–and clients–who are struggling with boundaries, the paramount question must be: Does this serve the patient’s therapeutic interests? If an act or an encounter threatens that goal, it is suspect, even if its exploitative potential is not obvious.
One respected psychologist has stated publicly that he sometimes plays tennis with a client and doesn’t regard it as an abuse of power. But how does swatting balls with a client promote the client’s needs? There are too many things that can happen on a tennis court to jeopardize the core intent of the therapeutic relationship: watching the therapist lose his temper and behave irrationally, colliding with him and inadvertently hurting him, finding out that he has a tasteless tattoo or laughs at an offensive joke, and soon. And no therapist could play a decent game and still keep his focus on protecting the client’s interests.
For her part, the, client is likely to feel honored and special, unable to see playing tennis with her therapist as a casual social event. When a shift in the boundaries carries the promise of providing far mote than the act itself, when it assumes undue symbolic weight, the client is likely to be at her most vulnerable.
Gina, a young woman in her 20s, who had been in therapy for about a year, was rushed to the hospital for emergency abdominal surgery. In response to her distressed phone call, John, her therapist, visited her the next day. Gina was in a great deal of pain when John appeared in the doorway of her hospital room. Saying little, he came in, sat at her bedside, took her hand when she held it out to him, and offered a few reassuring words. After a short while, and after making sure that Gina had friends coming to see her, John left.
For Gina, John’s visit meant that he cared about her and could appreciate the depth of her vulnerability and pain. She recognized the visit as an exception to the therapy frame and did not expect it to be repeated. Illness was not a means by which Gina ordinarily expressed her desires to be taken care of, so she did not fantasize, as some clients might have, about getting sick in order to receive John’s ministrations. After Gina recovered, she and John discussed the hospital visit, what it had meant to her, and its place in the context of their relationship.
While some therapists would have avoided the hospital visit, arguing that it takes the therapeutic relationship outside the confines of the office and could promise more than therapy can deliver, many practitioners believe that the decision should be based on the individual circumstances and relationship.
What seems most important in this case is that John was not cavalier about his behavior. He carefully thought out the decision to visit, was deliberate in his actions while at Gina’s bedside and later created a safe forum in which she could discuss the visits meaning with him. He did not make the mistake of thinking that his visit was equivalent to that of another friend; this was a professional visit that would have symbolic resonance.
Therapists who take their power seriously also take the boundaries of therapy seriously. When they bend the therapeutic frame, they do so carefully and explore the ramifications their action has for the client. They recognize that not all meanings may emerge at first, and that clients may be reluctant to acknowledge just how important a seemingly trivial exchange is to them.
Good therapists recognize, too, that the intense feelings that surface in sessions often gravitate toward the boundaries. And that touch, and other physical contact, may be the most emotionally laden and controversial boundary of all.
One of the problems is that a hug between two people of unequal power is not the same as a hug between equals. The person with greater power, in this case, the therapist, “rations” the hugs, and the client cannot “take” a hug whenever she wants one. This suggests to the client that the therapist’s hugs are of tremendous value. Then, too, there is always the possibility that a hug will stir sexual desire. Hugs tend to become a taboo subject, not discussed during sessions even when they are routinely offered at the end, and practically never discussed while they are happening.
How therapists think about touch varies widely Psychoanalytically oriented therapists are less likely to touch their clients because their theoretical model assumes that physical contact may gratify transference fantasies that need to be understood, not acted out. Therapists influenced by the humanistic and more recent recovery movements are more inclined to hug routinely at the end of sessions. Many therapists take a moderate position, offering a pat on the back or an occasional hug if the client asks for it or if a session is particularly grueling.
My research suggests that touch in this setting is seldom a simple social gesture. It is powerful, has mixed effects and far-reaching ramifications. A hug can easily become the locus for all of a client’s unresolved feelings about authority, power, limits, the forbidden, deprivation and gratification.
If a client knows that a hug would mean too much or confuse her about the nature of the relationship, she should draw the boundary and simply let the therapist know that she would prefer not to be hugged. And if the therapist’s hugs have become too important to her, she should be able to discuss their meanings with her therapist, without fear that the wrong answer will result in their being withdrawn.
Arlene is 49 and in training to become a therapist herself. She has been in therapy with Paul for three years. At the end of their first session, he asked if she wanted a hug. After that, the hug became a regular part of each session’s closing. Arlene became very attached to this ritual: “If I only see him once a week, that’s one hug a week instead of two. I’m embarrassed to admit that I think about it in those terms, but I do. The hug means caring, acceptance, validation. I was raised to feel it was wrong or bad to have any needs of my own. The hug says that it’s okay to give affection, it’s okay to be vulnerable, I don’t have to be ashamed.”
Arlene’s parents divorced when she was two, and she saw her father only on weekends. Arlene felt that her mother took things away from her if Arlene wanted them too much, or if they made her feel too special.
One afternoon, about a year and a half into Arlene’s therapy, Paul was visibly upset when he came into the waiting room to get her for their session. She looked at him sympathetically, and he said, “I think I need a hug.” Arlene was happy to oblige. “I was feeling very special and really good.”
At the time, Arlene was having “all sorts of fantasies” about Paul. Some were romantic, but mostly she imagined him as a “good daddy,” who embodied everything she didn’t get from her own father–“openness, affection and respect.” The next session, when Paul came into the waiting room to get Arlene, she rose immediately and hugged him, institutionalizing the spontaneous gesture of the prior session. She interpreted his lackluster response as tacit approval of this new ritual.
Two months after the initial breach, as Arlene rose from her chair and moved toward Paul to give him what had become their routine session-opening hug, he stopped her. “I’m not going to do this anymore,” he said. “You want something from me that I don’t want to give.” Arlene felt the rebuff was “a slap in the face.”
Paul later acknowledged that he never should have asked Arlene for a hug in the first place and should not have allowed the hugs to continue, but that now he had to put a stop to them in order to take care of himself. Arlene’s hugs felt too “greedy,” too “grabby,” too “possessive” and that made him uncomfortable.
Arlene felt so devastated by Paul’s remarks that she did not raise the subject of the hug again for many months. Once again, as in childhood, something good, something that made her feel special, had been taken away from her because she had been too greedy and let her needs show.
Paul’s initial boundary breach arose out of his own need: he spontaneously used his client to comfort himself and, in doing so, failed to put his client’s interests above his own. Psychologist Michael Kahn, Ph.D., author of Between Therapist and Client (W. H. Freeman, 1991), offers two other criteria for assessing the symbolic impact of a boundary shift: Is it a form of seduction, or of punishment?
Seduction need not be overtly sexual; any act that stirs some kind of desire in the client for the therapist is seductive. The client feels lured in and led to expect more than is possible, something beyond the usual therapeutic services. Punishment is anything the therapist does that hurts or damages the client in order to satisfy his own emotional needs.
When Paul terminated the opening hugs, he again justified his action on the basis of serving his own needs rather than Arlene’s–her greediness was making him uncomfortable. In both initiating the hug and in putting a stop to it, then, Paul had put his own interests above his client’s.
Paul’s request for the hug had seductive connotations. It lured Arlene into feeling as though she were special, not like other clients, and that Paul and she had a relationship beyond the bounds of the usual client-therapist alliance. Although it made Arlene feel temporarily powerful, it did not actually increase her power in the relationship in any way. To the contrary, she felt less able to predict or control what might happen next. She could not even talk about the hug for fear of losing it. So Paul erred further by allowing the crossing to become an unspoken secret between therapist and client.
If Paul had set the right therapeutic context, Arlene might have been able to use his perception that her hugs felt “greedy” to advance her understanding of herself. As the rationale for his rejection, the comment did more harm than good. In fact, the hug had such a heavy symbolic charge for Arlene that she could not help but seem greedy, especially because she expected anything good to be snatched away from her. When Paul halted the hugs, his behavior had punitive connotations: he withdrew his favors out of disapproval of Arlene’s behavior.
“The message he was giving me in therapy was it’s okay to feel, to be open, to give, to let yourself be vulnerable, to have needs–you don’t have to feel ashamed,” Arlene says. “But then when I got into a situation with him where I thought that’s what I was doing, I was told that I was wrong. He kicked the needy little girl part of me around.”
When a boundary shifts in therapy, the client often experiences a sense of dislocation, the ground giving way beneath her. She does not dare to question the therapist’s intent because the crossing feels like a bonus. In most psychotherapy, the medium of exchange is words, rather than actions, with therapists varying even in their degree of emotional expressiveness. Touch is more primal, more visceral–and more provocative.
The clients I have interviewed reported that hugs had the potential to become a sort of extra-therapeutic reward system, like the pediatrician’s lollipop at the end of a session. Along these lines, clients also reported that hugs readily took on punitive connotations since there was always a threat that they would be withheld if the client “misbehaved” during the session.
Often a boundary crossing unleashes the fantasy that deep, childlike wishes and needs are finally going to be met, that she is finally going to get what she has been waiting for all her life. The rules are gone, the sky is going to rain love.
For Arlene, Paul’s hugs were magical. They came from the person who seemed symbolically capable of rectifying all the failings of her father. His hugs were gold doled out at the end of sessions, more immediate and gratifying than the therapy itself. When Paul began offering a hug at the beginning of the sessions, implying that it was as much for him as for her, Arlene felt that she could finally get what she had always wanted, and hung on for dear life. These were the issues that Arlene and Paul needed to address if they were ever to get beyond the boundary breach.
Therapy is a fragile, paradoxical relationship always at risk of turning into something else–friendship, romance, the worship of devotee for guru. Boundaries can prevent this from happening. They remind client and counselor that by being therapy, there are things that their relationship can never be, but that what it is, can be relied upon.
A client is safer and maintains more power by staying inside the therapeutic frame rather than by attempting to alter it. Within its structure, a client can allow himself to be completely vulnerable. Good boundaries, however, are not equivalent to good therapy. Boundaries exist to protect the therapy; they are not the therapy itself. It is quite possible for a therapist to keep the boundary and lose the patient, by enforcing boundaries in a restrictive, legalistic, defensive manner.
One of the complaints I have heard most often from clients was just how bad, how invisible and impotent, their therapists’ lack of emotional responsiveness could make them feel. And some therapists certainly use the boundaries to maintain this emotional distance.
But a bound relationship does not have to be an emotionally distant relationship. Therapists can be warm, responsive and authentic, and still maintain a protective frame around the alliance. Clients may have an easier time with boundaries if they can recognize that therapeutic boundaries, as artificial as they sometimes seem, ultimately serve their best interests.
* Therapy takes place at regular times.
* Therapy takes place in therapist’s office.
* If therapist’s office is in home, it is clearly demarcated from living space.
* Therapist bills on regular basis.
* Client pays on regular basis.
* Therapist answers freely all questions about professional beliefs and practices.
* Therapist and client discuss client’s progress and revisit goals on regular basis.
* Therapist proposes possibility of consultation with another therapist if therapy at impasse.
* Therapist keeps everything discussed in sessions strictly confidential.
* Focus of therapy is on client.
* Client goes into business with therapist.
* Client performs some other service for therapist: baby-sitting, secretarial work, teaching assistance.
* Client invests in business endeavor associated with therapist.
* Client gives therapist keys to his Hawaiian condo for a weekend.
* Therapist sets client up on blind date.
* Therapist suggests that client see his spouse for other professional services.
* Client is a student in a class graded by the therapist.
* Therapist regularly takes phone calls during client’s session.
* Therapist screams, yells, cries, blames patient, in an out-of-control fashion.
* Therapist eats lunch during client’s session.
* Therapist discusses other clients’ experiences during client’s sessions.
* Client belongs to the same reading group as therapist.
* Client and therapist attend same large social event given by a third party.
* Therapist attends client’s wedding or other major life event.
* Client attends a lecture given by therapist.
* Client sees same therapist for individual therapy as other family members or friends.
* Client and therapist have tea or coffee during sessions.
* Therapist offers client a hug at end of sessions.
* Therapist visits client in the hospital.
* Therapist extends session when client is especially distraught and no one else is waiting.
* Therapist conducts sessions over telephone when client is out of town.
* Therapist lends client a book to read.
TO DISCLOSE OR NOT TO DISCLOSE
How much therapists should reveal about their own lives is one of the most difficult boundary quandaries. Clients have a right to know everything that they’d ask of any health professional–where a therapist received her education, what kind of license she holds, her areas of expertise and how many years she’s been practicing. But when questions cross over from professional qualifications to more personal matters, things can get tricky.
Should therapists divulge whether they are single, married for the fourth time or divorced? What about sexual orientation? Ethnic background or religious persuasion? Beliefs? Hobbies or interests? What about questions pertaining to the therapist’s own mental health, and her experience as a therapy client? The extent to which a therapist discloses information depends greatly on her treatment philosophy, how she was trained and her own personality.
Whether it’s in the client’s interest to know anything about these more personal matters is also subject to debate. Knowing too much can actually inhibit the client’s own truth-telling: “How can I talk about my sex life when she’s so straight?” “A guy who spends his weekends going to poetry readings is not going to understand how I feel about sports,” and so on.
Therapy may resemble an intimate relationship in some respects, but it’s not a social bond. It can be most hazardous when a therapist starts to treat it as any other casual friendship.
Perhaps a therapist makes a personal revelation when moved by a client’s display of intimacy or in a seeming effort to bond or show empathy. A woman whose therapist had a need to unburden herself in self-dramatizing accounts of her own worst childhood memories soon found herself more haunted by her therapist’s childhood traumas than by her own. A disclosure should not be so captivating, so seductive, so dramatic that the client feels that the therapist is asking for something from her, even though she may not be sure exactly what.
Then there are those therapists who position themselves as role models–“If I could get through this, so can you. Just just do what I did.” When a therapist repeatedly holds herself up as an icon of togetherness, alarm bells should go off. Good therapists don’t think of themselves as gurus or superior beings, and do not put their clients in the role of devotees.
Personal anecdotes should be shared only occasionally and judiciously. A therapist who takes her work seriously will look to see what impact her self-disclosures have on the client, and will invite the client to talk about it. She will continually question whether spilling about herself is in the client’s best interest. When a therapist’s disclosures are too intimate, too frequent, too drawn out or driven, or seem particularly self-indulgent, the client needs to ask herself, “Just why is my therapist telling me this?”–and then to turn around and pose the question to the therapist.
Sometimes a client needs a piece of information the therapist refuses to give up. This may be especially true when a client is trying to verify that the anger or sorrow or frustration she saw flash across the therapist’s face was really what the therapist was feeling. When faced with this situation, many good therapists say that they would acknowledge the feeling without dwelling on it.
Good therapists neither withhold nor disclose information about themselves capriciously. And they never lose sight of the fact that the therapy is not about them, it’s about the client.
DEBORAH A. LOTT believes that everyday niceties–like offering a handshake or borrowing a sweater–can take on an all-too-intimate meaning in the context of a therapist-patient relationship. Her article, Drawing Boundaries (page 48), is adapted from her new book, In Session: The Bond Between Women and Their Therapists (W.H. Freeman). “I was surprised at how many highly educated, sophisticated women gave their power away when they went into psychotherapy in ways they wouldn’t if they went to a medical practitioner,” says Lott, who writes regularly for the Psychiatric Times. Her last article for PT, on flirting, appeared in the February issue.
COPYRIGHT 1999 Sussex Publishers, Inc.
COPYRIGHT 2000 Gale Group