In this essay I give my views on the boundaries of individual psychotherapy—their necessity and the process of learning them, accepting them, then gaining from and leaving the therapy process. The learning process was long, and I realize now how I had to internalize a number of new concepts for the therapy to succeed.After much thought and work, therapy was beneficial and rewarding for me. I now know that because I took the process of psychotherapy seriously, it made my life more fulfilling and my relationships more meaningful. For me, psychotherapy was especially helpful in reinforcing my ability to deal with a chronic, debilitating, and life-threatening illness. It helped me make each day a gift, accept my imperfections, and live with uncertainty, frustration, and anger with more dignity and greater understanding.
The first photo represents, by its flowing river, wooded sides, and middle pile of branches, the possibility of persevering in life and of going forward despite obstacles and difficulties as well as the boundaries inherent in all of life, especially in psychotherapy. [Johnston Falls River, Banff National Park, Alberta, British Columbia © Jan Goddard-Finegold, M.D.]
What we say in the world
We rarely divulge our personal thoughts in public, unless we feel a sudden sense of commonality and connection with a person or group of people. As an example, I think of the way we talk unguardedly with seatmates on airplanes—perhaps because there is safety in anonymity and because the chance of seeing the person in the adjoining seat again is unlikely. In general, though, public relationships are uncertain, unknown, and uncontrollable. In such circumstances, our confessions, little voices of personal loss, or mean feelings may find their way to their subjects, to unsympathetic people known in common, or to difficult family members. Furthermore, we may be quoted in places or publications without our permission, leading to personal or legal embarrassments.
Psychotherapy as a “safe place” and its boundaries
The freedom to speak openly and unguardedly is confidential in very circumscribed situations: with our lawyers and our physicians; with our priests, rabbis, or ministers; and most notably, with our psychotherapists (psychiatric physicians; psychiatric, clinical, and family social workers; clinical psychologists; and licensed lay psychotherapists, for the most part). The relationship between a qualified psychotherapist and a patient is a “safe place,” as described by Dr Leston Havens.1 Nevertheless, I learned that there are rules that govern such a therapeutic relationship, rules that must be adhered to, that have stood the test of time, and that ensure physical and mental safety, for both the therapist and the patient.
While these rules, or “boundaries,” have been stated somewhat differently by various therapists, I describe them from my experience as follows: (1) The emphasis in therapy is almost exclusively on the life and thoughts of the patient; (2) The therapist concentrates on finding ways to communicate meaningfully and helpfully with the patient about his or her difficulties using examples and knowledge from the therapist’s training and experience; (3) While the personality of the therapist is paramount to his or her success in therapeutic relationships, the therapist does not share his personal life, family information or problems, and especially, identity of or information about other patients; (4) The therapist may find ways to build the patient’s self-esteem by expressing admiration or joy for the patient or his success during therapy as well as concern for the patient’s well-being. A competent psychotherapist, however, does not disclose sexual attraction or love for the patient (nor distaste or dislike of the patient). If the therapist has sexual or loving feelings for the patient, or truly dislikes a patient, referral to another therapist is the answer.
While boundaries enable the therapist to focus on the patient’s problems and issues, the strictness of boundaries is not necessarily that originally taught by Freud, ie, that the therapist show “neutrality, anonymity, and abstinence” toward the patient.2 As Dr Glen Gabbard suggests, the current day interpretation of Freud’s concepts of boundaries would most likely be described as “restraint” on the part of the therapist.3 This means that each therapist will spontaneously reveal emotional responses to the patient’s comments and, in a nonjudgmental way, will learn about, interpret, and to a helpful and honest extent, go with the flow of the patient’s internal world.3,4
Transference and countertransference
While there are other recurring psychological responses in psychotherapy (such as resistance, repression, projection, hostility, and displacement), recognizing and dealing with transference and countertransference are major issues in psychotherapy and make the boundaries of psychotherapy most important and protective. The empathetic use of boundaries by a therapist allows him to be warm and responsive to the patient, to make an environment of trust for the patient, and to allow the patient to feel validated and understood.3
Transference is not usually recognized by the patient (the therapist is trained to recognize both transference and countertransference); many patients feel that they have a special (frequently loving) relationship with their therapist or that they distrust or even hate their therapist. I felt that I had a special relationship with my physician-therapist, but soon it became apparent and acceptable to me that the therapist was helping with tools that did not involve a relationship of the kind exemplified by a close bilateral friendship, despite the fact that my therapist and I were a “good fit.” I also became aware of the need I sometimes had to please my therapist as I might have attempted to please my parents; I learned that this was not a good way to make progress in my therapy.
This is as intimate as it gets.
–Paul Weston, played by Gabriel Byrne, to a patient in psychotherapy in the PBS series, In Treatment.
When I became aware of the reasons my therapist did not share information about his personal life, I felt safer because this boundary was kept intact. I was not burdened with knowing the difficulties or worries in his life. In addition, the physical distance between my therapist and me in the treatment setting was always far enough that any urge to touch was avoided. Sometimes a therapist will give a patient a single touch on the shoulder (behind the patient) as the patient is leaving a particularly difficult emotional session. I think this allows the patient to feel reassured that the therapist is there for him, but I understand why hugs are, for the most part, avoided. There are circumstances in which a hug is appropriate (when a patient is in extreme distress because of a recent or unexpected death of a close friend or relative). In such cases, the reason for the hug is discussed in the therapy. Depending on the training of the therapist, handshakes may be either held back or used more commonly in psychodynamic psychotherapy practices.3 In general, physical contact with a patient should be done with care and forethought as to possible unwanted, or unexpected, consequences. My therapist does not give hugs or handshakes but, rather, speaks sympathetically and from his heart when unexpected emotional situations arise.
On another note, most of the time, my therapist waits for me to acknowledge our relationship in public situations to maintain doctor/patient confidentiality; I feel comfortable acknowledging him openly but unobtrusively.
The therapist’s responses to patient’s questions about personal issues
A therapist may respond to a patient’s question about his personal life with another question that brings out the patient’s inner capacity to solve problems. In this way, the therapist does not let go of personal boundaries but uses the natural inquisitiveness and interest of the patient to other ends. An example might be that the patient is interested in the therapist’s children and asks whether he has time to spend with them. The therapist might answer, “Do you think this question relates to your feelings about your father’s time spent with you as a child?” Answering a question with a question such as this used to irritate me when I was new to psychotherapy. Now as a seasoned warrior, I expect such a response and I am able to predict the question.
I have been developing my photographs as black-and-white art prints for many years. I felt that some of these prints showed my deepest feelings and, like sand tray objects, could be shared with my psychiatrist. He, as a consummate professional, found a unique way of accepting the prints without letting them be personal gifts. They now hang appropriately in one of the college’s offices, which is used for meetings and teaching sessions and where students and faculty can appreciate them. [Lou Gehrig © Pic Search]
Sharing, symbolism, and boundaries: objects that reflect therapeutic concepts
At Commonweal Retreat Center, a place of healing in northern California begun by Dr Rachel Naomi Remen for people with cancer and for health professionals who need rejuvenation, objects are used in sand trays to represent feelings and intuitions, unconscious needs or beliefs, and problems in the mental life that are often not recognized by the individual participating in the sand tray exercise.5
There is a natural tendency in the successful therapeutic relationship for the patient to want to share physical gifts, personally made gifts, or items like those in Dr Remen’s sand tray that represent meaningful concepts occurring in the work being done by the patient and the therapist. Sometimes the gift is symbolic of the difficult situation a patient is in and represents a concept of the way in which a patient wishes to be seen or an idea for the future.
As an example, my therapist had an avid interest in baseball, and sometimes he used ideas borrowed from baseball during therapy. I felt that a photo of Lou Gehrig from the New York Times exemplified how I wanted to be seen by my therapist and by others—a strong individual willing to continue at her highest capacity to the end of her life. I presented the picture to my psychiatrist and said that I would like him to keep it in his office as a reminder for him and to help me “remember the person I am and not the disease I am afraid that I may become.” He hung the photo in his office, and both of us have benefited from its meaning. Some psychotherapists may say that we violated the boundary rules; I think not. I think, rather, that this was a healing part of my therapy and an example of what I wanted to accomplish and how I wanted to live. This would have, however, become a problem if I were constantly bringing gifts to my therapist, especially gifts of large value. I was discouraged from doing this and truly began to understand the nature of the healing relationship in which I was engaged.a I also understand the way in which gifts can possibly be used as a way of “fending off any aggression or anger in the therapist.”3
Gratefulness for the one-sided nature of psychotherapy
After some time in therapy I became acutely aware of how special the therapeutic relationship really is. The true confidentiality became apparent. It was clear that when negative issues arose, there was time to work them out against a thinking “punching bag,” who would not wilt or show personal distress when I expressed difficult feelings. In fact, my “punching bag” therapist looked forward to such challenges, took them as meaningful outpourings from me, and used his training to help me express such feelings. Together we built a positive framework for accepting and dealing with the underlying causes of my anger, guilt, and sadness.
Realization of the goals of therapy: giving up fantasies
Psychotherapy is not an immediate cure-all. Some patients have the fantasy that a few sessions with a therapist will yield suggestions that will still the waters of distress. The process does not work this way. Others have the idea that what they say in therapy will always be accepted as correct, workable, and acceptable. Of what value would therapy be if this were true?
I have learned that there is much energy that goes into the ongoing process of psychotherapy. Certainly there are shortened forms of therapies; however, in most cases, I think that long-standing success occurs only after a long period of hard work on the part of both therapist and patient. I believe that during this work, the patient learns that the therapist will show where there is faulty or injurious thinking. Freud called this the “common work.”6 My therapist and I have called it our “project.”
Indeed, it has been a project, one that is now ending because my therapist and I feel that the goals of our project, which we clarified throughout the therapeutic process, have been met for the most part. This achievement has left me feeling a sense of success and the ability to carry on in life using the tools gained during the interactions with my therapist. When difficult emotional situations arise, I have an arsenal of psychological armaments with which to fight.
A caring, enduring, goal-oriented relationship
While the relationship between therapist and patient is limited by boundaries, those important conditions do not mean the relationship cannot be enduring, caring, respectful, and in some sense, intimate. The therapeutic relationship involves sharing thoughts that are meaningful, sometimes filled with uncertainty, guilt, fragmentation, hatred, hope, forgiveness, fear, love, all the emotions that make us human but also that are frequently kept in our most closeted selves. The fact that I have been able to share and discuss such feelings in safety with my psychotherapist has made our therapeutic relationship work. Our project will be enduring if its effects are enduring and if I am able to use it as a lifelong, continuing, learning enterprise. Likewise, caring and respect do not have boundaries and can exist for a lifetime between patient and therapist. For me, this is especially important, as I face an uncertain future, have had life-threatening problems already, and look to more.
Knowing that my psychiatrist has agreed to be available to help in any situation that requires end-of-life decisions gives me confidence. Also, it helps me know that if my husband has to deal with difficult decisions, those already defined by me in my directive to my physicians, he will have the support of my psychotherapist—a person who has known me and my mental state for a number of years. I have indeed shared my wishes and most precious thoughts with my husband; however, in a life-threatening situation for me, I believe he will appreciate having psychological support.
I do not expect my psychotherapist to act as my husband’s rabbi. Rather, he and I have discussed his role as interpreter of the wishes I have shared with him and as purveyor of reassurance to my husband that he is carrying out the desires I would want in the manner I would want. The fact that my psychotherapist is willing to help my husband in this way gives me great solace.
In the usual course of psychotherapy, moving on is a gradual process for the patient. However, some may choose to end therapy abruptly with total cessation of the relationship between patient and therapist (which may be harmful for the patient in the long run, as he may not be as prepared for psychological exigencies as he imagines). For others, the loss sustained by the patient during disengagement from therapy is a process in and of itself and one that has to be worked out just as other emotional issues have been conquered during therapy.7
For my therapist and me, the process has been gradual. Fortunately, it has become evident that not only am I no longer depressed but also I feel a confidence in dealing with emotional issues that I did not have before therapy; thus, we have negotiated a plan to end our sessions.7 I am confident that over a reasonable period, there will be complete disengagement, with an understanding that my therapy could be started again, if necessary. I also feel that I will continue a process of self-reflection after my therapy has formally ended.
Further consequences of long-term psychotherapy
When two people work together to solve the problems of one of them, using the expertise, common sense, experience, and caring of the other, there will be a relationship. In individual psychotherapy, that relationship will be built on trust, knowledge, and mutual respect and will have appropriate boundaries. Nevertheless, the relationship that develops over time, limited though it is in the way the therapist shares personal information, and confidential though it is from the therapist’s point of view, is a feeling one: the therapist and patient may feel loss at the end of such individual therapy; the therapist may have sadness because of the difficulties or physical illness of a patient. The same is true for the patient when a caring therapist becomes ill or dies; in fact, as a patient with depression, I had an additional burden when my first therapist died unexpectedly during my course of therapy. A relationship with boundaries is a safe relationship, but that does not mean that it does not have mutual feeling. This feeling contributed to making individual psychotherapy special, helpful, and valued by me. Also, I recognized the large repertoire of background, training, and skill on the part of my psychotherapist and, similarly, my degree of sincerity, perseverance, and determination for success. [Taos Ladder, © Jan Goddard-Finegold 1997]
This is why it has been a significant part of my life and a process that has helped me deal with my illness, my daily life, and the probability of my early death. I feel that I am prepared to meet each day, and the problems the future holds, with equanimity and grace; I am also prepared to meet uncertainty, frustration, and anger with understanding and acceptance. Currently, I am in the process of moving on from therapy and in life, but I know I will have a final forty-five minutes with my therapist in which I say “thank-you” and “good-bye” and during which I share this essay.
Dr Goddard-Finegold is a physician now disabled by a mitochondrial neuromyopathy who practiced pediatric neurology and neuro-development for 28 years at Baylor College of Medicine and Texas Children’s Hospital before retiring. She taught medical students, residents, and fellows during her career and was noted for her research on brain injury in premature infants. She is married to Dr. Milton Finegold, a pathologist who specializes in children’s liver diseases. They have three grown children, two grandchildren, and two very imperious dachshunds! This article is dedicated to James W. Lomax II, MD, Herbert I. Dorfan, MD, and my husband, Milton J. Finegold, MD
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