Boundaries. My old college dictionary keeps the definition simple with a one sentence definition. A boundary is simply something that indicates a limit. But what does that mean exactly when it comes to psychotherapy? It isn’t so simple.
I do not claim to be an expert on the ethical or legal ramifications around the topic. For that you need an ethicist or forensic psychologist.
But with more than 35 years of private practice, I’ve had to think hard about what it means to hold and respect boundaries in treatment. I share these thoughts only as a friendly reminder of the ethical and practical issues we all confront every day.
I’ve also included the guidelines I’ve adopted over the years for my own practice for your consideration.
Most practicing therapists agree that setting some limits around our relationship with our clients keeps them – and us – safe.
As fascinating and even fun as some clients may be, we know better than to invite them to become a new best friend. We understand that even a hint of sexually inappropriate behavior will confuse and even damage the client and have legal repercussions. Those are the basics.
But after that, what it means to have good boundaries gets murky.
Other than with a few key issues, codes of ethics don’t spell out exactly what ethical conduct means. The APA Code of Ethics, for example, is explicit that psychologists may not engage in exploitative relationships, sexual or other forms of harassment or sexual intimacies with clients.
It also makes clear that a psychologist must not participate in a multiple relationship with a client or with people who are close to the client if doing so would impair the effectiveness of the therapy or do harm.
Similarly, the NASW code of ethics prohibits sexual involvement with or harassment of clients and cautions against physical contact with clients if there is any danger of psychological harm. Even those sections leave a great deal to interpretation. Words like “exploitative”, “effective” and “psychological harm” aren’t exactly definitive. The codes leave a lot to common sense.
As we all know, common sense isn’t always “common.” Some would argue, for example, that any self-disclosure on the part of therapists or out of office contact or any physical touch is at best ill-advised and at worst harmful.
But it’s only true that there are many well-established and entirely ethical ways to do psychotherapy that include those very actions. Within the context of those therapies, it is, at times, perfectly appropriate for the therapist to self-disclose in order to show empathy or make a point, to take a walk with an anxious client during a session, to offer a client a ride home, to share a meal or to touch or hug in a non-sexual way when the client gives permission.
However, therapists who use such techniques must act with caution. According to forensic psychologist, Dr. Martin Williams, each of the acts listed above has been the subject of civil or licensing board litigation as examples of unethical or harmful psychotherapeutic conduct. Worse, they have been used as evidence of existence of an inappropriate sexual relationship with a client. See the following.
How then do we engage with clients in a way that is genuine and true to our training but that doesn’t open us up to accusations of unethical conduct or inappropriate sexual behavior? To protect ourselves and our clients, it’s a question that every therapist needs to take seriously and respond to mindfully. We cannot afford to take it for granted that we and our clients have the same definition of boundaries or regard their importance in the same way.
I’ve found the distinction drawn between boundary violation and boundary crossing to be a useful one. It’s also a helpful distinction to talk about with clients during the first session when we introduce our treatment plan.
Boundary violations are never okay. These are actions that are self-serving for the therapist, exploitive of the client and that ignore the implications of the power differential between therapist and client. Violations include things like engaging in flirting or sexual advances, exploiting a client financially, going into business with a client, accepting significant money and gifts or using sessions for our own purposes.
One of my clients, for example, shared with me that her former therapist insisted that they go shopping together to buy clothes for the therapist so the client could learn how to share.
A letter I received for our advice column was from a middle-aged and apparently very lonely woman. She wanted to know if it was okay that her therapist went on expensive vacations with her (at the client’s expense) since the client had no friends.
In another letter, a writer complained that the therapist only talked about her own divorce every time the client raised issues she was having with her husband. We’re all only too painfully aware of news stories about therapists who have violated the trust of vulnerable clients by getting sexually involved, sometimes in the name of helping them have a corrective experience with sex.
But boundary crossings are purposeful deviations from our usual practice in the service of the client. The essential difference is that crossing the boundaries is an honest therapeutic decision where the therapist accepts personal responsibility for that decision and there is clear benefit to the client.
Even Freud who emphasized the importance of boundaries at times, loaned clients his books and took clients on walks or shared meals. He even sent postcards to some of his patients when he traveled. We may not agree with his rationale but his notes indicate that he generally had one.
We can similarly make exceptions to general boundary rules as long as we do so with thoughtful consideration of what we are doing and why. Appropriate boundary crossings include such things as going for a walk with an anxious client to help him learn a new way to manage anxiety.
It may be helpful to make a house call to a client who can’t come to the office because he is recovering from a difficult surgery and needs some additional coaching with coping skills. Sometimes it’s useful to observe a family in vivo by doing a home visit.
Going to a milestone event can be an important validation of the work we’ve done – although I suggest that it’s usually not helpful to stay for the party.
Part Two will provide some basic guidelines for therapists to consider.
Path and fence photo available from Shutterstock