Managing boundaries in the therapeutic relationship.

Rachael Kelleher

MANAGING BOUNDARIES IN THE THERAPEUTIC RELATIONSHIP

Abstract

This paper will examine the ethical issues surrounding the management of boundaries in the therapeutic relationship both during therapy and outside the room. It will interpret ‘outside the room’ as the interactions with the client that occur before and after the therapy session ends. These may include insufficient closure, dual or multiple relationships, and out-of-office experiences. The paper will begin with examination of the literature and debate surrounding the definition of boundaries.  It will continue with a discussion of the research and the impact of these elements on professional practice. As the paper draws on psychotherapy and psychology literature, the term therapist is used to refer to both psychologists and psychotherapists who are engaged in therapeutic work with clients.  Policies and procedures which may guide best practice and the management of some of these ‘outside the room’ interactions are examined. Finally, the paper will conclude with a summary of the most salient ethical issues raised in the literature, as well as highlighting areas for future research.

 

Defining boundaries

A key framework for practicing ethical client-therapist interactions both inside and outside the therapy room is the concept of boundaries. Therapeutic boundaries are defined as “the edge of appropriate or professional behaviour, transgression of which involves the therapist stepping out of the clinical role”1. They play an important role in controlling the inherent power differential in the client-therapist relationship and allowing clients’ needs to be addressed and prioritised over the therapist’s own needs1. Addressing clients’ needs and maintaining professional boundaries also ties into psychologists’ ethical duty to act with integrity and responsibility towards clients2. The maintenance of boundaries helps preserve the integrity of the therapeutic relationship and expand the trust which the public holds towards therapists and clinicians3. This article attempts to explore the existing guidelines as regards common boundary queries facing therapists in practice, and to facilitate discussion around boundary-related issues which have not yet been covered by ethical guidelines or literature.

Ethical guidelines and therapeutic literature have reached a consensus that the therapeutic relationship between a therapist and the client exists with the sole purpose of enacting therapy.  While the therapeutic relationship progresses and becomes more personal as the client discusses more confidential topics, there is an increased likelihood of developing strong emotional bonds4. A strong emotional bond in itself does not constitute a boundary issue. However, whenever the therapeutic relationship deviates from its basic goal of treatment, it becomes non-therapeutic4. It is this deviation that is known as a boundary violation as it may result non-therapeutic activity4 .

Gutheil and Simon differentiate between two types of boundary issues; boundary violations and boundary crossings1. Boundary issues have also been referred to as boundary transgressions5. Boundary crossings are defined as a transient deviation from classical therapeutic activity that is harmless and is non-exploitative of the client. The boundary crossing may, in some instances, support the therapy. Examples might include scheduling clients outside regular hours, helping an elderly client with their coat or offering more frequent follow-up contact than strictly necessary. A boundary violation, meanwhile, is harmful to and exploitative of the client, as well as damaging to the therapy1. Examples might include sexual misconduct with clients, dual relationships (such as therapist and friend), inappropriate self-disclosure, conflicts of interest, inappropriate behaviour arising from transference and countertransference, and inappropriate touch. Related to these two definitions are the ‘slippery slope’ concept, which refers to the idea that what starts as one incident of boundary crossing may deteriorate into further and more frequent boundary violations6.

Boundary transgressions may be made by clients towards therapists and may commonly include asking personal questions, attempting to socialise, and being overly affectionate or abusive. It is important that therapists maintain boundaries to minimise and manage boundary transgressions, while simultaneously respecting the client’s authentic goals and autonomy.  Respect for the dignity of the client should always remain the fundamental ethical principle when therapists are approaching boundary problems7. However, defining what constitutes a boundary problem or transgression requires further discussion on the definition of boundaries themselves, explored below.

 

Difficulties in defining boundaries

Much of the ethical literature emphasises the complex and nuanced definition of boundaries. Deciding what constitutes a boundary violation or crossing is a complex issue. Bennett and colleagues’ model of the process of decision-making argues that the process is multi-factorial and complex, and that unambiguously right or wrong answers are rarely available to the decision-maker8. Thus, defining boundaries cannot merely be reduced to a list of approved and disapproved behaviours9. Neither can an informed consent document anticipate the entirety of boundary management dilemmas that a therapist may encounter10.

Several have maintained that therapists cannot be absolutist as regards boundary guidelines7,11. Beauchamp’s definition of therapeutic boundaries emphasises that they should not separate the client from the therapist7. Rather, appropriate boundaries should “define a fluctuating, reasonably neutral, safe space that enables the dynamic, psychological interaction between therapist and patient to unfold”7. This view is supported by Oldham and colleagues9, who argue that the definition of a boundary is context-dependent. Equally, the importance of cultural considerations has been emphasised in explaining that role boundaries may vary in their rigidity, depending on the role and on the cultural climate12. The therapists’ theoretical orientation may also play a role in determining the relative rigidity of boundaries, with psychodynamic tradition tending towards the view that out-of-office experiences can interfere with the transference process5. Ethical literature and therapeutic orientations vary on their stance as regards whether gift-giving by or to therapists constitutes a boundary crossing. There are no psychological codes of ethics which find all gift exchanges to be unethical, instead, there are ethically appropriate instances in which gifts may be given or received13. The nature of the gift may be important in interpreting this particular ethical boundary; for example, a more permanent gift (like an ornament) may be interpreted differently to a practical or perishable gift.

It has been noted that working in smaller or in rural settings can make it increasingly difficult for therapists to avoid certain boundary crossings, such as multiple relationships when they may live and work within the same community as their clients14. This idea is discussed in greater detail below.

 

Multiple relationships

Much research has been conducted into the process of dual or multiple relationships, whereby an individual may play both a professional role (as a therapist) and a personal role (for example, neighbour or friend) in the client’s life. The APA did not prohibit psychologists engaging in sexual relationships with clients until 197715, lending more insight into the relatively nascent nature of the debate regarding dual relationships and professional boundary maintenance10. While psychological bodies’ ethical stance against sexual relationships with clients is now absolutely clear, their stance on dual relationships is more complex.

The current ethical consensus reached by the American Psychological Association (APA) is that dual relationships constitute a boundary crossing but are not unethical in themselves16. According to article 3.05 of the APA’s code of professional conduct, dual or multiple relationships should be avoided where they are likely to “impair the psychologist’s objectivity, competence, or effectiveness in performing his or her functions as a psychologist, or otherwise risks exploitation or harm to the person with whom the professional relationship exists”. This article is also consistent with ethical guidelines produced by the Psychological Society of Ireland. Principal 4: Integrity, states psychologists “shall not use the professional relationship to exploit clients, sexually or otherwise, and they shall deal actively with conflicts of interest”2. The PSI guidelines also make specific reference to dual relationships, advising that they be avoided where possible2.

It has been argued that within some communities (for example, the military), avoiding multiple relationships is not always possible, and that such relationships may be enacted in such a manner that is still ethical14,17. The PSI notes that where it is not possible to avoid such relationships, psychologists must “take active steps to safeguard the students’, employees’ or clients’ interests”2. Again, Crowden notes the difficulty of defining boundaries within dual relationships, reporting that some ethical codes are unclear about when exactly an ethical crossing becomes an ethical violation14. Younggren and Gottlieb provide a comprehensive list of questions which the therapist should ask themselves before and during the enactment of a dual relationship, which may provide useful guidance in such situations17. The authors recommend that therapists ask if the relationship would be beneficial; that they obtain informed consent from the client regarding the risks; that therapists check if the decision-making process was well-documented in the client’s records, and importantly, the therapist must consider if they can truly be objective in evaluating the matter17. While a full examination of multiple relationships is outside the scope of this paper, a related scenario, out-of-office experiences, is explored hence.

 

Out-of-office experiences: Meeting clients outside of therapy

Meetings or interactions with clients outside of the office have previously been placed in the category of a ‘slippery slope’ interaction, and have been defined as being related to dual relationships5,18. Experiences which occur out of the therapy room, whether part of a treatment plan or not, have been regarded as being on the “slippery slope”5. There are three types of out-of-office experiences, all with different function: i) as part of a well-considered and empirically based treatment plan, ii) to increase therapeutic effectiveness, and iii) unplanned, random encounters which occur as part of normal living within a community5. Zur argues that only the third type of out-of-office experience may be considered as a dual relationship5.  Zur argues in favour of the utility of out-of-office experiences (where they constitute healthy dual relationships) in furthering the client-therapist alliance, and in allowing for a degree of flexibility in relation to clients’ needs5,19. The provision of several examples from his own professional practice demonstrates how therapy succeeded to a greater extent that it would have had Zur stuck more rigidly to boundary rules or to defensive practice strategies19. This seems to support the argument that engaging in these boundary crossings through practice of meeting his clients out of the office is, in this particular instance, ethically sound. Similarly, it is worth examining the ways that community-based outreach work by therapists, while outside of the frame, may provide different benefits to clients than traditional office-based therapy.

As in any ethical debate, the needs and well-being of the client must be considered in enacting a treatment boundary. Indeed, Younggren & Gottlieb17 argue that good care is a key component of risk management; and that the two notions should not be viewed as mutually exclusive. This is supported by Lazarus’ view that prioritising risk-management principles over human interventions constitutes “one of the worst professional or ethical violations” 20. Some vicarious trauma literature suggests that when a therapist is out in public, or lives in the same locality as their clients, the community may see them as representing ‘the cause’ of psychology21. The authors note that this provides an important example of where therapists are encouraged to work on their boundaries with the community.

 

Boundaries and supervision

As the present article is focussed on client-therapist interactions, a discussion of boundaries within the supervisory relationship is outside the scope of the current article. Boundaries within the supervisory relationship is a topic which merits a much more in-depth discussion of countertransference processes. However, supervision could certainly provide a useful and important space in which novice and experienced therapists alike can define therapeutic boundaries in a more structured manner, as well as exploring experiences of insufficient closure.

 

Therapeutic closure: A psychological boundary

A discussion of therapeutic boundaries must take into account the importance of creating psychological boundaries outside of the session – that is, therapists must be able to ‘switch off’ from thinking about clients’ issues after work. This can be challenging, as therapists and allied health professionals are frequently exposed to the traumatic experiences of their clients. While the reflective process is arguably a mark of expertise in a therapist22, regulating the quantity and content of one’s reflection on these traumatic emotions may be particularly demanding for the novice or trainee therapist. To do so requires regulating one’s emotional involvement22, and the use of a sophisticated paradigm known as the Cycle of Caring23. In this cycle, the therapist becomes attached emotionally to the client, works with them actively, and must then separate from them emotionally at termination of therapy.  This is a complex process which may invoke several reactions in the therapist.

Rønnestad24 hypothesizes that there are three styles of closure which occur in response to an overload of challenging or emotionally charged data. Premature closure and insufficient closure are maladaptive relational and professional boundaries that are either too rigid (premature) or overly loose (insufficient)24. Premature closure, as previously discussed, is a maladaptive defense mechanism whereby the therapist feels unable to meet the clients’ intense experiences or emotions and is similar in concept to countertransference25, 26. Examples may include only working within one therapeutic modality or with a particular age group of clients. Insufficient closure is likely to occur in novice therapists and refers to the inability to disengage from thinking about the client’s issues after the therapeutic session has ended27. The third type, functional closure, reflects best practice and is defined as the “appropriate [emphasis added] termination of the reflection process so that the practitioner can act therapeutically and not be stuck in continuous and non-progressive reflection”27.

The ethical importance of regulating out-of-hours thinking about one’s clients is underlined by the psychological and physical consequences of being overburdened by these thoughts. While some literature has noted that a certain degree of preoccupation with clients can be beneficial28 most research finds insufficient closure to be detrimental to therapists’ wellbeing and practice. When working with vulnerable populations, therapists listen to the distress experienced by the groups they are working with and may absorb some of this distress as a result29, 30. As they hold their clients’ emotions, therapists may experience a plethora of intense emotional reactions ranging from anger or terror, to sadness or relief.  Accordingly, insufficient closure, being a type of emotional boundary crossing, may be said to be linked to various negative sequelae including burnout and vicarious trauma31 . The literature to date identifies certain types of emotional reactions as “traumatic stress”32 which may result in Secondary Traumatic Stress (STS), Compassion Fatigue (CF), Traumatic Countertransference (TC), or Vicarious Trauma (VT)32. All of these reactions may have detrimental implications on therapists’ professional efficacy, staff turnover and organizational health33, 34.

The PSI ethical guidelines are clear around the importance of dealing appropriately with distress as an occupational hazard. Principle 2: Competence, states that psychologists must recognise the limits to their own professional capacity, and must not exceed them2. Principle 4, Integrity states that psychologists must maintain their own mental health and manage their own personal stress2. More specifically, the PSI guidelines advise psychologists to seek emotional support and/or supervision from colleagues if they experience feelings of stress or vulnerability as a result of professional dilemmas2.

Some literature suggests that trainee or novice therapists may struggle with insufficient closure and the associated sequelae to a greater extent than do experienced therapists27. One study of trainee therapists found that half the sample reported a self-sacrificing defense style, which was a risk factor for the development of vicarious trauma35.

Ethical guidelines are less specific in advising psychologists how to deal with insufficient closure.  A safe, structured, clinically supervised approach to discussing closure styles may be helpful in avoiding insufficient closure from negatively impacting the therapeutic relationship as well as the therapist’s own well-being33.

Aside from research by Skovholt, Rønnestad, and colleagues, insufficient closure does not appear to be well documented in the extant literature. Future research should seek to investigate the process and incidence of insufficient closure, and the therapeutic phenomena which may be related to it. Two such phenomena include transference and countertransference. Objective countertransference is defined by Cartwright and Read as “the therapist’s feelings or responses that are evoked by the client’s transference onto the therapist or the client’s interpersonal patterns of relating”36. Again, there is some debate as to the ethical management of transference. Ellis theorizes that transference and countertransference may have both beneficial and destructive impact on the therapeutic relationship37. Potential links between countertransference and insufficient closure could be explored in greater detail by future studies.

 

Discussion

This article has examined the ethical issues related to managing boundaries in the therapeutic relationship. It began with an exploration of boundaries, attempts to define them, and what happens when boundary issues arise. Insufficient closure, dual relationships, and out-of-office experiences were explored with reference to current theory and best practice guidelines. Overall, the literature seems ethically divided on many of these topics, particularly on boundary problems which appear to defy precise definition. Ongoing debate and research is valuable in contributing towards best practice and ethical education for therapists. Therapists’ own ethical thinking, which takes into account the human aspect of ethical decision-making, may be of particular use in situations requiring flexibility, and also in the absence of specific guidelines38. In conclusion, more attention is needed specifically in researching insufficient closure. Practical, specific ethical guidelines regarding its management should ideally be provided by professional bodies governing those who work in a therapeutic role. Such guidelines could serve to continue the ethical discussion as regards this issue, and potentially help inform therapists’ self-care practices.

 

 

References

  1. Gutheil TG, Simon RI. Non-sexual boundary crossings and boundary violations: The ethical dimension. Psychiatric Clinics of North America [Internet]. Elsevier BV; 2002 Sep; 25(3): A585–A592. Available from: http://dx.doi.org/10.1016/s0193-953x(01)00012-0
  2. Psychological Society of Ireland. Code of Professional Ethics. 2010. Available from https://www.psychologicalsociety.ie/footer/PSI-Code-of-Professional-Ethics-3
  3. Krishnaram V, Aravind V, Thasneem Z. Boundary Crossings and Violations in Clinical Settings. Indian Journal of Psychological Medicine [Internet]. Medknow; 2012;34(1):21. Available from: http://dx.doi.org/10.4103/0253-7176.96151
  4. Gutheil TG, Gabbard GO. The concept of boundaries in clinical practice: Theoretical and risk-management dimensions. The American Journal of Psychiatry. 1993. Feb.
  5. Zur O. Out-of-office experience: When crossing office boundaries and engaging in dual relationships are clinically beneficial and ethically sound. Independent Practitioner. 2001;21(1):96-100.
  6. Simon RI. Treatment boundary violations: Clinical, ethical, and legal considerations. Journal of the American Academy of Psychiatry and the Law Online. 1992 Sep 1;20(3):269-88.
  7. Beauchamp TL. The philosophical basis of psychiatric ethics. Psychiatric Ethics [Internet]. Oxford University Press; 2009 Jan;25–48. Available from: http://dx.doi.org/10.1093/med/9780199234318.003.0003
  8. Bennett BE, Bricklin PM, Harris E, Knapp S, VandeCreek L, Younggren JN. Assessing and managing risk in psychological practice: An individualized approach. The Trust; 2006; Available from: http://dx.doi.org/10.1037/14293-000
  9. Oldham JM, Skodol AE, Bender DS, editors. Essentials of personality disorders. American Psychiatric Publishing; 2009.
  10. Gottlieb MC, Younggren JN. Is there a slippery slope? Considerations regarding multiple relationships and risk management. Professional Psychology: Research and Practice. 2009 Dec;40(6):564.
  11. Ebert BW. Multiple relationships and conflict of interest for mental health professionals: A conservative psycholegal approach. Professional Resource Press/Professional Resource Exchange; 2006.
  12. Ingram DH. Intimacy in the psychoanalytic relationship: A preliminary sketch. The American Journal of Psychoanalysis [Internet]. Springer Nature; 1991 Dec;51(4):403–11. Available from: http://dx.doi.org/10.1007/bf01251035
  13. Zur O. Gifts in Therapy: Some are appropriate. The National Psychologist [Internet]. 2012 Sep. Available from http://nationalpsychologist.com/2012/09/gifts-in-therapy-some-are-appropriate/101741.html
  14. Crowden A. Professional boundaries and the ethics of dual and multiple overlapping relationships in psychotherapy. Monash Bioethics Review. 2008 Oct 1;27(4):10-27.
  15. American Psychological Association. (1977, March). Ethical standards of psychologists. APA Monitor, 22–23
  16. Behnke S. Multiple relationships and APA’s new ethics code: Values and applications. Monitor on Psychology. 2004;35(1)
  17. Younggren JN, Gottlieb MC. Managing risk when contemplating multiple relationships. Professional Psychology: Research and Practice. 2004 Jun;35(3):255.
  18. Strasburger LH, Jorgenson L, Sutherland P. The prevention of psychotherapist sexual misconduct: Avoiding the slippery slope. American Journal of Psychotherapy. 1992 Oct.
  19. Zur O. Boundaries in Psychotherapy: Ethical and Clinical Explorations. American Psychological Association; 2007.
  20. Lazarus AA. How certain boundaries and ethics diminish therapeutic effectiveness. Ethics & behavior. 1994 Sep 1;4(3):255-61.
  21. Centre for Violence Prevention and Recovery. Strategies for Trauma services: Advocate Education and Support Project Curriculum.Boston, MA; 2007. Available from https://vtt.ovc.ojp.gov/ojpasset/Documents/STS_Strategies_for_Trauma_Services_Staff-508.pdf
  22. Skovholt TM, Rønnestad MH, Jennings L. Searching for expertise in counseling, psychotherapy, and professional psychology. Educational Psychology Review. 1997 Dec 1;9(4):361-9.
  23. Skovholt TM, Trotter-Mathison M. The resilient practitioner: Burnout prevention and self-care strategies for counselors, therapists, teachers, and health professionals. Routledge; 2014 Apr 8.
  24. Rønnestad MH, Skovholt T. Berufliche Entwicklung und Supervision von Psychotherapeuten. Psychotherapeut [Internet]. Springer Nature; 1997 Sep 15;42(5):299–306. Available from: http://dx.doi.org/10.1007/s002780050079
  25. Rønnestad MH, Skovholt TM. En modell for profesjonell utvikling og stagnasjon hos terapeutere og rådgivere. Tidsskrift for Norsk Psykologforening (A model of the professional development and stagnation of therapists and counselors). Journal of the Norwegian Psychological Association. 1991; 28, 555–567.
  26. Rønnestad MH, Skovholt TM. The journey of the counselor and therapist: Research findings and perspectives on professional development. Journal of career development. 2003 Sep 1;30(1):5-44.
  27. Skovholt TM, Rønnestad MH. Struggles of the novice counselor and therapist. Journal of Career Development. 2003 Sep;30(1):45-58.
  28. Neufeldt SA, Karno MP, Nelson ML. A qualitative study of experts’ conceptualizations of supervisee reflectivity. Journal of Counseling Psychology. 1996 Jan;43(1):3.
  29. Morrissette PJ. The pain of helping: Psychological injury of helping professionals. Routledge; 2004.
  30. Rothschild B, Rand M. Help for the helper: Self-care strategies for managing burnout and stress. New York & London: WW Norton & Company. 2006.
  31. Newell JM, MacNeil GA. Professional burnout, vicarious trauma, secondary traumatic stress, and compassion fatigue. Best Practices in Mental Health. 2010 Jul 1;6(2):57-68.
  32. Kanno H, Giddings MM. Hidden trauma victims: Understanding and preventing traumatic stress in mental health professionals. Social Work in Mental Health. 2017 May 4;15(3):331-53.
  33. Knight C. Indirect trauma: Implications for self-care, supervision, the organization, and the academic institution. The Clinical Supervisor. 2013 Jul 1;32(2):224-43.
  34. Middleton JS, Potter CC. Relationship between vicarious traumatization and turnover among child welfare professionals. Journal of Public Child Welfare. 2015 Mar 15;9(2):195-216.
  35. Adams SA, Riggs SA. An exploratory study of vicarious trauma among therapist trainees. Training and Education in Professional Psychology. 2008 Feb;2(1):26.
  36. Cartwright C, Read, J. An exploratory investigation of psychologists’ responses to a method for considering “objective” countertransference. New Zealand Journal of Psychology. 2011; 40(1), 46–54.
  37. Ellis A. Rational and irrational aspects of countertransference. Journal of clinical psychology. 2001 Aug 1;57(8):999-1004.
  38. Cooper, R & McLeod, C & Gendle, K & Burbidge, F. (2010). Boundary issues in clinical psychology: A reflection on our practice. 17-19.

Author

Rachael Kelleher, Psychologist in Clinical Training, TCD/HSE.

=======================================================================

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out /  Change )

Google photo

You are commenting using your Google account. Log Out /  Change )

Twitter picture

You are commenting using your Twitter account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )

Connecting to %s