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Reflecting our attitudes towards touch, gifts, self-disclosure, dual relationships, bartering, home visit, attending a wedding, and other boundaries Opening statement by Ofer Zur, Ph.D As therapists most of us have been indoctrinated to uncritically and rigidly maintain boundaries and have been instructed:
The old rigid and fear-base dogmas and narrow risk-management principles were supposed to protect clients, but instead they have restricted our behavior, shaped our attitudes, negatively affected our therapeutic relationships, and decreased our effectiveness. Perhaps the most illogical (and quite paranoid) of these old dogmas, is the idea of the “slippery slope,” which claims that any simple touch is likely to lead to sexual violation of the client and a simple gift exchange or self-disclosure would inevitably result in exploitative social relationships. Boundary concepts in therapy include issues of self-disclosure; touch; bartering; home visits, attendance a celebrations such as a wedding, confirmation or Bar Mitzvah, a walk with a client in a nearby park, and other out-of-office experiences; practicing in a home office; and dual or multiple relationships. Therapists, counselors, ethicists, supervisors, graduate school professors, administrators, professional organizations, attorneys, judges, and licensing boards must realize that touch can be more clinically effective than words, self-disclosure is often instrumental in positive therapeutic relationships, gifts are one of the most basic and healthy human ways to express gratitude, and dual relationships are not only mandatory in some settings and unavoidable in others, but in fact they can increase therapeutic effectiveness in certain communities. I strongly believe that the meaning of boundaries in therapy can only be understood within the context of therapy, which includes client, setting, therapy, and therapist’s factor. What is effective and helpful with one client in certain context may not be helpful or, in fact, may be harmful with a different client in another context. No one (boundary) rule fits all. As therapists, we must know the difference in order to serve our clients well. Appropriate crossing a boundary are ethical and enables us to provide the highest level of care. Conversely, rigidly or fearful avoidance of all boundary crossing can be harmful. Online brochure: Boundaries in Therapy
Social Worker in Exile wrote:
Dr. Zur, it is with pain that I write that I am one of those clinicians whose license was REVOKED on the basis of this issue. My SW Board undertook an investigation of me, accusing that I had committed violations: organizing a free support group for rape/sexual abuse survivors that met for dinner and discussion (they framed it as "having dinner with former patients", even though two colleagues attended with me to co-facilitate), attending a sweatlodge to pray with patients, and arranging a sexual abuse web discussion group. No allegations of sexual, abusive, violent, or fraudulent conduct were alleged, and the Board could not find ONE patient who didn't have the highest praise for my character and technique; my record was spotless. But they believed that any dual (i.e., non-office appointment) interactions were inherently exploitative due to an "inherent power differential." They threw every myth in the book at me, while my patients lined up to support me! The Board called roll, then launched into discussion of revocation before I'd uttered a word, answered any question, or presented any defense. They exclaimed, "This stuff needs to be punished!" (throwing the charges on the table). When I asked to speak, they ignored me (even physically turning away in their chairs) and then struck my words from the record. Colleagues believe it was due to my being a male working with female victims, even though my former patients praised my professionalism and conduct.
06/28/10 13:38:20
Gerald W. Vest, ACSW/LISW/LMT wrote:
I commented earlier on how I/We use touch in our US Army Restortion & Resilience Center with soldiers and their families injured, wounded and diagnosed with PTSD. We offer many therapeutic touch programs--Reiki, medical massage, acupuncture, 15-Minute StressOut Program--and, all of our therapists and soldiers interact with our whole being--physically, mentally, emotinally and spiritually. We are having great success, I believe, because all of us know that touch is a healing response, just as love and respect for one another. Unfortunately, our helping professions have let the insurance and legal industries determine our practices. Do read Dr. Zur's article on this subject at http://www.zurinstitute.com... so that we can change this hostile, negative and fearful stance on our relationships with our clients and patients. Some of us believe that withholding touch from our clients can be unethical--and, please read our Code of Ethics at http://www.zurinstitute.com... that supports this reasoning.
10/18/09 07:25:33
Lee Myerhoff, Ph.D. wrote:
Hi Don Eisner. Your question brings up the basic issue of boundary crossing. The clinician must be skilled enough to relate the crossing to the needs of the patient's therapy. If the crossing does not advance the patient's therapy then I would question it. The clinician must know the client and the situation to assess possible negative consequences to the patient as well as the possible benefit to the client. Until the clinician is able to do this, he should be conservative about any crossing.
09/21/09 19:22:35
Donald A. Eisner, Ph.D. J.D. wrote:
Another technological advance may lead to new problems for therapists: namely texting via cell phones. Some therapists give out their cell phone numbers. What happens if a patient persists in excessive texting during and especially after the course of therapy . Will therapists be forced to continually get new cell phone numbers?
Donald A. Eisner, Ph.D. J.D. http://www.eisnerpsychlaw.com
09/08/09 18:54:54
amira wrote:
The technology issue is very interesting. It was a 16 years old patient who taught me the enormous value of e-mailing and texting as supplementary to ftf (face-to-face) sessions . After months of absolute silence during sessions we succeeded to enjoy good and fruitful theraputic relations. At first I was very sceptic.Since than I have the feeling that answering texts and e-mails can enrich the treatment and help the process.
09/08/09 13:21:35
Donald A. Eisner, Ph.D. J.D. wrote:
With the advent of rapidly changing technology new issues and challenges emerge in the context of boundary crossings versus violations. A psychotherapist posted some information about her college reunion on Facebook. When a former patient got onto the site, the therapist immediately stopped using Facebook. Has anyone faced any issues with Social Networking?
What about giving out your (office) cell phone, number, but therapy is now over? Are patients not allowed to call, and how would you stop the calls? Or what if there is ongoing texting, during and after therapy? What are your thoughts? Donald A. Eisner,Ph.D., J.D. http://www.eisnerpsychlaw.com
08/30/09 08:47:41
Anthony Bober, M.S.,MFT, MBA wrote:
Ms. Carr writes, "I wonder sometimes where the boundary is when it comes to when am I a therapist and when am I a friend, and when am I a person."
This is a question each and every therapist has to answer for him / her self. After 30 plus years, the answer for me is relatively simple. I am first and foremost a person with many needs, interests and friendships that are not expressed/acted on in the consultation room. I am aware of them and set them aside to maintain the necessary therapeutic neutrality beneficial for my patients. I take care of them outside the consulting room. Yes, I know for some this is blasphemous. After all I even believe my patients are in fact patients. I do not want my friends as patients and definitely do want to minister to my friends in a psychotherapeutic manner. My friends are friends. Glad to refer them to a colleague. Will our friendships be mutually beneficial? I hope so. However with patients I expect nothing beyond payment and respect. As for boundaries, these are therapeutic, ethical and legal in nature. No matter how one might wish to view these in a therapeutic context, step outside the realm of what your codes of ethics and the remotest perception on the part of the patient as stepping over the line, e.g. think borderline and dependent PD and watch your licensing board in action.
08/27/09 16:15:21
Jane wrote:
My therapist held me and sat next to me on the couch for several sessions. She gave me her personal cell phone number when I was suicidal. She said I was dissociating, but I disagree. She seduced me. I wanted her touch more and more. Then she terminated our relationship because she said I called her too much.
[Comment by moderator: Therapists must be careful when they are engaged in levels, frequency and intensity of connection that cannot be sustained or are counter-clinical or unethical. Corrections and shifts may necessary and must be made with full consideration of the client, therapists and the context of therapy.] After 7 years she called out of the blue and said she missed my voice. Is this ethical? [Comment by moderator: The question here is whether it is clinically appropriate and ethical to follow up with clients after termination. The obvious answer is that it depends on the client, timing, the relationship, the type of therapy, etc.]
08/26/09 20:52:40
Sandra Carr LMFT wrote:
I currently work in the HIV-AIDS program at the Health Department. I always offer to hug the clients by asking them if they would like a hug. I feel it is especially important to them since a lot of people are still afraid to touch a person with HIV/AIDS.
08/20/09 14:53:25
Marie wrote:
Thank you, thank you Sage Breslin for your comments and all of you who have used physical contact in some form for your clients. I can't stop blogging because I struggled to verbalize the "why's" of needing touch in therapy for sooo long and was dangerously depressed at times dealing with feeling so alone. Describing the room as too "amorphous" a container for emotion nails it totally; it accentuates and seals the isolation rather than relieving it. It has been more than three years since I finished working with a body-mind therapist and I have never felt more whole. It did for me all the things listed on the articles on this site where touch is used for those who have some history of sexual abuse. It could have been written by me. Through body therapy, I felt empowered, worthy of someone's attention and intervention, and validated. Physical contact increases trust and opens the door to more self-disclosure. My sense of self has never been more intact since that experience. Being able to cry my guts and my heart out being enclosed in someone's arms was a healing and major turning point in my life.
08/20/09 14:37:22
Sandra Carr LMFT wrote:
I want to bring into the discussion another angle to boundaries. I would like to know other therapist's reactions to what I am going to say. I wonder sometimes where the boundary is when it comes to when am I a therapist and when am I a friend, and when am I a person. I think I have been doing this so long that who I am is a therapist. I mean when people who are friends talk they share their personal experiences and feelings and are emotionally supportive to each other. I nearly always have the advantage of my knowledge, training and experience. I will see how that something I could say would benefit this person who is my friend. If I tell them, then I am being a therapist but withholding that information would feel wrong to me. I feel like the doctor who is driving down the road and stops to help. It would be wrong not to. I have told myself that as long as I am not charging a fee then I am not a therapist but a friend. I don't want to be a "therapist" to my friend in their eyes, but sometimes I think that that is what I am in their eyes. I wonder if when I retire will I begin to feel I am not a therapist but just a person? Or will a be a therapist to the end? Does anyone else every feel this way?
08/20/09 14:07:23
Sage Breslin, Ph.D. wrote:
I believe that boundaries provide a structure that allays anxiety for both client and clinician. However, the police state that we are now in regarding professional boundaries has become unwieldy.
As a Trauma specialist for 24 years, I have rubbed backs, held hands, rocked and cradled countless clients. When a client is processing historical abuse that has derailed life, the therapist becomes a container- the room is too amorphous and large to do this for the client. HOWEVER, in my efforts to provide a container, I never lose sight of what is in the best interest of my client, and ensure that the actions I take are not to meet my own needs. The remainder of my time with clients and students is spent in Personal Transformation work. In the retreat setting, the boundaries MUST shift. I am seen as both leader, guide, therapist and HUMAN. Clients access their material and respond to it, but also learn by the role modelling offered by instructors. By being HUMAN in those settings, we offer clients huge personal empowerment- we are no different than they are. We are not Gods subordinating them. We might have a little more experience, or bigger flashlights, but what we have and what we are, is what they can achieve as well if that is what they desire. It is delightful to watch old dependencies fade away and empowerment consumed whole!
08/20/09 11:47:41
George Redmon, CCMS,PC wrote:
I guess when making my point on boundaries and touch I should of explained, I am a blind Domestic Violence Counselor. In my case my clients understand the reallity that I use both touch and sound to navigate around the room to expedite and control the conversations. I do always believe that touch is a interval part of creating a bond with the client.
08/20/09 09:27:16
Samantha Nelson wrote:
Had we taken the strict standard of never truly engaging clients in a relationship of care and nurture, the emotional wellbeing of those individuals would have continued to suffer. There certainly need to be appropriate boundaries in place to protect a client, but there are times when, if appropriately done, a hug or some other "non-traditional" way of connecting (referring to a walk, an outing with a group, etc.) can be very beneficial to the client's health. As a Christian in the helping profession, boundaries are naturally blurred, which can be both good and bad. It's really only bad if the professional or helper are acting from wrong intents/motives or do not keep things safe.
08/20/09 09:12:33
Gerald Vest, LISW/ACSW wrote:
These comments are great and add important contributions to our boundary issues. For many years, I have taken my students from my holistic/integrative health classes to local nursing homes to learn and to introduce safe, skillful and nourishing touch with our elders. During one session, one of the residents asked: "Is there something wrong with me because none of the staff will 'touch me?" Recently, we took our wounded warriors to a Veterans Nursing Home in EP, TX. As a therapeutic field trip we invited our soldiers to give the Vets and their wives a touch program called the "15Minute StressOut." A news reporter was present and asked the elder vets if they received any healthy touch. Her response: "The most touch that we receive is from wheel chair to bed." These statements demonstrate how our professions have been inappropriate by not including safe touch in their practice. Special thanks to Dr. Zur for opening these discussions related to the "Myth of Touch" and boundary issues that limit health and relationships. Come on--"Let's Stay in Touch!"
08/20/09 07:58:43
LM in Maine wrote:
The continual sharing of intimate information and emotions behind closed doors between a man and a woman led to a closeness that spilled over in to the sexual realm - a normal progression. There is some sort of intellectual disconnect between what we are telling people in how to avoid emotional and sexual affairs in their lives and then, as therapists, proceeding to create the exact replication of that environment in therapy. Perhaps as Andrea Celenza says in her book on sexual boundary violations...the therapeutic setting is honestly seductive.
This is from Barbara ( see blog below) I find this extremely interesting. How do we participate in the imtimacy psyhotherapy requires but not create the atmosphere of an emotional affair, as she suggests we as therapists may unwittingly do? And is that avoidable or is the most important thing that we do not take the "honestly seductive" atmosphere into the physical realm? I am so interested to hear peoples' thoughts and experiences on this.
08/20/09 06:00:37
shelly foster wrote:
I believe in "healthy" touch and boundaries in psychotherapy. I do mostly group work and believe without question that touch is the most healing element of most of the work I do. I have been a therapist for over 20 years and I am extremely alarmed about too many graduates who are coming into psychotherapy with NO personal work (who have literally never seen a therapist of any kind except as a student, and are now expected to "treat" people) and have no actual skills to do this kind of work with people.
These individuals are either completely fearful of touch or they do not have any boundaries about touch and the the therapeutic choices they are making about their touch. Does anyone else share this concern?
08/19/09 21:45:28
Marie wrote:
I appreciate the comments revealing that there can be some variation in boundaries in therapy. Boundaries help everyone, but that they can be adapted for a particular client's need is heartening. I am only one voice, but in my journey as a client I appreciated even small instances of touch, for instance, from a psychiatrist couple, which were extremely beneficial to me. The issues were around an adopted child with attachment issues, not specifically about me, but coming from a background of some vague but very likely sexual abuse, I found it so very healing to receive even a bit of minimal touch/affection from these therapists. Being able to have that in a setting where you can feel very vulnerable but very safe was very healing. In a situation where touch is allowed it is, for sure, necessary to know what means what and to be clear but not to avoid touch just because it can be abused. We all know the utter importance of that, but to avoid all touch can also be harmful. For years and years I suffered from some pain in my emotional soul, every cell in my being at times just longing for a safe place to cry. Talk doesn't work at such times,it interrupts the flow, yet you need someone in communication with you, i.e.,response by physical contact. I hurt for a very long time until I found that. Hugs and holding trump feeling suicidal just about any day.
08/19/09 16:29:25
DF wrote:
When a primary barrier to connection is a patient's paranoia it simply does not work to keep to a rigid adherence to the same boundary with each patient. I disclose personal details in the service of creating a point of contact and frequently it is this show of "humanness" that allows my patients to develop some trust. Touch of course is another matter and there I do remain firm in keeping my policy of almost no physical contact other than a handshake. The boundary is different when talking with someone experiencing psychotic symptoms and I am finding that there are many tools to help create a safe and therapeutic environment.
08/19/09 14:45:42
Barbara Swafford wrote:
I think that the issue with boundaries is really the issue of attachment. Healthy attachments heal and healing attachments may include kind touch and a variety of other things like appropriate and helpful disclosures. Clients may want to give simple gifts to therapists that have greatly enriched and fostered the healing of their souls and relationships. The problem is that we are all simply humans and with the benefits of closeness, comes the risks of closeness.
The costs of ethical mistakes are so great emotionally for victims of therapy abuse that most never fully recover. One issue that everyone seems to shy away from honestly addressing is the issue of GENDER in the therapeutic setting and the differences in male and female primary relational needs. Almost all sexual boundary violations involve a male therapist and a female client. The majority of the offending therapists do claim that they were "in love" with their clients. Perhaps this is true. The continual sharing of intimate information and emotions behind closed doors between a man and a woman led to a closeness that spilled over in to the sexual realm - a normal progression. There is some sort of intellectual disconnect between what we are telling people in how to avoid emotional and sexual affairs in their lives and then, as therapists, proceeding to create the exact replication of that environment in therapy. Perhaps as Andrea Celenza says in her book on sexual boundary violations...the therapeutic setting is honestly seductive.
08/19/09 14:00:55
George Redmon, CCMS,PC wrote:
Very interesting subject. Issues of boundaries are always on the minds of counselors in my field. In Domestic Violence and crisis intervention the therapist works closely with the client. The measure of touch in some cases is required to make a good connection between counselor and client and to move the treatment forward. When one is working with clients dealing with sex issues, more thought must be used by the therapist.
08/19/09 12:51:43
Marie wrote:
I am going to chance it here and hope that it would be okay as a lay person to contribute something to this blog, because I feel the issue of touch in psychotherapy is something that really needs to be re-examined. I happened on Dr. Zur's site when I was going through a really hard time with this issue and read the Boundaries in Psychotherapy article, which said it all for me. No-touch-allowed therapists really need to listen to the other side. I went to traditional therapy for years, for self and for help with struggles my adopted children were having, but the primary, core issue that kept me going was needing a place to grieve my childhood, needing somebody's arms to cry into. This could not be achieved through talk-only therapy. There is a healing and communication in body centered therapy that just can't happen in regular therapy with some one just watching and observing you, however compassionately and empathetically. I have huge respect for the therapist I went to for so many years and gained SO much, but it was a therapist who used and allowed touch that allowed me to finally work through some pain that I had carried around for SO long. My childhood included the likelihood of early sexual abuse, and safe touch healed, corrected, and allowed an outlet for the pain.
08/19/09 10:36:55
Chantal Cohen, LMFT wrote:
I spent several years working in different villages in bush Alaska where everyone knows your business. Just being seen entering my office would have alerted everyone that you were there for counseling. Part of native culture is subsistence & it would be an insult not to accept salmon, moose, caribou, etc. In order for someone to come to counseling, you must first be accepted by the elders & by the community. This means attending funerals, going to potlatches, sharing personal information, entering someone's home or trying activities that are part of subsistence. Fishing, berry picking, making fry bread & eating muktuk were all essential in providing services. Everyone in the village would have been insulted had I not participated in cultural events or visit in their home. As a result, the majority of counseling took place outside of the office. Dual-relationships which exploit or cause harm are unethical.
When I lived in the Aleutians, I had to rethink my beliefs. For example, it was irrelevant to administer H-T-P drawings because there are no trees in the Aleutian or in the arctic. This taught me to look at the impact of environment & culture in an entirely different way. We must always adhere to the standard to know if the relationship helps or is harmful to that person, child or family.
08/19/09 09:20:00
John A. Riolo, PhD wrote:
Are our concept of boundaries a result of the theory or actions of the founding fathers and mothers of psychotherapy? Probably but not for the reasons we might expect. . As Fredric G. Reamer points out in his book Tangled Relationships, Freud himself took patients on vacation; He wrote personal to patients as well. Melanie Klien took at least one vacation and conducted analytic sessions on a bed in a hotel room. . D. W. Winnicott had patients living with him as part of their treatment; was reported to frequently hold hands of patients during whole or most of a treatment session and also confided to at least one patient details about his counter- transference reactions to another patent.
So boundaries in the early days were loose to nonexistent. Of course no one would suggest that we go back to the practices of the psychotherapy founders. That was a different time with different cultural mores. But perhaps our rigid notion of boundaries today is little more than a reaction formation to the embarrassment many of us might feel about how we behaved in the past. It can not be explained by theory or historical precedent.
08/19/09 08:52:12
SA wrote:
Perhaps those who see only one way of handling boundaries in therapy should get some training in family therapy. The cybernetics of cybernetics dispelled the myth long ago that the therpist can stand "outside" the client system and hold themselves aloof. Virginia Satir, Carl Whittaker, and others made excellent use of self in their work, and their traditions are carried on in people like Ken Hardy, Monica McGoldrick, and other multicultural therapists who criticize the myth of neutrality, as well as the work of many feminist therapists who contend that rigid boundaries feed into the "therapist as expert" hierarchy. It seems mostly the psychodynamic and cognitive behavioral therapists who still have a single-minded focus on "objectivity" and who criticize use of self as "countertransference." The book "Use of Self in Therapy" is an excellent resource. I wish rigidly psychodynamic supervisors would quit scaring trainees and interns out of use of self and labeling it "unethical." Their claims are groundless as self-of-therapsit work and self-disclosure has been an accepted part of the field since the 1970s for at least some models of therapy.
08/19/09 00:42:42
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August 17, 2009: Boundaries in Psychotherapy
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