Therapeutic Boundaries: Introductory Article

 

This introductory paper explores the nature of therapeutic boundaries. The nature of therapeutic boundaries has been debated since the very beginning of psychotherapy. From Freud and thereafter there has been no agreement among therapists of what constitutes appropriate boundaries. While agreements are hard to come by, boundaries are an inherent part of every practice. Whether it is the length or place of therapy, privacy issues or the level of personal engagement between therapist and client, these boundaries issues must be addressed in every clinical encounter.

Boundary is defined generally as the point at which something ends or the point or line beyond which it becomes something else. Beyond this general definition boundaries have multiple meanings and implications. Many definitions focus on geographical boundaries or political borders. Then there are biological boundaries, such as the skin or the membrane around brain. What unifies all the definitions and types of boundaries is the essential aspect that they differentiate between or separate two or more physical-actual or elusive-abstract entities. Understanding the nature of boundaries is extremely important because depending on how one defines, draws or erects them they can separate or unite, include or exclude, help or hinder or heal or harm. Boundaries can be rigid and impenetrable but also flexible and permeable. Many boundaries are like walls: man-made constructs which, therefore, can be erected or dismantled and allow for the addition of gates, doors or barriers.

Gutheil and Gabbard (1993) regard boundaries as the “edge” of appropriate behavior. Langs (1982), Smith and Fitzpatrick (1995) and many analytically oriented therapists discuss boundaries in terms of a therapeutic frame. The frame is described as including structural elements such as time, place, money, gifts and the content of psychotherapy. Boundaries in therapy define the therapeutic environment.

There are two types of boundaries in therapy:

1. Boundaries surround the therapeutic relationship. These are boundaries that are drawn around the therapeutic encounter like borders or frames. These boundaries are articulated in state and federal laws, professional codes of ethics and in the informed consent, office policies or the contract between therapist and client. They include:
   • Onset, termination and the total time period of therapy.
   • Place of therapy which may include a home visit, home-based therapy, adventure therapy and many other therapeutic encounters that take place outside the office. This also includes telehealth or what has also been called, web-based therapy, telemedicine, phone therapy or e-therapy.
   • Time and length of sessions.
   • Confidentiality, which is the ultimate boundary or safety zone around the therapeutic encounter.
   • Non-therapeutic encounters, such as incidental encounters and dual relationships. These also involve all forms of out-of-office experiences, such as a home visit or attending a wedding.
2. Boundaries of a second type are drawn between therapist and client. They involve the following issues:
   • Fees
   • Physical touch between therapist and client.
   • Therapist’s self-disclosure.
   • Gift exchange, either from client to therapist, therapist to client or between therapist and a third party.
   • Bartering.
   • Language.
   • Clothing.
   • Contacts between therapist and client between sessions.
   • Physical proximity of therapist and client during sessions.
   • Physical arrangements in the office.

Different theoretical orientations have different takes, interpretations and uses for the term therapeutic boundaries. While some emphasize the importance of clearly defined and consistently employed boundaries, others stress the therapeutic importance of flexibility and the dismantling of certain boundaries. Following are some examples:

• Family therapists have concentrated on the meaning, quality and functionality of boundaries between sub-systems and members within families and the nature of the boundaries around the families.
• Psychoanalysis differentiates between external boundaries around the therapeutic relationships and between patient and analyst, and internal boundaries between the ego and the repressed unconscious.
• Group therapists interested in social stratification that takes place in small groups.
• Feminist therapists critically look at the meaning of economic and social boundaries between men and women and between social and economic classes.
• Cognitive-behavioral therapists focus on the boundaries and relationships between people’s cognition, affect and behavior.
• Humanistic-Existential therapists concentrate on interpersonal boundaries.
• Body and somatic psychotherapists have emphasized the permeability of the boundaries between body and mind. Cognitive therapists have similarly emphasized the inherent link (i.e., permeable boundaries) between mind and body.
• Transpersonal and Spiritual therapists direct their attention to spiritual and physical boundaries or lack thereof.

One of the most common misunderstandings in psychotherapeutic ethics is the lack of differentiation between boundary violations and boundary crossings. Boundary violations occur when therapists cross the line of decency and integrity and misuse their power to exploit or harm clients. Boundary violations usually involve exploitive business or sexual relationships. Boundary violations are always unethical and are likely to be illegal (Gabbard & Lister, 1995; Gutheil & Gabbard, 1993; Williams, 1997, Zur, 2004a). Boundary crossings are very different from boundary violations and are more elusive and thus harder to define. Most broadly, boundary crossings refer to any deviation from the strictest professional role (Gutheil & Gabbard, 1998; Knapp & Slattery, 2004) or deviation from traditional, hands off, ‘only in the office,’ emotionally distant forms of therapy or departure from risk management procedures (Lazarus & Zur, 2002). Boundary crossings are often part of well-constructed treatment plans designed specifically to achieve a certain therapeutic goal or to increase therapeutic effectiveness. Boundary crossings are often an integral part of behavioral, cognitive-behavioral, humanistic, existential, group or feminist therapy. Some boundary crossings, such as incidental encounters between therapist and client outside the office or social dual relationships, are neither planned nor part of the treatment plan.

While maintaining boundaries and the therapeutic frame is the prime responsibility of therapists, clients co-contribute and co-define the nature and development of therapeutic boundaries (Knapp & Slattery, 2004). The movie What About Bob demonstrates boundary transgression initiated and carried out by a client who followed his analyst on his family vacation.

The term out-of-office experience describes any experience that takes place outside the standard boundaries of the therapy office, such as a home visit or accidental encounter at the local market (Zur, 2001a). By definition, all out-of-office experiences, or what have also been referred to as “boundary extensions” (Jones, Botsko, & Gorman, 2003), are boundary crossings, however, they can also be boundary violations and/or dual relationships.

There are seven types of out-of-office experiences.

• Home Visits
• Hospitals, Jails and Other Visits
• Interventions that are only possible outside the office space
• Attending celebrations or rituals outside the office
• Walking Side-by-Side Rather Than Sitting Face-to-Face
• Incidental encounters in the community
• Encounters outside the office as part dual relationships

The term dual relationship in psychotherapy refers to any situation where multiple roles exist between a therapist and a client (Bennett, Bryant, VandenBos, & Greenwood, 1990; Koocher & Keith-Spiegel, 1998; Pope & Vasquez, 1998). It often refers to the circumstance where there is a secondary relationship between therapist and client besides the therapeutic one. Dual relationships have often been mistakenly equated with boundary violations and sexual exploitation of clients. While all dual relationships are, at the minimum, boundary crossing, sexual or any other exploitative dual relationships are boundary violations. Boundary violations and exploitative and harming dual relationships are always unethical, counter-clinical and very often, illegal. While all non-exploitative, non-sexual dual relationships are boundary crossings, obviously, not all boundary crossings are dual relationships.

There are several types of dual relationships:

• A social dual relationship is where therapist and client are also friends.
• A sexual dual relationship is where therapist and client are also involved in a sexual relationship. Sexual dual relationships with current clients are always unethical and often illegal.
• A professional dual relationship is where therapist and client are also professional colleagues in colleges, training institutions or presenters in professional conferences.
• A business dual relationship is where therapist and client are also business partners or have employer-employee relationships.
• Communal dual relationship is where therapist and client live in the same small community, belong to the same church or synagogue and where the therapist shops in a store that is owned by the client or where the client works.
• Institutional dual relationships take place in the military, prisons, some police department settings and mental hospitals where dual relationships are an inherent part of the institutional settings.

Dual relationships can be avoidable, unavoidable or mandated.

• Voluntary-Avoidable: Usually these dual relationships take place in large cities or metropolitan areas where there are many therapists, many places to shop, worship or recreate.
• Unavoidable: These dual relationships are often found in isolated rural areas, small minority groups, disabled groups or spiritual communities or any small community in big metropolitan areas and training institutions.
• Mandated: These dual relationships take place in the military, prisons and in some police department settings.

Dual relationships can be concurrent or sequential.

• A concurrent dual relationship takes place at the same time as therapy.
• A sequential dual relationship takes place after therapy has ended. For example, after therapy ends a therapist decides to embark on social or business relationships.

Level of Involvement (Formulated by Schoener, 1997)

• Encounter: When a therapist runs into a client in the church or local market parking lot. This is a low or minimal level of involvement.
• Overlapping Relationships: When a client and therapist share occasional encounters, as in attending church services every Sunday.
• Multiple Relationships: When a client and therapist are very involved and share an ongoing social or business relationship.

The context of therapy is of high importance when it comes to boundaries.

The appropriate meaning and applicability of boundaries can only be understood and assessed within the context in which therapy takes place. The context of therapy consists of four main components: clients, setting, therapy and therapists.

Client factors include the following:

• Culture, country of origin, acculturation and language proficiency
• History, including history of trauma, sexual and/or physical abuse
• Age
• Gender
• Presenting problem, mental state and type and severity of mental disturbances
• Social-economical class
• Personality type and/or personality disorder
• Sexual orientation
• Social support
• Religious and/or spiritual beliefs and practices
• Finances, living conditions and transportation
• Physical health condition and level of physical mobility
• Prior experience with therapy and therapists

Setting factors include the following aspects:

• Outpatient vs. inpatient vs. day program
• Solo practice vs. group practice
• Office in medical building vs. private setting vs. home office
• Free-standing clinic vs. hospital based clinic
• Privately owned clinic vs. publicly run agency
• The presence or proximity of a receptionist, staff, other businesses, other professionals or other psychotherapists
• Locality:
  • Large, metropolitan area vs. small, rural town vs. Indian reservation
  • Affluent, suburban setting vs. poor neighborhood
  • Large university counseling center vs. small college counseling center
  • Major urban setting vs. remote military base, prison or police department setting
• Forensic settings and legal mandates:
  • Elective vs. mandated: Elective therapy vs. court mandated evaluation, therapy, sanity evaluation or fitness for duty evaluation
  • Hospitalization: Voluntary admission vs. involuntary hold
  • Mandated reporting: Child, elder or mentally ill person abuse reports or reports due to clients posing imminent danger to self or others

Therapy Factors include the following:

• Therapeutic factors:
  • Modality: Individual vs. couple vs. family vs. group therapy
  • Modality: Short term vs. long term vs. intermittent long-term therapy
  • Intensity: Therapy sessions several times a week vs. once a month consultation
  • Population: Child vs. adolescent vs. adult psychotherapy
  • Theoretical Orientation: Psychoanalysis vs. humanistic vs. group therapy vs. body psychotherapy vs. eclectic therapy
• Therapeutic relationship factors:
  • Quality and nature of therapeutic alliance, i.e., secure, trusting, tentative, fearful or safe connection. Intense and involved vs. neutral or casual relationships
  • Length, i.e., new vs. long-term relationship
  • Period, i.e., beginning of therapy vs. middle of therapy vs. towards termination
  • Idealized/transferencial relationships vs. familiar and more egalitarian relationships
  • Mutual respect, liking and trust vs. mutual disrespect (contempt), dislike, fear and distrust
  • Familiarity and interactivity in the community vs. only in the office, distanced relationship
  • Presence or absence of dual relationships and type of dual relationships, if applicable

Therapist factors include the following:

• Culture
• Age
• Gender
• Sexual orientation
• Experience and training

Context and Boundaries: Following are examples of how therapeutic boundaries are likely to significantly vary from context to context:

• Self-disclosure varies significantly between therapeutic orientations. While some self-disclosure is embedded in humanistic or feminist psychotherapy, it is clinically contraindicated for traditional, transference-based psychoanalytic psychotherapy.
• While a hug or an embrace is a normal form of greeting with a Middle Eastern or Latino client, a handshake may be the most acceptable form of touch when greeting clients of Northern European origin.
• Incidental encounters in the community are unavoidable and common in university counseling centers or in the gay and lesbian communities and in small towns, but this encounters are highly unlikely in large urban centers.
• Holding a young child on the family therapist’s lap can be appropriate in the context of family therapy, but this is certainly not the case with adults in any form of therapy.
• Bartering for goods or services may be acceptable and common in artist or agricultural communities, but bartering is unheard of in most middle or upper class urban settings.
• A home visit to the homebound elderly may be the only way to provide services to this population but would be highly inappropriate with a borderline, able client.
• Phone or email therapy may be appropriate with a rather high functioning client and most inappropriate with a suicidal, disoriented or deeply disturbed client.
• Taking a walk outside the office with a restless adolescent or depressed client may increase the effectiveness of psychotherapy, which is not likely to be the case with a highly paranoid or delusional client.
• Self-disclosure of therapist’s sexual orientation may be a pre-requisite for therapy with gay and lesbian clients, but this is not the case with most other populations.
• Receiving or giving gifts is very common and important in child therapy and with clients from Latino, Jewish and other cultures, but this is not always clinically appropriate with adults who tend to “buy” love and those from more formal cultures.
• Sequential dual relationships in post-graduate training is normal and expected, which is not necessarily the case with most other therapies.

In summary, boundaries in therapy refer to the parameters that define the therapeutic process or the therapeutic frame and also refer to issues that involve therapist-client relationships. Generally, therapeutic boundaries refer to issues of time, place, money, gifts and the content of psychotherapy, as well as to issues such as gifts, touch, self-disclosure, and bartering and dual relationships. Different therapists and theoretical orientations have different takes on therapeutic boundaries and what constitutes boundary violation. In general, boundary violation involves exploitation and/or harm of client by therapist and boundary crossing is a simple departure from the standard, hands-off emotionally distance form of therapy. Research has documented that boundary crossing, such as non-sexual touch, appropriate gifts, home visits, adventure therapy, have high clinical utility. Boundary crossing and unavoidable or appropriate dual relationships are neither unethical nor illegal. In fact, they are often positively correlated with increased therapeutic alliance, the best predictor of clinical outcome.

Resources:

• Online articles and resources
• Ethics Codes on Boundaries

Extensive references list

 
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