Boundaries

The term boundaries in psychotherapy refers to the therapist’s ability to establish and maintain a treatment frame, set a schedule, and honor times; maintain a professional relationship; and protect the patient from intrusions into privacy and confidentiality. The frame of treatment is the APPNs responsibility, and it is important in creating a safe environment for both the patient and the therapist. For patients with dysfunctional, out-of-control behaviors, adherence to limits and boundaries may be a major focus of the treatment. Most therapists do not allow eating, drinking, or smoking during sessions or any type of interruption during the session. All phones and beepers should be turned off. This is the patient’s time, and distractions from the business at hand are counterproductive to good psychotherapy.

Therapists’ violations of the frame, such as extending sessions longer than usual, being late for sessions, forgetting the session, not following the standard protocol for all patients for any reason, making special allowances for a particular patient, feeling the patient is special, social contact with the patient, and violating confidentiality, are all breaches of boundaries and can alert the therapist to countertransference issues that need to be addressed by the therapist. The therapist is often not aware initially of feelings toward the patient and becomes aware only by taking note of his/her own behavior and the signs of countertransference (Box 5-1).

Countertransference reflects feelings that the therapist has toward the patient and is similar in some respects to transference. Countertransference involves past significant relationships and includes attitudes, feelings, and thoughts about another person. Contemporary theorists believe that countertransference is a response to the patient’s transference, and as such, it can be used to understand the patient. Countertransference can serve as a barometer in the relationship with the patient for the self-aware therapist. Although countertransference is usually associated with breaches of boundaries or problems in relationship, such as those listed in Box 5-1, like transference, countertransference can also be positive, such as idealizing feelings or empathic resonance with the patient.

Countertransference involves activation of the therapist’s state-dependent memories in the relationship with the patient. As occurs in transference, countertransference reflects a particular physiologic state of consciousness triggered by the relationship, and therapists’ bodies can inform them about what is occurring. For example, one therapist reported that narcissistic patients triggered her to become exceedingly tired in sessions, so much so that she often struggled to stay awake. For another therapist, the same patient may elicit tension in the chest. This is because state-dependent memories are idiosyncratic biochemical profiles that depend on each therapist’s experiences and development and on the interaction with the patient’s contributions in the co-construction of the relationship.

Images and thoughts during the session can also alert the receptive therapist to what may be going on during the psychotherapeutic process. For example, one therapist had an image come to mind during a session with a patient from a movie scene he had seen that depicted a forbidden sexual encounter. This was a cue to the therapist about the erotic transference developing in the relationship, even though the manifest content of the session was seemingly about an unrelated topic. The astute therapist is aware of all emerging thoughts, images, and sensations, without judgment or censorship, as manifestations of countertransference. They are considered important data about the therapeutic relationship and deepen the therapist’s understanding about the unfolding process.

A therapist using his/her feelings as a clue to what may be going on for a patient is referred to as autognosis, and this can be very helpful in understanding the patient. Autognosis is similar but different from the nursing concept of therapeutic use of self, originally described by Travelbee (1971). Therapeutic use of self is the ability to use one’s personality consciously and in full awareness in an attempt to establish relatedness and to structure nursing interventions (Travelbee, 1971). In contrast, autognosis is using one’s feelings to deepen understanding of the patient and use of oneself to “diagnose” the nature of the patient’s problems. Often, these feelings are more implicit and not fully conscious.

Two types of countertransference identified by Racker (1968) are concordant and complementary. Concordant identification is a process in which the therapist takes on the experience of a patient’s personality as if it were his/her own. For example, when interacting with a sad patient, the therapist begins to feel sad. Complementary identification occurs when the therapist is treated transferentially by the patient as if the feelings were true. For example, one patient who had a critical father began to feel criticized and judged by the therapist, and the therapist did feel induced to act punitively toward the patient. Often, these types of countertransferential responses are transitory and serve to deepen the therapist’s understanding of the patient. The therapist who is able to monitor his/her own emotional reactions, thoughts, and fantasies throughout a session can deepen the process in a way that otherwise may not be possible. “Sexual feelings, hostile feelings, and boredom are all responses to clients that therapists must handle within the process of treatment unless these reactions become unmanageable or are unresponsive to supervision and consultation” (Norris et al., 2003, p. 519). All feelings—the good, the bad, and the ugly—occur and can be used in the service of the therapeutic process by self-aware therapists. Strategies to enhance self-awareness are included in Chapters 3 and 10.

The relational-psychodynamic therapist may address or interpret the co-created countertransference, whereas the cognitive-behavioral therapist is more likely to notice but not address it directly. Chapter 8 on psychodynamic psychotherapy discusses countertransference further. Even if the therapist decides it is best not to address what is going on with the person, the work is enhanced. For example, a patient who was in therapy seemed so vulnerable and childlike that the therapist would often have fantasies of protecting and rescuing her. Even though this was not directly addressed with the patient in treatment, knowing this allowed the therapist to contain these feelings so support could be provided without infantilizing the patient. Occasionally, feelings can be so intense about a patient that they may be difficult to contain and be therapeutic. “Strong countertransference feelings can be invoked when working closely with patients who are resistant to change” (Jones, 2004, p. 18).

Supervision and one’s own therapy can help to process emotional reactions. Life-long supervision is always a good idea, but extra consultation with an experienced therapist can help in managing countertransference. Supervision consists of meeting regularly, much like therapy sessions, and discussing issues germane to the work of psychotherapy that the therapist needs help with. Often, supervision is a mixture of the patient’s issues and the therapist’s issues, because the latter impacts the treatment process in significant, often unconscious ways. For example, one young woman who came for therapy was extremely demanding and devaluing to the point that the therapist was defensive and dreaded her appointment each week. Discussing this patient in supervision helped the therapist to be more objective and understand how her own issues were triggered by the patient’s devaluation. The therapist then was able to be more empathic and understand how the patient must have felt in her relationship with her devaluing mother.

Empirical and clinical studies on countertransference have found five interrelated factors that are important for management of countertransference. These include therapist qualities of self-insight (i.e., aware of one’s own feelings), self-integration (i.e., intact, basically healthy character structure and ability to set boundaries), empathy, anxiety self-management, and conceptualizing ability (i.e., therapist understands the patient’s dynamics theoretically) (Hays et al., 1991). Therapists who possess these characteristics are seen as excellent by peers and can control countertransference acting out, and it is thought that these qualities are positively related to treatment outcome. In contrast, the therapist may have personality characteristics that are called chronic countertransference, such as a tendency toward rescuing the patient, being overly supportive or solicitous, or being authoritarian or antiauthoritarian and frequently violating the rules or frame of treatment. These attitudes can create chaos in the therapeutic relationship, and the therapist may need psychotherapy in addition to a consultation to ameliorate such traits. It is essential to monitor countertransferential feelings throughout therapy because these feelings are implicit and state dependent, and they may come to awareness only through ongoing self-reflection. Countertransference can significantly enhance or inhibit the therapeutic process. Seeking consultation and keeping documentation in clinical notes is essential and protects the therapeutic relationship and patient from therapist boundary problems. Theory and personal awareness are key to managing countertransference (Gelso & Hayes, 2002).

The most egregious violation of boundaries is that of a sexual relationship with the patient. Sexual misconduct ranks as one of the highest causes of malpractice actions against mental health providers (Norris et al., 2003). Often, patients express wishes to be closer to the therapist, occasionally sexually or as a friend. It is the therapist’s job to assist the person in understanding the wish for closeness and not to gratify it, no matter how well intended. Even a slight boundary violation sends the wrong signal and may lead to more serious violations. In discussing why the therapist should not hug the patient, even if requested, McWilliams (2004) says, “… physical contact of this sort collapses the ‘space’ between the two parties—the area of symbolization, play, and ‘as-if’ relating—that has been so carefully constructed over the course of the therapeutic work. Such a collapse reduces to a concrete physical act the complex metaphorical meanings of the longing to be held, and it creates unconscious anxiety that other strivings—ones that are not so attractive (such as the wish to attack physically or exploit sexually)—may also be acted out” (pp. 190-191).

Nurses are used to touching their patients, and with the emphasis in some psychiatric nurse practitioner roles as primary mental health care practitioner, may leave the nurse psychotherapist on a slippery slope. The blurring of boundaries in advanced practice nursing is only beginning to be addressed in the literature (McCabe & Burnett, 2006). Relatively few studies on touching patients in psychiatric settings have been conducted, and none has addressed touching in the role of APPN psychotherapist. Gleeson and Timmins (2004) studied caring touch, in contrast to task touch, in a long-term setting for older patients who suffer from dementia. They conclude with the caution against the widespread adoption of caring touch as an intervention for ethical reasons. Another qualitative study of seven outpatients, who had previously been hospitalized for psychosis, found that some of the informants felt violated and oppressed when touched by someone with whom they did not have an established relationship (Salzmann-Erikson & Erikson, 2005). One study examined therapeutic touch in inpatient psychiatric settings with adolescent patients and found positive results (Hughes et al., 1996). Although some forms of therapeutic touch do not involve actually touching the patient (i.e., the nurse may keep hands an inch or two away from the patient’s body), use of this or any kind of touch significantly changes the parameters of the psychotherapy frame. The setting, situation, patient population, and other factors dictate boundaries for the APPN role. The blurring of boundaries mandates that each APPN set limits based on the patient’s welfare. Because research on the APPN relationship with the patient and the integration of touch and psychotherapy has not been conducted, it is prudent to regard touch as a boundary violation. If the APPN conducts a physical assessment at intake or admission, it is not appropriate to continue with that person in ongoing psychotherapy. Erring on the side of caution ensures a judicious and ethical practice.

Self-Disclosure

Minimal self-disclosure is part of maintaining a professional relationship. Self-disclosure is defined as the therapist revealing something personal. The therapeutic technique of immediacy described in Chapter 3 is a type of self-disclosure, in which the therapist reveals feelings about him/herself in relation to the patient or the therapeutic relationship. Therapists must be aware of their own motives and thoughts relating to self-disclosure. Gabbard (2004) says, “Because we cannot be sure what we are up to when we are disclosing our own feelings to the patient, self-disclosure should be thought about carefully before using it.” Self-disclosure should not be used to meet the therapist’s own narcissistic or intimacy needs in that the focus is shifted from the patient. This can interfere with the flow of the session and may confuse or burden the patient. It is essential for APPNs to be aware of patients with whom they would be more likely to confide, because this may herald a potential boundary issue.

Based on an extensive review of the research on self-disclosure, Hill and Knox (2002) suggest the following practice guidelines for therapists:

Regarding the last point, the less self-disclosure by the therapist, the more the transference is thought to be heightened. Less self-disclosure may be more helpful for some patients who are higher functioning so that through discussion of the transference, profound learning and change may occur.

However, for those who use more immature defenses, such as projection, it may be better if the therapist is judiciously self-disclosing and more “real” so that less implicit feelings, thoughts, and state-dependent memories from the past are transferred onto the therapist, resulting in less distortion. Patients who are paranoid especially may need the therapist to be candid because they may project so much that it is important to inform them what aspects of their observations are accurate and what is being misinterpreted. Answering nondefensively and without evasion is usually warranted. For example, one patient who was schizophrenic asked the therapist why she dressed like a hippie. The therapist responded good-naturedly, “I kind of like these 60s outfits; I think I look groovy.” The inherent inequity in the therapeutic relationship creates a climate in which dependency and some distortion are inevitable, with one vulnerable person requesting caretaking from another. The dependency triggered by psychotherapy can be particularly problematic for those needing stabilization and for those who have been chronically disempowered.

Another thorny issue related to self-disclosure and maintaining boundaries is how to answer patients who ask personal questions. If the patient asks the therapist personal questions, the therapist can say, “I’ll be glad to answer that, but first I’m wondering what your thoughts are about that and how is it that you are asking?” If the patient persists in asking personal questions that the therapist does not want to answer (e.g., “Are you divorced?” or “How many children do you have?”), the therapist should listen for the latent content and explore what the patient is really asking for. For example, “Are you married?” may mean “Are you available?” or “Are you gay?” Often, the question is really about the person wondering whether the therapist can be trusted and reflects concerns about whether the therapist likes him/her, can understand his/her culture, and can relate to the patient. The patient may be unsure about the intimacy of therapy versus the intimacy of a personal relationship. The therapist can say, “You are very curious about me. Can you tell me more about that?” or “This is your time to talk about you.” If the person persists, and the therapist does not want to answer the question, it is best to say this honestly, “I am not comfortable answering personal questions about myself, but I am interested in how this information is important to you.” It is possible to spend the whole session on the meaning of the person’s question by reflecting, “It sounds as if you are feeling that if I am not married like you, I will not be able to understand how you feel.” The therapist and patient then explore the context for this belief. It is only through inviting the patient to express his/her reservations about therapy and about you that the process can proceed. Being curious, interested, and open to all communication are essential skills for all therapists.

Fees

Issues about fees are ongoing as part of the frame, and it is essential to discuss in the initial session (see Chapter 3). Financial arrangements should be handled in a manner appropriate to the treatment context. Even though the patient has signed a contract about the cancellation policy and fees were discussed at that time, the policy may need to be revisited as therapy proceeds. Undoubtedly, the patient will cancel and “forget” that he will be charged for missed sessions as the policy proscribes. Understanding money issues in psychotherapy is essential. For example, paying late may be a signal that the patient expects to be taken care of or forgetting to pay may be a passive aggressive act, and there may be any number of other unconscious reasons that the patient may deviate from the agreed fee structure and cancellation policy. Addressing and exploring the behavior to clarify the psychological meanings and to reiterate the frame for payment is imperative. Often, forgetting to pay reflects deeper meanings than at first glance.

It is not good practice for the patient or the therapist to allow a large outstanding bill to accumulate. A better alternative is to explore the meaning of not paying and help the person deepen his/her understanding while maintaining the frame of the contract. Higher-functioning patients usually honor the therapist’s fee structure and are easier to work with when exploring money issues than those who are lower functioning. For example, one patient who was a therapist herself expected a reduced fee after her insurance company changed and she no longer had good coverage for outpatient psychotherapy. In exploring this subject with her, deep feelings of sadness and abandonment surfaced from her childhood related to the caretaking role she had played with her mother, who had significant financial problems. Implicit neural networks associated with dependency and entitlement were triggered in therapy when she was asked to “caregive” the therapist by paying more out-of-pocket fees for her sessions. As the therapist explored these issues and reworked them in the present, the patient was able to make new neural connections that allowed her to continue in treatment and pay the charged fee. This awareness reverberated to other areas of her life, and she benefited financially in her own practice as a consequence of her work on this issue. Often, money issues in treatment reflect similar difficulties for the person outside the therapy.

Lateness and No Shows

Essential to maintaining the frame is the therapist’s reliability and consistency of sessions. The therapist must be on time for sessions. Changing appointment times often creates chaos, and the patient may not honor the commitment if the therapist is a poor example. Informing the patient well ahead of time when you will be gone and trying to reschedule, if possible, are common courtesies and essential for integrity of the frame. The patient’s lateness and not showing up for appointments are likely to be forms of resistance, but it is important to understand that tardiness and absence may be caused by an unforeseen circumstance. Emergencies, such as illness, lack of child care, transportation problems, or weather problems, do occur. It is important to determine whether this is an isolated event or a pattern is developing. If the lateness is a one-time event, you can open a discussion by observing, “I notice you were late today.” However, if the person has been late two or three times in a row, the cause is most likely resistance, which should be addressed, or the person may leave treatment altogether. It may be better to wait until an opening in the session presents itself, or the person’s defenses may increase. If an opening does not present itself, the therapist can say, “You have been 10 minutes late for the past two weeks, and it seems hard for you to get here on time.” The person may launch into the “real reasons” for the tardiness. The therapist can then ask, “Do you have any other feelings about coming here lately?” Approaching with curiosity and understanding conveys caring and allows the patient to explore what is going on. It is important for the therapist to adhere to the established time for the session and not extend the time another 10 minutes if the patient is 10 minutes late.

If the person does not show up for a scheduled session and does not call, most therapists assume that the patient will come to the next session and do not contact the person. However, if two sessions are missed, the person is usually called, and a message is left that states, “I had in my appointment book that you were coming yesterday at 3, and you did not come. I hope everything is okay. Please call if you would like to schedule an appointment. I look forward to hearing from you.” Adding the last sentence is helpful, because the person may feels that the therapist is angry if s/he has missed several times. If the person calls, confirms, comes the following week, and has not missed before, the therapist must explore what is going on with the person, because the resistance must be addressed if the patient is to continue. If the person does not address the absence, the therapist can ask, “How did you feel about missing the past few weeks?” If this is the first time a session was missed, the therapist can reiterate the policy once before instituting it the next time. If the patient calls and says s/he wants to end treatment, the therapist should suggest that the person come in to discuss the issue first. Even if issues are discussed and the patient still wants to terminate against the therapist’s best judgment, it can still be helpful to the patient to meet for a final session. The therapist can use this opportunity to explore what is going on and leave the door open for future work when the patient is ready. However, if the person does not call or come to the next confirmed appointment and has missed three sessions in a row, a termination of treatment letter (see Appendix I-23, p. 173) should be sent to the person. This official termination letter protects the therapist from legal liability if the person has difficulties later. Chapter 14 provides further discussion of termination.