Drawing Boundaries

To Ruth, offering her sweater seemed well within the limits of her professional role, demonstrating concern for Lana's welfare and making sure that therapy wouldn't come to a standstill because of her client's discomfort. But for Lana, the sweater wasn't just any sweater. Lana associated the garment with Ruth. Indeed, during therapy sessions, Lana sometimes found it easier to look at the sweater and think about Ruth in the abstract than to look Ruth in the eye.

One of the issues Lana was dealing with in therapy was her tendency in close relationships to "lose herself" in the other person. Then she would get angry at herself for her own malleability, and withdraw. Lana imagined that, unlike her, Ruth was impervious to the influence of others, totally self-contained. Lana admired and feared this self-containment. The prospect of putting on Ruth's sweater made Lana nervous because it brought up complicated feelings about closeness and distance. Moreover, if the sweater did not fit, Lana might have to confront the differences between herself and her therapist in too visceral a way.

Boundaries are a crucial element in patient-therapist interaction. First and foremost, they recognize the inherent power inequity of the relationship and set limits for the therapist's expression of power. Second, they set a structure for the relationship, providing a consistent, reliable, predictable, knowable frame for a process that remains somewhat mysterious.

Most therapists agree about the broad basics. For example, a client should be able to count on a particular appointment time, which is not changed frequently or capriciously, and a set fee for sessions. Therapy should take place in the office, not in exotic locales. Practitioners should not engage in ongoing secondary relationships with clients.

Beyond these fundamental limits, however, there are a host of situations where the delineation of a boundary is less clear, situations that fall outside the formal ethics codes and lie instead on the cusp of principles and technique. Should a therapist who runs into a client at a restaurant, party or at the local gym engage in social chitchat or cut and run? Can a client and therapist both serve on the same school board or charity committee without distorting their therapeutic alliance? Should a client who has worked for years in her sessions to be able to sustain a romantic relationship expect her therapist to attend her wedding? Can a therapist give a compassionate hug to a patient after a particularly painful session?

How a therapist answers these questions may depend on theoretical persuasion and even personal bent. The individual therapist, in the sanctity of his office, often decides them alone. That is why some therapists drink tea with their clients during sessions and others do not; some have family photos in view and others banish them; some will attend an occasional social function where a client is present, and others will leave a party if they spot a client across the room; some will hug routinely, some will hug only if asked, and some will flinch at even a handshake with a client.

For therapists--and clients--who are struggling with boundaries, the paramount question must be: Does this serve the patient's therapeutic interests? If an act or an encounter threatens that goal, it is suspect, even if its exploitative potential is not obvious.

One respected psychologist has stated publicly that he sometimes plays tennis with a client and doesn't regard it as an abuse of power. But how does swatting balls with a client promote the client's needs? There are too many things that can happen on a tennis court to jeopardize the core intent of the therapeutic relationship: watching the therapist lose his temper and behave irrationally, colliding with him and inadvertently hurting him, finding out that he has a tasteless tattoo or laughs at an offensive joke, and so on. And no therapist could play a decent game and still keep his focus on protecting the client's interests.

For her part, the client is likely to feel honored and special, unable to see playing tennis with her therapist as a casual social event. When a shift in the boundaries carries the promise of providing far more than the act itself, when it assumes undue symbolic weight, the client is likely to be at her most vulnerable.