Boundaries, inside and outside the therapy room

Do you greet your clients with a casual wave and “hey” or a firm handshake, or do they sometimes get a hug? Do you discuss what the client should expect if you bump into each other in public? And in what situations are you made most aware of the therapeutic boundaries, whether inside or outside your practice?

Therapeutic boundaries relate to many things, from the therapist’s self-disclosure, touch, and exchange of gifts to bartering and fees, length and location of sessions and contact outside the office. Issues with boundaries can come up in the therapy room, or appear outside of the sessions. For instance, a client might ask you to reveal personal information about your life (Do you have children?) or you might live in the same neighborhood and have to deal with encounters on the streets. These types of situations might shed some light on the complexity of boundaries, and make you think about when boundary crossings are beneficial and when they can turn into harmful violations.

A boundary violation happens when a therapist crosses the line of decency and integrity and misuses his/her power to exploit a client for the therapist’s own benefit. Boundary violations usually involve exploitive business or sexual relationships. They are always unethical and often illegal. But harmful boundary violations are different from boundary crossings, and, when appropriately employed, the latter can increase clinical effectiveness and therapeutic outcome (Zur, 2018).

Helpful boundary crossings

From a psychoanalytical point of view almost all boundary crossings are detrimental to the transference and the clinical work. The perspective of the depravity of boundary crossings communicates that crossing boundaries is likely to lead us down the slippery slope to exploitative sexual relationships. The message is that we should never leave the office with a client, be very careful about gifts, never socialize with clients and limit physical contact to a handshake.

But particularly behavioral, humanistic, existential, group, feminist, Ericksonian and family therapies often support many forms of helpful boundary crossings, with the belief that boundary crossing, when executed with the clients’ welfare in mind, is likely to enhance therapeutic alliance — the best predictor of therapeutic outcome.

A few examples of beneficial boundary crossings could include walking with an agoraphobic client to an open space outside the office (common in CBT), self-disclosure as a way of offering an alternative perspective, exemplifying cognitive flexibility, creating an authentic connection, increase therapeutic alliance or leveling the playing field, or take a depressed client on a vigorous walk (Zur, 2018).

Dual Relationships

Dual relationships are also referred to as multiple relationships, and occurs whenever multiple roles exist between a therapist and a client. Dual relationships are subtypes of boundary crossing, and aren’t in all cases unethical. For instance, therapists practicing in small communities will regularly encounter unavoidable dual relationships, e.g. the person who pumps gas might also be their client. Such unavoidable dual relationships can also happen in small, distinct populations in larger metropolitan areas, e.g. LGBTQIA, handicapped, various minorities, religious congregations, and other distinct small societies. In these communities, the duality and prior knowledge of each other are arguably preconditions for the development of trust and respect, and so, non-sexual, non-exploitative dual relationships and familiarity between therapists and clients are not only normal but can, in fact, increase trust (Zur, 2018).

While dual relationships may be sometimes unavoidable, therapists have to pay close attention to the harm that can arise from them, especially where there is a conflict of interest. Conflicts of interest are often present in situations where the client is also a student, employee, employer or business partner. Of course, sexual dual relationships are always unethical, counter-clinical and illegal in most (if not all?) countries.

The Ethics of Boundaries and the Standard of Care

Interestingly, there are no clear guidelines that specifically deal with boundary crossings. The APA’s and almost all other professional organizations’ codes of ethics do not regulate non-sexual touch, gifts, length of sessions or self-disclosure. Of course, they all have a mandate to avoid harm and exploitation and respect clients’ integrity and autonomy and say things like: “Multiple relationships that would not reasonably be expected to cause impairment or risk exploitation or harm are not unethical” (APA, 2016, section 3.05).

The standard of care is defined as qualities and conditions that should prevail in a particular mental health service. The requirements of the standard are closely dependent on circumstances, and is closely tied to a theoretical orientation. The examples of boundary crossings mentioned above clearly fall within the standard of care of behavioral, humanistic, family, and other non-analytic therapies. However, boards, courts and ethics committees too often confuse the standard of care with analytic standards or with risk management guidelines. This confusion has caused injustice to therapists, when boards’ and courts’ experts apply an analytic criterion and proclaim clinically appropriate boundary crossings and dual relationships to be below the standard of care.

Of course, intentional boundary crossings should be implemented with two things in mind: the welfare of the client and therapeutic effectiveness. Boundary crossing, like any other intervention, should be part of a well-constructed treatment plan which takes into consideration the client’s problem, personality, situation, history, culture, etc. and the therapeutic setting and context. Boundary crossings with certain clients, such as those with Borderline Personality Disorders or those who are acutely paranoid are not usually recommended, since effective therapy with such clients often requires well-defined boundaries of time and space. Dual relationships, since they always entail boundary crossing, impose the same criteria on the therapist. Even when such relationships are unplanned and unavoidable, the welfare of the client and clinical effectiveness should always be the main concern (Zur, 2018).

Reference: Zur, O. To Cross or Not to Cross: Do boundaries in therapy protect or harm. Psychotherapy Bulletin, 39 (3), 27–32. Posted by permission of Division 29 (psychotherapy) of APA (updated 2018).