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Yesterday’s Ethics Vs. Today’s Realities

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JA2012-1Boundaries in an Age of Informality

By Mary Jo Barrett

As the status of the therapist has shifted from that of an oversized figure with Svengali-like powers to that of an overworked and underpaid service provider at the mercy of the client-consumer who might sue him or her for some infraction, what are we to make of our traditional ethical codes?

Traditionally, psychotherapists have thought of ethics as a kind of Old Testament list of "thou shalts" and "thou shalt nots":

Thou shalt have no connection with the client-emotional, sexual, occupational, financial, social, Facebook-except psychotherapy.

Thou shalt not breach confidentiality and loosen thy tongue about the client or what happens in therapy, even to your spouse or closest friends, particularly after a few glasses of wine.

Thou shalt not blab on about thyself or thy family or thy marital status or anything else without an ironclad clinical rationale for the therapeutic use of "self-disclosure."

Thou shalt forego dual relationships with clients; neither a borrower nor a lender be with them, nor engage in joint business ventures with them, nor hire them as nannies.

Thou shalt not exploit thy privileged position with the client to further thine own personal interests.

In sum, thou shalt remember thy boundaries and keep them holy.

Detailed ethics codes emerged in the new and somewhat amorphous profession of psychotherapy because its practitioners weren't exactly physicians, priests, or friends, but some amalgamation of these, requiring their own behavioral guidelines. The basic idea of the codes was to keep the therapist-a potentially revered and intimidating figure with a powerful emotional influence in the client's life-honorable, trustworthy, and discreet.

Through the years, as therapy became more widespread and society more informal, some of these guidelines have become increasingly ambiguous. As the general public has come to regard therapists as just another kind of service provider, rather than a potential Svengali, the relative power of therapist and client has shifted, as well as the role of ethics. In fact, if anybody needs protection today, it might be the overworked and underpaid therapist, who's at the mercy of clients who might bring suit for some peccadillo. Society has become more litigious, and nightmare scenarios-whether realistic or simply hyperbolic-of therapists being hauled into court and their careers ruined for some presumptive transgression have proliferated. Getting ethics CEs has become a grim requirement, not only for licensure, but as some small protection against the looming threat of aggrieved clients and their lawyers, like a wreath of garlic cloves to ward off legal vampires.

Presumably, the great majority of us recognize the importance of behaving ethically with our clients and wouldn't engage in unethical behavior, even if we could get away with it. As therapists, we intuitively know we can't do good therapy unless we're trustworthy and dependable, respect our clients' confidentiality, and maintain decent boundaries between ourselves and them. What's not as widely understood is that the way we share our ethical vision with our clients is as important to the practice of therapy-to the entire process of therapy-as any treatment model or clinical philosophy. An acute sensitivity to ethical issues doesn't just protect the client from overt harm or us from liability; it gives us the framework within which we can do clinical work. Our ethical stance isn't an add-on to therapy, or even merely a protective shield for the client, though it certainly is that: it's the foundation of therapy itself.

The Importance of Safety

The central ethical concern in therapy, the one around which all the others hinge, is boundaries. I began to understand this 21 years ago (a decade into my therapy career), when I began a regular program of exit interviews with terminating clients, systematically asking them what they thought had been most helpful about their experience in treatment. I asked about the intervention, the relationship, the practical advice offered, the office decor, the ease of parking, and for any other feedback they had. Thousands of interviews later, with similar input about clients from numerous other therapists and agencies, the answer was overwhelmingly clear: regardless of why these clients had sought treatment, what they valued and remembered most was feeling "safe" in therapy.

The essential factor for clients to benefit from therapy was the sense that they'd entered a secure haven, which provided a time and space set off from the tumult and emotional confusion of their "regular" lives. There they could concentrate on doing the reflective, difficult work they needed to do to make the changes they desired for themselves. They required a guide who was empathically on their side, hopeful about their future, and open to their free expression of thoughts and feelings, but detached enough not to be sucked into their emotional morass. They absolutely needed to believe that what happened in therapy would stay in therapy, and that included the therapist. This meant the therapist wouldn't regularly pop up in their daily life, and they might allow themselves the illusion that the therapist never left the office and was always there waiting for them when needed. In short, this therapeutic safe house was built on a foundation of unambiguous boundaries, confidentiality, and hopefulness, conveyed by a trustworthy expert in a collaborative engagement suspended from ordinary life. These features of the therapeutic process emerge precisely from those boring old ethical rules and regulations that were established with the specific purpose of safeguarding clients' interests.

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3 comments

  • Comment Link Monday, 26 November 2012 14:43 posted by Janine Muller

    A wonderful clinical article around boundaries. As an LCSW, I pride myself on maintaining clear and consistent boundaries and have also come to better understand how they can unintentionally blurred.

    I had experienced some unfortunate personal experiences that impacted some of my "own stuff" and this in turn, impacted some areas in ways in which I could have never imagined. Some boundaries started to become blurred and I never realized what it looked like from the other side. Some of the challenges I thought I handled and failed to yeild to the understanding that I really needed some professional help myself instead of trying to manage it on my own. In the end, my lack of awareness may well have created a sense of not being safe for my clients, something I would have never consciously intended or created.

  • Comment Link Monday, 10 September 2012 10:32 posted by Cynthia Wall, LCSW (california)

    Dear Mary Jo, thank you for this! I am just beginning to develop a CEU class called "Ethics in a Small Town Private Practice." This type of issue (caterer) comes up constantly, and you did a marvelous job of dissecting it from facts and feelings to using it for teaching. I'm going to suggest my participants read it for our purposes of unraveling their own issues.

  • Comment Link Saturday, 04 August 2012 11:38 posted by daniel wolpert

    This is a great article, and it is clearly geared towards therapy in the big city. I'm a pastor with a previous career in psychotherapy and so I do a fair amount of pastoral counseling. My wife is a physician in the same town. Dual relationships are an inescapable fact of life in our context. If we didn't have other relationships with those we see in our office, we'd have to barricade ourselves in our house and starve to death. Interestingly, in historic healing/spiritual communities, dual relationships were also well recognized. In one of the most famous example of the 20th century, Thomas Merton was the spiritual director for his abbot, the man who had a great deal of power over his daily life. Having lived in the small town context for many years, I realize that the main essential boundary is confidentiality within the office. Of course many times people do 'get away' and see those outside the community for intimate services, and when they need this, people seem quite able to make this choice. However, I have come to believe that seeing each other in an array of community contexts actually adds to a sense of safety and well being rather than detracts from it.