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Yesterday’s Ethics Vs. Today’s Realities - Page 2

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Setting the Boundaries

We all know that the collaboration between therapist and client-the therapeutic alliance-is the keystone of therapy. What many therapists may not realize is how much clarifying boundary issues means in establishing and strengthening that collaboration. Boundaries are what make us all feel safe and grounded in a variety of situations; around a relationship in therapy, they create a secure perimeter, which makes possible the level of emotional freedom and authenticity that's critical to successful treatment.

I believe clients need to know up front what makes therapy different from all other relationships. As I've come to appreciate the importance of boundaries and safety to my clients, I've woven a clarification of those issues into the fabric of treatment from the very beginning of each case, sometimes from the first phone call. When clients call to make an appointment, I ask whether this is their first therapy experience. I then follow up during therapy sessions with questions like, "What do you think happens in therapy?" or "How do you think therapy works?" If they've already been in therapy, I ask what's worked for them in their past therapy experiences and, of course, what hasn't worked for them. I explore their opinion about what style of therapist they like and their overall expectations. I explain that I've learned that clients appreciate a collaborative, predictable structure and discuss how we can work together to make their therapy experience as transparent as possible.

I often say, "This is a unique relationship. I'll get to know you very, very well, and know the most intimate details about your life, but you'll never know me on that level. Although we may become best friends of sorts, I'll never hang out with you, and when things are going at their best, we'll probably begin to end the relationship." Often I'll take time to define with clients what makes them feel safe and what types of relationships they feel safe in. Then we'll explore how we can bring those ingredients into our work together.

Because of my focus on safety and collaboration early on, I talk directly about issues that might not occur to other therapists. For example, within the first few sessions, I make it a point to find out whether there may be potential overlap between my clients and me in our personal lives. If you live and practice in a small town, a commercially self-sufficient suburb of a large city, or even a city neighborhood, chances are you'll run into a client at least every now and then-at a party, a business you frequent, a PTA meeting, or perhaps in the shower of the local fitness center (this has happened to me). So I bring up the potential for confusing encounters early on, and discuss with clients how we might deal with possible meetings outside of therapy.

I routinely ask my clients, "If I see you out in public, how do you want to handle this? How should we acknowledge each other, if at all? What if we run into each other and you're with a friend?" Many clients look at me as though I'm crazy, asking if this isn't a bit excessive, and I tell them that it might be, but I've had lots of clients for whom this was a very big deal. Indeed, some clients have told me, "Let's pretend we don't know each other," which is fine with me. Many have no idea how they might handle a chance meeting, so I'll offer some suggestions. "We could just nod and smile, but not engage in conversation. If we met at a party, we could talk and have a ready-made story about how we know each other. At the other extreme, we could openly greet each other and you could just introduce me to all and sundry as your therapist." Most people prefer a little more discretion, since once the information is out, they've lost control of it and have no idea who might ultimately know. Many cautiously choose Option A: we'll nod and pass like ships in the night.

These conversations create an accepted etiquette that clarifies and smoothes over otherwise awkward situations, minimizing the amount of subsequent second-guessing. Particularly for clients new to therapy, unexpected encounters can loom large in their minds, causing days of rumination and requiring an hour of processing during the next session. We spend a good deal of time talking about what might be called the internal boundary issues of therapy: what clients can expect to happen in therapy and what I can do to make them feel secure during the process. If they've been in therapy before, I ask them what was helpful and what wasn't. One client, George, told me that he'd often felt during therapy that his previous therapist, a highly successful, much-published academic with a somewhat reserved manner, thought he was boring and kind of a loser. At that time, George was depressed, hated his job, and was worried about his own future. Whether or not his own lack of self-esteem made him unjustifiably anxious about his therapist's opinion, there was something about the latter's manner that made George afraid to ask him outright what he thought of him. "Besides, he probably wouldn't have told me the truth, anyway," he said. I asked George how we could best avoid the same situation, and he didn't exactly know. I told him a little about my own personal style, so he wouldn't have to spend hours pondering what I meant when I spoke or acted in a certain way. I said I often take long pauses during therapy or draw a deep breath to gather my thoughts before saying something: this is just thinking, not silent disapproval. "When either of those things happens," I said, "I'll share with you what's going on with me."

In addition, I told him I was just born a touchy person. "Sometimes, I automatically reach out and gesture toward someone, or even touch a client lightly, to make a point." Not only that, I tell people that when I have pronounced feelings or thoughts about something, my voice can be rather loud. Some people find this aggressive, even irritating. I tell clients that if I get too loud for them, not to be afraid to tell me to chill out. They won't be the first: I've had clients literally say to me "Whoa, calm down!" I lay out my "hugging policy": if they say they need a hug, I'll do it at the end of the session, but never without being asked. Since I have a small office, I tend to sit close to people. If this bothers a client, I'll back off. In fact, one client was so anxious that she asked me to leave the office door open for the first few sessions-and I did.

These may not seem like boundary issues as they're traditionally defined, but they make the client feel safe and contained like good boundaries are intended to do. What's impressed me repeatedly in talking with former clients is how often therapists (me included), unintentionally make clients feel violated. These are rarely the egregious violations, sexual or otherwise, that alarm ethics boards or end up in law courts. They're the small, sometimes careless, often unconscious acts that exacerbate clients' sense of vulnerability, powerlessness, and anxiety. Clients often say that they don't understand what the therapist was doing or why he or she wouldn't directly answer their questions, and they were put off by what seemed like high-handed behavior. One woman client once confided to me, "My first therapist was a kind man, who said he cared about me, yet he always seemed to be engaging in power plays. For example, he could cancel appointments less than 24 hours in advance, but if I did, I was charged. I asked him many times about his therapy methods, but he never really answered my questions, and it seemed to me he was defensive. I never had any idea what exactly was happening or what I was supposed to be doing or feeling. I'm not saying he ever did anything wrong or bad. But I just always felt off balance, one down, and without any control in therapy."

Clear structures and predictability are necessary to the healthy boundaries of the therapy process. The therapist's respectful and empathic demeanor can help clients build up a healthy sense of their own personal boundaries, which they may never have had the chance to develop before. Unfortunately, without meaning to, the therapist may replicate the abusive relationships in the client's past. We may be "nice people" and experts in our model of therapy; we may know the rules of ethics by heart, and still be completely unconscious of how our clients experience us. That's why it's necessary to make our intentions to keep therapy safe as transparent as possible.

Let's Have an Affair

Now, you might think that having spent so much time thinking and writing about my principles, as well as doing everything I can to follow them in my clinical practice, I'd seldom get caught in the insidious kinds of ethical binds so common in our field. You'd be wrong. Sometimes, the issues become so subtle and complex that we may alienate clients when we're trying our best to protect them. Regardless of how careful and painstaking we try to be, the vagaries of life, human temperament, and personal limitations can be counted on to prevent us from ever becoming proud of our own perfection. In short, stuff happens.

Louise, a caterer, had entered therapy with a history of childhood sexual abuse from several people close to her and a violent first marriage. A compulsive shopping addict who'd run up a great deal of credit-card debt, she had a pattern of wanting to be the favorite of teachers and other authority figures, who regularly took her into their confidence and told her she was their prize student. Throughout her life, many of these relationships had become sexual, although never turning into long-term, intimate connections. She didn't see them as abusive, yet she realized that, in the end, her needs weren't being met or even recognized. Although I regularly give my boundary and safety spiel to everyone in the beginning stages of therapy, it was clear that, with Louise, this discussion was crucial. I assured her, even though she never asked or seemed worried, that I wouldn't be a person in a position of power who'd use her as my prize. Early on, when we discussed the possibility of running into each other at an event she was catering, we decided that we'd only nod to each other if we met. She appreciated these discussions and said that there was "a transparency" she'd never thought of before to our therapy work. She proved to be an eager, intuitive, and likeable client and everything went swimmingly during our first few months of work.

Then one day, while I was at an out-of-state training, I got a call from my eldest son. "Mom," he said, obviously excited, "Marie [his fiancee] and I have found the perfect caterer for the wedding. She has a fantastic menu, she's reasonably priced, and she really seems to get what we're all about. We're so relieved! We want to have a tasting for both families in a couple of weeks, and I want you to look at your schedule and tell us some times when you can do it." Did I feel a warning tingle? Maybe, but I live in a pretty big town and there are lots of caterers around. I felt genuinely happy for my son and his bride to be, who'd spent months agonizing over this decision. "That's fabulous!" I said. "What's the caterer? I wonder if I've eaten their food." His response: "The name is Let's Have an Affair-do you know them?"

Yep, it was Louise's business, all right. I think I may have gasped. I know I stopped breathing and paused, but years of crisis-intervention training have made me quick on my feet. "Sweetie, that's just great. I'm really happy for you. Now, I'm due to begin my workshop, so I'll talk to you when I get back."

Now what? Clearly, I couldn't tell my son, "You can't use her: she's in therapy with me," without compromising her confidentiality. It seemed just as clear to me that I couldn't allow this dual relationship with Louise, because all the official rules and regulations forbade it, and my gut told me that for sure I didn't want to have a client putting my son's wedding reception together. I have a strict policy that, if invited, I'll attend clients' important transitional life ceremonies like weddings and funerals, since I'm already involved in the emotional and spiritual preparation for these ritual events, but I don't do parties, receptions, or wakes, which are purely social. However, I should add that if some transcendent Ethics Board in the Sky had thundered down an order to me that I had to invite one client to my son's wedding, Louise would have been the one. I felt great affection for her, and we had a mutually trusting, respectful clinical relationship. Now, just the thought of the "tasting"-the six of us, chit-chatting with Louise about the filet of beef or the red snapper-gave me hives. I had to have a conversation with her. Luckily, I thought, Louise and I had spent a lot of time discussing boundary issues, so we were both prepared for this discussion and it should go fairly smoothly. Silly me.

Louise walked into her next appointment with a huge smile on her face. Before even sitting down, she excitedly burst out, "Did your son tell you? Isn't this great?! I'll finally be able to give back to you in the most perfect of circumstances. I know I'll be paid for my services, and I'll give you the most beautiful, delicious wedding reception you could ever imagine!" Clearly, the ethical boundary issue had occurred to her, but she'd decided that being paid for her work, rather than doing it for free, mitigated any concern.

I explained to her that her catering the wedding not only violated my own personal sense of ethics, but it was a violation of the official ethical codes of social workers and family therapists. I said, "Louise, my profession has a code of ethics that states that I cannot engage in another professional relationship with you outside the confines of therapy."

She immediately became angry. "You don't need to show me anything. I'm not going to sue you. They want me to cater their wedding, I want to do it, and I don't think you can stop me. You can't tell your son and his fiancee that I'm your client, because then I could sue you!" At a later point in our exchange she said, "You wouldn't even be paying me. The kids have already told me what parts of the wedding you're paying for, and the catering isn't among them."

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3 comments

  • 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.