Currently, the field is so deluged with dire warnings of imminent professional ruin that many therapists practice under a cloud of fear. There's now a huge literature on the subject of risk management, including scores of books with titles like Fifty Ways to Avoid Malpractice, by Robert Henley Woody, and On Your Side: Protecting Your Mental Health Practice from Litigation, by J. Michael Adams. The insurance industry provides its own, often pricey, version of risk-management workshops. Psychoanalytic literature supports the risk-management view of therapeutic boundaries, but for theoretical reasons, rather than legalistic or financial ones. Newsletters on the subject abound. For example, American Professional Agency, Inc., a professional liability insurance company, regularly publishes a newsletter called Insight: Safeguarding Psychologists Against Liability Risks. At our professional meetings, in the legal columns that are now a regular feature of our journals, and at workshops and seminars, legal professionals, usually without any clinical training whatsoever, are giving their opinions about how we should practice, what we're allowed to do, and what we should never do—and scaring us to death in the process.
The Chilling Effect of Self-Watchfulness
The most frequently uttered words coming from these sources seem to be "don't" and "never." Consider the commandments regularly issued against what these experts consider dangerously risky behaviors. "Don't touch your clients—a handshake is the outer limit!" "Minimize self-disclosure; keep your anonymity intact!" "Never venture outside the office with a client!" "Don't accept gifts from a client!" "Never socialize or share a meal with a client." As Richard Leslie, an attorney specializing in psychotherapy issues and a consultant to the American Association of Marriage and Family Therapy, put it in one all-purpose rule, "If you have to ask, don't do it!"
The problem with these blanket condemnations is that many of the forbidden acts may be among the most powerful therapeutic methods at our disposal. We know that touch is one of the most elementary human ways to relate, and can have a powerful reassuring and healing effect. Self-disclosure can help fearful and defensive clients connect with us, and learn from us through modeling—a proven cognitive-behavioral intervention in itself. Sometimes going to the client, rather than making the client come to us, is the only reasonable way of doing therapy: take, for example, the empirically successful home-based family therapies with juvenile offenders, or therapy with a homebound sick or elderly client. A gift may be an important way for a client to express gratitude; refusing it could be deeply offensive and shaming. Sharing a meal with an anorexic client is often part of an effective, system-based treatment plan. "Dual relationships" with clients are often unavoidable and therapeutically helpful for a therapist who works in a small town or rural setting—your children may go to the same school as your clients' children; you may belong to the same church or synagogue. Conscientious, ethical therapists know all this, but even as we necessarily engage in these "forbidden" activities in the interest of being good therapists, we may feel a shudder of apprehension that we're somehow dangerously flouting rules written in stone.