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.
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.
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.
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."
The Good Old Slippery Slope
Ethical issues may seem obvious until you get embroiled in one. Most of what takes us, as therapists, close to the "no-go" line aren't the biggies (sex, expensive gifts, business partnerships, major confidentiality violations), but the less obvious ones, which make hard cases in the end. At the margins, many ethical issues are really judgment calls. It's not so easy in the thick of things to see a bright, shining line dividing the therapy relationship from some other relationship.
I have a consultation team on my side. To me, such a group is critical to helping any therapist think and make decisions about the kinds of thorny ethical issues that come up all the time in therapy. I like sports metaphors. As a therapist, you're something like an athlete, who must stay in shape to be ready for whatever comes at you during the game. You must have a coach and a team on your side who support you, challenge you, and tell you when you're in danger of screwing up. You can tell a good consultation group anything—"I've got a crush on a client," "My client wants to give me a pricey gift and will feel hurt and rejected if I say no," or even "My client has been hired to cater my son's wedding." The list goes on and on, and a consultation group will give you perspective on how to sort through it.
During good therapy, clients feel protected enough to let go of the defenses that shackle them to unhappy and unsuccessful patterns of living. In that environment, they can feel freer than ever before in their lives; they can allow themselves to be inspired and encouraged—empowered—to reenvision the world and the meaning of their lives. That therapy can do that is, in my opinion, due as much to the right understanding of boundaries as to any particular methodology. In fact, clients will forget all those brilliant interventions and masterful insights of ours, but they'll remember how we made them feel. Did we help them feel safe and secure enough to be bold, to look at the world with new eyes, to believe that within themselves they do have the wisdom and imagination to remake their lives? To me, therapy is genuinely a kind of sacred space—a sense that's been reinforced for me by many, many clients who've said the same thing. So, from my standpoint, the original Great Law of Good Therapy that we began with remains constant: remember thy boundaries, and keep them holy!
This blog is excerpted from "Yesterday's Ethics Vs. Today's Realities" by Mary Jo Barrett. The full version is available in the July/August 2012 issue, Ethics in the Digital Age: How Casual is Too Casual?
Read more FREE articles like this on Ethics.
Or, find articles just like this one in our Archives on the new, enhanced Networker mobile app! Click here for more details.
Want to read more articles like this? Subscribe to Psychotherapy Networker Today! >>
Photo © Art Valero