__________________________________________________ Professional Boundaries in Mental Health Care
BUILDING TRUST An inherent power differential exists in the therapeutic relationship between the client, who is placed in a position of vulnerability as she or he seeks help, and the practitioner, who is placed in a position of power because of her or his professional status and expertise [36]. When the client sees the counselor sitting in a chair, with a diploma or licensure on the wall, it can be intimidating. To help mitigate these feelings with the client, it is important to maintain a sense of professionalism while working to build trust and rapport. Part of that professionalism includes setting limits and explaining what they are in the context of therapy. The familiarity, trust, and intensity of the therapeutic relation- ship create a powerful potential for abuse that underscores the need for careful attention to the ethical aspects of profes- sional care [36]. Trust is the cornerstone of the therapeutic relationship, and counselors have the responsibility to respect and safeguard the client’s right to privacy and confidentiality [4]. Clients have expressed what they believe to be essential conditions for the development of trust in the therapeutic relationship. These include that the clinician [37]: • Is perceived as available and accessible • Tries to understand by listening and caring • Behaves in a professional manner (evidenced by attri- butes such as honesty in all interactions) • Maintains confidentiality • Relates to the client as another adult person rather than as an “expert” • Remains calm and does not over-react to the issue under discussion Only when satisfied that the clinician is sufficiently experi- enced, professional, flexible, and empathic can a foundation for therapy be laid. Clients acknowledge that this takes time and that the trustworthiness of the therapeutic relationship may be tested. If the relationship is perceived to be wanting, clients indicate that they would have difficulty continuing it [37]. THE VALUE OF FLEXIBILITY Rigid boundaries can negatively reinforce the power differential that exists between the client and the counselor. Rigid bound- aries may serve the fears and needs of counselors who are new to the profession and/or concerned with the implications of boundary violations. However, rigid boundaries can lead to harm for the client who perceives that the “rules” are more important than his or her welfare. While rigidity and remote- ness on the counselor’s part may help ensure that boundaries are intact, they do not accurately reflect the intended role of boundaries in clinical practice. Boundaries should never imply coldness or aloofness. As stated, clients value flexibility, caring, and understanding. Within conditions that create a climate of safety, flexible boundaries can accommodate individual
differences among clients and counselors and allow them to interact with warmth, empathy, and spontaneity [38]. Firm, intractable boundaries may be a comfort to the helping profes- sional; however, fixed rules cannot capture the complex reality of the therapeutic relationship [36]. EMPOWERING AND PROTECTING THE CLIENT Boundaries and effective limit setting in sessions help to empower and protect clients by teaching and reinforcing the skills they need to become healthy. Boundaries set the parameters and expectations of therapy, so it is important to articulate them in such a way that each client’s understanding of them is clear. Counselors should constantly and actively make judgements about where to draw lines that are in the client’s best interests [39]. Boundaries begin the moment a client enters the room. Indicate which chair is yours and where it is acceptable for the client to sit. Take note of where your seat is in relation to the door should an emergency arise. Be sure to maintain an appropriate amount of space between yourself and the client. Too much space can feel impersonal and too little can feel invasive. Consider the décor of the setting. Clients may become distracted by the counselor’s personal artifacts and family photographs and may place their focus on the counselor rather than on their own therapeutic work. Some clients with poor boundaries may become preoccupied with the counselor’s family, which can become a source of transference. Clients often enter therapy with a history of prior boundary violations (e.g., childhood sexual abuse, domestic violence, inappropriate boundary crossings with another professional) that leave them with persisting feelings and confusion regard- ing roles and boundaries in subsequent intimate relationships [40]. Consequently, they may test the boundaries as children do. The counselor should recognize these boundary dilem- mas and manage them by reiterating the boundaries calmly and clearly [39]. The counselor must also set and maintain boundaries even if the client threatens self-harm or flight from therapy. This can be extremely challenging when faced with a client’s primitively motivated, intense demands. However, counselors should recall that one description of the tasks with clients with primitive tendencies is to resist reinforcing primi- tive strivings and to foster and encourage adult strivings [41]. Winnicott refers to this as a “holding relationship,” wherein the counselor acts as a “container” for the strong emotional storms of the client. The act of holding helps reassure the cli- ent that the clinician is there to help the client retain control and, if necessary, assume control on his or her behalf [42]. Due to the potential issues and challenges that the client brings to therapy (e.g., cognitive deficits, substance abuse/ addictions, memory issues, personality disordered manipula- tions), it is important to maintain a record of instances when the articulated boundaries and limits have been ignored or violated. For example, a client is habitually late, despite know-
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