Professional Boundaries in Mental Health Care _ _________________________________________________
Empathy is a multi-level process of relating to others. It encom- passes both an emotive experience and a cognitive one. It includes an intellectual component (namely, understanding the cognitive basis for the client’s feelings), and it implies the ability to detach oneself from the client’s feelings in order to maintain objectivity [14]. While engaged in empathic listen- ing, mental health professionals should remain responsive to feedback and alter their perspective or understanding of the client as they acquire more information [14]. Empathy may be summarized by the ability to [15]: • See the world as others see it. • Be nonjudgmental. • Understand another person’s feelings. • Communicate your understanding of that person’s feelings. Empathy should not be confused with sympathy, which may be defined as an affinity, association, or relationship between persons wherein whatever affects one similarly affects the other. Compared with empathy, sympathy is a superficial demonstra- tion of care. With sympathy, you feel sorry for the client; with empathy, you feel the client’s pain. Although a counselor can get caught up in the client’s feelings, he or she should always strive to empathically understand what the client is experienc- ing while maintaining emotional detachment. This potentially provides a broader perspective that extends beyond the cli- ent’s situational distress. Mental health professionals want to employ the best tools in order to affect change in their clients without causing harm, and empathy surpasses sympathy in terms of effectiveness. Research has validated the importance of empathy, unconditional positive regard, and congruence for achieving an effective therapeutic relationship [16]. Compassion-focused therapy is a rapidly growing, evidence- based form of psychotherapy that pursues the alleviation of human suffering through psychological science and engaged action [17]. According to Gilbert, the following are attributes of compassion-focused therapy [18]: • Sensitivity: Responsive to distress and needs; able to recognize and distinguish the feelings and needs of the client. • Sympathy: Being emotionally moved by the feelings and distress of the client. In the therapeutic relationship, the client experiences the counselor as being emotion- ally engaged with their story as opposed to being emo- tionally passive or distant. • Distress tolerance: Able to contain, stay with, and toler- ate complex and high levels of emotion, rather than avoid, fearfully divert from, close down, contradict, invalidate, or deny them. The client experiences the counselor as able to contain her/his own emotions and the client’s emotions.
• Empathy: Working to understand the meanings, func- tions, and origins of another person’s inner world so that one can see it from her/his point of view. Empathy takes effort in a way that sympathy does not. • Nonjudgment: Not condemning, criticizing, shaming, or rejecting. It does not mean nonpreference. For exam- ple, nonjudgment is important in Buddhist psychology, which emphasizes experiencing the moment “as it is.” This does not mean an absence of preferences. Empathic Boundaries Counselors strive to achieve empathy with their clients while maintaining boundaries that protect their own energies. Pro- fessionals should ‘‘sense the client’s private world as if it were [their] own, without ever losing the ‘as if’ quality,’’ and while not becoming entangled with their perception of the client [10; 19]. It takes work to maintain a healthy distance emotionally while feeling and intuiting what the client is saying. Too much sympathy, or working with empathy without proper boundaries in the therapeutic relationship, drains the counselor of energy and leads to burnout. In a study of 216 hospice care nurses from 22 hospice facilities across Florida, it was found that trauma, anxiety, life demands, and excessive empathy (leading to blurred professional boundaries) were key determinants of compassion fatigue risk [20]. In other words, there can be too much of a good thing. In order to motivate client change, there should be a limit to the use of empathy in therapy. Empathy is but one tool that a compassionate mental health professional can use to ensure client growth.
TRANSFERENCE AND COUNTERTRANSFERENCE
The term transference was coined by Freud to describe the way that clients “transfer” feelings about important persons in their lives onto their counselor. As Freud said, “a whole series of psychological experiences are revived, not as belonging to the past but applying to the person of the physician at the present moment” [21]. The client’s formative dynamics are recreated in the therapeutic relationship, allowing clients to discover unfounded or outmoded assumptions about others that do not serve them well, potentially leading to lasting positive change [22]. Part of the counselor’s work is to “take” or “accept” the transferences that unfold in the service of understanding the client’s experience and, eventually, offer interpretations that link the here-and-now experience in session to events in the client’s past [23]. The intense, seemingly irrational emotional reaction a client may have toward the counselor should be recognized as resulting from projective identification of the client’s own conflicts and issues. It is important to guard against taking these reactions too personally or acting on the emotions in inappropriate ways [24]. Therapists’ emotional reactions to their patients (countertransference) impact both the treatment process and the outcome of psychotherapy.
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