Exploring the Issues of Boundaries (Managing Ethical Issues) – Psychology

1. Issues of boundaries – what are boundaries & how can they be defined?

McLeod gives a general definition of a boundary as a demarcation line to separate territories (McLeod, 2013). However, boundaries in professional therapy are not physical and do not demarcate a physical structure. There are no lines, posts or markets. As Guthiel and Gabbard (1998) puts it, in counselling boundaries may be defined as the envelope within which the therapeutic treatment occurs. There is a lot of insistence that the treatment must occur only within the envelope and not out of it, as it would be counterproductive to the treatment. We shall discuss this further later.

Lack of definition of Boundary

There is consensus among the scholarly community that there is a dearth of definition of boundary in the context of clinical psychology and therapeutic counselling. Even after far back as 26 years ago in 1993, Gutheil and Gabbard (1993) could not find an adequate definition and commended that the term was too broad to be contained in one particular definition. Zur (2010) remarks about the difficulty in finding such a definition in literature and that psychotherapy has always had a tough time defining boundaries.

Recently there has been much research into an obvious but gross violation of boundary that is sexual violation. However, this is really a narrow field, and even though quite serious does not present any new opportunity for research.

Webb, (1997) advises that we should look at the boundaries from the counsellor’s perspective more instead of the clients to get a better idea, as the conventional models of boundary studies have always focussed on issues of boundary management and prevention of violations.

Importance of Boundary

Boundaries are an important tool to get a sense of the kind of relationship that exists between the counsellor and the patient. It helps to draw out the limits and define the parameters of the relation. Although boundaries were not used traditionally to test the quality of the relationship, recent studies are being conducted in recognition of it as an important tool.

McLeod (2009) notes that there is a rising debate amongst the community concerning the consequences of using boundaries to define the counsellor patient relationship. The idea of boundary essentially says that there is a limit to which a person can be test and beyond that limit there is a ‘violation’ or ‘transgression’ in a relationship which can even result in medical malpractice. It is thus very important that the counsellor addresses the issue of boundaries with the client during the first meeting itself or whenever appropriate at the earlier. This is not only for the protector of the counsellor but also the client so that he may be able to feel in control, take a judgment call and generally be more open during the therapy session.

Types of boundaries

Structural Boundaries

Structural boundaries may be said to be the rough set of rules that we understand to define a relationship between a counsellor and a patient. They are the ground rules that holds together the civility and legitimacy of the relationship and the process of counselling. As Smith, et. al (2012) states, some examples of structural boundaries are limitations of time, frequency of allowed visits, underlying contract, confidentiality issues, fee, time of day, etc.

As McLeod (2011) puts it when the client wishes to have a session and explore and issue in depth, one the first things to do before starting a session is to allocate a safe space not just physically but also set the limits in terms of issues, time, confidentiality, etc.

Rigid v. Flexible Boundaries

McLeod (2013) characterises rigid v. flexible boundaries to be permeable or impermeable. There is considerable debate in the community regarding which approach to follow. Scholars such as Jacobs (2010) considers it prudent to adopt rigid and impermeable boundaries arguing it is for the client’s own safety. However, others such as Prever (2010) considers flexibility especially important to bring about a positive impact in the therapeutic process. Arguments on both sides can be appreciated. Proponents of the flexible system argue that it is better for creating a more organic and human system. Extremists of this line of thought even propose that the entire idea of boundaries itself should be done away with as it would stifle the vocation of therapy (Mearns and Thorne, 2013). On the other side scholars such as Reeves (2015) considers the fact that flexibility fails to offer a uniform experience to the client (such as extension of time of the session) may actually harm the efficacy of the therapeutic process. It is however inimical to insist on siding with one line of though or the other because in reality most situations offer require a mix of rigidity and flexibility. As Ryan (2010) notes, the degree of mixing would depend on professional instructs of the therapist, the objective of the client and circumstances.

Interpersonal Boundary – Davies (2007) notes that interpersonal boundaries differ from structural boundaries in that they arise from the relationship between the therapist and the client whereas structural boundaries such as confidentiality and time define the terms of the relationship itself. According to Gutheil and Brosdky (2008) these are pragmatic but individualist factors. Examples are the training received by the therapist, the cultural differences between the parties and the pre-conceived notions about the role of the therapist due to that difference. Interpersonal boundaries also may be defined in the social context. In other words questions like does the therapist know the patient outside of counselling, are they related, intimate, sexual, etc. define also define interpersonal boundaries.

Intrapersonal Boundaries:

The concept of interpersonal boundaries delves into the psyches of both the patient and the counsellor. Mostly recognisably it can be explained by taking the concept of id, ego and superego which reigns of different levels of consciousness, semi consciousness and unconscious states of mind which influence our sense of right and wrong or acceptable or unacceptable from a visceral sense.

2. How boundary might be a difficult/challenging issue for you or the counsellor/therapist in general? 

Coe (2008) notes that even though the issue of boundaries is one of the most important and crucial issues in the practice of therapy, comparatively very little practical advice, guides or manuals is available in the market to tackle this issue. Coe further notes that this lack of inexperience becomes an especially difficult challenge when the professional has to deal with special needs groups such as children instead of regular adults.

Further, as Olsen (2010) remarks, the nature of counselling is such that it is conducted in private due to privacy, sensitivity and confidentiality issues. This results in very little advice, supervision or oversight being available to counsellors on the field and forces them to reply on their own gut feeling and professional experience. Some help in clearly identifying and constructively utilising boundaries is thus the need of the hour.

The psychotherapy relationship isn’t just close, it is likewise delicate. The advisor has the expert obligation to keep the customer’s prosperity as the essential focal point of the relationship. At the point when a psychotherapist dismisses this obligation, a lapse or violation of boundaries is probably going to occur. The therapist must always remember that he or she is not the friend of the client. He is a doctor and the client is the patient. When these lines blur, and the relationship crosses over to the dimension of affability, the interest of the patient may be jeopardised. Even though in retrospect it is clear to see as such, at the time, moments of boundary lapse are difficult to recognise by oneself. For e.g. It has been seen from research that poor limits, explicitly those that end up in sexual connections, are awful for clients. (Bates and Brodsky, 1989)

Ethicists like Gabbard (1998), has argued that if unchecked, the loosening of boundaries may have a kind of domino effect, and they can unwind the entire therapeutic relationship. However, the real challenge is that in reality it is difficult to maintain such rigid patient doctor boundaries. As remarked by various scholars and practitioners that it is essential that boundaries must be flexible keeping in mind patient to patient variation and tolerance. (Austin et. al. 2006). One of the greatest practical difficulties in maintaining this distance between the doctor and the patient is the fact that outside of the doctor’s chamber the counsellor has a social life. No one lives in isolation as a hermit. Thus, it is often observed that the paths of therapist and the counsellor cross in real life. It is up to the therapist to judge whether to acknowledge this encounter and engage in it, or to avoid it. For e.g. some counsellors could even leave a restaurant immediately if they saw patient over there. There rule of thumb is to consider whether there could be any benefit from the client in this out of the chamber encounter; or at least, if there could be any harm. This judgment comes with practice and experience and is one of the real intangible challenge of the profession.

Some clients are very boundary conscious

Dr. Hartmann (1997), conducted some studies and social experiments to find out the degrees of boundaries in different people. He concluded that most people have varying levels of boundary sensitivity which he described as ‘boundary thickness or thinness’. Thus, what may be acceptable or therapeutically efficacious for one client may not be so for another. As McLeod (2009) puts it, every person on this planet has a central fault that they struggle with. Michael Balint, the famous psychoanalyst calls this the “basic fault”. Basic faults can be things like pessimism, depression, despair, guilt, etc. However, some clients struggle with the basic fault of living in fear of people supposedly encroaching on their boundary. For such kinds of people, it is obviously very dangerous to go forward with the therapy session without briefing the patient in details about what the boundaries are – it might be helpful to adopt a more ‘rigid’ approach initially in such a situation – for the protection of both the patient and the professional.

The need for boundaries in high level counselling

In embedded care centres like such as hospitals, healthcare centres or doctor’s chambers, there will always be special or difficult cases where the matter may be felt should be referred a specialist or a consultant instead. In specialist counselling offices, extra care is taken to maintain clear-cut boundaries and present a strict and professional image before the client. While it is obvious that details are written in the contract before start of sessions, it not uncommon to hand over or put in view of the client leaflets and brochures explaining to the client about confidentiality and the exceptions of it whereby the client runs a risk, strict time lines or even topics of discussion. This is because in embedded care systems, usually the patient would have personally been acquainted with the care givers and know the terms of their relationship and the personal human nature of the caregiver. So, the client is in an empowered position to take a decision himself on what should be appropriate to divulge and to what extent. However, specialist cases are transferred cases where the specialist does not know the client or the full history. Thus, restricting the terms and topics of discussion becomes absolutely essential.

A few clients might be more hesitant than others, with regards to clarifying their challenges, and therapists must know that these people require a touchy methodology. By offering consolation, sympathy and validity, customers will turn out to be progressively agreeable in an advising domain. Connecting with the client is just conceivable once they are adequately loose and agreeable.

Utilizing open-ended inquiries additionally energizes a reaction from a client, and should frame a noteworthy piece of the guiding content. The connection between a therapist and client depends on a unilateral discussion. It is the instructor’s mandate to effectively tune in and delicately challenge the customer, where fitting and this is extremely difficult.

3. If you are not aware of it or don’t manage it well, what could possibly happen to the counsellor, the client and/or the counselling relationship/process? 

Having a good understanding of boundary issues that can crop up during sessions and because of the different temperaments to each client is very essential to build a successful practice as a therapist. A lack of defined boundary management practices qualified by professional flexibility to a limited degree as gauged by experience would can lead to a loss of clients and reputation to the extent of legal action in a court for malpractice or violation of privacy, losing of professional license, disrepute and personal feelings of inadequacy.

Boundary crossings vs. boundary violations

According to Glass (2003) are boundary crossings are acceptable and benign that venture a little beyond the established standards of practice already defined, in an attempt to provide the patient with a little more personalised and creative care. According to Gutheil and Gabbard (2013) these don’t result in any lasting harm to the patient but in fact, if undertaken correctly, would result in therapeutic benefit itself and may be in support of specialist and advanced treatment.

In contrast boundary violations are not at all benign, but are threatening – which the client considers as violations of their personal space. It does not result and a therapeutic benefit and will actually be detrimental to the counselling effort. The client may consider it as an unforgivable violation of their personal space warranting a termination of their arrangement with the therapist, even to the extent of suing for malpractice also. In the larger concern, this can put a permanent scar in the mind of the client regarding the counselling process and make result in him opting out of the mode of therapy itself.

Counsellor protection

The majority opinion about boundaries in therapy is that they exist to protect primarily the interest of the client. It is not surprising that this is the prevailing strain of thought, as the client is seen as the weaker on in the relation with the counsellor or therapist at a possible of power and influence. However, modern scholars such as Kent (2013) remarks, boundaries are not only established for the protection of the client but rather of the counsellors too. Bond (2015) even states that sometimes protection of counsellors is necessary in case of situations of extreme emotional outbursts from the clients which can put the counsellor even in the way of physical harm. Proctor (2014) thus argues that for management practices to be holistic and encompass the viewpoints and needs of all parties, the need to protect the therapist is as important as the protection of clients and this should be included in an ethical standard guide for clients as well.

Malpractice Litigation

Negligence in maintaining boundaries is a main source of malpractice suit. Boundary infringement take numerous structures. Sexual contribution is a repetitive issue that can cause genuine damage. (Weinberg v Board of Registration in Medicine, 2005)

Indeed, even without sensual physical contact, material boundary intersections can, in any event, obliterate or meddle with treatment, and at most, harm the patient and lead to case. For the most part, boundaries are damaged by any demonstration that changes s the shapes of the therapy relationship.

A moral infringement alone might be deficient to establish a noteworthy break of obligation or standard of consideration. An infringement of a group of morals or a disciplinary standard isn’t in itself considered a noteworthy breach of duty of care or professional duty (Fisherman v Brooks, 1986).

Likewise, with rules and guidelines, if an offended party can demonstrate that a disciplinary principle that was proposed to ensure the person in question was damaged, that might be proof of negligence. While carelessness gives the standard premise to malpractice case, other lawful speculations may likewise bolster such suits, including rupture of guardian obligation, attack of protection, ludicrous behaviour (careless infliction of extraordinary emotional trauma)

In conclusion, malpractice suit is troublesome for clients and counsellors alike. Its obtrusive viewpoints influence ameliorative treatment; continuous patient-advisor, individual, and familial connections; and expert notorieties and employments. Its deferrals, cost, passionate tolls, and inborn vulnerabilities recommend that it is in light of a legitimate concern for all gatherings to determine such debate before starting suit or as right on time as possible after case has started.

4. What could you do to make sure you’re aware of it and ways to manage it well?

It is very important that counsellors are aware of boundary demarcations and ethical standards and key understanding of boundary issues as it is one of the most common areas of complaints from clients against therapists.

Jenkins (2003) conducted a study concluding that dilemmas arising from boundary issues and client complaints can challenge the competence of the counsellor and threaten their sense of accomplishment. Theriault and Grazzola (2005) describe feeling of incompetence as moments when a counsellor loses faith in his ability and judgment so much so that his effectiveness and proficiency is reduced or diminished. These feelings invade both novice and experienced therapists.

However, the effective management of boundaries allows it to be utilised as a tool to achieve therapeutic relief and its understanding is crucial to therapy management. (Amis, et. al. 2017)

Utilising boundaries as a means to grant autonomy to the client

Saintfort (1991) suggests that one of the major causes of stress during therapy for the client is a perceived lack of control over the flow or content of the conversation. The effect of this perceived lack of control is the client distancing himself from the session, developing a sense of defensiveness and mistrust towards the therapist, and harbouring feelings of negativity that the therapist is not working for the benefit of the client. Other than making the session unproductive control issues are also morally unethical practice for the therapist. It is thus encouraged for the therapist to relinquish some amount of control to the client to promote his sense of control and empowerment that will reduce stress and bring about openness and comfort. Relinquishing control in favour of the client increases the willingness of the client to participate and increases the productivity of the session.

Behavioural experiments.

As suggested earlier, a uniform standard of boundaries cannot be applied to all persons because everyone has a different saturation point. It is thus important to find the threshold of each client to allow maximum flexibility to optimise openness but beyond which point issues of boundary violations may arise. ‘Behavioural experiments’ may be conducted by therapists similar to ones conducted by Bennett-Levy, et. al. (2004) on clients at different stages of the counselling process to find their varying thresholds. For examples, clients with issues regarding over-sensitivity to personal boundaries were made to sit close to or farther away from their therapist, an agoraphobic person was made to endure counselling in a locked room, a client afraid of the outside was made to take bus journeys to close and faraway destinations, etc.

Using time as a tool for boundary management

We have already discussed above in the session of time as boundary, how the limitations on session time can be a practice of ethical autonomy to remind the client that the session has a specific purpose which is not to be mixed with life in general and this only specific topics should be discussed in the session to achieve a definite objective or therapeutic effect. Elliot (1991) suggests the further breakup of the session time into smaller units such as turns for each person to speak which can last for maybe as short as a couple of minutes for each person. According to Elliot these small strips of time can be ventured as a ‘micro-process’ and the systematisation of the events in such a way can itself give a therapeutic benefit for the patient.

Using contracts to define boundaries

A ‘counselling contract’ or an understanding shared between the advisor and the client in which the outline of the boundaries of the therapeutic relationship is demarcated. A contract guarantees that the guiding procedure will be performed in a decent, protected and proficient way and features the obligations of the instructor towards clients, just as the duties of the client towards the advocate. A contract is likewise a straightforward reason for educated consent of the client (Dale (2003:4))

Ordinarily, an advisor will verbally exhibit the real purposes of the contract before sessions initiate to guarantee their client is content with the terms of the work that is be completed. This underlying verbal introduction empowers the clients to make inquiries and illuminate any focuses inside the agreement on which they are not clear. The advisor may then present the talked about subtleties by means of a composed record that will be marked by both the instructor and client.

The contract shouldn’t be an extensive report. It is typically a solitary page (most extreme two pages) long and contains a rundown of things that are essential for making a sheltered, secret and expert advising administration.

The use of contracts to establish boundaries is very common. A contract helps in defining the difference between the counselling session and other relationships in general and provide a sandbox framework within which the define and encompass the process of counselling. We have already discussed how contracts are essential from a legal standpoint to avoid malpractice and can be the easiest way to move the clients towards realisation of ethical autonomy especially in a specialist or consultant situation.

Fee as a boundary

Some scholars such as Herron and Sitkowski (1986) have argued that the practice of taking a fee for each session can be viewed as an instrument of defining boundaries. The thought dates back to the era of Sigmond Freud who proposed that fees themselves have an element of sacrificial nature to them. A fee ensures that the patient has some ‘skin in the game’ and signifies that he is willing to take the session seriously. Thus, to achieve this objective it has been proposed that fees charged should be variable in nature depending on the affluence of each client – what may be acceptable to one may be exorbitant or unaffordable to another. Cerney (1990) suggests that the sense of seriousness provided by fees itself has a therapeutic effect in themselves and thus the process is actually beneficial to the client and the counselling process. 

Working within the boundary of competency

One specific kind of intrapersonal concern for the therapist is the boundary of competency. As Bond (2015) remarks, it is important that therapists confine their activities and discussions in the sessions to the actual professional competencies that the therapist is trained in. Factors such as knowledge, skill and judgment would factor into this concern. If the Counsellor bites more than he can chew – for eg. ventures upon an area which should have been referred to a specialist, the therapist puts the safety of the client in danger by mismanaging the afflict of the client actually advising him of the wrong thing. Professionally, this is especially of concern as it would make the therapist liable to the extent of malpractice or predatory practice and may put the credibility of the whole organisation or association at risk.

BIBLIOGRAPHY

Amis, Kirsten. Boundaries, Power and Ethical Responsibility in Counselling and Psychotherapy, SAGE Publications, 2017.

Austin, W., Bergum, V., Nuttgens, S., & Peternelj-Taylor, C. (2006). A re-visioning of boundaries in professional helping relationships: Exploring other metaphors. Ethics and Behavior, 16, 77-94.

Bates, C. M., & Brodsky, A. M. (1989). Sex in the therapy hour: A case of professional incest. New York: Guilford.

Bond, T. (2015). Standards and ethics for counselling in action (4th ed). London: SAGE Publications.

Cerney, M.S. (1990) Reduced fee or free psychotherapy: uncovering the hidden issues, Psychotherapy Patient , 7, 53– 65.

Coe, J. (2008). Being clear about boundaries. The Independent Practitioner, Spring, 9-12.

Davies, M. (2007). Boundaries in counselling and psychotherapy. Twickenham: Athena Press.

Elliott, R. (1991) Five dimensions of therapy process, Psychotherapy Research , 1, 92– 103.

Gutheil, T. and Gabbard, G. (1998) Misuses and misunderstandings of boundary theory in clinical and regulatory settings, American Journal of Psychiatry , 155, 409– 14.

Gutheil, T.G. and Brodsky, A. (2008). Preventing boundary violations in clinical practice. New York: Guilford Press.

Hartmann, E. (1997) The concept of boundaries in counselling and psychotherapy, British Journal of Guidance and Counselling.

Herron, W.G. and Sitkowski, S. (1986) Effect of fees on psychotherapy: what is the evidence? Professional Psychology: Research and Practice.

Jacobs, M. (2010). Psychodynamic counselling in action (4th ed). London: SAGE Publications.

Jenkins, P. (2003). Therapist responses to requests for disclosure of therapeutic records: an introductory study. Counselling and Psychotherapy Research 3 (3) 232- 238.

McLeod, John, and Julia Mcleod. Counselling Skills : A Practical Guide For Counsellors And Helping Professionals, McGraw-Hill Education, 2011. ProQuest Ebook Central, https://ebookcentral.proquest.com/lib/monash/detail.action?docID=798251.

McLeod, John. Counsellor’s Workbook : Developing a Personal Approach, McGraw-Hill Education, 2009.

Mearns, D. & Thorne, B. (2013). Person-centred counselling in action (4th ed). London: SAGE Publications.

Mearns, D. & Thorne, B. (2013). Person-centred counselling in action (4th ed). London: SAGE Publications.

Olsen, C. (2010). Ethics: The fundamental dimension of counselling psychology, In. M. Milton (Eds.), Therapy and Beyond Counselling Psychology Contributions to Therapeutic and Social Issues. Chichester: John Wiley & Sons Ltd.

Prever, M. (2010). Counselling and supporting children and young people: A person- centred approach. London: SAGE Publications Ltd.

Proctor, G. (2014). Values and ethics in counselling and psychotherapy. London: SAGE Publications.

Reeves, A. (2015). Working with risk in counselling and psychotherapy. London: SAGE Publications.

Smith, V., Collard, P., Nicholson, P. & Bayne, R. (2012). Key concepts in counselling and psychotherapy: A critical A-Z guide to theory. Maidenhead: Open University Press

Webb, S. B. (1997). Training for maintaining appropriate boundaries in counselling. British Journal of Guidance & Counselling, 25 (2) 175-188.

Zur. O. (2010). Boundaries in psychotherapy: Ethical and clinical explorations. Washington: American Psychological Association.

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