Boundaries

I think the opinions on this issue are so strong none of us will really agree. It's hard for me to articulate why I think boundary issues are so important and why even more so in the field of therapy but I will try. In essence, some of the minor things like a pat on the shoulder, an email or text here or there, etc..., are really not a big deal on their own. What is a big deal is how these gestures are interpreted by the patient. We may like to think a T knows their us so, or that we even know ourselves, but sometimes we don't. Many people find themselves feeling emotions they didn't know they had or doing things they never thought they'd do. Some of these benign gestures outside the confines of an office can elicit feelings of closeness that are out of proportion to the real relationship, and that is not healthy at all. In fact, that is less healthy than working with a T who wouldn't let these things happen in the first place, IMHO.

Your T should absolutely be able to share some information and minor disclosures so long as it is relavent, why not? They do care and usually intend to do their best to be there for and help us, but it must be within healthy limits. Just like we wouldn't meet our pcp in a coffee shop to discuss test results, we shouldn't expect the same from our psychiatrist or therapist just because the profession is centered around mental health and not physical. A T's job is tough because they deal with emotional states, and things can get tricky. T's need to protect their own mental health too. The 50 minutes we are in their office is about us, but outside the session it is not all about us, it's about them too. And a good T will practice these boundaries while still retaining their humanity. If not, we should find someone who can.

My shrink is an MD as well and he does a good job with this, but a while back I was met with one boundary of his that really irked me at the time. I have test anxiety and didn't want to repeat my dismal performance on the GRE's to get into grad school, so I asked him if he could write a letter for me confirming my ADD diagnosis (which he made) which might exempt me or at least offer me accommodations for the exam. He initially said sure- and if came in for a session to help him write it he wouldn't charge the office's fee (about $75). When I went in, he changed his mind and said no. He said if I got a neuropsyche exam done that supported my ADD diagnosis (made by him), he would write a letter but not otherwise. He said my ADD issues hadn't really been part of our work together so he didn't feel comfortable. I was pretty hurt and took it so personally, which he could tell. So he explained again that he knew he made the diagnosis, but from what he's seen of me, I'm so high functioning that I don't seem to need the accommodations. I was still annoyed when I left, but after a while I did get it. I think I was the first patient to ask for such a letter pertaining to entrance exams and initially wanted to help me out since I was moving forward and making real progress. But when he gave it more thought, he had to think about it and came to the conclusion that one letter to me as a favor could open the door for many more favors I might ask of him. And that may have ended up being the case, how are he or I really to know. We both need these boundaries. That's not a very personal example, but its similar, I hope...

I forgot to answer the second part of your question Archipelago. I agree with you that boundaries (and therapy in general) is best individualized to the patient. I’m not saying this is the case with you-but enmeshment and co-dependency can be confused with flexibility, maybe for those of us who didn’t have appropriate models when growing up. Changing who you are for another is not always a sign on flexiblility but often a symptom of not having a healthy sense of self. It’s often used to avoid abandonment, avoid the possibility of others being angry at you, or fears of being rejected. It can be used in a manipulative way too-‘I did so and so for you, and this is how you treat me now?’, or to sustain an idealized image of yourself ‘see all the sacrifices I make for others’…just a take from someone who grew up in a very toxic environment.

Again, from the psychological sense, my T models self-acceptance and worthiness by reinforcing his own boundaries, even if that means I’ll be angry at him, including saying no. This is something that has had a huge impact on me, my being, my sense of self. It is the experience that I am not defined by how others treat me. This modeling has allowed me to internalize this message, and it has been life changing.

I think generally speaking personal boundaries and idea of people as separate individuals are more of a modern thing and also more of a Western thing. Not to say others don't have it or never had it, but the emphasis on it and recognition of it and certainly so much talk about it...

I agree that there are a lot of views that probably can't be reconciled. Still there can be understanding among differences. I agree with you, and have said so, maybe more in another thread, that I don't believe the client should ever lose sight of the fact that the therapeutic relationship is not reciprocal. That doesn't mean there isn't mutuality or even affection. It just means that it is one way, not two way. And that makes the relationship safe so there is no harm and real work can be done.

In your specific case, I am sorry you experienced hurt. I'm not sure I would interpret it as about a boundary issue (favors). Rather I see it as a doctor's ethics, perhaps being overly cautious, but they sorta have to be that way. The reason I think so, without knowing your story fully, is that when training in assessment, we discussed the diagnosis and accommodations for learning disabilities and ADD. Some sort of testing is usually required to confirm the diagnosis so I don't think a shrink's letter would do it all by itself. He probably didn't realize that fully or became uncomfortable with having that responsibility, knowing it could be scrutinized. Just a guess, but offering a slightly different way to see it.

Autumn, thanks for your thoughtful response. I agree with you more than I disagree. What I thought though was how therapist do change from client to client to match them. This is not a sign of lack of sense of self, but quite the opposite. So it can be flexibility though it can also be what you say as well. And with clients often is.

Rosondo, what you say is an important point. We have a very individualistic culture. Other cultures, whether in the past or just different, are more collectivist, or don't stress self-sufficiency in the way that we do. They accept interdependence as the reality of human existence. As a Buddhist and also as someone who does an "intersubjective" type of therapy, I am more inclined toward that alternative.