What’s the Limit? Maintaining and Understanding Boundaries in Psychotherapy

What’s the Limit? Maintaining and Understanding Boundaries in Psychotherapy

by F. Diane Barth
Psychotherapist F. Diane Barth takes a critical look at boundaries, both personal and therapeutic, as an essential ingredient to healthy relationships.

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Anita* was an experienced therapist who consulted with me about a client who consistently arrived late for sessions and refused to leave when his time was up. “I don’t usually have difficulties setting limits with clients,” she told me. “But I’ve tried everything with him, and nothing is working. In our last session, I told him that I was going to have to start charging him for the extra time. He just said, ‘okay.’ And he still didn’t leave.”

We all know that boundaries are extremely important in any psychotherapy relationship, but they are not always easy to define or to maintain. They’re also not always easy to identify.

Defining Boundaries in Psychotherapy

What is a boundary, in fact? I like what a group of physicians has said: “A boundary may be defined as the ‘edge of appropriate professional behavior, transgression of which involves the therapist stepping out of the clinical role or breaching the clinical role.” I also like what Gary and Joy Lundberg write in their book I Don’t Have to Make Everything All Better: In daily interactions with others, boundaries “are statements of what you will or won’t do, what you like and don’t like, how far you will or won’t go, how close someone can get to you or how close you will get to another person…they are your value system in action.”

boundaries are your value system in action.
These definitions apply to both therapists and clients, yet other factors also play important roles. For instance, how we set and maintain boundaries reflects not only our personal and professional values, but also respect for our clients and their boundary needs. Furthermore, boundaries reflect something important about our respect for ourselves.

In fact, this was one of the problems that Anita was struggling with. She wanted her client to respect her, and his behavior around the scheduling of sessions felt to her as though he was disrespecting her. She was having difficulties finding a way to maintain her boundaries, her self-respect, and his respect for her

Boundaries also reflect important information about a relationship between two people, whether the relationship is a personal one or a professional one. Boundaries can be ephemeral and often confusing, in part because they embody the often-unclear lines of connection and separation in a relationship. In psychotherapy, a significant amount of work is done within the relationship between therapist and client. Individuals have an opportunity to work on their relational difficulties. Boundaries, whether they have to do with office rules, payment, scheduling, electronic communication or a therapist’s personal life can become the medium for exploring, understanding and working on issues that emerge in a client’s life with others.

Freud sometimes made house calls to do therapy with patients and often interacted with them socially
Freud sometimes made house calls to do therapy with patients and often interacted with them socially; such behavior is seen as boundary-crossing today. Yet the Internet has created dramatic changes in traditional boundaries. While some therapists refuse to communicate anything other than appointment times in electronic communication, many others conduct psychotherapy online and by telephone, even exploring the benefits of doing online psychotherapy with clients in their beds.

Boundaries Have Meaning

While both a therapist’s and a client’s boundaries need to be clarified and respected, a therapist’s curiosity about any boundary question that comes up for a client can be an important tool in the therapeutic process. In their Psychotherapy.net essay on doing therapy with clients in bed, Giré and Burgo tell us, “Therapists need to pay ongoing attention to boundaries and transference issues, of course; but if we’re mindful, we can also focus on the purpose and meaning of any boundary transgressions.”

For instance, over the years many clients have asked to hug me. Physical contact between therapist and client has long been an area of controversy, and, of course, a question of boundaries. Not only is it significant in terms of potential sexual coercion and assault, but it also raises important questions about both the therapist’s and the client’s comfort with non-sexual physical touch.

“I think I want to be touched,” he said. “It’s not that. But I think I’m afraid that I’m going to be rejected”
I am not a particularly physically demonstrative person and do not always find that kind of contact comfortable. Because I know that to cross my own boundary in those cases would be harmful to the therapeutic work, I have found ways to tactfully and gently refuse the request, often explaining that it is one of my own boundaries that I am careful not to override. Such an explanation often leads to a client’s apologies, and sometimes to a painful discussion of their fear that they are not only unlovable, but also so repulsive that no one would ever want to touch them.

In one instance, with a client who seemed to go out of his way to make himself as unattractive as possible, I asked if it was possible that he actually did not want to be touched. He seemed taken aback by my question, but then he began to wonder out loud. “I think I want to be touched,” he said. “It’s not that. But I think I’m afraid that I’m going to be rejected; so, I sort of set it up that I’m so disgusting that I know that it’s going to happen.” I replied that that made sense to me. I said that I thought he was trying to take control of something that he feared. “It’s better if it doesn’t come as a surprise,” he agreed. “Somehow it doesn’t hurt so much that way.” That client and I spent many years working together, and the process of trying to understand what might be going on with each of us, and within our relationship, helped us to understand some extremely important, complex and subtle aspects of many of his other relationships.

I have learned to share this information about myself with clients in a way that often leads to our finding other ways that they can feel soothed and comforted by me and close to me without touching. In many instances, the process of talking about our different needs has also opened areas in which they struggle with similar issues in their personal lives.

Role Modeling and Boundaries

How we look at and work with boundaries can also serve as a role model for clients, whether it is in the service of protecting their own or respecting the boundaries of others.

For example, there are times when I am comfortable hugging a client. I am not always sure exactly what makes me feel comfortable with the contact, but I have learned to respect my internal communications – the same way that I encourage clients to pay attention to their own wishes not to always do what someone else wants them to do.

how we look at and work with boundaries can also serve as a role model for clients
Not too long ago, two separate clients who were struggling with painful realities in their lives brought up the issue of hugs. Both had been in therapy with me for some time. One shyly asked if it would be okay if she hugged me. The other told me that I was not to hug her and was not even to look at her sympathetically. In both cases, I agreed to the request. I also asked if we could talk about what their requests were about – what they were hoping for and what they were hoping to avoid. And finally, I asked if they could talk to me about their responses to my response.

I was willing to accept and respond to what they needed, but I also maintained my curiosity about what was going on beneath the surface – what either the hug or the restrictions meant in terms of the larger picture of their lives. In part I was able to provide this kind of approach because of my awareness and respect for my clients’ boundaries and for my own.

Exploring, Understanding and Maintaining Boundaries

To return to Anita: as we attempted to understand her client’s refusal to accept her boundaries, we began to see that the dynamic between them was complicated not only by each of their personal dynamics, but also by social and cultural factors. “I feel like he’s being sadistic,” she said. “By refusing to accept limits that I set, he’s setting up a ‘MeToo’ situation. He’s being an aggressive male and putting me in the position of being a compliant victim. And I refuse to be in that position.”

by refusing to accept limits that I set, he’s setting up a ‘MeToo’ situation
In his book Attachment in Psychotherapy, David Wallin explores some of the links between a client’s behavior, a clinician’s reactions, and unarticulated, often unknown attachment issues. Because I thought that her client’s behavior might be related to some unspoken, maybe inaccessible relational dynamics, I asked Anita if she could imagine talking about her dilemma with her client. At first she doubted that it would be useful. “Why would I make myself vulnerable in that way?” she asked.

I told her that I thought by sharing some of her dilemma, she might also be putting into words some feelings and relational issues that her client was enacting with her. I said that I thought he might even be relieved that she was able to articulate something that he felt but could not talk or even think about. I said that I also was hoping that by putting her dilemma into words, she would be altering the power struggle between them. She decided that there was really nothing to lose. “I’ve tried everything else I can come up with,” she said.

When he arrived late for his next appointment, Anita brought up the combination of his late arrival and refusal to leave on time. She said, “I’ve been thinking about what’s going on here, and, although I’m not sure you’re going to like them, I’d like to share my thoughts with you. Would that be okay with you?” He nodded, but she said he looked uncomfortable. She then told him what she had told me.

The client seemed deeply moved by her comments. After sitting quietly for a few minutes, he said, “
Wow. I’ve been feeling resentful that you have all the power in this relationship. And you’ve been feeling assaulted by me
Wow. I’ve been feeling resentful that you have all the power in this relationship. And you’ve been feeling assaulted by me. I think you might have just solved a puzzle I’ve been unable to solve for a long time. I haven’t even had a way to think about until now.”

He went on to explain that he often seemed to get into similar kinds of power struggles at work and in his personal relationships with women. “I’ve always felt like I was the one who was being forced to do things against my will,” he said slowly. “But maybe other people feel like you do—like I’m the one who’s pushing them around. That’s really weird. But it kind of explains why people get so mad at me when I’m feeling like I’m just trying to protect myself.”

This insight did not change the power struggle completely, nor did it magically shift the client’s difficulties with other people. In fact, they had to repeatedly revisit the same dynamics both in their relationship and as they discussed his interactions with other people in his life. The client began arriving closer to the proper time for his appointment, but he continued to have difficulty leaving. But now they were able to look at some of the reasons for both behaviors, not as a power struggle, but as an attempt to control both the connection to and the separation from his therapist. Exploration revealed that he found separation extremely painful, but that he was embarrassed to admit how much it hurt him to have to leave—or to be left by—someone he felt close to.

Theirs was a long and productive therapeutic relationship, and the early struggle over the end of sessions became an experience that the two of them referred to over and over again as a template for understanding what was going on when the client began testing boundaries and acting (and feeling) like a rebellious teenager.

Conclusion

Boundaries are crucial to any relationship, including a relationship between a therapist and a client. Yet these often unclear, ephemeral lines between connection and separation and self and other can become the means by which we can understand a client’s self and relational struggles. A clear and consistent frame protects the work of therapy. But that work can be greatly enhanced through the process of exploring, understanding and reflecting on those boundaries.

*names and identifying information changed to protect privacy  

© 2019 Psychotherapy.net LLC
Bios
F. Diane Barth F. Diane Barth, LCSW, is a psychotherapist and psychoanalyst in private practice in New York City, where she also runs private study groups. She has taught and supervised at numerous psychotherapy training institutes in New York and regularly speaks to groups about a wide range of mental health issues. Her articles have appeared in professional journals and as chapters in professional books, and she has edited and co-edited several special issues of professional journals. She has a popular blog on Psychology Today and is the author of I Know How You Feel: The Joy and Heartbreak of Friendship in Women’s Lives (Houghton Mifflin Harcourt, February, 2018); An Integrative Approach to Clinical Social Work,(Springer, 2015); and Daydreaming: Unlock the Creative Power of Your Mind (Penguin, 1998).