PhD/PsyD Boundaries and behavior

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erg923

Regional Clinical Officer, Centene Corporation
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I am seeing a patient in primary care for brief therapy. I am being tempted to share personal details and anecdotes about my life that I am not normally tempted to do with other patients. Nothing wild or inappropriate in terms of the content, just certain interests and interesting facts/stories that I know she might like or get a kick out of. Yes, the patient is female. She is in her 50s and I don't think this is ANY way sexual, but I still wonder why this is?

She is one of the few patient who has ever really engaged/asked me about the few personal effects I keep in my office (hence my temptation to elaborate on them), and I do have quite a bit of sympathy for her and her story and situation-perhaps more than the typical patient I see. This is also a bit strange too though, because there is nothing particularly unusually or unique about her history and presentation. Before anyone asks, no, she does not look like my mother or remind me of her in any way.

Maybe some part of me thinks this will further the therapy, or maybe its just selfish indulgence? I dont know.

I'm not keen on the psychoanalytic idea of the rigid "therapeutic frame", but do have to wonder why this is happening with this patient, and if what I am tempted to do is perhaps more "professionally inappropriate" than I may be seeing here in the moment?

Thoughts?
 
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I am seeing a patient in primary care for brief therapy. I am being tempted to share personal details and anecdotes about myself/my life that I am not normally tempted to do with other patients. Nothing wild or inappropriate in terms of the content, just certain interests and interesting facts/stories that I know she might like or get a kick out of. Yes, the patient is female. She is in her 50s and I don't think this is ANY way sexual, but I still wonder why this is?

She is one of the few patient who has ever really engaged/asked me about the few personal effects I keep in my office (hence my temptation to elaborate on them), and I do have quite a bit of sympathy for her and her story and situation-perhaps more than the typical patient I see. This is also a bit strange too though, because there is nothing particularly unusually or unique about her history and presentation. Before anyone asks, no, she does not look like my mother or remind me of her in any way.

Maybe some part of me thinks this will further the therapy, or maybe its just selfish indulgence? I dont know.

I'm not keen on the psychoanalytic idea of the rigid "therapeutic frame", but do have to wonder why this is happening with this patient, and if what I am tempted to do is perhaps more "professionally inappropriate" than I may be seeing here in the moment?

Thoughts?

I think that sharing personal details or experiences can be helpful and humanizing in the therapeutic relationship. Of course, we've all been cautioned by supervisors (and, perhaps by various schools of psychotherapeutic instruction) to take care to always keep a professional/appropriate frame but I think that the working therapeutic relationship (especially in the early stages) needs to be 'calibrated' (for lack of a better term) and there are things that the therapist can do/say to try to adjust things between himself and the client into a 'useful zone' that is friendly (but not too intimate), that is focused (but not cold/analytical/distant), and that facilitates the therapeutic work. For me, being 'human' to my clients (veterans, these days) means not being too 'stuck up' or distant so I have to take care to project appropriate professionalism, but also let my human side show and be as informal with them as they seem comfortable with me being. I always carefully monitor their responses to my 'adjustments' and try to adjust my own approach based on their response (of course, routinely--especially early in the therapy--asking them how they thought the session went and what worked for them vs. what may not have worked for them).

Sometimes I find myself using humor, or informality, or anecdotes when the therapeutic process, for whatever reason, feels too 'stiff' or formal or when I'm trying to set the client at ease and (to my mind at least) help them feel comfortable. Of course (as you mention in your post), there's the whole male/female dynamic and/or sexual tension thing and we always have to take care not to elicit or deepen that kind of dynamic in therapy.

Thinking about this from another angle, doing therapy and always being 'on' and 'professional' with our clients (and for most of our work week) is extremely taxing emotionally and intellectually...you may just like (not necessarily in a sexual way) the client and you may feel comfortable stepping out of the 'therapist' role in your interactions with her.

Then again, as therapists (and human beings) our internal responses to our clients can serve as important 'instruments' in therapy, perhaps indicating what their behavior is 'pulling' from us...maybe she really wants to be liked by you (or all authority figures in her life); maybe she's particularly lonely/vulnerable right now and this can be explored in an appropriately helpful therapeutic fashion. Maybe you can help her clarify what she wants from other people (especially in the form of interpersonal intimacy) and explore ways of her getting those needs met in her life outside of therapy.

In any case, I applaud your introspection on this topic and willingness to foster discussion.
 
Then again, as therapists (and human beings) our internal responses to our clients can serve as important 'instruments' in therapy, perhaps indicating what their behavior is 'pulling' from us...maybe she really wants to be liked by you (or all authority figures in her life); maybe she's particularly lonely/vulnerable right now and this can be explored in an appropriately helpful therapeutic fashion. Maybe you can help her clarify what she wants from other people (especially in the form of interpersonal intimacy) and explore ways of her getting those needs met in her life outside of therapy.

Beautifully stated.
 
...primary care for brief therapy....
She is one of the few patient who has ever really engaged/asked me about the few personal effects I keep in my office...

Guess: patients often see you for specific need. This patient has some kind of natural ease and also expresses interest in parts of you significant enough to merit putting in the room, and not treating you as an object that is there to serve their needs but as another person with a life outside of therapy with her (which surprisingly few patients realize, it often seems to me). A positive reaction followed by a desire to perform a behavior to increase the frequency of the patient's behavior makes sense to me.
 
Has a previous therapist worked with this client? If so, I might listen to how she described the previous therapist. For all you know, they spend 50 min a week chatting it up like BFFs. Her frame of reference might be pulling at you to recreate what she thinks therapy is supposed to be.
 
I think it partially depends on the specific theoretical stance and chief complaint. CBT for mdd or insomnia, probably not. DBT for borderline, hell no. FAP for a disorder of self, probably. Freudian psychoanalaysis, no. Relational psychoanalysis, maybe.

As I have revealed before, I go to psychoanalysis not for an axis I thing but as a means to learn more about my own defense structure and how that plays out in my own life. Used to go to a big name, don't anymore. That person revealed a shared interest, but the revelation was to indicate that we could communicate through metaphors in that interest. Helped communication, didn't change how I felt about him.
 
I am seeing a patient in primary care for brief therapy. I am being tempted to share personal details and anecdotes about my life that I am not normally tempted to do with other patients. Nothing wild or inappropriate in terms of the content, just certain interests and interesting facts/stories that I know she might like or get a kick out of. Yes, the patient is female. She is in her 50s and I don't think this is ANY way sexual, but I still wonder why this is?

She is one of the few patient who has ever really engaged/asked me about the few personal effects I keep in my office (hence my temptation to elaborate on them), and I do have quite a bit of sympathy for her and her story and situation-perhaps more than the typical patient I see. This is also a bit strange too though, because there is nothing particularly unusually or unique about her history and presentation. Before anyone asks, no, she does not look like my mother or remind me of her in any way.

Maybe some part of me thinks this will further the therapy, or maybe its just Selfish indulgence? I dont know.

I'm not keen on the psychoanalytic idea of the rigid "therapeutic frame", but do have to wonder why this is happening with this patient, and if what I am tempted to do is perhaps more "professionally inappropriate" than I may be seeing here in the moment?

Thoughts?

When it comes to self-disclosure, I personally would err on the side of caution, especially in the earlier stages of treatment. Without knowing why this particular patient has sought treatment, it's hard to even begin to predict how she may respond to learning personal information about her therapist.

I wonder why this patient is interested in you when therapy is supposed to be the one hour (or however long) about her. Is there a particular point during the session she asks you questions? At the beginning, at the end, when she wants to deflect attention away from herself? While self-disclosure can certainly enhance some, not all, therapeutic relationships, they should be made after careful consideration and directly relate to the patient's treatment.

The temptation to disclose personal information because there are "certain interests and interesting facts/stories that I know she might like or get a kick out of," does not sound therapeutic IMHO. How does this benefit her treatment? It shifts attention away from the patient and focuses on you. What you share, how long it takes you share it, and how often you share can have a substantial impact on the therapeutic relationship and her progress.

When boundaries becomes blurred, it can become a slippery slope. Until you can clearly identify what about this patient tempts you to deviate from your typical routine, I would hold off on sharing personal information that isn't clinically relevant.

I also want to say that I'm impressed by the level of insight and courage to share this story.
 
Maybe some part of me thinks this will further the therapy, or maybe its just selfish indulgence? I dont know.

And maybe it will be totally irrelevant to the process or outcome of therapy- a simple piece of typical human interaction where members of our species share information about each other solely for the sake of knowing more or having others know more. As long as you are skillful in controlling the relevant stimuli, the irrelevant ones are unlikely to play any significant role.
 
I think it will be harmless. But, I don't think I'm going to indulge any of it because it is in fact the case that a large part of her problem is a focus on others and other's behavior to the point of being detrimental to insight into her own behavior.
 
I think it will be harmless. But, I don't think I'm going to indulge any of it because it is in fact the case that a large part of her problem is a focus on others and other's behavior to the point of being detrimental to insight into her own behavior.
I think you probably hit the nail on the head right there. 🙂 Good job using your own countertransfernce to guide your understanding of the patients dynamics. Sometimes that old analytic stance of countertransfernce being bad and always tied to our mothers or sex or both can get in the way of a more useful comceptualization.
 
I think it will be harmless. But, I don't think I'm going to indulge any of it because it is in fact the case that a large part of her problem is a focus on others and other's behavior to the point of being detrimental to insight into her own behavior.

I think I err on the side of "more willing to self disclose" than the average psychologist; I have often found that very small and targeted self disclosures enhance the therapeutic relationship, build rapport, and put clients at ease (think: small talk you would make with almost any stranger that alludes to shared interests or experiences). That being said, the way you have described the situation, although I would agree with you that it's likely harmless, I'm not sure I see the therapeutic benefit, and might err on the side of caution and refrain from indulging.
 
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