Therapy with more "natural" boundaries?

[ClinPsycMasters]

It is no secret that "helping" has become progressively more and more professionalized. This is a common trend of course. Professionalization comes with a set of boundaries. In helping professions, these boundaries define the profession and its various subdivisions, (e.g. social work, clinical psychology, psychiatry) the roles, legal issues, and ethics. They also define and shape the therapeutic relationship.

I was reading a book about an accomplished mental health professional who, one cold night, seriously considered giving a ride to a poor family--whom he met with regularly for therapy. The details of the case are beside the point but suffice to say that no other government funded and social programs were available, and that such assistance would have meant a lot to that family. Yet, he could not violate doctor-patient boundaries.

We are not permitted to help our clients like that, even though it feels like such a natural thing to do. What do I mean by "natural"? I mean that a good neighbor, a friend, or simply a compassionate human being who was aware of the family's difficulties, would do so. And they wouldn't demand any money for it either.

Sometimes seemingly small acts of kindness and helping behavior can make a bigger difference to a person's well-being, than can particular cognitive techniques or psychodynamic interpretations.

Sometimes reality is harsh. The patient is not distorting reality but seeing it crystal clear. Many times the person is doing the best they can; hence, trying to reframe the issues or providing new psychological tools are not that helpful. I'm not speaking of a wealthy client who is dealing with a narcissistic injury. I'm speaking of clients with few resources, those who do not know if they would be able to put food on the table tomorrow, wondering if their body can take the beating of two very demanding physical jobs, and fearing an uncertain future for their little kids.

I am not suggesting removing all boundaries. That's ludicrous. We all have boundaries and we need boundaries. A therapist who takes on the role of a savior is not going to have enough resources to maintain his own sanity and peace of mind. A select number can and do, but most get burned out pretty fast. What I am suggesting is more flexible boundaries, the idea that you do not have to do X but that you can if you so choose.

We rationalize why we need these boundaries. We categorize: This is my area, and that is somebody else's. Or we say that such boundaries are in fact conducive to effective therapy. We can help, we proclaim, but only in this specific way, at this time and in this place. We could help in a different way but that's not part of our job description.

However, all these boundaries that we are supposed to respect do create this inauthenticity about the relationship. We are not specializing in car repair. We are humans trying to help other humans who are suffering. Something like giving someone a ride on your way home is a grand gesture. It makes you human. You're not a professional doing a job. The client may assume that the sympathy in the session is part of your job description. Same with all that empowering stuff. We are doing this to achieve a specific results. It's all technique, they may assume. But to give the person a ride when it's freezing and she has have a few little ones with her? Well, that's something else!

Please note that I am not suggesting that anyone should violate their professional boundaries as there are legal consequences. I made this post to engage others in a discussion about what it means to help others in today's society and how we can do it better. The change can be inspired from below but it can only take effect from above; in other words, the rules need to change.

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[PorkDumplings]

I dunno, it seems kind of like a slippery slope.

 

[SingingCow]

You articulated my thoughts very well. The rigid adherence to these "boundaries" has once made me wonder if I should leave the clinical profession and just be a better neighbor, friend, family instead.

It can be a slippery slope, thus the rules and regulations. It'd be sad, however, if what motivated us to do or not do something was based on our fear that we might be sued. What if the focus was on whether and why this would benefit the client's psychological well-being and the therapeutic process?

It is no secret that "helping" has become progressively more and more professionalized. This is a common trend of course. Professionalization comes with a set of boundaries. In helping professions, these boundaries define the profession and its various subdivisions, (e.g. social work, clinical psychology, psychiatry) the roles, legal issues, and ethics. They also define and shape the therapeutic relationship.

I was reading a book about an accomplished mental health professional who, one cold night, seriously considered giving a ride to a poor family--whom he met with regularly for therapy. The details of the case are beside the point but suffice to say that no other government funded and social programs were available, and that such assistance would have meant a lot to that family. Yet, he could not violate doctor-patient boundaries.

We are not permitted to help our clients like that, even though it feels like such a natural thing to do. What do I mean by "natural"? I mean that a good neighbor, a friend, or simply a compassionate human being who was aware of the family's difficulties, would do so. And they wouldn't demand any money for it either.

Sometimes seemingly small acts of kindness and helping behavior can make a bigger difference to a person's well-being, than can particular cognitive techniques or psychodynamic interpretations.

Sometimes reality is harsh. The patient is not distorting reality but seeing it crystal clear. Many times the person is doing the best they can; hence, trying to reframe the issues or providing new psychological tools are not that helpful. I'm not speaking of a wealthy client who is dealing with a narcissistic injury. I'm speaking of clients with few resources, those who do not know if they would be able to put food on the table tomorrow, wondering if their body can take the beating of two very demanding physical jobs, and fearing an uncertain future for their little kids.

I am not suggesting removing all boundaries. That's ludicrous. We all have boundaries and we need boundaries. A therapist who takes on the role of a savior is not going to have enough resources to maintain his own sanity and peace of mind. A select number can and do, but most get burned out pretty fast. What I am suggesting is more flexible boundaries, the idea that you do not have to do X but that you can if you so choose.

We rationalize why we need these boundaries. We categorize: This is my area, and that is somebody else's. Or we say that such boundaries are in fact conducive to effective therapy. We can help, we proclaim, but only in this specific way, at this time and in this place. We could help in a different way but that's not part of our job description.

However, all these boundaries that we are supposed to respect do create this inauthenticity about the relationship. We are not specializing in car repair. We are humans trying to help other humans who are suffering. Something like giving someone a ride on your way home is a grand gesture. It makes you human. You're not a professional doing a job. The client may assume that the sympathy in the session is part of your job description. Same with all that empowering stuff. We are doing this to achieve a specific results. It's all technique, they may assume. But the person a ride when it's freezing and she has have a few little ones with her? Well, that's something else!

Please note that I am not suggesting that anyone should violate their professional boundaries as there are legal consequences. I made this post to engage others in a discussion about what it means to help others in today's society and how we can do it better. The change can be inspired from below but it can only take effect from above; in other words, the rules need to change.

 

[jdawgg]

I think boundaries protect the sanctity of the therapist-client relationship. The power differential inherent in the therapist-client relationship cannot be understated. Confusing the client regarding our role by acting as a friend is not doing our client any favors and it inhibits our own ability to be objective.

This is not to say that boundary crossings (walking with a client with agoraphobia, lunch with a client with anorexia) cannot be beneficial, but giving a client a ride in your car can be pretty problematic in my view. It could be justified if the client was in danger because of, say, a snowstorm and the therapist (1) behaves professionally during the ride, deferring clinical issues to the next meeting; (2) carefully records the situation and context when next in the office; and (3) explores or debriefs the patient on the experience at the next session, also recording that.

 

[ltj999]

It is quite a dilemma. Part of being a good psychologist is having great empathy for others. But then comes the paradox of switching it off at times.

I think this is just part of the very strange nature of the therapeutic relationship. The strange duality of creating rapport with others regardless of their ideology, religion, etc; potentially ideas that we may be against is always a constant issue.

But could giving a ride and slightly changing the dynamic of the relationship be a good thing? Are we just resistant to such changes because we have been conditioned by our education that such contact is negative? Perhaps it could result in great positive change as suggested above.

 

[Therapist4Chnge]

I see where you are coming from, but I just can't start down that slippery slope. I probably am more rigid with my beliefs than most clinicians, but I've found that any blurring of boundaries has the opportunity to do more harm than good.

A few weeks ago I had a patient ask me for $30. S/he was in a tight spot and it would have helped them because they had no job, no housing (staying with friends), and few resources to change anything. 99.9% of people would say, "Even so, I can't lend them money."' How about if they needed cab fare ($15?)? A bit harder. How about $10 so they could get themselves food for the next few days? How about $5 for lunch? How about $3 for coffee at the cafe across the street? What is okay, and what is not? Does it matter if they can pay you back? What happens if the person can pay you back, but they forgot their wallet that day? How about if it is a child and you know they aren't eating enough at home?

 

[krisrox]

Hmmm. Very interesting thread. I'm the type of person who would never hesitate to give a stranger a ride, but this case certainly makes me think a bit. T4C, when you put it in monetary terms, it doesn't seem okay. Hmm...

What if you were to refer your clients to other places that could help them. Maybe give them a number to register for public aid rides, or a local food pantry. What about giving the client other information rather than what they need. It's the "teach a man to fish" philosophy.

 

[KillerDiller]

We are not permitted to help our clients like that, even though it feels like such a natural thing to do. What do I mean by "natural"? I mean that a good neighbor, a friend, or simply a compassionate human being who was aware of the family's difficulties, would do so. And they wouldn't demand any money for it either.

Aside from issues that may come up in the professional relationship, I think problems also arise because psychologists already have neighbors, friends, and families of their own. They walk by homeless people on the street and feel the same pulls and demands that others feel. Essentially, being a psychologist does not make you immune to all the other demands of life. I believe that although we can care about the welfare of lots and lots of people, we are limited in our ability to care for many people at the same time. I think that meeting needs of clients outside of session opens the door to feeling very overburdened. Confining the compassion to inside the session allows us to account for the toll the work takes on us more efficiently.

I know you understand this, I'm not suggesting that you don't. I also hear your point about changing the boundaries so that we can provide these services if we so choose. But I have to wonder how many of us after hearing can would really take it as should.

 

[ClinPsycMasters]

I see where you are coming from, but I just can't start down that slippery slope. I probably am more rigid with my beliefs than most clinicians, but I've found that any blurring of boundaries has the opportunity to do more harm than good.

A few weeks ago I had a patient ask me for $30. S/he was in a tight spot and it would have helped them because they had no job, no housing (staying with friends), and few resources to change anything. 99.9% of people would say, "Even so, I can't lend them money."' How about if they needed cab fare ($15?)? A bit harder. How about $10 so they could get themselves food for the next few days? How about $5 for lunch? How about $3 for coffee at the cafe across the street? What is okay, and what is not? Does it matter if they can pay you back? What happens if the person can pay you back, but they forgot their wallet that day? How about if it is a child and you know they aren't eating enough at home?

Tough questions indeed!

 

[JockNerd]

Whose needs are being addressed here? The client's need for a ride home, or the therapist's need to feel that he/she is being "caring" or alleviating anxiety that he/she is not fixing what he or she perceives to be the client's problem? My guess is the latter.

Take it to its logical extreme--a client might benefit from me giving them all of my money. Clearly no one would advocate that.

 

[lookitssara]

My program is a counseling masters one, and it is (maybe inherently) less rigid about this relationship. Given that, we are instructed to do what the client (patient, whatever you're comfortable with) needs, outside of money. The only time that giving rides (for any reason) was discussed as forboden was with children/adolescents, particularly to health appointments.

For instance, school counselors are told they may need to stay at school after hours so parents who work during school hours can come in. Community counselors are told to recognize that due to gender roles in other cultures, they may primarily speak to a husband when it is the wife with mental health concerns. Most of this is due to their teaching of cultural appropriateness and working with people from diverse backgrounds. I agree that it is definitely a slippery slope, but at least our (not-so-clinical) program is advocating for a softer boundary.

 

[justme08]

Whose needs are being addressed here? The client's need for a ride home, or the therapist's need to feel that he/she is being "caring" or alleviating anxiety that he/she is not fixing what he or she perceives to be the client's problem? My guess is the latter.

Take it to its logical extreme--a client might benefit from me giving them all of my money. Clearly no one would advocate that.

👍 - Hey, JN, I'm sure there is at least one out there that would advocate it🙂

 

[teo3099]

.

 

[ClinPsycMasters]

Whose needs are being addressed here? The client's need for a ride home, or the therapist's need to feel that he/she is being "caring" or alleviating anxiety that he/she is not fixing what he or she perceives to be the client's problem?

The client's need for ride home.

See, that's the problem with using psychology to distort our own perceptions and justify why we choose to do or not do X. I am speaking of a very basic human need (the family shivering in cold waiting for bus) but you reframe the situation in a way that a caring deed becomes indicative of therapist's impotence. This is how we justified sleeping with clients not too long ago.

This is not to romanticize any helping behavior. Your point is well taken. The skeptic in me often second-guesses seemingly benevolent acts: But why did he really give a billion dollars to charity? Or why did he stop to help that lady--the voluptuous young woman wearing a short skirt and smiling seductively? And why did I really go into this field?

But I digress. As I said in my original post, getting a ride would have meant a lot to that family. To elaborate, there was a history of sexual abuse and a whole bunch of other stuff. The financial situation was very bad, and at times they needed to borrow money to take the bus--three buses--to come for therapy.

I did not suggest that one should, but that one be permitted to give a client a ride home and that sort of thing. The aforementioned therapist was going in the same direction and had he given them a ride, he would have dropped them off at a place closer to their place of residence, where they could take a single bus straight home.

 

[Student4Life0]

The client's need for ride home.

See, that's the problem with using psychology to distort our own perceptions and justify why we choose to do or not do X. I am speaking of a very basic human need (the family shivering in cold waiting for bus) but you reframe the situation in a way that a caring deed becomes indicative of therapist's impotence. This is how we justified sleeping with clients not too long ago.

This is not to romanticize any helping behavior. Your point is well taken. The skeptic in me often second-guesses seemingly benevolent acts: But why did he really give a billion dollars to charity? Or why did he stop to help that lady--the voluptuous young woman wearing a short skirt and smiling seductively? And why did I really go into this field?

But I digress. As I said in my original post, getting a ride would have meant a lot to that family. To elaborate, there was a history of sexual abuse and a whole bunch of other stuff. The financial situation was very bad, and at times they needed to borrow money to take the bus--three buses--to come for therapy.

I did not suggest that one should, but that one be permitted to give a client a ride home and that sort of thing. The aforementioned therapist was going in the same direction and had he given them a ride, he would have dropped them off at a place closer to their place of residence, where they could take a single bus straight home.

So I'm curious then, what would you do? Would you have given them the ride? I have to admit that I would have a very hard time just walking away from the family. I firmly believe that keeping with boundaries is essential to the therapeutic relationship. And yes, there's the old expression "Give an inch and they take a mile." But I think this is a tough situation. Perhaps it depends on the specific client, their situation, and how you think they would react to your actions. And if said therapist did give the ride, I think that they would need to process it with the family in the next session. It is all very tricky...

 

[ClinPsycMasters]

In theory I would have given them a ride but in reality I would worry about all kinds of things before I make that kind of decision. I think it takes a very strong-minded person to do that. Some therapists are very clear about who they are and what they are willing to do and what they absolutely refuse to do. Professional boundaries feel safe because there are rules and law behind them, holding them up. I don't have to define my role...it's defined for me. A strong-minded person can be more flexible with her boundaries, and not worry about slithering down the slippery slope, eventually getting burned out or sued for all she's got.

That sort of thing happens in real life too and that's when you get to really see what you're made of. You do a favor for the neighbor and the next day he expects the same. It was a one time thing, you say. He seems mildly upset. What does it mean to be neighborly? Unlike in professional psychology, there are no clear rules or boundaries. Social institutions like religion and tradition have lost much of their influence on the society. We need to make our own rules it seems.

Like Yin and Yang, "yes" is complemented by "no." Boundaries are necessary no matter what. I am simply suggesting more flexibility, one that would permit the therapist more personal authority in deciding on his role in the client's life.

 

[teo3099]

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[ClinPsycMasters]

So what if you can handle it but the client can't? The rules aren't there just for weak-minded therapists; they protect the clients as well. No matter how well-intentioned you are, there are unpredictable consequences to seemingly harmless actions. Some actions may truly be innocuous, but how can you know? Are you willing to risk a client's well-being? A strong mind isn't going to help you from getting sued, either--it's not really up to you, especially when you step into complicated situations.

I did not say the rules were for the weak-minded. I said the strong-minded therapist is able to be more flexible and not worry about going down the slippery slope--which you had hinted at in your previous post. It is not to say that the strong-minded therapist (i.e. one with clear sense of who they are and what they value) does not benefit from predetermined professional boundaries. However, he is shrewd enough to know when and how to deviate from it.

As far as harming the person, I do not see how giving someone a ride in the freezing cold can be harmful. Unless you're a "strict Freudian." 😉 I'm looking at this from a humanistic perspective.

The various rules and laws that we have are important. I don't want to get sued. And the person/client/human being does not want to get hurt. These rules, however, are somewhat arbitrary. You only need to look at history of psychotherapy and the sorts of relationships that were considered therapeutic, to get a sense how fickle the rules really are. In other words, there are no guarantees that a small and judicious deviation from the rules is going to be disastrous or that abiding by rules, as if they were the Ten Commandments, would keep the person out of harm's way.

Ignoring the legal aspect of it, I can not think of a compelling reason to refuse helping the person in that situation. Again, this is about a specific situation with a well-known client, knowing that fulfilling a very basic need overrides other concerns inherent to the therapeutic relation.

You aren't his psychologist. He's not calling you doctor and inviting your expertise on his extremely personal issues in exchange for money. (Doesn't that sound complicated enough already?) You have professional responsibilities as a therapist that require you to make considerations in your actions that don't exist in other relationships. It just isn't the same.

I'm not a psychologist, period. I have my masters only and do assessments mostly, when I'm not doing research or eating pizza. 🙂

You are absolutely right. The professional patient-doctor or client-therapist relationship is a professional one, defined by APA. The relationship is also defined by all sorts of enforceable rules and laws. It is also a business. We provide a service in exchange for money. The therapeutic relationship has all these other dimensions to it, and that's the reality. Ignore them and expect a rude awakening.

The point that I was making--and it's perhaps the romantic in me--was that the humanistic aspect of the relationship comes first. Of course, it is very difficult to realize these more idealistic dreams the way the society is currently structured and governed.

 

[FadedC]

Well talking about slippery slopes, saying that a certain area of the professional rules don't apply to you because your more strong minded or otherwise know better and can work around it seems like a very dangerous thing to do. I'm sure that's how just about every ethical violation gets it's start.

But for the original question, I don't really know what I would do. I think it would have to be a judgement call based on just how bad I felt it would be if they didn't get a ride compared to the potential for harming our relationship by helping them. If it was just another everyday bus ride in the cold for the family I'd be unlikely to intervene. But if their car broke down and they had no way to get home otherwise then I might be more inclined to.

 

[Therapist4Chnge]

As far as harming the person, I do not see how giving someone a ride in the freezing cold can be harmful. Unless you're a "strict Freudian." 😉 I'm looking at this from a humanistic perspective.

While I appreciate your desire to "help" people, this could do more harm than good. My first thought after reading your post was, "what if the patient displayed strong BPD features and/or already had boundary issues? Do they have a trauma history?"

What if you were viewed as "the knight in shining armor"? Or as "going above and beyond for your patients"? Or "having a special relationship with patients you really like and/or care for"? I am big on establishing clear boundaries because much of my training was with patients who had co-morbid Axis-II Dx's, and the above would definitely threaten those boundaries.

I'd write more, but I have a tee time to catch. 😀

 

[teo3099]

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[zenman]

I was reading a book about an accomplished mental health professional who, one cold night, seriously considered giving a ride to a poor family--whom he met with regularly for therapy. The details of the case are beside the point but suffice to say that no other government funded and social programs were available, and that such assistance would have meant a lot to that family. Yet, he could not violate doctor-patient boundaries.

What would Milton Erickson do?

Coming from a poor family and having once walked 18 miles throughout the night due to not having a ride, I'd give them a ride and not agonize over it.

 

[ClinPsycMasters]

And it surprises me to hear that you can't imagine a reason why it would be a bad idea. There's a reasonable chance that it isn't a bad idea and would do no harm. I can imagine, though, dozens of reasons of varying outlandishness that the ride could be a bad idea. What if you cause a car accident and injure or kill your client? What if they start to feel that the relationship is something *more* than professional? What if YOU start to feel that way? What if they have boundary issues like in some previously mentioned axis-2 disorders? What if they expect a ride every time it's cold--can hearing yes one and then no be confusing to them? What if they see your Iron Maiden CD case and can't think of you as a professional anymore 😉? What if they start to feel indebted to you and want to invite you to dinner?

This is funny. That's like my train of thought when I get anxious, imagining the worst possible scenario. Why stop there? What if during the session you confront the patient and they get a heart attack? what if you confront them and they commit suicide? What if you cancel an appointment and they commit suicide? What if they trip over your chair and fall down and die? What if they choke on the candy you offer them? What if they fall in love with you during the session and your refusal leads to them killing themselves? 🙂

Or let's think about the "cold night" situation and consequences of not giving them a ride. They need to take three buses to get home. It's a family with some young ones, as I said before. What if the kids catch pneumonia and die? What if the buses have an accident? What if they get raped while walking home at night? What if they get run over by a car? What if they slip and fall on the ice and break their bones? What if a punk kidnaps one of the kids or steals whatever money they have with them? What if they see you driving by and get so pissed at you for not caring, they give up coming to therapy, which eventually leads to horrible consequences? What if a drug dealer is finally able to tempt the disheartened mother while she's running to catch the next bus?

There is more of course. Some of these exaggerations are of course funny...and sad if realized...but you get my drift, I hope. As I had said earlier, knowing the client and knowing that there were no social programs available to help them get out of the situation for the time being, and knowing that the patient was not actively psychotic and did not meet the criteria for particular personality disorder prone to boundary violations, etc etc, I would certainly give them a ride.

I wouldn't want to be providing any other person with a "basic need". I would hope to help develop skills for them to provide for themselves. Solving a problem like that could be empowering for them and by giving the ride, I take the opportunity away for them to do it themselves.

What is wrong with providing a basic need? We do that in the session, don't we? Do you not turn up the heat if the client is shivering in their chair? Or do you empower them by asking them to turn up the heat? Kidding. 🙂 Do you not provide a safe and secure place for them in the session?

I did once have an actively psychotic patient and I was trying to do a quick cognitive assessment with them. Unfortunately my mind was somewhere else (the secretary wasn't there and there seemed to be an argument going on in the waiting room) and I think the patient picked up on my distress and became agitated and nearly hit me. For a psychotic patient, one of the best things you can do in the session is provide a sense of safety and security. That's a basic need in my view.

I do understand what you're saying though. I do want to empower people. It's a great feeling. I want them to feel competent and independent. Unfortunately, at times words are not enough. At times every single system that is supposed to be there for them fails them. Bureaucracy gets in the way. That's when I like to have the option to help in other ways if I think it's appropriate. Again, the rules need to change. I don't like to get sued nor reprehended anymore than the next person.

p.s. I'm enjoying our discussion. It's forcing me to think about my ideals more clearly. Thank you.

 

[ClinPsycMasters]

I'd write more, but I have a tee time to catch. 😀

You lucky fun-loving bastard!

 

[teo3099]

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[BSWdavid]

Some of this depends on the client population. For example, I know many therapists who work with children and families that do a lot of home-based counseling. They are required to assist the children with rides to and from sessions, often taking them out of the home for counseling, etc. I don't know if I agree with this as I don't personally like the idea of home-based services, but unfortunately many consumers don't have reliable transportation, etc. and in order to work with these folks, one may have to blur boundaries.

While I am a strong advocate for professional boundaries, there are some instances that require you to be a human first and foremost. Personally, if I were a consumer, waiting in the cold for a bus with my family and my therapist passed me by without a care, I would wonder how I would respond. I certainly would not expect he/she to provide a ride, but their lack of concern may undermine my belief that he/she had my best interests at heart. What could that do to the therapeutic alliance? Personally, I doubt I would return to that therapist. I get boundaries and respect them very much, but come on. I am reminded of numerous examples where people have been mugged, raped, and murdered in the street and individuals watching from their windows, etc. did nothing. If you noticed your client being raped around the corner, would you not intervene because of a fear of boundary issues? Which takes precedence? Sometimes, maintaining distance isn't what is best for the client; context is key when making ethical decisions.

I realize that this is a very difficult decision and there are no hard and fast rules. Understanding the context and weighing the pros and cons is important. I honestly don't think providing a ride for client in such a situation would necessarily present a boundary problem. If it was happening on a regular basis, that is a different story. Good therapists know when to push boundaries and when to pull them back in. Rigidity probably doesn't work very well when dealing with diverse populations.

If you are dealing with a BPD client who you fear will have boundary problems, then you might decide that providing a ride will do more harm than good; however, this may not be the case with all or even most of the clients (again, depending on populations served). Make a judgement call in this situation and ask yourself what is ultimately best for that client. Acting to rigid may actually prove to be more harmful than helpful.

BTW: As I noted earlier, I am fairly clear when it comes to boundary issues; however, I realize that in this profession I will likely face many challenges to those boundaries and will have to push said boundaries from time-to-time. Why have we gotten to the point that we fear that acting too "human" is a bad thing? I think while many of us believe it is essential in order to protect client and therapist, much of it also has to do with the power differential and maintaing an elite status. Maybe there is a part of us that is afraid of becoming to "real" with our clients. I dunno; just my thoughts.

 

[SingingCow]

BTW: As I noted earlier, I am fairly clear when it comes to boundary issues; however, I realize that in this profession I will likely face many challenges to those boundaries and will have to push said boundaries from time-to-time. Why have we gotten to the point that we fear that acting too "human" is a bad thing? I think while many of us believe it is essential in order to protect client and therapist, much of it also has to do with the power differential and maintaing an elite status. Maybe there is a part of us that is afraid of becoming to "real" with our clients. I dunno; just my thoughts.

Because you may get sued for "being human"; if you act according to your professional boundaries and rules laid down by the "higher power", you are more "protected"? j/k

 

[deleted343839]

Do you want to be a helper? Or do you want to be a therapist who wants your scope of practice to include a broad range of things that can be called "helping"?

The former is easy to do. As you have observed, most of the "help" that people in the world need does not require an advanced degree or license. Volunteer at a food pantry, work a crisis hotline, tutor or mentor homeless kids, be an advocate for abused families, etc. Do these things in your discretionary time, not in the capacity of your professional role. There is more than enough needed help to go around.

You can also do a great deal of helping within your scope of practice. When you have a client who can somehow make it to therapy sessions but can't manage to get a ride home, perhaps the goals of therapy need to change to be more concrete and solution-focused. You are distinguished by the TYPE of help that you can provide - for instance, helping clients achieve autonomy. You should also have lists of social services agencies at easy reach for referrals. Some of the most helpful things I have ever done as a therapist are giving referrals to people who know better than me how to take care of a need that I cannot provide.

And if you find yourself in a situation where you feel obliged to give a client a ride, give a client $5 for food, whatever, OWN IT. Document it. Chances are these kindnesses will never come back to haunt you, and some may be remembered for a very long time. But also ask yourself the tough questions - are you a savior, or are you one of many "helpers" who is doing nothing to fundamentally change that person's situation?

(I speak as someone from a not-so-well-off background who was once very kindly given heating fuel from the fuel guy during the winter when we ran out. So I am sensitive to these issues, but I also know both sides of this story.)

 

[PorkDumplings]

But also ask yourself the tough questions - are you a savior, or are you one of many "helpers" who is doing nothing to fundamentally change that person's situation?

I would hope that maybe this is just a poor choice of words, but I think there's a big problem in conceptualizing the therapist, either on the part of the therapist or the client, as a "savior."

 

[zenman]

Yep, that could get you nailed to a cross.

 

[deleted343839]

I would hope that maybe this is just a poor choice of words, but I think there's a big problem in conceptualizing the therapist, either on the part of the therapist or the client, as a "savior."

Of course there is, and that's the point I was trying to make. It is not uncommon to wish to "save" a client from some perceived peril, even when doing so might undermine the goals of therapy. I've seen more than one colleague inadvertently fall into a "savior" script and role ("There is no one else," "I can help them in ways others can't/won't," etc.).

Perhaps I should have used quotes.

 

[psychmama]

It is not uncommon to wish to "save" a client from some perceived peril, even when doing so might undermine the goals of therapy. I've seen more than one colleague inadvertently fall into a "savior" script and role ("There is no one else," "I can help them in ways others can't/won't," etc.).

Sometimes I've heard this referred to as a "rescue fantasy". I think we all can have these in a mild form at one time or another. That's the reasoning behind the boundaries, in my opinion. To give us therapists some structure when caught up in the very human tendency to want to rescue our clients from their problems. I think of it as a raft to cling to in stormy seas.

That's not to say that the whole boundary thing cannot be overdone, or that it's never a good idea to break the frame of therapy. Still, as someone who's inclined to 'rescue' I appreciate the boundaries and think twice before crossing them. But I have crossed them on occasion. In life there often are no simple answers about what to do, and sometimes you'll only know in hindsight if you made the right choice.

 

[Therapist4Chnge]

The "rescue fantasy" brings up some interesting counter-transference issues, which I have often seen in cases where the provider is "too close" to the patient. It may sound cold, but both the professional and the patient must be protected, which is why boundaries must be clear and uncrossed.

 

[PsychGraduate]

100% agreed.

 

[Ollie123]

Agree with others on the "rescue" fantasy. I think this is a VERY common trap to fall into (albeit to varying degrees) and is probably one of the easiest ways for early therapists to end up on the road to burnout. I certainly fell into this early on, when my second client turned out to have a pretty severe case of Borderline PD (among 3-4 other diagnoses) and had a number of other circumstances in her life that caused problems. That one client very nearly made me switch to the experimental track...even 1-2 years later I'm now much more confident I'd have been able to handle it better, although I still think I'm far from being the ideal clinician to handle a case like that. One of the trickiest aspects of therapy for me has been allowing myself to display normal affect with the client (both for rapport, and for modeling) while still maintaining enough emotional distance to keep myself from burning out or from inadvertently crossing professional boundaries.

As for the original question - I can understand both sides of the argument but would certainly err on not giving the client a ride, though transportation issues are certainly something that merit discussion as part of treatment. The biggest reason for me is actually not about concern for the therapeutic relationship, but more about concerns for that client's relationship with other healthcare providers.

I have had several clients who believe that healthcare workers who do not go WAY beyond what anyone would consider reasonable in order to help them is "bad/uncaring/etc.", and in some cases this has had significant negative impacts on their health. The therapeutic relationship can be damaged by a boundary-crossing like this, but I'm not convinced it would render it beyond repair. My concern is how it would affect their relationship with other healthcare providers. In these cases, I'm not convinced any amount of "debriefing" at the next session would impact the fact that I made myself out to be a hero in this person's life, and may have made the other medical staff who play as important (or more important) a role in this person's life look like crappy, uncaring individuals. Even with appropriate debriefing, I have reinforced the stereotyped view that anyone who does not do these things is a crappy healthcare worker and not worth going to.

It is worth noting that in not all cases would I have predicted the client felt this way about the healthcare system. Indeed, sometimes it didn't come out until the end of therapy. To me, the damage that would have been done by something as simple as a "ride home" in those situations outweighed any potential benefits. Certainly if the situation is extreme enough, I would intervene in order to ensure the client's safety - though this would likely involve utilizing some social service agencies or the local PD rather than taking care of it myself. Finally, its important to note that difficulty is often a matter of perception - something that seems to have gotten lost in this thread. Some client's might not think anything of waiting 30 minutes in the cold for a bus...that is how they live their life. What may seem shocking to us they may not think twice about. Unless I have reason to believe it poses a significant danger (not just significant unpleasantness), I am not inclined to intervene in such cases as I think it poses a judgment on their life or lifestyle that I am not comfortable making.

 

[PsychGraduate]

I take the lead from the medical doctors here. I often want to "intervene" or "help" a client outside of the therapeutic relationship... instead I just volunteer to work with and teach others... that gives me the opportunity to provide more personal efforts of benefit.

 

[zenman]

The "rescue fantasy" brings up some interesting counter-transference issues, which I have often seen in cases where the provider is "too close" to the patient. It may sound cold, but both the professional and the patient must be protected, which is why boundaries must be clear and uncrossed.

Is this rigid? I saw a Vietnam vet yesterday who is still screwed up, not only from combat but from the lack of a celebration upon returning. I seriously thought about giving the big guy a hug and "welcome" him home and thank him for his service. I could have arranged some type of welcome home ceremony with a bunch of people and have a proper big shebang, but in all likelihood I may not see him before my rotation is over. Damn, I should have just hugged him. I'm guessing it would not have messed him up any more than he already is.