One point that comes up with great frequency in these discussions is the matter of children; clearly, the aforementioned issues are completely different for children. For instance, play therapy may involve rolling on the floor with the child-patient, an action hard to defend with adults. Thus, boundaries in child psychiatry are harder to define. As child psychiatry boundary issues are rarely discussed in the literature, surely this represents an area for more investigation and discussion by child psychiatrists.
Time issues frequently emerge in discussions of boundaries. Many clinicians believe that a regular appointment for a standard time is a valuable aspect of the frame of psychotherapy (Langs, 1982). However, sometimes it is necessary to extend the time of an appointment on an emergency basis. This situation can be distinguished from becoming so engrossed with a patient or a patient's narrative that the therapist loses track of time and repeatedly runs over the designated appointment time.
Trips outside the office are a common way station on the path to greater boundary problems. Can you do psychotherapy over lunch in a restaurant? If you do not talk with your mouth full, it seems theoretically possible, but 1) it is not a confidential setting (people passing by could overhear the conversation), and 2) it does not look like therapy-it looks like a date and thus is not above suspicion. On the other hand, certain behavior-therapy approaches to variants of social phobia might well involve leaving the office to confront, say, the phobic situation as the last step in a desensitization program.
Hugs are another source of confusion among mental health care professionals. In the "old days" when everyone wanted to be Leo Buscaglia, Ph.D., hugs were seen as a form of benign, occasional physical contact punctuating the surrounding therapeutic expanse of talk. Needless to say, it is different now. All hugs have become suspect because of their potential erotic content, an effect intensified among victims of trauma.
An exception might be made for HIV-positive patients because of their status in many clinical settings as "lepers," untouchable without latex armor. I have suggested that clinicians who work with HIV-positive patients should contrive to touch such patients nonsexually at some point during each therapeutic encounter, e.g., by a handshake, pat on the shoulder or squeeze of the arm, specifically to counter the social ostracism such patients may feel.
Finally, self-disclosure remains an area of controversy. A fundamental tension appears to exist between two notions. The first notion is the clinical value of the therapist's relative anonymity, even to the point of becoming the "blank screen" envisioned in early analytic writings. The second notion is the emphasis in some therapeutic circles on the value of the "real relationship" with the therapist, one component of which may be the therapist's self-revelation of personal details, real-world advice or expression of personal values.
Arguments for the first-more reticent-approach stress how information about the therapist may burden patients and constrain or even foreclose certain areas of free discussion. To use a straightforward example, a patient who is told that her therapist is Roman Catholic may find it more difficult to discuss a contemplated abortion. Opponents of this view note that all therapists are constantly disclosing information about themselves willy-nilly through channels ranging from body language and speech to choice of office decor.
Proponents of a more self-revelatory approach also suggest that the reality of the therapist is humanizing, demystifying and de-idealizing in a manner that fosters greater autonomy and less dependence in the patient with greater therapist-patient egalitarianism and less authoritarianism from the therapist.
This matter almost certainly requires decision-making on a case-by-case basis. One author (Maroda, 1991) has suggested that-in certain specific therapeutic impasses-even disclosure of countertransference dynamics may be constructive. Self-disclosure may facilitate authentic engagement in the therapeutic process in one context, but seductive, coercive or destructive intrusion on a patient in another. The therapist's sensitivity to the issue of boundary transgression and reliance on the traditional standbys of documentation and consultation provide the greatest security against the potential harmful impacts on patients and preservation of clinical effectiveness.
Finally, therapy works best when it is seen as work, gratifying for its own sake. The time-honored principles of abstinence and neutrality are still essential components of this endeavor.