In this essay I give my views on the boundaries of individual psychotherapy—their necessity and the process of learning them, accepting them, then gaining from and leaving the therapy process. For me, the learning process was long, and I realize now how I had to internalize a number of new concepts for the therapy to succeed. After much thought and work, therapy was beneficial and rewarding for me. I now know that because I took the process of psychotherapy seriously, it made my life more fulfilling and my relationships more meaningful. For me, psychotherapy was especially helpful in reinforcing my ability to deal with a chronic, debilitating, and life-threatening illness. It helped me make each day a gift, accept my imperfections, and live with uncertainty, frustration, and anger with more dignity and greater understanding.
The photo represents to me, by its flowing river, wooded sides, and middle pile of branches, the possibility of persevering in life and of going forward despite obstacles and difficulties as well as the boundaries inherent in all of life, especially in psychotherapy. Johnston Falls River, Banff National Park, Alberta, British Columbia © Jan Goddard-Finegold, M.D.
What we say in the world
We rarely divulge our personal thoughts in public, unless we feel a sudden sense of commonality and connection with a person or group of people. As an example, I think of the way we talk unguardedly with seatmates on airplanes—perhaps because there is safety in anonymity and because the chance of seeing the person in the adjoining seat again is unlikely. In general, though, public relationships are uncertain, unknown, and uncontrollable. In such circumstances, our confessions, little voices of personal loss, or mean feelings may find their way to their subjects, to unsympathetic people known in common, or to difficult family members. Furthermore, we may be quoted in places or publications without our permission, leading to personal or legal embarrassments.
Psychotherapy as a “safe place” and its boundaries
The freedom to speak openly and unguardedly is confidential in very circumscribed situations: with our lawyers and our physicians; with our priests, rabbis, or ministers; and most notably, with our psychotherapists (psychiatric physicians; psychiatric, clinical, and family social workers; clinical psychologists; and licensed lay psychotherapists, for the most part). The relationship between a qualified psychotherapist and a patient is a “safe place,” as described by Dr Leston Havens.1 Nevertheless, I learned that there are rules that govern such a therapeutic relationship, rules that must be adhered to, that have stood the test of time, and that ensure physical and mental safety, for both the therapist and the patient.
While these rules, or “boundaries,” have been stated somewhat differently by various therapists, I describe them from my experience as follows: (1) The emphasis in therapy is almost exclusively on the life and thoughts of the patient; (2) The therapist concentrates on finding ways to communicate meaningfully and helpfully with the patient about his or her difficulties using examples and knowledge from the therapist’s training and experience; (3) While the personality of the therapist is paramount to his or her success in therapeutic relationships, the therapist does not share his personal life, family information or problems, and especially, identity of or information about other patients; (4) The therapist may find ways to build the patient’s self-esteem by expressing admiration or joy for the patient or his success during therapy as well as concern for the patient’s well-being. A competent psychotherapist, however, does not disclose sexual attraction or love for the patient (nor distaste or dislike of the patient). If the therapist has sexual or loving feelings for the patient, or truly dislikes a patient, referral to another therapist is the answer.
While boundaries enable the therapist to focus on the patient’s problems and issues, the strictness of boundaries is not necessarily that originally taught by Freud, ie, that the therapist show “neutrality, anonymity, and abstinence” toward the patient.2 As Dr Glen Gabbard suggests, the current day interpretation of Freud’s concepts of boundaries would most likely be described as “restraint” on the part of the therapist.3 This means that each therapist will spontaneously reveal emotional responses to the patient’s comments and, in a nonjudgmental way, will learn about, interpret, and to a helpful and honest extent, go with the flow of the patient’s internal world.3,4
Transference and countertransference
While there are other recurring psychological responses in psychotherapy (such as resistance, repression, projection, hostility, and displacement), recognizing and dealing with transference and countertransference are major issues in psychotherapy and make the boundaries of psychotherapy most important and protective. The empathetic use of boundaries by a therapist allows him to be warm and responsive to the patient, to make an environment of trust for the patient, and to allow the patient to feel validated and understood.3
