The trouble with being yourself
Caroline Cupitt
Consultant Clinical psychologist
Oxleas NHS Foundation Trust
Boundaries
“A boundary is the edge of appropriate
behaviour at a given moment in the
relationship between a client and worker…”
Gutheil & Brodsky (2008)
Boundary crossings
Boundaries are flexible and moveable
In assertive outreach we tend to use loose
boundaries, and sometimes deliberately cross
boundaries to aid engagement.
How do we know when this is OK and when it is
not?
Dilemmas about boundaries
Take a few moments to think of a dilemma you
have faced. Pick one which,
• Involves yourself;
• In assertive outreach setting;
• When you were genuinely unsure where the
boundary should be, or had concerns about
how it turned out.
Here are some of mine…
Dual relationships
• Bumping into clients outside of work, how do
you acknowledge each other?
– e.g. someone else in the house invites a friend
round for dinner who turns out to be a client of
the service where I work
• When friends or relations receive services,
how can it not affect your relationship?
– e.g. a new referral at a team meeting
– e.g. a case presentation at a training day
When extending your role
• When using unusual techniques to enhance
engagement, colleagues can sometimes be
critical. How far can creativity go?
– e.g. meeting in cafes, pubs, etc
– e.g. offering gifts of large vegetables
• Doing outreach visits, your personal values
can be challenged. Should you compromise
the personal for the professional role?
– e.g. an unexpected prawn curry
When personal values are challenged
• By questions or assumptions about invisible personal
characteristics, e.g.
– Religion
– Sexual orientation
•
•
•
•
•
Political, e.g. visiting MacDonalds
Diet, e.g. vegetarians
Hygiene, e.g. accepting drinks
Smoking - changes in NHS guidance
Alcohol
When using particular models of
intervention
• Collaborating on a service development
project, service users become colleagues and
you may need to openly share your views on
issues. Does this then affect what future work
you can do together?
• If we promote involvement in the politics of
mental health, is it OK to go to meetings or
demonstrations with service users, e.g. about
the new MHA?
Anything else?
• Does your dilemma fit into one of these
categories?
• What other kinds are there?
Why does this keep happening to me?
• Service type, e.g. assertive outreach
– Need for genuineness
– Long term relationships with clients
– Intensive involvement in people’s lives
• Living on your patch
• Socialising in a small community
• …
Historical therapeutic boundaries
The early psychotherapists such as Freud were quite
relaxed about their boundaries.
Freud is said to have,
“sent patients postcards, lent them books, gave them
gifts…provided them with extensive financial support
in some cases and on at least one occasion gave a
patient a meal”
(Lipton, 1977)
Winnicott analyzed a close friend, socialized with
patients, took in a child patient as a boarder.
(Winnicott, 1947)
Detachment
By the mid-century therapists were being expected to
be more detached.
The 1960s generated a reaction to this, in favour of
more humanistic approaches, where the therapist
showed greater warm and self disclosure.
By the late 70s and into the 80s awareness of child
sexual abuse grew, and also concern about the
effects of therapist sexual misconduct.
Pope (1988) found 8.3% male therapists and 1.7%
female therapist had had sexual involvement with
clients.
In recent times
The 1990s saw intense preoccupation with therapy
boundaries.
Most guidance was in the form of “dos and “don’ts”
There was some backlash against this (e.g. Lazarus,
1994) from people who felt their practice was unduly
restricted.
More recently there has been a movement towards
more flexible, context dependent guidelines.
There is starting to be the suggestion that some
boundary crossings could come from benevolent
intent and yield positive results.
However we still need to be very alert to violations
Types of boundary violation
1. Putting short term needs and desires ahead
of the long term interest of the client
e.g. inappropriate gifts, gossiping, intimacy
2. Our desire to help is so strong we can’t think
clearly
e.g. inappropriate self disclosure, touch
3. Circumstances don’t make boundaries easy
to draw
e.g. rural areas, small communities, engagement
work
Codes of conduct
• Nursing and Midwifery Council (2004) NMC code of
professional conduct: standards for conduct,
performance and ethics, London: NMC.
• General Social Care Council (2002) Code of Practice
for Social Care Workers, London: GSCC.
• British Psychological Society (2006) Code of Ethics
and Conduct, Leicester: BPS.
• General Medical Council (2006) Good Medical
Practice, London: GMC.
• And many more…
But
“Ethics codes can…never be a substitute for the active
process by which the individual therapist…struggles
with the…unique constellation of…demands of
helping another person.
Ethics that are out of touch with the practical realities
of clinical work, with the diversity and constantly
changing nature of the therapeutic venture, are
useless”
Pope and Vasquez (1998)
Practical issues
The bottom line, is that any intervention should be for
benefit of the client.
How can we know what will benefit someone?
Different models of mental health work have different
views about where the boundaries between worker
and client should lie.
In the same way, different contexts will make the same
behaviours either ethical or inappropriate.
Informal or formal relationships
“ There are distinct advantages to addressing the adult
in the patient, in terms of fostering the adult
observing ego for the alliance. Trainees often do not
see the paradox of expecting adult behaviour on the
ward from someone they themselves call ‘Jimmy’,
which is what people called the patient when he was
much younger”
Gutheil and Gabbard (1993)
On socializing
“Nothing in the theory of behaviour therapy would or
should preclude socializing with patients, taking
meals with them, giving them gifts, or treating
them in their homes, schools or offices. Hugging
patients might reinforce the therapists potency as a
reinforcer for the patient and, thus might be
supported theoretically”
Marquis (1972)
Social exclusion
When working with people with severe social
disabilities,
“some self-disclosure, real two-way interaction
and sharing, is essential in forming an
effective relationship with someone who has
few, if any, other close relationships.”
Perkins and Dilks (1992)
But
“The vulnerability to crossing boundaries in nontheraputic ways comes from elemental needs
and feelings, together with a misdirection of
the clinician’s desire to help and a
misapplication of the assumption of mutuality
and reciprocity in human relationships”
Gutheil and Brodsky (2008)
A way forward…
“For a proper understanding and resolution of
boundary questions in daily practice, we need
to shift the focus from the surface to the
depth of a patient-therapist interchange – that
is, from a given act to its therapeutic (or
counter therapeutic) purpose, meaning,
impact, and – above all – context.”
Gutheil and Brodsky (2008)
Exercise
Consider your dilemma again.
Describe your approach to the boundaries in terms of
therapeutic (or counter therapeutic)
• purpose
• meaning
• impact
• context
– both the service setting
– and model of intervention used
Consider the effects of changing the context
– a different service setting
– and/or a different model of intervention
For example
The unexpected prawn curry – I accepted.
• Purpose: To avoid causing offence.
• Meaning: By accepting the gift I cut through any notion that I
might be suspicious of her. However it may also have
suggested that I was just like any other guest, crossing our
usual boundary.
• Impact: She took pleasure in watching me eat and said
goodbye warmly. I managed to (sort of) enjoy it.
• Context: our last meeting
– the service setting: assertive outreach, home visits
– model of intervention used: CBT, collaborative
• Changing the context: This would not have felt OK if we had
not been meeting in her home or working collaboratively. If it
had not been our last meeting, I would have felt more
concerned about crossing our usual boundary.
Reaching Out begins with a
discussion of:
– engagement
– the team approach
– assessments
– team case formulation
– managing stress and burnout
for staff.
The second half of the book focuses
on the task of delivering
psychological therapies and
considers a range of models
including psychodynamic therapy,
family therapy, cognitive
behaviour therapy and community
approaches.
To be published September 2009
www.routledgementalhealth.com
Suggested Reading
• Cupitt, C. (ed) Reaching out: the psychology of
assertive outreach. Routledge, forthcoming.
[Chapter 10 concerns ethics and professional boundaries]
• Gutheil, T.G. & Brodsky, A. (2008). Preventing
Boundary Violations in Clinical Practice. Guilford
press.
• Perkins, R. & Dilks, S. (1992). Worlds apart: working
with severely socially disabled people. Journal of
Mental Health, 1, 3-17.