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Section 10
Ethical and Clinical Considerations

Question 10 | Test | Table of Contents

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This final section will examine four areas that require particular attention concerning the setting of constructive and clear boundaries: physical contact, pity, overidentification, and detrimental dependence.

Personal Warmth vs. Professional Qualities.
Some therapists may give the impression that any step over the line of a clear boundary into a friendly and relaxed demeanor may be unprofessional. Where did this notion of a dichotomy between strictly personal and so-called professional qualities originate? Should mental health professionals be wary of and question the apparent impersonal character of professionalism?

4 Areas for Setting Constructive Clear Boundaries

♦ Area # 1 - Physical Contact
As you are well aware, as a general rule, we are not a society that condones very much touching, especially among strangers. You may find a clerk in a store who physically touches the palm of your hand in returning change. You may be jostled in a crowd. Strangers may impulsively hug the man or woman next to them in the midst of an important sports event. However, the occasions when touching among strangers is socially sanctioned can probably be counted on one hand.

Because touching is socially not condoned, but can be a very effective means of establishing rapport or showing understanding, the limits to physical contact in the mental health professional and client relationship deservedly have received attentionOne of the most basic societal acknowledgments where therapists, in in-patient settings, depart dramatically from accepted social norms of physical contact is found in the legal foundations of informed consent. The legal concept of battery is based on society's deep prohibition against unconsented touching.

As you know, by giving informed consent, the patient is saying, in effect, I give you and others involved in my care consent to stroke, rub, poke, or even puncture or cut me, depending on what you are licensed by society to do as a part of your professional procedures. You have experienced this if you have worked in an in-patient unit. If a person on the street attempted such activity with a stranger, he or she would end up in jail.

Obviously, the permission to make physical contact in an in-patient setting already puts the mental health professional and patient relationship into a special category where usual socially acceptable distances are breached on a regular basis. Informed consent is the contractual basis of the professional and patient relationship. Many cultural, social, and personal factors will come together to create a patient's comfort zone regarding physical contact and you naturally are guided by a sensitivity to individual differences.

Some types of physical contact are not deemed acceptable under any conditions, even with the consent of the patient. As you know, by law you cannot make contact with a patient with an intent to harm him or her physically or psychologically. If you do, you will be charged with sexual or other physical abuse. This boundary seems, at first, all too clear, but the following case studies will undoubtedly provoke some added thought on your part.

Sexual Touching and Not-So-Clear Boundaries
The type of touching that has received the most attention is physical contact delivered with an intent to excite or arouse the patient sexually. Although sexual intercourse is the most verboten, the prohibitions are not limited to it.

For example, the National Association of Social Workers Code of Ethics makes a statement similar to many other professions' codes: "The social worker should under no circumstances engage in sexual activities with clients." To take the devil's advocate position to further expand your definition of a clear boundary, ask yourself…Why should it be forbidden if a client consents to or even seems to invite sexual contact?

The strongest argument against this type of contact is that it betrays the reasonable expectations built into the essence of the client relationship. Patients have a right to receive the best care possible without having to satisfy the professional's needs. Shades of "meeting the professional's needs" have been discussed earlier in this course.

Let's look into a not-so-clear boundary area. How does this relate to sexual harassment laws? The importance of the idea that sexual distance must be maintained is being aired today in the notion of "sexual harassment." As you know, the United States Equal Employment Opportunity Commission (EEOC) defines harassment as unwelcome sexual advances, requests for sexual favors, other verbal or physical conduct, and even activity that creates a hostile or unwelcome work environment for the person who feels "harassed." At the heart of the discussion is the degree of distance and quality of exchanges that must be maintained for respect to be expressed.

Emotional-Psychological Boundaries.
Next, after looking at the personal contact boundary regarding maintaining boundaries constructively, here are some situations in which the therapist's responses and psychological attachments can interfere with respect for the client. The term "enmeshment" summarizes these boundary situations aptly.

As you know, in interactions with the client, the therapist who has become enmeshed often develops an emotional connection with, or an emotional availability, to his or her client. This can ultimately lead to client feelings of anger or emotional pain and to a sense of abandonment once the therapy ends. The process of enmeshment may also complicate provision of adequate care at a later time. In an in-patient situation, for example, this can occur if the patient sees the other care team members as not caring sufficiently or as providing inadequate care, in comparison with the therapist who is enmeshed.

In these moments a "self-conscious distance zone" should be created to enable each to gain or regain perspective. Underlying the problems created in these situations are the dynamics of what exactly is detrimental.

♦ Area # 2 - Pity
One common situation in which emotional boundaries may have to clearly be set involves a therapist who, in an attempt to respond well to his or her patient, becomes so entangled in the apparent futility of their patient's plight that it becomes impossible to think about the patient or act in a way that really serves the patient's best interests.

However, as I'm sure you have experienced, it is not at all unnatural for mental health professionals to become periodically so involved in patient's dilemmas that we take these problems home with us. Almost any mental health professional can recall the time he or she had trouble falling asleep or was moved to tears or laughter by a sudden tragic or joyful announcement touching a client's life. There is, however, as you know, a significant difference between this depth of caring, which stimulates a purely human response, and fruitless or destructive enmeshment. The problem can be illustrated with the following case of a client of mine.

♦ Case Study: Michael
Michael Anderson was admitted to the psychiatric ward of City Hospital after the police brought him there from the streets. The police found him unconscious in a doorway of a downtown office building. Michael is a 29-year-old alcoholic. His mother died when he was 12 years old, and he left home to live on the streets shortly after that. He recently learned that his father died of a heart attack shortly after he ran away from home.

Craig Hopkins, a health care student in the practicum portion of his education, is also 29 years old. His similarity to Michael Anderson, however, ends there. Craig Hopkins grew up in an upper-middle-class home and served as an officer in the Marines. He has never had close contact with an addict before, but he finds Michael very warm and human during his initial interactions. Michael is admitted to the detoxification unit where he will spend the next week or so. They both chat when Craig has a few minutes, and, over the next few days, Craig arrives at the conclusion that Michael has had more than his share of misfortune.

The next day, when Craig goes into Michael's room, he finds Michael doubled up, writhing in agony. With a trembling voice, Michael tells him that the doctor has not given him anything to take the edge off his withdrawal from alcohol. To Craig's surprise, Michael grabs him by the wrist and pleads, "Please, please, I can't stand this agony. If you will just get me something to drink, just enough to make it over the hump, I swear I'll never touch another drop. If I can't get a little relief, I will kill myself. The doctor is a sadist."

Craig tears himself away and leaves the room. That night, however, he cannot sleep. He is haunted by the pictures of Michael. Craig sees clearly the beads of sweat that clung to Michael's face as he spoke; He thinks that Michael is clearly all alone in the world; He is angry at Michael's physician for not making detox a little easier for Michael.

"They're all liars."
The next day, when Craig goes toward Michael's room, a nurse stops him, saying that Michael is in a restless sleep and experiencing some visual hallucinations. The nurse says. "You've got to watch these alcoholics. They're all liars. They'll do anything to manipulate the staff to give them more of the drug."

Craig remembers Michael's pleading eyes the day before and is overcome with a desire to make a sharp retort to the nurse's statements. He goes instead to Michael's room and slips a half pint of whiskey into the drawer of the bedside stand and makes enough noise so that Michael stirs from his tortured sleep and sees what he is doing. He is not sure why he does this, but he quickly turns and leaves.

What do you think about Craig's conduct? He has reached the point where he is responding impulsively rather than with genuine caring because the situation is so painful to him. Such a feeling exceeds sympathy and is more closely related to pity. Because pity distorts the objective perspective necessary to resolve the real problem, he ceases to be of help. In fact, he may include himself among the patient's many problems.

As you know, the boundary of pity can be communicated to the patient in one meeting as well as over a period of time. Facial expression can instantly convey one's feelings. Quick nervous movements, coupled with a sudden departure, are sometimes correctly interpreted as expressions of pity. The desire not to talk about the patient's problem, and trite comments such as, "It'll be fine, I'm sure," can also be interpreted to mean "Poor, poor you."

As you are well aware, you cannot solve this type of problem arising from pity simply by enmeshing yourself more deeply into the patient's personal life. Of course, your pity is in response to a real need of a client or patient. I am sure that you have found like I, what is called for is sympathetic acknowledgment of the person's dilemma. However, at the same time you need to establish clarity that your professional role sets boundaries on what you will be able to do to intervene constructively in his or her plight.

♦ Area # 3 - Overidentification
Another situation in which emotional boundaries and psychological distance must be maintained to assure respect arises when you, the health professional, have trouble seeing the patient as a unique individual. The patient may so perfectly embody a stereotype that in your eyes he or she becomes that stereotype.

The patient may so remind you of someone else that the patient becomes that person, or you may have had an experience so similar to the patient's that you believe your experiences to be identical. In all three instances such a reaction is called Overidentification and is another variety of enmeshment. Because elsewhere we have discussed dynamics present in stereotyping and countertransference, we will now concentrate our discussion on the third type of situation.

At first, it seems counterintuitive that having had similar experiences may actually hinder the effectiveness of health professional and patient interaction at times. Everyone has had the experience of beginning to relate a traumatic, or exciting, event only to have the other person interrupt with, "Oh! I know exactly what you mean!" and then go on to describe his or her own story. As you know, one feels cheated at such times, thinking, "No, that's not what I meant, but you are more interested in telling me about yourself than in listening to me!" The way such overidentification works within the mental health professions can be illustrated with a client of mine named Grace.

♦ Case Study: Grace
Grace Green, an elementary school teacher, became interested in teaching language skills to hearing-impaired children after her third child, Laura, who was born deaf, successfully learned to communicate by attending special classes for those with hearing impairment. Mrs. Green enrolled in a health professions course directed toward training teachers of hearing impaired persons.

During her clinical education, she was surprised and alarmed that some of the mothers requested that she not be assigned to their children. Finally, she approached one of the mothers whose child she had been working with and with whom she felt comfortable. "What's wrong?" she asked. "Do they think I'm incompetent because I am an older student? Is it my personality? I want so much to help these children, and I can't understand what I'm doing wrong."

The embarrassed mother replied, "Well, since you asked, I'll give you a direct answer. I don't feel this way, but some of the mothers think that you don't understand their children's difficulties because every time they start to tell you something about their children, you immediately interrupt with an experience that your child had."

In short, overidentification leads to the boundary challenge of an "I-know-how-you-feel" reaction that can be helpful or can convince your client of the complete opposite. The therapist who is astute enough to discern that he or she may be overidentifying will also be able to see that attempts to become close to the patient by pointing out superficial similarities between their experiences are being interpreted by the patient as the therapist's desire to talk about his or her own problem.

As mentioned earlier, overidentification is very basic boundary, but perhaps one you need to reevaluate concerning clients you are currently treating. You should not be falsely led to believe that a closeness has been established. A technique to establish a clear boundary here is to maintain greater distance until the uniqueness of your client emerges.

♦ Area # 4 - Detrimental Dependence
This situation is the most complex. It addresses the awkwardness that ensues when a relationship that began with appropriate boundaries has still led to circumstances signaling to the therapist that a new set of boundaries must be established. This type of situation often is precipitated by the true affection that many people in the mental health professions relationships learn to feel for each other.

We identify some signs that affection, a positive component of the relationship, has spilled over into enmeshment and make some general suggestions about what can be done to rectify the situation to set a clear boundary. Obviously, affection is more likely to develop in situations where an ongoing relationship exists. One example of how a problematic dynamic of setting clear boundaries can arise is illustrated in a client I treated -- Jason, a paraplegic.

♦ Case Study: Jason
Jason has been a patient at University Rehabilitation for 6 months. His affable, optimistic spirit has made him very popular with the staff. At 23 years of age, he was involved in a car accident in which his fiancé was killed. Some members of the therapy team have long suspected that Jason's optimism is a veneer for the deep sorrow and frustration resulting from this sudden, dramatic change in his life.

One day he tearfully tells Morgan, a health professions student who has been treating him, that he is depressed and desperately lonely. Up to this point, their interaction has been full of banter and they have felt quite comfortable with each other. Morgan does not divulge to the rest of the staff Jason's expression of depression and loneliness, but that night on the way home, she stops by his room to see him.

In the following weeks, she begins to visit him more often. She finds him attractive, they share common interests, and he is obviously happy in her company. During this time, however, Morgan also leads her own private life, going on dates and interacting with a world of other people. However, Jason lies in bed thinking about her, and in the afternoons, he counts the minutes until she arrives.

During her Christmas vacation, Morgan visits her friends in a distant city and has a marvelous time. When she returns, bursting with enthusiasm and eager to share her stories, she finds Jason sullen and angry at her for staying away from him for so long. He has arranged for her to receive a present from him which sits, unopened, by the bed. He says, "That's for you. Take it if you want." Then he turns his back to her.

As you can well see, Jason's reaction indicates that he feels she has betrayed their relationship and rejected him. He has now reached the point where leaving her to go to his own home will mean relinquishing an immediate enjoyment and, perhaps, someone he thought was a friend. Morgan, who acted in good faith on her feelings of warmth and affection for Jason, has thus unwittingly fostered detrimental, rather than constructive, dependence. Her subsequent attempts to explain her sudden withdrawal may have profound, lasting effects on Jason. Instead of being a friend and confidant, as he had hoped, she will become just another of a long line of rejections he has experienced. He has relied on her more than she had intended or was able to manage.

For you to assess the warning signs of detrimental dependence, periodic reexamination of your own motives and conduct, or a colleague's assessment of your relationship, can help, too. To maintain appropriate professional distance and clear boundaries, a rule of thumb, as you know, is temper your warmth and affection with awareness that the other person's needs and wishes may exceed or differ from your own. A clear boundary checking technique I use is periodic reflection regarding the conduct I am observing from my client.
Reviewed 2023

Peer-Reviewed Journal Article References:
Barnett, J. E. (2011). Psychotherapist self-disclosure: Ethical and clinical considerations. Psychotherapy, 48(4), 315–321. 

Dugbartey, A. T., & Miller, M. (2009). Review of Boundaries in psychotherapy: Ethical and clinical explorations [Review of the book Boundaries in psychotherapy: Ethical and clinical explorations, by O. Zur]. Canadian Psychology/Psychologie canadienne, 50(1), 42–43. 

Jungwirth, J., & Walsh, R. (2020). Ethics and imagination in psychological practice. The Humanistic Psychologist.

Mayer, D. M., Ong, M., Sonenshein, S., & Ashford, S. J. (2019). The money or the morals? When moral language is more effective for selling social issues. Journal of Applied Psychology, 104(8), 1058–1076.

Pinner, D. H., & Kivlighan, D. M. III. (2018). The ethical implications and utility of routine outcome monitoring in determining boundaries of competence in practice. Professional Psychology: Research and Practice, 49(4), 247–254.

Tylim, I. (2004). Ethical notes on disrupted frames and violated boundaries. Psychoanalytic Psychology, 21(4), 609–613.

QUESTION 10
What are four areas that require particular attention concerning the setting of constructive clear boundaries? To select and enter your answer go to Test.

Overall, therapists must be responsible for setting boundaries that are worthy of the trust that our clients place in us due to the nature of our role. While we are accountable to our client and to society as a whole, we must be accountable primarily to ourselves, because only you can be aware of your ethical boundaries. While your own fallibility makes it highly probable that you make mistakes at times, you should develop sufficient self-awareness to know when you have done so and to resist the tendency to rationalize your behavior, as we all do. By examining your rationalizations you can avoid repetition of mistakes.