The trouble with being yourself

Caroline CupittConsultant 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 moveableIn 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 boundariesTake 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 boundariesThe 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)

DetachmentBy 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 timesThe 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 cliente.g. inappropriate gifts, gossiping, intimacy

2. Our desire to help is so strong we can’t think clearlye.g. inappropriate self disclosure, touch

3. Circumstances don’t make boundaries easy to drawe.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 non-theraputic 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)

ExerciseConsider 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 exampleThe 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.