Exploring the issues of boundaries (managing ethical issues)

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Author Note
 Table of Contents
1. Issues of boundaries - what are boundaries & how can they be defined?.............................4
Lack of definition of Boundary..............................................................................................4
Defining boundary by ethics..................................................................................................5
Importance of Boundary........................................................................................................5
Types of boundaries...............................................................................................................6
2. How boundary might be a difficult/challenging issue for you or the counsellor/therapist in
general?....................................................................................................................................10
Some clients are very boundary conscious..........................................................................10
The need for boundaries in high level counselling..............................................................11
3. If you are not aware of it or don't manage it well, what could possibly happen to the
counsellor, the client and/or the counselling relationship/process?.........................................12
Boundary crossings vs. boundary violations........................................................................12
Counsellor protection...........................................................................................................13
4. What could you do to make sure you're aware of it and ways to manage it well?..............14
Utilising boundaries as a means to grant autonomy to the client.........................................14
Behavioural experiments......................................................................................................15
Using time as a tool for boundary management..................................................................15
Using contracts to define boundaries...................................................................................16
Fee as a boundary.................................................................................................................16
Working within the boundary of competency......................................................................17
BIBLIOGRAPHY....................................................................................................................18
1. Issues of boundaries - what are boundaries & how can they be defined?
McLeod gives a general definition of a boundary as a demarcation line to separate territories

(McLeod, 2013). However, boundaries in professional therapy are not physical and do not

demarcate a physical structure. There are no lines, posts or markets. As Guthiel and Gabbard

(1998) puts it, in counselling boundaries may be defined as the envelope within which the

therapeutic treatment occurs. There is a lot of insistence that the treatment must occur only

within the envelope and not out of it, as it would be counterproductive to the treatment. We

shall discuss this further later.

Lack of definition of Boundary

There is consensus among the scholarly community that there is a dearth of definition of

boundary in the context of clinical psychology and therapeutic counselling. Even after far

back as 26 years ago in 1993, Gutheil and Gabbard (1993) could not find an adequate

definition and commended that the term was too broad to be contained in one particular

definition. Zur (2010) remarks about the difficulty in finding such a definition in literature

and that psychotherapy has always had a tough time defining boundaries.

Recently there has been much research into an obvious but gross violation of boundary that is

sexual violation. However, this is really a narrow field, and even though quite serious does

not present any new opportunity for research.

Webb, (1997) advises that we should look at the boundaries from the counsellor’s perspective

more instead of the clients to get a better idea, as the conventional models of boundary

studies have always focussed on issues of boundary management and prevention of

violations.
Importance of Boundary
Boundaries are an important tool to get a sense of the kind of relationship that exists between

the counsellor and the patient. It helps to draw out the limits and define the parameters of the

relation. Although boundaries were not used traditionally to test the quality of the

relationship, recent studies are being conducted in recognition of it as an important tool.

McLeod (2009) notes that there is a rising debate amongst the community concerning the

consequences of using boundaries to define the counsellor patient relationship. The idea of

boundary essentially says that there is a limit to which a person can be test and beyond that

limit there is a ‘violation’ or ‘transgression’ in a relationship which can even result in medical

malpractice. It is thus very important that the counsellor addresses the issue of boundaries

with the client during the first meeting itself or whenever appropriate at the earlier. This is not

only for the protector of the counsellor but also the client so that he may be able to feel in

control, take a judgment call and generally be more open during the therapy session.

Types of boundaries
Structural Boundaries

Structural boundaries may be said to be the rough set of rules that we understand to define a

relationship between a counsellor and a patient. They are the ground rules that holds together

the civility and legitimacy of the relationship and the process of counselling. As Smith, et. al

(2012) states, some examples of structural boundaries are limitations of time, frequency of

allowed visits, underlying contract, confidentiality issues, fee, time of day, etc.

As McLeod (2011) puts it when the client wishes to have a session and explore and issue in

depth, one the first things to do before starting a session is to allocate a safe space not just

physically but also set the limits in terms of issues, time, confidentiality, etc.
Rigid v. Flexible Boundaries

McLeod (2013) characterises rigid v. flexible boundaries to be permeable or impermeable.

There is considerable debate in the community regarding which approach to follow. Scholars

such as Jacobs (2010) considers it prudent to adopt rigid and impermeable boundaries

arguing it is for the client’s own safety. However, others such as Prever (2010) considers

flexibility especially important to bring about a positive impact in the therapeutic process.

Arguments on both sides can be appreciated. Proponents of the flexible system argue that it is

better for creating a more organic and human system. Extremists of this line of thought even

propose that the entire idea of boundaries itself should be done away with as it would stifle

the vocation of therapy (Mearns and Thorne, 2013). On the other side scholars such as

Reeves (2015) considers the fact that flexibility fails to offer a uniform experience to the

client (such as extension of time of the session) may actually harm the efficacy of the

therapeutic process. It is however inimical to insist on siding with one line of though or the

other because in reality most situations offer require a mix of rigidity and flexibility. As Ryan

(2010) notes, the degree of mixing would depend on professional instructs of the therapist,

the objective of the client and circumstances.

Interpersonal Boundary – Davies (2007) notes that interpersonal boundaries differ from

structural boundaries in that they arise from the relationship between the therapist and the

client whereas structural boundaries such as confidentiality and time define the terms of the

relationship itself. According to Gutheil and Brosdky (2008) these are pragmatic but

individualist factors. Examples are the training received by the therapist, the cultural

differences between the parties and the pre-conceived notions about the role of the therapist

due to that difference. Interpersonal boundaries also may be defined in the social context. In
other words questions like does the therapist know the patient outside of counselling, are they

related, intimate, sexual, etc. define also define interpersonal boundaries.

Intrapersonal Boundaries:

The concept of interpersonal boundaries delves into the psyches of both the patient and the

counsellor. Mostly recognisably it can be explained by taking the concept of id, ego and

superego which reigns of different levels of consciousness, semi consciousness and

unconscious states of mind which influence our sense of right and wrong or acceptable or

unacceptable from a visceral sense.

2. How boundary might be a difficult/challenging issue for you or the
counsellor/therapist in general?

Coe (2008) notes that even though the issue of boundaries is one of the most important and

crucial issues in the practice of therapy, comparatively very little practical advice, guides or

manuals is available in the market to tackle this issue. Coe further notes that this lack of

inexperience becomes an especially difficult challenge when the professional has to deal with

special needs groups such as children instead of regular adults.

Further, as Olsen (2010) remarks, the nature of counselling is such that it is conducted in

private due to privacy, sensitivity and confidentiality issues. This results in very little advice,

supervision or oversight being available to counsellors on the field and forces them to reply

on their own gut feeling and professional experience. Some help in clearly identifying and

constructively utilising boundaries is thus the need of the hour.

The psychotherapy relationship isn't just close, it is likewise delicate. The advisor has the

expert obligation to keep the customer's prosperity as the essential focal point of the

relationship. At the point when a psychotherapist dismisses this obligation, a lapse or

violation of boundaries is probably going to occur. The therapist must always remember that

he or she is not the friend of the client. He is a doctor and the client is the patient. When these

lines blur, and the relationship crosses over to the dimension of affability, the interest of the

patient may be jeopardised. Even though in retrospect it is clear to see as such, at the time,

moments of boundary lapse are difficult to recognise by oneself. For e.g. It has been seen

from research that poor limits, explicitly those that end up in sexual connections, are awful

for clients. (Bates and Brodsky, 1989)

Ethicists like Gabbard (1998), has argued that if unchecked, the loosening of boundaries may

have a kind of domino effect, and they can unwind the entire therapeutic relationship.

However, the real challenge is that in reality it is difficult to maintain such rigid patient

doctor boundaries. As remarked by various scholars and practitioners that it is essential that

boundaries must be flexible keeping in mind patient to patient variation and tolerance.

(Austin et. al. 2006). One of the greatest practical difficulties in maintaining this distance

between the doctor and the patient is the fact that outside of the doctor's chamber the

counsellor has a social life. No one lives in isolation as a hermit. Thus, it is often observed

that the paths of therapist and the counsellor cross in real life. It is up to the therapist to judge

whether to acknowledge this encounter and engage in it, or to avoid it. For e.g. some

counsellors could even leave a restaurant immediately if they saw patient over there. There

rule of thumb is to consider whether there could be any benefit from the client in this out of

the chamber encounter; or at least, if there could be any harm. This judgment comes with

practice and experience and is one of the real intangible challenge of the profession.

Some clients are very boundary conscious

Dr. Hartmann (1997), conducted some studies and social experiments to find out the degrees

of boundaries in different people. He concluded that most people have varying levels of

boundary sensitivity which he described as ‘boundary thickness or thinness’. Thus, what may

be acceptable or therapeutically efficacious for one client may not be so for another. As

McLeod (2009) puts it, every person on this planet has a central fault that they struggle with.

Michael Balint, the famous psychoanalyst calls this the “basic fault”. Basic faults can be

things like pessimism, depression, despair, guilt, etc. However, some clients struggle with the

basic fault of living in fear of people supposedly encroaching on their boundary. For such

kinds of people, it is obviously very dangerous to go forward with the therapy session without
briefing the patient in details about what the boundaries are – it might be helpful to adopt a

more ‘rigid’ approach initially in such a situation – for the protection of both the patient and

the professional.

The need for boundaries in high level counselling

In embedded care centres like such as hospitals, healthcare centres or doctor’s chambers,

there will always be special or difficult cases where the matter may be felt should be referred

a specialist or a consultant instead. In specialist counselling offices, extra care is taken to

maintain clear-cut boundaries and present a strict and professional image before the client.

While it is obvious that details are written in the contract before start of sessions, it not

uncommon to hand over or put in view of the client leaflets and brochures explaining to the

client about confidentiality and the exceptions of it whereby the client runs a risk, strict time

lines or even topics of discussion. This is because in embedded care systems, usually the

patient would have personally been acquainted with the care givers and know the terms of

their relationship and the personal human nature of the caregiver. So, the client is in an

empowered position to take a decision himself on what should be appropriate to divulge and

to what extent. However, specialist cases are transferred cases where the specialist does not

know the client or the full history. Thus, restricting the terms and topics of discussion

becomes absolutely essential.

A few clients might be more hesitant than others, with regards to clarifying their challenges,

and therapists must know that these people require a touchy methodology. By offering

consolation, sympathy and validity, customers will turn out to be progressively agreeable in

an advising domain. Connecting with the client is just conceivable once they are adequately

loose and agreeable.

Utilizing open-ended inquiries additionally energizes a reaction from a client, and should

frame a noteworthy piece of the guiding content. The connection between a therapist and

client depends on a unilateral discussion. It is the instructor’s mandate to effectively tune in

and delicately challenge the customer, where fitting and this is extremely difficult.
3. If you are not aware of it or don't manage it well, what could possibly
happen to the counsellor, the client and/or the counselling
relationship/process?

Having a good understanding of boundary issues that can crop up during sessions and

because of the different temperaments to each client is very essential to build a successful

practice as a therapist. A lack of defined boundary management practices qualified by

professional flexibility to a limited degree as gauged by experience would can lead to a loss

of clients and reputation to the extent of legal action in a court for malpractice or violation of

privacy, losing of professional license, disrepute and personal feelings of inadequacy.

Boundary crossings vs. boundary violations

According to Glass (2003) are boundary crossings are acceptable and benign that venture a

little beyond the established standards of practice already defined, in an attempt to provide

the patient with a little more personalised and creative care. According to Gutheil and

Gabbard (2013) these don’t result in any lasting harm to the patient but in fact, if undertaken

correctly, would result in therapeutic benefit itself and may be in support of specialist and

advanced treatment.

In contrast boundary violations are not at all benign, but are threatening – which the client

considers as violations of their personal space. It does not result and a therapeutic benefit and

will actually be detrimental to the counselling effort. The client may consider it as an

unforgivable violation of their personal space warranting a termination of their arrangement

with the therapist, even to the extent of suing for malpractice also. In the larger concern, this

can put a permanent scar in the mind of the client regarding the counselling process and make

result in him opting out of the mode of therapy itself.

Counsellor protection
The majority opinion about boundaries in therapy is that they exist to protect primarily the

interest of the client. It is not surprising that this is the prevailing strain of thought, as the

client is seen as the weaker on in the relation with the counsellor or therapist at a possible of

power and influence. However, modern scholars such as Kent (2013) remarks, boundaries are

not only established for the protection of the client but rather of the counsellors too. Bond

(2015) even states that sometimes protection of counsellors is necessary in case of situations

of extreme emotional outbursts from the clients which can put the counsellor even in the way

of physical harm. Proctor (2014) thus argues that for management practices to be holistic and

encompass the viewpoints and needs of all parties, the need to protect the therapist is as

important as the protection of clients and this should be included in an ethical standard guide

for clients as well.

Malpractice Litigation
Negligence in maintaining boundaries is a main source of malpractice suit. Boundary

infringement take numerous structures. Sexual contribution is a repetitive issue that can cause

genuine damage. (Weinberg v Board of Registration in Medicine, 2005)

Indeed, even without sensual physical contact, material boundary intersections can, in any

event, obliterate or meddle with treatment, and at most, harm the patient and lead to case. For

the most part, boundaries are damaged by any demonstration that changes s the shapes of the

therapy relationship.

A moral infringement alone might be deficient to establish a noteworthy break of obligation

or standard of consideration. An infringement of a group of morals or a disciplinary standard

isn't in itself considered a noteworthy breach of duty of care or professional duty (Fisherman

v Brooks, 1986).

Likewise, with rules and guidelines, if an offended party can demonstrate that a disciplinary

principle that was proposed to ensure the person in question was damaged, that might be

proof of negligence. While carelessness gives the standard premise to malpractice case, other

lawful speculations may likewise bolster such suits, including rupture of guardian obligation,

attack of protection, ludicrous behaviour (careless infliction of extraordinary emotional

trauma)

In conclusion, malpractice suit is troublesome for clients and counsellors alike. Its obtrusive

viewpoints influence ameliorative treatment; continuous patient-advisor, individual, and

familial connections; and expert notorieties and employments. Its deferrals, cost, passionate

tolls, and inborn vulnerabilities recommend that it is in light of a legitimate concern for all

gatherings to determine such debate before starting suit or as right on time as possible after

case has started.

4. What could you do to make sure you're aware of it and ways to manage
it well?
It is very important that counsellors are aware of boundary demarcations and ethical

standards and key understanding of boundary issues as it is one of the most common areas of

complaints from clients against therapists.

Jenkins (2003) conducted a study concluding that dilemmas arising from boundary issues

and client complaints can challenge the competence of the counsellor and threaten their sense

of accomplishment. Theriault and Grazzola (2005) describe feeling of incompetence as

moments when a counsellor loses faith in his ability and judgment so much so that his

effectiveness and proficiency is reduced or diminished. These feelings invade both novice

and experienced therapists.

However, the effective management of boundaries allows it to be utilised as a tool to achieve

therapeutic relief and its understanding is crucial to therapy management. (Amis, et. al. 2017)

Utilising boundaries as a means to grant autonomy to the client

Saintfort (1991) suggests that one of the major causes of stress during therapy for the client is

a perceived lack of control over the flow or content of the conversation. The effect of this

perceived lack of control is the client distancing himself from the session, developing a sense

of defensiveness and mistrust towards the therapist, and harbouring feelings of negativity that

the therapist is not working for the benefit of the client. Other than making the session

unproductive control issues are also morally unethical practice for the therapist. It is thus

encouraged for the therapist to relinquish some amount of control to the client to promote his

sense of control and empowerment that will reduce stress and bring about openness and
comfort. Relinquishing control in favour of the client increases the willingness of the client to

participate and increases the productivity of the session.

Behavioural experiments.
As suggested earlier, a uniform standard of boundaries cannot be applied to all persons

because everyone has a different saturation point. It is thus important to find the threshold of

each client to allow maximum flexibility to optimise openness but beyond which point issues

of boundary violations may arise. ‘Behavioural experiments’ may be conducted by therapists

similar to ones conducted by Bennett-Levy, et. al. (2004) on clients at different stages of the

counselling process to find their varying thresholds. For examples, clients with issues

regarding over-sensitivity to personal boundaries were made to sit close to or farther away

from their therapist, an agoraphobic person was made to endure counselling in a locked room,

a client afraid of the outside was made to take bus journeys to close and faraway destinations,

etc.

Using time as a tool for boundary management

We have already discussed above in the session of time as boundary, how the limitations on

session time can be a practice of ethical autonomy to remind the client that the session has a

specific purpose which is not to be mixed with life in general and this only specific topics

should be discussed in the session to achieve a definite objective or therapeutic effect. Elliot

(1991) suggests the further breakup of the session time into smaller units such as turns for

each person to speak which can last for maybe as short as a couple of minutes for each

person. According to Elliot these small strips of time can be ventured as a ‘micro-process’

and the systematisation of the events in such a way can itself give a therapeutic benefit for the

patient.
Using contracts to define boundaries
A 'counselling contract' or an understanding shared between the advisor and the client in

which the outline of the boundaries of the therapeutic relationship is demarcated. A contract

guarantees that the guiding procedure will be performed in a decent, protected and proficient

way and features the obligations of the instructor towards clients, just as the duties of the

client towards the advocate. A contract is likewise a straightforward reason for educated

consent of the client (Dale (2003:4))

Ordinarily, an advisor will verbally exhibit the real purposes of the contract before sessions

initiate to guarantee their client is content with the terms of the work that is be completed.

This underlying verbal introduction empowers the clients to make inquiries and illuminate

any focuses inside the agreement on which they are not clear. The advisor may then present

the talked about subtleties by means of a composed record that will be marked by both the

instructor and client.

The contract shouldn't be an extensive report. It is typically a solitary page (most extreme two

pages) long and contains a rundown of things that are essential for making a sheltered, secret

and expert advising administration.

The use of contracts to establish boundaries is very common. A contract helps in defining the

difference between the counselling session and other relationships in general and provide a

sandbox framework within which the define and encompass the process of counselling. We

have already discussed how contracts are essential from a legal standpoint to avoid
malpractice and can be the easiest way to move the clients towards realisation of ethical

autonomy especially in a specialist or consultant situation.

Fee as a boundary
Some scholars such as Herron and Sitkowski (1986) have argued that the practice of taking a

fee for each session can be viewed as an instrument of defining boundaries. The thought dates

back to the era of Sigmond Freud who proposed that fees themselves have an element of

sacrificial nature to them. A fee ensures that the patient has some ‘skin in the game’ and

signifies that he is willing to take the session seriously. Thus, to achieve this objective it has

been proposed that fees charged should be variable in nature depending on the affluence of

each client – what may be acceptable to one may be exorbitant or unaffordable to another.

Cerney (1990) suggests that the sense of seriousness provided by fees itself has a therapeutic

effect in themselves and thus the process is actually beneficial to the client and the

counselling process.

Working within the boundary of competency

One specific kind of intrapersonal concern for the therapist is the boundary of competency.

As Bond (2015) remarks, it is important that therapists confine their activities and discussions

in the sessions to the actual professional competencies that the therapist is trained in. Factors

such as knowledge, skill and judgment would factor into this concern. If the Counsellor bites

more than he can chew – for eg. ventures upon an area which should have been referred to a

specialist, the therapist puts the safety of the client in danger by mismanaging the afflict of

the client actually advising him of the wrong thing. Professionally, this is especially of

concern as it would make the therapist liable to the extent of malpractice or predatory

practice and may put the credibility of the whole organisation or association at risk.
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