Month: August 2014

On boundaries

A day or two ago, I found myself discussing the notion of ‘boundaries’ with my supervisor. It was an unusual discussion to have in some ways as I am currently working in neuropsychology. ‘Boundaries’ is one of those terms bandied about freely by mental health types and it usually refers to what you do/do not reveal about yourself to patients. So you might tell someone you’re gay if you think it might be useful therapeutically, or you might tell them that you’re not immune to black moods (it’s interesting how revelatory something like this can be). I don’t expect many people would tell their patients that they were HIV-positive, however, or that they were going through relationship difficulties or that they drank too much. Even when we speak of our real selves, we’re very boundaried about it.

The idea is that therapy is for the patient and that you, as the therapist, shouldn’t turn the therapy into your space. Some people believe in the ‘blank canvas’ therapist, who tells nothing of their life and simply absorbs what the patient has to say. Typically, this is the case in psychodynamic psychotherapy. In neuropsychology, where I assess people’s memory and attention and visuospatial skills and discuss the impact that multiple sclerosis or a stroke have had on them, there’s rarely a need to say anything about myself. It’s something that’s discussed much more frequently with supervisors and colleagues when you’re doing more typical therapy.

To my mind, boundaries are a funny old thing and I sometimes watch with wry amusement as we try to work out what is (in)appropriate to disclose. I have known people to tussle with telling a patient they are gay, but few people have reservations wearing wedding rings. Lots of people refer to their opposite-sex partners, unashamedly disclosing that they at least tend towards heterosexuality. I know clinicians who talk about their children; some who will, in certain circumstances, show patients photographs of them. I have no especial issue with any of this because all therapy is different. I have bonded with some patients over taste in films; others with my reasonable knowledge of 1960s rock music. When you do short-term work, which is increasingly the case in the NHS, you haven’t the luxury of building a relationship over months or years. You have to do it quickly. Successful therapy (I accept the vagueness of that term) is almost always accompanied by a good therapeutic relationship. For me, that is based on a common humanity.

But boundaries are about more than what you say or don’t say about yourself. They’re also about how you behave. This has been on my mind a lot recently, probably because, as I creep ever-closer to the end of clinical training and attain the dizzy heights of qualified status, I am trying to work out what kind of clinician I would like to be. I’d like to be a good one, obviously, but I don’t know how that’s defined. Is it based on whether my patients like me? Is it based on whether they turn up? Is it about whether they feel ‘better’ (more vagueness) or self-harm less often? Is it based on my assessment of my capability? Is it based on my flexibility?

Often in MH we focus on problems and therefore therapy is aimed at making problems smaller. That’s reasonable, but I have come to view that rather blunt measurement with some skepticism. As I said, a human science. The truth is that, post-qualification, I might not have the flexibility to do what I think the patient might benefit from, or the time to do the things they want to. The last thing you want to do as a psychologist is open up a can of worms, get a really good idea of the person you’re seeing, and then fail to address most of it because you can only see them half a dozen times. There’s a notion that there are no side effects from psychology; that we can do no harm. We can do harm very easily and it takes a lot of thought to try to avoid it. So perhaps as clinicians we need to focus less on doing ‘good’ and more on ‘not doing anything bad’. If we take that view, clinical practice might look very different. I might make my patients cry less because I focus less on the things that make them cry. I can still have a good relationship with them: we can chat, go to lunch, take walks. There’s evidence that these things can be therapeutic and, as we know, having someone simply sit and listen and give a damn is enormously beneficial to most people. Perhaps giving someone a lift to the dentist if they can’t use public transport is more help than asking them how many times they left the house last week. Maybe taking them to the CAB to complain about their crap housing is better than telling them to drink less. Maybe giving them the bus fare so they can see you again is better than telling them to only buy ten cigarettes. Is it the end of the world if I go to a coffee shop with someone and buy them a cuppa from my own back pocket? I don’t think it is. I think it’s a gesture of kindness and humanity. It’s more equal than the ‘I buy mine and you buy yours’ mentality that often pervades these things. Yes, there’s a symbolism to spending your own money on a patient, but two quid on a hot drink is hardly the same as a tenner on the horses. And why shouldn’t we? We often earn more than our patients; it’s unlikely to be financially catastrophic. As to the symbolism, perhaps it suggests that you think your patient is worth £2. It’s a gesture; it doesn’t need to become a habit.

It’s a mark of how entrenched the concept of boundaries is that this, to some, seems radical. As far as I’m aware, there’s no evidence which suggests that not buying your patient tea leads to better outcomes than buying it. Similarly, I doubt there’s anything out there to suggest that getting them to scrabble around for the bus fare is beneficial compared to driving them yourself. Maybe it’s less about ‘the patient’ and more about ‘the psychologist’. Having a patient in your car makes the division between work and personal life less clear. But to think that it’s set in stone is absurd: when you see a patient you’re probably also thinking about the fact you’ve misplaced your diary, or that you need to book a hotel for the weekend, or that you rowed with your partner that morning, or that you shouted at your kids or that the insurance needs renewing. The divide between personal and professional is more often drawn in sand. Given that, then, perhaps there’s room to reconsider ‘boundaries’ and whose benefit they’re really for.