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This post was co-written with Mitchell M. Handelsman, PhD, whose blog is "The Ethical Professor" and who co-authored the book Ethics for Psychotherapists and Counselors.
At the end of May we received this comment in response to a previous blog entry. Here is the heart of the comment:
"i(female) am getting some uneasy feelings, that my therapist (male) is overly concerned with his own boundary issues that he is reluctant to get too involved in my 'stuff'. he doesn't push the agenda, he just sits, he has commented too many times (3 or 4, a few months ago)about how he would not have an affair on his wife (leaving me feeling that my pain and vulnerability are leaving me too exposed and 'naked', with a married man in a room, the two of us alone). it makes me feel very uncomfortable, and that i am doing something wrong to make him need to state the obvious...and there is a big part of me that wants to scream WHO IS ASKING YOU TO, BUDDY!!"
"i am really trying to get well, to think straight, and his inconsistant, but often very hands off approach is just leaving this all really frustrating. i hate to leave, and i have never seen another therapist, so i guess i may just find something better. he is a nice guy, i think (?) he tries, i wouldn't say hard, but, yes, he often tries. what should i see??"
".... and then i am PISSED that he can't handle, maybe three phone calls during a VERY UPSETTING NINE MONTH PERIOD, to get a thought answered....without feeling like he needs to put up some boundaries!! and these were short calls!! two minutes!!! i am married!! give me a BREAK!! do therapists really think we are wrong to feel a bit of dependence upon them??"
We sympathize with this person's desire to have a good relationship with the therapist, the desire to "get well, to think straight," and her confusion about what the therapist is doing, about the boundaries between the client and the therapist, and about what good therapy may look like. We also know that our response won't be entirely satisfactory, because we can't say definitively whether the therapist is behaving ethically or unethically or whether the commenter should stay with the therapist or leave. To give such specific advice would be disrespectful of everybody involved, and unethical on our part! But we hope to say some things in this small space that will help our commenter (and others) think through some of the really important issues she raised.
The psychotherapy relationship-perhaps more than any other professional relationship-is very potent and very fragile at the same time. By potent we mean that it can be a relationship that really enhances your life and helps the client grow; herein lies the benefit for being in therapy. Whether the issue is mental illness, bad experiences, or problems in living, good therapy can help people make huge improvements in thoughts, feelings, and/or behavior.
Good psychotherapy means hard work by both the therapist and by the client. There is nothing magical about therapy or the psychotherapeutic relationship.
Getting better does not always mean automatically feeling better. Psychotherapy is rarely a smooth process. Like the stock market, it will have ups and some downs. But if there is a good match between the client and therapist, the therapy relationship is a healthy one, and the client is willing to make good investments (work hard, allow self to feel, make healthy changes), there will be a good pay off!
But remember, therapy is also fragile, by which we mean that the relationship is delicate and must be handled with care; that's one of the major responsibilities of the therapist. For therapy to have the best outcomes, it needs to occur in a safe place and involve an emotionally healthy relationship with a competent therapist. This is where the notion of boundaries comes in. The psychotherapy relationship can feel very intimate and similar to a good friendship; but it's not a friendship and it's not a two-way intimate relationship. The therapeutic relationship is really meant to be one-sided in very important ways: Psychotherapists are there to work hard for clients-but not the other way around and clients will most likely share some very personal information. Therapists, however, will not or should not reciprocate by sharing the same kind or level of personal information. Clients may feel dependent on their therapist for support, understanding, and expertise, but good therapy means this dependence on the therapist is transformed to self-confidence and the client's ability to cope with and even thrive in life and relationships outside of therapy.
When it comes to professional boundaries, the therapist has the ethical responsibility to keep them in place. There are problems in having boundaries too diffuse or too rigid. Sometimes it's hard to know what is just right, and often therapists and clients feel differently about the optimal type of boundaries. Therapists doing good work should be able to explain why they have and enforce the boundaries they have. And by the way, gender of the therapist shouldn't matter. Although clients may have preferences for a therapist of a particular gender (or cultural group), the key to good therapy is a good alliance between client and therapist, not necessarily gender, culture, etc.
One option for our commenter is to talk with her therapist about her concerns, and about whether therapy is working. Indeed, the best therapy often includes dialogues between therapist and client, on a regularly determined basis, that cover the following honest and hard questions : (1) Did we set measureable goals for therapy? (2) What are the goals? (3) How close is the client to achieving them? (4) If goals have been accomplished, what are the next steps for ending therapy? (5) If the client is not close to achieving the goals, what has derailed the process? (6) If the goals haven't been achieved, what type of referral should be made to another therapist (that is, if the client wants to keep seeking out therapy).
Another option, of course, is for our commenter to end work with her current therapist and shop for a different therapist. If she chooses that option, we would encourage her to think about the questions she would like answered about a new therapist and the type of work they would do before making a commitment. Here are just a few questions she might consider.
What kind of training have you received and what degree(s) do you have?
How many years have you been doing psychotherapy?
How long have you been helping people with my sort of problems?
Based on what I've told you about my goals and concerns, what therapeutic approach do you think will work best?
What kind of therapy do you do?
What are the most important ethical principles for you?
Therapy is a huge investment and being a wise consumer of psychotherapy is critical. Interestingly, although there are lots of books on other types of important investments in life (investing in the stock market or getting a college education) there are few books that really tell you how to get the best for your money in psychotherapy-including what to look for when shopping for a psychotherapist. And there are no books that detail the kinds of unethical and unprofessional behavior that psychotherapists may engage in, and the specific warning signs clients can look for.
We passionately believe, and hundreds of research studies show, that psychotherapy can bring about powerful and wonderful results. It can often be a life-changing experience. We have written in this blog, and will continue to write, about the types of questions to explore with the therapist when it appears that therapy is not being beneficial, the unique aspect of the therapy relationship, and questions to ask when shopping for a psychotherapist.
