The Rules of Therapist-Client Boundaries, and When to Break Them

When you decide to become a therapist, you do so for many complex, and often personal reasons.

Many future psychologists will fall in love with the study of the brain and behavior when they hear the captivating—although undeniably unethical—story of a little boy named Albert who was given a phobia of a white rat by two bored scientists who had a nine-month-old child in their care and the power to see what they could accomplish by pairing loud noises with a white furry object.

Others fall in love with Freud's psychoanalytic theories, the tales of drug-fueled dream analysis that center around complex and disturbing family issues and illicit sexual fantasies shunned by society.

Personally, I have often wondered how many of us ended up in the mental health field in order to fix our own past, our own past selves.

Why had someone not shown up in our childhood to give us the support that we needed? And is this the reason we choose to help others?

Perhaps. Nonetheless, for one reason or another, there are so very many of us that are in the mental health profession.

To be a psychologist, we attend four years of college, followed by five years of graduate school, where we are force-fed stringent rules about doctor–patient boundaries—some of which are logical and clearly intended to protect the privacy of the patient, while others come off as cold, hollow, and slightly bizarre.

When I went to graduate school, the following rules were quite emphatically drilled into my head:

1. If you see your patient in public, do not acknowledge that you know them, unless your patient acknowledges you first. Even then, eye contact and conversation should be kept to a minimum, and, obviously, it would be wildly inappropriate to disclose the professional relationship.
2. Upon first meeting a new patient, it is considered quite rude to ask your patients if they had any difficulty finding your office, since this implies an expectation of weakness on their part. Unfortunately, as it so happens, it is extremely difficult to find my current office, due to poor construction and inadequate signage. Also, my current office space used to be a series of homes. For all of these reasons, it is not unusual for me to have to guide a new patient to my office by flagging them down as if I am an airline employee working on the tarmac waving two large red glowing sticks of light. On the off chance that some lucky soul does manage to find my office without having to call in the coast guard, I am, in fact, fascinated and curious about how they managed this task.
3. Silence is golden. (As opposed to awkward.) Yeah…If your therapist starts your session in silence, they’re just following instructions. Many graduate school programs are trained to encourage that awkward waiting room silence that in my personal life makes me blurt out every random thought that enters my brain. But…the point of therapy is to learn to sit through the difficult moments and to grow comfortable in learning how to survive the unpleasantness that life will throw at you. This is because the reality is that life is probably going to hand you more unhappiness than happiness, and there won’t be anything we can do to stop it. Although it doesn’t seem very fair, or just, Karen Horney, a German psychoanalyst, had a very simple explanation for this: We are born alone and helpless in a hostile world. We are born alone. And in those beginning moments of therapy, you will feel alone. It will be up to you when and where to start. Even if it feels uncomfortable. Especially if it feels uncomfortable. But, with a good therapist, odds are that you won’t feel alone for very long.

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The therapeutic relationship isn’t meant to last forever. Patients become parents or grandparents, with growing responsibilities. Therapists move to different states, countries, or time zones. We grow up. We grow apart. We change. Can I tell you a secret? The end of the therapeutic relationship is hard for the therapist as well. A few weeks ago, I discovered a tremendous billing error that had occurred with a company I had relied on for the past three years to handle the majority of my patients. As a result of this, and feeling somewhat embarrassed, I had to reach out to several of my former patients to inquire about their insurance information from years long past. And I found the experience to be an absolutely lovely opportunity to be forced to reconnect.

It was wonderful to break this rule about saying goodbye and not looking back.

One former patient was about to board a plane from Iceland to Morocco, taking the trip of her lifetime that she had always spoken about. Another had purchased a gorgeous home that just so happened to have permits for a bed and breakfast—something he had never thought about doing, although, as soon as he told me, I knew it would be a perfect match for him since he had always been such a natural people person. Another patient who had moved after going through a rather rough breakup shared with me that she was married and pregnant with her second child, and one more patient mentioned that she and her fiance had broken off their engagement, and she was confident that it was the right decision.

Your therapist doesn’t always get to see your happily ever after ending, and our job is structured like that for a reason. Psychology is a science, just like any other, with a beginning and an end date of treatment, albeit one that you, the patient, get to decide. And this wonderful, accidental peek I was gifted into my patients' lives as a result of a billing error, was a much-needed gift after several difficult years for both patients and therapists.

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