Monday, August 11, 2008

Therapeutic Boundaries

My telephone voice mail message asks that people leave their name, phone number, and convenient times to be reached. Patients get my cell phone for emergencies. I want to hear from them before they jump off a bridge.

And it saves me from hearing that complaint, "You don't return my phone calls." This way everyone knows the cell's tied to the hip. They can leave a message if they get voice mail and have a fairly good chance of reaching me.

Like many therapy docs out there, I have a solo practice. There is no middle person between me and my patients. Consequently messages have a fairly good chance of drowning in my work drawer. Occasionally I open it; this keeps me straight.

Thankfully, patients tend not to overuse the cell phone privilege. Everyone knows that minutes aren't free; there are limits to all good things in life, and I communicate therapeutic boundaries pretty well.

Patients know, for example, that we're not friends, unless, of course we are.* Everyone tends to feel like friends by the end of the day in therapy, unfortunately, so we have to watch this, hold to a fairly solid black line, a good boundary between us.

This is a lot easier than you might think. The limits of a therapeutic relationship are spelled out, often with words, words like, I don't like to talk on the phone. I need to see you to feel you.

And yet. . .it's not good to get too rigid about things in life. Sometimes the boundaries have to be permeable, and you know I'm all about elasticity.

The Story

One evening I had a definite need for some space from my practice, didn't want to hear from anyone. So before I even left the office, I made all of the calls that I knew needed to be made if I wanted any special uninterrupted time with the tube.**

I hadn't watched television in weeks. Nobody was home. I had the remote. It was exactly as good as it gets.

A good hour passed and there I was in the same position, water glass ready to spill, exercycle ready for a spin, should the spirit move, and yet another Law and Order about to start.

My phone rings.

It is the one patient I really had wanted to hear from, the one I thought for sure I would have heard from earlier. But here it is, 10:00 pm. This is against the rules, basically, for non-emergencies. Who can think straight at 10:00 pm?

I answer.

He says, "I hope it's not too late, I'm so sorry."

I go, "Well, actually, it kind of is. You think we could do this first thing in the morning? Maybe 8:30?" In the past he's called me early in the morning, earlier than 8:30 am.

He hesitates. "Well, all right. Maybe that will work."

But I read that hesitation, worry a bit. We hang up and a moment later he calls back.

"Oh, I was trying to reach someone else. So sorry."

And I go, "No, no, don't hang up. Let's talk."

"Are you sure?" he asks guiltily.

"A hundred percent."

All of a sudden the television has turned boring and inconsequential and the human in me kicks in, the one that doesn't separate from the therapeutic community very easily. This person is sedated in the evening with the blogosphere or less virtually real things like books, newspapers, magazines, friends and family. And occasionally, television.

The patient says something absolutely extraordinary. He tells me that someone in their family has had a medical emergency and he and his wife have been called in to babysit. He has finally put the last child to bed, otherwise he never would have called me so late. He is also sure that there is no chance in ___ he could have called me in the morning. Little children don't exactly let you talk on the phone. They're really distracting. A simple three to five minute phone call turns into torture.

So hearing this, I'm glad he's caught me, glad he had another call to make. We talk a couple of minutes and both feel better about how to approach his treatment plan.

A few minutes is usually all this takes. And yes, I have to be grounded, in the mood. I won't even answer the phone otherwise, not usually. Professionalism is about being nice.

Like everything else, therapeutic boundaries are best when they're elastic, flexible. Rules are made to be broken. We use our sixth sense to know when to break them.

Obviously, you still need to put up fences if you're a therapy doc. You need benchmarks. Boundaries need to be nicely drawn with wide-tipped, Marks a Lot markers, but we leave spaces, occasional perforations.

And you know, it's not necessary to suffer through another television show, just to make the point.

therapydoc

*You wouldn't think of giving your friends professional advice unless you've been in practice for about a hundred years.

**Televisions used to have these things called "picture tubes" so you might hear this expression, to this day, from those of us forever trapped in our time warps.

27 comments:

Mark said...

Great decision, I am sure that you both slept better that night.

Funny how the "tube" is out of sync with the American lexicon, who would have thought?

therapydoc said...

A quick explanation. When I said I need to see you, feel you, I don't mean feel as in physically touch anyone. Like, ever.

porcini66 said...

I have been grateful for the perforations more than once, as without HIS perforations, I likely wouldn't have allowed any holes in MY armor either. And he sensed that and went with it. Funny thing is that as we have grown together, neither of us would think of abusing the other - the relationship that we have is just too.. intimate.

It's an amazing thing, what you do. Thanks.

Deb said...

Great post and such an important topic!

porcini66 said...

Oh, and I meant intimate in the good way! Not as in "intimate", but ya know,intimate as in close, trusting, cherished, treasured. Just wanted to make sure that was clear...

Syd said...

I think that it's great that you talked to him. You never know how you might have helped someone.

Jay said...

Thank you for articulating something I have always known but could never explain - the need to maintain boundaries and keep them flexible. Quite a balancing act we do, but so worth it.

ilanadavita said...

Thanks for sharing this story. i am sure your patients appreciate your flexibility.

WeightingGame said...

only once have I used the "in case of emergencies, call 911 or I can be reached on my cell at..." And I wholeheartedly believed - and still do - that it WAS an emergency. My then-therapist answered and helped me in a very critical time and I was so grateful. But then...I got a bill. A very high bill, for that half hour on the phone. I felt hurt - I know he's running a business but for some reason, I felt taken advnatge of, like he was charging me double for an impromptu phone call. I'm over it now, but just hadn't thought of it until this blog!

therapydoc said...

Yo, WEIGHTING: I'll do that, too, but it has to be planned out first. That surprise bill isn't right.

But if a therapist does this, telephone therapy, we really can't bill insurance (maybe it varies state to state), and the patient really is using the doctor's time for free. This is what we do, attend to you. We aren't shooting the breeze. We're doctoring.

This is why some of us tell patients in advance that they have to keep their phone calls short, three to five minutes. Otherwise we come to resent them for stealing our time, and that's never a good thing, but it's a reality.

wendy said...

I find myself going back and forth, is it an emergency? or is it only an emergency to me? what if I don't call and everything goes to hell, what if I do call and she doesn't think it is significant? So I don't call and somethimes I make it through alright. Other times, I end up in the emergency room wondering how the hell it came to this.
The boundaries are so difficult for me to find, even if they have been marked with huge brick walls... Always a challenge...
Strange, I was just thinking about calling and saw this blog this am - I think I will wait - I remembered it is her day off...

therapydoc said...

Wendy, that's the crux of the matter. It's not about (to me) whether it's an emergency or not. It's about respect for someone's life.

This is so terribly hard, so difficult a concept, I fear. Are we supposed to feel less than because we want to talk to someone and we can't?

Life's not fair in that way. This is where you grow, however. (You, meaning any reader).

You say, I can't go here, but I can go there. You find something else to do. You build self. Learn something, go somewhere.

Add to you.

You don't need to pound on the same old doors for attention, you need less than you think. And if you pound too much, it's likely the door will shut permanently and you'll get hurt.

This is the essence of giving. Space, a huge, huge gift. Again, a very, very hard concept for many people to grasp, for reasons way to complicated to go into right now.

SeaSpray said...

Interesting post and you sound like a skilled and compassionate therapist.

My wonderful counselor gave me extra time, took calls and was there for me beyond sessions. I had been going through a rough time in my marriage and I feel that I grew up in his office. I started seeing him when I was 28 because of my difficult marriage but I also ended up doing work on myself because of my dysfunctional background. (dysfunctional was used so much in the 80s..do they still say that?)Does the name Woody Allen conjure up any ideas for how long I went to this doctor? ;)

I owe him a lot. He is one of the key people in my life that has affected me profoundly for the better. i learned so much.

I believe there was transference and counter transference. I say that because I used to tell a friend who was a counselor about our sessions and that is what she thought. Have you ever written on that subject?

There was a time when I thought I could not go forward without him in my life and then one day, I announced that I thought we went as far as we could because i was helped and I knew I had things to do that I wasn't willing to do at that time. He seemed taken aback. I said I would come back after some time away but never did. I amazed myself.

I had written pros for him once and the following is from the latter part of it:

"And yet, I wish there was something I could do for him... I could pray for him and care at a distance.

But most of all... proclaiming my independence would be the greatest gift.

Then he'll know his work is done..and I'll be finally free.

And I'll forget my special friend... the friend I never had."

I actually wrote that for him at a time I couldn't imagine not going to him but I knew that was the goal because we would have accomplished what we set out to do.

Sorry so long... delete if you wish. :)

I love how you write and teach through your posts. :)

Thank you! :)

Anonymous said...

Taggi

Allctheyears I've been in therapy I have never called her SOS.
I justthink I cancope on my own and there is not much she can do.
Its not a medical emergancy

therapydoc said...

Seaspray and anyone else who is interested,

Independence surely is the goal. Family therapists like me might say, however, just like a functional parent might say, after launching a child,

You're good. Call me if you need me. People go through stuff.

And what I mean by that is, even when you're independent, you go through stuff.

So like, I never "terminate" forever, not usually. I say, assuming we're all still here and you still have my card :)

bluejeansocialwork said...

I think you got it right on the money with this post about boundaries. Expressing the rules at the outset is essential--I learned that the hard way by not doing it. Once some level of comfort is reached in practice, it feels good to have the flexibility to bend the rules as necessity or compassion dictates. Thanks for the post.

SeaSpray said...

That's a nice way to leave it TD. I don't remember (It was 1996) how we left it. knowing me...I must've said that I would come back if necessary but I don't remember. I did talk a couple of times on the phone about a concern for older son but that resolved too.

I wonder if I hurt him by just disappearing? I never thought I could do it but one day I just got thinking about it all, recognized all that was accomplished and that there was an impasse that I wasn't willing to cross over. It was kind of an epiphany moment and was birthed from within. It just happened.

I had given him many cards and little gifts over the years and it was obvious that I adored and respected him.

I know he was fond of me. I wonder if my abruptly doing that hurt him? Even though professional...I would think there is still a close bond in a productive, mutually comfortable therapeutic relationship.

He retired and moved but if I knew where he was, I would right him the best thank you letter I have ever written in my life because I have much to be grateful for from having worked with him. Maybe someday I will blog with all I have learned from that experience. :)

And I would want to tell him of all the things that are so much better now.

I think he would be pleased. :)

I hope he is experiencing much joy and blessings in his life. ;)

Kathy with a K said...

What an important post! Boundaries are a wonderful thing; and even better, are therapists who use them! Thanks for the wise words.
(I like your comments on "termination". Very helpful.)

Kathy with a K said...

What an important post! Boundaries are a wonderful thing; and even better, are therapists who use them! Thanks for the wise words.
(I like your comments on "termination". Very helpful.)

Yaya said...

This is a very interesting post. I've been seeing my counselor for 8 years and we are, ironically, neighbors. I didn't know this 4 years ago when we bought the house we bought that she lived right there. I thought it would be weird, but it's not. There are two sides, the friendly-neighborly-hello side and then the therapy side, depending on where we cross paths. I wonder if this is a stranger circumstance for her to deal with then it is for myself?

therapydoc said...

I have that, too.

I see people in my community as patients, relatively frequently, so we run into each other at the grocery store all the time. We tend to smile and say hi, just like we would with anyone else, and continue on with the hunt.

Anonymous said...

taggi

There was a time when I would see my therapist at the gym or Yoga class
or at the swimming pool which was wierd
but she was totaly ok.
She even asked me if I wanted to change therapists .

Anonymous said...

Taggi
Anon

I have a question

How does one deal with the cancelation of appointments ?(by the therapist)
How do you as a therapy doc handel such a situation?

therapydoc said...

Taggi,

This can translate into another example of disrespecting a therapist's time. But not always, and the art is figuring out what's what.

Such a big topic, I think it deserves its own post. I'll get to it, but you might have to remind me.

Anonymous said...

Taggi

I meant that the therapist has to
cancel an appointment, not the client.
(The therapist said its due to family reasons).

I do understand that the therapist is human too with his or her own issues to deal with but...

Anonymous said...

Taggi

I meant that the therapist has to
cancel an appointment, not the client.
(The therapist said its due to family reasons).

I do understand that the therapist is human too with his or her own issues to deal with but...

therapydoc said...

We'll talk about that, too. Thanks, Taggi