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.