Setting Firm Boundaries With Social Agencies

In a recent blog entry, I described a situation in which I had set a boundary with an agent of an outside child welfare group not to attend a therapy session with a woman with whom we both worked. 

A commenter noted that I might have allowed the social worker to attend the meeting “as long as the patient agrees in advance, especially when the patient is physically present in the room when the information is exchanged.” The obvious reference is to the supposed notion of giving the patient a choice, an appeal to the patient’s autonomy. But there are two things wrong with this line of reasoning. 

First, many patients come to therapy precisely because they have been socialized to suppress their own wants and needs. Well, you say, wouldn’t this be just the thing to build her autonomy, to offer her the option of agreeing or refusing the meeting? I see this as offering a Hobson’s Choice, that is, a situation in which you are supposed to make a choice but you do not have a real choice because there is only one thing that you can have or do. Another way of phrasing a Hobson’s Choice is, “take it or leave it”; in reality there is no choice at all. 

In this case, the woman was under the gun of child protective services, not for anything she had done, but for being married to a man whose son had abused her daughter. This woman lived in fear of losing her child unless she complied with anything asked of her. To ask this woman to agree or refuse a plan when in fact she really felt she had no choice actually negated rather than enhanced her autonomy. 

We therapists need to be exceedingly careful when we propose things that supposedly help patients grow in autonomy. We must be sure that we are not putting them in a double bind, seen by psychoanalysts as at the heart of psychosis. 

The second thing wrong with the line of reasoning taken by the commenter had to do with my refusing to allow a situation in which I was asked to collude with the authorities in exerting power over her decisions. As I told the commenter who said I had been rigid, “…yes, I was being rigid: I have a firm boundary against being used as an instrument of social control in the name of "helping". 

The social worker had already made an appointment with a therapist at the community mental health services—who I assume was more amenable to a role as a social control agent—and my assumption was that the patient kept the appointments and either jumped or didn't jump the hoops set by social services. But I was determined to set boundaries between social control agencies —which I acknowledge are needed—and the therapeutic environment of my office. 

This situation also challenges us to reflect on the power differential in therapy, a topic I’ll discuss in the next blog.

Leslie Durr, PhD, RN, PMHCNS-BC is an advanced practice psychiatric-mental health nurse with a private psychotherapy practice in Charlottesville, Virginia.

The views expressed on this blog are solely those of the blog post author and do not necessarily reflect the views of Psych Congress Network or other Psych Congress Network authors.