A Test of External Boundaries: When Outside Entities Threaten the Therapeutic Relationship

In a recent blog entry, Dr. Durr  responded to commenter discussion about the best decision in the scenario described below.

Boundaries are a crucial element in patient-therapist interaction because they recognize the inherent power differential of the relationship and set a structure for the relationship, providing a consistent, predictable frame for the therapeutic process. 

The education—both basic and continuing—of all the mental health disciplines includes references to these boundaries within the patient-therapist relationship. When these boundaries are not adhered to, they may be called “boundary crossings” or “boundary violations”. 

Basically, boundary crossings are brief excursions across boundaries that may be inadvertent but can be purposeful if done to meet a special therapeutic need. Examples are: giving a supportive hug to a grieving client, lending a mindfulness CD to a client, or making a home visit to a bed-ridden patient. 

Boundary violations can result when there is confusion between the needs of the therapist and those of the patient. Such violations are characterized by excessive personal disclosure by the therapist or even a reversal of roles. Boundary violations can cause distress for the patient and damage the therapeutic relationship. 

So, therapists spend a good deal of time thinking about what might be called internal boundary issues of therapy. But what about external boundaries? Not too long ago, I had an experience that tested both my knowledge and resolve about therapeutic boundaries. 

A patient, Mrs. Smith, came to my practice referred by another client. She explained that she and her husband had had contact with the county’s Social Services Agency regarding an allegation of abuse/neglect relating to her stepson and Mrs. Smith’s daughter, both of whom lived with Mr. and Mrs. Smith.  Also involved with the children was a volunteer with an agency of court ordered special advocates for children (CASA). 

CASA is a child advocacy organization that seeks to provide trained volunteers to speak for abused and neglected children who are the subjects of juvenile court proceedings. It was created in 1977 in Seattle, Washington, to assist in obtaining information for judges and providing follow-up monitoring of court orders. 

A judge realized that he needed help in determining what was in the best interest of the children whose cases he had before him in court. He came up the idea of training volunteers to be advocates for abused and neglected children. CASA volunteers are citizens who want to help children; they receive intensive screening and in-depth training about abused children and how to speak for them. 

After our second meeting, Mrs. Smith gave me permission to let the social worker from Child Protective Services (CPS) and a CASA worker know that she was in therapy and how many times we had met, and she signed a release to that effect.  At our third meeting though, she stated that the social worker and the CASA volunteer wanted to attend one of our sessions to talk about goals for her. 

A few days later, the CPS social worker left a voice message at my office outlining that she wanted to attend a session to set some specific goals for Mrs. Smith and stating that other therapists were OK with this. 

Calling the social worker, I got her voicemail and left a message explaining that:

• I was happy to hear any concerns and goals she would like Mrs. Smith to work on as she also addressed them with her and
• I would be happy to continue to let her know that Mrs. Smith was coming to therapy and doing the work.
• It would not be possible for her to attend a meeting because of confidentiality issues, the issue of coerced treatment, and putting me in a position of dual allegiance as both a therapist and an agent of social control and
• I didn't know how the other therapists she mentioned who “are OK with this arrangement” don't have ethical issues with it and how they actually bill for the session, as then it is not psychotherapy. 

At our fourth meeting, Mrs. Smith expressed so much anxiety that social services would remove her daughter from their home that she wanted to do anything the social worker requested. She mentioned that the social worker had made an appointment for her with a therapist at the community mental health center, and we agreed that she would await that appointment and terminate our work for now. 

I sent a letter to the social worker outlining the above and that we had terminated due to Mrs. Smith’s fear of the consequences if she did not comply with the social worker and stated that if that plan did not transpire, and Child Protective Services were not holding the removal of her daughter to achieve its plans/goals, she could call me for further appointments.