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Understanding Boundaries and Containment in Clinical Practice

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The authors propose to investigate the meaning and purpose of boundaries within and around the therapeutic experience. A boundary is more than a simple line delineating one space from another; it is an entity with properties that demand a response if they are to be negotiated. Boundaries circumscribe a space that can be viewed objectively, or experienced subjectively, as a 'container'. For the uninitiated, this therapeutic container can be difficult to penetrate. Even health professionals such as GPs and psychiatrists often do not know how to access psychotherapy organisations and their referral networks. Also, real constraints on the availability of counselling and psychotherapy within the National Health Service, and the cost of private sector services, may prohibit access to the help being sought. The book explores aspects such as the gradual evolution of therapeutic boundaries in psychodynamic work, boundary development in infancy and childhood, the role of the therapist's mind and the therapeutic setting, confidentiality and issues such as money and time.Understanding Boundaries and Containment in Clinical Practice is a volume in the clinical practice monograph series from The Society of Analytical Psychology. This series is intended primarily for trainees on psychotherapy and psychodynamic counselling courses, and for those who are newly qualified. These compact editions will be invaluable to all who wish to learn the basics of major theories derived from the work of Freud and Jung, from an integrated viewpoint. The authors are Jungian analysts trained at the SAP, highly experienced in both theory and practice.

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Chapter One: Why Boundaries?

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Why are boundaries, and the processes of containment, considered so important to psychodynamic work? Why set aside the same room and the same hour each week for counselling or psychotherapy? Why do the sessions last for a particular length of time? Why are we so careful about giving ample notice of holiday breaks? Those unfamiliar with the work might exclaim, ‘Surely clients can cope with some irregularity!’ In fact, might it not be better, as the wider culture and the media so often tell us, not to encourage too much dependency in this way, particularly in focused, shorter-term work? This chapter explores some of the thinking and assumptions behind these patterns.

Initially, Freud conducted his investigations much as a medical doctor. For example, in the case of Frau Emmy von N, he ‘ordered her to be given warm baths and I shall massage her whole body twice a day’ (Freud & Breuer, 1895d, p. 50). A brilliant theoretician and clinician, Freud gradually began to analyse the psychological constructions that underpinned such physical treatments. In particular he elucidated the importance of the transference; i.e., the unconscious relationship between patient and clinician. For example, in the case history of ‘Dora’ Freud wrote,

 

Chapter Two: Boundary and Containment in Child Development

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Prenatal experience

The very beginnings of life take place in a confined space with clear boundaries. For the first nine months of life the mother's womb is the container that defines the space in which development takes place. This space is defined physically by the walls of the amniotic sac and the womb. It is defined emotionally before, during, and after conception by the hopes and expectations of the parents. At times it is even defined by a lack of hope and expectation. If the father is absent, or even unknown, the space in which the earliest development takes place is still shaped by that fact, by what the mother imagined or hoped the father to be and perhaps by what her experience of her own father and mother was. So, at a time long after their deaths, the grandparents and their parents can still play a part in defining that first space in which the embryo is conceived. In Jungian terms, the collective unconscious has ‘collected’ around the conception, thus affecting the emotional climate into which the baby is born nine months later.

 

Chapter Three: Nuts and Bolts

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‘How can I tell you anything. I don't know you; this isn't a real relationship.’

Most therapists will hear some version of these words in the course of their daily work. To an extent the patient is correct – the relationship between therapist and patient does not feel like a customary social encounter because it is not one. It is a therapeutic encounter to which both parties pay a particular kind of attention. The therapist attempts to maintain a therapeutic attitude in which to listen and talk to the client in as non-judgemental a way as possible. In this chapter we look at how the therapist's careful attention to concrete boundaries helps to construct and maintain the container within which both therapist and patient can feel safe to work. These boundaries are shaped in the main by contractual agreements such as time, money, and space, and it is aspects of these that are considered here.

Assessment

The patient has negotiated his way through cultural and personal ambivalence, obtained a referral to a qualified counsellor or psychotherapist, and the first assessment appointment has been made.

 

Chapter Four: The Containing Mind

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Within the more tangible boundaries of therapeutic work, discussed in the previous chapter, reside the less tangible boundaries, the relationship between the therapeutic couple and the mental space available to therapist and patient being the most important.

The contents of the therapist's mind

The therapist's thought processes will have been influenced in part by the theoretical model or models he is using to think about his patient's material. Although Jung tried not to promote particular techniques for therapy, he did acknowledge the need for the therapist to be both knowledgeable as well as flexible in responding to the patient. Knowledge of theory, received through a recognized professional training, helps to prevent the therapist basing interventions on personal opinion. However, as Jung advocated, theoretical ideas should emerge from an understanding of the patient's material and not from an imposition of the therapist's thinking (Jung, 1935, par. 8).

Methodology and theoretical stance operate ‘behind the scenes’, framing his responses to the patient's material. They are ‘behind the scenes’ because they are not known about directly by the patient. Yet, they provide a frame of reference for all the reading, lectures, theoretical discussions, previous work, and papers that have contributed to the therapist's training over time. From this reservoir of experience and learning, the therapist extracts meaning to fit what the patient brings. This boundary is somewhat porous. For example, as the patient begins talking about the significance of his childhood pet, the therapist might find himself remembering the dog he also owned as a child. Of course, the therapist does not say, ‘That sounds like the dog I had as a boy. I loved him dearly.’ On the other hand, he might use the experience indirectly to recollect how meaningful a child's pet can be.

 

Chapter Five: Boundaries within Organizational Settings

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The internal, mental boundaries of the therapist's mind can become even more important within settings outside the somewhat protected environment of the private consulting room. This chapter gives a series of clinical examples (based on actual situations) that illustrate how ethical and boundary issues can dramatically affect, and be affected by, the workplace.

An NHS out-patient psychotherapy service

As part of her continuing professional development, a community psychiatric nurse worked psychotherapeutically with a woman who had been sexually abused. Although they had met for some considerable time and their relationship seemed a good one, the patient did not show any significant improvement, particularly in her ability to relate to others. She remained convinced that people did not like her. She did not express any feeling, particularly anger.

In supervision it emerged that the CPN behaved much as she might in her nursing practice, where the understanding of boundaries was very different. Instead of waiting to see how the patient might wish to begin the session, she greeted her, asked how she was and how her week had been. At the end the CPN would touch her arm and wish her a good week. The supervisor suggested that the CPN apply stricter boundaries – not open the conversation, touch the patient, or wish her a pleasant week ahead.

 

Chapter Six: Confidentiality

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The concepts of boundary and confidentiality are closely linked. Psychotherapy, counselling, and psychoanalysis are all based on the premise that the patient is free to say whatever is on his mind and the therapist is similarly free to think. It is a common assumption that the boundaries around a session are not only to do with time and space but also with an assurance that what is communicated between therapist and patient will largely stay in the room. Like the well-sealed vessel used by the alchemists, the confidential nature of therapeutic work is meant to provide a secure container in which difficult and sometimes volatile feelings can be exposed. The trust that develops over time is, to a large extent, encouraged by this sense of privacy.

Views on confidentiality differ within the therapeutic community. Some, like Christopher Bollas, a contemporary psychoanalyst, make the case for absolute confidentiality. Bollas (2003, p. 157) maintains that the psychoanalytic method of free association and evenly suspended attentiveness depends on free expression. Free expression is undermined if confidentiality is compromised in areas such as sexuality and violence (although it could be argued that all areas of personal pain might be similarly affected). The therapist needs to be able to ‘listen freely’ rather than to ‘listen out’ for information that would compel him to report the patient to the authorities. Bollas writes, ‘We must argue that confidentiality is held by our profession – not by our patients – so that we may discuss our patients with colleagues, clear in our minds that in so doing we are not referring our patients to the criminal justice system’ (ibid., p. 173).

 

Chapter Seven: Professional Boundaries and Containment

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Introduction

Given the nature of the experience in the consulting room, it is not surprising that the ‘therapeutic couple’, the therapist and client, need reliable support and containment. The consulting room and the space around it form a part of their immediate physical boundary. An ethos of confidentiality forms a less tangible, but equally important, boundary. Beyond this, one could imagine a series of concentric circles that, like the layers of an onion, define and encircle the therapeutic experience. The outermost layers, farthest from the consulting room, are the legal constraints, government mandates, and cultural expectations of society. These enclose other layers represented by professional registration bodies as well as the Codes of Ethics and guidelines of the training body. Within the layer framed by the therapist's training is the containment of the therapist's own therapy and supervision, the theoretical model(s), and the therapist's belief system. In situations where the work takes place outside the therapist's own consulting room, the constraints of the institution form yet another layer of containment. Even the way the therapist makes use of her mind and understands her role become significant aspects of containment around the therapy. Of course any of these layers can, at times, represent a lack of containment.

 

Chapter Eight: Ending

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Directly or indirectly, endings take one back to the beginning, back to why the client came in the first place and to what has happened between therapist and client since that time.

The difference between ending and stopping

One of the central issues in finishing the work is the difference between ending and stopping. Ending is a process. Stopping is just that – stopping. Ending involves a planned interaction between two people over time. Stopping does not. In between are the grey areas – an ending process agreed but, consciously or unconsciously, sabotaged. Having allowed time to draw things to a close, space for saying good-bye, reflection, or mourning, the client may simply not come, or, even more difficult, might arrive ten minutes before the end of the last session! For whatever reason, he cannot face the process involved in ending; instead, he has chosen to stop. From the counsellor's point of view, he leaves her to do the work of ending by herself, and that is not easy. She has to let go of the client in his absence and deal with all the feelings of being left in this manner, of the work being incomplete. Just as an unmourned child can affect the parents’ relationship to the next sibling, so an unresolved ending with the counsellor might affect her relationship to the next client.

 

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