Using Boundary Crossings As Creative Therapy Instead of Slippery Slopes Course Director Gail E. Robinson, MD Annual Convention of the American Psychiatric Association – May 2008 CREATIVE MOMENTS & CHALLENGING EVENTS IN THERAPY -- BENDING RULES TO HELP Gary R. Schoener * INTRODUCTION From the New York Times, Metropolitan Dairy section, 22 December 2005 Being asked to perform a psychiatric consultation on a hospitalized adolescent is rarely pleasant. Fortunately, this teenager seemed placid as I approached his bed. His mother was seated nearby, immersed in her knitting. I walked over and introduced myself to him. He looked right through me and started screaming at the top of his lungs: “I can’t see! I can’t see!” I had never before seen such a dramatic example of hysterical blindness. I tried not to betray my concern as I casually asked his mother, “How long has this been going on?” She never even looked up as she replied, “Ever since you stepped in front of his television.” Isaac Steven Herschkopf, M.D. Yes, there are all sorts of boundaries challenges in professional work. On occasion I tell my students and professional audiences that I once spent an entire psychotherapy session holding hands with a 26 year old woman together in a quiet darkened room. That disclosure usually elicits more than a few gasps and grimaces. When I add that I could not bring myself to end the session after 50 minutes and stayed with the young woman holding hands for another half hour, and when I add the fact that I never billed for the extra time, eyes roll. *Gary R. Schoener, M.Eq., Licensed Psychologist & Executive Director, Walk-In Counseling Center, 2421 Chicago Avenue S., Minneapolis, Minnesota 55404 (612) 870-0565 or 870-0574 The Center was the recipient of the 1977 Gold Achievement Award in Hospital & Community Psychiatry from the APA. The Center's website is at: www.walkin.org The author's personal email is [email protected] He is the senior author of Psychotherapists' Sexual Involvement With Clients: Intervention & Prevention (1989) and is a frequent expert witness in cases involving alleged professional boundary violations. The center offers training on professional boundaries and ethics for a wide range of professional audiences, and also programs on boundaries and ethics in clinical supervision. Furthermore, the center provides assessment of professionals who have engaged in boundary violations, as well as the development of rehabilitation plans. For additional information on sexual boundary violations and also a number of publications: the reader is referred to a website with a number of helpful publications: www.advocateweb.org 1 Then, I explain that the young woman had cystic fibrosis with severe pulmonary disease and panic- inducing air hunger. She had to struggle through three breaths on an oxygen line before she could speak a sentence. I had come into her room, sat down by her bedside, and asked I how I might help her. She grabbed my hand and said, "Don't let go." When the time came for another appointment, I called a nurse to take my place. By this point in my story most listeners, who had felt critical of or offended by the "hand holding," have moved from an assumption of sexualized impropriety to one of empathy and compassion. The real message of the anecdote, however, lies in the fact that I never learned this behavior in a classroom. No description of such an intervention exists in any treatment manual or tome on empirically based psychotherapy. Gerry Koocher, Ph.D., President, American Psychological Assn. From Pope, Sonne, & Greene (2006) What Therapists Don’t Talk About and Why. BACKGROUND Through the years our staff at the Walk-In Counseling Center (www.walkin.org) have utilized training exercises in Boundaries in Professional Relationships: A Training Manual (Milgrom, 1992). Through the vehicle of these exercises it has become clear that there are few things which are "never OK. Furthermore, in reality it is exceedingly difficult to define clear boundaries which would be in effect across various service modalities and practice styles (with the exception of avoiding sex with clients). When one looks at a variety of programs, settings, and clients, it is clear that a wide range of "rules" do not apply across the board. It is equally clear that there are numerous instances which workshop participants can identify in which some sort of a boundary crossing might be appropriate, or even the best approach to a clinical situation. Lazarus & Zur (2002) raise a number of such issues, and Zur (2005) discusses this in detail in an article entitled “Beyond the Office Walls: Home Visits, Celebrations, Adventure Therapy, Incidental Encounters and Other Encounters Outside the Office Walls which can be accessed on the internet at Http://www.drzur.com/outofofficeexperiences.html . Although I myself have many times referred to "the slippery slope" when discussing boundaries, I am inclined to agree with Dr. Jerome Kroll (2001) that the concept of the "slippery slope" is itself quite a slippery concept. In many instances the so-called slippery slope is in actuality a sequence of boundary crossings or violations done by a professional who is focused on his or her own needs, or who is quite impaired. The well-adjusted and thoughtful practitioner for the most part does not appear to be at great risk of suddenly finding him or herself on a "slippery slope" from which escape is not possible. Furthermore, these issues become more complex when viewed in a forensic context – that is from the perspective of how boundary crossings may be misperceived in the context of treating a difficult situation. Well worth reading are Gutheil (2005) and Dvoskin (2005). Others have written about the challenges some clients represent such as Caudill’s (1996) article “The Dangerous Myth of the Predatory Therapist. To clarify this challenge, I will briefly note several workshop exercises which are discussed in depth in Milgrom's (1992) Boundaries in Professional Relationships: A Training Manual. These are described in more detail in the handout Tools for Preventive and Remedial Boundaries Training which was prepared for a symposium on Boundaries Education: An Expert Update on Diverse Approaches & Settings chaired by Dr. Gregg Gorton at the 2003 APA convention in San Francisco. However, for the purpose of the current presentation, I will briefly describe these exercises in hopes of not only sharing a training aid, but in more clearly illustrating how these boundaries work. 2 PERSONAL vs. PROFESSIONAL This exercise requires a blackboard, flip chart, or overhead projector. At the top of the page write the word "Personal" on one side and "Professional" on the other side of the page. PERSONAL vs. PROFESSIONAL The task is to provide characteristics or descriptions of relationships which might differentiate personal from professional relationships. The responses are written down as in the example below: No payment Fee paid, or service provider paid Can be forever Time-limited Can meet anywhere Generally meet in office What should be apparent is that there is not a line or barrier down the middle of the page and depending on the nature of the service lines may be draw at varying spots on each of what are obviously continua. WHAT'S OK, MAYBE OK, NEVER OK? This exercise requires a blackboard, flip chart, or overhead projector. The presenter creates three columns -- with "Always OK" on one side, "Maybe OK" in the middle, and "Never OK" on the other side: ALWAYS OK MAYBE OK NEVER OK The presenter then asks for something that is "Always OK" in a given type of professional relationship. Whatever is given, the presenter then asks the audience if everyone agrees. Most end up in the "Maybe OK" column. Most behaviors end up in the middle column -- Maybe OK. An example is given below of how a discussion about the propriety of hugging can lead to the articulation of a variety of principles: GENERALLY OK PROBABLY NOT OK HUGS Goodbye at the end of service To respond to the client's affection To support grieving client To "smooth over" anger To reassure a child To "reparent" an adolescent To support an AIDS patient Hug lasting several minutes Sideways -- arm around shoulder Brief hug -- a few seconds To convince someone she's still attractive 3 SOME NOTES ON ETHICAL ISSUES Decisions about boundary crossings can be weighed using five ethical principles: (1) BENEFICENCE: likelihood that it will help, or benefit the client. Can you articulate potential positive goals or outcomes from this boundary crossing? (2) NON-MALEFICENCE: likelihood that it will not harm the client. Can you describe possible negative outcomes and discuss how you will minimize these risks, or explain how the risks are trivial compared to the potential benefits? (3) AUTONOMY: likelihood that it will foster the client's autonomy. Does this boundary crossing reinforce the client's independence or personal choices? (Bear in mind that some boundary crossings undermine this by increasing the care-taking by the therapist.) (4) FIDELITY: the degree to which it is true to what was promised. Does this carry out the professional role and is it faithful to the helping contract, or does it stray from the therapist role? (5) JUSTICE: balancing the needs or rights of one versus another -- those of your client vs. others in their family or in the community. This principle is very challenging because it moves away from simple consideration of what is best for the client and takes into account the welfare of others. There are several potential components: (A) Risks to Others: Is someone else at risk of harm? The issue of a duty to warn third parties of danger from a client, involves the competing principles of Justice vs.