Boundaries are the
issues in life, which define what is me versus what is not me."
It is the clarity in boundaries, which allow us as individuals to function as
independent, fair people with a sense of respect for other peoples sense
of self. In the course of development, good parenting helps the child create his
or her own boundaries between him and the rest of the world. It is when the parent
of the three-year-old settles a fight over toys that she is creating for the child
a simple boundary between what is mine and what is not mine."
The parent of a young teenager stopping the use of abusive language is also setting
boundaries. Boundaries give us a clear sense of our selves and a sense of security
around which we are as individuals.
As therapists, we set boundaries with our clients in all our
interactions and help clients create a clearer sense of self, which may not have
emerged in the course of development. Our clients become more healthy functioning
people in terms of their give-and-take with the people around them. The client
with a clear sense of her own boundaries is neither victim nor victimizer, but
interacts with consideration of her needs and the other persons need.
in the therapeutic relationship take many shapes. It may be an issue of time or
money. It may be the amount of information we as therapists want to reveal to
our clients about our feelings and lives. Another consideration may be the type
of issues which are appropriate or inappropriate to talk about. In some situations,
boundaries may take action in what we are willing to allow our client to do or
to say without some overt action, reaction and intervention in their lives.
all these situations, the therapist needs to think through the meaning of the
boundary and the fairness of the boundary. Essentially, as therapists our boundaries
are being tested client by client. Special consideration needs to be given to
the developmental and diagnostic issues around boundary setting. The following
is a look at the use of boundaries according to diagnosis.
The schizophrenics confused sense of self presents
the constant need for clarifying in very basic ways.
James, a young twenty-two-year-old,
had his first psychotic episode after an especially stressful semester at a prestigious
school. His delusions cleared very quickly after stabilizing on an anti- psychotic
medication. His therapist decided since he had functioned on a relatively high
level prior to this episode and since he was unable to tolerate no more than twenty
to thirty of minutes in her office to schedule two half-hour sessions a week at
the same time on separate days. The use of time, both in terms of the amount of
time in the session as well as the time of day, became a clarifying boundary for
James who was able to use the shortened time periods to begin forming a relationship
with his therapist without excessive anxiety.
an attractive woman in her forties, who had numerous psychotic episodes and several
hospitalizations when she forgot to take her medication, was referred for follow-up
after a recent hospitalization. She presented with confused sense of self, but
was over-controlling in her manner, not allowing the therapist to interact with
her. An unusual part of her behavior was to sit in the therapists desk chair,
despite the fact that the office was very clearly set up. The therapist repeatedly
asked Marie to change seats with no discussion of the confusion session after
session. Gradually, Marie began to realize for herself which was her chair and
her therapists chair, and would after some hesitation take the chair which
she came to designate as my place." The
very concrete use of space and seating was for this client a defining issue of
who was who, although it was not until four years into therapy that
she was able to even approach the issues of self-other confusion in terms of her
thoughts and behavior.
Acting-out behavior, chaotic relationships, inability
to control effect are primary hallmarks of boundary failures in the borderline
client. Boundary setting with this type of client becomes especially difficult
because of the constant challenges and escalation of behavior when boundaries
are inconsistently set.
is a twenty-five-year-old young adult whose responsible, stable work life covers
up the chaos in her relationships with families and friends. She is articulate
and demanding with people who tend to reject her after experiencing her demanding
nature. She came to therapy because of a recent series of rejections by men with
whom she was trying to establish a relationship. During the first month of therapy,
Janice slowly began to reveal her suicidal thoughts and showed the therapist the
self-inflicted scratches on her arms. As these thoughts emerged and were verbalized,
Janice began leaving desperate messages and pages for her therapist, which could
not go unheeded. The response to these calls was a trip to nearby ER where her
presentation was less dramatic. After several weeks of daily calls at random times
and numerous trips to the local hospital, Janices therapist implemented
a plan of daily check-in calls where Janice would call at a specific time and
for a specific amount of time to verbalize any concerns. The therapist did not
tie the calls to her suicidal thoughts, but as a way of staying connected. Over
the course of the next six weeks, Janice called daily for a five-minute check-in
during her lunch hour. The concerns about hurting herself turned very quickly
to the difficulties in her work and family life. After two months, the therapist
begins to taper the number of calls and amount of time gradually. With Janice,
the therapist was able to set a very clear but safe boundary through the use of
regular phone contacts to reduce the pattern of chaos, and increasing demands
which were focused on suicidal thoughts.
six months of weekly therapy, Roberta, a thirty-year-old mother of two children
ages five and seven revealed a thoughts of hurting her children. Further exploration
of her fantasies lead to the reality of a situation where Roberta would leave
her children alone in the evenings for amounts of time which ranged up to seven
or eight hours, occasionally not coming home at all. When questioned even in the
gentlest fashion about any behavior, Roberta would become enraged with her therapist
and several times had stormed out of the office to skip the next several appointments.
As a mandatory reporter, the therapist had to deal with this situation. Through
an extended session in which the focus was Robertas needs to have a life
of her own balanced with the needs of her children, Robertas therapist was
able to move this woman to self-reporting and essentially asking for help in managing
her children. It was not until several months later that Roberta was able to reveal
to her therapist the reduction in fantasy life and relief in taking better care
of her children, when the call to Protective Services was made. With Roberta,
the therapist, despite her patients history of rage, was able to establish
clear boundaries around appropriate childcare through decisive boundary- setting
taking the form of reaching out to Protective Services.
Perhaps of all patients the need for boundary setting is the
most necessary and most difficult to implement because of the nature of the disturbance.
a fifty-year-old married father of four, was well-stabilized in on medication,
which reduced his thought patterns which kept him from interacting with family.
Compulsive behavior and fears which took the form of hoarding were being dealt
with a concrete behavioral treatment, in which the therapist would sort a file
or a pile which John would bring with him. His anxiety around letting go was gradually
reduced. As John became healthier, the therapist directly dealt with Johns
unwillingness to either use his insurance coverage or pay his bill in a timely
fashion. With minimal discussion, the therapist instituted a weekly accounting
of his bill, asking John to bring his checkbook with him as well as insurance
forms. After one session of forgetting, during which John and the therapist wrote
and signed a contract for payment, John regularly brought his checkbook and insurance
forms. Each session the last five minutes was used to focus on payment. There
was no discussion of the underlying issues, but instead John made the decision
about how he was paying for the session. Gradually, as this became more routine,
the therapist extended the time-frame to monthly payments. The behavioral approach
and the clear boundary around payment helped to reduce Johns anxiety level
and promoted behavioral alternatives.
Clients with this range of disorders have trouble modulating
their effective levels and show a lack of self-soothing behavior. Frequently,
the client will attempt to have the therapist join in the anxiety- provoking behavior.
a forty-year-old mother of two adolescent children, had been referred by her PCP
after she revealed a long-term pattern of agoraphobic behavior. When the situation
was acute, Jean would have multiple panic attacks daily and would stay in bed
or in her bedroom until the symptoms reduced. Jean had refused medication and
therapy until she wanted to be able to go to her parents fiftieth anniversary
party in a nearby city. Initially, Jean was seen in one home visit in which the
therapist set the limit that Jean could not start working on her panic problems
until she began medication. Despite numerous plaintive phone calls in which Jean
refused a medication consult and asked for more home visits, the therapist clearly
reiterated the need for medication and the lack of effectiveness. This pattern
continued through two months of weekly calls until it became clear to Jean that
the therapists boundary setting was firm. Jean accepted the referral and
after two missed appointments began medication, which provided a dramatic reduction
in her panic threshold. Over the course of the next six months, Jean came to the
therapists office for increasingly longer periods of time with a concurrent
reduction in her fears. Within a years time Jean was able to make the trip
to her parents' home, which was nearly one hundred miles away.
With abusing clients, the focus of boundary setting must
first focus on the substance abuse before any other issues can be addressed.
a forty-year-old police officer, was on the verge of being placed on administrative
leave for a pattern of verbal abuse to his colleagues and calls. It was immediately
clear that this occurred after a night of drinking with his buddies. Gary did
not see a problem and was told that he could return to therapy whenever he wanted.
For several months Gary returned to the therapist, having been put at a desk job
after being accused of physically abusing an arrest. Gary found the situation
intolerable, requesting a letter of medical clearance from the therapist, which
she refused. Over the next six weeks, the situation rapidly declined in Garys
life with his wife leaving him. Despite his focusing on his life problems, the
therapist refused to join him in these discussions, but kept the focus of the
need to control his drinking. After several weeks, Gary was told that he needed
additional help or therapy would end. By this time, Gary was both desperate enough
and attached to the one person who he felt listened to him that he reluctantly
agreed to attend three AA meetings a week. It was over a year after this clear
setting of a boundary between therapy and drinking, that Gary returned to the
therapist with two months of sobriety behind him.
above cases demonstrate the use of boundaries in therapy to initiate growth-producing
patterns. Whether it is an issue of medication, time, money or behavior the therapist
can use boundaries in these arenas to promote changes in behavior.
Carol Fizer, LCSW, Weston, Massachusetts, worked with rescue workers at the World Trade Center following the September 11th attacks. She is an Independent Clinical Social Worker in the greater Boston area. Carol trained with the International Critical Incident Stress foundation and Smith College School for Social Work.
- Fizer, Carol LCSW, employed by Healthcare Training Institute to research and write the article, Power Dynamics: Considerations Across Diagnostic Categories.
sentences and phrases are in bold type, in each Section of this Manual, for the
purpose of highlighting key ideas for easy reference.
What are primary hallmarks of boundary failures in the borderline client?
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