The trouble with being yourself

1
The trouble with being yourself

• Caroline Cupitt
• Consultant Clinical psychologist
• Oxleas NHS Foundation Trust

2
Boundaries

• A boundary is the edge of appropriate behaviour
  at a given moment in the relationship between a
  client and worker
• Gutheil Brodsky (2008)

3
Boundary crossings

• Boundaries are flexible and moveable
• In assertive outreach we tend to use loose
  boundaries, and sometimes deliberately cross
  boundaries to aid engagement.
• How do we know when this is OK and when it is
  not?

4
Dilemmas about boundaries

• Take a few moments to think of a dilemma you have
  faced. Pick one which,
• Involves yourself
• In assertive outreach setting
• When you were genuinely unsure where the boundary
  should be, or had concerns about how it turned
  out.
• Here are some of mine

5
Dual relationships

• Bumping into clients outside of work, how do you
  acknowledge each other?
• e.g. someone else in the house invites a friend
  round for dinner who turns out to be a client of
  the service where I work
• When friends or relations receive services, how
  can it not affect your relationship?
• e.g. a new referral at a team meeting
• e.g. a case presentation at a training day

6
When extending your role

• When using unusual techniques to enhance
  engagement, colleagues can sometimes be critical.
  How far can creativity go?
• e.g. meeting in cafes, pubs, etc
• e.g. offering gifts of large vegetables
• Doing outreach visits, your personal values can
  be challenged. Should you compromise the personal
  for the professional role?
• e.g. an unexpected prawn curry

7
When personal values are challenged

• By questions or assumptions about invisible
  personal characteristics, e.g.
• Religion
• Sexual orientation
• Political, e.g. visiting MacDonalds
• Diet, e.g. vegetarians
• Hygiene, e.g. accepting drinks
• Smoking - changes in NHS guidance
• Alcohol

8
When using particular models of intervention

• Collaborating on a service development project,
  service users become colleagues and you may need
  to openly share your views on issues. Does this
  then affect what future work you can do together?
• If we promote involvement in the politics of
  mental health, is it OK to go to meetings or
  demonstrations with service users, e.g. about the
  new MHA?

9
Anything else?

• Does your dilemma fit into one of these
  categories?
• What other kinds are there?

10
Why does this keep happening to me?

• Service type, e.g. assertive outreach
• Need for genuineness
• Long term relationships with clients
• Intensive involvement in peoples lives
• Living on your patch
• Socialising in a small community

11
Historical therapeutic boundaries

• The early psychotherapists such as Freud were
  quite relaxed about their boundaries.
• Freud is said to have,
• sent patients postcards, lent them books, gave
  them giftsprovided them with extensive financial
  support in some cases and on at least one
  occasion gave a patient a meal
• (Lipton, 1977)
• Winnicott analyzed a close friend, socialized
  with patients, took in a child patient as a
  boarder.
• (Winnicott, 1947)

12
Detachment

• By the mid-century therapists were being expected
  to be more detached.
• The 1960s generated a reaction to this, in favour
  of more humanistic approaches, where the
  therapist showed greater warm and self
  disclosure.
• By the late 70s and into the 80s awareness of
  child sexual abuse grew, and also concern about
  the effects of therapist sexual misconduct.
• Pope (1988) found 8.3 male therapists and 1.7
  female therapist had had sexual involvement with
  clients.

13
In recent times

• The 1990s saw intense preoccupation with therapy
  boundaries.
• Most guidance was in the form of dos and
  donts
• There was some backlash against this (e.g.
  Lazarus, 1994) from people who felt their
  practice was unduly restricted.
• More recently there has been a movement towards
  more flexible, context dependent guidelines.
• There is starting to be the suggestion that some
  boundary crossings could come from benevolent
  intent and yield positive results.
• However we still need to be very alert to
  violations

14
Types of boundary violation

• Putting short term needs and desires ahead of the
  long term interest of the client
• e.g. inappropriate gifts, gossiping, intimacy
• Our desire to help is so strong we cant think
  clearly
• e.g. inappropriate self disclosure, touch
• Circumstances dont make boundaries easy to draw
• e.g. rural areas, small communities, engagement
  work

15
Codes of conduct

• Nursing and Midwifery Council (2004) NMC code of
  professional conduct standards for conduct,
  performance and ethics, London NMC.
• General Social Care Council (2002) Code of
  Practice for Social Care Workers, London GSCC.
• British Psychological Society (2006) Code of
  Ethics and Conduct, Leicester BPS.
• General Medical Council (2006) Good Medical
  Practice, London GMC.
• And many more

16
But

• Ethics codes cannever be a substitute for the
  active process by which the individual
  therapiststruggles with theunique constellation
  ofdemands of helping another person.
• Ethics that are out of touch with the practical
  realities of clinical work, with the diversity
  and constantly changing nature of the therapeutic
  venture, are useless
• Pope and Vasquez (1998)

17
Practical issues

• The bottom line, is that any intervention should
  be for benefit of the client.
• How can we know what will benefit someone?
• Different models of mental health work have
  different views about where the boundaries
  between worker and client should lie.
• In the same way, different contexts will make the
  same behaviours either ethical or inappropriate.

18
Informal or formal relationships

• There are distinct advantages to addressing the
  adult in the patient, in terms of fostering the
  adult observing ego for the alliance. Trainees
  often do not see the paradox of expecting adult
  behaviour on the ward from someone they
  themselves call Jimmy, which is what people
  called the patient when he was much younger
• Gutheil and Gabbard (1993)

19
On socializing

• Nothing in the theory of behaviour therapy
  would or should preclude socializing with
  patients, taking meals with them, giving them
  gifts, or treating them in their homes, schools
  or offices. Hugging patients might reinforce the
  therapists potency as a reinforcer for the
  patient and, thus might be supported
  theoretically
• Marquis (1972)

20
Social exclusion

• When working with people with severe social
  disabilities,
• some self-disclosure, real two-way interaction
  and sharing, is essential in forming an effective
  relationship with someone who has few, if any,
  other close relationships.
• Perkins and Dilks (1992)

21
But

• The vulnerability to crossing boundaries in
  non-theraputic ways comes from elemental needs
  and feelings, together with a misdirection of the
  clinicians desire to help and a misapplication
  of the assumption of mutuality and reciprocity in
  human relationships
• Gutheil and Brodsky (2008)

22
A way forward

• For a proper understanding and resolution of
  boundary questions in daily practice, we need to
  shift the focus from the surface to the depth of
  a patient-therapist interchange that is, from a
  given act to its therapeutic (or counter
  therapeutic) purpose, meaning, impact, and
  above all context.
• Gutheil and Brodsky (2008)

23
Exercise

• Consider your dilemma again.
• Describe your approach to the boundaries in terms
  of therapeutic (or counter therapeutic)
• purpose
• meaning
• impact
• context
• both the service setting
• and model of intervention used
• Consider the effects of changing the context
• a different service setting
• and/or a different model of intervention

24
For example

• The unexpected prawn curry I accepted.
• Purpose To avoid causing offence.
• Meaning By accepting the gift I cut through any
  notion that I might be suspicious of her. However
  it may also have suggested that I was just like
  any other guest, crossing our usual boundary.
• Impact She took pleasure in watching me eat and
  said goodbye warmly. I managed to (sort of)
  enjoy it.
• Context our last meeting
• the service setting assertive outreach, home
  visits
• model of intervention used CBT, collaborative
• Changing the context This would not have felt OK
  if we had not been meeting in her home or working
  collaboratively. If it had not been our last
  meeting, I would have felt more concerned about
  crossing our usual boundary.

25

• Reaching Out begins with a discussion of
• engagement
• the team approach
• assessments
• team case formulation
• managing stress and burnout for staff.
• The second half of the book focuses on the task
  of delivering psychological therapies and
  considers a range of models including
  psychodynamic therapy, family therapy, cognitive
  behaviour therapy and community approaches.
• To be published September 2009
• www.routledgementalhealth.com

26
Suggested Reading

• Cupitt, C. (ed) Reaching out the psychology of
  assertive outreach. Routledge, forthcoming.
• Chapter 10 concerns ethics and professional
  boundaries
• Gutheil, T.G. Brodsky, A. (2008). Preventing
  Boundary Violations in Clinical Practice.
  Guilford press.
• Perkins, R. Dilks, S. (1992). Worlds apart
  working with severely socially disabled people.
  Journal of Mental Health, 1, 3-17.