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Section 3
Power Dynamics: Considerations Across Diagnostic Categories

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By Carol Fizer
Overview

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 people’s 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.

Therapeutic Boundaries
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 person’s need.

Boundaries 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.

In 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 Schizophrenic Patient
The schizophrenic’s 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.

Marie, 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 therapist’s 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 therapist’s 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.

The Borderline Client
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.

Janice 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, Janice’s 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.

After 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 Roberta’s needs to have a life of her own balanced with the needs of her children, Roberta’s 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 patient’s 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.

Obsessive-Compulsive Disorders
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.

John, 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 John’s 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 John’s anxiety level and promoted behavioral alternatives.

Anxiety Disorders
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.

Jean, 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 parent’s 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 therapist’s 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 therapist’s office for increasingly longer periods of time with a concurrent reduction in her fears. Within a year’s time Jean was able to make the trip to her parents' home, which was nearly one hundred miles away.

Substance Abusive Clients
With abusing clients, the focus of boundary setting must first focus on the substance abuse before any other issues can be addressed.

Gary, 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 Gary’s 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.

Summary
The 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.

NOTE: sentences and phrases are in bold type, in each Section of this Manual, for the purpose of highlighting key ideas for easy reference.

QUESTION 3
What are primary hallmarks of boundary failures in the borderline client? To select and enter your answer go to Test.

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