Understanding Boundaries and Containment in Clinical Practice

Rebecca Brown, Karen Stobart

• Publisher: Routledge
• Year: 2018
• ISBN:
  9780429923494
• Edition: 1
• Topic: Psychology
• Subtopic: History & Theory in Psychology
• Index: Psychology

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.

Chapter One
Why Boundaries?

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,

If the theory of analytic technique is gone into, it becomes evident that transference is an inevitable necessity . . . Transference is the one thing the presence of which has to be detected almost without assistance and with only the slightest clues to go upon, while at the same time the risk of making arbitrary inferences has to be avoided. [Freud, 1905e, p. 116]

He was developing an understanding of the need for, and value of, boundaries between analyst and patient. The difficulties encountered in maintaining such boundaries became clearer as the emotional effect of the patient upon the analyst was understood. This is termed the counter-transference and Jung was one of the first of the early followers of Freud to understand the importance of the concept and its implications for practice.

Jung identified a powerful process, which he described as ‘participation mystique’, in which both patient and analyst could become unconsciously merged (Jung, 1953, par. 253). Jung understood its dangers, but the underlying psychological mechanism was not really understood until Klein identified the process of projective identification (Klein, 1946, p. 8). She explored how the infant deals with early anxieties by projecting them into the mother and realized that the infant may then identify the mother with the unpleasant feelings that have been evacuated by projection; hence the term projective identification.

For a long time, countertransference experiences were regarded as a hindrance to treatment and to be minimized. Then, the dynamics of projective identification were further elucidated by analysts such as Bion, who realized the vital developmental role played by the mother’s mind in processing (detoxifying) and making meaningful the infant’s projections (Bion, 1970). Analysts realized that in a parallel way countertransference could also represent a powerful therapeutic tool. Working with, rather than trying to dispense with, the countertransference can, however, involve the therapist in complex interpersonal exchanges. In this context, the delineation of, and adherence to, strict professional boundaries has become vital.

A secure and safe container

The process occurring in the therapeutic space needs the protection of both concrete boundaries and the more intangible sense of containment. Almost all psychotherapeutic approaches utilize processes in the work similar to those of maternal containment (although awareness of this might vary). When powerful emotions are being addressed, or are as yet in the background, a secure container for those feelings is important, if not essential. A routine that is familiar provides a safe and reliable setting in which to experience that which is not safe and reliable, that which might be new, shaky, or perhaps even explosive.

In chemistry the conditions in which an experiment is conducted are kept as stable and constant as possible. In this way, the interacting chemicals are protected from contamination, and the chemist is protected from harm. Jung used images from the work of medieval alchemists to describe the therapeutic encounter. The alchemists chemical experiments, which were attempts to turn dross into gold, were depicted in a series of mystical pictures, the Rosarium Philosophorum (Jung, 1946). Jung likened the therapeutic process to the alchemical container, or ‘vas’, which is depicted in the Rosarium as a royal bath. One image shows a naked king and queen – patient and therapist – descending into the bath. Their nakedness illustrates the vulnerability of the participants in the therapeutic process. Undressing without undue embarrassment requires the security of a contained, very private, boundaried space. We could say that in therapy the ‘chemicals’ are the conscious and unconscious thoughts and feelings of the patient and therapist.

Michael Fordham, a Jungian analyst, who worked extensively with children, developed Jung’s work on containment:

. . . the alchemical vessel in which [the alchemists] substances were heated must be firmly closed so that nothing shall escape from it. In the relation between the mother and her baby the mother’s containing function is essential; first she contains her baby physically in her womb, then she holds him in her arms and also contains him in her mind and her emotions. Periodically, in an emotional crisis, all she is required to do is to hold her baby whilst he works through an emotional conflict. . . . But the containment is not only physical. In the first place her maternal reverie reflects and digests her infant’s state of mind and she can feed back to her baby the result of her mental but non-verbal activity through action and talk. [Fordham, 1985, p. 209]

Highlighting the invisible

In the course of ordinary life, boundaries are broken all the time. The bus is scheduled to arrive at 8.30; invariably it comes later. You have arranged to speak with a colleague in private; more likely than not you are interrupted. Intrusions of one kind or another can happen so frequently that we come to expect them or hardly notice when they do. In our conscious life, you might say we become acclimatized to such changes, but in therapeutic work boundaries and the interactions that take place around them matter in a different way. In creating a safe and reliable frame around the work, the boundaries themselves become the focus of feelings when their containing function ‘fails’. Unlike the bus that comes late so often we no longer notice or even expect it to happen, it is the opposite – invariably the sessions do start on time so that when they do not, we notice with a heightened sense of perception. Although we do not set out to break boundaries and the containment they provide, when it does happen it can be like putting a magnifying glass to a hitherto invisible part of the psyche. That was one of the reasons for the early emphasis in psychoanalysis on the ‘blank screen’ of the consulting room. The blank screen highlights what would be missed if the background were more changeable.

The therapeutic encounter aims for a time to keep out an important aspect of ordinary social life, the aspect that says, ‘It doesn’t matter’, or ‘in polite circles we don’t make a fuss’. In long-term counselling and in most forms of psychotherapy we set out to notice what, on a social level, might be insignificant infringements. It is this aspect of therapy that can be satirized in popular culture, as if those of us engaged in the enterprise are somewhat strange in our preoccupation with sessions starting and ending, holiday breaks, and payment of accounts. The therapeutic dialogue is not like an ordinary conversation in which the ‘hiccups’ of social interaction are disregarded. Even in the initial assessment, the boundary issues (whether appointments are kept, whether the person arrives on time, whether he can tolerate interventions) might highlight aspects of the patient’s personality that he could not tell you about directly.

The work is facilitated by the fact that the boundaries are ordinarily in place and so the impact of a change is heightened. Conditions that promote stability include the fixed times of the sessions and confidentiality. But, however carefully boundaries are maintained, there are times when the unexpected happens: the counsellor is unexpectedly delayed, someone else walks into the room, or there is a misunderstanding about holiday dates. These breaks of the boundary can form bridges to important aspects of the work: boundaries that were broken in childhood (such as betrayal by an important carer) or issues of distrust in the patient’s current life.

Clinical example

The client brings up something new and significant just as the end of the session approaches. The counsellor is tempted to extend the time in order to explore it. But if the client is accustomed to the usual length of his sessions, the timing of his new material is probably not mere chance. Consciously or unconsciously, he might have done this because he could count on the session ending at a particular time and could therefore save himself from getting into more than he could manage; he is relying on an unchanging setting to guard his psychological safety. He wants a small portion of this new ‘food’ and not a whole plateful!

Illuminating the shadow

Whatever the type of treatment – counselling, psycho-therapy, or analysis – what the person brings into the room are feelings and reactions that he might be facing for the first time in his life and, possibly, communicating to another for the first time. The fact that he is there in the room is indicative that this time he has chosen to face his problems in a different way. The therapy might ultimately involve some relief, but not usually without some discomfort or pain as well.

Those parts of our psyches that are hidden and that we find difficult to face, Jung called ‘the shadow’. Boundaries and containment encourage trust, which in turn provides a better situation for the exploration of these difficult shadow areas. This is particularly so because much of what we encounter in the shadow is itself related either to a previous breakdown of trust or to trust not having been established in the first place. In spite of the fact that a client might have come to therapy to get in touch with shadow aspects he is likely to feel some resistance to that exploration. However, regular appointments and knowing about holiday breaks well in advance are a part of the solid path that will make a difficult journey more possible.

Confidentiality

Confidentiality, different from secrecy, is a cornerstone of psychodynamic work. It is rarely absolute: counsellors and therapists usually discuss cases with a supervisor; the counsellor might work in an institutional setting where other members of the team will have access to some information; there are circumstances – for example, child abuse – in which statutory authorities may, of legal necessity, become involved. However, in the ordinary course of the work the assumption is that what goes on in the room is private; it is part of a therapeutic context and not a social one. As far as possible, the organic process that is happening between client and counsellor/therapist needs to stay within the room. The client might, naturally, share some of the content and feelings with friends or family but this is not encouraged because the process can be ‘diluted’ if the focus of the work in the ‘here and now’ is shifted outside.

A space for the opposites to come together

The emphasis on the unconscious in psychodynamic work, whether explicit or implicit, carries with it a respect for the unspoken. We try to make sense not only of what is said but also of non-verbal forms of communication that at times contradict the verbal. If we only hear ‘directed thought’ (rational logic) and not also ‘undirected thought’ (associative or free-flowing thought), we lose a part of the whole – the ‘opposites’ that Jung believed only together can make sense of the internal world. The contained space and the attitude towards a contained space help to create the conditions needed for these opposites to come together. The capacity to wait and listen for the opposite to emerge depends on the internal sense of containment that we learn through our training and bring from within ourselves (ultimately, from our own experience of therapy).

Clinical example

An eighteen-year-old girl comes for help to decide whether to keep her baby or have an abortion. At first she expresses her desire to get rid of the baby; she feels it would be better, and knows her mother would want her to do so. But the counsellor notices her holding and rubbing her tummy as she speaks. The girl is surprised when this is remarked upon, and then bursts into sobs of grief about the prospect of losing her precious baby.

If the counsellor had identified with the more conscious and immediate feeling, the girl’s less conscious feelings would have been missed. The counsellor’s capacity to contain and maintain a thinking space allowed other feelings to emerge. Whatever decision is made eventually, it will have been valuable for the young woman to discover her ambivalence.

Promoting thought through frustration

So far, we have looked at boundaries in relation to their capacity to make the space within them more secure, less threatening, more integrative, and more confidential. There is another aspect of their function that would at first appear to be in contrast to these factors. This concerns the function of frustration. In this sense, the experience of ‘coming up against a boundary’ can feel harsh or unwelcoming. A regular pattern of times might be secure in the sense that it is consistent, but it might also feel withholding or unyielding. Given that there is enough of a working alliance established, this experience of frustration can eventually lead to the development of insight.

Clinical example

A patient found the rigid session times made him feel intolerable rage toward his kindly therapist. He could not express what was, to him, a shameful feeling, but was disheartened because his therapy was going round and round in circles: ‘just going over the same old things’. The therapist did not give up. She sensitively contained the patient’s frustration until one day he mentioned that he had been a ‘Truby King baby’: fed at very regular and prescribed times that did not coincide with his hunger. The obvious, but until then unconscious, link was made, and the patient ‘let go’ his rage with great relief.

The therapist’s need for containment

The emphasis thus far has been on the client and how boundaries and containment affect his experience of counselling or therapy. However, the boundaries around the work have an impact on both participants. The counsellor or therapist, although he comes to the session with the greater experience, faces this particular client on this particular day for the first time. In order to explore the unknown, the practitioner also needs the containment of a boundaried space that is not interrupted, that happens at regular intervals, and that has anticipated breaks. The boundaries around the space help the therapist to feel contained, so that he in turn becomes part of the containing space around the client.

A warm, comfortable, quiet, and uninterrupted space, and the boundaries that maintain this, are a vital protection for the therapist’s capacity to keep his mind available for the therapeutic encounter. We are only too aware of how fragile a particular state of mind can be, how vulnerable a train of thought is to distraction, noise, or interruption. There are times when a client himself might not notice a boundary being out of place, but if the impingement affects the therapist’s ability to function in a containing manner, the client might notice or be affected by a change in the therapist’s demeanour.

Acting out

Boundaries serve another protective function and that is in relation to the potential for strong emotions to be acted out. Boundaries remind both participants that, although highly intimate and personal, the therapeutic encounter must not include violence, social contact, or sexual behaviour. For example, at times it can be difficult for the client to distinguish between adult sexual feelings and powerful infantile attachment to a parent. If the therapist does not have adequate supervision for this difficult work, and especially if it touches too closely on his own personal unresolved issues, the feelings might be acted upon.

Jung’s understanding of the potential for the therapeutic process to affect and transform both participants led him to emphasize the necessity for the practitioner’s own personal therapy. Adequate supervision and personal therapy are a part of the safety net that helps the therapist to contain the material in the session and to continue to understand it symbolically.

Summary

We began this chapter by asking why boundaries are important to the therapeutic process. They create a safe and secure container for the work. They help to illuminate what Jung termed ‘the shadow’ – our unknown side. They help to highlight what might otherwise be difficult to see unless it is thrown into relief and magnified. They facilitate confidentiality and trust. They encourage ‘the opposites’ to emerge. They promote thought and enhanced ego-functioning through an increasing ability to tolerate frustration. They contribute to a necessary sense of security for the practitioner who in turn can be more containing for the patient. They are, finally, a protection for both patient and therapist against acting out.

Table of contents

• Cover
• Half Title
• Title
• Copyright
• Contents
• ABOUT THE AUTHORS
• PREFACE TO THE SERIES
• INTRODUCTION
• CHAPTER ONE Why Boundaries? Including the historical development of ideas
• CHAPTER TWO Boundary and Containment in Child Development
• CHAPTER THREE Nuts and Bolts Including assessment, beginning, time, fees
• CHAPTER FOUR The Containing Mind
• CHAPTER FIVE Boundaries Within Organizational Settings
• CHAPTER SIX Confidentiality
• CHAPTER SEVEN Professional Boundaries and Containment Including training, registration, Codes of Ethics and good practice
• CHAPTER EIGHT Ending
• REFERENCES
• INDEX