Guidelines about Boundaries in THERAPY

This is my post for my Tuesday “words” post.

Finding a therapist that is a good fit is hugely helped by the internet. In addition, if you’re confused at any point about the therapy and your therapist’s boundaries, You can find a lot of top ten lists online about therapist’s boundary violations.

In fact, here is a great list of 30 things to watch out for in your relationship with your therapist. All are very good things to notice; a few things on the list are sometimes ok if you feel your therapist has your best interests in mind (ie. when therapy is free of charge, what are the terms of the contract?)

http://www.therapyabuse.org/p2-wrong-questionable-treatment.htm

Here is another good, slightly humorous view of top ten things you might not know about therapists:

http://www.bustle.com/articles/61462-10-things-therapists-wish-youd-understand-about-what-they-do

I thought I might have something to add to these very good tips and important boundaries to the only thing I think might be missing from these types of lists:

THE INTERNET and SMART PHONE DOS AND DONTS in THERAPY

The internet and other technology make every field completely confusing again and cause us to scratch our heads and reconsider the way we do what we do. From the law to the music business to anything, we need new GUIDELINES:

The Internet (social media, websites, etc.)

DO NOT GOOGLE or LOOK UP former patients:

One interesting mention of the internet in the second link was about how therapists do think about former patients more than you’d imagine but we still don’t/shouldn’t google them to see what is going on with them.

I know that is a good one, as I have been tempted, when thinking about a former patient, to look them up and see how they’re doing/what they’re doing. I have NOT done so with anyone, as I saw a big STOP sign in my head and it was a fleeting “fantasy”.

Social Media makes things extra fun and confusing:

USE SOCIAL MEDIA THERAPEUTICALLY ONLY:

It is great for people to find support and other people going through their experience, whatever media they are using, Youtube, Facebook Groups, Facebook, Pinterest, etc. I often recommend to patients who are interested and use social media, that they look for support groups and other things online, AS WELL AS out in the physical world.

I have watched a few Youtube videos made by patients and listened to Podcasts. The reason is important: The patient wanted me to and asked me to and it was always an important aspect of their therapy work, especially self-esteem and recovery topics. I have even used Youtube videos in session when appropriate.

In addition art therapy gives a patient alternate ways to express him/herself, including through social media. Think of it as similar to brining in some art you made between sessions that is relevant for therapy.

SOME DON’TS OF SOCIAL MEDIA. Some seem obvious:

DOn’t be Facebook “friends” with any patient and with former patients, with some exceptions about former patients. You cannot control patients accidentally seeing posts of yours and finding out you know someone in common. There are proper ways to handle this which would be a post in itself. Start with asking your patient about it  or if you found something, telling them as soon as possible and exploring this.

DON’T connect on  LINKED IN with patients and most former patients. If you’re in the same field, art therapy, you may not be able to avoid some LINKED IN stuff and can have a little more flexible boundaries about it. I never accept Invitations to Connect from current patients; I don’t usually bring it up unless my patient is on LINKED IN a lot or brings it up themselves.

TWITTER: Can I “follow” some patients on Twitter? My answer would be what’s the reason? I have avoided it except in cases where someone had something important related to treatment on Twitter. As a rule, I abstain.

FACEBOOK PAGES: I have public Facebook pages that I cannot avoid patients finding and considering “liking” my page. As they are related to therapy and art, I consider it ok for patients to do that only if they decide on their own for some reason. Also, I do not look a lot at who is “liking” my pages and don’t care much about how many followers or who. IF you’re very into that, be aware of any feelings about patients liking your posts or not…

In some cases you may have liked someone’s Facebook page and then found a patient involved with it. There are cases when you can’t avoid this, especially having patients who are/were art therapists and got a diploma from the same place. Your worlds will be very close and it’s a good boundary test to be aware of this. (IF I am attending an event or workshop etc. and a patient is likely to be there, I process this with the patient before hand.

BLOGS:

This is a huge question mark for me. Do any of my patient s or former patients follow or ever read my blog? I actually don’t know. When I post here, I am aware that a patient may come across my blog, so I do have that in mind. As a rule, if it does not come up, I of course do not bring it up, and if it does in the future, I would of course explore the topic with my patient. I have read a patient’s blog only if they give me the link and it is connected to their recovery and they want me to see it.

Therapist bloggers out there: Please share any further guidelines and experiences! You can put it in my comments section.

Blogging Classes: Most therapists out there don’t take these classes, but I do, and I even recommend some of them to patients. If I recommend a particular class, I do not enroll in it, even if I thought I wanted to before. If I found a patient in a class, I would address that and most likely leave the class or at least stay passive (no posts or comments on Blogging U site).

DOs and Donts of SKYPE/Video session: A big topic to address in future…

This is by no means an exhaustive list. Next post could be about the SMARTPHONE and boundaries. It’s a fascinating aspect of therapy and books or at least long chapters could be written about the uses and abuses of the SMARTPHONE technology…

 

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Movie: “Back From the Edge” – Borderline Personality Disorder

I just recently watched this video on Youtube. I highly recommend it to everyone: other clinicians who work with BPD or who want to learn more about it, people with BPD, people with loved ones with BPD, and those who know nothing about it.

The good news is that there is finally scientific evidence that Borderline Personality Disorder is actually a biological even hereditary illness not that different from diabetes or bipolar disorder. Those suffering from it are relieved to find out what is “wrong” with them and that it is not their fault that they suffer so much, that there is a name for and description of what they struggle with and they are not alone with it. I am especially glad to see them cover the whole issue of diagnosis and show how people who find out they have BPD are so relieved and also feel that they are understood and that they now know what is going on with them and because it can be explained very precisely and all their “symptoms” are mentioned and described in a way that they resonate with the whole diagnosis, there is great hope for them to recover fully and lead happier, more satisfying lives and have better relationships and hope for love with others.

I think this is a great example of the usefulness of diagnosis and the DSM 5 (the diagnostic tool for people in the mental health and substance disease field). It argues against people’s beliefs that some diagnoses are not good and make a person feel worse or sentenced or that having BPD and being told you have it means you are “one of those crazy sick people”. It also helps people encountering BPD in themselves and others have more patience and understanding of the terrible self harm behaviors and very extreme amount of suicidal thoughts, wishes and attempts.

In terms of treatment and hopes for recovery, the movie shows how people benefit greatly from the most documented and researched treatment: DBT, Dialectical Behavior Therapy, founded and invented by Dr. Marsha Linehan. There is also brief discussion of other treatments, especially psychodynamic, however, they leave out a newer treatment called “Mentalization”, maybe because it wasn’t well known when the movie was made. I still don’t understand much about Mentalization, except that it was founded by a psychoanalyst but is not psychoanalysis. I believe it focuses on cognition and accessing the reasoning part of the brain to get the patient out of the amygdala, which is the “fight or flight” response; people with BPD have different brain chemistry from people with “normal” brains. The reason they are so highly reactive, sensitive and emotional in response to interactions with others that other people do not react to or receive as hostile and dangerous is that their brains are wired differently and thus, while ill, people with BPD spend a lot more time trapped in the amygdala. With mentalization, I believe there is some emphasis on learning about responses of other people to the patient’s behavior or reactions and learning to look more neutrally at interactions with others.

Anyway the basic principles of DBT therapy are explained and patients describe how it helped them to learn to self regulate and decrease their extreme symptoms. The movie is not an exhaustive description of DBT as it empasizes the experiences of people with BPD, before effective treatment and after as well as their family’s experiences before and after.

The Relationship Map: A Great Art Therapy Intervention!

The Relationship Map is very simple in structure: it is a mandala (sacred circle) drawn on a colored square piece of paper with a smaller circle inside it.

I have found it very useful to do this “intervention” with many adults patients, especially people working on their relationships with other people and learning to set better boundaries. The goal is to build/establish a balance between rigid and loose boundaries, thus “flexible” boundaries. If you imagine a barrier that feels like a brick wall, that is a rigid boundary. An overflowing puddle is an image of a loose kind of boundary, whereas a flexible boundary would be some thing that can move and tighten and loosen based on the circumstances of the here and now, so it is a balancing act, and we all have challenges working on our boundaries. The people who seem to find this exercise the most helpful and useful are those whose boundaries are too loose. They merge easily with others and have a hard time setting limits and saying no. Things like giving people money with no consideration of their own finances, overly caretaking, doing things that later make them feel resentful and upset, but caught in a bind where they feel they have to be “nice” and saying No I won’t do that, or I don’t like when you do that, or I disagree with you, feels like they are being “mean”.

We all have had challenges at crossroads in our lives where we look around and question our relationships and sometimes “weed the garden” and get rid of anything toxic, which could be very deeply rooted.

The first step is to pick a colored square piece of paper and put a paper plate about the size of a face on it and trace a circle. Right away you have a symbol of the self, a mandala. Then I invite you to write your name in the middle with the colored sharpie of your choice and put a heart or other shape around it. Then you write down qualities about yourself such as kind, creative, optimistic, good friend, compassionate original,adventurous, kind or whatever you come up with. It’s a time I will observe to my patient, “You forgot such and such” and give then additional qualities I know to be true about then that they overlooked.

Next, you draw a smaller circle with isn’t the big circle. The big circle can be conceived of as a barbed wire fence with xs in it and then the area outside it you write toxic zone. That is the area to put the people you can’t interact with at all anymore who have become poisonous. It is very therapeutic to have your therapist witness you place bad abusive people in your life in the toxic zone. I am not a proponent of the theory that forgiveness frees you. I actually believe there are people who are so damaging to you that you cannot forgive their actions unless that person realized how terrible s/he has been to you and take responsibility and apologize which, is not a frequent thing. So putting even your own parents in the toxic zone and bring supported about setting a form bound site of no longerletting them into your life is a very powerful aspect of healing.

Another dimension of this relationship map involves, what you start with, whom you put where, and whether you include your therapist herself in it. I also give people an opportunity to suggest people include dead people or animals as well with a different color or shape around them. Some of the nuance of the use of the circles is where you put the person. a person could be right on the line, meaning they are going in one direction or another soon but you’re not quite sure, or someone you just met would be appropriate to put in the outer circle. When someone puts new people in the inner circle, it provides a great opportunity to discuss their patterns of trusting right away and letting people in too quickly perhaps.

The other great thing about this relationship map is that you put the date on it, and make a new one a few months later. I usually have the patient do the whole thing and then bring out the older one and we can see what has happened, who has moved where, who has disappeared altogether, who has appeared, etc.

Below are images of an example of how to make a map like this.
Having a visual diagram is actually a very powerful way to take a good look at the relationships in your life and re evaluate what you want from others and, most importantly, who deserves to share your good qualities that you wrote in the beginning…

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