Have you ever fantasized about being friends with your therapist? She smiles when you arrive, and she truly likes you. Her eyes shine with empathy, and she laughs at your jokes. Can’t you just be friends, once your therapy is over?
No, you can’t. Let me tell you a true (albeit disguised) story about therapeutic boundaries, and why we need them, therapist and client alike.
Sally became my client eight years ago, slinking into my office against her will. Her husband was at his wit’s end with her depression. A normally zesty woman, she had stopped socializing, and was barely keeping her job. She spent most of her days in her PJs, sluggish and weepy. Her husband was beside himself with worry and insisted she start therapy.
Usually, people who are sent to therapy against their will are guarded and resentful. Not Sally. To my surprise, this petite woman willingly settled into our work, stating “I probably should have started therapy years ago.” She knew she wasn't taking care of herself, and that she was in danger of losing her job, if not even her marriage. Without complaint, she committed to therapy, and worked diligently on her self-destructive patterns.
The Sally I met eight years ago is a different Sally now. This new Sally gets her work done and exercises regularly. This new Sally smiles and reaches out to her friends. This new Sally is close with her husband. We have done excellent work together.
In case it isn’t clear, I like Sally very much. She is witty and charming, with a sly smile. She talks intelligently about authors, theater, and music. She loves to travel. In short, I have a lot in common with her. We have bonded over the years.
She calls me “Doc.”
Last month, Sally started to feel unwell. She began having bad headaches, and symptoms of malaise and confusion. Her physician thought it was due to a recent medication change, which made sense. We waited for the medication change to settle down.
Sally arrived at her most recent appointment saying “I feel a little better, but not much.” Her headaches had improved, but she was still having periods of confusion, getting mysteriously lost on familiar roads. I recommended she consult a specialist. “I wonder if you could have Lyme disease?” I suggested to her, an avid deep woods hiker. We set our next appointment date.
It was time for Sally to leave my office. She tried to stand up, but her strong legs failed her. “I… can’t” she mumbled, her usually clear speech suddenly hard to hear.
I sat down again, facing her. “Take your time. It’s OK.”
She stared at me. Her face fell blank. She looked like a different person.
“I think you should call your doctor.”
Sally pulled out her phone. She stared at me again, quizzically. “What?”
“You were going to call your doctor.”
She pushed buttons on her phone, but nothing happened. She couldn’t remember what I asked her to do. She also couldn’t remember how to make a phone call.
I observed her, thoughts flashing rapidly inside my head. Something bad was happening to Sally, right in front of me. She was having rapid mental status changes. I grabbed my briefcase and turned off the lights. “OK, we are going to go to the emergency room.”
“Yes, right now.”
Tentatively, slowly, Sally followed me out to my car. She tried to enter the wrong car door. She couldn’t put her seat belt on. She stared blankly at her phone. I wrapped her seat belt around her slim hips, a more intimate gesture than I had ever made with her, my client of eight years.
I drove us to the hospital, a quick five minute trip. She stared straight ahead, emotionless, so incredibly unlike Sally. After I checked her in, and gave a quick history, the nurse swept her back immediately, chanting “Stroke protocol! Stroke protocol!” into the hospital intercom.
I waited in the emergency room. I waited for the CT scan to be done, and I waited for Sally’s husband to arrive. I felt simultaneously essential and completely out of place. I was the only one present who could give crucial medical information, so the stroke team pumped me for everything I knew. Yet, I was not Sally’s partner, relative or friend. Yes, I knew her intimately, but I had no place in that room. In fact, I had only ever known her in one room: my own office.
Sally’s husband arrived. We greeted each other with smiles and handshakes. I knew all about him. He probably knew a lot about me too, but we had never met. I updated him and he nodded, gravely.
The doctor entered the room, blonde hair pulled back in a ponytail. Her voice was matter of fact but her tone was gentle. She faced Sally, her back to us. She asked, “Can I give you information on your medical status, with these people present? I stood there, completely out of place.
“Your symptoms led us to think you had a stroke. But the CT scan doesn’t show a stroke. You need more testing, but it probably isn’t that. Instead the CT scan does show a large mass in your brain.”
Sally’s husband and I sighed simultaneously. The words “large mass” hung in the air. But when I looked at Sally, her face was impassive. She didn’t understand.
“We will be transferring you. You will need surgery.”
After the doctor left, I decided to leave too. Part of me wanted to stay. I wanted to comfort Sally’s husband. I wanted to talk more with Sally. But, another part of me squirmed knowing I was so out of place. As much as I cared, I did not belong in that emergency room.
“I’m going to go now. I’m glad you are in the hospital. They will take good care of you here.” I held Sally’s hand. I hadn’t touched her hand since the first time we met, eight years ago, when we shook hands in greeting. But now I grabbed her hand, avoiding the IV tubes nearby.
Sally looked at me, face still impassive. But even if she didn’t understand that she might have a brain tumor, she still knew who I was.
I listen to people’s stories all day long. My heart goes along for the ride. I feel the sadness, the anger, the disappointment. I go to dark places with my clients. But, at the end of 45 minutes, my clients depart, and I have to shake it off. I need to be fully available for the next client, just 15 minutes later. The boundaries of my profession protect me from being swamped with emotion. I connect with clients deeply, but only at the prescribed time, in the prescribed setting, with the prescribed expectations, in the prescribed time limit.
I love my clients, pretty much every one of them. But I am clear on how much I need these boundaries to keep working. The boundaries are like a plastic shield around a patient with a compromised immune system. The patient needs that shield to keep going, to keep from being overwhelmed by germs. I also need that shield to keep going, to keep from being overwhelmed by people’s problems. That shield protects me, so that I can keep on working, helping clients as best I can.
These therapeutic boundaries protect both of us. My clients know the sessions are solely about them and their needs. They don’t need to worry about me, and no emotional reciprocity is expected. I am there to help them get better. Full stop. The boundaries protect me too. I could not carry so much sadness, with an open heart, without the ability to say to myself, “That’s it. No more.”
Move on. Next.
I abandoned my boundaries when Sally was in my office. It was an emergency. I’m grateful I was there, and I am proud that I knew what to do. I wouldn’t have it any other way. But…
I am still in recovery from the day. Now, more than ever, I know how much I need those boundaries for protection. I laid the shield down, and bore witness to a tragedy. I didn’t learn about this tragedy second-hand, in the protection of my office, a week later. This time I was right there, listening to her dire health news as it was delivered, in real time. It crushed me.
I cannot be friends with my clients, no matter how much I care for them, and they care for me. I need that plastic shield of boundary to keep going.
Respect the boundary. It protects all of us.