The Importance of Therapeutic Boundaries
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Counselors teach their clients what healthy interactions are through the use of therapeutic boundaries. Boundaries are invisible limits that inform your client what is normal behavior, within the treatment process. This includes behavior inside and outside of the therapy session.
Therapeutic boundaries create safety and protection for your client, as he or she learns what to expect from the counselor in each session. It is the counselor’s responsibility to create and maintain this professional relationship.
Boundaries start at the first encounter with your client and continue throughout the counseling process. The counselor’s role is to clearly explain what is happening and why, while keeping the client informed throughout the development of treatment.
At the intake or evaluation, counseling professionals discuss the limits and definition of confidentiality, the consent to treat form, HIPPA (including releases of information), and the client-therapist agreement, which outlines the parameters of therapy.
Use this initial time to clarify what the expectations are. A counselor treats the client for the symptoms presented, according to his or her treatment plan. Clients often expect their first session to be a time of them talking about their problems. It is important to inform your client when setting the initial appointment, what to anticipate for this first session, and how it will be different from your subsequent sessions.
Another important boundary to consider is your specific therapy orientation, competency, and treatment style. If you are not qualified to treat the client, a referral must be provided to another counselor.
Boundaries and effective limit-setting help to empower and protect clients by teaching and reinforcing the skills they need to become healthy. Limits build respect and client engagement. Even when a client disagrees about a boundary, over time he or she will respect and trust you. Limits are good for the client because it protects them from the power differential in healthcare relationships.
The Imbalance in the Therapy Relationship
Clients come to therapy vulnerable and in need of your help and expertise. Counselors are placed into an authority role, which is a position of power.
At times, you will know more about your client than their own family and friends, while the client knows very little about you. It is important to remember this dynamic and think of the ethical counseling principle: Do no harm.
Even when client’s ask about your personal life, it is important to not tell them too much. You can acknowledge that it is normal for them to be curious and want to know more about you. Remind them that the purpose of counseling is to keep the focus on their symptoms and progress.
Sharing or self-disclosing to your client needs to be done mindfully. You do not want to burden your client with the personal details of your life, yet you do not want to seem you are hiding behind a professional façade. It is important to ask yourself before you share personal information: does this serve my needs or does this serve the client’s needs?
The nature of therapy is the sharing and exchanging of personal information from client to counselor. Over time, it is not unusual for your client to feel connected to you. Some clients believe you are their friend. You can recognize this feeling but state that you cannot be a friend because you are bound by the parameters of a professional relationship.
The American Counseling Association (2014) provides you with a code of ethics which “sets forth the ethical obligations of ACA members and provides guidance intended to inform the ethical practice of professional counselors.” It clearly states the following non-counseling roles are prohibited with your clients:
- A.5.a. Sexual and/or Romantic Relationships Prohibited
- A.5.b. Previous Sexual and/or Romantic Relationships
- A.5.c. Sexual and/or Romantic Relationships with Former Clients
- A.5.d. Friends or Family Members
- A.5.e. Personal Virtual Relationships with Current Clients
In these more grey areas, counselors need to take caution:
- A.6.a. Previous Relationships
- A.6.b. Extending Counseling Boundaries
- A.6.d. Role Changes in the Professional Relationship
- A.7. Roles and Relationships at Individual, Group, Institutional, and Societal Levels
Building Trust with Clients
According to the American Counseling Association (2014) code of ethics, “Counselors facilitate client growth and development in ways that foster the interest and welfare of clients and promote [the] formation of healthy relationships. Trust is the cornerstone of the counseling relationship, and counselors have the responsibility to respect and safeguard the client’s right to privacy and confidentiality.”
Trust is built through consistency, over a span of time. As a therapist, you need to be aware of your own behaviors and what they communicate to your client. One way to build trust is to have consistent and clear boundaries. Highly intuitive clients notice everything. This can include cutting the client’s hour short, allowing for extra time at the end of a session, to not returning a phone call in a timely manner.
Clients also pay attention to your words and nonverbal body language. They can tell if you are stressed, tired, angry, tense, or scared. Therapists are human and far from perfect. You can be a model for healthy relationships when you take responsibility for your behaviors.
If a client initiates a discussion about one of these inconsistencies, admit it. This serves as a psychoeducational moment for your client. They learn it is okay for them to be imperfect human beings. Your authenticity builds trust.
The relationship between client and counselor often acts as a microcosm for how the client acts in relationships outside of the office walls. Many of your clients have not learned healthy ways of communicating or relating. It is within the therapeutic hour that you teach your client how to express themselves assertively and become an active listener. Also, your client will learn self-regulation skills, in order to sit with difficult emotions, without reacting.
Not only does the counselor need to maintain proper boundaries with their clients but also with themselves. Without proper therapeutic boundaries, you are at risk for compassion fatigue, vicarious trauma, and burnout.
What Are Compassion Fatigue, Vicarious Trauma, and Burnout?
The first step a counselor can take is to educate themselves about compassion fatigue, vicarious trauma, and burnout. Through these learnings, you become aware of the signs of each and take appropriate action. In order to prevent professional trauma and fatigue, it is essential to not only take advantage of supervision but also collaborate with the peers you work with.
Compassion fatigue is also known as caring too much. Empathy is a wonderful tool in therapy and can be beneficial to your client. An excessive amount of caring without proper self-care boundaries, however, can be harmful to a counselor.
When you are empathic, your energetic boundaries are at risk from absorbing too much of your client’s feelings, thoughts, and experiences. The result is you end up feeling overwhelmed and exhausted. These symptoms can prevent you from empathizing or having compassion towards others and even yourself. It is important to maintain limits, such as keeping work at work, taking lunch and dinner breaks, along with instituting your own self-care practices outside of work. Having a healthy balance between work and home is essential to being a compassionate counselor.
Vicarious trauma can develop from compassion fatigue and occur when you work with clients who have experienced trauma. When you lack professional personal boundaries, over time, your fundamental beliefs about the world can change from the repeated exposure to traumatic material. It can be traumatizing to hear other’s trauma or too much traumatic material throughout the day. You may need to decrease your caseload if it is heavy with clients who have experienced trauma. In some instances, you may experience the symptoms of posttraumatic stress even though you have not directly witnessed the trauma.
Symptoms of Posttraumatic Stress Disorder from the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM–5; American Psychiatric Association, 2013)
A. Exposure to actual or threatened death, serious injury, or sexual violence in one (or more) of the following ways:
- Directly witnessing the traumatic event(s).
- Witnessing, in person, the event(s) as it occurred to others.
- Learning that a traumatic event(s) occurred to a close family member or close friend.
- Experiencing repeated or extreme exposure to aversive details of the traumatic event(s).
These are the symptoms you as a counselor could experience, if you have vicarious trauma:
B. Presence of one or more of the following intrusion symptoms associated with the traumatic event(s).
- Recurrent, involuntary and intrusive memories of the traumatic event(s)
- Recurrent distressing dreams in which the content and/or affect of the dream are related to the traumatic event(s).
- Dissociative reactions (e.g., flashbacks) in which the individual feels or acts as if the traumatic event(s) were recurring.
- Intense or prolonged psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event(s).
- Marked physiological reactions to internal or external cues that symbolize an aspect of the traumatic event(s).
C. Persistent avoidance of stimuli associated with the traumatic event(s) (one or both required):
- Avoidance of or efforts to avoid distressing memories, thoughts, or feelings about or closely associated with eth traumatic event.
- Avoidance of or efforts to avoid external reminders(people, places, conversations, activities, objects, or situations) that arouse distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s).
D: Negative alterations in cognitions and mood associated with the traumatic event(s) (two or more required):
- Inability to remember an important aspect of the traumatic event(s) (typically due to dissociative amnesia and not to other factors such as head injury, alcohol, or drugs)
- Persistent and exaggerated negative beliefs or expectations about oneself, others, or the world. (e.g., “No one can be trusted” The world is completely dangerous”)
- Persistent distorted cognitions about the cause or consequences of the traumatic event(s) that lead the individual to blame himself/herself or others
- Persistent negative emotional state (e.g., fear, horror, anger, guilt, or shame)
- Markedly diminished interest or participation in significant activities
- Feelings of detachment or estrangement from others
- Persistent inability to experience positive emotions (e.g., inability to experience happiness, satisfaction, or loving feelings).
E. Marked alterations in arousal and reactivity associated with the traumatic event(s). 2 or more of the following:
- Irritable behavior and angry outbursts
- Reckless or self-destructive behavior
- Exaggerated Startle Response
- Problems with concentration
- Sleep Disturbances
Burnout is the physical and emotional exhaustion counselors experience when they have low job satisfaction. This experience leaves counselors feeling powerless and overwhelmed at work. You may have too much of a workload or are not receiving adequate support from your work environment.
For this reason, some counselors who switch jobs or occupations may find relief from burnout. Those who experience compassion fatigue or vicarious trauma would not find relief by switching jobs. Another piece of burnout is having unrealistic work expectations, which can drive you to do too much. If a counselor’s burnout is due to these faulty thoughts, switching jobs would not relieve burnout.
When you create therapeutic boundaries, consider the stress you manage at home, as well as in the office. You may normally work well but find your energy is more vulnerable due to stress at home, grief, trauma, living through a pandemic, or being a caregiver with your family.
These additional stressors, when added to your therapeutic work, can create a vulnerability not only for compassion fatigue but also vicarious trauma and burnout. This is why therapeutic boundaries are essential to every counselor’s wellbeing and effectiveness.