Opinion and Debate : Boundaries

Turner, V., 1999. Opinion and Debate : Boundaries. Reformulation, ACAT News Summer, p.x.

I was struck by a recent article in the Journal of Psychosexual & Marital Therapy on the importance of maintaining clear boundaries in the patient/therapist relationship. This is particularly problematic in Hong Kong which is essentially a small village. The expatriate community makes up a very small percentage of the total population (approx. 2%) thus we expats are constantly running into each other at social, sporting and business events. We also tend to frequent the same local markets, supermarkets & shops. For therapists with good case loads therefore, this means a high proportion of unavoidable out-of-office contact with our patients. We have all worked on various ways of dealing with this and, outlined below, are some of the situations I myself have encountered and how they have been handled. I would however, very much appreciate thoughts from other therapists on this knotty issue.

First, at the initial therapy session with patients, after giving the standard brief explanation of CAT, how it works and how therapy generally proceeds, I then comment on the importance of confidentiality and of how this is particularly significant in HK. It is explained to patients that, HK being a very small place, the chances are that we will bump into each other at some point. It is therefore up to the patient whether or not s/he wishes to acknowledge or be acknowledged by me. The patient effectively takes the responsibility for making the first move in this situation. Most patients have no problem acknowledging their therapist but there are some for whom if it became known they were having psychological help, the professional consequences would be severe.

For me, bumping into patients is a fairly regular occurrence and I cannot predict where it will happen or how it will feel, either to me or to the patient. This very much depends on the circumstances under which we meet. It is usually fine, but occasionally it is not. Below, some of the scenarios are outlined and these are listed in what I consider to be ascending orders of difficulty.

Casual Encounters
These might be in supermarkets, shops, in the street, at the cinema etc. They are not too difficult & generally a "Hello, how are you?", before moving on quickly with a very busy air to stall them telling you in detail how they are will suffice. Some patients do find it embarrassing however, to discover that their therapist actually buys food and toilet paper! Encounters at the hairdresser or in the gym are a little more difficult but manageable.

Professional Meetings
Psychologically-minded people are naturally interested in psychological events, thus patients do frequently attend the meetings of our Psychotherapy Society. A recent event at which Dr. Anthony Clare spoke was particularly well attended and those of us in the "caring profession" were mingling with a considerable number of our patients. I also gave a talk on CAT to the Society and found it a little disconcerting to see in the audience, among other patients, the particular patient who had given permission for me to use her material. Clearly, there is no question of "letting one's hair down" or revealing intimate details about oneself, but there has to be a little social give & take. The issue here is getting the balance right, but this is probably easier in the quasi-professional setting of a psychotherapy meeting than in the following situations:-

Cocktail Parties & Other Social Events
These are tricky. One cannot give advance notice to hosts, whether professional or friends, that patients may be attending. Nor is it politically correct to ask to vet the guest list! Thus one has to be alert for possible encounters with patients. With larger gatherings, it is perhaps not quite so difficult. Moving on frequently, avoiding the group containing the patient(s), making excuses to go to the bathroom, refilling one's glass etc. is easily enough done. It can be harder for the patient however, who is, for the first time, seeing their therapist not as a projection of their fantasy but in the reality of herself as a happily married woman with a high-profile husband. (One patient had actually seen me as a poor, overworked single woman, having to force myself to the daily grind of earning my crust). Not all patients survive encountering this reality but, as with any patient who terminates early, one has to learn not to take it personally, but to reflect on the experience in order to learn and grow professionally.

Company Events. Corporate Wife Duty.
Nor can I tell my husband that the social event for which his company has put out a three-line whip may include patients who could be distressed at finding themselves placed next to me. The immediacy of my husband's very solid & powerful presence as opposed to the more distant and abstract idea of him as a husband also means worries about confidentiality reappear. One the question of confidentiality in this context, at the very first therapy session I spell out to prospective patients from my husband's company exactly who and what his position is in the company. They are thus quite clear about this beforehand and can make up their own mind as to whether they wish to continue seeing me. If they still wish to proceed (and most do), this is their own informed decision. I also let them know that, quite apart from my own professional code of ethics, my husband is in a position where being party to such confidences might have serious ethical consequences for him. We are each at great pains not to divulge (or to hear) anything of a sensitive nature.

It can be difficult for me however, making small talk over wine and a dinner hosted by the hierarchy with someone of whose problems I have intimate knowledge and whose problems may be humiliating, embarrassing and difficult. This is particularly so in the case of those patients who have sexual problems. There is of course, a range of conversational topics peculiar to HK which can be used to cover awkward silences, e.g. "How long have you lived in HK?, "How do you like living here?" etc., etc., but generally the evening has just to be endured.

I don't refuse to treat people from the company for the very good reason that there are very few properly trained therapists in HK. Those of us who are trained & licensed find ourselves doing a lot of restorative work on patients who've been damaged by their previous under-trained and inexperienced therapists. (One patient had seen six therapists prior to discovering CAT - saying something for that patient's powers of endurance). I feel strongly that people needing help should not be excluded from getting the help they seek, i.e. penalised, by virtue of where they work. The company doctors "collude" with this in that they have seen how effective (and speedy) CAT can be and as a consequence are happy to refer patients.

I recently found myself in a couple of situations that may be unique. The first was an emergency visit to a hospital where the doctor on call who treated me was one of my patients. We have since agreed to terminate therapy, since the physical intimacy necessarily involved in a doctor/patient relationship, even though minimal, nevertheless ensured that the strictly non-physical therapeutic relationship could not survive.

The second concerned location. Our offices were suddenly flooded as a result of poor renovation work being carried out on the above floor. This necessitated finding alternative quarters at short notice to take ourselves and our patients. My own temporary re-location was in my local G.P.'s practice. It was manageable working alongside professionals who knew more about my body than I do, but it was difficult to find that another of my patients who is also a doctor had (unknown to me), recently moved to that particular practice. Working there was not logistically a problem in that I avoided the tea area & basically kept to my room when not ushering patients in or out. It is of concern however, that this particular doctor - whose major difficulties are around boundaries - now has access to my personal medical files. Changing medical practices is not an option, this being part of the package provided by my husband's company. The doctor and I have talked about this and again, terminated CAT. I also feel the doctor is ethical, but it remains a difficult one for me.

In Conclusion
There are obviously many more situations and instances that could be quoted, but the experiences outlined above give a flavour of some of the difficulties encountered in working professionally in a small town. Any comments, thoughts etc. would be gratefully received - maybe we could also start a discussion page in our newsletter?

Viv Turner

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Full Reference

Turner, V., 1999. Opinion and Debate : Boundaries. Reformulation, ACAT News Summer, p.x.

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