Chapter 5: Attitudes and Boundaries

There are two key components that can either help or hurt any relationship, especially a therapist-client relationship: attitudes and boundaries.  In this chapter of our text, Fundamentals of Case Management Practice, we explore both the boundaries that we put in place and the existing boundaries that we fail to observe.

What are attitudes?
Attitudes relate to how we see other people, feel about them and interact with them. Try as you might to hide a negative attitude, your client will eventually figure out how you really feel.  It is imperative that you, as a helper, learn your own fears, sensitivities and errors in judgement; knowing these and being able to forgive them will put you as the helper in a better position to see the good that comes out of mistakes.  And the next logical step of course would then be being better able to understand other people that are making mistakes.  The moral of the story is that being able to accept life's struggles as important lessons and recognize that it is the essence of being human gives us new insight and growth potential that is second to none.

There are three key helping attitudes that, even when lacking much in the way of formal training, are essential to being an effective therapist: warmth, genuineness, and empathy.

• Warmth refers to being friendly, nonjudgmental, and receptive.  Through action, body language, and listening skills, the client feels that they are worthy of your attention and are valued by you.  Make no mistake; warmth is not dominating; it is respectful and facilitates growth and change.  
• Genuineness is just as it sounds - presenting the authentic person that you are at all times; being open, honest, and true to yourself.
• Empathy refers to the ability to relate to how the person is feeling, from their point of view, even if you have never experienced the same situation.  It goes beyond hearing what the client says and involves hearing the meaning behind the words' this is sometimes referred to listening with a "third ear".  It is important to remember that empathy is not synonymous with sympathy.  While they are similar they are also very different.  With empathy you are not feeling sorry for the person, as you would a friend that is pain.

To be effective in these three attitudes, one must remain nonjudgmental; as humans this is certainly easier said than done!  In psychology, as a therapist, there is no room for judgment or transference of morals and beliefs.  When looking at the world through our own moral lenses, we set the stage for a helping relationship that is anything but!  Be aware, up front, that you are entering a field that's expecting to deal with upset or dissatisfied people.  They will act out, they will be uncooperative and they won't always want to see things your way.  Like it, lump it, or chose another career path.

How Clients Are Discouraged

Discouraging a client can have serious repercussions in terms of the clients self-esteem, confidence or move toward independence; and there are more ways to discourage a client that by simply telling them that they are not capable:

• Push, force, or in some way shame the client into moving toward a goal
• Compare the client to someone else, including yourself
• Too much time focusing on the mistakes of the client
• Demand that the client work harder and harder, despite their best efforts
• Insist that the client do things your way
• Dominate the client
• Demand perfection or unrealistic outcomes
• Threaten the client
• Being insensitive in your interactions: failing to notice or praise any positive step forward or accomplishment made by the client.

Most helpers are not intentionally discouraging. in fact some are put into a position of direct contact with clients whom they have no experience in working with and to combat the fear they feel in themselves about the uncertainty of the situation, they become dominating which leads to a false sense of control.  This false sense of control is from where many of the discouraging actions listed above stem.

Understanding Boundaries

As a helper, your mission, should you chose to accept it, is to erect and maintain useful boundaries while refusing those that are not.  Boundaries are set in place to protect both us as helpers and the clients.  To protect the helper, whoa?! What would the helper need to be protected from?  Sometimes the helper will encounter a situation that stirs up emotions that they themselves have not completely dealt with.  When we encounter such a situation, sometimes we protect ourselves by becoming the superior participant in the helping relationship.  The boundaries that result as we wield our power is prohibitive to any therapeutic change.  At other times, we will encounter clients that remind us in some form or fashion of ourselves or a situation that we have been in.  When we allow ourselves to view the client in this way, we become a problem for the client rather than part of the solution.  

Seeing yourself and the Client as Completely Separate Individuals

What happens when:

1. The client reminds you of you?
• We tend to get aggravated at their excuses for not being as strong as we were in the same situation
• The client threatens our sense of self, especially if the client presents a weakness that we too struggle with
• In either situation, we tend to push steps and courses of action on the client that worked for us, without regard for what may or may not work for the client
2. The client reflects on you (how the client makes you look as a professional)?
• Some therapists think that their clients must be "cured" and live happy, healthy lives in order for them (the therapists) to look good as professionals.
• We feed our own professional ego by allowing the success of the client to feed our competence or imagined importance.  Therapist know better but therapist are human and want to make a positive impression like workers in any other profession.

Erecting Detrimental Boundaries

1. False Attributions
• 2 common but false assumptions about people
1. People who look like me will think and act like me: just because we share a common race or culture with another person does not mean that we will share the same set of values, opinions or way of life.
2. People who do not look like me are not like me at all, but very different: Just as it is untrue that people from the same background are the same, it is also not true that people from different backgrounds are different.  I know; take a minute to process that circular logic for a moment.  But think about it.  The color of your skin or your place of origin does not define your brain.  You may encounter someone from another part of the world that is very similar to you in every aspect.  
• The point is to keep an open mind and remove stereotyped thinking from your mindset.  Take the client as an individual without assumptions based on who you think they are by looking at them.
2. False Power
• This is a boundary that serves more as a brick wall and is fueled by our own desires to exert:
1. Authority
2. Power
3. Competence
• As a result, we stop talking with the client and start talking to the client, barking orders instead of collaborating for success.  This runs the risk of intimidating the client and offsetting any potential for positive gain.

What is Transference? 

Transference is a collection of feelings and attitudes the client holds about you as a result of your reminding them of someone else from their life.  There are 2 types:

1. Positive Transference: occurs when the client likes you
2. Negative Transference: occurs when the client does not like you

There are a few key things to remember about transference:

1. A client can go cycle between positive and negative transference throughout the therapeutic relationship; This is especially true when maintaining professional boundaries: the client may start with positive feelings that become negative.
2. accept transference whenever it exists: It is neither good nor bad.
3. The ability to accept transference behaviors while maintaining healthy professional boundaries is important in order for the client to continue to feel safe.
4. When clients reacts to you in inappropriate ways, use reflexive listening to show the client that you are listening, you want to understand, and that you are not judging them.  This further maintains the safe environment.

What is Countertransference?

Countertransference (CT) is similar to transference except that it is the therapist that is projecting attitudes and emotions onto the client.  This happens for a couple of different reasons:

1. the client reminds the therapist of someone from his or her past
2. the issue and/or situation that the client presents with reminds the therapist of a similar situation in the therapists life.  

Also similar to transference, there are two types of CT:

1. Positive CT occurs when the client reminds the therapist of someone held in regard from the therapist's life, such as a deceased elderly aunt very loved by the therapist.  This could lead the therapist to give preferential treatment and/or special favors to this client.
2. Negative CT occurs when the client reminds the therapist of someone that was a source of angst in the therapist at some point, such as a younger brother that was always bullying the therapist.  This could lead the therapist to be inappropriately harsh or demanding to the client.

It is important to be aware of our feelings, acknowledge them, and accept them in order to overcome them.  CT feelings serve as a good indication that we have issues that we have issues we have not yet resolved and that we need to seek help in that area (yes, therapists seek therapy too!) so that we can continue to benefit our clients.

What are others saying about the matter?
In surfing the internet, there is no shortage of articles discussing the importance of boundaries and attitudes in therapeutic relationships and/or case management settings. I stumbled upon a little gem of an article that I found to be pretty interesting, but it did not fit the same mold of the majority of the search results.  Instead, in "Misuses and misunderstandings...", Gutheil and Gabbard take the stance of devils advocate, acknowledging how a good thing can be taken to the extreme.  The article gives excellent examples and really illustrates the importance of their use but the tender balance that must be maintained by not going too far.  While written in 1998, it draws to my mind the recent incident where the little boy was suspended from school for assault with a deadly pastry when he ate his pop tart into the shape of a gun.  I think the article is certainly worth your time to explore:   Gutheil, T. G., & Gabbard, G. O. (1998). Misuses and misunderstandings of boundary theory in clinical and regulatory settings. American Journal of Psychiatry, 155, 409-414.

Ask and ye shall... be confused!
The topic matter on the surface seems fairly cut and dry, but as with all things, interpretation opens quite the gateway.  To be honest, from the chapter alone I did not have a question to consider posting.  Once I found read and re-read the article from Gutheil and Gabbard, I looked back over the chapter reading and something occurred to me; What is the line between confronting a client in a therapeutic setting to encourage change and discouraging a client?  The textbook lists several different ways that we could inadvertently discourage our clients, but some of them are also techniques used (in moderation of course) to confront a client in a therapeutic way.  Isn't part of our job to help "push" (push sounds harsh, perhaps nudge is a better word choice) our clients toward goals and change?  How do we know that their "best efforts" have been exerted (as indicated in the How Clients Are Discouraged section above); if we do not nudge them along and facilitate change then aren't we ethically failing them or taking their money to merely enable them to continue their behave (and thus continue to pay us)?