Establishing Boundaries with Patients

• re you comfortable with your clients using your personal number? 
• Do you want to offer telehealth services?
• How do you feel about physical touch, like hugs?

When discussing boundaries, most often it helps to begin with physical boundaries. A physical boundary acts as a layer of protection and separation. When you learn to set physical boundaries, it becomes easier to visualize how to set emotional or intellectual boundaries. There are several ways for a therapist to establish physical boundaries, beginning with communication channels.

Decide if you are more comfortable providing your cell phone number directly to your patients’ or if you want to secure a separate phone specifically for work. Or, maybe you prefer to keep professional communications to email. However you choose to communicate with your patient, it matters that you’re upfront with what you are comfortable with. 

Some patients like text counseling, others may only want to go to therapy if the sessions are online. Generally, email is enough for most scheduling, payment, and cancellation conflicts. A therapist that offers virtual chat therapy needs to be comfortable with their typing and texting skills. Reflect on the pros and cons of each communication style and look into using a combination of methods with your patients. 

Texting

Pros: 

• Personal communication method
• Appeals to younger generation
• Fastest and highest priority
  
  

Cons: 

• Need to set firm boundaries during personal time
• Might create a sense of being “always-on,” contributing to burnout

Phone or Video Calls

Pros: 

• Accessible communication method
• Expands therapist and patient availability
• No need for a physical office 
  
  

Cons: 

• Lack of in-person information like body language 
• Need to set firm boundaries during personal time

Email

Pros: 

• Traditional professional method
• Relatively quick response rate during business hours
• Paper trail for easy documentation
  
  

Cons: 

• Slow and unreliable in cases of high risk patients
• Can feel less personal

Use your professional judgement to guide which communication method is best for each patient. It’s also important to take into consideration the reachability of the communication method you use for patients with higher risk assessments or patients that require hospitalization. In situations with higher risk, minimizing timing between responses is something to prioritize. Look into refreshing your skills on treatment planning via tele-mental health.

With the rise of telehealth, you need to think about whether digital therapy is a service you want to provide. Some practices are even moving toward a completely digital platform. Choosing to see patients virtually increases accessibility to mental health providers. To learn more about the advantages of telehealth, think about taking a self-paced program on foundations in digital therapy. 

Although, some professionals prefer to see and be with their patient in-person which provides its own benefits. There are particular therapies that are difficult to facilitate virtually, like art therapy or eye movement desensitization and reprocessing (EMDR). A hybrid model maximizes the amount of patients you are able to reach. 

In-Person

Pros: 

• Physical presence and support
• Can observe body language 
• Less distractions and dedicated space
  

Cons: 

• Expensive for therapists and patients
• Clients are limited to those within a reasonable commuting distance

In the therapy room, it is incredibly important to set boundaries on physical touch. Some therapists choose to include the use of touch as part of their healing practice. Hugging your patient is a topic that carries a lot of weight, so it’s best to limit any physical contact unless consensual and necessary to the patient’s treatment. There are situations in which therapists like to incorporate touch, like helpful hugs or a pat on the shoulder, while staying secure with their physical boundaries.

An extension of a physical boundary is a sexual boundary. California lawmakers and licensing boards share that therapy never includes sexual behavior. Patients or therapists may have feelings of attraction arise, and it is always the place of the therapist to demonstrate ethical behavior. 

• How much do you charge per session? Do you take patients on a sliding scale basis? 
• How do you approach a patient who is behind on payments?
• What types of insurance do you accept?
• Do you accept gifts?

Like physical boundaries, material boundaries are firm. Material boundaries relate to the financial side of running a practice. As much as your work centers around your patient’s health and wellbeing, you need to ensure that your financial health is in a stable place to be able to provide that unwavering emotional support. Understanding the financial importance of this work allows you to be kind to yourself when you’re not able to fit a patient into your schedule.

Do market research to see how much professionals with your credentials are charging per session in your area. In certain established practices, a therapist is able to take on patients who pay on a sliding fee scale. A sliding fee scale is when a therapist charges using a price range depending on the patient’s family size and income rather than charging their usual set price. This provides an alternative option to a standard payment where the aim is to make therapy more affordable to patients with differing incomes or those who don’t hold health insurance. There are very real costs to starting your own private practice and part of establishing material boundaries is learning to discuss payment issues. It’s important to learn to ask about missed payments with compassion for your patient’s situation and your own. 

Additionally, the practice of accepting or giving material gifts depends on the therapists. Part of your therapeutic boundaries may include not accepting gifts from your patients. Or if you decide you are comfortable giving and receiving gifts, choose an appropriate monetary limit that applies to every patient and stick to it.

• When is the end of your work day?
• What is your cancellation policy?
• How do you remind patients that their session is ending?

Many individuals have opposing views on time. Some therapists may not be bothered by a patient running 5 minutes behind, while others may see it as rude. There are also cultural distinctions in the way people view time which is important to consider when treating different patients. In the world of appointments, time limits matter and it helps to know how to set these boundaries. 

There are several ways therapists create boundaries with their time. 

1. Decide how many hours you are able to work in a day. 
2. Set a reliable schedule for your patients and yourself. 
3. Create a dependable cancellation policy. 
4. End sessions on time, gently.

First, you should decide on how many hours you are able to work in a day, then stick to a time to leave the office and emails behind. Knowing how many patients you are able to handle helps with cultivating emotional balance as you set therapeutic boundaries. 

Explore this webinar and article as an example of creating emotional balance in the forensic psychology field. 

• Vicarious trauma, Compassion Fatigue, and Burnout 
• What causes them and how do we prevent them?

Another example, you might make a decision to leave the office at 6PM regularly. Make a reliable schedule by providing a consistent, set therapy time for your patients that stays relatively the same throughout their treatment. Of course, there are times when you need to cancel or reschedule an appointment which is why it helps to have a cancellation policy. 

Cancellation policies work in two ways. They allow you to schedule your day according to unseen changes. And, it’s essential to discuss with your patients the reasons that are causing them to miss sessions. A conversation centering on therapeutic boundaries shows that you care for your patient to show up and guides the patient to participate in their own self-development.

 Also, learn to gently notify your patient that the time is approaching the end of their appointment. It helps to use the last moments of therapy to center your patient rather than having them disclose their emotionally traumatic experiences where you won’t be able to help them ground. End sessions on time so you create an opportunity to center yourself between patients.

• What do emotional boundaries look like in your practice?
• What are your local crisis hotline numbers?
• What are your favorite coping mechanisms?

Emotional boundaries are one of the most valuable sets of tools in your kit. It’s essential to know how to leverage empathy without taking on your patients’ burdens as your own. Many therapists have their own therapist in addition to a strong list of coping mechanisms. Find out early on what brings you joy and try to do it often throughout the week. It may even help to set up a routine between each patient as you settle with your patients’ stories when the time allows.

For when you take time away from work, learn to create a network of support for your patients. It helps to be familiar with other therapists in the area in this case. Also, take the time to learn the crisis hotline numbers in your area. Providing this information builds a bridge of additional support for your patients in the times you’re unavailable. It also connects them to local resources. Those resources are valuable in the times where you take a vacation away from work or when you need to meet the expectations of a demanding client.

Transference and countertransference are also important to take into mind when setting emotional boundaries.

• Transference is when a patient experiences a difficult time distinguishing feelings that are coming up in therapy and then projects those feelings onto the therapist, according to the APA dictionary.
• Countertransference works in the opposite way where the therapist becomes affected by their own feelings while treating their patient. 

When in intimate settings like therapy, the intense presence of emotions can be confusing for the patient. An example of transference may include a child with a weak parental relationship sharing sentiments that they see you as a maternal, paternal, or guardian figure in their life. This cultural diversity/cultural competence psychology program describes the issues of transference and countertransference in their relation to industries like police work and public safety. 

Professional mental health workers learn how to explore these feelings while promoting healthy emotional boundaries. In particular cases, a therapist may see a resemblance of themselves or someone they know in their patient. Part of professional psychology work is learning to manage personal emotions and biases that arise to the surface. 

Here are several resources for mental healthcare workers to manage their emotional bias: 

• Minimizing Bias in Forensic Decision Making
• Cognitive Bias: A Cause for Concern
• Parenting Capacity Assessments in Child Protection

Activities that occupy and immerse the senses are great ways of tuning in with your own emotions. Use your favorite scents, physical activities, comfort foods, and whatever else it takes to ensure that your emotional needs are fulfilled before guiding someone else through their own.

• How do you approach a patient when you disagree with them?
• What psychology theories guide your practice?
• When and how much will you self-disclose?

Intellectual boundaries refer to the theoretical sets of ideas that guide your practice. Regardless, therapy respects all types of religions and spirituality. Certain therapists choose to include their faith as part of their therapeutic model and certain clients seek out psychologists specifically with knowledge of their faith. Remember to keep clear boundaries in cases where faiths and ideas of spirituality differ. The ultimate goal is to create a safe space where your patient is able to share their thoughts despite whether you agree or not. 

Therapists tend to identify with and prefer to integrate one or two psychological ideologies in their practice. Knowing what ideas guide you also prepares your patients on what to expect. For example, a transformational therapist is more inclined to draw on somatic approaches to explore the mind body connection. In addition, self-disclosure is an important concept when setting intellectual boundaries. Ask yourself if disclosing a personal story is beneficial to the client first. There are cases in which patients do benefit from listening to a personal experience from their therapist.

When therapists establish strong boundaries with patients, they are able to provide the comfort of predictability. There are times where you’ll feel intricately wrapped up in your patient’s healing journey, so learning to create clear expectations of acceptable behavior helps protect both the therapist and the patient.