Understanding Boundaries and Containment in Clinical Practice
This monograph considers the construction, maintenance and usefulness of professional and personal boundaries in clinical work. It will be of interest to mental health professionals, counsellors and psychotherapists as well as to the general public who may wish to think about the operation and impact of boundaries in their personal as well as work environments. The theoretical approach is psychoanalytic in its broadest sense, drawing on both Freudian and Jungian concepts. These are supported by many clinical examples taken from counselling, psychotherapy and institutional work.
The authors make an assumption that psychodynamic counselling, psychotherapy and more intensive work, although they share many aspects of a theoretical body of knowledge, are different and this difference should be valued rather than glossed over. Although the authors are primarily involved in intensive work in their own practices, they have a background in counselling and social work as well as experience of work in institutional settings. Despite the fact that the content of a therapist's intervention may differ depending on the kind of therapeutic work he is doing, the use of boundaries and containment supporting his response will have much in common. The chapters about the rationale behind the use of boundaries and containment in therapeutic work will be of particular interest to counselling and psychotherapy trainees and their course tutors and teaching staff.
The image of an onion with its many layers enclosing a central core is used as a metaphor to describe the many circles of containment that, when well functioning, can protect the 'therapeutic couple'. These layers begin with the most immediate, the therapist's mind. They then encompass the physical nature of the consulting room itself, the time and fee arrangements for the session and expectations about confidentiality. Further layers outside the consulting room are provided by the therapist's experience of training and the training organisation's code of ethics. Within a short time frame there will be an additional layer of containment in the government's plans for registration of the professions of counselling and psychotherapy.
The book begins with an exploration of why boundaries and containment have come to hold such an importance in therapeutic work. The very boundaries that are so often the focus of jokes or of a disbelieving public have a history and rationale that is crucial to and supports therapeutic work. Issues such as the need for a safe place in which to express unfamiliar, sometimes forbidden or volatile feelings, the importance of confidentiality, the need to 'magnify' otherwise elusive reactions - these are all part of the containment that boundaries can provide.
The authors postulate that an individual sense of boundary begins with the infant's earliest experience - the womb as container. This is modified and influenced by external environmental factors such as the child's carers and other important relationships as well as internal factors such as the ability to bear frustration. The book continues with an exploration of each stage of a child's development and looks at how the response to boundaries at different ages can affect what may be brought into the consulting room years later.
The authors describe how concrete factors such as predictable beginnings and endings of sessions, fees, and the physical structure and content of the consulting room are crucial to the formation of the less concrete envelope of trust and co-operation around the therapeutic session. They also consider the much more internal containment of the therapist's mind and how the training, supervision and personal therapy of the practitioner help to develop an internal sense of containment and 'boundariness' which informs the work. It is the therapist's use of and relationship to this mental space that can provide a contained space for therapeutic work. This is why the therapist also needs the containment of safe boundaries -- to cushion and protect this mental functioning. It is in part such containment that in turn helps the patient reconstruct personal boundaries which may be more helpful than the rigid defences so often employed when help is first sought.
Space is also given to an exploration of therapeutic work in a number of familiar institutional settings: a GP surgery where the counsellor attempts to create a contained space for her work, a hostel for young homeless people who respond violently to a lack of containment, an NHS psychotherapy department, a social work home visit to a tenant whose boundaries have been breached by a robbery and a parochial church council that loses the containment of its vicar. In each case the creative use of boundaries as well as the response to a lack of containment is described.
The last chapter on ending therapy looks at the many reasons why this can happen prematurely and suggests how to approach such difficulties. It also looks at the tasks of an ending that is allowed sufficient time.
The authors make an assumption that psychodynamic counselling, psychotherapy and more intensive work, although they share many aspects of a theoretical body of knowledge, are different and this difference should be valued rather than glossed over. Although the authors are primarily involved in intensive work in their own practices, they have a background in counselling and social work as well as experience of work in institutional settings. Despite the fact that the content of a therapist's intervention may differ depending on the kind of therapeutic work he is doing, the use of boundaries and containment supporting his response will have much in common. The chapters about the rationale behind the use of boundaries and containment in therapeutic work will be of particular interest to counselling and psychotherapy trainees and their course tutors and teaching staff.
The image of an onion with its many layers enclosing a central core is used as a metaphor to describe the many circles of containment that, when well functioning, can protect the 'therapeutic couple'. These layers begin with the most immediate, the therapist's mind. They then encompass the physical nature of the consulting room itself, the time and fee arrangements for the session and expectations about confidentiality. Further layers outside the consulting room are provided by the therapist's experience of training and the training organisation's code of ethics. Within a short time frame there will be an additional layer of containment in the government's plans for registration of the professions of counselling and psychotherapy.
The book begins with an exploration of why boundaries and containment have come to hold such an importance in therapeutic work. The very boundaries that are so often the focus of jokes or of a disbelieving public have a history and rationale that is crucial to and supports therapeutic work. Issues such as the need for a safe place in which to express unfamiliar, sometimes forbidden or volatile feelings, the importance of confidentiality, the need to 'magnify' otherwise elusive reactions - these are all part of the containment that boundaries can provide.
The authors postulate that an individual sense of boundary begins with the infant's earliest experience - the womb as container. This is modified and influenced by external environmental factors such as the child's carers and other important relationships as well as internal factors such as the ability to bear frustration. The book continues with an exploration of each stage of a child's development and looks at how the response to boundaries at different ages can affect what may be brought into the consulting room years later.
The authors describe how concrete factors such as predictable beginnings and endings of sessions, fees, and the physical structure and content of the consulting room are crucial to the formation of the less concrete envelope of trust and co-operation around the therapeutic session. They also consider the much more internal containment of the therapist's mind and how the training, supervision and personal therapy of the practitioner help to develop an internal sense of containment and 'boundariness' which informs the work. It is the therapist's use of and relationship to this mental space that can provide a contained space for therapeutic work. This is why the therapist also needs the containment of safe boundaries -- to cushion and protect this mental functioning. It is in part such containment that in turn helps the patient reconstruct personal boundaries which may be more helpful than the rigid defences so often employed when help is first sought.
Space is also given to an exploration of therapeutic work in a number of familiar institutional settings: a GP surgery where the counsellor attempts to create a contained space for her work, a hostel for young homeless people who respond violently to a lack of containment, an NHS psychotherapy department, a social work home visit to a tenant whose boundaries have been breached by a robbery and a parochial church council that loses the containment of its vicar. In each case the creative use of boundaries as well as the response to a lack of containment is described.
The last chapter on ending therapy looks at the many reasons why this can happen prematurely and suggests how to approach such difficulties. It also looks at the tasks of an ending that is allowed sufficient time.
