Boundaries and Borderline Personality Disorder
The concept of boundaries in psychotherapy refers to the limitations placed on the therapy relationship that serve to maintain professional and therapeutic appropriateness. Boundaries are widely recognized as essential elements of any professional helping encounter, but have been given special attention in psychotherapy due to the increased psychological vulnerability inherent in psychotherapeutic treatment. We have included this brief segment on boundaries because of observations that (1) patients with Borderline Personality Disorder (BPD) tend to have difficulties with their own personal boundaries, and (2) many case reports of boundary violations in the clinical literature involve patients with BPD (Gabbard & Wilkinson, 1994; Gutheil, 1989).
Boundaries exist to safeguard the therapy and both participants. Boundaries operate at various levels, including role, time, place, money, gifts, services, clothing, language, self-disclosure, and physical contact (Gutheil & Gabbard, 1993). A boundary at any of these levels is either maintained, crossed, or violated. For example, meeting in the clinician’s office maintains a boundary regarding place; extending the length of sessions represents a crossing of the time boundary; the therapist hiring the patient to babysit his children represents a violation of boundaries at several levels.
Boundaries rely heavily on context, and thus may be fluid and difficult to firmly define (Gutheil & Gabbard, 1998). Therapists likely confront boundary issues on a daily basis (Pope & Keith-Spiegel, 2008), and it is probably impossible to practice psychotherapy effectively without crossing boundaries now and then. Boundary crossings – depending on their context and meaning to the patient – may be benign, or may contribute positively to the therapeutic alliance and to the outcome of therapy. A therapist who refuses to accept a minor gift in the interest of maintaining a boundary will probably devastate a patient who struggles to feel accepted by others. Even where boundary crossings are non-beneficial or undesirable, such incidents can typically be reflected upon and discussed between patient and therapist (Gutheil & Gabbard, 1998). This may even lead to a productive area of exploration regarding the meaning of the boundary crossing and its relevance for other issues faced by the patient.
Boundary violations, on the other hand, are neither benign nor beneficial. A boundary violation – whether intended by the therapist or not – involves some form of harm to the patient (Gutheil & Gabbard, 1993). The most harmful, but by no means the only, form of violation involves sexual contact between therapist and patient. Patient-therapist sexual contact is unequivocally always considered a boundary violation. While some sexual boundary violations involve predatory therapists, many are reported to involve therapists who failed to attend to earlier problematic developments in the therapy relationship. These often involve therapists’ excessive self-disclosure, failure to establish appropriate limits, and poorly managed countertransference issues. A slippery slope of boundary crossings may culminate in the tragic outcome of a sexual boundary violation. It is important to underscore that the prevention of such harmful incidents is always the
responsibility of the therapist.
Boundary issues may be of particular concern in the treatment of BPD because of the identity problems associated with the disorder. Internal psychological boundaries are conceptualized as being associated with identity. Patients with BPD may also frequently operate in less-reflective modes of thinking known as teleological and psychic-equivalence modes (Fonagy et al., 2002). In these cognitive modes, actions or things lose their fluid, symbolic value and instead concretely replace a psychological position. For example, a patient might not be able to infer from the therapist’s benign attitude that she cares about his wellbeing; in the patient’s mind, the therapist must physically do something (like offer a hug) to demonstrate her care for him. Under such circumstances, a therapist would do well to maintain her role in attempting to help the patient sort out his psychological difficulties, rather than be pulled in to a physical enactment in the hopes of reassuring the patient.
There is an excellent literature available regarding boundaries and countertransference management in psychotherapy (e.g. Gabbard & Lester, 1995; Gabbard & Wilkinson, 1994; Gutheil & Gabbard, 1993; Pope & Keith-Spiegel, 2008). Some of this is particularly focused on work with patients who suffer from BPD. Perhaps the most crucial advice to therapists seeking to prevent and/or manage boundary difficulties is to acknowledge their own vulnerabilities regarding boundary issues, and to regularly seek consultation and supervision.