Wednesday, April 16, 2008

Therapy and Boundaries

This is to address a couple comments on my last post. It also addresses things I have thought about, wondered about in therapy, things that made me stopped doing things I really enjoyed doing, because I beacame afraid I may be perceived as crossing boundaries.

In my previous post "Co-Blogging Re-visited and a Therapeutic Epiphany", both Dr. Shock and Jcat encouraged me to to continue towards trying a co-blog with my pdoc, in spite of some reservations about this being a means of avoiding the person to person communication issues I have, or a way of overstepping the therapeutic boundaries.

I agree with Dr. Shock when he says not to generalize another therapy's belief onto my relationship and therapy with my pdoc. That was a powerful comment and really made me think. I believe my pdoc and I have a really good and mutually respectful therapeutic alliance. I am not one to try to cross boundaries. In fact my crossing boundaries might signify a breakthrough in my therapy, because I am always so conscientious about doing the "right" thing, about not ever making a mistake, or taking a chance.

I, like Jcat, find it easier to express myself clearly in writing. Like her I have wondered about, and was careful to not cross anything I felt was a boundary.

I used periodically send cards to my pdoc , just to say thanks. I never saw this as stepping over a line, or "acting out". I saw it as, and meant it to be, a symbol of kindness, caring, and to let him know that even though my mood never seemed to get better, I valued his seeing me. Of course one could look for a subtext here: I was fearing abandonment because I felt I was an incredible burden on Dr X. because I was so unwell and not making any progress. I sent the cards to let him know I wanted to continue trying, that I found him helpful and that I really wanted to keep seeing him. That is all true, but the cards were more like a thank you for his consistently being there when I needed someone.

I live on a flower farm, and I used to sometimes bring flowers to my appts for Dr. K. I stopped doing it because I felt really self -conscious that maybe that was crossing a boundary. Flowers seemed too personal, even though there were thousands of them growing all around me, and I found joy in giving them away. It is a shame I felt wierd about bringing some to Dr. X, because the act of choosing the flowers, arranging the bouquet, and the joy of giving a beautiful gift heartfelt gift to him. actually inspired me, the giver.

When I was saying Ms. Fuller gave me food for thought, it was that she reminded me of some of the things I used to do, and stopped doing, because of my fear of crossing boundaries. There is obviously something there, because I rarely bring flowers in, or send cards anymore, because I feel uncomfortable for some reason, though I'm not sure why.

I was also thinking she has a point about how it is really important for me to learn to speak what I seem so easily to write. Despite that I feel I really have been able to speak up many times, because I write.

I think writing directly to my pdoc, about my experience in therapy, as long as we have an agreement that his portion takes place within the therapeutic hour, will only enhance my already great experience in therapy with Dr.X. I will remain conscientious of the boundaries between us; they are as important to me as they are to him. I am looking forward to trying a private co-blog with my pdoc.


The Silent Voices in my Mind said...

Have you considered printing out your blog entry and taking it with you to therapy? That's what I do when I want to go over the contents with my doc. There are a couple pluses there for me. He puts it in my chart so it's on hand. I get my thoughts organized and clear and I don't forget them. But I still have to bring it up and talk about. (Which is easier said than done sometimes!)

Aqua said...

Hi The Silent Voices in my Mind,

Thanks for the comment. Yes, I have done that many times. Often when I cannot get what I want to say out I bring a printout of what I wrote in my blog, have Dr. X. read it and then I feel I am able to discuss it.

I think that type of interaction was what started me thinking about sharing my entire blog in therapy sessions. The idea of a co-blog seems to take that one step further and would provide me with written feedback that may help me more clearly see myself from another's perspective.

If you have followed my blog for a while you will see that I waver between complete trust and faith in my pdoc's desire, ability and efforts to help me, and then I sometimes feel an intense fear that he will leave me, or has an agenda above and beyond what is said in therapy. I really think seeing feedback in a solid written, (unchangeable by my mind)form can help me work through those fluctuating beliefs.

jcat said...

Sometimes you really are my psychological twin....

Yeah, first patient principle has to be, I guess, 'respect the limits'. But I don't think that that necessarily conflicts with some personal interaction with a therapist. Taking flowers when you live on a flower-farm and they will be enjoyed by the doc and/or his staff shouldn't be an issue. Not unless you are somehow going to interpret the giving and/or appreciation as an invitation to jump his bones at the next appt. Think not!!

The whole issue of writing vs verbalising stuff? Yes, sometimes we do need to learn to talk about conflict. But shit, I am 42. I have trained myself enormously in verbalising stuff, but sometimes there are still things that I am just not going to say, but that would/should be part of the therapeutic relationship. If I can't do it by now, the choice is not how I say it, but whether I write it or just don't say anything ever. I figure a 1 or 2 line email then is ok. BUT, as you say, there is no expectation of it being read at any other time than scheduled, and if it is mentioned, then it's time to try bite the bullet and respond verbally.

In some ways, SA is fairly relaxed about therapeutic relationships and their boundaries. No-one is going to condone any kind of major transgression, but maybe we are less rigid, and that can sometimes help. Tdoc practices from her home, I know her husband, he and I talk often about birds (and he rescues some for me as part of his work as a landscaper), she talks about inlaws and stepkids and other domestic hassles, we hug often, I bring flowers or candles sometimes, she makes coffee and offers me home-made biscuits....
crossing boundaries? Probably. Has it strengthened the therapist/patient relationship? Yes. Are we "friends"? No. But I know that she is on my side, that I do matter to her, and it helps a lot in the therapy side. Pdoc is a bit more complicated. He is my absolute 'perfect 10' in a man, and he knows that I think that. But above all, he is my doctor. I trust him, I respect him, I will think about what he says and mostly go along with his ideas. We also swap music links and MP3s, I cut CDs that I think he will enjoy (but..only if I am making them for myself anyway), we exchange occasional mails about research or interesting articles from journals. I might email him re a non-urgent med question, he might reply. Less intrusive than a page or cell-call. We hug at the end of most appointments. Expectations? Zero. I am more compliant sometimes, because I care about him and that makes me want to try harder at being well. It doesn't change anything major, but it does help. I don't take him flowers - but I do sometimes for his office staff, who enjoy them immensely!

They are very different relationships, but in both cases we are almost definitely crossing the traditional boundaries, and I don't really think that that should automatically be a bad thing. Sometimes perceptions change with time, as do methods of communication and other social conventions.

As long as the basic premise is that the relationship between therapist and patient is first and foremost a therapeutic, care-giving one that also involves payment by the care-receiver, is it really that important how it is expressed? If it is understood that cards, or printouts of written thoughts, or SMSs or emails or co-blogging, or whatever communication there always part of that therapy... isn't it maybe better to establish the communication channels rather than to close them off just because they don't conform to the traditional hour-on-the couch format?

Aqua said...

Thanks for the note. You put alot of thought into your reply. I agree when you said, "better to establish the communication channels rather than to close them off just because they don't conform to the traditional hour-on-the couch format".

As long as the boundaries are agreed upon and both patient and therapist feel comfortable with the style of communication. I would hope, if my pdoc was uncomfortable with cards, or flowers, or whatever, he would say something.

Oh yeah...have a super holiday. Swim lots! Drink lots!! and have LOTS of fun!!!

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