Boundaries

The psychologist's interest in boundaries is the source of much well deserved mockery. Apart from the jargonistic deployment of "boundaries" as a justification for various therapeutic prohibitions (second only, perhaps, to the use of "inappropriate"), the enforcement of a boundary often looks like an effective way of keeping a genuine relationship at bay.

Of course there is a certain necessity to boundaries. Apart from the fact that a professional relationship has to begin and end somewhere (you really don't want your therapist following you home), the moments when a boundary is pushed can provide a useful source of discussion. Take the example of a clear start time for psychotherapy sessions. If someone is repeatedly 15 minutes late for therapy, that is something to be interested in. Sometimes life gets in the way and people are late. No one should be getting too hung up on lateness - we're all adults. But if someone is repeatedly late then something might be going on. A polite person, reluctant to hurt a therapist's feelings, might be having reservations about the sessions. Noticing the lateness and discussing it is a way of drawing attention to something that might be important.

But boundaries can definitely be a fetish for psychologists. There is a deliciously daft example of this in Allan Young's "Harmony of Illusions," a history and anthropology of PTSD and its treatment. Young spent some time conducting fieldwork in a VA hospital during the 1980s. As part of this work he sat in on trauma focused psychotherapy groups where Vietnam veterans were encouraged to broach the atrocities they had witnessed or participated in. Because the therapeutic model put a high value on disclosure, the group members were expected to stay with the difficult content of the sessions and not engage in avoidance. Young describes how the group entered a crisis when it seemed to the psychologists that one of the members was going to the bathroom rather a lot during the discussions.

Because these frequent bathroom trips looked (to the psychologists) a lot like avoidance, the psychologists felt they had to address them. A rule was put in place - no bathroom trips during the group sessions. If that sounds unreasonable to you then you can imagine the reactions of group members. There was something of a revolt and, stuck between the need to stand their ground (notice the power struggle that has immediately snuck in) and the need to be reasonable  the facilitators had to find a solution. The apparently face saving solution elected was for group members to urinate into wastepaper bins in the group room. This met the ordinary human need to urinate without sacrificing the psychologists' insistence on staying in the room to engage with trauma narratives.

Of course, urinating into a bin in a group therapy room is not only undignified, it is patently absurd. It is hard to imagine that the vets in this group weren't aware of this, and Young describes how they availed themselves of the opportunity to relieve themselves with what became an unsustainable frequency. There is a kind of check-mate that has happened here. The staff's desire to focus so heavily on rules over good sense allows the veterans to adhere to the letter of the law while ignoring its spirit. If the facilitators felt any horror at their proximity to increasingly full buckets of pee, they had only themselves to blame.

Versions of this kind of struggle are the bread and butter of inpatient mental health care. It is par for the course that protocols will be set and violated, and that this kind of thing will be grist for discussion. But the descent into naked power struggle is far too frequent. When this happens the staff have the double advantage to setting rules (however unreasonable) and then blaming patients for their violation. If you must leave the room to pee then it has to be your avoidance/aggression/personality disorder that is to blame. This is getting things all wrong. Yes, boundary transgressions (and isn't the language of boundaries so accusatory!) should be discussed. But if some sort of staff/patient power struggle emerges, it is the job of the staff to see this unfolding and to sidestep it. This may have to involve a climb-down and a dose of good old fashioned humility. Of course people go to the bathroom as a form of avoidance (at least, I know I do). If that starts happening then discussion is a better way out than ad hoc rule creation. Any sensible polity can only implement laws that don't burden its participants unreasonably.