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Section 6
Therapist Comfort

Question 6 | Test | Table of Contents

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Four Boundary Questions
The following are four values that constitute a basic premise of the therapeutic relationship. Let's look at how even the most basic of concepts present boundary questions. Here is an example of each of the four values:

♦ #1. The worth of the individual. A basic premise right? Think again. Who determines how worthy someone is to retain custody of his or her children? When you write your recommendations to the court, what was the boundary or limit you set in your report regarding the intensity and frequency of abuse for the "rehabilitated" parents seeking to regain custody?

♦ #2. The right of self-determination is also a basic ethical premise that raises boundary issues. Later, we will explore the issue of suicide. However, with a suicidal client you treated, where did you set the boundary between freedom and commitment to an in-patient unit?

♦ #3. A third philosophical basis of the therapeutic relationship is the right to share the benefits of society. But at what point does your client with a substance-related disorder lose his rights to share the benefits of society? Let's explore this one further. Some substance-use treatment professionals have criticized the classification of substance-use disorders by the DSM, Diagnostic and Statistical Manual, as simplistic and too straightforward.

They have argued that substance use cannot be forced into the two arbitrary categories of abuse or dependence, but rather that substance use represents a continuum that ranges from non-use to dependency. With your last "substance-related disordered client," what criteria did you use to set a boundary in the gray area of the DSM classification system, which many view as inadequate, regarding court orders to a treatment facility and depriving the client of his or her right to benefit from societal freedom?

♦ #4. The mutual rights and responsibility between your client and society is a philosophical basis of the mental health professions. Now, regarding the boundary between rights of your client, versus the rights of society...ask yourself...the last time your client threatened to harm an identifiable other, where and how in your mind did you draw the limit regarding a need to warn or not warn the other party?

The point to be made here is that, even in the most basic of premises regarding our mental health profession you are drawing ethical boundaries.

♦ Four Basic Premises Examples
From the preceding examples, select one which is most meaningful. Here are the four basic premises examples again:
1. Your recommendations to the court for treatment decisions about custody in a child abuse case;
2. Suicide and commitment;
3. Substance abuse; and
4. Duty-to-warn regarding threats to an identifiable other. Ask yourself…how do I set boundaries with this difficult issue?

♦ Strategy for Setting Boundaries Effectively with Clients
It has been my experience that I set boundaries effectively with clients when I feel I am able to gain personal objectivity. How do I gain this objectivity? By increasing my personal awareness regarding my needs, weaknesses, and strengths.

By "awareness" I mean my ability to deal with my personality patterns and client issues, as they may relate to my life experience, which may cloud my ability to relate to the client.

I look at my level of openness. I look at my ability to be aware of values, attitudes, and patterns of behaving in the groups of which I consider myself to be a part. Lastly, I look at my ability to differ and stand alone when necessary…should I need to act as an advocate for the client. It is one thing to recognize my shortcomings and another to change them.

4 Factors for Rating Your Ability to be Ethically Comfortable

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We have explored your attitudes and how they are linked to learned behaviors and gender culture.

Now let's
increase your self-awareness of the impact of your personal needs in light of defense mechanisms, security versus growth, and middle-class values.

♦ Defense Mechanisms
Regarding defense mechanisms, the nature of life's demands are such that there are times when it is constructive to make temporary use of defense mechanisms like denial, projection, regression, fantasy, and so on. As you know, this helps us to guard against anxiety and pain that would otherwise be overwhelming.

For example, I treated a client, Jane, who used denial as a reaction to her husband's physical abuse. Only when it extended to her daughter was Jane able to overcome her fear, face reality, and make use of help and resources.

As you know, you need to be able to recognize the presence of defense mechanisms both in yourself and in your clients. Ask yourself whether your uses of defenses are constructive or destructive, whether consciously or unconsciously aware at the time. As you know, your selection of a particular defense mechanism is strongly influenced by your background.

For example, do you have a family member that uses humor to deal with painful feelings? If not, what coping mechanisms did your family use...denial? projection? regression? Think for a minute…when a client uses these mechanisms, do you become uncomfortable because they mirror your issues? Do you need to more consciously set a boundary between your feelings about a client's use of a defense mechanism and the ones you employ?

♦ Learning to Use Yourself More Effectively
To assist with this process of learning to know and use yourself more effectively related to your awareness of setting ethical boundaries with your clients, ask yourself the following questions:

5 Questions to Know Yourself

-- 1.
How do I think and feel about myself? Answer in one word or a short phrase.
-- 2. What is my self image?
-- 3. Do I feel I am physically or intellectually handicapped in some area or do I feel I am whole?
-- 4. Do I see myself as old, middle-aged, or young?
-- 5.
Am I fat, thin, or average?

I feel one of the most important factors in self-awareness, and thus in setting ethical boundaries with clients, is how you feel about yourself. I know when I feel I like myself, I usually relate in a more open, receptive manner to my clients. Let's explore this further.

♦ 4 Factors in Rating Your Ability to be Ethically Comfortable with Yourself
According to Brems, in "Dealing with Challenges in Psychotherapy and Counseling," your ability to be comfortable with yourself is based on the following four factors:

Factor #1. Awareness of and ability to accept yourself as a fallible person and therapist with strengths and weaknesses. We have already covered cultural role expectations placed upon males being the "white knight," so to speak and having all of the answers, and females to being submissive. How are you at self-acceptance?

Factor #2. Development of a flexible adaptive pattern that does not demand perfection of yourself and hence does not expect it of others. We as therapists always strive to accept our lack of perfection, but where are you right now? Rate yourself, on a scale from 1 to 10. One is low, being a total lack of your imperfection, and 10 is high, being a total acceptance of your imperfections.

Factor #3. Regarding your ability to be comfortable with yourself, how would you rate your capacity to recognize and deal with the impact of negative attitudes? Are you a female who feels discriminated against regarding the last promotion or special privilege handed out to a male in your agency? Or are you male, who feels he is the victim of reverse-discrimination?

Factor #4. Acceptance of the fact that self-liking is not static or unchanging. Self-acceptance and liking involves a continuous process of awareness, assessment, and flexibility.

The point to be made here is, setting ethical boundaries with clients begins with your comfort level with yourself as a basis for making objective treatment decisions.

- Brems, C. (2000). Dealing with Challenges in Psychotherapy and Counseling. New York: Brooks and Cloe.
Reviewed 2023

Peer-Reviewed Journal Article References:
Brainerd, C. J., & Bookbinder, S. H. (2019). The semantics of emotion in false memory. Emotion, 19(1), 146–159.

Conlin, W. E., & Boness, C. L. (2019). Ethical considerations for addressing distorted beliefs in psychotherapy. Psychotherapy, 56(4), 449–458. 

Franeta, D. (2019). Taking ethics seriously: Toward comprehensive education in ethics and human rights for psychologists. European Psychologist, 24(2), 125–135.

Glebova, T., Foster, S. L., Cunningham, P. B., Brennan, P. A., & Whitmore, E. (2012). Examining therapist comfort in delivering family therapy in home and community settings: Development and evaluation of the Therapist Comfort Scale. Psychotherapy, 49(1), 52–61.

Slone, N. C., & Owen, J. (2015). Therapist alliance activity, therapist comfort, and systemic alliance on individual psychotherapy outcome. Journal of Psychotherapy Integration, 25(4), 275–288. 

Your ability to be comfortable with yourself is based on what four factors? To select and enter your answer go to Test.

Section 7
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