Boundaries and being human

If you ever do any study in the ‘helping people’ professions, you’ll probably come across information about professional boundaries. Boiled down to the simplest level these are usually something along the lines of ‘don’t ever be friends with your patients because it’s bad’.

I’m a huge fan of boundaries, especially when they’re really clear, easy to understand, and everyone benefits from them. I hate being in a situation where I’m not sure what would or wouldn’t be appropriate, where if I do something wrong I’ll feel really embarrassed. Boundaries define and protect relationships and ensure mutual respect and choice about how people interact. Good boundaries help to prevent abuse, domination, manipulation, merging and all the various ways we human beings rub up against each other that diminish and dis-empower the other person. Relationships without boundaries are really vulnerable to the normal weaknesses and limitations of each person really wreaking havoc on the other, often despite good intentions. The more important the relationship, the more important that good, clear boundaries are in place. They’re not just a way of pushing away people we don’t like!

Professional boundaries are supposed to mean that someone going to a therapist can be secure that the therapist is not best friends with their partner/boss/parent, that they are going to put aside their own needs and issues and focus completely on the person in front of them. There’s a really good reason for these kind of boundaries in intensive one to one work with people, and it’s depressing how many therapists are struck off each year for failing really big obvious ones like don’t sleep with the client! These kind of boundaries have also been adopted by most other helping professions – doctors, social workers, disability carers, mentors, and so on. There’s been a trickle down effect where what’s best in therapy is assumed to be best practice everywhere else too. This comes with some problems.

One of the big issues with professional boundaries being this rigid is that this doesn’t work so well outside of city life. Out rural, in small towns, and in any other culture that operates within self contained tribes, this approach founders. Small town psychiatrists find themselves in a position where they cannot technically befriend any of the local community. Any event, be it sports, a gathering of friends, church or club, will have people present they have or are treating. Either they leave, live a fairly solitary existence, or reshape a few of the guidelines to better fit their circumstances.

People with high needs disabilities also find themselves in a difficult situation with these boundaries. If they are not allowed to become close or attached to any person who is paid to care for them, we can create a very unnatural situation. To be surrounded not by family or friends, but by staff to whom you are not allowed to give a birthday card, receive a hug, or invite to a celebration can be painfully lonely. I know the shame that comes with becoming aware that the only people in my life who show me any care are paid to be there, not coming over because they actually just like me. Boundaries are supposed to protect our humanity, not force us to deny it.

In mental health the kind of care provided may be less physically intimate, but we still put people in the strange situation of being only able to receive care. Our ideas about recovery are often geared towards a kind of meaningless hedonism – look after yourself! People with disabilities are not permitted to give care to the staff. An idea that was designed to prevent abuses actually entrenches an uneven power relationship and has built into our care system two distinct, separate, and often warring groups – those who give ‘care’, and those who receive it. Human beings need to express both, and we need relationships in which give and take both operate. When I was trying to rebuild a shattered life I tried to volunteer with a number of different organisations and was persistently knocked back for this reason. One of them told me outright –

You’re not one of the people who gives help, you’re one of the people who needs it.

Given a choice, I can tell you which group I’d rather belong to! The reality is, we all belong to both. At the moment, the people who have the luxury of doing the giving are telling off the unfortunate ones who need support for feeling humiliated by it. We’ve created a system where most of those who work in mental health would be intensely humiliated to ever need support from the services they work in. Most doctors would be horrified to be detained and hospitalised for mental illness. Our staff talk about reducing stigma and not being too proud to ask for help, but it’s a brave few who walk that talk.

We currently have a strange situation in mental health where those with a passion for the topic train and work within the field, meaning they cannot befriend those most in need of friends. The services get frustrated that the rest of our culture who have other passions and trained for different fields, don’t turn up to our activity centres and befriend those most in need. We’ve accidentally removed from our social networks most of the people with the heart to be great friends to those most profoundly affected by mental illness. The message to people with severe mental illness is; our research tells us that friends, family, and feeling like you are useful and your life is meaningful are critical to managing your condition. But you can’t get any of that from us.

One of the organisations I tried to volunteer with had policy written to prevent any kind of personal attachment between client and staff. We were only to fulfil the role given to us, which was to help around the house. We were forbidden from chatting with the client any more than necessary. Sitting down with a cup of tea was specifically mentioned as inappropriate. Accepting anything from the client, even a thank you card was not permitted. We were to ignore the client completely if we encountered them in any other setting. And a supervisor would be closely monitoring the cases, if it was suspected that a client was becoming attached to a volunteer, we would immediately be assigned to a different client. My blood ran cold. The thinking was that these rules would prevent abuse and dependence. I don’t know if they do that. I do know that they take away something vital, that they allow us to meet the expressed need – to wash dishes or tidy a garden, while ignoring all the deeper needs for contact, humour, affection, and care. I know that children who have every physical need met while being starved emotionally do not thrive. I don’t believe the situation is any different for those of us with mental illness, disabilities, or our elderly.

I think we need to rework our ideas about these kind of boundaries. One of the developments in mental health that excites me is the introduction of the peer work role. Whilst most organisations are currently in the process of narrowing the definition of this role, it has at least started with notions of equality and shared humanity. We can move services towards practices that are more human, towards nurturing relationships that have more scope for mutuality, towards meeting real needs instead of fulfilling job requirements. Towards modelling the inclusiveness and equality we wish to create in society instead of lecturing from the sidelines. Kindness, compassion, respect, and warmth are not optional extras when working in these fields. They ARE the job.

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