Understanding Boundaries and Containment in Clinical Practice

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111 The Society of Analytical Psychology Monograph Series

2 Hazel Robinson (Series Editor)
3 Published and distributed by Karnac Books
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6 Other titles in the SAP Monograph Series
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Understanding Narcissism in Clinical Practice
8 Hazel Robinson & Victoria Graham Fuller
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Understanding Perversion in Clinical Practice:
1011 Structure and Strategy in the Psyche
1 Fiona Ross
2 Understanding the Self–Ego Relationship in Clinical Practice:
3 Towards Individuation
4 Margaret Clark
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UNDERSTANDING
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CLINICAL PRACTICE
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6 Rebecca Brown and
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118 Finchley Road, London NW3 5HT
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9 Copyright © 2008 Rebecca Brown and Karen Stobart
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1 The rights of Rebecca Brown and Karen Stobart to be identi-
2 fied as the authors of this work have been asserted in accor-
3 dance with §§ 77 and 78 of the Copyright Design and Patents
Act 1988.
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All rights reserved. No part of this publication may be repro-
6 duced, stored in a retrieval system, or transmitted, in any
7 form or by any means, electronic, mechanical, photocopying,
8 recording, or otherwise, without the prior written permission
9 of the publisher.
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1 British Library Cataloguing in Publication Data
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A C.I.P. for this book is available from the British Library
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ISBN: 978 1 85575 393 8
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6 Edited, designed and produced by The Studio Publishing
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111 Contents
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9 ABOUT THE AUTHORS vii
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PREFACE TO THE SERIES ix
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2 INTRODUCTION xiii
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CHAPTER ONE
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Why Boundaries? 1
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Including the historical development of ideas
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7 CHAPTER TWO
8 Boundary and Containment in Child
9 Development 13
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1 CHAPTER THREE
2 Nuts and Bolts 27
3 Including assessment, beginning, time, fees
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5 CHAPTER FOUR
6 The Containing Mind 49
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8 CHAPTER FIVE
9 Boundaries Within Organizational Settings 59
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CHAPTER SIX
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Confidentiality 73
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111 CHAPTER SEVEN

2 Professional Boundaries and Containment 83
3 Including training, registration, Codes of
4 Ethics and good practice
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6 CHAPTER EIGHT
7 Ending 93
8 REFERENCES 121
9 INDEX 125
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1011 Rebecca B rown is a Training Analyst with the Society of
1 Analytical Psychology and also supervises for the British
2 Association of Psychotherapists and the London Centre
3 for Psychotherapy. She is a former Chair of the Society
4 and has been involved for many years in its analytic train-
5 ing programme. She is also involved in running a public
6 programme for counsellors and psychotherapists in
7 Oxford. Her background is in counselling, psychiatric
8 social work, and psychotherapy.
9
2011 Karen Stobar t is a Professional Member of the Society of
1 Analytical Psychology, working in private practice in
2 London and in the National Health Service as a
3 Consultant Psychotherapist (Adult).
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111 Preface to the Series

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1011 This series of clinical practice monographs is being
1 produced primarily for the benefit of trainees on psycho-
2 therapy and psychodynamic counselling courses. The
3 authors are Jungian analysts who have trained at the
4 Society of Analytical Psychology, with extensive experience
5 of teaching both theory and practice.
6 The rationale for this series is in part to do with the
7 expensive and time-consuming task of accessing all the
8 pertinent books and papers for any one clinical subject.
9 These single-issue monographs have been kept relatively
2011 brief and cannot claim to be comprehensive, but we hope
1 that each volume brings together some of the major theo-
2 rists and their ideas in a comprehensible way, including
3 references to significant and interesting texts.
4 Much of the literature provided for students of
5 psychotherapy has been generated from four or five-times
6 weekly analytic work, which can be confusing for students
7 whose psychodynamic courses may be structured on the
8 basis of less frequent sessions. The authors of these mono-
9 graphs have aimed to hold this difference in mind. In the
30 Introducton and elsewhere, their use of terminology is
1 explored. We have borrowed gratefully from the work of
2 our supervisees in many settings, and we are above all
311 indebted to our patients. Where a patient’s material is
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111 recognizable, their permission to publish has been given.

2 In other cases, we have amalgamated and disguised clini-
3 cal material to preserve anonymity.
4 When a training is ‘eclectic’, that is, offering several
5 different psychodynamic perspectives, a particular diffi-
6 culty can arise with integration – or rather non-integration
7 of psychoanalytic and Jungian analytic ideas. The teaching
8 on such trainings is often presented in blocks: a term
9 devoted to ‘Freud’, another to ‘Jung’, and so on. It is
1011 frequently the students who are left with the job of trying
1 to see where these do and do not fit together, and this
2 can be a daunting, even depressing, experience. SAP
3 analysts are in a better position than most to offer some
4 help here, because its members have been working on this
5 integration since the organization was founded in 1936
6 (incorporated in 1946). Although retaining a strong rela-
7 tionship with ‘Zurich’ or ‘Classical’ Jungian scholarship,
8 SAP members have evolved equally strong links with
9 psychoanalysis. Recent years have brought a number of
2011 joint conferences to supplement the many ‘cross-party’
1 alliances.
2 Any patient, but particularly a trainee, will naturally
3 tend to adopt the language of his or her therapist when
4 talking about their work. Those readers who are unfamil-
5 iar with Jungian terms may wish to consult the Critical
6 Dictionary of Jungian Analysis (Samuels, Shorter & Plaut,
7 1986), while those unfamiliar with psychoanalytic terms
8 may turn to The Language of Psychoanalysis (Laplanche &
9 Pontalis, 1988). But all patients are united by their
30 human suffering far more than they are divided by
1 language. Just as people from non-western cultures have
2 to make what they can of their western-trained
311 psychotherapists, so each patient–therapist pair eventually
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111 evolves a unique way of understanding their joint experi-

2 ences in the consulting-room. It is our view that each
3 stream of psychotherapy has strengths and weaknesses,
4 and the wise trainee will take the best bits from each. We
5 hope that this series may help a little with the psycho-
6 dynamic ‘Tower of Babel’.
7 We want to thank Karnac for their patience and help in
8 bringing the series to publication. Our intention is to
9 gradually add further volumes on some of the principal
1011 clinical issues. I therefore want to end by thanking my
1 colleagues within the SAP for their work so far – and for
2 their work to come.
3
Hazel Robinson
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Series Editor
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111 Introduction
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8 We propose to investigate the meaning and purpose of
9 boundaries within and around the therapeutic experience.
1011 The term boundary is borrowed from geography; as in
1 geography, boundaries can function as barriers or delin-
2 eators. They can ‘keep in' or 'keep out'; they can hinder or
3 enable safe passage from one place to another. A boundary
4 is more than a simple line delineating one space from
5 another; it is an entity with properties that demand a
6 response if they are to be negotiated.
7 Boundaries circumscribe a space that can be viewed
8 objectively, or experienced subjectively, as a 'container'.
9 For the uninitiated, this therapeutic container can be
2011 difficult to penetrate. Even health professionals such as
1 GPs and psychiatrists often do not know how to access
2 psychotherapy organizations and their referral networks.
3 Also, real constraints on the availability of counselling and
4 psychotherapy within the National Health Service, and
5 the cost of private sector services, may prohibit access to
6 the help being sought.
7 Chapter One, ‘Why Boundaries?’, addresses the grad-
8 ual evolution of therapeutic boundaries in psychodynamic
9 work. Freud’s understanding of the power of the transfer-
30 ence led him to develop guidelines for the treatment of
1 psychoanalytic patients (Freud, 1912b). Jung expanded
2 this into an understanding of the effect a patient may have
311 upon the therapist, known as countertransference. In
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Introduction
111 science, the conditions in which any experiment is con-

2 ducted are kept as stable and constant as possible; the
3 inter-reacting chemicals are protected from possible cont-
4 amination from without while being themselves confined
5 within a container. These conditions and procedures are
6 necessary in order to determine the meaning of the
7 observed interaction. Of course, in therapy we are dealing
8 with the living and largely unknowable material of the
9 human mind, but the value of the container is similar.
1011 The safety provided by reliability, regularity, confiden-
1 tiality, etc. allow the client to express aspects of his past
2 and present experience usually felt to be too painful or
3 shameful to be shared with others. This can result in a
4 relationship of intimate trust in, and sometimes depen-
5 dence on, the therapist. Significant childhood experiences
6 are often re-experienced and understood for the first time.
7 Chapter Two offers a brief exploration of boundary devel-
8 opment in infancy and childhood and shows how aspects
9 of this development can be expressed years later in the
2011 consulting room.
1 The intimate therapeutic encounter is defined by prac-
2 tical constraints that differentiate therapeutic ‘space’ from
3 the outside world. Chapter Three explores issues such
4 as money and time. Patients who place themselves in such
5 a vulnerable position are protected in part by an individ-
6 ual therapist’s professional sense of self. Chapter Four
7 describes the central importance of the containing func-
8 tion of the psychotherapist’s mind, constructed through
9 training and personal therapy or analysis. Chapter Five
30 describes how therapeutic work can be affected by
1 the setting in which it is taking place. These issues will
2 be explored in depth throughout by the use of clinical
311 examples.
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111 The use of clinical material by the authors immediately

2 raises the issue of confidentiality, explored in depth in
3 Chapter Six. It is difficult to balance the need to illustrate
4 what actually happens in therapy with the need to protect
5 the confidentiality of the relationship. We have decided to
6 use fictitious examples based on the factual experience of
7 our and others’ work.
8 Chapter Seven explores some of the issues involved in
9 the professional boundaries that surround the practising
1011 psychotherapist. This includes the Codes of Ethics and
1 good practice of the training organizations, and legislation
2 relevant to clinical work. Chapter Eight, which explores
3 issues to do with endings, brings the book to a close.
4
5
6 About terminology
7
8 In this monograph we are addressing our remarks to
9 counsellors, psychotherapists, psychiatrists, trainees of
2011 these professions and indeed any other mental health
1 practitioners, who are working with people at an intensity
2 of one or two sessions per week. Naturally, some of what
3 we say may also be applicable to more intensive forms of
4 intervention such as psychoanalytic psychotherapy or
5 analysis, but these are beyond the scope of this book
6 except for the remarks about referring patients. Although
7 there are areas of overlap between psychotherapy and
8 analysis, (particularly for psychotherapists who themselves
9 may have been in analysis), there are also important differ-
30 ences in the use of transference/countertransference inter-
1 pretations and in the approach to unconscious material.
2 The terms ‘counsellor’, ‘therapist’, and ‘psychothera-
311 pist’ are problematic. Ten or more years ago, each term
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111 would have had a less ambiguous meaning. The past

2 decade has brought much muddying of the waters and the
3 terms are now often used interchangeably and in our
4 opinion loosely, if not incorrectly. Although some aspects
5 of the therapeutic work of counsellors and psycho-
6 therapists do overlap or at times form a continuum, there
7 remain important differences between the two professions
8 that we do not wish to ignore. The picture is complicated
9 by the fact that some experienced counsellors, particularly
1011 those doing longer-term work, might work in a way closer
1 to what would ordinarily be termed psychotherapy, while
2 other mental health professionals who use the term
3 psychotherapy are working in a way closer to what most
4 people would call counselling! When there are aspects of
5 the work that pertain to both counsellor and psycho-
6 therapist, we will use the terms ‘therapeutic work’ or
7 ‘practitioner’, or ‘counsellor and psychotherapist’.
8 Otherwise, we will refer to these professions separately.
9 The clinical examples will use the designation of the
2011 original worker.
1 Equally, we are not using the terms ‘psychotherapist’
2 and ‘psychotherapy’ in the all-inclusive sense that they are
3 often used today to include the whole range of psycho-
4 therapeutic work and mental health workers. We think
5 this can be confusing both to the public and to the profes-
6 sionals’ own understanding of who they are and what they
7 do. While there are many different professionals who can
8 offer treatment to the patient, their titles are presently
9 different and the nature of what they do can be different.
30 A rather dull but better all-inclusive term for the wide
1 range of practitioners working in the field would be
2 ‘mental health practitioners’. Such a term acknowledges
311 the range of therapeutic workers who work with mental
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111 health problems, but does not ‘paper over’ the differences
2 between them.
3 The terms ‘client’ and ‘patient’ are again words that
4 have had clearer boundaries in the past. Traditionally,
5 counsellors tended to refer to ‘clients’, whereas psycho-
6 therapists tended to use the designation ‘patients’ – partic-
7 ularly in a hospital or institutional setting. More recently,
8 some psychotherapists have preferred to use the term
9 ‘client’ because of its more ordinary, less medical connota-
1011 tion. In some instances, we have used the word ‘client’ in
1 order to help differentiate between this form of interven-
2 tion and the more intensive forms such as psychoanalytic
3 psychotherapy and analysis. In the clinical examples we
4 use the actual designation of the person being treated.
5 Finally, we have decided to use the pronouns ‘he’ and
6 ‘she’ interchangeably and inclusively. As both the client/
7 patient and the counsellor/psychotherapist may be either
8 male or female, the terms ‘he’ and ‘she’ will, in the context
9 of therapeutic work, mean either ‘he’ or ‘she’. The more
2011 politically correct terminology of ‘s/he’ or ‘he and she’
1 tends to become cumbersome especially when used
2 repeatedly.
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111 CHAPTER ONE

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4 WHY BOUNDARIES?
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7 Why are boundaries, and the processes of containment,
8 considered so important to psychodynamic work? Why
9 set aside the same room and the same hour each week for
1011 counselling or psychotherapy? Why do the sessions last for
1 a particular length of time? Why are we so careful about
2 giving ample notice of holiday breaks? Those unfamiliar
3 with the work might exclaim, ‘Surely clients can cope
4 with some irregularity!’ In fact, might it not be better, as
5 the wider culture and the media so often tell us, not to
6 encourage too much dependency in this way, particularly
7 in focused, shorter-term work? This chapter explores some
8 of the thinking and assumptions behind these patterns.
9 Initially, Freud conducted his investigations much as a
2011 medical doctor. For example, in the case of Frau Emmy
1 von N, he ‘ordered her to be given warm baths and I shall
2 massage her whole body twice a day’ (Freud & Breuer,
3 1895d, p. 50). A brilliant theoretician and clinician,
4 Freud gradually began to analyse the psychological
5 constructions that underpinned such physical treatments.
6 In particular he elucidated the importance of the trans-
7
ference; i.e., the unconscious relationship between patient
8
and clinician. For example, in the case history of ‘Dora’
9
Freud wrote,
30
1 If the theory of analytic technique is gone into, it
2 becomes evident that transference is an inevitable neces-
311 sity . . . Transference is the one thing the presence of
4 1
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Understanding Boundaries and Containment in Clinical Practice
111 which has to be detected almost without assistance and

2 with only the slightest clues to go upon, while at the same
3 time the risk of making arbitrary inferences has to be
4 avoided. [Freud, 1905e, p. 116]
5
He was developing an understanding of the need for, and
6
value of, boundaries between analyst and patient. The
7
8 difficulties encountered in maintaining such boundaries
9 became clearer as the emotional effect of the patient upon
1011 the analyst was understood. This is termed the counter-
1 transference and Jung was one of the first of the early
2 followers of Freud to understand the importance of the
3 concept and its implications for practice.
4 Jung identified a powerful process, which he described
5 as ‘participation mystique’, in which both patient and
6 analyst could become unconsciously merged (Jung, 1953,
7 par. 253). Jung understood its dangers, but the underlying
8 psychological mechanism was not really understood until
9 Klein identified the process of projective identification
2011 (Klein, 1946, p. 8). She explored how the infant deals
1 with early anxieties by projecting them into the mother
2 and realized that the infant may then identify the mother
3 with the unpleasant feelings that have been evacuated by
4 projection; hence the term projective identification.
5 For a long time, countertransference experiences were
6 regarded as a hindrance to treatment and to be mini-
7 mized. Then, the dynamics of projective identification
8 were further elucidated by analysts such as Bion, who real-
9 ized the vital developmental role played by the mother’s
30 mind in processing (detoxifying) and making meaningful
1 the infant’s projections (Bion, 1970). Analysts realized
2 that in a parallel way countertransference could also repre-
311 sent a powerful therapeutic tool. Working with, rather
2 2
Why Boundaries?
111 than trying to dispense with, the countertransference can,

2 however, involve the therapist in complex interpersonal
3 exchanges. In this context, the delineation of, and adher-
4 ence to, strict professional boundaries has become vital.
5
6
7 A secure and safe container
8
9 The process occurring in the therapeutic space needs the
1011 protection of both concrete boundaries and the more
1 intangible sense of containment. Almost all psychothera-
2 peutic approaches utilize processes in the work similar to
3 those of maternal containment (although awareness of
4 this might vary). When powerful emotions are being
5 addressed, or are as yet in the background, a secure
6 container for those feelings is important, if not essential.
7 A routine that is familiar provides a safe and reliable
8 setting in which to experience that which is not safe and
9 reliable, that which might be new, shaky, or perhaps even
2011 explosive.
1 In chemistry the conditions in which an experiment is
2 conducted are kept as stable and constant as possible. In
3 this way, the interacting chemicals are protected from
4 contamination, and the chemist is protected from harm.
5 Jung used images from the work of medieval alchemists to
6 describe the therapeutic encounter. The alchemists chem-
7 ical experiments, which were attempts to turn dross into
8 gold, were depicted in a series of mystical pictures, the
9 Rosarium Philosophorum (Jung, 1946). Jung likened
30 the therapeutic process to the alchemical container, or
1 ‘vas’, which is depicted in the Rosarium as a royal bath.
2 One image shows a naked king and queen – patient and
311 therapist – descending into the bath. Their nakedness
4 3
5
6
111 illustrates the vulnerability of the participants in the ther-

2 apeutic process. Undressing without undue embarrass-
3 ment requires the security of a contained, very private,
4 boundaried space. We could say that in therapy the
5 ‘chemicals’ are the conscious and unconscious thoughts
6 and feelings of the patient and therapist.
7 Michael Fordham, a Jungian analyst, who worked
8 extensively with children, developed Jung’s work on
9 containment:
1011
. . . the alchemical vessel in which [the alchemists]
1
substances were heated must be firmly closed so that
2
nothing shall escape from it. In the relation between the
3
mother and her baby the mother’s containing function is
4
essential; first she contains her baby physically in her
5
womb, then she holds him in her arms and also contains
6
him in her mind and her emotions. Periodically, in an
7
8 emotional crisis, all she is required to do is to hold her
9 baby whilst he works through an emotional conflict. . . .
2011 But the containment is not only physical. In the first
1 place her maternal reverie reflects and digests her infant’s
2 state of mind and she can feed back to her baby the result
3 of her mental but non-verbal activity through action and
4 talk. [Fordham, 1985, p. 209]
5
6
7 Highlighting the invisible
8
9 In the course of ordinary life, boundaries are broken
30 all the time. The bus is scheduled to arrive at 8.30; invari-
1 ably it comes later. You have arranged to speak with a
2 colleague in private; more likely than not you are inter-
311 rupted. Intrusions of one kind or another can happen so
2 4
Why Boundaries?
111 frequently that we come to expect them or hardly notice

2 when they do. In our conscious life, you might say we
3 become acclimatized to such changes, but in therapeutic
4 work boundaries and the interactions that take place
5 around them matter in a different way. In creating a safe
6 and reliable frame around the work, the boundaries them-
7 selves become the focus of feelings when their containing
8 function ‘fails’. Unlike the bus that comes late so often we
9 no longer notice or even expect it to happen, it is the
1011 opposite – invariably the sessions do start on time so that
1 when they do not, we notice with a heightened sense of
2 perception. Although we do not set out to break bound-
3 aries and the containment they provide, when it does
4 happen it can be like putting a magnifying glass to a hith-
5 erto invisible part of the psyche. That was one of the
6 reasons for the early emphasis in psychoanalysis on the
7 ‘blank screen’ of the consulting room. The blank screen
8 highlights what would be missed if the background were
9 more changeable.
2011 The therapeutic encounter aims for a time to keep out
1 an important aspect of ordinary social life, the aspect that
2 says, ‘It doesn’t matter’, or ‘in polite circles we don’t make
3 a fuss’. In long-term counselling and in most forms of
4 psychotherapy we set out to notice what, on a social level,
5 might be insignificant infringements. It is this aspect
6 of therapy that can be satirized in popular culture, as if
7 those of us engaged in the enterprise are somewhat strange
8 in our preoccupation with sessions starting and ending,
9 holiday breaks, and payment of accounts. The therapeu-
30 tic dialogue is not like an ordinary conversation in which
1 the ‘hiccups’ of social interaction are disregarded. Even
2 in the initial assessment, the boundary issues (whether
311 appointments are kept, whether the person arrives on
4 5
5
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111 time, whether he can tolerate interventions) might high-

2 light aspects of the patient’s personality that he could not
3 tell you about directly.
4 The work is facilitated by the fact that the boundaries
5 are ordinarily in place and so the impact of a change is
6 heightened. Conditions that promote stability include the
7 fixed times of the sessions and confidentiality. But,
8 however carefully boundaries are maintained, there are
9 times when the unexpected happens: the counsellor is
1011 unexpectedly delayed, someone else walks into the room,
1 or there is a misunderstanding about holiday dates. These
2 breaks of the boundary can form bridges to important
3 aspects of the work: boundaries that were broken in child-
4 hood (such as betrayal by an important carer) or issues of
5 distrust in the patient’s current life.
6 Clinical example
7
The client brings up something new and significant just
8
as the end of the session approaches. The counsellor is
9
tempted to extend the time in order to explore it. But if
2011
the client is accustomed to the usual length of his sessions,
1
the timing of his new material is probably not mere
2
chance. Consciously or unconsciously, he might have
3
done this because he could count on the session ending at
4
a particular time and could therefore save himself from
5
getting into more than he could manage; he is relying on
6
an unchanging setting to guard his psychological safety.
7
He wants a small portion of this new ‘food’ and not a
8
whole plateful!
9
30 Illuminating the shadow
1
2 Whatever the type of treatment – counselling, psycho-
311 therapy, or analysis – what the person brings into the
2 6
Why Boundaries?
111 room are feelings and reactions that he might be facing for
2 the first time in his life and, possibly, communicating to
3 another for the first time. The fact that he is there in the
4 room is indicative that this time he has chosen to face his
5 problems in a different way. The therapy might ultimately
6 involve some relief, but not usually without some discom-
7 fort or pain as well.
8 Those parts of our psyches that are hidden and that we
9 find difficult to face, Jung called ‘the shadow’. Boundaries
1011 and containment encourage trust, which in turn provides
1 a better situation for the exploration of these difficult
2 shadow areas. This is particularly so because much of what
3 we encounter in the shadow is itself related either to a
4 previous breakdown of trust or to trust not having been
5 established in the first place. In spite of the fact that a
6 client might have come to therapy to get in touch with
7 shadow aspects he is likely to feel some resistance to that
8 exploration. However, regular appointments and knowing
9 about holiday breaks well in advance are a part of the solid
2011 path that will make a difficult journey more possible.
1
2
3 Confidentiality
4
5 Confidentiality, different from secrecy, is a cornerstone of
6 psychodynamic work. It is rarely absolute: counsellors and
7 therapists usually discuss cases with a supervisor; the
8 counsellor might work in an institutional setting where
9 other members of the team will have access to some infor-
30 mation; there are circumstances – for example, child abuse
1 – in which statutory authorities may, of legal necessity,
2 become involved. However, in the ordinary course of the
311 work the assumption is that what goes on in the room is
4 7
5
6
111 private; it is part of a therapeutic context and not a social

2 one. As far as possible, the organic process that is happen-
3 ing between client and counsellor/therapist needs to stay
4 within the room. The client might, naturally, share some
5 of the content and feelings with friends or family but this
6 is not encouraged because the process can be ‘diluted’ if
7 the focus of the work in the ‘here and now’ is shifted
8 outside.
9
1011
1 A space for the opposites
2 to come together
3
4 The emphasis on the unconscious in psychodynamic
5 work, whether explicit or implicit, carries with it a respect
6 for the unspoken. We try to make sense not only of what
7 is said but also of non-verbal forms of communication
8 that at times contradict the verbal. If we only hear
9 ‘directed thought’ (rational logic) and not also ‘undirected
2011 thought’ (associative or free-flowing thought), we lose a
1 part of the whole – the ‘opposites’ that Jung believed only
2 together can make sense of the internal world. The
3 contained space and the attitude towards a contained
4 space help to create the conditions needed for these oppo-
5 sites to come together. The capacity to wait and listen for
6 the opposite to emerge depends on the internal sense of
7 containment that we learn through our training and bring
8 from within ourselves (ultimately, from our own experi-
9 ence of therapy).
30
Clinical example
1
2 An eighteen-year-old girl comes for help to decide
311 whether to keep her baby or have an abortion. At first she
2 8
Why Boundaries?
111 expresses her desire to get rid of the baby; she feels it
2 would be better, and knows her mother would want her
3 to do so. But the counsellor notices her holding and
4 rubbing her tummy as she speaks. The girl is surprised
5 when this is remarked upon, and then bursts into sobs of
6 grief about the prospect of losing her precious baby.
7 If the counsellor had identified with the more conscious
8 and immediate feeling, the girl’s less conscious feelings
9 would have been missed. The counsellor’s capacity to
1011 contain and maintain a thinking space allowed other feel-
1 ings to emerge. Whatever decision is made eventually, it
2 will have been valuable for the young woman to discover
3 her ambivalence.
4
5
6 Promoting thought through frustration
7
8 So far, we have looked at boundaries in relation to their
9 capacity to make the space within them more secure, less
2011 threatening, more integrative, and more confidential.
1 There is another aspect of their function that would at first
2 appear to be in contrast to these factors. This concerns the
3 function of frustration. In this sense, the experience of
4 ‘coming up against a boundary’ can feel harsh or unwel-
5 coming. A regular pattern of times might be secure in the
6 sense that it is consistent, but it might also feel withhold-
7 ing or unyielding. Given that there is enough of a working
8 alliance established, this experience of frustration can
eventually lead to the development of insight.
9
30
Clinical example
1
2 A patient found the rigid session times made him feel
311 intolerable rage toward his kindly therapist. He could not
4 9
5
6
111 express what was, to him, a shameful feeling, but was

2 disheartened because his therapy was going round and
3 round in circles: ‘just going over the same old things’. The
4 therapist did not give up. She sensitively contained the
5 patient’s frustration until one day he mentioned that he
6 had been a ‘Truby King baby’: fed at very regular and
7 prescribed times that did not coincide with his hunger.
8 The obvious, but until then unconscious, link was made,
9 and the patient ‘let go’ his rage with great relief.
1011
1
2 The therapist’s need for containment
3
4 The emphasis thus far has been on the client and how
5 boundaries and containment affect his experience of
6 counselling or therapy. However, the boundaries around
7 the work have an impact on both participants. The coun-
8 sellor or therapist, although he comes to the session with
9 the greater experience, faces this particular client on this
2011 particular day for the first time. In order to explore the
1 unknown, the practitioner also needs the containment of
2 a boundaried space that is not interrupted, that happens
3 at regular intervals, and that has anticipated breaks. The
4 boundaries around the space help the therapist to feel
5 contained, so that he in turn becomes part of the contain-
6 ing space around the client.
7 A warm, comfortable, quiet, and uninterrupted space,
8 and the boundaries that maintain this, are a vital protec-
9 tion for the therapist’s capacity to keep his mind available
30 for the therapeutic encounter. We are only too aware of
1 how fragile a particular state of mind can be, how vulner-
2 able a train of thought is to distraction, noise, or inter-
311 ruption. There are times when a client himself might not
2 10
Why Boundaries?
111 notice a boundary being out of place, but if the impinge-

2 ment affects the therapist’s ability to function in a
3 containing manner, the client might notice or be affected
4 by a change in the therapist’s demeanour.
5
6
7 Acting out
8
9 Boundaries serve another protective function and that is
1011 in relation to the potential for strong emotions to be acted
1 out. Boundaries remind both participants that, although
2 highly intimate and personal, the therapeutic encounter
3 must not include violence, social contact, or sexual behav-
4 iour. For example, at times it can be difficult for the client
5 to distinguish between adult sexual feelings and powerful
6 infantile attachment to a parent. If the therapist does not
7 have adequate supervision for this difficult work, and
8 especially if it touches too closely on his own personal
9 unresolved issues, the feelings might be acted upon.
2011 Jung’s understanding of the potential for the therapeu-
1 tic process to affect and transform both participants led
2 him to emphasize the necessity for the practitioner’s own
3 personal therapy. Adequate supervision and personal ther-
4 apy are a part of the safety net that helps the therapist to
5 contain the material in the session and to continue to
6 understand it symbolically.
7
8 Summary
9
30 We began this chapter by asking why boundaries are
1 important to the therapeutic process. They create a safe
2 and secure container for the work. They help to illumi-
311 nate what Jung termed ‘the shadow’ – our unknown side.
4 11
5
6
111 They help to highlight what might otherwise be difficult

2 to see unless it is thrown into relief and magnified. They
3 facilitate confidentiality and trust. They encourage ‘the
4 opposites’ to emerge. They promote thought and en-
5 hanced ego-functioning through an increasing ability to
6 tolerate frustration. They contribute to a necessary sense
7 of security for the practitioner who in turn can be more
8 containing for the patient. They are, finally, a protection
9 for both patient and therapist against acting out.
1011
1
2
3
4
5
6
7
8
9
2011
1
2
3
4
5
6
7
8
9
30
1
2
311
2 12
111 CHAPTER TWO

2
3
4 BOUNDARY AND CONTAINMENT
5
6
IN CHILD DEVELOPMENT
7
8
9
1011 Prenatal experience
1
2 The very beginnings of life take place in a confined space
3 with clear boundaries. For the first nine months of life the
4 mother’s womb is the container that defines the space in
5 which development takes place. This space is defined
6 physically by the walls of the amniotic sac and the womb.
7 It is defined emotionally before, during, and after concep-
8 tion by the hopes and expectations of the parents. At
9 times it is even defined by a lack of hope and expectation.
2011 If the father is absent, or even unknown, the space in
1 which the earliest development takes place is still shaped
2 by that fact, by what the mother imagined or hoped the
3 father to be and perhaps by what her experience of her
4 own father and mother was. So, at a time long after their
5 deaths, the grandparents and their parents can still play a
6 part in defining that first space in which the embryo is
7 conceived. In Jungian terms, the collective unconscious
8 has ‘collected’ around the conception, thus affecting the
9 emotional climate into which the baby is born nine
30 months later.
1 This first space, then, has both a physical and an
2 emotional boundary. Modern infant research is refining
311 our understanding of how the child might experience this
4 13
5
6
111 earliest container, the womb. It is certainly not the quiet

2 place we had once thought, for the infant experiences a fair
3 amount of noise from the mother’s internal organs. We
4 now know he might even hear noise originating from
5 outside the mother’s body. He might find his thumb. He is
6 affected by the mother’s emotional state as reflected in her
7 hormones and in turn from their effect on such things as
8 the blood supply to the uterus. He is affected by what she
9 puts into her body (food, drugs, nicotine), by what she
1011 might or might not be able to secure for herself (support or
1 love) and even by what is put into the larger container of
2 the room, house, or wider environment in which she lives
3 (the smoke and pollutants of others, both actual and
4 metaphorical). A recent study found a correlation between
5 the food a mother eats during pregnancy and the food a
6 child prefers later on (Mennella, 2005). There is also the
7 question of who else shares in that wider container with
8 the mother and how their interactions affect the emotional
9 space that she and the growing foetus inhabit. In this chap-
2011 ter we shall be considering some of the individual’s early
1 experiences of boundary and containment and how these
2 can affect what might be brought years later into the
3 consulting room. It is interesting how a pregnancy that is
4 not wanted can affect the child to such an extent that in
5 therapy years later he might have strong feelings about
6 being seen.
7
8
9 Neonatal experience
30
1 In utero and in the very first moments of life outside the
2 womb, the skin functions as a boundary between the
311 baby’s inside and his outside, between mother and baby.
2 14
Boundary and Containment in Child Development
111 Karpf, in a recent article went as far as to describe the skin

2 as ‘the perimeter of the self, our rim, our envelope, the
3 point where our insides become outsides, the personal
4 becomes the social’. She further explains that ‘the cells
5 which go to make up the central nervous system are the
6 same ones which form the skin, and they develop in the
7 embryo at the same time’ (Karpf, 1999, p. 7). It is perhaps
8 not accidental that we sometimes use the terms ‘thick- or
9 thin-skinned’ to denote the capacity to protect ourselves in
1011 relation to another person, to indicate the importance of
1 this earliest of boundaries. It is well recognized that some-
2 one coming into counselling or psychotherapy will need to
3 have developed some kind of defensive structure (or we
4 could say ‘skin’) to be able to cope with the demands of
5 exposing himself, and particularly so in the more intensive
6 forms of the therapeutic work. Quite often, the initial
7 stages of the work will be focused on helping the individ-
8 ual develop just such resources so as to be able to survive
9 the very experience he is embarking on. The boundaries
2011 and sense of containment that we create around the thera-
1 peutic experience could be seen as contributing to or
2 adding another layer of this protective ‘skin’.
3 Michael Fordham’s work on infancy postulates a
4 ‘primary self’ that, even in the earliest days of life, directs
5 an active encounter between baby and the outside world
6 (Fordham, 1985). Once born, there is a space ‘between’
7 that is affected by both mother and baby and, of course,
8 by others in that environment. The baby is both
9 contained (or not) in a physical and emotional holding
30 space and at the same time is a part of that containment
1 between himself and his mother.
2 The experience of the space between mother and baby
311 will be very different depending on the personalities
4 15
5
6
111 involved and on who else shares that space. The first baby
2 with a full-time mother might be protected from early
3 separation and intrusion or could be submerged into the
4 undiluted impact of her emotions. That same child
5 coming into an established family with several siblings,
6 so close there is little space of his own or so distant there
7 is little contact between children, has a very different
8 experience. The variations are infinite – one or two
9 parents, a step-parent, a grandparent, a same-sex partner
1011 or close friend – all have some impact, even if only indi-
1 rect, through the mother’s attitude and experience of
2 them, on the space the baby inhabits.
3
4 Clinical example
5 A client who is an only child with an absent father comes
6 into counselling oblivious to other clients – just as if he
7 were still ‘on his own’. His apparent insensitivity to the
8 starting and ending times of the sessions seems to demon-
9 strate an unchallenged assumption that there is simply no
2011 one else around. It is as if all the space belongs to him and
1 his mother (or, in the transference, that part of the coun-
2 sellor whom he expects to share his perception). Not only
3 does he not ‘see’ the evidence of other clients/siblings, he
4 also cannot ‘hear’ his counsellor’s attempts to draw his
5 attention to the beginning and ending boundaries. It is as
6 if he has brought his sense of a mute (or absent) father
7 into the consulting room and therefore cannot hear the
8 counsellor’s words.
9
30 Oral experience
1
2 Even during the earliest days of life the baby has already had
311 considerable experience of boundary and containment.
2 16
111 Issues to do with feeding now become central, because this

2 is where interaction so repeatedly and intensely takes place
3 during this period. The mouth itself is a container, and thus
4 can contain something else (the nipple, the thumb, or the
5 corner of a blanket, for example) or can represent a lack of
6 containment (vomiting, or an inability to latch on to the
7 breast effectively). These are physical experiences, but they
8 also seem to have the capacity to become a template for a
9 whole range of feelings throughout childhood and on into
1011 adult life.
1 By the time a client comes into the consulting room, it
2 will be hard for the practitioner to know what he brings of
3 these early years. These might only emerge only over time,
4 if then. Although in some instances it might not be appro-
5 priate to suggest links with the past (because of the short
6 term nature of the work, what you judge the client can
7 handle, or the depth at which the work takes place), never-
8 theless, it would be surprising if these links were not there
9 in some form. For example, they might be seen in the
2011 vehemence with which your words are spat out or in the
1 restless discomfort at being in a confined space with you.
2
3 Clinical example
4
5 Let us look in more detail at the first example – the client
6 spitting out the counsellor’s words so vehemently. The
7 counsellor might respond by reintroducing what has been
8 said in a more palatable form; notice the word ‘palatable’
9 and its association with the mouth and food. Perhaps the
30 remark is still unacceptable, and is rejected again. Maybe
1 the counsellor tries again, doing metaphorically what the
2 mother might have done in introducing unfamiliar food –
311 cutting it up into smaller chunks, mashing up the lumpy
4 17
5
6
111 bits, or maybe even changing to a different brand name (a

2 bit like using a different theoretical construct or explana-
3 tion). Only later, when none of these alterations seems to
4 have worked, does the counsellor ‘catch on’. It turns out
5 that it was not the content or consistency of the remark at
6 all that was being rejected, but the emotional climate of the
7 interaction that was disturbing and was being re-enacted
8 in the consulting room. In other words, the patient experi-
9 enced the counsellor’s concern as anxiety and an attempt
1011 at control. From his vantage point, the original mother’s
1 determination to feed her baby so that he would grow
2 vigorously was being inadvertently repeated in the coun-
3 sellor’s determination to find a way of helping her client to
4 grow emotionally. The client ‘spat out’ her attempts much
5 as he spat out his mother’s early feeds, which he experienced
6 as full of anxiety and control. He could not tell the coun-
7 sellor what was wrong any more than he could as a baby
8 verbalize his problem for his mother. The ‘spitting out’
9 was the only communication he had. He needed the coun-
2011 sellor, and previously his mother, to figure out what it
1 meant.
2
3 Pre-oedipal
4
5 We use the term pre-oedipal to define the baby’s earliest
6 awareness of ‘otherness’, often occurring before there can
7 be a conscious sense of separate persons or of triangular
8 relationships. The vagueness of the term ‘the other’ is
9 important, for it illustrates the fact that anything other
30 than ‘what is already’ can become ‘the other’ for the baby.
1 In its most concrete form this might be an ‘other’ person,
2 but equally it could be a less familiar aspect of mother
311 herself – the appearance of her walking away to an ‘other’
2 18
111 place, seen from an ‘other’ angle. Here, mother herself

2 becomes ‘the other.’ It could also be the presence of a
3 different emotional climate or an aspect of mother turned
4 away, lost in her own thoughts. But the importance for us
5 in the context of boundaries and containment is that
6 ‘other’, by its very nature of ‘otherness’, brings the indi-
7 vidual up against a boundary of what ‘already is’ or ‘has
8 been’ and introduces the notion of difference and there-
9 fore the concept of ‘twoness’ or ‘threeness’ in its most
1011 primitive form. Again, this experience of ‘other’, happen-
1 ing so early in life, seems to form a template that affects
2 later responses to experiences, and especially so during
3 later years when Oedipal phantasies and triangular rela-
4 tionships take centre stage.
5
6
7 The emergence of teeth and
8 the depressive position
9
2011 Sometime in the first year, the baby will develop teeth. In
1 the context of boundaries and containment, teeth can
2 define a space or create a boundary in a manner different
3 from gums or lips. The emergence of these new, harder,
4 more sharply defined objects in the baby’s mouth proba-
5 bly creates a greater consciousness of biting down, grip-
6 ping, and holding on. These are all actions that result in
7 the space within the mouth being separated from the
8 space without. Kleinians speak of the emergence of the
9 depressive position at this time. The baby begins to have
30 the capacity to know that the mother who walks away and
1 might frustrate his needs is the same mother who at other
2 times can be nurturing and available for him. Meta-
311 phorically, he is allowing the ‘good breast’ (or the mother
4 19
5
6
111 who is there for him) and the ‘bad breast’ (the mother
2 who is not) to belong to one person.
3
4 Clinical examples
5 In terms of the consulting room experience, the client
6 might ‘bite down on’ our words or our presence. He
7 might find it hard to leave at the end of the time and
8 therefore make it hard for us to release that grip. He might
9 hold on to our words tenaciously and perhaps anxiously,
1011 and be unable to grasp their meaning in the way that had
1 been intended. He might be worried that if he ‘lets go’ or
2 relaxes enough to ‘take them in’ (metaphorically ‘swallow-
3 ing the therapeutic food’) it will somehow be lost. This
4 might not be because of his counsellor’s actual communi-
5 cations, but because he comes with the expectation based
6 on early experience that what he does not hold firmly in
7 place could disappear. So he brings to issues of boundary
8 and containment, for example, a holiday break or a period
9 of silence in the session, a response informed by this
2011 expectation of uncertainty. Of course, over time we hope
1 that he will be affected by a different experience – our reli-
2 ability; the fact that things talked about in one session are
3 not necessarily lost and do turn up again even without
4 his ‘holding on’. He might find that he spontaneously
5 remembers or that the counsellor sometimes remembers
6 for him. Over time, he begins to have a reparative experi-
7 ence. He can relax in our presence and so can take in and
8 be sustained by our ‘food’ in the therapeutic encounter.
9
30 Anal–urethral experience
1
2 The next ‘peak’ of development as far as issues of bound-
311 ary and containment are concerned is the period of time
2 20
111 (roughly eighteen months to three years) ‘around’ toilet

2 training. Toilet training is only the outer, most visible sign
3 of a complex period of separating out from the parents, of
4 defining more precisely the boundary between the child’s
5 perception of himself and those in his world who are
6 important but are not himself. It is almost as if the expe-
7 rience of the urine and faeces being at first inside and a
8 part of his body and then outside and clearly separate
9 from his body becomes a metaphor for so many of the
1011 experiences of this age – separating out, defining the
1 boundary between me and mine, and you and yours, or
2 not mine.
3 It is interesting that the toddler of this age shows great
4 interest in opening and closing doors, opening and clos-
5 ing lids (particularly the toilet), or struggling with the
6 garden gate long before he can reach the latch. These are
7 all objects that define space by creating a boundary
8 around it. This external differentiation and his interest in
9 the process is a reflection of the inner process of differen-
2011 tiation that is going on at the same time.
1
2 Clinical example
3
4 Sometimes a parent does not recognize the underlying
5 emotional struggle that accompanies the child’s physical
6 development. Likewise, the therapist can miss a client’s
7 unresolved struggles with separation that he might bring
8 from this period of time. The therapist can get caught up
9 in the therapeutic equivalent of putting things into the
30 right container and lose sight of the fact that the patient
1 might have been struggling to have an independent view
2 from her and the maturation this can represent. Here it is
311 all too easy to make badly timed interventions, hoping he
4 21
5
6
111 will be a good, well-trained patient and not recognize the

2 hurt that might inadvertently be inflicted on his emerging
3 independence.
4
5
6 Oedipal experience
7
8 The oedipal stage of development is one of the more
9 frequently talked about periods of life, both clinically
1011 among professionals and in the wider world among
1 writers, film-makers, and the culture at large. Many
2 parents will know the complications of three children
3 playing; sooner rather than later (usually just when you
4 have sat down with a cup of coffee!) you are called upon
5 to mediate. Many of us remember ourselves or a child
6 saying, ‘But I want to marry Daddy (or Mummy) when I
7 grow up!’ Lovers know the pain of the third person who
8 comes between them, creating an impossible triangular
9 relationship.
2011 Many of the broken relationships of the adult years
1 stem from an unsatisfactory resolution of oedipal conflicts
2 at the age of three or four. The child who has not found
3 a way of holding on to one important relationship while
4 maintaining another to someone equally important
5 (perhaps his other parent) remains vulnerable later on.
6 Just as the myth from which this developmental period
7 takes its name suggests, the child caught in an oedipal
8 entanglement with one parent might well ‘kill off ’ the
9 chance of fruitful encounter with the other. He cannot
30 sustain both relationships and, therefore, a threesome just
1 cannot exist. As a result, he cannot allow himself to expe-
2 rience his parents as a couple. As the classical story
311 portrays so vividly, there are the seeds here of a terrible
2 22
111 tragedy, because in the end one or both of the possible

2 encounters must be killed off and with it the capacity for
3 a depth of relationship with more than one love object at
4 a time. It is not difficult to imagine how the complications
5 of this period might affect boundary and containment
6 issues.
7
8 Clinical example
9
1011 Not infrequently, someone comes to counselling with the
1 intention of exploring his inner thoughts and feelings
2 only to find that there is a wall of guilt blocking access to
3 the very area he had thought he was free to explore. This
4 can happen because he finds himself about to confide to
5 someone else intimate details about a relationship with a
6 significant other. It is as if the counsellor is seen as a
7 potentially significant person (the third side of an oedipal
8 triangle) about to break in on a boundary that until now
9 has contained only the client and his parent, partner,
2011 child, etc. In his thoughts there might have been a kind
1 of unspoken, exclusive loyalty to this other that feels
2 threatened by exposure, even in confidential surround-
3 ings, to a third person, the counsellor. Sometimes explor-
4 ing the anxiety about the confidential nature of the setting
5 is enough to free such ambivalence. However, if the
6 conflict is deep-seated, it is much more likely that this
7 particular ‘no-go’ area will have to remain in abeyance
8 until a greater sense of trust has developed in the rela-
9 tionship. Sometimes, the relationship with a therapist
30 who becomes emotionally important to the patient is felt
1 as too great a threat to existing relationships and the work
2 breaks down. In other cases, and especially where there is
311 the opportunity for longer-term work, the client might
4 23
5
6
111 need to discover repeatedly and over time that the coun-
2 sellor has no intention of breaking him and his partner
3 apart or of criticizing him for angry thoughts about his
4 partner.
5
6
7 Adolescence
8
Adolescence is a period of time when boundary and
9
containment issues can emerge at full intensity – at times,
1011
like a Force Nine gale! There is something about the
1
passion of this period that feels like a continuation of the
2
passions of the two-year-old, having been put on hold or
3
in abeyance over the intervening years. In actuality, it is
4
more likely that the work of separating out has been going
5
on unnoticed in the background and now re-emerges on
6
centre stage. Anyone who has lived in close quarters with
7
an adolescent will know the degree to which the major
8
issues of this time are invariably about boundaries: bound-
9
aries of time – how late will they be out?; boundaries of
2011
place – which pub or club is considered appropriate or not
1
by the parent?; boundaries of ownership – whose car is it
2
and who has the right to use it?; boundaries about whose
3
place it is anyway to make a judgement about any of these
4
questions. Teenagers tend to take action. If there is space
5
for the parents’ point of view at all, it might be for about
6
thirty seconds with the television on while he is on the
7
phone to a friend already making arrangements about the
8
issue they wished to discuss before he phoned!
9
30
Clinical example
1
2 One can imagine various re-enactments of this period in
311 the consulting room. For instance, the therapist will have
2 24
111 made clear her dates for the Christmas break only to find
2 that a particular client has not heard what she has tried
3 to communicate and arrives during her holiday week.
4 It might be that this person never moved beyond an
5 adolescent non-communicating phase with a parent; he
6 switched off and got a kind of secret space that way, under
7 his control. Although he is not aware of the ‘mistake’, and
8 is quite certain that it was the therapist’s, he might, in
9 coming during her free time, be indulging a wish to have
1011 a secret space with her. At the time this cannot be put into
1 words, because he is caught up in an adolescent world
2 where it would be unacceptable to let on to himself or to
3 her that the contact matters that much. In any case, he
4 could feel there is an issue of principle here. Who has the
5 right over the counselling space? Just as the adolescent
6 struggles with his parents over the car or the telephone, is
7 the space the therapist’s or his? At some level he might be
8 saying that the session belongs exclusively to him and it is
9 for him to decide when it happens, irrespective of her
2011 breaks or wishes. If he allows himself to ‘hear’ the holiday
1 dates correctly, he will have to give up his control of the
2 situation and face his feelings about the break ‘breaking
3 through’ into his conscious thought.
4
5
6 Summary
7
8 This has been a brief look at some developmental issues
9 and their implications for what might be brought to
30 the consulting room years later. The illustrations are
1 examples only. They could just as well have happened
2 differently or have been linked to a different period of life;
311 in fact, most probably not to just one experience, but to
4 25
5
6
111 a whole complex mixture of experiences. They have been

2 highlighted separately in this manner only to make it
3 easier to demonstrate the possible dynamics.
4 How we respond to any of these situations will depend
5 on the context of the work. With shorter-term or less
6 intensive work, having a sense of the developmental issues
7 that inform the individual’s response in the here and now
8 will, in the main, form a part of our understanding. It is
9 held in the back of our minds, and in this indirect manner
1011 forms part of the framework in which we work. There
1 might be no direct discussion of links between the here
2 and now and the past, but it will still contribute to the
3 boundary that we are providing around the work. Maybe
4 this understanding functions like the presence of the
5 unknown father referred to earlier. He is not there physi-
6 cally for the child but has an effect on the child’s space
7 because of being held in mind by the mother. In such
8 work, our understanding of the dynamics affects the
9 emotional climate of the session despite the fact that it is
2011 not spoken of directly.
1 There are some people in longer-term counselling, and
2 many in psychotherapy, for whom the links between the
3 past and the present are a helpful means of making sense of
4 disturbing feelings and behaviour. What we say and how
5 we say it is beyond the scope of this book, but it will be
6 determined in part by the nature of the boundaries around
7 the work. These will include the experience of the practi-
8 tioner, the nature of the supervision, the frequency at which
9 the patient is being seen, whether it is in the beginning,
30 middle, or end of the session, whether it is in a session
1 before a weekend break or followed closely by another
2 session. It will also depend on the emotional climate of that
311 particular day for both the counsellor and the client.
2 26
111 CHAPTER THREE

2
3
4 NUTS AND BOLTS
5
6
7
‘How can I tell you anything. I don’t know you; this isn’t
8
a real relationship.’
9
Most therapists will hear some version of these words
1011
in the course of their daily work. To an extent the patient
1
is correct – the relationship between therapist and patient
2
does not feel like a customary social encounter because it
3
is not one. It is a therapeutic encounter to which both
4
5 parties pay a particular kind of attention. The therapist
6 attempts to maintain a therapeutic attitude in which to
7 listen and talk to the client in as non-judgemental a way
8 as possible. In this chapter we look at how the therapist’s
9 careful attention to concrete boundaries helps to construct
2011 and maintain the container within which both therapist
1 and patient can feel safe to work. These boundaries are
2 shaped in the main by contractual agreements such as
3 time, money, and space, and it is aspects of these that are
4 considered here.
5
6
7 Assessment
8
9 The patient has negotiated his way through cultural and
30 personal ambivalence, obtained a referral to a qualified
1 counsellor or psychotherapist, and the first assessment
2 appointment has been made.
311 The assessment is likely to include:
4 27
5
6
111 ● the presenting problem, i.e., the reason the patient is

2 seeking treatment;
3 ● an outline of the patient’s personal and family history
4 which led to his seeking psychotherapy;
5 ● whether or not the patient has a supportive enough
6 network of family, colleagues, or friends;
7 ● whether the patient would benefit from the type
8 of therapy being offered and, if not, which kind of
9 therapeutic approach would be more appropriate
1011 (e.g., open-ended or short-term, psychodynamic or
1 cognitive).
2
3 It is probable that the focus of work established at the
4 beginning of therapy will have changed shape by the end.
5 This might be for a whole host of conscious and uncon-
6 scious reasons, which we shall discuss in Chapter Eight. It
7 could also be because the client has ‘outgrown’ what the
8 present counsellor can do for him or because he needs
9 something different from what is being offered. Within
2011 the mental health field there are different approaches and
1 specialities that might be more or less appropriate for
2 different clients.
3 Sometimes a judgement can be made about this at the
4 beginning of the work and a referral made at that point. In
5 other instances, the most appropriate kind of help will
6 only emerge in the process of the work, as if the work itself
7 were a kind of ongoing assessment. In some cases, the
8 practitioner will wear more than one hat. He might have
9 worked with the client in a counselling capacity before
30 having also trained as a psychotherapist. He might decide
1 that the client who originally came with a particular prob-
2 lem in mind is now open to working in greater depth.
311 Given his advanced training, he considers continuing to
2 28
Nuts and Bolts
111 work with him. On the other hand, there might be

2 constraints placed on the practioner by funding, by insti-
3 tutional guidelines, or by a training that did not include
4 more intensive work. All these factors can make ‘referral
5 out’ necessary.
6 In the case of referral, there will be an end to the thera-
7 pist’s involvement with the client. The work will continue
8 elsewhere. How and whether that work proceeds will
9 depend to some extent on how the referral process is
1011 handled. The therapist now becomes an intermediary,
1 responsible for both an ending and for a link to a new
2 beginning elsewhere. Depending on the setting and the
3 amount of control over it, there might be only one session
4 to facilitate the transfer, a number of sessions, or, in the
5 ideal case, whatever amount of time the therapist and
6 client feel is necessary. Obviously, the time available will
7 determine how the ending unfolds. Another determining
8 factor will be the capacity of the client to consider what is
9 happening and to acknowledge it at this particular stage in
2011 the therapeutic process.
1 The duration of the present therapy is also likely to
2 affect the intensity of the client’s feelings in coming to an
3 end. However, it is important to recognize that attachment
4 can also take place within a very short period of time,
5 sometimes instantaneously. It can happen without even
6 meeting in person. A therapist’s name might have been
7 suggested to a potential client. He might have had only
8 telephone contact and have been told the therapist does
9 not have a vacancy. The therapist who is subsequently seen
30 can be felt to be second best, never coming up to the
1 expectations bestowed on the first therapist in his absence.
2 Equally, someone comes for one session and then feels
311 terribly displaced by the suggestion that it might be more
4 29
5
6
111 appropriate for him to go elsewhere. Because of the nature

2 of his need, he may have formed an instant bond. Even
3 with very short or minimal contact, there is the task of
4 helping the client to come to an end and to invest enough
5 elsewhere for the referral to work.
6 At times, and despite our best efforts, the link cannot be
7 made and the referral fails. The patient might refuse to
8 move, consciously or unconsciously angry at what is
9 perceived as a rejection. What the therapist attempts to set
1011 up for him is then rejected in retaliation, or the client,
1 having told his story, might be unable or unwilling to tell
2 it all over again to someone else. A referral might repeat
3 too exactly an earlier experience of betrayal that he might
4 or might not be able to disclose, or even recognize, at this
5 stage. In such instances, the therapist might have to decide
6 whether, despite not being ideal, there is good enough fit
7 with the client’s needs to proceed with the work himself
8 (especially if there is sound supervision in place), or
9 whether he needs to allow the client to stop prematurely,
2011 hoping that he might start again in the future.
1 In some instances, patients in therapy within the setting
2 of an institution continue to be seen by a succession of
3 practitioners rather than being referred outside for the
4 long-term uninterrupted work they so clearly need.
5 Clinically, we must question this practice and wonder
6 whether this is an indication of institutional ‘omnipo-
7 tence’. When a patient’s need is compromised in this
8 manner, we must ask whether the system is unable to face
9 its own lack of resources or, perhaps, its envy of other prac-
30 titioners. Just as our clients sometimes have to face their
1 omnipotence, so therapists and institutions must not
2 assume they can do everything. We would go so far as to
311 say that it is unethical not to let a client go if it appears that
2 30
Nuts and Bolts
111 he would benefit from a different kind of help available

2 elsewhere. The therapist or institution that has a clear view
3 of what it can and cannot do makes an important concep-
4 tual boundary around the work.
5 In this regard, it may be that therapeutic work has been
6 affected by the inclusive nature of our present culture.
7 Inclusion has had many positive outcomes, but it has also
8 led to the assumption that everyone can do everything and
9 to a lack of differentiation. We are all familiar with the
1011 growth of supermarkets and how their selling of every-
1 thing under one roof has contributed to the demise of the
2 specialist High Street shop. On a smaller scale, each shop
3 now wants to sell a range of goods to corner the market.
4 The bank sells insurance. The newsagent sells flowers. The
5 hairdresser sells greetings cards. The list is endless. Perhaps
6 it is not surprising that the mental health professional is
7 also tempted to make claims for his ‘shop’ to suit every
8 passer-by.
9 Assessment is a more complicated process than we can
2011 do justice to in this context. The curriculum of a recog-
1 nized training and the relevant counselling/psychotherapy
2 literature will provide more comprehensive treatment of
3 the subject.
4
5
6 The first session
7
8 If an assessment of the patient’s suitability for therapeutic
9 work has not already been made, the first meeting(s)
30 usually become an assessment. Once the assessment has
1 taken place and mutually convenient times and fees have
2 been agreed, these early sessions will include a discussion
311 of therapeutic expectations. However, there will also need
4 31
5
6
111 to be a discussion about practical arrangements. This will

2 include the length of individual sessions (usually fifty
3 minutes, but this can vary), whether a fee will be charged
4 for sessions cancelled by the patient when the therapist is
5 working, the timing and arrangements for payment of
6 accounts, and the name and address of the patient’s GP to
7 inform him that the patient has started counselling or
8 psychotherapy. Where appropriate, it should also include
9 information about travel, parking, and whether a waiting-
1011 room is available. Some therapists provide written guide-
1 lines to supplement what is said to the patient.
2 The patient might ask the therapist where she trained
3 and how long she has been in practice. The patient is enti-
4 tled to this information, even if the therapist might also
5 want to explore why the patient wants to know.
6
7 Beginnings and ends of sessions
8
9 Patients can feel uncomfortable on entering the consult-
2011 ing room and having to negotiate the space with the ther-
1 apist. This can be a reflection of many personal anxieties
2 and difficulties, but it also reflects the common experience
3 that entry, especially in the early stages of therapy, is diffi-
4 cult. For many people the beginning is daunting – they
5 are unsure whether they are welcome or not, or afraid of
6 what they might reveal of themselves in an unguarded
7 moment. They can be paralysed by other fears, such as
8 boring the therapist, or perhaps wishing they had never
9 ventured into this experience in the first place.
30
Case example
1
2 A patient could not make his usual session time the
311 following week and the therapist agreed to see him on
2 32
Nuts and Bolts
111 another evening when he did not usually work. However,

2 the therapist forgot to make a note of this in his diary and
3 subsequently arranged for a friend to come on the same
4 evening as the patient. When the doorbell rang, the ther-
5 apist opened the door. In the dimly-lighted hallway, the
6 therapist could see only an outline, not the features of the
7 person at the door. The therapist’s mind had composed
8 the image of the friend and warmly greeted him. When a
9 different person came into view the therapist suddenly
1011 realized that reality did not correspond with the expected
1 image; he had momentarily failed to recognize his patient.
2 This is an example of what we see being influenced by
3 what we expect to see. Therefore Bion advises us:
4
The first point is for the analyst to impose on himself a
5
positive discipline of eschewing memory and desire. I do
6
not mean that ‘forgetting’ is enough: what is required is
7
a positive act of refraining from memory and desire.
8
[Bion, 1988, p. 31]
9
2011 Bion challenges the therapist to refrain from thinking he
1 knows the patient on the basis of past meetings so that he
2 remains open to finding out about the patient in the
3 present meeting. The complementary ‘rule’ for the patient
4 is that he tries to talk about whatever is on his mind at
5 that moment.
6 Similarly, patients can find the ending and leaving of
7 the session difficult. They might try to overcome the diffi-
8 culty by enquiring after the therapist, ‘Are you doing
9 anything nice this weekend,’ or by suddenly revealing
30 “I’ve never told anyone this before but . . .’ right on the
1 dot of time. Undeniably, the process of coming and going
2 is hard, but it is important that the therapist recognizes
311 this and does not try to change the phenomenon by
4 33
5
6
111 attempting to ‘make it better’. Trainees initially wonder

2 whether they should end a session on time if their patient
3 is still distressed. Comments such as ‘we can talk about
4 that next time’ are sometimes felt to be necessary and may
5 help to contain the immediate anxiety. However, they can
6 also create an expectation that the patient should continue
7 with this issue at the next session, even though it may no
8 longer be of immediate concern.
9
1011
Time
1
2 A crucial aspect of time in psychodynamic work is that it
3 encompasses both conscious and unconscious time.
4 Unconscious ‘time’ has the quality of timelessness. Freud,
5 in describing the characteristics of the unconscious,
6 writes,
7 The processes of the system Ucs. are timeless, i.e. they are
8 not ordered temporally, are not altered by the passage of
9 time; they have no reference to time at all. Reference to
2011 time is bound up . . . with the work of the system Cs.
1 [Freud, 1915, p. 187]
2
3 One implication of this is that present, past, and future
4 can all be experienced within the time span of a single
session as if they all existed in the present. Thus, a
5
patient’s inner experience of time affects the meaning
6
attributed to what is happening in the outer time of
7
the session. It is fascinating to observe how. in the uncon-
8
scious. different time intervals can be equated.
9
30
Case example
1
2 An extremely punctual patient arrived two minutes late for
311 a session. Usually she was exactly on time. In discussion it
2 34
Nuts and Bolts
111 emerged that the two minutes represented a two-week

2 break in the therapy which she had been anticipating. In
3 the unconscious, as in dreams, time is experienced in a
4 different way to consciousness. In this case two minutes
5 and two weeks were equated. It was as if she were saying,
6 ‘If you lose two weeks of our time, I will retaliate and lose
7 two minutes of the session.’
8
9 Apart from the actual words expressed, how the patient
1011 uses the beginning and end of the session can be instruc-
1 tive. Some arrive late, some early. Some look at a watch
2 continually, others not at all. Fifty minutes might be expe-
3 rienced as too long, too short, or just right. The same
4 patient can experience each of these reactions on different
5 occasions. If a patient communicates in this non-verbal
6 way, it is important to try to understand what is being
7 experienced. For instance, a patient who continually
8 arrived early was, unconsciously, seeking to intrude on
9 imagined siblings.
2011 Another who arrived late was, unconsciously, re-enact-
1 ing a pattern of deprivation. In a session when a patient
2 said very little the therapist assumed he was withholding
3 something. In reality, the patient had been conducting an
4 intense, silent conversation and felt the session much too
5 short. A patient who experienced a session as extra long
6 imagined that the therapist was treating him as a special
7 case and allowing extra time.
8 Patients react differently to the end of the session.
9 One patient experienced this as a rejection, phantasizing
30 that the therapist was all too relieved to be rid of her. It
1 emerged that in her phantasy the patient was relating to a
2 mother whom she experienced as never having enough
311 time for her. Another patient, believing himself subject to
4 35
5
6
111 the therapist’s power and control, felt relieved to get out
2 of his sessions. Patients’ attempts to extend the time might
3 be a non-verbal indication that they can only get what
4 they need by stealing it. Patients who repeatedly do this
5 might be indicating that they want to address something
6 they have so far neglected, or perhaps that they need more
7 sessions per week. In the latter case, the counsellor might
8 begin to think about referring the patient to a psycho-
9 therapist or analyst who is trained in more intensive work.
1011 In any event, what is important is that the therapist tries
1 to understand what is being done to the boundary and
2 talks about this in a meaningful way with the patient.
3 Usually the time of the session, once agreed, is kept as
4 fixed as possible. However, many patients today have to
5 work shifts, or are not in a position to refuse extra
6 demands at the end of the working day. Within reason, it
7 is sometimes necessary to be flexible. Nevertheless,
8 Tuesday afternoon is not the same as Friday morning, and
9 it is important to keep in mind that feelings of loss can
2011 occur with even a seemingly minor change. This can be
1 the case even if the patient is relieved that the request for
2 change has been accommodated. It can be tempting for
3 both therapist and patient to avoid feelings to do with
4 such change and to assume that everything is the same as
5 long as eqivalent time has been provided. The novelty of
6 coming at a different time can also be stimulating, titil-
7 lating, or anxiety provoking, among other reactions.
8 Sometimes a patient who usually comes after work and
9 finds it difficult to avoid focusing on work issues can
30 access more personal material in a session rearranged to an
1 early morning time.
2 Jung’s concept of synchronicity is an interesting contri-
311 bution to our understanding of time. He conceptualizes
2 36
Nuts and Bolts
111 synchronicity as a symbolic connection between appar-

2 ently unconnected events, or meaningful coincidence.
3 That is, two events may coincide, but one has not caused
4 the other. He writes,
5
Synchronistic events rest on the simultaneous occurrence
6
of two different psychic states. One of them is the
7
normal, probable state (i.e. the one that is causally explic-
8
able) and the other, the critical experience, is the one that
9
cannot be derived causally from the first. [Jung, 1952,
1011
par. 444]
1
2 In the same paper Jung says, ‘Synchronicity therefore
3 means the simultaneous occurrence of a certain psychic
4 state with one or more external events which appear as
5 meaningful parallels to the momentary subjective state
6 . . .’ (Jung, 1952, par. 441).
7
8 Clinical example
9 A young man was referred for psychotherapy to determine
2011 whether this would be a suitable form of treatment for his
1 depression. The consultation went badly. Although the
2 young man rephrased everything the therapist said, and
3 appeared very annoyed with the whole procedure, he
4 denied ever feeling angry about anything. The therapist
5 struggled with his own growing feelings of irritation and
6 anger. After reflection on the unsatisfactory nature of the
7 first consultation, another was offered. The young man
8 agreed, but on the way to the second consultation was
9 involved in a car accident and ended up going to a casu-
30 alty department at the session time. The next appoint-
1 ment was cancelled because one of his children fell down
2 a slide. Again the man found himself in the casualty
311 department at the corresponding time.
4 37
5
6
111 After consultation with colleagues, the therapist recog-

2 nized that for this young man even a consultation about
3 entering a therapeutic relationship was felt unconsciously
4 to be too dangerous. Thinking about the meaning of these
5 simultaneous events led to an understanding that there
6 was a meaning in the timing of the accidents that related
7 to the unconscious fears of this young man, despite the
8 fact that the accidents were not directly caused by his
9 anxiety.
1011
1
2 Money
3
4 Money can be a complex area of therapeutic work. The
5 level of the fee can be a barrier to some patients. Most
6 training organizations make provision for this by provid-
7 ing reduced fee schemes. Some (usually time-limited)
8 psychotherapy and counselling is available within the
9 National Health Service (NHS). There is considerable
2011 cost attached to NHS therapy, in the form of salaries and
1 overheads, even though this is not reflected directly in fees
2 charged to the patient.
3 Fees charged in private practice define the formal nature
4 of the transaction by making it clear that the therapist is
5 providing a professional service: what is purchased is time,
6 space, and the therapist’s skilled and committed involve-
7 ment with the patient. The time and space are not usually
8 transferable if a patient is ill, or misses a session. It is
9 common practice that sessions which are not attended still
30 have to be paid for – because they remain available to the
1 patient.
2 Patients in therapy, as stated previously, enter uncon-
311 scious time. Because of this there can be a reawakening of
2 38
Nuts and Bolts
111 infantile defences and attitudes. Therefore, money can

2 assume an importance and acquire a meaning that has
3 very little to do with actual resources. Careful considera-
4 tion of the patient’s attitude to money can reveal a great
5 deal about his inner world.
6
7
8 Clinical example
9
A professional woman expressed her very great desire to
1011
begin therapy but an equal conviction that she could not
1
afford it. This puzzled the therapist, as the woman had no
2
dependants, reasonably secure employment, and no
3
immediate debts. The therapist was concerned, as the
4
patient was clearly suffering a great deal of emotional
5
pain. She decided to investigate the financial situation in
6
7 some detail. The patient explained to the therapist how
8 she arranged her finances: she paid all bills with standing
9 orders and direct debits, and money was put aside for
2011 holidays, clothes, etc. On the face of it this sounded very
1 organized and reasonable, but the result was that in divid-
2 ing the money so carefully the patient had no concept of
3 the ‘whole’ of what she earned. When that was considered
4 she realized that the money for therapy could be released
5 by slightly reducing the amount being saved. The way the
6 patient treated her income could be seen as a description
7 of her own inner experience – feeling broken up and with-
8 out internal resourcefulness, ‘broke’. She allowed no
9 money for the therapy just as she allowed no money for
30 her immediate needs. In dividing it up she was, paradox-
1 ically, re-enacting her inner sense of deprivation.
2 The symbolic significance that money has for each
311 individual can be most illuminating. Another patient,
4 39
5
6
111 who could quite easily afford to pay, withheld fees because
2 of a strong feeling that the therapist was stealing from and
3 exploiting him: the therapist was not the ‘mother’ he
4 hoped for – the mother who has no needs of her own and
5 gives unconditionally, without being paid. A patient, who
6 also seemed to be in conflict over payment, found the
7 money once her resentment towards the therapist was
8 articulated.
9 Spending money on themselves can leave some patients
1011 feeling overly guilty. They might think of themselves as
1 unworthy of such expenditure, or worry that they are
2 having an experience other family members do not have.
3 Such patients might also believe the therapist is entirely
4 dependent on their money and therefore feel overly
5 responsible for her welfare.
6 Money can also be problematic for the therapist.
7 Therapists working in private practice need to eat, pay
8 their own bills, have sufficient non-working time, and
9 enjoy a reasonable standard of living. Yet it is sometimes
2011 difficult to admit this. The therapist is not immune to
1 phantasies of self-sufficiency, of being ‘able to manage’, or
2 undermined by the phantasy that it is the duty of some-
3 one in a ‘caring profession’ to sacrifice his own needs. He
4 might believe that he is not good enough because his
5 patients cannot afford the high fees that other therapists
6 command. He might be unable to charge the standard fee
7 because of such feelings of unworthiness, or shame at his
8 own need for money. On the other hand, an unrealistic
9 sense of entitlement, and of his own importance, might
30 lead him to set fees that are prohibitively high for ordi-
1 nary patients.
2 The setting of appropriate fees is therefore something
311 that does need careful thought, and perhaps consultation
2 40
Nuts and Bolts
111 with colleagues. Of course, there are also situations where

2 the cost of therapy is covered by a salary, and money does
3 not come into the session in so concrete a form. Neverthe-
4 less, the question of what value the session has for the
5 patient, and of how much the therapist thinks it is worth,
6 is still relevant.
7
8
9 The consulting room and its environs
1011
1 The concrete reality of therapeutic space is that the
2 consulting room is a room belonging to, rented by, or,
3 in an institution, assigned to the therapist. Any room that
4 is regularly used acquires a sense of belonging for the
5 therapist for whom it is designated. Thus, the room and
6 its furnishings can reveal much information about the
7 therapist, as well as providing material for the client’s
8 phantasy.
9 Therapists need to be aware of the effect of the room’s
2011 location in the outside world. The patients of therapists
1 working in a psychiatric hospital might be troubled by the
2 presence of more seriously ill patients in the waiting area.
3 Some patients might have the phantasy that mental illness
4 is as contagious as, for example, the common cold.
5 When a therapist is working from home, noises of
6 family life can sometimes be overheard in the consulting
7 room. Because these noises are associated with the thera-
8 pist’s family, they can arouse oedipal anxieties in the
9 patient. Although it can be useful to learn about the
30 patient’s phantasies, occasionally too great an anxiety can
1 lead to acting out or a breakdown of the therapy. For this
2 reason, considerable thought needs to be given to how the
311 room can become a safe container for the patient. It is
4 41
5
6
111 important that the therapist’s private living area be as

2 separate as possible, so that the impact of family life is
3 minimized. Access to a lavatory is important, and a wait-
4 ing area, where possible.
5 Opinions vary about the arrangement of the room.
6 Most therapists sit at a slight angle to the patient so he has
7 a choice of whether or not to look at the therapist. If the
8 therapist has been trained in more intensive work, there
9 will also be a couch.
1011 Some therapists think the furnishings should be
1 invested with as little personal significance as possible. If
2 an object is too important to the therapist the aim of
3 interpretations can be to protect the object rather than to
4 understand the client’s projections.
5
6 Clinical example
7
8 A therapist introduced a small Victorian table to her
9 consulting room, thinking that it would make the room
2011 more attractive. One day a patient, in a particularly angry
1 phase of the therapy, threatened to break up the table. The
2 therapist found her concern divided between preserving
3 the table and understanding the patient’s aggressive feel-
4 ings. It was, therefore, impossible to maintain an ‘analytic
5 attitude’ and to interpret, non-judgementally, the passion-
6 ate anger the patient felt towards the therapist.
7 Therapists need to be aware of their own need for a safe
8 area to work. In this case, the threat of violence quickly
9 receded once the therapist became conscious of her split
30 loyalties, and was able to interpret this. But if a patient
1 persists in the type of abuse and/or threatening behaviour
2 that makes it impossible to work or that unduly frightens
311 the therapist (even if such situations are very rare), it
2 42
Nuts and Bolts
111 might be necessary to find a way to bring the therapy to

2 an end.
3 The therapist’s need for safe containment can be
4 neglected, especially in ‘caring’ organizations such as
5 hospitals. Here, the needs of the patient are usually
6 considered paramount, and the fact that all treatment
7 takes place within relationships might not be taken into
8 account. Attention to the boundaries of the container and
9 to the needs of the therapist make the work safer for both
1011 therapist and patient. This is supported by a professional
1 training and ongoing supervision, but it is also necessary
2 for therapists to have undergone personal counselling or
3 therapy in order to have reached sufficient understanding
4 of their own personal boundaries.
5 There is also physical space outside the consulting room
6 where the therapist might meet his patient. Usually thera-
7 pist and patient do not meet intentionally outside the
8 therapeutic ‘hour’, but a patient who lives in the same area
9 might be met in local shops or other facilities. Professional
2011 patients are sometimes encountered at conferences or
1 talks. The therapeutic relationship is present between ther-
2 apist and patient whether or not they are in the consulting
3 room. When meetings do occur, some way of politely
4 acknowledging each other might need to be negotiated.
5 Whatever happens, it is important to talk about such
6 meetings within the context of a subsequent session.
7
8 Clinical example
9 A young male patient went to open the door of the con-
30 sulting room at the end of a session. The doorknob came
1 off in his hand, leaving him and the therapist trapped in
2 the room. The room opened on to a balcony adjoining a
311 neighbour’s balcony. Both were able to climb over on to
4 43
5
6
111 next door’s balcony and were allowed through by a

2 bemused neighbour.
3 The importance of this event lies not only in that it
4 happened, but in the subsequent thinking that could be
5 done about it. The material (the actual event) could be
6 thought about by both therapist and patient to explore its
7 psychological meaning. This was possible because the
8 ‘container’, though broken at this point, had been safe
9 enough for the work to proceed when the unexpected
1011 occurred.
1 When something so unusual happens many resonances
2 are found within the patient’s past and the internal state
3 of the therapist. This young man had spent many hope-
4 less hours in his childhood trapped with his disturbed
5 father. He insisted on locking the doors, drawing the
6 curtains, and not letting the boy out to face the suspected
7 dangers of the outside world. In this event both patient
8 and therapist had ‘relived’ the trauma, but, in this case, a
9 way out was found. With time, the patient was able to
2011 understand and to come to terms with his fears of being
1 trapped if he committed himself to any form of relation-
2 ship. Unconsciously, he had feared that other people, like
3 his father, would restrict his freedom and want to ‘keep
4 him at home’.
5 Jung emphasized the importance of the therapist’s
6 awareness of his own involvement in the therapeutic
7 process. He saw both patient and therapist as being in
8 the ‘vas bene clausum’ (well-sealed vessel) of the relation-
9 ship. In the above case, the therapist also had to face
30 her part in the event. She had not paid attention to signif-
1 icant details – such as the gradually loosening doorknob
2 – that might have alerted her. With this patient she had
311 been concentrating on the positive aspects of the work,
2 44
Nuts and Bolts
111 such as his regular attendance and his willingness to

2 understand her interpretations. With another patient she
3 might have questioned such compliance, but here she
4 had, unconsciously, sought to avoid being seen as a parent
5 ‘with a screw loose’ who might try to trap him. This
6 unconscious denial prevented her from recognizing that
7 she was in danger of re-enacting the role of such a parent.
8 This became real by her inadvertently locking the patient
9 in with her.
1011 We have been describing some aspects of the boundary
1 that contains both therapist and patient. There are also
2 boundaries between therapist and patient. Here, it is rele-
3 vant to mention the convention in psychodynamic thera-
4 pies that physical contact between therapist and patient
5 does not occur. However, in some cultures it is common
6 practice to shake hands or even to hug someone on arrival
7 or departure. Explaining that this is against the therapist’s
8 Code of Ethics might make a refusal less personally hurt-
9 ful, but it is also important to explore what the ‘refusal’
2011 means to the patient. Of course, therapists working with
1 children, or physically ill and/or dying patients, may
2 modify their practice, but it remains important to under-
3 stand why this is happening. These and other aspects of
4 Professional boundaries are explored in Chapter Seven.
5
6
7 Telephone, e-mail and text contacts
8
9 Therapists sometimes have to cancel sessions at short
30 notice. Patients might also need to convey factual infor-
1 mation between sessions. But telephone conversations
2 between sessions can be problematic. If the conversation
311 strays into emotional areas it can be difficult to contain.
4 45
5
6
111 The patient might enter a free-associative state, but with-

2 out the containment ordinarily provided by the session.
3 A different situation arises when the phone contact
4 results from an emotional crisis. The therapist might need
5 to provide an emergency boundary by indicating a time
6 limit to his availability, and reminding the distressed and
7 possibly confused patient about the existing structure of
8 his sessions.
9 Occasionally, a patient might not be able to attend a
1011 session and request fifty minutes of telephone time
1 instead. How this is dealt with varies between individual
2 therapists but, again, it is important to consider the effect
3 on the ongoing therapeutic relationship. In general, it is
4 better to contain the conversation, reminding the patient
5 of his next available session. If necessary, and if the thera-
6 pist can do so, an earlier appointment might be offered.
7 Telephone counselling is a skill in its own right. In any
8 case, fifty minutes on the phone, where it can be difficult
9 to maintain the usual silences of the consulting room, can
2011 be overly intense. A prolonged conversation might arouse,
1 rather than contain, the patient’s distress.
2 Modern technology might encourage some patients to
3 want to use e-mails and text messaging with their thera-
4 pist. It would be hard not to see this as an attempt to have
5 a more personal relationship with the therapist and to
6 wonder why a phone call is not sufficient. As with previous
7 situations, it is important, when possible, to bring what is
8 being expressed unconsciously into the consulting room.
9
30 Note-keeping
1
2 Note-keeping has become an important issue for thera-
311 pists (see Chapter Six). As a minimum, notes should
2 46
Nuts and Bolts
111 indicate the name and address of the patient and when he
2 started and finished therapy. More extensive process notes,
3 such as those used in supervision, need to be destroyed as
4 soon as they are no longer needed. Some therapists also
5 choose to record significant sessions, such as when the
6 patient expresses suicidal ideation or when the therapist
7 gives him holiday dates. Some therapists prefer to keep
8 notes of the session separately from the official record.
9 However, if notes exist they cannot be destroyed once a
1011 legal process has begun. It is essentially a matter of
1 personal choice and practice, but the therapist does need
2 to keep in mind that a court of law can subpoena notes
3 and, in general, they have to be made available.
4
5
6
7
8
9
2011
1
2
3
4
5
6
7
8
9
30
1
2
311
4 47
5
6
111
2
3
4
5
6
7
8
9
1011
1
2
3
4
5
6
7
8
9
2011
1
2
3
4
5
6
7
8
9
30
1
2
311
2
111 CHAPTER FOUR

2
3
4 THE CONTAINING MIND
5
6
7 Within the more tangible boundaries of therapeutic work,
8 discussed in the previous chapter, reside the less tangible
9 boundaries, the relationship between the therapeutic
1011 couple and the mental space available to therapist and
1 patient being the most important.
2
3
4 The contents of the therapist’s mind
5
6 The therapist’s thought processes will have been influ-
7 enced in part by the theoretical model or models he is
8 using to think about his patient’s material. Although Jung
9 tried not to promote particular techniques for therapy, he
2011 did acknowledge the need for the therapist to be both
1 knowledgeable as well as flexible in responding to the
2 patient. Knowledge of theory, received through a recog-
3 nized professional training, helps to prevent the therapist
4 basing interventions on personal opinion. However, as
5 Jung advocated, theoretical ideas should emerge from an
6 understanding of the patient’s material and not from an
7 imposition of the therapist’s thinking (Jung, 1935, par. 8).
8 Methodology and theoretical stance operate ‘behind
9 the scenes’, framing his responses to the patient’s material.
30 They are ‘behind the scenes’ because they are not known
1 about directly by the patient. Yet, they provide a frame of
2 reference for all the reading, lectures, theoretical discus-
311 sions, previous work, and papers that have contributed to
4 49
5
6
111 the therapist’s training over time. From this reservoir of

2 experience and learning, the therapist extracts meaning to
3 fit what the patient brings. This boundary is somewhat
4 porous. For example, as the patient begins talking about
5 the significance of his childhood pet, the therapist might
6 find himself remembering the dog he also owned as a
7 child. Of course, the therapist does not say, ‘That sounds
8 like the dog I had as a boy. I loved him dearly.’ On the
9 other hand, he might use the experience indirectly to
1011 recollect how meaningful a child’s pet can be.
1 The methodology, largely acquired through training
2 and subsequent supervision, provides a means of orienta-
3 tion to the patient’s material. For example, most psycho-
4 dynamic practitioners will have learned (sometimes with
5 difficulty) to wait and ‘not know’ in response to their
6 patient’s communications. This particular method
7 provides an important space for the patient to elaborate
8 his feelings and for the therapist to consider what has been
9 said before responding. It is an important boundary,
2011 providing time and openness for the therapeutic
1 encounter. It is, of course, important that it does not
2 function too rigidly.
3 The timing of interpretations – that is, when to
4 respond to the patient’s material – can be difficult to get
5 ‘right’. A patient might begin to explore an area when the
6 therapist, unable to contain his own understanding,
7 rushes in. This can be a kind of showing off and/or an
8 inability to wait for the patient to reach his own conclu-
9 sions. The patient can feel his inner space has been
30 invaded. He has not been allowed to discover his own
1 ability to know himself.
2 For example, a therapist hearing that a patient has
311 suffered sexual abuse might assume that this issue would
2 50
The Containing Mind
111 be the focus of the therapy. But for the patient, talking
2 can mean reliving the shame and denigration of the orig-
3 inal experience. It can mean re-experiencing the voyeuris-
4 tic sadism of the abuser in the therapist. The therapist’s
5 relative silence might give the patient the impression that
6 his ambivalent response to the therapist has disappointed
7 him. The patient’s reluctance might be interpreted as ‘he
8 will not talk’, or ‘he cannot make use of the opportunity
9 to help himself’. In such circumstances, the patient can
1011 end up feeling more abused. He may have come to ther-
1 apy not to deal with the abuse issue directly but to
2 re-discover a safe place in which to explore his feelings.
3 The therapist’s mental space, largely inaccessible to the
4 patient, is most in evidence when the therapist makes an
5 interpretation. In talking about a patient’s material, the
6 therapist reveals that he has been having thoughts or
7 making links that the patient has not previously known.
8 This capacity to make use of the mind has been understood
9 and described in various ways by different theoreticians.
2011
1
2 Triangular space
3
Freud’s Oedipus Complex provides a means of under-
4
standing the dynamics of ‘threesomes’. The triangle of
5
mother, father, and child, and their inevitable conflicts,
6
involves the developing child in experiences of excite-
7
ment, envy, jealousy, rage, or fear in relation to his obser-
8
vation and/or phantasy of his parents’ sexual relationship,
9
a relationship which excludes the child. Britton, a
30
contemporary Freudian, writes:
1
2 The acknowledgement by the child of the parents’ rela-
311 tionship with each other unites his psychic world, limiting
4 51
5
6
111 it to one shared with his two parents in which different

2 object relationships can exist. The closure of the Oedipal
3 triangle by the recognition of the link joining the parents
4 provides a limiting boundary for the internal world. It
5 creates what I call a ‘triangular space’ – i.e., a space
6 bounded by the three persons of the oedipal situation and
7 all their potential relationships. It includes, therefore, the
8 possibility of being a participant in a relationship and
9 observed by a third person as well as being an observer of
1011 a relationship between two people. [Britton, 1989, p. 86]
1
2 Triangular space can also be thought of as an individ-
3 ual’s relationship to two varying states of mind. Britton
4 describes how the infant’s capacity to manage the Oedipal
5 triangle is important in the development of thought and
6 the toleration of frustration. In the consulting room the
7 existence of triangular space might mean the patient being
8 able to tolerate the therapist having a partner or, perhaps,
9 a mind capable of thoughts that exclude the patient.
2011 The Transcendent Function is a rather complex Jungian
1 concept that describes the capacity of the mind to bridge
2 conscious and unconscious thought. This bridging aspect
3 functions as a ‘third hand’ for the therapist. Describing the
4 Transcendent Function as a ‘third hand’ applies the
5 Oedipal concept of the ‘threeness’, not in its usual sense as
6 applying to three different persons or entities, but to three
7 aspects of one thing: the therapist’s mind (the conscious,
8 the unconscious, and the bridge between or the
9 Transcendent Function). The therapist makes use of the
30 Transcendent Function (or perhaps it is more accurate to
1 say the Transcendent Function makes use of the therapist,
2 because the bridging process takes place spontaneously in
311 response to the patient’s material). An image or thought
2 52
The Containing Mind
111 forms in the therapist’s mind that has the potential for
2 insight into previously inaccessible material. The therapist,
3 finding her conscious mind insufficient to understand the
4 patient, is aided by the spontaneous intervention of the
5 Transcendent Function to help make sense of it. The ther-
6 apist cannot will this to happen; rather she is the recipient
7 of its activity through a general sense of openness to the
8 experiences (Jung, 1958).
9
1011 Container–contained
1
2
3 In his description of the container and the contained, the
4 psychoanalyst Wilfred Bion provides a model of how
5 mother and child, therapist and patient use each other’s
6 minds (Bion, 1970, p. 72ff). The infant projects into the
7 mother overwhelming feelings that he needs understood.
8 It is essential to the infant that the mother does some
9 work on these feelings (consciously or unconsciously tries
2011 to understand their meaning) before returning them in a
1 form he can incorporate. In order to do this, the mother/
2 therapist must have an area of internal triangular space
3 (the thinking container) within which to transform the
4 received material before giving back (interpreting) feelings
5 in a more digestible form. Similarly, Winnicott writes of
6 the infant’s experience of time being managed by the
7 holding and containing function of the mother (Winni-
8 cott, 1985, pp. 76–77). Didier Anzieu describes how the
9 child comes to experience his skin as an interface bound-
30 ary between internal and external. This provides an expe-
1 rience of ‘. . . an encompassing volume in which he feels
2 himself bathed, the surface and the volume affording him
311 the experience of a container’ (Anzieu, 1989, p. 37).
4 53
5
6
111 Jung’s approach emphasizes the relationship between

2 therapist and client as the container within which both are
3 working. He uses an analogy to marriage to help explain
4 these dynamics. In the marital relationship the partners
5 project different aspects of themselves into each other. As
6 a healthy relationship develops, both partners begin to
7 withdraw these projections and become more able to
8 experience the other as someone different and not an
9 extension of themselves (Jung, 1931b, par. 331–342). In
1011 a similar manner, therapeutic work involves the patient
1 unconsciously projecting aspects of himself into the ther-
2 apist, his therapeutic partner. In other words, he makes
3 assumptions about the therapist that are actually about
4 himself. Gradually, the therapist understands the nature of
5 these projections. One of the objects of psychotherapy
6 and some kinds of counselling is to think and talk about
7 these projections with the patient so the projected quali-
8 ties can eventually be ‘returned’. The extent and depth to
9 which this can be done depends on the nature and inten-
2011 sity of the therapy and the ability of the patient to ‘hear’
1 such communications.
2 Fordham reminds us that the patient is not contained
3
within the mind of the therapist as a passive object await-
4
ing treatment, nor is the outcome of the treatment the
5
sole responsibility of the therapist. The patient also plays
6
a vital part. He writes,
7
8 . . . it is sometimes maintained that a patient is healed by
9 the analyst’s love, and that in being a ‘good parent’, he
30 can redress the faults of his patient’s upbringing or heal
1 the patient’s self image. It is an idea of the infant self-
2 representation that has become damaged by his mother’s
311 treatment of him. That, though it can happen, implies far
2 54
The Containing Mind
111 too innocent an understanding of mother–infant interac-

2 tion; it leaves out the infant’s part in creating a good
3 enough mother. The study of mothers and infants
4 demonstrates clearly that a mother can be a good enough
5 mother with one child and not with another in the same
6 family, or that an infant can virtually create a good
7 enough mother by the precision of his signs and the
8 apparent knowledge of what his mother can tolerate and
9 what she cannot. [Fordham, 1985, p. 216]
1011
1
2 Transference and countertransference
3
4
5 An understanding of the power of the transference led
6 early psychoanalysts to begin to establish guidelines
7 (boundaries) for the treatment of their patients. Freud
8 warns against enacting the role projected on to the thera-
9 pist by the patient and advises the latter to stick to the
2011 path of interpretation rather than action. He writes,
1
2 However much the analyst might be tempted to become
3 a teacher, model and ideal for other people and to create
4 men in his own image, he should not forget that that is
5 not his task in the analytic relationship, and indeed that
6 he will be disloyal to his task if he allows himself to be led
7 on by his inclinations. If he does, he will only be repeat-
8 ing a mistake of the parents who crushed their child’s
9 independence by their influence and he will only be
30 replacing the patient’s earlier dependence by a new one.
1 In all his attempts at improving and educating the patient
2 the analyst should respect his individuality. [Freud,
311 1940a, p. 175]
4 55
5
6
111 Jung understood the great importance of the patient’s

2 effect on the therapist (i.e., the countertransference), both
3 as a therapeutic tool and as a potential to disturb, even
4 injure, the therapist. He writes:
5
6 In any effective psychological treatment the doctor is
7 bound to influence the patient; but this influence can
8 only take place if the patient has a reciprocal influence on
9 the doctor. You can exert no influence if you are not sus-
1011 ceptible to influence. It is futile for the doctor to shield
1 himself from the influence of the patient and to surround
2 himself with a smoke-screen of fatherly and professional
3 authority. By so doing he only denies himself the use of
4 a highly important organ of information. The patient
5 influences him unconsciously none the less, and brings
6 about changes in the doctor’s unconscious which are well
7 known to many psychotherapists: psychic disturbances or
8 even injuries peculiar to the profession, a striking illus-
9 tration of the patient’s almost ‘chemical’ action. One of
2011 the best known symptoms of this kind is the counter-
1 transference evoked by the transference. [Jung, 1931a,
2 par. 163]
3
4 This projection of feelings inevitably occurs as part of a
5 therapeutic endeavour because it is the unconscious
6 means by which the patient communicates with the thera-
7 pist. The therapist’s experience of such projections form
8 the basis of his countertransference. The countertransfer-
9 ence is initially an unconscious communication and, if it
30 is not brought to consciousness and understood by the
1 therapist, can result in acting out. In many breach of
2 ethics’ cases the therapist has become unconsciously iden-
311 tified with the patient’s projections, thereby losing the
2 56
The Containing Mind
111 separateness of his own mind. What should be symbolic

2 becomes concrete. Talk about intimacy becomes confused
3 with actual intimacy. What has been lost is triangular
4 space, the sense of the ‘third’, represented by the thera-
5 pist’s mind (internal triangular apace) as well as his profes-
6 sional organization and its Code of Ethics (external
7 triangular space). When there is no triangular space there
8 is no containment for projections and acting out can
9 occur.
1011
1
2
3
4
5
6
7
8
9
2011
1
2
3
4
5
6
7
8
9
30
1
2
311
4 57
5
6
Understanding Boundaries in Clinical Practice
111
2
3
4
5
6
7
8
9
1011
1
2
3
4
5
6
7
8
9
2011
1
2
3
4
5
6
7
8
9
30
1
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311
2 58
Boundaries Within Organizational Settings
111 CHAPTER FIVE

2
3
4 BOUNDARIES WITHIN
5
6 ORGANIZATIONAL SETTINGS
7
8
9 The internal, mental boundaries of the therapist’s mind
1011 can become even more important within settings outside
1 the somewhat protected environment of the private
2 consulting room. This chapter gives a series of clinical
3 examples (based on actual situations) that illustrate how
4 ethical and boundary issues can dramatically affect, and
5 be affected by, the workplace.
6
7
An NHS out-patient
8
9
psychotherapy service
2011
1 As part of her continuing professional development, a
2 community psychiatric nurse worked psychotherapeuti-
3 cally with a woman who had been sexually abused.
4 Although they had met for some considerable time and
5 their relationship seemed a good one, the patient did not
6 show any significant improvement, particularly in her
7 ability to relate to others. She remained convinced that
8 people did not like her. She did not express any feeling,
9 particularly anger.
30 In supervision it emerged that the CPN behaved much
1 as she might in her nursing practice, where the under-
2 standing of boundaries was very different. Instead of wait-
311 ing to see how the patient might wish to begin the session,
4 59
5
6
111 she greeted her, asked how she was and how her week had
2 been. At the end the CPN would touch her arm and wish
3 her a good week. The supervisor suggested that the CPN
4 apply stricter boundaries – not open the conversation,
5 touch the patient, or wish her a pleasant week ahead.
6 Initially, the patient was very upset. She accused the
7 CPN of not touching her any more because she was
8 disgusted by her sexual abuse. She said the silence at the
9 beginning was an ordeal. She wanted to leave therapy but
1011 her GP advised her to continue. After a while, the patient
1 began to understand that despite this change the therapist
2 was prepared to think about her feelings and her anger.
3 She was not rejecting the patient, but providing a setting
4 where these could be expressed. As the patient began to
5 feel contained by the therapist’s firmer boundaries, she felt
6 safer in expressing her feelings. This enabled her to take
7 more risks in her personal life. Gradually, her relationships
8 improved to the extent that the therapy was able to end.
9 From the beginning the therapeutic relationship was at
2011 risk of failing because of a lack of appropriate boundaries.
1 Had it not been for skilled supervision and the GP’s inter-
2 vention the therapy might have continued forever with
3 little or no improvement.
4
5
6 A hostel for young homeless people
7
8 Brian began working in a hostel for young homeless
9 people. He appreciated the atmosphere in the project
30 and the staff ’s awareness of the emotional needs of resi-
1 dents. They placed great importance on the construction
2 and maintenance of boundaries because they were aware
311 that residents had missed out on secure boundaries in
2 60
111 childhood. The building’s external boundaries were very

2 prominent, because it backed on to a solid rock face while
3 at the front was a busy main road. Brian was impressed
4 that the internal boundaries seemed just as solid. The
5 hostel was an old family hotel converted into bed-sits.
6 There were many locked doors and each resident had a key
7 to his own bedroom. Staff retained keys to other impor-
8 tant areas – the kitchen, fridge, and food cupboard, etc.
9 There were also significant boundaries to do with time.
1011 Residents could stay for only six months. Appointments
1 had to be made to see their key worker. There was a
2 curfew at night. It was expected that rent would be paid
3 on time. Chores had to be done promptly. These time
4 boundaries were the most difficult for residents, and staff
5 understood this as an indication that self-discipline had
6 been minimal in their family homes and time therefore
7 had little meaning.
8 Despite the apparent emphasis on boundaries, Brian
9 soon realized that a lot of drugs were being smoked in the
2011 hostel. He found the staff’s acceptance of this worrying,
1 because the hostel rules explicitly stated that substance
2 abuse was grounds for eviction. However, colleagues reas-
3 sured him that residents received drug counselling and
4 there was no need to worry. Brian also realized that some-
5 times staff ‘rewarded’ residents by leaving the front door
6 open late at night, ‘forgetting’ to lock the fridge, or ‘ignor-
7 ing’ the stack of alcohol pushed to the back of the shelves.
8 One of his ‘key-worker’ residents confided in him that
9 the residents were planning a ‘birthday bash with presents
30 for everyone’. Brian suspected that other staff would have
1 been told the same thing. As no one mentioned the plans
2 he was afraid that saying something might break the
311 boundary of trust if he had been told ‘in confidence’.
4 61
5
6
111 Brian was on leave the weekend of the ‘bash’, and

2 returned to find a silent, deserted building. The residents’
3 rooms stood empty and the staff sat despondently in the
4 TV lounge. The party had gone horribly wrong. Drugs
5 and alcohol had unleashed a flood of pent-up emotion
6 that the locked doors could not contain. All the residents
7 had been asked to leave the hostel. The exclusions were
8 not necessarily permanent. The staff promised to recon-
9 sider each person’s situation individually.
1011 Over the ensuing weeks Brian was part of a series of
1 ‘debriefing’ meetings arranged with an external consultant
2 to assist the staff group in understanding what had
3 happened. The members of the group realized that they
4 had worked within an unconscious assumption that
5 because they controlled the physical boundaries of the
6 hostel they also contained the emotions of the residents.
7 This overlooked the true reality of the situation. The staff
8 had received no supervision for their work: there had
9 been an assumption that because they were young they
2011 would understand the, mostly young, residents. There-
1 fore, the staff had been unaware of their own contribution
2 to the ‘cocktail’ of emotions. One key issue was the degree
3 to which the staff had projected their own adolescent need
4 to challenge boundaries on to the residents, to avoid being
5 like ‘bad’ parents. Being careless with keys and drugs
6 colluded with the residents’ desire to escape from reality
7 by whatever means possible. Also, the staff group had
8 not acknowledged their own need for acceptance by the
9 residents.
30 The staff had established outer boundaries but had
1 applied them so inconsistently that they reinforced the
2 residents’ view that boundaries are arbitrary and uncon-
311 taining. Had the staff been able to maintain boundaries
2 62
111 consistently and fairly, the residents might have learned

2 that thinking about painful feelings can be a way of
3 controlling impulsive, destructive behaviours. This exam-
4 ple illustrates how over-reliance on outer boundaries can
5 mask the lack of strong inner boundaries.
6
7
8 A parochial church council
9
1011 The departure of its vicar left a church, situated in a pros-
1 perous suburban area, without a leader. Considerable time
2 elapsed before the post was advertised. During this time a
3 sub-committee of the Parochial Church Council was set
4 up to manage church affairs. The previous vicar had
5 managed the church in a very boundaried, but democra-
6 tic, style. Meetings had been held in the hall attached to
7 the church. All Council members were involved in deci-
8 sion-making.
9 When the vicar left, the sub-committee took its posi-
2011 tion very seriously and assumed ‘parental’ responsibility
1 for running of the church. However, they quickly began
2 to resent the way their decisions were challenged by other
3 parishioners who, in the sub-committee’s eyes, were
4 ungrateful. The boundaries within which the sub-
5 committee originally functioned began to subtly shift. It
6 was decided it would be much more comfortable to meet
7 in each other’s homes rather than in the church hall.
8 Over time, the sub-committee members began to lose
9 their sense of accountability to the church congregation.
30 Fewer and fewer of their decisions were referred back to
1 the Parochial Church Council. The crunch finally came
2 when the sub-committee decided to use funds raised by
311 the summer fair to finance two of its members on a
4 63
5
6
111 pilgrimage rather than to subsidise parishioners who

2 wished to attend the summer camp, as was the usual prac-
3 tice. It seemed that enjoying the comfort of their own
4 homes had isolated them from the reality of parishioners
5 who were not as well off. Not surprisingly, the fair was not
6 well attended and for the first time ran at a deficit.
7 A member of the Parochial Church Council app-
8 roached the diocese asking for help to heal the split that
9 had developed between the Council and the sub-commit-
1011 tee. A meeting took place with a diocesan representative
1 within the church hall, so all present were once again
2 within the ‘official’ container. As the two groups chal-
3 lenged each other, what had happened gradually became
4 understood. The sub-committee became aware of how
5 they had retreated from the enormity of their task and the
6 other Council members realized that they had left the
7 responsibility for running the church with the sub-
8 committee. Members were able to admit their grief at the
9 loss of their vicar, an important aspect of their former
2011 containment. The return to the container (represented by
1 the church hall and the diocesan representative) facilitated
2 the return to the reality of working with the Bishop to
3 find a new vicar – thus restoring the boundary around the
4 congregation.
5
6
7 A home visit
8
9 John, a young volunteer from Victim Support, was sent to
30 visit an elderly man, Frank. An intruder had broken into
1 Frank’s flat, threatened him, and run off with his money.
2 John was greeted by the old man saying, ‘You look a bit
311 young. What use are you going to be?’ Frank grabbed
2 64
111 John’s identity card and inspected it with suspicion. He

2 began a tirade against the caretaker of his apartment
3 block, the police, the intruder, and the volunteer, who had
4 ‘taken his time to visit’. Ten minutes later they were still
5 in the doorway. John knew he had to exercise sensitivity,
6 but to be of help he also had to gain access to a private
7 space. Despite feeling attacked himself, John realized that
8 the old man was probably reliving the trauma of standing
9 in his doorway, and not being able to stop the intruder
1011 pushing past into the flat.
1 John decided to tell Frank how long he would stay and
2 that he felt it would be best if they spoke in the lounge
3 where they could be comfortable. Once in the lounge,
4 John suggested to Frank that he sit on the sofa. John sat
5 on a chair at some distance from Frank in order to give
6 him a sense of his own space. The television was on. John
7 asked Frank whether it would be a good idea to turn it off
8 so they could talk without distraction. Frank agreed. Then
9 Frank was able to express his underlying distress, his
2011 shame at his vulnerability, and his fear of the intruder’s
1 return. John was able to listen and to make suggestions
2 about improving the safety of his flat. He finished at the
3 prearranged time and arranged to visit again.
4 In this case, the volunteer was sufficiently sensitized by
5 his training and supervision to recognize the value of his
6 countertransference response (his feeling of being
7 attacked) in dealing with Frank’s very real fear of his home
8 boundary being broken into again. John gave him time on
9 the doorstep to get accustomed to his presence and made
30 clear his own boundaries (of time and space). Once within
1 the flat, John was able to create a safe container around
2 the interview by maintaining a respectful distance and by
311 indicating his interest through careful listening.
4 65
5
6
111 A personal emergency while at work

2
3 A psychotherapist’s son has broken his leg and she has to
4
leave the clinic immediately. The secretary is asked to
5
inform patients that their appointments have been
6
cancelled. If the therapist does not wish her patients to be
7
given personal details of why she is not available, the
8
secretary will need to be informed of this. If at all possi-
9
ble, a brief discussion about what the secretary should say
1011
is not only courteous but an important aspect of main-
1
taining the professional boundary. The therapist is likely
2
to be aware that some patients will be upset, and if there
3
is time, might communicate this to the secretary. The
4
patients, and possibly also the secretary, will need an
5
6 opportunity to talk with the therapist about the event at
7 their next meeting.
8 Secretaries and receptionists are essential to the efficient
9 running of hospital and GP clinics, and most medical
2011 support staff will be aware of the need for confidentiality,
1 particularly with relations wanting information about
2 patients. Because the boundaries around psychotherapeu-
3 tic practice are unusual, and do not conform to societal
4 norms, they might present a particular challenge to
5 support staff. They might need help in managing the
6 powerful feelings that such boundaries can arouse.
7
8
9 A GP surgery
30
1 Vanessa took up her counselling post within a GP’s
2 surgery with great enthusiasm. She had clear views about
311 the importance of boundaries in counselling work, but
2 66
111 was not prepared for the lack of boundaries having such
2 an impact on her ability to work. This GP practice was
3 situated within a regional Health Centre, but their catch-
4 ment area was small, serving only those people registered
5 with them. The counsellor quickly became aware of the
6 rivalry that existed between Health Centre and GP staff
7 in sharing inadequate space. The division of tasks and
8 responsibility was also complicated. A district nurse and
9 health visitor employed by the GP practice were based
1011 within the Health Centre, but the Health Centre also
1 employed its own team of nurses. In some instances both
2 Health Centre and GP practice nurses were offering the
3 same services, e.g., baby clinics, antenatal clinics, and
4 well-woman clinics.
5 It became apparent to Vanessa that meetings between
6 Health Centre and GP practice staff designed to facilitate
7 conflict resolution were being used to snipe at each other.
8 An example occurred during a clinical meeting when the
9 GP practice’s district nurse reported on a course he had
2011 attended about treatments for sexual abuse. The Health
1 Centre nursing manager interrupted to point out that
2 since a member of her staff group had attended a similar
3 course, his report was redundant. The district nurse asked
4 for clarification on an aspect of the recommended treat-
5 ment that he had not understood. The health centre nurse
6 then admitted that she had left the course at lunchtime
7 due to a migraine and had not heard the relevant infor-
8 mation! Rather than talking about the lack of funding and
9 space, both staff groups found reasons not to cooperate.
30 Such an atmosphere made it impossible for useful infor-
1 mation and sharing of resources to occur. When resources
2 are scarce, resentment can easily be projected from one
311 part of the organization to another.
4 67
5
6
111 Vanessa discovered she had not been allocated a room

2 in which to see her clients. The GP practice manager
3 explained that she could not have the same room each time.
4 On one occasion Vanessa was using the room belonging to
5 the dental suite. The dentist was not expected that day but,
6 as Vanessa was soon to discover, appointments had been
7 rescheduled to deal with a backlog. As usual, Vanessa put
8 an ‘Engaged’ notice on the door to avoid intrusion and
9 went to collect her client. As she returned to the room with
1011 her client, she was confronted by the dental clerk who
1 explained that extra appointments had been arranged later
2 that afternoon. During the course of the session the dentist
3 herself walked in, but left when she realized the room was
4 in use. Vanessa’s client remarked, ‘An apology wouldn’t
5 have gone amiss, just barging in like that.’ A little later the
6 session was again interrupted by the phone ringing.
7 Ordinarily, Vanessa ignored the phone when with a client,
8 but the dentist rushed in to take the call in case it was one
9 of her patients. During the session the client remained
2011 sympathetic towards her struggling counsellor.
1 The following week Vanessa listened carefully for
2 anything that might reflect the client’s reaction to the previ-
3 ous week’s incidents. She detected that the client did indeed
4 feel some resentment that Vanessa had not protected the
5 session from impingement. The client said it reminded her
6 of her childhood when she felt her mother did not protect
7 her from witnessing the domestic violence of the house-
8 hold. She had always wished her mother would leave her
9 father and take the children with her. This association
30 showed that the client had picked up the unconscious
1 violence between members of staff in the previous week’s
2 intrusions. Such boundary violations are a frequent occur-
311 rence when there is a struggle for scarce resources.
2 68
111 The presence of a counsellor in a workplace, whether

2 medical, educational, or industrial, can at times provoke
3 rivalrous feelings among colleagues. Other staff might feel
4 they have failed when a referral has to be made for more
5 specialized treatment. There might be envy of the coun-
6 sellor who can spend so much time with one individual
7 or of the patient who receives so much attention. In
8 response, the counsellor’s work might be devalued in a
9 number of ways, such as careless intrusion.
1011 This example illustrates how rivalries and muddled
1 boundaries can affect the whole ethos of the organization.
2 This can be further complicated in medical settings where
3 ‘invasive’ procedures on a patient’s body (crossing physi-
4 cal boundaries) can encourage the practitioner to become
5 insensitive to interpersonal boundaries.
6
7 Institutional defences
8
9 It is important that boundaries do not become so imper-
2011 meable that they turn into barriers. Increasingly, working
1 practice is governed by institutional and legal codes.
2 Unfortunately, these sometimes have the opposite effect to
3 what was intended. Rather than safeguarding, they can
4 challenge the safe boundaries around work. A close
5 examination of working practices often reveals a system of
6 defences against the anxiety of work (Menzies Lyth,
7 1988). Institutions can unwittingly create a culture of ‘us
8 and them’. In part this is defensive, a means of dealing
9 with the very real anxiety of working with stress and pain.
30 For example, the managers of a local hospital were
1 under pressure to cut costs and decided to close down
2 some wards without informing the medical staff. The pres-
311 sure contributed to their anxiety to such an extent that
4 69
5
6
111 they did not think about the effect on patients for whom
2 beds would still have to be found. In hierarchical organiza-
3 tions where there are poor channels of communication,
4 the same boundary that protects the professional from too
5 much anxiety can, unfortunately, protect him from an
6 awareness of the patient’s anxieties. Patients whose worries
7 are pushed away might become depressed, or might resent-
8 fully attack the boundaries that isolate them from the staff.
9 When members of the local community became aware of
1011 the planned cuts, they angrily attacked members of the
1 medical staff, who had themselves been kept in ignorance.
2 A joint protest march on the hospital’s management head-
3 quarters by members of the public and the medical staff
4 turned into a violent confrontation. Only after the police
5 were called did the management team offer a room in
6 which to hold an emergency consultation meeting. Here,
7 belatedly, they were able to agree a compromise.
8 If the boundaries between levels of staffing had been
9 more permeable, earlier consultation might have pre-
2011 vented a difficult situation from developing into a crisis.
1 How a workplace is constructed will affect the work that
2 it is possible to do within it. Managers’ appreciation of
3 psychological boundaries can promote a sense of contain-
4 ment for the people working in an institution and help
5 them to work more effectively. Unfortunately, some
6 management cultures do not seem to understand that staff
7 members are themselves within the container with the
8 patients. They are more comfortable with a culture of ‘us’
9 (professionals) and ‘them’ (patients). This rigidity can lead
30 to a lack of awareness of patients’ anxieties.
1 Similarly, it is incumbent on senior staff to recognize
2 the impact of painful work on the emotional life of their
311 workers and to provide staff support and supervision
2
111 where appropriate. When professional staff ignore, or fail

2 to appreciate, the impact of this kind of work on their
3 emotional life, tragedy can result. Unfortunately, it is not
4 uncommon for people within the caring professions to
5 seek relief from their feelings in drink, drugs, and, in
6 extreme cases, suicide. A vital element of training, there-
7 fore, should be encouraging an awareness of the impor-
8 tance of containment in the workplace. Allowing space to
9 think, providing safe clinical supervision (i.e., not pro-
1011 vided by direct managers) either individually or in groups,
1 and providing access to confidential staff counselling are
2 the main elements of such containment.
3
4 Summary
5
6 These examples of work within different settings highlight
7 the complexity of boundary issues outside the consulting
8 room. The CPN had to manage a transition to a more
9 boundaried relationship with her psychotherapy client.
2011 Brian, in the hostel for young homeless people, had to
1 understand how he had become caught up in the ambiva-
2 lent attitude of the staff group to maintaining secure
3 boundaries. The church sub-committee and Parochial
4 Church Council had to recognize the implications of their
5 failure to maintain the container (the church itself ) for
6 their decision-making process. John, the Victim Support
7 worker, had to negotiate boundaries within the client’s
8 own flat after the robbery.
9 Within any institution, or in premises shared with
30 others, there is an additional dynamic – other people and
1 their expectations. Vanessa, the GP counsellor, had to
2 engage with the attitudes of professional colleagues, as
311 well as coping with the client work itself.
4 71
5
6
111
2
3
4
5
6
7
8
9
1011
1
2
3
4
5
6
7
8
9
2011
1
2
3
4
5
6
7
8
9
30
1
2
311
2 72
Confidentiality
111 CHAPTER SIX

2
3
4 CONFIDENTIALITY
5
6
7 The concepts of boundary and confidentiality are closely
8 linked. Psychotherapy, counselling, and psychoanalysis are
9 all based on the premise that the patient is free to say
1011 whatever is on his mind and the therapist is similarly free
1 to think. It is a common assumption that the boundaries
2 around a session are not only to do with time and space
3 but also with an assurance that what is communicated
4 between therapist and patient will largely stay in the
5 room. Like the well-sealed vessel used by the alchemists,
6 the confidential nature of therapeutic work is meant to
7 provide a secure container in which difficult and some-
8 times volatile feelings can be exposed. The trust that
9 develops over time is, to a large extent, encouraged by this
2011 sense of privacy.
1 Views on confidentiality differ within the therapeutic
2 community. Some, like Christopher Bollas, a contempo-
3 rary psychoanalyst, make the case for absolute confi-
4 dentiality. Bollas (2003, p. 157) maintains that the
5 psychoanalytic method of free association and evenly
6 suspended attentiveness depends on free expression. Free
7 expression is undermined if confidentiality is compro-
8 mised in areas such as sexuality and violence (although it
9 could be argued that all areas of personal pain might be
30 similarly affected). The therapist needs to be able to ‘listen
1 freely’ rather than to ‘listen out’ for information that
2 would compel him to report the patient to the authorities.
311 Bollas writes, ‘We must argue that confidentiality is held
4 73
5
6
111 by our profession – not by our patients – so that we may

2 discuss our patients with colleagues, clear in our minds
3 that in so doing we are not referring our patients to the
4 criminal justice system’ (ibid., p. 173).
5 On the other hand, Dr Richard Lucas, a psychiatrist
6 and psychoanalyst, (Lucas, 2002, p. 2) argues for a bal-
7 ance between the rights of the individual and the needs of
8 society. ‘Normally, one would expect that patient confi-
9 dentiality would be preserved at all times, in relation to
1011 analytic therapy. Potentially dangerous situations are far
1 more likely to arise over inappropriate maintaining of
2 confidentiality.’ In other words, there are occasions when
3 not ‘reporting’ can lead to patients being a risk to them-
4 selves and others; patients who deny or rationalize their
5 illness pose a particular problem for the therapist. In these
6 cases it is essential for them to be able to talk openly with
7 the psychiatrist, GP, and responsible relations.
8 ‘The right to confidence is based on the idea that the
9 information belongs to the person who imparted it –
2011 rather as though it was a piece of property’ (Layton, 2003,
1 p. 151). The legal implication of this is that the informa-
2 tion contained in a therapist’s notes belongs to the patient.
3 If a patient wants to see or disclose the notes, the thera-
4 pist is obliged to hand them over. However, this contrasts
5 with the opinion offered by the BCP [now BPC] Working
6 Group on Confidentiality in the concluding article of the
7 same journal that featured Layton’s paper: ‘Assured and
8 predictable neutrality and confidentiality are absolutely
9 central to psychoanalytic psychotherapy and psychoanaly-
30 sis without which the existence of these as available treat-
1 ments is seriously compromised for all patients; and some
2 practitioners would say it is impossible to practise’ (BCP,
311 2003, pp. 193–194).
2 74
Confidentiality
111 Limitations
2
3 Many factors in the social, legal, and institutional context
4
of therapy constrain the impermeability of the confiden-
5
tial framework; confidentiality is not the same as secrecy.
6
When a patient reveals serious intent to commit
7
suicide, information about having committed a crime, or
8
evidence of paedophilia, confidentiality is immediately
9
challenged. Questions about safeguarding the patient, the
1011
therapist, and the public will all need to be considered.
1
In private practice, it might be necessary to inform the
2
patient’s GP when there are changes in his emotional state
3
that could require a change of medication or hospital
4
admission. Within an institution where a patient is seen
5
6 by a number of different professionals, communication
7 between them is often necessary. For example, a therapist
8 working with a schizophrenic patient might notice
9 increasing evidence of disturbed sleep patterns and delu-
2011 sional thoughts. It is part of the therapist’s duty of care to
1 inform the patient’s psychiatrist. Therapists working with
2 recovering substance abusers might need to tell relevant
3 team members if the patient begins ‘to use’ again. Here,
4 the therapist is part of a team and as such must function
5 within the treatment network. Howe ve r, the therapist
6 should bear in mind that the patient is also part of the
7 team involved in his care. The patient should be consulted
8 when the therapist is considering contacting another
9 professional involved in his care. But, ultimately, the ther-
30 apist has a duty of care to ensure the safety of the patient,
1 so information about potentially harmful changes in
2 behaviour might have to be disclosed even against a
311 patient’s wishes.
4 75
5
6
111 Clinical examples

2
1. A teacher of previous blameless record is unable to resist
3
escalating sexual contact with young adolescent pupils in
4
his school. Prosecutable behaviour has already occurred,
5
but is not yet public. He knows he is in need of help, but
6
is not sure where to seek it. He would be ‘safe’ in going to
7
his priest, as he could legally maintain absolute confiden-
8
9 tiality. But a doctor or psychotherapist would be bound
1011 by the GMC guidelines and the Children Act (1989) to
1 contact Social Services. The therapist who continues to
2 work with the patient might put others at risk in not
3 informing the authorities. On the other hand, the thera-
4 pist who reports the incident is likely to lose the patient
5 and the possibility of helping him in the longer term.
6 2. A young psychiatrist in training reported to his
7 psychoanalyst that he was aware of paedophilic desires.
8 He did not say whether he intended to act on his feelings.
9 With the agreement of the patient, the analyst stopped the
2011 analysis but offered once-weekly supportive therapy. He
1 did not report the patient to the authorities and the
2 patient remained in the training. Subsequently, the psy-
3 chiatrist abused a ten-year-old boy. Ten years later, when
4 the boy was twenty-one years old, the analyst was sued for
5 not doing more to protect the child. The analyst was
6
found guilty of negligence for not informing the college
7
authorities at the time about his patient.
8
9 3. A twenty-year-old history student who lived alone
30 was brought to the Emergency Department by neighbours
1 after an attempted suicide. A provisional diagnosis of
2 acute schizo-affective disorder was made by the duty
311 doctor, and, after a brief admission, home treatment was
2 76
Confidentiality
111 agreed as a safe alternative. Although at that time the

2 patient was not in a sufficiently lucid state of mind to give
3 consent to her family being contacted, the Community
4 Mental Health Team invited her parents, who lived
5 abroad, to come to London to meet with them.
6 Over time, it became clear that this breaking of con-
7 fidentiality had particular significance. The patient had
8 been attempting to gain independence from her parents’
9 controlling ambitions for her, and she felt that this had
1011 now been undermined. She believed that her own aca-
1 demic interests had always been undervalued by her
2 parents, who regarded financial success as all-important.
3 At college, she had been very successful in her course work
4 and slowly began to make friends, but this success was
5 itself stressful for her because of her fear of high expecta-
6 tions.
7 Although it seemed ethically ‘right’ to have broken her
8 confidentiality and included her family, it was experienced
9 by the patient as a repeat of her parents’ controlling
2011 behaviour. Ideally, the need for confidentiality has to be
1 balanced against the need to help the individual
2 concerned as appropriately as possible. How that balance
3 is reached in each case is rarely straightforward.
4
5 4. A young man was referred for therapy to deal with
6 relationship problems. He had experienced an emotion-
7 ally and physically deprived childhood. The parents were
8 emotionally distant and had to work long hours to sup-
9 port a large family. It gradually emerged that there had
30 been a terrible tragedy in the family history. A close rela-
1 tion who was mentally unstable had fatally wounded
2 another family member. This was a secret shared but not
311 talked about by the immediate and extended family.
4 77
5
6
111 The patient had succeeded professionally and had a

2 financially rewarding but demanding job, which involved
3 high profile deals. The therapist, impressed by the impor-
4 tance of the patient’s job, agreed to see him later than
5 usual because of his long work hours.
6 Despite the therapist’s impression of an enviably
7 rewarding job, the patient soon began to complain about
8 unhappiness at work and a feeling that he was being
9 bullied. He decided to undertake further training to try to
1011 secure an even better job. Preoccupied with whether he
1 would ‘measure up’, he spoke of wanting to leave therapy
2 in order to fulfil the demands of his course. The therapist
3 therefore assumed they were working towards an ending.
4 The patient’s situation at work started to deteriorate
5 rapidly. Suddenly he went to his GP and secured a sick
6 note for stress. He immediately sought legal advice in
7 order to make an official complaint to the Employment
8 Tribunal because of ‘unfair treatment’ at work. The GP
9 telephoned the therapist. There was a shared concern
2011 about the emotional impact of an adversarial legal system
1 on their patient’s fragile mental state. Following this
2 conversation, the therapist wrote to the GP to confirm
3 their discussion.
4 Without any warning, the therapist received a written
5 request for the clinical notes from the patient’s legal team.
6 On discussion, at his next session, the patient told him
7 that he believed the clinical notes would provide useful
8 evidence of his mistreatment at work. The therapist
9 believed that this was unlikely, because his notes were
30 mostly concerned with the interaction between himself
1 and the patient, and his countertransference responses,
2 not information about the work situation. He wrote
311 back refusing to pass on the notes on the grounds of
2 78
Confidentiality
111 confidentiality. He explained that disclosure could be

2 harmful to the patient’s well-being, and the notes, written
3 for the therapist’s own use, were unlikely to make sense to
4 anyone else.
5 Unknown to the therapist, the GP’s medical notes had
6 also been requested by the patient’s legal team, and the
7 GP had released them. The medical notes included the
8 letter sent by the therapist. On the basis of this letter, the
9 patient’s legal team renewed their efforts to obtain the
1011 therapist’s notes. By this time, the patient’s Tribunal case
1 for compensation had begun, and his claim was being
2 opposed by his employer. The patient’s lawyer wrote
3 again, explaining that the employer’s solicitors were now
4 also pressing for the notes to be produced. They explained
5 that a court-appointed psychiatrist was compiling a report
6 on the patient’s mental state and that the therapist’s notes
7 would provide evidence of the patient’s state of mind at
8 the time of the work problems.
9 Being unfamiliar with the legal system, the therapist
2011 felt increasingly anxious and intimidated. As pressure to
1 release the notes increased, he realized that something was
2 being acted out that probably belonged in the therapy.
3 However, it was difficult to work on this because the ther-
4 apy itself was now in a confusing state. The compensation
5 claim absorbed all of the patient’s interest; he no longer
6 mentioned leaving but did not seem to be interested in
7 the therapist’s efforts to link his anger with the employer
8 to himself or his parents. Ashamed about being in such a
9 muddle, the therapist tried to deal with the pressure alone
30 rather than seek the advice of colleagues. Feeling bullied,
1 he decided again to refuse to release the notes.
2 Suddenly, one Monday morning, the therapist was
311 ordered to attend the Employment Tribunal Hearing in
4 79
5
6
111 two days’ time with his patient and the legal team. The
2 therapist was told that he would be asked to defend his
3 decision not to provide the notes, and was advised to
4 bring his own legal representation because he might be
5 personally liable for costs in excess of £40,000 if he lost.
6 At last, the therapist contacted his professional organiza-
7 tion for advice, and was referred to a solicitor who
8 explained that the therapist had no case because the
9 patient himself did not object to his notes being handed
1011 over. She reassured the therapist that the patient’s confi-
1 dentiality would be preserved because the notes would be
2 seen only by the court-appointed psychiatrist. She added
3 that the Tribunal’s primary duty is to the interests of
4 justice: ‘inconvenience, embarrassment or other difficul-
5 ties caused to a witness are less important. It is up to the
6 tribunal to decide whether or not the notes are relevant,
7 not the therapist.’
8 Feeling humiliated and violated, the therapist released
9 his notes with the stipulation that they be seen only by the
2011 psychiatrist. He did not attend the Tribunal. The patient
1 came to his next session very angry with the therapist. He
2 had seen the notes because copies of them had, in fact,
3 been distributed to everyone present at the Tribunal,
4 including the patient himself. He had lost his case and
5 blamed the therapist. He left the session early and did not
6 return.
7 Without adequate supervision or self-reflection, the
8 therapist had become caught up in a painful re-enactment
9 of the patient’s family situation. It would appear that the
30 therapist was over-impressed by the client’s high-profile
1 job. From the very beginning this affected his usual
2 boundary setting, leading him to offer an appointment
311 time outside his ordinary working hours. No doubt he
2
111 was also unconsciously influenced by a desire to be a

2 ‘better parent’, one who could be expansive with time.
3 Despite giving the client adequate time, the therapist
4 could not counter the patient’s fear of his anger, the
5 ingrained ethos of family secrecy, and his own envy of his
6 patient’s high-profile life. This combination of factors
7 probably made it impossible for secret feelings to do with
8 anger and revenge to be dealt with confidentially in the
9 consulting room. Instead, the client projected his anger
1011 with his parents on to his employers and then expected his
1 therapist to use his confidential notes to assist the Tribunal
2 attack on the employers. Unconsciously, of course, he was
3 attacking the ability of the therapist and the therapeutic
4 relationship to help him – in effect re-enacting the origi-
5 nal family murder. It was as if he were saying, ‘the consult-
6 ing room is not a high-profile enough place to reveal the
7 family secret (the employer/parent ‘bullying’). I must find
8 a more suitable place’. Sadly, this case is a good example
9 of how being bullied can lead to the victim himself
2011 becoming the bully. The client ended up bullying the
1 therapist into court and destroying his own potential life-
2 line. Interestingly, in exposing the situation in a court
3 setting, he also put his own behaviour ‘in the dock’. Had
4 there been adequate supervision and the therapist more
5 aware of his own feelings, at an earlier stage, the collusion
6 between his and his client’s over-valuing of the high-
7 profile life might have been averted and the outcome been
8 very different.
9
30
1
2
311
4 81
5
6
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2
3
4
5
6
7
8
9
1011
1
2
3
4
5
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7
8
9
2011
1
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3
4
5
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7
8
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311
2 82
Professional Boundaries and Containment
111 CHAPTER SEVEN

2
3
4 PROFESSIONAL BOUNDARIES
5
6 AND CONTAINMENT
7
8
9
1011
1
Introduction
2
3 Given the nature of the experience in the consulting
4 room, it is not surprising that the ‘therapeutic couple’, the
5 therapist and client, need reliable support and contain-
6 ment. The consulting room and the space around it form
7 a part of their immediate physical boundary. An ethos of
8 confidentiality forms a less tangible, but equally impor-
9 tant, boundary. Beyond this, one could imagine a series of
2011 concentric circles that, like the layers of an onion, define
1 and encircle the therapeutic experience. The outermost
2 layers, farthest from the consulting room, are the legal
3 constraints, government mandates, and cultural expecta-
4 tions of society. These enclose other layers represented by
5 professional registration bodies as well as the Codes of
6 Ethics and guidelines of the training body. Within the
7 layer framed by the therapist’s training is the containment
8 of the therapist’s own therapy and supervision, the theo-
9 retical model(s), and the therapist’s belief system. In situ-
30 ations where the work takes place outside the therapist’s
1 own consulting room, the constraints of the institution
2 form yet another layer of containment. Even the way the
311 therapist makes use of her mind and understands her role
4 83
5
6
111 become significant aspects of containment around the

2 therapy. Of course any of these layers can, at times, repre-
3 sent a lack of containment.
4
5 Legal constraints
6
7 The cases described in the previous chapter illustrate the
8 impact of the law on the therapeutic process. In ‘Con-
9 fidentiality’ case example 4 (see pp. 77–81), the bound-
1011 aries around therapy were challenged by the court in its
1 request for information contained in the patient’s notes.
2 Fortunately, this is relatively uncommon, but when it does
3 happen there is a real danger that the information gleaned
4 from session notes might be used to the disadvantage of
5 the patient. Disclosure can be detrimental to his mental
6 health and can bring the therapeutic relationship to an
7 end. Although legally a therapist can ask that disclosure be
8 limited to particular parties (e.g., the court-appointed
9 psychiatrist), the court can decide to release the notes to
2011 everyone involved. In reality, it appears that each case is
1 fought on a case by case basis. The therapist in this posi-
2 tion needs to consult with colleagues, the training organi-
3 zation, and probably legal advisers. The acts concerned are
4 the Data Protection Act (1998), the Human Rights Act
5 (1998) and the Access to Health Records Act (1990).
6 In the case of paedophilia, the relevant law is the
7 Children Act (1989). Unfortunately, these laws are both
8 comprehensive and vague.
9
30 Codes of Ethics
1
2 In therapy things can, and sometimes do, go wrong. Jung
311 (1946, par. 364–365) writes extensively of the dangers of
2 84
111 ‘psychic infection’; by this he means the therapist, because

2 of his emotional proximity to the patient, is in danger of
3 being infected by his feelings. ‘Psychic infection’ is what
4 allows the therapist to experience the client’s feelings
5 within himself (the countertransference). Although an
6 understanding of the countertransference can lead to ther-
7 apeutic change, Jung warned that it is not easy for the
8 therapist to become aware of what is happening and there
9 is always a danger of the therapist taking action rather
1011 than thinking and, hopefully, interpreting. Jung recog-
1 nized this problem and was the first to ‘demand that
2 anybody who intends to practise psychotherapy should
3 first submit to a training analysis, yet even the best prepa-
4 ration will not suffice to teach him everything about the
5 unconscious’ (ibid. par. 366).
6 Each training organization currently recognized as a
7 member of either the United Kingdom Council for Psy-
8 chotherapy (UKCP) or the British Psychoanalytic Council
9 (BPC, formerly British Confederation for Psychothera-
2011 pists, or BCP) must implement a Code of Ethics that
1 delineates behaviour which is unprofessional. The areas
2 covered by Codes of Ethics include: the prohibition
3 against sexual or financial exploitation of patients and
4 supervisees, the obligation to maintain patient confiden-
5 tiality, fraudulent claims about qualifications, etc. Codes
6 of Ethics are generally available to the public upon
7 request.
8 Sometimes a process meant to address and understand
9 the needs of the patient becomes one that is more
30 concerned to protect the therapist. Gabbard and Lester,
1 experts in boundary violations in psychotherapy, evalu-
2 ated and treated more than seventy cases of therapists who
311 had sexual relationships with their patients (Gabbard &
4 85
5
6
111 Lester, 1995). Gabbard’s suggestions for attempting to

2 prevent this include ongoing supervision, education on
3 ethics as part of training, more rigorous training analy-
4 sis/therapy, and consideration of the therapist’s level of
5 satisfaction outside of work. However, total prevention is
6 unrealistic, even where a trainee’s therapist is required to
7 report to the training committee (Sandler, 2004).
8
9
1011 Complaints and appeals’ procedures
1
2 Ethics complaints have traditionally been handled by a
3 committee of members from within the organizations
4 themselves. This practice is gradually changing to that of
5 a regulation committee including lay members and oper-
6 ating outside each individual organization.
7 Ethics committees have the power to investigate
8 complaints and, in minor cases, to provide an opportunity
9 for conciliation. When a major complaint is upheld, sanc-
2011 tions can be recommended. The therapist concerned
1 might be asked to have further therapy or supervision or,
2 in the most severe cases, might be suspended from prac-
3 tice or expelled from the organization.
4
5
6 Codes of practice or practice guidelines
7
8 Codes of practice differ from Codes of Ethics. They are
9 recommendations about best practice in support of the
30 regulatory boundaries contained in the Codes of Ethics.
1 They cover issues such as the necessity to make clear
2 the contractual expectations of the practitioner before
311 therapy begins (e.g., charging fees for missed sessions), the
2 86
111 responsibility to appoint professional executors who can

2 act on a member’s behalf in the event of sudden incapacity
3 or death, the requirement for practitioners to undertake
4 regular continuing professional development, including
5 supervision, and guidelines for liaison with GPs and other
6 mental health professionals involved with the patient.
7 Most Codes of Ethics expect the professional to refrain
8 from claiming to possess qualifications he does not
9 possess, and from practising beyond the limitations of his
1011 training. The clear intention is that the work done should
1 correspond to the training and experience of the individ-
2 ual therapist. Yet it is not uncommon to find patients
3 continuing in long-term non-intensive work who might
4 never improve without more specialized or intensive help.
5 Of course, they might not come to any harm, but they
6 could get bored or discouraged and eventually stop.
7 Problems can develop later when they need further help
8 but might dismiss counselling or psychotherapy because it
9 has already been tried. Had the original therapist recog-
2011 nized that the patient needed a different kind of help, he
1 could have been referred on and perhaps have continued
2 to develop.
3
4
5 Issues of differentiation
6
7 In addition to the cultural pressure against differentiation
8 spoken of in Chapter 3 there is confusion about how to
9 value different kinds of therapeutic work. Because the
30 words ‘psychotherapist’ and ‘psychotherapy’ might for
1 some have a higher status than ‘counsellor’ and ‘coun-
2 selling’, there can be a strong pull towards using these
311 terms loosely, if not inappropriately. Slippage in word
4 87
5
6
111 usage occurs because, understandably, the practitioner

2 wants the work to be valued. However, this tendency
3 could be seen as an aspect of magical thinking – using a
4 word to create what the practitioner wants to be rather
5 than becoming what he wants to be through further train-
6 ing or belief in his own distinctive work as something of
7 equal value. It would be similar to a farmer who wishes to
8 paint declaring that he is a painter rather than a farmer
9 who paints pictures. It is interesting that the public itself
1011 appears to use the term ‘counselling’ more often than
1 ‘psychotherapy’. This might be in order to demystify the
2 work and/or because this label somehow feels less fright-
3 ening.
4 The more we value the distinctiveness of what each
5 practitioner brings to therapeutic work, the less often do
6 terms such as ‘psychotherapy’ have to be used in an indis-
7 criminate manner to confer value or status. It is to be
8 hoped that the practitioner’s realistic belief in his capacities
9 is, in the end, what confers value on his work. Para-
2011 doxically, the use of the term ‘psychotherapy’ in an overly
1 inclusive way actually devalues counselling and other
2 forms of intervention, for it implies that these disciplines
3 cannot stand under their own rubric and that there is not
4 sufficient meaning in their own distinctiveness. To acquire
5 value they have to assume someone else’s label.
6 Forthcoming statutory regulation of the profession may, in
7 any case, provide limitations around such fluid use of
8 terms.
9 The confusion in the valuation of therapeutic work
30 is often augmented by a confusion of terminology.
1 Grammatically, we confuse who is doing the work (the
2 psychotherapist) with what is being done (the psycho-
311 therapy) and both of these with how it is being done
2 88
111 (psychotherapeutically). Although it is accurate to say that

2 different professionals are all working psychotherapeuti-
3 cally, they are not necessarily doing the same kind of
4 psychotherapy work nor are they all necessarily
5 psychotherapists. Equally, various professionals might all
6 be practising psychotherapy (in a variety of forms), but
7 they are not necessarily all psychotherapists. It seems that
8 doing psychotherapy slips all too easily into being a
9 psychotherapist.
1011 An interesting example of this came in the form of a
1 flyer advertising the work of a local counsellor. Her own
2 training was as a counsellor, but because the name of her
3 training organization included the words counselling and
4 psychotherapy, her own work was described as counselling
5 and psychotherapy. Not only was this confusing, it was
6 also clearly misleading. She was promoting work for
7 which she was not trained and this, according to most
8 Codes of Ethics, is unethical.
9
2011 Clinical example
1
A recently-qualified counsellor brought a new client for
2
supervision. The client had found her name through a
3
website and had conveyed a sense of urgency and desper-
4
ation, even on the telephone. The first meeting was filled
5
with a pressured and emotional description of the client’s
6
7 anguish, and the counsellor had found it difficult to get a
8 word in edgeways. Towards the end of that meeting, the
9 counsellor interrupted to suggest that they talk about
30 practicalities, such as the possible timing of a regular
1 session. The client unexpectedly revealed that she was
2 expecting to come three times weekly, because ‘that’s what
311 psychotherapy is, and that’s what I want’.
4 89
5
6
111 The counsellor was taken aback; she had been trained
2 to see clients once-weekly, but realized that she was listed
3 on the website under the category of ‘Counselling and
4 psychotherapy’. Without thinking it through, she had
5 gone along with the client’s assumptions and expectations,
6 seeing her for a second and third session during the same
7 week before coming to supervision. She presented her
8 experience of becoming overwhelmed by the client’s mate-
9 rial, which included some quite paranoid ideas about her
1011 neighbours having drilled an observation hole in the party
1 wall. When the counsellor had linked the client’s anxiety
2 to the forthcoming weekend break, the client suddenly
3 looked at her in a suspicious way and asked if she was a
4 ‘mind-reader’.
5 Supervision highlighted the counsellor’s lack of experi-
6 ence with frequent sessions. They considered how the
7 ethical issue of the counsellor not having been straight
8 with the client about her level of skills had resulted in a
9 clinical dilemma: how to proceed in the best interests of
2011 the client. It was agreed that the counsellor would give the
1 client the choice of continuing with her once a week, or
2 going to someone else for more frequent therapy.
3 Another strand of the complex issue of differentiation
4 is the theoretical underpinning of therapeutic work.
5 Psychodynamic work in all its variations—counselling,
6 psychotherapy, and analysis – is supported by a body of
7 theoretical knowledge. Although in many cases the work
8 of these practitioners is very different, the same theory
9 tends to be used by all. Of course, this makes some sense,
30 because the person being helped is the same even if the
1 practitioner is different and has different training. In addi-
2 tion, it is important to understand the dynamics of the
311 psyche even if that knowledge is not used directly in the
2
111 work. On the other hand, the use of common texts can
2 be confusing and lead the practitioner unwittingly to have
3 expectations of himself for which his training has not
4 equipped him. A clinical example of a patient in three
5 times weekly psychotherapy might be interesting to read
6 but, as is clear from the above example, the pace and
7 nature of the work would be very different from a client
8 who attends counselling once a week or a patient who
9 attends a psychiatric appointment even less often. It is
1011 important to match the content and manner in which
1 interpretations are made with the intensity and spacing of
2 sessions. A comment made about a patient’s vulnerability
3 might be tolerable if he is returning the next day and can
4 clarify or protest against its meaning. The same comment
5 made to the same patient who is not seen again for a week
6 could be devastating. He might have been hurt, but
7 cannot clarify what was meant for a week. His thoughts
8 might build up and become persecutory; he could be
9 filled with uncontainable anxiety. The practitioner who
2011 uses a variety of theoretical texts must be clear in his mind
1 how he is using them, with whom, and in what context.
2
3
4
5
6
7
8
9
30
1
2
311
4 91
5
6
111
2
3
4
5
6
7
8
9
1011
1
2
3
4
5
6
7
8
9
2011
1
2
3
4
5
6
7
8
9
30
1
2
311
2 92
Ending
111 CHAPTER EIGHT

2
3
4 ENDING
5
6
7 Directly or indirectly, endings take one back to the begin-
8 ning, back to why the client came in the first place and to
9 what has happened between therapist and client since that
1011 time.
1
2 The difference between ending
3 and stopping
4
5 One of the central issues in finishing the work is the
6 difference between ending and stopping. Ending is a
7 process. Stopping is just that – stopping. Ending involves
8 a planned interaction between two people over time.
9 Stopping does not. In between are the grey areas – an
2011 ending process agreed but, consciously or unconsciously,
1 sabotaged. Having allowed time to draw things to a close,
2 space for saying good-bye, reflection, or mourning, the
3 client may simply not come, or, even more difficult, might
4 arrive ten minutes before the end of the last session! For
5 whatever reason, he cannot face the process involved in
6 ending; instead, he has chosen to stop. From the counsel-
7 lor’s point of view, he leaves her to do the work of ending
8 by herself, and that is not easy. She has to let go of the
9 client in his absence and deal with all the feelings of being
30 left in this manner, of the work being incomplete. Just
1 as an unmourned child can affect the parents’ relationship
2 to the next sibling, so an unresolved ending with the
311 counsellor might affect her relationship to the next client.
4 93
5
6
111 In those cases where the client insists on stopping and

2 thereby eliminating the ending process, it is useful to ask
3 oneself and to consider with the client (if he is still there)
4 why he needs to do so. What is it that he fears in this
5 ending space to such an extent that he needs it not to
6 happen? The answer will almost certainly contain mater-
7 ial vital to the continuation of the work and thereby to the
8 client’s further understanding. Whatever is in the answer
9 might contain the essence of his psychic blockage not only
1011 now, but for years prior to arriving in the consulting
1 room. In addition, the material in the blockage, if it can
2 be considered, will contain the potential for further devel-
3 opment of the work either in an extension of the current
4 work, with someone else when a referral is being made, or,
5 should he decide to finish at this stage, maybe within the
6 client’s own development. Of course, sometimes a patient
7 reappears later on to face what could not be faced earlier.
8
Clinical example
9
2011 The client who stops rather than ends will have all sorts of
1 means, conscious and unconscious, at his disposal to ensure
2 that it happens in just that way. He might arrive for the last
3 ten minutes of the last session, as we have suggested. The
4 therapist might think, ‘Ten minutes is ten minutes, quite a
5 lot can happen in that time.’ This is true, but if he is deter-
6 mined to stop rather than to end, he might have enlisted
7 further support for his intention. This will be the occasion
8 when his wife will have had to attend her ailing mother and
9 have left the two-year-old behind with him. The two-year-
30 old might have been brought along to the session or be in
1 the car outside. Now the therapist is left with ten minutes
2 in which to end and a much more complex situation – does
311 she consider the immediate danger to the two-year-old left
2 94
Ending
111 outside in the car, the two-year-old behaviour of the client

2 putting her in an impossible position, or the two-year-old
3 in herself, who might want to scream in rage and say it’s all
4 too much; how could she be expected to cope in such
5 circumstances. Oh, and we forgot to mention, because he
6 has not been to his sessions for some weeks, there is also an
7 unpaid account to be presented and paid within this time!
8 He will probably face the therapist with the two-year-old
9 assertion that as he was not here for the sessions he should
1011 not have to pay for them.
1 One way of deciphering this scene is to speculate about
2 the common element – the two-year-old. This might have
3 been a difficult time for this young man, when he was, in
4 actuality, two. Perhaps he was blocked at that age,
5 metaphorically left outside in the car or dragged along
6 when mother was preoccupied with other events in her
7 life. Maybe something happened to him at that age which
8 was not an ending with due notice, but something that
9 stopped abruptly – a significant person dying without
2011 warning, an important carer who left without saying
1 good-bye. It is as if he is bringing this reality into the
2 consulting room in a manner which reflects how it
3 happened then – without warning and with no space to
4 do anything about it. Perhaps there were too many needs
5 of too many people to be considered in the emotional
6 equivalent of ten minutes. And, of course, two-year-olds
7 pay for the time and space they take up, so from the two-
8 year-old perspective a final account feels irrelevant!
9 Sometimes the two-year-old aspect of the client can be
30 rescued at the last minute by a somewhat older internal
1 figure (perhaps a more trusting self developed during a
2 previous phase of work together assisted by the therapist’s
311 judicious use of interpretation). If not, the therapist will
4 95
5
6
111 need to deal with her own feelings about the work being
2 left in this manner and to have done some thinking about
3 what feelings were being enacted by the client. It could be
4 just the therapist’s luck that he will turn up punctually the
5 next week at his old time and be totally baffled that a new
6 client is being shown into the room in his space! This
7 could be another clue. Maybe the precipitate ending all
8 those years ago had to do with a sibling that had arrived
9 ‘without notice’, a sibling whom all these years later he
1011 was compelled to revisit.
1 Of course, this is an example of someone who could not
2 face the ending because of the opportunity it would have
3 provided for reliving the pain of what was blocking him.
4 In contrast, a different person might have been able to use
5 a period of ending to face some of this upset. This might
6 have been the basis for consolidating the work with him,
7 extending the contract to work on new areas, or referring
8 him on for psychotherapy or even analysis with the expec-
9 tation that the experiences of loss beginning to emerge in
2011 the ending process could be given further space. In any
1 case, this is a good example of how the process of ending,
2 or indeed even the attempt to avoid having an ending, can
3 throw into the arena quite new material that has not been
4 accessible earlier in the work. It is as if our imagined client
5 believes that the counsellor will become, for example, the
6 mother who actually deserted him so long ago. To some
7 extent, of course, this is true. Space given to the ending can
8 provide a forum for experiencing feelings of loss about the
9 ending of the work together and this could connect with
30 other experiences of unresolved loss in the past. It could be
1 that the client has an accurate sense of his own limitations
2 in this regard. Experiencing the loss of the counsellor and
311 other unresolved losses might actually be too much for
2 96
Ending
111 him, given his immature ego development and the possi-
2 bility that the work will not be continuing. Equally, the
3 client might have developed quite a shrewd intuition over
4 years of dealing with vulnerable caretakers and be able to
5 judge that the present counsellor could not cope with the
6 level of his distress that would be evoked.
7 But isn’t it interesting or ironic that, in attempting to
8 avoid the pain of an ending, our client actually comes back
9 the following week, as if to retrieve unconsciously what he
1011 had been so determined to leave out, his loss and pain.
1 One could understand it both as a repetition compulsion,
2 meeting without warning the new ‘client/sibling’, and as
3 an attempt, albeit an awkward one, to retrieve the space he
4 so adamantly insisted he did not need. The central point
5 here is that ending contains a process essential to the work
6 and raises issues for both the client and the counsellor
7 which might not be revealed until that ending process
8 begins. Thus, it is a paradox of the work that some of the
9 most painful material might come at a time when the end
2011 is in sight, just when the client begins to imagine life with-
1 out the support of the therapeutic encounter. It is no
2 surprise that an ending might be strongly resisted.
3
4
5 The practical aspects of ending
6
7 The final account
8
9 Stopping or ending therapy involves both emotional and
30 practical aspects. An important practical issue is the final
1 account and the question of when to present it. If it is left
2 to the last session to be consistent with a pattern of giving
311 it at the end of the month, it might be forgotten by either
4 97
5
6
111 counsellor or client. Alternatively, it can be given one or

2 several sessions before the end. This introduces a change
3 of pattern, but maybe one that helps to signal in a
4 concrete manner that the overall pattern of sessions is
5 about to change. The timing of the account itself might
6 form a part of the discussion of the ending and might
7 raise feelings about it. These might focus around the fact
8 that this is the final account and how it feels not to be
9 having another in the future, indeed not to be in this rela-
1011 tionship in the future.
1
2 The timing of the ending
3
4 A practical and emotional aspect of ending is its actual
5 timing – when to do it. In some of the shorter-term forms
6 of the work, and especially where a service provider is
7 involved, the end might be prescribed from the begin-
8 ning. There might be a maximum number of sessions
9 provided, and both counsellor and client are restricted by
2011 this external definition of need. In other situations, there
1 might be a shortage of resources and what there is, is
2 divided into small portions. When need is defined in a
3 manner that does not coincide with professional judge-
4 ment it can raise an ethical dilemma. In some cases, the
5 counsellor might feel strongly enough about the client’s
6 need for continued therapy to consider referral elsewhere
7 so that a compromise does not have to be made.
8 In other instances, the timing is prescribed at the
9 beginning, not by an outside body or the institution, but
30 by the client himself. This might be for reasons of finance,
1 practical factors such as moving house or job, or a need
2 to contain the experience for fear of being overwhelmed
311 by it. Of course, there is often a subtle and complex
2 98
Ending
111 interaction between the concrete and emotional reasons

2 for ending. Nevertheless, in these instances, the ending is
3 fixed from the beginning. One enters the encounter with
4 the end already in mind.
5 This is a very different pattern from the open-ended
6 one, whether short-term or long-term. The open-ended
7 situation leaves the when, how, and why of the ending to
8 be decided. In some cases, this could mean that the timing
9 of the ending can be more closely related to therapeutic
1011 need. In others, it means it is different from the fixed
1 ending, but presents other complications. First of all, how
2 does one know when to end when it has not been
3 prescribed? Sometimes, although the client is working in
4 an open-ended context, he has come with a specific goal
5 in mind. ‘I want to sort out what to do about . . .’ When
6 he gets to this point, he has a sense of having reached a
7 decision and he stops. There is a more or less clear time
8 to do so. Sometimes, he stops not because he has reached
9 a decision, but because he discovers in the course of the
2011 work that the original dilemma could not be addressed in
1 such concrete terms. There was not an answer to be
2 found, but a process to go through whose value lay in
3 discovering that there was not an answer as such. There is
4 yet another possibility. The original search, whether or not
5 it leads to a resolution, puts the client in touch with a
6 desire to take the exploration further. It might be that the
7 original more limited search was his means of testing the
8 water and of discovering that it was safe to proceed, but
9 from now on in a less focused manner.
30 Having continued in an open-ended manner, how does
1 one know when to end? Generally speaking, it gradually
2 becomes apparent that change is occurring and this signals
311 a time to end. So, directly or indirectly, it comes into the
4 99
5
6
111 material. Outside interests – people, events, or activities –

2 begin to take greater precedence. We will discuss the
3 defensive use of these outside interests later, but here we
4 are referring to a natural refocusing of energy, no doubt as
5 a result of some of the work that has been done. Other
6 signs of beginning to move towards an ending can be that
7 the counsellor is not needed so frequently to sort out
8 conflicts or feelings. The process is beginning to happen
9 without the counsellor, between sessions. Increasingly, the
1011 client comes to report the problems he has successfully
1 resolved rather than the problems he cannot solve alone.
2 In an ideal situation, where the therapist has choice
3 over the timing of the ending, how much time does she
4 allocate to the process? In our experience, there are two
5 quite different patterns – one in which it feels possible for
6 client and counsellor to designate a suitable time for
7 ending and one in which the answer only emerges as the
8 process of ending proceeds. Which pattern occurs in any
9 particular situation will depend on the individual, the
2011 nature of the work so far, and the kinds of unresolved
1 issues that the ending will inevitably produce. Most
2 psychodynamic work is based on an assumption that the
3 ending contains a process essential to the work and raises
4 issues that might not be revealed until that ending process
5 begins. This is what makes it so difficult to know how
6 much time to allocate to the ending. In facing the ending,
7 the therapeutic couple are on virgin territory. The thera-
8 pist has never ended with this particular patient, so is not
9 sure what to expect. The patient has not yet ended, so he
30 also does not know what to expect. Using a geographical
1 analogy, how does one plan a given amount of time for a
2 journey when it is not known what that journey will entail
311 or where the destination will be?
2 100
Ending
111 Clinical examples

2
A patient with a powerful memory of a traumatic leave-
3
taking early in life wants to set a date far in advance, as if
4
expecting an equally traumatic experience. In fact, because
5
of work over a number of years in relation to the pain of
6
holiday breaks, the trauma does not occur as expected. By
7
the time the end does arrive, she is in touch with a gradu-
8
ally evolving empowerment, a sense that she carries some-
9
thing of lasting value inside her from the therapy.
1011
On the other hand, another patient whose parent left
1
him so early that he could not consciously recognise the
2
‘parting’, cannot imagine there being enough to deal with
3
in more than a few weeks of ending, despite the value he
4
has placed on the therapy. In the event, the patient expe-
5
riences strong feelings of depression and fear of rejection
6
as he becomes aware of the therapist’s reluctant agreement
7
to an overly short ending. The patient had defended
8
against his feelings of being left until the end was under
9
way and he could no longer ‘not know’ about them. It was
2011
as if he had at last been able ‘to see’ the absent parent leav-
1
ing and re-experience at first hand what that earlier depar-
2
ture had meant. He was forced to acknowledge the power
3
of his feelings and adjust the time of the ending to reflect
4
more realistically what he was going through in relation to
5
leaving the therapy.
6
7
8 The meaning of stopping
9 or ending prematurely
30
1 The previous two clinical examples illustrated two quite
2 different ways of finding the ‘right’ kind of space in which
311 to end. Quite often, however, it seems that the client feels
4 101
5
6
111 a need to stop or end in a way that the therapist consid-

2 ers premature. This section is a series of mini-vignettes
3 giving some of the most common situations. Most practi-
4 tioners will be able to put flesh and bones on these exam-
5 ples from their own experience with patients, or maybe
6 from their own therapy. However, before we proceed, it is
7 important to point out that many of the same remarks, if
8 said in a different, non-defensive manner, could convey a
9 different meaning. As is so often the case in therapy, it is
1011 the intent behind the words that is as important as the
1 words themselves.
2
3 ‘We’re not really getting anywhere’
4
5 This, of course, could be an accurate statement of a mutu-
6 ally frustrating stalemate. But think for a moment of one
7 kind of stalemate – a state of paralysing fear. A patient
8 might have proceeded without too much difficulty for the
9 first six months of counselling. After a while, the work hits
2011 a plateau during which little new material is offered and an
1 element of ‘dullness’ permeates the encounter. That kind
2 of statement might be used by the patient as an indication
3 that it is time to end. It is quite easy to collude with the
4 patient’s wish in an attempt to value what she has done so
5 far, or perhaps not to be hurt oneself by the implied criti-
6 cism. Howe ve r, thinking back to Jung’s theory of the
7 opposites and applying it here, the therapist could specu-
8 late that it is not that the patient is getting nowhere, but
9 the very opposite – that she is in fact getting somewhere
30 and it is the expectation of this ‘somewhere’ that is par-
1 alysing. The stalemate in the work might be the patient’s
2 intuitive sense that the work is nearing unfamiliar, poten-
311 tially difficult areas and she is afraid of continuing. So, in
2 102
Ending
111 this instance, stopping or ending is in the interests of

2 maintaining equilibrium. Being alert to the opposites can
3 help to open up such a discussion.
4
5 ‘I have better things to do with my time,
6 money, etc’
7
8 Again, this could be an indication of good reality testing,
9 an indication that it is indeed time to move on. But said
1011 in a certain manner and with a denigrating tone, the ther-
1 apist might be less than convinced. From the patient’s
2 point of view, it could be a justifiable retaliation, though
3 perhaps not conscious. He could feel, ‘You are taking my
4 time and money and using it for your own ends. I have
5 had enough of this; I will take my time and money and
6 use it elsewhere, therefore depriving you of resources
7 just as you attempt to deprive me.’ Or, ‘I am envious of
8 what I see you getting. You don’t appear to value me
9 for my own sake, so I will take my resources elsewhere
2011 or use them for myself.’ How much can be brought
1 into the open will depend on the intensity of the work
2 being done and on how able the patient is to acknowledge
3 such negative feelings. But when the patient is able to
4 use the opportunity to explore such feelings and the coun-
5 sellor/therapist is able to face hearing them, there might
6 no longer be a need to force an ending. In fact, having had
7 the space to consider his reservations about the therapist,
8 he might feel that the therapy is now worth the money he
9 was previously reluctant to spend. Although the therapist
30 and patient might not have recognized it at the time, he
1 might have been saying, ‘Can you help me find a way
2 of making this encounter more valuable?’ The value lay
311 in the encounter that it was possible to have about his
4 103
5
6
111 feelings. The patient was, in fact, correct. He was not

2 getting value for money because he could not use the ther-
3 apy to be open with his feelings!
4
5 ‘This just makes me more depressed. I felt happier
6 before I came than now’
7
8 There are some people for whom psychodynamic coun-
9 selling or therapy is not the appropriate choice. It does
1011 make them more depressed in a way that they cannot
1 seem to use. But here we are considering the person who
2 can make use of the therapeutic setting, but is finding it
3 difficult at this particular time. It is important to recog-
4 nize that the first part of this statement – ‘This just makes
5 me more depressed’ – might be an accurate assessment of
6 the client’s experience. The person who has coped with
7 life by denying his feelings might find endings in particu-
8 lar a challenge. If he has learned to cope in this manner,
9 beginning to explore feelings that have been put aside for
2011 years can indeed make him depressed. To the general
1 public or the person who has recently started therapy it
2 can seem a nonsense coming to therapy and as a conse-
3 quence getting more depressed, but this can be the case.
4 It seems ironic that a complaint made to justify stopping
5 or ending might in fact be an indication that things are
6 happening; that it is worth pursuing the course because
7 feelings are being stirred up inside and the patient who
8 formerly cut off from his depression is now aware of it.
9 But, of course, this is not comfortable. And this might be
30 what the patient is saying in pointing out that he is more
1 depressed. He is pointing to the pain he is experiencing –
2 wanting help with it or wanting the therapist to know
311 how much it hurts and what he is having to endure.
2 104
Ending
111 Although his words sound like a simple desire to stop,

2 they might be a way into the experience of committing
3 himself to therapy. He might be asking the therapist in the
4 only way he can to engage with him over the struggle, not
5 to stop doing so.
6
7 ‘I have a new job/baby/boss/position/house/wife/
8 girlfriend, etc. so I really have no choice about
9 having to stop therapy’
1011
1 We have put these numerous possibilities together
2 because, viewed from the perspective we are taking in this
3 section, they can all be viewed as ways of acting out – not
4 the action in itself, but the accompanying drive to sabo-
5 tage the therapy (often largely unconscious). In such cases,
6 the therapist is often handed the situation after the fact –
7 the job has been sought and accepted, the marriage
8 arranged, the house sale completed. In other situations,
9 where behaviour is more conscious, or at least potentially
2011 more conscious, the intention or plans might be brought
1 to therapy at an earlier stage. The ‘I have no choice’ part
2 of the statement is probably an indication of its uncon-
3 sciousness and its ‘drivenness’. It is also accurate in the
4 sense that the patient is in the grip of such powerful forces
5 within the experience of his therapy that he finds himself
6 in a desperate need to leave.
7 Oedipal conflicts, if experienced too intensely, can lead
8 the patient to seek a premature ending. Oedipal conflicts
9 have to do with triangular relationships, with the feelings
30 that get stirred up in the interaction between three people
1 – three friends in a playground, a husband, wife, and
2 lover, a child and his two parents, a husband, wife, and
311 mother-in-law, for example. This can be an arena in which
4 105
5
6
111 powerful feelings of being included, excluded, being in

2 competition with, having loving and hateful feelings
3 towards others, get played out. The therapist might step
4 into this arena even at the first session. We have spoken
5 earlier about how therapy can fail at the very beginning
6 because the patient finds that loyalty to his partner or
7 parent will not allow him to include the therapist as a
8 significant other in his life. Because at some stage he was
9 not able to move from relating to one other important
1011 person to being able to relate to more than one person at
1 a time, he might get into difficulty in making a commit-
2 ment to therapy. He might be literally faced with a choice
3 between his wife and his therapist. Finding himself in an
4 untenable situation with both wife and therapist, he must
5 extract himself from one. He feels he has a choice to have
6 one, but not to have both.
7 In this situation the therapist will at times have to allow
8 the therapy to finish prematurely. At other times, the
9 patient will have the capacity to consider the conflicting
2011 loyalties that he is experiencing. Knowing that the thera-
1 pist understands his dilemma, and experiencing over time
2 that she does not pressure him to go further into his feel-
3 ings than he can manage, might allow him to continue
4 until he is more able to cope with the inevitable conflict.
5 Occasionally, a patient feels under so much pressure that
6 understanding on the part of the therapist is not suffi-
7 cient. He might, for instance, need to cut down his
8 session time as the only way short of stopping completely
9 to allay his overbearing guilt about disloyalty to his part-
30 ner. In time, as he works less intensely, he might be able
1 to use the additional session again. A similar pattern can
2 happen in relation, not to another person, but to a place
311 or a position such as a new home, job, or outside interest.
2 106
Ending
111 The place of the third person in the triangle is taken by

2 this loyalty and he is again in conflict, needing to pursue
3 one or the other, but not both.
4
5 ‘I no longer have symptoms so I no longer need to
6 come here’
7 One of Jung’s innovations was to look at symptoms in a
8 new way. He saw them not as something to be eliminated,
9 but as a means of drawing attention to a hitherto unno-
1011 ticed aspect of the patient’s personality – as if he were
1 saying to himself and others, ‘This is where I am hurting.’
2 Jung developed his form of treatment partly in response
3 to the bizarre behaviour of psychotic patients. He took
4 exception to the label ‘irrational’ and, as he so often did,
5 turned it on its head, wondering what the symptom might
6 be communicating that was actually quite ‘rational’. In
7 other words, symptoms were seen as a form of symbolic
8 language that needed to be deciphered according to an
9 inner system of logic. Although we are not discussing
2011 work with patients in psychotic states, Jung’s approach has
1 been used by modern-day Jungians in the consulting
2 room to consider what the symptom means. It is not
3 considered an irrational language, rather an unknown or
4 forgotten one. Part of its purpose is to draw our attention
5 to something that we might otherwise ignore.
6 Viewed from this angle, the symptom that disappears
7 soon after therapy commences has already served an impor-
8 tant function. It has mobilized the patient, and maybe
9 those around him, to take action. It has alerted the thera-
30 pist. We can assume that some relief is being experienced.
1 The patient is in a place of safety and concern and might
2 not need this particular means of communication any
311 longer because he has heard and we are alerted. But a
4 107
5
6
111 symptom disappearing is not the same as being in good

2 health or no longer needing help. It is almost as if the symp-
3 tom has done its part of the job in getting the therapy estab-
4 lished and now expects the interaction between patient
5 and therapist to take over. On many occasions this is exactly
6 what happens. Having been alerted to a problem, the
7 patient is able to use the therapeutic experience to begin to
8 look at his own previously neglected conflicts and feelings.
9 In other instances, it is much less straightforward. The
1011 patient has gained some relief, maybe even in the first
1 session. But his thinking is concrete. If the wound can no
2 longer be seen, why go to the doctor for further bandages?
3 He finds it hard to believe that there might be more,
4 longer term, wounding inside that cannot be seen so
5 easily. Sometimes, he will resist any suggestion along these
6 lines and will have to stop prematurely until perhaps
7 another symptom brings him back to the therapist or
8 someone else. Over time, a series of mishaps might be the
9 only thing to convince him of his underlying need. Very
2011 often, people come to therapy at a time when they begin
1 to see a pattern of happenings in their lives, when they can
2 no longer explain them away as separate, random events.
3
4 ‘I think this is really a physical problem that needs
5 medical attention’
6 Sometimes this statement is made explicitly. At other times
7 the patient simply gets ill, sometimes to such an extent
8 that he can no longer come to therapy. Remember that we
9 are looking in this section at ways of ending prematurely.
30 Illness can be used in this manner, but not all illness
1 is therefore defensive. Again we are talking about the
2 meaning and intent behind the illness, not the illness per
311 se. It is important that physical problems are investigated
2 108
Ending
111 medically in their own right, particularly as we have

2 become aware of the complexity of the interaction
3 between mind and body. It seems probable that feelings
4 can cause illness through their interaction with hormones.
5 On the other hand, there is little doubt that physical prob-
6 lems cause stress and that the two also interact in ways we
7 do not yet understand.
8
9 Clinical example
1011 A patient comes to therapy with every intention of using
1 the sessions to explore his unhappiness. But somehow the
2 words and understanding of the counsellor do not reach
3 him. He is looking for the ‘hands on’, practical kind of
4 comfort that a medical practitioner might be able to offer.
5 When he has a physical problem in the course of therapy
6 he yearns for this kind of direct care and feels that in
7 choosing to come to therapy he has made a mistake. He
8 suggests stopping therapy and consulting a medical
9 specialist. It is not surprising that his father was a doctor
2011 and that only through physical care at times of illness
1 could he communicate his love and affection for his son.
2 Physical symptoms are concrete and for many patients
3 less frightening than emotional ones. They do not carry
4 the same overtone of blame, shame, connection to mental
5 illness or, at worst, madness. Often they can be put right
6 more immediately, with the secondary gain of physical
7 care and comfort, and there might be a greater expecta-
8 tion that the pain will not go on forever.
9
30 Protecting the therapist
1
2 In the above paragraphs we have suggested a number of
311 ways in which the therapy might come to an impasse.
4 109
5
6
111 There is another factor that might operate, one that is

2 often concealed behind more obvious reasons, both from
3 the therapist and, sometimes, from the patient himself.
4 The therapy might get stuck. The therapist might come
5 under strong pressure to stop because there are powerful
6 unresolved feelings towards the therapist that threaten to
7 break through into consciousness and from which there is
8 an equally strong need to protect both therapist and
9 patient. It might be that other negative feelings can and
1011 have been expressed in the course of the work, but ack-
1 nowledging dissatisfaction with someone who is appar-
2 ently trying to help might be one step too far. This can be
3 the case when it is not a specific thing that has been upset-
4 ting, but a more general feeling of not getting on, of the
5 therapist not being right. It can also be the case when
6 strong erotic or aggressive feelings so disturb the patient
7 that he would rather end the therapy than reveal them. It
8 is as if there is a terrible secret that cannot be told.
9
Clinical example
2011
1 There are times when a particular match of patient and
2 therapist does not seem to work. In some instances a
3 patient might move on to work more successfully with
4 another person. On the other hand, a patient might have
5 grown up feeling that he was in the wrong family, but
6 unable to put it right or to say anything for fear of hurting
7 his parents. This is an example of someone who produced
8 all sorts of practical reasons why it was reasonable to stop
9 therapy, and as soon as possible, before the power of his
30 negative feelings became too great to hold back. One day
1 the therapist said, ‘Something just isn’t right.’ The patient
2 – a usually controlled young man – burst into tears. With
311 relief, he could finally admit that things weren’t right. He
2 110
Ending
111 didn’t feel they got on because he had so many secret

2 dissatisfactions with the therapist. This ‘letting go’ of feel-
3 ings and of the shame that surrounded them enabled the
4 therapy to become unstuck and eventually to continue.
5
6 ‘Do you want me to stay?’
7 Any of the above examples of premature ending could be
8 used by the patient as a means of discovering whether the
9 therapist wants him enough to struggle to keep him. Does
1011 the therapist care enough in a personal way to go to some
1 effort to hold on to him? After all, the prospect of leaving
2 brings up the immediate relationship between patient and
3 therapist, and if it is felt to be premature it can challenge
4 the therapist’s judgement in a very personal manner.
5 Despite the therapist maintaining a neutral stance, a
6 patient might become aware that his leaving in such a
7 manner does matter to the therapist and therefore he
8 matters. This reassurance might enable him to continue.
9
The effect on the therapist
2011
1 The attempt to stop or end prematurely can be experi-
2 enced by the therapist as, and often is, an attack on the
3 therapeutic work. It might be an unconscious attack and
4 therefore one that the patient has little control over. But
5 whatever the particular dynamics, it is likely to have an
6 effect on the therapist. In some of our examples, the
7 encounter led to a breakthrough and the recognition of
8 difficult and previously unexpressed feelings that in turn
9 allowed the therapy to progress. In other cases, the ther-
30 apy had to end, at least for the time being, despite the
1 ending being in the therapist’s judgement premature.
2 However, the patient is only one part of the equation.
311 The therapist is the other, and the process of dealing with
4 111
5
6
111 the intention to stop prematurely and of having to face a

2 premature end can take its toll. For one reason or another,
3 the patient does not want to continue. We can understand
4 this in many of the ways outlined above, but it can also be
5 experienced as a personal attack (which on some occasions
6 it is!). There is something about this particular kind of
7 attempt by the patient that invariably seems to ‘fit’ with
8 the therapist’s uncertainties about her own work. The
9 combination can make it virtually impossible to know
1011 whether or not one is at this moment competent and can
1 raise anxieties that the patient, in his desire to leave, is prob-
2 ably right to do so. The therapist begins to feel that she is
3 indeed the bad therapist, not unlike the patient’s bad
4 mother. Just at a time that she needs her stability, she may
5 become anxious and unsure. This is a time when super-
6 vision is crucial. The patient can so undermine the thera-
7 pist she does ‘become’ the bad mother and does not know
8 how to cope. Outside reflection can restore her equilibrium
9 (good maternal instincts) and save the therapy. Also the
2011 knowledge that what the patient is doing to the therapist is
1 probably what was done to him in the past – feeling thor-
2 oughly bad because of being rejected – can help.
3
4
5 The task or purpose of an ending
6
7 We have taken a long time to get to one of the central
8 issues of ending. Let us assume that an ending happens,
9 not prematurely, but in a ‘good-enough’ fashion. What is
30 the task or purpose of this phase of the work? It is a truism
1 to say that each ending will be unique, and we do not
2 have space to go into the many individual variations.
311 However, there are certain ingredients common to an
2 112
Ending
111 ending. In the most general terms, it is a time to remem-

2 ber the past, to reflect on the time spent together, and to
3 anticipate the future. More precisely, it will involve some
4 or all of the following processes.
5
6 Looking at change
7 The approaching end is likely to throw into relief what
8 has happened since the beginning of the work. This will,
9 in turn, highlight what change or development has taken
1011 place. Naturally, there will be a difference between the end
1 of a short-term counselling or psychotherapy contract and
2 several years of more intensive psychotherapy. Neverthe-
3 less, even a few sessions, or indeed a single session, can
4 have an ending phase and the possibility of change within
5 that time. The young mother we spoke of earlier, uncer-
6 tain about whether or not to keep her baby, might have
7 come to an important, though painful decision within a
8 few sessions. To do this, she will have had to face what she
9 could not face when she first approached the counsellor –
2011 the feelings of rejection towards the baby that she was
1 keeping hidden from herself because of the strong reac-
2 tion of her mother. Despite the short-term nature of this
3 piece of work, the counsellor gave her space – unlike her
4 mother – to acknowledge her other feelings and so to
5 come to a decision.
6 Sometimes, change is obvious to both client and coun-
7 sellor. At other times, it will be apparent only to the prac-
8 titioner. For some of the people who seek help, change of
9 any kind might be an unfamiliar state or, if it does occur,
30 it might be rarely talked about. In such cases, the coun-
1 sellor will need to take the lead and point out what might
2 be obvious to her, but have been largely unnoticed by the
311 client himself.
4 113
5
6
111 Making a space for gratitude and thanks

2 It will depend on the patient’s openness and on the nature
3 of the relationship with the counsellor whether and to
4 what extent the changes that have occurred can be
5 acknowledged and whether there can be mutual pleasure
6 in what has happened in the work together. When it is
7 possible for such feelings to be openly recognized, then it
8 might be possible for the client to know about and express
9 gratitude or thanks for the time together and for the
1011 change that has occurred. Some people will have the
1 words to express this; for others, finding such words might
2 be a new and important aspect of the work during this
3 ending phase. Many people come to therapeutic work
4 with little or no experience of having been thanked or
5 recognized themselves, or of expressing such appreciation
6 to someone else. Silence might not mean they do not feel
7 appreciative but simply that they have not heard such
8 words used about themselves or know how to use them
9 about others. Helping such a person find, use, and expe-
2011 rience the words might be an invaluable part of the
1 ending experience. Other people will express such feelings
2 concretely through gifts, tears, or perhaps a cautious
3 smile. When unexpected, the counsellor can feel caught
4 off guard. Some thinking or reflection about the process
5 beforehand might help to contain a sense of embarrass-
6 ment or awkwardness. There are times such as these when
7 it is helpful to the client for the counsellor to be able to
8 respond on an ordinary social level.
9
30 Acknowledging what has happened
1
2 In contrast to what might have changed in the work, there
311 will also be expectations that have not been met, the
2 114
Ending
111 inevitable disappointments. It is, of course, just as impor-

2 tant to have space to express such feelings as it is for those
3 of appreciation. Again, this will depend on the relationship
4 between therapist and client and on the client’s capacity
5 for self-reflection. It will also depend on the therapist’s
6 own openness and the extent to which she can tolerate
7 hearing what might be said. Having space to acknowledge
8 what has not happened can, paradoxically, allow it to start
9 happening. Facing this kind of disappointment or anger
1011 with a significant person might be a part of what did not
1 happen in the past and until now has not happened
2 between therapist and client.
3 Acknowledging what has not happened is important
4 for other reasons. It can set the stage for the future–for
5 what the client might want to return to later on, what he
6 might be able to continue with on his own, or sometimes
7 what he decides at the eleventh hour to continue with in
8 his present therapy. Of course, it is possible that what was
9 not done could not have been done given the situation the
2011 client was in or the limitations on time (which he might
1 have curtailed so it could not happen). However, it is still
2 important to recognize the expectations that were not met.
3 It might even be possible to acknowledge, with the
4 wisdom of hindsight, what part the client himself played
5 in the way the work evolved.
6
7 Feelings about ending
8
9 An important aspect of the ending is having time and
30 space to have feelings about the relationship finishing.
1 The relationship has occurred within the boundaries of a
2 professional contract, but for both parties involved it will
311 usually have had a personal element. Inevitably there will
4 115
5
6
111 be feelings about the relationship ending, and this can be

2 the case even when the contact has been difficult, little has
3 happened, or when the desire to end has been a preoccu-
4 pation from the very beginning.
5 Acknowledging loss is like any other kind of mourning
6 in that it is one way of helping to deal with, and eventu-
7 ally to mitigate, the pain. When it is left undone or
8 cannot be done, it can be difficult for both client and
9 therapist. For the client, it can mean being left with unex-
1011 pressed feelings that can affect his future equilibrium in a
1 variety of ways. In some cases, it can be the unconscious
2 motivation behind the client’s attempts to remain in
3 touch afterwards, by phoning, writing letters, calling in
4 on the therapist, attempting to meet in public, or other-
5 wise intruding on her privacy.
6 Likewise, there are dangers for the counsellor of not
7 acknowledging to himself or perhaps a supervisor what the
8 ending has meant. When there is no space for this kind of
9 reflection, the counsellor, like the patient, can ‘act it out’
2011 unconsciously. This can take the form of ‘living off one’s
1 work’ or of using a new patient to fill the emotional space
2 left by another, thereby not allowing the new patient to
3 have his own space. Although the relationship between
4 counsellor and patient is not reciprocal, it will have a
5 meaning for both. It is important for each to have a space
6 to recognize that meaning so as to prevent its enactment.
7
8
9 After the ending
30
1 In the foregoing discussion we have been focusing on
2 what it is possible to explore with the client during the
311 ending phase of the work. Because the end is the end, and
2 116
Ending
111 in addition might reveal previously unrecognized feelings

2 (which could take both client and counsellor by surprise),
3 there will inevitably be reactions after the ending when
4 the work of reflection continues alone or with a super-
5 visor. In the ideal situation, enough has gone on in the
6 work together for the client to internalize helpful aspects
7 of his counsellor or psychotherapist which then becomes
8 the basis for an independent existence afterwards. Apart
9 from the practical changes that might have occurred, it is
1011 to be hoped that there will have been a change in self-
1 awareness or in how the client thinks about himself.
2
3
4 Summary and conclusion
5
6 How does one end – or draw a boundary around – our
7 discussion on boundaries? The common theme in all of
8 the chapters has been the central and, indeed, defining role
9 of boundaries and containment in psychodynamic work,
2011 whether in short- or long-term counselling or in any of the
1 various forms of psychotherapy. Looking at the function of
2 boundaries and containment in the larger world outside
3 therapeutic work, it is not an exaggeration to say that what
4 is inside the containing perimeter is, to some extent,
5 defined by the nature of the outside boundary.
6 When we look at a landscape, our eyes are drawn to the
7 defining edges of the fields – the hedgerows, the stone
8 walls, the farm gates, the stiles and fences that form the
9 boundaries. Although they are not the only aspect of the
30 landscape or of what happens within their perimeter, they
1 do have a powerful influence on what happens inside. For
2 instance, as some of the traditional boundaries of the
311 landscape, the hedgerows, have been eliminated to allow
4 117
5
6
111 the farmer greater scope and ease in planting his crops, the
2 quality of the space within has changed for the wildlife
3 that depends on the hedgerow edges of fields to survive.
4 Likewise, stone walls that have been allowed to deteriorate
5 determine the nature of the livestock that can be kept
6 inside. Whether you identify with the wildlife or with the
7 farmer, boundaries and the effect of what happens at and
8 within them are vital.
9 Another theme that has been implicit in the book is
1011 that interaction very often happens at boundaries. This
1 is true in the psychotherapeutic world as well as in the
2 world beyond. Consider neighbours chatting or, indeed,
3 fighting over the garden fence. Consider wars, both
4 national and civil, over defining, indeed defending, inside
5 space from outside space. Here, the exact placement of a
6 boundary becomes something for which some would
7 literally kill or be killed. Consider celebrations and anni-
8 versaries at the beginning or end of a new space. It is at
9 this boundary between the old and the new that we stop
2011 to acknowledge the importance of what has happened
1 within the perimeter of the old space, perhaps the first
2 twenty-five years of a marriage, or to consider what will
3 happen at the beginning of the new space, perhaps, for the
4 student, the beginning of university, or, for a country, the
5 installation of a new leader.
6 Indeed, it is often at such times that people decide to
7 come into therapy in the first place. It is in the nature of
8 boundaries that they have a defining function. Therefore,
9 they can bring into focus issues that until then have
30 remained hidden. For example, a hard working executive
1 maintains an impossibly demanding work schedule until
2 he has a heart attack. How often do we hear later that this
311 was the defining moment of his life—the point at which
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111 he could no longer ignore the pleas of doctor, family, and

2 friends, maybe even himself. In a dramatic manner, the
3 heart attack draws an immediate boundary around his
4 work. It says, ‘You are stopping now. This is the limit.’ As
5 we review the preceding period of time, the time before
6 the attack, the first twenty-five years of a marriage, or
7 years of work at the time of retirement, patterns are
8 thrown into relief. It is not surprising that these times are
9 often called ‘turning points’, times at which decisions are
1011 made to alter direction or to face what could not be seen
1 while in the middle of the experience. Thus, boundaries
2 have the capacity to make us question fundamental
3 aspects of our lives.
4 It is not accidental that this sort of ‘stock-taking’ so
5 often happens at boundaries. When we mourn and cele-
6 brate the end of a life at the funeral, we are in large part
7 considering the meaning of that life to us. We are stop-
8 ping at a boundary and taking time to acknowledge what
9 has been before. In a much more trivial way, when we stop
2011 to climb over a stile or negotiate a farm fence, we pause
1 and might notice the landscape that we have just walked
2 over or that we are about to tackle. So, boundaries and the
3 containment defined by them provide a setting in which
4 to see patterns, to evaluate, to consider, to change direc-
5 tion, and, most importantly, to confer meaning. It is all of
6 this that we are doing in and through our therapeutic
7 work.
8 Perhaps the ultimate question we might ask about the
9 use of boundaries and containment in our work is this: to
30 what extent does the person in therapy or counselling feel
1 safely contained? Is it sufficient to facilitate the things that
2 might be involved in that encounter – the exploring, the
311 expression of thought and feeling, and the self-reflection?
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5
6
111 For, in the end, we are attempting to provide a space in

2 which the person can begin to establish the trust necessary
3 for the work to happen.
4
5
6
7
8
9
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2
3
4
5
6
7
8
9
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2
3
4
5
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References
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3
4
5
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9
von N. S.E., 2: 48–105. London: Hogarth.
30 Gabbard, G. O., & Lester, E. P. (1995). Boundaries and
1 Boundary Violations in Psychoanalysis. New York: Basic
2 Books.
311 Human Rights Act (1998). London: HMSO.
4 121
5
6
References
111 Jung, C. G. (1931a). Problems of modern psychotherapy. In:

2 The Practice of Psychotherapy, C.W., 16: para. 114–174.
London: Routledge & Kegan Paul.
3
Jung, C. G. (1931b). Marriage as a psychological relationship.
4 In: The Development of Personality, C.W., 17: para.
5 324–345. London: Routledge & Kegan Paul.
6 Jung, C. G. (1935). Principles of practical psychotherapy. In:
7 The Practice of Psychotherapy, C.W., 16: para, 1–27.
8 London: Routledge & Kegan Paul.
Jung, C. G. (1946). Specific problems of psychotherapy III:
9 The psychology of the transference. In: The Practice of
1011 Psychotherapy, C.W., 16: para. 353–401. London: Rout-
1 ledge & Kegan Paul.
2 Jung, C. G. (1952). Synchronicity: an acausal connecting prin-
3 ciple. In: The Structures and Dynamics of the Psyche, C.W.,
8: para. 816–968. London: Routledge & Kegan Paul.
4 Jung, C. G. (1953). The spirit mercurius. In: Alchemical
5 Studies, C.W., 13: para. 239–303. London: Routledge &
6 Kegan Paul.
7 Jung, C. G. (1958). The transcendent function. In: The
8 Structures and Dynamics of the Psyche, C.W., 8: para.
131–193. London: Routledge & Kegan Paul.
9
Karpf, A. (1999). My weeping skin: crying without tears. In:
2011 Journal of the British Association of Psychotherapists, 36:
1 3–14.
2 Klein, M. (1946). Notes on some schizoid mechanisms. In:
3 Envy and Gratitude, and Other Works, 1946–1963.
4 London: Hogarth.
Layton, A. (2003). Setting the scene III: The perspective of a
5 sympathetic outsider. British Journal of Psychotherapy, 20:
6 149–156.
7 Lucas, R. (2002). Report on Conference. APP Newsletter, 27.
8 Mennella, J. (2005). Monell Institute of Philadelphia As
9 reported in the Independent Newspaper, John Von
Radowitz, 28 November 2005.
30 Menzies Lyth, I. (1988). Containing Anxiety in Institutions:
1 Selected Essays, Vol. 1. London: Free Association.
2 Sandler, A.-M. (2004). Institutional responses to boundary
311 violations. International Journal of Psychoanalysis, 85:27–43.
2 122
References
111 Winnicott, D. W. (1985). The capacity for concern In: The

2 Maturational Processes and the Facilitating Environment.
3 London: Hogarth.
4
5
6
7
8
9
1011
1
2
3
4
5
6
7
8
9
2011
1
2
3
4
5
6
7
8
9
30
1
2
311
4 123
5
6
111
2
3
4
5
6
7
8
9
1011
1
2
3
4
5
6
7
8
9
2011
1
2
3
4
5
6
7
8
9
30
1
2
311
2 124
Why Boundaries?
111 INDEX
2
3
4
5
6
7
8
9
1011
1
2
3
4 abuse, 42, 51 boundaries, xiii–xv, xvii,
5 child, 7, 75–76 1–7, 9–11, 13–16,
6 sexual, 50–51, 59–60, 67, 19–21, 23–24, 26–27,
7 76 31, 36, 43, 45–46,
8 substance, 61, 71, 75 49–50, 52–53, 55,
9 Access to Health Records Act, 59–71, 73, 83–86, 115,
2011 84, 121 117–119
adolescent, 24–25, 62 British Confederation of
1
ambivalence, 9, 23, 27 Psychotherapists
2 anxiety, 18, 23, 34, 36, 38, (BCP), 74, 85, 121
3 41, 69–70, 90–91 British Psychoanalytic
4 Anzieu, D., 53, 121 Council (BPC), 74, 85
5 assessment, 5, 27–28, 31, Britton, R., 51–52, 121
6 104
7 child, 7, 13–14, 16, 21–22,
8 baby, 4, 8–10, 13–16, 26, 50–51, 53, 55, 105
18–19, 113 see also: see also: baby, infant,
9
child, infant, mother–child
30 mother–child relationship
1 relationship -hood, xiv, 6, 17, 44, 50,
2 Bion, W. R., 2, 33, 53, 121 60–61, 68, 77
311 Bollas, C., 73, 121 Children Act, 76, 121
4 125
5
6
Index
111 Code(s) of Ethics, xv, 45, 26–28, 36, 67–69, 71,

2 57, 83–87, 89 89–90, 93, 96–98, 100,
3 code(s) of 103, 109, 113–114,
practice/guidelines, xiii, 116–117
4
29, 32, 55, 83, 86–87 countertransference, xv,
5 Community Mental Health 2–3, 55–56, 85 see also:
6 Team, 77 transference
7 community psychiatric
8 nurse (CPN), 59–60, Data Protection Act, 84, 121
9 71 dependence, xiv, 1, 40, 55
1011 confidentiality, xiv–xv, 6–7, depression, x, 19, 70, 101,
9, 12, 23, 61, 66, 71, 104
1
73–77, 81, 83, 85
2 Employment Tribunal,
conscious(ness), 4–6, 9,
3 18–19, 25, 28, 30, 78–81
4 34–35, 42, 52–53, 56, ending
5 93–94, 101, 105, 110 session, 5–6, 16, 33
6 see also: therapy, xv, 29, 78,
93–101, 103–105, 108,
7 unconscious(ness)
111–117
8 container/containment,
ethics, 56, 86 see also:
9 xiii–xiv, 1, 3–5, 7–17,
Code(s) of Ethics
19–21, 23–24, 27, 34,
2011
41, 43, 45–46, 50, Fordham, M., 4, 15, 54–55,
1 53–54, 57, 60, 62,
2 121
64–65, 70–71, 73–74, Freud, S., xiii, 1–2, 34, 51,
3 83–84, 86, 91, 94, 55, 121
4 97–98, 100, 114, 117,
5 119 Gabbard, G. O., 85–86,
6 counselling, ix, xiii, xvi, 1, 6, 121
7 10, 15–16, 23, 25, 28, General Medical Council
31–32, 38, 43, 46, 54, (GMC), 76
8
61, 66, 71, 73, 87–91, general practice/
9 102, 104, 113, 117, practitioners (GPs), xiii,
30 119 long-term, 5, 26, 32, 60, 66–68, 71,
1 117 74–75, 78–79, 87
2 counsellor(s), xv–xvii, 6–10,
311 16–18, 20, 23–24, Human Rights Act, 84, 121
2 126
Index
111 independence, 21–22, 55, National Health Service

2 77, 117 (NHS), xiii, 38, 59
3 infant, 2, 4, 11, 13–14, 39, notes, 33, 46–47, 74,
52–55 see also: baby, 78–81, 84
4
child, mother–child
5 relationship object, 23, 42, 52, 54
6 institution(s), xvii, 29–31, Oedipus/oedipal, 19,
7 41, 69–71, 75, 83, 22–23, 41, 51, 53
8 98 conflict(s), 22, 105
9 pre-, 18–19
1011 Jung, C. G., ix–x, xiii, 2–4, triangle, 23, 51–52 see also
1 7–8, 11, 13, 36–37, 44, relationship(s),
49, 52–54, 56, 84–85, triangular
2
107, 122 open-ended/short term
3 work, 17, 28, 99, 113
4 Karpf, A., 15, 122 other, 18–19, 23, 54, 106
5 Klein, M., 2, 19, 122
6 Parochial Church Council,
7 Layton, A., 74, 122 63–64, 71
8 Lester, E. P., 85–86, 121 phantasy, 19, 35, 40–41, 51
9 Lucas, R., 74, 122 projection, 2, 42, 53–57,
62, 67, 81
2011
Mennella, J., 14, 122 projective identification, 2
1 mental health psyche, 5, 7, 37, 51, 56, 85,
2 professional(s), xv–xvi, 90, 94
3 28, 31, 87 psychiatrist(s), xiii, xv,
4 mental health/illness, 74–76, 79–80, 84
5 xvi–xvii, 41, 77–79, 84, psychoanalysis, x, 5–6, 55,
6 109 73–74
7 Menzies Lyth, I., 69, 122 psychodynamic, ix–xi, xiii,
money, xiv, 27, 38–41, 1, 7–8, 28, 34, 45, 50,
8
103–104 100, 104, 117
9 mother–child relationship, psychology/psychological,
30 2, 4, 13–20, 26, 35, 40, 1–2, 6, 56, 70
1 53–55, 68, 95–96, psychotherapist(s), x,
2 112–113 see also: baby, xiv–xvii, 27–28, 36, 56,
311 child, infant 66, 76, 89, 117
4 127
5
6
Index
111 psychotherapy, ix, xi, xiii, telephone, 29, 45–46

2 xv–xvii, 1, 3, 5–6, 15, therapeutic
3 26, 28, 31–32, 37, 54, encounter, xiv, 3, 5,
59, 66, 71, 73, 85, 10–11, 20–21, 27, 50,
4
87–91, 96, 113, 97
5 117–118 experience, xiii, 15, 83,
6 long term work, 5, 30, 87, 108
7 99, 117 process, 3–4, 11, 29, 44,
8 psychoanalytic, xv, xvii, 84
9 74 relationship, 38, 43, 46,
1011 referral, xiii, xv, 27–30, 36,
60, 81, 84
1 69, 87, 94, 96, 98 space, xiv, 3, 41
2 relationship(s), x, xiv–xv, 1, work, xiv, xvi–xvii, 5, 15,
3 22–23, 27, 38, 43–44, 31, 38, 49, 54, 73,
4 46, 49, 51–52, 54–55, 87–88, 90, 111, 114,
59–60, 71, 77, 81, 84, 117, 119
5
93, 98, 111, 114–116 Transcendent Function,
6 52–53
see also: therapeutic
7 sexual, 51, 85 transference, xiii, xv, 1, 16,
8 triangular, 18–19, 22, 55–56 see also:
9 105, see also: Oedipus/ countertransference
2011 oedipal triangle
1 unconscious(ness), xv, 1–2,
Sandler, A.-M., 86, 122
2 4, 6, 8, 10, 13, 28, 30,
separation, 16, 18–19, 21,
3 34–35, 38, 44–46,
24, 56–57
4 52–54, 56, 62, 68, 81,
sibling(s), 16, 35, 93, 96–97
5 85, 93–94, 97, 103,
Social Services, 76
105, 111, 116 see also:
6 stopping, 93–94, 97, 101,
conscious(ness)
7 103–104, 106, 109,
119 United Kingdom Council
8 for Psychotherapy
subject/subjective, 37, 140
9 (UKCP), 85
supervision, 11, 26, 30, 43,
30 47, 50, 59–60, 62, 65,
1 71, 80–81, 83, 86–87, violence, 11, 42, 68, 73
2 90, 112
311 synchronicity, 36–37 Winnicott, D. W., 53, 123
2 128

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BROWN_Prelimsfinal.

qxd 10/31/07 4:04 PM Page i

111 The Society of Analytical Psychology Monograph Series

111 CHAPTER SEVEN

111 About the Authors

111 Preface to the Series

Preface to the Series

111 recognizable, their permission to publish has been given.

Preface to the Series

111 evolves a unique way of understanding their joint experi-

111 science, the conditions in which any experiment is con-

111 The use of clinical material by the authors immediately

111 would have had a less ambiguous meaning. The past

111 CHAPTER ONE