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Writer's pictureProf Christopher Paul Szabo

THE VALUE OF: Boundaries




What are boundaries?

Boundaries are essentially the “rules of engagement” and they set the scene for the therapeutic process to unfold by providing a structure. From the beginning of my relationship with a patient, boundaries influence our expectations of each other. Boundaries are important because they are a framework for us to engage providing for certain expectations which create a measure of predictability. Predictability is essential for trust to grow between my patients and I. This sets the tone for treatment.


Boundaries exist along a spectrum of flexible to rigid. Although at times implicit and other times explicit, boundaries relate to a range of situations such as dress, punctuality, duration of consultation, physical setting/location of consultation, physical/intimate contact/relationships, confidentiality, use of language and so on.


Boundaries provide predictability and certainty

Predictability is a concept worthy of repetition. It is predictability that provides certainty, as much as there can ever be certainty. I want my patients to know what they can expect from me. I want them to be reassured that I will provide them with what they expect, and hopefully what they need. In return, although not specifically a boundary issue - I need certainty from them too - that they will be completely honest and frank in their sharing with me. This helps me to help them to the best of my ability.


Confidentiality

Confidentiality is a non-negotiable boundary, and ensuring my patients understand what confidentiality entails is critical to providing the best care I can. What is said to me, what is shared in my consulting room stays there without exception save for specific, extreme, circumstances e.g., an active threat of suicide or homicide. My patients must know with certainty that their stories are safe with me. Patients are vulnerable and they share the most intimate details of their existence with me. It is absolutely vital that my patients feel comfortable and safe to share everything. Confidentiality is a boundary that is essential for this sharing to happen. My patients must know that I will keep their stories safe, because it is only when I know everything that I can treat and care for them appropriately.


Trust is the key ingredient

In all of my doctor-patient relationships, I have witnessed how boundaries that contribute to predictability and certainty, as well as the boundary of confidentiality, lead to trust. For trust to grow, and strengthen, consistency is important. Over time my patient and I get to know each other. My patients must trust me to listen to them, to really hear what they are saying – and to be honest. But trust is not a one way street. I need to be able to trust that my patients will work towards implementing what we agree on, and if they run into a problem or are scared that they care share this with me and that I will help them the best I can to move forward.


Every relationship has boundaries

As a psychiatrist I see how the boundaries that exist in my doctor-patient relationships extend into the personal life of patients. The example set between us can help patients see how important boundaries are in all their relationships. What happens in my consultation room can inform patients how to develop boundaries outside of it. It’s as if my consulting room can become a microcosm for the outside world. From the consulting room to everyday life. The old adage applies: good fences make good neighbours.


The value of boundaries is undeniable in the doctor-patient relationship. I hope that whether you are a doctor or a patient you see that whilst boundaries are limits they are not limiting. Whilst boundaries are generally understood within the context of professionalism on the part of the doctor, patients have their role to play too.



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