Setting boundaries in a treatment setting is no different than the boundaries we set in relationships; after all, the patient and therapist are in a relationship.
Consider your current relationships either with a partner or close friend. Imagine, or perhaps remember, when that person did something to repeatedly break the rules of what you agreed upon. Affairs are typical examples in partnerships as grounds for breaking up; mean-spirited competitiveness, devaluation, and the sharing of secrets are why friends choose to end friendships. We typically feel hurt, angry, and sad when faced with these realities. Many take the 'higher' ground when someone trespasses and breaks the mutually understood verbal contract that goes into most relationships. Others fight back similarly and share their emotional pain with the person who transgressed and with others.
When patients repeatedly break the therapeutic relationship's boundaries, consequences also occur. Patients with complex trauma, severe personality issues, and eating disorders often struggle with boundaries, usually because a primary caregiver severely breached or intruded on them during childhood (Scheel). Often, these patients seek retaliation and choose the therapist as the target of their childhood rage. In doing so, they can preserve the relationship with the person who grossly harmed, used, or exploited them in childhood.
Therapists delve into powerful emotions, states, and harmful behaviors of people with histories of repeated childhood trauma.
Here's a hypothetical example, familiar to many trauma therapists, that illustrates the history of severe childhood trauma in the case of a patient with an eating disorder and her behavior as an adult:
Alice is a middle-aged woman with a history of Bulimia, cutting, and suicidal behavior. Her symptoms were likely causal factors in her twins' stillborn deaths when Alice was 20. She had no other children. Alice developed gestational diabetes and neglected to care for it during her pregnancy. She binged on sugar and carbohydrates, which followed a night of laxatives or fasting to compensate for the calorie intake.
Alice had severe marital difficulties and a childhood marred by a smothering and dependent mother; her father regularly watched porn while Alice was in the room. She had physical and emotional outbursts toward her husband regularly. She was abusive and exploitative, reflecting repetitions of how her parents treated her as a child. Alice accepted little responsibility for her husband's retreat from her; he did not want to meet her abuse with abuse. He chose to withdraw, as this was the safer option. Alice refused medication, and when she consulted with a psychiatrist, she lied about the severity of her behavior toward her husband and the seriousness of her Bulimia.
Alice routinely broke all boundaries necessary for outpatient care. Her defenses mainly were projection, rationalization, and denial—consistent with a diagnosis of borderline personality disorder and with childhood trauma. Additionally, her comfort with lying and manipulation was consistent with sociopathy. Her therapist recommended that Alice seek an intensive outpatient program and speak candidly to a psychiatrist. She refused. Alice consistently quit treatment only to return; the therapist resumed several times. Eventually, the therapist refused until Alice received more intensive treatment. Alice began a campaign of rage to ferret out the associations, former patients, and families of the therapist and used social media to target them and devalue her therapist. She suffered profoundly and caused suffering to punish others and herself.
Author and psychoanalyst Melanie Klein described this level of destructiveness in the individual as a desire to destroy life in oneself and others. Gentle and kind people who set appropriate boundaries awaken the individual's disdain and contempt (this often occurs with their therapists) (Mucci, p. 206). Often, these patients continue with therapy because they need a relationship to attack and a "vital/vibrant kind of exchange to satisfy their sadism" (Mucci, p. 207). Anyone in the individual's sphere who does not gratify them quickly becomes the scapegoat and target of their aggression." (Scheel.)
Enter the age of social media. These types of severely damaged patients are increasing in numbers. They spend their time looking to destroy. These patients fill their social media with harmful posts about their friends, others they have never met, and their therapists. They eliminate any empathic effort by their therapists to help them.
Therapists are increasingly vulnerable to attempts to discredit them by very ill patients. Patients use social media to spew their rage, reflect on their history of abuse, and destroy all good in the person who makes the most effort to help. Often, they feel guilty and remorseful, but when faced with no longer having access to their therapist, they resort again to rage and, due to the accessibility of social media, mete out their fury yet again.
These individuals provide written comments wherever they can find an opportunity, often creating false accounts claiming to be the person they seek to destroy. Therapists face legal and ethical standards to protect these very ill patients, even when they are within their legal right to respond to vitriolic posts or even contact the police or an attorney and give their names for stalking the therapist via social media and others connected to the therapist. Most therapists continue to protect their patients' privacy at the expense of their reputations. They have tremendous empathy for the pain of their patients.
Many social media outlets, especially those without knowledge or properly vetted sources to engage with mental health practices, will allow opportunities for comments about practitioners. When these social media platforms are asked by healthcare providers for the vitriol about them to be removed, especially when the healthcare provider never created the profile, the social media outlet often refuses. The platform urges the practitioner to "verify" the business as their own and then comment back on the comments made about the therapist. In doing so, the practitioner is not only acknowledging a business social media platform they never approved but also directly engaging with the former patient, which signifies, for many practitioners, a breach of their ethical conduct to protect the patient's privacy.
Many years ago, a producer of a significant prime-time show created by someone who suffered the tragic loss of their child asked if I would do a segment on their show about eating disorders. I felt honored and said, "Yes!" Following that was the producer's statement that for me to appear on the show, I had to find a willing person (patient) to come on the television show with me to talk about their eating disorder experience. My answer quickly became, "No!" Boundaries are there for a reason.
Kernberg. O. Borderline Conditions and Pathological Narcissism. J. Aronson. New York. 1975.
Mucci. C. Borderline Bodies. Affect Regulation Therapy for Personality Disorders. W.W. Norton & Co. London. 2018
Scheel. J. PTSD and Its Relationship to Eating Disorders Symptoms and behaviors represent both the victim and abuser. Psychology today.com. March 29, 2016
Scheel. J. When complex trauma and severe character pathology meet. psychologytoday.com. August 15, 2022
Segal. H. Introduction to the work of Melanie Klein. Routledge Books. London. 1964