Balancing Boundaries with Therapeutic Connection
Introduction
The original schema therapy model developed by Young et al (2003) encouraged therapists working with clients with ‘borderline personality disorder’ to give as much extra time as they are willing to give to clients, because they need a high degree of reparenting. In addition, the therapist should provide a means of contact for clients who experience suicidal thoughts and are at risk of taking their own life so the client can call the therapist before they make any attempts. This is based on an agreement at the beginning of therapy that the client will speak with the therapist before they take any action. However, Young et al., (2003) also recognises that a client’s needs are unlikely to be satiated by the therapist’s input and so there has to be a balance between the client’s needs and the therapist’s needs.
Having talked about how to manage the dilemma of navigating clients’ needs versus therapists’ needs with many supervisees, I have written about this topic to help you to think through some of the important points to consider when making an agreement about crisis contact.
Writing this blog was more challenging than I anticipated, which I think is a reflection of the complexity of this topic. The boundaries are hard to define and the decisions are personal to each therapist. The needs of the client and possibly the therapist will also shift and change over the therapeutic journey. These are all challenges and dilemmas we have to consider as schema therapists. A well as reading this blog, take this topic to supervision, discuss it with your peers and comment on this post. I would love to hear your thoughts on the ways in which you navigate crisis support and extra time reparenting your clients.
Contact in a Crisis
Contact in a crisis is where the therapist provides a means of communication for their suicidal client to contact the therapist before they attempt to take their own life. The very nature of this agreement is that the client can make contact with the therapist at any time, but only if the situation is very serious and their life is at risk.
Due to the heavy responsibility this agreement places on therapists, the risk of agreed boundaries being violated and the difficulty this might pose for the implementation of schema therapy in practice, Nadort et el., (2009) conducted a randomized research trial comparing the implementation of schema therapy for ‘borderline personality disorder’ (BPD) with and without crisis support by the therapist outside of office hours.
There were no significant differences in the effectiveness of schema therapy for alleviating ‘BPD’ when provided with or without crisis support outside of office hours. The researchers concluded that there wasn’t enough evidence, considering the added burden to therapists, to justify offering additional crisis support for every patient. It should only be considered in special cases. If you are considering offering this option, here are some points to consider.
Considerations for Crisis Contact |
What constitutes a crisis? |
Response time |
Might you be too busy to return a call and manage a crisis? |
Managing periods of leave or sickness. |
Method of contact: text, phone call or email. |
Crisis contact only or contact for emotional support? |
During office hours or 24/7 contact |
Will you resent offering this over time? |
Considering the outcome of the research and the burden to therapists, I encourage my supervisees to consider alternative arrangements to manage the risk of suicide for clients. In public sector settings in the UK, there are likely to be clear boundaries which do not allow contact outside of office hours. Regardless of your setting, schema therapy requires a significant emotional investment within the bounds of the therapeutic hour. Offering more than this may risk emotional exhaustion for therapists.
Alternative Crisis Support
If you don’t want to offer crisis contact, help your client to research the helplines and statutory services available to support them during periods of intense distress. Consider the scenarios that might arise between sessions and how your client could manage them with their internal coping strategies, people and social settings that might provide a distraction, people they can ask for help and how they can make their environment safe.
Here is a useful template for a crisis management plan:
Developing and following the plan is likely to be a work in progress because any of the following might arise that interfere with agreements made:
The client is so overwhelmed by their modes that they do not connect to their healthy adult sufficiently to know they are triggered or to remember they have a plan to support them.
The client’s punitive critic tells them that they don’t deserve to follow a plan to keep themselves safe.
The angry child mode refuses to follow the plan as it will be difficult or it won’t feel soothing or to punish the therapist for not being available.
Calling services can activate and reinforce schemas as the client may not receive a compassionate response.
The need to detach from the feelings of the vulnerable child and the critic mode is too great and so there isn’t motivation to follow the plan and keep themselves safe.
I have found it helpful to discuss the aims of seeking support when in crisis with clients who have felt resistant to calling helplines or statutory services. Understandably, the client wants someone to step in and help soothe their distress in those moments, and they may imagine receiving the soothing that you would provide to them. When this is not available, clients may struggle to see the value in any other option. In these scenarios, I have looked with my client at the aim of speaking with a volunteer or paid mental health specialist on the phone. For example, talking through their distress may slow their mode flipping down sufficiently to get their healthy adult on board or to provide a distraction from acting on harmful thoughts.
It can be important to recognise that the care they receive from a helpline is unlikely to meet all their needs, but to look at what they can take from it that helps to prevent any behaviour that puts their life at risk.
Extra Reparenting Time
As well as offering crisis contact, Young also encouraged therapists to provide as much additional reparenting as they could to their clients to demonstrate to the client that they matter and that the therapist really cares about them.
It is hard to define what ‘giving extra time’ might constitute as there are many possible options. For example, it could include offering an additional ten minutes at the end of a session when a client would benefit from support to regulate themselves. It could be email contact between sessions, phone calls when going through a difficult period or a birthday card.
I have no doubt from my experience that the limited reparenting stance is one of the most potent aspects of schema therapy. I think it is also important for therapists to consider the boundaries of any additional care they provide over and above the therapeutic hour. Working out where these boundaries lie can feel very tricky, especially when therapists have schemas such as emotional deprivation, defectiveness, abandonment, unrelenting standards and approval seeking.
One way of navigating this is to use the following tools for limited reparenting, which impact less on the therapist’s time outside of the therapeutic hour.
Tools for limited reparenting:
Scheduled emails: clients struggling with abandonment fears or emotional deprivation have benefited from and appreciated a scheduled email during periods of leave with a short message reassuring the client that they will be returning soon. Be sure to agree this with your client before your leave and inform them that the email is scheduled.
Transitional objects: a shell chosen from the beach for your client or a small figurine they can keep close can be a good reminder to a client with an emotional deprivation schema that they are important to you.
Audio flashcards: an audio message recorded on the client’s phone with messages for their vulnerable child can help a client to manage their defectiveness schema between sessions.
These tools can be used to help prevent crises from arising and to provide that additional reparenting sorely needed by many of our clients, without pulling the therapist away from the time they need to rest and recuperate outside of their therapeutic work.
Conclusion
Early writings in schema therapy from Young et al (2003) encouraged therapists to provide crisis support and as much extra reparenting as they could to clients diagnosed with borderline personality disorder. However, a research trial concluded that additional crisis contact outside of office hours does not significantly alter the effectiveness of schema therapy for this group.
Considering the burden of providing crisis contact therapists should think carefully about agreements for managing suicide risk. The boundaries around giving extra time for reparenting could also be challenging for therapists to manage considering their own schemas. I discussed points to consider and tools therapists can use to think through and manage additional support for clients, without compromising the therapist’s time for rest outside of their emotionally intensive schema therapy work.
This is a complex topic that will likely challenge every schema therapist at one point or another. I would love to hear your feedback about how you manage the boundaries around the schema therapy you offer.
References
Nadort, M., Arntz, A., Smit, J. H., Giesen-Bloo, J., Eikelenboom, M., Spinhoven, P., van Asselt, T., Wensing, M., & van Dyck, R. (2009). Implementation of outpatient schema therapy for borderline personality disorder with versus without crisis support by the therapist outside office hours: A randomized trial. Behaviour Research and Therapy, 47(11), 961–973. https://doi.org/10.1016/j.brat.2009.07.013
Young, J. E., Klosko, J. S., & Weishaar, M. E. (2003). Schema therapy: A practitioner's guide. Guilford Press.
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