Boundaries

Doctors and therapists are often slow to adopt new technology, so it comes as no surprise that the explosion in modes of communication has thrown medicine and therapy into turmoil. For some doctors, the refusal to use even email at all stems from the medicolegal exposure of such an accessible paper trail. Others have embraced email, Skype and texting to offer easier access for patients in need.

The reluctance of a therapist to use electronic communication has a philosophical basis. One axiom of therapy is absolute adherence to the frame: the practical structure of the relationship is critical for its success. The agreement includes the time and length of the session, the amount of the fee and mode of payment and how the session transpires. In therapy jargon, the code word for these decisions is boundaries. This used to mean limited contact outside of the therapy except for emergencies and, of course, phone was the only option. With the current, ever growing smorgasbord of modes of communication, boundaries have become much, much murkier.

Interestingly, as I discussed in the last post, the eating disorder treatment community has embraced the ease of keeping in touch with patients but not without controversy. Let me start with some positive results supported by the professional community at large. A prominent psychiatrist in North Dakota ran a study testing Cognitive Behavioral Therapy for Bulimia Nervosa via Skype and found the success rate was equivalent to face-to-face therapy. There are also pilot programs which involve sending text messages to patients with eating disorders to support them through the day. Because these studies were standardized, the texts were generic and impersonal, but the concept was very progressive. Under the guise of research standardization and academic support, these pilot studies pushed the boundaries of therapy within an acceptable framework but implied the need for further testing of these limits in typical eating disorder therapy.

In addition, I have spoken to colleagues who treat eating disordered patients, and many have significant contact with their patients by phone, email or text. However, most therapists conceal this information until they know you're a like-minded soul, and I can understand why. To begin with, the general fear of new forms of communication has plagued every step forward in technology: the telephone, television, computer and cell phone have all been branded evil in their time. That fear invades the therapy community at large. I have been questioned at length as to how text messaging a patient can be professional. I have been chastised by an inpatient psychiatrist for emailing with a patient. And this was a psychiatrist, mind you, who was all too eager to read confidential emails made available by a third party without the patient's consent! But, in my mind, the risk of exposure is far outweighed by the unquestioned benefit and progress that comes both from extra time and especially from communication that is not in person. And that is why, as complicated as the process can be, reassessing the boundaries of eating disorder treatment is so important.

I explained in the last post how a patient with an eating disorder is bombarded all day with thoughts and internal pressure to rely on her symptoms in order to live in the world. No matter how effectively and consistently the time is spent in therapy, patients will need more help to learn how to resist the urges to use eating disorder symptoms and how to use other coping mechanisms. Faster, easier and more accessible communication can aid in this process.

But another benefit to electronic communication is the obvious: it is a disembodied act. The shame of being seen and of feeling one’s body while with another person--especially in the exposed reality of therapy--inhibits more honest communication. Often the anxiety of physically being with the therapist simply shuts down the patient's ability to think clearly at all. Despite these challenges, the consistency of regular office sessions can lay the groundwork for therapeutic breakthroughs in between sessions. In a private place where the patient is not seen, the intensity of the shame diminishes, and she is able to think more clearly and express her feelings more honestly. As the therapy helps the patient separate the eating disorder from her self-worth and identity, she needs to use any opportunity to speak for herself and needs to have someone there to hear her, to mark the moment of success. These steps forward undoubtedly move recovery along faster and help the patient find new ways to counter the eating disorder on her own.

But loosening the boundaries of communication has a profound effect on the nature of treatment and the therapeutic relationship. The continuity of contact means that sessions mark the dedicated but not exclusive time of the treatment. The relationship is more natural and fluid, unlike the limited weekly allotment of most therapy relationships. The clear message to the patient is that therapy must follow her, both literally and figuratively, through the week to have any success in treatment. The expectations of the patient and therapist are significant and the commitment to the therapy and to each other must be strong because the stakes are high and the process of recovery arduous. The nature of this relationship forces the patient to reconsider her reluctance to have hope, to engage in personal relationships and to imagine a life free of the disorder. Perhaps most importantly, the loosening boundaries highlight the paradoxical (to the eating disorder) belief that the patient is a valuable, meaningful person. How else can she reconcile her vicious internal self-hatred with the reality of her treatment?

The next post will continue to discuss boundaries in the context of a question often posed by patients that I briefly discussed a few posts ago: is the therapeutic relationship real?