Last week during a supervision session with a psychiatry resident, my text message alert interrupted. The text was from a friend. She said her teenage daughter has been acting-out- breaking curfew and being disrespectful. She knows I work with teens and young adults, and asked if I could evaluate the teenager for depression.
After glancing at the text, I asked the resident, “Why can’t I treat my friend’s teenage daughter?”
Tentative, he guessed, “Boundaries?”
My thought had been: It would almost certainly ruin a good friendship.
Medical care relationships might successfully comingle with friendships. (Might.) But psychological therapies are different. How could I forget if I heard of my friend’s unhealthy behavior in the family from her daughter? And sitting down with my friend saying, “I think you need to learn to talk to your daughter differently,” would not only prove unwelcomed, the advice would likely be ignored. When friends offer unwanted advice, who listens?
The contract with a treatment professional is different. People walk in the door and risk telling their problems to a stranger, hoping to receive sage guidance or sound medical interventions. They walk in the door ready to listen. Friends don’t.
The resident was right. It was an issue of boundaries. Boundaries are a vital part of mental health relationships. But the problem with boundaries is that many people seem confused about what they are. Not just friends who need advice on parenting, even treatment professionals struggle to define “boundaries.”
Recently I was speaking to a colleague who said she couldn’t speak honestly about her own mental health history in public because: “boundaries.” I told her I didn’t think boundaries equated simply to privacy.
Or other professionals will use the word exclusively regarding physical contact with patients or clients by therapists. “I can’t make physical contact with them. I need to have boundaries.” But I know some wonderful, ethical, well-boundaried therapists who regularly hug their clients.
As I began to discuss boundaries with the resident, he referenced both of the above interpretations. He said, “You probably shouldn’t treat her daughter because your friend knows personal information about your life. And you probably hug your friends, you wouldn’t do that with patients.” But I didn’t think he had it quite right. I’m a pretty open book. Nothing my friend knows about me would necessarily have to be hidden from patient families. And I’ve been known to hug a patient now and then, if they ask and it feels appropriate.
I offered him another definition of boundaries:
Boundaries are rules in relationships. Fences. Necessary because, as the saying goes, “Good fences make good neighbors.”
All relationships have boundaries, not just mental health care relationships. Marriages, parent-child, and even fellow PTA members follow a set of rules (often unspoken) regarding the rules of engagement. The rules help us understand what is okay, and what is not, in each relationship. When those rules are broken, conflict, hurt feelings, and misunderstandings result.
If someone is my personal friend, our relationship has different rules than the relationships I have with my patients and their families. My friends listen to my problems, come to my house, and have my home phone number. My patients do not. However, my patients hold a privileged position of a different kind. They are guaranteed my full attention during their scheduled time, no matter whether I am having a bad day, feeling tired, or having a problem of my own. Friends have to take the good and the bad. Patients’ needs take priority over mine.
So, no, I cannot evaluate a friend’s teenage daughter for depression. But I’m sure I can give her the name of a terrific colleague who can.