OUT OF THE FRAME: BOUNDARIES in ONLINE PSYCHOTHERAPY
Vol 8 #2
Alan Eppel MB, FRCPC, Jordon Charlebois MD, Blaire McKim MD
Online psychotherapy has been practiced for over a decade (1,2,3) . Telemedicine was introduced in Canada and Australia more than two decades ago. This was deployed to provide services to remote communities with limited access to medical and psychiatric care and for patients who had problems attending clinics for appointments (1 ).
Use of video conferencing for patient visits has had only limited adoption by most practitioners. The emergence of the novel Coronavirus pandemic and the imposition of social distancing have radically increased the use of video conferencing to provide psychotherapy.
Video conference facilitated psychotherapy has some obvious advantages: accessibility, convenience, flexibility and reduced costs (1 ). Despite the rapid and widespread implementation of online therapies due to the public health emergency there has been little consideration of whether this change in service delivery method alters the nature of the therapeutic relationship.
Historically psychodynamic therapies have been practiced within well defined boundaries. These limits are clearly distinct from normal personal and social interactions. Thomas Gutheil and Glen O. Gabbard, in a classic paper, described the concepts of boundaries, boundary crossings and boundary violations in psychotherapy (4). They write that boundaries are maintained with regard to the roles of the therapist and the patient; time of sessions; location; clothing; language; gifts; conflicts of interest; social conversation and interaction; and physical and sexual contact.
The “frame” is an essential concept in the practice of psychotherapy. This refers to the rules both explicit and implicit, norms, and boundaries within which psychotherapy is carried out (4,5,6). The frame is an artificial construction designed to facilitate psychotherapy and create an environment that is clearly separate from the patient’s normal day-to-day life. For non-dynamic therapies this framework is often less circumscribed and may allow for more elements of the “real relationship” to be part of the therapy.
The following are established components of the frame (4,6):
- Psychotherapy is carried out in an office setting. The process involves the patient waiting in the waiting area and then being called to the therapist’s office. The therapist may meet the patient in the waiting room and accompany him or her back to the office.
- The office provides a professional atmosphere that implicitly mitigates against socially casual behaviours. Where these do emerge they become the subject of exploration or limit setting.
The office setting may nevertheless reveal aspects of the therapist’s personality through the choice of décor, pictures, furniture, and ornamentation. This can give patients some sense, largely unconsciously, about the therapist’s interests and attitudes.
- Disclosure: the Frame to varying degrees precludes disclosure of personal details by the therapist. This does vary depending on the modality of psychotherapy that is practiced. Patients may have certain personal questions such as whether the therapist is married, or has children. These questions are handled in accordance with the norm that the focus of therapy is on the patient and that the relationship is asymmetrical. Prior to the widespread use of the internet patients generally knew little about the therapist. In the present age considerable personal information can be found online about therapists and patients and this may need to be addressed in therapy.
- Physical space facilitates the regulation of distance (proxemics) and awareness of non-verbal communication, posture, body movement and gestures (kinesics) . Perception of eye gaze is also an important component of dyadic communication. The therapist needs to be aware of these dimensions in order to properly assess emotional states and attune to them.
Video Conferencing: What is Seen and Not Seen
Videoconferencing inherently changes the normal frame.
Therapy is carried out with patients who are in their homes. The therapist may also be working from home. This may allow the therapist to view aspects of the patient’s living environment but also, obviously, could allow the patient to “access” the therapist’s home.
Setting: the patient may be located in a room which is not appropriate for the conduct of therapy e.g. in the bedroom, lying down or sitting on a bed.
The on-screen images of both patient and therapist appear larger and closer, creating the sense of a more intrusive interaction. The normal physical distance is removed. This may create feeling of a more intimate interaction with an unconscious lowering of boundaries.
The lower part of the participants bodies is usually not seen on the screen which may exclude awareness of body movement and posture, “somatic markers” of affect.
Dress code: there is a potential for the adoption of a more casual dress code both by therapist and patient.
The patient may be more likely to drink coffee, eat, or smoke in their own home. There may be distractions by telephones, members of the family or pets interrupting the session or in fact being present during the interview but off screen, literally “out of the frame”.
Based on this review and clinical experience during this period the following recommendations are made:
- Redefine the new frame prior to the commencement of video therapy.
- Agree on an appropriate setting for therapy to take place. It is possible that there are no alternatives to a patient’s bedroom during the pandemic lockdown. In this case the room should be set up such that there is an area with a chair facing the camera, at an appropriate level, and separated from the bed, washroom and closet. In some video conferencing software there is an option for the use of a virtual background. However this only hides the patient’s location and does not change it.
- Smoking, eating, drinking tea or coffee should be avoided unless this was part of the practice in the office setting.
- The therapist should dress in the same manner as if he or she were in the office.
- Patients should also dress as is appropriate to an office visit.
Where there are deviations from these parameters these should be addressed as part of the therapy with exploration of the therapeutic relationship and transference. Therapists should monitor their countertransference.
Patients should agree to ensure privacy and confidentiality in the home setting.
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- Gutheil T, Gabbard GO. The concept of boundaries in clinical practice: theoretical and risk-management dimensions. Am J Psychiatry 1993, 150: 188-196
- DeJong S, Benjamin S, Anzia J. Professionalism and the internet in psychiatry: what to teach and how to teach it. Acad Psychiatry 2012, 36: 5: 356 – 362.
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