SHIFTING BOUNDARIES: THERAPEUTIC WORK AND LEADERSHIP - PATRICK TOMLINSON (2020)

Date added: 08/10/20

I cannot think of anything in the last 50 years that has caused such a sudden and widespread disruption of global life and work, such as Covid-19. The invisible virus and our responses to it have redefined our lives in a very tangible way. Previously unimaginable restrictions have been put in place. Our boundaries in life and work have been redrawn. In some occupations, work has been made impossible. For example, air travel. In others, there has been a rapid reorganization, with many implications, which we do not know yet. Ordinary, everyday experiences have a beginning, a middle and end. In this situation, while there will be an end, we do not know when it will be or what it will look like. We are in a daily situation of huge uncertainty. However, at the same time the restrictions put in place, seem to have provided containment for some traumatized young people, and maybe others, who have found the narrowing down of daily life to be less challenging. Joana Cerdeira, a psychologist and supervisor in residential care, Portugal, commented, 

Some children who are usually very disorganized appear to have settled quite well. It is almost as if the physical containment that arises as a result of the pandemic, provides safety.  

The importance of boundaries
My work has always been with services to children and young people who have suffered from trauma and other adversities. I no longer work directly with children but with individuals and organizations who do. In work with traumatized children, the establishment of clear and appropriate boundaries is a central part of the work. This is true of all therapeutic work. One of the main reasons for this is that complex childhood trauma involves a lack of boundaries. The child may be treated as if she has no personal boundary, for example, in abusive situations. The child may not be recognized as a child with her own needs. She may be used to gratify an adult’s needs. Therefore, the boundaries between people and roles are confused, muddled, inconsistent and sometimes non-existent. Bessel van der Kolk et al. (2007, p.424) summarize why this is so important,

Since interpersonal trauma tends to occur in contexts in which the rules are unclear, under circumstances that are secret, and in conditions where issues of responsibility are often murky, issues of rules, boundaries, contracts, and mutual responsibilities need to be clearly specified and adhered to (Kluft, 1990; Herman, 1992). Failure to attend strictly to these issues is likely to result in a recreation of aspects of the trauma itself in the therapeutic situation. 

In therapeutic work, there are many reasons why clear boundaries are so important. A person without personal boundaries is an undifferentiated person, or what Donald Winnicott (1962) called an unintegrated person. A sense of personal identity and self is usually well on the way to being established in early infancy. The infant begins to know that her mother is a separate person with her boundary. This is a difficult and even frightening realization. The infant may try to control and merge with the mother as a defence against this. Growth takes place because of the mother’s firmly held boundary and containing presence. This presence is not one that is always free of anxiety, but one in which anxiety can be thought about rather than reacted to. 

Boundaries that are firm, clear and consistent help contain anxiety. In other words, boundaries help provide structure. Events in daily life that have a clear beginning, middle, and end can be understood and internalized. Those that work with clients whose boundaries are weak or undeveloped, and who have difficulty containing anxiety, know the consequences where boundaries become unclear. One person I work with, Rui Lopes who is a Director of a therapeutic residential home for young people told me recently,

It has never been so evident how the emotional state of the adults affects the states of young people. When an adult is anxious, nervous, and sad, kids are reacting to that – mirroring the state of mind and the emotional states – I have never seen that so strongly before.

Once an adult in the work situation becomes unable to contain his anxiety, this also becomes uncontaining for the child for many reasons. An adult who cannot contain his feelings, will not be able to contain a child’s. A child’s past traumas may be associated with an overwhelmed adult – when adults were most likely to lose control and become unsafe. Consistency, the ability to think and to be non-reactive are all challenged when overwhelmed. What is felt inside is all too suddenly felt on the outside and vice-versa. The boundary between internal and external worlds is lost or weak. Improving this boundary is a major task of therapy. So, the person is more able to distinguish between the two. For example, what a traumatized child feels about herself may also be what she believes others and the world to be like, and vice-versa. For instance, I am dangerous – the world is dangerous. I am unlovable – others do not love me. Experiencing that the two can be separate is a slow and fragile process. The steadiness of an adult with a clear sense of their boundaries, but receptive and attuned to the child is the basis for growth.  

Setting and breaking boundaries
Different boundaries have different levels of permeability or flexibility. Some boundaries must not be broken or crossed under any circumstance. These may be described as absolute limits. There are other boundaries, that we expect to be tested and crossed. Emotional growth may not even be possible without testing and crossing boundaries.  A boundary draws a line between what is allowed and what is not. The line must be flexible enough to allow enough of whatever is desired but not too much. For example, saying to a young person, you can go out but need to be back by 9 pm. This may be containing for the child and it may also create an interest and curiosity in what happens after 9 pm? It can be argued that the boundary sustains desire of something a little out of reach. We want children to be protected from negative external influences, but we also want them to explore and learn how to manage themselves in the world. The child psychotherapist, Phillips (2009, p.1), in his paper ‘In Praise of Difficult Children’, said that, 

The upshot of all this is that adults who look after adolescents have both to want them to behave badly, and to try and stop them.

Phillips (p.2) says that the adult provides something to truant from and the adolescent discovers something to truant for. In therapeutic work as well as in ordinary development, there is often hope when boundaries are challenged. When a true sense of self starts to emerge in a previously compliant child, for instance.  We start to see the ‘true’ rather than ‘false’ self (Winnicott, 1960).  Child and Adolescent Psychotherapist, van Heeswyk (1997, p.3) explains the ambivalence involved in this kind of boundary setting,  

“Typically views held by adults in regard to adolescents are, to say the least, ambivalent.  We see them as vulnerable victims, or as young sadists who inflict terrible damage on others; we fear them as posing grave danger to our cars, property, jobs, morals and way of life, or fear for them as an endangered species requiring special protection; we envy their freedom and hopefulness, or cling to them as the only hope for ourselves and the planet; we curse and constrain their wild impulsivity, or seek to facilitate and encourage their escape from the repressive convention that constrains the school-children that they were and the adults they will become.”

The same kind of ambivalence towards the restrictions imposed by the virus situation has become clear. Protesters (boundary breakers) are both criticized and praised. It all depends on which side of the fence you are sitting. 

Different types of boundary
The following are different examples of boundary that we need to be aware of and manage in a way that is supportive of the therapeutic task.

•    Boundaries between the worker/caregiver and child
•    Boundaries between children
•    Boundaries between workers, professional disciplines, roles, and departments
•    Physical boundaries, within the home, marking personal spaces, e.g. a child’s bedroom
•    Personal and professional boundaries
•    Boundaries around behaviour, i.e. rules and the limits of what is acceptable and what is not
•    The boundary between the conscious and unconscious

To support the therapeutic task the whole organization will need to be clear about its boundaries (Barton, Gonzales, and Tomlinson, 2012, p.129).  Boundaries can be literal and tangible, like a fence or wall or they can be implicit. In one home I worked in we were replacing the garden fence. Even when the old fence was knocked down the children still asked if they could step over the boundary, to get a ball for example. The boundary was still clear despite the removal of the physical marker. The children were contained inside the boundary not literally by the fence but by their relationships with the adults. With young people who have suffered complex trauma, physical and tangible boundaries can be especially important. Menzies Lyth (1985, p.245) explains how having a clear boundary, such as a door where permission to enter must be given, can have a positive effect on the development of identity, 

It gives a stronger sense of belonging to what is inside, of there being something comprehensible to identify with, of there being ‘my place’, or ‘our place’, where ‘I’ belong and where ‘we’ belong together.

Boundary changes due to the virus situation
A profound characteristic of a virus is that it is invisible as it travels from one person to another. There is a complete lack of boundary for the virus. The virus cannot live without infiltrating a host. A person we are close to may also be toxic with potentially disastrous consequences. The virus does not discriminate between people. So, someone who looks after you may also be a danger by being too close. There is a parallel to the root of complex childhood trauma. Where those who are supposed to love and look after you, hurt you. The psychological, as well as biological implications, are clear for those who work closely with vulnerable people. In therapeutic work with traumatized children, the concept of emotional contagion is familiar. As Lanyado (1989, p.140) described, 

Disintegration is catching – and the staff are prone to it too.  At times staff may feel anxious that they too could collapse like a house of cards. This is an extreme situation – but I am sure there are few of us working in these settings who don’t feel this way at times.  The child’s extreme anxieties can eventually threaten the integrity of their closest adults.

This is relevant to the concepts of vicarious trauma, secondary traumatic stress, toxic stress, and burnout. Now alongside the potential emotional contagion, there is also the risk of physical contagion. The two also feed into each other. The physical risk can cause anxiety, which if it is chronic can weaken the immune system. A person’s life may be at risk due to anxieties about the virus, rather than the virus itself. Therefore, the management of anxiety is vitally important to contain and hold such a fragile situation. This is central to the task of everyone involved – leaders, managers, carers, and therapists. It always is important but is brought so sharply into focus during a crisis. A calm, regulating presence is required. 

The family therapist and leadership consultant, Friedman (1999, p.232) uses the metaphor of a transformer in an electrical circuit to describe the process of containment. The electrical current (anxiety) enters the transformer. The transformer can either be designed to step-up or step-down the current. He refers to a comment made to him, 

My mother was a step-up transformer, all right. If there was anxiety in the room and she was present, you could count on it escalating. It went into her at 110 and came out at 11,000.

Friedman claims that it is presence rather than action that tends to calm down anxiety. But as he explains this is not easy,

Part of the conceptual leap from action to presence is that all leaders, parents, or presidents, have been trained to do something – that is to fix it.

He continues, “To the extent that leaders and consultants can maintain a non-anxious presence in a highly energized anxiety field, they can have the same effects on that field that transformers have in an electrical circuit”.  One unhelpful and defensive way of appearing non-anxious is to shut-off or disconnect. As Friedman (p.183) states,  

Anyone can remain non-anxious if they also try to be non-present. The trick is to be both non-anxious and present simultaneously.

What is the impact of all this?
With the pandemic, we have experienced a huge change, along with fear. There has not been much warning or time to process all these changes. The impact upon us is potentially exhausting to deal with. Some people have remarked how tiring it is to be staring at a screen all day with online meetings. While there may be some truth that online work can be tiring, it is difficult to know how much of the tiredness is more a symptom of dealing with change. Change can be exciting, especially when we have time to make a choice. Change forced upon us without warning is more likely to provoke, fear, anxiety, and uncertainty. 

Therapeutic processes tend to have high levels of predictability and consistency. They are usually negotiated with a degree of control. It is part of what can make things safe. Now everything is suddenly different with so much unknown. Some of the boundaries are gone and management of boundaries is less controlled. The space of the meeting room has suddenly changed into the family domain with all the potential interruptions and distractions. Of course, how these things are managed can be a valuable part of the therapeutic work.  

Relationships, in general, can become less clear during this crisis. Who is the carer and the cared-for may not be so obvious? In therapy work, clients are likely to inquire about the health of their therapist, etc. In the present circumstances, these questions may be an objective and healthy concern rather than a neurotic symptom. These changes alter the nature of relationships. What is shared or not between people, changes.  The normal hierarchies are challenged. This is not necessarily a bad thing, but it means we might be uncertain where the boundaries are.

Friedman (1999, p.234) who referred to leadership as belonging to everyone from parents to presidents, claimed that, 

"Leadership begins with the management of one’s own health" .… and "…a leader functions as the immune system of the institution or organization he or she ‘heads’ (p.182)."

Friedman argued that an immune system is primarily not about fighting off threats but preserving the integrity of the organism. It is fascinating how he wrote over 20 years ago about viruses in a literal and metaphorical sense. He explained how a virus or 'parasite' impacts on cells, individuals, families, organizations, and societies. He claimed that the processes from cell to societal levels were universal and could only be managed at all levels by a healthy sense of self-differentiation. So, the first vital thing we need to do is to manage our self and do everything possible to be in a healthy mind-body state. To be a calming self-differentiated presence. Such a leader can be present amid emotional turmoil, actively relating while calmly maintaining a sense of direction. With this capacity, he or she can affect the whole system of relationships and reduce the level of anxiety in it, whether it is a family, organization, or society. 

References
Barton, S., Gonzalez, R. and Tomlinson, P. (2012 Therapeutic Residential Care for Children and Young People: An Attachment and Trauma-informed Model for Practice, London and Philadelphia: Jessica Kingsley Publishers 

Cerdeira, J. (2020) Psychologist, Supervisor (consultant), Residential Children’s Home, Portugal – Comment on LinkedIn 13th April 2020.

Friedman, E.H. (1999) A Failure of Nerve: Leadership in the Age of the Quick Fix, New York: Church Publishing, Inc.

Herman, J.L. (1992) Trauma and Recovery, New York: Basic Books

Kluft, R. (1990) Incest-Related Syndromes of Adult Psychopathology, Washington, DC: American Psychiatric Press

Lanyado, M.  (1989) United We Stand, Maladjustment and Therapeutic Education, Vol. 7, No. 3, p. 136-146

Lopes, R. – Director of Residential Care Home, Portugal, Comment – 2020 04 15

Menzies Lyth, I. (1985) The Development of the Self in Children in Institutions, in Containing Anxiety in Institutions: Selected Essays Vol. 1., London: Free Association Books (1988)

Phillips, A. (2009) In Praise of Difficult Children, LRB Vol. 31 No. 3, London: London Review of Books

van der Kolk, B.A., McFarlane, A.C. and van der Hart, O.  (2007) A General Approach to Treatment of Posttraumatic Stress Disorder, in van der Kolk, B. A., McFarlane, A. C. and Weisaeth, L. (eds.) Traumatic Stress: The Effects of Overwhelming Experience on Mind, Body and Society, New York: Guilford Press

van Heeswyk, P. (1997) Analysing Adolescence London, Sheldon Press

Winnicott, D.W. (1960) Ego Distortion in Terms of True and False Self, in The Maturational Process and the Facilitating Environment (1972) London: Hogarth Press and the Institute of Psychoanalysis

Winnicott, D.W. (1962) Ego Integration in Child Development, in, The Maturational Process and the Facilitating Environment, Hogarth Press and the Institute of Psychoanalysis: London (1972)

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