The Patients Who Can’t Close the Door

“The patient may not fully ‘know’ that their mind or body belongs to them and that access to either occurs by invitation and consent.”

Some patients have difficulty creating a private space for their online therapy appointments: they don’t close the door when other people are in the house; they close it but allow others to walk in anyway; they let children or pets interrupt.

Of course, emergencies and unforeseen events happen, but I’m not talking about those. I’m talking about recurring patterns. When intrusions are the norm, that is psychological information.

Some patients struggle to maintain boundaries with others. Some seem relatively unaware of their therapist’s boundaries. I’ve heard of patients bringing their phone and therapist into bed, or onto the toilet. (Therapists can also have boundary problems; I once heard of a therapist conducting sessions from her bed with her partner just out of camera view.)

Recurring intrusions into therapy sessions raise questions about how the patient experiences boundaries in their other relationships. Some people struggle to distinguish wanted from unwanted contact, both emotional and physical. Some have difficulty separating their own desires from those of others. Some don’t recognize when they are intruding on others. Online therapy doesn’t create these difficulties, but it can cast them in high relief in the therapy relationship.

Patients who permit ongoing intrusions may be communicating something crucial about how they experience self and others. This is something for therapist and patient to explore, not gloss over. Therapists must also recognize that recurring intrusions compromise the therapy frame and interfere with therapy.

The therapy frame is the “envelope” in which therapy occurs. Its elements include predictability, defined roles and responsibilities, the boundaries of the therapy relationship, and especially privacy.

The reasons for blurred boundaries can run deeper than meets the eye. Psychoanalyst Gillian Isaacs Russell makes this point:

“It is unreasonable to expect the patient to be able to provide a safe setting for themselves, if they have never had that basic experience of safety and cannot even imagine it. So many patients come into therapy having experienced early impingement.”1

In other words, the patient may not fully “know” that their mind or body belongs to them and that access to either occurs by invitation and consent. Likewise, they may not fully appreciate that others’ minds and bodies belong to the other person.

This kind of not knowing traces to the earliest years. It comes about when a parent treats a child as an extension of themselves, or denies them the privacy of their own mind or body. In some cases, a parent or caregiver inserts themselves relentlessly into the child’s experience. In others, a parent may be so emotionally needy that the child’s bids for separation and individuation are experienced as threats.

Such patients need the therapist’s help to know that safe boundaries are even possible and what it feels like to have them. This kind of embodied knowing does not come from explanations. It emerges from the lived experience of secure boundaries in the therapy relationship.

The challenge in psychotherapy is that difficulties around boundaries and privacy often play out in the background, in actions, not words. It would be a rare patient who could say in words, “We’re getting into uncomfortable topics and I’ve arranged interruptions so we don’t go too deep,” or “I never understood that I am entitled to have private thoughts and feelings or decide for myself what I choose to share.”

The therapist’s task is to help bring the boundary difficulties from the background into the foreground, where they can be acknowledged and discussed in words.

Here is a sampling of some things a therapist might say, at the right time and place, to help bring privacy and boundary concerns into the therapy relationship:

• “I notice that your husband (child, roommate, etc.) entered your room several times. It seems like it’s difficult to protect your privacy during our meetings.”

• “It’s not possible to discuss your experience more deeply when your dog jumps up on you each time an emotional topic comes up.”

• “I’m not comfortable having our therapy session while you are lying in bed without a shirt. I’d like to pause our session here and resume when you are fully dressed and sitting up.”

The therapist’s task is to help bring the boundary difficulties from the background into the foreground, where they can be acknowledged and discussed in words, not just lived out in actions. The shift from background to foreground is part of “making the unconscious conscious.”