The benefits of better boundaries in clinical practice

For many psychologists, setting robust boundaries in clinical therapy practice is a vital skill often learned through difficult interactions with patients and colleagues. Teri Strong, PhD, owner of a private practice in Eugene, Oregon, and former chair of APA’s Board of Professional Affairs, remembers when she allowed sessions to occasionally run long with one patient who was dealing with complex trauma. When she tried to consistently stop sessions on time, the patient responded with, “I guess I am just too hard to deal with.”

“By being too flexible, I was giving a mixed message about therapeutic boundaries that are needed for effective therapy,” said Strong. “Boundaries are there to protect me and the client.” She talked to the patient about how boundaries can facilitate the healthy relationship needed for effective therapy rather than signal that something is wrong with the patient. They agreed to start preparing to end a session 10 minutes early by checking in, wrapping up the work they had done, and focusing on self-care tools the patient could use until the following session.

While setting boundaries for ending a session, payment deadlines, contacting a therapist after hours, and other expectations may feel uncomfortable, avoiding these conversations can take a toll on therapists, both emotionally and physically. Clinicians may start extending work hours and depleting their financial resources, which can lead to feeling undervalued. “The risk of failing to establish healthy boundaries is that you are worse at everything, at home and at work,” said Laura Boxley, PhD, director of clinical neuropsychology training in the department of psychiatry and behavioral health at The Ohio State University and former chair of APA’s Advisory Committee on Colleague Assistance (ACCA). “You may see emerging health challenges, like depression, sleep disturbance, poor diet, substance use, and cognitive fog.”

In fact, for clinicians, healthy boundaries are a form of self-care that can reduce the risk of workplace burnout, defined by the World Health Organization as the result of chronic workplace stress that isn’t managed. Symptoms include feelings of energy depletion or emotional exhaustion, increased mental distance from a job, feelings of negativism or cynicism related to work, and reduced professional efficacy. According to APA’s 2024 Practitioner Pulse Survey, early career psychologists reported higher levels of burnout and stress than senior career psychologists. More than 50% of early career psychologists with 10 or fewer years of work experience agreed to feeling burned out, compared with 18% of psychologists in advanced career stages.

One strategy to avoid burnout is learning how to make decisions based on core personal values rather than defaulting to compliance based on expectations, said Sunita Sah, MD, PhD, MBA, author of Defy: The Power of No in a World That Demands Yesopens in new window. In her book, she reframes the negative connotation of defiance to a proactive force for self and society. “For clinicians, setting boundaries is a value-based act of protecting time, energy, and capacity so they can keep providing high-quality care,” said Sah, an organizational psychologist and professor at Cornell University’s SC Johnson College of Business. “Defiance in this context is a form of care, not just for the therapist but also for the patient.”

Although setting boundaries is especially difficult at a time when demand for mental health services far outstrips supply, defiance is a skillset that can be learned, Sah said. With practice and a willingness to potentially endure temporary emotional discomfort when setting boundaries, therapists are modeling healthy relationships to patients and protecting the therapeutic alliance.

Learning to set boundaries requires self-awareness and practice, particularly because many people have been socialized to say “yes” to more responsibilities and activities than they feel comfortable agreeing to, Sah explained. “Under pressure, we often comply because it is our natural default, and we need to rewire our brains and train ourselves to say ‘no,’” she said. One strategy to avoid these “compliance traps” is to pause briefly before agreeing to a request and respond with “Let me get back to you about that.” Another tactic is to talk to oneself in the third person because this provides space for an individual’s values to re-enter the decision process. “I may say, ‘Sunita, is this what you really want to do? Does this go against your values?’” said Sah.

She also recommends practicing these responses out loud prior to situations because “the mouth gets used to saying it and the ears get used to hearing it,” Sah said. For example, a therapist setting boundaries with a patient about contact outside a session could practice the following script: “I understand this is important, but I want to make sure I am providing the best care so I can’t over-extend myself. For your safety and mine, I keep these boundaries.”

When meeting with a new patient, Strong explains the meaning and value of the therapeutic alliance, including defining and managing appropriate boundaries. She gives patients information on support that is available if they are experiencing an emotional crisis outside the session, such as contact information for colleagues who are on-call, community crisis lines, and online resources. She has a separate phone for her practice, and she responds to texts only during normal business hours. “These boundaries require a delicate balance because clients necessarily bond with therapists, yet we are asking them to understand that there are limits to the types of interactions we have because we are not family or friends,” she said.

By having these conversations at the outset, she maintains her ethical responsibility to provide quality care and patients can experience the benefits of appropriate boundaries. “This helps them learn how to form healthy relationships, how to manage their own thoughts and feelings, and be more independent in both increasing the support they need and in using effective coping strategies,” she said.

Boundaries can also be helpful when patients are sharing traumatic experiences, said Sonila Sejdaras, PsyD, founder of two group practices based in Chicago. “Clients sometimes believe it is beneficial to share as much as possible as quickly as possible about their trauma, but I’ve learned the importance of slowing down the process,” she said. “Sometimes I am upfront that I am intentionally interrupting the client because it could be more damaging to move too quickly.” She checks in to see how patients are feeling, helps them focus on the somatic experience. During the session, she may guide them to practice grounding techniques if they are feeling retraumatized, and they learn to apply these techniques if they experience flashbacks or rumination outside the session.

If a session is coming to an end and the patient continues to feel activated by a traumatic memory, Sejdaras typically says something like “I am so sorry that this happened, and we are running out of time. I can tell this is traumatic, and here are the options.” If her schedule allows, she will offer to extend an additional 30–60 minutes, or she will try to find another opening sooner than the usual weekly meeting. “If clients sense this compassion when setting boundaries, this puts them at ease,” she said.

Although high-demand clinical settings can foster a work culture that leads to burnout, clinicians can buck this trend by acknowledging their limitations. “Many of us get drawn into poor boundaries because we are trying to pretend conditions are different than they are,” said Boxley. “We pretend to have more resources, more time, more passion, and more energy than we actually have, but accepting our humanity is a powerful personal and professional gift.”

There are often warning signs when psychologists need to consider setting stronger boundaries. “I’ve had times when I said ‘yes’ too much, and I was working evenings and weekends,” said Catherine Vieira-Baker, PhD, an assessment coordinator at South Coast Educational Collaborative in Massachusetts, an organization that provides services to children with disabilities. “I started feeling physically exhausted, had energy for nothing but work, and began forgetting things like my planner or lunch.” She frequently receives requests from other school districts that do not have enough help managing the volume of evaluations for students to qualify for special education, and it would be easy to become over-extended.

Now she keeps a detailed spreadsheet of her caseload, which informs her decisions about whether she is available to accept referral evaluations for students outside the collaborative. If she is unable to complete the evaluation within the prescribed timeline, she works with the district to find solutions, such as asking if the testing can be delayed to a time when she is available or she finds a colleague who has time. Vieira-Baker, also the vice chair of APA’s Board of Professional Affairs, admits that though she often feels guilty when she can’t help, she has learned that the quality of her work suffers if she stretches herself thin. “I don’t want to get to the point of being an impaired provider,” said Vieira-Baker.

Early in her career, Sejdaras felt pressure to see patients primarily during evenings and weekends because she saw other therapists working these hours and she assumed patients were busy during the day. “Scheduling brings up a lot of guilt for many therapists,” she said. “But I was also a mom, and I wasn’t seeing my son as much as I wanted by keeping this schedule.” She started asking patients if they would be available during the day, and she was surprised to find that many were willing to move their appointments to times during regular business hours. By advocating for herself, her patients started advocating for themselves to make time for mental health appointments during normal business hours.

Boundaries related to money matters are another aspect of clinical practice that can be difficult to navigate, especially because logistics related to payment or salary can seem contrary to values of being warm and generous. “We receive a lot of training in school about service to others and social justice, but not much about how to prioritize our own needs, values, and finances,” said Ian Bonner, PsyD, owner of Freelife Behavioral Health in Chicago, a group practice with seven therapists. “But money is one aspect of a therapeutic relationship that needs to be discussed with clients.”

He once had a patient who had fallen behind on his $20 copayments for sessions to the point of having $400 in copayments due. Bonner avoided this issue for months and finally told the patient to pay the full amount before the next session to continue therapy. Bonner learned that the patient, who had severe ADHD, needed to ask his wife for the credit card in order to pay, but he was avoiding the shame of her reaction to his forgetfulness. “We were colluding in each other’s avoidance,” said Bonner. “After this conversation, we could talk about how avoidance was a major theme in his life and how to overcome this pattern.”

Therapists also have a responsibility to ensure patients are receiving an adequate level of care, and sometimes patients may be dealing with issues that are outside a provider’s training. In these cases, therapists may need to set a boundary about who they are willing to treat.

Bonner previously worked with a patient who sought therapy for stress and anxiety but had a history of an eating disorder that became active again. Bonner explained to the client that this condition warranted a higher level of care, and he needed the patient to attend an intensive outpatient treatment to continue the weekly sessions with him.

Strong has worked with patients who expressed disappointment about being referred to a therapist who is more qualified to treat a specific issue. “These are delicate situations,” she said. “But we have a responsibility to ensure they get the right treatment, and most patients will understand.”