INTERPERSONAL, Setting Boundaries in Relationships —_ SUMMARY Boundary problems are described in two forms: too much closeness (difficulty saying “no” relationships) and too much distance (difficulty saying “yes” in relationships). Ways to set healthy boundaries are described. ORIENTATION “don't trust people and I can't reach out to them, What happened in Viet Nam is too horri- ble to talk about, I lost faith in the human race.” “Every time I have run into trouble with my sobriety, it has been because of a man. I picked up coke for the first time because of a man; picked up alcohol after rehab because of wanting to please a man. I also have been in some very abusive situations—physical and sexual—that I am sure did not hel my PTSD. My relationship with Steve now is not healthy. He is married, uses coke, controls me, does not encourage mental health or posi- tive feedback, and does not like me out at AA or any other functions. Lam aware now that if Tenter into this relationship again, it will be very risky for me, At this point itis very dif- fieult for me to say no, But now Fm practicing.” The concept of “boundaries” is explored, with attention to how PTSD and substance abuse can lead to boundary problems and how boundary setting can be practiced. Boundary prol lems usually translate into either too much closeness or too much distanee. Thus, in today’s topic, two simple strategies are offered: saying “no” (lo create distance from unhealthy rela- tionships) and saying “yes” (to create closeness in healthy relationships). When patients have difficulty saying “no” in relationships, it typically represents an ill- fated attempt at love that ultimately results in isolation or exploitation. They try too hard to please others and in the process lose themselves. Often there is a fear that if limits are set in a 265266 Treatment Topics relationship, others will respond negatively with anger, abandonment, emotional abuse, or even physical violence, This may represent both realistic fears based on their life experiences and, at the same time, an overgeneralized distrust in which their traumatic past overshadows the present. Learning to say “no” in the present, therefore, requires them to differentiate who s safe versus unsafe, as well as how and when to say “no.” Saying “no” to abusive relation ships is a erucial issue for some patients and is addressed in its own handout. (It is also sug- gested that if a patient is in a situation of domestic violence, the therapist contact a hotline that specializes in this very complicated area, and seek consultation and supervision.) For pa- tients who are prone to violating others’ boundaries (another form of boundaries that are too close), see the topic Healing from Anger, which addresses that in detail. Finally, it can also be observed that too-close boundaries may be a source of strength at times, allowing patients to connect fluidly with others to initiate relationships and, in psychotherapy, ereating an intense attachment ean serve as a developmental stage toward later healthy relationships. Learning to say “yes” is important for patients who have isolated themselves too much from others. Reaching out, making meaningful connections, and allowing one’s vulnerable side to show through are all essential parts of rebuilding trust in relationships. This may be especially difficult for men and/or war veterans (who may feel a need to appear “strong”, and for survivors of interpersonal trauma in which humiliation or shame was prominent. Healthy boundaries are usually emphasized in interpersonal relationships but are equally important intrapersonally (within oneself). For example, how can patients talk to themselves to avoid going out and buying drugs, or to leave their jobs at a normal time rather than overworking? Such internal role plays ean be just as useful as external ones for some pa- tients, and they keep the focus on changing oneself rather than trying to change others. It also can help patients to see that the inter- and intrapersonal realms are often parallel—how they treat themselves is similar to how they treat others. Ifit is hard to say “no” to oneself, it may be hard to say “no” to others. Ifit is hard to say “yes” to oneself, it may be hard to say “yes” to others too. Countertransference Issues ‘The main countertransference issue is making sure to fully understand what makes it difficult for a patient to say “no” or “yes” in a particular situation. Sometimes itis easy to conduct role plays in ways that do not go deep enough—that do not address the very real emotional obsta~ cles that prevent setting healthy boundaries. For example, a patient may conduct a role play beautifully on saying “no” to a friend about getting high, but when probed says, “In real life, I ‘wouldn't be able to say that.” Processing that level of the patients struggle then becomes the focus. Also, a caveat: When exploring a patient's destructive relationships, the therapist may be drawn to convey judgment or criticism of people in the patients life (e.g, “Your aunt is not there for you at all). It is important that the therapist to respect the patient's attachments. Even in damaging relationships there are usually some genuinely positive aspects that make it difficult for the patient to leave. Supporting the patient's own criti helpful, as is offering honest feedback from the perspective of the patient’s needs (e-g., “I'm concerned that you may not be getting from your aunt what you feel you need”).Setting Boundaries in Relationships 267 ‘Acknowledgment Handout 5, Boundary Problems Associated with PTSD and Substance Abuse, is drawn largely from Herman (1992). SESSION FORMAT 1. Check-in (up to 5 minutes per patient). See Chapter 2. 2. Quotation (briefly). See page 271. Link the quotation to the session—for example, “Today we're going to talk about setting boundaries in relationships. Really listening to your inner needs can help.” 3. Relate the topic to patients’ lives (in-depth, most of session). a. Ask patients to look through the handouts, which can be used separately or to- gether. Cover them in multiple sessions if you have the time. See “Session Con- tent” (below) and Chapter 2 Handout 1: Healthy Boundaries Handout 2: Too Much Closeness: Learning to Say “No” in Relationships Handout 3: Too Much Distance: Learning to Say “Yes” in Relationships Handout 4: Getting Out of Abusive Relationships Handout 5: Boundary Problems Associated with PTSD and Substance Abuse (optional) b, Help patients relate the skill to current and specific problems in their lives. See “Session Content” (below) and Chapter 2 for suggestions. 4. Check-out (briefly). See Chapter 2. SESSION CONTENT Handouts 1, 2, and 3: Setting Boundaries in Relationships Goals 1 Discuss healthy versus unhealthy boundaries (Handout 1). © Explore ways to say “no” in relationships, for patients who are too enmeshed (Hand- out 2) 13 Explore ways to say “yes” in relationships, for patients who are too detached (Hand- out 3), Ways to Relate the Material to Patients’ Lives * Role plays. Rehearse out loud how patients can set boundaries with themselves and others, Handouts 2 and 3 have lists of scenarios to role-play ifa patient has difficulty identify- ing a real-life current situation, When a patient is role-playing setting a boundary with her- or268 Treatment Topics ”" For example, if the “inner himself, the therapist may want to play the patient's “inner voie voice” wants to work too many hours, how would the patient respond to that voice to set a boundary? + Drug refusal training. This is role playing specifically focused on saying. “no” to sub- stances. It is one of the most essential safety skills for patients to learn, Patients should re- hearse out loud and memorize at least one or two ways to say “no” to themselves and others when tempted by substances. * Discussion “Do you have more difficulty setting a boundary with yourself or with others?” “Do you think your boundaries are too close or too distant?” “How can setting boundaries keep you safe?” “Why is setting boundaries in relationships important?” “Why might PTSD and substance abuse make it hard for someone to establish healthy boundaries?” * "Do you have problems setting boundaries in relationships? What are some exam- ples in your life right now?” ‘© "Can you remember any recent example in which you were successful in setting a boundary with yourself or someone else? What made that possible?” ‘© “If someone says to you, what would you say to set a boundary?” * “Ifyou say to yourself . what would you say to set a boundary with yourself?” Suggestion Although most patients are fine with this topic, very occasionally someone feels upset when reading about boundary problems. If this occurs, it is helpful to be reaffirming and comforting with the patient, For example: “You dor't have to keep reading this if you don't, want to—you can set a boundary right here in the session and say ‘no’ to this sheet! makes sense that it might be upsetting to read this,” or "Everyone has problems in relation- ships.” Handout 4: Getting Out of Abusive Relationships Goal © Help patients evaluate whether they are in any destructive relationships, and identify ways to protect themselves from those. Ways to Relate the Material to Patients’ Lives + Self-exploration. Ask patients to take the brief self-test at the top of the handout to de- termine whether they are currently in a destructive relationship. Ifa patient has no destruc- tive relationships, you may want to skip this handout. You could then return to the other handouts as needed.