Psychiatrist/patient boundaries: When it’s OK to stretch the line

• increase if misconduct is based on patient complaints
• decrease if self-reports are used
• decrease even further if based on official investigations.⁴

American psychoanalyst Frieda Fromm-Reichman reportedly offered her colleagues a not-so-humorous admonition: “Don’t have sex with your patients; you will only disappoint them.”⁴

Nonsexual boundary violations—such as accepting gifts, entering into business arrangements, or trying to influence a patient’s political or religious beliefs or sexual orientation—occur more frequently than sexual misconduct.¹² Although the impact of nonsexual violations generally is less serious, any relationship that coexists with the therapeutic relationship has the potential to impair your judgment and contaminate your ability to focus exclusively on your patient’s well-being.¹³ Be cautious about any decision that could affect the treatment relationship.¹⁴

Triangle relationships.Originally, this term referred to the patient/therapist/psychiatrist triad. The term now has a broader meaning that includes:

• encroachments into care by managed care companies and government regulatory agencies
• interactions with the patient’s family members
• providing psychiatric care in non-traditional settings such as schools or prisons
• serving as an expert witness.¹⁵

The framework of trust once considered a core feature of the psychiatrist/patient relationship is being undermined by a funding system that demands efficiency and economy.¹⁶ Recognizing that some settings sacrifice patients’ clinical needs to the interests of the organization, the APA’s Guidelines for Ethical Practice in Organized Settings stipulate that the psychiatrist must “strive to resolve these conflicts in a manner that is likely to be of greatest benefit to the patient” by (for example):

• informing a patient of financial incentives or penalties that limit your ability to provide appropriate treatment
• not with holding information the patient could use to make informed treatment decisions, including treatment options not provided by you.⁶

Psychiatrists who doubt that the system—such as a mental health clinic, hospital, or managed care contract provider or reviewer—upholds the standard of acceptable care have the “ethical responsibility” to improve the system.⁶

Another change in mental health care attempts to limit psychiatrists to “medication management” so that less expensive professionals can provide adjunctive therapies. The treating psychiatrist bears some responsibility, however, for the appropriateness of the patient’s therapeutic options.⁶ According to Reid,¹⁷ psychiatrists are responsible for knowing something about the care, treatment style, credentials, and even ethics of those with whom they share treatment or to whom they refer patients.

The American Academy of Child and Adolescent Psychiatry (AACAP) Code of Ethics addresses the unique challenges encountered when a patient’s opinions differ from those of parents and other authority figures, such as school staff. The AACAP standards consistently direct the psychiatrist to keep the child’s interest primary, explaining that “the child and adolescent psychiatrist may be called upon to participate in attempts to control or change the behavior of children or adolescents…[but] the child and adolescent psychiatrist will avoid acting solely as an agent of the parents, guardians, or agencies.”¹⁸

Another triangle can occur when a treating psychiatrist serves as an expert witness or other evaluator for forensic or disability purposes. The American Academy of Psychiatry and the Law (AAPL) recommends that psychiatrists avoid acting as expert witnesses for their patients or performing patient evaluations for legal purposes.¹⁹ While recognizing that certain situations may require a psychiatrist to serve a dual role, the AAPL stresses that sensitivity to differences between clinical and legal obligations remains important.

Avoid serving as an expert witness for your patient. The intrusion of another role into the doctor/patient relationship can alter the treatment process and permanently color future inter actions. Likewise, treating an individual whom you previously evaluated for forensic purposes raises similar concerns, including the possibility of a mercenary motivation. Even when no such motivation exists, these situations can create the appearance that you have conscripted a vulnerable individual into your practice.

Emerging trends

Crossings vs violations. Efforts to distinguish when an action is unethical or illegal have led some to differentiate boundary crossings from boundary violations. Unfortunately, the 2 terms continue to be used synonymously, which confuses rather than clarifies the issue:

• Boundary crossings are aimed at enhancing the therapist’s treatment efforts—such as a hug instead of a hand shake at the end of a particularly difficult treatment session.
• Boundary violations are invariably harmful and unethical because they serve the therapist’s needs rather than the patient’s needs or the therapeutic process.²⁰

Rather than trying to differentiate between crossings and violations or to determine under what circumstances changing boundaries is acceptable, Sheets²¹ conceptualizes a boundary not as a line to cross, but as a continuum of behavior. Under-involvement is at one end, over-involvement at the other, and a “zone of helpfulness” is in the middle.