Evidence-Based Reviews

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

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Some boundary crossings are therapeutic, but beware the ‘slippery slope’ to violations.


 

References

Dr. M is facing financial challenges with his fledgling private practice and begins consulting at a weight loss clinic to supplement his income. He finds him-self attracted to Ms. Y, a weight-loss patient he is treating. They seem to click interpersonally, and he extends his office visits with her. Ms. Y clearly enjoys this extra attention, and Dr. M begins including personal disclosures in his conversations with her.

In his residency training, Dr. M was taught never to date a current or former patient, but he views this situation as different. Ms. Y is seeing him only for weight loss, and he rationalizes that he is providing her with medical care, not “psychiatric” care. On 2 occasions he gives her a limited quantity of benzodiazepines for mild anxiety, which he considers a transitory stress-related condition and not an “official” DSM-IV-TR disorder.

Eventually, Dr. M asks Ms. Y to dinner and she accepts. After they begin dating, he decides to transfer her to another clinic physician “just to be safe.”

Although many psychiatrists assume that psychiatrist/patient boundaries are well defined by ethical and legal standards, boundary issues are a complex and controversial aspect of clinical practice. Psychoanalysts initially defined psychiatrist/patient boundaries as a way of structuring the unique and intimate relationship that evolves during analysis.1,2 The introduction of other therapeutic techniques and changes in health care funding have combined to make psychiatrist/patient boundaries far more complex.

Boundary violations are about exploitation. Both the American Medical Association (AMA) and the Canadian Medical Association warn members to “scrupulously avoid using the physician/patient relationship to gratify their own emotional, financial, and sexual needs.”3

Boundaries represent the edge of appropriate behavior and serve 2 important purposes:

  • They separate the therapeutic relationship from social, sexual, romantic, and business relationships and from relationships that transform into caretaking of the psychiatrist by the patient.
  • They structure the professional relationship in ways that maintain the identity and roles of the patient and the professional.4

Psychiatry’s unique dilemmas

As are all physicians, psychiatrists are governed by the 9 biomedical ethics set forth in the AMA’s Principles of Medical Ethics. The American Psychiatric Association (APA), however, acknowledges that psychiatry has a “broader set of moral and ethical problems and dilemmas” that are unique to and magnified by the mental health setting.5 The APA has adopted 39 standards in addition to those set forth by the AMA. The first standard captures the unique responsibilities inherent in the psychiatrist/ patient relationship: A psychiatrist shall not gratify his or her own needs by exploiting the patient (Box).6

Sexual contact with patients is inherently harmful to patients, always unethical, and usually illegal.7 The rate of sexual misconduct among psychiatrists is unknown. National Practitioner Data Bank information is not available to the general public.8 Based on literature reviews and data from individual states9,10 and government agencies,11 an estimated 6% to10% of psychiatrists have had inappropriate sexual relations with patients.12 Estimates of sexual misconduct by psychiatrists:

BOX

Psychiatrist/patient boundaries: What the APA says

All physicians are required to practice in accordance with the American Medical Association’s Principles of Medical Ethics. Because these guidelines can be difficult to interpret for psychiatry, the American Psychiatric Association provides further guidance with The Principles of Medical Ethics with Annotations Especially Applicable to Psychiatry. The following excerpts from annotations to the first 2 principles spell out the basic concepts underlying appropriate psychiatrist/patient boundaries:

‘A psychiatrist shall not gratify his or her own needs by exploiting the patient. The psychiatrist shall be ever vigilant about the impact that his or her conduct has upon the boundaries of the doctor/patient relationship, and thus upon the well-being of the patient. These requirements become particularly important because of the essentially private, highly personal, and sometimes intensely emotional nature of the relationship established with the psychiatrist.

‘The requirement that the physician conduct himself/herself with propriety in his or her profession and in all the actions of his or her life is especially important in the case of the psychiatrist because the patient tends to model his or her behavior after that of his or her psychiatrist by identification. Further, the necessary intensity of the treatment relationship may tend to activate sexual and other needs and fantasies on the part of both patient and psychiatrist, while weakening the objectivity necessary for control. Additionally, the inherent inequality in the doctor-patient relationship may lead to exploitation of the patient. Sexual activity with a current or former patient is unethical.’

Source: Reference 6

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