Boundary Violation Issues and Risk Management Concerns In Psychiatry

This excerpt from a recent PLUS Journal article titled “Boundary Violation Issues and Risk Management Concerns In Psychiatry” (published in the September 2011 issue). Author Jonathan D Rubin from Kaufman Borgeest & Ryan LLP analyzes the risk management issues to consider when underwriting coverage for psychiatric professionals. From the article:

Boundary Violations

Transference and counter-transference are inherent in the issues related to boundary violations that occur in therapy. Psychiatrists will encounter patients who frequently exhibit borderline and narcissistic personalities. These patients can be prone to manipulate the relationship between the psychiatrist and patient and often view the relationship with their psychiatrist as involving issues of control and power. This dual phenomenon, which can occur together or apart in psychiatric treatment, needs to be recognized and promptly addressed in therapy. When it occurs, the ability of the psychiatrist to keep objective can be dangerously impacted and weakened if not handled correctly.


Examples of Boundary violations can include:

  • frequent changing of appointments
  • increasing appointments
  • setting up appointments at the end of session days
  • exchanging of gifts, going for coffee or meals outside of the session
  • hugging, holding hands, kissing, massaging the patient
  • treatment of friends and relatives
  • waiving of fees
  • allowing the patient to find out personal information about the provider such as if they have kids, where they went to school, where they went on vacation.

Other violations can include:

  • telling a client that you are angry at them
  • using self-disclosure as a therapy technique
  • having a client address you by your first name
  • accepting gifts
  • asking for favors
  • lending money
  • inviting clients to a party or social event
  • disclosing details of current personal stress to a client
  • making house calls to patients

These issues are also frequently seen, for example, in the topics related to whether sessions run overtime and when patients request additional time for treatment. Of course, sexual relations and sexual intercourse of any kind during treatment are among the most serious boundary violations. This list is by no means exhaustive but certainly highlights the areas where violations have and can occur.

It is a difficult situation where the provider wants to present a humane and humanistic environment in which the patient feels secure and comfortable in order that he can talk and share issues related to his current problems. This is a difficult balance of which the psychiatrist must always be aware and try to deal with in a way to keep professional boundaries at all times. Nevertheless, this balance is one that cannot be minimized, compartmentalized or compromised by crossing boundaries like the ones listed previously.

Where prescribing medications to patients can be a large component of the care, it is essential to stay consistent and keep a record of the dosages and what is being done. It is also important that there be frequent face-to-face treatment with the patient, especially with a patient on psychotropic medications. A psychiatrist should not be doing frequent phone sessions unless there are frequent in-person assessments which track the patient’s reaction to medications. In this context, a patient can seek to cross boundaries by requesting medications without the proper assessments as a favor or special consideration by the doctor. These types of manipulative requests must be resisted and denied.

Psychiatric Litigation

Psychiatric litigation is on the rise as are board complaints. As such, a standard of boundary maintenance is critical to each psychiatrist in the provision of care to his patients. A bright line approach of course cannot always be kept in place, but that is why a psychiatrist must have a support network in place and be willing to reach out to his insurance carrier or hotline where he can talk about troubling and difficult issues within the context of the client/patient relationship as these issues arise rather than after a problem occurs. Boundary violations may all be seen as a departure from traditional psychiatric care. In order to avoid dual relationships and boundary violations, it is critical that the provider develop a treatment care plan for the provision of care. It is important that a diagnosis be arrived at, and that the provider is aware of what this diagnosis means in the context of patient vulnerability and the patient’s attempts to manipulate or control the session or the doctor.

While every case is different, the standard of care remains the same and must be followed by the psychiatrist where he is aware of transference, counter-transference and boundary maintenance. As new doctor-patient relationships commence and proceed with treatment, the efforts by certain patients to test boundaries will occur. Doctors must be aware of these patients and the situations. In our experience, borderline patients are especially prone to test boundaries in an effort to control situations and manipulate the psychiatrist. The psychiatrist should not shy away from appropriate termination of a patient when a patient continually refuses to respect boundaries. Records maintained by the provider must indicate that conversations occurred regarding boundary maintenance. In the event of litigation, these records are critical to pointing out that boundary maintenance was something that the psychiatrist was aware of and attempted to maintain. These records are also critical in defending against claims of patient abandonment.


In terms of present versus former patients, once there is a termination or an ending to the therapeutic relationship, it is easier for a dual relationship to commence and boundary violations can become less paramount and important. However, even in these situations, it is always best to take a strict approach and try to avoid these relationships whether they are professional, business ­related, or romantic. Even if a relationship begins after proper termination and after the lapse of reasonable time, the psychiatrist remains vulnerable and the former patient may even then complain to a licensing board or may bring a malpractice lawsuit depending on the applicable statute of limitations (2~ years in New York, for example) to try to obtain money damages when these relationships sour. As these relationships started from a position of unequal strength and influence in connection with the provision of professional services, conflicts are much more apt to occur if a future relationship occurs.

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Midwest Golf Outing 2012 – Photos

The Midwest Chapter held its annual golf outing at Cog Hill Golf Club. Seventy-nine golfers participated on a gorgeous day for golf.

What’s Up at PLUS? Q2 2012

PLUS continues to focus on industry-leading programs, events, and initiatives to provide for and advance the professional liability insurance community. Here’s what we’ve been working on at headquarters over the past quarter…

25th Annual PLUS International Conference
Registration for the 2012 PLUS Conference is open!  The registration brochure should have arrived on your desk – You may also register on line at

The theme this year is Register now for the 25th Annual PLUS International Conference“Generations: Changing the Face of Professional Liability”, recognizing and celebrating 25 years of PLUS and its dynamic and evolving membership. Join us as we learn and celebrate with four generations in the workforce. 15 sessions in 3 tracks – Executive Liability, Errors and Omissions, and Emerging Issues & Hot Topics – provide great C.E. credit options for attendees.

Leadership Session & Strategic Planning
In May, the PLUS Board hosted a leadership session in Dallas. The session focused on strategic planning, and led to some points that the Board explored further at its meeting the following day. Watch this space and others for more information about the plan being developed.

Diversity Task Force
The PLUS and PLUS Foundation Boards formed a joint task force to address how we can become a more diverse organization and share lessons learned with the industry. We have engaged diversity officers at 3 insurance companies (Chubb, Travelers, and Chartis) to help us define our purpose and goals.

Global Growth
Recently PLUS has utilized a consultant to help us define and begin to undertake a global growth strategy. A business plan and preliminary budgets have been developed for implementation in 2013. Watch as we build on the success of our April events in Singapore and Hong Kong as we reach out to professionals in global international markets.

Chapter Events
Thirty-seven chapter events have been held in the first half of 2012. Regional events are a valued opportunity for quality education, timely information, and professional and business development.  Attendance at chapter events continues to grow, with registrations 25% ahead of last year.  Chapter involvement is an ideal channel for developing future leaders and recruiting new members.

Golf & Bowling Fund Raisers
Chapters continue to do their part to raise funds for the PLUS Foundation. In 2012, eight chapters will host golf outings and one chapter will host a bowling tournament to benefit the PLUS Foundation.

Over 1,000 professionals have attended PLUS webinars on Kidnap & Ransom, D&O/FDIC Claims, HIPAA, and D&O/FCPA. Upcoming webinars will address PLI exposures for insurance companies, D&O and the 10th Anniversary of SOX, and a year-end claims review. If you have an idea you’d like to see PLUS cover in a webinar click on the link in the title of this section.

PLUS University
The 2012 session of PLUS University is planned for August 20-21 at the Hyatt Regency in Chicago. Students receive a complimentary digital copy of the Fundamentals of Liability Insurance/CGL curriculum modules. PLUS will continue to enhance the format of PLUS University for 2013 and beyond.

Diamond Sponsors
PLUS recently added two additional Diamond Sponsors (Argo Group and Chubb), bringing us to 5 total Diamond Sponsors (with AXIS, Monitor, and Travelers). Call Executive Director Derek Hazeltine at 952-746-2580 for information about Diamond Sponsorships.

PLUS Curriculum Updates
We are in the midst of updating the PLUS Curriculum and RPLU exams, which will be an on-going process to ensure that material is fresh and relevant. Click on the title of this section for the latest listings of updated study material and exams.

Women’s Leadership Network
Upcoming WLN Regional Events are scheduled for September 4th in Los Angeles and October 4th in New York City (featuring Dana Perino:  Former White House Press Secretary and Co-Host of Fox’s The Five). Click on the link in the title of this section for details and registration information.

Foundation Conference Cause 2012: Ronald McDonald House Charities of Chicagoland
Now in its ninth year, the Conference Cause program is designed as a philanthropic outlet for professional liability practitioners – a way to give back to the communities where the PLUS Annual Conference is held. Make your contribution – financially or of your time.  All donations benefit the Ronald McDonald House Charities. Donate at the above link and/or email for information about the volunteer event taking place November 6th.

Thank you for your involvement with PLUS. If you have feedback on any of the above items please feel free to comment through this post or email us – we’re not putting our email addresses in here so we don’t get spammed, but you can find us here.