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:
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 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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