Boundary violations and departments of psychiatry

Abstract

Objective: To explore a number of issues related to boundary violations in psychiatry, including the relationship between the individual physician and his or her patient and broader issues related to various dilemmas arising in academic departments of psychiatry.

Method: Several potentially troublesome scenarios are presented and discussed in the contexts of 1) the doctor-patient relationship, 2) sexual boundary violations, and 3) nonsexual forms of exploitation, such as finances, confidentiality, dual relationships, and relationships with industry.

Conclusions: A number of examples of boundary problems involving psychiatrists have been explored, and although some of these behaviours are clearly forbidden and harmful, others are less clear and require careful consideration if the profession is to arrive at a thoughtful consensus.

PIP: Trust, integrity, and a commitment to the patient's needs and well-being are essential to effective psychotherapy. Psychiatrists with poor impulse control, exaggerated views of their own specialness, excessive needs for affirmation, or unacknowledged longings for care and nurturance are at risk of succumbing to the intimate enticements of the psychotherapeutic relationship. Academic departments have a responsibility both to prevent and respond to transgressions of professional boundaries and to develop a consensus regarding the parameters of professional conduct. The capability of psychiatrists to serve as effective role models for their trainees may be nullified by the failure to address boundary issues. This article presents examples of boundary problems potentially encountered by psychiatrists. Although sexual contact represents the most extreme and publicized form of boundary violation, nonsexual forms of exploitation involving finances, confidentiality, dual relationships, and relationships with the pharmaceutical industry also are salient. A significant factor in the occurrence of boundary violations is the view that one is "above the rules" and entitled to broaden the parameters of physician privilege and professional conduct.