Navigating Boundaries in the Context of Culture, Ethnicity, and Religion

A Muslim psychiatrist, prominent in the small Muslim community of the state in which he practices, was approached by Jay (fictitious name), a member of the same Muslim community who secretly identifies as nonbinary, to provide psychiatric evaluation and treatment to them (Jay’s pronoun). Jay had been reluctant to seek mental health treatment for themself and at least one other member of their family who is under their tutelage but was emboldened by their shared religion. The psychiatrist, however, is torn. While he understands the importance of offering care to individuals in his community who usually avoid mental health treatment, he wonders if he will be able to avoid boundary violations as he is bound to meet the potential patient(s) at community events.

Dilemmas such as these are not uncommon. Similar concerns arise in patient-psychiatrist relationships in which there is ethnic, religious, language, and cultural concordance, as well as in small rural areas where everyone practically knows everyone else. Issues of boundary crossings or violations are of primary concern, as well as the potential for breach of confidentiality.

Boundary crossings occur when a psychiatrist’s behavior deviates from the usual (and strict) professional conduct expected in a patient-psychiatrist relationship, often in a manner that does not harm but may in fact benefit the patient. In contrast, in boundary violations, such deviations from the norm are harmful and exploitative of the patient. They may be beneficial to the psychiatrist at the expense of the patient. Most psychiatrists are familiar with the slippery slope model of boundary crossings/violations taught in residencies, which has been misinterpreted by many psychiatrists to mean that all boundary crossings may lead psychiatrists down a slippery slope that ultimately ends in boundary violations. Consequently, psychiatrists avoid humane interactions with patients that fall out of the norm of usual psychiatric care such as accepting an inexpensive gift from a patient.

To address this quagmire, Richard Martinez, M.D., proposed a view of boundary interactions with patients that balances the potential of harm/exploitation of patients with potential benefits to patients, including improved therapeutic alliance. Behaviors such as sexual intimacy with or obtaining financial advice from a patient, attending a patient’s wedding or the funeral of a patient’s family member, making coffee for a patient, hugging a grieving patient, to mention a few, fall into categories proposed by Martinez and require the balancing described earlier. The context and the psychiatrist’s intention in adopting the atypical behavior are important considerations, but so is the patient’s (or other’s) interpretation of the psychiatrist’s behavior. Unfortunately, harm can occur to a patient despite a psychiatrist’s best intentions; thus, the psychiatrist must be at heightened alert whenever a boundary is likely to be or has been crossed, even when such crossing is likely to enhance the therapeutic alliance.

Back to Jay. The psychiatrist Jay approached is right to be concerned. In addition to the understandable discomfort that would arise whenever their paths crossed in community events, the risk of violation of confidentiality is high. Unlike other subspecialties of medicine, identifying someone as a patient, a breach of confidentiality, carries more weight and meaning when the physician is a psychiatrist.

Weighing the options in such cases and making a decision can be frustrating. On the one hand, attending Jay’s celebrations or family member’s funeral may enhance the therapeutic alliance; on the other hand, not attending may leave the impression that the psychiatrist does not care. There are other considerations as well—attending the funeral may have unintended consequences, including creating an erroneous perception of intimacy. Then, there is the added challenge of treating family members with similar reasons as Jay for seeing the psychiatrist. Also, purposely ignoring a patient in public may seem odd and culturally inappropriate.

Jay may not appreciate the challenges involved in their request of the psychiatrist. However, the relative scarcity of psychiatrists means that most psychiatrists face these kinds of scenarios and must therefore develop a plan for addressing them. For example, should the psychiatrist elect to honor Jay’s request, I recommend an initial appointment before accepting them as a patient, to discuss said challenges and establish a strict modus operandi, addressing areas such as how to relate with each other in public, the psychiatrist’s inability to attend important events concerning Jay or their family members, and other countercultural restrictions that a treatment relationship may engender. It would be important for Jay to understand the ramifications of their request in order to make an informed decision to proceed. Jay may ultimately elect to not receive treatment from the psychiatrist as a result, in which case the psychiatrist should encourage them to seek treatment and refer them to a trusted, culturally humble, and sensitive colleague. ■

Charles C. Dike, M.D., M.P.H., is chair of the APA Ethics Committee and former chair of the Ethics Committee of the American Academy of Psychiatry and the Law. He is also a professor of psychiatry; co-director of the Law and Psychiatry Division at the Yale University School of Medicine; and medical director in the Office of the Commissioner, Connecticut Department of Mental Health and Addiction Services.