Forensic, Boundary Concerns

Q. Is liability coverage for forensic services standard in all medical malpractice insurance policies?

A. The number of psychiatrists undertaking forensic work is increasing, and it is inevitable that lawsuits will follow. Accordingly, it is becoming increasingly necessary to carry malpractice insurance that covers forensic activities. Thus, it is recommended that psychiatrists involved in forensic psychiatry review their medical malpractice policy as not all insurance carriers recognize the specific exposures in the practice of psychiatry, and therefore some do not cover forensic services. The APA-endorsed Psychiatrists’ Professional Liability Insurance Program does include forensic psychiatric services in the basic policy.

For a copy of “Risk Management Practical Pointers for Psychiatric Forensic Practice,” visit the Web site of the Psychiatrists’ Program at www.psychprogram.com.

Q. I have treated a patient for a number of years; she is doing well, but needs continued treatment. The patient has always struggled with her financial obligation, but currently is very concerned about being able to continue to pay for treatment. She has asked if she could, on a temporary basis, work off a portion of her charges for each session. She has suggested cleaning my office, doing my shopping, filing, and so on. Initially I was opposed to her suggestion, but several of my colleagues do not think there would be a problem with such an arrangement. Would it be O.K. to agree to this arrangement?

A. This is just one example of the new frontier in boundary violations—those not involving sexual relations.

Most people think that the term “boundary violation” refers only to sexual relationships between a psychiatrist and a patient; this is not so. Boundary violations can result from numerous types of “multiple” or “dual” relationships. Such relationships can occur any time that a psychiatrist deals with patients in more than one capacity, blending the therapeutic professional relationship with social or business interactions. Multiple or dual relationships can lead to allegations that the psychiatrist took unfair advantage of the treatment relationship to exploit or otherwise further the psychiatrist’s personal, religious, political, or business interests. As a rule, once you are the patient’s psychiatrist, that is all you can be.

Since multiple or dual relationships with patients give the appearance of impropriety and raise the possibility of exploitation of the therapeutic relationship, psychiatrists are advised to avoid such relationships. Even if the psychiatrist has only the best intentions, if something goes wrong, the patient can easily allege that the psychiatrist was motivated by factors other than the therapeutic relationship.

Specifically, psychiatrists are advised to avoid barter arrangements with patients or patients’ relatives, even if such arrangements would benefit both the doctor and patient. As pointed out by the APA Ethics Committee, unless both parties to the barter arrangement report the value of the services received as income, the barter is illegal. Even if both parties report the barter arrangement appropriately, structuring such an arrangement is problematic. For example, in the scenario presented, is one hour of office cleaning equivalent to one hour of therapy? What if the patient’s work is not acceptable?

Instead, psychiatrists are advised to consider working out a payment plan to help patients meet their financial obligations. If this is unacceptable, the psychiatrist may need to consider termination of the treatment relationship and referral to community mental health services or other services that provide mental health treatment.

More information is available in the 2001 editions of the Ethics Primer of the American Psychiatric Association and Opinions of the Ethics Committee on the Principles of Medical Ethics With Annotations Especially Applicable to Psychiatry. ▪

This column is provided by PRMS, manager of the Psychiatrists’ Program, for the benefit of members. More risk-management information is available by visiting the Program’s Web site at www.psychprogram.com, calling (800) 245-3333, ext. 389, or sending an e-mail to [email protected]