An underdiscussed professional issue that can put psychiatrists in
career-damaging situations is where to draw boundaries in nonprofessional
relationships with former patients.
The complexities of personal, professional, business, and community
relationships with former patients can affect psychiatrists criminally and
financially, as well as undermine their professional standing, according to
experts speaking at a symposium at APA's 2008 annual meeting in Washington,
D.C., in May.FIG1
The APA ethics guideline barring posttreatment romantic relationships
leaves unclear the many other possible posttreatment circumstances that
psychiatrists can face, such as unplanned interactions with former patients in
small-town settings where it is impossible to avoid such encounters, for
Addressing complexities in posttreatment relationships between
psychiatrists and their patients are (from left) Carl Malmquist, M.D., Malkah
Notman, M.D., Linda Jorgensen, J.D., and Elissa Benedek, M.D.
Credit: David Hathcox
"This is an issue that doesn't get a lot of discussion," said
Malkah Notman, M.D., a professor in the Adult Psychiatry Residency Program at
Cambridge Health Alliance and a consultant to APA's Ethics Committee, who
paraphrases the ethics ban on posttreatment sexual relationships as"
once a patient, always a patient."
This posttreatment ban "doesn't address the range of posttermination
relationships," she said.
Of course it is broadly accepted that posttreatment sexual relationships
between a physician and his or her former patient are unethical. But does the
same rule hold true about business dealings with former patients, for example?
Similarly murky is the question of whether psychiatrists can accept barter in
lieu of cash as payment for treatment.
"The key issue is [whether it is] exploiting a patient," Notman
said. But, even that standard "leaves some of these issues
Among the most ambiguous relationships are those entered into during
hospital stays, when a physician may only have brief contact with another
doctor's patient. The rules on posttreatment relationships also can be muddied
by former patients who were previously colleagues or social acquaintances.
Notman noted that one-time consultations for therapy and one-time medical
compliance checkups have much less impact on patients than long-term treatment
Linda Jorgenson, J.D., a Massachusetts attorney who has represented many
individuals allegedly abused by their psychotherapists, said the central issue
for current and former patients is the power imbalance between doctor and
patient. Patients' vulnerability requires boundaries to protect the
therapeutic process and to keep them safe, she said.
So what is the rule in a case in which a former patient seeks a
relationship with his or her physician years after the physician-patient
relationship has ended? Jorgenson said the safest thing to do is to"
forget it." Although such relationships are unlikely to end up in
a catastrophic legal case, they can. Even happy relationships can end with one
party nursing a grievance that "raises all sorts of
possibilities," in terms of the legal fallout.
Jorgenson noted that the standard that translates as "once a patient,
always a patient," in terms of romantic relationships, creates a legal
danger for psychiatrists, especially because it is much stricter than
standards used by other professionals in mental health care. Some states have
criminalized such relationships, and they have become grounds for a civil
lawsuit or loss of medical license.
Elissa Benedek, M.D., a clinical professor of psychiatry at the University
of Michigan Medical Center and a past president of APA, said most of the cases
dealt with now fall into the "gray area" of ethics guidelines and
the law because the most egregious cases of patient abuse seem to have
occurred much more often in previous decades, while today are much more
Although posttreatment relationships are full of gray areas, Jorgenson said
one issue on which psychiatrists should draw a clear line is bringing a former
patient into their home. She described one recent case in which a former
patient was hired to work as a psychiatrist's nanny, and she later sued for
over $1 million after there was a falling out.
Financial collaborations with former patients should be avoided, Notman
maintained. She also advised against seeking or accepting investment advice
Notman also suggested that psychiatrists reference a key resource that
comes with APA membership, namely APA's Principles of Medical Ethics With
Annotations Especially Applicable to Psychiatry.
Or they can contact a member of APA's Ethics Committee or the staff member
who coordinates the work of that committee, who will refer a member to the
relevant APA guideline. ▪