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, office 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. Am I right or are they?

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, but this is not so. Boundary violations can result from numerous types of "multiple" or "dual" relationships. Such relationships can occur anytime that a psychiatrist relates to patients in more than one relationship, whether professional, social, or business, in addition to being in the treatment relationship. Multiple or dual relationships can lead to allegations of taking 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 of intentions, if something goes wrong, there will be allegations that there were nontherapeutic motivations involved.

Specifically, psychiatrists are advised to avoid barter arrangements with patients or patients’ relatives, even if such an arrangement 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. Also, how will the barter arrangement be structured? Is one hour of therapy equivalent to one hour of work? What if the work is not acceptable?

Instead, psychiatrists are advised to consider working out a monthly 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.

Additional information can be found 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. ▪

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