When Being Human Is a Boundary Crossing
“Many people are so overwhelmed by the intensity and intimacy of the therapeutic relationship that they experience an otherwise inconsequential gesture or statement as a full-fledged romance or romantic intrusion.” —O.B. Caudill, quoted by Thomas Gutheil and Archie Brodsky, Preventing Boundary Violations in Clinical Practice
After a busy day in the office, a psychiatrist goes home to have dinner with her family. At 8 p.m., when the kids are settled into doing their homework, she returns a call from a patient from earlier in the day. To the doctor, this is merely an issue of time management. For the patient, it could seem like unusual behavior and be interpreted as a sign that the patient is either very special or very troublesome to the doctor.
Rising from her chair at the end of a session, a patient stumbles and loses her balance. The psychiatrist reflexively catches the patient’s elbow to steady her and leads her to the door with this support. This chivalrous gesture could leave the patient feeling either grateful to the doctor, romantically aroused, or intruded upon, depending on the patient.
Like many subtle boundary crossings, these examples demonstrate ways in which a psychiatrist may view his or her behavior as innocuous or helpful while a patient might perceive it as confusing, frightening, unwanted, or seductive. The psychiatrist may remain oblivious to the effect of his or her behavior unless the patient is brave enough to discuss what happened, which temporarily shifts to the patient the responsibility for managing the therapeutic relationship, a function ordinarily assumed by the psychiatrist.
Left unaddressed, the tension from these rifts in the therapeutic relationship occasionally lead patients to initiate a complaint to an ethics committee or a licensing board. A single hug initiated by a psychiatrist in celebration of a patient’s achievement, an exchange of a photograph of the psychiatrist so the patient can have a transitional object, or frequent phone contact outside of regularly scheduled sessions, while potentially therapeutic, can at times be perceived by the patient—and regulatory authorities—as inappropriate.
How might a psychiatrist behave in the fairly human ways in the above illustrations while fulfilling the expectation that his or her behavior not disrupt the treatment? Any time a psychiatrist’s behavior varies from its usual course, the psychiatrist should consider discussing it. As is often stated in residency training, “It’s not what you say (or do), it’s what you say (or do) next.” It may be useful to run through the following steps each time professional behavior falls outside the norm.
Reflect on what happened. How was this behavior different from the usual? Is there something about this particular patient that elicited unusual behavior? Is there something going on in the psychiatrist’s life that is shifting him or her away from standard practice? What are the ways the patient might perceive and respond to this departure from the norm?
Consider consultation. If the transference or countertransference feels unusual or intense, supervision may be beneficial. If the psychiatrist is vulnerable because of a life crisis, psychotherapy may be helpful. Seeking guidance, even if it’s just for reassurance, is always a good idea.
Acknowledge the boundary crossing to the patient as a way of inviting discussion. This might happen right away at the moment of the unusual behavior, such as, “I know I’m calling later than usual. I sometimes return calls in the evening so I can have dinner with my family.” Or it might happen in the next session or several sessions later if consultation is required.
Apologize if the patient expresses discomfort as a result of your behavior and invite further exploration. “I’m sorry that when I grabbed your elbow, it felt patronizing to you. Are there other times when you have felt patronized by me or by others?”
Psychiatrists are not automatons. It is inevitable that at times a psychiatrist’s behavior will surprise or upset a patient when it differs from expectations of how the profession behaves. Employing one’s observing ego to preempt departures from the norm when possible, reflecting on what precipitated a boundary crossing, seeking consultation, and discussing the interaction with the patient, including an apology if appropriate, allow the psychiatrist to reestablish his or her professionalism and restores equilibrium in the treatment relationship. ■
