Boundary Issues of Concern

Psychiatrists in practice or in training are well aware of one of the golden rules regarding boundary violations: Thou shall not sleep with your patient. American psychiatry is more conservative than other medical specialties in this regard in that the prohibition is lifelong regardless of the duration of treatment with the patient. American psychiatry is also unique in that the same indefinite prohibition bars psychiatrists from engaging in intimate relationships with their patients’ close family members and friends.

There are, of course, less prominent but equally serious boundary violations other than sexual relations with patients or a patients’ relatives. The case of Dr. Jerome Oremland, a prominent California psychiatrist, is one example. According to a report by KQED on October 3, 2016, John Pierce, a patient, alleged that his psychiatrist, Dr. Oremland, induced Mr. Pierce to give him at least 12 works of highly valued art. The psychiatrist argued that the patient had consented to their business dealings and that the art he had received from the patient was given willingly as payment for psychiatric treatment. The patient further alleged that Dr. Oremland used many of their sessions to solicit art, propose financial schemes (including investments), and discuss other subjects unrelated to treatment. Furthermore, the patient allegedly made repairs in Dr. Oremland’s home, offices, and rental units; helped clear out the home of Dr. Oremland’s deceased brother; and cleaned his pool. Mr. Pierce began therapy with Dr. Oremland in 1984 but brought a lawsuit against him in 2015. The court trial began shortly after Dr. Oremland’s death in 2016, and Dr. Oremland’s estate eventually settled with Mr. Pierce. In addition to being a private practitioner, Dr. Oremland had been chief of psychiatry at the Children’s Hospital in San Francisco and a clinical professor of psychiatry at UCSF. He also wrote books on the intersection of art and psychology.

The familiar case of Dr. Isaac Herschkopf is another example; he was the subject of a Wondery podcast series turned into TV comedy series titled “The Shrink Next Door.” Dr. Herschkopf was accused of exploiting his patient Marty Markowitz for personal gain over three decades. In April 2021, the New York Department of Health revoked Dr. Herschkopf’s medical license. In a later lawsuit, Dr. Herschkopf was found guilty of 16 charges of misconduct, including negligence, moral unfitness, fraudulent practice, and exercising undue influence, which were all related to his work as a psychiatrist.

There are less dramatic but still problematic boundary crossings such as when a psychiatrist in private practice agrees that a patient may pay off treatment costs by doing some work for the psychiatrist. Other examples include a psychiatrist hiring a patient, for example, a skilled plumber, to work in the psychiatrist’s office or home at the patient’s going rate or obtaining investment tips from a successful investment banker patient. In these situations, questions arise about the physician-patient relationship. Even when the psychiatrist believes he or she is treating the patient fairly—such as paying the going rate for work done for the psychiatrist—the psychiatrist is clueless regarding how the patient is interpreting the arrangement: Does the patient experience it as exploitative? What are the patient’s unspoken expectations? What if the patient’s work in the psychiatrist’s office is inferior or the investment advice results in a loss? Would these outcomes influence the physician-patient relationship? Even compassionate acts such as writing off the bill of patients who are unable to pay or paying for an indigent patient’s medications should make the psychiatrist pause for thought. To avoid potential misinterpretation of the psychiatrist’s intentions or complaints of inequitable practices or favoritism, the psychiatrist should be ready to do the same for other indigent patients. It would be better to establish neutral policies for all indigent patients than to appear to favor some over others.

Regarding social media, I am still surprised to hear of psychiatrists who are friends with their patients on Facebook, Instagram, Twitter, or the like. Even communication by text or email can be problematic. These connections blur the boundaries of the physician-patient relationship and could induce patients to believe they have a more personal relationship with the psychiatrist than is realistic or warranted.

Further, issues of privacy, security, and expectations regarding response times are additional concerns. Patients who send an email or text may expect an immediate response, and any delay in response could be negatively interpreted. While friending patients on social media sites is more fraught with ethics breaches, communication by email or text must be carefully managed so as to leave no room for misunderstanding by the patient. In addition, these communications should be documented in the patient’s treatment record.

Finally, boundary issues can also occur between work colleagues. Psychiatrists, regardless of gender, have gotten into trouble for complimenting colleagues for their appearance or blowing kisses their way. It is much better to keep interactions professional and to confine compliments to the work habits, talents, or skills of co-workers.

In summary, psychiatrists should be alert regarding the possibility of boundary violations when interacting with patients and colleagues. Boundary issues are not always unethical per se, but they should never be undertaken without some reflection. These are just some questions to keep in mind: Whose best interest is being served? What are the psychiatrist’s motives? Is there a risk of harm to or exploitation of the patient or gratification of the psychiatrist? ■

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 an associate professor of psychiatry and co-director of the Law and Psychiatry Division at the Yale University School of Medicine.