Be Prepared to Set Limits Before Boundary Is Reached

Sadly, somewhere, sometime, Dr. Sick, Dr. Predator, and Dr. Hysteric are in.

Such are some of the shorthand names that Thomas Gutheil, M.D., a forensic psychiatrist and professor of psychiatry at Harvard Medical School, gives to psychiatrists who violate the boundaries between patient and therapist.

Credit: Ellen Dallager

Not all boundary violations in psychiatry have to do with sex, although that topic still dominates ethical issues in psychiatry, said Gutheil at APA's 2010 Institute on Psychiatric Services in Boston in October. And not all boundary violations are initiated by physicians; patients cross lines as well. Some accusations are false, but an added burden falls on psychotherapists to avoid any real or perceived boundary violation because of their codes of professional ethics and the need to maintain a high level of trust between therapist and patient for a successful therapeutic alliance.

Violations of the line between personal and professional behavior come in two degrees, said Gutheil. Boundary crossings occur when the therapist simply steps out of the therapeutic role. Offering a tissue to a sniffling patient may not be therapy, but it is good manners, he said. Boundary violations, however, are actions that exploit and harm the patient and often impair therapy.

The list of ethical complaints patients have leveled at psychiatrists in recent years includes accepting gifts from patients, taking the patient to lunch, asking the patient for advice (often financial), offering gifts for referrals, revealing too much personal information, accepting a party invitation, and joining the patient's book group.

With regard to psychiatrists' revealing too much about themselves, he said, “Every self-disclosure burdens the patient and reverses the parties' roles.”

In general, boundary violations occur when behavior occurs outside the time, place, or activity appropriate to therapy, he said, drawing on years of court testimony and consultation to cite the potholes on the road to professional ruin.

“Start by asking yourself, ‘Is this what a therapist does?’” he said.

It also means not engaging in a unique therapy (that is, a therapy that other psychiatrists do not do), so that the therapy becomes more important to the therapist than to the patient.

Extra-long sessions or those at odd hours, like 2 a.m. to 6 a.m., are also unwise. Places other than office settings are poor choices to hold therapy sessions—restaurants and automobiles are examples, said Gutheil. Intense conversation in such locations gives the appearance of being on a date.

If a blizzard or other extraordinary circumstance leads to offering the patient a ride, for example, Gutheil urged retaining a professional demeanor, documenting the encounter the next day, and discussing it with the patient at the next office visit: “What was it like for you to ride in a car with me?”

Money can sometimes be an issue as well. “Forgetting” to charge for therapy raises the question of whether the therapist is getting paid in a less impersonal currency.

“Always document the circumstances and rationale for not charging a patient if you decide to treat without payment,” said Gutheil.

Psychiatrists should not hug patients, he said, blaming the 1960s therapy guru Leo Buscaglia for starting that unwelcome trend. The only exception might be for HIV-positive patients for whom a modest, nonsexual, physical contact, like a handshake or pat on the shoulder, can lower the patient's sense of shame or stigma.

Reports of sexual misconduct by psychiatrists with patients have decreased because of increased ethical sensitivity to such behavior and publicity surrounding cases that get into the media. Psychiatrists are more aware today that such behavior is always wrong and that they can lose their licenses over it.

Nevertheless, some members of state regulatory boards still overreact to accusations of boundary violations, harboring suspicions of sex between doctor and patient foremost in their minds, said Gutheil. For instance, merely using a patient's first name has been construed as sexual misconduct by some boards, while others see any last appointment of the day as a likely sexual encounter, he said.

Sexual misconduct may have declined, but it has not disappeared. There are no excuses, because the therapist can never blame a seductive patient, said Gutheil.

“If both parties are competent adults, both are responsible for their actions, but only the therapist is liable for a violation because only the therapist has a professional code of conduct to be violated,” he said. Therapists are required to place the needs and interests of patients ahead of their own.

Those who don't have earned places in Gutheil's lexicon of shame.

On the male side, “Dr. Loman” (named after the protagonist in “Death of a Salesman”) is going through a midlife crisis and deals with it by falling madly in love with a patient. “Dr. Sick” is characterized by an Axis I problem, hypomania, grandiosity, and often stimulant abuse. “Dr. Predator” is psychopathic, exploiting multiple patients in multiple ways—physically, socially, financially, sexually. “Dr. Weird” is schizoid and paraphilic.

Nor are female clinicians exempt, said Gutheil. “Dr. Hysteric” has unresolved Oedipal conflicts and gets involved with male patients. “Dr. Mother” is a lesbian who gets involved with female patients, in a relationship that is first nurturing and later sexual.

Problems can also arise from the patient's side, too. Patients may falsely accuse therapists out of revenge or retaliation. In one case, a patient threatened to file a charge of molestation against a psychiatrist if he didn't change the diagnosis in the chart.

When cases of eroticized transference arise, the therapist should seek supervision. Reporting the problem removes it from the realm of the guilty secret, and the therapist also may get specific suggestions for defusing the problem. If false claims do arise, it may help to show that the clinician sought help beforehand.

The best defense is prevention, and that should begin in training, said Gutheil. He bemoaned the decline in psychodynamic training that followed the rise of biological psychiatry and psychopharmacology.

“I don't care what your ideology is, you need to teach transference and countertransference to your trainees,” he said. “It's part of their equipment for the real world.”

Trainees should also learn about legal and clinical pitfalls and to be alert to “exceptions” from their standard practices.

“Be clear in your own mind when it's time to set limits, and prepare responses in advance for when those limits are reached,” he emphasized.