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Boundaries

We are all familiar with the notion of boundaries in clinical practice – in fact, most of us have spent a lot of time thinking about the subject and trying to work out where our professional boundaries lie.

If your peer group is like mine, the value of boundaries and what does or does not constitute a violation of them is a frequent topic of conversation.

What constitutes a boundary violation?

Most of us (though unfortunately not all) choose not to have an intimate relationship with the people we see professionally. But would you accept an invitation to a patient’s wedding? Would you go for coffee with a client if you ran into them in the street or have a drink with them if you encountered them in a bar? Would you go to the opening of their art exhibition, attend their creative writing workshop or use their plumbing services?  It gets complicated doesn’t it?

For most of us the answer to ALL the above questions is a pretty firm and absolute NO. However, sometimes circumstances make it very difficult to maintain strong boundaries.

What if your patient Jim is the only plumber in town? You have known Angela professionally for 20 years and spent a long time in your consultations with her encouraging her artistic ambitions. What if she wants you to see the works she has produced with your encouragement? What if you are a single woman working as a GP in a small rural town and the only men you meet are the ones who come to see you as a patient?

Surely the same rules don’t apply to GPs!

There is a difference between being a GP and being a therapist when it comes to boundaries – but not much of a one. GPs often have enough knowledge of their patient’s life circumstances and emotional states to complicate any kind of social or emotional involvement outside of work, to interfere with objectivity and to create a power imbalance.

Decisions about where boundaries lie depends on many variables including the nature of the professional interaction, the practitioner’s level of training and skill and the mental health needs of the patient/client.

What about phone calls, text messaging and email?

 Most people would (and do) recoil at the idea of giving patients/clients their mobile phone number. That’s a perfectly reasonable boundary to set. However, practitioners trained to deliver dialectical behaviour therapy provide their mobile phone number as a matter of course so their patients/clients can ring for support when they need it. It’s part of the therapy model but it is bounded by its own set of rules including the fact that the practitioner’s role in those circumstances is only to remind their patient/client to use the coping skills they have learnt in face-to-face therapy sessions. The boundaries are there – they are just sitting in a different place.

Generally, someone declaring their romantic interest in a doctor or therapist would be reason to end the professional relationship. In a recent case in Victoria that is not what happened. A psychiatrist with a respected history of managing treatment resistant conditions chose to continue treating a patient who had revealed erotic feelings towards him. A subsequent complaint against him by the patient to the Victorian Civil and Administrative Tribunal for violating boundaries in caring for her based on his use of text and email messaging was not upheld.

The Tribunal found that the practitioner had been very clear in articulating where the boundaries lay, that he had faultlessly documented all communication with the patient (they do actually look at all your phone and email records when investigating a complaint like this) and that the clinical purpose of these communications had been satisfactorily explained.

The other side of the coin

There is also the boundary that prevents us from seeing our good friends and family members as patients or clients to consider. Apart from the risks inherent in keeping secrets to protect the friendship there’s a real danger of objectivity flying out the window. It’s not always possible, especially for GPs, to avoid this situation, but the general rule is the closer you are personally to someone the more important it is not to be their therapist.

References:

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Dr Jan Orman

Jan is Sydney GP, private psychological medicine practitioner in Sydney’s inner west and a GP educator for Black Dog Institute.

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