Ethics Commentary: Psychotherapy: Professionalism, Boundaries, and the Therapeutic Relationship

Healing is the heart of medicine and, by definition, is the central commitment of the therapeutic relationship. In psychiatry, the therapeutic relationship can become deeper and richer in its meaning and influence. The special quality of the therapeutic relationship in psychiatry derives in part from the nature of mental illnesses that carry with them great anguish. The personal suffering associated with mental disorders, related conditions, and difficult life events that bring a patient into the care of a psychiatrist can be immense, cause a profound sense of vulnerability, and may be poorly understood by others—even among those closest to the patient. The therapeutic relationship in psychiatry, particularly but not exclusively in the context of psychotherapy, is also distinct in the House of Medicine because the psychiatrist uses not only special expertise but also the sequence of interactions between psychiatrist and patient—truly the dynamics that exist in the relationship itself—in the service of bringing about greater health in the patient. For these reasons, healing in psychiatry arises through trust in the psychiatrist and the aim of the therapeutic relationship is dedicated to the patient’s well-being.

Professional boundaries are the guidelines for the behavior of the psychiatrist in establishing a trusting therapeutic relationship with the patient. Boundaries help demonstrate that the aim of the relationship is solely to help the patient. Predictability in the frame of the relationship fosters this aim and safeguards against potential harms, that is, it fulfills the ethical principles of beneficence and nonmaleficence. For example, in the practice of psychotherapy, meeting in a consistent place and for a well-defined amount of time and having consistent routines for communication outside of individual sessions are behaviors that work together to convey a sense that the professional is reliable and responsible—worthy of the patient’s trust. These behaviors help create a context in which the patient may more freely share thoughts, memories, emotions, and private concerns, necessary for the therapeutic process. Stated differently, frequent changes to the meeting place, times, and forms of communication may convey to the patient that his or her well-being is not as important as other competing demands in the professional’s schedule. The patient may feel uncertain of the professional’s sense of commitment to the patient’s care and implicitly may suggest that the psychiatrist’s interests, not the patient’s advancing health and well-being, are dominant in the relationship.

The need to communicate—through word and deed—the sole intent of helping the patient is the reason why other kinds of transactions are, in the main, incompatible with the therapeutic relationship. It is understood and correct that professionals in our society receive fair compensation for their services. Beyond this exchange, however, financial interactions should be avoided and, similarly, interactions that are social in nature should be avoided or, at worst, limited. In smaller or closed settings, such as in rural areas, college campuses, military or veteran settings, and distinct religious or cultural communities, some overlapping relationships may be difficult or impossible to avoid, and in such situations extra efforts to safeguard the professional role and the beneficent intent of the therapeutic relationship will be necessary. Irrespective of setting, sexual interactions are not ethically acceptable in the context of therapeutic relationships and are considered professional boundary violations because, by definition, the interests of the therapist, rather than the patient’s interests, come into play. More strongly, when therapeutic and sexual relationships overlap, the gratification of the therapist comes at the cost of exploitation of the patient, and such actions absolutely rupture trust in the therapeutic relationship, damage the well-being of the patient, and may lead to allegations of professional misconduct of the physician. This prohibition of a romantic or sexual relationship between physician and patient, as a fundamental commitment in professional ethics, is held across all fields of medicine.

Crossing of professional boundaries sometimes occur in the context of a therapeutic relationship. The meaning and impact of these boundary “crossings” will differ according to the kind of interaction, its intent, and the resilience of the relationship. A geriatric psychiatrist who visits and holds the hand of his medically ill patient on a hospital unit is crossing usual professional boundaries, but it is a compassionate and kind action, serves the well-being of the patient by providing comfort in a time of exceptional distress, and is ethically acceptable. Offering a very nervous patient a cup of tea at the beginning of a therapeutic interaction may help put the patient at ease, but the astute clinician will recognize that the patient may experience the interaction as more “social” than “medical”—and there may be an unexpected “side effect” of this therapeutic “intervention.”

Another illustration of a behavior that is considered a boundary crossing is self-disclosure by the psychiatrist in a therapeutic dialogue with a patient. If the self-disclosure seeks to create a greater sense of empathic connection with the patient, then the crossing is essentially a technique with a positive purpose in the treatment of the patient. If the self-disclosure is driven by the need of the psychiatrist to deal with his own feelings of anxiety or self-worth, aroused by issues that are emerging in the therapeutic dialogue, then the boundary crossing is a potential professional concern. A robust therapeutic relationship will certainly survive such crossings, but they should be a signal to the psychiatrist that he or she might benefit from supervision or guidance from a wise colleague. If boundary crossings become a repeated pattern and relate to the needs of the therapist rather than serve the well-being of the patient, then this behavior is more appropriately viewed as a boundary transgression or violation because of the potential for harm.

Gifts in the context of the therapeutic relationship pose interesting ethical dilemmas, and with greater appreciation of issues arising in cross-cultural medicine, the “requirements” related to professionalism are no longer as certain as in the past. On the one hand, it is well established that very elaborate or expensive gifts are not ethically permissible in the therapeutic relationship because “pleasing” or specially “rewarding” the physician is not a legitimate aim of care. On the other hand, in certain cultures, the giving of symbolic gifts is central to demonstrating respect and is the act of a person with self-respect. To turn away such a gift would create damage in the therapeutic relationship and undermine the goal of advancing the health and well-being of the patient. In other situations, however, accepting a gift may connote a special “deal” or “understanding” between a physician and patient and may set in motion a dynamic that does not facilitate the good of treatment. Careful consideration must be given to gifts and how they enter the therapeutic dynamic between physician and patient, keeping in mind that a boundary crossing may quickly become a boundary violation with damaging effects.

Practitioners and ethicists alike think about the variations in therapeutic relationship that may have ramifications for the professional boundaries. For instance, are the expectations surrounding boundaries the same in the care of children or elders as they are in the care of adults? Do the boundary expectations change when a therapeutic interaction occurs on a single occasion—for instance, with a brief evaluative consultation in a primary care setting—as opposed to a long-term psychotherapy relationship with multiple interactions? Are the expectations the same for supportive therapy as they are for psychoanalysis? Are expectations different when patients come from special cultural backgrounds where, for instance, gift-giving is customary when dealing with professionals? Should earlier career physicians be held to the same expectations as later career physicians? The answers may seem obvious—but perhaps not to all who have opinions and a legitimate “stake” in the health professions. In recent national discussions, for instance, physicians have raised whether it could, under some circumstances, be ethical to have a romantic relationship with a patient whose care ended years before. In education circles, interesting issues surrounding standards for physicians’ professional appearance (e.g., tattoos, piercings) have challenged traditionally-held views of the role and identity of the clinician and therefore professional boundaries. In evaluating each of these variations, expectations for professional boundaries, that is, behaviors of the physician in the therapeutic relationship, should be governed by the commitment to advance patient health and well-being.

Professionalism in the therapeutic relationship necessitates adherence to ethical standards that are based on principles such as beneficence and nonmaleficence. Applying these rather abstract concepts to real situations can be challenging—perhaps vexing, even—and yet therapeutic boundary keeping is a clear example of how ethical principles can be thoughtfully translated to professional practices. Adherence to the paired principles of beneficence and nonmaleficence ensures that the therapeutic relationship remains ethically grounded and further instantiates the role of the physician as healer.

Q&A

• 1. Which of the following pairs of ethical principles should govern professional boundaries in the therapeutic relationship?

  	A.	Beneficence and Justice
  	B.	Beneficence and Nonmaleficence
  	C.	Compassion and Nonmaleficence
  	D.	Compassion and Veracity
  	E.	Nonmaleficence and Veracity

• In the following questions, indicate whether a psychiatrist accepting the gift, in each of the circumstances described below, is a boundary crossing or a boundary violation:

  	A.	Boundary Crossing
  	B.	Boundary Violation

• ______2. A Navajo patient offers the turquoise and silver necklace that she is wearing as a gift after receiving a compliment from her psychiatrist.

• ______ 3. At her third session, a shy 8-year-old child with anxiety tentatively offers her drawing as a gift to her psychiatrist.

• ______ 4. An elder patient brings home-baked nutbread to her psychiatrist at the winter holidays.

• 5. Under which of the following circumstances is sexual contact between a psychiatrist and patient seen as ethically permissible according to the American Psychiatric Association’s Principles of Medical Ethics With Annotations Especially Applicable to Psychiatry?

  	A.	Always
  	B.	When the psychiatrist and patient have terminated their therapeutic relationship
  	C.	When the psychiatrist and patient mutually consent to the sexual relationship
  	D.	Never

Answers : 1 B; 2 B; 3 A; 4 A; 5 D