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Be mindful of health professional/patient relationship boundaries

Elyse Sunshine
Lonny Rosen

By Elyse Sunshine and Lonny Rosen

A health professional is in a position of power and trust and must establish and maintain appropriate professional boundaries with patients. As such, health professionals must be aware of the required social, physical or psychological boundary or “space” needed between the professional and the client or patient. Most regulatory authorities recognize two types of boundary transgressions: crossings and violations. Boundary crossings can sometimes occur through misunderstandings and carelessness. Boundary violations are harmful and exploitative acts. Below are a few recent examples where boundaries were crossed or violated:

- A psychiatrist voluntarily surrendered her licence after pleading no contest to allegations of professional misconduct, including that she failed to maintain appropriate boundaries with her patients. The psychiatrist had hired one of her patients to act as her own private nurse after she had surgery and offered to rent her home to her, and had other patients run errands for her, including picking up medication and groceries. These were all boundary crossings in which the psychiatrist took advantage of the patients, and were considered by the Discipline Committee of the College of Physicians and Surgeons of Ontario (the CPSO) to be failures to meet the standard of practice as a physician and a lack of skill and judgment as a therapist.

- A medical esthetician and receptionist in a cosmetic surgeon’s office was also the surgeon’s patient. The Inquiries, Complaints and Reports Committee (the Committee) concluded that the surgeon “clearly crossed boundaries in treating someone who was an esthetician/receptionist in his office for many years” and that he “exhibited poor ethical judgment.” The surgeon was given an oral caution and required to complete a specified continuing education or remediation program (SCERP).

- Recently, the Discipline Committee of the College of Physicians and Surgeons of Ontario found that a psychiatrist had committed an act of professional misconduct in that she engaged in sexual abuse of a patient. The boundary issues began when, during an appointment with a patient, the psychiatrist began to cry and disclosed to her patient her marital problems. The patient was unsure what to do and gave her a hug. Later he invited the psychiatrist to his house to have dinner with him and his wife. She accepted. The two began to see each other socially. The relationship escalated to a sexual relationship over a period of four years, while the psychiatrist was still treating the patient. Following an investigation, the Discipline Committee ordered the Registrar to revoke the psychiatrist’s certificate of registration and she was to appear before the panel to be reprimanded.

In another case, a psychologist’s patient made a complaint to the College of Psychologists of Ontario (the CPO) regarding certain concerns he had during his treatment. The Committee considered the complaint and issued advice and two cautions to the psychologist. One caution related to professional boundaries. Two years later, the psychologist sent an aggressive message to the same patient’s wife on Facebook after reading a negative review on the website RateMD (alleging it was the patient who wrote the review). The psychologist also responded aggressively to the complaint on RateMD. The Committee characterized the psychologist’s communications as “demonstrating a pattern of engaging in boundary violations.” The Committee issued a caution and required the psychologist to complete a SCERP. The Health Professions Appeal and Review Board confirmed this decision.

Why these boundary crossings were harmful

The common element in cases where boundary crossings result in discipline or remedial measures such as cautions and SCERPS is that they result in a risk of harm to the patient or client or to the professional-patient relationship, and it matters not whether the treatment relationship commenced after the social/employment/other relationship. The currency of dual relationships can always result in boundary crossings.

The CPSO Discipline Committee noted that even though the psychiatrist in the first example stated that there “is no pressure” for the patient to accept her offer to be her nurse, the therapist-patient relationship resulted in an inherent pressure that could not be eliminated. The risk of harm from employing or offering to rent a home to a patient was that tension in that relationship could result in tension within the professional-patient relationship and an ultimate severing of same, to the detriment of the client or patient. Similarly, personal disclosures to a patient, communications via Facebook or other public sites or communications with a patient’s spouse could have the effect of blurring boundaries and undermining the treatment relationship. Finally, the fact that a patient may be the one who initiated any social or sexual relationship is irrelevant; if the health professional acquiesces and participates in such relationship, she will have crossed a fundamental boundary and can expect to face consequences that may range from a caution to sanctions up to and including revocation.

Takeaway

Health professionals should always be mindful of the requisite boundaries in a relationship with a patient. If a health professional finds themselves in a situation where the boundaries are unclear, it is best to approach the situation with caution. Most health professional colleges have policies or guidelines on maintaining the appropriate boundaries with patients. If you have a question about professional boundaries or the case discussed above, please contact us.

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