Difference between personal and Frequently asked …

1 This information guide is intended as a quick reference guide for psychiatrists. The information is a guide only and is not a substitute for professional advice. If Difference between personal and Frequently asked questions you need further advice and support, please contact the Psychiatrists' Support Service or one of the organisations listed at the end of this information guide. professional relationships Q. Why are boundaries important in these days of Doctors and others who get into trouble around boundaries recovery and equality? have often confused their personal life with their professional A. Boundaries are there to keep both doctor and patient Definition life. A helpful exercise is to get a group of colleagues together safe. They recognise that, although everyone has equal to brainstorm the differences , identify any areas that might value as citizens, the professional relationship is inherently Gabbard & Lester (1995) describe boundaries with a need some attention and make changes accordingly.

2 Imbalanced; that what patients need is for professionals to metaphor: Visitors to the Grand Canyon note that they are do what they are there to do, and to behave with integrity. protected from falling into the chasm by a guardrail placed EXCESSIVE personal SELF-DISCLOSURE. strategically at the edge of the canyon. This safety measure Q. What should I do if I become aware that I have feelings allows children (and adults) to play and enjoy themselves As in personal relationships, in a professional setting towards a patient which are concerning? while being at minimal risk for catastrophe. Although personal disclosure typically has the effect of bringing the A. It is normal to have a whole range of feelings towards patients [ professional ] boundaries in general are more flexible than two parties closer together, whereas excessive disclosure (sometimes called countertransference') and in themselves a guardrail, in some areas, such as sexual contact, they are radically changes the dynamic, so that the focus shifts from these are ethically neutral occurrences.

3 The key skill is in their just as unyielding'. These authors summarise professional the patient to the professional . In almost every case of clear identification, in sharing with a colleague or mentor, and boundaries as a set of behaviours concerning: role, time, violations of sexual boundaries there are a series of steps in taking appropriate action. It is when feelings are acted on place and space, money, gifts, services, clothing, language, taken on the way, always including a significant increase in that problems arise. It is worth reflecting with a mentor or self-disclosure, and physical contact. self-disclosure by the clinician. Care needs to be given to supervisor on the circumstances in which these feelings have the how and when of disclosures, and open discussion with arisen, as there may be important lessons about work with colleagues and mentors is essential.

4 The patient, or about what is going on for you, personally and Boundary crossings and boundary professionally. violations Impact of violations Q. What should I do if I have already overstepped a The literature (Gabbard & Myers 2008) defines boundary boundary with a patient? crossings as happening when the normal boundaries are Violations of boundaries can lead to a need for long-term psychological help for patients, who may be affected due to: A. Both GMC guidance and general professional ethics require crossed in some way, which may be beneficial to the client. failure to have the problems for which help was sought dealt openness and accountability (General Medical Council Violations are defined as always being harmful, or having with; worsening of the original problems; impaired ability 2013b). If you believe you have crossed a boundary in a way the potential to cause harm.

5 National guidance is clear that to approach or trust other professionals; and additional that risks causing significant harm to a patient, you should doctors must not use their professional position to establish damage caused by the breach of trust (Devereux 2010). consider being open about this with colleagues; as a matter of or pursue a sexual or improper emotional relationship with a Effects may range from confusion through to suicidal feelings integrity an apology to the person/persons concerned should patient or someone close to them; they must treat patients and attempts. The practitioner who violates boundaries will be considered. Contacting your professional association, the with dignity and must protect patients from risk of harm be affected through disciplinary enquiries and professional GMC and your defence organisation will also be important.

6 Posed by another colleague's conduct. The safety of patients is paramount. If one has concerns about a colleague, it is sanction, up to being removed from the medical register. Q. Can practitioners who have transgressed ever be safe necessary that appropriate steps be taken without delay. Others affected can include colleagues, other patients, the to work again? Please refer to the General Medical Council's (GMC; 2013a,b) employing organisation, friends and family. A. There is some evidence to suggest that this is possible for and the Royal College of Psychiatrists' guidance listed at the some practitioners (Coe & Gabbard 2012). Gabbard and end of this information guide (Subotsky et al 2010; Royal College of Psychiatrists, 2013). Social media and boundaries others in the USA have shown that rehabilitation is possible;. the key issue is in the identification of contextual and risk Blurring of personal and professional lives is increasingly factors, and the development of rehabilitation plans which The fiduciary relationship played out online (British Medical Association 2011; General are directly connected to these.)

7 The GMC will always take Medical Council 2013c). The simplest approach to social action on improper relationships, and will be informed in its What always remains constant in the psychiatrist patient media is to completely separate personal social media sites decision-making by the remedial action taken, the level of relationship is its fiduciary nature. A fiduciary relationship from professional ones, and to have the highest level of insight and the specific circumstances of the transgression. involves trust and duty: the patient places their trust and privacy in place on personal sites. Openness and honesty following a transgression are key. confidence in the professional who has a duty to act in the Q. Who violates boundaries? best interest of the patient. The power dynamic is critical. Power arises from professional education and knowledge; Other contextual issues A.

8 Although there have been a number of cases where multiple knowledge about the individual client; the power to provide offences have been committed by psychiatrists against or withhold treatment; and statutory powers. Breach of Developing awareness and responsibility around cultural patients ( the psychiatrists Kerr and Haslam who were this trust undermines both the immediate doctor patient and religious concerns of patients is important in the context subject to a major inquiry in 2005), these cases are relatively relationship and the public's trust in the profession as a of understanding boundaries such as touch and social uncommon. Assessment and rehabilitation experts report that whole. invitations. doctors at all stages of their careers may violate boundaries and that there are higher rates for people who are further Royal College of Psychiatrists (2013) Vulnerable Patients, Safe Doctors: Good Practice in our Clinical Relationships (2nd edn) (College Report CR180).

9 Royal College ahead in their professional careers (Coe 2012). of Psychiatrists. The majority of transgressions seem to be committed Subotsky F, Bewley S, Crowe M (eds) (2010) Abuse of the Doctor Patient Relationship. by clinicians who themselves experience personal and RCPsych Publications. professional stress, sometimes with additional trauma. It is important to attend to personal stress and burnout as early as possible, and to communicate with colleagues and mentors Further reading about this. Please see also PSS guides 5, 6, 14 and 15. PSYCHIATRISTS'. SUPPORT. Adshead G (2012) What the eye doesn't see: relationships, boundaries and forensic mental health. In professional and Therapeutic Boundaries in Forensic Mental Health Practice (eds A Aiyegbusi, G Kelly): 13 32. Jessica Kingsley Publishers. Sources of further help and support BMA Doctors for Doctors BMA Counselling (24 hours a day, 7 days a week) and the Doctors British Medical Association (2007) Accepting Donations from Patients.

10 BMA. British Medical Association (2012) Medical Ethics Today: The BMA's Handbook of Ethics and Law (3rd edn). BMJ Books. SERVICE. Advisor Service: 08459 200 169 Celenza A (2007) Sexual Boundary Violations Therapeutic, Supervisory and Email: Website: Academic Contexts. Aronson. Council for Healthcare Regulatory Excellence (2009) Clear Sexual Boundaries Information guide being/about-doctors-for-doctors between Healthcare Professionals and Patients: Information for Patients and Carers. CHRE. for psychiatrists The Clinic for Boundaries Studies General Medical Council (2008) Conflicts of Interest. GMC. Training and support services Halter M, Brown H, Stone J (2007) Sexual Boundary Violations by Health Professionals Website: An Overview of the Published Empirical Literature. Council for Healthcare Tel: 0203 468 4194 Regulatory Excellence. Hughes P, Kerr I (2000) Transference and countertransference in communication On London Deanery between doctor and patient.