Professional boundaries in mental health care

Psychotherapy

Australasian Psychiatry 2023, Vol. 31(6) 764–767 © The Royal Australian and New Zealand College of Psychiatrists 2023

Article reuse guidelines: sagepub.com/journals-permissions DOI: 10.1177/10398562231191662 journals.sagepub.com/home/apy

Being a ‘good’ doctor: Understanding and managing professional boundaries is challenging and can lead to stress and burnout

Lisa Lampe School of Medicine and Public Health, University of Newcastle College of Health, Medicine and Wellbeing, New Lambton Heights, NSW, Australia

Rita Hitching School of Medicine and Public Health, University of Newcastle College of Health, Medicine and Wellbeing, New Lambton Heights, NSW, Australia

Trent Ernest Hammond NepeanClinical School, Faculty ofMedicine andHealth, TheUniversity of Sydney, PenrithNSW2751, Australia

Jeannie Park Northern Sydney Local Health District, St Leonards, Australia

Dominique Rich School of Medicine and Public Health, University of Newcastle College of Health, Medicine and Wellbeing, New Lambton Heights, NSW, Australia

Abstract Objective: The aim is to increase the understanding of non-sexual boundary challenges and potential personal and professional impacts on doctors and medical students. Method:We examined peer-reviewed and grey literature and published commentary and cases from Australian health practitioner boards and medico-legal insurance companies. Key ideas relating to the objective of our study were subsequently framed into a narrative. Results: Compared to ‘sexual’ boundary crossings, the literature examining ‘non-sexual’ boundaries is scanty, frag- mented, and difficult to find. There are gaps in knowledge around the prevalence and consequences of non-sexual boundary challenges and crossings, although the safety and wellbeing of health professionals and patients are of concern. Non-sexual boundary crossings may represent a ‘slippery slope’ to boundary violations. Opportunities for doctors and medical students to access relevant training appear limited. Conclusions: We identified several categories of boundary challenges based on context, the nature of the existing relationship, and the type of behaviour. Non-sexual boundary challenges may be related to stress, burnout, and risk for future boundary violations. Future research to investigate the impacts on doctors andmedical students in maintaining professional boundaries in their relationships with patients and colleagues, their specific training needs, and the effectiveness of training in reducing work-related stress and burnout is needed.

Keywords: boundary challenge, boundary crossing, boundary violation, professional boundary, burnout, doctor, physician, medical student, wellbeing

Professional boundaries have been defined as the ‘edge’ of appropriate professional behaviour, maintaining the expected and accepted psycho-

logical and social distance between health professionals and patients.1 This distance protects patients from the power differential2 and helps preserve the relative ob- jectivity of medical decision making.3 Boundaries also refer to the limits on acceptable interactions between the health professional and their patient. Interactions with the patient should arise from and be directed towards

meeting their medical needs, be within the scope of the health professional’s expertise, and contextually appro- priate. Acceptable boundaries can also be understoodwith

Corresponding author: LA Lampe, School of Medicine and Public Health, University of Newcastle College of Health, Medicine and Wellbeing, Level 3 Education Building, John Hunter Hospital, New Lambton Heights 2305, NSW, Australia. Email: [email protected]

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reference to the health professional’s usual practices, in- cluding location of consulting and hours of practice.4

The doctor–patient relationship has long been regarded as fiduciary in nature, in that doctors are expected to put the patient’s needs before their own and avoid conflicts of interest.5 There is a wide agreement in the literature that, as the individual with greater power in the relationship, it is the health professional’s responsibility to establish and maintain appropriate boundaries.

Aims The main purpose of our literature review was to syn- thesise information about non-sexual boundaries and develop a new understanding of the topic to support planned research. We sought to understand more about types and impacts of non-sexual boundary challenges.

Data sources and methodology A broad search (peer-reviewed, professional, and grey lit- erature) was conducted using the keywords above. The search was hampered by association of the term ‘pro- fessional boundaries’ with different meanings including interprofessional scope of practice or, as in the current re- view, professional relationships. Although the primary fo- cus of the reviewwas ondoctors andmedical students, there was a much larger literature derived from the nursing, psychology, and social work professions which was in- cluded where the research team considered the findings to have relevance for doctors andmedical students. A searchof the codes of conduct published by peak or certifying health professional associations in Australia (including medicine, dentistry, physiotherapy, occupational therapy, chiro- practic, and pharmacy)was conducted. Finally, thewebsites of medical defence associations in Australia were searched for publications concerning professional boundaries. There were no exclusion criteria.

A qualitative approach based on thematic analysis was adopted. Categories of non-sexual boundary challenges were developed through an iterative process involving consideration of suggestions in the literature and inter- pretations of the literature by the research team. The literature on impacts of non-sexual boundary crossings was synthesised into a narrative.

Results Categories of non-sexual boundary challenge

We developed 10 categories of non-sexual boundary challenges presenting the risk of boundary crossing or violation. Category names reflect common usage in the literature or descriptive names developed by the re- searchers. Table 1 lists categories developed together with brief descriptions and examples.

Impacts of boundary drift, crossings, and violations

In an influential and widely cited article, Gutheil and Gabbard6 described a psycho-therapeutic framework for

understanding professional boundaries. This seminal ar- ticle distinguished ‘boundary crossings’ from ‘boundary violations’. Since then, ‘boundary drift’ has been de- scribed,2 as contemplation of a potential boundary crossing, or a behaviour that is close to the boundary.

In a boundary crossing, the health professional engages in an interaction with a patient that is outside of indicated therapeutic interventions or the professional’s usual prac- tice. Boundary drift and boundary crossings may not nec- essarily be intentional nor cause harm to the patient. However, harmsmay be subtle, including loss of objectivity, conflicts of interest, distorted patient expectations, or a perception of patient exploitation. They may increase the risk of future boundary violations (the ‘slippery slope’).7

Boundary violations, by accepted definition, cause or have the potential to cause harm to patients and involve a behaviour that prioritises the health professional’s wants or needs over the patient’s.8 In the medical pro- fession, even the perception of a boundary crossing can harm a doctor’s reputation.9 In health settings, the focus on boundary violations and crossings has traditionally been on sexual transgressions. However, many non- sexual categories of boundaries are described in the lit- erature, mainly according ‘special’ patient status, pro- viding clinical favours to non-patients, dual and multiple relationships, accepting and receiving gifts, physical contact, self-disclosure, and social media interaction.

Various influences on boundary crossing behaviour have been described, including the health professional’s own emotional vulnerability, ‘moral weakness’, exploitative character traits, and ignorance.4,10

Boundaries in different contexts, locations, and specialities

Some practice contexts may offer particular challenges to maintaining boundaries, including rural, remote, or isolated practice, where social relationships outside the professional one are commonandoftenunavoidable, thus creating ‘dual’ or ‘multiple’ relationships with a patient.11 Other contexts include doctors in highly specialised practice or specialities with relatively small numbers of practitioners, whose ex- pertise may be sought out by friends, family members, or colleagues. It has also been suggested that as the population ages, doctors in specialities such as oncology and palliative caremay increasingly come across patients withwhom they have existing social, collegial, or family relationships.

Professional boundaries also apply to roles not directly concerned with patient care, for example, in relation to medical andnon-medical colleagues (‘corridor consultations’ and requests for prescriptions), and teaching and mentoring of students and junior colleagues. There is limited researchon professional boundaries in relationships such as supervisor– trainee, faculty–student, andmentor–mentee. A potential for boundary violations arises from the power differential in the faculty–student (and supervisor–trainee) relationship which resides in the teacher’s (or supervisor’s) professional status and responsibility for evaluating the student’s (or trainee’s)

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skills, and the student’s vulnerability and dependence on the teacher for guidance and pass/fail grading.

The connection between boundary challenges and burnout

Burnouthas beendescribedbypioneering researchers in the field as a psychological syndrome emerging as a prolonged response to chronic interpersonal stressors on the job.12

Early research identified key characteristics of burnout as

emotional exhaustion, cynicism, reduced personal ac- complishment, and depersonalisation.13 Consequences of burnout include erosion of compassion and reduced quality of patient care, reductions in work performance, increased risk of medical errors, prematurely leaving a career in medicine, and decreased life satisfaction.14–16

Boundary violations have been referred to as an ‘un- recognized risk for burnout’.17 The prevalence of burnout in doctors is uncertain, in part due to inconsistencies in

Table 1. Categories of non-sexual boundaries and potential impacts

Category name Brief description or example Potential impact/s

Clinical favour Requests for medical services by non-patients. For example, ‘corridor consultations’; requests by a colleague for prescriptions or referrals

Harm to person seeking medical service because doctor may not know full medical history; discontinuity of care; loss of medical decision-making objectivity because interaction is occurring outside of usual doctor–patient relationship

Dual relationship New or existing social relationships in addition to the doctor–patient relationship, for example, a doctor becomes a client of a patient who is a fitness trainer

Conflict of interest; deliberate limitation of scope of medical review to preserve patient privacy; power differential. Damage to both personal and professional relationships if things go wrong

Edge of clinical role

The limits of indicated medical care. From a Medical Defence Organisation, the example of a doctor who sent a patient music and picture files designed to be uplifting; as another example, offering a patient a lift in the car

Could create unrealistic expectations in the patient or damage to the doctor’s reputation if motivations are misconstrued (in the real-life case relatives feared the patient was being groomed for an inappropriate relationship and made a complaint)

Emotional guarding

Deliberately withholding expression of affect or responding to a patient’s display of emotion. For example, with a patient perceived as ‘too needy’

Psychological aspects of patient care compromised; objectivity may be adversely impacted

Gift-giving Gifts offered by patients to doctors or vice versa May create a sense of obligation that could impact objectivity of medical decision making; risk to reputation via impressions that may be created

Non-sexual physical contact

For example, hugging May create false sense of intimacy and impact patient expectations; risk to reputation

Self-disclosure Sharing personal information or experiences May create false sense of intimacy for patient; risk to reputation

Social media Becoming ‘friends’ on social media May create false sense of intimacy for patient; risk to reputation and privacy

Special patient Making special arrangements for a patient, such as seeing them outside of usual hours or in other than the usual practice setting

May create unrealistic expectation for continued special treatment, and patient may become angry or resentful if this doesn’t happen; could be the start of the ‘slippery slope’ to boundary violation; may create reputational risk if situation misconstrued by others; departure from usual treatment approach may lead to risks for patient

Transactional Substitution of usual processes around payment for medical services with alternatives, such as bartering of goods or services. For example, a patient offers to provide an artwork or the doctor suggests that they could clean the office in return for medical services. Can also be seen in supervisor/student situations, for example, offering employment to the student outside the supervisory relationship

As the less powerful in the relationship, the patient may feel unable to refuse a request for alternative payment type or to negotiate the true value; fear that to decline may adversely impact treatment; risk to reputation if others form the view that patient (or student) is being exploited

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research methodology and definition of the syndrome. In the Australian National Mental Health Survey of Doctors and Medical Students,18 rates of reported emotional ex- haustion were high, especially in doctors under 30 years of age (47.5%). A recent review estimated a 21%–35% prev- alence rate with significant increases since the COVID-19 pandemic.19 Higher levels of stress and burnout have been reported in younger doctors and in some specialities; gender associations are less consistent.16

There is a close connection between stress and burnout,16

and negotiating boundary challenges can be stressful, particularly in the absence of training and guidance.20Most health professional codes of ethics and codes of conduct forbid some boundary violations explicitly, such as sexual relationships. However, there is little guidance in the lit- erature and professional codes of practice regarding non- sexual boundary challenges. Many commonly encoun- tered situations in professional settings may be complex and associated with ambiguity concerning boundary lines; the uncertainty in how to respond can exacerbate the as- sociated stressfulness.21 Likewise, it can be difficult to refuse the request of a friend, family member, or colleague for a script or ‘corridor consultation’. Training has the po- tential to increase skills and confidence but is generally lacking at both undergraduate and post-graduate levels.

Peak psychology bodies appear to have given most consid- eration to guidance on professional boundaries. The Aus- tralian Psychological Society (APS) complements its ‘Code of Ethics’with a series of 28 EthicalGuidelines,which apply the Code to issues encountered in everyday professional prac- tice.22 However, a search of the Australian national associ- ations of other health professions didnot reveal anypractical guidelines that can be applied to everyday professional practice to help professionals navigate boundary issues.

Summary and recommendations Effective management of non-sexual boundary challenges could contribute to a reduction in stress and burnout, help keep doctors in the profession, and increase patient safety. A greater understanding of the issues for Australian doctors and medical students in managing non-sexual boundary challenges would address a significant gap in the research literature. This may allow for the identification of educa- tional targets and opportunities to provide the training and guidance that may lead to greater skill and confidence in managing boundary challenges.

Disclosure RH, TH, JP, and DR report no conflict of interest. In the past 3 years LL has received honoraria for submissions to Mindcafe eDigest, speaker fees from Lundbeck P/L and Mental Health Practitioners Network, and travel support from the Lundbeck Institute. The authors alone are responsible for the content and writing of the article.

Funding The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Centre for Brain and Mental Health Research Support Grant (Faculty of Health and Medicine, University of Newcastle); Avant Foundation, grant number 2021/000085.

Ethical approval and consent No ethical approval was required for this research. No patients were involved and therefore no consent required.

ORCID iDs LA Lampe  https://orcid.org/0000-0001-5540-8810 TE Hammond  https://orcid.org/0000-0002-5341-6531

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