Overview of Boundaries, Ethics, and Professionalism by Glen O. Gabbard, M.D. Brown Foundation Chair of Psychoanalysis and Professor of Psychiatry Baylor College of Medicine

What is Professionalism? The essence of professionalism is to serve the interests of the patient above the professional’s self-interest. Professionalism aspires to altruism, accountability, excellence, duty, honor, integrity, and respect for others.

Professionalism is how you behave with patients and co-workers when no one is watching.

Differences Between Professional and Personal Relationships Relationship Characteristic Professional Relationship Personal Relationship Money Money is paid to the professional for patient care Shared Length Limited to the duration of the treatment May last a lifetime Location Confined to locations where treatment is provided according to community standards Meeting places vary according to the nature of the relationship Purpose To provide care to patient To enjoy oneself Adapted from British Columbia Rehabilitation Society, 1992

Differences Between Professional and Personal Relationships (cont.) Relationship Characteristic Professional Relationship Personal Relationship Structure Defined by the appointment length and nature of care required Spontaneous and unstructured Power Differential & Assymetry In fiduciary relationships, the professional provides a service to the patient in a setting that is asymmetrical by design No fiduciary relationship, and thus no power differential or asymmetry Responsibility for the relationship The professional establishes and maintains the relationship and operates within an ethics code Shared Preparation for the relationship The professional is trained, and the patient places trust in the professional’s skill Equal Adapted from British Columbia Rehabilitation Society, 1992

Unprofessional Behaviors Negligence Exploding in anger at co-workers Boundary violations Dishonesty Sexual harassment Contemptuous behavior towards patients Bullying

Common Boundary Violations Sexual relationships with patients Business transactions/dual relationships Acceptance of large gifts Denigrating or sexually provocative language Barter/Mishandling of fees Misuses of the examination Inappropriate types of physical contact Excessive self-disclosure

Sexual Boundary Violations Egregious and exploitative behaviors that violate the principles of ethical conduct, harm the patient, are often not discussable, and are generally part of a repetitive pattern

Why are Boundary Violations Unethical? Power differential Transference phenomena Impaired ability to give informed consent A ripoff A professional cannot provide objective care when a sexualized relationship exists

Sexual impropriety Sexual transgression Sexual violation proper 3 CATEGORIES OF SEXUAL MISCONDUCT Sexual impropriety Sexual transgression Sexual violation proper Medical Council of New Zealand 1992

SEXUAL IMPROPRIETY Refers to gestures or expressions disrespectful to the patient’s privacy and sexually demeaning to the patient Many cases of sexual harassment involving unwanted advances, sexually explicit remarks, and denigrating comments would fall under this category.

SEXUAL TRANSGRESSION Involves sexualized and inappropriate touching of the patient that falls short of actual sexual relations Kissing, touching of the breasts or genitals not appropriate for the exam, or performing a physical exam without gloves

SEXUAL VIOLATION PROPER Refers to sexual relations between a professional and a patient It makes no difference who initiates the contact and whether or not love has been professed Oral sex, anal intercourse, genital intercourse, and mutual masturbation

THE SLIPPERY SLOPE PHENOMENON

Place and Space Hospital Clinic Private Office

TIME Length of appointments Time of appointments

ACCEPTANCE OF LARGE GIFTS Expectation of special treatment Suppression of anger Unconscious bribe

SELF-DISCLOSURE Role reversal Burdening the patient with personal problems or family matters

Sexually Provocative Clothing Unprofessional Dress Sexually Provocative Clothing

Language

Business Transactions The fundamental problem with dual relationships Exchange of fee should be the limit

Physical Contact Handshake is usually limit Cultural differences The problem of the hug

MENTALIZATION The capacity to recognize one’s own perception as subjective and the awareness that another’s perception might be quite different based on that person’s subjectivity. The capacity to reflect on one’s internal world as fallible and one of only several possible perceptions