Accessibility Page Navigation
Style sheets must be enabled to view this page as it was intended.
The Royal College of Psychiatrists Improving the lives of people with mental illness

Professional Boundaries

To contact the Psychiatrists' Support Service please telephone: 020 7245 0412  or e-mail: pss@rcpsych.ac.uk

What are Professional Boundaries?

They relate to the way you behave in your role as a doctor, and could relate to a range of areas of your work; for instance time, place and space, money, gifts, services, clothing, language, self-disclosure and physical contact.

You might cross a boundary because you think it could benefit your patient. However, if crossing the boundary could have a negative impact and potentially cause harm, this is known as a ‘violation’.

Patient safety is paramount. Doctors must not use their professional position to establish or pursue a sexual or improper emotional relationship with a patient or someone close to them. They must treat patients with dignity and protect them from harm posed by another colleague’s conduct.

Developing awareness and responsibility around patients’ cultural and religious concerns is important to understand boundaries such as touching or social invitations.

 

The Fiduciary Relationship

Doctors who get into trouble around boundaries often confuse their personal life with their professional life.

It is critical that you maintain a fiduciary relationship with your patients. It involves trust and duty - the patient places trust and confidence in the professional who has a duty to act in the best interest of the patient.

Breach of this trust undermines not just the doctor–patient relationship but the public’s trust in the profession.

 

Disclosing Personal Information to the Patient

Disclosing personal information about yourself to the patient can bring you closer, which may have advantages in terms of encouraging the patient to talk about themselves  – but excessive disclosure radically changes the dynamic. In most examples where sexual boundaries are violated, the doctor has provided an excessive amount of information about himself or herself.

Blurring of personal and professional lives is increasingly played out online. The simplest approach is to have separate personal and professional social media profiles, with the highest level of privacy on personal sites.

 

Impact of Violations

Violating professional boundaries can lead to long-term psychological issues for patients because:

  • The problems they initially sought help for still remain
  • The original problems have been made worse
  • Their ability to approach/trust other professionals is impaired
  • Additional damage is caused by the breach of trust

Patients may feel confused or even suicidal. The doctor will face disciplinary enquiries and professional sanction, including in the worst cases being removed from the medical register. Colleagues, other patients, the employing organisation, friends and family may also be affected.

 

FAQs

Why are boundaries important?

Boundaries keep doctors and patients safe. The professional relationship must be upheld as patients need professionals to behave with integrity and do their job.

 

What should I do if I become aware of feelings towards a patient?

It’s normal to have a range of feelings towards patients. Sometimes called ‘countertransference’, these are ethically neutral occurrences. The key skill is clearly identifying these feelings, sharing with a colleague or mentor and taking appropriate action. Problems arise when feelings are acted on.

It’s worth reflecting with a mentor or supervisor how these feelings developed, as there may be important lessons about working with patients or any personal/professional issues you may have.

 

What should I do if I have already overstepped a boundary with a patient?

Both GMC guidance and general professional ethics require openness and accountability. If you believe you’ve crossed a boundary risking causing significant harm to a patient, consider being open about this with colleagues. As a matter of integrity, apologise to those concerned. It’s important to also contact your professional association, defence organisation and the GMC.

 

Can practitioners who have transgressed ever be safe to work again?

There’s evidence from Gabbard and others in the USA to suggest that rehabilitation is possible for some practitioners. The key issue is identifying contextual and risk factors and developing rehabilitation plans in light of these factors.

The GMC will always take action on improper relationships and its decision-making will always be informed by the remedial action taken, level of insight and specific circumstances of the transgression. Openness and honesty following a transgression are key.

 

Who violates boundaries?

Multiple offences committed by psychiatrists against patients are relatively uncommon. Assessment and rehabilitation experts report that doctors at all stages of their careers might violate boundaries. There are higher rates for people who are further ahead in their professional careers.

The majority of transgressions seem to be committed by clinicians experiencing personal and professional stress, sometimes with additional trauma. It’s important to address personal stress and burnout as early as possible and to communicate with colleagues and mentors about it.

If you have concerns about a colleague, take appropriate steps without delay. Please refer to the General Medical Council’s (GMC; 2013a,b) and the Royal College of Psychiatrists’ guidance listed at the end of this information guide (Subotsky et al 2010; Royal College of Psychiatrists, 2013).

We thank Mr Jonathan Coe, Managing Director, Clinic for Boundaries Studies, for his help preparing this guide.

 

The information is a guide only and is not a substitute for professional advice. If you need further advice and support, please contact the Psychiatrists’ Support Service or contact one of the service in our resource book.

 

© Royal College of Psychiatrists 2016

Login - Members Area

If you don't have an account please Click here to Register

Make a Donation
Information Standard 2