Boundaries are the perimeters of the therapeutic relationship that create a healthy sense of personal space. They are set to clarify both parties’ expectations, limitations, and a safe therapy frame. They also help preserve the integrity of the relationship and expand therapeutic trust. However, in psychiatry, when the therapeutic relationship is prolonged and more confidential and personal matters are discussed, the likelihood of developing solid emotional bonds and crossing boundaries grows. The fundamental ethical principle of a therapist is respect for the client’s dignity. It entails respecting their choices and goals and the concept of autonomy that fosters the client’s independence and separateness as a self-directing individual. In addition, this concept calls upon the promotion of a self-determination attitude of the client as it forms the core of boundary preservation.
However, physicians sometimes ignore these boundaries despite defining their therapeutic territory. As per most studies, the main reasons why physicians ignore boundaries is due to misconduct, poor skills, or adverse patient reactions. Under misconduct, physicians act in their own best interest instead of the patient’s best interest. So, they fail to observe the boundaries of the professional or therapeutic relationship and exploit the client sexually, emotionally, or financially (Dickeson, 2019). Most physicians who have overstepped the therapeutic boundaries due to poor skills are negligent or incompetent (Dickeson, 2019). Overstepping boundaries also occur due to adverse reactions that stem from an incompatibility between the client and the treatment plan, with consequences ranging from anxiety to psychosis (Dickeson, 2019). The client can also overstep boundaries from unintentional self-disclosures.
Therapeutic communication and relationship are fractured if boundaries are ignored or overstepped. For example, if the client makes an unintentional self-disclosure, it may lead to embarrassment or discomfort. As a result, they may not be motivated or inspired to be productive in therapy for fear of creating a tense environment. This leads to poor communication, which may cause poor patient outcomes. When the physician oversteps the boundaries, the main effect is harm to the patient. Harm entails but is not confined to depression, anxiety, regression, post-traumatic stress disorder, depersonalization, suicidal ideation, and dependency (Shanafelt, 2021). All these negative consequences make the patient resistant to open up or even attend therapy for being taken advantage of due to their vulnerability.
However, these consequences can be avoided when both parties set healthy boundaries and focus on communication-focused therapy. It helps create a safe space for the client to open up and communicate without fear of being taken advantage of. For the physician, it allows them to abide by the principles of autonomy, beneficence, nonmaleficence, and fiduciary partnership, as they are the key to effective therapeutic relationships (Slobogian et al., 2017).
Hattab, A. S. (2021). Healthcare Ethics: From Medical Paternalism to Patient Autonomy. Handbook of Healthcare in the Arab World, 1603-1619. Springer International Publishing.
Shanafelt, T. D. (2021). Physician well-being: where are we and where are we going? Mayo Clinic Proceedings, 96(10), 2682-2693.https://doi.org/10.1016/j.mayocp.2021.06.005
Slobogian, V., Giles, J., & Rent, T. (2017). #Boundaries: When patients become friends. Canadian oncology nursing journal = Revue canadienne de nursing oncologique, 27(4), 394â€“396.