Managing Unavoidable Boundary Crossings During Treatment

After returning from a walk outside a psychiatric hospital in an urban area, a female patient accused her accompanying staff member of sexual abuse, much to the surprise of staff members of the unit, as the patient had not exhibited such behaviors in the past. The patient had been going on walks with staff members three days a week for the past four weeks as part of her treatment plan, and had gone out several times with the accused staff member without incident.

As investigation of the complaint of abuse commenced, opinions among staff were split. Some staff members opined that all complaints of sexual abuse must be believed, while others were less sure as they sought to uphold the rights of the accused staff member. Matters were further inflamed when race was introduced in the discussion, the patient being a White female and the staff a Black male. Tension on the unit boiled over.

This case presents significant implications for clinicians and psychiatric hospital administrators with patients who have long lengths of stay, mostly at state institutions but not exclusively so. These hospitals house individuals with serious and refractory illness, often characterized by risk of danger to self or others. The process of recovery is generally slow and includes graduated integration into the community, usually accomplished initially by walks outside of the hospital unit with staff. In addition, therapists may take patients out of the unit for therapy sessions on the belief that the therapeutic alliance may be enhanced in a natural environment removed from the oppressive inpatient unit.

It is unclear, however, if staff members consider the potential ramifications of these interventions. For example, I once heard of the case of a female patient with a history of physical assaults who was on a regular psychiatric unit. The unit leadership casually stated that she left the unit only for walks with a male staff member who was apparently the only one comfortable with taking her out. The unit leadership had not insisted on other staff members taking her out when that staff member was off duty. This situation was rife with potential problems that were surprisingly unappreciated by staff until brought to their attention.

Although taking walks with patients outside of a hospital unit may be an important step in their recovery and community integration, it has potential risks for patients and staff that should always be considered. The formal setting of a hospital environment creates, maintains, and reinforces formal boundaries between a patient and the clinical staff that may be lost in the informal environment of the community. As patient and staff member become comfortable with each other during such outings, barriers are likely to be broken, allowing intimate details of their lives to be discussed. Staff may be less likely to guard against inappropriate self-disclosure, which may shift the clinician-patient relationship into a friend relationship or much more.

Staff members should be friendly with patients but not be their friend. The Oxford Dictionary defines a friend as “a person with whom one has developed a close and informal relationship of mutual trust and intimacy.” This slippery slope may lead to boundary crossings and violations. Transference and countertransference issues may become unmanageable, with disastrous consequences. To compound matters, it is sometimes impossible to appreciate how patients interpret discussions or behaviors outside of the usual limits of a hospital or how patients’ mental disorders distort their understanding of events at a particular time.

This article is not intended to suggest that outings with staff outside of the confines of a hospital should be prohibited as a clinical practice. It is intended, however, to raise awareness of the risk of boundary violations associated with it. Additionally, staff should be alert to the reality that a patient’s psychiatric disorder could cause the patient to misinterpret discussions with or behavior of staff in a way that could be detrimental to them.

As a result, no boundary should be crossed casually, and every boundary crossing should prompt a careful reflection by the staff member and be corrected immediately. Walking with a patient in a secluded area or outside the view of others should be avoided. Staff should be vigilant for behavior or comments that indicate patients see their relationship as more than a clinician-patient relationship and address it with the clinical team and the patients.

Doing so protects patients and staff members from untoward activities, misinterpretations, or indefensible accusations. It is better to be cautious and safe than sorry. ■