00:00
So we talked about ways that you can positively engage
with the patient and negatively engage with a patient,
which now brings us to the question of "How do we
set boundaries in our relationship with a patient?"
So, a boundary is any kind of accepted social,
physical, or psychological space between people.
00:19
Now I'm sure you've all experienced
this if you've gotten on an elevator.
00:23
You know, this sort of it just a common, even
subconscious way that people organize themselves
when they get on to an elevator; the more
people that come in, then they, you know,
decrease the space between people but
generally people try to find their own space
and give other people
space around them.
00:40
But in medicine and in clinical medicine, the
therapeutic relationship inherently involves
crossing boundaries that in other
situations would be inappropriate.
00:50
So at the top, we need to think about distinctions
between boundary crossings and boundary violations.
00:56
As we will talk about boundary crossings are things
that the clinician is going to need to be cautious about.
01:03
Whereas boundary violations are forbidden, the clinician
needs to avoid any kind of boundary violations.
01:10
So there may be social
boundary crossing.
01:13
So, when you're actually taking
history, you're exploring personal
and potentially very sensitive information
with a patient which may not be done,
you know, in other social circumstances or
at a dinner party you're not going to get
in to really intimate details about your life whereas
when you're talking with a clinician it may be,
you know, expected and needed really to
establish the therapeutic relationship
to figure out how to
best help that patient.
01:42
There may be physical boundary crossings
that we just commonly perform.
01:45
So, doing a physical examination or laying
hands on the patient to figure out,
you know, what the diagnosis is,
that is in other circumstances
would be a boundary crossing but inherent
as part of the taking care of a patient.
02:02
And there may be psychological
boundary crossings that we do.
02:04
So, I talked about the patient's during
personal or sensitive information,
but it also is the time where the
patient maybe emotionally vulnerable.
02:12
So, in other places where they might
try to keep their emotions in check
when they are with a clinician in the therapeutic
relationship, they are sharing their emotions.
02:21
They could get emotionally upset and crying
and even angry, you know, potentially.
02:27
That emotional vulnerability is just
part of the clinical encounter.
02:34
So, we know that boundary crossings
are happening, you know,
all the time in therapeutic
relationships.
02:40
Some are going to be neutral.
02:42
So after you've gotten permission
to do a physical exam, you know,
checking the patient's pulse, no stakes involved and
the patient's generally going to be accepting of that.
02:54
The actual positive boundary crossing might be
well the support of touch that I mentioned,
you know, so the patient is emotionally
reacting to some hard news,
putting your hand on their shoulder to
comfort them provides some support to them.
03:09
They may welcome that. There may also be,
you know, the negative boundary crossing.
03:14
So, the patient that's anxious and you are,
you know, thinking well you have, you know,
"I have to reach out to the patient"
but if they are unreceptive to that
and that causes more anxiety, that
can be a negative boundary crossing.
03:30
So, there are going to be some considerations
for thinking about these boundary crossings.
03:36
It's important to first point out, you know, so
even though they're happening all the time for us,
they may have greater
significance for the patient.
03:44
So, we might think it's inconsequential
or really we don't have any, you know,
intentions that are negative, but it may be misinterpreted by the
patient in another way and have great significance for them.
03:58
It's important to know about, you know,
any cultural or ethnic sensitivities.
04:03
You know, a classic example might
be for women in Islamic cultures.
04:09
Maybe inappropriate to examine the women
in the absence of a male family member.
04:16
So knowing, you know, a
little bit about the patient
and the cultural background might help to
avoid any negative boundary crossings.
04:27
So, the important goal is, you
know, really going to recognize
which situations may cross a boundary and what you can
do to make sure it's not a negative boundary crossing.
04:41
Be alert to possible
misunderstandings.
04:43
So try to see things from the patient's
perspective, try to read the patient.
04:48
Some of that is also reading their
body language, how are they reacting.
04:52
If you are, you know, trying to do a therapeutic touch
or something or you know trying to reach out to them,
make sure that they don’t have any
misunderstandings about your intentions.
05:04
Some of it is, you know, do
just stepping back and say
"Well, what would a neutral
observer think of your conduct?
Would they think this is inappropriate
as a boundary crossing?"
And also know that, you know, relatively
minor trivial boundary crossing
if that keeps up might progress to more serious
boundary crossings and even violations.
05:28
So, you know, trying to really be attentive
and aware of where these things might lead
and avoiding going down
that slippery slope.
05:40
Okay, so let's talk about one kind of possible
boundary crossing and often clinicians
might be confronted with the idea of
whether to accept a gift from a patient.
05:53
So patients and their family members may be
very thankful for the care that they received
and one way that they can demonstrate
that is to give a gift to the clinician.
06:07
So, often it's benign, often it's good motivations
from the patient of why they're doing this
but the concern is that it could
create a boundary violation.
06:16
So, depending on the circumstances,
the nature of the gift,
this may cross a boundary where it's inappropriate
to the health of the therapeutic relationship.
06:27
It changes the dynamics in a negative way
so you have to be attentive to this.
06:33
You might have heard the concept of transference.
06:36
So this is where the patient is
taking some past relationship,
you know, maybe a parent or an
authority figure from their childhood
and then they are projecting
onto a new person
and their current life the dynamics that
were involved in that prior relationship.
06:55
So this creates, you know, patterns
of behavior or emotional reactions
that originated from
those past experiences
but now are being displaced on to a new
person, in this case the clinician.
07:09
So for something like
gift giving, you know,
is it a reaction or emotional dynamic that the
patient is trying to appease an authority figure,
you know, for some past trauma that they might
have had with an authority figure in the past.
07:27
So, these opportunities for
transference can happen,
it's more common to happen if the patient
is vulnerable as a result of illness.
07:35
That vulnerability creates a need to reach
out and try to connect with other people.
07:43
The patient, as we talked about, generally
is revealing more about themselves
than the clinician is
sharing about their life.
07:52
So that uneven relationship dynamic
might lead to more transference,
you know, the patient wanting to be more
reliant or dependent on the clinician.
08:04
And also because we talked about, you
know, patients maybe more free to share
their emotions in the clinical encounter that the
clinician often has to keep their emotions in check.
08:16
Again, that dynamic may
lead to transference.
08:21
So when you're thinking about gift
giving, you have to take a pause of
"Why is the patient
giving me this gift?
What's the meaning and
significance of it for them?"
Is it just an expression of gratitude
or is there a deeper meaning to this
that maybe it's going to affect the relationship
dynamics that we have in the therapeutic relationship.
08:41
And it's also important to point out that we as
clinicians can also have transference phenomenon.
08:47
What we call counter
transference.
08:50
So we're bringing our own stuff
into a clinical encounter.
08:53
Our own biases, our own emotional
needs, things from our past
that may then be varying on the relationships
we developed with our patients.
09:04
So that dynamic interaction
ultimately shapes, you know,
the outcomes of the therapeutic
relationships we do establish,
which is just to say that we need to be
self-aware, we need to self-monitor.
09:18
You know, if we see that there's a
relationship dynamic that's developing
that might eventually lead
to a boundary violation,
maybe we seek some counsel from a peer
of how would you handle the situation.
09:31
You know, I see something developing
here that I need to, you know,
avoid going you know crossing a
boundary or going into a violation.