Boundary Crossings

by Mark Hughes, MD, MA

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    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.

    About the Lecture

    The lecture Boundary Crossings by Mark Hughes, MD, MA is from the course Communication with Patients and within the Health Care Team.

    Included Quiz Questions

    1. Recognizing situations that may cross a boundary
    2. Being ambivalent toward misunderstandings
    3. Disregarding cultural sensitivities
    4. Trivial boundary crossings never lead to serious boundary crossings.
    5. Benign crossings are always inconsequential to a patient.
    1. The subconscious projection of emotions
    2. The conscious projection of emotions
    3. The subconscious ego
    4. The conscious ego
    5. Gift transfer
    1. A clinician's emotional projection onto a patient
    2. A patient's emotional projection toward another patient
    3. A patient's emotional redirection toward a clinician
    4. A clinician's emotional redirection toward another clinician
    5. A child's emotional redirection toward a clinician

    Author of lecture Boundary Crossings

     Mark Hughes, MD, MA

    Mark Hughes, MD, MA

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