Boundary Issues
October 7, 2002As a lawyer, it has always struck me that one of the most difficult tasks especially that psychiatrists must undertake relates to the appropriate management of boundaries within the doctor-patient relationship. From my perspective as counsel, the boundaries often appear to be elastic and involve a consideration of many diverse issues. The concept of boundary management is itself elusive, tied to psychodynamic or “analytic” approach to psychiatry - an approach which may not be relevant to the clinical setting in which the practitioner actually practises medicine. Boundary crossings can, as I understand it, in some circumstances, be a very effective tool in the doctor-patient relationship. Boundary violations, on the other hand, are deemed inappropriate. In some circumstances, a boundary crossing may become a boundary violation. Sorting these issues out, from a legal perspective, can be very difficult. A somewhat cursory review of published literature did not identify any thorough statements on appropriate boundary management in the child psychiatrist-patient relationship. I was, however, able to obtain a copy of the American Academy of Pediatrics policy statement on boundary management in the pediatrician family-patient relationship. I attach a copy for review and consideration.
Again, from a non-medical perspective, it strikes me that one of the most problematic areas in this field relates to the fact that children have a very different understanding of boundaries than adults. Their sense of physical and personal space is very different and their desire to be attached/comforted can also be quite different than the adult expectation. Controls may also have to physical, e.g., restraining the hyperactive child. Further, play as a form of therapy may involve a degree of physical closeness that would otherwise be improper. Again, and from a legal perspective, the test of appropriate boundary management would likely be viewed very differently in the context of a complaint from a child than when it is from an adult.
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