1. Overview of Boundaries, Ethics, and Professionalism
by Glen O. Gabbard, M.D. Brown Foundation Chair of Psychoanalysis and Professor of Psychiatry Baylor College of Medicine

2. What is Professionalism?
The essence of professionalism is to serve the interests of the patient above the professional’s self-interest. Professionalism aspires to altruism, accountability, excellence, duty, honor, integrity, and respect for others.

3. Professionalism
is how you behave with patients and co-workers when no one is watching.

4. Differences Between Professional and Personal Relationships
Relationship Characteristic
Professional Relationship
Personal Relationship
Money
Money is paid to the professional for patient care
Shared
Length
Limited to the duration of the treatment
May last a lifetime
Location
Confined to locations where treatment is provided according to community standards
Meeting places vary according to the nature of the relationship
Purpose
To provide care to patient
To enjoy oneself
Adapted from British Columbia Rehabilitation Society, 1992

5. Differences Between Professional and Personal Relationships (cont.)
Relationship Characteristic
Professional Relationship
Personal Relationship
Structure
Defined by the appointment length and nature of care required
Spontaneous and unstructured
Power Differential & Assymetry
In fiduciary relationships, the professional provides a service to the patient in a setting that is asymmetrical by design
No fiduciary relationship, and thus no power differential or asymmetry
Responsibility for the relationship
The professional establishes and maintains the relationship and operates within an ethics code
Shared
Preparation for the relationship
The professional is trained, and the patient places trust in the professional’s skill
Equal
Adapted from British Columbia Rehabilitation Society, 1992

6. Unprofessional Behaviors
Negligence
Exploding in anger at co-workers
Boundary violations
Dishonesty
Sexual harassment
Contemptuous behavior towards patients
Bullying

7. Common Boundary Violations
Sexual relationships with patients
Business transactions/dual relationships
Acceptance of large gifts
Denigrating or sexually provocative language
Barter/Mishandling of fees
Misuses of the examination
Inappropriate types of physical contact
Excessive self-disclosure

8. Sexual Boundary Violations
Egregious and exploitative behaviors that violate the principles of ethical conduct, harm the patient, are often not discussable, and are generally part of a repetitive pattern

9. Why are Boundary Violations Unethical?
Power differential
Transference phenomena
Impaired ability to give informed consent
A ripoff
A professional cannot provide objective care when a sexualized relationship exists

10. Sexual impropriety Sexual transgression Sexual violation proper
3 CATEGORIES OF SEXUAL MISCONDUCT
Sexual impropriety
Sexual transgression
Sexual violation proper
Medical Council of New Zealand 1992

11. SEXUAL IMPROPRIETY
Refers to gestures or expressions disrespectful to the patient’s privacy and sexually demeaning to the patient
Many cases of sexual harassment involving unwanted advances, sexually explicit remarks, and denigrating comments would fall under this category.

12. SEXUAL TRANSGRESSION
Involves sexualized and inappropriate touching of the patient that falls short of actual sexual relations
Kissing, touching of the breasts or genitals not appropriate for the exam, or performing a physical exam without gloves

13. SEXUAL VIOLATION PROPER
Refers to sexual relations between a professional and a patient
It makes no difference who initiates the contact and whether or not love has been professed
Oral sex, anal intercourse, genital intercourse, and mutual masturbation

14. THE
SLIPPERY
SLOPE
PHENOMENON

15. Place and Space
Hospital
Clinic
Private Office

16. TIME
Length of appointments
Time of appointments

17. ACCEPTANCE OF LARGE GIFTS
Expectation of special treatment
Suppression of anger
Unconscious bribe

18. SELF-DISCLOSURE Role reversal
Burdening the patient with personal problems or family matters

19. Sexually Provocative Clothing
Unprofessional Dress
Sexually Provocative Clothing

20. Language

21. Business Transactions
The fundamental problem with dual relationships
Exchange of fee should be the limit

22. Physical Contact
Handshake is usually limit
Cultural differences
The problem of the hug

23. MENTALIZATION
The capacity to recognize one’s own perception as subjective and the awareness that another’s perception might be quite different based on that person’s subjectivity.
The capacity to reflect on one’s internal world as fallible and one of only several possible perceptions