This document discusses legal and ethical aspects of boundary violations in psychiatry. It defines boundaries and different types of boundary violations including minor crossings and harmful transgressions. Key principles for maintaining proper boundaries are abstinence, neutrality, patient autonomy and respecting human dignity. Guidelines are provided for minimizing risks of sexual and non-sexual boundary violations through education, supervision, and managing allegations confidentially. Legal actions are outlined for patients who experience violations and management of offending doctors.

1. LEGAL ASPECT OF BOUNDARY
VIOLATIONS IN PSYCHIATRY
By- Dr. Vijay Kumar Saini
Resident, Dept of Psychiatry
SP Medical College, Bikaner(Rajasthan)

2. • “I will come for the benefit of the sick
remaining free of all intentional injustice, of all
mischief, and in particular of sexual relations
with both female and male persons”.
(Hippocratic oath)

3. DEFINATIONS
• Boundaries: These define the limits of the
doctor–patient relationship in certain conditions,
as this is a fiduciary relationship, wherein the
patient entrusts his or her well-being to the
doctor.
• Gabbard and Nadelson have recently defined
boundaries as the parameters that “describe the
limits of a fiduciary relationship in which one
person (a patient) entrusts his or her welfare to
another (a physician), to whom a fee is paid for
the provision of a service

4. • Boundary guidelines maintain the integrity of
therapy and safeguard both the therapist and the
patient.
• Boundary crossings: These are minor
‘departures’ in some of the above areas that are
neither harmful, nor exploitative. Indeed, in
certain contexts they might even be appropriate.
• Boundary violations: In these transgressions, the
doctor exploits the doctor–patient relationship
for his personal or sexual gain. Boundary
violations are invariably harmful.

5. Important Principles of Boundaries
• Rule of Abstinence- One of the foremost
principles is the rule of abstinence, which states
that the therapist must refrain from obtaining
personal gratification at the expense of the
patient.
• Duty to Neutrality- it means knowing one's place
and staying out of the patient's personal life. The
relative anonymity of the therapist ensures that
self-disclosures will be kept at a minimum, thus
maintaining therapist neutrality.

6. • Patient Autonomy and Self- Determination -
Obtaining informed consent for proposed
procedures and treatments also preserves the
autonomy of the patient.
• Fiduciary Relationship - As a matter of law, the
physician-patient relationship is fiducial.
• Respect for Human Dignity-"A physician shall be
dedicated to providing competent medical
service with compassion and respect for human
dignity

7. Boundary guidelines for psychotherapy
• Maintain relative therapist neutraliity
• Protect confidentiality
• Obtain informed consent for treatments and
procedures
• Interact verbally with patients
• Ensure no previous, current, or future
personal relationship with the patient

8. • Minimize physical contact
• Preserve relative anonymity of therapist
• Establish a stable fee policy
• Provide consistent, private, and professional
setting
• Define time and length of sessions

9. Important Reasons for boundary
violations
• Mismanagement of ‘transference and counter-
transference’
• Personality, illness related and life situation
vulnerabilities in some patients and doctors
• Lack of training (in MHP), in how to anticipate and
deal with boundary issues when dealing with
patients
• Lack of awareness on risks of ‘dual relationships’
between doctors and patients
• Impaired therapist and vulnarable patients

10. Impaired Therapists
• Impaired therapists usually experience great
difficulty in establishing and maintaining
acceptable treatment boundaries.
• Therapists who suffer from severe character
disorders tend to repeat boundary deviations.
impaired by alcohol, drugs, and mental illness,
situationally distressed by personal crises, or
suffering from a paraphilia, particularly
frotteurism.

11. Vulnerable Patients
• Every patient, by virtue of being a patient, is
vulnerable to psychological damage from
therapists who commit boundary violations.
Psychotic and borderline patients are
particularly at risk for psychic injury.

12. Various mechanisms postulated in
boundary violations
• Mismanaged transference & Counter transference
• Unconscious re-enactment of incestuous fantasy
• Rescue fantasy
• Manic defence
• Exception fantasy
• Masochistic surrender
• Projective identification
• Settling down the rowdy man

13. Types of Boundary Violations
• Sexual boundary Violations-
• Surveys in America have revealed that
between 6% and 10% of psychiatrists have
engaged in erotic activity with their patients .
• Most cases involve a male therapist and a
female patient, while approximately 20% of
cases involve a same-sex dyad, and in 20% of
cases the therapists are female

14. • Sexual activity with a patient damages the healing
capacity of psychiatric treatment.
• One survey of psychiatrists found that 65% of those
who had been sexually involved with patients felt that
they were in love with the patient, and 92% believed
that the patient was in love with them.
• In fact, such feelings may have had their origins in
transference and counter transference; by acting on
the feelings rather than working in therapy to
understand them, the psychiatrist harms the treatment
and the fiduciary relationship.

15. Sequence in sexual boundary
violations/Slippery Slope (Gabbard &
Simon)
Sexual violation does not occur ‘out of blue’,
started from crossing to violations. The common
sequence as follows-
• a transition from last-name to first-name basis;
• then personal conversation intruding on the
clinical work;
• Therapy sessions become less clinical and more
social
• Patient is treated as ‘special’ or confidant
• Therapist self-disclosures occur

16. • Therapy sessions become extended in time
• then some body contact (e.g., pats on the
shoulder, massages, progressing to hugs);
• then trips outside the office
• then sessions during lunch,
• sometimes with alcoholic beverages;
• then dinner;
• then movies or other social events; and finally
sexual intercourse.

17. Some harmful consequences to the
patient of boundary violations
• Emotional turmoil
• Shame, fear or rage
• Guilt and self-blame
• Isolation and emptiness, disengagement from
services
• Cognitive distortion
• Identity confusion

18. • Emotional lability
• Sexual dysfunction
• Mistrust of authority, paranoia
• Depression
• Self-harm
• Suicide

19. Non sexual boundary violations
• TIME
Time is, of course, a boundary, defining the limits of the
session. The beginnings and endings of sessions-starting or
stopping late or early-are both susceptible to crossings of this
boundary. Such crossings may be subtle or stark.
• PLACE AND SPACE
The therapist's office or a room on a hospital unit is obviously
the locale for almost all therapy. Exceptions usually constitute
boundary crossings but are not always harmful. Some
examples include accompanying a patient to court for a
hearing, visiting a patient at home, and seeing a patient in the
intensive care unit after an overdose or in jail after an arrest.

20. • MONEY
fee received by the therapist is the only appropriate and
allowable material gratification to be derived from clinical
work .
• CLOTHING
Clothing represents a social boundary the transgression of
which is usually inappropriate to the therapeutic situation.
Excessively revealing or frankly seductive clothing worn by
the therapist may represent a boundary violation with
potentially harmful effects to patients.
• SELF-DISCLOSURE AND RELATED MATTERS
• LANGUAGE
• GIFTS- Even small gift from patient may raise the
exceptions of patient to doctors and they may expect
return from patient.

21. Potential non-sexual boundary
violations
• Excessive self-disclosure
• Special fee arrangements (low or free)
• Extending time beyond what was initially
agreed
• Allowing telephone calls between sessions
• Extra-therapeutic business relationships

22. • Socialising with the patient
• Calling each other by first name
• Treating the patient as a friend or confidant/e
• Touching or frequent hugs

23. An anonymous postal survey on the awareness of the existence
of boundary violations by doctors and therapists in india was
conducted among psychiatrists and clinical psychologists
practising in Karnataka( By Dr. Sunita Kurpad,2010)
Action of doctor/
therapis
Number of respondents
(Percentage
Taking gifts for personal use from
patients
15(29)
Becoming friends with patients 10(20)
Accepting free services from
patients
9(18)
Actively socialising with patients 7 (14)
Undue disclosing about self to
patient
7(14)
inappropriate/ unnecessary physical
examination
1(2)
inappropriately touching patient 1(2)

24. Management principles of patients who have
experienced SBVs by an earlier therapist
• Treating therapists must be aware of their own
transference and counter-transference issues
• For therapists, it can be uncomfortable to hear
complaints about a colleague
• Therapists should not rationalize the behavior
of the offender and must convey the
understanding that the patient has been
exposed to inappropriate exploitation

25. • The therapist’s responsibility is always to
prevent the miscarriage of treatment in the
face of any and all pressures.
• The spouse or other family members may
need support or therapy and their difficulties
must be addressed
• The legal context of the therapy must be
appreciated and the therapist should avoid
the dual role of therapist and legal adviser

26. Draft of Guidelines for doctors on
Sexual boundaries (IPS Guidelines)
• It is the ethical duty of all doctors to ensure
effective care for their patients.
• While the laws relating to sexual abuse in India
generally pertain to women, these Guidelines aim
to be gender neutral and serve as a guide to a
code of conduct on doctors of any gender, and to
protect patients of all genders too.
• Doctors should ensure that they do not exploit
the doctor patient relationship for personal,
social, business or sexual gain.

27. • Doctors are reminded that even consensual
sexual activity between patients and doctors
irretrievably changes the therapeutic nature of
the doctor patient dynamic. it can be said that
consent in a power imbalanced relationship is not
true consent.
• Any non consensual sexual activity would amount
to sexual abuse/ molestation/ rape and doctors
would be answerable to the law of the land.
(Indian Penal Code laws relate to rape, child
sexual abuse, sexual molestation, adultery and
sexual harassment in the workplace)

28. Relevant sexual history and sensible physical
examination in presence of chaperone and indication
and findings of examination should be documented.
• If treatment that requires the patient to be sedated is
used (like electroconvulsive therapy, or any procedure
that requires anaesthesia), a nurse should be present
during the induction and recovery of anaesthesia.
• A minimum time frame of one year should elapse after
the doctor patient relationship is terminated, after
which it may be permissible for a doctor to have a
sexual relationship with a patient .

29. • it would be useful to note that sometimes NSBVs
can slip intoSBVs. It would be important for all
doctors to be alert to warning signals in their own
( or in their colleagues) , as well as patients
behaviour in these situations.
• Doctors are reminded to ensure that they use
social media responsibly, as it can inadvertently
lead to a blurring of professional boundaries.
• As doctors are to ensure they do not exploit the
doctor patient relationship for sexual gain, it
would also imply that these Guidelines extend to
protect the family members of patients too.

30. • Any failure to follow these Guidelines, if reported
to the Indian Psychiatric Society (IPS) will be
referred to the Ethics Committee.
• Though these Guidelines pertains primarily to
patients, doctors are reminded that similar care
should be extended to interactions with students,
colleagues and other professionals in the
multidisciplinary team- indeed anyone who is in a
„power imbalanced relationship‟ with the doctor.

31. • False allegations can occur. It is important for
doctors to be alert to warning signals and risk
situations.
• The Indian Psychiatric Society recognizes that
SBVs are not restricted to any particular group
of doctors, indeed not restricted to doctors
alone, but occurs in all professional groups

32. Measures for reducing risks of
boundary violations
• Improve awareness about boundary issues by educating
all health professionals, patients and care givers
• Ensure some level of supervision in clinical practice
• Develop clear guidelines in managing allegations
confidentially and effectively
• Encourage hospital/health management/medical
societies in India to implement the guidelines

33. • Ensure people investigating BV allegations are trained,
do not cause further problems to patient victims and
are aware of possibility of false allegations
• Manage the patient victim safely and effectively
• Manage the offending doctor compassionately but
effectively. He/she may need support to handle
consequences of legal actions.
• If needed, ensure legal advice for all involved – patient
victim, offending doctor and ‘third party doctors’

34. Legal Action
For the patients/Alleged Victims:-
• It is best to follow the reporting process in your hospital.
Generally the Chief of Services is informed and matter
reported to the Hospital Enquiry Committee.
• Usually a written complaint is required. Patients also have
the choice to make a complaint to the local medical council,
or to file a complaint with the police under the Indian Penal
Code (Section 354 A).
• The Medical Council of India’s current Code of Ethics
prohibits ‘adultery or improper conduct/ association with
patients’ (Misconduct Chapter 7). The Indian Psychiatric
Society has convened a Task Force on Sexual Boundaries in
2015, and they published Guidelines on this issue in 2016.

35. • Statement in the MCI’s current Code of Ethics
which deals with ‘improper conduct’ (Chapter 7 )
• Misconduct 7.4 Adultery or Improper Conduct:
Abuse of professional position by committing
adultery or improper conduct with a patient or by
maintaining an improper association with a
patient will render a Physician liable for
disciplinary action as provided under the Indian
Medical Council Act, 1956 or the concerned State
Medical Council Act.

36. • As per Section 354 A of the Indian Penal Code, sexual
harassment is a crime.
• However, sometimes patients and care givers do not
want to file a police complaint as they may have some
anxieties or concerns about the whole process.
• They may report it to the hospital authorities with a
request to take appropriate action against the doctor,
which can be done after conducting a proper
enquiry. It is important for all concerned to take legal
advice. If rape is alleged, it is better dealt by the
criminal justice system.

37. IPC Sec 354(A)
1 . A man committing any of the following
acts—
• physical contact and advances involving
unwelcome and explicit sexual overtures; or
• a demand or request for sexual favours; or
• showing pornography against the will of a
woman; or
• making sexually coloured remarks, shall be
guilty of the offence of sexual harassment.

38. • Any man who commits the offence specified in
clause (i) or clause (ii) or clause (iii) of sub-section
(1) shall be punished with rigorous imprisonment
for a term which may extend to three years, or
with fine, or with both.
• Any man who commits the offence specified in
clause (iv) of sub-section (1) shall be punished
with imprisonment of either description for a
term which may extend to one year, or with fine,
or with both

39. You Decide……
Critically examine their own actions by asking
themselves the following questions:
• Is this activity a normal, expected part of
practice for members of my profession?
• Might engaging in this activity compromise my
relationship with this patient? With other
patients? With my colleagues? With my
institution? With the public?

40. • Could this activity cause others to question my
professional objectivity?
• Would I want my other patients, other
professionals, or the public to know that I
engage in such activities?

41. Some Examples
• Mr. D, an independent contractor, has been Dr. H’s patient
for three years. During a visit, he overhears Dr. H talking to
a colleague about some remodeling for Dr. H’s home. Later
in the visit he hands Dr. H his business card and tells Dr. H
that he will do the remodeling for a great price because he
appreciates the care he has received from Dr. H.
• While Dr. T was on rotation in the family medicine clinic, he
noticed Ms. L in the waiting room when she came to
consult his colleague, Dr. M. After 2 weeks later, Dr. T
bumped into Ms. L at the grocery store near his home. He’d
like to see her again and is thinking of asking her out.

42. • Dr. M sits on the board of a nonprofit community group
that serves inner city adolescents through after school and
summer activity programs. Mr. G, a local businessman, has
been his patient for some time. When Mr. G comes for a
routine visit during the group’s annual fund-raising drive,
Dr. M asks him for a contribution.
• Dr C is approaching a young female patient, Ms D, who, in
addition to considerable personality difficulties with fragile
mood disorder suicide attempt. During therapy Ms D’s
condition changes to a more sustained hypomanic episode
during which she becomes overfamiliar, seductive and
repeatedly asks Dr A out for dinner. She also makes Dr A
disclose that he is single and lives alone since a break-up
with his last girlfriend. Dr A waits until Ms D’s mental state
stabilises and, after arranging the termination of therapy,
accepts her dinner invitation. After few glasses of wine,
they have consensual sex.

43. • As you discuss a case with a colleague, she
tells you that she has been trying a new
approach with an emotionally “needy”
patient. She has extended the session time
beyond the customary 45 minutes, seeing him
at the end of the day for 1½ hours. She also
begins and ends each session with a hug,
which she feels is necessary to assure the
patient of her care and concern. Is this
behavior ethical?

44. REFRENCES
• Sunita Kurpad et al. is there an elephant in the room? Boundary violations in the
doctor-patient relationship in india. indian Journal of Medical Ethics Vol Vii no 2
April - June 2010
• Robert I. Simon .Treatment Boundary Violations: Clinical, Ethical, and Legal
Considerations.. Bull Am Acad Psychiatry Law, Vol. 20, No. 3, 1992
• Sameer P. Sarkar. Boundary violation and sexual exploitation in psychiatry and
psychotherapy: a review. Advances in Psychiatric Treatment (2004), vol. 10, 312–
320
• PaulE Garfinkel, Barbara Dorian, Joel Sadavoy, Rmichael Bagby Boundary
Violations and Psychiatry.. CanJPsychiatry,Vol 42, September 199
• Draft of Guidelines for Doctors on Sexual Boundaries. The Bangalore Declaration
Group and Indian Psychiatric Society (IPS) Task Force on Boundary Guidelines .
• ETHICS AND THE DOCTOR–PATIENT RELATIONSHIP. Claire Zilber M.D.
• Ethical Boundaries in the Patient-Clinician Relationship . A Report by the National
Ethics Committee of the Veterans Health Administration .July 2003
• All about elephants in rooms and dogs that do not bark in the night: Boundary
violations and the health professional in India Sunita Simon Kurpad,Tanya
Machado, Ravindra B. Galgali, Sheila Daniel. Indian Journal of Psychiatry 54(1), Jan-
Mar 2012
• Boundary Issues and Violations. Law and Psychiatry. WILLIAM H.REID