Wednesday, October 26, 2011

Guest Blogger Dr. Jesse Hellman on "Acting Professionally."

Psychiatrists “friending” their patients or interacting with them on Facebook led to the discussion of professional boundaries on Podcast #62. I thought of expanding the discussion because the oft-advised “act professionally” is less than truly helpful: how does one know what is professional? That does not elucidate the underlying principles. I’m talking about one aspect of this below, and am posting this to see what ideas others have. If possible, try to look below the concrete example to expose the underlying principle. 

The psychiatric relationship is a special extension of what is considered proper in all relationships in which one engages someone for professional ends. A mechanic, accountant, electrician, each has access to certain information and he is to use it only for the purpose intended. When you invite an electrician into your home he is to concentrate on the task at hand, not dwell on your art or the design of the home, and certainly not on how beautiful you are. 

A psychiatric patient opens up extremely sensitive personal information, potentially much more embarrassing and intimate than that seen by other physicians. The psychiatrist needs to behave in a way that not only takes no advantage of the information but also keeps the focus on what will help the patient. 

The more the psychiatrist holds to this dictum not only is it easier for the patient to speak openly but the psychiatrist may learn of things that the patient has revealed to no one, perhaps information that he has had trouble admitting even to himself. 

Keeping to proper boundaries is very important in psychiatry. Certain remarks which are common in ordinary social situations would be quite seductive in a psychiatric session. We do not use our patients for our own gratification. That is the basic principle and it is essential if we are to help them.


rob lindeman said...

My foundational principles are these:

All I owe the family are my professional services. All they owe me is money.

I try to stick to that. Many parents in the practice call me by my first name. It makes me feel uncomfortable because it undermines professional distance necessary to do this job right.

Oh, and don't be a physician to your friends. Very. Bad. Idea.

wv = opredge: Nordic ready-to-eat breakfast treat

Anonymous said...


Your next to last line says it all: we do not use our patients for our own gratification. I wish that were always true. It is tough given that some doctors go into the field to fulfill certain ego needs and they do use their patients to that end. It is easier to feel good about the self, albeit fleetingly, when someone else is in worse shape that you are and you are there to help them. To some extent, if the doctor does not go too far, the needs of the doctor and patient dovetail. The key would be that it is not apparent to the patient that the doctor is meeting any of their own needs other than to make a living. So yes, that is why boundaries are important; it is tougher to be saviour to your patients when you see them at set times with reasonable limits in all things. it is also why it is very important for doctors to have a sense of who they are as human being and individuals aside from their doctor so that they can step out of that role on their own time and get their needs met by people who are not their patients. Those doctors are also more likely to recognize when their own problems interfere, or have a high chance of interfering with patient care.
It really should not matter whether a patient calls a doctor by their first name. Patients tend to be called by their first name. We usually call our mechanics by their first name. If a doctor is careful to call all patients Mr, Ms, or even Dr, the the patient should take the hint. If they do not, the professionalism of the doctor will be what helps them maintain the proper distance, not what name the patient or parent of a patient uses.

Sunny CA said...

The analogy with tradesmen amused me because a contractor I interviewed (but did not hire) stepped on the scale in my bathroom to see what he weighed, then commented on his weight. Another I did hire used my computer while I was away from the house, without permission. So tradesmen have their boundary issues also.

I have appreciated my psychiatrist's professionalism. From a patient perspective, there is a feeling of security that comes with predictability of the interaction. My psychiatrist is always on time, always there as scheduled, always polite and respectful, always supportive, always listens. In a sense, the best way to be a "friend" to a patient is to be totally professional in conduct and not overstep boundaries. In any sort of internal or external chaos the stability of the therapeutic relationship due professionalism of the practitioner serves the patient best.

Liz said...

i could not agree can be a slippery slope so we all should be bound by this most important ethical issues....and no friending on facebook...bad idea.

Anonymous said...

A psychiatrist should not be a friend. I could never imagine me being friends with my psychiatrist had we met under different circumstances. Yeah, we would probably get along, but I doubt we would go out for coffee together.
Also, I would never call my Dr. by her first name. I am a Dr. too, the PhD kind, and I feel addressing her by first name is a definite boundary crossing. I have a professional relationship with my psychiatrist and I find it more comfortable for me to use her professional title, Dr.

Bridget said...

I can't imagine doing your job and being friends with a client. It's just not possible...whatever the relationship is,it's not therapuetic

jesse said...

Boundaries are so important! Sunny's comment is right on target: the contractor who stepped on the scale crossed a line. He did not have access to the bathroom for anything else but to address his task, and stepping on the scale was doing something else.

Frequently patients talk about areas of their lives that are very interesting. But we pursue only that of use to the patient, however curious we may be about it, or however much we might enjoy the subject.

What is a problem is that occasionally a therapist goes off the path without recognizing it. Sometimes he is pursuing something for his own interest and might even be convinced it is for the patient's sake.

Certainly there would be certain things gratifying for the therapist to know, to have a window on. Hopefully the therapist is sufficiently honest with himself to be aware of that. That is inevitable, and the extent that the therapist is aware of his own curiousity and voyeuristic impules the more likely that he would treat such material in a professional manner.

An analyst in NY gathered from one of his patients that her husband's company was about to turn down a takeover offer. He acted on this and was convicted of insider trading.

Anonymous said...

It is my experience and belief that every good shrink has been shrunk by at least one, if not more shrinks. And since I am posting anonymously while I can call up Jesse and Dinah's last names with little effort, there is not so much at stake for me to say this. But having been trained psychoanalytically in Manhattan (which I think is the rock the Messiah gave to the Jews to enlighten all of America--why He lets Woody Allen stay there I am not sure...) I know there is a difference in attitudes in the notion of professionalism in East vs. West Coast precisely because of the psychoanalytic training on the East Coast and the cognitive-behavioral or whatever-it-is-they-do-out-here-training that varies on the West Coast. (They would have been better off sticking with family systems and Rogerian models, but the psychologists it seems gained ground with their impossible-to-do-get-you-nowhere cognitive-behavioral work.)
All this opinion making having been done, as a patient having made lasting progress working with a psychoanalyst, I have to say that my analyst violated the rules of professionalism that have just been heralded: she chronically ran late and, fortunately, she could see I was not a navel-gazer neurotic. She communicated clearly to me numerous times that my feelings were normal for "adults who were abused as children". I am certain that is not in the psychoanalytic handbook anywhere.
With monthly medication management patients I do provide more of a "holding environment" and stay on the "normal" track and do not challenge them as I would possibly do if they were in therapy weekly,etc. (It is not easy for me to be normal acting because I am Sideways after all....)
However, with psychotherapy patients I find that approaching them as a "person" and not as a demi-god is much better for psychotherapy of the weekly insight oriented kind that my patient population: 48 down to 18--seem to find authentic and which they state lets them be themselves and not a "presentation of themselves" to please yet another critical, anxious authority figure.
I, at 43, and all of us after, are from the generation of divorce. While some people might find the blank constancy of a psychiatrist comforting, I think that with the exception of the chronically, persistently mentally ill, savvy, insightful therapy seekers do not believe the therapist as authority figure/edifice model.
Being the beginning of what appears to be a multi-generational failure of many adults to even fake it as parents, many younger patients will not buy into the psychiatrist as parent model because they already know there are no free lunch programs.

Anonymous said...

It make sense to include the dynamics of psychiatrists and therapists who run mental health support forums for the public. Why are these venues consistently ignored??

Anonymous said...

"Certain remarks which are common in ordinary social situations would be quite seductive in a psychiatric session."

Can you explain this please?