Psychiatrist’s Tryst with Compassion and Boundaries

It was a usual day in a psychiatry ward—we had consultant rounds. Everyone was immersed in an intense discussion and assessment of a patient. Then came another patient strolling. We would often have patients with mental illness interrupting the rounds. They would often barge in, sit in doctors’ chambers, and be “uninvited attendees.” Even the guard’s assistance would not deter them. Often, our patients would be disinhibited but not to an extent that needs physical restraint or seclusion. It is rationalized that disinhibition is a symptom of mental illness. Psychiatrists often respond with empathy, choose to exercise tolerance or accommodation, or, at times, overlook certain patient behaviors.

The treating team continued the assessment, lined up on one side of the table in a semi-circle, with the consultant in the center and the patient in discussion seated opposite to him. The team continued to pretend the non-existence of the male patient, with chronic schizophrenia, who had started strolling around. On his way back, he tried shaking hands with a female resident seated at the flank. The discussion continued for another 10 seconds before the consultant stopped and asked her if the patient was trying to snatch her phone. The resident replied, “No sir, he just touched my hand and went away.”

The experiences of my journey as a psychiatrist started flowing through my mind. There have been instances when patients asked if I was married, instances of overfamiliarity where patients would often greet me persistently, screaming to greet even when taking rounds in the opposite corner of the ward, and instances where patients would not leave the interview. A patient had wanted to click the photo of my attire on the pretext of “good design.” A psychiatrist friend shared an experience about a patient turning up for an online consultation in a vest. Once, right in front of me, a schizophrenia patient suddenly threatened to slap my colleague. Also, my observation has been that these experiences occur barring gender. I have seen my male colleague “Dr. X” struggling with a female patient with mania; with a glimpse of him anywhere, she would often scream, “I like you, X.”

As I emerged from my thoughts, the consultant insisted on registering an “incident report,” a documented record that simply records the occurrence of a specific event, with the Medical Officer. It does not necessarily involve police or legal action. He reviewed the ongoing treatment and directed to make changes in the patient’s treatment plan. Knowledge of psychopathology at times leads us to make accommodations. Should we consider such incidents actionable or acceptable? Where do we draw the lines? Are lines that blurry in the field of Psychiatry? Would the resident have reacted similarly if the incident happened outside the Psychiatry ward? How would a doctor who is not a psychiatrist respond to such an incident?

Such experiences have accompanied all psychiatrists during their careers. The understanding of transference and countertransference changes us in some way. Often, we experience discomfort when patients lack the art of “proxemics”—the sense of space they need to maintain between themselves and the doctor. We hardly do anything about it. Do we file an incident report, immerse ourselves into optimizing the treatment as the patient is still symptomatic, or let it go? Do we do all of it or none of it? These are the dilemmas.

Such instances are an occupational hazard for which we may have developed a reasonable accommodation. These do make us uncomfortable. However, asserting the rights of a treating doctor by turning psychiatry wards into high-security cells/units, entering wards with security guards, or restricting the patient may lead to the seclusion of patients. This will hamper the establishment of rapport. In a psychiatry setting, establishing rapport is the essence of the doctor-patient relationship. Imagine carrying out Mental Status Examinations with two guards standing by the side. It is tough to strike a balance between the rights and responsibilities of a psychiatrist. The balance between reasonable accommodation and asserting the rights of a psychiatrist is very fine.

Establishing clear communication at the outset can help to manage the expectations of both the patients and caregivers. Educational materials or pamphlets for patients and their families that outline acceptable behavior and boundaries within the clinical setting should be created. Distribution of these materials during initial consultations and subsequently may help forge a therapeutic environment of mutual respect and understanding. Additionally, the use of behavioral techniques, such as modeling and reinforcement, can further support the establishment and reinforcement of these boundaries and acceptable behaviors, contributing to a more effective therapeutic environment.

In conclusion, issues related to boundary violation range from violation of personal space such as interruption in OPDs and clinical rounds, violation of personal space—inappropriate patient behaviors and comments—to struggle in handling boundary violation events while balancing clinicians’ rights with patients’ well-being. To address the challenges in navigating complex interactions, young psychiatrists can seek guidance from experienced colleagues and engage in open discussions about challenging cases. Establishing peer support groups offers a safe platform for seeking advice and emotional support from fellow professionals once to twice a month. Regular workshops focused on boundary management and the formulation of clear incident-handling protocols can further empower psychiatrists. These measures collectively contribute to a sense of security and confidence in providing optimal care for individuals with mental illness, ensuring the well-being of both patients and psychiatrists.