Maintaining treatment boundaries in small communities and rural areas.

Psychiatrists and other mental health professionals practicing in small communities and rural areas encounter unique situations and customs that may complicate the task of maintaining treatment boundaries. Boundary adjustments are frequently required that do not disturb the psychiatrist-patient relationship. The authors discuss specific boundary problems that arise in maintaining the psychiatrist's neutrality; fostering the psychological separateness of the patient; protecting confidentiality; ensuring that the psychiatrist has no previous, current, or future personal relationship with the patient; preserving anonymity of the psychiatrist; and establishing a stable fee policy. Four vignettes illustrate boundary issues that may be encountered in psychiatric practice in small communities. The authors suggest that applying the rule of abstinence, which states that the therapist must abstain from obtaining personal gratification at the expense of the patient, can help therapists distinguish between boundary issues, crossings, and violations.