All about elephants in rooms and dogs that do not bark in the night: boundary violations and the health professional in India.

Sexual and non-sexual boundary violations occur in the health professional-patient relationship all over the world as well as in India. However, the issue is rarely, if ever, discussed here in a frank and rational manner. This paper discusses the challenges faced by all health professionals and particularly mental health professionals in handling this problem in India. Health professionals can now either let things remain as they are or try to change things for the better, despite the inherent risks in attempting the latter. Since knowledge about boundary issues is essential for effective healthcare, prevention of boundary violations by oneself and reducing harm to patients should a violation occur by another professional, it is important that all health professionals are aware of the issues involved.

INTRODUCTION

Boundaries define the limits of any professional–client relationship. The importance of defining and respecting boundaries in the doctor–patient relationship has received much attention in Western literature.[12] Boundaries delineate issues ranging from confidentiality, gift taking, to physical touch[3] [Table 1]. It is the doctor's responsibility to respect the fiduciary duty arising from the doctor–patient relationship. Boundary violations (BVs) can occur when there is blurring between professional and personal roles and identities. Dual relationships can occur in social, business, romantic, or sexual spheres. Both non-sexual and sexual boundary violations (NSBVs and SBVs) are known to cause various problems.[245] The primary focus of this paper is BVs that occur in the context of an emotional relationship between the patient and doctor. However, as BVs are generally recognized by actions and not ‘intent’, we also mention some acts where there is no question of an ‘emotional relationship’ and are no different from other acts of sexual abuse such as ‘inappropriate touch’.

Table 1

Boundaries in the doctor–patient relationship

Most doctors are exemplary in their professional roles and it may be only a few that fall short of that ideal. However, some ‘offenders’ can turn out to be serial offenders.[6] SBVs are a particularly serious issue as it is not openly discussed. One could assume that BVs are not a problem in India because they do not get publicity in rational academic fora. However, the recently published ‘Elephant in the room study’, an anonymous survey among psychiatrists and clinical psychologists in Karnataka on awareness about BVs, has shown that both NSBVs and SBVs occur in the health professional–patient relationship in India, but not all mental health professionals (MHPs) are aware of it.[4] BVs are known to occur in all subgroups of health professionals. An opinion published from Pakistan challenged the perception that BVs are a (Western) culture-bound syndrome by noting that BVs are not discussed in our South Asian cultures, as ‘such incidents are buried and not allowed to surface’.[7]

As the broad issues are similar when one discusses any health professional–patient relationship, for ease of terminology we have used the term ‘doctor’–patient relationship in this paper. We have used ‘he’ to refer to the doctor, though BVs are known to be committed by female doctors as well.[1] Patient victims can also be male or female, but we have used ‘she’ as a generic to refer to them. We have retained the word ‘patient’ instead of ‘client’ as we feel ‘doctor–patient’ relationship conveys the nuances of the relationship better than ‘doctor–client’.

This paper draws attention to this global phenomenon in the context of the particular difficulties in handling it safely in India. It has been noted that one of the reasons for ignoring this problem of sexual abuse, i.e., the reason for the ‘elephant in the room’, is that even attempting to handle this issue can be aversive to all involved.[4] MHPs such as psychiatrists, clinical psychologists, and psychiatric social workers have a pivotal role in beginning to address the issue effectively, having both the knowledge on behavioral aspects of sexual abuse and clinical expertise in problem solving skills.

NEED FOR UNIVERSAL AWARENESS AMONG MENTAL HEALTH PROFESSIONALS

Though all health professionals need to be aware of boundary issues, MHPs have an additional responsibility for various reasons.

Knowledge about boundary issues is not only essential for effective healthcare but also for prevention of BVs by oneself and in reducing harm to patients should a violation occur by another professional

Some patients seek medical help or therapy for the mental health or personality difficulties, which make them vulnerable to BVs

BVs can lead to further emotional problems; therefore, unless the treating therapist is aware that BVs can occur in India, he or she is unlikely to recognize or handle it effectively

The doctor/therapist who violates sexual boundaries needs to be confronted and may need psychiatric or psychological evaluation

If the victim and offending doctor give different versions of the ‘incident’, the MHP may be asked to take on the role of an ‘expert witness’, despite some inherent limitations[8]

Though false allegations by patients are supposedly rare, it is by no means uncommon in India.[4] As it can have devastating consequences, MHPs may be asked to deal with this issue as well

As MHPs are also teachers, the ethical issues in managing boundaries have to be taught, discussed, and supervised. Lack of training in boundary issues can sometimes lead professionals into difficulties or putting themselves in ‘at risk’ situations for false allegations.

The importance of maintaining boundaries

Maintaining boundaries ensure that it is the need of the patient and not the doctor that is met in the interaction.[1] It does not imply having a cold or distant relationship.[9] On the contrary, it allows a framework for a warm, caring and supportive relationship with the doctor, ensuring the patient's physical as well as psychological well-being. Respecting boundaries protects both the patient and the doctor.

Reasons for boundary violations

The inherent power differential in the doctor–patient relationship can make some patients vulnerable to abuse. The doctor has the knowledge and skill to help the patient at a time of physical or emotional distress. Table 2 lists the reasons for boundary violations. However, it has also been criticized that ‘concepts of transference and counter-transference may appear muddlesome and can be used as a potential smokescreen for malpractice’.[6]

Table 2

Reasons for boundary violations

Dual relationships and BVs in social and business issues

Dual relationships occur when there is a blending of professional as well as non-professional roles. Humanistic and existential therapy can see dual relationships as an important and integral part of the treatment plan.[3] However, the risk is that boundaries can get blurred and exploitation can occur, as roles can become confused. Most patients need the structure provided by clear and consistent boundaries. If not, the management of transference and counter-transference can become impossible, creating conflicts of interest and jeopardizing professional judgment to the detriment of patient care. NSBVs such as socializing/friendships with patients, accepting gifts for personal use, undue self-disclosure, and special low fees are some examples of BVs, which can lead to difficulties in the doctor–patient dynamic.[2] The same holds true for other dual relationships such as business dealings; even if the doctor does not expect personal benefit, for example, soliciting an advertisement for a conference brochure.

In our recent Elephant study, there was a disagreement whether gift taking could be construed as a BV in the Indian culture. Traditionally, in India, when no fee is charged for a service (e.g., education), then it was deemed acceptable to accept a gift in kind. In clinical practice where patients are charged fees, an apparent expression of gratitude can change the doctor–patient dynamic, if the doctor is not alert to it. One also needs to think twice about accepting gifts (if they are for personal use) at the termination of therapy, since the relapse rates in psychiatry (and other medical conditions), ensure that one cannot assume that the termination of therapy or treatment signals the end of the doctor–patient relationship. Interestingly, in the ancient Ayurvedic text Caraka Samhita, the oath of initiation into medicine prohibited physicians from accepting any gifts other than food from women. That too had specific guidelines – “No offering of meat by a woman except at the behest of her husband or guardian will be accepted by thee.”[10]

Dual relationships that would not reasonably be expected to cause problems, risk exploitation or harm are not considered unethical. A home visit done only for clinical reasons and not involving any secondary relationship is obviously not a problem.[3] Sometimes, a social or business contact can become inevitable, especially within smaller community/town/rural area. Here, it is important that the doctor does not exploit, or even look like he is exploiting the doctor–patient relationship in any way.[4] However, one should remember the dangers of the well-known ‘slippery slope’, where sometimes NSBVs can slip into SBVs.[11]

Boundary violations in romantic and sexual areas

A number of doctors have admitted to being sexually attracted to patients in the West. However, few actually go on to have a sexual relationship with them.[5] Data on doctors disciplined for sexual abuse of patients in the US has shown certain specialties such as psychiatry, gynecology and general practice to be at ‘higher risk’ than surgery, anesthesiology and pediatrics. The typical profile is that of an older doctor in an urban area working in a non-academic center.[12] Yet, we now also know that ‘boundary issues arise in all therapies and for all clinicians, apparently irrespective of the number of years of experience and even for those practicing only psychopharmacology’.[13] Doctors with ‘personality disorders’, mental illness like hypomania or having a crisis in their personal lives such as bereavement or separation are more likely to enter into a relationship with patients.[5] Some female therapists may be attracted to young charming men with personality problems and think they can help ‘settle him down’ by providing him with love.[2]

Sexual contact that occurs in the context of an emotional relationship between the doctor and patient is more easily seen as NSBVs, which ‘slipped into’ SBVs. Legally speaking, these can be seen as ‘consensual’ acts between adults. Ethically speaking, such acts are not truly ‘consensual’ due to the power differential in the relationship. It is possible for patients to be attracted to a doctor who is caring and supportive at a moment of crisis, but it should always be the responsibility of doctors not to take any advantage of the situation.[14] Though doctors who abuse tend to rationalize their behavior, the consequences of the SBV are nearly always damaging to patients and similar to incest.[515] Not only sexual intercourse, but taking an unnecessary sexual history, sexual talk, and inappropriate touching can also qualify as an SBV. Some actions like ‘inappropriate physical examination’, where the patient might not even realize that she has been subjected to an unnecessary touching/procedure, are really no different from other acts of sexual abuse. In some cases, where SBVs have occurred, the ‘NSBVs’ do not seem much different ‘in spirit’ from ‘grooming techniques’ used by sexual abusers in other vulnerable groups like children.[16]

Physical touch has been classified as an NSBV in the West. However, in India, physical touch has less of a cultural sanction, especially when strangers of the opposite gender meet. Usually, greeting a person with the traditional ‘namaste’ with folded hands is more common than shaking hands. Some public displays of affection which seem to be culturally acceptable in India are touching or hugging the elderly, hugging children and same gender adults holding hands (though we are not aware of any specific studies on this issue). Therefore, in India, physically touching a patient except in the context of appropriate physical examination could be risky because even if the doctor does not mean anything inappropriate by a ‘comfort touch’, the patient especially if a victim of past sexual abuse/grooming, might misunderstand the gesture of the doctor. Of course, there are some clinical situations where a comfort touch is obviously appropriate. For example, if a patient is in physical distress.

Drawing the line between boundary crossings and violations

Sometimes brief ‘excursions’ from the usual doctor–patient relationship may occur without harm. ‘Excursion’ implies a return to the usual professional relationship.[17] Examples of boundary ‘crossings’ could include gift taking (e.g., accepting something made by the patient such as a painting and keeping it in the ward/office), self-disclosure (in an appropriate context), or special fee arrangements (by the organization for which the doctor works, rather than the doctor on his own individual capacity). It is known that these can sometimes actually benefit patients. However, boundary ‘violations’ exploit the doctor patient–relationship, especially in business and sexual relationships and harms the patient.

Excessively rigid boundaries have been criticized as being more about the therapist's fears rather than the patient's needs and interfering with sound clinical judgment. The ‘slippery slope’ of NSBV to SBV has been criticized as paranoid and unnecessarily sexualizing boundaries.[3] It has been suggested that some Asian, African American and Latino cultures may have different expectations when it comes to boundary crossings.[3] However, as one of the responses to the publication of the Elephant study pointed out, sometimes the ‘curtain of culture’ is used to allow the ‘seeds for BV (to be) sown’ in developing countries.[18] All this would indicate that having clear nuanced guidelines on this issue in India will help both doctors and patients.

ETHICAL GUIDELINES AND THE LAW

Though there is no blanket mandate against NSBVs, there has been a strict mandate against sexual relationships with patients in medical codes of practice. Over 2,000 years ago, the Hippocratic Oath specifically stated ‘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.’ The Medical Council of India (MCI), does state that ‘adultery or improper conduct …or maintaining improper association with a patient’, makes a doctor liable for disciplinary action.[19] However, ‘improper conduct’ is not defined. In India, the need to amend the law on adultery itself has been much debated in non-academic fora, from the point of reverse gender inequality, to the need to reduce adultery from a criminal to a civil offence.[2021]

It has been stated that ‘law is the minimum of morals’.[22] Regarding BVs, ‘law is the minimum of ethics’. Ethical guidelines should guide the doctor's behavior rather than only the letter of the law. The American Medical Association states that even a relationship with a former patient is unethical ‘if the physician uses or exploits trust, knowledge, emotions or influence derived from the previous professional relationship’.[23] Ethical difficulties can still arise when personal relationships are allowed after a specified period, post-termination of the doctor–patient relationship.[24] Recently, the MCI spelt out what is acceptable and what is not in terms of relationships between doctors and pharmaceutical companies.[25] Though the doctor–patient relationship is more complicated than doctor–pharmaceutical relationship, it would still be useful if guidelines on doctor–patient relationship are a little more explicit than what is now available (e.g., would it be acceptable for doctors to take gifts for personal use at the end of treatment?). Equally, it is important that guidelines are seen as guidelines and not rules (especially on NSBVs) as the role of ‘context’ is extremely important.[26] The therapeutic nature of the doctor–patient relationship should allow doctors the flexibility to use clinical judgment and common sense when needed.[27] As Menninger's oft quoted teaching, “When in doubt, be human”.[27] At the time of submission of this article, the MCI has been disbanded over allegations of corruption. We acknowledge that currently the MCI has to deal with matters more urgent than the doctor–patient relationship.[28] But one hopes that the MCI can soon look at these issues so pertinent to medical care. We accept that there is a reality check between a code of ethics and its enforceability, but we have to start somewhere.

Regarding medical doctors in India, it is at least possible to register a complaint with the MCI. As far as we are aware there is no central registering authority for clinical psychologists, social workers and some other health professionals in India. In these situations, the patient can usually approach the institutions and consumer courts for redressal in civil cases.

Elephants in rooms and dogs that do not bark in the night

It would seem that in the West, acknowledging the elephant in the room, i.e. the sexual abuse of patients by doctors, began when patient victims beginning to feel safe enough to make complaints.[29] The professional malpractice/compensation issues may have also contributed towards professional bodies taking a stance on this issue.[2] In India, it can still be hazardous to make an allegation of sexual abuse. Recently, media attention was focused on the case of a 14-year-old girl who was allegedly molested by a senior policeman. It was reported that “It took the legal system 19 years, 40 adjournments, and more than 400 hearings; and the court finally pronounced the policeman guilty under Section 354 IPC (molestation) and sentenced him to 6 months imprisonment and a fine of Rs 1,000. The patient and family were harassed and finally the young girl (had) committed suicide.”[3031] The authors cannot opine on whether these represent the facts of the case or not,[32] but this is the public perception on what can happen if one makes allegation of sexual abuse in India, especially against someone in a position of relative power. Given this perception even in a situation where there can be no debate on the question of ‘consent’, it is perhaps unrealistic to expect patient victims to be willing to make complaints. In the case of the young teenager, it was the ensuing public outcry that led to a tougher sentence.[33]

All this puts a greater responsibility on the medical fraternity in India to take proactive action on this issue. The MCI's ethical guidelines does state that ‘A physician should expose, without fear or favor, incompetent or corrupt, dishonest or unethical conduct on the part of members of the profession’.[19] Concealing BVs in a colleague has been likened to an enabling member of an incestuous family, keeping the ‘family secret’ that enables the perpetrator to continue the abuse.[34]

However, even countries which have systems in place to support ‘whistle blowing’ by ‘third party doctors’ (doctors to whom patients or care givers subsequently disclose a history of abuse), have acknowledged practical dangers and difficulties.[3536] Regarding the behavior of third party doctors, the analogy to the ‘silence of the dog in the night’ in the Sherlock Holmes story ‘Silver Blaze’ seems appropriate. In this story, the mystery surrounding the theft of a race horse was solved by noticing what did not happen, i.e., the dog did not bark at night. Holmes correctly deduced that the dog did not raise an alarm as he did not realize that a crime was being committed because he knew the ‘offender’.[37] When third party doctors hear of allegations of SBV by someone they know, sometimes they cannot even imagine that it could be true. There is also a possibility that false allegations get more publicity among doctors.[4]

Management of patients who have experienced SBVs

Managing patients who have experienced SBVs needs expertise, as patients are requesting help from the same system which has let them down once before. There are some excellent reviews available on this topic.[38] Some important points are listed in Table 3. It is not necessary that the therapist be a woman. If the patient has experienced sexual abuse in childhood, she may distrust women if her impression of women is based on ‘a mother who facilitated her abuse or stood by impotently while her daughter was exploited’.[38] It is known that the patient's ambivalence about the previous therapist is likely to be profound. After therapy, many patients make significant recoveries but some drop out of therapy and some even go back to the abusive therapist.

Table 3

Management principles of patients who have experienced SBVs by an earlier therapist[38]

Ideal enquiry process and management of ‘offending’ doctor

Doctors and hospitals should have clear documented procedures to handle allegations of BVs, mandated by the MCI. Patients and carers should be involved in review procedures. Till more is known about the profile of offenders in India, it is important not to generalize from those who get media publicity. Systems also need to be in place to effectively manage the ‘allegedly’ offending doctor. Some suggestions (based on Western literature) would be:

He should be advised against trying to contact the patient while the enquiry is going on

As some offenders are neither psychopathic nor serial offenders, they too might benefit from ‘compassionate regard for their special needs, with implementation of normal disciplinary measures’[5]

If evidence of mental illness is found, it should be treated

Counseling support to handle consequences such as loss of job or public humiliation might be needed

Specific education interventions can be tried to promote behavioral change.[39] As one mental health expert noted (on behavioral intervention and rehabilitation in offenders who are genuinely remorseful) “…Do we believe that behavior can change? If we do not, we are in the wrong business”[40]

If the medical license is revoked, it can be given back after a period of time, so long as he agrees to work under supervision. ‘Practice limitations’ can ensure future patients are not put at risk[234]

In a rare situation, where the doctor and patient both feel that they are genuinely ‘in love’ and want to continue their relationship, the doctor should be encouraged to discuss this with a colleague and transfer the patient's care to another doctor. However, it may be important for doctors to remember that transference and counter-transference issues persist beyond the termination of the doctor–patient relationship, and sometimes termination occurs solely to enable sexual relations.[24] As another response to the Elephant paper pointed out, the validity of consent in ‘consensual’ relationships can be questioned when the psychiatrist involved with the patient is also the treating psychiatrist and this makes for a thin line between SBV and sexual molestation.[41] This is indeed true of any ‘power imbalanced relationship’

Cases involving children, intellectual disability and other situations where the question of ‘consent’ does not even arise, are criminal acts and are better handled by the criminal justice system, like the recent case of a serial offender pediatrician in the US.[42]

PREVENTION

Improved awareness would be central to prevention. The need to train all health professionals, not just medical undergraduates and postgraduates on boundary issues has been highlighted by us elsewhere.[4] Medical students need to be sensitized to boundary issues and taught how to take appropriate sexual history and physically examine patients without making them uncomfortable.[43] Similarly, doctors should ensure that when surgical procedures and electroconvulsive therapy take place (in fact, any procedure where the patient is likely to be sedated or drowsy), nursing staff are present not just during the procedure but during the induction and recovery from anesthesia. Staff performance (irrespective of status) should be regularly reviewed. As NSBVs can slip into SBVs, supervision of clinical practitioners can reduce the risk of BVs.[44] As BVs also happen by senior doctors who may not lend themselves easily to supervision, it is important to have systems in place for supervision through peer groups for continuous professional development. It has been suggested that no one who practices psychotherapy is ‘too old and senior’ for supervision.[2] That is good clinical practice, not just a safeguard against BVs.

However, since countries that have dealt with this issue for years have failed to eradicate it, we should focus on educating patients and carers. Educating them would be an important way to reduce the risk of SBVs or even allow for early recognition of ‘warning signals’ at the beginning of the slippery slope.[45] Special care is needed for vulnerable groups such as patients with substance dependence, intellectual disability, chronic mental illness, children, adolescents, elderly and forensic patients. Patients and carers should know what to expect in terms of physical examination or sexual therapy (otherwise they might not even realize that they have been subjected to some unnecessary/inappropriate behavior).

In India, the Mental Health Act of 1987, requires periodic inspection of all psychiatric centers.[46] Perhaps, now one additional thing can be checked, i.e., who is practicing counseling, psychotherapy, sexual therapy or doing home visits and whether they are being supervised. We realize that this will not prevent BVs but naming and acknowledging the problem will raise awareness. As some centers in India offer mental health services without adequate supervision, it is important that carers check on the quality of professional help available before blindly admitting patients in these places. With the burgeoning private practice in metros, doctors also need to be educated on how to avoid boundary violations, with special care regarding home visits. The risks of BVs can be reduced if clear procedures are in place [Table 4].

Table 4

Measures that can reduce risks of boundary violations

Benefits of dealing with the Elephant despite the dangers

Though there are inherent risks to both patients and doctors in dealing with the Elephant, this is something that has to be handled.[434] There are parallels to difficulties which arise in dealing with child sexual abuse (CSA). The moving preface of the John Jay Commission report (requested by the United States Conference of Catholic Bishops), outlines the difficult duty that academicians have to study and report on CSA.[47] Not dealing with SBVs will definitely affect patients’ and care givers’ faith in the medical system, just as not dealing with clergy perpetrated sexual abuse (CPSA) adversely affected faith in God and the church in the US.[48] An understandable concern would be that patients may hesitate to access much needed medical and psychiatric care despite the availability of many ethical health professionals. However, the public, media and government response to the swine flu pandemic in India bear testament to the fact that given the correct information, influential people can ensure that the issue is handled responsibly. That would be crucial, otherwise everyone would end up feeling that it would have been better to leave the Elephant in the room alone. Even doctors who have strongly endorsed the need to be sensitive about boundary issues in the West have noted that an over-reaction can be counter-productive.[26]

Nearly 20 years ago, it was noted that the discomfort on confronting this issue (in the West) stems from the desire to preserve both the ‘private and the public image of the profession…’.[34] More than 15 years ago, Professor Agarwal stated (regarding ethical behavior by doctors in India), “…Medical men should not brush aside unethical acts of their colleagues. Quite often such practices are encouraged under the assumption that it will save their institution or profession from disrepute. Protecting such persons does more harm than good to the profession as well as the institute.’[49] Perhaps, ensuring that both the patient and the offending doctor are treated with dignity will make it easier to make complaints. Another important reason for us to deal with this issue is to fulfill our obligation to teach medical students by serving as the right role models. If we fail to deal with this issue now, we risk demonstrating the gap between teaching medical ethics and practicing it.

Recent media reports in India have shown that the Elephant (a global, not an Indian phenomenon) exists in other traditionally respected groups too, such as teachers, religious leaders and the armed forces. Doctors in India now have an opportunity to take the lead in tackling sexual abuse in our society, as effective action might best be achieved by the groups themselves. In India, to expect victims to do something about sexual abuse will only delay effective action. It is important to aim for ideal, ethical medical and psychiatric care, rather than settle for less citing terms like ‘available resources’ and ‘ground realities’. As the renowned physician William Osler said in his address to medical students 100 years ago, “The practice of medicine is an art, not a trade; a calling, not a business; a calling in which your heart will be exercised equally with your head.” Respecting boundaries will ensure that doctors can use their heart to benefit patients, and not to harm them.