Thank you for the interview, “Protect yourself against patient assault,” and the accompanying reprint of Dr. John Battaglia’s article “Is this patient dangerous?” (Current Psychiatry, November 2006). Both give sound clinical guidelines for psychiatrist safety without being insensitive or “blaming the victim” in the case of Dr. Wayne Fenton’s tragic death allegedly at the hands of a patient. Although implicit, however, the need to develop and maintain appropriate boundaries needs to be more explicit and discussed.
From what we know, Dr. Fenton saw the patient in his office on a weekend with no one else present other than the patient’s father, who waited outside. One eulogy said that Dr. Fenton helped install a carpet in a different patient’s residence after the patient was released from the hospital. Both examples surely are instances of going “the extra mile” to help troubled patients, and Dr. Fenton was known as a master clinician who received some of the most difficult cases.
On the other hand, customary boundaries regarding how and where to see patients were not taken. Perhaps Dr. Fenton thought the rewards of breaking these boundaries outweighed the risks. Nevertheless, development and maintenance of boundaries should be undertaken as one way to ensure safety. When making exceptions, extra precaution should be taken.
H. Steven Moffic, MD
Professor of psychiatry and behavioral medicine
Medical College of Wisconsin
Dr. Battaglia responds
I wholeheartedly agree with Dr. Moffic’s points about the need to take extra precautions when going outside customary boundaries. However, our discipline treads in muddy waters on the issue of what is appropriate when working outside such boundaries.
The extremes of sexual or financial exploitation are clear, but otherwise the entire spectrum of interaction between patient and clinician can be appropriate under certain circumstances. For example, in my work with the Madison (WI) Program of Assertive Community Treatment, I often see patients in their homes, help them with grocery shopping, or assist them with other daily tasks. Although these behaviors do not fit an office model, they are not uncommon in community work and do not necessarily break boundaries.
John Battaglia, MD
Program of Assertive Community Treatment
Associate clinical professor of psychiatry
University of Wisconsin-Madison Medical School