Managing boundaries when your patients are your neighbors
When you see a patient outside of a clinical setting, follow the patient’s lead, but avoid discussing his or her problems
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Psychiatrists—especially residents—often prefer to reside close to the hospitals in which they train and work. Training programs in urban settings may offer their residents housing either attached to the hospital or immediately adjacent to it.
Psychiatry residents often discover their most ill patients also prefer to live close to the hospital. They become acquainted with their neighbors on the streets and in the emergency room. As a consequence, new residents must learn how to maintain appropriate boundaries in these situations.
Patients as neighbors
Chronic psychiatric patients are likely to utilize the services of the closest hospital. Individuals with severe mental illness seem especially prone to move to and live in areas near a hospital. For example, a study of VA patients with schizophrenia, bipolar disorder, and depression found those with schizophrenia and bipolar disorder were more likely to move closer to their health care providers.1 Also, many hospitals and training programs are located in inner-city areas, where individuals with severe mental illness are known to cluster.2-4
When encountering their chronically mentally ill patients on the street, psychiatric residents could have a host of reactions—ranging from becoming over-involved in their patients’ lives to completely avoiding them—that could cause them and their patients significant distress. The literature on boundary management in these situations is immense, and conclusions often are nebulous. Most authors suggest if a psychiatrist encounters a patient outside of the office, he or she should follow the patient’s lead while trying to avoid discussing the patient’s problems in public.5
It is important for residency training programs to educate residents on how to manage these professional boundaries. Residents should seek out support from their training department when they encounter these difficult situations.
The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.
1. McCarthy JF, Valenstein M, Blow FC. Residential mobility among patients in the VA health system: associations with psychiatric morbidity geographic accessibility, and continuity of care. Adm Policy Ment Health. 2007;34(5):448-455.
2. DeVerteuil G, Hinds A, Lix L, et al. Mental health and the city: intra-urban mobility among individuals with schizophrenia. Health Place. 2007;13(2):310-323.
3. Almog M, Curtis S, Copeland A, et al. Geographical variation in acute psychiatric admissions within New York City 1990-2000: growing inequalities in service use? Soc Sci Med. 2004;59(2):361-376.
4. Silver E, Mulvey EP, Swanson JW. Neighborhood structural characteristic and mental disorder: Faris and Dunham revisited. Soc Sci Med. 2002;55(8):1457-1470.
5. MacKinnon RA, Michels R, Buckley PJ. The psychiatric interview in clinical practice. 2nd ed. Arlington VA: American Psychiatric Publishing Inc.; 2006.