In this paper the authors use a psychoanalytic perspective to understand observations about the modes of self-deception that operate in physicians who have been dishonest or have engaged in other transgressions of ethics guidelines. They emphasize that it is inaccurate to categorize physicians as simply honest or dishonest, ethical or unethical. Physicians who have been ethical practitioners may rationalize sexual relations with patients, stealing from professional treasuries, lying, or other transgressions while convincing themselves that they have acted in an honourable manner. The authors share their experience of evaluating these phenomena in over 300 physicians who were referred to a specialized treatment centre by licensing boards, hospitals, physician health organizations or ethics committees. They note the high prevalence of defensive compartmentalization, temporal splitting and projective disavowal as means of tolerating behaviours they would generally regard as unethical. They also examine the implications of these modes of self-deception for psychotherapy.
Professional boundaries refer to the “edge” or limit of appropriate behavior in the clinical setting. The fundamental ethical principal involved is respect for the patient’s dignity and autonomy. Because there is a potential for exploitation of the patient due to the power differential and asymmetry between psychiatrist and patient, the following dimensions of the treatment frame must be considered: location, time, behavior, language, dress, confidentiality, self-disclosure, money and gifts, dual relationships, and physical/sexual contact. Context is crucially important in assessing professional boundaries. Hence, relatively benign boundary crossings must be differentiated from exploitative boundary violations. Preventive strategies, such as education, self-monitoring, and regular consultation should be part of the practice of all clinicians. The domain of the Internet is a recent context that has emerged, and psychiatrists must now be attuned to boundary issues in cyberspace.
Psychotherapy has traditionally been regarded as the purview of psychiatry rather than neurology. Yet, the doctor-patient relationship is fundamental to both specialties, and the principles that derive from psychotherapy theory and practice apply to that relationship regardless of the specialty. It is common knowledge that a large proportion of patients seen in the context of the practice of medicine have some kind of emotional disturbance. Moreover, patients with organic disease may also have significant emotional difficulties that complicate both the primary illness and its treatment. This experience inevitably has drawn attention to the need for the nonpsychiatric physician to have an understanding and proficiency in psychiatric diagnosis and psychotherapeutic principles. In this article, we consider basic psychotherapeutic principles that are useful in the everyday practice of neurologists and other nonpsychiatric physicians. These skills are important not only for practical reasons, but also because responsiveness to their emotional distress is essential to maintain empathy and caring as cornerstones of the art of medicine. With the use of clinical examples to illustrate these principles, we hope that readers can apply them to their own clinical experiences.
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