Self-respect and Self-protection
It is essential that psychiatrists protect themselves from being ex-ploited by patients. This principle is necessary to protect clinicians and patients alike. Many patients seeking treatment have endured abusive relationships in which being victimized became the price for maintaining human connectedness. For such patients, efforts to exploit the psychiatrist may be an action-question that inquires:
Must one of us be injured in order for us to have a close relationship?
By setting a proper role model for self-respect and self-caretaking, the psychiatrist imparts the following message to the patient:
Relationships need not be structured on the basis that one or both parties must be exploited. If I as the doctor allow you to hurt me, I am setting a poor role model.
Psychiatrists should attempt to discuss the meaning of any exploitive behavior on the patient’s part as soon as possible. With unstable or impulsive patients who are prone to acting out, confron-tation should be timed to maximize safety. For example, it would be more prudent to interpret the manipulative aspects of a patient’s suicidal behavior after the patient is admitted to a hospital. If a patient makes a sudden physical overture such as attempting a sex-ually provocative embrace, it must be dealt with the same urgency as a physical assault. The psychiatrist should inform the patient that such behavior is inconsistent with coherent treatment (Epstein, 1994; Shor and Sanville, 1974, pp. 228–231; 58). It is generally risky to allow repeated exceptions such as last-minute prolongation of sessions, repeated lateness in paying fees, excessive intrusion into the psychiatrist’s personal space in the form of regular and frequent late night phone calls, or taking items from the office.
Certain psychiatrists find themselves avoiding confronta-tion with an exploitive patient out of fear of the latter’s narcissistic rage. This is an indication of an escalating situation that may lead to further boundary violations either by the patient or the psychia-trist. A useful explanation of this behavior is provided in Gabbard’s (1994) description of a subgroup of clinicians who become sexu-ally involved with patients as part of a self-defeating pattern of behavior he termed “masochistic surrender”. These practitioners are unable to defend against being tormented by certain highly demanding patients. They succumb to the patient’s importunings, sometimes while in a dissociated state, even though they may know their behavior is wrong. Gabbard (1994) argued that the ab-errant behavior of these clinicians is rooted in an impaired ability to cope with their own aggressive feelings, resulting in their feel-ing that it would be sadistic to set limits on the patient.