“Boundary violations” typically occur when a mental health practitioner does something in the context of treatment which would be more appropriate if he or she and the patient had a personal, as opposed to professional, relationship with one another. For example, dating patients is clearly verboten, but there are lots of gray areas such as how the practitioner should respond if there is some change in the relationship between him or her and the patient.

Example of gray areas include what to do if the practitioner and the patient encounter each other in public, or if the patient and the practitioner are parties to some business transaction, such as when a patient becomes the practioner’s landlord.

It seems to me that there are some potential gray areas with boundaries in telepsychiatry. Here are three examples:

First, I have had patients show me their home by moving their laptop around as they had their session. I haven’t seen anything that I feel would be unprofessional, but it does strike me that most mental health professionals don’t make house calls, and telepsychiatry is a little like a house call sometimes, as people knock on the patient’s door or their pet runs up to them during a session.

Second, both therapist and patient tend to dress more casually at home. Again, I haven’t seen anything that I thought was inappropriate, but I have wondered about whether I should change from whatever I’m wearing at home into something less casual out of respect for the patient, or whether it’s just silly of me to wonder about it.

Third, I’ve talked about using a shoji screen at home when I do telepsychiatry from there. My office at home is considerably more messy than the one at my practice, and I think that I would rather leave it like it is and hide the background with a shoji screen.

I don’t have any answers here, but, as time goes on, I’m sure some boundary issues are bound (sorry for the pun) to come up in telepsychiatry.

At work, I’ve been aware of what’s in the background when I’m talking to patients, and I’m slowly moving things so that there isn’t anything to distract people with whom I speaking on Skype video calls.

Last week, I needed to do a Skype session on short notice, so I decided to do it from my home office. I rushed over to the computer, turned it on, and was making sure that the webcam was working when I noticed how bad the background was. I’ve been getting the place painted, and everything goes from one room to another in piles, following the painter. I noticed that the visual impression I was going to make on my patient was terrible.

Luckily, I had a shoji screen around and just stuck it behind me, so everything worked out fine.

I’m still learning though, I’ve never seen any patients in my home, but I’m beginning to realize that doing telepsychiatry from home requires me to think ahead more than I have been doing.