Dual agency, dual relationships, boundary crossings, and associated boundary violations: A survey of military and civilian psychiatrists

We hypothesized that psychiatrists with high dual-agency potential (militar y and health maintenance organization [HMO] psychiatrists) were more likely than non-HMO civilian psychiatrists to engage in dual relationships, repor t pressures to do so, participate in other general boundary-crossing activi ties, and report associated counter-therapeutic outcomes (boundary violatio ns). Ninety military and 191 demographically matched civilian psychiatrists reported the number of boundary-crossing activities (including dual relati onships) and associated counter-therapeutic outcomes in the preceding year with adult patients, Military and HMO psychiatrists reported greater extern al pressures than non-BMO civilian psychiatrists to engage in dual relation ships; however, all three groups were similar in their reported numbers of dual relationships. The reported boundary-crossing activities and dual rela tionships studied here are not necessarily associated with reported boundar y violations. The relative risk of a particular boundary crossing associati ng with harm to a patient likely depends on the therapeutic context and sho uld be determined on a case-by-case basis.