Q.

Our agency has an outpatient client who lives in a neighboring state. His home is located about 150 miles from our office.  He has been seen by the same psychiatrist for about 10 years.  The client suffers many serious physical as well as emotional problems as a result of a tragic accident. Our concern is that we are unable to provide this client with the same level of service that we can offer clients who live locally or within our county.  We either directly provide or have access to community services and resources that can be accessed in emergency and non-emergency situations. We have discussed transferring the client to a provider in his own community. However the client does not wish to leave his treating psychiatrist and has repeatedly and emphatically stated that without his psychiatrist he would commit suicide. We want to do what is best for this client but we are limited by geographics.
 

A.

I understand further from our discussion that the client has a picture of the psychiatrist at home and kisses it each day as a thankful gesture.  The patient was being seen by the psychiatrist in a private practice prior to transfer to your facility.

Allowing the patient to continue with the psychiatrist is an exception to your normal procedure but it may be justified in light of your psychiatrist's concern that transfer to another psychiatrist could result in dangerous decompensation.

The patient's focus on the psychiatrist for a long period of time with a picture of the psychiatrist at the patient's home indicates to me the possibility of boundary violations. At a minimum, I would want to know how the psychiatrist's picture came into the patient's possession. Of course, it could be entirely innocent.  However, it is prudent to inquire further.

I suggest that you review the Mental Health Risk Retention Group case study on investigating sexual misconduct allegations for guidance on how to proceed. In summary in addition to the matters treated in the case study, I suggest for this situation that you review the psychiatrist's notes of treatment and talk to the psychiatrist's supervisor and to the psychiatrist to determine whether or not there is anything to be concerned about.

Assuming there are no boundary issues, the decision in part should rest on whether the patient is competent to understand the issues and to make a decision to continue with the psychiatrist when your facility cannot provide its full complement of services. If the patient is competent to understand the issues and make decisions, I suggest that you have him sign a release which fully discloses your concerns about not being able to provide full services.  A determination of competency should be documented. Someone other than the psychiatrist should be involved in the determination and discussion.

You could also refer him to a local provider for local services and allow him to continue with your psychiatrist so long as the local provider is agreeable.