"Inflating" bills refers to charging the insurance carrier a higher fee than the therapist is actually charging the patient. When this happens, the therapist pock-ets the difference or applies it to the patient's portion of the fee. Also, thera-pists must distinguish between three sep-arate billing situations: illegal balance billing, charging one's insurance com-pany profile fee to the insurer, and charging the patient a normal dis-counted fee-which is perfectly reason-able and is universally done." For ex-ample, it is illegal under most Blue Cross agreements in most states to bill a pa-tient $100, accept the $60 Blue Cross payment and bill the patient for the balance of $40. It is a perfectly accepta-ble approach for the psychiatrist to bill Blue Cross for his or her profile fee of $60 but charge a patient who is paying out of pocket only $40. The profile fee, in this instance, is being discounted but not within the agreement with Blue Cross. When insurance benefits have been maximized or insurance is not part of the payment process, the therapist is free to directly negotiate fee arrange-ments with the patient.
Boundary violations in therapy
Dishonesty over billing matters is a major boundary violation that is certain to have adverse consequences for the patient's treatment. Moreover, such practices may be exposed in court and the therapist's credibility can be severely undermined if the therapist becomes embroiled in a lawsuit with the patient at a later date.
Some patients undergoing treatment may find themselves unable to pay their bills. To do so, patients may offer to barter cars, jewelry, property, or other valuable items. The coin of the realm must literally always be money, the only acceptable medium of exchange when receiving payment from patients. Pa-tients who desperately feel they need treatment, or who experience intense, positive transference feelings toward the therapist often are unable to render an arm's-length assessment of the monetary value of their possessions.
Similarly, therapists should tactfully refuse large gifts from patients and, if possible, the opportunity should be taken to investigate the meaning of the gift in the service of the treatment. This is not easily accomplished since some patients will feel devastated by having their gifts questioned. Some therapists graciously accept small gifts given by patients at the termination of therapy and leave it unanalyzed. A good rule to follow is that full compensation for one's services is obtained from the fee received from the patient and the professional gratification derived from conducting competent therapy.
Therapists who become involved in business dealings with patients may later be accused of undue influence when pur-chasing valuable goods or property from the patient at below market value, or where the patient leaves the witting ther-apist a large amount of money in a Litigation is usually aimed at voiding the business contract or will. Although monetary damages against the therapist are not usually sought, the burden of proof is on the patient's estate to show that undue influence occurred.
Psychologist ethics violations
Finally, the use of "insider informa-tion" obtained from the patient and used for the personal advantage of the thera-pist occurs with disturbing frequency. An example of self-serving occurred when a psychiatrist used a stock tip ob-tained from a bank executive's wife dur-ing the course of therapy to turn a large pr~fit.~"fter the Securities and Ex-change Commission learned from the patient of this transmission of "insider" information about a merger, it charged the psychiatrist with profiting illegally. Profits of $26,933.74 were surrendered. The psychiatrist was fined $150,000, sentenced to five years probation and 3,000 hours of community.
Psychiatrists working in managed care settings frequently face major ethical concerns and potential serious double agent roles.55 "Negative incentives" to cut costs at the expense of diminished quality of care is a major threat to the therapist's fiduciary commitment to pat i e n t.
Double agent roles frequently create the occasion for boundary violations in treatment. The problem of conflicting loyalties is a major concern to many psychiatrist^.^^ It is also a common prob-lem for other mental health profession-als, lawyers, bankers, accountants, and a host of other professionals serving in fiduciary capacities. In the Hastings report5%ntitled, In the Service of the State: The Psychiutrist as Double Agent, the problem of double agentry was stud-ied from the perspective of the psychia-trist's conflicting loyalties when simul-taneously serving the patient and an agency, institution, or society. For ex-ample, for the military psychiatrist, the professional duty owed to the soldier (patient) versus the loyalty to military's best interests poses a potential double agent role. Prison psychiatrists often are confronted with the conflict of having to serve the interests of their prisoner patients, prison officials, and society. School psychiatrists must balance the interests of the student, the parents, and the school administration. Psychiatrists working in mental institutions must manage the conflicting duties to their patients with those of the institution and society. With the emergence of the Tar-usoffduty to warn endangered third par-ties, the preservation of the patient's confidentiality conflicts with society's needs to be protected from harm. But as noted in the Hastings report, what has traditionally been called double agentry is, in fact, multiple agentry with conflict-ing responsibilities and confused loyal-ties due to of undefined purposes and contradictory goals.
Ethics violation examples
Boundary violations, particularly those involving breaches of confidential-ity, frequently occur when therapists must serve both the patient and a third party. Dual roles often skew the thera-pist's maintenance of appropriate treat-ment boundaries. Therapists should in-form patients from the very beginning concerning any limitations placed on the patient's treatment, particularly limits on confidentiality due to dual responsi-bilities of the therapist. Suits for breach of confidentiality may arise from unau-thorized d i s c l o ~ u r e s . ~ ~
Therapists may hold personal agendas that create a conflict of interest that can disturb a position of neutrality and cre-ate legal liability. For example, in Roe v. Doe,61a psychiatrist was sued by a for-mer patient for publishing a book that reported verbatim material from the
therapy including the patient's thoughts, feelings, and fantasies. In concluding that no valid patient consent for the disclosure existed, the court admonished the defendant stating, among other things, that a physician who enters into an agreement with a patient to provide medical attention im-pliedly covenants to keep in confidence all disclosures made by the patient concerning the patient's physical and mental condition as well as matters discovered by the physician in the course of the examination or treatment . . . such is particularly and necessarily true of [the] psychiatric relationships.
Treatment boundaries set by the ther-apist fluctuate in response to the dynamic, psychological interaction be tween therapist and patient. As a consequence, boundary excursions inev-itably occur in almost every therapy. The boundary sensitive therapist usually can reestablish treatment boundaries be-fore the patient is psychologically harmed. Epstein and Simon62 have devised an Exploitation Index that provides therapists with early warning indicators of treatment boundary viola-tions. A survey of 532 psychiatrists who were administered the Exploitation In-dex revealed that 43 percent found that one or more questions alerted them to boundary violations. Twenty-nine per-cent felt that the questionnaire stimu-lated them to make specific changes in future treatment practices.63
Although "minor" boundary viola-tions may initially appear innocuous, they may represent inchoate progression to eventual exploitation of the patient. If basic treatment boundaries are violated and the patient is harmed, thera-pists may be sued, charged with ethical violations, and lose their professional licenses.
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