title: Individual risk factors for physician boundary violations: the role of attachment style, childhood trauma and maladaptive beliefs.
abstract: OBJECTIVE
  The assessment and remediation of boundary-challenged health care professionals is enhanced through examination of individual risk factors. We assessed three such factors - attachment style, childhood trauma and maladaptive beliefs - in 100 attendees (mostly physicians) of a continuing medical education (CME) professional boundaries course. We propose a theoretical model that draws a causal arc from childhood maltreatment through insecure attachment and maladaptive beliefs to elevated risk for boundary violations.
  
  
  METHODS
  We administered the Experiences in Close Relationships Questionnaire Revised (ECR-R), Childhood Trauma Questionnaire (CTQ) and Young Schema Questionnaire (YSQ) to 100 health care professionals attending a CME course on professional boundaries. Experts rated participant autobiographies to determine attachment style and early adversities. Correlations and relationships between self-ratings and expert ratings and among different risk factors were examined.
  
  
  RESULTS
  One fifth of participants reported moderate to severe childhood abuse; sixty percent reported moderate to severe emotional neglect. Despite this, average attachment anxiety and attachment avoidance were low, and more than half of participants were rated "secure" by experts. Childhood maltreatment was correlated with attachment anxiety and avoidance and predicted expert-rated insecure attachment and maladaptive beliefs.
  
  
  CONCLUSIONS
  Our findings support a potential link between childhood adversity and boundary difficulties, partly mediated by insecure attachment and early maladaptive beliefs. Furthermore, these results suggest that boundary education programs and professional wellness programs may be enhanced with a focus on sequelae of childhood maltreatment, attachment and common maladaptive thinking patterns.
authors.affiliation: University of California, San Diego Medical Center Department of Psychiatry at UCSD Medical Center and Faculty, UCSD PACE Program, San Diego, CA, USA. Electronic address: kai@kaimacdonald.com.
authors.forename: Kai
authors.initials: K
authors.lastname: MacDonald
authors.affiliation: Northgate point clinic University of California, Davis Department of Psychiatry and Behavioral Sciences, Sacramento, CA, USA.
authors.forename: Andrés F
authors.initials: AF
authors.lastname: Sciolla
authors.affiliation: Department of Family and Preventive Medicine, University of California, San Diego, School of Medicine, La Jolla, CA, USA.
authors.forename: David
authors.initials: D
authors.lastname: Folsom
authors.affiliation: Department of Family and Preventive Medicine, University of California, San Diego, School of Medicine, La Jolla, CA, USA.
authors.forename: David
authors.initials: D
authors.lastname: Bazzo
authors.affiliation: Department of Family and Preventive Medicine, University of California, San Diego, School of Medicine, La Jolla, CA, USA.
authors.forename: Chris
authors.initials: C
authors.lastname: Searles
authors.affiliation: American Foundation for Suicide Prevention, Washington, D.C., USA.
authors.forename: Christine
authors.initials: C
authors.lastname: Moutier
authors.affiliation: University of California, San Diego Medical Center Department of Psychiatry at UCSD Medical Center and Faculty, UCSD PACE Program, San Diego, CA, USA.
authors.forename: Michael L
authors.initials: ML
authors.lastname: Thomas
authors.affiliation: Department of Family and Preventive Medicine, University of California, San Diego, School of Medicine, La Jolla, CA, USA.
authors.forename: Katherine
authors.initials: K
authors.lastname: Borton
authors.affiliation: Department of Family and Preventive Medicine, University of California, San Diego, School of Medicine, La Jolla, CA, USA.
authors.forename: Bill
authors.initials: B
authors.lastname: Norcross
mesh_terms: D000223:Adaptation, Psychological / Q000502:physiology*; D000328:Adult; D002648:Child; D002649:Child Abuse / Q000523:psychology*; D004995:Ethics, Professional / Q000193:education*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D009769:Object Attachment; D010817:Physician-Patient Relations / Q000941:ethics*; D010820:Physicians / Q000523:psychology*; D012307:Risk Factors
keywords: Attachment; Childhood maltreatment; Fitness to practice; Physician health and wellness; Professionalism