Dual Relationships, Multiple Relationships, & Boundary Decisions

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Dual Relationships, Multiple Relationships, & Boundary Decisions

Kenneth S. Pope, Ph.D., ABPP
I've gathered together the following resources that may be helpful in thinking through dual relationships, multiple relationships, and other boundary issues.

The major categories of this section are

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Here are descriptions of and links to the sections:

  1. widely-used decision-making guides (including Sonne's "Nonsexual Multiple Relationships: A Practical Decision-Making Model For Clinicians; Younggren's "Ethical Decision-making and Dual Relationships"; and Gottlieb's "Avoiding Exploitive Dual Relationships: A Decision-making Model");

  2. excerpts addressing dual relationships and multiple relationships from the standards and guidelines of professional associations (with links to the original documents) including American Association for Marriage and Family Therapy (AAMFT); American Association of Christian Counselors; American Association of Pastoral Counselors; American Association of Sex Educators, Counselors and Therapists; American Board of Examiners in Clinical Social Work; American Counseling Association; American Mental Health Counselors Association; American Music Therapy Association; American Psychoanalytic Association; American Psychological Association; American School Counselor Association; Association of State and Provincial Psychology Boards; Australian Association of Social Workers; Australian Psychological Society; British Association for Counselling & Psychotherapy; British Association of Social Workers; British Columbia Association of Clinical Counsellors; California Association of Marriage and Family Therapists; Canadian Counselling Association; Canadian Psychological Association; Canadian Traumatic Stress Network [Reseau Canadien du Stress Traumatique]; European Association for Body-Psychotherapy; European Federation of Psychologists' Associations; Feminist Therapy Institute; Irish Association for Counseling & Therapy; National Association of Social Workers; and Psychological Society of Ireland;

  3. quotes and Information about boundaries in therapy & counseling from articles, books, & studies;

  4. articles on dual relationships, multiple relationships, and other boundary topics from American Psychologist, Professional Psychology, American Journal of Psychiatry, etc. ("A Practical Approach to Boundaries in Psychotherapy: Making Decisions, Bypassing Blunders, and Mending Fences"; "Misuses and Misunderstandings of Boundary Theory in Clinical and Regulatory Settings"; "The Concept of Boundaries in Clinical Practice: Theoretical and Risk-Management Dimensions"; "A Study Calling for Changes in the APA Ethics Code regarding Dual Relationships, Multiple Relationships, & Boundary Decisions"; "Dual Relationships Between Therapist and Client: A National Study of Psychologists, Psychiatrists, and Social Workers"; "Dual Relationships: Trends, Stats, Guides, and Resources"; "Nonsexual Multiple Relationships & Boundaries in Psychotherapy"); and

  5. related resources on this site.

Decision-Making Guides for Dual Relationships and Multiple Relationships

A Practical Approach to Boundaries in Psychotherapy: Making Decisions, Bypassing Blunders, and Mending Fences

This article by Patricia Keith-Spiegel and Ken Pope notes that "nonsexual boundary crossings can enrich psychotherapy, serve the treatment plan, and strengthen the therapist-client working relationship. They can also undermine the therapy, disrupt the therapist-patient alliance, and cause harm to clients. Building on Gutheil and Gabbard's (1993) conceptualization of boundary crossings and boundary violations, this article discusses and illustrates grounding boundary decisions in a sound approach to ethics. We provide 9 useful steps in deciding whether to cross a boundary, describe common cognitive errors in boundary decision-making, and offer 9 helpful steps to take when a boundary crossing has negative effects."

Avoiding Exploitive Dual Relationships: A Decision-making Model [Psychotherapy]

This article by Michael C. Gottlieb presents a decision-making model to help therapists and counselors consider potential dual or multiple relationships and to avoid those that are exploitive.

Ethical Decision-making and Dual Relationships

This article by Jeffrey N. Younggren discusses 8 questions that therapists and counselors can ask when deciding whether to enter into a dual or multiple relationship.

Nonsexual Multiple Relationships: A Practical Decision-Making Model For Clinicians

This article by Janet L. Sonne provides a "model designed to guide the therapist through deliberations regarding a potential nonsexual multiple relationship with a client. The model contains several elements previously identified by existing theoretical models and clinical guidelines for ethical decision-making in mental health practice, as well as by some few research findings. In addition, several new elements suggested by research in more general moral reasoning are included."

Formal Standards and Guidelines for Dual Relationships, Multiple Relationships, and Professional Boundaries

NOTE: Please follow this link for a more comprehensive array of professional standards and guidelines than those below.

 

American Association for Marriage and Family Therapy (AAMFT) Code of Ethics

Excerpt: "Therapists, therefore, make every effort to avoid conditions and multiple relationships with clients that could impair professional judgment or increase the risk of exploitation. Such relationships include, but are not limited to, business or close personal relationships with a client or the client's immediate family. When the risk of impairment or exploitation exists due to conditions or multiple roles, therapists document the appropriate precautions taken..... Marriage and family therapists do not provide therapy to current students or supervisees.... Marriage and family therapists ordinarily refrain from accepting goods and services from clients in return for services rendered. Bartering for professional services may be conducted only if: (a) the supervisee or client requests it; (b) the relationship is not exploitative; (c) the professional relationship is not distorted; and (d) a clear written contract is established."

American Association of Christian Counselors: Code of Ethics

Excerpt: "Dual relationships involve the breakdown of proper professional or ministerial boundaries. A dual relationship is where two or more roles are mixed in a manner that can harm the counseling relationship. Examples include counseling plus personal, fraternal, business, financial, or sexual and romantic relations. Some dual relationships are not unethical—it is client exploitation that is wrong, not the dual relationship itself. Based on an absolute application that harms membership bonds in the Body of Christ, we oppose the ethical-legal view that all dual relationships are per se harmful and therefore invalid on their face. Many dual relations are wrong and indefensible, but some dual relationships are worthwhile and defensible.... While in therapy, or when counseling relations are imminent, or for an appropriate time after termination of counseling, Christian counselors do not engage in dual relations with counselees. Some dual relationships are always avoided—sexual or romantic relations, and counseling close friends, family members, employees, or supervisees. Other dual relationships should be presumed troublesome and avoided wherever possible.... The Christian counselor has the burden of proving a justified dual relationship by showing (1) informed consent, including discussion of how the counseling relationship might be harmed as other relations proceed, and (2) lack of harm or exploitation to the client. As a general rule, all close relations are unethical if they become counselor-client or formal lay helping relations. Dual relations may be allowable, requiring justification by the foregoing rule, if the client is an arms-length acquaintance—if the relationship is not a close one. This distinction is crucial in the applications below.... Christian counselors do not provide counseling to close family or friends. We presume that dual relations with other family members, acquaintances, and fraternal, club, association, or group members are potentially troublesome and best avoided, otherwise requiring justification.... Christian counselors avoid partnerships, employment relations, and close business associations with clients. Barter relations are normally avoided as potentially troublesome, and require justification; therefore if done, barter is a rare and not a common occurrence. Unless justified by compelling necessity, customer relations with clients are normally avoided.... Christian counselors do not provide counseling to fellow church members with whom they have close personal, business, or shared ministry relations. We presume that dual relations with any other church members who are clients are potentially troublesome and best avoided, otherwise requiring justification. Pastors and church staff helpers will take all reasonable precautions to limit the adverse impact of any dual relationships....Christian counselors do not terminate counseling to engage in dual relationships of any kind. Some counselors and their former clients will agree that any future counseling will be done by someone else if, after legitimate termination, they decide to pursue another form of relationship."

American Association of Pastoral Counselors: Code of Ethics

Excerpt: "We recognize the trust placed in and unique power of the therapeutic relationship. While acknowledging the complexity of some pastoral relationships, we avoid exploiting the trust and dependency of clients. We avoid those dual or multiple relationships with clients which could impair our professional judgment, compromise the integrity of the treatment, and/or use the relationship for our own gain. A multiple relationship occurs when a pastoral counselor is in a professional role with a person and 1) at the same time is in another role with the same person, 2) at the same time is in a relationship with a person closely associated with or related to the person with whom the pastoral counselor has the professional relationship, or 3) promises to enter into another relationship in the future with the person or a person closely associated with or related to the person. In instances when dual or multiple relationships are unavoidable, particularly within congregations or in family or couples counseling, we take reasonable steps to protect the clients and are responsible for setting clear and appropriate boundaries."

American Association of Sex Educators, Counselors and Therapists: Code of Ethics

Excerpt: "The member shall not engage in any dual relationship, regardless of nature or circumstances, with a consumer or with persons who have a primary relationship with a consumer served by the member if such dual relationship could potentially be detrimental to or jeopardize the well-being of a consumer. A dual relationship occurs when a member is in a professional role with a person and (1) at the same time is in another role with the same person, and/or (2) at the same time is in a relationship with a person closely associated with or related to the person with whom the member has the professional relationship, and/or (3) promises to enter into another relationship in the future with the person or a person closely associated with or related to the consumer."

American Counseling Association: Code of Ethics

Excerpt: "Counselors must make every effort to avoid dual relationships with clients that could impair their professional judgment or increase the risk of harm to clients. When a dual relationship cannot be avoided, counselors must take appropriate steps to ensure that judgment is not impaired and that no exploitation occurs."

American Mental Health Counselors Association: Code of Ethics

Excerpt: "Mental health counselors are aware of their influential position with respect to their clients and avoid exploiting the trust and fostering dependency of the client. a) Mental health counselors make every effort to avoid dual/multiple relationships with clients that could impair professional judgment or increase the risk of harm. Examples of such relationships may include, but are not limited to: familial, social, financial, business, or close personal relationships with the clients. b) When deciding whether to enter a dual/multiple relationship with a client, former client or close relationship to the client, mental health counselors will seek consultation and adhere to a credible decision-making process prior to entering this relationship. c) When a dual/multiple relationship cannot be avoided, mental health counselors take appropriate professional precautions such as informed consent, consultation, supervision and documentation to ensure that judgment is not impaired and no exploitation has occurred d) Mental health counselors do not accept as clients, individuals with whom they are involved in an administrative, supervisory or other relationship of an evaluative nature."

American Music Therapy Association: Code of Ethics

Excerpt: "The MT [Music Therapist] will not enter into dual relationships with clients/students/research subjects and will avoid those situations that interfere with professional judgment or objectivity (e.g., those involving competitive and/or conflicting interests) in their relationships."

American Psychoanalytic Association: Principles & Standards of Ethics for Psychoanalysts

Excerpt: "It is not ethical for a psychoanalyst to engage in financial dealings with a patient, or in the case of a minor patient, the parent(s) or guardian(s) beyond reimbursement for treatment; or to use information shared by a patient or parent(s) or guardian(s) for the psychoanalyst's financial gain."

American Psychological Association: Ethical Principles of Psychologists and Code of Conduct

Excerpt: "A multiple relationship occurs when a psychologist is in a professional role with a person and (1) at the same time is in another role with the same person, (2) at the same time is in a relationship with a person closely associated with or related to the person with whom the psychologist has the professional relationship, or (3) promises to enter into another relationship in the future with the person or a person closely associated with or related to the person. A psychologist refrains from entering into a multiple relationship if the multiple relationship could reasonably be expected to impair the psychologist's objectivity, competence, or effectiveness in performing his or her functions as a psychologist, or otherwise risks exploitation or harm to the person with whom the professional relationship exists. Multiple relationships that would not reasonably be expected to cause impairment or risk exploitation or harm are not unethical. (b) If a psychologist finds that, due to unforeseen factors, a potentially harmful multiple relationship has arisen, the psychologist takes reasonable steps to resolve it with due regard for the best interests of the affected person and maximal compliance with the Ethics Code....Barter is the acceptance of goods, services, or other nonmonetary remuneration from clients/patients in return for psychological services. Psychologists may barter only if (1) it is not clinically contraindicated, and (2) the resulting arrangement is not exploitative."

American School Counselor Association: Ethical Standards for School Counselors

Excerpt: "Professional school counselors: (a) Avoid dual relationships that might impair their objectivity and increase the risk of harm to students (e.g., counseling one’s family members or the children of close friends or associates). If a dual relationship is unavoidable, the school counselor is responsible for taking action to eliminate or reduce the potential for harm to the student through use of safeguards, which might include informed consent, consultation, supervision and documentation. (b)Maintain appropriate professional distance with students at all times. (c) Avoid dual relationships with students through communication mediums such as social networking sites. (d) Avoid dual relationships with school personnel that might infringe on the integrity of the school counselor/student relationship."

Association of State & Provincial Psychology Boards: Code of Conduct

Excerpt: "Psychologists recognize that multiple relationships may occur because of the psychologist's present or previous familial, social, emotional, financial, supervisory, political, administrative or legal relationship with the client or a relevant person associated with or related to the client. Psychologists take reasonable steps to ensure that if such a multiple relationship occurs, it is not exploitative of the client or a relevant person associated with or related to the client. Prohibited Multiple Relationships. 1. A multiple relationship that is exploitative of the client or a relevant person associated with or related to the client is prohibited. Psychologists take all reasonable steps to ensure that any multiple relationships do not impair the psychologist's professional judgment or objectivity or result in a conflict of interest with the client or a relevant person associated with or related to the client. 2. Multiple relationships that would not reasonably be expected to impair a psychologist's judgment or objectivity or risk harm to the client or relevant person associated with or related to the client are not expressly prohibited."

Australian Association of Social Workers: Code of Ethics

Excerpt: "Recognising that conflicts of interest can arise from engaging in dual or multiple relationships with clients, former clients, research participants,students, supervisees or colleagues, social workers will set and enforce explicit, appropriate professional boundaries to minimise the risk of conflict, exploitation, or harm."

Australian Psychological Society: Code of Ethics

Excerpt: "Members must avoid dual relationships that could impair their professional judgment or increase the risk of exploitation. Examples of such dual relationships include, but are not limited to, provision of psychological services to employees, students, supervisees, close friends or relatives."

British Association for Counselling & Psychotherapy: Providing a Good Standard of Practice & Care

Excerpt: "Dual relationships arise when the practitioner has two or more kinds of relationship concurrently with a client, for example client and trainee, acquaintance and client, colleague and supervisee. The existence of a dual relationship with a client is seldom neutral and can have a powerful beneficial or detrimental impact that may not always be easily foreseeable. For these reasons practitioners are required to consider the implications of entering into dual relationships with clients, to avoid entering into relationships that are likely to be detrimental to clients, and to be readily accountable to clients and colleagues for any dual relationships that occur."

British Association of Social Workers: Code of Ethics for Social Work

Excerpt: "Social workers have a duty...To set and enforce explicit and appropriate professional boundaries to minimise the risk of conflict, exploitation or harm in all relationships with current or former service users, research participants, students, supervisees or colleagues; To avoid any behaviour which may violate professional boundaries, result in unintentional harm or damage the professional relationship..."

California Association of Marriage and Family Therapists: Ethical Standards

Excerpt: "Marriage and family therapists are aware of their influential position with respect to patients, and they avoid exploiting the trust and dependency of such persons. Marriage and family therapists therefore avoid dual relationships with patients that are reasonably likely to impair professional judgment or lead to exploitation. A dual relationship occurs when a therapist and his/her patient engage in a separate and distinct relationship either simultaneously with the therapeutic relationship, or during a reasonable period of time following the termination of the therapeutic relationship. Not all dual relationships are unethical, and some dual relationships cannot be avoided. When a dual relationship cannot be avoided, therapists take appropriate professional precautions to insure that judgment is not impaired and that no exploitation occurs."

Canadian Counselling & Psychotherapy Association: Code of Ethics

Excerpt: "Counsellors who work as counsellor educators, trainers, and supervisors establish relationships with their students, trainees and supervisees such that appropriate relational boundaries are clarified and maintained, and dual relationships avoided."

Canadian Psychological Association: Canadian Code of Ethics for Psychologists (3rd edition)

Excerpt: "As public trust in the discipline of psychology includes trusting that psychologists will act in the best interests of members of the public, situations that present real or potential conflicts of interest are of concern to psychologists. Conflict-of-interest situations are those that can lead to distorted judgment and can motivate psychologists to act in ways that meet their own personal, political, financial, or business interests at the expense of the best interests of members of the public. Although avoidance of all conflicts of interest and potential exploitation of others in not possible, some are of such high risk to protecting the interests of members of the public and to maintaining the trust of the public, that they are considered never acceptable.... The risk level of other conflicts of interest (e.g., dual or multiple relationships) might be particularly dependent on cultural factors and the specific type of professional relationship.... It is the responsibility of psychologists to avoid dual or multiple relationships and other conflicts of interest when appropriate and possible."

European Association for Body-Psychotherapy: Ethical Guidelines & Code

Excerpt: "he therapist generally avoids working in dual relationships e.g. with employees, close friends, relatives etc. He/she recognises that social contact outside therapy may create complications and avoids it when possible, or clarifies its impact on the therapy. If containment of the therapeutic situation becomes insufficient, the therapist terminates the therapy. The termination procedure includes at least one session with him/herself and client consulting an outside professional to help clarify the contractual relationship. Further procedure as above. Generally the therapist does not enter into private or other types of professional relationships, e.g. as a consultant, with the client or with his/her intimates."

Federation of State Medical Boards: Addressing Sexual Boundaries - Guidelines for State Medical Boards

Excerpt: "Sexual misconduct by physicians and other health care practitioners is a form of behavior that adversely affects the public welfare and harms patients individually and collectively... Physician sexual misconduct exploits the physician-patient relationship, is a violation of the public trust, and is often known to cause harm, both mentally and physically, to the patient "

Feminist Therapy Institute: Code of Ethics

Excerpt: "A feminist therapist recognizes the complexity and conflicting priorities inherent in multiple or overlapping relationships. The therapist accepts responsibility for monitoring such relationships to prevent potential abuse of or harm to the client."

Irish Association for Counseling & Therapy: Code of Ethics & Practice

Excerpt: "Set and monitor appropriate boundaries during the practitioner/client relationship, and make these explicit to the client.... Be acutely aware of the problematic nature of dual relationships (for example, with trainees, business associates, employees or clients), and recognize that it is not always possible to avoid them (e.g. when offering services in a small community, or engaging in training). Where it is possible, practitioners shall avoid such relationships; where it is not, they shall take appropriate steps to safeguard the interests of those involved."

National Association of Social Workers: Code of Ethics

Excerpt: "Social workers engaged in evaluation or research should be alert to and avoid conflicts of interest and dual relationships with participants, should inform participants when a real or potential conflict of interest arises, and should take steps to resolve the issue in a manner that makes participants' interests primary."

Psychological Society of Ireland: Code of Professional Ethics

Excerpt: "Be acutely aware of the problematic nature of dual relationships (with, for example,students, employees or clients), and recognize that it is not always possible to avoid them (e.g. when offering services in a small community, or engaging in person-centered teaching or training). Where it is possible, psychologists shall avoid such relationships; where it is not, they take active steps to safeguard the students', employees' or clients' interests."

Quotes and Information about Boundaries in Therapy & Counseling from Articles, Books, & Studies

 

Suzette Speight ("An exploration of boundaries and solidarity in counseling relationships" in The Counseling Psychologist, 2012): "Boundaries are complex, involving much more than managing risk. In fact, the placement, management, flexibility, and negotiation of therapeutic boundaries constitute a cultural enterprise. The cultural context provides the structure from which to consider the therapeutic relationship and its boundaries."

Ken Pope & Patricia Keith-Spiegel ("A Practical Approach to Boundaries in Psychotherapy: Making Decisions, Bypassing Blunders, and Mending Fences" in Journal of Clinical Psychology: In Session, 2008, vol. 64, #5, pages 638-652): "Nonsexual boundary crossings can enrich therapy, serve the treatment plan, and strengthen the therapist-client working relationship. They can also undermine the therapy, severe the therapist-patient alliance, and cause immediate or long-term harm to the client. Choices about whether to cross a boundary confront us daily, are often subtle and complex, and can sometimes influence whether therapy progresses, stalls, or ends. We put ourselves in the best position to make sound decisions when we develop an approach to boundary crossings that is grounded in our general approach to ethics; stay abreast of the evolving legislation and case law, ethical standards, research, theory, and practice guidelines; take into account the relevant contexts for each client; engage in critical thinking that avoids the common cognitive errors to step away from our clinical responsibilities, avoid personal responsibility for our decisions, and rationalize our choices and behavior; and, when we make a mistake or suspect that our boundary decisions have led to trouble, use all available resources to figure out the best course of action to respond to the problem."

Almari Ginory, Laura Sabatier, Laura Mayol, & Spencer Eth ("Addressing therapeutic boundaries in social networking" in Psychiatry: Interpersonal and Biological Processes, 2012):"An anonymous voluntary survey regarding Facebook use was distributed to current psychiatry residents through the American Psychiatric Association (APA) listserv.... 95.7% had current Facebook profiles, and 9.7% had received friend requests from patients. In addition, 18.7% admitted to viewing patient profiles on Facebook.... Specific guidance regarding social mediawebsites and the potential for ethical difficulties should be offered to trainees." 

Tom Gutheil & Glen Gabbard ("Misuses and Misunderstandings of Boundary Theory in Clinical and Regulatory Settings" in American Journal of Psychiatry, 1998): "we have also observed a perhaps predictable overreaction to boundary concerns and an associated misapplication of the underlying principles. While such excesses are often proffered as indicia of patient protection, the perversion of boundary theory may place professionals at risk for undeserved sanctions and may potentially harm patients themselves by frightening the professionals into rigidity in therapeutic interactions. This extreme position is captured by a cartoon that shows a male patient putting forth his hand for a handshake with his female therapist: the latter looks disdainfully at the outstretched hand and sneers, 'Nice try!'... Boards themselves vary to a striking degree in their rigor, flexibility, and, regrettably, punitive attitudes toward the clinicians they license."

Robert Simon & Daniel Shuman (Clinical Manual of Psychiatry & Law, American Psychiatric Publishing, 2007, p. 212): "It is always the therapist's responsibility to maintain appropriate boundaries, no matter how difficult or boundary testing the patient may be.... The conduct of psychotherapy is an impossible task because there are no perfect therapists and no perfect therapies. Knowing one's boundaries, however, makes the impossible task easier."

Paul Appelbaum & Thomas Gutheil (Clinical Handbook of Psychiatry & the Law, 4th Edition, Lippincott Williams & Wilkins, 2007, p. 144): "The following example captures some basic principles of boundary management: A clinician leaves the office at the very end of the weekday and notes that a heavy snowfall with deep drifts has occurred during the day. Driving home, he sees the last patient of the day struggling on foot, and offers the patient a potentially life-saving lift home or to local transport in his car. The clinician (1) behaves professionally during the ride, deferring clinical issues to the next meeting; (2) carefully records the situation and context when next in the office; and (3) explores or debriefs the patient on the experience at the next session, also recording that. The three general principles noted may constitute the critical distinguishing factors in subsequent challenges between a crossing and a violation."

Barry Farber (Self-disclosure in Psychotherapy, Guilford Press, 2006): "All disclosures reflect decisions about the boundaries between the private self and the outer world. All revolve around a basic question: What elements of our private world will we express to the outer world? Most often, disclosures involve negotiating an appropriate balance between the helpfulness of sharing a part of ourselves with another and the inappropriateness of even danger of overdoing it, of perhaps sharing too much too soon. Psychotherapy, a place of nearly total confidentiality, provides a rich and unique settings in which to examine this quintessentially human conflict. In doing so, in studying the nature and consequences of disclosure, we can enrich our understanding of interpersonal relations in general and of something fundamental about the psychotherapeutic process."

Jeffrey Barnett ("Boundary Issues and Multiple Relationships: Fantasy and Reality" in Professional Psychology: Research and Practice, August, 2007, p. 403): "When considering crossing boundaries with a client, psychologists should work to be sure that (a) their intention is motivated by the client's treatment needs and best interests and not by their own needs; (b) the boundary crossing is consistent with the client's treatment plan; (c) the boundary crossing is sensitive to the client's diagnosis, history, culture, and values; (d) the boundary crossing—and the reasoning supporting it—is documented in the client's record; (e) the boundary crossing is discussed, if possible, with the client in advance to ensure his or her comfort with the plan and to prevent misunderstandings; (f) the power differential present is considered, and the client's trust is not exploited; and (g) consultation with a respected colleague is used to guide the psychologist's decision."

Aaron Jeffrey & Tammy Austin ("Perspectives and practices of clinician self-disclosure to clients: A pilot comparison study of two disciplines" in American Journal of Family Therapy, 2007, vol. 35, #2, pp. 95-108): "Data suggest that [Marriange and Family Therapists] believe clinician self-disclosure enhances the therapeutic relationship more than [Clinical Slocial Workers] do. CSWs are less likely to disclose personal information to clients, although MFTs and CSWs disclose on similar topics when they do self-disclose."

Gerald Koocher & Patricia Keith-Spiegel (Ethics in Psychology: Professional Standards & Cases, 2nd Edition, Oxford University Press, 1998, p. 197): "Psychologists can be helpful, caring, empathic human beings and maintain professional parameters with which they effectively relate to clients, students, or other service consumers. We again acknowledge the impossibility of setting firm boundaries appropriate for every consumer under every circumstance. We are concerned, however, that inappropriate crossings are often rationalized as benevolent or therapeutic. As Brown states, 'In the many cases in which I have testified as an expert witness regarding abuses in psychotherapy and the standards of care, it is a very common experience for me to hear the accused therapist pleading the cause of greater humanity, and even love, as the rationale for having had sex with, breast fed, slow-danced with, gone into business with, move in with, and so on with the complaining client' (1994, p. 276)."

Janet Sonne ("Nonsexual Multiple Relationships: A Practical Decision-Making Model For Clinicians," 2006): "The term nonsexual multiple relationships has created great confusion in our profession-and great controversy. You may have heard in workshops or read in books or journals that hugging a client, giving a gift to a client, or meeting a client outside of the office constitutes a multiple relationship and is prohibited by our ethics code or by the standard of care sustained by professional licensing boards. Not accurate. You may also have heard or read that telling a client something personal about yourself or unexpectedly encountering a client at a social event are examples of unprofessional multiple relationships. Again, not accurate. The inaccuracies, or errors, in our thinking about nonsexual multiple relationships, mire us in confusion and controversy. The errors cripple our movement towards a comprehensive and practical model of ethical decision-making regarding multiple relationships with clients."

Christa Peterson ("Common Problem Areas & Their Causes Resulting in Disciplinary Actions" in Professional Conduct & Discipline in Psychology by L. Bass, S. DeMers, J. Ogloff, C. Peterson, J. Pettifor, R. Reaves, T. Retfalvi, N. Simon, C. Sinclair, & R. Tipton, American Psychological Association & Association of State & Provincial Psychology Boards, 1996, p. 83): "A large survey of mental health professionals found that male psychologists rated examples of social and financial dual relationships as more ethically appropriate than did female respondents. This study also showed that male therapists are more likely to engage in nonsexual dual relationships with clients of the opposite sex than their female counterparts."

Ken Pope & Melba Vasquez (Ethics in Psychotherapy & Counseling: A Practical Guide, 4th Edition, Wiley, 2011): "The need for clarity about boundaries can be misunderstood as the need for inflexible boundaries.... Clarity in thinking through boundary issues for each client is essential. Reflexively applying a rigid set of rules...can never be an acceptable substitute for thinking through boundary issues for an individual client as clearly and carefully as possible. A central theme of this book is that we cannot shift responsibility to a set of rules.... Every client is unique in some ways, as is every therapist. Each situation is unique in some ways, and situations continue to change. Nothing can spare us the personal responsibility of making the best effort we can to assess the potential effects of boundary crossings...and to act in the most ethical, informed, aware, and creative way possible. Decisions about boundaries must be made with the greatest possible clarity about the potential benefits and harm, the client's needs and well-being, informed consent and informed refusal, and the therapist's knowledge and competence."

Ken Pope & Danny Wedding ("Nonsexual Multiple Relationships & Boundary Issues in Psychotherapy" in Current Psychotherapies, 9th Edition edited by R. Corsini & D. Wedding; Brooks/Cole, 2010):

[begin excerpt]

In the 1980s and into the 1990s, a vigorous, wide-ranging, and healthy controversy over therapists’ nonsexual multiple relationships and other boundary excursions blossomed. Was it good practice for a therapist to enter into dual professional roles with a client, serving, say both as a client’s therapist and as that client’s employer? What about multiple social roles? Is it helpful, hurtful, or completely irrelevant for a therapist to provide therapy to a close friend, spouse, or step-child? Are there any potential benefits or risks to social outings with a client (meeting for dinner, going to a movie, playing golf, or heading off for a weekend of sightseeing), so long as there is no sexual or romantic involvement? Are financial relationships (say, the therapist borrowing a large sum from a client to buy a new house or car, or inviting a client to invest in the therapist’s new business venture) compatible with the therapeutic relationship? What about lending a client money to help pay the rent or buy food and medications? Under what circumstances should a therapist accept bartered services or products as payment for therapy sessions?

The 15 years or so from the early 1980s to the mid-1990s saw these and other questions about multiple relationships and boundaries discussed—and often argued—from virtually every point of view, every discipline, and every theoretical orientation. In 1981, for example, Samuel Roll and Leverett Millen presented “A Guide to Violating an Injunction in Psychotherapy: On Seeing Acquaintances as Patients.” In her 1988 article on 'Dual Relationships,' ethicist Karen Kitchener provided systematic guidance to readers on the kinds of 'counselor-client relationships that are likely to lead to harm and those that are not likely to be harmful' (p. 217).... Similarly, in the 1985 edition of their widely used textbook Ethics in Psychology: Professional Standards and Cases, Patricia Keith-Spiegel and Gerald Koocher discussed ways in which boundary crossings may be unavoidable in good clinical practice and presented ways to think through the ethical implications of specific dual relationships or other boundary issues. Patrusksa Clarkson, who wrote 'In Recognition of Dual Relationships,' discussed the 'mythical, single relationship' and wrote that 'it is impossible for most psychotherapists to avoid all situations in which conflicting interests or multiple roles might exist' (1994, p. 32). Vincent Rinella and Alvin Gerstein argued that 'the underlying moral and ethical rationale for prohibiting dual relationships (DRs) is no longer tenable' (1994, p. 225). Similarly, Robert Ryder and Jeri Hepworth (1990) set forth thoughtful arguments that the AAMFT ethics code should not prohibit dual relationships. Jeanne Adleman and Susan Barrett (1990) took a fresh and creative look, from a feminist perspective, at how to make careful decisions about dual relationships and boundary issues. Laura Brown (1989; see also 1994b) examined the implications of boundary decisions from another perspective in 'Beyond Thou Shalt Not: Thinking about Ethics in the Lesbian Therapy Community.' Ellen Bader (1994) urged that the focus on the duality of roles be replaced by an examination of whether each instance did or did not involve exploitation. Elisabeth Horst (1989) and Amy Stockman (1990) were among those who explored issues of dual relationships and boundaries in rural settings. Melanie Geyer (1994) examined some of the decision-making principles that had evolved for evaluating multiple relationships and boundary issues in rural settings and adapted them for some of the unique challenges faced by Christian counselors (and counselors for whom other religious faiths are a focus of practice). Ethics & Behavior was one of many journals in the 1980s and early 1990s that spotlighted the richness of creative thinking in this area. In 1994 it published a special section in which prominent authorities debated diverse approaches to the issue of boundaries in therapy (Borys, 1994; Bennett, Bricklin, & VandeCreek, 1994; Brown, 1994; Gabbard, 1994; Gottlieb, 1994; Gutheil, 1994; Lazarus, 1994a, 1994b).

The care with which these diverse articles and books in the 1980s and first half of the 1990s examined a diverse array of contextual issues such as the nature of the community (e.g., rural or small town) and the therapist’s theoretical orientation, in thinking through whether a specific multiple relationship or boundary crossing was likely to be healing or hurtful, helped develop a more complex appreciation for both the potential benefits and the risks in this area.

[end excerpt]

Articles on Dual Relationships & Multiple Relationships

A Practical Approach to Boundaries in Psychotherapy: Making Decisions, Bypassing Blunders, and Mending Fences

Here's the abstract: "Nonsexual boundary crossings can enrich psychotherapy, serve the treatment plan, and strengthen the therapist-client working relationship. They can also undermine the therapy, disrupt the therapist-patient alliance, and cause harm to clients. Building on Gutheil and Gabbard's (1993) conceptualization of boundary crossings and boundary violations, this article discusses and illustrates grounding boundary decisions in a sound approach to ethics. We provide 9 useful steps in deciding whether to cross a boundary, describe common cognitive errors in boundary decision-making, and offer 9 helpful steps to take when a boundary crossing has negative effects."

The Concept of Boundaries in Clinical Practice: Theoretical and Risk-Management Dimensions [American Journal of Psychiatry]

The influential article, widely-cited in the literature and ethics cases, that proposed the disticnction between boundary crossings and boundary violations, described how to assess each boundary crossing on a case-by-case basis that takes into account the context and situation-specific facts, and that explored diverse boundaries such as role, time, place and space, money, gifts, services, clothing, language, self-disclosure, and physical contact.

Dual Relationships Between Therapist and Client: A National Study of Psychologists, Psychiatrists, and Social Workers [Professional Psychology]

This national survey of 4,800 psychologists, psychiatrists, and social workers examined attitudes and practices regarding dual professional roles, social involvements, financial involvements, and incidental involvements; patterns of beliefs and behaviors were analyzed in light of 10 factors: therapist gender, profession, age, experience, marital status, region of residence, client gender, practice setting, theoretical orientation, and practice locale.

Misuses and Misunderstandings of Boundary Theory in Clinical and Regulatory Settings [American Journal of Psychiatry]

Abstract: "Objective: This paper outlines a number of misapplications of boundary theory in both regulatory settings and clinical situations. Method: The authors review clinical vignettes that illustrate the difference between boundary crossings, which lead to productive work in psychotherapy, and boundary violations, which are harmful to the patient and exploit the patient's vulnerable position. They also discuss developments in the field that have led to an excessively rigid and defensive posture on the part of some clinicians that may lead to less than optimal psychiatric treatment. They survey recent developments in the wording of state statutes that broadly define sexual misconduct in psychotherapy. Results: This review of the current status of boundary theory in both the law and clinical practice suggests that an overreaction has occurred that requires correction. Conclusions: The critical role of context must be considered whenever a boundary problem has been alleged, and boundaries must be regarded as flexible standards of good practice rather than lists of generically forbidden behavior."

An Essential Article on Boundaries: How The Field Began To Focus on Distinguishing Boundary Crossings (Helpful or Neutral) from Boundary Violations (Harmful) in the Early 1990s

This 2007 work examines how a landmark article on boundaries helped transform our understanding and formed the framework for what seems to be the predominant view of boundaries today.

Dual Relationships: Trends, Stats, Guides, and Resources

This brief article notes trends in dual relationships over recent decades, including patterns and statistics, examines the relevant research findings, provides links to several decision-making guides for those considering entering into dual or multiple relationships or other boundary crossings (which may or may not be boundary violations), provides scenarios and questions for classroom or workshop discussion, and gives the URLs for online references.

A Study Calling for Changes in the APA Ethics Code regarding Dual Relationships, Multiple Relationships, & Boundary Decisions [American Psychologist]

A national survey of psychologists resulted in a call for changes to the APA ethical principles in the areas of dual relationships, multiple relationships, and boundary issues so that the ethics code would: (1) define dual relationships more carefully and specify clearly conditions under which they might be therapeutically indicated or acceptable, (2) address clearly and realistically the situations of those who practice in small towns, rural communities, remote locales, and similar contexts (emphasizing that neither the current code in place at the time nor the draft revision under consideration at that time fully acknowledged or adequately addressed such contexts), and (3) distinguish between dual relationships and accidental or incidental extra-therapeutic contacts (e.g., running into a patient at the grocery market or unexpectedly seeing a client at a party) and to address realistically the awkward entanglements into which even the most careful therapist can fall.

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Bobby AAA
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