“Dual relationships” are not just about sex. The basic idea is that a therapist should just be a therapist for any particular client. If a therapist is also the client’s business partner, employee, employer, close friend, family member, creditor, debtor, or colleague, things start to get messy. Legitimate questions begin to arise about the therapist’s judgment, motivations, and treatment. You could be sued—or more likely, disciplined by your board—for engaging in any “dual relationship.”
For example, suppose that a therapist and client form a joint business venture. The business causes stress in the client’s life, but the therapist’s financial future depends upon the venture succeeding. Can the therapist really provide effective treatment in this situation?
All of the ethical codes forbid such an obvious and pronounced conflict of interest. The codes are concerned with three main problems: (1) the therapist might influence and exploit the client, due to the therapist’s unique influence over the client; (2) the therapist’s professional judgment may be impaired, leading to ineffective or incompetent counseling; and (3) there may at least be an appearance of either (1) or (2), which would cast the therapist and the profession in a bad light.
But the profession does not speak with a unified voice on this issue. Not everyone agrees that multiple relationships or boundary-crossing acts in themselves, apart from the potential exploitation and impaired judgment, are unethical.
In some cases, pushing a relationship beyond conventional parameters clearly serves a therapeutic purpose. A young woman in New York City, for example, was hospitalized during a psychotic episode. At the hospital, she continually vented bitter feelings against her therapist for not “caring” about her. Then, she escaped from the hospital. Her therapist went out searching for her client immediately, combing through the bars and clubs of Greenwich Village. At midnight, the therapist found her, and drove her back to the hospital. The client proceeded to make great strides in treatment, and after making a major recovery, credited the “midnight rescue mission” for demonstrating the depth of the therapist’s concern.
Some authors contend that this type of benefit can, in some cases, extend to attending a client’s wedding or graduation ceremony, attending the funeral of someone close to the client, helping the client in a situation of need, etc. (See, for example, Kenneth S. Pope & Melba J.T. Vasquez, Ethics in Psychotherapy and Counseling: A Practical Guide, 4th ed. (Hoboken, N.J.: John Wiley & Sons, Inc., 2011), pages 235-41.) The argument in favor of such boundary-crossing focuses on the support that the client may feel in having a therapist who cares and is willing to “go the extra mile,” and the fact that exploitation of the client, or impaired professional judgment, appear to be remote or minimal risks in many such cases.
Also, clients may interpret professional boundaries differently, according to their cultural background. In some cultures, for example, refusing to accept a gift carries strong “shaming” connotations. Therefore, you will have to make such calls with sensitivity to possible cultural implications.
As many have noted, multiple relationships are basically unavoidable in many small towns, rural communities, or certain subcultures. It may be impossible to treat someone who is not connected to you already, directly or through family or friends. If this is the case, your rationale for treating that client anyway may reflect upon the absence or weakness of other treatment options.
Even advocates for intentional “boundary-blurring” acts as a legitimate part of therapy, however, emphasize the need to maintain firm and clear borders to the professional relationship. In other words, while the perimeter may be extended outward for a particular client, on a specific occasion, this should not lead to any weakening or dissolution of the boundary itself. If it does—if you and the client essentially become close friends—you cannot ethically continue to treat.
If you do employ caring “boundary-blurring” acts with particular clients, realize that doing so heightens your ethical obligations. The ethical codes do not forbid doing this, but they emphasize the need for precautions.
The AAMFT Code of Ethics, for example, provides that MFTs should “make every effort to avoid conditions and multiple relationships with clients that could impair professional judgment or increase the risk of exploitation.” When there is any risk of impairment or exploitation, “therapists document the appropriate precautions taken.” (AAMFT Code of Ethics, § 1.3.)
Such precautions can, and probably should, include the following.
- Consultation. Seek the guidance of a trusted and thoughtful colleague.
- Informed consent. Explain the potential risks of such boundary-blurring acts with the client, and involve the client in the decision.
- Document the rationale. In your notes, explain the rationale for crossing a particular boundary, including the potential benefits as well as risks. Describe your process: what documents (such as ethical code provisions) did you consider, with whom did you consult (and what did they say), and what discussions did you have with the client.
If something does go awry, such that there is now a reasonable likelihood that the multiple relationships or boundary-crossing will exploit the client or impair your professional judgment, you may need to refer the client to another therapist. If you can resolve the issue in another way—such as by ceasing any boundary-crossing or multiple-relationship activities—this may be acceptable.
The bottom line, as in many other areas of medical ethics, is that the client’s needs and well-being come first. You cannot blur a boundary, engage in a multiple relationship, or continue treating a client simply because you want to do so. If it looks like you favored your own interests—and thereby created a risk of exploitation or impaired professional judgment—a licensing board or court will not view this favorably.
Also recognize that, as a human being, this objectivity will be difficult for you. How easy it is to convince ourselves that we are acting for the right reasons! This is why you should take guidance from your ethical rules, sound out a principled colleague, and scrutinize the situation as objectively as possible.
These steps will help temper your self-serving rationalizations. If they are carefully documented—as they must be—they will protect you in the event of a board investigation, ethics complaint, or lawsuit.
In sum, ensure that any multiple relationships or boundary-blurring activities do not place the client, or the quality of your treatment, at risk. Carefully document your process, and your rationale, for any deviations from conventional professional parameters.
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