Professional Boundaries in Psychotherapy

Posted by Ivan Perkins, JD

October 30, 2017 at 8:24 AM

bigstock-Risk-Management-6814519.jpgThere is one ridiculously easy trick to avoiding a malpractice lawsuit, a board investigation, and the loss of your license. (And it is making law and ethics advisors FURIOUS!!!)

Ready? Ok, here it is. Don’t have sex with a client.

In terms of sheer risk reduction, those six words carry the density of a neutron star. Roughly half of all malpractice lawsuits against therapists, according to one estimate, allege sexual abuse.

And when this happens, it can be professionally catastrophic for a therapist. You can be convicted of criminal sexual exploitation, spend time in prison, and find yourself publicly registered as a sex offender. Your license and your profession would evaporate, forever. At best, you may simply face a demand for hundreds of thousands of dollars from your client’s attorney—and be forced to settle.

Sex is just one of the many ways that you can have an illegal or unethical “dual relationship.” 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 in a professional, social, philanthropic, or other group, things start to get messy. Legitimate questions 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.

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 that often go with them, are always 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.[1]

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.[2] 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.”

If you do employ caring “boundary-blurring” acts with particular clients, realize that doing so heightens your ethical obligations. 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.”

Such precautions can 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 them 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.

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.

The bottom line, as in many other areas of medical ethics, is that the client’s needs and well-being come first. 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. We discuss professional boundaries in psychotherapy in greater depth in CE No. 1, Minimizing Legal-Ethical Risk in Psychotherapy.

And, of course, don’t have sex with a client.

If you purchase any of our CE courses during the month of October, you'll receive a special introductory discount of 20% off! Just enter CEBLOG20 in the coupon code box at checkout. This code can be used one time per user. This offer will only last through October 31st, though, so act now for a great discount! You will have access to the courses for a year!

 

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References:
[1] 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), page 238.

[2] Pope & Vasquez, Ethics in Psychotherapy and Counseling, 4th ed., pages 235-41.

Topics: Professional Development, Continuing Education

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