“Can’t We Meet At Starbucks?” - Multiple Relationships and Other Ethical Issues by Pamela H. Harmell, Ph.D. 3 Credit hours - $44 Last revised: 02/11/2007 Course content © copyright 2005-2007 by Pamela H. Harmell, Ph.D.. All rights reserved. ContinuingEdCourses.Net DBA SocialWorkCoursesOnline.com is approved by the Association of Social Work Boards (ASWB) to offer continuing education for social workers, through the Approved Continuing Education (ACE) program. ContinuingEdCourses.Net DBA SocialWorkCoursesOnline.com maintains responsibility for its courses. ASWB provider #1107. ContinuingEdCourses.Net DBA SocialWorkCoursesOnline.com is approved by the National Board for Certified Counselors (NBCC) as an NBCC-Approved Continuing Education Provider (ACEP) and may offer NBCC-approved clock hours for events that meet NBCC requirements. ContinuingEdCourses.Net DBA SocialWorkCoursesOnline.com solely is responsible for all aspects of the program. NBCC provider #6323. ContinuingEdCourses.Net DBA SocialWorkCoursesOnline.com is approved by the California Board of Behavioral Sciences (CA-BBS) to offer continuing education for MFCCs (MFTs) and LCSWs. CA-BBS provider #3311. ContinuingEdCourses.Net DBA SocialWorkCoursesOnline.com is approved by the Ohio Counselor, Social Worker, & Marriage and Family Therapist Board (OH-CSWMFT) to offer continuing education for counselors, social workers, and MFTs. OH-CSWMFT provider #RST080501 & #RCX010801. Take the Course Take the Test Buy your Certificate

LEARNING OBJECTIVES

This is an intermediate level course. Upon completion of this course, mental health professionals will be able to:

• List five behaviors which will minimize the risk of a malpractice suit
• Apply the Ethics Code to one clinical situation involving a multiple relationship
• List six steps to prevent potential boundary violations
• Discuss the pros and cons for therapist self-disclosure
• Describe record keeping procedures for risk management

COURSE OUTLINE

Section A. Introduction And Review
Section B. Boundary Violations
Section C. Multiple Relationships
Section D. Multiple Relationships in a Rural Practice
Section E. Ethics of Accepting Referrals
Section F. Therapist Self-Disclosure
Section G. Risk Management

AUTHOR DISCLAIMER

Thank you for choosing to take this course!

The material contained in this course is the professional and personal understanding of the course author’s interpretation of the experts that will be cited throughout the text. Should any person wish to use this material for any purpose other than basic continuing education as it is presented here, that person should seek the original sources for his or her personal understanding.

The authors cited are accepted and published experts in the fields of legal and ethical issues in psychology, social work (SW), and marriage and family therapy (MFT). Described herein are current opinions, case law when applicable, California statute, and interpretations of the APA Ethics Code, the ethics codes related to social work (National Association of Social Work – NASW and Clinical Social Work Federation – CSWF) and California Association of Marriage and Family Therapy (CAMFT). The fine work of Celia B. Fisher, Ph.D., Chair of the APA Ethics Code Task Force, who completed the current revision (Fisher, 2003), has been used throughout this document.

This is not in any way a legal document; it does not offer legal advice or interpretations other than those of the experts as cited. This material is not meant as a personal or clinical consultation, nor is it intended as a substitute for contact with an ethics committee, attorney, or professional consultant.

Since this applies to each section of the course, it will only be stated this once.

For those of you who have taken courses prepared by this author, some of the introductory Section A will be repeat material. However, much of the material in this section is updated and new, including vignettes, examples, and citations. It is important for participants who are completely new to a course by this author to have the same foundation as those who are already familiar with topics such as elements of malpractice, and for them to receive an introduction to the use of Ethics Codes.

I hope you enjoy the journey!

SECTION A: INTRODUCTION AND REVIEW

Learning Objectives

• To understand the basic elements of malpractice with regard to negligent treatment of a client or patient
• To become familiar with the importance and use of professional ethics codes

INTRODUCTION TO THE COURSE

Your professional organizations have established codes of ethics that provide guidelines for appropriate practice and behavior. The ethics codes are necessarily broad in order for application to various situations and circumstances. They are general rather than specific. Your own awareness and familiarity with the principles of your profession and your problem-solving skills will determine how you translate these guidelines into behavior and attitudes. Welfel (2006) notes that ethics codes are not to be used in a cookbook fashion, but are to be one of many factors used in making decisions in challenging situations. It is essential that each mental health professional remain aware of the limitations of the professional codes (Herlihy & Corey, 2006).

Throughout the course, you will be asked to take brief quizzes that are aimed at helping you learn and retain the material.

When applicable, sections from the various codes (APA, NASW, CSWF, and CAMFT) will be presented. You will have the opportunity to click on a ‘SKIP’ button so you can find the appropriate code for your profession.

BRIEF INTRODUCTION TO LAW

Question

Our American system of law is separated into two divisions, federal and state. In most cases, federal law supersedes state law, except in special situations. Can you think of one? Federal law is superseded by state law:

1. When someone who is not a U.S. citizen commits a felony
2. In some cases where murder is the crime
3. With HIPAA, when state law gives more protection to patient’s records

If you guessed (c), you are correct! With HIPAA laws, which are federal laws (which will be discussed in another section), state law supersedes federal law if the state law provides more protection for the patient’s records and to the patient in general. You may wish to record your answer for future review.

(SKIP) INTRODUCTION TO THE APA CODE OF ETHICS

The complete title of the document is Ethical Principles of Psychologists & Code of Conduct (APA, 2002). The need for an ethics code arose after World War II when psychologists developed group tests to help the armed services quickly evaluate draft eligibility and to provide mental health services to returning soldiers. After numerous task force revisions and drafts approval by the membership, the first code was adopted by APA in 1952 and published in 1953.

The purposes of the current ethics code are many, including 1) establishing the integrity of the profession, 2) providing a guide for proper and expectable professional behavior, 3) securing public trust, 4) self-monitoring, and 5) the ability to adjudicate (APA, 2002; Please see Fisher, 2003 for most recent interpretation of 2002 code). By adjudicate, the APA means to have the power to settle an ethics violation judicially by the ethics committee of the American Psychological Association.

There are five important reasons for having an ethics code:

• To prevent government intrusion into the profession of psychology
• To aid professional autonomy in the practice of psychology
• To avoid undue interference into the profession from outside regulators
• To assert self-regulation of psychology
• To protect the profession from internal discord

In other words, without an ethics code, therapists would be vulnerable to outside regulators who might use their powers of adjudication in cases of ethics violations. Worse still, outside regulators might use inappropriate standards to adjudicate ethics violations when those standards are not applicable to therapists. It is always more appropriate for those within the profession to make decisions about fellow therapists who violate the ethics of the profession rather than outside parties who are less familiar with the profession.

BASICS OF THE APA ETHICS CODE

The current code was adopted in 2002, and took effect in June 2003.

There are two primary sections:

The Aspirational & Unenforceable Sections

The Introduction section discusses the intent and organization of the code and provides guidance only. It is not a legal document. Even though some states adopted the 1992 Code as legal and binding (for example, Georgia adopted the 1992 code as a legal document), the creators did not have this in mind when they wrote it. The Ethics Code looks at “reasonable” prevailing current judgment and considers the dictates of one’s own conscience while strongly encouraging professional consultation with colleagues.

Client/Patient Terminology

All through the text of the APA Ethics Code, the two terms, client and patient are combined. The combination refers to whom a therapist is providing treatment, intervention, or assessment services. The term “organizational clients” or “organizations” or simply “clients” refers to organizations or representatives of organizations for which the therapist may provide consultation, personnel evaluations, test development, or other psychological services (Fisher, 2003).

The Preamble section discusses psychologists’ commitment to science in the improvement of the lives of others. Psychologists have a lifelong effort to act ethically. The primary focus and goal of the Ethics Code is to protect and enhance the welfare of the client/patient along with protection of the individuals and groups with which psychologists work. This includes the education of the members of the APA, students of psychology, and the public in general.

The General Principles AE guide and inspire psychologists to act with the very highest ideals, considering patient welfare as the primary focus.

Enforceable

The 82 numbered standards are the only enforceable part of the Code. These can be used in adjudication proceedings of any local or state ethics committee or an APA ethics committee, and have been used in malpractice suits and licensing board violations.

Question

The APA Code of Ethics is a legal document:

1. True
2. False

Answer: (b) false. The document is NOT to be used as a legal document, but as a guideline and set of standards to follow for psychologists.

Question

The Aspirational (Unenforceable) section of the code contains:

1. Aspirations, guidelines, introduction
2. Introduction, guidelines, aspirations
3. Introduction, preamble, general principles A through E

Answer: (c) Introduction, Preamble, General Principles.

(SKIP) INTRODUCTION TO CAMFT ETHICAL STANDARDS

The complete title of the document is PART I: Ethical Standards for Marriage and Family Therapists and PART II: Procedures for Handling Complaints of Violations of the Code of Ethical Standards for Marriage and Family Therapists. The effective date of the current revision is May 1, 2002. Members of CAMFT are expected to not only abide by these Ethical Standards, but to be familiar with them and “applicable California laws and regulations governing the conduct of licensed marriage, and family therapists, interns and trainees” (CAMFT, 2002, p. 3).

The purposes of an ethics code for psychotherapists are many-facetted. They include: establishing the integrity of the profession, provision of a guide for proper and expectable professional behavior, securing public trust, self-monitoring, and the ability to adjudicate. Adjudicate refers to acting as judge when another MFT violates the ethics code.

There are five important reasons for having an ethics code in any profession:

• To prevent government intrusion
• To aid professional autonomy
• To avoid undue interference from outside parties
• To assert self regulation
• To protect the profession from internal discord

In other words, marriage and family therapists, without an ethics code, would be vulnerable to outside regulators who might use their powers of adjudication in cases of ethics violations. Or worse still, outside regulators might use inappropriate standards to adjudicate when those standards are not applicable to marriage and family therapists.

BASICS OF THE CAMFT ETHICS CODE

There are two primary sections:

Enforceable

The 92 numbered standards of Part I, are the only enforceable part of the Code, however, the Ethical Standards is NOT a legal document. Both Part I, Ethical Standards, and Part II, Handling Ethical Complaints, are only valid in California. However, many of the Ethical Standards are quite similar to the national code used by the American Association of Marriage and Family Therapists (AAMFT). To review the AAMFT Code of Ethics see www.aamft.org. The AAMFT Code of Ethics can be used in any state or ethics committee adjudication proceedings, and has been used in malpractice suits and licensing board violations. Normally, if there is a state set of codes, they will be used for any proceedings within that particular state, such as the CAMFT Ethical Standards in California.

Question

The CAMFT Ethical Standards is a legal document:

1. TRUE
2. FALSE

The answer of course is false (b), as mentioned earlier, the document is NOT to be used as a legal document, but as a guideline and set of standards.

Question

Marriage and Family Therapists may only see families or couples.

1. TRUE
2. FALSE

The answer is (b) as explained above.

(SKIP) INTRODUCTION TO BOTH SOCIAL WORK ETHICS CODES

The National Association of Social Workers (NASW)

TO DOWNLOAD OR “BOOKMARK” THE NASW CODE OF ETHICS

http://www.socialworkers.org/pubs/code/code.asp

The national version of the ethics code NASW was approved by the delegate assembly in 1996. It is intended to serve as a guide to social workers who may or may not be clinical social workers for everyday professional conduct. It has four sections, the last of which includes 51 specific numbered standards that will be the focus of this course along with the Code of Ethics of the Clinical Social Work Federation (CSWF) for clinicians.

The chart that follows displays the four major sections in more detail:

The Clinical Social Work Federation (CSWF)

TO DOWNLOAD OR “BOOKMARK” THE CSWF CODE OF ETHICS

http://www.cswf.org/www/CSWF%20Ethics%20Code%20Prtctd.pdf

In the Preamble of this document, CSWF states:

The objective of the profession of clinical social work is the enhancement of the mental health and the well-being of the individuals and families who seek services from its practitioners. The professional practice of clinical social workers is shaped by ethical principles that are rooted in the basic values of the social work profession. These core values include a commitment to the dignity, well-being, and self-determination of the individual; a commitment to professional practice characterized by competence and integrity, and a commitment to a society that offers opportunities to all its members in a just and nondiscriminatory manner. (CSWF, 1997, P. 1)

The Code of Ethics of the CSWF is specific to clinical social work and will be quoted when relevant in this course. The chart below describes the contents of the CSWF Code of Ethics:

The purposes of an ethics code for psychotherapists are many-facetted, including establishing the integrity of the profession, provision of a guide for proper and expectable professional behavior, securing public trust, self-monitoring, and the ethics committee’s ability to adjudicate (to act as judge when another social worker violates an ethics code).

There are five important reasons for having an ethics code in any profession

• To prevent government intrusion
• To aid professional autonomy
• To avoid undue interference from outside parties
• To assert self regulation
• To protect the profession from internal discord

In other words, LCSWs, without an ethics code, would be vulnerable to outside regulators who might use their powers of adjudication in cases of ethics violations. Or worse still, outside regulators might use inappropriate standards to adjudicate (judge ethical violations) when those standards are not applicable to LCSWs.

Question

The NASW and CSWF ethics codes are legal documents:

1. TRUE
2. FALSE

The answer of course is false (b), as mentioned earlier, the document is NOT to be used as a legal document, but as a guideline and set of standards.

Question

Social workers can only work in hospitals or clinics and not in private practice settings:

1. TRUE
2. FALSE

The answer is false (b) as explained earlier as well.

THE ELEMENTS OF MALPRACTICE

There are four elements of a civil suit for malpractice. All four have to be believed to be satisfied in a court of law. In some cases, the difficulties of attempting to prove a civil suit, or defending against a complaint, are reflected in an out-of-court settlement. Sometimes the malpractice carrier advises that the expense—both emotionally and financially—is not worth the risk of going to court for the plaintiff.

A civil suit for malpractice is defined as “a lawsuit between two citizens where the issue is whether the therapist has breached the standard of care.” (Black’s Law Dictionary, 1996) “Standard of care” will be defined below.

Duty of Care. A Duty of Care arises when there has been an agreement between the therapist and a current client that the pair will work together in a therapeutic relationship. In most cases, a therapist-patient relationship should be established within the first few sessions because, after two or three sessions, a patient does begin to develop an assumption that he has begun treatment. It is important to be completely clear from the start under what circumstances the patient is being seen. Is it merely a two time evaluation for consideration of longer-term therapy? Is the work being done merely as an evaluation using assessment instruments? Was something said to the patient that indicated long-term therapy had begun? Or is the relationship based upon a brief 6-week behavioral model of treatment? If a civil suit should occur, and the parties had not decided whether they wished to work together by the third session or so, the court may decide for them that a “duty of care” had been established. Exchange of money alone does not establish a duty of care; however, if there is nothing else for the court to consider, it may look at any financial matters in an attempt to establish responsibility.

Standard of Care. This broad term refers to the level of proficiency against which any other therapist’s work will be measured or compared. In other words, what any other trained psychotherapist would do with reasonable experience. This is also known as the minimum below which a therapist must not fall (Stromberg, et al., 988; Caudill & Pope, 1994).

Generally, the standard of care is defined by state statute (e.g., California Penal Code 11166, child abuse reporting law; California Welfare and Institutions Code 5150, involuntary hospitalization) and the current ethics code of the profession. Another factor that establishes the standard of care in a profession is something called “case law.” Case law is a “collection of reported cases that form the body of jurisprudence within a given jurisdiction.” (Black’s Law Dictionary, 1996, p. 84) This means that when judges adjudicate a case in an appeals court, it becomes precedent, and must be followed thereafter. Case law is just as powerful as statute, and must be followed just as closely as law that has progressed through the traditional legislative process.

Caudill & Pope (1995) define standard of care as “the minimum standard below which a practitioner cannot fall. It is based on the average competent professional, not the best or the brightest.” (p. 564) This is generally known as the “reasonable therapist doctrine.” These authors go on to explain that competent treatment can lead to unsuccessful results without meaning that the treatment was negligent. “Errors in judgment are not necessarily malpractice…instead if the requisite degree of skill and care is used, a judgment call that proves wrong is not actionable.” (p. 564)

Demonstrable Harm. Can hurt or harm be shown to have occurred to the “victim”? If so, what are her damages? The idea is to return a harmed individual (client or patient) to the condition in which the person existed prior to the harm. This is done in only one possible way in a civil suit—a monetary judgment. In many cases of demonstrable harm with psychotherapist defendants, the damage claimed is psychological in nature. Therefore, it is much harder to prove and harder to approximate the financial award.

Proximate Cause. Proving that the therapist’s wrongful conduct caused the damage, and that it was the direct or proximate cause of the harm of the plaintiff’s injury, is probably the most difficult element to establish. However, attorneys will try to impose liability upon the therapist for his acts that “caused” the damage to the client. The question is—Would the client have been damaged if the therapist had done anything differently? Where injury is alleged to occur, the client must still prove that the alleged injury is caused by the psychotherapist’s breach of the standard of care. In 1991, the California Supreme Court adopted a definition of proximate cause easily understandable to lay people—the “substantial factor” element. Was the therapist’s action a “substantial factor” in causing the patient’s injury? (Caudill & Pope, 1995)

CAROL VIGNETTE

Carol has been seeing Therapist Green for five months. She calls Therapist Green saying she is suicidal and “does not want to go on anymore.” Therapist Green tells Carol to “perk up” and to stop being so down. He tells her to “go to a club with her friends and start acting like someone her age instead of an old woman” so that she can have a good time and “be normal.”

Carol feels terrible after this conversation with Therapist Green. In a suicide attempt, she takes an entire bottle of her antidepressant medication in along with a bottle of alcohol. When she calls Therapist Green the next day feeling ill and depressed, he tells her, “Look, Carol, you aren’t my only client! I am too busy to spend all this time on the phone with you. I will see you at our next appointment. Now, just relax.”

Soon after, Carol takes the rest of her medication and winds up in the hospital. Her family consults an attorney who is considering filing a lawsuit based upon the four elements of a malpractice suit.

Question

Since Carol and Therapist Green had been seeing each other in a therapeutic environment, the first element of a malpractice suit has been met because there was:

1. Duty of Care established
2. A breach of the Standard of Care
3. Demonstrable Harm evident
4. Proximate Cause shown

Answer: (a) duty of care is established when a client-therapist relationship is developed or created.

Question

Therapist Green was probably not adhering to his Ethics Code, the statutes of his state, or the recent case law. Therefore, he probably:

1. Did not create a Duty of Care
2. Breached the Standard of Care
3. Created Demonstrable Harm
4. Provided Proximate Cause

Answer: (b) breaching the standard of care of his profession by not adhering to the ethics code.

Question

Since Carol wound up in the hospital after talking with Therapist Green, this probably is evidence of:

1. Duty of Care
2. Breach of Standard of Care
3. Demonstrable Harm
4. Proximate Cause

Answer: (c) demonstrable harm. Since his patient ended up in the hospital, harm was demonstrated.

Question

If Carol would have been fine had her therapist treated her in a more appropriate manner, this is proof of:

1. Duty of Care
2. Breach of Standard of Care
3. Demonstrable Harm
4. Proximate Cause

Answer: If it could be proven (which would be very difficult to do) that the patient would not have suffered damages (or they would not have been as serious), had Therapist Green done anything differently, then (d) proximate cause can be claimed by the attorney of the patient.

METHODS OF PREVENTING MALPRACTICE

Experts in legal and ethical matters agree on these methods of minimizing the risk of a malpractice suit (Caudill & Pope, 1995; Welfel, 2002; Clayton & Bongar, 1994; Cranston et al., 1988).

• Professional consultation (discussed later)
• Personal therapy
• Membership in professional associations
• Continuing education
• Familiarity with current treatment methods
• Familiarity with current journals
• Knowledge of the current standard of care
• Proper referrals (e.g., hospitalization, medication, adjunctive treatment)
• Proper documentation of patient care

CONSIDERING CLIENTS IN THE EARLY PHASE

There are numerous elements to be considered when a new client calls for an appointment for treatment. Regardless of who is seeking therapy or making a referral, there are five main factors that must be considered. These “five always” (which can be remembered by the shortcut, “CCARQ”) are:

Culture

What is the culture of the person seeking treatment with you? Lee and Richardson (1992) tell us that every therapy relationship is a “cross-cultural” relationship because everyone who enters a psychotherapist’s office is of a different culture from the therapist. Additionally, it is not wise to “judge a book by its cover.” In other words, a potential client may look or sound one way, but live in a completely different multicultural family than what appears at the initial visit. For instance, a client may be an African-American with a Chinese domestic partner. Therapists should never make assumptions about a client’s culture and cultural sensitivities, or those of a client’s family.

Counter-transference

This means that every client must be considered for the possible impact she has, or may have, on the therapist. The therapist must be able to intelligently evaluate his condition, reactions, behavior, feelings, and ability to handle difficult situations in order to avoid the negative effect of counter-transference on the therapeutic relationship (e.g., premature termination, inappropriate behavior by the therapist).

Area of Competence

All therapists should be able to handle all the diagnoses in the DSM; however, this is not realistic. What this actually means is that therapists must be able to identify their limitations—when they should refer a client due to lack of training, counter-transference, or inexperience. In actuality, psychotherapists are expected to know how to handle all diagnoses or know when to refer out due to lack of expertise, competence, or desire to treat or know when to get proper consultation when gaining new skills and competencies.

Rule Out General Medical Condition or Substance Abuse

It is mandatory to rule out any general medical condition or substance abuse that may reasonably be causing, or be related to, mental health symptoms. For example, a person who has panic attacks or any other “head-to-toe” symptoms of anxiety disorders may be suffering from a hormonal imbalance or thyroid dysfunction rather than an actual DSM diagnosis. A medical doctor must rule out general medical conditions (See Axis III in the DSM-IV-TR, APA, 2002) prior to treatment for a mental disorder, particularly one that includes physical symptoms. A psychotherapist cannot rule out a GMC or substance abuse in the blood stream (lab tests) because it is outside of his or her area of competence (medicine).

Question the Reporter

It is not uncommon for a new client to attribute his range of symptoms to another person close to him, such as a significant other or loved one. For example, we might hear, “My significant other is an alcoholic and I don’t know what to do,” when the caller or our primary patient is actually the person with a drinking problem.

INTRODUCTION TO ACCOUNTABILITY

There are four mechanisms holding psychotherapists accountable for our actions as mental health professionals. A brief description of each follows:

Mechanism 1 – State Licensing Boards

A state licensing board is the agency that “giveth and taketh away” the ability to practice psychology. It decides how many hours of continuing education must be taken to renew the license and continue practicing, it regulates penalties for improper practice behaviors, and it can take action if a therapist fails to respond to its dictates.

Mechanism 2 – Ethics Committees

This second mechanism sets guidelines of practice that are considered the standard of care in the profession. It can also take sanctions against the therapist for improper behavior.

Mechanism 3 – Civil Suit for Malpractice

Mechanism 3 is a generally unpleasant factor of American society – when one citizen takes civil action against another citizen. In a civil suit, the only thing being claimed is financial damages, and the only remedy is money. However, punitive damages are also a possibility where the court awards extra financial damages as punishment in a particularly egregious situation. A psychotherapist does not want to be confronted by this element of accountability, as it is generally grindingly slow and complex, not to mention painfully expensive.

Mechanism 4 – Criminal Allegations (Attorney General Involvement)

Criminal allegations are the least likely of the four mechanisms holding a therapist accountable for practice behavior. If there is an unfortunate outcome where the state attorney general goes after a therapist’s license and prosecutes for criminal allegations, the therapist who is found guilty can find herself spending time in a jail cell.

Accountability Vignette Example

Suppose you are hungry at your lunch hour and decide to enter a McBurger restaurant. You sit down quietly in a small booth, with your new Jonathan Kellerman mystery, hoping to get a minute of peace before a busy afternoon. The server comes by and gives you a menu.

When the server returns, you decide to order the chili with a diet cola. The server tells you he will be right back with your order. You read another chapter of your book and enjoy the time off.

A few minutes later, the server delivers a cola and the chili, telling you to “enjoy your meal.” It smells good.

As you take a sip of the cola, you begin to salt the chili. You cool off the chili by letting some cool air flow through the thick chili. You cannot believe what you see, so you look more closely… it looks like there is a FINGER on the spoon! It seems you have been served a bowl of chili with someone’s finger in it!

Question

The definition of Duty of Care is:

1. what another reasonable therapist would do in your situation
2. proof of damage
3. an established relationship

Answer: (c) Duty of Care is defined as an “established relationship between the therapist and client.”

Question

Did the McBurger server and the McBurger establishment have a “Duty of Care” with you?

1. Yes, because they gave you a menu in preparation to serve you food
2. No, because they were only doing an evaluation of you to decide if they wanted to serve you
3. No, because no relationship is established until you pay

Answer: (a) As in a therapy relationship, once service is offered in the restaurant, via being given a menu, the relationship has been established. This is the same as offering service to a potential client without saying it is an evaluation.

Question

The definition of Standard of Care is:

1. What the most recent ethics code says
2. What a judge says
3. Reasonable therapist standard, statute, case law, ethics code

Answer: (c) Standard of care is four things: reasonable therapist standard, statutes, case law, and ethics codes.

Question

Did McBurger practice the Standard of Care of the restaurant profession with the chili they served to you? Why, or why not?

1. No, because it is the standard of care to serve FINGER-LESS chili!
2. Yes, because it probably was not a finger anyhow

Answer: (a) The standard of care was not met because the chili had a foreign object in it that was unexpected and inappropriate.

Question

The definition of demonstrable harm is:

1. Was someone hurt physically?
2. Was someone hurt psychically?
3. Can harm be shown in a court setting?

Answer: (c) Demonstrable harm can be shown in a court setting.

Question

Did you suffer demonstrable harm after this event?

1. Yes, I can never eat chili again, I am anorexic and nauseous
2. Yes, I can never eat in a restaurant again
3. Yes, I now suffer from PTSD and cannot grocery shop

Answer: The issue here is that the “demonstrable harm” is anything that you and your lawyer claim (that is true). Any of these answers are possible. If this were a real case, and a psychotherapist were being sued for malpractice, the issues would certainly be different, yet the claims would be similar and the four elements would be identical.

Question

The definition of proximate cause is:

1. What is the cause of the demonstrable harm?
2. Is the demonstrable harm something the defendant did or failed to do?
3. Can the demonstrable harm be remedied with money?

Answer: (b) Is the demonstrable harm due to something the restaurant or chef or server or staff did or failed to do? This is relevant to any civil suit.

Question

How can Proximate Cause be applied to the finger-in-the-chili situation?

1. It does not apply
2. It would have to be that the chef or someone at the restaurant made an error and actually put the finger in the chili
3. Only the chef could have put in the finger for this element to apply

Answer: (b) In this case, the chef or someone else at the restaurant would have had to do something that caused the damages. The test is whether the damage would not have occurred If the person had not done the act.

REFERENCES

American Psychiatric Association. (2002). Diagnostic and Statistical Manual of Mental Disorders, fourth edition – Text Revision. APA: Author.

American Psychological Association. (2002). The principles of psychologists and code of conduct. American Psychologist, 57, 1060-1073.

Gardner, B. (Ed.) (1996). Black’s Law Dictionary, (1996). St. Paul, MN: West Publishing Co.

Caudill, B., & Pope, K. (1995). Law and Mental Health Professionals. Washington, DC: APA

Clayton, S., & Bongar, B. (1994). The use of consultation in psychological practice: Ethical, legal & clinical considerations. Ethics & Behavior, 4, 43-57.

Fisher, C. (2003). Decoding the Ethics Code: A Practical Guide for Psychologists. Thousand Oaks, CA: Sage.

Lee, C., & Richardson, B. (1992). Multicultural Issues in Counseling: New Approaches to Diversity. Alexandria, VA: American Counseling Associates.

Stromberg, C. (et al.) (1988). The Psychologist’s Legal Handbook. Washington, DC: The Council for the National Register of Health Care Providers in Psychology.

SECTION B: BOUNDARY VIOLATIONS

Learning Objectives

• Understanding general boundary violation ethics
• To avoid multiple relationships
• To learn updates, current ethics codes, and standard of care for multiple relationships

INTRODUCTION TO BOUNDARY VIOLATIONS

Radden (2001) reports that the discussion of boundary violations is filled with confusion partially because the words describe a wide variety of behaviors. These include:

Physical contact between treater and patient (non-sexual touching, such as pats and hugs, as well as sexual intimacy); forms of self-disclosure on the part of the treater about personal matters, such as the insertion of aspects of the treater’s personal life into the therapeutic discussion; breaches of confidentiality by the treater, what would otherwise be known as conflicts of interest (for instance when the treater initiates or permits a social or business relationship to exist at the same time as the therapeutic one, or when other gratification for the therapist); and finally, an assortment of improprieties associated with the therapeutic engagement (fee-setting, gift-giving, and appointment times and places, for example). (2001, p. 320)

Radden considers this definition “misleadingly broad,” saying, “boundary violation seems to encompass almost any form of exploitation and/or any behavior likely to diminish the therapeutic effectiveness of the engagement.” (p. 310)

Definition Difficulties

MULTIPLE RELATIONSHIPS

In Harmell’s 1998 article “Multiple Multiple Relationships Relationships,” she noted that ethics committees and licensing boards have always had difficulty defining the terms dual and multiple relationships. This began with major figures in the field such as Freud and Jung, both of whom straddled the line with their patients, although the “line” had not yet been solidly set. (Since the article was written in 1998, the author did not have a chance to include the more recent definitions of sexual behavior credited to former President Clinton, who appeared to segregate oral sex from sexual behavior entirely, giving a new slant to sexual terminology). This is mentioned here to demonstrate the difficulty inherent in an open society such as that of the United States in coming to a consensus on sexual terminology.

Definitions

Sonne (1994, p. 376) defines multiple relationships as “situations in which the psychotherapist functions in more than one professional relationship, as well as those in which the psychotherapist functions in a professional role and another definitive and intended role, as opposed to a limited and inconsequential role growing out of and limited to a chance encounter.” In other words, multiple roles can be concurrent, or follow each other. Either way, it is generally considered a boundary violation. Positive limit-setting is something all therapists must master by placing restrictions when responding to patient requests, and then reframing their response to therapeutically meet the patient’s legitimate need.

Despite Sonne’s excellent description of the term multiple relationship, it remains difficult to produce an exact and absolute definition that will cover all situations in all locations for all people involved.

Boundary Violations

Because patients discuss emotional and highly personal matters, intimacy is created. It is the psychotherapist who is responsible for maintaining proper limits, keeping the therapy focused, and handling counter-transference and needs for personal gratification without involving the patient inappropriately (Harmell, 1998). Some psychotherapists try to rationalize conducting a business relationship with a patient as well as a therapeutic one simultaneously or after the therapy is over. According to the earlier definition, this constitutes a multiple relationship and is unethical.

Adding to the confusion about boundary violations is the fact that the literature refers to boundaries that occur both internally and externally. These terms are often used freely in the language of psychology. Internal boundaries refer to psychic boundaries that enter into the psychodynamic realm of discourse. External boundaries are more likely to refer to a situation in which inappropriate actions on the behalf of the therapist overlap the external boundaries of the patient in some inappropriate way. To add to the confusion, it is often noted that those who inappropriately intrude upon the external or internal boundaries of a patient have weak or problematic internal boundaries of their own.

Conceptualization becomes difficult when we evaluate the breadth of the usage of these words. Further, judgments of boundary violation seem to be context sensitive. According to Gutheil and Gabbard (1998) it is always required to place the activity in “contextual framing” in order to determine if it is an innocuous boundary crossing or an unethical boundary violation. Context includes:

1. The treater’s professional ideology

2. The presence or nature of the informed consent by the patient

3. The point of therapy in which the behavior occurs

4. The respective cultures of the therapeutic dyad

5. Such environmental factors as:

• Whether therapy occurs in a small town or in an urban center
• Whether public transportation is available or not

Gutheil and Gabbard point out that a therapist who decides to give a patient a ride home in his or her car during a blizzard could be looked upon differently depending upon where the therapy is taking place. If it is a small prairie town as opposed to a large city with a subway system, whether the patient feels forced to accept the ride, or other such elements are the contextual sensitivities of each situation. Thus, it becomes impossible to provide one definition to cover the entire class of behaviors and activities of boundary violations.

Question

The primary reason it is difficult to develop a definition of “boundary violation” in psychotherapy is due to the concept of:

1. Internal boundaries
2. Contextual sensitivities
3. External boundaries

Answer: (b) is the best answer, as contextual sensitivities must always be considered because they change the details and interpretation of the facts of the situation

Once again, context is the primary element that determines how to interpret whether there has been a boundary violation.

Example:

Brown (1994) wrote about the futility of trying to give a single definition, then trying to avoid all forms of potential boundary violations using this single definition. Brown proposed conceptual criteria for looking at boundary violations using four criteria that appeared in the literature:

1. The client is objectified or treated like an object rather than a person

2. The therapist gratifies his or her impulses through the behaviors

3. The therapist’s needs become more important than the needs of the client

4. The client feels violated

Although this model attempts to avoid the definitional difficulties and ambiguities of the Gutheil and Gabbard definition discussed earlier, all raise challenges in interpretation.

For example, it seems impossible to designate all behaviors that gratify the therapist’s impulses as boundary-violating (Brown’s Criterion 2). Behavior engaged in for some other well-considered and therapeutic purpose may also happen to gratify the therapist’s impulses as well. Indeed, if therapy was not gratifying for the therapist, few therapists would continue in the profession and it would cease to exist.

Brown’s Criterion 3, where the therapist’s needs become more important than the needs of the client, is a dangerous phenomenon. For example, sometimes therapists violate boundaries by becoming overly sympathetic, or dreaming about a client, or failing to take the time to seek proper consultation or help with the treatment plan. Although, one must consult and fully understand how to handle these possible counter-transference reactions in order to avoid improper boundary violations in advance, this criterion alone fails to properly define boundary violation.

Criterion 4, wherein the client feels violated, is also unsatisfactory, according to Radden (2001). An oversensitive or even paranoid client is likely to feel violated with no actual violation. Thus, Criterion 4 is not a good definition point for boundary violation because the client may feel his or her boundaries have been violated without a true violation having occurred.

Boundary violation discussions rely on two basic conceptual features that Brown does not include in his work on boundary violation. For example, Garfinkel, Dorian, Sadavoy, and Bagby (1997) focus on asking the questions:

(1) Is the behavior in question potentially exploitative, and

(2) Is the behavior in question potentially detrimental, or at least not conducive, to therapeutic success?

It is important to note that lack of empathy for a client, lack of momentum, and other more subtle issues may be potentially detrimental to the therapeutic success, but fail to violate a boundary. It is fairly easy to give several examples of exploitation and detrimental activities that jeopardize the therapeutic relationship and exploit the client without violating the therapeutic boundary. Other examples of detrimental treater behaviors that do not violate boundaries are:

• improperly overcharging clients
• providing unnecessary care
• providing inadequate care

It remains a puzzle as we continue to try to define boundary violation (Radden, 2001).

Boundary Transgressions Defy Categories

Thinking in categories is helpful and useful in order to make difficult concepts more understandable. As we have seen already, it is impossible to give a simple definition to “boundary violation.” Having a definition or a clearly stated boundary can give a false sense of security in which therapists may visualize an invisible line that creates a boundary that can be stopped before crossing (McGuire, 1996). It is, however, not that simple. For example, many therapists have clear boundaries and policies about accepting gifts from clients. However, cultural issues may enter into such decision-making. Additionally, where one’s practice is located—a large or small town (to be discussed later)—is also a factor in making a decision about accepting gifts.

Although making categories is helpful, it is important to remember most transgressions cross over into several areas, not just one area such as location or setting of practice, and merge into more than one category.

Attempt to Categorize Boundary Transgressions

Physical Boundary Transgressions

• Any type of touching besides accidental touching that is non-sexual
• Hugging, kissing, fondling
• Any type of sexual touching

Physical Boundary Transgressions do not always fit the usual and customary definitions mentioned above. For example:

1. A new client comes into the office and sits in “your” chair.

2. An intern you are supervising asks you to attend his wedding.

3. A patient whose husband recently died reaches for your hand during a session.

4. A student stays after class and asks for a ride home during a rainstorm.

Emotional Boundary Transgressions

• Using clients to satisfy the emotional needs of the therapist
• Misusing client information to satisfy emotional needs of the therapist

Emotional Boundary Transgressions may manifest in the following ways:

1. The therapist uses the sessions to talk about himself rather than focusing on the client

2. The therapist over- or under-charges a specific client for her own reasons that are not therapeutic but are personal

3. The therapist loans the client money or other personal items

4. The therapist invites the client to a party in the home of the therapist

Psychological Boundary Transgressions

• Using psychological tools to humiliate or trick another or potential “victim”

One who uses Psychological Boundary Transgressions is generally conscious of what one is doing to another person. There is an attempt to control the situation, or to be the more powerful person. For example:

1. Using an offensive term in a session in order to put a client on guard

2. Shaming a client in front of others (e.g., “You aren’t doing well at work. Maybe you need more training.”)

3. During a session, the therapist answers the phone several times

4. The therapist consistently runs late or ends early for sessions with a specific client without discussion on the matter

Sexual Boundary Transgressions

• Any type of inappropriate clothing in the office
• Any type of inappropriate sexual behavior (touching or not) in the office
• Any type of inappropriately sexual innuendo or language in the office with clients

Sexual Boundary Transgressions are easy to stop when they involve clothing or subtle behavior. However, inappropriately sexual language or innuendo is more difficult to track. For example:

1. A therapist winks at a client during a session in a sexual manner

2. A female therapist wears a skirt that is too short to properly cover her legs during a session

3. A therapist, when listening to the sexual fantasies of a patient, begins to discuss his own sexual fantasies as well

4. A therapist comments on how “sexy” the client looks during the session

Question

Therapist Dean was in the middle of a messy divorce, so when his attractive, young client arrived for her session wearing a skimpy outfit, he was unsure what to do. He became so flustered that he told her he is getting a divorce, and he wished she were not his patient because he would like to go out with her because she really turns him on. Which form of Boundary Transgression is this?

1. Physical Boundary Transgression
2. Emotional Boundary Transgression
3. Psychological Boundary Transgression
4. Sexual Boundary Transgression

Answer: This question is a bit more complicated, as the best answer is (d), Sexual Boundary Transgression. He never touched her, so (a) is eliminated. Even though (b) Emotional Boundary Transgression does overlap here, it is not as good an answer as Sexual Boundary Transgression. There does not seem to be any deliberate attempt to outsmart the patient by Therapist Dean or to make her feel overpowered, so (c) Psychological Boundary Transgression is eliminated.

(SKIP) APA ETHICAL STANDARDS THAT APPLY TO MULTIPLE RELATIONSHIPS

APA 3.05 Multiple Relationships

This standard specifically prohibits having a professional role simultaneously with:

(a) Another role with the same person

(b) Or is in a relationship with another person closely associated with, or related to, the person with whom the psychologist has the professional relationship

(c) Or promises to enter into another relationship in the future with the person or a person closely associated with or related to the person

The consideration here is to ask if the multiple relationship could reasonably be expected to impair objectivity, competence, or effectiveness?

This is the first time the code has formally noted that not all multiple relationships are unethical if they do not risk exploitation or harm or do not impair the clinician’s judgment.

APA 10.05 Sexual Intimacies with Current Therapy Clients/Patients

This is never appropriate under any circumstances.

APA 10.06 Sexual Intimacies with Relatives or Significant Others of Current Therapy Clients/Patients

This is never appropriate under any circumstances, nor is it ever appropriate to terminate therapy to begin a sexual relationship under these circumstances.

APA 10.07 Therapy with Former Sexual Partners

This is never appropriate under any circumstances.

APA 10.08 Sexual Intimacies with Former Therapy Clients/Patients

APA adheres to the “almost never” rule here. However, if a psychologist does engage in such activity after the two year prohibition, at the very least the following seven elements must be considered:

(1) The amount of time that has passed since therapy terminated

The time that has passed changes the context of the situation. If the amount of time that has passed is twenty-six months versus twenty-six years, it is more understandable that the pair might consider having a sexual relationship and that the therapeutic relationship may be more distanced than if it was only two or three years in the past.

(2) The nature, duration and intensity of the therapy

The difference between a therapist who was an intern who performed an intake as opposed to a licensed psychologist who participated in an eight-year analysis with the patient makes a significant difference in the decision whether to have a sexual relationship with the former patient.

(3) The circumstances of termination

It is critical to consider the circumstances of the termination, whether it was valid and sincere, or simply for the purpose of starting a sexual relationship as soon as possible. For example, does the sexual relationship begin at the end of the second year (as soon as legally and “ethically” possible under the APA Code and state laws that apply), versus much later in their lives?

(4) The client’s personal history

The client who has a history of suing psychotherapists or others in the medical field may not be the best person to have a sexual relationship with after therapy ends, even after the two year waiting period.

(5) The client’s current mental status

The patient’s mental health should also be considered along with family life and diagnosis. For example, if the client were diagnosed with Borderline Personality Disorder, the fact that the person might be considerably unstable would be a serious consideration.

(6) Likelihood of adverse impact on client

The APA added this to the language of the Code in order for psychologists to take the time to consider if a romantic relationship with a former patient would create further stimulation of past trauma.

(7) Any statements or actions made by therapist inviting the possibility of a post termination sexual or romantic relationship with client

For example, suggesting if the client were not a client, a relationship might be possible. Many clients report their therapists telling them “If you were not my client, I would like to date you!”

Question

What does it say in the APA Ethics Code that automatically makes the psychotherapist’s behavior unethical?

1. All sessions with a psychotherapist are psychotherapy when dealing with a court appearance
2. Sex with a patient prior to a two year delay after a valid termination is not appropriate
3. Leaving unsolicited messages with sexual content for a patient is unacceptable behavior

Answer: (b)—sex with a patient prior to a two year delay after a valid termination is not ethical and, in some states, not legal. It is important for each professional to become familiar with the laws in his state regarding sex with patients.

(SKIP) CAMFT ETHICAL STANDARDS THAT APPLY TO MULTIPLE RELATIONSHIPS

STANDARD 1: Responsibility to Patients

STANDARD 1.2 - This is a general code that explains that MFTs avoid dual relationships that could impair professional judgment or lead to exploitation. A dual relationship exists when:

1. The therapist and patient engage in a distinct and separate relationship either simultaneously with therapeutic relationship, or during a reasonable period of time following the termination of the therapeutic relationship

2. Not all multiple relationships are unethical and some cannot be avoided

STANDARD 1.2.1 – Sexual activity during therapy or within two years of termination is unethical.

STANDARD 1.2.2 – Other acts that are unethical dual relationships are borrowing money from a patient, hiring a patient, doing business with a patient, having a close personal relationship with a patient, having close relations with a patient’s relative, etc. is unethical.

STANDARD 1.2.3 – MFTs do not enter therapy with sexual partners.

SOCIAL WORK CODES THAT APPLY TO MULTIPLE RELATIONSHIPS

(SKIP) SOCIAL WORK ETHICAL STANDARDS THAT APPLY TO MULTIPLE RELATIONSHIPS

NASW Code of Ethics

Standard 1.09 – Sexual Relationships (a-d)

(a) Under no circumstances do SW have sexual activity with patients.

(b) SW do not engage in sexual activities or sexual contact with patient’s relatives or others who have a close personal relationship with the patient. SW do not have sexual contact with relatives of their patients. The SW maintains the entire burden for setting clear and appropriate boundaries, culturally and otherwise.

(c) SW do not engage in sexual activity with former patients except under the most extraordinary circumstances.

(d) SW do not provide services to those with whom they have had sexual relationships.

Standard 1.11 – Sexual Harassment

SW do not sexually harass clients which includes sexual advances, solicitation, requests for sexual favors.

CSWF Code of Ethics

Standard 3 – Relationships with Clients (a&b)

(a) CSW are responsible for setting clear boundaries about dual and multiple relationships. The do not take chances where there is an opportunity for patient exploitation, especially when the CSW is seeing two or more patients who know each other.

(b) CSW do not engage in sexual activity with former patients except under the most extraordinary circumstances. CSW do not provide services to those with whom they have had sexual relationships.

REFERENCES

Applebaum, P., & Gutheil, T. (1991). Clinical Handbook of Psychiatry & Law. Baltimore: Williams & Wilkins.

Brown, L. (1994). Boundaries in feminist therapy: a conceptual formulation, in Bringing Ethics Alive (pp. 29-38). Edited by Gartrell, N. New York: Harrington Park Press.

Clayton, S., & Bongar, B. (1994). The use of consultation in psychological practice: ethical, legal, and clinical considerations. Ethics & Behavior, 4, 43-57.

Corey, G., Corey, M., & Callanan, P. (1998). Issues & Ethics in the Helping Professions. Pacific Grove, CA: Brooks/Cole.

Garfinkel, P., Dorian, B., Sadavoy, J., Bagby, R. (1997). Boundary violations and departments of psychiatry. Can J of Psychiatry, 51, 357-375.

Gutheil, T. & Gabbard, G. (1998). Misuses and misunderstandings of boundary theory in clinical and regulatory settings. Am J of Psychiatry, 155, 409-414.

Harmell, P.H. (Sep-Oct, 1998). Multiple multiple, relationships relationships. The Los Angeles Psychologist.

Jensen, D. (July-Aug, 2005). So what exactly is a dual relationship? The Therapist. San Diego: CAMFT.

Kapp, M. (1987). Interprofessional relationships in geriatrics: Ethical & legal considerations. Gerontologist, 27, 547-552.

Radden, J. (2001). Boundary violation ethics: Some conceptual clarifications. J of Am Acad Psychiatry & Law, 29, 319-326.

Sonne, J. (1994) Multiple relationships: Does the new ethics code answer the right question? Professional Psychology: Research and Practice, 25, 336-343.

Stromberg, C. (et al.) (1988). The Psychologist’s Legal Handbook. Washington, DC: The Council for the National Register of Health Care Providers in Psychology.

SECTION C: MULTIPLE RELATIONSHIPS

Learning Objectives

• To gain familiarity with the continuum of multiple relationship situations
• To gain knowledge about the precursors to therapist sexual misconduct
• To learn what therapists have to say in retrospect about having sexual relations with patients
• To learn implications for practice and prevention

Multiple Relationships: A Continuum from Destructive to Therapeutic

Moleski and Kiselica (2005) make a case for the continuum model of multiple relationships ranging from destructive to therapeutic in nature, scope, and complexity. Therapists are constantly balancing their own values and needs with those of the patient along with the ethics codes of their profession and the regulations of their licenses. However, none of these provides more than guidelines with any absolute answers. “Consequently, practitioners must combine their understanding of ethical codes with sound judgment to serve the best interests of their clients.” (Moleski & Kiselica, 2005, p. 3)

Destructive Multiple Relationships: Sexual and Non-sexual

Sex with Current Patient

There is very little disagreement that a sexual relationship with current patient is considered the most destructive. Indeed, in survey research done by Borys and Pope (1989) 98% of the nearly 5,000 mental health professionals asked cited “sexual activity with a client before termination of therapy” as never ethical (p. 289).

Despite this attitude, survey research has found therapist respondents admitting to having sex with current patients in percentages up to 12% (Stake, 1999). More alarming still, research done by Pope and Bajt (1988) in which senior experts belonging to state ethics committees, authors of ethics texts, and diplomats of the American Board of Professional Psychology were surveyed, 9% indicated that they had engaged in sex with a client.

Sex with Former Patient

Sexual relations with a former patient is less universally as destructive as is sex with a current patient, as demonstrated by the decision to allow psychotherapists to have sexual relations with a patient after a normal and valid termination after the two year period has elapsed. Many experts complain the two year delay is an arbitrary time frame with no real reasoning behind it, and that it contradicts the therapists dictum to do no harm and to enable patient autonomy (Hartlaub, Martin, & Rhine, 1986; Gabbard, 1994; Gotlieb, 1993; Harmell, 1998).

Part of the problem is that rather than analyzing the transference and counter-transference phenomenon, the pair might ignore what is vital to the therapy and the patient’s health. The therapist becomes just another person, rather than one who can help the patient overcome hurdles and process issues.

A patient hoping to fulfill the attraction in the future will lose an important part of the therapeutic relationship, perhaps hiding from the clinician parts of himself in hopes of pursuing this secondary relationship. Clients may consciously or unconsciously sabotage their own therapeutic efforts (Moleski & Kiselica, 2005).

Non-sexual Multiple Relationships

Most authors write that even non-sexual multiple relationships can be harmful to the primary therapeutic relationship because they have the possibility of overriding the therapy relationship. For example, should the patient and the therapist go into a business deal together (as discussed in Section B) and the deal fails, the therapy relationship is in jeopardy. Because the therapist often has influence over the patient, she is in a position to exploit the patient for her own benefit (Moleski & Kiselica, 2005).

A particularly interesting form of non-sexual multiple relationship occurs when a recovering therapist attends a recovery meeting which his patient is also attending. Doyle (1997) states that either or both parties may risk sobriety, along with anonymity as a person in recovery. Each deserves the freedom to practice his or her program without the other person as witness. It is up to the therapist to protect the well-being of both parties so that neither become a victim of a harmful multiple relationship.

Therapeutic Multiple Relationships

On the other end of the continuum are the secondary relationships that some consider complementary to the primary therapeutic relationship. These relationships may enable and enhance the primary counseling relationship, not only in rural settings but in large, urban cities as well. Refusing therapy patients because of fear of this therapy overlap may prevent those in need from receiving services in rural settings (Doyle, 1997).

Cultural issues often require therapists to overlap certain areas of their practice styles that might not ordinarily overlap. For example, accepting a gift in order to enhance the patient’s receptiveness to therapy, or in order to show respect for one’s culture is not necessarily acceptable to Western-trained therapists. However, if not accepting the (reasonably priced) gift would thwart the alliance between the therapist and client or otherwise disturb the relationship, it would clearly be an appropriate and therapeutic “multiple relationship” to accept the gift.

In the past…

As we all know, the history of psychology is fraught with famous therapists who had all manner of relationships with their patients (see Freud and Jung by Linda Donn). Freud analyzed his daughter Anna, as well as fed his clients meals. Melanie Klein invited a client to join her where she vacationed. She placed him on her hotel bed and analyzed him for two hours (Moleski & Kiselica, 2005).

Protection for Therapists

Corey et al. (1998) recommend the following guidelines when thinking through potential problem boundary areas before they have a chance to cause trouble:

1. Set healthy boundaries from the outset
2. Secure the informed consent of clients and discuss with them both the potential risks and benefits of dual relationships
3. Remain willing to talk with clients about any unforeseen problems and conflicts that may arise
4. Consult with other professionals to resolve any dilemmas
5. Seek supervision when dual relationships become particularly problematic or when the risk for harm is high
6. Document any dual relationship in clinical case notes
7. Examine your own motivations for being involved in dual relationships
8. When necessary, refer clients to another professional

Question

What is meant by the “continuum model” of multiple relationships?

1. Therapists should examine their own motives for being involved in a dual relationship with a former patient
2. Having a sexual relationship with a past patient is not as destructive as having a sexual relationship with a current patient
3. Multiple relationships with patients range from destructive for the patient to therapeutic for the patient

Answer: The answers above contain two distracters and one best answer. Answer (a), although true, is not the definition of the continuum model. Answer (b) is also true, but is not the correct answer as it is not a definition of continuum model. Thus, answer (c) is the correct answer as it does give the correct definition of the continuum model for multiple relationships.

Precursors to Therapist Sexual Misconduct – Survey Research Findings

Attorneys, when asked, report that most therapists who have sexual relationships with their patients do not simply have a normal and routine psychotherapy relationship with the patient one day, and suddenly sail into a romantic relationship the next. Therapists who get into a sexual relationship with a patient are generally vulnerable due to a counter-transference problem leading up to the sexual violation. For example, some therapists unfortunately gain false confidence about their continuing sexual attractiveness during and after a divorce or separation from a significant other by using patients to fulfill roles that should be filled by non-patients.

For most therapists, the idea that one would desire a patient so intensely that he would risk a hard-earned license, family life, professional reputation, and financial security seems difficult to imagine. However, as reflected by enormously high malpractice premiums for psychotherapists, the entire profession pays the price for those who do not follow the prescribed and agreed upon standards.

Recent research has indicated that the motivation for sexual boundary transgressions most often involved “unconscious, denied, or compartmentalized conflicts about which the therapist had little insight.” (Celenza, 1998, p. 380) The author of the research goes on to say that the issues that had motivated these therapists to seek sexual relationships with their patients were usually related to “personal conflicts in the character of the therapist, rendering the therapist vulnerable to enactments when intolerable helplessness, loss of self-esteem, or rage were evoked.” (p. 381)

The convergence of results from seventeen subjects’ personal interviews, clinical observations, background information, the Rorschach and Thematic Apperception Tests of both therapists who had transgressed and, where possible and appropriate, the patient-victim, were used in Celenza’s procedures and analysis. The author stresses that this is not a controlled or prospective study at this point, but a way of shedding light on, and further educating the profession in, this vital area of boundary violation.

Six Precursors to Multiple Relationships

Celenza (1998) found six features that fell into the following categories:

(1) Long-standing and Unresolved Narcissistic, Neediness, and Lifelong Struggles with Low Self-esteem.

Each therapist in this study reported lifelong feelings of inadequacy, failure, and unworthiness. All therapists reported feeling this way all of their lives. In the therapy where the therapist committed the boundary violation, the therapist’s needs had gradually become the focus of the therapy. In some cases, this occurred more subtly by disclosing personal matters at first, then soliciting sympathy or soothing from the patient. The patient often reported feeling powerless and reluctant to confront the therapist who appeared to be an authority figure. Ninety four percent of the therapists reported feeling a paradox of powerlessness in relation to the therapy. These patients reported feeling as if angry feelings toward the therapist were not allowed under any circumstances (Celenza, 1998).

(2) Childhood History of Sexualized Pre-genital Needs.

Celenza reported therapists in this survey study indicated they had no conscious awareness of “having been over-stimulated as a child.” (p. 382) Only one of them reported having been the victim of outright sexual abuse. The study did reveal, however, that the sexualization would take the form of covert seductiveness and over-stimulation “in the context of an emotionally depriving relationship with a parental figure.” (p.381) Additionally, the seductiveness that was done in a covert manner always occurred in the context of an emotionally repressed and sexually prohibitive environment within the therapist’s family. A few memories reported were:

• Therapist recalled memories of a mother in a conservative and religious family undressing in an asexual manner (not intentionally seductive) and was not aware that this behavior had the potential to stimulate a child.
• Therapist recalled his mother preventing him from hugging her or holding her hand. He did recall the mother encouraging him to tell her about his own multiple sexual exploits.
• Therapist recalled mother being warm and loving to nine sisters while being unaffectionate and unpredictable toward him, the only son. Father was described as “enjoying his manhood” and pursuing typically male hobbies such as building cars and racing hotrods.
• Therapist recalled both parents as “Edwardian, very formal, unaffectionate, and repressive” (pp. 382-383), and sleeping in different rooms and having little contact with each other. Slaps on the hand were the routine form of punishment for “naughty” behavior. He longed to be slapped more often because this was his only form of being touched by his parents. Everyone knew father had gay lovers visiting in the afternoon with which he showered; no one in the family openly acknowledged these visits.

These childhood experiences have the power to result in unresolved needs that can be replayed in the therapeutic relationship. (Twemlow & Gabbard, 1989; Gabbard, 1994a)

(3) Restricted Awareness of Fantasy

This was especially true of those therapists who had the most guilt and self-reproach over the boundary transgression. ”Because a restriction in the ability to use fantasy impedes the capacity to imagine multiple levels of meaning (e.g., to recognize or consider transference, counter-transference, and defense functions), feelings are taken at face value.” (Celenza, 1998, p. 383) Celenza asks the question, “What mechanism failed to prohibit the therapists from acting their counter-transference or fantasy feelings about their patients?” Some of the material that was revealed in the research was:

• Exploration of therapist’s feelings showed an inability to perceive aggression in themselves
• Exploration of therapist’s feelings showed an inability to perceive aggression in others
• Many therapists were unable to acknowledge the boundary transgression as a hostile act toward the patient
• These therapists had moralistic views
• Many of the therapists were self-depriving
• Therapists reported their conscious fantasies lacked aggressive play themes and other impulses considered by themselves to be repugnant or immoral
  • Gabbard (1994b) observes this represents an impairment in fantasy functions
  • “This accords with Freud’s [1911/1958] early discovery that consciousness plays a central role in the capacity to delay, that it is those impulses that are unconscious that are most likely to be acted out.” (Celenza, 1998, p. 384)

It was reported by one therapist that he thought his job was to eliminate his anger and he found it impossible to sustain any anger in relation to a difficult past. Another developed panic attack symptoms at the funeral of a high school athletic coach who had refused to accept him on to the team. In analysis as an adult, he learned he unconsciously believed his anger and frustration at the coach had caused the coach’s death. Other therapists realized in therapy that their “seething rage underneath a placid and good exterior” hid severely aggressive feelings from themselves and others. It seems these therapists were unaware of their responsibility in the event and often felt seduced by the patient-victim. Indeed, one therapist remarked after the boundary violation, “My body responded; I did not.” (Celenza, 1998, p. 384)

(4) Ample Precedence in Family History of Therapist of Boundary Transgressions by Parental Figure

It seems that boundary-violating therapists in this group often experienced and witnessed a parental figure gratify his or her own sexual needs with a partner outside the parental dyad. The child (now the adult therapist) reenacted the scene in a secret and forbidden context, mirroring the patient’s wish to have a sexual relationship with an equally forbidden object with which the therapist colludes. Both parties are caught in this reenactment (Gabbard, 1994c).

(5) Intense and Unconscious Unresolved Anger toward Authority Figures

In one survey, subject-therapists reported they thought the researchers were actually working with them to work against the licensing board that had taken action against the therapist’s license for the boundary violation, and that they were actually attempting to reverse the suspension. Another therapist who was also a pastoral counselor reported he got sexually involved with a patient in order to “f**k God and f**k the church.” (Celenza, 1998, pp. 385-386).

One element found in every subject, and the one the researcher reports as the most important, was an acute inability to tolerate any part of the negative transference expressed by his or her patients. This was true of all his or her patients, not only the one with which the sexual relationship occurred. One therapist denied that any of his patients ever had any hostile, negative, or devaluing projections toward him. Indeed, when deeper questioning took place, the patients with whom these therapists became involved were experienced as particularly angry and hostile.

(6) Circumventing of Unconscious Counter-transference Hate through Misuse of Conscious Counter-transference “Love”

When these therapists were particularly threatened by the possibility of being exposed to their own aggression, they used techniques such as overly gratifying the client, and becoming seductive and suggestive, and even manipulative. They had an intense need to be seen as caring and giving by the patient, perhaps to ward off the fear of being exposed to their own anger and rage, or the patient’s anger and rage. They displayed intolerance for counter-transference hate or negative feelings toward the patient and quickly adjusted these feelings into the opposite feelings of more tolerable counter-transference love.

Celenza reports the seduction of the patient often occurred at the time the therapist felt the least helpful and the therapy was at the worst impasse. The therapists tried to connect with the patient on some level. “I was reaching the end of my rope. I didn’t know how to help her. So I seduced her because I knew how to do that.” (Celenza, 1998, p. 388)

Psychotherapists Reflect on Their Sexual Boundary Violations – Research and Professional Implications

Three factors have been implicated by the research as influencing the occurrence and continuation of sexual and nonsexual multiple relationships:

(1) The connection between sexual and non-sexual professional boundary crossing

Authors report a relationship between sexual and non-sexual boundary-crossing, using the “slippery slope” analogy. It seems when there is an erosion of nonsexual boundaries, there is a very consistent deterioration to sexual transgressions (Lamb, Catanzaro, & Moorman 2003). Earlier research reported therapists who admitted actual sexual boundary transgressions had previously engaged in nonsexual boundary transgressions such as crying in front of a patient or disclosing personal information.

(2) Difficulty in exacting a definition for dual or multiple relationships

As previously noted, this is a recurrent theme among experts who author articles on the subject. Many experts ask how the American Psychological Association can deem nonsexual behaviors as unacceptable when definitions are vague and over-inclusive (Ebert, 1997; Lamb et al., 2003). Additionally, theoretical differences add to the confusion and differences in defining multiple relationships, causing many to disagree within the profession (Williams, 1997).

(3) Therapist characteristics putting them at risk

Lamb et al. (2003) report mixed findings in previous research regarding characteristics that put therapists at risk for becoming vulnerable to sexual transgressions with patients. However, researchers have developed various methods of evaluating this factor. Therapists’ self-reports and reflections about issues in their lives that made them particularly vulnerable will be discussed later in this section.

Psychotherapists Talk about the Experience of Violating Boundaries

What life circumstances did psychotherapists who practiced the prohibited behavior with patients, supervisees, or students report they believed had an influence on the development of the prohibited sexual relationships? Lamb et al. (2003) identified two general types of circumstances in their research:

Type One – Factors related to dissatisfaction in their personal lives

• Marital problems
• Employment issues
• Money issues
• Loneliness
• Insecurity
• New baby
• Parent died
• New job

Type Two – Actual activities or interactions related to the other person

• Social interactions brought familiarity
• Continued contact after therapy ended
• Dreamed and fantasized about the person
• Continued seeing patient after therapy should have terminated

Of thirteen rationales offered to those surveyed, researchers identified three general types of reasons or circumstances that the psychotherapists chose most often:

Rationale 1: No harm, thus I proceeded – 40% of the responses

Typical answers from the participants that fell into this category are:

• An egalitarian relationship existed
• I did not see the relationship as falling under an ethical violation
• There was no harm to the other person
• The therapy relationship was over so there was no dual role
• The time since termination was sufficient

Here, it seems that these therapists used the defense mechanisms of rationalization and denial to decide that no harm could be foreseen. Therefore, there is no real reason not to proceed with a sexual relationship with the patient, supervisee, or student. It is understood that this type of thinking and non-analysis of the situation does not serve the profession nor does it follow the goals of the profession where the welfare of patient is primary.

Rationale 2: Consulted and/or negotiated – 32% of the responses

Typical answers from the participants that fell within this category are:

• I clarified this through peer consultation then proceeded
• We agreed that the formal therapy relationship would not occur again
• The two relationships were kept separate through discussion with the patient

While consultation is the standard of care, without receiving a consultation from a qualified professional who has expertise in the area in question, the consultation could be deemed inadequate and may not protect the therapist from liability. Consulting with a professional who merely agrees with the therapist’s point of view is not a consultation, but merely a “meeting of the minds” that cannot be used to validate the standard of care when a practitioner is in question about a treatment plan or an activity within the profession. Thus, simply receiving a consultation does not fulfill the standard of care initiative.

Rationale 3: Continued although I knew the behavior was problematic and/or unethical – 28% of responses

Typical answers from the participants that fell within this category are:

• I saw the relationship as problematic but I continued
• I knew I was violating ethical standards but I did it anyway

Worse still, approximately fifty percent of this group indicated they terminated the professional psychotherapy relationship with the patient to proceed with the romantic or sexual relationship (Lamb et al., 2003).

Collegial Involvement/Peer Consultation was Sought at Some Point

The majority of the offending therapists (80%) reported they sought peer consultation at some time during the ordeal. All appeared to view consultation positively. There seems to be a good deal of naiveté about how to deal with overtures from patients, how to seek and receive formal consultation in this area, how to break off the sexual relationship once it begins, and how to find written materials related to professional boundaries and vulnerabilities (Lamb et al., 2003). Researchers suggest that there be more required detailed and explicit discussions, role-play activities, and mandated workshops for graduate students in order to prepare them for future difficulties with boundary issues in their clinical work.

Overall Professional Implications Reported

Thirteen of the 368-subject pool admitted having at least one sexual boundary violation as a professional psychotherapist (3.5%). The following chart displays the recent, more specific findings from Lamb et al.’s. (2003) research:

Researchers attempted, and failed, to find a significant connection between reported sexual boundary violations as a former client, supervisee, or student and as a practicing professional (Lamb & Catanzaro, 1998). Using different methodology, Jackson & Nuttall (2001) did find that therapists who reported severe childhood sexual abuse in their past may actually be at a greater risk for engaging in boundary violations of a sexual nature with their own clients.

Specific Implications for Practice and Prevention

In reviewing the reflections of therapists who engaged in sexual relationships with clients, supervisees, or students (or permutations thereof), the researchers found six specific implications. The authors hope their findings “can provide helpful insight to those who are currently involved with (or about to enter into) sexual or problematic nonsexual relationships and to those who have become aware of such behavior in their colleagues.” (Lamb et al., 2003, p. 106)

The six specific implications for practice and prevention are as follows (see Lamb et al., 2003, p. 106):

1. Dissatisfaction in therapist’s own life

Professionals who had inappropriate sexual relationships with clients, supervisees, or students experienced dissatisfaction in their own lives that may serve as a cue to their increased risk of engaging in a sexual relationship. What this may suggest is that such cues, if actually known to the therapist, can be a signal the need to discuss the issue and may have the potential to serve as prevention.

2. Sexual relationships are generally brief

The course of the relationships is not long nor are they always positive. Approximately one-half of the involved psychotherapists reflected that “all in all,” the relationship was not worth having. The idea is to provide vulnerable clinicians with this type of post hoc information that may prompt further self-reflection regarding the value of pursuing such a relationship.

3. Involvement affects professional work

Importantly, the prohibited behavior was found to affect professional work with other clients, supervisees, and students. This finding supports the critical standard of care issue related to professional consultation and peer consultation as an accepted method of double-checking one’s own judgment and minimizing the chance of following through on the pursuit of an appropriate sexual relationship.

4. “It isn’t harmful!”

Shockingly, forty percent (40%) of those questioned who violated sexual boundaries did not view this type of involvement with patients, supervisees, or students as harmful to the other individual. “This suggests a need for several possible educative actions.” (Lamb et al., 2003, p. 106)

• Education about sexual transgressions given by:
• Licensing boards
• APA Ethics Office
• Training facilities
• State Ethics Committees
• Graduate Schools

5. Increase clarity and decrease ambiguity regarding how to evaluate ethical propriety of engaging in relationships after the formal relationship has ended

There is a broad range of actions that fall upon a continuum with regard to engaging in a multiple relationship. There are instances in which a therapist will dispense with a “normal” therapeutic relationship with a patient specifically to engage in a romantic or sexual relationship with him. This course of action is generally viewed by most psychotherapists as inappropriate in all situations and is never a way of justifying the development of such a sexual relationship (APA, 1988).

6. Peer consultation

As mentioned earlier, peer consultation is a major source of support, education, clarification, and intervention, and can serve as a deterrent regarding these types of relationships. Sometimes consultation is not sought due to professional arrogance, discomfort, and perceived personal costs such as negative repercussions. Authors have commented on professional hesitance to seek consultation (Biaggio, Duffy, & Staffelback, 1998; Mahoney, 1997).

REFERENCES

American Psychological Association. (1988). Ethics Committee report. American Psychologist, 43, 897-904.

Biaggio, M., Duffy, R., & Staffelback, D. (1998). Obstacles to addressing professional misconduct. Clinical Psychology Review, 18,273-285.

Borys, D. & Pope, K. (1989). Dual relationships between therapist and client: A national study of psychologists, psychiatrists, and social workers. Professional Psychology: Research and Practice, 20, 283-293.

Campbell, C., & Gordon, M. (2003). Acknowledging the inevitable: Understanding multiple relationships in rural practice. Professional Psychology: Research & Practice, 34, 430-434.

Celenza, A. (1998). Precursors to therapist sexual misconduct – preliminary findings. Psychoanalytic Psychology, 15, 378-395.

Corey, G., Corey, M., & Callanan, P. (1998). Issues & Ethics in the Helping Professions. Pacific Grove, CA: Brooks/Cole.

Donn, L. (1988). Freud and Jung. NY: MacMillan.

Doyle, K. (1997). Substance abuse counselors in recovery: Implications for the ethical issue of dual relationships. J of Counseling & Development, 75, 428-432.

Ebert, B. (1997). Dual relationship prohibitions: A concept whose time never should have come. Applied and Preventive Psychology, 6, 137-156.

Freud, S. (1958). Formulations on the two principles on mental functioning. (In J. Strachey (Ed. and Trans.), The Standard Edition of the Complete Psychological Works of Sigmund Freud (Vol. 12, 215-226). London: Hogarth Press. (Original work published 1911))

Gabbard, G. (1994a). Reconsidering the APA’s policy on sex with former patients: Is it justifiable? Professional Psychology: Research and Practice, 25,329-335.

Gabbard, G. (1994b). Sexual excitement in the analyst. J of the American Psychoanalytic Association, 42, 1083-1106.

Gabbard, G. (1994c). Sexual misconduct. (In J. Oldham & M. Riba (Eds.), Review of Psychiatry (pp. 433-456). Washington, DC: American Psychiatric Press)

Gottlieb, M. (1993). Avoiding exploitive dual relationships: A decision-making model. Psychotherapy, 30, 41-48.

Harmell, P.H. (Sep-Oct, 1998). Multiple multiple, relationships relationships. The Los Angeles Psychologist.

Harmell, P.H. (1987). The Effects of Therapist Self-Awareness of Counter-transference. Unpublished doctoral dissertation.

Hartlaub, G., Martin, G., & Rhine, M. (1986). Recontact with the analyst following termination: A survey of 71 cases. J of Am Psychoanalytic Association, 34,895-910.

Jackson, H. & Nuttall, R. (2001). A relationship between childhood sexual abuse and professional sexual misconduct. Professional Psychology: Research and Practice, 32, 200-204.

Lamb, D., & Catanzaro, S. (1998). Sexual and nonsexual boundary involving psychologists, clients, supervisees, and students: Implications for professional practice. Professional Psychology: Research and Practice, 29, 498-503.

Lamb, D., Catanzaro, S., Moorman, A. (2003). Psychologists reflect on their sexual relationships with clients, supervisees, and students: occurrence, impact, rationales, and collegial intervention. Professional Psychology: Research and Practice, 34, 102-107.

Mahoney, M. (1997). Psychotherapists’ personal problems and self-care patterns. Professional Psychology: Research and Practice, 28, 14-16.

Moleski, S., & Kiselica, M. (2005). Dual relationships: A continuum ranging from the destructive to the therapeutic. J of Counseling & Development, 83, 3-11.

Pope, K. & Bajt, T. (1988). When laws and values conflict: A dilemma for psychologists. American Psychologist, 43, 828.

Twemlow, W., & Gabbard, G. (1989). The lovesick therapist. (In G. O. Gabbard (Ed.), Sexual exploitation in professional relationships (pp. 71-87), Washington, DC: American Psychiatric Press.

Williams, M. (1997). Boundary violations: Do some contended standards of care fail to encompass commonplace procedures of humanistic, behavioral, and eclectic psychotherapies? Psychotherapy, 34, 238-249.

SECTION D: MULTIPLE RELATIONSHIPS IN A RURAL PRACTICE

Learning Objectives

• To gain understanding of multiple relationships in rural practice
• To prevent multiple relationships in rural practice

Introduction to Section D

Most psychotherapists do not practice in rural communities. However, with the large population of Baby Boomers thinking about cutting back and/or retiring, it is something that is being discussed more and more by those who have never considered it. In addition, psychology professors report their students are considering rural communities as possible places to set up clinical practices and raise families.

Introduction to the Rural Community

Multiple relationships, or the holding of another relationship with a client, patient, supervisee, or student, along with the professional relationship, have long been considered problematic. A special intensity and complexity pervade every aspect of rural life that makes decision-making about multiple relationships with clients difficult (Erickson, 2001; Hargrove, 1986; Jennings, 1992; Welfel, 2002).

Erickson (2001) has chosen to focus on nonsexual multiple relationships due to the fact that virtually all ethics codes forbid sexual relationships with patients. Therefore, she uses nonsexual multiple relationships, which are not universally forbidden, so that the unique differences between urban cities and small towns may be openly compared.

Characteristics of Rural Communities

By virtue of the definition of a rural community, the population is limited, meaning that it is much more likely that residents know each other and share common experiences more often than do members of larger communities.

The 2000 United States Census described “rural community” as an area with a population density of less than 500 people per square mile (United States Census Bureau, 2002). Although rural communities may be similar in terms of population density, they certainly are just as varied with regard to individuality as their larger counterparts.

Campbell and Gordon (2003) have delineated several distinctive characteristics that may be helpful in understanding why multiple relationships are more prevalent in rural practice than in urban practice:

• People are known in family, social, and historical contexts. In larger cities, people are often known by the work they do or where they live rather than by their family legacy in the community in which they live. In smaller communities, it is much more common to know a person as whose son, daughter, or grandchild they are. Rural mental health professionals often know details about their patients such as what type of car is driven, salary information, and the like, and may indeed worship at the same place as their patients (Campbell & Gordon, 2003).
• Rural residents want to know details about their neighbors and want to be known by others in the community. Gathering places such as coffee shops, barbershops, and grocery stores serve as settings for hearing the latest news in the community and sharing one’s own new experiences. Where anonymity is carefully prized in larger cities, rural areas are much less interested in this option; this makes the establishment of clear boundaries for the psychotherapist practicing in small towns extremely difficult (Campbell & Gordon, 2003; Coyle, 1999). The rural therapist must be careful not to ignore his or her patient outside of the office (Coyle, 1999).
• Diversity and change are minimized and controlled in rural communities. Through the control of change, stability and predictability are promoted. Therefore, new residents must accommodate to the local norms and the existing power structure. The therapist who enters this picture is a definite outsider. To be successful in a rural community, the new therapist must quickly learn to accommodate to the community norms in various areas of life.
• Relationships among rural residents are generally long-term. Relational bonds tend to be long-term, as residents are less likely to leave for occupational or educational purposes. Access to public transportation decreases as residents do not have a need to leave, are less mobile, and more likely to remain continuously in one area.
• Rural community members may collude in tolerating some behavior while denouncing other behavior. The therapist new to the rural way of life must be prepared to accept tolerance for various forms of discrimination and acceptance for various forms of abuse. For example, there may be intolerance for differences in sexual orientation, while there is acceptance of drunkenness and domestic violence (Mulder & Chang, 1997).
• Psychological problems are to be dealt with by members of the family, clergy, or the family medical doctor. Church plays a more core role in the lives of rural residents (Campbell & Gordon, 2003). The authors present this as the reason why family and clergy, rather than the professional psychological community, are the primary source of support in times of need. Family physicians are figures of authority, are trusted, and play a prominent role in most families.
• Non-community members are distrusted and viewed with suspicion. Outsiders are generally a potential threat to the way of life of a rural community. Residents may have been hurt in the past by outsiders who have brought about harmful changes on a financial or personal level. Once accepted, the community therapist becomes a trusted ally. The residents will only turn to an outsider if she is thought of as a “superstar” or perhaps an emergency resource (Campbell & Gordon, 2003).
• Multiple levels of relationship are expected and seen as “normal.” Since anonymity is not particularly valued, local residents expect to relate to others (including the therapist) at the filling station, the coffee shop, the drug store, the place of worship, and children’s events. The therapist must become involved in these activities in order to become accepted.

Clearly, multiple relationships are inevitable and expected; in fact, in rural communities, they are encouraged.

Characteristics of Rural Psychotherapists

Federal programs have been set up to financially encourage therapists and other mental health practitioners to locate their psychotherapy practices in rural areas (Campbell & Gordon, 2003). However, Campbell and Gordon (2003), in their literature review, were unable to find data on the success of any of these programs in getting clinicians to continue living and practicing in rural communities after the financial incentive ended.

The authors did find several characteristics in their own observations (not yet substantiated by empirical research) that could “serve as hypotheses for research on successful rural “mental health practitioners”. (p. 432):

• Rural therapists are comfortable with the rural lifestyle and probably grew up in a similar area or environment. Clearly, it is much easier to integrate into a community when one knows the norms, standards, and expectations. Therapists, just like any other people who make a change in lifestyle, must be comfortable with the new lifestyle and willing to make several changes. For psychotherapists, one of the changes is the most difficult of all—having multiple relationships that are not unethical, not exploitative, and do not harm clients in any way. In large cities, therapists are not confronted with this decision-making process on a daily, perhaps hourly, basis. In the rural lifestyle, one must be comfortable with the loss of anonymity and privacy.
• Rural therapists take active steps to integrate directly into the community. Since suspicion is one of the problems in a rural community with which the therapist must deal, the sooner he enters the community activities the better. Rural therapists must learn to be active and visible members of service groups, places of worship, and other community organizations and agencies that facilitate their active commitment to the community. In sum, the rural therapist must not only be willing to do these things, but must be comfortable doing these things.
• Rural therapists have broad and general practices and are not specialists. In most large cities, there is a specialist on every corner for every DSM-IV-TR diagnosis. Not so in rural communities. Because of the shortage of therapists in rural settings, those who do choose to set up practice in smaller cities work with a broad range of diagnoses and ages, and must provide a large array of assessments and services.
• Rural therapists are comfortable with a relatively high profile in the community. Psychotherapists, once accepted, tend to be placed along side physicians and clergy in that their opinions and insights are sought as local experts (Campbell & Gordon, 2003).
• Rural therapists have a higher tolerance for blurring of boundaries, both professional and personal. It is never completely comfortable for a psychotherapist to accept multiple relationships due to the strict prohibition against them, and the trained inclination to avoid such relationships in general. However, the rural therapist comes to expect such a relationship to occur in some context outside of the office.

Teaching Self-Sufficiency for Rural Practice

Most clinical programs fail to address the challenges unique to rural therapists on the job (Kersting, 2003). Programs that want to respond to rural needs must pay greater attention to the idiosyncrasies of working with a rural population, according to an interview with rural psychologist Garret Evans, Psy.D. (Kersting, 2003, p. 1). Beth Hudnall Stamm, Ph.D., a self-described “rural girl,” is Deputy Director at the Institute for Rural Health at Idaho State University where students have a chance to participate in rural research, educational outreach, policy creation, and clinical activities. Dr. Stamm says, “We give [students] the extra training they need to foster a smooth transition into a rural professional life.” (Kersting, 2003, p. 2)

Recruiting promising undergraduates, and in some instances, high school students from rural areas and encouraging them to consider psychology is taking place more in order to bring the rural cultural perspective into the profession. Dr. Stamm tells Kersting, “Even the five years or so someone spends training at an urban university can change them and make it hard for the community to accept their care. So it’s helpful if we can keep them in [rural] communities part of the year through summer placements and practica.” (Kersting, 2003, p. 3)

Dr. Stamm notes a traineeship in rural psychology is not enough to assure that one is prepared for the rigors of a rural practice. One must be fluent in health policy issues and be able to perform outcome evaluations for government grants as well.

Finances

In addition to finding grant money to fund services in clinical settings, rural therapists also need to know how to be their own money managers and be able to run a business without benefit of a group practice. Most rural therapists also supplement their income with contracts from schools and other agencies such as prison systems.

The Scope of the Difficulty with Rural Communities

Multiple relationships have been thought of as the primary unethical behavior one can engage in as a psychotherapist and something to be avoided at all costs. However, multiple relationships are truly a reality in those who practice in a rural environment (Younggren, 2002).

There are three primary difficulties inherent with multiple relationships in rural communities that have been recognized by numerous authors (Cohen & Cohen, 1999; Corey, Corey, & Callanan, 1988; Herlihy & Corey, 1997; Welfel, 2002). No matter how appealing the situation is to the professional, the responsibility for the final decision lies with the therapist. Additionally, the clinician is obligated to use a formal decision-making procedure including consultation and documentation. The therapist, by