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This is a beginning to intermediate level course. Upon completion of this course, mental health professionals will be able to:
Authors’ Note: Almost all case scenarios presented in this course are adapted from actual incidents. We use improbable names throughout to enhance interest and ensure that identities of all parties are not discernible. It is not our intention to trivialize the seriousness of the issues. As part of our disguising process, we also randomly assign various professional designations and earned degrees or licensure status. Also, for ease of presentation, we use the term "therapist" throughout to refer to anyone delivering psychotherapy or counseling services to clients.
The materials in this course are based on current published ethical standards and the most accurate information available to the authors at the time of writing. Many ethical challenges arise on the basis of highly variable and unpredictable contextual factors. This course material will equip clinicians with a basic understanding of core ethical principles and standards related to the topics discussed and ethical decision-making generally, but cannot cover every possible circumstance. When in doubt, we advise consultation with knowledgeable colleagues and/or professional association ethics committees.
If you were to have an ethics complaint pressed against you, we can make an educated guess as to the basis of the charge: an alleged boundary violation. Ethics charges based on inappropriate role-blurring account for the majority of ethics complaints and licensing board actions (Bader, 1994; Koocher & Keith-Spiegel, 2016; Montgomery & Cupit, 1999; Neukrug, Milliken, & Walden, 2001; Sonne, 1994). Often, no one could have seen it coming. Boundary issues can arise in ways that therapists may not initially predict or even recognize. But, in too many cases therapists behaved in ways that seem completely out of touch with the impact their decisions and actions had on those with whom they had a professional relationship. Legal suits and the cost of defending licensing board complaints cause professional liability insurance rates to rise, thus harming all therapists. Sadly, the stigma and the stress endured by the therapist if found guilty can be debilitating (Warren and Douglas, 2012).
Among the most significant changes in the ethics codes of professional organizations are those related to the drawing of boundaries between therapists and their clients. Over the last couple of decades we have witnessed a relaxation of rigid restrictions. The reasoning for this has included the recognition that boundary crossing cannot be totally avoided, some belonging under certain circumstances may even be helpful to the client (or at least cause them no harm), and sometimes boundary crossings are mandated (Barnett, 2017a).On the surface, the loosening of restrictions also feels more protective of therapists, allowing for leeway as to how therapists and their clients interact. At the same time, however, additional burdens are placed on therapists because the rules are no longer firm. Decision-making can be trickier and more challenging, because one is at the mercy of one’s own judgment and potentially unacknowledged biases. What the therapist may deem as an acceptable, even helpful, boundary crossing may be experienced as inappropriate or harmful by the client, as will be discussed further. Our main goal for this course is to make a strong case for vigilance and ongoing self-awareness when making decisions about boundary crossing with clients.
Consider these scenarios:
With the exception of boundary violations that clearly violate any standard of care, ethics codes cannot possibly give specific guidance when it comes to mandating appropriate ways to socially interact with counseling and psychotherapy clients across all possible situations. Many boundary crossings can involve no ethical transgressions and even prove beneficial to the client. However, as we will illustrate, remaining vigilant regarding our own needs and vulnerabilities as well as those of our clients is fundamental to ethical practice. Whenever personal needs take precedence, rationalization can inhibit sound professional judgment that too easily leads to unanticipated consequences for clients and even the precipitous destruction of therapists’ own careers.
As for our examples, not everything turned out well in the actual cases upon which they are based. The distraught mother scenario illustrates a double boundary crossing. To offer the client extra time seems a kind gesture but runs counter to the therapeutic agreement. In the future, this actual client felt entitled to extra time and resented not getting it. In the meantime, clients-in-waiting have an agreed upon appointment obligation altered. One can feel sympathy for the distraught mother, but the matter does not qualify as an emergency. In fact, the mother might more appropriately focus on other actions (e.g., locating a lawyer). Yet at other times, offering extra time would be prudent, such as in a true emergency situation.
The client who was asked for a favor turned into a bit of a fiasco. The client asked if they could stop on the way home and have dinner together. The therapist refused politely, noting he had to get home to his family. But now the client, who later became a stalker, knew where he lived. This was a fairly new client with some issues that should have signaled caution on the part of the therapist. His myopic focus on his own convenience ended up costing him dearly.
Regarding the client struggling with her winter coat, what seems like an obvious helpful gesture requires brief reflection. This seemingly helpful act involves physical contact, and not all clients will feel comfortable with that. Some may even feel it as intrusiveness. Asking before acting is essential.
The client who brought coffee and sweets to the 10 a.m. therapy session perceived the sessions to reveal a budding friendship. She began to focus less on her own issues and more on that therapist as someone with whom she could have a relationship with outside of the office. The therapist finally picked up on what was going on and attempted, unsuccessfully, to pull the relationship back to the business of therapy. The client experienced the request to cease bringing coffee and sweets as both an insult and a rejection. She never returned to therapy. Although this case did not result in an ethics complaint, the therapist felt guilty over failing to better perceive how meeting his own needs for what seemed like an innocent pleasure caused pain for a client he liked.
The economically strapped landscaper provides a more complicated case, and we will have more to say about bartering later. However, in such cases, taking someone up on what seems like a good match can turn into an ordeal. In an actual similar case, the therapist credited only a fraction of the therapy cost, requiring the landscaper to work almost 14 hours to “pay” for one weekly therapy session. Ultimately, the client successfully sued the therapist for exploitation.
The self-disclosing therapist felt concern when the client began to cancel sessions and soon quit coming altogether, perhaps because the “pulling back” felt like rejection. Self-disclosure can be appropriate, but it should always be done based on clinical indicators and client welfare, as we shall discuss further, rather than on the therapist’s desire to entertain or to promote oneself.
In the actual case involving the sale of an automobile to a client, the therapist’s car failed to live up to the client’s expectations, and he demanded the return of some of the sale price to pay for repairs. Unfortunately, the therapist became defensive and told the client that the client must have caused the damage. The therapeutic alliance evaporated, and the client successfully sued the therapist in small claims court.
Finally, certifying the need for an emotional support animal, as opposed to a trained service animal (e.g., Seeing Eye Dog) has become a matter of growing ethical concern. Rigorous criteria for such certifications do not exist, yet opportunities to “get pets certified” as necessary support companions abound on the internet. Many psychotherapists may feel compelled to support their clients’ wishes without recognizing all of the legal implications (e.g., determining that one’s client has a mental disability requiring use of a support animal under Americans with Disabilities law). (See: Younggren, Boisvert & Boness, 2016.)
Boundaries between therapist and client come in many forms – from crisp to fuzzy – and exist in various influential contexts (Gutheil & Gabbard, 1993; Zur, 2017). Crossing them has many potential effects. As Pope and Keith-Spiegel (2008) note, “Nonsexual boundary crossings can enrich psychotherapy, serve the treatment plan, and strengthen the therapist-client working relationship. They can also undermine the therapy, disrupt the therapist-patient alliance, and cause harm to clients” (p. 638).
The work of mental health professionals is conducive to permeable role boundaries because so much of it occurs in the context of establishing emotionally meaningful relationships, very often regarding intimate matters that the client has not spoken of to anyone else. Yet, mental health professionals continue to hold differing perceptions of role mingling. These perceptions range from conscious efforts to sustain objectivity by actively avoiding any interaction or discourse outside of therapeutic issues to loose policies whereby the distinction between therapist and best buddy almost evaporates. However, even those who would stretch roles into other domains would condemn conspicuous exploitation of clients.
Some mental health professionals decry the concept of professional boundaries, asserting that they promote psychotherapy as a mechanical technique rather than relating to clients as unique human beings. Such rigid, cold, and seemingly aloof “cookbook” or “manualized” psychotherapy, the critics of strict boundaries say, inhibits the formation of empathy and the natural process of psychotherapy. Instead, acting as a fully human therapist provides the most constructive way to enhance personal connectedness and honesty in therapeutic relationships (Hedges, 1993) and may actually improve professional judgment (Tomm, 1993). Critics even contend that boundary violations have been improperly inserted into ethics codes, training programs, and licensing and malpractice litigation (Lazarus & Zur, 2002).
Those critical of setting firm professional boundaries further assert that role overlaps become inevitable and that attempting to control them by invoking authority (e.g., ethics codes) oversimplifies the complexities inherent in the psychotherapy process and creates the practice of defensive therapy (Bogrand, 1993; Clarkson, 1994; Ryder & Hepworth, 1990). The answer, they say, involves educating both clients and therapists about unavoidable breaks and disruptions in boundaries and to ensure that therapists understand that exploitation is always unethical, regardless of boundary issues.
As the scenarios at the onset of this course reveal, however, exploitation is not the only harmful result of boundary crossings. We believe that the therapist retains ultimate responsibility for keeping the process focused. As Gabbard (1994) concludes, “Because the needs of the psychotherapist often get in the way of the therapy, the mental health professionals have established guidelines … that are designed to minimize the opportunity for therapists to use their patients for their own gratification” (p. 283).We see no reason why maintaining professional boundaries needs to diminish a therapist's warmth, empathy, and compassion. The correct task is to match therapy style and technique to a given client's needs (Bennett et al., 1994). This requires a clear vision, unencumbered by the therapist’s personal agendas and problems. Stress, for example, can spiral downward to distress, then impairment, and finally improper behavior (APA Board of Professional Affairs Advisory Committee on Colleague Assistance, n.d.). Furthermore, we believe that lax professional boundaries can act as a precursor to exploitation, confusion, and loss of professional objectivity.
We do understand that one cannot possibly avoid all nonprofessional interactions with one’s clients. However, we also agree with Pope's (1991) contention that, “the professional therapeutic relationship is secured within a reliable set of boundaries on which both therapist and patient can depend” (p. 23). Conflicts, which are more likely to arise when boundaries blur, compromise the disinterest (as opposed to lack of interest) prerequisite for sound professional judgment. As Borys (1994) contended, clear and consistent boundaries provide a structured arena, and this may constitute a curative factor in itself. In short, the therapy relationship should remain a safe sanctuary (Barnett, 2017) that allows clients to focus on themselves and their needs while receiving clear, clean feedback and guidance. Frank discussions about boundaries with clients during the initial informed consent phase is also recommended. Cultural traditions, geography (e.g. small rural v. large urban setting), age, and client personality and vulnerabilities are among the factors that can guide such discussions.
The ethics code of the American Psychological Association (APA, 2010) offers a clear definition of multiple role relationships. Multiple role relationships occur when a therapist already has a professional role with a person and:
To qualify for the definition of multiple role relationship then, the initial relationship typically requires an established connectedness between the parties. The primary role relationship is usually with an ongoing therapy, counseling client, student, or supervisee. Limited or inconsequential contacts that grow out of chance encounters would not normally fall under the definition or cause for any ethical concerns.Multiple role relationships may occur via action, as when a therapist hires a client as a housekeeper. Or they can take the form of a proposal for the future while therapy remains ongoing, as when a therapist and a client plan to go into business together or agree to start a sexual relationship upon termination of therapy, thus altering the dynamics of the ongoing professional relationship. Zur (2017) has categorized multiple role relationships by types. These include social/communal, professional, business, instructional, forensic, sexual, and digital. These categories are illustrated in the cases offered here.
Nonsexual consecutive role relationships with ex-clients do not fall under any specific prohibitions in the APA code (APA, 2010). However, based on post-therapy incidents described in this course, we advise caution even after a natural termination of the professional relationship. We have good evidence that certain types of complex therapist-client interactions can later prove harmful (Bennett, Bricklin, & VandeCreek, 1994, Smith & Fitzpatrick, 1995) and that duty to clients does not necessarily end with therapy termination.
Ethics codes of all major mental health associations mandate that therapists refrain from entering a multiple relationship if objectivity, competence, or effectiveness in performing professional functions could become impaired, or if exploitation is a risk. However, not all multiple role relationships with clients are necessarily unethical so long as no exploitation or risk of harm to the client or the professional relationship can be reasonably expected.
We agree that careful consideration should occur prior to softening the boundaries of any professional role, and we also remain unconvinced that accurate outcome predictions involve a simple exercise in judgment. If that were so, therapists would have the lowest divorce rate of any professional group! Alas, no evidence of such foresight exists. Indeed, the life of a psychotherapist carries its own risks for burnout and stress that negatively affect their relationships with others (Epstein & Bower, 2005).
We also contend that justification for entering into some types of multiple role relationships with persons in active treatment does not exist. Sexual and business relationships, for example, pose inherent risks regardless of who is involved. Neither can be defended as reasonable dimensions to impose on a therapy relationship.
Finally, we will comment on how easy it is to rationalize, to convince ourselves that an action is justifiable in a particular situation. All therapists are vulnerable to self-delusion when their own needs get in the way, even those who are competent and have been scrupulously ethical in the past (e.g., Keith-Spiegel, 2014, Koocher & Keith-Spiegel, 2016; Lowell, 2012, Merritt, Effron, & Monin, 2010; Monin & Miller, 2011, Tenbrunsel & Messick, 2004).
Kitchener (1988) suggests assessing the appropriateness of boundaries by using three guidelines to predict the amount of damage that role blending might create. Role conflict occurs, says Kitchener, when expectations in one role involve actions or behavior incompatible with another role. First, as the expectations of professionals and those they serve become more incompatible, the potential for harm increases. Second, as obligations associated with the roles become increasingly divergent, the risks of loss of objectivity and divided loyalties rise. Third, to the extent that the power and prestige of the psychotherapist exceeds that of the client, the potential for exploitation is heightened.
Gottlieb's oft-cited (1993) model for avoiding exploitative multiple relations tracks the level of the therapist’s power (from interventions where little or no personal relationship was established with a client to clear power differential with profound influence) with the duration (or expected duration) of the professional relationship and the clarity of termination (defined as the level of mutual satisfaction with the conclusion of therapy and the likelihood that the client will have further professional contact). Thus, if after two years of intense therapy and a tenuous termination whereby the client may need to return at any time, no additional roles should be contemplated. However, after a Saturday afternoon “self-empowerment workshop” that resulted in a mutually agreeable one-time experience, the risk, if the therapist enters into another role with an attendee, seems minimal. The success (or failure) of this new role relationship would be more about what the parties do as consenting adults as opposed to the brief professional experience.
Brown (1994) adds two additional factors that, if present, heighten the risks of harm. First, “objectification” can occur, with the therapist using the client as an “it” for the purpose of providing entertainment or convenience. Second, boundary violations usually arise from impulse rather than from carefully reasoned consideration of any therapeutic indications. Thus, hugging a client is not unethical per se, but an assessment of any potential hazards or misunderstandings should precede such an act.
All therapists face some risk for inappropriate role blending (Keith-Spiegel, 2014). Those with underdeveloped competencies or poor training may prove more prone to improperly blending roles with clients. However, even those with excellent training and high levels of competence may relate unacceptably with those with whom they work because their own boundaries fail. Some may feel a need for adoration, power, or social connection. We must face the unfortunate reality that psychotherapy and counseling services provide an almost ideal climate – a “perfect storm” if you will – for emotionally or morally precarious mental health professionals to gratify their personal needs. The settings are private and intimate. The authority falls on the side of the therapist. Moreover, if things turn sour, the therapist can simply eliminate the relationship by unilaterally terminating the client and can deny that anything untoward occurred should a complaint be initiated by a client.
Most psychotherapists have engaged in some measure of self-disclosure with their clients (Pope, Tabachnick, & Keith-Spiegel, 1987; Yeh & Hayes, 2011), and many studies have examined the role played by self-disclosure in the process of therapy (e.g., Barnett, 2011; Davis, 2002; Farber, Berano, & Capobianco, 2004; Kim, Hill, Gelso, et al., 2003; Miller & McNaught, 2016; and Peterson, 2002). Indeed, when a client walks through the door, immediate clues become apparent: therapist’s approximate age, dress style, decor preferences, certificates on the wall, photographs on the desk, perhaps a wedding ring. Today’s clients probably searched Google to learn more about who they will be meeting.
Multiple authors have discussed the advantages of self-disclosure. Done thoughtfully and judiciously, revealing pertinent information about oneself can facilitate empathy, build trust, and strengthen the therapeutic alliance (e.g., Kronner & Northcut, 2015; Levitt, Minami, Greenspan, Puckett, et al., 2016; McBeath, 2015; Miller & McNaught, 2016).
However, those who engage in considerable and revealing self-disclosure with clients stand at greater risk for forming problematic relationships with them. Whereas well-considered illustrations from the therapist’s life may help make a point or signal empathy, the decision to use personal data as an intervention comes down to a matter of professional judgment.
Mildred Yappy, Ph.D., thought that disclosing her own experiences with weathering extra-marital affairs would be helpful to her distraught client who recently discovered that her husband was in a sexual relationship with a co-worker. Instead, this client began to feel that the therapy environment was polluted rather than safe and clean. She quit therapy feeling even more adrift.
It is difficult to know in advance how a given client will respond to a self-disclosure, particularly when the subject is in sensitive territory for the client. Dr. Yappy’s disclosures may have solidified a trusting bond with a client who found shared misery comforting, but client reactions are difficult to predict even when therapists pause to ask themselves, “What is the purpose of what I am about to share with my client?”
Contextual issues are also important; these include the therapist’s theoretical orientation and treatment approaches as well as client factors such as culture, gender, mental health history, current treatment needs, and agreed-on goals. However, even though becoming too relaxed when sharing one’s own personal life (or ignoring unexpected client reactions to disclosures) may not result in a formal ethics charge, effective psychotherapy can be compromised (Barnett, 2011).
Of course, clients may instigate inquiries about their therapists’ personal lives. It seems reasonable to expect that some clients would want to know as much as possible about the person in whom they are placing so much trust. Therefore, we agree with Lazarus's (1994) contention that it feels demeaning to have a question dismissed and then answered by another question; “Do you have children, Dr. Stone?” “Why do you ask me that, Stanley?” Not all clients’ questions should be answered, of course, and the wise therapist will explore the intent of a client who seems too inquisitive. A skillful therapist can respond without demeaning the client in the process.
At the same time Internet searches make considerable information on anyone readily available. Like any other individual who prefers some modicum of privacy, psychotherapists must understand that information posted on personal and social sites will become known to curious clients and may lead to inquiries or promote some other types of boundary blurring. (See Kolmes, 2017; Reamer, 2017.)
Professional or personal isolation can cloud therapists’ judgments. The next case involves an indignant response to a fading career, compounded by an absence of close ties with family or friends. Dr. Grandiose might elicit some sympathy were it not for her ill-conceived approach to dealing with her own issues.
A well-known and outspoken therapist, Panacea Grandiose, Ph.D., alienated the professional community over the last several years with her personal attacks on colleagues who criticized her and her theoretical foundation as outmoded. However, Grandiose continued to maintain a successful practice, and her clients became the focus of her life. She hosted frequent social events in her home and invited herself along on clients' vacations. Colleagues in the community became concerned that Grandiose had developed a cult of sorts, made up of high-paying, perennial clients who also provided her with adoration, loyalty, and “family.”
We have noted that many cases involving boundary blurring (including sexual ones) occur among therapists who maintain solo practices, often in isolated offices away from other mental health professionals. It seems that something about therapists either choosing to work in isolation, or the isolating conditions themselves, foster the potential clouding of professional standards of care. Or perhaps some therapists have experienced rejection by their colleagues, as with Dr. Grandiose, and turn to inappropriate substitutes for support and validation. Regardless of the reason, an insular practice with no provisions for ongoing professional contact diffuses professional identity, thus putting appropriate decision-making at risk.
Some therapists practicing within certain therapeutic orientations are probably more vulnerable to charges of boundary violations. For example, Williams (1998) notes that humanistic therapy and encounter group philosophies depend heavily on tearing down interpersonal boundaries. Such therapists often disclose a great deal about themselves, hug their clients, and insist on the use of first names. These therapists also become, according to Williams, vulnerable to ethics charges even though their practice is consistent with their training.
Some therapists who specialize in working with a particular population or in certain settings may need to exercise extra vigilance because the nature of the services or service settings are conducive to (or even require) relaxed boundaries. Sports psychologists, for example, often travel, eat, and “hang out” with a team, and may find themselves called upon to fill water bottles and help out with whatever else needs doing (Anderson, Van Raalte, & Brewer, 2001; Zur, 2017). An even more complex relationship exists for mental health professionals embedded in military units in close quarters with an obligation, unlike embedded journalists, to tend to the unit’s needs and even engage in combat (Johnson, Ralph, & Johnson, 2005). In such instances, very fuzzy edges may constitute an inherent element of practice rather than qualifying as inappropriate.
Pastoral counseling, wherein the therapist may also function as the client’s religious guide, presents a sensitive pre-existing dual role.
Mildred Devine requested counseling for what she called a “spiritual crisis” from her minister, Luther Pew, who also held a license in marriage and family counseling. Ms. Devine experienced deep sadness, hopelessness, and questioned her faith. At that time, Pew was dealing with his own troubles and struggling to manage his large congregation. When Ms. Devine relayed her feelings, blaming God for having forsaken her, Rev. Pew responded by pouring out details of his own family problems, including the particulars of a drinking problem in his youth. Pew hoped this intense session would prove helpful, figuring that Devine would gain confidence from knowing that even he had to face and overcome hardships. Devine, however, became upset by these revelations, passed them along to other parishioners, and left the church.
Rev. Pew appears to have seriously mismanaged his parishioner’s clinical depression by failing to recognize its intensity and his own lack of competence to treat it. He also interjected too much of his own life while failing to recognize that Ms. Devine asked Pew for spiritual guidance only. Pew should have focused on his role as a pastor and simultaneously referred Ms. Devine to someone competent to treat her depression.
However, therapists who belong to a religious community as parishioners can also easily experience challenging multiple roles. As Sanders (2017) points out, parishioners have common values and gather together to share each other’s burdens. A therapist/parishioner should, therefore, maintain some discretion when treating another parishioner.
Funnel Mask sought the professional assistance of Shudi Tell, M.A., a counselor in the same large parish. Mask needed to talk to someone because, as the church treasurer, he was embezzling small amounts of money every week. He was in debt due to family illnesses, and seemed to want Mr. Tell’s acceptance of his actions, given his needs to care for his family, as opposed to dealing with guilt or seeking a way to return the funds. Mr. Tell attempted to convince Mask to create some plan to make things right, but Mask expressed disappointment and left the room.
Mr. Tell is in a bind. Mask’s behavior, though illegal, does not meet a legally mandated disclosure requirement or a “duty to warn” to prevent harm. Even if he told someone, Mask had hidden his tracks well and could deny it. Mr. Tell’s ethical obligations require that he maintain his obligation of confidentiality to Mr. Mask.
Finally, as job prospects become tighter, therapists have invented new marketplace niches for themselves. “Personal coaching,” “psychologically-based” home organization services, "authentic happiness" workshops, and “pet therapy” are but a few examples. Indeed, “psychotherapy branding” has risen to a consulting career of its own, helping therapists zone in on a niche, such as specializing in video game addicted adolescents, military wives, or repeat DUI offenders (Gottlieb, 2012).
Training standards for many offshoots of psychotherapy are virtually nonexistent, expectations on the part of clients run high, and boundaries seem more likely to become confusing for both clients and therapists. Proceed with caution.
Labrador Fido, MFCT, decided to advertise his services as a “canine counselor” focusing on treating families who have difficulties managing their dogs. When a German shepherd puppy became even more aggressive toward the family’s younger children after several sessions with Mr. Fido, the parents complained, charging him with incompetence. Fido defended himself by saying that he was a licensed professional who loved dogs and that the family interfered with his relationship with the animal in ways that derailed the therapy. This defense was not persuasive to an ethics committee.
No matter how long you have practiced as a mental health professional, specific risks link to each career development period. We will briefly describe those that can be associated with early, mid-level, and later career stages.
Therapists who engage in inappropriate role blending often come from the ranks of the relatively inexperienced. Many have come from graduate programs where students developed complex relationships with their educators and supervisors. Similarly, the internship or residency period often involves role blending, including social, evaluative, and business-related activities (Slimp & Burian, 1994). Not all supervisors are themselves good role models (Landany, Mori, & Mehr, 2013). It may be that many therapists new to functioning independently have had an insufficient opportunity to observe professionals who have put appropriate boundaries in place.
Kat Kopy, LCSW, enjoyed her last supervisor because he was funny and flirty and took her out for drinks after every session. She decided that her clients would benefit from the same kind of relationship. Her client, Roger Rage, misunderstood her affable demeanor and their after-session coffee house excursions, and assumed that she was attracted to him. When she recoiled as Roger attempted a kiss on her lips, he felt humiliated and angry. He slapped her face hard, breaking her glasses.
The mid-career period can pose risks for those therapists whose professional or personal life has not panned out according to the dreams of their youth. Divorce or other family-based stresses involving teenage or young adult children, onset of a chronic illness, and apprehension about aging as well as other mid-career difficulties can impair professional judgment. Research findings reveal that the majority of therapists who engage in sexual relationships with their clients do so while middle-aged. The next cases illustrate what can go wrong.
Des Pondent, Ph.D., age 46, felt like a failure compared to his wife’s successful and still-rising career. When a young woman whose self-esteem needed boosting showered praise on him, he anticipated her sessions above all others. Therapy was often followed by coffee and soon more extensive outings together and eventually ended up in a motel where the proprietor did not expect guests to bring luggage or stay for more than a couple of hours. Dr. Pondent thought it best to terminate therapy as the relationship became more intimate, thinking that would shield him from future criticism. Unfortunately for him, the now ex-client became more insistent that they see each other even more often and in nicer places. Dr. Pondent, who had no intention to leave his family, tried to call off the affair. The ex-client was furious, felt abandoned and rejected, and contacted an ethics committee. Her evidence against him consisted of emails, text messages and compromising photographs she had surreptitiously taken with her smart phone. (Story adapted from Keith-Spiegel, 2014.)
Justin Singleman, Ph.D., was in a tight financial squeeze, what with child support for his two young children and college tuition assistance for the two older ones. He told his life story to one of his longer-term clients who tried to console Dr. Singleman by offering him a free apartment to get through a transition period. However, after a few months the client suggested that Dr. Singleman should move on to his own place. Dr. Singleman became upset and terminated the client. He also refused to move, forcing the client to go through an ugly eviction process.
Dr. Pondent’s expectation that an abrupt termination for the purpose of continuing a sexual relationship would protect him from ethical scrutiny was a serious error. He was ultimately expelled from his professional association and lost his license to practice. Dr. Singleman appears to have become himself emotionally impaired, and his own client was ultimately forced to bear the brunt of it.
Another elevated risk period can occur at the far end of the career cycle. Sometimes older therapists have, perhaps without full awareness, come to see themselves as “evolved” beyond questioning or as having earned some sort of “senior pass” bequeathing the freedom to do things their own way. Pepper (1990) discusses the psychodynamics of charismatic, grandiose, authoritarian senior therapists who may harm clients by encouraging complicated multiple relationships. We know of ethics cases involving therapists who have practiced for 40 or more years who illustrate this phenomenon. Here is just one:
Alan Groupie, Ph.D., age 73, went into business with a famous movie star who suffered from severe depression. Groupie eventually became his manager and moved in with the celebrity. He personally monitored all of the celebrity’s activities, charging his usual fee of $150 per hour, 24 hours a day, 7 days a week. This arrangement lasted for more than a year until the celebrity’s attorney stepped in and filed extortion charges against Groupie.
Not every client can cope with unintended effects of boundary crossings. Trust issues often lie at the heart of the matter. Clients seen at social service and other out-patient community agencies may become disenfranchised due to deficits in cognition, judgment, self-care, and self-protection, as well as holding little social status and power. Such clients are at greater risk for exploitation (Walker & Clark, 1999).
Clients who have experienced victimization through violent attacks or abuse due to difficulties with trust or ambivalence surrounding their caretakers also benefit from clear boundary setting, despite their frequent testing of such boundaries (Borys, 1994). Clients with self-esteem or individuation problems often depend on the constant approval of others for confirmation. Therapists who weaken boundaries by reassuring such clients that they are “special” by taking them to lunch, giving them gifts, or disclosing excessive detail from their own lives may unwittingly collude with this pattern, thereby reinforcing the pathology (Borys, 1994).
Clients who have suffered early deprivations and have not fully mourned the finality of the past may still seek to meet their residual needs by earning favor with those who were physically or emotionally unavailable. Developing a therapeutic relationship often mobilizes high hopes that the therapist will substitute for or replenish losses of the past. If the therapist responds as a rescuer, a totally inappropriate cycle becomes established, and the client will again experience the loss because a therapist never can (and never intended to) replace a parent or past relationship (Borys, 1994). In this context, we gain considerable insight into the psychodynamics behind the many charges of “abandonment” brought by clients involved in multiple role relationships with their therapists.
The technique of positive limit setting should be mastered by all psychotherapists. It involves placing restrictions when responding to the client's request while, at the same time, reframing the response in a way that meets a legitimate underlying need. Essentially this requires therapists to ask themselves how their potential comments or interventions will likely benefit their clients. Below is an example of positive limit setting.
An emotionally needy child, who had witnessed domestic violence, asked his therapist where he lived. When the therapist asked why the child wanted to know he replied, “Maybe if my parents start fighting again, I could come to your house.” The therapist replied, “I want you to be safe, but I’m not always home and I would not want you to get lost.” The therapist suggested that the if violence erupted at home the child might go to the local fire station (a block from his home) and ask the people on duty to help him, noting that there is always someone there.
Here the therapist addressed the client’s need with a problem-focused solution and rationale that did not leave the child feeling patronized or without support.
We designed a table to help decide whether a professional should even contemplate blending roles. We have adapted from Anderson and Kitchener (1998), Brown (1994), Gottleib (1993), Kitchener, (1988), Younggren & Gottleib (2004), and added our own observations and research. Of course, each situation that arises has its own idiosyncrasies that must be reflected upon before acting. Furthermore, most risks can be contemplated along a continuum as opposed to the dichotomous scheme we present here. However, if an honest reflection results in any feature of a possible new role tending toward the “more risky” column, we advise considerable caution.
Considerations Regarding Added Role Dimensions
Relevant therapeutic issues or socio-cultural factors (e.g. diagnosis, client’s religion and traditions, family situation and dynamics)
Unclear whether an added role would be wise
Clear indications favoring an added role
Therapist/client power differential
Therapist and client expectations
Therapist and client obligations in the contemplated relationship
Duration (or expected duration) of therapy
Termination (or expected termination)
Conflicted / no time specifiable
Prospects that client requires follow-up later
Extent to which therapist’s personal needs would be gratified more than those of the client
Very small; negligible
Impulsivity of the therapist
Degree of client pathology or abuse history
Firmness of client’s personal boundaries
Degree of client’s autonomy
Duration of therapist’s professional experience
At least one year of active, independent practice
Extent to which confidentiality can be indefinitely maintained
Therapist’s access to collegial interaction and support
Extent of client’s understanding of, and informed consent to, the contemplated added relationship
The worst-case outcome scenario of the contemplated relationship remains relatively benign
A consultation with a colleague about the contemplated relationship has taken or will take place before going forward
Our concern is that many people are adept at not seeing what they don’t want to recognize in themselves, especially if their own need-satisfaction is at issue, so they do not accurately predict what problems could arise. The next section lists cautionary signals in more concrete terms, making the decision less vulnerable to excuses.
Mental health professionals can be helpful, caring, empathic human beings who maintain professional parameters within which they effectively relate to their clients. We again acknowledge the impossibility of setting firm boundaries appropriate for every client under every circumstance. We remain concerned, however, that inappropriate crossings are often rationalized as benevolent or therapeutic (Keith-Spiegel, 2014; Koocher & Keith-Spiegel, 2016). Rationalizations can even include blaming the client for untoward consequences.
Here we offer another personal assessment in the form of some early warning signs of nonsexual boundary crossings that could cause confusion and disadvantage clients. These signals, some of which are adapted from Epstein and Simon (1990), Keith-Spiegel (2014), Pope and Keith-Spiegel (2008), and Walker and Clark (1999), include the following:
Perhaps the most difficult message for us to convey in writing is just how right it might feel at the time to slip into a more complex role with those receiving our services. Our brief case scenarios summarize situations that often unfold over weeks or months. As a result, we may have failed to convey sufficiently the perceptions and rationalizations that so often develop, often in baby steps. Perhaps the brightest red flags should pop up any time you say to yourself, “This person will be different,” or “This particular circumstance doesn't qualify as a role conflict.” Pause to then ask yourself, “How will doing this help the client?”
Miscalculations are easy to make when it comes to boundaries, especially if we are distracted, taken by surprise, or focusing too much on our own needs. Pope and Keith-Spiegel (2008) offer seven major errors that can occur:
If you begin to sense the professional role stretching into any area unrelated to the purpose of the professional relationship, pause immediately to evaluate the situation. Imagine the worst-case scenario in terms of outcome should the present course continue – often what seems like minor risk can end badly – and seek consultation with a peer. This makes good sense considering that we can seldom fully predict harmful outcomes in advance.
Some invitations to blend roles can prove so tempting that they blind the practitioner to pre-existing obligations or cause damaging rationalizations.
Phil T. Assessor, Ph.D., earned $1,500 in insurance reimbursement for conducting a neuropsychological evaluation of Vic Tem, who had been injured in an automobile accident, at the request of Mr. Tem’s neurologist. One of Dr. Assessors conclusions suggested that Mr. Tem might have overstated the level of symptoms he was reporting. Five years later, a lawsuit involving the driver of the automobile that struck Mr. Tem progressed to trial. The driver’s attorney retained Dr. Assessor at a fee of more than $10,000 to rebut Mr. Tem’s claim of damages. When challenged on his ethics, Dr. Assessor replied, “I only saw Mr. Tem on one occasion five years ago, and he was no longer my client.”
In this instance Dr. Assessor blended the role of psychological evaluator with that of subsequent adverse expert witness. Although Dr. Assessor’s services to Mr. Tem had ended five years earlier, Dr. Assessor still owed Mr. Tem a duty of care and protection from harm. Despite the high compensation opportunity, Dr. Assessor should have understood that blending in a role adverse to his client could not be rationalized away.
Finally, Pope and Keith-Spiegel (2008) suggest that when you do decide that a planned boundary crossing would assist the client, engage in an informed consent process (e.g., before taking a phobic client for a walk in the local mall to window shop). Then keep detailed notes on any planned boundary crossing that describe why this did or will help the client. Always confer with trusted colleagues if you have any doubts about your decision.
The APA ethics code long discouraged exchanging anything other than money for therapeutic services. However, APA has nearly reversed itself in recent years. The 1992 APA ethics code allowed for bartering, but also included a strongly worded caution against such arrangements, citing the potential for taking advantage of clients and distortion of the professional relationship. The current codes of the American Psychological Association, American Counseling Association, and Association of Marriage and Family Therapy leave only the admonition that professional judgment be used regarding clinical contraindications and that no potential for exploitation or taking advantage of clients exists before entering into barter agreements with clients. The National Association of Social Workers allows bartering without exploitation or coercion, and also specifies that it be done only in limited circumstances, warning that the social worker would have the full burden of proving that the arrangement was not detrimental to the client or the professional relationship.
Why has bartering for mental health and counseling services transformed from a forbidden practice to a nearly incidental ethical matter? In more recent times, insurance coverage for mental health services has since decreased and the general economic downturn has impacted negatively on almost everyone in some way.
On the surface, allowing bartering in hard economic times may seem like a win-win situation for clients who want therapy and therapists who want clients, many of whom may have skills or objects to trade. Lawrence (2002) even asserts that those who cannot pay for therapy should be able to barter and that therapists unwilling to take any attendant risks are not worthy of the job! We acknowledge that entering into bartering agreements with clients appears reasonable and even a humanitarian practice toward those who require mental health services but are uninsured and strapped for cash. We also acknowledge that many bartering arrangements proved satisfactory to both parties.
A gifted seamstress agreed to make clothes in exchange for counseling. The client was satisfied with the agreement because she needed counseling and had plenty of time available to sew. The therapist's elation was summarized by her giddy remark at a cocktail party, “I am most assuredly the best-dressed shrink in town.”
This case illustrates the potential darker side of barter arrangements. Because the therapist openly acknowledged, with delight, her dual relationship at a social gathering, she apparently never considered any risk of exploitation. What will happen when an outfit does not fit properly or does not meet the therapist's expectations? What if the client becomes displeased with the therapy or becomes too busy in her own life and she begins to feel like a one-woman sweatshop? What if the therapist remains so satisfied with the relationship that she creates within the client an unnecessary dependency to match her own? These “what ifs” are not idle speculation when one considers incidents of bartering that have already gone awry.
Kurt Court, Esq. and Leonard Dump, Ph.D., met at a mutual friend’s home. Mr. Court’s law practice was suffering because of what he described as “mild depression.” Dr. Dump was about to embark on what promised to be a bitter divorce. They hit on the idea of swapping professional services. Dr. Dump would see Mr. Court as a psychotherapy client, and Mr. Court would represent Dr. Dump in his divorce. Mr. Court proved to be far more depressed than Dr. Dump anticipated. Furthermore, Court's representation of Dump was erratic, and the likelihood of a favorable outcome looked bleak. Yet, it was Mr. Court who brought ethics charges against Dr. Dump. Court charged that the therapy he received was inferior and that Dump spent most of the time blaming him for not getting better faster.
This case illustrates not only the unfortunate results that can occur when the follow-through phase of bartering results in unhappy clients, but also the vulnerable position in which the therapists place themselves.
Charges of exploitation become heightened when the value placed on the therapist’s time and skills are set at a higher rate than those of the clients. Moreover, because the therapist’s hourly rate will more likely exceed that of what one would pay for a client’s skills, this risk probably exists in the majority of exchange agreements.
Elmo Brush agreed to paint the rooms in the home of Paul Peelpaint, Ph.D., in exchange for counseling Brush's teenage daughter. Dr. Peelpaint saw the girl for six sessions and terminated the counseling. Brush complained that his end of the bargain would have brought $1,200 in a conventional deal. Thus, it was as though he paid $200 a session for services for which Peelpaint's other full-paying clients paid $100. Dr. Peelpaint argued that he had satisfactorily resolved the daughter's problems, and the arrangement was valid because task was traded for task, not dollar value for dollar value.
Trading a one-time service with a known cost estimate, based on Brush's own professional experience, with a service that cannot be cost estimated in advance spells trouble from the beginning. Brush's daughter might have required 50 sessions, valued at $5,000, if Dr. Peelpaint was willing to conduct as many sessions as therapeutically necessary and had been collecting his usual fees. Dr. Peelpaint's attitude also reveals little regard for fairness toward Brush. Some of the ethical complexities of Dr. Peelpaint's case might have been avoided had he hired Brush outright, leaving Brush free to make an independent decision about engaging Peelpaint as his daughter's therapist after the painting job was finished.
Sometimes others who do not understand the implications of doing so propose bartering arrangements. Consider the following posting to Craig’s List (spelling errors included).
Barter counseling for bathroom repair “My husband is a capible counselor, licensed but not good at home repairs and construction. I will trade his expertise for your time with him as a counselor if you can help us with tub and tile repair and pluming. We had a termite problem that we fixed but the place needs a new floor. If you or a loved one are struggling with depression, or anger issues, or bipolar, he is your man. He is an excellent counselor. We have our own non-profit and give to others without charging so our financial situation is limited, but looking to trade!”
Aside from the spelling errors, the counselor’s spouse has no clue about the potential complications of her solicitation. Does she really want an angry plumber in the bathroom?
So far, we have discussed exchanging a service for a service. Here, we explore more fully the exchange of professional services for tangible objects. It has been suggested that this form of bartering is less problematic because a fair market price can be established by an outside, objective source. However, the actual value of goods often depends heavily on what buyers are willing to pay. This means that determining the true value can prove challenging, and charges of exploitation could easily arise. We know of instances of service-for-item bargaining that turned out poorly. Therefore, we urge considerable caution when an object is traded for professional services, and even when purchasing an item outright from a client.
When Manifold Benz, Ph.D., learned that his financially strapped client planned to sell his classic automobiles to pay outstanding therapy and other bills, Dr. Benz expressed an interest in one of the cars. Benz said that had seen the same model at an auto show for $19,000, and that he would offer to credit the client with 200 hours of therapy in exchange for the car. The client stood 100 hours in arrears at the time.
Benz is exploiting his client by committing him to a specific number of future therapy sessions that the client may not need. Further, we do not know if the price Benz suggested represents fair market value, and this may prove difficult to determine precisely given the rarity of the item. (The fact that Benz had allowed a client to fall 100 hours in arrears demonstrates another ethical issue.)
Flip Channel, Ph.D., allowed Penny Pinched to pay her past due therapy bill with a television set that Penny described as “near new.” However, when Dr. Channel set it up in his home, the colors were faded, and the picture flickered. He told Penny that the television was not as she had represented it, and that she would have to take it back and figure some other method of payment. Penny angrily retorted that Dr. Channel must have broken it because it was fine when she brought it to him. When Channel insisted that the TV was defective, Penny terminated therapy and contacted an ethics committee. She charged that he broke both a valid contractual agreement and her television set.
Dr. Channel found himself in a no-win situation because of the television fiasco. A therapeutic relationship was also destroyed in the process. Channel could have avoided a confrontation and perhaps saved the relationship by junking the TV without mentioning it to Ms. Pinched. Nevertheless, the therapeutic alliance might have suffered anyway due to lingering resentment that might leak out toward his client. In the actual case, the client sought therapy to deal with sexual abuse as a child. Boundary crossings with clients who were badly betrayed are contraindicated (Keith-Spiegel, 2014).
It is important to recognize two points: First, therapists have the responsibility of assuring that they do not take advantage of their clients. Second, therapists should not get involved in helping clients sell their property. If clients have something of true value to sell, they can easily find many ready markets through Internet sites, reaching thousands of potential buyers at little or no cost to sellers.
Because therapeutic services typically involve a combination of trust, sensitive evaluations, social influence, and the creation of some measure of dependency, the potential for conflicts of interest and untoward consequences always exist with bartering agreements (Gandolfo, 2005; Gutheil & Brodsky, 2008). We contend that it is impossible to confidently ascertain which clients will be well-suited to a nontraditional, negotiated payment system and which should be turned down, especially near the outset of the therapeutic relationship. By definition, bartering involves a negotiation process. Is a client in distress and in need of professional services in a position to barter on an equal footing with the therapist? Furthermore, even therapists feel attracted by a good deal. How does this pervasive human motive play itself out in a bartering situation with clients?
When a client suggests a bartering arrangement, therapists without a clearly understood “no-barter policy” can find themselves in any of three situations that could cause discomfort for all concerned. First, if a therapist is known to barter, especially probable in small communities, turning down an unwanted proposal could feel like a rejection, which could hamper some clients’ mental status. Second, must a therapist accept something unneeded or unwanted? Imagine telling a client, “Well, I sometimes accept goods for services, but I’m allergic to potatoes and I don’t need a blender.” Third, how does a therapist react when one client with whom you have a bartering arrangement refers someone who also wants to barter, but the referral is clearly not clinically suited to such an arrangement? These predicaments may not end up on ethics committee tables, but illustrate sticky matters, with a potential to cause the kinds of hassles that therapists certainly would prefer to avoid.
A rarely discussed and serious bartering complication involves restrictions typical in many professional liability insurance policies that specifically exclude coverage involving business relationships with clients (Canter et al., 1994; Knapp, Younggren, VandeCreek, Harris & Martin, 2013). Liability insurance carriers may interpret bartering arrangements as business relationships and decline to defend covered therapists when bartering schemes go awry. To obscure matters even further, recipients must declare the fair market monetary value of bartered goods or services as income on their income tax returns. Failure to do so constitutes tax evasion. The client may seek to deduct the cost of goods paid for mental health services and will need proper receipts. To fully meet legal requirements (and thereby behave in a fully honest and ethical manner) requires detailed documentation, creating another type of interaction with the client. The therapist who declared that there was nothing illegal about doing therapy for free and nothing illegal about that client agreeing to work in the therapist’s dress shop for free has set up both of them for charges of income tax fraud and, for the therapist, labor law violations.
If one still decides to undertake a bartering arrangement, we recommend preparation of a written contract that judiciously protects the client’s welfare – one that the client clearly finds agreeable.
We further recommend that therapists avoid instigating a bartering relationship. To the extent that the client sees the therapist as the more authoritative individual in the relationship, or feels dependent on the therapist for emotional support, it may prove very difficult for a client to refuse the therapist’s proposal.
Finally, bartering organizations capable of providing arm’s length relationships between clients and therapists do exist. The use of such resources can defuse most of the ethical risks we have discussed. However, new concerns about client confidentiality, screening clients for appropriateness, and the integrity of the bartering organization remain as potentially sticky issues.
Friends and family members frequently seek advice from mental health professionals. When more than factual information or casual advice is requested, a temptation may arise to enter into professional or quasi-professional relationships with good friends or family members. Therapists may reason that they can more easily provide especially good counsel because trust already exists. Furthermore, therapists may express a willingness to see these “clients” at bargain rates or at no cost whatsoever.
Despite the seeming advantages of offering professional services to friends or family members, sustained therapy relationships should be avoided. Although close relations and psychotherapy exist in the context of intimacy, striking differences exist between the purpose and process of the two.
Successful personal relationships cost nothing and aim for:
Professional relationships, on the other hand, normally involve payment to the therapist and aim for:
When we superimpose these two types of relationships, the potential for adverse consequences to all concerned increases substantially. Notice how the differences become oppositional, meaning that expectations can clash and trust can more easily be broken.
Short-term support in times of crisis may qualify as an exception. Responding to a frantic call from a friend in the middle of the night is something friends do for each other. Should the friend require more than temporary comforting, offer a referral. Otherwise, as the following case illustrates, unexpected entanglements can occur, even when therapists intend to be benevolent.
Weight-reduction specialist, Stella Stern, L.M.H.C., agreed, after many requests, to work on a professional basis with her good friend Zoftig Bluto. Progress was slow, and most of Bluto's weight returned shortly after she lost it. Dr. Stern became impatient because Bluto did not seem to take the program seriously. Bluto became annoyed with Dr. Stern's irritation as well as the lack of progress. Bluto expressed disappointment in Dr. Stern, whom she believed would be able to help her lose weight quickly and effortlessly. The once close relationship grew distant.
Dr. Stern's friend could not commit to the obligations of the professional alliance, but expected results anyway.
Faulty expectations, mixed allegiances, role confusion, and misinterpretations of motives can lead to disappointment, anger, and sometimes a total collapse of relationships.
In conclusion, therapists are free to be completely human in their friendship and family interactions and to experience all of the attendant joys and heartaches. Their skills might prove helpful by offering emotional support, information, or suggestions. When the problems become more serious, however, the prudent course of action involves help in finding appropriate alternative care.
Another ready source of potential client contacts flows through therapists’ circles of acquaintances. A member of the same gym or church may request professional services. Disallowing casual acquaintances as potential clients would, in general, qualify as unacceptable to consumers as well as to therapists. This section illustrates cautions that one should consider before taking on clients who base their request for your services on the fact that they know you slightly from another context.
Felina Breed, Ph.D., practiced psychotherapy and also raised pedigree cats. Many of her therapy clients were the “cat people” she met at shows. The small talk before and after treatment sessions usually involved cats. Clients also occasionally expressed interest in purchasing kittens from Dr. Breed. She agreed to sell them to her clients, which eventually came back to haunt her. When the therapy process did not proceed as one client wished, he accused Dr. Breed of using him as a way to sell high-priced kittens. Another client became upset because Dr. Breed sold her a cat that never won a single show prize. This client assumed that if the therapist raised “loser cats,” the trustworthiness of her therapy skills also fell into question.
Dr. Breed did not adequately meet her responsibility to suppress her acquaintance role while engaging in a professional role. This disconnection can usually occur without untoward consequences if the continuation of the former acquaintance role does not require more than minimal energy or contact and avoids any conflicts of interest. The risks and contingency plans for likely incidental contact with clients should be discussed during the initial session. In Dr. Breed's case, that would have meant refraining from extended discussions of cats before or after the therapy session and abstaining from selling cats to any ongoing therapy client.
So what differences exist between a friend who one should not accept as a therapy client, and an acquaintance who may appropriately become one? Making the distinction is not clear-cut because sociability patterns among therapists themselves vary considerably. Contextual issues, such the potential for frequent interactions with the acquaintance in other settings, also demands consideration. You might ask yourself questions such as: Is the person seeking my services also a person I would invite home for dinner, or whom I would visit in the hospital rather than just send a get well card, or with whom I would share more than routine information about my personal life? If your answer to these sorts of questions is “yes,” then that person is more of a friend than an acquaintance.
A twist on the acquaintance peril involves dealing appropriately with solicitations for services by someone who also holds some influence or advantage over you. Examples include a request to work with his alcoholic wife from the head of admissions of the local college to which your daughter has applied, or a call for an appointment for marriage counseling from the advisor who manages your financial portfolio. Unless alternative services are unavailable, we encourage therapists placed in such awkward positions to explain the dilemma to prospective clients and offer to help find alternative resources.
Psychotherapy has been referred to as, among other things, “the purchase of friendship” (Schofield, 1964). As already noted, we contend that it is precisely the differences between psychotherapy and friendship that account for therapy’s potential effectiveness. Friendships should ideally begin on an equal footing, with each party capable of voluntarily agreeing to the relationship.
The various complications that can arise when ongoing clients become friends are illustrated in the following cases. Do take note of the therapists’ delayed awareness that anything was amiss – a common phenomenon that creates unwelcome surprises.
Soon after Patty Pal began counseling with Richard Chum, L.M.F.T., Patty asked Dr. Chum and his wife to spend the weekend at their beach house. The outing was enjoyable for all. During the next few sessions, however, Ms. Pal became increasingly reluctant to talk about her problems, insisting that things were going well. Dr. Chum confronted Ms. Pal. She broke down and admitted that she had been experiencing considerable distress, but feared that if she revealed more Chum might choose to no longer socialize with her and her husband.
Patty Pal found herself in a double bind. As Peterson (1992) observed about boundary violations in general, the client is always faced with a conflict of interest; No matter what they do, they risk losing something. Pal did not press ethics charges, but had she done so, a committee would likely have found Dr. Chum guilty of exercising poor professional judgment.
Will Crony, Ph.D., had treated Buddy Flash for two years. They had also invited each other to their homes. Flash gave especially elegant parties, often attended by many influential community leaders, some of whom later became Crony’s clients. During one such event where liquor flowed freely, Flash and Dr. Crony argued over what, to Crony, seemed a trivial political disagreement. However, Flash terminated therapy and wrote to an ethics committee, complaining that Dr. Crony had kept him as a client for the sole purpose of capitalizing on his social status.
An ethics committee found in favor of Flash.
When can more intimate social friendships be formed with former clients without the danger of multiple role complications? Conservative critics say, “Never.” An ex-client may want or need to reenter therapy, and a clear pathway - including the beneficial effects of continuing transference - should remain open for them.
The American Psychological Association (2010) and the American Association of Marriage and Family Therapists (2015) ethics codes do not specify prohibitions against nonsexual post-termination friendships. The American Counseling Association (2014) and National Association of Social Workers (2008) codes do include “former clients” in their admonition to refrain from complicated roles without ensuring that harm or exploitation are not at issue.
If a post-therapy friendship disappoints or turns sour, elements of issues that came up during therapy may resurface, raising new doubts in the client. The therapist a client believed he or she knew so well may not completely resemble their professional persona as in a nonprofessional context and may fail, as Neale (2010) puts it, to be that idealized friend.
Sue Nami, Ph.D., and her ex-client Marsha Nullify fully expected that they would get along exceptionally well because the therapy experience was extremely positive for both of them. However, Nullify found Dr. Nami overbearing and controlling in casual social situations, and Nullify's other friends intensely disliked Nami’s strident manner. Nullify began to doubt Nami’s overall competence and distanced herself from the post-therapy friendship. She also began to suspect that the previous therapy was probably inept. She felt exploited and lost and sought the counsel of another therapist who encouraged her to press ethics charges against Nami.
Nullify's charges against Dr. Nami came before an ethics committee, but not because of the allegations that Nullify brought forward. Proof of alleged incompetence failed to materialize, but what became clear to both a surprised respondent and the complainant was the finding of a multiple role relationship violation. The investigation revealed that during Nullify’s therapy, Nami had clearly planned their evolving friendship and its longer-term continuation. Ironically, Nami herself provided these facts as a defense against Nullify's charges. This scenario also illustrates how one can never count on a new, imposed role working out as well as the first one. Nami’s authoritative personality worked well with this client in therapy, but played out poorly away from the office.
So, can therapists ever safely establish friendships with former clients? The findings in a critical incident survey by Anderson and Kitchener (1996) suggest that nonsexual, nonromantic relationships occur with some regularity among therapists and their previous clients, but the judgments of the ethics of such relationships reveals little consensus. The view that friendships with clients are always off limits might deny opportunities for what could become productive, satisfying, long-term relationships. Gottlieb (1993, 1994), a strong supporter of maintaining clear professional boundaries, also believes that social relationships with some types of ex-clients may prove acceptable. Here is one example from our files:
Mountain bike enthusiast Wilber Wheel consulted Spike Speedo, Ph.D., whom he had casually met at a biking exhibition. The therapeutic relationship went well and terminated after 16 sessions. The two men found themselves in the same race a few months later and realized that they enjoyed knowing each other on a different basis. A close friendship endured for 25 years, and Speedo delivered the eulogy at Wheel’s funeral.
The relationship between Wheel and Speedo was not superimposed or even contemplated during active therapy and the connection that drew the men together and sustained them was not based on therapeutic issues.
Clients offering gifts to their therapists has been a matter of lively discussion. How gifts are received requires careful forethought and application due to how they might have an impact on both treatment relationships and outcomes (Barnett & Shale, 2013). Some clients may offer gifts in an attempt to equalize power within the relationship (Knox, Hess, Williams, & Hill, 2003). Gifts should always be understood and evaluated within the context in which they are given (Hundert, 1998; Zur, 2007).
The less discussed issue is when therapists offer gifts to their clients, creating an instant multiple role relationship of therapist and benefactor. Offering clients gifts requires special forethought.
Many clients coming into therapy feel ignored, abandoned, violated, or uncared for and may more easily misinterpret the motivation of therapists who give them gifts. Besides the potential complications and misunderstandings, there is an ever-present possibility that the therapists' own motives of benevolence are unconscious rationalizations for self-serving intentions. In short, the therapist must ask, “Do I just want to be liked?”
Benny Nowalls, Ph.D., often gave many of his clients little trinkets he thought they would enjoy. The gifts included decorative key chains, figurines, and stuffed animals. He also sent them cards when he went on vacation, hugged them often, worked out alongside them at the gym, and met them for lunch. Eventually, several clients complained about Dr. Nowalls for a variety of reasons, most dealing with abandonment issues.
Dr. Nowalls felt stunned that some of those to whom he had been, in his own mind, so kind and giving, turned on him. He could never grasp how the multiple intrusions of his personal essence into his clients' lives initiated dependencies he could never ultimately satisfy. From another perspective, seeking gratification by attempting to please clients presents a serious problem, whereas helping clients to manage their feelings toward the therapist, both positive and negative, can prove beneficial. The question arises as to whether clients can feel free to address negative feelings with a therapist who gives them gifts (Gabbard, 1994).
The therapist’s motives for gift giving are not necessarily unconscious or rationalized. The next case illustrates a therapist who had a strategic purpose in mind.
Herman Hustle, Ph.D., gave all of his clients, current and past, expensive cheese baskets at Christmas time. He confided to a colleague, “I want them to think about me as this terrific guy and then pass my name along to their friends.”
Dr. Hustle wants to drum up business and is attempting to enlist clients as his sales force. Clients will not likely complain, and the tactic does not violate any ethical rule, but it borders on the unprofessional. Some clients may also feel obligated to reciprocate.
So, can therapists ever give their clients gifts or do favors for them? We say “Yes,” on occasion and after careful consideration. Offering a book to a client may prove helpful when therapeutically indicated, especially if the client has a limited budget. Therapists may also go out of their way to help clients locate other needed resources relevant to improving their overall life situation. Small favors based on situational needs and common sense, such as giving a client a quarter for the parking meter, would raise no concerns. In these acceptable cases, no ulterior motives pertain, and the scope either relates to the therapy or is of a very specific and limited nature. A special situation can arise with child clients. Here, at times, it may be appropriate to give a small gift attending to the symbolic meaning that would advance the therapeutic function. For example, an anxious child about to leave for three weeks of summer camp might feel soothed and emboldened by the gift of a flashlight.
Finally, consider the generous therapist who agrees to see a financially strapped client at no cost. This may set up a gift-giving dilemma, at least in the client’s view. If a client no longer has the ability to pay, and the therapist believes that continuation is important to the client’s well-being, we suggest use of a reduced fee schedule or sliding scale that makes the fee affordable. This also deflects the negative impact on the proud client who would not welcome charity.
Dumped tried unsuccessfully to use the defense that three years had passed and the ethics code allows clients and their therapists to start a sexual relationship two years after termination. She felt the flipside of this principle should apply as well. The Ethics Committee rejected this argument because it is explicitly forbidden in the ethics code of the American Psychological Association for good reason; once one engages in sex with someone, the relationship dynamics are forever altered.
Jane Dumped reluctantly accepted Casa Nova as a client when he showed up at her office three years after Nova left her sitting alone in an expensive restaurant, a date to celebrate her 33rd birthday. Nova claimed that Dumped was the only one who would understand his wayward ways with women. It wasn’t until the third session that Dumped admitted to herself that she was focusing on feeling vengeful and found herself eliciting and then delighting in Nova’s woes. She told him she couldn’t help and sent him out the door. Nova felt ripped off and pressed ethics charges, claiming that Dr. Dumped only wanted to humiliate him for rejecting her years earlier.
In times of declining reimbursement for the delivery of psychotherapy services, it may feel tempting to relax the criteria used for accepting clients and, in the process, compromise ethical obligations (Shapiro & Ginzberg, 2003). Word of mouth from colleagues and current or previous clients generates many referrals. However, care must be taken when satisfied clients recommend you to their own close friends or close relations. The potential for conflict of interest, unauthorized passing of information shared in confidence, and compromises in the quality of professional judgment constitute ever-present risks. Carefully considering what could go wrong and estimating its likelihood may both save a therapeutic alliance and avoid an ethics complaint.
Dum Tweedle felt pleased with his individual therapy and asked Rip Divide, Ph.D., to counsel his fiancée, Dee, in individual therapy. Dum eventually pressed ethics charges against Dr. Divide for contributing to a breakup, a process that began, Dum alleged, at the time Dee entered therapy. He contended that Dr. Divide encouraged Dee to change in ways that were detrimental to him and to their relationship. Dr. Divide contended that it was his responsibility to facilitate positive growth in each party as individuals, a responsibility he felt he had upheld.
Dr. Divide ignored the invisible “third client,” namely the relationship between the two clients and attempted the improbable task of treating a couple as unconnected entities.
Sometimes warning signals appear, even if in a somewhat offhanded way, that the unwary therapist might miss. The next case, loosely adapted from a scenario provided by Shapiro and Ginzberg (2003), illustrates one such situation.
Paris Jug told her therapist, Ed Ipus, M.S.W., that she was recommending him to her mother for counseling. Ipus was elated because these were self-paying clients. So, when Paris then giggled and said, “You will see how much more loveable I am than her,” he failed to recognize the subtle warning. Therapy with the mother was difficult because her main complaints were about Paris, and Paris spent much of her time attempting to manipulate Ipus into saying that she was sane compared to her crazy mother. He decided to make things simpler by terminating the mother, who then pressed ethics charges for abandonment and emotional harm.
Mr. Ipus was highly remiss in taking on the referral in the first place, knowing the intense issues between his ongoing client and her mother. He obviously should have told Paris that he could not ethically treat her mother and maintain a professional obligation to her.
One interesting challenge with respect to accepting referrals of close acquaintances or current clients can arise with cultural overtones. In some cultures refusing to accept a referral can cause a “loss of face” or humiliation. A friend, relative, or acquaintance may feel disrespected if the therapist declines their request for services or attempts to make a referral. There are many culturally acceptable ways to handle such situations and avoid public disrespect to the referring or requesting party, such as offering to make a “better referral to a more qualified person to help with the particular problem.”
We do not suggest that accepting referrals from current clients is necessarily inappropriate. Therapists must, however, assess as thoroughly as possible the relationship between the potential client and the referral source, the potential client and the context in which the established client and the referral know each other, and the motivations of the client in making the referral (Shapiro & Ginzberg, 2003). If things have the potential to become sticky, we advise referring the potential client to a suitable colleague.
Role clashes become impossible to avoid for mental health professionals working in small or isolated communities. The goal is not to vigorously attempt to avoid all situations where roles may be blended but to thoughtfully manage them (Barnett, 2017b).
As anyone who has lived in a rural town can readily attest, face-to-face contacts with clients outside of the office inevitably occur, sometimes on a daily basis. Clients likely belong to some of the same groups or engage in activities that bring them face-to-face outside of the office. Sometimes in specific incidents, management requires some creativity. One psychologist, who was the only mental health provider within a 60-mile radius, relayed to us the special care taken to ensure that he and his client, the only sixth-grade teacher in town, could avoid difficulties that might arise due to the presence of the psychologist's rebellious 12-year-old son in her class. Another small-town marriage counselor shared the burden of scheduling neighbors so as to avoid unwelcome face-to-face meetings in the waiting room.
Unfortunately, demand for services in rural areas often exceeds resources (Barnett, 2017b; Benson, 2003; Schank & Skovholt, 2006). The few therapists in town will know many of their clients in other contexts, and the townspeople will also know a great deal about the therapists and their families. Therefore, in small rural areas, boundary guidelines demand consideration in relation to the sociocultural contexts of the community (Roberts, Battaglia, and Epstein, 1999).
Attributes of small communities further complicate ethical dilemmas in the context of delivering therapy services. Information passes quickly, and standards of confidentiality among professionals and community service agencies may become relaxed to the point where information, originally shared in confidence, becomes widely known. In smaller, isolated communities, gossip can be rampant, making it even more difficult to ensure client confidentiality (Sleek, 1994).
Residents of small communities are often more hesitant to seek professional counseling and do not quickly trust outsiders, preferring to rely on their kinship ties, friends, and clergy for emotional support. Because those who do seek therapy prefer someone known as a contributing member in the community, it may not be possible to simply commute from a neighboring town and expect to have much business. Ironically, then, earning acceptance and trust means putting oneself in the position of increasingly complicated relationships (Stockman, 1990; Campbell and Gordon, 2003). Consider, for example, what might happen when a client also works as a salesperson at the local car dealership. When the therapist buys a new car, the client may feel deeply offended if the therapist purchases it from someone else. Yet, would the therapist have the same latitude to negotiate the price? Would the client feel obligated to give the therapist a better deal than anyone else would receive? And what if the car turns out to be a lemon? This is the kind of dilemma that small town therapists must routinely manage and perfect answers are not always obvious.
Just because mental health professionals in smaller communities cannot easily separate their lives entirely from those of their clients does not mean that professional boundaries become irrelevant. On the contrary, therapists must make deliberate efforts to minimize possible confusion. For example, no matter how small the community, a therapist and a client should never need to socialize only with each other, such as meeting for dinner. Potentially risky acts over which therapists always have complete control regardless of community size can still be easily avoided. The therapist can maintain confidentiality and refrain from chiming in during gossip sessions taking place outside of the office. The therapist’s family may also need instruction on how to interact in certain situations, while minimizing the details as to why.
The therapist in the next case failed to attend to more than one ethical requirement, despite the more accepted practice of bartering in rural communities.
Due to stresses caused by economic hardships, the Peeps required more marriage counseling sessions than originally estimated. The Peeps' chicken farm income was insufficient to pay the regular bills, let alone therapy. Ronald Rooster, M.S.W., proposed that he would accept 2,000 chicks to continue counseling, provided the therapy did not last beyond a year. Dr. Rooster’s wife had long wanted to start a chicken farm, so this deal would also fulfill one of the therapist’s needs. The Peeps reluctantly agreed to Rooster’s offer. Soon thereafter, a lethal virus dangerous to humans and believed to be carried by poultry resulted in the destruction of millions of chickens in Canada, driving up the price of chickens from their non-flu area. The Roosters made a huge profit, and, at the same time, found themselves in business competition with the Peeps. The Peeps felt locked into a therapy situation that they felt very uncomfortable with, and eventually successfully sued Dr. Rooster.
This case, adapted from Roberts Battaglia, & Epstein (1999), reveals the highly unethical role blending that can occur in rural settings where roles are often already blended. Taking an exchange in advance for services that may not be needed is only the tip of the iceberg. Bartering a vulnerable client’s assets to start a business that then competes with the client was unconscionable.
Small communities also exist outside rural areas or geographical isolation. Close-knit military, religious, cultural, or ethnic communities existing within a much larger community can pose similar dilemmas. Therapists working in huge metropolitan settings can experience what amounts to small-world hazards, and the same need to view role conflicts in a sociocultural context pertains. The primary advantage of working in a heavily populated area is the availability of more alternatives. Yet still, even when one cohesive population is embedded in a large city, complications similar to those faced by rural therapists can arise. Gay, bisexual, and transgender communities in urban settings provide one example (Kessler & Wechsler, 2005).
Lisa Lorne, Ph.D., specialized in counseling lesbian women. She accepted a client new to the city into her therapy group, and during the second session the new woman announced that she had just met someone named Sandra Split and that they were going to be seeing each other. Dr. Lorne was still devastated by Sandra Split’s recent break-up up with her after 16 years together.
If Dr. Lorne’s own issues would make it impossible to work with a specific client, arranging for some alternative that keeps the client’s best interests in mind is well advised. Furthermore, the new client is very likely to learn of Split’s relationship with Lorne sooner rather than later. Another less dramatic situation that may cause complex interactions that require vigilance for gay, lesbian, bisexual, or transgendered therapists involves frequent socialization venues, both private and public.
Discoveries that may emerge during the course of therapy can often be handled by maintaining the professional role without regard for the coincidences that link the therapist and client in other ways. Things can, however, become more complicated, as illustrated in the next case.
Sid Fifer consulted Ron Wrung, Ph.D., after Fifer's offensive and antisocial behavior caused increasing trouble in his family and at work. Early in therapy, Fifer casually revealed that he and the therapist's wife worked for the same large company, though in different locations and different departments. Several weeks later, Fifer was fired. He charged that Dr. Wrung must have told his wife about what he talked about in therapy, which she, in turn, shared with the company boss. Wrung vehemently denied sharing material about Fifer or any other client with his wife or anyone else.
Dr. Wrung was a casualty of the type of circumstances that one could neither easily predict nor prevent. Therapists will more likely be judged culpable when they recognize a small-world hazard in advance and when other alternatives clearly existed. Here, other treatment options did exist, but Wrung assumed that the remote connection between the client and his wife would preclude any conflict. Although Dr. Wrung was not found guilty, enduring an ethics investigation is stressful. The matter might have been avoided had Wrung instigated a discussion about confidentiality and how it related to this distant connection.
The future will likely see an increase in the use of electronically-based distance forms of therapy. These may ease the shortage of resources and relieve some of the ethical problems inherent in rural communities and other small-world situations when appropriate options are scarce (Bischoff, Hollist, & Smith, 2004; Farrell & McKinnon, 2003). Of course, with Teletherapy, other ethical challenges pertain.
Therapeutic goals can sometimes be better achieved outside a professional office-style setting. Delivering therapy in clients’ residences may forestall the need for hospitalization or alleviate difficulties for clients who are physically frail or do not drive (Knapp & Slattery, 2004). Action-oriented therapies, including crisis modalities, may involve ecological involvements with clients. For example, a therapist might accompany his “fear of flying group” on a flight from Chicago to Indianapolis and back. A stress reduction group might hold a special weekend at a serene lakeside lodge. A mental health professional, as part of an established eating disorder clinic program, may go out to eat pizza or other “real food” with a client to assist in addressing anxiety about eating in a realistic context.
Excursions beyond traditional professional settings require careful forethought to preclude subsequent charges of exploitation because of multiple role or conflict-of-interest overtones, confusion, or impairment of the therapists’ objectivity. When employing an atypical setting or technique, it becomes critical to clarify the therapeutic context and the activity.
Homa Cloister feared crowds. Her therapist, Rip Vivo, Ph.D., suggested that they go out to dinner at busy, fancy restaurants after therapy sessions as a way of conditioning her to feel more comfortable around people. He did not charge an additional fee for the after-hour activity, but did require her to pay the dinner bill. The treatment proved ineffective and uncomfortable for this client. Homa later charged that Dr. Vivo exploited her by disguising a free meal ticket as psychotherapy.
Lynn Bones broke both legs skiing and would not be able to drive for six weeks. Bud Visit, L.M.H.C., agreed to see Bones in her apartment until she could arrange transportation to his office. Upon arriving, he found that Bones had prepared lunch for the two of them, including wine. They chatted about politics and the weather while eating. After three such sessions in Bones’ apartment, the therapy sessions shifted in that Bones began to treat Mr. Visit as a friend rather than as a therapist. Six week later when sessions resumed in the office, Visit attempted to get things back on track in his professional setting. An affronted Bones decided to find another therapist.
Vivo's technique with his claustrophobic client may have an appropriate therapeutic rationale, but he included the trappings of a social event and structured the financial aspects poorly. Mr. Visit settled too comfortably into the temporary therapy venue, and the relationship shifted just enough to compromise it. Those who make home-based visits or offer community-based treatment of those with serious mental problems must remember that boundaries are challenged in ways that do not ordinarily present themselves in professional office or hospital settings (Knapp and Slattery, 2004; Perkins, Hudson, Gray, et al., 1998). Mr. Visit should have anticipated the dynamics of a home-based setting and prepared his client with the ground rules, which would not have included meals or alcohol.
Earning a living without leaving one’s own house has become more of an option than ever before. One can easily understand the increasing popularity of working out of one’s home, both from convenience and financial standpoints. While not inherently inappropriate or codified as unethical, we do not advise conducting therapy in one’s home. If one must conduct therapy in a private home, the room should be furnished along the lines of a typical therapy office, and ideally have its own entrance. Some clients, however, may find receiving therapy anywhere in the therapist's home (even in a dedicated home office or converted garage) confusing, and their emotional status could become compromised by connotations attached to the setting. The therapist who practices out of her own living quarters also risks professional isolation, unless colleagues are actively sought out in other venues. Some clients could potentially become burdens or pose risks to the family if the client acts out in strange or frightening ways. Unless the home-office therapist has another location available to screen new clients for suitability, one cannot know in advance what level of pathology may walk through the door.
Every mental health professional is at the mercy of coincidence, and a totally unexpected compounding of roles may occur by chance (Barnett, 2017 b). Although the appropriate response may prove difficult to discern, therapists must actively attempt to ameliorate the situation as best they can, trying to avoid devaluing or diminishing anyone in the process. A therapist’s response, which must often follow quickly, will depend on several factors. Confidentiality issues usually pertain. Unless the therapist and client have discussed how to handle situations when they encounter each by chance, the therapist will not know how to take the client's preferred option into account. The urgency of the situation can also become a factor.
When dealing with unforeseen factors, most of the time no lasting multiple role relationship actually develops. The nature of the encounter itself determines, in large measure, the impact of the unanticipated encounter. Seeing each other in line at the post office sits at one end of the continuum, meeting naked in the gym shower falls near the other. Most therapists who have had unintended encounters with ongoing clients express surprise, uncertainly about what to do, discomfort, anxiety, and embarrassment. Most also feel concerned about confidentiality and boundary complications (Sharkin & Birky, 1992).
Whereas fluke crossings will more likely occur in smaller communities, unexpected situations can arise anywhere. In fact, both incidents described in the next cases occurred in large metropolitan areas.
During a New Year's Eve event at a fashionable restaurant with some friends, Eva Close, M.S.W., spots one of her clients at a table across the room. This client is particularly sensitive about therapy and constantly worries about anyone finding out that she even knows a psychotherapist. Mrs. Close and her husband had planned this evening for weeks and paid $200 in advance. Mrs. Close thinks she may be able to stay in her corner of the dining area, but as people begin to drink they also move around the room to chat with others and make new friends. Mrs. Close's husband and friends urge her to “get out there and dance.”
Mrs. Close may have to figure out how to keep a low profile at the New Year's Eve event. She should not become intoxicated. Given the client's intense feelings, it would have been quite appropriate for Close to have earlier attempted to ensure that important events do not overlap with those of her client. In small communities, clients with such intense concerns about discovery might better be referred to someone in an adjacent city, or perhaps for telephone or Web-based counseling.
Fortuna Yikes, Psy.D., agreed to have dinner with friends and a blind date that her friends had arranged for her. When she arrived at the restaurant and peeked inside, she recognized the man sitting with her friends as one of her clients.
In the real story, the therapist was able to leave the restaurant before being seen. She paged her friends in the restaurant from her mobile phone, telling them that she had fallen ill. Because such twists of fate do happen, and quick exits may not be an option, we suggest that therapists actively attempt to know in advance the identities of people with whom they will be interacting in any intimate social situation.
We also encourage mental health professionals to raise the issue early on about chance meetings with their clients outside therapy. Some clients will prefer to pretend that the two do not know each other. Others may favor acting as though they are acquaintances and want to exchange brief greetings.
We suggest that therapists not take the lead during such chance encounters, and that the clients understand in advance that the decision to interact with or ignore each other rests entirely with them. Clients should feel assured that the therapists will be comfortable either way. We suggest discussing this with all clients early on. That way, the therapist does not have to remember which reaction each client prefers (and even these preferences could vary, depending on the circumstance). This strategy poses no risk that the client will perceive the therapist as rejecting because the client will know always to take the lead when the two notice each other outside the office setting. With a pre-approved plan well in place, common situations involving clients, such as finding oneself in the same line at the grocery store, can be handled somewhat gracefully and without incurring more than minimal discomfort. Pulakos (1994) surveyed clients who had already experienced outside encounters with their therapists and found that 54% of clients expressed that they would want a brief acknowledgement, 33% would want a conversation, and only a small number would want to be ignored. Twenty-one percent would want a different response than the one they received. These results verify that no one size fits all.
A number of work settings can pose ethical challenges when the client is not the sole focus of concern. Therapists working in prisons, the military, schools, hospitals, or as supervisors or are court-appointed are among those in settings where following policy may pose conflicts (Johnson & Johnson, 2017; McCutcheon, 2017; Ward & Ward, 2017; Younggren & Gottlieb, 2017). For example, demands of the agencies employing therapists may conflict with the needs and welfare of the agencies’ clients. Confidentiality may be forced to be compromised. This dilemma is increasing as managed care takes over privately contracted services between therapists and clients.
Paul Plastique, Ph.D., provides psychotherapeutic care to children with chronic medical conditions at Megahealth Memorial Hospital. For three years, he has worked with eight-year-old Zachary Mug through several stressful craniofacial surgical procedures to deal with malformations caused by Crouzon Syndrome. Zack has experienced self-esteem and peer problems, school disruption, and painful recoveries, but Zack and his parents feel that Dr. Plastique understands him and his life experiences very well. The Mug family is covered by Monolith Insurance through Mr. Mug’s employer. Monolith recently "carved out" their mental health benefits and subcontracted these to C.F.I. Care Services. Contract talks between C.F.I. Care and Megahealth Memorial Hospital on a new contract for mental health services have broken down. While Zack will still get medical and surgical care through Megahealth Memorial covered by Monolith, Dr. Plastique’s psychotherapeutic services will no longer be covered. C.F.I. Care has referred Zack and his family to a counselor in the community who has no familiarity with Crouzon Syndrome or children with craniofacial abnormalities requiring surgical intervention.
The issues confronted by Dr. Plastique and the Mug family have become all too common as third-party payers continually strive for economic advantage using carved out contracts and competitive pricing agreements. Coordinated continuous care in a single setting by therapists with the most relevant training and experience has become increasingly difficult to maintain. Perhaps Dr. Plastique and the Mug family can make a special circumstances plea to C.F.I. Care or Monolith Insurance. Perhaps Megahealth Memorial will offer some reduced fee to the Mug family in the absence of coverage. Perhaps Dr. Plastique’s practice is such that he can continue to treat Zack outside of the Megahealth system. More likely than not, however, Dr. Plastique and his client will find themselves trapped in an arcane world of contractual and fiscal constraints that allows little latitude to consider the best interests of individual patients.
Government policy, legal requirements, or the welfare and safety of society in general may sometimes clash with therapists’ judgments regarding what constitutes the best interests of individuals with whom they work. The identification of priorities and loyalties can cause acute stress and conflict-of-interest dilemmas. The APA ethics code, for example, specifies that psychologists should refrain from accepting a professional role when personal, scientific, professional, legal, financial, or other interests or relationships could reasonably be expected to impair their objectivity, competence, or effectiveness or expose an individual or an organization to any harm or exploitation (APA, 2010). Often, therapists are not in an objective position when acting under such conditions because the more powerful of the conflict sources, such as the legal system or the employer, may issue sanctions if the therapist’s actions do not comport with the position of the more powerful party.
Today's seemingly looser restrictions on nonsexual multiple roles, as compared to three decades or so ago, may well place unaware therapists at greater risk than earlier, stricter ethics codes. Why? Because fewer specific prohibitions beyond avoiding “exploitation” and “harm” remain. These are very general terms, somewhat vague, and easily open to interpretation.
Here is our concern: Any client who claims to have been “exploited” or “harmed” when roles became complicated could be difficult to challenge and refute, and unpredictable ethics committees and juries will make their findings on a case-by-case basis. Therefore, decisions to cross boundaries should be discussed with the client and documented in case it ever become necessary to defend venturing into territory other than the professional role with a client (Pope & Keith-Spiegel, 2008; Younggren & Gottlieb, 2004).
Finally, complicated roles can lead to an increased risk of engaging in sexual relationships with clients. Critics of this slippery-slope argument suggest that this thinking is a holdover from rigid psychoanalytic theory. However, data confirm that therapists with blurry role margins do not necessarily stop with gift giving, conducting sessions in the park, inviting clients out to dinner, or a giving a kiss on the cheek. Surveys have established a relationship between nonsexual and sexual boundary crossing (Borys, 1988; Borys & Pope, 1989; Lamb and Catanzaro, 1998). This association should not come as any surprise, given that many forms of nonsexual multiple role behaviors are those also routinely associated with dating and courtship rituals.
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