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Boundary Crossings and the Ethics of Multiple Role Relationships
by Gerald P. Koocher, Ph.D., ABPP and Patricia Keith‑Spiegel, Ph.D.

3 CE credits - $74

Last revised: 08/30/2013

Course content © copyright 2010-2013 by Gerald P. Koocher, Ph.D. and Patricia Keith-Spiegel, Ph.D. All rights reserved.


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Learning Objectives

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 to have a basic understanding of core ethical principles and standards related to the topics discussed and to 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.

COURSE OUTLINE

  1. INTRODUCTION
  2. THE BATTLE OVER BOUNDARIES: WHAT IS AN ACCEPTABLE CROSSING?
  3. WHAT DEFINES A MULTIPLE ROLE RELATIONSHIP?
  4. EVALUATING MULTIPLE ROLE RELATIONSHIPS
    1. Risk Assessment
    2. Risky Therapists
    3. Self-Disclosing Therapists
    4. Professional Isolation
    5. Therapeutic Orientation and Specialty Practices
    6. Risky Career Periods
    7. Risky Clients
    8. Making Blending Decisions
    9. Red Flag Alerts
  5. BARTERING ARRANGEMENTS WITH CLIENTS
    1. Exchanging Services
    2. Exchanging Services for Goods
    3. Final Considerations about Bartering
  6. CROSSING BOUNDARIES WITH THOSE ONE ALREADY KNOWS
    1. Delivery of Services to Close Friends and Family Members
    2. Accepting Acquaintances as Clients
    3. Socializing With Current Clients
    4. Becoming Friends with Clients After Therapy Ends
    5. Accepting Past Lovers as Clients
  7. GIVING GIFTS TO CLIENTS
  8. ACCEPTING CLIENTS' REFERRALS OF THEIR CLOSE RELATIONS
  9. RURAL SETTINGS AND OTHER SMALL-WORLD HAZARDS
  10. NONTRADITIONAL THERAPY SETTINGS
  11. UNANTICIPATED ENCOUNTERS WITH CLIENTS
  12. WHEN THERAPISTS ARE CAUGHT IN THE MIDDLE
  13. FINAL THOUGHTS

The qualities that bring a therapy or an analysis to life may be the very qualities that bring us toward an edge, the crossing of which can be hugely harmful.

– Steven Behnke (2006)

INTRODUCTION

If you ever find yourself charged with an ethical violation, chances are the complaint will allege a boundary violation.  While reviewing the cases in this course, you will note the pervasive incidence of harm caused by therapists who behaved in ways that seem completely out of touch with the impact their decisions and actions had on those with whom they worked. Ethics charges based on role blurring account for the majority of ethics complaints and licensing board actions (Bader, 1994; Montgomery & Cupit, 1999; Neukrug, Milliken, & Walden, 2001; Sonne, 1994). Legal suits and the cost of defending licensing board complaints cause professional liability insurance rates to rise, thus harming all therapists (Bennett, et al., 1994). Finally, the stigma and the stress endured if found guilty can be debilitating (Warren and Douglas, 2012). 

More recent relaxing of previously stiff rules regarding the maintenance of boundaries also creates an unanticipated decision-making dilemma that we will discuss later.  And, unfortunately, many boundary issues may arise in ways that therapists may not initially predict or even recognize.

Consider these scenarios:

With the exception of boundary crossings 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 were 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 cost 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. Asking before acting is essential.

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 on the therapist’s desire to entertain or self-promote.

Finally, 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 fix the car. Unfortunately, the therapist became defensive and told the client that he must have done something to cause the damage. The therapeutic alliance evaporated, and the client successfully sued the therapist in small claims court.

THE BATTLE OVER BOUNDARIES

Boundaries between therapist and client come in many forms – from crisp to fuzzy – and exist in various influential contexts (Gutheil & Gabbard, 1993). 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).

Mental health professionals continue to hold differing perceptions of role mingling. These perceptions range from conscious efforts to sustain objectivity by avoiding any interaction or discourse outside of therapeutic issues to extremely relaxed 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). Lazarus (1994) puts it bluntly: “Practitioners who hide behind rigid boundaries, whose sense of ethics is uncompromising, will, in my opinion, fail to really help many of the clients who are unfortunate enough to consult them” (p. 253). Critics even contend that boundary violations have been improperly inserted into ethics codes, training programs, and licensing and malpractice litigation (Lazarus & Zur, 2002).

Those who criticize setting firm professional boundaries further assert that role overlaps become inevitable, and 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 educate therapists that exploitation is always unethical, regardless of boundary issues.

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. The therapist, however, 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 view the therapy relationship as rich and complex in its own right, and see no reason why clear boundaries need 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 often act as a precursor to exploitation, confusion, and loss of professional objectivity.

We do understand that one cannot possibly avoid all nonprofessional interactions or contact 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. Clear and consistent boundaries provide a structured arena, and this may constitute a curative factor in itself (Borys, 1994). In short, the therapy relationship should remain a sanctuary in which clients can focus on themselves and their needs while receiving clear, clean feedback and guidance.

WHAT DEFINES A MULTIPLE ROLE RELATIONSHIP?

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 or counseling client. 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 start a sexual relationship upon termination of therapy, thus altering the dynamics of the ongoing professional relationship.

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 lesson, 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 prove harmful (Bennett, Bricklin, & VandeCreek, 1994, Smith & Fitzpatrick, 1995) and that duty to clients does not necessarily end with therapy termination.

EVALUATING MULTIPLE ROLE RELATIONSHIPS

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 a risk of exploitation might result. 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, we remain unconvinced that accurate outcome predictions of relationships 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 family relationships (Epstein & Bower, 2005).

We also contend that a  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 delude 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, Lowell, 2012, Merritt, Effron, & Monin, 2010), Monin & Miller 2011, Tenbrunsel & Messick, 2004).

Risk Assessment

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 consensual individuals as opposed to the brief professional experience. That is, the therapist and the workshop attendee may go out together only to find that they have nothing in common and even grate on each other’s nerves. However, the prior role could remain barely at issue.

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.

Therefore, in sum, we have the following factors to assess when contemplating a blending of roles:

Risky Therapists

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 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 or can even deny that anything untoward occurred.

Self-Disclosure by Therapists

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; and Peterson, 2002). 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. Absorbing therapy time with extended renditions of one’s own personal history and family issues is not typically justifiable. Gutheil (1994) notes, and our experience on ethics committees confirms, that excessive self-disclosure of personal information to clients often precedes sexual misconduct with clients.

Of course, clients may be the ones to instigate inquiries about their therapists’ personal lives. It seems reasonable to expect that some would want to know as much as possible about the person in whom they place 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. Shell?” “Why do you ask me that, Maurice?” Not all clients’ questions should be answered, 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.

Professional Isolation

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 ruthless personal attacks on colleagues, especially whenever anyone criticized as outmoded her theoretical foundation. 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.

Therapeutic Orientation and Specialty Practices

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). 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. Several weeks later, she made a serious suicide attempt and required hospitalization for several months.

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 only for spiritual guidance. Pew should have focused on his role as a pastor and simultaneously referred Ms. Devine to someone competent to treat her depression.

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 particular niche, such as specializing in video game addicted adolescents, military wives, and repeat DUI offenders (Gottlieb, 2012). Training standards for these 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.

Risky Career Periods

No matter how long you have practiced as a counselor or other mental health professional, specific risks link to each career development period. We will briefly describe those 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. Furthermore, some therapists experienced appalling supervisory models, involving sexual advances and other improper behaviors when they were students (Glaser & Thorpe, 1986; Pope, Levenson, & Schover, 1980).

Kat Kopy, LCSW, enjoyed her last supervisor because he was funny and flirty and took her out to for drinks after every session. She decided that her clients would benefit from the same kind of happy relationship. Her client, Roger Rage, misunderstood her affable demeanor and their after-session coffee house excursions, believing 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 profession or life in general 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, PhD, 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 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, loaded with emails she had saved and photos she had quietly 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 tuition assistance for the two older ones in college. He told his life story to one of his longer-term clients who tried to console Justin by offering him a free apartment to get through a transition period. However, after a few months the client suggested that he should move on to his own place. An angry Justin became enraged and terminated the client. Justin 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 had 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 having evolved beyond questioning or having earned some sort of “senior pass” bequeathing the freedom to do whatever they please. 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.

Gloria Vast, Ph.D. refers to herself as the “grand dame of psychology.” For many years she has run large encounter groups based on her long-standing, best-selling book, Touch Yourself, Touch the Universe. Now in her late 60s, she pays several of her current clients a minimum wage to assist her. If her client-workers become disaffected, she berates them and sometimes banishes them. One client expelled from the circle successfully pressed charges of exploitation with a state licensing board.

Alan Groupie, Ph.D. 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 his 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.

Risky Clients

Not every client can tolerate 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 because of 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 27/7.

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.

MAKING ROLE BLENDING DECISIONS

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 towards the “more risky” column, we advise considerable caution.

Evaluating Additional Roles with Psychotherapy Clients

Considerations Regarding Added Role Dimensions

More Risky

Less Risky

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

High

Low

Therapist and client expectations

Incongruent

Congruent

Therapist and client obligations in the contemplated relationship

Disparate

Similar

Duration (or expected duration) of therapy

Longer-term

Short-term

Termination (or expected termination)

Conflicted / no time specifiable

Mutual/Satisfactory

Prospects that client requires follow-up later

Very likely

Unlikely

Extent to which therapist’s personal needs would be gratified more than those of the client

Considerable

Very small; negligible

Impulsivity of the therapist

High

Low

Degree of client pathology or abuse history

High

Low

Firmness of client’s personal boundaries

Loose

Solid

Degree of client’s autonomy

Low/needy

High/self-confident

Duration of therapist’s professional experience

Beginning practitioner

At least one year of active, independent practice

Extent to which confidentiality can be indefinitely maintained

Not likely

Very likely

Therapist’s access to collegial interaction and support

Little/isolated

Considerable

Extent of client’s understanding of, and informed consent to, the contemplated added relationship

Minimal

Full

The worst-case outcome scenario of the contemplated relationship remains relatively benign

No

Yes

A consultation with a colleague about the contemplated relationship has taken or will take place before going forward

No

Yes

The problem 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.

Red Flag Alerts

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, 2008).

Rationalizations even include blaming the client for untoward consequences. A senior psychologist was successfully sued in a highly publicized case wherein her personal life and that of a young male client became completely intertwined until he wanted out. She told a news reporter, “I went out of my way to help him and he paid me back by destroying my career. I should have known. Once a snake, always a snake.”

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. 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 (Canter, Bennett, Jones, et al., 1994). This makes good sense considering that we can seldom fully predict harmful outcomes in advance. As Brown (1994) wisely stated, “The goal of an ethical decision is not to avoid any and all violations of boundaries, for this is impossible. Instead, the goal is to remain on the more innocuous end of the continuum, in the position where the abuse and exploitation of the power of the therapist are minimized”(p. 279).

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.

BARTERING ARRANGEMENTS WITH CLIENTS

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 code has dropped the introductory cautionary statement, leaving only the admonition that professional judgment be used regarding clinical contraindications and potential for exploitation before entering into barter agreements with clients. The American Counseling Association (2005) also warns against exploitation and taking any unfair advantage of clients, notes that cultural and community standards be taken into account, and mandates that any concerns be discussed and that there be a written contract. The American Association of Marriage and Family Counseling (2012) lists similar sensitivity, but also specifies that the client (or supervisee) must be the one who requests a barter arrangement. Finally, the National Association of Social Workers (2008) 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 psychological services transformed from a forbidden practice to a nearly incidental ethical matter? In the late 1980s, the vast majority psychologists, according to a large national survey, had never accepted a service or product payment for therapy, and those that had did so only rarely (Borys & Pope, 1989). However, insurance coverage for mental health services has since decreased and the general economic downturn has impacted negatively on almost everyone in some way. Thus, more people seeking psychotherapy may lack the ability to afford it, but they may possess skills or objects to trade (Hill, 1999).

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. We acknowledge that entering into bartering agreements with clients appears reasonable and even a humanitarian practice towards 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. Here are a few examples that have come to our attention:

In each of these situations community mental health resources were scarce as were the clients' assets, and exploitation did not present an issue. The services were of limited duration, the economic value of the exchanges was not excessive. The clients’ needs were specific, circumscribed, and did not involve complex transference issues or open-ended demands. The chances of untoward results were minimal in all three cases, although the marriage and family counselor accepting the fresh produce did confide to us that “being practically knee deep in 150 pounds of corn presented a logistical challenge.”

Exchanging Services

Let us now compare the above examples to another example that also appears to operate smoothly, at least for now.

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.

Decora Shod, D.S.W., was treating a client who owned a furniture manufacturing outlet. Dr. Shod mentioned that she was in the process of redecorating her home. The client offered to let Shod select furniture from his warehouse at his cost if Shod would see him at a greatly reduced rate. The client reasoned that they would both benefit because Shod would be receiving more for far less than she could in retail outlets, and the client could also save money. Shod agreed to the proposal. In therapy, Shod increasingly confronted the client in areas in which she felt the client was self-destructive and defensive. The client reacted negatively and contacted an ethics committee, charging Shod with attempting to lock him into unnecessary treatment until her home was completely refurnished.

These cases illustrate 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. Court's impatience and Shod's confrontations might have worked appropriately under simpler circumstances. However, because of the intertwining of nonprofessional issues in each situation, Dr. Dump was perceived as retaliatory and Dr. Shod as self-serving.

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 towards 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.

X. Ploit, Ph.D. offered an unemployed landscaper, Sod Flower, the opportunity to design and redo his grounds in return for psychotherapy. Dr. Ploit charged $100 an hour and credited Flower at a rate of $15 an hour, which meant that Flower worked over 6 hours for every therapy session received. Flower complained to Dr. Ploit that the amount of time he was spending on the therapists large grounds prevented him from entering into full-time employment. Dr. Ploit responded that Flower could choose to terminate therapy and return when he could afford to pay the full fee.

Dr. Ploit's case is even more complicated and bothersome. Ploit figured the amount due for an ongoing service considerably below the going rate for a skilled landscaper. The bartering contract most likely did contribute substantially to the client's difficulties. When the landscaper-client complained, the therapist interrupted the agreement and abandoned the client. In the actual incident, the client eventually successfully sued the therapist for considerable damages.

Notta Rembrandt proposed that she paint a portrait of Gig Grump, Psy.D. in exchange for psychotherapy. Dr. Grump posed, and Rembrandt received therapy on an hour-for-hour basis. On the 11th session, Grump viewed the almost-completed portrait for the first time and expressed dissatisfaction, calling it “hideous.” An insulted Rembrandt insisted that the portrait was superb and “captured Grump's soul.” The conversation escalated into a fervent argument. Rembrandt grabbed her canvas, stomped out, and did not return. Dr. Grump sent Rembrandt a bill for 10 sessions. Rembrandt filed an ethics charge. Grump responded that the whole arrangement was the client's idea, and he had no responsibility for the outcome.

Possible transference and countertransference issues notwithstanding, the arrangement between Rembrandt and Grump began as a shaky one, given the wide variability in artistic tastes. Rembrandt prevailed in her ethics complaint. Grump's attempt to fault the client was not a persuasive defense, although he did offer to withdraw his bill. Sometimes others who do not understand the implications of doing so propose bartering arrangements. Consider the following posting to Craig’s List.

Barter counseling for bathroom repair

“My husband is a capable and (sic) effecive counselor, licensed...but he is not good at home repairs/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 plumbing. We had a termite problem that we fixed but the place needs a new floor and other stuff...if you are struggling with depression or bipolar, he is your man ... maybe your spouse, child, etc. He is truly 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! thanks.”

Aside from problems with spelling and punctuation, the psychologist’s spouse has no clue about the potential complications of the solicitation. Does she really want the services of a bipolar plumber?

Exchanging Services For Goods

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 (Canter et al., 1994). However, the actual value of goods often depends heavily on what buyers are willing to pay for them. 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 as a result 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 towards 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).

When Gemmy Sparkle wanted to buy a house, she decided to start selling her mother’s antique jewelry. She brought an exceptionally nice piece to show her therapist, Marilyn Buyit, M.S.W. Buyit asked how much Sparkle wanted for it, and Sparkle quoted her a price that seemed quite reasonable given the size of the rubies. Buyit bought it outright for the quoted price, paying cash. Over a year later, and after the therapy relationship had successfully terminated, Sparkle learned that the piece was worth far more than Buyit paid for it. Sparkle called Buyit, asking for an additional $2,000. A stunned Ms. Buyit refused.

In the actual case, the client took the therapist to small claims court and told everyone that the therapist had “taken her for a ride.” The client did not prevail, but the local paper of the small town carried a brief article about the case. The therapist’s client base fell substantially and the residual effects had not gone away, even two years later. Even though the therapist had paid the full asking price, the ex-client’s distress took a toll on the therapist’s practice.

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 and with no need of therapist involvement.

Final Considerations Regarding Bartering

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, Bennett et al., 2007). 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 (Woody, 1998) – one that the client clearly finds agreeable. A colleague told us of a client who needed money and offered the therapist the opportunity to purchase the client’s rare antique carved Chinese screen. The client had even gone to the trouble of researching its likely market value at the local museum. However, there were clear indications that parting with this possession would be extremely emotionally painful for the client, and it also seemed very likely that the client would never again have the financial capacity to replace it. As much as our colleague admired the screen, she knew that she was not the right person to purchase it, and, instead, referred the client to a financial counselor to search for alternative solutions to his financial crisis.

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.

CROSSING BOUNDARIES WITH THOSE ONE ALREADY KNOWS

Providing Services to Close Friends and Family Members

Mental health professionals come to expect frequent requests for advice from friends and family members. Queries range from how to handle a child's acting out against other children to how to convince a proud grandmother with short-term memory loss to move into an assisted living facility. When more than factual information or casual advice is indicated, 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 function 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 become easily 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 cases illustrate, 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 friendship became greatly diminished.

The school recommended an intellectual assessment of 9-year-old Freddy. Freddy’s father, Paul Proud, asked his brother, Peter Proud, Ph.D. to perform it. The results revealed some low-performance areas and a full-scale IQ score of 93. Paul was very upset with his psychologist-brother for “not making the boy look good to the school.”

Faulty expectations, mixed allegiances, role confusion, and misinterpretations of motives can lead to disappointment, anger, and sometimes a total collapse of relationships. Dr. Stern's friend could not commit to the obligations of the professional alliance, but expected results anyway. Dr. Proud's brother assumed that a close family member would willingly fudge test results.

To conclude this section, 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 a competent referral.

Accepting Acquaintances as Clients

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. Nevertheless, the simple exercise below might prove useful, with “PC” standing for the potential client whose status requires consideration.

If your answer is “yes” to any of the below, the potential client is likely a friend:

If your answer to any of the below is “yes,” the potential client is probably 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 from the head of admissions of the local college to which your daughter has applied to work with his alcoholic wife, 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.

Socializing With Current Clients

Commentators on the nature of psychotherapy have referred to it 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. However, as Bogrand has put it, “When the therapist or teacher offers the client or student friendship, it is an offer that cannot be refused” (1993, p. 10). Here, we explore the ethical issues that emerge when therapists socialize in non-professional settings with ongoing clients.

The various complications that can arise when 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 an unwelcome surprise.

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.

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. During one such event, 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.

Raphael Baroque, professional artist, complained to an ethics committee that Janis Face, Ph.D. did not follow through with her promises. Baroque had been Dr. Face's client for more than a year, during which time she praised his artwork and accompanied him to art shows. She even promised, according to Baroque, to introduce him to some collectors. Baroque began to feel so self-assured that he terminated therapy, fully expecting that their mutual interest in his career would continue. However, Dr. Face did not return his calls. Baroque became frantic. When contacted by an ethics committee, Dr. Face explained that she always unconditionally supported her clients. But, because Baroque was no longer a client, she had no further obligation to him.

Ethics committees found in favor of both Flash and Baroque. The therapists had intertwined their lives in ways that confused the clients. Baroque, especially, experienced harm because of Dr. Face's failure to fully grasp the potential consequences of the significant dependency she had nurtured in her client.

Becoming Friends with Clients After Therapy Ends

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 (2001) ethics code do not specify prohibitions against nonsexual post-termination friendships. The American Counseling Association (2005) 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. However, if the 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 person as in a nonprofessional context and may fail, as Neale (2010) puts it, to be an 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 Nomi’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 outside of 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.

Here the relationship 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.

GIVING GIFTS TO CLIENTS

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. We usually find it prudent to refrain from bestowing gifts on clients.

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 towards 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 a situational need and common sense, such as giving a client a quarter for the parking meter, would not raise concerns. In these acceptable cases, no ulterior motives pertain, and the scope either relates to the therapy or has 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 3 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.

Providing Psychotherapy to Former Lovers
Avoiding soliciting or accepting an ex-lover as a client seems like a no-brainer, but it does happen on occasion. 

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.

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 has sex with someone, the dynamics are forever altered.

ACCEPTING CLIENTS' REFERRALS OF THEIR CLOSE RELATIONS

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 save both a therapeutic alliance as well as 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 said, 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.

Tuff Juggle, Psy.D. accepted Jane Amiga as a client with full knowledge that she and Sandy Comrade, an ongoing client, were best friends and that aspects of the friendship were serious treatment issues for Sandy. He reasoned that he could compartmentalize them sufficiently and that the women would benefit from the fact that he knew them both. One day, he slipped and shared with Sandy something that Jane had told him during a private session. Jane brought ethics charges against Juggle for breach of confidentiality.

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. Although Dr. Juggle's situation involved a less engrossing relationship between two clients, that the friendship was an issue should have provided a sufficient front-end warning. Juggle's slip of the tongue to the wrong party provides an example of an ever-present pitfall when consulting people who know each other well enough to share some of the same material during their individual sessions. Even the sharpest of memories may fail under such circumstances.

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 the 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, and he needed the income. 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 a much saner person than was her 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 at the onset that he could not ethically treat her mother while he also had 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 clinician declines their request for services or attempt 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 to make the referral (Shapiro & Ginzberg, 2003). If things have the potential to become sticky, we advise referring the potential client to a suitable colleague.

RURAL SETTINGS AND OTHER SMALL-WORLD HAZARDS

Role clashes become impossible to avoid for mental health professionals working in small, isolated communities. 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. One psychologist, who was the only mental health provider within in a 60 miles 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 to avoid unwelcome face-to-face meetings in the waiting room. Yet another therapist requested guidance from an ethics committee when a client's alcoholic and abusive husband yelled profanities at him at every opportunity - in the barbershop, bowling alley, restaurant, market, and even as they passed each other in their cars.

One estimate suggests that almost 25% of the 62 million people who live in small towns and rural areas suffer from some sort of mental or emotional problem (Roberts, Battaglia, and Epstein, 1999). Unfortunately, demand for services often exceeds resources in these locales (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 et al., 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 (Hargrove, 1986; Solomon, Hiesberger, & Winer, 1981). 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 simply to 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 – and everyone will know of the purchase, what make and model, and where it was purchased – 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 good 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 constant and deliberate efforts to minimize the 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, such as giving gifts to clients, 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 et al. (1999), reveals the highly unethical role blending that can still 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 staunchly 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.

NONTRADITIONAL THERAPY SETTINGS

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 Los Angeles to San Diego 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.

Several encounter group members charged that the counselor associated with the Touchit Clinic conducted weekend retreats at a local hotel in a way that facilitated coercive and promiscuous behavior among the participants. They believed that various exercises encouraged and stimulated some members to become obnoxious and to pressure others into sexual activity after the formal evening activities concluded.

Lynn Bones broke both legs skiing and would not be able to drive for 6 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. The Touchit Clinic staff did an insufficient job of setting ground rules and monitoring compliance. 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 a convenience and financial standpoint. While not inherently inappropriate, 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) 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. For example, a client could act out in 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.

UNANTICIPATED ENCOUNTERS WITH CLIENTS

Every mental health professional is at the mercy of coincidence, and a totally unexpected compounding of roles may occur by chance. 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 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 of the 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 not have been inappropriate 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 actually 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 bank, 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 actually received. These results verify that no one size fits all.

WHEN THERAPISTS ARE CAUGHT IN THE MIDDLE

We have focused on multiple role relationships in which the mental health professionals directly occupied one of the roles. However, situations can arise that pinch therapists between two or more other forces. For example, demands of the agencies employing therapists may conflict with the needs and welfare of the agencies’ clients. This dilemma is increasing as managed care takes over privately contracted services between therapists and clients (Smith & Fitzpatrick, 1995).

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 through the use of 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.

FINAL THOUGHTS

Using the most recent ethics code of the American Psychological Association (2010), the seemingly looser restrictions on nonsexual multiple roles, as compared to three decades or so ago, might actually place the unaware therapist at far 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. The same theme holds for the ethics codes of other professional associations that warn against exploitation and harm.

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 always be documented should it ever become necessary to defend a venture into another 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 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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