Multiple Relationships in Psychotherapy and Counseling

Unavoidable, Common, and Mandatory Dual Relations in Therapy

Ofer Zur

• Publisher: Routledge
• Year: 2016
• Print ISBN: 9781138937789
• eBook ISBN: 9781317384250
• Topic: Psychology
• Subtopic: Mental Health in Psychology
• Index: Psychology

This first-of-a-kind analysis will focus exclusively on unavoidable and mandated multiple relationships between clients and psychotherapists. The book will cover the ethics of a range of venues and situations where dual relationships are mandated, such as in the military, prisons/jails, and police departments, and settings where multiple relationships are unavoidable, such as rural communities; graduate schools and training institutions; faith, spiritual, recovery or 12-step, minority and disabled communities, total institutions, and sport psychology. The complexities of social network ethics and digital dual relationships, such as clients becoming "friends" or "fans" on their therapists' social media pages are discussed.  Finally, the book will discuss the complexities multiple roles that inevitably emerge in supervisory relationships.

Part I

Introduction and Ethical Decision Making for Boundaries and Multiple Relationships in Psychotherapy and Counseling

INTRODUCTION

Ofer Zur

Part I (Chapters 1 and 2) provides a general introduction to the ethics of multiple relationships and puts them into the context of other therapeutic boundaries, such as gift giving and receiving, bartering, touch, self-disclosure, and language.

In Chapter 1, Dr. Barnett introduces the constructs of boundaries and contrasts boundary crossing with boundary violations. He defines the term multiple relationships and discusses how the codes of ethics delineate ethical multiple relationships. The chapter discusses ethical decision making and the importance of informed consent, especially in settings where multiple relationships are unavoidable. It concludes with a list of recommendations that can serve therapists as guidelines for handling multiple relationships.

In Chapter 2, Dr. Younggren and Dr. Gottlieb provide one of the most inclusive lists available of settings and situations where therapists face multiple relationships, multiple duties, or multiple loyalties. The chapter differentiates between mandated dual relationships, administrative duality, and civil duties, including reporting laws, criminal duality, and other types of mandated multiple relationships, and unavoidable multiple duties. It ends with a discussion about risk management and informed consent regarding mandatory multiple relationships and multiple duties.

CHAPTER 1

AN INTRODUCTION TO BOUNDARIES AND MULTIPLE RELATIONSHIPS FOR PSYCHOTHERAPISTS

Issues, Challenges, and Recommendations

Jeffrey E. Barnett

Boundaries are defined as the ground rules of the professional relationship that help establish, and provide guidance on, acceptable and unacceptable behaviors by psychotherapists (Knapp & VandeCreek, 2012). Boundaries provide “a therapeutic frame which defines a set of roles for the participants in the therapeutic process” (Smith & Fitzpatrick, 1995, p. 499) and, when effectively and appropriately applied, they “provide a foundation for this relationship by fostering a sense of safety and the belief that the clinician will always act in the client’s best interest” (p. 500). In essence, the thoughtful and appropriate application of boundaries helps psychotherapists to most appropriately and effectively assist their clients in an ethical and clinically effective manner (Moleski & Kilesica, 2005; Zur, 2007).

Psychotherapists have a significant responsibility to do their best to ensure that their actions serve their clients’ best interests and that clients are not exploited or harmed. This responsibility has been described by Jorgenson, Hirsch, and Wahl (1997) as a fiduciary responsibility to one’s clients. This means that the psychotherapist agrees to act in the client’s best interests. Yet, as this book will clearly illustrate, doing so is not always easy and straightforward. Depending on the setting and context, mental health practitioners may have multiple obligations, roles, and allegiances that make applying our responsibilities to clients and others quite complex and challenging.

BOUNDARIES IN PSYCHOTHERAPY: AVOIDING, CROSSING, AND VIOLATING BOUNDARIES

There exists a wide range of boundaries that are relevant to the psychotherapy relationship. Examples include touch, self-disclosure, time and place of treatment, interpersonal space, gifts, clothing, language, finances, and multiple relationships.

Each of these boundaries falls on a continuum that ranges from avoiding it completely to participating in it actively in a variety of ways. Depending on the specific situation, a particular action or behavior by the psychotherapist may be found to be helpful, harmful, or benign, appropriate or inappropriate, and ethical or unethical.

A widely used way of conceptualizing the boundaries continuum is to view them as being avoided, crossed, or violated (Smith & Fitzpatrick, 1995). For the boundary of touch, an example of avoiding this boundary would be having a policy that forbids engaging in any physical contact with clients. While such an approach would be counterproductive and inappropriate for many clients, in some settings and situations this may be necessary. For example, such a prohibition against physical touch might be seen on inpatient units or in prison settings.

To violate a boundary means that the boundary is traversed but that it is done in a way that holds a significant potential for exploitation of, or harm to, the client; that is clinically contraindicated, that is not consistent with the client’s treatment plan or history, that violates legal and/or ethics standards, that violates social or cultural norms or mores for the client, and that takes advantage of the client’s dependence and trust. With the boundary of touch, an example of a boundary violation is engaging in sexual or intimate touch with a client.

To cross a boundary means that the boundary has been traversed (e.g., engaging in touch with a client), but that it is done in a way that is not clinically contraindicated, that is consistent with the client’s treatment needs and history, that is culturally appropriate and responsive to the client’s background and preferences, that does not exploit or harm the client, and that does not violate the client’s dependence and trust. Additional considerations include the psychotherapist’s intent and motivations for engaging in the behavior in question, how this action or behavior is perceived by the client (Barnett, Lazarus, Vasquez, Moorehead-Slaughter, & Johnson, 2007a; Zur, 2007), the psychotherapist’s theoretical orientation, and the nature of the treatment being provided (Williams, 1997). An example of boundary crossing with touch is to shake a client’s extended hand.

BOUNDARY CHALLENGES

As is hopefully evident from the above discussion, an absolute avoidance of all boundaries is neither desired nor possible. In fact, boundary crossing can be seen as essential to developing and maintaining an effective psychotherapy relationship (Zur, 2007; Zur & Lazarus, 2002). In an effort to avoid unethical and harmful behaviors, some psychotherapists may take an overly conservative approach to boundaries in the psychotherapy relationship. But, a rigid risk-avoidance application of boundaries (i.e., rejecting a client’s small symbolic gift or a handshake) can actually result in harm to the client by creating a sterile or even shaming relationship that does not promote a positive therapeutic alliance (Barnett et al., 2007a, Gottlieb & Younggren, 2009).

To determine if certain actions are boundary crossings or boundary violations one must consider the client’s age, gender, culture, history, and diagnosis, as well as the therapeutic approach employed, the psychotherapist’s age, gender, culture, training, and, as was noted above, the setting in which treatment takes place.

MULTIPLE RELATIONSHIPS

An important boundary issue of relevance for many psychotherapists is that of multiple relationships, the focus of this book. Multiple relationships involve participating in one or more additional relationships or roles with clients, former clients, or significant others in their lives in addition to the psychotherapy relationship or beginning psychotherapy with an individual with whom a psychotherapist has previously maintained an additional relationship. A range of multiple relationships is possible. Examples include business relationships, personal or social relationships, and romantic or sexually intimate relationships, among others.

The Ethical Principles of Psychologists and Code of Conduct (American Psychological Association (APA) Ethics Code; APA, 2010) addresses the nature and extent of multiple relationships in Standard 3.05, Multiple Relationships, stating:

A psychologist refrains from entering into a multiple relationship if the multiple relationship could reasonably be expected to impair the psychologist’s objectivity, competence or effectiveness in performing his or her functions as a psychologist, or otherwise risks exploitation or harm to the person with whom the professional relationship exists.

Multiple relationships that would not reasonably be expected to cause impairment or risk exploitation or harm are not unethical.

(p. 6)

Thus, the APA Ethics Code, like most other codes of ethics, is very clear in stating that not all multiple relationships are unethical and must be avoided. It is only those that hold a significant potential to adversely impact the psychotherapist’s objectivity and judgment and/or to place the client at significant risk of harm that should be avoided. These admonitions are consistent with the guidance provided above on how to successfully navigate boundaries, yet, at times may prove challenging for psychotherapists.

Other standards in the APA Ethics Code (APA, 2010) that provide additional guidance relevant to multiple relationships include Standard 3.04, Avoiding Harm, and Standard 3.06, Conflicts of Interest. Standard 3.04 states “Psychologists take reasonable steps to avoid harming their clients/patients . . . and others with whom they work, and to minimize harm where it is foreseeable and unavoidable” (p. 6). Standard 3.06 adds:

Psychologists refrain from taking on a professional role when personal, scientific, professional, legal, financial, or other interests or relationships could reasonably be expected to (1) impair their objectivity, competence, or effectiveness in performing their functions as psychologists or (2) expose the person or organization with whom the professional relationship exists to harm or exploitation.

(p. 6)

As will be seen, each of these standards plays a significant role in each psychotherapist’s decision-making process when considering if a planned multiple relationship is acceptable and appropriate. To complicate the matter, as this book illustrates, avoiding multiple relationships, even those that may hold the potential to be harmful to clients, is not always possible in settings where multiple relationships at times are mandatory, such as in the military and correctional facilities.

Mental health professionals should be aware that some multiple relationships are avoidable, some are unavoidable, and some are mandated. Those multiple relationships that hold great potential to exploit or harm clients and that are easily avoidable should definitely be avoided (e.g., becoming partners in a real-estate business with a client, engaging in a sexual relationship with a client). In settings where multiple relationships are mandated or unavoidable, mental health professionals must carefully consider their divided allegiance and how to best meet potentially conflicting agendas and obligations.

Military psychologists, for example, must provide clinical services in a system where their “client” is not the person sitting across from them seeking mental health treatment. In fact, their client is actually the Department of Defense and their ultimate obligation is the combat-readiness of the service members to whom they provide clinical services. Furthermore, at times, commanders will refer service members for treatment with the clear goal being to get the service member combat-ready (regardless of what the service member’s goals are). Many military psychologists will experience the tension of divided loyalties or what Kennedy and Johnson (2009) call “mixed agency,” due to the owing of obligations to both the individual service member and the military service overall. This can create frequent dilemmas regarding treatment planning and goal setting, treatment decisions, and confidentiality. Many of these issues may be addressed in the informed-consent process.

Additional multiple relationship challenges in insular or isolated communities, such as rural communities, isolated military bases, and certain ethnic or racial and LGBT communities, include being in multiple relationships and not having other options. A military psychologist on an aircraft carrier or a remote base may be required to provide treatment to her or his commander, the individual who is her or his boss, or even his or her bunk mate. Similarly, a child psychologist may be the only one with such specialty in a remote rural community and may need to evaluate or provide treatment to his or her child’s classmates or friends. While making a referral might be desirable, at times there are no referral options and the decision to be made is how to best manage the multiple relationship, not if this situation is optimal.

As with boundaries in general, there will be those multiple relationship situations that will be clearly appropriate and those that will be clearly inappropriate. For example, a psychotherapist in a rural setting where there are few other professionals to whom one may refer a client may agree to treat a member of his or her religious congregation. This may be seen as quite different from entering into an intimate romantic relationship with a current client or providing marital therapy to one’s parents in law. But, not all multiple relationship decisions are so clear and straightforward. Most frequently, they are more ambiguous and the decision-making process is more complex and challenging.

ETHICAL DECISION MAKING

Important guidance to consider when deciding if a planned multiple relationship is acceptable is found in the aspirational ethical ideals of the profession, as articulated in the General Principles of the APA Ethics Code (APA, 2010).

Beneficence and Non-maleficence

This involves providing help and assistance to clients while avoiding harm to them. Further, psychologists “are alert to and guard against personal, financial, social, organizational, or political factors that might lead to misuse of their influence” (p. 3).

Fidelity and Responsibility

Under these principles, psychologists fulfill expected obligations to clients and only act in ways that serve their clients’ best interests. This includes that psychologists “seek to manage confl...

Table of contents

• Cover Page
• Multiple Relationships in Psychotherapy and Counseling
• Title
• Copyright
• Contents
• Notes on Contributors
• Acknowledgments
• Introduction: The Multiple Relationships Spectrum: Mandated–Unavoidable–Common–Ethical–Unethical . . . and Beyond
• PART I Introduction and Ethical Decision Making for Boundaries and Multiple Relationships in Psychotherapy and Counseling
• PART II Mandatory Multiple Relationships in Military, Police, and Forensic Settings
• PART III Unavoidable Multiple Relationships
• PART IV Common-Normal Multiple Relationships in Higher Educational Settings
• PART V Multiple Relationships in Cyberspace
• PART VI Multiple Relationships and Multiple Roles in Unique Settings of Supervision
• Index