Dual or Multiple Relationships in Psychotherapy

Course excerpt from Ethics & Boundaries in Psychotherapy

Dual RelationshipDual relationships (Zur, 2014) refer to situations where two or more connections exist between a therapist and a client. Examples of dual relationships are when a client is also a student, friend, employee or business associate of the therapist. Zur defines many types of dual relationships, including social, professional, business, communal, institutional, forensic, supervisory, sexual, and digital, online, or internet dual relationships. While all dual relationships involve boundary crossing, exploitive dual relationships are boundary violations.

Multiple relationships are situations in which a therapist is engaged in “one or more additional relationships with a client in addition to the treatment relationship. Multiple relationships may be sexual or nonsexual. Nonsexual multiple relationships may include social, familial, business or financial relationships, and possibly others. Multiple relationships are distinguished from incidental contacts. Incidental contacts are situations in which the psychologist and client have an interaction in another setting that is unplanned and very brief. Examples may include noticing that the psychologist and client are attending the same concert or community event, being members of the same organization, or briefly crossing paths in the community” (Barnett, 2014).

For many psychologists practicing in rural and small communities, dual relationships are everyday occurrences. The person who bags groceries in the supermarket, pumps gas, works in a dentist’s office or chaperones children on school field trips may often also be the therapist’s client.

Unavoidable dual relationships are also the norm within numerous small populations in larger metropolitan areas, such as gay/lesbian, handicapped, various minorities, religious congregations and other such distinct small societies. In fact, duality, mutual dependence and prior knowledge of each other are prerequisites for the development of trust and respect in these communities.

Zur (2005) goes further in expressing the idea that “rigid avoidance of all boundary crossings and dual relationships raise two major concerns: First, I am concerned that rigid implementation of such boundaries decreases therapeutic effectiveness. Second, as exploitation as a rule happens in isolation, I am concerned that the isolation imposed by rigid boundaries increases the likelihood of exploitation of, and harm to, clients. Rigid boundaries in fact increase the therapist’s power and, therefore, increase the chance of a client being exploited.”

Epstein & Simon (1992) developed an “Exploitation Index” for clinicians to use to evaluate their own boundary maintenance. Some areas which require self-awareness and watchfulness by one’s supervisors or consultants are:

• Obvious therapist distress or upset
• Therapeutic drift — shifting style and approach to a given client
• Lack of goals and reflection on progress in therapy
• Therapy which exceeds normal length for a client of that type in the particular therapist’s practice
• Exceeding areas of competence, reluctance or unwillingness to refer for other types of therapy, assessment, etc.
• Unwise techniques such as hugs or excessive touch
• Becoming enmeshed in client’s life — treating close friends or family members
• Unique vulnerabilities like attraction to or over-identification with client

Multiple relationships are addressed in most professional codes of ethics. For example, the AAMFT Code of Ethics addresses the issue in Article 1.3:

Marriage and family therapists are aware of their influential positions with respect to clients, and they avoid exploiting the trust and dependency of such persons. Therapists, therefore, make every effort to avoid conditions and multiple relationships with clients that could impair professional judgment or increase the risk of exploitation. Such relationships include, but are not limited to, business or close personal relationships with a client or the client’s immediate family. When the risk of impairment or exploitation exists due to conditions or multiple roles, therapists take appropriate precautions.

The NASW Code of Ethics describes multiple relationships (“dual or multiple relationships occur when social workers relate to clients in more than one relationship, whether professional, social, or business. Dual or multiple relationships can occur simultaneously or consecutively”) and addresses them in Article 1.06 (c):

Social workers should not engage in dual or multiple relationships with clients or former clients in which there is a risk of exploitation or potential harm to the client. In instances when dual or multiple relationships are unavoidable, social workers should take steps to protect clients and are responsible for setting clear, appropriate, and culturally sensitive boundaries.

Several other dimensions are added by the APA Code of Ethics Article 3.05 Multiple Relationships, which expands the concept to include relationships with individuals who are associated or related to clients:

(a) A multiple relationship occurs when a psychologist is in a professional role with a person and (1) at the same time is in another role with the same person, (2) at the same time is in a relationship with a person closely associated with or related to the person with whom the psychologist has the professional relationship, or (3) promises to enter into another relationship in the future with the person or a person closely associated with or related to the person.

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.

In summary, it seems clear that multiple relationships are of interest in the ethics codes of most major professional organizations. Are they innately hazardous for client and therapist? Not necessarily. Are they cause for ethical alertness and introspection? Yes.

Ethics & Boundaries in Psychotherapy is a 3-hour online continuing education (CE/CEU) course intended to give psychotherapists the tools they need to resolve the common and not-so-common ethical and boundary issues and dilemmas that they may expect to encounter in their everyday professional practice in the 21st century. Among the topics discussed are definitions of boundaries; resolving conflicts between ethics and the law; boundary crossings vs. boundary violations; multiple relationships; sexual misconduct; privacy and confidentiality in the age of HIPAA and the Patriot Act; ethics issues with dangerous clients; boundary issues in clinical supervision; ethics and cultural competency; ethical boundaries in use of social media; ethical practice in teletherapy; fees and financial relationships; and a 17-step model for ethical decision making. * This course satisfies the ethics & boundaries requirement for license renewal of Florida counselors, social workers & MFTs. Course #30-77 | 2015 | 40 pages | 21 posttest questions

Professional Development Resources is approved by the American Psychological Association (APA) to sponsor continuing education for psychologists; the National Board of Certified Counselors (NBCC ACEP #5590); the Association of Social Work Boards (ASWB #1046, ACE Program); the California Board of Behavioral Sciences (#PCE1625); the Florida Boards of Clinical Social Work, Marriage & Family Therapy, and Mental Health Counseling (#BAP346) and Psychology & School Psychology (#50-1635); the Ohio Counselor, Social Worker & MFT Board (#RCST100501); the South Carolina Board of Professional Counselors & MFTs (#193); and the Texas Board of Examiners of Marriage & Family Therapists (#114) and State Board of Social Worker Examiners (#5678).

Multiple Relationships Not Always Bad

By Ofer Zur, PhD

Entering into dual relationships with psychotherapy patients has been a topic of significant controversy in professional psychology. Although these types of extratherapeutic alliances have generally been considered to be unethical conduct, some authors recently have supported their development as both ethical and, in some cases, even therapeutic.

I was surprised to read the statement of my esteemed colleague, Ed Zuckerman, PhD, in the last issue of The National Psychologist (Nov/Dec, 2011), whereas part of an article on “The Fiduciary Heart of Ethics“ he stated, “We have an ethical obligation to avoid multiple relationships.”

This statement is in contrast to the APA’s code of ethics, (Section 3.05), which clearly states that: “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 not always badMultiple relationships not reasonably expected to cause impairment or risk exploitation or harm are not unethical.

Zuckerman’s statement and discussion of multiple relationships are not only incorrect, unsupported and outdated, but also are in clear contrast to the standard of care of psychotherapy and counseling. For example, multiple relationships are mandated in military settings where psychologists often have primary loyalty to the Department of Defense and only a secondary loyalty to the person they are treating in the consulting room. Multiple relationships are inherent in some correctional settings, such as prisons, where psychologists have a responsibility to the security of the institution, as well as to the mental health of actual patients.

Zuckerman, who to the best of my knowledge, lives in Pennsylvania, should be aware that multiple relationships are unavoidable in small communities and rural areas, which are quite prevalent in his state. In fact, they are a normal and healthy part of such interconnected communities. Familiarity and multiple relationships between all members of small communities, including health care providers, is how such communities survive and thrive.

Not all multiple relationships are created equal. There are different types of multiple relationships:

  • A social multiple relationship is one in which a therapist and client are also friends, acquaintances or have some other type of social relationship within their community.
  • A professional multiple relationship is where a psychotherapist/counselor and client, are also professional colleagues in colleges or training institutions, presenters in professional conferences, co-authors of a book, or other situations that create professional multiple relationships.
  • Institutional multiple relationships take place in the military, prisons, some police departments and mental hospitals where multiple relationships are an inherent part of the institutional settings.
  • Forensic multiple relationships involve clinicians who serve as treating therapists, evaluators and witnesses in trials or hearings.
  • Supervisory relationships inherently involve multiple relationships and multiple loyalties. A supervisor has a professional relationship and duty to the supervisee and to the client, as well as to the profession.
  • A sexual multiple relationship is where a therapist and client are also involved in a sexual relationship.

Sexual multiple relationships with current clients are always unethical. A business multiple relationship is generally ill-advised. These are relationships, in which a therapist and client are business partners or have an employer-employee relationship.

Multiple relationships can be ethical or unethical, legal or illegal, and can be avoidable, unavoidable or mandated. They can also be planned and anticipated or unexpected. Then they can be concurrent or sequential and can also very with different levels of involvement, from low/minimal to intense.

In summary:

  • Non-sexual multiple relationships are not necessarily unethical or illegal.
  • Multiple relationships can’t be avoided in many settings and are mandated in others.
  • Multiple relationships are a healthy part of small and rural communities.
  • Sexual multiple relationships with current clients are always unethical.

Non-sexual multiple relationships do not necessarily lead to exploitation, sex or harm. The opposite can be true. Multiple relationships can reduce isolation and prevent exploitation rather than lead to it. Almost all professional association codes of ethics do not mandate a blanket avoidance of multiple relationships.

Source: Ethics & Risk Management: Expert Tips VI