Multiple Relationships, & Boundary Issues in Psychotherapy

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Nonsexual Multiple Relationships & Boundaries in Psychotherapy

Ken Pope & Danny Wedding

The following section on nonsexual multiple relationships and boundaries in psychotherapy is from a chapter that is currently in press in Current Psychotherapies, 8th Edition edited by Raymond Corsini and Danny Wedding, scheduled to be published by Brooks/Cole in early 2007. The chapter is "Current Challenges and Controversies" by Ken Pope and Danny Wedding. The publisher, Brooks/Cole, holds the copyright to the chapter excerpt below. © 2007 Brooks/Cole, all rights reserved.

In the 1980s and into the 1990s, a vigorous, wide-ranging, and healthy controversy over therapists’ nonsexual multiple relationships and other boundary excursions blossomed. Was it good practice for a therapist to enter into dual professional roles with a client, serving, say both as a client’s therapist and as that client’s employer? What about multiple social roles? Is it helpful, hurtful, or completely irrelevant for a therapist to provide therapy to a close friend, spouse, or step-child? Are there any potential benefits or risks to social outings with a client (meeting for dinner, going to a movie, playing golf, or heading off for a weekend of sightseeing), so long as there is no sexual or romantic involvement? Are financial relationships (say, the therapist borrowing a large sum from a client to buy a new house or car, or inviting a client to invest in the therapist’s new business venture) compatible with the therapeutic relationship? What about lending a client money to help pay the rent or buy food and medications? Under what circumstances should a therapist accept bartered services or products as payment for therapy sessions?

The 15 years or so from the early 1980s to the mid-1990s saw these and other questions about multiple relationships and boundaries discussed—and often argued—from virtually every point of view, every discipline, and every theoretical orientation.

In 1981, for example, Samuel Roll and Leverett Millen presented “A Guide to Violating an Injunction in Psychotherapy: On Seeing Acquaintances as Patients.”

In her 1988 article on “Dual Relationships,” ethicist Karen Kitchener provided systematic guidance to readers on the kinds of “counselor-client relationships that are likely to lead to harm and those that are not likely to be harmful” (p. 217). According to Kitchener, the kinds of dual relationships that were most likely to be problematic were those in which there were “(1) incompatibility of expectations between roles; (2) diverging obligations associated with different roles, which increases the potential for loss of objectivity; and (3) increased power and prestige between professionals and consumers, which increases the potential for exploitation” (p. 217).

Similarly, in the 1985 edition of their widely used textbook Ethics in Psychology: Professional Standards and Cases, Patricia Keith-Spiegel and Gerald Koocher discussed ways in which boundary crossings may be unavoidable in good clinical practice and presented ways to think through the ethical implications of specific dual relationships or other boundary issues.

Patrusksa Clarkson, who wrote “In Recognition of Dual Relationships,” discussed the “mythical, single relationship” and wrote that “it is impossible for most psychotherapists to avoid all situations in which conflicting interests or multiple roles might exist” (1994, p. 32).

Vincent Rinella and Alvin Gerstein argued that “the underlying moral and ethical rationale for prohibiting dual relationships (DRs) is no longer tenable” (1994, p. 225).

Similarly, Robert Ryder and Jeri Hepworth (1990) set forth thoughtful arguments that the AAMFT ethics code should not prohibit dual relationships.

Jeanne Adleman and Susan Barrett (1990) took a fresh and creative look, from a feminist perspective, at how to make careful decisions about dual relationships and boundary issues.

Laura Brown (1989; see also 1994b) examined the implications of boundary decisions from another perspective in “Beyond Thou Shalt Not: Thinking about Ethics in the Lesbian Therapy Community.”

Ellen Bader (1994) urged that the focus on the duality of roles be replaced by an examination of whether each instance did or did not involve exploitation.

Elisabeth Horst (1989) and Amy Stockman (1990) were among those who explored issues of dual relationships and boundaries in rural settings.

Melanie Geyer (1994) examined some of the decision-making principles that had evolved for evaluating multiple relationships and boundary issues in rural settings and adapted them for some of the unique challenges faced by Christian counselors (and counselors for whom other religious faiths are a focus of practice).

Ethics & Behavior was one of many journals in the 1980s and early 1990s that spotlighted the richness of creative thinking in this area. In 1994 it published a special section in which prominent authorities debated diverse approaches to the issue of boundaries in therapy (Borys, 1994; Bennett, Bricklin, & VandeCreek, 1994; Brown, 1994; Gabbard, 1994; Gottlieb, 1994; Gutheil, 1994; Lazarus, 1994a, 1994b).

The care with which these diverse articles and books in the 1980s and first half of the 1990s examined a diverse array of contextual issues such as the nature of the community (e.g., rural or small town) and the therapist’s theoretical orientation, in thinking through whether a specific multiple relationship or boundary crossing was likely to be healing or hurtful, helped develop a more complex appreciation for both the potential benefits and the risks in this area. In 1989, a survey (return rate = 49 percent) of 1,600 psychiatrists, 1,600 psychologists, and 1,600 social workers found that therapists’ behaviors and beliefs about a wide range of dual relationships and other boundary issues tended to be significantly associated with factors such as:

  1. Therapist’s gender
  2. Therapist’s profession (psychiatrist, psychologist, social worker)
  3. Therapist’s age
  4. Therapist’s experience
  5. Therapist’s marital status
  6. Therapist’s region of residence
  7. Client’s gender
  8. Practice setting (such as solo or group private practice or outpatient clinic)
  9. Practice locale (size of the community)
  10. Therapist’s theoretical orientation (Borys & Pope, 1989; see also Baer & Murdock, 1995; Lamb & Catanzaro, 1998; Lamb, Catanzaro, & Moorman, 2004)

Research Leading to a Call for a Change in the APA Ethics Code

The first ethics code of the American Psychological Association was empirically based. APA members responded to a survey asking them what ethical dilemmas they encountered in their day-to-day work. A replication of that survey, performed 50 years after the original, led to a call for a change in the APA ethics code regarding dual relationships.

The second most often reported ethical dilemma that psychologists reported was in the area of blurred, dual, or conflictual relationships. These responses from such a wide range of psychologists led the investigators, Pope and Vetter (1991), to include in their report a call for changes to the APA ethics code in the areas of dual relationships, multiple relationships, and boundary issues so that the ethics code would, for example,

1. define dual relationships more carefully and specify clearly conditions under which they might be therapeutically indicated or acceptable;

2. address clearly and realistically the situations of those who practice in small towns, rural communities, remote locales, and similar contexts (emphasizing that neither the current code in place at the time nor the draft revision under consideration at that time fully acknowledged or adequately addressed such contexts); and

3. distinguish between dual relationships and accidental or incidental extratherapeutic contacts (e.g., running into a patient at the grocery market or unexpectedly seeing a client at a party) . . . [in order] to address realistically the awkward entanglements into which even the most careful therapist can fall.

The following section from the American Psychologist report of the study presents the relevant findings, examples, specific suggestions for changes, and reasoning:

[begin excerpt from 1991 Pope & Vetter American Psychologist study]

Blurred, Dual, or Conflictual Relationships

The second most frequently described incidents involved maintaining clear, reasonable, and therapeutic boundaries around the professional relationship with a client. In some cases, respondents were troubled by such instances as serving as both “therapist and supervisor for hours for [patient/supervisee’s] MFCC [marriage, family, and child counselor] license” or when “an agency hires one of its own clients.”

In other cases, respondents found dual relationships to be useful “to provide role modeling, nurturing and a giving quality to therapy”; one respondent, for example, believed that providing therapy to couples with whom he has social relationships and who are members of his small church makes sense because he is “able to see how these people interact in group context.”

In still other cases, respondents reported that it was sometimes difficult to know what constitutes a dual relationship or conflict of interest; for example, “I have employees/supervisees who were former clients and wonder if this is a dual relationship.”

Similarly, another respondent felt a conflict between his own romantic attraction to a patient’s mother and responsibilities to the child who had developed a positive relationship with him:

I was conducting therapy with a child and soon became aware that there was a mutual attraction between myself and the child’s mother. The strategies I had used and my rapport with the child had been positive. Nonetheless, I felt it necessary to refer to avoid a dual relationship (at the cost of the gains that had been made).

Taken as a whole, the incidents suggest, first, that the ethical principles need to define dual relationships more carefully and to note with clarity if and when they are ever therapeutically indicated or acceptable. For example, a statement such as “Minimal or remote relationships are unlikely to violate this standard” (“Draft Ethics Code of the American Psychological Association,” 1991, p. 32) may be too vague and ambiguous to be helpful. A psychologist’s relationship to a very casual acquaintance whom she or he meets for lunch a few times a year, to an accountant who only does very routine work in filling out her or his tax forms once a year (all such business being conducted by mail), to her or his employer’s husband (who has no involvement in the business and with whom the psychologist never socializes), and to a travel agent (who books perhaps one or two flights a year for the psychologist) may constitute relatively minimal or remote relationships. However, will a formal code’s assurance that minimal or remote relationships are unlikely to violate the standard provide a clear, practical, valid, and useful basis for ethical deliberation to the psychologist who serves as therapist to all four individuals? Research and the professional literature focusing on nonsexual dual relationships underscores the importance and implications of decisions to enter into or refrain from such activities (e.g., Borys & Pope, 1989; Ethics Committee, 1988; Keith-Spiegel & Koocher, 1985; Pope & Vasquez, 1991; Stromberg et al., 1988).

Second, the principles must address clearly and realistically the situations of those who practice in small towns, rural communities, and other remote locales. Neither the current code nor the current draft revision explicitly acknowledges and adequately addresses such geographic contexts. Forty-one of the dual relationship incidents involved such locales. Many respondents implicitly or explicitly complained that the principles seem to ignore the special conditions in small, self-contained communities. For example,

I live and maintain a . . . private practice in a rural area. I am also a member of a spiritual community based here. There are very few other therapists in the immediate vicinity who work with transformational, holistic, and feminist principles in the context of good clinical training that “conventional” people can also feel confidence in.

Clients often come to me because they know me already, because they are not satisfied with the other services available, or because they want to work with someone who understands their spiritual practice and can incorporate its principles and practices into the process of transformation, healing, and change. The stricture against dual relationships helps me to maintain a high degree of sensitivity to the ethics (and potentials for abuse or confusion) of such situations, but doesn’t give me any help in working with the actual circumstances of my practice. I hope revised principles will address these concerns!

Third, the principles need to distinguish between dual relationships and accidental or incidental extratherapeutic contacts (e.g., running into a patient at the grocery market or unexpectedly seeing a client at a party) and to address realistically the awkward entanglements into which even the most careful therapist can fall. For example, a therapist sought to file a formal complaint against some very noisy tenants of a neighboring house. When he did so, he was surprised to discover “that his patient was the owner-landlord.” As another example, a respondent reported,

Six months ago a patient I had been working with for 3 years became romantically involved with my best and longest friend. I could write no less than a book on the complications of this fact! I have been getting legal and therapeutic consultations all along, and continue to do so. Currently they are living together and I referred the patient (who was furious that I did this and felt abandoned). I worked with the other psychologist for several months to provide a bridge for the patient. I told my friend soon after I found out that I would have to suspend our contact. I’m currently trying to figure out if we can ever resume our friendship and under what conditions.

The latter example is one of many that demonstrate the extreme lengths to which most psychologists are willing to go to ensure the welfare of their patients. Although it is impossible to anticipate every pattern of multiple relationship or to account for all the vicissitudes and complexities of life, psychologists need and deserve formal principles that provide lucid, useful, and practical guidance as an aid to professional judgment. (Pope & Vetter, 1992, pp. 400–401)

[end excerpt from 1991 Pope & Vetter American Psychologist study]

Some Helpful Sets of Guidelines

The topic of multiple relationships and boundary issues is complex and rich with multiple points of view from diverse perspectives. Fortunately for therapists and counselors, there is no shortage of well-informed, thoughtful, practical guides to this area. For those in search of decision-making help as they think through the various issues, here are six highly respected and widely used sets of guidelines:

  1. Gottlieb’s 1993 guide in “Avoiding Exploitive Dual Relationships: A Decision- Making Model” (Note: This set of guidelines is on the web at http://kspope.com/ dual/index.php)

  2. Faulkner and Faulkner’s 1997 guide for practice in rural settings in “Managing multiple relationships in rural communities: Neutrality and boundary violations”

  3. Lamb and Catanzaro’s 1998 model in “Sexual and Nonsexual Boundary Violations Involving Psychologists, Clients, Supervisees, and Students: Implications for Professional Practice”

  4. Younggren’s 2002 model in “Ethical Decision-Making and Dual Relationships” (Note: This set of guidelines is on the web at http://kspope.com/dual/index.php; see also Younggren & Gottlieb, 2004)

  5. Campbell and Gordon’s 2003 five-step approach for considering multiple relationships in rural communities in “Acknowledging the Inevitable: Understanding Multiple Relationships in Rural Practice”

  6. Sonne’s 2006 “ Nonsexual Multiple Relationships: A Practical Decision-Making Model for Clinicians” (Note: This set of guidelines is on the web at http://kspope.com/ dual/index.php.)

 

For those seeking guidance in internship settings, Burian and Slimp (2000) wrote a helpful article titled “Social Dual-Role Relationships during Internship: A Decision-making Model” (see also Slimp & Burian, 1994).

Finally, excerpts addressing nonsexual dual relationships, multiple relationships, and boundary issues in psychotherapy from the standards and guidelines of professional associations (with links to the original documents), published articles, research studies, widely used guides, and other resources in the area of multiple relationships and other boundary issues are online at http://kspope.com/dual/index.php.

What Does The Research Say About Nonsexual Touch in Psychotherapy?

Pope, Sonne, and Holroyd (1993) documented the ways in which nonsexual physical touch within therapy had acquired a “guilt by association” with sexual touch. Their review of the research and other professional literature found no harm from nonsexual touch per se, although context, culture, and meaning should always be considered before touching a patient. They emphasized that when consistent with the patient’s clinical needs and the therapist’s approach, nonsexual touch can be comforting, reassuring, grounding, caring, and an important part of the healing process. When discordant with clinical needs, context, competence, or consent, even the most well-intentioned nonsexual physical contact may be experienced as aggressive, frightening, intimidating, demeaning, arrogant, unwanted, insensitive, threatening, or intrusive.

On Not Overlooking How Difficult This Topic Tends to Be for Us

In closing this section, it’s worth noting what a difficult challenge this area is for mental health practitioners. Part of the difficulty is the difficulty of psychotherapy itself. We can never go on automatic pilot, never let the formal standards and guidelines do our thinking for us, and never let the general principles obscure the uniqueness of every therapeutic encounter.

Awareness of the ethics codes is crucial to competence in the area of ethics, but the formal standards are not a substitute for an active, deliberative, and creative approach to fulfilling our ethical responsibilities. They prompt, guide, and inform our ethical consideration; they do not preclude or serve as a substitute for it. There is no way that the codes and principles can be effectively followed or applied in a rote, thoughtless manner. Each new client, whatever his or her similarities to previous clients, is a unique individual. Each situation also is unique and is likely to change significantly over time. The explicit codes and principles may designate many possible approaches as clearly unethical. They may identify with greater or lesser degrees of clarity the types of ethical concerns that are likely to be especially significant, but they cannot tell us how these concerns will manifest themselves in a particular clinical situation. They may set forth essential tasks that we must fulfill, but they cannot tell us how we can accomplish these tasks with a unique client facing unique problems. . . . There is no legitimate way to avoid these struggles. (Pope & Vasquez, 1998).

But another part of the difficulty is the topic itself, how often we jump to conclusions, rely on stereotypes, or fail to consider carefully what is actually occurring, rather than what seems to be happening. Former APA president Gerry Koocher provides a vivid example of how others tend to react when he tells them about crossing time boundaries (i.e., letting a session run far beyond its schedule), financial boundaries (i.e., not charging), and other boundaries with one of his clients.

On occasion I tell my students and professional audiences that I once spent an entire psychotherapy session holding hands with a 26-year-old woman together in a quiet darkened room. That disclosure usually elicits more than a few gasps and grimaces. When I add that I could not bring myself to end the session after 50 minutes and stayed with the young woman holding hands for another half hour, and when I add the fact that I never billed for the extra time, eyes roll.

Then, I explain that the young woman had cystic fibrosis with severe pulmonary disease and panic-inducing air hunger. She had to struggle through three breaths on an oxygen line before she could speak a sentence. I had come into her room, sat down by her bedside, and asked how I might help her. She grabbed my hand and said, “Don’t let go.” When the time came for another appointment, I called a nurse to take my place. By this point in my story most listeners, who had felt critical of or offended by the “hand holding,” have moved from an assumption of sexualized impropriety to one of empathy and compassion. The real message of the anecdote, however, lies in the fact that I never learned this behavior in a classroom. No description of such an intervention exists in any treatment manual or tome on empirically based psychotherapy. (2006, p. xxii)

References

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Baer, B. E., & Murdock, N. L. (1995). Nonerotic dual relationships between therapists and clients: The effects of sex, theoretical orientation, and interpersonal boundaries. Ethics & Behavior, 5, 131–145. Bennett, B. E., Bricklin, P. M., & VandeCreek, L. (1994).

Response to Lazarus’s “How certain boundaries and ethics diminish therapeutic effectiveness.” Ethics & Behavior,4(3), 263–266.

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