A Study Calling for Changes in the APA Ethics Code regarding Dual Relationships, Multiple Relationships, & Boundary Decisions
The original ethics code of the American Psychological Association was empirically based, the result of a survey of the membership, asking them what ethical dilemmas they encountered.
Almost half a century later, Pope and Vetter replicated that study and published their findings in American Psychologist.
They found that the second most frequently reported ethical dilemmas were in the area of "blurred, dual, or conflictual relationships."
On the basis of their findings, Pope and Vetter called for changes to the APA ethical principles 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) and to address realistically the awkward entanglements into which even the most careful therapist can fall.
The excerpt that follows comes from that 1992 American Psychologist article.
For those interested, please follow this link to the complete article.
Excerpt from "Ethical Dilemmas Encountered by Members of the American Psychological Association: A National Survey" (American Psychologist, March, 1992, vol. 47, #3) by Kenneth S. Pope & Valerie A. Vetter:
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 therapeutically indicated or acceptable. For example, a statement such as "Minimal or remote relationships are unlikely to violate this standard" ("Draft," 1991, p. 32) may be too vague and ambiguous. 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 is 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, 1988; Ethics Committee, 1988; Keith-Spiegel & Koocher, 1985; Pope & Vasquez, 1998; 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.