Nonsexual Multiple Relationships:
A Practical Decision-Making Model For Clinicians
[This article received the 2007 American Psychological Association Division 42 Award as Best CE Article in The Independent Practitioner]
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- An Essential Article on Boundaries: How The Field Began To Focus on Distinguishing Boundary Crossings (Helpful or Neutral) from Boundary Violations (Harmful) in the Early 1990s.
- Dual Relationships: Trends, Stats, Guides, and Resources.
- A Study Calling for Changes in the APA Ethics Code regarding Dual Relationships, Multiple Relationships, & Boundary Decisions (American Psychologist)
- Dual Relationships Between Therapist and Client: A National Study of Psychologists, Psychiatrists, and Social Workers (Debra Borys & Ken Pope)
- The Concept of Boundaries in Clinical Practice: Theoretical and Risk-Management Dimensions (Thomas Gutheil & Glen Gabbard)
- Avoiding Exploitive Dual Relationships: A Decision-making Model (Michael Gottlieb)
- Ethical Decision-making and Dual Relationships (Jeffrey Younggren)
- Nonsexual Multiple Relationships & Boundaries in Psychotherapy (Ken Pope & Danny Wedding)
- Ethics of Practice: The Beliefs and Behaviors of Psychologists As Therapists [American Psychologist]
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- Ethical Dilemmas Encountered by Members of the American Psychological Association [American Psychologist]
The term nonsexual multiple relationships has created great confusion in our profession-and great controversy. You may have heard in workshops or read in books or journals that hugging a client, giving a gift to a client, or meeting a client outside of the office constitutes a multiple relationship and is prohibited by our ethics code or by the standard of care sustained by professional licensing boards. Not accurate.
You may also have heard or read that telling a client something personal about yourself or unexpectedly encountering a client at a social event are examples of unprofessional multiple relationships. Again, not accurate.
The inaccuracies, or errors, in our thinking about nonsexual multiple relationships, mire us in confusion and controversy. The errors cripple our movement towards a comprehensive and practical model of ethical decision-making regarding multiple relationships with clients.
Two Causes of Errors
The causes of the inaccuracies are many, I believe, but there are two that stand out. First, the definition of nonsexual multiple relationships tends to "morph" during professional discussions. The term is confused with the concepts of incidental or accidental contacts (unintended or brief interactions with a client outside of the therapy context [Pope & Vetter, 1992]) and boundary crossings (benign, constructive interactions with a client that cross the traditional external boundaries that frame the therapeutic relationship [Gutheil & Gabbard, 1998]).
The 2002 APA ethics code states: "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 relatinship 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" (APA, 2002, p. 6). Consistent with Kitchener's (1988) emphasis on the role conflicts inherent in multiple relationships, this definition asserts that they involve two separate and distinct roles for the psychologist-a professional one and another (professional or other). Further, the terms "relationships" and "roles" imply that there is an intended, ongoing, and substantive social interchange between the professional and the other person. Seen in this light, none of the examples of therapist behavior cited above necessarily represents multiple relationships per se. The specific therapist behaviors do not, by themselves, define a multiple relationship. They are examples of incidental or accidental contacts, or boundary crossings. They become behaviors within multiple relationships only if the professional were to assume another role in another relationship with the client. A second reason for the inaccuracies is the uneasiness that the topic of nonsexual multiple relationships arouses.
The 2002 APA ethics code now acknowledges what several have proposed and research has suggested-nonsexual multiple relationships are not always avoidable and may be, but are not necessarily, unethical (e.g., Barnett & Yutrzenka, 1994; Borys & Pope, 1989; Ebert, 1997; Gottlieb, 1993; Kitchener, 1988; Sonne, Borys, Haviland, & Ermshar, 1998; Williams, 1997; Younggren & Gottlieb, 2004). The possibility that the clinician may not be able to avoid a situation for which there is no simple right or wrong standard of conduct raises concerns that a client may be harmed and/or that the therapist may be professionally sanctioned. The anxiety that ensues are likely to cause "brain freeze" when the therapist is confronted with the challenge of recognizing a nonsexual multiple relationship with a client and then deciding whether or not to engage in it.
The results of the confusion and the controversy regarding nonsexual multiple relationships are that therapists often fail to engage in a careful, reasoned ethical decision-making process. Instead, they may not even recognize that they are about to engage in a multiple relationship with a client or they may engage in premature closure of the decision-making process. Their conduct, then, is more likely to be impulsive, or at best, not fully deliberated. One immediate danger of such behavior by a clinician is that the client may be deprived of potential benefit or actually harmed by the decision. A second danger is that the profession never moves beyond confusion and controversy to the development of comprehensive and practical models to help therapists "in the trenches" make the complex clinical decisions they need to regarding nonsexual multiple relationships.
The Decision-Making Model
The purpose of this article is to present a new model designed to guide the therapist through deliberations regarding a potential nonsexual multiple relationship with a client. The model contains several elements previously identified by existing theoretical models and clinical guidelines for ethical decision-making in mental health practice, as well as by some few research findings. In addition, several new elements suggested by research in more general moral reasoning are included. At first glance, the array of elements is likely to induceinduce tension, frustration, or some other negative feeling in any of us, including the desire to stop reading this article and move on to some other endeavor. But we may find some relief or some reassurance if we can view the list as an aircraft pilot does her preflight checklist prior to take-off. The pilot knows that a methodological review of the many elements involved in the complex process of flying helps ensure a safe flight for us all.
The elements are grouped into four major factors: therapist factors, client factors, therapy relationship factors, and other relationship factors. Each element is described briefly.
Ethical Sensitivity: Welfel (2002) proposes that the development of "ethical sensitivity" is the first step in the ethical decision-making process for mental health practitioners-that is, an awareness of potential ethical challenges. She suggests that this sensitivity depends on education in the ethical dimensions of our work, as well as an open mental set about the "commonness, complexity, and subtleties of ethical dilemmas" (p. 26). Clearly, the type of training in ethics (rather than the amount of training [cf., Haas, Malouf, & Mayerson, 1988]) is an important consideration; therapists must have a requisite knowledge of the current ethical principles in order to be ethically sensitive. Further, as Williams (1997) argues, the time period of the training is likely also to be critical. Though therapists are required to be knowledgeable of changes in ethics codes, the time in which they are trained establishes a base of perception and understanding that remains with the therapist throughout their careers.
Willingness to Expend Cognitive Effort: Research findings suggest that a number of psychologists confronting ethical dilemmas are willing to implement decisions generated by "expedience and opportunism" rather than by careful analysis (Koocher & Keith-Spiegel, 1998, p. 15). In their discussion of moral decision-making, Street, Douglas, Geiger, & Martinko (2001) argue that the "level of cognitive expenditure" invested by the decision-maker is critical for the recognition of the ethical dilemma and in the action that results (p. 265). The level of cognitive effort, in turn, is determined by individual and situational factors such as the person's ability to tolerate ambiguity vs. need for closure.
Guiding Ethical Principles: The originators of several of the general ethical decision-making models for mental health professionals and others note the important role of the practitioner's guiding moral values and principles in the process (e.g., Kitchener, 2000; Koocher & Keith-Spiegel, 1998; Knapp, Gottlieb, & Handelsman, 2004; Knapp & VandeCreek, 2003; Welfel, 2002). For example, a therapist who adheres most closely to the ethical principle of "do no harm" (nonmaleficence) may tend more to refrain from entering into a nonsexual multiple relationship-given a heightened concern for possible negative outcomes for the client-than one who holds as of greater primacy the principle of autonomy that emphasizes clients' right to self-determination.
Gender: The gender of the therapist may influence both the therapist's recognition of an ethical dilemma, and the process and the outcome of decision-making regarding a nonsexual multiple relationship with a client. Gilligan (1982) argues that men and women differ in the bases of their moral reasoning; men tend to focus on issues of justice and women on relationship issues. Kimmel (1991) notes that men tend to be more "risk favorable" and women tend to be more conservative in their ethical decision-making in a psychological research context. Other research findings suggest that male therapists tend to rate multiple relationships with clients involving another professional role or a social or business role as more ethical than female therapists (e.g, Borys & Pope, 1989). In addition, male therapists engage in more social and dual professional relationships with clients than female therapists (e.g., Borys & Pope, 1989; Haas, Malouf, & Mayerson, 1988).
Culture: The therapist's cultural background likely contributes to the recognition and resolution of ethical dilemmas regarding boundaries and multiple relationships. For example, in some cultures strict adherence to personal space and role boundaries is considered polite and respectful; in others, such behavior is experienced as cold, rude, and rejecting.
Religion/Spirituality: Therapists' religious affiliations vary and provide a kind of cultural context that affects decision-making regarding nonsexual multiple relationships. For instance, some religions support, and even encourage, extended relationships among fellow members beyond those specifically related to worship. Often clients are referred to or request services from specific therapists because they share a religious affiliation and the clients wish to explicitly integrate faith or spirituality into the therapy (Llewellyn, 2002).
Profession: The therapist's profession (e.g., marriage and family therapist, social worker, psychologist, psychiatrist) also provides a cultural context that affects the therapist's perceptions of appropriate versus inappropriate multiple relationships. For example, research findings suggest that psychiatrists rate social/financial involvements with clients as significantly less ethical than do psychologists and social workers (Borys & Pope, 1989).
Theoretical Orientation: Although research findings are not consistent, there is some empirical evidence and much clinical discussion that the theoretical orientation of the therapist/decision-maker affects both the perception of the possible ethical challenges regarding multiple relationships and the subsequent decision to enter or refrain from entering such relationships (e.g., Borys & Pope, 1989; Haas, Malouf, & Mayerson, 1988; Williams, 1997). In one study, therapists who practice within a psychodynamic orientation rate social/financial and dual professional involvements with clients as significantly less ethical than do therapists of all other orientations (including cognitive, behavioral, humanistic, and eclectic). Psychodynamic therapists also report lower frequencies of social/financial involvements with clients than humanistic and cognitive therapists, and of dual professional relationships with clients than cognitive therapists. Humanistic therapists report the highest frequency of dual professional relationships with clients (Borys & Pope, 1989).
Years of Experience as a Therapist: Less experienced therapists (less than 10 years) rate social/financial and dual professional involvements with clients as significantly less ethical than those with much more experience (30 or more years; Borys & Pope, 1989). Interestingly, in the same study this element is not related to the therapist's actual decision to become involved in such relationships.
Character Traits: Certain character traits are also likely to influence the therapist's ability to recognize an ethical dilemma regarding a nonsexual multiple relationship, as well as to move through the decision-making process (Ebert, 1997). As noted above, Street et al. (2001) suggest that the level of cognitive expenditure a therapist is willing to invest in deliberating an ethical dilemma is determined in part by such individual factors. For example, a therapist with a strong need to please others may be less likely to recognize the potential ethical challenges that arise when a client requests that the therapist share a business venture. Other influential character traits may include the therapist's tolerance of ambiguity, narcissism, need for control, and risk-taking orientation.
Gender: The client's gender is another important element in the therapist's decision-making process. For example, a male therapist may assume that a male client would likely benefit from playing on the same team in a community baseball league as the therapist because men "relate" through sports.
Culture: Gutheil & Gabbard (1998) describe a boundary crossing scenario in which the client's culture (midwestern United States) differed from that of her therapist. The therapist's advance to help the client take off her coat, which in his Viennese culture was regarded as polite and chivalrous, was interpreted by her as intrusive and even exploitative. In the same vein, an invitation by a therapist of one culture to engage in a social multiple relationship, though intended to be gracious, may be perceived by a client of another culture as pushy.
Religious/spiritual: Just as the therapist's religious and/or spiritual affiliation is an important element for consideration in the decision-making process, so too is that of the client. Therapist and client expectations of and reactions to a potential nonsexual relationship are likely affected by the fact that they share a religious affiliation, or even a specific congregation or spiritual group, or, conversely, that they come from very different religious or spiritual orientations.
Psychosocial Strengths and Vulnerabilities: Much has been written admonishing the therapist to consider the client's psychological and social strengths and vulnerabilities when confronted with the challenge of a potential nonsexual multiple relationship (e.g., Ebert, 1997; Moleski & Kiselica, 2005). Most of the guidelines highlight the extreme care that must be exercised when the client is diagnosed with borderline or narcissistic personality disorder. Certainly the degree to which the client suffers from any psychological disorder (including personality disorders, psychotic disorders, delusional disorders, dissociative disorders) that impairs the ability to understand or negotiate boundaries in the therapeutic relationship is a crucial element. Social strengths and vulnerabilities, including the depth of the client's social network beyond the therapist, are also important elements for consideration.
History of Prior Boundary Violations: Clients commonly enter therapy with a history of prior boundary violations such a childhood sexual abuse, domestic violence, or inappropriate boundary crossings with another professional (including teachers, clergy, and prior therapists). Such experiences often leave a client with persisting feelings and confusion regarding roles and boundaries in subsequent intimate relationships, requiring careful monitoring and managing by the therapist.
Therapy Relationship Factors:
Nature of Therapeutic Relationship: Previous investigators suggest that there are several features of the therapy relationship that are likely to influence the therapist's recognition of and decision about a potential multiple relationship. One such feature is the degree to which the client fully understands the nature of the therapy and engages in informed consent (e.g., Ebert, 1997; Gutheil & Gabbard, 1998). The process of informed consent offers both the therapist and client the opportunity to clarify their respective roles and expectations in the therapy relationship, including the termination of the therapy. The absence of such clarity undoubtedly contributes to confusion regarding the boundaries of the relationship. A second critical feature is the nature of the client's emotional reaction (or transference) to the therapist. For example, the decision regarding whether to enter into a multiple relationship with a client is no doubt more complicated when the client has an intensely (and unrealistically) positive or negative emotional reaction to the therapist.
Power Differential: Gottlieb (1993) presents one of the earliest decision-making models for therapists deliberating about entering a multiple relationship. He argues that the power differential between the therapist and the client is a central element in the process-the greater the power differential, the higher the risk that entering into another relationship will result in harm to the client. Gottlieb adds that the power differential must be assessed both from the perspective of the therapist and of the client.
Duration: Gottlieb's (1993) model also highlights the importance of the duration of the therapy relationship. Short-term biofeedback therapy implies a different kind of therapeutic relationship than psychodynamic psychotherapy that has spanned ten years. The existence of another relationship, and another role for the therapist and the client, will likely have very different meanings in each situation.
Practice setting: Some research suggests that the settings in which therapists work (i.e., solo private practice, outpatient clinic, group private practice, inpatient facility, community outreach programs) affect their perceptions of the ethical vs. unethical nature of multiple relationships. For example, solo private practitioners rated social/financial involvements with clients as significantly less ethical than did group private practitioners or therapists in outpatient clinics (Borys, & Pope, 1989). Research findings to date have not demonstrated a relationship between therapists' work setting and their decisions to enter into multiple relationships (Borys & Pope 1989; Haas, Malouf, & Mayerson, 1988). It is reasonable, however, to expect that therapists in practice settings that emphasize or demand extra-therapeutic involvements (e.g., community outreach programs) will have different perceptions and make different decisions than clinicians in those settings that have no such expectations, or even explicit prohibitions (i.e., "clinic rules"), about such interactions.
Practice Locale: As noted above, one of the most celebrated changes reflected in the 2002 APA ethics code regarding multiple relationships is the recognition that such nonsexual relationships are not always avoidable and are not always unethical. Several colleagues highlight the fact that practitioners in small and/or specialized communities such as the military, rural communities, deaf communities, sports athlete communities, and university communities commonly encounter potential nonsexual multiple relationships with their clients (e.g., Barnett & Yutrzenka, 1994; Brown & Cogan, 2006; Guthmann & Sandberg, 2002; Helbok, Marinelli, & Walls, 2006; Iosupovici & Luke, 2002). Research suggests that the locale is a significant element in therapists' perception of the ethicality of nonsexual multiple relationships and their decisions regarding entering into them. For example, Borys & Pope (1989) found that therapists who live and work in a single small community rated social/financial and dual professional relationships as more ethical than those who lived and worked in the same suburban or urban area or who lived and worked in different communities. Further, small town therapists engaged in financial multiple relationships significantly more frequently than practitioners in other practice locales.
Other Relationship Factors:
Clarity of change in nature and function of relationship: Kitchener (1988) argues that the potential for harm to a client in a multiple relationship increases with confusion and misunderstanding about the changes in the roles of both the client and the therapist imposed by the existence of another relationship in addition to the therapy relationship. Other colleagues emphasize the importance of the client's informed consent regarding the additional relationship (e.g., Ebert, 1997; Moleski & Kiselica, 2005; Younggren & Gottlieb, 2004). The informed consent process should include an understanding that the client may end the non-therapy relationship without negatively affecting the therapy relationship (Burien & Slimp, 2000).
Professional's motivation for engaging in the other relationship: In their early ethical decision-making model, Haas & Malouf (1989) emphasize the importance of the professional's motivation for engaging in another relationship with a client. The key question (which has been integrated into subsequent models [e.g., Ebert, 1997] and training experiences [e.g., Pope, Sonne, & Greene, 2006]) is whether the co-occreence of the two relationships (i.e., the therapy relationship and the other relationship) is designed to meet the needs oof or enhance the benefits for the client or the therapist.
Professional's affective response to the potential additional relationship: Existing models and guidelines for decision-making regarding nonsexual multiple relationships reflect a historical emphasis on the role of reason in ethical judgments. More general ethical decision-making literature posits that such judgments are also greatly influenced by the feelings that the situation evokes and that moral dilemmas vary in the extent to which they trigger emotional processing (e.g., Betan & Stanton, 1999; Greene, Sommerville, Nystrom, Darley, & Cohen, 2001; Meara, Schmidt, & Day, 1996; Rest, Bebeau, & Volker, 1986). We know practitioners who can recite the rational reasons why they should not engage in a multiple relationship with a high probability of resulting in client harm, but do so anyway. Later they ask themselves: "What was I thinking?" Perhaps the more relevant question is: "What was I feeling? Fear..., anger..., pity..., excitement..., intrigue...?"
Potential for Role Conflict: By definition, multiple relationships involve at least two roles for the therapist and two for the client. For instance, a therapist who enters into a business deal with a client assumes a second role of business partner, as does the client. Kitchener (1988) and Ebert (1997) argue that the decision to enter a multiple relationship should necessarily depend on the degree to which the roles may become incompatible. For example, the roles of "therapist" and "business partner" may conflict when the "therapist" is obligated to protect the welfare of the client and the "business partner" wants to protect his own financial interest, even at the expense of his partner/client.
Potential for Benefit for Client: Several colleagues have spoken and written about the potential for benefit for the client involved in a nonsexual multiple relationship (e.g., Williams, 1997). Specifically, a decision to engage in a multiple relationship with a client may take into account the potential for an additional relationship to enhance the therapist's knowledge of the client, the client's trust in the therapist, and the enhancement of the therapeutic alliance.
Potential for Harm to Client: The 2002 APA ethics code outlines four domains of potential harm to the client that, if present, would define the multiple relationship as unethical. First is the impaired objectivity of the therapist, a likely by-product of role incompatibility for the therapist. Second, the multiple relationship may impair the competency of the therapist. For instance, the addition of a second relationship may add to the therapist's sense of involvement with and responsibility for the client's life. The therapist may then be tempted to extend clinical interventions into arenas beyond those of the therapist's training or experience. The third domain of potential harm is that the multiple relationship may impair the ability of the therapist to safeguard the client in the primary professional relationship (i.e., the therapist's effectiveness). For example, the secondary relationship may threaten the client's confidentiality. It may not be clear to the client or to the therapist which communications that are protected ethically and legally and which are not. The last domain of potential for harm is the exploitation of the client by the therapist. The risk for exploitation is undoubtedly linked to other factors described above-for example, the character of the therapist, the strengths and vulnerabilities of the client, the power differential in the therapy relationship, and the therapist's motivations for entering into the multiple relationship.
Potential for Harm to Third Parties: Burian and Slimp (2000) present a model for decision-making regarding social multiple relationships during internship. One of the elements they include in their model is the degree to which the addition of another relationship to the supervisory relationship negatively impacts third parties (i.e., other interns, other staff members). In the same manner, the involvement in a nonsexual multiple relationship between a therapist and a client may cause confusion, dissillusionment, anger, feelings of envy, or other regative reactions in third party observers (i.e., other professionals, other clients, family members odf the therapist or client.)
Setting of the Other Relationship: The degree to which the setting of the other relationship is distinct from that of the therapy relationship likely influences the therapist's perception of the nonsexual multiple relationship and the decision to enter into it. For example, the decision-making process is different for the therapist who considers employing a client to work in his or her office or home than for one who considers employing a client in a business in another town that therapist co-owns with his cousin.
Locale of the Other Relationship: Just as in the case of the locale of the therapy relationship, the locale of the other relationship may be in one of the small, specialized communities in which the multiple relationship is unavoidable and not necessarily unethical.
Nonsexual multiple relationships between therapists
and clients have received much attention lately in the professional literature
various law and ethics workshops. Unfortunately, the attention has not
and calm, the best conditions for engaging in complex decision-making.
The purpose of this article was two-fold. First, I presented a clarification
of the definition of nonsexual multiple relationships because
confusion continues to hampet meaningful discussion of the construct. Second,
I presented a new model that integrates several
elements of existing theoretical models, research findings, and clinical
guidelines regarding nonsexual multiple relationships specifically,
and moral reasoning more generally. The model is designed to serve as a
for therapists to consider as they engage in the complex process of recognizing
and then deciding whether or not to enter nonsexual relationships with
(Contact information: email@example.com)
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