The recent revision of the ACA Code of Ethics significantly changes the ethical guidelines related to dual relationships. Careful review of the specific ethics code language addressing dual relationships is imperative in order to navigate this prevalent ethical issue. Though the 1995 code offered guidance on the topic of dual relationships, the 2005 ACA Code of Ethics provides more explicit guidelines about which dual relationships are ethically acceptable and which are strictly prohibited. Dual relationships exist on a continuum ranging from potentially beneficial interactions to harmful interactions. One dual relationship that is always considered harmful is a sexual relationship with a client. The 2005 revision of the ACA Code of Ethics reiterates and expands the ban on sexual relationships with clients. Under the new code, counselors are ethically prohibited from engaging in sexual relationships not only with clients but also clients’ partners or family members (Standard A.5.a.). Another substantive revision is the extension of the time ban on sexual relationships with former clients. In the 1995 code, the specified period of waiting was two years, with extensive justification after two years that such a relationship would not be harmful to the former client. The 2005 code extends this period to five years. Echoing the previous code, the 2005 code states in Standard A.5.b. that “Counselors, before engaging in sexual or romantic interactions or relationships with clients, their romantic partners or client family members after 5 years following the last professional contact, demonstrate forethought and document (in written form) whether the interactions or relationship can be viewed as exploitive in some way and/or whether there is still potential to harm the former client; in cases of potential exploitation and/or harm, the counselor avoids entering such an interaction or relationship.” Though sexual relationships with clients are clearly prohibited, nonsexual relationships are ethically permissible under certain circumstances. Like a dual relationship that is sexual, a nonprofessional dual relationship has the potential to blur the boundaries between a counselor and a client, create a conflict of interest, enhance the potential for exploitation and abuse of power, and/or cause the counselor and client to have different expectations of therapy. The 1995 code instructed counselors to avoid nonsexual dual relationships when it was possible to do so. The Ethical Code Revision Task Force felt that this instruction was being interpreted as a prohibition on all dual relationships, including relationships that could be beneficial to the client (see “Ethics Update” in the March 2006 issue of Counseling Today). Thus, the 2005 code revisions clarify that certain nonsexual interactions with clients can be beneficial, and therefore, those relationships are not banned (Standard A.5.c.). The 2005 code also provides examples of potentially beneficial interactions, including “attending a formal ceremony (e.g., a wedding/commitment ceremony or graduation); purchasing a service or product provided by a client (excepting unrestricted bartering); hospital visits to an ill family member; mutual membership in a professional association, organization or community” (Standard A.5.d.). When engaging in a potentially beneficial relationship with a client or former client, however, the counselor is expected to “document in case records, prior to the interaction (when feasible), the rationale for such an interaction, the potential benefit and anticipated consequences for the client or former client and other individuals significantly involved with the client or former client.” Standard A.5.d., “Potentially Beneficial Interactions,” further clarifies that “Such interactions should be initiated with appropriate client consent,” and if harm occurs because of the nonprofessional interactions, counselors are expected to “show evidence of an attempt to remedy such harm.” In settings such as rural communities and schools, nonsexual dual relationships are often impossible to avoid. The 1995 code provided guidance on managing unavoidable dual relationships, stating that the counselor was expected to “take appropriate professional precautions such as informed consent, consultation, supervision and documentation to ensure that judgment is not impaired and no exploitation occurs.” Though this language is no longer explicitly stated, such precautions still seem warranted. The 2005 ACA Code of Ethics also provides guidelines for supervisory relationships, stating that “Sexual or romantic interactions or relationships with current supervisees are prohibited” (Standard F.3.b.). Furthermore, the ethics code clearly states that “Counseling supervisors do not condone or subject supervisees to sexual harassment” (Standard F.3.c.). It should be noted that not only is sexual harassment unethical, it is also illegal. Counseling supervisors are expected to “clearly define and maintain ethical professional, personal and social relationships with their supervisees” (Standard F.3.a., “Relationship Boundaries With Supervisees”). The standard goes on to say that “If supervisors must assume other professional roles (e.g., clinical and administrative supervisor, instructor) with supervisees, they work to minimize potential conflicts and explain to supervisees the expectations and responsibilities associated with each role.” The 2005 ACA Code of Ethics also cautions counseling supervisors to remain aware of “the power differential in their relationships with supervisees” (Standard F.3.e.). The code further clarifies that “Counseling supervisors avoid accepting close relatives, romantic partners or friends as supervisees” (Standard F.3.d.). Standard F.3.a. also advises counseling supervisors not to engage in “any form of nonprofessional interaction that may compromise the supervisory relationship.” If a counseling supervisor believes a nonprofessional relationship with a supervisee has the potential to benefit the supervisee, Standard F.3.e. provides that supervisors take precautions similar to those taken by counselors who engage in potentially beneficial dual relationships with clients. It goes on to say that “Before engaging in nonprofessional relationships, supervisors discuss with supervisees and document the rationale for such interactions, potential benefits or drawbacks, and anticipated consequences for the supervisee.” The 2005 ethics code addresses other dual relationships as well, including relationships between counselor educators and students and relationships between researchers and research participants. Standard F.10. sets guidelines for counselor educators and students that are similar to the ethical guidelines for supervisors and supervisees. Standard G.3. virtually mirrors these rules for researchers and their research participants. The 2005 ACA Code of Ethics clarifies that nonsexual dual relationships are not prohibited; however, navigating dual relationships can be challenging. Counselors are ethically mandated to approach dual relationships with care and caution. Informed consent is a critical component of engaging in nonsexual dual relationships with clients, and this includes specifying the potential negative consequences of such a relationship. It is wise for counselors to consult when faced with a dual relationship to ensure that clients are not harmed. Though the standards related to dual relationships in the ACA Code of Ethics have undergone significant changes, the spirit of their intent can still be summarized in one sentence: Do what is in the best interest of the client. Mary A. Hermann, a professor of counselor education at Virginia Commonwealth University, and Sharon Robinson-Kurpius, a professor of counseling and counseling psychology at Arizona State University, are members of the ACA Ethics Committee. Letters to the editor:
In 1988, after practicing as a Psychological Assistant in Berkeley, California, for four years, Dr. Ofer Zur, a licensed psychologist and director of the Zur Institute, LLC, settled in the small community of Sonoma, California, where he immediately opened up his own private practice. And at first, things went smoothly. He established himself as an expert in his field and as an involved and well-respected member of his community. Still, as is wont to occur in a small town, the inevitable happened: a couple he socialized with on a regular basis asked for his professional guidance with their struggling marriage. Based on what Zur had been taught from the very beginning of his days as a mental health professional, he informed the couple he was not the right man for the job because of his preexisting personal relationship with them. The couple was outraged. Feeling conflicted, Zur brought his dilemma to attorneys, supervisors, ethics experts, and experienced therapists, all of whom told him that taking this couple on as clients would be crossing a clear line. Dual relationships (also known as "multiple relationships"), refer to a situation in which multiple roles exist between a therapist and a client. For example, when a client is also a friend or family member, it is considered a dual relationship. If a client is also an employee or business associate, it is considered a dual relationship. If a therapist regularly comes across a client in any setting outside of the therapist's office — a bowling league, a country club, a school setting, karaoke night — it's considered a dual relationship and, in most cases, is officially frowned upon. The rules are so ingrained in the industry culture that it seems like a no-brainer. And when pushed to explain the rules, professionals generally explain that avoiding dual relationships is necessary because, otherwise, a therapist might misuse their power and influence and exploit clients for their own benefit. And in fact, this is what's stated in most professional organizations' code of ethics. But when one looks more closely at the rules, one tends to find a lot of gray areas. For example, in the National Association of Social Workers (NASW) Code of Ethics (2008), there is a line acknowledging that some multiple relationships are unavoidable, and which then states that "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" (section 1.06). Similarly, the California Association of Marriage and Family Therapists (CAMFT) Code of Ethics (2011) states that "not all dual relationships are unethical, and some multiple relationships cannot be avoided" (p.10). The American Psychological Association (APA) Code of Ethics of 2010 even states that "multiple relationships that would not reasonably be expected to cause impairment or risk exploitation or harm are not unethical" (p. 6). But how is one to find the line between an unethical and ethical dual relationship? Especially considering the variety of situations that could lead to such a relationship? For one thing, there are dual/multiple relationships that are actually mandated by law. For example, military clinical psychologists or psychiatrists on active duty fulfill multiple roles. They act as both commissioned military officers and psychotherapists-clinicians. Because of this, the work they do can often seem at odds. As Zur describes is, part of the responsibility of military psychologists is to enhance the combat readiness of the unit, while also helping traumatized soldiers overcome their PTSD. Because of these conflicting responsibilities, a solder's mental health can play second fiddle to a unit's need to see that soldier in combat duty again, as quickly as possible. Other examples of mandated relationships include psychotherapists who work in prisons and jails, and who are also prison guards. Or forensic psychologists who must report their findings to a prison warden, leading to a loss of trust in the psychologist, by the client. There are also unavoidable — though not necessarily mandated — dual relationships, such as those that occur within a small community, when it's a given that a therapist will cross paths with a client in multiple settings. Zur preaches a more open-minded, less restrictive view of dual relationships, claiming that "the context within which multiple relationships take place is, without a doubt, one of the most important factors in determining their appropriateness." In fact, he believes that — in certain instances — a purposeful dual relationship can prove helpful to a client's progress. How? For one thing, Zur believes that a client's familiarity with his therapist's spiritual beliefs and personal ethics will only helps him trust his therapist more readily. By extension, he believes this level of familiarity can aid in shortening the length of therapy and increasing its effectiveness. He also feels that the isolation of the strict therapist/client relationship might allow for incompetent therapists to remain unaccountable for long periods of time, enabling them to continue therapy even when the client does not get better. He also feels it's possible for the avoidance of all dual relationships to only exacerbate the power dynamic within the therapist/client relationship, which can easily lead to exploitation. And these are only a handful of the arguments Zur makes in support of considering dual relationships. One must "go through a thoughtful, ethical, decision-making process to determine what ethical, legal, and clinically appropriate actions they can or cannot or should or should not pursue," says Zur. Of course, not everyone within the field fully agrees with Zur's viewpoints. Michael Plaut, a licensed psychologist who has both served on and chaired Maryland's Board of Examiners of Psychologists, finds many of Zur's points valid. After all, he concedes, it's almost impossible to avoid running into a patient or client at a social event, in a supermarket, or at a religious venue. But he's concerned, primarily, with the language Zur uses in his arguments. "His writing seems to focus on a justification of boundary crossings and dual relationships rather than a balanced, practical consideration of how decisions about dual relationships are best made," said Plaut. So how is the decision-making process best approached when it comes to finding that sometimes thin line between ethical and unethical? Plaut has several suggestions. One suggestion — which he's written about in the Handbook of Clinical Sexuality for Mental Health Professionals, for which he contributed a chapter on understanding and managing professional/client boundaries — is to go through the process of making a "progressive boundary analysis." What this means is that, if someone is considering crossing a boundary, they should ask themselves what the implications of doing so might be. Are further crossings more likely to happen if one boundary is crossed? Another question Plaut believes professionals should ask themselves: Are we really meeting the patient's needs or are we satisfying our own need to be needed? "An honest answer to this question is critical in crossing any boundary," he says. He goes on to explain that professionals' roles "as parents, teachers, and therapists is hopefully to help our charges get to the point that they do not need us anymore in order to thrive on their own. By exploiting their dependency on us, we are ultimately not helping them at all to achieve that level of self-sufficiency. I am not my patient's friend and I am not my student's friend. Ultimately, our clients need to find personal support in other places. It is part of our job to help them do that, rather than to provide excessively for their needs." Finally, Plaut suggests consulting with fellow professionals. He advises documenting everything and then, in times of uncertainty, consulting with a colleague you trust. And in the end, his suggestions are not so very different from the ones Zur lists out in the Zur Institute's Guidelines For Non-Sexual Dual Relationships In Psychotherapy. Though two of his guidelines do stick out: "2. Intervene with your clients according to their needs, as outlined in each of their treatment plans, and not according to any graduate school professor's or supervisor's dogma or even your own beloved theoretical orientation." And: "5. Do not let fear of lawsuits, licensing boards or attorneys determine your treatment plans or clinical interventions. Do not let dogmatic thinking affect your critical thinking. Act with competence and integrity while minimizing risk by following these guidelines." In these guidelines, Zur encourages professionals to move beyond what they may have been taught in their training, and to apply additional critical thinking to the decision-making process. Still, when it comes to both Zur and Plaut, the inclination seems to be to err on the side of caution. Sure, the codes of ethics in regards to dual relationships may seem very unambiguous. But the rules and the limits that are in place are there because of what might happen. Plaut puts forth the following scenario: Suppose you accept an invitation to a patient's wedding. On the one hand, this could be considered a supportive gesture, and could prove beneficial to the therapeutic relationship. On the other hand, you may end up confronting another ethical issue: breach of confidentiality. In a case like this, it might be useful to discuss with the patient beforehand how each of you might respond if someone asked how you knew each other. Is the patient comfortable disclosing that? How should you respond as a therapist to such a question from someone you meet at the wedding? When you consider all the possibilities, making a clear decision about the efficacy of a dual relationship becomes even more complex. Plaut also lays out an analogy, likening the laws of dual relationships to the act of following the speed limit. While we may understand on an intellectual level why the speed limits are the way they are, we often toe the line, going above the speed limit... but not so far we're likely to be pulled over. Still, if we are pulled over, we don't try to talk our way out of a ticket by insisting we didn't hurt anyone. Because we know that speed limits are set in response to the perceived risk of harm and we know that, even if no one else was hurt, we've still broken the law. Plaut, S.M. (2010). Understanding and managing professional-client boundaries. In Levine, S.B., Risen, C.B., & Althof, S.E. (Eds.). Handbook of Clinical Sexuality for Mental Health Professionals, 2nd Ed. New York: Routledge, pp. 21-38. Zur, O. (Winter 2014). Not All Multiple Relationships Are Created Equal: Mapping the Maze of 26 Types of Multiple Relationships. Independent Practitioner. pp. 15 -22. (article image via) |
It is considered unethical for a clinician to enter a business relationship with a client.
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