TRENDS, STATS, AND RESOURCES
During the last decade or so, few topics in the area of clinical ethics sparked such intense consideration as dual relationships and related phenomena, with numerous articles and books offering thoughtful explorations of virtually every possible view. Not every author uses terms in a way that is exactly the same as every other author, but generally the context if not an explicit definition makes it clear whether a term like dual relationship is used in its broadest possible sense or to examine only a subset (e.g., only dual professional roles; only blending a professional role with a social, financial, or romantic relationship; or only dual relationships that seem to place clients at undue risk for harm).
After a national study looking at the range of beliefs and practices in regard to a few nonsexual dual relationships (ref 1 below), a 1989 article focused exclusively on the diverse beliefs and behaviors in this area (ref 2). This survey of 4,800 psychologists, psychiatrists, and social workers (with a 49% return rate) examined how both views and practices tended to vary in regard to 10 factors: therapist gender, profession, age, experience, marital status, region of residence, client gender, practice setting, theoretical orientation, and practice locale.
The patterns in regard to these 10 factors are fascinating. For example, male therapists are more likely than female therapists not only to endorse but also to engage in various nonsexual dual relationships. (Other studies have shown that the same gender pattern holds for sexual dual relationships.) Psychiatrists are less likely than psychologists or social workers to view social or financial involvements with patients as ethical. The article concludes with 10 recommendations, such as that training programs need to present students with researched-based literature and other readings so that they may evaluate for themselves the full range of views, evidence, and approaches in this area.
A 1992 study (ref 3) used the method that had been the basis of developing APA's original ethics code (i.e., asking psychologists to describe the dilemmas they encountered in their day-to-day practice). Based on the findings, the authors called for changes in the ethical principles, 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) address realistically the entanglements into which even the most careful therapist can fall.
For therapists and counselors seeking resources, fortunately there have been countless guides published in articles and books, helping clinicians carefully weigh the factors, values, and possibilities in trying to arrive at the best possible decision about whether entering into various kinds of relationships with a client makes clinical and ethical sense. In addition to the more general decision-making aids, there are resources for virtually every kind of specialty practice and context (e.g., a 3-level model for family therapists involved with religious communities to negotiate dual relationships; a decision-making model for social dual-role relationships during internships). One of the most frequently cited general models is Mike Gottlieb's "Avoiding Exploitive Dual Relationships: A Decision-Making Model" (ref 4).
In addition to examples of boundary crossings from my own work (see, e.g., ref 5), Melba Vasquez and I presented a number of nonsexual dual relationship scenarios and questions (ref 6), which appear below. The premise of this 1998 book is that formal statements such as ethics codes "cannot do our questioning, thinking, feeling, and responding for us. Such codes can never be a substitute for the active process by which the individual therapist or counselor struggles with the sometimes bewildering, always unique constellation of questions, responsibilities, contexts, and competing demands of helping another person. . . . Ethics must be practical. Clinicians confront an almost unimaginable diversity of situations, each with its own shifting questions, demands, and responsibilities. Every clinician is unique in important ways. Every client is unique in important ways. Ethics that are out of touch with the practical realities of clinical work, with the diversity and constantly changing nature of the therapeutic venture, are useless" (pp. xiii-xiv).
The value in using these scenarios and questions to consider nonsexual dual or multiple relationships and other forms of boundary crossings "may be in direct proportion to the ability. . . to disclose responses that may be politically incorrect, 'emotionally incorrect,' or otherwise at odds with group norms or with what some might consider the 'right' response" (p. 68).
The questions focus not only on thinking through these situations but also feeling our way through them. Our emotional responses -- whether acknowledged, discounted, or denied -- to a situation may influence our thoughts and behavior. Each set of questions begins by focusing on the initial feelings evoked by the scenario.
All articles in the reference section below -- with the exception of Mike Gottlieb's -- are currently at this site, where they may be read, downloaded, or printed out. Just click the links in the reference section below for each article. Mike is currently checking on the copyright status of his article so that it too may be included at the site. Meanwhile, Mike is happy to mail a reprint to anyone who sends him a request at firstname.lastname@example.org. Additional materials will be added in the coming weeks and months.
[NOTE: The following material is from the chapter on "Multiple Relationships" in Ethics in Psychotherapy and Counseling: A Practical Guide, Second Edition, and is presented here only for personal, individual use. The copyright is held by Jossey-Bass, Inc., Publishers. For any use that involves copyright issues, please contact the publisher.]
SCENARIO #1: You decide to teach a course in basic psychopathology as part of the local community college's associate of arts degree program. You show up on the first day of class and see that there are ten students who have signed up. Two of them are current psychotherapy clients in your practice.
1. How do you feel?
2. Does their presence change how you teach your first class session?
3. What options do you have for addressing this issue?
4. What do you think you would do?
5. How, if at all, would you address this issue in the chart notes for these two clients?
SCENARIO #2: You live in a very small community. You are the only psychotherapist providing services through the local managed care plan. One day one of your closest friends, someone you have known for several decades, shows up at your office, seeking therapy.
1. How do you feel?
2. Do you share any of your feelings or concerns with the client during this session? If so, what do you say?
3. Assume that you do not believe that you can serve as therapist in light of your close friendship with this person. However, the patient points out that not only are you the only one designated to provide therapy under the managed care plan, but that since you are also virtually the only one anywhere near this small community who matches the client in terms of characteristics that the patient feels are important (that is, the patient believes that only someone who matches the patient's gender, race, and sexual orientation will understand the issues and be able to help), the patient can't really get help from anyone but you. How do you address this? What are your options? What steps would you take?
SCENARIO #3: You've been suffering some financial losses and are close to bankruptcy. You will probably lose everything if you are unable to sell your house. You have been trying to sell your house for close to two years and have not received a serious offer. You hold yet another open house. The only person to show up is one of your psychotherapy clients who says, "This is a great house! I hadn't really thought about buying a house--I just enjoy going out on Saturday mornings and looking at different homes. But now that I see this house, I'd love to buy it and live here!. And although I'd be buying such a great house anyway, its nice that it'll you'll be getting the money. I'll be happy to pay the asking price, but I wonder if it's not worth quite a bit more than what you're asking."
1. How do you feel?
2. What do you think you would say?
3. What options do you consider?
4. What do you think you'd end up doing?
SCENARIO #4: A couple, who are your close friends, are aware that you will probably be spending Thanksgiving alone. They invite you to share Thanksgiving day with them, preparing the meal during the morning, feasting at lunch, going for a leisurely walk in the woods during the afternoon, then returning for a light dinner. You show up to discover that they have, without letting you know, invited another "unattached" person who is presumably your blind date for the day. That person is currently a client to whom you've been providing psychotherapy for two years.
1. How do you feel?
2. What are your options?
3. What do you think you would do?
4. How, if at all, would your feelings, options, or probable-course change if the person was a former client?
5. What if, rather than your client, the person was your therapy supervisor?
6. What if the person was your own therapist?
SCENARIO #5: During a session a client mentions that, because of her job, she receives many free tickets to concerts, plays, and other events. She loves giving them to her various doctors because she greatly appreciates their hard work and because it costs her nothing although the face value of the tickets is high. She tells you that she has already mailed to you the day before a pair of tickets to an upcoming concert because you had happened to mention that you are a fan of the performer, who has never held a concert in your part of the country before. You have tried to find tickets to take your daughter, who very much wants to attend, but tickets were immediately sold out and no source seems to have them available at any price.
1. What do you feel?
2. What issues do you consider?
3. Is there any more information that you would want before deciding what to do? If so, what information would you seek?
4. Under what conditions, if any, would you accept the tickets?
5. After the session is over, how, if at all, would you describe this situation in your chart notes?
SCENARIO #6: You are very involved in your community, and you'vejust been appointed to a new board, which is engaged in the kind of activism you value. You attend your first board meeting to discover that one of your new clients is also on the board. Your client comes over at a break to tell you how pleased she is that you share similar values and will be working closely together.
1. How do you feel?
2. What feelings do you imagine that your client might be experiencing?
3. What issues do you consider?
4. What do you think you would say to your client?
5. Would you remain on the board or not? What reasoning leads you to this decision?
6. How, if at all, would you chart this interaction?
1) Pope, K.S., Tabachnick, B.G., & Keith-Spiegel, P. (1987). Ethics of practice: The beliefs and behaviors of psychologists as therapists. American Psychologist, vol. 42, pages 993-1006.
2) Borys, D.S. & Pope, K.S. (1989). Dual relationships between therapist and client: A national study of psychologists, psychiatrists, and social workers. Professional Psychology: Research and Practice, vol. 20, pages 283-293.
3) Pope, K.S. & Vetter, V.A. (1992). Ethical dilemmas encountered by members of the American Psychological Association: A national survey. American Psychologist, vol. 47, pages 397-411.
4) Gottlieb, M.C. (1993). Avoiding exploitive dual relationships: A decision-making model. Psychotherapy: Theory, Research, Practice, Training, vol. 30, pages 41-48
5) Biography. (1995). American Psychologist, vol. 50, pages 241-243.
6) Pope K.S., & Vasquez, M.J.T. (1998). "Dual Relationships Scenarios & Questions" from the chapter on "Multiple Relationships" in Ethics in Psychotherapy and Counseling: A Practical Guide, Second Edition. San Francisco: Jossey-Bass.