Ethical Guide to Multiple Relationships and Therapy
John C. Buckner
Jason P. Austin
Therapy is a process that explores our past and often brings out issues that we have not dealt with for a while. This can be scary for many of us. With movies and television giving the therapy process a negative stigma, the decision to pursue therapeutic services is often a difficult one (Kaplan, 2008; Vogel, Gentile, & Kaplan, 2008; Vogel, Wade, & Hackler, 2007). However, what television and Hollywood producers forget to mention is that there exist ethical codes and boundaries that prevent therapists from forming multiple relationships with their clients to protect the therapists and their clients.
But do these ethical codes actually protect both parties? Given that not every therapist conducts himself or herself in an unprofessional, problematic manner similar to those portrayed in the media (Borys & Pope, 1985), what do these ethical codes actually prohibit? What do they encourage? These questions are important when considering therapeutic treatment. The purpose of this literature review is to inform the reader about the ethical guide that has been laid out for therapists to use concerning the nature of multiple relationships. This review also touches on the ongoing debate concerning the ethical nature of multiple relationships.
Therapists are trained to join and create a therapeutic alliance with their clients. It is well known that the relationship between client and therapist is extremely important in the therapeutic process. As therapists begin to work with clients, both parties develop a deep, meaningful connection with each other–perhaps unlike any relationship the client has ever experienced. This meaningful relationship can be a powerful instrument that assists in bringing about therapeutic change. Unfortunately, these powerful connections may affect the better judgment of the therapist, causing the therapist to put the therapeutic process in harm’s way by adopting additional roles and relationships with his/her clients. These types of roles and relations are known as dual or multiple relationships. According to Woody and Woody (2001), a multiple relationship is defined “as a situation in which the [therapist] functions in roles associated with a professional relationship with a client and also assumes another definitive and intended role that is not inconsequential or a chance encounter” (p. 44).
Little research has been conducted on the negative effects of multiple nonsexual relationships with clients; in fact, some argue that they may be helpful (Freud & Krug, 2002, as cited in Ringstad, 2008). However, the negative effects of sexual relationships between therapist and client have been well established. Bouhoutsos, Jolroyd, Lerman, Forer, and Greenburg (1983) reported that sexual relationships with therapists affect clients emotionally, socially, and sexually in negative ways. Their experience in therapy is most often a negative one that impacts their personality and family life.
As a result of such problems, most, if not all, ethical codes have adopted clear, firm statements that sexual conduct with clients is a violation and unethical. These codes leave no room for misinterpretation of what is ethical and what is unethical when it comes to sexual multiple relationships. However, the American Psychology Association (APA) (2004), American Association of Marriage and Family Therapists (AAMFT) (2001), and American Counseling Association (ACA) (2005) have a built-in expectation of sexual conduct with previous clients–one that includes time frames. It states that therapists are not to engage in sexual relations with previous clients for two to five years after termination of the therapeutic relationship (depending on which organization governs the licensure of the therapist).
The APA (2004) code of ethics outlines the specific and lengthy criteria in which a sexual relationship may be deemed ethical to enter into even after the two-year time frame has ended. The AAMFT (2001) does not provide criteria as specific as the APA’s, but states that therapists must “demonstrate that there has been no exploitation or injury to the former client or to the client’s immediate family” (p. 1). Ryder and Hepworth (1990) suggest that these expectations are only included in the codes of ethics to ensure that the boundaries established do not facilitate the behavior they are designed to prevent, adding that “more restrictive rules, beyond some point, can lead to less compliance” (p. 129).
Much has been researched about sexual relationships of therapists and clients, yet, to date, little research has been carried out on nonsexual or nonromantic multiple relationships. Further, most of the research conducted in this area has concentrated solely on the fields of psychology and psychiatry, and does not account for other mental health disciplines that focus on the process of talk therapy. Those neglected are primarily Marriage and Family Therapists (MFTs), Licensed Professional Counselors (LPCs), and Licensed Professional Social Workers (LPSWs), as psychologists and psychiatrists primarily conduct assessment concerning mental illness (Schindler, Berren, Hannah, Beigel, & Santiago, 1987). This is quite surprising, since the most common reported violations of the code of ethics in the therapy profession concern multiple relationships (Stanley, 2001). For the purpose of this literature review, we will focus on the aspects of multiple relationships in relation to disciplines that focus on the process of talk therapy.
As Stanley (2001) reports, the AAMFT code of ethics violations review states that 40% of violations reported in the year 2001 were multiple relationships issues. Over half of that 40% concerned sexual misconduct with clients. However, many of the ethical violations were of nonsexual or nonromantic basis. Stanley states that multiple relationships were the largest category of violations. Despite the firm prescription of clear courses of action that therapists are expected to employ when faced with the possibility of sexual multiple relationships with clients, many therapists still find themselves in such situations. Clipson (2005) suggests that there is another reason for this problem:
Sexual involvement between therapist and client may be the culmination of a more general breakdown in roles and relationship boundaries that begin on a nonsexual level. This link is predicted by the systems perspective, which views . . . behaviors within a relational system as interrelated. Changes in one arena are expected to affect those in other realms of behavior. (p. 176)
According to the above statement, sexual misconduct between a therapist and his/her clients often start by the formation of non-sexual multiple relationships.
McLaurin, Ricci, and McWey (2004) stated that by focusing on the apparent unimportant behaviors and decisions concerning ethical issues, therapists would be more likely to avoid descending an ethical slippery slope. This leads many to think of the connection between risky nonsexual and nonromantic multiple relationships and more severe boundary violations–such as sexual relationships with clients. Still, many of the ethical codes remain unclear and ambiguous. One of these is the AAMFT (2001) ethical code on the “proper conduct concerning multiple relationships with clients. The AAMFT Code of Ethics (2001) states that
Marriage and family therapists are aware of their influential positions with respect to clients, and they avoid exploiting the trust and dependency of such persons. Therapists, therefore, make every effort to avoid conditions and multiple relationships with clients that could impair professional judgment or increase the risk of exploitation. Such relationships include, but are not limited to, business or close personal relationships with a client or the client’s immediate family. When the risk of impairment or exploitation exists due to conditions of multiple roles, therapists take appropriate precautions. (p. 1)
Notably, the words “avoid and “could contribute to the ambiguity of the code. The word “avoid implies that therapists do not have to comply completely when forming multiple relationships, but must simply put forth necessary effort not to allow the formation of relationships that “[impair] professional judgment or increase the risk of exploitation” (p. 1). To make it more difficult, the word “could suggests that a therapist is to have foresight of the possible future outcomes concerning multiple relationships. If he/she fails to predict and misses a potential “could have,” dangerous and unknown outcomes could result. Regrettably, considering possible negative outcomes of any relationship is only possible when the relationship in question is occurring or has occurred.
Nonetheless, Ryder and Hepworth (1990) state that the establishment of clear and straightforward rules could cause more trouble by requiring the therapist to be “more distant and use a technique-oriented approach” (p. 129), having a negative cascade effect on the therapeutic relationship. Thus, responsibility is left on the shoulders of each individual therapist to pass professional judgment on each situation. This leaves the challenges of navigating the messy particulars of multiple relationships in the hands of the therapist. Leaving this freedom of choice to the therapist can be a proverbial double-bladed sword.
Although the responsibility is left to the therapists, the final power to judge is left to the relevant ethics board. Contrary to the therapists, the ethics board has 20/20 hindsight on the “could haves.” From the view of the ethics committee, the fact that a complaint was filed indicates that the therapist involved did not take the precautions necessary to avoid multiple relationships that “[impaired] professional judgment” and “[increased] the risk of exploitation” (AAMFT p. 1).
Germaine (1996) conducted a study examining the attitudes and behavior of substance abuse counselors (SACs). Twenty-two percent of the SACs reported that these kinds of multiple relationships were helpful, and over two thirds reported that these relationships were neither helpful nor harmful. Although there is little empirical evidence of such relationships being beneficial or harmful, individuals still argue both sides.
Justification for Avoiding Multiple Relationships
Anderson and Kichener (1996) categorize nonsexual and nonromantic multiple relationships. The eight categories are: (a) personal or friendship, (b) social interaction and events, (c) business or financial, (d) collegial or professional, (e) supervisory or evaluative, (f) religious affiliation, (g) collegial or professional plus social, and (h) workplace. Although some or all of these relationships may seem harmless to some, it is commonly accepted in the helping profession that “therapists should exercise caution in developing additional relationships with clients” (Woody & Woody, 2001, p. 46).
While little empirical evidence supports the helpfulness or harmfulness of such multiple relationships, there exists a study of the negative effects of multiple relationships on the therapist’s wellbeing. Nigo (2004) conducted a study that followed up on Anderson and Kichener’s (1996) eight types of multiple relationships. Nigo mailed open-ended surveys to therapists in British Columbia, asking them about problematic multiple relationships in the context of the eight categories above.
Several problematic themes emerged in the therapists’ responses. Problems reported by therapists in multiple relationships included: role confusion and discrepancy; discomfort experienced by therapist or client; negative effect on therapist’s work or life; maintaining client’s confidentiality and anonymity; negative impact on therapeutic relationship; and limited alternatives.
Another rationale for the avoidance of multiple relationships is the benefit of the client. Pipes (1997) provides eight reasons for limiting multiple relationships: (a) clients may need help in the future, and the developing a relationship after therapy “will cause difficulties if the client wants to resume treatment” (p. 48); (b) some clients are vulnerable following termination of therapy, and these clients are more prone to exploitation; (c) as a result of the therapeutic alliance, some clients have strong feelings for their therapist, and the feelings heighten the chance of the client to make bad decisions in and after the therapy relationship; (d) the therapist may be asked to furnish records or testify in court in behalf of their pervious client, and this process would be less complicated if there is not another relationship between the therapist and client; (e) the client is entitled to the assurance that the therapist does not have any motives other than the client’s wellbeing; (f) modeling issues arise when a client sees a therapist involved in other relationships with previous clientsóclients may think it is okay to have blurred boundaries in their own lives; (g) if the post-therapy relationship “goes south,” the clients are at greater risk of detrimental effects; and (h) it is advisable for the therapist to steer clear of the multiple relationships for legal reasons, as the interpretations of ethical standards vary from board to board and state to state.
Professional boundaries exist to help maintain limits for the protection of the client and the therapist; boundaries establish rules of conduct that define what should be included or excluded from the participial relationship. Multiple relationships are inevitable; nevertheless, steps to avoid relationships that threaten the professional therapeutic relationship must be taken. Smith and Fitzpatrick (1995) explain that there is a difference between boundary crossing and boundary violations. Peterson (1987, as cited in Woody & Woody, 2001) defines “boundary crossing” as going away from the clinical relationship, which may not be harmful to the client or the therapeutic relationship, and a “boundary violation” as a deviation of the clinical relationship that places the client and the therapeutic process at risk. Yet, multiple boundary crossings can constitute a slippery slope towards boundary violations.
Gutheil and Gabbard (1993) explain that certain boundary crossings should not be allowed, as they place the therapist on a slippery slope that could lead to an ethical violation. Time limitation–beginning and ending the session punctually–is one of these boundaries. This is considered a red flag boundary violation and can lead to the offending therapist being susceptible to other boundary crossings and violations. In fact, moving the session to the first or last session of the day for the time element is one of the most common boundary crossings that lead to sexual misconduct cases between therapist and client (Woody & Woody, 2001).
The second crossing mentioned by Gutheil and Gabbard (1993) is place and space. Meeting a client outside of the therapeutic setting, giving a client a ride home, or having therapy at the client’s home are all examples of boundary crossing. A therapist needs to have clear therapeutic goals or objectives when seeing clients outside of the office, and should exercise extreme caution (Woody & Woody, 2001). This may send the message that the therapist is playing another role–friend, lover, and so on–to their clients. Therefore, seeing clients outside the therapeutic environment can blur boundaries and send unclear messages concerning inappropriate conduct.
Gutheil and Gabbard (1993) then explain that therapists should not engage in bartering and business with patients. Money payment is the most widely accepted form of compensation for therapeutic services. Further, if therapists indulge the belief that therapy is no longer effective, troubling changes to the therapeutic relationship could occur. Therapists should have their clients pay for their services to maintain this boundary. If the payment becomes too much for the client, adjustments of payment rate should be discussed. Gutheil and Gabbard (1993) argue that when payment is not received or bartering takes place, boundaries are blurred.
These types of relationships are even more prevalent in rural, religious, professional, or university settings, and may happen while working with some minority groups, leading Clipson (2005) to assert that some “take a position that seems simplistic and unrealistic” (p. 197) when it comes to avoiding multiple relationships. Continuing on this idea, Clipson said that some controversial writings assert that
While acknowledging that dual [multiple] relationships per se are not unethical, [many] view such relationships as so fraught with the potential for exploitation they recommend that if a dual [multiple] relationship can be avoided, it would be unwise not to do so. (p.197)
In order to discern the prevalence of multiple relationships, Borys and Pope (1985) conducted a national survey asking social workers, psychologists, and psychiatrists about their beliefs and behaviors on the subject. They found that less than 10% engage in multiple relationships. Although 38% disclosed details of their personal stress to a few clients, 21% have gone out after a session with a few clients, 10% provided therapy to a current student or supervisee with a few clients, and 21% stated that they bought something from a few clients, 85% accepted a small gift from a few clients, 35% had accepted an invitation to a special occasion with a client, and 30% became friends with a client after termination. Borys and Pope (1985) also found that male therapists tend to engage in multiple relationships more often than female therapists.
Among the findings from this study are five activities rated by the participants as always unethical. These are: having sex with a current client, selling something to a client, having sex with a client after termination, inviting a client to a special event, and providing therapy for an employee.
Another national study, carried out by Germaine (1996), considered the attitudes and behaviors of substance abuse counselors (SACs) about multiple relationships. SACs reported expecting small gifts 56% of the time and conducted therapy for a friend or family member of a client 49% of the time, while 39% of SACs reported disclosing personal stresses to a client, 36% admitted to becoming friends with a client after therapy, and 30% reported accepting an invitation to a special occasion from a client.
Rigstad (2008) undertook a study of attitudes and behaviors associated with multiple relationships of MFTs and LPSWs, and found that male therapists engage in multiple relationships more often than female therapists. Further, male therapists are more likely to disclose personal stress to a client than female therapists. Yet, female therapists reported taking small gifts from clients more often than male therapists. It was also found that individuals belonging to professional organizations are less likely to become friends with a client after termination, or to go out to eat with a client after a session.
Belonging to a professional association also affected how therapists ethically perceived multiple relationships. Therapists who belonged to a professional association emphasized five items likely to result in unethical behaviors more strongly than those who did not belong to a professional organization. Among these behaviors were going out to eat with a client after a session, accepting a gift under $10, selling something to a client, and providing therapy for current employees. The study did not indicate whether an analysis of the difference between MFTs and LPSWs had been conducted.
Rigstad (2008) suggests that the finding of difference in attitudes and behaviors between therapists who belong to associations and those who do not may have occurred due to continuing education that professions require their members to undergo. Nonetheless, Rigstad (2008) states that these findings are inconclusive, and that more research is needed before we might truly understand the implications of continuing education. Still, Clipson (2005) suggests that continuing education involving issues that may lead to unethical multiple relationships can be helpful.
Only a few studies have looked at multiple relationships as they affect MFTs (Brock & Coufal, 1994, as cited in Woody & Woody, 2001).
Guidelines to Help Protect the Client and the Therapist
It has been argued that avoiding multiple relationships altogether is impossible (Younggren & Gottlieb, 2004); however, it is important to observe guidelines to protect both therapist and client. Documentation is an important resource in managing specific situations, such as rural settings or work with ethnic groups, as it carefully describes efforts taken to avoid harming clients. Documentation of previous cases includes paperwork that explains what steps were taken to clarify roles and boundaries to the client and notes what explanations of possible negative outcomes were provided to clients.
Think through possible multiple relationship scenarios. What are the possible outcomes? What impacts will this have on the client’s professional life and on the therapist’s? Will the perceived obligations of the relationship limit the client’s decision-making? In what ways will this relationship affect the therapeutic relationship? To ensure that all bases are covered and all parties protected, think in worst-case scenarios (Clipson, 2005).
Clipson (2005) explains that self awareness of one’s own needs, in combination with an understanding of one’s vulnerability to the client’s pull to create a complementary match and meet attachment needs and wants, can create an awareness of the formation of possible problematic multiple relationships. Therapists must be in touch with their life’s stresses and losses, and should seek professional help if these factors place the client-therapist relationship at risk. Having this awareness can assist therapists in being the first to know when problematic multiple relationships are developing; this is preferable to learning about problems from a client, state board, or attorney.
Consultation could also assist therapists in processing possible problematic multiple relationships. Consultations with fellow professionals could help therapists reconsider possibilities that have been overlooked. An objective perspective can help with emotional and anxiety-charged aspects of multiple relationships, such as sexual feelings, aggressive impulses, financial conflicts, and so on (Clipson, 2005). Documentation by the therapist conducting the consultation, detailing what was discussed and what steps will be implemented to reestablish professional boundaries, is also advised.
Last, Clipson (2005) pointed out six warnings signs that a therapist can reflect upon to determine if therapeutic boundaries are eroding. These warning signs are: (a) strong feelings toward a client, either positive or negative; (b) reduction in structure of boundaries such as place and time; (c) excessive and uninhibited self-disclosure; (d) gratifying most of a client’s needs and wants; (e) touching the clients; (f) avoidance of seeking consultation and supervision.
These red flags are a good measure of where therapists’ professional boundaries exist in regards to his/her relationship with clients. Knowing the integrity of these relationship boundaries can help maintain them, thus implementing “professional judgment” (AAMFT p.1) and decreasing “the risk of exploitation” (AAMFT p. 1) of the client.
In summary, therapists need to be “aware of their influential positions” (AAMFT p.1) with those they help, and should know that multiple relationships can undermine the boundaries of the therapeutic relationship. Further, these multiple roles can be harmful to the therapist as well as the clients. Nevertheless, a therapist must learn how to navigate these roles without causing harm to the therapeutic relationship. This can be done by consulting, having self-awareness, understanding the warning signs, and consulting documentation.
The decision to obtain therapeutic services is rarely a light one. Considering everything discussed in a therapeutic context, it is important that the relationship between a therapist and his/her client be one that both parties considers safe and secure. The dynamics of human beings cannot be limited to one facet of the personality, and neither can the dynamics of therapy. While debate on the severity of multiple relationships has merit, every therapist and client is susceptible to them. However, while argued to be unavoidable, these multiple relationships must be governed and dealt with in a manner that is considered understanding to both the therapist and the client, a manner that maintains the high ethical standards of the therapy field.
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