How Consensus Regarding The Prohibition Of Dual Relationships
Has Been Contrived
By Ofer Zur, Ph.D.
Adapted from: Lazarus, A. A. and Zur, O. (Eds.) (2002). Dual Relationships and Psychotherapy, New York: Springer. Chapter 1, pp. 3-24. Printed with permission.
Table Of Contents
The Core Group of Experts
How Consensus Has Been Achieved
The goal of this chapter is to describe the means that have been used to promote a consensus that dual relationships are ipso facto detrimental. Throughout this book, it has been emphasized that dual relationships are unavoidable in many settings and communities and that judicious boundary crossings can enhance treatment effectiveness. Many of the contributors to this book have documented how the codes of ethics of all major professional psychotherapy associations do not consider dual relationships to be inherently unethical. In this chapter I will present eleven methods that have been used to manufacture the mistaken view and commonly held belief that dual relationships are essentially unethical, harmful, and dangerous.
For the reader who may be browsing and has not read the preceding chapters, I will state again that dual relationships in psychotherapy refer to any situation in which multiple roles exist between a therapist and a client. Examples of dual relationships are when the client is also a student, friend, family member, employee, or business associate of the therapist. Like the rest of the book, this chapter focuses only on non-sexual dual relationships. Sexual dual relationships with current clients are always unethical. It must be fully understood that it is imperative to avoid any dual relationship that might impair the therapist's or counselor's objectivity, competence, or effectiveness in performing his or her professional duties and functions. Likewise, great care must be exercised to ensure that the dual relationship will not expose the client to any form of exploitation or harm.
As any discerning reader who has perused several sections will undoubtedly have discovered, this book does not offer a blanket endorsement of dual relationships. Instead, the goal is to advocate a message that is consistent with most updated Codes of Ethics that simply caution therapists to be thoughtful and careful when they engage in dual relationships with their clients. Like any other clinical intervention, dual relationships should be employed as part of a well-articulated, individually tailored treatment plan that is discussed with and agreed upon by the clients.
Noam Chomsky's (1988) model of manufactured consent offers help in understanding how the urban analytic risk-management approach has come to dominate the field of psychotherapy. This domination is true for the field of ethics in general and dual relationships in particular. Manufactured consent has been described as the process whereby a few people in a certain sub-culture are positioned to have an overwhelming power to influence public opinion, decision-making, and the determination of how such a culture functions. In applying this understanding to the field of psychotherapy and dual relationships, it becomes clear that the profession has been dominated by a handful of people in key positions who disseminate and control the flow and type of information available to the rest of profession. Manufactured consent in the area of psychotherapy is presided over by people who are not necessarily conscious of or conspiratorial in their manipulations. Mostly they are committed professionals with a strong belief in their ideas and great determination to convince the remainder of the field to support them and practice the "right way." The net result, however, is what Hedges (1993) described as the "malignant concept of dual relationships" (p. 47) and the raison d'être throughout this book is to provide a benevolent and balanced account of this significant topic.
The Core Group of Experts
The saturation of the professional literature on the depravity of dual relationships and the absence of the supportive view is fueled by the handful of "authorities" who hold, as predicted by Chomsky (1988), significant positions of power. These positions include book and journal editors, chairpersons and members of boards, committees and task forces, professors and department heads at universities and colleges, authors of articles and books, and expert consultants and witnesses for courts. Their influence continues to be felt in a wide range of settings, from disciplinary actions by regulatory boards, to the formation of codes of professional conduct. Above all, their influence has established and supported a pervasive belief among professionals about the depravity of dual relationships. What will be referred to as "the core group" includes Bersoff (1999), Borys (1992, 1994, Borys & Pope, 1989), Brown (1994), Epstein (Epstein & Simon, 1990), Gabbard & Gutheil (Gutheil and Gabbard, 1993), Kitchener (1988, 1996), Koocher (Keith-Spiegel & Koocher, 1985, Koocher & Keith-Spiegel, 1998), Langs (1974), Pope (1986, 1988, 1989, 1990, 1991), Simon (1989, 1991, 1992, 1995), Sonne (1994), and Strasburger and Jorgenson (Strasburger, Jorgenson, & Sutherland, 1992). These writers and scholars advocate for, disseminate, and preserve the belief that almost all dual relationships are fundamentally unethical and harmful.
How Consensus Has Been Achieved
Manufactured consent that dual relationships are basically unethical, clinically ill-advised, exploitative, and harmful and often lead to sex has been achieved and fueled through the following means:
- Dissemination of the belief that dual relationships are basically and fundamentally unethical. The propagation of the erroneous idea that dual relationships are almost always unethical has been one of the most powerful tools in manufacturing consent about the presumed destructive nature of dual relationships. The often quoted ethicist Kitchener (1988) claims that "all dual relationships can be ethically problematic and have the potential for harm" (p.217). O'Connor-Slimp & Burian (1994) state: "American Psychological Association's (1992) Ethical principles of Psychologists and Code of Conduct mandates that most types of multiple or dual relationships be avoided" (p.39). Craig (1991) asserts: "Ethical counselors cultivate unambiguous relationships . . . Unethical counselors cultivate dual relationships" (p. 49). While giving some lip service and acknowledgment that dual relationships are not always avoidable the writings of the above-mentioned core group promote the falsehood that almost all dual relationships are basically unethical. Some of the above scholars have served on the task forces that developed several of the codes of ethics cited above. Yet they still disseminate the misinformation that almost all dual relationships are fundamentally unethical.
- Overflow in professional literature of the idea that dual relationships are harmful and exploitative. The aforementioned influential writers and the like-minded core group have been by far the most frequently cited authors on the topic of dual relationships. They often quote each other incessantly and at times almost exclusively. A few examples may be found in Borys (1994), Gabbard (1994) and Gutheil (1994), in which the writers from the core group comprised 83%, 60% and 75% of the citations, respectively. In Bersoff's (1996) widely used ethics textbook, four (44%) of the nine entries on dual relationships in therapy are authored or co-authored by Pope, and the remaining five (56%) written by other authors from the above-mentioned list. Such a repetitive and at times exclusive circulation of a set of references creates a sense that it is the only valid position available in the professional literature and hence cultivates an illusion that dissent does not exist and consent about the depravity of dual relationships is universal.
- Lack of acknowledgment of opposing perspectives. Articles that represent a more inclusive attitude toward non-sexual dual relationships, such as Barnett (1992), Barnett & Yutrzenka (1994), Brown (1991), Hedges (1993), Jennings (1992), Lazarus, (1994), Sears (1990), Smith (1990), Stockman (1990), and Tomm (1993), have been generally excluded from most articles and texts on ethics. A few striking examples out of the dozens of books and articles published after the above articles appeared that refer to almost none of them (in their supposedly balanced, ethical and scientific discussion of dual relationships) are Bersoff (1996), Gabbard & Nadelson (1995), Kitchener (1996), Simon (1995), Sonne (1994), and St. Germaine (1996). Perhaps the most outstanding example lies in the extensive reference list of the text by Pope & Vasquez (1998), in which Pope includes 48 citations of his own work but none of the above references. In fairness, it should be noted that Bersoff's second edition (1999) includes an article by Lazarus (1994), who presents a positive view of dual relationships.
- Inordinate dependence on psychoanalytic theory to refute the arguments of non-analytic practitioners who support dual relationships. The endlessly cited works of analytically oriented writers such as Epstein (Epstein & Simon, 1990), Langs (1974), Lakin (1991), and Simon (1991, 1995) are very common in the articles that demonize dual relationships. According to these authors, almost any deviation from the strict analytic blank screen stance results in the nullification of therapeutic effectiveness and causes harm. The rigid analytic orientation of these authors blinds them and their followers to the fact that most practitioners do not adhere to, believe in, or practice analytic theory. The works of these analytically oriented writers have been used to justify the imposition of strict rules and even administrative and civil sanctions on all practitioners, regardless of their orientation (Lazarus, 1994; Williams, 1997, 2000; Zur, 2001b).
- Methodical avoidance of references to non analytic clinical practices supportive of dual relationships. Behavioral, cognitive-behavioral, humanistic, group, family, and existential therapeutic orientations are among the most practiced orientations today. Their practitioners, when appropriate, endorse what are considered clear boundary violations by most ethicists, psychoanalysts, and risk management advocates. The most influential critics and opponents of dual relationships ignore the works of Bugental (1986) or Yalom (1980) on Existential therapy, Ellis (1977) on Rational Emotive Behavior therapy, Rogers (1942) on Humanistic therapy and Lazarus (1989, 1997) on Multimodal therapy. For instance, the aforementioned are conspicuously almost entirely absent in the writings of Bersoff (1996, 1999), Borys & Pope (1989), Brown (1990), Epstein & Simon (1990), Kitchener (1988), Keith Spiegel & Koocher (1985), Koocher & Keith-Spiegel (1998), Pope (1988, 1989, 1990), Simon (1991), and Strasburger et al. (1992).
- Dearth of recognition of beneficial dual relationships. Most of the professional literature fails to note that dual relationships are not only sometimes unavoidable, but in fact can be beneficial (e.g., Brown, 1991; Hedges, 1993; Herlihy & Corey, 1992; Jennings, 1992; Lazarus, 1994, 1998; Sears, 1990; Smith, 1990; Stockman, 1990; Tomm, 1993; Zur, 2000, 2001a). This type of lacuna is known to be extremely effective in spawning half truths. Here are a few examples of such non-information. In Keith-Spiegel & Koocher's (1985) classic textbook, and in its second revision (Koocher & Keith-Spiegel, 1998), the chapters on dual relationships include 51 and 55 cases, respectively, of dual relationships. Almost none of these exemplifies a positive outcome. Austin (1998), Borys (1992), Grosso (1997), Nagy (2000), Pepper (1991), Simon (1989), Sonne (1994), and the widely quoted text by Pope & Vasquez (1998) mostly fail to present meaningful documentation about beneficial dual relationships. In fairness, it should be noted that Koocher & Keith-Spiegel (1998) include some references to resources supporting dual relationships. However, the 30-page chapter on dual relationships devotes fewer than a couple of pages to positive views of dual relationships.
- Ignoring the inevitability of dual relationships in military, rural, and other close-knit communities. The known fact that not all therapists practice in large urban areas or in communities where therapists' anonymity is possible or desirable has been largely ignored by writers, such as Austin (1998), Epstein & Simon (1990), Langs (1974), and many others. It has been given lip service by writers such as Bersoff (1999), Koocher & Keith-Spiegel (1998), Pope & Vasquez (1998), and Sonne (1994), but who still maintain a general stance against the incorporation of dual relationships in psychotherapy. Even though all major professional associations have changed their codes to accommodate settings in which dual relationships are unavoidable, the literature on dual relationships rarely acknowledges this reality (Hedges, 1993). Absent from the majority of literature on the topic is the inevitability of dual relationships in small, tight-knit, interconnected groups of people such as those found in rural (Barnett, 1996; Barnett & Yutrzenka, 1994; Hargrove, 1986; Jennings, 1992; Schank, 1998; Schank & Skovholt, 1997), church (Geyer, 1994; Montgomery & DeBell, 1997), military (Barnett & Yutrzenka, 1994; Johnson, 1995; Staal & King, 2000), lesbian (Brown, 1989; Smith, 1990), feminist (Brown, 1991; Heyward, 1993; Lerman & Porter, 1990), and ethnic minority communities (Sears, 1990). Most scholars either avoid mentioning this inevitability or minimize it by devoting only a few insignificant statements to the subject.
- Equation of dual relationships with exploitation, harm, and betrayal. Most writers present dual relationships not only as essentially unethical but also as harmful and exploitative and highly likely to lead to sex. Austin's (1998) book opens the Dual Relationships chapter with: "Any relationships with a client other than the therapeutic relationships constitute a dual relationship. A client has the right to be treated by a therapist who will not exploit their trust" (p. 450). Kitchener (1996) links dual relationships with lack of integrity, betrayal, and untrustworthiness: "Multiple relationships that cross boundaries and distort the contract between psychologists and those with whom they work further exemplify a lack of integrity since they involve betrayal of trust between a psychologist and the person with whom he or she entered into a relationship" (p. 62). Sonne (1994) suggests the resemblance of dual relationships to drunk driving, and Koocher & Keith-Spiegel (1998), like so many other writers, associate most dual relationships with inherent harm and conflict of interest. Literature on the topic is mostly devoid of any mention that dual relationships are not synonymous with harm and exploitation, and in fact can strengthen trust, increase clinical effectiveness, and reduce the chance of exploitation (Herlihy & Corey, 1992; Lazarus, 1994, 1998; Sears, 1990; Tomm, 1993; Williams, 1997; Zur, 2000, 2001a).
- Advocating the necessity to avoid dual relationships for the purpose of risk management. According to popular belief, risk management is a valid reason to avoid dual relationships. Risk management is the process whereby therapists refrain from engaging in certain behaviors and interventions, not because they are clinically ill advised, harmful, or wrong, but because they may appear improper in court (Williams, 1997, 2000). Besides dual relationships, other practices considered high-risk and therefore not advisable by most attorneys and ethicists include scheduling clients at the end of the day, self-disclosure, leaving the office with a client, and giving a client a comforting hug (Austin, 1998; Pope & Vasquez, 1998; Woody, 1998). Fear of lawsuits and of hyper-vigilant regulatory and consumer protection agencies has created great dread and trepidation among therapists, particularly around the issue of dual relationships (Ebert, 1997). "Risk Management" may sound like practical or pragmatic advice, but in fact is a misnomer for a practice in which fear of licensing boards and attorneys, rather than clinical considerations and the needs of the client, determines the course of therapy.
- Promotion of a connection between non-sexual and sexual dual relationships: The supposition of a "slippery slope." One of the main arguments against dual relationships is the snowball effect, described by Gabbard (1994) as follows: " . . . the crossing of one boundary without obvious catastrophic results (making) it easier to cross the next boundary." (p. 284). Kenneth Pope (1990-b), a prominent authority on ethical matters asserts, what has become a professional standard " . . . non-sexual dual relationships, while not unethical and harmful per se, foster sexual dual relationships" (p. 688). Based on the same perspective, Strasburger et al. (1992) state: "Obviously, the best advice to therapists is not to start (down) the slippery slope, and to avoid boundary violations or dual relationships with patients" (p. 547-548). Borys & Pope (1989), as well as Evans (1997), and Sonne (1994), also generally agree that non-sexual dual relationships are likely to lead to harm or sexual dual relationships. Sonne describes how a therapist and client who play tennis with one another can easily begin to carpool or drink together. Sonne goes on to declare that "With the blurring of the expected functions and responsibilities of the therapist and client comes the breakdown of the boundaries of the professional relationship itself" (p. 338). Clearly, the most distinguished scholars on dual relationships imply a direct causal link not only between dual relationships and harm, but also between sexual and non-sexual dual relationships. While the slippery slope claim has been shown to be illogical, fear-based, and syllogistic (Ebert, 1997; Lazarus, 1994; Zur, 2001a), it is nevertheless referred to extensively and presented as evidence-based and factual rather than as a hypothetical speculation. It is reminiscent of those who fear and believe that one puff of marijuana will inevitably result in hard core drug addiction.
- Distribution of illusory research findings based on partisan inquiries and falsely representative samples. Several surveys have been conducted on dual relationships in therapy, most of which have significantly low return rates that put the validity of the findings into question. The return rates reported by Baer & Murdock (1995), Borys & Pope (1989), Epstein, Simon, & Kay (1992), Lamb & Catanzaro (1998), Pope, Tabachnick, & Keith-Spiegel (1987), Ramsdell & Ramsdell (1993), and Sharkin & Birky (1992) were 38%, 49%, 21%, 60%, 45%, 26%, and 32% respectively. Given the witch hunt-like atmosphere around the issues of boundaries and dual relationships (Ebert, 1997; Herlihy & Corey, 1992; Lazarus, 1998; Williams, 1997), most therapist or client respondents who believe that crossing traditional boundaries can be curative are highly unlikely to respond to such surveys (Yalom, 1997; Williams, 2001, 2002). Researchers' promises of confidentiality and anonymity are not likely to help such practitioners to overcome their deep fear and trepidation of loss of license, public shame, and prosecution. In addition to sampling problems, many of the survey instruments suffer from a significantly biased wording of questions, which in turn affects the validity of the instruments. Consistent with the general perpetuation of the myth of the depravity of dual relationships, the criticism of existing research has been largely ignored by the researchers themselves and by those who back their conclusions on these questionably validated studies.
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All of the major professional associations unanimously acknowledge that non-sexual dual relationships are neither always unethical, nor always avoidable. Using very similar wording, all the codes (e.g., American Psychological Association, 1992) emphasize that therapists must avoid any form of sexual interaction with clients, and that they must exclude only those non-sexual dual relationships that might impair their judgment and objectivity, or harm or exploit patients. Additionally, dual relationships are unavoidable in many settings, such as rural, military, deaf, church, ethnic minority, and other small communities. Dual relationships have also been shown to be beneficial clinically as they increase trust, familiarity, and therapeutic alliance between therapists and clients. Nevertheless, the faulty belief that non-sexual dual relationships are essentially unethical, are inherently exploitative, and inevitably lead to sex and harm continues to dominate the field of psychotherapy. This chapter documents several ways by which consent has been manufactured in regard to the opposition to dual relationships.
Notably, there are a handful of journals and books that consistently have not been part of this movement to manufacture consent about the depravity of dual relationships. The few publications that repeatedly encourage critical thinking about the complexities of non-sexual dual relationships primarily include three journals: Professional Psychology: Research and Practice (e.g., Schank & Skovholt, 1997; Hansen & Goldberg, 1999), Psychotherapy: Theory, Research, Practice, Training (e.g., Rubin, 2000; Williams, 1997), and The Independent Practitioner (e.g., Saunders, 2001; Williams, 2001; Zur, 2001a). Similarly, the limited number of books that also support this line of critical thinking include Herlihy & Corey (1992), Heyward (1993), Howard (1986) and Lerman & Porter (1990).
To discard the option of healthy, productive non-sexual dual relationships in psychotherapy based on the inaccurate negative impression imposed by gatekeepers and others in opposition of dual relationships is not only unfair to clients, but an insult to the concept of critical thinking and inimical to the purpose of the profession. If the misinformation currently being disseminated is effective in curtailing the willingness of therapists to act according to the best interests of clients, then the patterns of blind compliance and fear-based avoidance behaviors will become even more entrenched.
The key for therapists' effectiveness is to be well-informed and think critically while keeping in mind the simple objective of best serving the client. Hansen & Goldberg (1999) reflect on the presentation of dual relationships as harmful and "slippery": ". . .when a psychologist sees professional behavior contrary to his or her personal values, the observer may well cry 'unethical,' when a more apt response might be 'I disagree.'" (p. 499).
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