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The codes of ethics of psychotherapists' professional associations have evolved through the years to suit the increasing awareness and knowledge of the field in regard to dual relationships and other relevant issues. Most codes during the mid-twentieth century and ensuing decades (i.e., APA, 1953) concentrated on the general points of promoting client welfare and discouraging abuse of power by therapists. The concerns with therapeutic boundaries came to the forefront of the field after Gestalt therapy, with Frederick Perls at the helm, became enormously popular during the sexual revolution of the 1960s. In response to the sexually and other permissive attitudes of the 1960s and 1970s, there was pressure on psychology and counseling to articulate and provide more specific guidelines regarding therapists' conduct vis-á-vis their clients. As a result, consumer protection agencies, licensing boards, and legislators joined ethicists and psychotherapists in establishing clear restrictions with regard to therapist-client sexual dual relationships. Therapists were instructed not only to resolutely avoid sexual relationships but also to make every effort to avoid any kind of boundary crossing and dual relationship because, as the (unfounded) myth went, it starts them on the slippery slope towards sexual dual relationships and harm.

The increasingly litigious culture of the 1980s and thereafter as well as the increased focus on risk management in medicine, led to more spoken and unspoken injunctions against any deviation from hands-off, only-in-the-office, "no self-disclosure" therapy. Dual relationships, like bartering, gifts, nonsexual touch, and dual were generally viewed as hazards from a risk management standpoint and the first step in the slippery slope towards sexual relationships. The early 1990s witnessed a growing acknowledgment that nonsexual dual relationships were unavoidable under some circumstances, such as in rural areas, small towns, military settings, and among constituents of distinct individual communities, such as churches, the deaf, gay men and lesbians, and other minorities. Partly in response to this growing awareness, several professional associations (i.e., APA, ACA, NASW) revised their codes of ethics, particularly with regard to dual relationships.

A few years into the 21st century we have seen even more profound changes. Professional associations, such as APA (2010), ACA (2014), ASPPB (2005) and USABP (2007) published codes of ethics that present a non-rigid, flexible and context based approach towards boundaries. As with this document, almost all current major organizations' codes of ethics clearly acknowledge that sexual relationships with current clients are always unethical, not all (non-sexual) dual relationships are unethical and some dual relationships are not avoidable. Regretfully, there is still a widespread false impression among psychotherapists, ethics committees, "experts," judges and licensing boards that dual relationships are essentially unethical and harmful.

To circumvent the possibility of contributing to the confusion surrounding the codes of ethics, the next section is composed of exact-direct quotes about dual relationships, lifted verbatim from the codes of ethics of the major professional associations. Because sexual dual relationships with current clients have always been unethical in the codes of ethics of all psychotherapists' professional associations, the passages that follow contain primarily those principles that directly relate to non-sexual dual relationships.

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The Current Codes of Ethics, Verbatim

American Art Therapy Association (AATA), Ethical Principle for Art Therapists (2003)

Standard 1.5 states: Art therapists refrain from entering into a multiple relationship if the multiple relationship could reasonably be expected to impair the art therapist's competence or effectiveness in performing his or her functions as an art therapist, or otherwise risks exploitation or harm to the person with whom the professional relationship exists.
A multiple relationship occurs when an art therapist 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 relationship with a person closely associated with or related to the person with whom the art therapist 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. Multiple relationships that would not reasonably be expected to cause impairment or risk exploitation or harm are not unethical.

[Dr. Zur's comments: Like many professional organizations, The American Association of Art Therapists (AATA, 2003), has replaced its old (1995) rigid, unreasonable and impossible guidelines regarding dual relationships with a more reasonable, appropriate and realistic guidelines.]

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American Association of Marriage and Family Therapists (AAMFT) Code of Ethics

Section 1.3, states: 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 or multiple roles, therapists document the appropriate precautions taken.

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American Association of Pastoral Counselors (AAPC) Code of Ethics (2012)

Principle V, states: "We make every effort to avoid dual relationships with such persons that could impair our judgment or increase the risk of personal and/or financial exploitation." (Emphasis added).

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American Board of Examiners in Clinical Social Work (ABE) Ethics Code (2006)


Section 1.5. States:
5. Clinical social workers do not use clients for self-interest, do not socialize with clients in a manner detrimental to treatment, and do not exploit clients or engage in sexual harassment or sexual relationships with supervisees, students, employees, research subjects, or current and former clients. The clinician carries the burden of determining that a relationship is appropriate, not detrimental, and does not violate boundaries of roles.

Dr. Zur's comments: Like many other professional organizations, ABE does not seem to recognize that dual relationships can be unavoidable and mandatory is certain setting (i.e., military, corrections) and unavoidable in small communities (i.e., rural, LGBT, church, deaf)]

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American Counseling Association (ACA) Code of Ethics and Standards for Practice (2014)

A.1.d. Support Network Involvement
Counselors recognize that support networks hold various meanings in the lives of clients and consider enlisting the support, understanding, and involvement of others (e.g., religious/spiritual/community leaders, family members, friends) as positive resources, when appropriate, with client consent.

A.5.a. Sexual and/or Romantic Relationships Prohibited
Sexual and/or romantic counselor–client interactions or relationships with current clients, their romantic partners, or their family members are prohibited. This prohibition applies to both in-person and electronic interactions or relationships.

A.5.b. Previous Sexual and/or Romantic Relationships
Counselors are prohibited from engaging in counseling relationships with persons with whom they have had a previous sexual and/or romantic relationship.

A.5.c. Sexual and/or Romantic Relationships With Former Clients
Sexual and/or romantic counselor–client interactions or relationships with former clients, their romantic partners, or their family members are prohibited for a period of 5 years following the last professional contact. This prohibition applies to both in-person and electronic interactions or relationships. Counselors, before engaging in sexual and/or romantic interactions or relationships with former clients, their romantic partners, or their family members, demonstrate forethought and document (in written form) whether the interaction or relationship can be viewed as exploitive in any 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 into such an interaction or relationship.

A.5.d. Friends or Family Members
Counselors are prohibited from engaging in counseling relationships with friends or family members with whom they have an inability to remain objective.

A.5.e. Personal Virtual Relationships With Current Clients
Counselors are prohibited from engaging in a personal virtual relationship with individuals with whom they have a current counseling relationship (e.g., through social and other media).

A.6. Managing and Maintaining Boundaries and Professional Relationships
A.6.b. Extending Counseling Boundaries

Counselors consider the risks and benefits of extending current counseling relationships beyond conventional parameters. Examples include attending a client’s formal ceremony (e.g., a wedding/commitment ceremony or graduation), purchasing a service or product provided by a client (excepting unrestricted bartering), and visiting a client’s ill family member in the hospital. In extending these boundaries, counselors take appropriate professional precautions such as informed consent, consultation, supervision, and documentation to ensure that judgment is not impaired and no harm occurs.

A.6.c. Documenting Boundary Extensions
If counselors extend boundaries as described in A.6.a. and A.6.b., they must officially document, 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. When unintentional harm occurs to the client or former client, or to an individual significantly involved with the client or former client, the counselor must show evidence of an attempt to remedy such harm.

A.6.d. Role Changes in the Professional Relationship
When counselors change a role from the original or most recent contracted relationship, they obtain informed consent from the client and explain the client’s right to refuse services related to the change. Examples of role changes include, but are not limited to

  1. changing from individual to relationship or family counseling, or vice versa;
  2. changing from an evaluative role to a therapeutic role, or vice versa; and
  3. changing from a counselor to a mediator role, or vice versa. Clients must be fully informed of any anticipated consequences (e.g., financial, legal, personal, therapeutic) of counselor role changes.

A.6.e. Nonprofessional Interactions or Relationships (Other Than Sexual or Romantic Interactions or Relationships)
Counselors avoid entering into nonprofessional relationships with former clients, their romantic partners, or their family members when the interaction is potentially harmful to the client. This applies to both in-person and electronic interactions or relationships.

[Dr. Zur's comments: Like the 2004 code, the new code acknowledges that indeed not all concurrent or sequential dual and multiple relationships are unethical or avoidable. Section A.5.e. Personal Virtual Relationships With Current Clients, which states that "Counselors are prohibited from engaging in a personal virtual relationship with individuals with whom they have a current counseling relationship (e.g., through social and other media)." is extremely vague and unclear in terms of what constitutes "personal virtual relationships" in the digital age. This section seems to be written by 'uniformed digital immigrants' rather than by 'informed digital natives.' While the code seems to acknowledge that extending boundaries may be beneficial, it also mandates that counselors who are involved in such boundary crossing "ensure that judgment is not impaired and no harm occurs." Obviously, counselors cannot 'ensure' that no harm occurs; they can only avoid boundary crossings that "could reasonably be expected to impair" (to use APA terminology) the counselors "objectivity, competence, or effectiveness." Later on in the text the code does state correctly "When unintentional harm occurs" acknowledging that counselors cannot 'ensure,' but only do their best or do what is reasonable. The Bartering section is highly appropriate as it acknowledges that bartering, especially within certain cultures, is ethical and appropriate. For unclear reasons, the code states that sexual or romantic relationships with former clients are prohibited for a period of 5 years following the last professional contact, unlike the codes of APA and CAMFT, which have only 2 years of 'cooling period'.]

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American Mental Health Counselors Association (AMHCA) Codes of Ethics (2010)

Section 3. Dual/multiple Relationships
Mental health counselors are aware of their influential position with respect to their clients and avoid exploiting the trust and fostering dependency of the client.

a) Mental health counselors make every effort to avoid dual/multiple relationships with clients that could impair professional judgment or increase the risk of harm. Examples of such relationships may include, but are not limited to: familial, social, financial, business, or close personal relationships with the clients.

b) When deciding whether to enter a dual/multiple relationship with a client, former client or close relationship to the client, mental health counselors will seek consultation and adhere to a credible decision-making process prior to entering this relationship.

c) When a dual/multiple relationship cannot be avoided, mental health counselors take appropriate professional precautions such as informed consent, consultation, supervision and documentation to ensure that judgment is not impaired and no exploitation has occurred

d) Mental health counselors do not accept as clients, individuals with whom they are involved in an administrative, supervisory or other relationship of an evaluative nature.

Section 4. Exploitive Relationships
Mental health counselors are aware of the intimacy and responsibilities inherent in the counseling relationship. They maintain respect for the client and avoid actions that seek to meet their personal needs at the expense of the client.

a) Romantic or sexual relationships with clients are strictly prohibited. Mental health counselors do not counsel persons with whom they have had a previous sexual relationship.

b) Mental health counselors are strongly discouraged from engaging in romantic or sexual relationships with former clients. Counselors may not enter into an intimate relationship until five years post termination or longer as specified by state regulations. Documentation of supervision or consultation for exploring the risk of exploitation is strongly encouraged.

[Dr. Zur's comments: The new code is similar to the 2000 code and is generally reasonable as it acknowledges that some dual relationships cannot be avoided. It is odd that the code mandates that ". . . mental health counselors will seek consultation . . ." rather than leaving it to the practitioners to determine what is the best ethical decision making to follow.]

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American Psychiatric Association (ApA) Principles of Medical Ethics.
With Annotations Especially Applicable to Psychiatry
(2010)

Does not mention dual or multiple relationships. It simply outlines the general principles that appear in all other codes, of the mandate to avoid exploitation and harm to patients. Additionally it states: "Sexual activity with a current or former patient is unethical."

[Dr. Zur's comments: ApA statement that therapists cannot have sexual relationships with former clients does not give any time limit. It is absurd to think that if a psychiatrist sees a client for one session and twenty years later meets the ex-client in a party, they cannot have sexual relationships if they choose to.]

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American Psychological Association (APA) Ethical Principles of Psychologists and Code of Conduct

(The revised Code is Effective as of June 2010), Section 3.05 on Multiple Relationships offers a clearer than ever before an acknowledgement that dual relationships are not always unethical.

  1. 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 relationship 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.

    A psychologist refrains from entering into a multiple relationship if the multiple relationship could reasonably be expected to impair the psychologist's objectivity, competence, or effectiveness in performing his or her functions as a psychologist, or otherwise risks exploitation or harm to the person with whom the professional relationship exists.

    Multiple relationships that would not reasonably be expected to cause impairment or risk exploitation or harm are not unethical.

  2. If a psychologist finds that, due to unforeseen factors, a potentially harmful multiple relationship has arisen, the psychologist takes reasonable steps to resolve it with due regard for the best interests of the affected person and maximal compliance with the Ethics Code.
  3. When psychologists are required by law, institutional policy, or extraordinary circumstances to serve in more than one role in judicial or administrative proceedings, at the outset they clarify role expectations and the extent of confidentiality and thereafter as changes occur. (APA, 2010, Multiple Relationships section, para 1-4).

[Dr. Zur's comments: It is important to note that the 2002, and later the 2010, code of ethics has added an important statement, "Multiple relationships that would not reasonably be expected to cause impairment or risk exploitation or harm are not unethical." Additionally, it is important to note that the code does not consider sequential, non-sexual dual relationships as dual relationships. This seems to mean that activities by therapists who become friends or start business relationships after termination of therapeutic relationships, as long as there was no promise of such relationships, are not covered by the code of ethics. This has significant ramifications as it counters the claim by many psychoanalytic and other scholars, risk management experts and attorneys who focus on the supposedly lasting impact of transference beyond the termination date. For more information on this issue, see Zur, 2007]

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Association Of State And Provincial Psychology Boards Report of Activities (ASPPB) (2005)

III. B. Multiple Relationships

  1. Definition of multiple relationships. Psychologists recognize that multiple relationships may occur because of the psychologist's present or previous familial, social, emotional, financial, supervisory, political, administrative or legal relationship with the client or a relevant person associated with or related to the client. Psychologists take reasonable steps to ensure that if such a multiple relationship occurs, it is not exploitative of the client or a relevant person associated with or related to the client.
  2. Prohibited Multiple Relationships.
    1. A multiple relationship that is exploitative of the client or a relevant person associated with or related to the client is prohibited. Psychologists take all reasonable steps to ensure that any multiple relationships do not impair the psychologist's professional judgment or objectivity or result in a conflict of interest with the client or a relevant person associated with or related to the client.
    2. Multiple relationships that would not reasonably be expected to impair a psychologist's judgment or objectivity or risk harm to the client or relevant person associated with or related to the client are not expressly prohibited.

[Dr. Zur's comments: Using similar language to that of APA and other recently modified codes, ASPPB "recognized' that multiple relationships "may occur because of the psychologist's present or previous familial, social, emotional, financial, supervisory, political, administrative or legal relationship with the client or a relevant person associated with or related to the client." Appropriately, it qualifies that "Multiple relationships that would not reasonably be expected to impair a psychologist's judgment or objectivity or risk harm to the client or relevant person associated with or related to the client are not expressly prohibited."]

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Australian Ethics Codes for Psychologists, Social Workers

The Australian Psychological Society (APS) Code of Ethics (2003), principle B7 states: Members must avoid dual relationships that could impair their professional judgment or increase the risk of exploitation. Examples of such dual relationships include, but are not limited to, provision of psychological services to employees, students, supervisees, close friends or relatives

Australian Association of Social Workers (AASW) Code of Ethics (2002) section 4.1.4 g. states: recognising that conflicts of interest can arise from engaging in dual or multiple relationships with clients, former clients, research participants, students, supervisees or colleagues, social workers will set and enforce explicit, appropriate professional boundaries to minimise the risk of conflict, exploitation or harm.

Australian Institute of Welfare and Community Workers (AIWCW) Code of Ethics (1999) does not mention specific prohibition of dual or multiple relationships. It simply outlines the general principles that appear in all other codes, of the mandate to treat clients with respect.

Psychotherapy and Counselling Federation of Australia (PACFA) Ethical Guidelines section on Exploitation states:
- Counsellors must not exploit clients, past or present, in financial, sexual, emotional or any other way.
- Counsellors should consider that the deeper the involvement with the client's emotional life during Counselling, the less likely is the possibility of a subsequent equal relationship following termination of therapy. Counsellors must seek professional supervision should any attempt to build a relationship with a former client be considered.

[Dr. Zur's comments: All the above four Australian professional associations' codes of ethics provide the general mandate that therapists must avoid exploitation, sexually and otherwise and treat clients with respect and dignity.]

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California Association of Marriage and Family Therapists (CAMFT)
Ethical Standards for Marriage and Family Therapists (2011)

Section 1.2 states:
DUAL RELATIONSHIPS-DEFINITION: Marriage and family therapists are aware of their influential position with respect to patients, and they avoid exploiting the trust and dependency of such persons. Marriage and family therapists therefore avoid dual relationships with patients that are reasonably likely to impair professional judgment or lead to exploitation. A dual relationship occurs when a therapist and his/her patient engage in a separate and distinct relationship either simultaneously with the therapeutic relationship, or during a reasonable period of time following the termination of the therapeutic relationship. Not all dual relationships are unethical, and some dual relationships cannot be avoided. When a concurrent or subsequent dual relationship occurs, marriage and family therapists take appropriate professional precautions to ensure that judgment is not impaired and that no exploitation occurs.

1.2.1 UNETHICAL DUAL RELATIONSHIPS: Other acts that would result in unethical dual relationships include, but are not limited to, borrowing money from a patient, hiring a patient, engaging in a business venture with a patient, or engaging in a close personal relationship with a patient. Such acts with a patient's spouse, partner or family member may also be considered unethical dual relationships.

1.2.2 SEXUAL CONTACT: Sexual intercourse, sexual contact or sexual intimacy with a patient, or a patient's spouse or partner, or a patient's immediate family member, during the therapeutic relationship, or during the two years following the termination of the therapeutic relationship, is unethical. Should a marriage and family therapist engage in sexual intimacy with a former patient or a patient's spouse or partner, or a patient's immediate family member, following the two years after termination or last professional contact, the therapist shall consider the potential harm to or exploitation of the former patient or to the patient's family.

1.2.3 PRIOR SEXUAL RELATIONSHIP: A marriage and family therapist does not enter into a therapeutic relationship with a person with whom he/she has had a sexual relationship or with a partner or the immediate family member of a person with whom he/she has had a sexual relationship.

Section 4.1 adds:
DUAL RELATIONSHIPS: Marriage and family therapists are aware of their influential position with respect to students and supervisees, and they avoid exploiting the trust and dependency of such persons. Marriage and family therapists therefore avoid dual relationships that are reasonably likely to impair professional judgment or lead to exploitation. Provision of therapy to students or supervisees is unethical. Provision of marriage and family therapy supervision to clients is unethical. Sexual intercourse, sexual contact or sexual intimacy and/or harassment of any kind with students or supervisees is unethical. Other acts which could result in unethical dual relationships include, but are not limited to, borrowing money from a supervisee, engaging in a business venture with a supervisee, or engaging in a close personal relationship with a supervisee. Such acts with a supervisee's spouse, partner or family member may also be considered unethical dual relationships.

Section 6.3 adds:
DUAL RELATIONSHIPS WITH RESEARCH PARTICIPANTS: Researchers respect participants' freedom to decline participation in or to withdraw from a research study at any time. This obligation requires special thought and consideration when researchers or other members of the research team are in positions of authority or influence over participants. Marriage and family therapists, therefore, make every effort to avoid dual relationships with research participants that could impair professional judgment or increase the risk of exploitation.

Section 8.4 adds:
DUAL ROLES: Marriage and family therapists avoid providing both treatment and evaluations for the same clients or treatment units in legal proceedings such as child custody, visitation, dependency, or guardianship proceedings.

The CAMFT code clearly and appropriately states that "Not all dual relationships are unethical, and some dual relationships cannot be avoided" its injunction against "borrowing money from a patient, hiring a patient, engaging in a business venture with a patient, or engaging in a close personal relationship with a patient" is probably one of the most extreme standards set by any professional organization. It is unrealistic and unreasonable to always avoid business and personal relationships in rural and small communities. It is definitely impossible to avoid "close personal relationships" in the military or on Native American Reservations or in any small, rural or isolated communities. This code may mean that MFTs are not likely to be able to practice effectively in small or isolated communities. Avoiding bartering for services (i.e., "hiring a patient") may deprive many cash-poor but skill-rich clients from obtaining therapy. The absolute statement that borrowing money is unethical seems to criminalize simple action of a therapists who may borrow a couple of dollars for a bus fair from a client until the next session. To read more about bartering, go to http://www.zurinstitute.com/bartertherapy.html, about rural communities, go to http://www.zurinstitute.com/online/rural14.html and about appropriate dual relationships, see Zur, 2007]

It is interesting to note that at least one code of ethics, that is of CAMFT, is extremely restrictive and equally unrealistic and unreasonable when it comes to small, rural or isolated communities in regard to business ventures between psychotherapists and clients when its states "Other acts that would result in unethical dual relationships include, but are not limited to, borrowing money from a patient, hiring a patient, engaging in a business venture with a patient, or engaging in a close personal relationship with a patient. Such acts with a patient's spouse, partner or family member may also be considered unethical dual relationships." (2011, section 1.2.1. Unethical Dual Relationships). Such codes may means that many therapists cannot practice is such small isolated communities and that people is these communities are not likely to have the mental health services they need from MFTs.

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Canadian Counseling Association (CCA) Code of Ethics (2007)

Section B, Counseling Relationships, subsection B8, Dual Relationships, states:
Counselors make every effort to avoid dual relationships with clients that could impair professional judgment or increase the risk of harm to clients. Examples of dual relationships include, but are not limited to, familial, social, financial, business, or close personal relationships. When a dual relationship can not be avoided, counselors take appropriate professional precautions such as informed consent, consultation, supervision, and documentation to ensure that judgment is not impaired and no exploitation occurs.

[Dr. Zur's comments: Like the code of 1999, the 2007 code, appropriately, acknowledges that some "dual relationship cannot be avoided.]

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Canadian Psychological Association (CPA) Code of Ethics for Psychologists (2000)

Section III.33, states:
Avoid dual or multiple relationships (e.g. with clients, research participants, employees, supervisees, students, or trainees) and other situations that might present a conflict of interest or that might reduce their ability to be objective and unbiased in their determinations of what might be in the best interests of others (Avoidance of Conflict of Interest Section, para. 3) (Emphasis added).


Section III.34, states:
Manage dual or multiple relationships that are unavoidable due to cultural norms or other circumstances in such a manner that bias, lack of objectivity, and risk of exploitation are minimized. This might include obtaining ongoing supervision or consultation for the duration of the dual or multiple relationship, or involving a third party in obtaining consent (e.g., approaching a client or employee about becoming a research participant). (Avoidance of Conflict of Interest section, para. 4)

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Center for Clinical Social Work (CCSW) Ethics Code

Section 1.5. States:
Clinical social workers do not use clients for self-interest, do not socialize with clients in a manner detrimental to treatment, and do not exploit clients or engage in sexual harassment or sexual relationships with supervisees, students, employees, research subjects, or current and former clients. The clinician carries the burden of determining that a relationship is appropriate, not detrimental, and does not violate boundaries of roles.

[Dr. Zur's comments: Like many other professional organizations, ABE does not seem to recognize that dual relationships can be unavoidable and mandatory is certain setting (i.e., military, corrections) and unavoidable in small communities (i.e., rural, LGBT, church, deaf)]

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Feminist Therapy Institute (FTI) Feminist Therapy Code of Ethics (1999)

III. Overlapping Relationships
A. A feminist therapist recognizes the complexity and conflicting priorities inherent in multiple or overlapping relationships. The therapist accepts responsibility for monitoring such relationships to prevent potential abuse of or harm to the client.
B. A feminist therapist is actively involved in her community. As a result, she is aware of the need for confidentiality in all settings. Recognizing that her client's concerns and general well-being are primary, she self-monitors both public and private statements and comments. Situations may develop through community involvement where power dynamics shift, including a client having equal or more authority than the therapist. In all such situations a feminist therapist maintains accountability.

[Dr. Zur's comments: It is surprising that the Feminist Therapy Code of Ethics takes such a clear stance that ". . . client's concerns and general well-being are primary" This seems contrary to feminist philosophy about the importance of community and egalitarian relationships. The concern with confidentiality in regard dual relationships is unnecessary as detailed in my Out-Of-Office paper]

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National Association of Alcoholism and Drug Abuse Counselors (NAADAC)
Ethical Standards (2004)

Principle 7, Dual Relationships, states:
I understand that I must seek to nurture and support the development of a relationship of equals rather than to take unfair advantage of individuals who are vulnerable and exploitable.

  • I shall not engage in professional relationships or commitments that conflict with family members, friends, close associates, or others whose welfare might be jeopardized by such a dual relationship.
  • Because a relationship begins with a power differential, I shall not exploit relationships with current or former clients for personal gain, including social or business relationships.
  • I shall not under any circumstances engage in sexual behavior with current or former clients.
  • I shall not accept substantial gifts from clients, other treatment organizations, or the providers of materials or services used in my practice.

[Dr. Zur's comments: NAADAC statement that therapists cannot have sexual relationships with former clients does not give any time limit. It is absurd to think that if an Alcohol and Drug abuse counselor sees a client for one session and twenty years later meets the ex-client in a party, they cannot have sexual relationships if they choose to.]

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The National Association of Social Workers (NASW) Code of Ethics (2008)

Standard 1.06.c, states:
Social workers should not engage in dual or multiple relationships with clients or former clients in which there is a risk of exploitation or potential harm to the client. 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. (Dual or multiple relationships occur when social workers relate to clients in more than one relationship, whether professional, social, or business. Dual or multiple relationships can occur simultaneously or consecutively.) (Conflict of Interest Section, para. 3)

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National Board for Certified Counselors (NBCC) Code of Ethics (2012)

5. NCCs shall not engage in harmful multiple relationships with clients. In the event that a harmful multiple relationship develops in an unforeseen manner, the NCC shall discuss the potential effects with the client and shall take reasonable steps to resolve the situation, including the provision of referrals. This discussion shall be documented in the client's record.

14. NCCs who provide clinical supervision services shall not have multiple relationships with supervisees that may interfere with supervisors' professional judgment or exploit supervisees. Supervisors shall not supervise relatives.

19. NCCs shall recognize the potential harm of informal uses of social media and other related technology with clients, former clients and their families and personal friends. After carefully considering all of the ethical implications, including confidentiality, privacy and multiple relationships, NCCs shall develop written practice procedures in regard to social media and digital technology, and these shall be incorporated with the information provided to clients before or during the initial session. At a minimum, these social media procedures shall specify that personal accounts will be separate and isolated from any used for professional counseling purposes including those used with prospective or current clients. These procedures shall also address "friending" and responding to material posted.

21. NCCs who use digital technology (e.g., social media) for professional purposes shall limit information posted to that which does not create multiple relationships or which may threaten client confidentiality.

84. NCCs shall carefully consider ethical implications, including confidentiality and multiple relationships, prior to conducting research with students, supervisees or clients. NCCs shall not convey that participation is required or will otherwise negatively affect academic standing, supervision or counseling services.

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Northamerica Association of Masters in Psychology (NAMP)
Ethical Standards and Code of Conduct (2000)

Standard 3.3 states:
"Master's Psychologists shall exercise all possible precautions regarding "dual-relations" of any kind, and should avoid social contact with individuals such as clients, students, and supervisees in order to avoid actual or apparent exploitation. When, due to unanticipated circumstances, the provider discovers that a dual-relationship[s] exist, the provider exercises all possible care within the guidelines set forth in these ethical principles."

[Dr. Zur's comments: The position taken by the Northamerica Association of Masters in Psychology (NAMP, 1997) of absolute avoidance of dual relationships contradicts the stance of all major professional organizations. Either it is a reflection of outdated, unrealistic thinking, or a significantly restrictive measure taken in an attempt to help masters-level psychologist-therapists gain equality with doctoral-level psychologists.]

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United States Association for Body Psychotherapy (USABP) Ethical Guidelines (2007) states:

V Multiple Relationships
Body Psychotherapists avoid exploitive multiple relationships. A multiple relationship occurs when a Body Psychotherapist is in a psychotherapeutic relationship with a person and is at the same time, or sequentially, in another relationship with the same person. Body Psychotherapists make a distinction between normally occurring community interactions and multiple relationships. Body Psychotherapists do not accept as a client anyone with whom they have had a sexual, close personal. or financial relationship or family or relatives of such persons. The boundaries of the therapeutic relationship should be clearly defined otherwise they have the potential to impair judgment, cause damage and undermine the purpose of the therapy.

1. Considerations about potential exploitation include the: nature and intensity of the professional relationship and of the secondary relationship, stage of therapy, amount of transference, degree of the role conflict, level of communication skills, and existence of an evaluative role.

2. Body Psychotherapists are aware of the differences in power that may exist in their relationships with clients, students and supervisees. Body Psychotherapists will be sensitive to the real and ascribed differences in power, be responsible for bringing potential issues into the awareness of those involved, and be available for reasonable processing with those involved.

3. In some situations, for example in small geographical or modality communities, a multiple relationship that is non-exploitive may be undertaken. In these cases, the Body Psychotherapist takes precautions to protect the client from exploitation and damage. Such precautions may include, but are not limited to, acknowledgment of the multiple relationship and its inherent risk to the client, ongoing dialogue, informed consent, documentation, and case consultation and/or supervision.

4. In the event that a Body Psychotherapist is providing services to several persons who have a relationship (partners, parents and children, siblings, families) the therapist attempts to clarify at the onset of the therapy, the relationship they will have with each individual. At any time, if it becomes apparent that the Body Psychotherapist is in multiple relationships which compromise the treatment situation or threaten to impair the objectivity or judgment of the therapist in any way, they clarify, adjust or withdraw from conflicting roles.

5. Barter is the acceptance of goods or services from clients in return for psychological services. Body Psychotherapists do not barter (including work exchange) unless the bartering arrangements are appropriate in the context of the therapeutic relationship, indicated by the needs of the client, and for the welfare of the client. Where bartering is used, the therapist and client make agreements in writing related to the exchange of goods or services to ensure that both understand the scope and limitations of the agreement. Body Psychotherapists consult or obtain supervision to ensure that the bartering arrangement is not harmful to the client, that the client is being given fair value in the exchange, and that no exploitation of and/or damage to the client is involved.

6. As teachers, Body Psychotherapists acknowledge that their relationships with students and/or supervises include factors which often make avoiding multiple relationships difficult. They monitor their teaching and supervision relationships to ensure that they do not become exploitive and/or damaging. Body Psychotherapists do not have sexual relations with students or supervisees and do not subject them to sexual harassment.

Dr. Zur's comments: This 2007 code of ethics has significantly revised the guidelines in regards to dual relationships compared to the last revision of 2001. It eliminated statements in the 2001 code, such as "Body psychotherapists avoid multiple relationships whenever possible" and "Body psychotherapists do not barter (including work exchange) for therapeutic services unless there is a compelling need to do so." Instead, the 2007 code appropriately and realistically states that "In some situations, for example in small geographical or modality communities, a multiple relationship that is non-exploitive may be undertaken" and "Body Psychotherapists do not barter (including work exchange) unless the bartering arrangements are appropriate in the context of the therapeutic relationship, indicated by the needs of the client, and for the welfare of the client."]

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The Ethics Codes in Solidarity

Among the codes of all major psychotherapists' organizations, there is no blanket prohibition of non-sexual dual relationships. The American Psychiatric Association (2010) and the National Board for Certified Counselors (1998) exclude dual and multiple relationships from their codes altogether. These codes appropriately concentrate on preventing harm and exploitation of patients by therapists, as opposed to dictating a uniform course of action for therapists about dual relationships.

There are unified principles among the codes of ethics of all major professional organizations concerning dual relationships in psychotherapy. Once the hindering factors of misinformation and prejudice are discarded, the platform of these codes is clear:

  1. Sexual dual relationships with present clients are always unethical.
  2. Non-sexual dual relationships are not always avoidable.
  3. Non-sexual dual relationships are not always unethical.
  4. Therapists must avoid only the dual relationships that might:
    * Impair their judgment and objectivity.
    * Interfere with performing therapy or supervision effectively.
    * Harm or exploit patients.

Summary

In contrast to the widespread belief that non-sexual dual relationships are inherently unethical, the codes of ethics of all major professional organizations place no ban on non-sexual dual relationships and in fact acknowledge dual relationships as sometimes unavoidable. Instead of supporting the opinion that dual relationships are unethical under any circumstances, the codes dictate that only those relationships likely to impair judgment and objectivity, interfere with the therapeutic work, or harm or exploit patients ought to be avoided.

Understanding the ethics codes is imperative in order to make informed decisions about dual relationships. Blind trust in other practitioners' interpretations of these codes does not constitute a thorough process of gathering information. Therapists familiar with the ethics codes will realize that non-sexual dual relationships are neither always unethical nor always avoidable, and thus will be better prepared to make choices about dual relationships that attend to the needs of the client. When the propensity to practice based on fear of litigation or licensing boards is set aside and replaced by first-hand knowledge of the ethics codes themselves, dual relationships can be accurately regarded as yet another opportunity to help clients.

 

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