By Ofer Zur, Ph.D.
Table Of Contents
Definition & Key Terms
Guidelines for Boundaries
Non-Sexual Dual Relationships
Types of Multiple Relationships
Guidelines to Dual Relationships
Context of Therapy
The purpose of this page is to:
- Give clear and accurate facts, information and guidelines about boundaries and dual relationships in psychotherapy and counseling.
- Fight the dogma and fear that has been dominating the issue of boundaries and dual relationships.
- Bring critical thinking and rationality to the discussion of boundaries and dual relationships.
- Increase the effectiveness of therapists.
- Help attorneys, judges and experts comprehend the complexities of boundaries and dual relationships.
Definition & Key Terms:
Boundaries in therapy define the therapeutic-fiduciary relationships or what has been referred to as the “therapeutic frame.” They distinguish psychotherapy from social, familial, sexual, business and many other types of relationships. Some boundaries are drawn around the therapeutic relationships and include concerns with time and place of sessions, fees and confidentiality or privacy. Boundaries of another sort are drawn between therapists and clients rather than around them and include therapists self-disclosure, physical contact (i.e., touch), giving and receiving gifts, contact outside of the normal therapy session, use of language, clothing and proximity of therapist and client during sessions.
Boundary crossings and boundary violations refer to any deviation from traditional, strict, ‘only in the office,’ emotionally distant forms of therapy or any deviation from rigid risk-management protocols. Boundary violations occur when therapists cross the line of decency and violate or exploit their clients. Boundary crossing often involved clinically effective interventions, such as self-disclosure, home visit, non-sexual touch, gifts or bartering.
Dual relationships or Multiple Relationships in psychotherapy refers to any situation where 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. This page focuses only on non-sexual dual relationships.
Boundary Crossings & Boundary Violations In Psychotherapy
Key Points
- Boundary violations and boundary crossings in psychotherapy refer to any deviation from traditional, strict, ‘only in the office,’ emotionally distant forms of therapy. They mostly refer to issues of self disclosure, length and place of sessions, physical touch, activities outside the office, gift exchange, social and other non-therapeutic contact and various forms of dual relationships. Basically, they may all be seen as a departure from the traditional psychoanalytic proceedings.
- Boundary violations in therapy are very different from boundary crossings. While boundary violations by therapists are harmful to their patients, boundary crossings are not and can prove to be extremely helpful.
- Harmful boundary violations occur typically when therapists and patients are engaged in exploitative dual relationships, such as sexual contacts with current clients. Exploitative business relationships also constitute boundary violations.
- Boundary crossings can be an integral part of well formulated treatment plans or evidence-based treatment plans. Examples are, flying in an airplane with a patient who suffers from a fear of flying, having lunch with an anorexic patient, making a home visit to a bed ridden elderly patient, going for a vigorous walk with a depressed patient, or accompanying a patient to a dreaded but medically essential doctor’s appointment to which he or she would not go on their own.
- Potentially helpful boundary crossings also include going on a hike, giving a non-sexual hug, sending cards, exchanging appropriate (not too expensive) gifts, lending a book, attending a wedding, confirmation, Bar Mitzvah or funeral, or going to see a client performing in a show.
- Boundary crossings are not unethical. Ethics code of all major psychotherapy professional associations (e.g., APA, ApA, NASW, ACA, NBCC) do not prohibit boundary crossings, only boundary violations.
- Therapeutic orientations, such as humanistic, behavioral, cognitive, behavioral, family systems, feminist or group therapy are more likely to endorse boundary crossings as part of effective treatment than analytically or dynamically oriented therapies.
- As with dual relationships, what constitutes harmful boundary violations according to one theoretical orientation may be considered helpful boundary crossings according to another orientation.
- Like dual relationships, boundary crossings are normal, unavoidable and expected in small communities such as rural, military, universities and interdependent communities such as the deaf, ethnic, gays, etc.
- Different cultures have different expectations, customs and values and therefore judge the appropriateness of boundary crossings differently. More communally oriented cultures, such as the Latino, African American or Native Americans, are more likely to expect boundary crossings, and frown upon the rigid implementation of boundaries in therapy.
- Not all boundary crossings constitute dual relationships. Making a home visit, going on a hike, or attending a wedding with a client and many other ‘out-of-office’ experiences are boundary crossings which do not necessary constitute dual relationships. Similarly, exchanging gifts, hugging, or sharing a meal are also boundary crossings but not dual relationships. However, all dual relationships, including attending the same church, bartering, playing in the same recreational league, constitute boundary crossings.
- There is a prevalent erroneous and unfounded belief about the ‘slippery slope’ that claims that minor boundary crossings inevitably lead to boundary violations and sexual relationships. This somewhat paranoid approach is based on the ‘snow ball’ effect. It predicts that the giving of a simple gift likely ends up in a business relationship. A therapist’s self disclosure becomes an intricate social relationship. A non-sexual hug turns into a sexual relationship.
- A rigid attitude towards boundary crossings stems, in part, from what has been called ‘sexualizing boundaries.” This is another distorted view that sees all boundary crossings as sexual in nature.
- Boundary crossings with certain clients, such as those with borderline personality disorder, must be approached with caution. Effective therapy with some clients may require a clearly structured and well-defined therapeutic environment.
- As with dual relationships, boundary crossings should be implemented according to the client’s unique needs and the specific situation. It is recommended that the rationale for boundary crossings be clearly articulated and, when appropriate, included in the treatment plan.
- The meaning of boundaries and their appropriate application can only be understood and assessed within the context of therapy. The context of therapy consists of four main components: clients, setting, therapy and therapists.
- Client factors include: Culture, history — including history of trauma, sexual and/or physical abuse — age, gender, presenting problem, mental state and type and severity of mental disturbances, socio-economic class, personality type and/or personality disorder, sexual orientation, social support, religious and/or spiritual beliefs and practices, physical health, prior experience with therapy and therapists, etc.
- Setting factors include: Outpatient vs. inpatient; Solo practice vs. group practice; Office in medical building vs. private setting vs. home office; Free-standing clinic vs. hospital based clinic; Privately owned clinic vs. publicly run agency; The presence or proximity of a receptionist, staff or other professionals. It also includes Locality: Large, metropolitan area vs. small, rural town vs. Indian reservation; Affluent, suburban setting vs. poor neighborhood vs. university counseling center; Major urban setting vs. remote military base, prison or police department setting.
- Therapy factors include:
Therapeutic factors, such as modality: Individual vs. couple vs. family vs. group therapy; Short term vs. long term vs. intermittent long-term therapy; Intensity: Therapy sessions several times a week vs. once a month consultation; Population: Child vs. adolescent vs. adult psychotherapy; Theoretical Orientation: Psychoanalysis vs. humanistic vs. group therapy vs. body psychotherapy vs. eclectic therapy.
Therapeutic relationship factors: Quality and nature of therapeutic alliance, i.e., secure, trusting, tentative, fearful or safe connection. Intense and involved vs. neutral or casual relationships; Length, i.e., new vs. long-term relationship; Period, i.e., beginning of therapy vs. middle of therapy vs. towards termination; Idealized/transferencial relationships vs. familiar and more egalitarian relationships; Familiarity and interactivity in the community vs. only in the office, distanced relationship; Presence or absence of dual relationships and type of dual relationships, if applicable.
- Therapist factors include: Culture, age, gender, sexual orientation; Scope of practice (i.e., training and experience).
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Non-Sexual Dual Relationships And Multiple Relationships In Psychotherapy
Key Points
- Non-sexual dual relationships are not necessarily unethical or illegal. Only sexual dual relationships with current clients are always unethical and sometimes illegal.
- Non-sexual dual relationships do not necessarily lead to exploitation, sex, or harm. The opposite is often true. Dual relationships are more likely to prevent exploitation and sex rather than lead to it.
- Almost all ethical guidelines do not mandate a blanket avoidance of dual relationships. All guidelines do prohibit exploitation and harm of clients
Types of Dual Relationships:
- A social dual relationship is where therapist and client are also friends or have some other type of social relationship. Social multiple relationships can be in person or online. Having a client as a Facebook ‘friend’ on a personal, rather than strictly professional basis, may also constitute social dual relationships. Other types of therapist-client online relationships on social networking sites may also constitute social dual or multiple relationships.
- A professional dual relationship or multiple relationship is where psychotherapist or counselor and client are also professional colleagues in colleges, training institutions, presenters in professional conferences, co-authoring a book, or other situations that create professional multiple relationships.
- A special treatment-professional dual relationship may take place if a professional is, in addition to psychotherapy and counseling, also providing additional medical services, such as progressive muscle relaxation, nutrition or dietary consultation, Reiki, etc.
- A business dual relationship is where therapist and client are also business partners or have an employer-employee relationship.
- Communal dual relationships are where therapist and client live in the same small community, belong to the same church or synagogue and where the therapist shops in a store that is owned by the client or where the client works. Communal multiple relationships are common in small communities when clients know each other within the community.
- Institutional dual relationships take place in the military, prisons, some police department settings and mental hospitals where dual relationships are an inherent part of the institutional settings. Some institutions, such as state hospitals or detention facilities, mandate that clinicians serve simultaneously or sequentially as therapists and evaluators.
- Forensic dual relationships involve clinicians who serve as treating therapists, evaluators and witnesses in trials or hearings. Serving as a treating psychotherapist or counselor as well as an expert witness, rather than fact witness, is considered a very complicated and often ill-advised dual relationship.
- Supervisory relationships inherently involve multiple roles, loyalties, responsibilities and functions. A supervisor has professional relationships and duty not only to the supervisee, but also to the supervisee’s clients, as well as to the profession and the public.
- A sexual dual relationship is where therapist and client are also involved in a sexual relationship. Sexual dual relationships with current clients are always unethical and often illegal.
- Digital, online or internet dual relationships that take place online on social networking sites, such as Facebook or Twitter, or on blogs, chats, or LinkedIn, constitute unique dual or multiple relationships. These can be professional (i.e., on LinkedIn or Facebook pages), social (i.e., Facebook or other social networking sites) or other types of multiple relationships that take place on chats, Twitter, blogs, etc.
- An additional and rather rare form of dual relationship includes adoption, when a therapist legally adopts a former child client who was put up for adoption. Multiple relationships also occur when a client refers a friend, family member or colleague to therapy with the same therapist that he/she works with.
Dual Relationships Can Be Avoidable, Unavoidable Or Mandated
- Voluntary-avoidable: Usually these dual relationships take place in large cities or metropolitan areas where there are many therapists, many places to shop, worship or recreate.
- Unavoidable: Multiple relationships are often unavoidable in rural areas, sports psychology, drug and alcohol recovery inpatient, outpatient or 12 step programs, such as AA, and on Native American reservations. Supervisory relationships inherently involve multiple role and multiple relationships, as supervisors have responsibility to the supervisee, the client, the community, and the profession at large. Dual relationships are sometimes unavoidable in institutions, such as mental hospitals.
- Common – Normal: Dual relationships are common and generally normal among disabled groups, spiritual/faith communities, LGBTQI communities and in any small community within or nearby big metropolitan areas. Multiple relationships are a common part of universities and colleges as well as training institutions, such as psychoanalytic, cognitive-behavioral, somatic and other teaching institutions. Dual relationships can also be a common part of adventure therapy or nature therapy. As time goes by, we witness more acceptance of digital or online multiple relationships, primarily among young therapists and young clients who often tend to blur the line between therapeutic and social boundaries, especially in social media.
- Mandated: These dual relationships take place primarily in the military, prisons, jails and in some police department settings. Inherent in these settings is that the mental health professional is mandated to have multiple accountabilities. At times, psychologists in forensic mental institutions are also involved in mandated multiple relationships (especially when ordered by a judge to serve in a dual role of evaluator and treater).
- Unexpected: Unexpected multiple relationships occur when a therapist is not initially aware that the client they have been working with is also a friend, colleague, co-worker or even an ex-spouse of another client. Similarly, unexpected dual relationships take place when, unbeknownst to the psychotherapist, the client joins the therapist’s church, book club, or baseball recreation league. Digital or online multiple relationships, including social networking, can catch therapists by surprise. These digital or online dual relationships often take place on social networking sites, such as Facebook or Twitter, or on blogs, chats, LinkedIn or even on dating sites.
Dual Relationships Can Be Concurrent Or Sequential
- A concurrent dual relationship takes place at the same time as therapy.
- A sequential dual relationship takes place after therapy has ended. For example, after therapy ends a therapist decides to embark on social or business relationships.
Level of Involvement
- Low-minimal level: When a therapist runs into a client in the local market or in the theatre parking lot.
- Medium level: When a client and therapist share occasional encounters, as in attending church services every Sunday or occasional PTA meeting.
- Intense level: When therapist and client socialize, work, attend functions or serve on committees together on a regular basis.
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Multiple Relationships – Additional Points
- The prohibition of dual relationships may be unconstitutional as it may infringe on people’s constitutional rights of freedom of association.
- Exploitative therapists will exploit with or without dual relationships.
- Avoiding all dual relationships keeps therapists in unrealistic and inappropriate power positions, increasing the likelihood of exploitation.
- The prohibition of dual relationships leads to increased isolation, which has several serious ramifications:
- Isolation can increase the chance of exploitation of clients by therapists.
- Isolation in therapy may reduce effectiveness because client’s difficulties, which were often caused by familial/childhood isolation, often cannot be healed by further therapeutic isolation.
- Isolation forces the therapist to rely on the client’s report as the main source of knowledge. Therapeutic effectiveness can be diminished by excluding collateral information and by exclusive reliance on a client’s subjective stories.
- Not all therapeutic approaches disparage dual relationships. The most practiced and empirically based approaches, such as Behavioral, Humanistic, Cognitive, Family Systems, Group and Existential therapy, at times see dual relationships as an important and integral part of the treatment plan.
- Most graduate and post-graduate education not only instills fear of licensing agencies and lawsuits, but also delivers inadequate instruction in personal integrity, individual ethics, and how to navigate the complex issues of boundaries, duality, and intimacy in therapy.
- Introducing dual relationships may alter the power differential between therapists and clients in a manner that can facilitate better health and healing.
Guidelines For Non-Sexual Dual Relationships In Psychotherapy
Treatment plans:
- Develop a clear treatment plan for clinical interventions which are based on the context of therapy. As indicated above, the context includes client, therapy, setting and therapy factors. Client’s personality, culture, DX, gender, etc., are of the highest importance in determining the TP.
- Intervene with your clients according to their needs, as outlined in each of their treatment plans, and not according to any graduate school professor’s or supervisor’s dogma or even your own beloved theoretical orientation.
- Some treatment plans may necessitate dual relationships however, in other situations dual relationships should be ruled out. Make sure you know the difference.
- If planning on entering a dual relationship you must take into consideration the welfare of the client, effectiveness of treatment, avoidance of harm and exploitation, conflict of interest, and the impairment of clinical judgment. These are the paramount and appropriate concerns.
- Do not let fear of lawsuits, licensing boards or attorneys determine your treatment plans or clinical interventions. Do not let dogmatic thinking affect your critical thinking. Act with competence and integrity while minimizing risk by following these guidelines.
- Incorporate dual relationships into your treatment plans only when they are not likely to impair your clinical judgment, or create a conflict of interest.
- Do not enter into sexual relations with a client because it is likely to impair your judgment and nullify your clinical effectiveness.
- Remember that treatment planning is an essential and irreplaceable part of your clinical records and your first line of defense.
- Consult with clinical, ethical or legal experts in very complex cases and document the consultations well.
Prior to and during therapy which includes dual relationships:
- Study the clinical, ethical, legal and spiritual complexities and potential ramifications of entering into dual relationships.
- Attend to and be aware of your own needs through personal therapy, consultations with colleagues, supervision or self-analysis. Awareness of your own conscious and unconscious needs and biases helps avoid cluttering the dual relationship.
- Before entering into complex dual relationships, consult with well-informed and non-dogmatic peers, consultants, and supervisors.
- When you consult with attorneys, ethics experts and other non-clinical consultants make sure that you use the information to educate and inform yourself rather than as clinical guidelines. Separate knowledge of law and ethics from care, integrity, decency and above all effectiveness. Remember you are paid to help and heal, not to protect yourself.
- Discuss with your clients the complexity, richness, potential benefits, drawbacks and likely risks that may arise due to dual relationships.
- Make sure that your office policies include the risks and benefits of dual relationships and that they are fully explained, read and signed by your clients before you implement them.
- Make sure your clinical records document clearly all consultations, substantiations of your conclusion, potential risks and benefits of intervention, theoretical and empirical support of your conclusion, when available, and the discussion of these issues with your client.
Clinical integrity and effectiveness:
- Remember you are setting an example. Model civility, integrity, emotionality, humanity, courage, and, when appropriate, duality.
- As a role model, telling your own stories can be an important part of therapy. Make sure that the stories are told in order to help the client and not to satisfy your own needs.
- Remember that you are being paid to provide help. At the heart of all ethical guidelines is the mandate that you act on your clients’ behalf and avoid harm. That means you must do what is helpful, including dual relationships when appropriate.
- Answer clients’ basic and legitimate questions about your values and beliefs, including your thoughts on dual relationships.
- Continue to keep excellent written records throughout treatment. Keep records of all your clinical interventions, including dual relationships, additional consultations and your own and your clients’ assessment of treatment and its progress.
- Evaluate and update your approach, attitudes, treatment plans and above all effectiveness regularly.
- If you find yourself in a dual relationship which either is not benefiting the client or is causing distress and harm, or has unexpectedly brought about conflict of interest, consult and, if necessary, stop or ease out of the dual relationship in a way that preserves the client’s welfare in the best possible way.
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