REEL THERAPY
Ethical and Professional Issues
for Therapists
Boundary
 The “edge” of appropriate behavior
 Designed to create an atmosphere of
safety/predictability within which treatment can
thrive
 Professional boundaries: Absence of sexual
contact, fee arrangements, length of sessions,
asymmetry of self-disclosure etc.
Crossings and Violations
Therapist allows boundary
between therapist and
client to be broken
Boundary Crossing
 Lazarus and Zur: Boundary crossing is any
deviation from traditional analytic and risk
management practices (i.e. the strict, only in the
office, emotionally distant forms of therapy)
 Benign
 Ultimate effect of the deviation of the usual
behavior may be to advance the therapy in a
constructive way that does not harm the patient
Boundary Violation
 Using the client for the clinician’s benefit
 Clearly harmful to or exploitable of the
client
 Examples: Therapist hugs client at end of
each session, repeated disclosure of
therapist’s personal problems, sexual
contact
Keys
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Timing/Stage of treatment
Treatment setting
Treatment type
Patient characteristics
Community, Culture
Content
Menninger: “When in doubt be human.”
Supervision
A middle aged male therapist is seeing a
female client in her early 20’s for the first
time. They hold hands the entire session.
Crossing or violation?
1.10 Physical Contact
Social workers should not engage in physical
contact with clients when there is a possibility
of psychological harm to the client as a result
of the contact (such as cradling or caressing
clients). Social workers who engage in
appropriate physical contact with clients are
responsible for setting clear, appropriate, and
culturally sensitive boundaries that govern
such physical contact.
Self-Disclosure
Any behavior or
verbalization that reveals
personal information
Self-Disclosure: Therapeutic Benefits
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Models/educates
Fosters therapeutic alliance
Validates reality
Normalizes
Provides hope
Sets norms of honesty/equality
Self-Disclosure: Risks
 Reverse roles, client does not want to hurt
clinician etc.
 “Slippery Slope”: Boundary violations, such as
sexual involvement
 Perceive she is special to the therapist
 Focus on clinician’s problems
 Comfort clinician instead of receive attention
 Feel ignored
Ava worked with a woman, Karen, who had been
sexually abused by her father. After about a year of
sessions, Karen was still blaming herself and did not
feel comfortable going to a support group. Also, she
was unable to disclose the details of the abuse to her
husband, with whom she experienced intimacy issues.
Ava decided to share that she had been sexually
abused by her father and that is why she had
developed this specialty. She also shared that she
had difficulty moving from a place of shame and
sense of responsibility for the abuse.
Karen seemed surprised, relieved, and a little
disquieted to hear from Ava. She asked Ava a number
of questions about how she worked through the
shame and guilt, and conversations ensued that
helped Karen shed some of these emotions. In
response to Ava asking her how it affected her to have
this information about her therapist, Karen said, “It
makes me feel protective of you and worried about if I
will say things that will be hard for you to hear, or give
you flashbacks. Now I’m watching you to see if you
are O.K.” (See slide 19 citation)
You are a therapist who just found out that
you have breast cancer. How do you tell
your clients that you are sick without
making it their issue and staying focused
on their treatment plan?
Martha has been working with a couple for over a year
and she has developed a strong rapport with them.
Martha is a lesbian and generally does not disclose
that personal information to her clients. The couple is
devoutly Mormon. On two or three occasions the
couple has asked Martha about her husband and she
lied about her relationship status or changed the
direction of the conversation [continued].
She is concerned that the disclosure would
offend the couple and/or harm the therapeutic
relationship and is also concerned about
being incongruent. She is sure the clients
sense the incongruence.
 Should Martha have responded differently?
 What would you do?
 Have you found yourself in a similar situation?
Self-Disclosure Guidelines
 Be transparent tentatively and briefly, and look
for feedback from client.
 After any type of disclosure, keep turning the
conversation back to client’s concerns and
their story.
 Be aware of where the disclosure might take
you emotionally--so you can stay emotionally
present and focused on the feelings and
thoughts of the client.
Self-Disclosure Guidelines
 Present dilemmas from your life and what it was like
to grapple with them, rather than solutions.
 Be aware of what level of disclosure is comfortable for
you.
 Be attentive to what transparency can mean in your
particular work setting (and/or community).
 Overall, keep thinking about your intent whenever you
disclose.
From Transparency and Self-Disclosure in Family Therapy: Dangers and
Possibilities, Janine Roberts (Janine@educ.umass.edu). Published in
Family Process, March 2005, Vol. 44, No. 1, pp. 45-63.
1.06 Conflicts of Interest
(c) 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.)
3.05 Multiple Relationships
(a) 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 another
relationship in the future with the person or a person
closely associated with or related to the person.
[continued on next slide]
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….
(b) 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.
A.2.a. Informed Consent
Clients have the freedom to choose whether to enter
into or remain in a counseling relationship and need
adequate information about the counseling process
and the counselor. Counselors have an obligation to
review in writing and verbally with clients the rights
and responsibilities of both the counselor and the
client. Informed consent is an ongoing part of the
counseling process, and counselors appropriately
document discussions of informed consent throughout
the counseling relationship.
A.5.c. Nonprofessional Interactions or Relationships
(Other Than Sexual or Romantic Interactions or
Relationships)
Counselor-client nonprofessional
relationships with clients, former clients,
their romantic partners, or their family
members should be avoided, except when
the interaction is potentially beneficial to
the client. (See A.5.d.)
A.5.d. Potentially Beneficial Interactions
When a counselor-client nonprofessional interaction
with a client or former client may be potentially
beneficial to the client or former client, the counselor
must document in case records, 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. [continued on next slide]
A.5.d. Potentially Beneficial Interactions
Such interactions should be initiated with
appropriate client consent. Where
unintentional harm occurs to the client or
former client…the counselor must show
evidence of an attempt to remedy such harm.
Examples of Potentially Beneficial
Interactions (A.5.d.)
 Attending a formal ceremony (e.g.
wedding/commitment ceremony or
graduation)
 Purchasing a service or product provided by a
client or former client (excepting unrestricted
bartering)
 Hospital visits to an ill family member
 Mutual membership in a professional
association, organization or community
 Sexual or nonsexual
 Current or former client
 Cultivated by the counselor/client or
brought about by circumstance
 Not all boundary crossings are necessarily dual
relationships:
 Out of Office: Making a home visit, going on a
hike/walk, attending a wedding etc.
 Exchanging gifts, hugging, etc.
 All dual relationships are boundary crossings (i.e.
attending same church, bartering, taking same yoga
class)
 Incidental or accidental contact.
DR: Decision-Making Model
 Is entering into the secondary relationship necessary, or should I
avoid it?
 Can the multiple relationship potentially cause harm to the client?
 If harm seems unlikely or avoidable, would the additional
relationship prove beneficial?
 Is there a risk that the secondary relationship could disrupt the
therapeutic relationship?
 Can I evaluate this matter objectively? Motivations/Needs?
Younggren and Gottlieb, Managing risk when contemplating multiple
relationships, (Professional Psychology: Research and Practice 2004; 35,
255-260.)
Other Considerations
 What is the client’s emotional vulnerability?
 What is the degree of role overlap?
 The “slippery slope”: minor boundary
compromises could lead to more substantial
boundary violations.
 Imagine the worst case scenario.
 Supervision. Supervision. Supervision.
 Document.
Thoughts?
“I was conducting therapy with a child and soon
became aware that there was a mutual attraction
between myself and the child’s mother. The strategies
I had used and my rapport with the child had been
positive.
Nonetheless, I felt it necessary to refer to avoid a dual
relationship (at the cost of the gains that had been
made.)”
John has been seeing 14 year old Kevin for three months. A
productive relationship seems to be developing. The focus of the
therapy has been on helping Kevin work through the loss of his
relationship with his biological father. He moved out a year ago
and has had no contact with Kevin. Kevin reports being unhappy
in school and appears to be mildly depressed. During a recent
session, Kevin said that he might be enrolling in Bay Bridge
Academy, a small private school. Upon hearing that, John felt his
chest tighten. His 14-year-old daughter is a student at Bay Bridge
and involvement in her school activities is a source of great
pleasure and pride for him.
What Should John Do?
 Possibly start with the physical sensation. What is it? Anxiety?
Annoyance?
 Sit and consider the opportunities and challenges. Differentiate
his experience and needs from those of Kevin’s.
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John can collaborate with Kevin about how to deal with incidental
contact (“Let’s talk about how you and I are going to make this
work.”) As a result, Kevin may feel taken seriously.
John may worry about the possibility of supervising extracurricular
activities, including overnights.
Kevin and John’s daughter may develop a social or dating
relationship.
 Consult with a colleague(s). Look at possibility of
being too impaired to continue with Kevin.
 Include Kevin and mother in decision-making process
regarding referral.
CONSIDERATIONS WHEN CONTEMPLATING A
FRIENDSHIP WITH A FORMER CLIENT
 The length and nature of the counseling relationship (power
differential)
 Client diagnoses or issues
 Circumstances and clarity of termination
 The possibility that the client might want to return to counseling
 Unresolved transference or countertransference issues
 Whether any harm to client can be foreseen
Herlihy & Remley. Legal and ethical challenges in counseling. In
Locke, Myers, & Herr (Eds.),The handbook of counseling (pp. 69–90) (2001).
 A former client makes a friend request or requests to
follow you on twitter. How would you respond to these
requests?
 Would your response be any different if the client
wants to connect on Linked In, a business social
media site?
 Do you have a policy in place that you share with
clients regarding email, social media, etc?
“One of the most common failings of many
psychotherapists is not having a regular peer
consultant or consultation group from which to
obtain feedback.”
Brandt Caudill, Esq.
Cara, a mother of young twin boys, was
hospitalized following a suicide attempt and
diagnosed with DID. She and her husband were
assigned to a therapist for marital therapy.
Between sessions the therapist took long walks
on hospital grounds with Cara. The husband
eventually left the marriage after he discovered
Cara had an affair prior to hospitalization. Soon
afterward, after a four month stay, Cara was
discharged.
Cara called the therapist a week later to discuss a
personal problem. The therapist gave Cara her
beeper number and they eventually talked on the
phone daily. The therapist called DSS on Cara’s
behalf when she said that she had no money to
feed her sons. Later, uncomfortable with giving
her money, the therapist shopped for groceries for
Cara. Later it was help with rent, gas and electric
bills and then lunch, tennis and an art class
together. The relationship eventually became
intimate.
 Recently ended a 10 year relationship
 Work provided her with her only emotional
sustenance
 Drinking alone at night
 Family of origin issues
 Never took an ethics course on boundaries
ACA Code of Ethics
Section C Professional Responsibility
Introduction
In addition, counselors engage in self-care
activities to maintain and promote their
emotional, physical, mental and spiritual wellbeing to best meet their professional
responsibilities.
Who (Self) Cares?
 Assess your deep motives for becoming a therapist
beyond “to help people”. How are these facilitating or
hindering self-care?
 What energizes or depletes you in your work?
 How do you let go? Restore yourself? What keeps
your spirit alive?
 What gets in the way? What do you need to do
differently?
 Who do you talk to?
Develop a relationship with yourself that
is so strong that the first person you ask
what they think about something is
yourself.
Cheryl Richardson, Personal Coach
Save the Dates
 Monday, November 11th: Portland 1.5 Hours CE
(open to general public)
TaborSpace 5441 SE Belmont Street
Coping With Loss During The Holidays
 Friday, January 31st: Portland 6 Hours CE
“When In Doubt Be Human”: The Ethics of the
Therapeutic Relationship
Save the Dates
 Friday, February 7th: Corvallis 6 Hours CE
“You’re Breaking Up With Me?”: The Ethics of
Termination
 Webinar, Date TBD 1.5 Hours CE
Loss, Lincoln and Resiliency: What Do Abraham
Lincoln and Research Say About A Griever’s Capacity
to Cope
Michael Kahn, LPC, JD
 Michael@reeltoreal.biz
 704.962.8023
 www.michaelkahnworkshops.com
Bibliography
 Engstrom, Movie Clips for Creative Mental Health Education
(Plainview, NY, Wellness Reproductions and Publishing 2004)
 Kottler, On Being a Therapist (San Francisco, Jossey-Bass 2010)
 Kottler and Carlson, Bad therapy: Master therapists share their
worst failures (New York, Brunner-Routledge 2003)
 Pope, Sonne and Greene, What Therapists Don’t Talk About and
Why: Understanding Taboos That Hurt Us and Our Clients
(Washington, DC, APA 2006)
Bibliography
 Psychopathology Committee of the Group for the
Advancement of Psychiatry, Reexamination of
Therapist Self-Disclosure (Psychiatric Services 2001;
52:1489-1493)
 Zur, Boundaries in Psychotherapy (Washington, DC,
APA 2007)