Ethics of Multiple Relationships
and
The Case of Pat
www.SteveFranklinMSW.com
Codes of Ethics
posted on
PsychotherapySaintLouis
YahooGroups listserv.
ACA Code of Ethics 2005
Revised AAMFT Code of Ethics, effective July 1, 2001
APA Ethical Principles of Psychologists and
Code of Conduct 2010 Amendments
Code of Ethics of the National Association of Social Workers
Approved by the 1996 NASW Delegate Assembly and revised
by the 2008 NASW Delegate Assembly
The Case of Pat
Time frame:
almost 9 years ago, through this year.
Chris sought help
after being kicked out of marriage
(by Pat)
for having an affair
The Case of Pat
Chris’s spouse, Pat, softened
Chris wanted Pat to attend
Subsequently, to start couple’s
counseling
AAMFT 1.3
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 take appropriate precautions.
ACA
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.
A.5.d. Potentially Beneficial Interactions
.. the counselor must document in case records..
….Examples of potentially beneficial interactions
… attending a formal ceremony
(e.g., a 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.
APA
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 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.
(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.
10.02 Therapy Involving Couples or Families
(a) When psychologists agree to provide services
to several persons who have a relationship
(such as spouses, significant others, or parents and children),
they take reasonable steps to clarify at the outset
(1) which of the individuals are clients/patients and
(2) the relationship the psychologist will have with each person…
(b) If it becomes apparent that psychologists
may be called on to perform potentially conflicting roles
(such as family therapist and
then witness for one party in divorce proceedings),
psychologists take reasonable steps to
clarify and modify, or withdraw from, roles appropriately.
http://www.division42.org/IPfiles/IPFall03/prof_practice/multiple.html
Celia B. Fisher, Ph.D.;
Multiple Relationships and the New APA Ethics Ethics Code
Standard 3.05 does not prohibit
attendance at a client’s/patient’s, student’s, employee’s, or
employer’s family funeral, wedding, or graduation;
the participation of a psychologist’s child
in an athletic team coached by a client/patient;
gift giving or receiving with those
with whom one has a professional role;
or from entering into a social relationship with a colleague
as long as these relationships would not reasonably be expected
to lead to role impairment, exploitation, or harm.
Incidental encounters with clients/patients at religious
services, school events, restaurants, health clubs,
or similar places are not unethical.
Nonetheless, psychologists should always consider
whether the particular nature of
a professional relationship might lead
to misperceptions regarding the encounter.
If so, it may be wise
to keep a record of such encounters.
NASW
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.)
(d) When social workers provide services
to two or more people who have a relationship with each other
(for example, couples, family members),
social workers should clarify with all parties
which individuals will be considered clients
and the nature of social workers’ professional obligations
to the various individuals who are receiving services.
Social workers who anticipate a conflict of interest
among the individuals receiving services
or who anticipate having to perform
in potentially conflicting roles
(for example, when a social worker is asked to testify
in a child custody dispute or divorce proceedings involving clients)
should clarify their role
with the parties involved and take appropriate action
to minimize any conflict of interest.
Issues of Sexual Intimacy
(Not pertinent to Case Study)
AAMFT
1.4 Sexual intimacy with clients is prohibited.
1.5 Sexual intimacy with former clients … is …
prohibited for two years following the termination …
…should not engage in sexual intimacy
with former clients after the two years …
Should therapists engage in
sexual intimacy with former clients …
burden shifts to the therapist to demonstrate
that there has been no exploitation or injury
ACA
A.5.a. Current Clients
Sexual or romantic counselor–client interactions
or relationships with current clients, their
romantic partners, or their family members
are prohibited.
A.5.b. Former Clients
Sexual 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.
APA
10.05 Psychologists do not engage in sexual
intimacies with current therapy clients/patients.
10.06 (or) with individuals they know to be
close relatives, guardians, or significant others
of current clients/patients. Psychologists do not
terminate therapy to circumvent this standard.
10.07 Psychologists do not accept as therapy
clients/patients persons with whom they have
engaged in sexual intimacies.
10.08 (a) Psychologists do not engage in sexual
intimacies with former clients/patients for at
least two years after cessation or termination of
therapy.
(b) Psychologists do not engage in sexual intimacies with
former clients/patients even after a two-year interval
except in the most unusual circumstances.
[and] bear the burden of demonstrating that there has been
no exploitation, in light of all relevant factors, including
(1) the amount of time that has passed since therapy terminated;
(2) the nature, duration, and intensity of the therapy;
(3) the circumstances of termination;
(4) the client's/patient's personal history;
(5) the client's/patient's current mental status;
(6) the likelihood of adverse impact on the client/patient; and
(7) any statements or actions made by the therapist during
the course of therapy suggesting or inviting the possibility of
a posttermination sexual or romantic relationship with the
client/patient.
NASW
1.09 Sexual Relationships
(a) Social workers should under no circumstances
engage in sexual activities or sexual contact
with current clients, whether such contact is
consensual or forced.
(b) [or with] clients’ relatives or other individuals
with whom clients maintain a close personal
relationship when there is a risk of exploitation or
potential harm to the client.
… Social workers—not their clients, their clients’
relatives, or other individuals with whom the client
maintains a personal relationship
—assume the full burden for setting clear,
appropriate, and culturally sensitive boundaries.
(c) Social workers should not engage in sexual activities or
sexual contact with former clients because of the potential
for harm to the client.
If social workers engage in conduct contrary to this
prohibition or claim that an exception to this prohibition is
warranted because of extraordinary circumstances,
it is social workers—not their clients— who assume the full
burden of demonstrating that the former client has not been
exploited, coerced, or manipulated, intentionally or
unintentionally.
(d) Social workers should not provide clinical services
to individuals with whom they have had
a prior sexual relationship. ….
The Case of Pat
Pat and Chris reconciled.
Couples counseling recurred from
time to time.
Pat and Chris also sought individual
counseling
from time to time.
The Case of Pat
Pat works in family services field*
and would occasionally refer
individuals to me for counseling.
[*Family Services field: Attorneys, CASA’s,
Counselors, Children’s Division workers, GAL’s,
Judges, etc]
APA 3.07
Third-Party Requests for Services
When psychologists agree to provide services to
a person or entity at the request of a third
party, psychologists attempt to clarify at the
outset of the service the nature of the
relationship with all individuals or organizations
involved. This clarification includes the role of
the psychologist (e.g., therapist, consultant,
diagnostician, or expert witness), an
identification of who is the client, the probable
uses of the services provided or the information
obtained, and the fact that there may be limits
to confidentiality.
The Case of Pat
In recent case:
Pat is an issue discussed by counseling
clients in session.
Conversations between Pat and me
become subjects of conversation in
client sessions.
The Case of Pat
Pat requested client notes.
I declined.
Client obtained order from Judge
compelling me to release information.
I reluctantly comply.
ACA A.5.e.
Role Changes in the Professional Relationship
When a counselor changes a role from the original
or most recent contracted relationship, he or she
obtains informed consent from the client …
Examples of role changes include
1.
changing from individual to
relationship or family counseling, or vice versa;
2. changing from a nonforensic evaluative role
to a therapeutic role, or vice versa;
… Clients must be fully informed of any
anticipated consequences
(e.g., financial, legal, personal, or therapeutic)
http://kspope.com/dual/index.php
Dual Relationships, Multiple
Relationships, & Boundary Decisions
Ken Pope & Patricia Keith-Spiegel
"A Practical Approach to Boundaries in Psychotherapy: Making
Decisions, Bypassing Blunders, and Mending Fences"
Journal of Clinical Psychology: In Session, 2008, vol. 64, #5, pages 638-652):
"Nonsexual boundary crossings can enrich
therapy, serve the treatment plan, and
strengthen the therapist-client working
relationship. They can also undermine the
therapy, sever the therapist-patient
alliance, and cause immediate or long-term
harm to the client. Choices about whether
to cross a boundary confront us daily, are
often subtle and complex, and can
sometimes influence whether therapy
progresses, stalls, or ends…”
Ethical Decision-making and Dual Relationships
Jeffrey N. Younggren, Ph.D., ABPP
http://kspope.com/dual/youggren.php
Is the dual relationship necessary?
Is the dual relationship exploitive?
Who does the dual relationship benefit?
Is there a risk that the dual relationship could
damage the patient?
Is there a risk that the dual relationship could
disrupt the therapeutic relationship?
Am I being objective in my evaluation of this matter?
Have I adequately documented the decision making
process in the treatment records?
Did the client give informed consent regarding the
risks to engaging in the dual relationship?
Dual Relationships between Therapist & Client:
A National Study of Psychologists, Psychiatrists, and Social Workers
Debra S. Borys
Kenneth S. Pope
http://kspope.com/dual/research2.php
4,800
psychologists, psychiatrists, and social workers
were surveyed
(return rate = 49%)
Ethical? 1=never 2rarely 3 sometimes 4 mostly 5always NS Not sure NR no response
1 2 3 4 5 NS NR
Accepting a gift worth under $10
3.0 13.0 38.4 40.1 5.0 0.4 0.2
Accepting a client's invitation to a special occasion
6.3 26.3 41.0 20.8 4.6 0.8 0.1
Accepting a service or product as payment for therapy 21.4 30.0 28.2 12.7 2.7 4.2 0.7
Becoming friends with a client after termination
14.8 38.4 32.0 10.2 2.1 1.9 0.6
Selling a product to a client
70.8 18.0 7.5 0.9 0.3 2.1 0.5
Accepting a gift worth over $50
44.9 37.0 13.1 1.4 0.8 2.3 0.5
Providing therapy to an employee
57.9 26.2 10.9 2.1 0.2 2.4 0.4
Engaging in sexual activity with a client after termination 68.4 23.2 4.2 0.6 0.3 2.6 0.7
Disclosing details of current personal stresses to a client 26.0 39.3 29.5 2.9 1.3 0.5 0.5
Inviting clients to an office/clinic open house
26.6 24.7 21.5 15.4 5.8 5.0 0.9
Employing a client
49.9 29.5 14.5 2.8 1.2 1.5 0.5
Going out to eat with a client after a session
43.2 37.9 13.6 2.4 0.8 1.4 0.5
Buying goods or services from a client
36.7 35.4 20.6 4.7 0.7 1.5 0.3
Engaging in sexual activity with a client
98.3 0.5 0.0 0.1 0.6 0.4 0.0
Inviting clients to a personal party or social event
63.5 29.2 4.6 0.7 0.5 1.2 0.2
Providing indiv. therapy to client’s relative/friend/lover
12.6 21.4 38.8 21.4 4.2 1.0 0.5
Providing therapy to a current student or supervisee
44.4 31.0 16.0 5.4 1.0 2.0 0.4
Allowing a client to enroll in one's class for a grade
39.0 28.0 18.0 7.6 1.9 5.2 0.4
1 2 3
4 5 NR
Accepted a gift worth under $10
14.0 56.5 11.3 5.9 11.5 0.8
Accepted a client's invitation to a special occasion
64.0 28.0 3.3 2.4 1.4 0.8
Accepted a service or product as payment for therapy
82.6 13.9 2.8 0.2 0.1 0.8
Became friends with a client after termination
69.0 26.5 3.2 0.2 0.3 0.7
Sold a product to a client
97.1 1.4 0.7 0.0 0.1 0.7
Accepted a gift worth over $50
92.4 5.8 0.3 0.2 0.2 1.1
Provided therapy to an employee
87.5 9.3 1.7 0.3 0.2 1.1
Engaged in sexual activity with a client after termination 95.3 3.9 0.0 0.0 0.0 0.8
Borrowed less than $5 from a client
97.0 1.7 0.0 0.2 0.1 1.1
Disclosed details of current personal stresses to a client 60.1 30.7 7.4 0.6 0.2 1.0
Borrowed over $20 from a client
98.7 0.1 0.1 0.0 0.0 1.1
Invited clients to an office/clinic open house
88.7 3.7 3.5 1.1 2.0 0.9
Employed a client
91.2 7.5 0.4 0.1 0.0 0.8
Went out to eat with a client after a session
87.4 10.5 0.9 0.2 0.0 1.1
Bought goods or services from a client
77.6 20.5 1.1 0.1 0.0 0.8
Engaged in sexual activity with a current client
98.7 0.4 0.1 0.0 0.0 0.8
Invited clients to a personal party or social event
92.1 6.7 0.3 0.2 0.0 0.8
Providing indiv. therapy to client’s relative/friend/lover
38.0 36.0 21.6 2.1 1.4 0.8
Provided therapy to a then-current student or supervisee 88.9 8.4 1.5 0.2 0.1 0.9
Allowed a client to enroll in one's class for a grade
95.2 2.3 1.1 0.1 0.3 1.3
1 = no clients 2 = few, 3 = some 4 =most 5 = all clients, NR = no response
Zur, O. (2011).
Dual Relationships, Multiple Relationships & Boundaries
In Psychotherapy, Counseling & Mental Health.
http://www.zurinstitute.com/dualrelationships.html.
Types of Dual Relationships:
•Social
•Professional
•Treatment Professional
•Business
•Communal
•Institutional
•Forensic
•Supervisory
•Sexual.
digital, online or internet ??
Dual relationships can be ..
Voluntary-avoidable:
Unavoidable:
Mandated:
Unexpected
Dual relationships can be ..
concurrent
sequential
Level of Involvement can be ..
Low-minimal level
Medium level
Intense level
GUIDELINES FOR NON-SEXUAL DUAL
RELATIONSHIPS IN PSYCHOTHERAPY
Treatment plans:
1. Develop a clear treatment plan for clinical interventions which
are based on the context of therapy….
2. Intervene with your clients according to their needs…
3. Some treatment plans may necessitate dual relationships
however, in other situations dual relationships should be ruled
out. Make sure you know the difference.
4. 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.
5.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.
6.Incorporate dual relationships into your treatment plans only when they
are not likely to impair your clinical judgment, or create a conflict of interest.
7.Do not enter into sexual relations with a client because it is likely to impair
your judgment and nullify your clinical effectiveness.
8.Remember that treatment planning is an essential and irreplaceable part
of your clinical records and your first line of defense.
9. 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:
10.Study the clinical, ethical, legal and spiritual complexities and potential ramifications of
entering into dual relationships.
11.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.
12.Before entering into complex dual relationships, consult with well-informed and nondogmatic peers, consultants, and supervisors.
13.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.
14.Discuss with your clients the complexity, richness, potential benefits, drawbacks and
likely risks that may arise due to dual relationships.
15.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:
16. Remember you are setting an example. Model civility, integrity,
emotionality, humanity, courage, and, when appropriate, duality.
17. 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.
18. 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.
19. Answer clients' basic and legitimate questions about your values and
beliefs, including your thoughts on dual relationships.
20. 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.
21.Evaluate and update your approach, attitudes, treatment plans and
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.