Avoiding Dual Relationships
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Professional Mental Health Ethics
A Training Resource
By James J Messina, Ph.D., CCMHC, NCC, DCMHS-T
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Minimize the Risk of Getting into a Dual Relationship with a Client
Identify measures aimed at minimizing the risks:
- Set healthy boundaries from the outset
- Secure informed consent of clients
- Discuss both potential risks and benefits
- Consult with other professionals to resolve any dilemmas
- Seek supervision when needed
- Document in clinical case notes
- Examine your own motivations
- Refer when necessary
Handling Bartering
Prior to establishing a Bartering Relationship with a client consider:
- Evaluate whether it puts you at risk of impaired professional judgment
- Never barter for services since they set you up for an unwanted or uncomforable dual relationship
- Determine the value of goods in a collaborative fashion
- Determine the appropriate length of time for arrangement
- Document the arrangement
- Consult with experienced colleagues or supervisors
- Minimize unique financial arrangements
- If bartering is used, it is better to exchange goods rather than services
- Both therapist and client should have a written agreement for the compensation by bartering
Woody point out that bartering is neither ethically nor legally prohibited, and mental health professionals have the choice of accepting or rejecting bartering. If a professional chooses to accept a bartering agreement, he or she will have the burden of proving that it was proper (1998). Woody goes on to give the following guidelines to insure the propriety of a bartering agreement:
1. Unique financial arrangements should be minimized; that is, terms and conditions for any compensation, including the use of bartering, should be as close to established practices as possible and be consonant with the prevailing standards of the profession.
2. The rationale for any compensation decision, including the use of bartering, should be documented in the case records.
3. Discussions about any financial matters should be detailed in writing, giving equal emphasis to what is said by the mental health professional and the client.
4. If bartering is used, there should be a preference for goods instead of services; this will minimize (but not eliminate) the possibility of inappropriate personal interactions.
5. The value of the goods (or services) should be verified by an objective source; this may, however, involve additional cost.
6. To guard against any semblance of undue influence, both parties should reach a written agreement for the compensation by bartering.
7. Any new, potentially relevant observations or comments about compensation by bartering should be entered into the client's records, even though a previous agreement exists.
8. The agreement should contain a provision for how valuations were determined and how any subsequent conflicts will be resolved (e.g., a mediator); this may, however, involve additional cost (and a concern about confidentiality), which will have to be accommodated by the mental health professional (i.e., the added expense should not elevate the cost to the client beyond the established service fee).
9. If a misunderstanding or disagreement begins to develop, the matter should be dealt with by the designated conflict resolution source (e.g., a mediator), not the mental health professional and client; again, recall the issues of added cost and concern for confidentiality stated in the preceding guideline.
10. If monitoring by the individualized treatment plan reveals a possible negative effect potentially attributable to the compensation arrangement, it should be remedied or appropriate termination of the treatment relationship should occur (1998).
Reference:
Woody, R.H. (1998). Bartering for psychological services. Professional Psychology: Research & Practice, 29(2), 174-178
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Accepting Gifts from Clients: To Accept or Not to Accept
Questions to consider in making a decision of whether or not to accept gifts from the client
- What is the monetary value of the gift?
- What are the clinical implications of accepting or rejecting the gift?
- When in the therapy process is the offering of a gift occurring?
- What are the therapist’s motivations for accepting or rejecting a client’s gift?
- What are the cultural implications of offering a gift?
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Socializing with Former or Current Clients
Potential disadvantages:
- Therapists may not be as challenging as they need to be with clients they know socially because of a need to be liked and accepted by the client.
- Counselors’ own needs may be enmeshed with those of their clients to the point that objectivity is lost.
- Counselors are at greater risk of exploiting clients because of the power differential in the therapeutic relationship.
- If you develop a friendship with a former client, then he or she is not eligible to use your professional services in the future
Sexual Attractions in the Client-Therapist Relationship
Attraction to clients is a prevalent experience among both male and female therapists.
The most common reactions of therapists:
- Surprise
- Guilt
- Anxiety about unresolved personal problems
- Fear of losing control
- Fear of being criticized
- Confusion about boundaries and roles
- Confusion about actions
Recommendation for Dealing with Sexual Attraction to a Client
To minimize the likelihood of sexual transgressions by clinicians:
- Learn to recognize sexual attractions and how to deal with these feelings constructively and therapeutically.
- Seek professional support during times of personal loss or crisis.
- Examine and monitor feelings and behaviors toward clients continually.
- Know the difference between having sexual attraction to clients and acting on this attraction.
- Learn about the possible adverse consequences for clients and therapists who engage in sexual activity.
- Establish and maintain clear boundaries when a client makes sexual advances toward you.
- Terminate the therapeutic relationship when sexual feelings obscure objectivity.
- Recognize that direct explicit disclosures of sexual feelings can run the risk of harming clients and may therefore be unethical.
- Rather than making any explicit communication of sexual feelings for clients, acknowledge caring and warmth within the therapeutic relationship.
- Practice a risk management approach (e.g., be aware of timing and the location of scheduled appointments, non-erotic touch, and general self-disclosure.
- Be open to using supervision, consultation, and personal therapy throughout your career.
Harmful Effects of Sexual Contact With Clients
Clients who are the victims of sexual misconduct suffer dire consequences:
- Distrust of the opposite sex
- Distrust of therapists and the therapeutic process
- Guilt
- Depression
- Anger
- Feeling of rejection
- Suicidal ideation
- Low Self-Esteem
Legal Sanctions against Therapists who are sexual violators
Negative consequences for therapists include:
- being the target of a lawsuit
- being convicted of a felony
- having their license revoked or suspended by the state
- being expelled from professional organizations
- losing their insurance coverage
- losing their jobs
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References for Dual Relationships
Dual Relationships and Maintaining Boundaries in Counseling
Anderson, S.K. & Kitchener, K.S. (1998). Nonsexual Posttherapy relationships: A conceptual framework to assess ethical risks. Professional Psychology: Research and Practice, 29(1), 91-99.
Audet, C.T. (2011). Client perspective of therapist self-disclosure: Violating boundaries or removing barriers. Counseling Psychology Quarterly, 24(2), 85-110. DOI: 10.1080/09515070.2011.589602.
Barnett, J.E. (2014) Sexual feelings and behaviors in the psychotherapy relationship: An ethics perspective. Journal of Clinical Psychology: In Session, 70(2) 170-181. DOI: 10.1002/jclp.22068
Baer, B.E. & Murdock, N.L. (1995). Nonerotic dual relationships between therapists and clients: The effects of sex, theoretical orientation and interpersonal boundaries. Ethics & Behavior, 5(2), 13-144.
Bleiberg, J.R. & Baron, J. (2004). Entanglement in dual relationships in a university counseling center. Journal of College Student Psychotherapy, 19(1), 21-34. DOI: 10.1300/j035v19n01_05.
Bridges, N.A. (2010). Clinical writing about clients: Seeking consent and negotiating the impact on clients and their treatments. Counseling & Values, 54(2), 103-116.
Clipson, C.R. (2005) Misuse of psychologist influence: Multiple relationships. Journal of Aggression, Maltreatment & Trauma, 11(1/2), 169-203. DOI: 10.1300/J146v11n01•13.
Cottone, R.R. (2005). Detrimental therapist-client relationships-beyond thinking of “dual” or “multiple” roles: Reflections on the 2001 AAMFT code of ethics. American Journal of Family Therapy, 33(1), 1-14. DOI: 10.1080/01926180590889284.
Doyle, K. (1997). Substance abuse counselors in recovery: Implications for the ethical issue of dual relationships. Journal of Counseling & Development, 75(6), 428-432.
Fisher, C.D. (2004). Ethical issues in therapy Therapist self-disclosure of sexual feeling. Ethics & Behavior. 14(2), 105-121.
Gabbard, G.O. (1996). Lessons to be learned from the study of sexual boundary violations. American Journal of Psychotherapy, 50(3), 311-322.
Haug, I.E. (1999). Boundaries and the use and misuse of power and authority: Ethical complexities for clergy psychotherapists. Journal of Counseling & Development, 77(4), 411-417.
Hayes, J. (2014). “Well I got a few of my own”: Therapists' reactions to attraction, sex and love in psychotherapy. Journal of Clinical Psychology, 70(2), 119-122. DOI: 10.1002/jclp.22063.
Kagle, J.D. & Giebelhausen, P.N. (1994). Dual relationships and professional boundaries. Social Work, 39(2), 213-220.
Kitchener, K.S. (1988). Dual role relationships: What makes them so problematic? Journal of Counseling & Development, 67(4), 217-221.
Kolbert, J.B., Morgan, B. & Johnston, M.B. (2002). Faculty and student perceptions of dual relationships within counselor education: A qualitative analysis. Counselor Education & Supervision, 41(3), 193-206.
Lazarus, A.A. (1994) How certain boundaries and ethics diminish therapeutic effectiveness. Ethics & Behaviors, 4(3), 255-261.
Martin, C., Godfrey, M., Meekums, B. & Madill, A. (2011). Managing boundaries under pressure: A qualitative study of therapists’ experiences of sexual attraction in therapy. Counselling and Psychotherapy Research, 11(4), 248-256. DOI: 10.1080/14733145.2010.519045
Moleski, S.M. & Kiselica, M.S. (2005). Dual relationships: A continuum ranging from the destructive to the therapeutic. Journal of Counseling & Development, 83(1), 3-11.
Nigro, T. (2004). Counselors’ experiences with problematic dual relationships. Ethics & Behavior, 14(1), 51-64.
Pope, K.S. (1991). Dual relationships in psychotherapy. Ethics & Behavior, 1(1), 21-34.
Pope, K.S. & Keith-Spiegel, P. (2008). A practical approach to boundaries in psychotherapy: Making decisions, bypassing blunders, and mending fences. Journal of Clinical Psychology, 64(5), 638-652. DOI: 10.1002/jclp.20477.
Reamer, F.G. (2003) Boundary issues in social work: Managing dual relationships. Social Work, 48(1), 121-133.
Rodgers, N.M. (2011). Intimate boundaries: Therapists' perceptions and experiences of erotic transference within the therapeutic relationship. Counselling and Psychotherapy Research, 11(4), 266-274. DOI: 10.1080/14733145.2011.557437
Shapiro, E.L. & Ginzberg, R. (2003). To accept or not to accept: Referrals and the maintenance of boundaries. Professional Psychology: Research & Practice, 34(3), 258-263.
Shavit, N. (2005). Sexual contact between psychologists and patients. Journal of Aggression, Maltreatment & Trauma, 11(1/2), 205-239. DOI:10.1300/J146v11n0114.
Younggren, J.N. & Gottlieb, M.C. (2004) Managing risk when contemplating multiple relationships. Professional Psychology: Research and Practice, 35(3), 255-260. DOI: 10.1037/0735-7028.35.3.255.
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Work in Rural Communities
Cohn, T.J. & Hastings, S.L. (2013). Building a practice in rural settings: Special considerations. Journal of Mental Health Counseling, 35(3), 228-244.
Curtin, L. & Hargrove, D.S. (2010). Opportunities and challenges of rural practice: Managing self and ambiguity. Journal of Clinical Psychology, 66(5), 549-561. DOI: 10.1002/jclp.20687
Gonyea, J.L.J., Wright, D.W. & Earl-Kulkosky, T. (2014).Navigating dual relationships in rural communities. Journal of Marital and Family Therapy, 40(1), 125-136. doi: 10.1111/j.1752-0606.2012.00335.x
Harowski, K., Turner, A.L., LeVine, E., Schank, J.A. & Leichter, J. (2006) From our community to yours: Rural best perspectives on psychology practice, training and advocacy. Professional Psychology: Research and Practice, 37(2), 158-164. DOI: 10.1037/0735-7028.37.2.158
Jameson, J.P. & Blank, M.B. (2007). The role of clinical psychology in rural mental health services: Defining problems and developing solutions. Clinical Psychology: Science & Practice, 14(3), 283-298. DOI: 10.1111/j.1468-2850.2007.00089.x.
Johnson, M.E., Brrems, C., Warner, T.D. & Roberts, L.W. (2006). The need for continuing education in ethics as reported by rural and urban mental health care providers. Professional Psychology: Research & Practice, 37(2), 183-189. DOI: 10.1037/0735-7028.37.2.183.
Nickel, M.B. (2004). Professional boundaries: The dilemma of dual & multiple relationships in rural clinical practice. Counseling & Clinical Psychology Journal, 1(1), 17-22.
Robinson, W.D., Geske, J., Backer, E., Jarzynka, K., Springer, P.R., Bischoff, R., Olson, M. & Swinton, J. (2012). Rural experience with mental illness: Through the eyes of patients and their families. Family Systems & Health, 30(4), 308-324. DOI: 10.1037/a0030171
Scopelliti, J., Judd, F., Grigg, M., Hodgins, G., Hulbert, C., Endacott, R. & Wood, A. (2004). Dual relationships in mental health practice: Issues for clinicians in rural settings. Australian & New Zealand Journal of Psychiatry, 38(11/12), 953-959. 10.1111/j.1440-1614.2004.01486.x.
Schank, J.A. & Skovholt, T.M. (1997) Dual-relationship dilemmas of rural and small-community psychologists. Professional Psychology: Research and Practice, 28(1), 44-49.
Smalley, K.B., Yancey, C.T., Warren, J.C., Naufel, K., Ryan, R. & Pugh, J.L. (2010). Rural mental health and psychological treatment: A review for practitioners. Journal of Clinical Psychology, 66(5), 479-489. DOI: 10.1002/jclp.20688
Ulzen, T., Williamson, L., Foster, P. & Parris-Barnes, K. (2013). The evolution of a community-based telepsychiatry program in rural Alabama: Lesson learned-a brief report. Community Mental Health Journal, 49(1), 101-105. DOI: 10.1007/s10597-012-9493-2.
Werth, J.L., Hastings, S.L. & Riding-Maton, R. (2010). Ethical challenges of practicing in rural areas. Journal of Clinical Psychology, 66(5), 537-548. DOI: 10.1002/jclp.20681
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Bartering
Avitzur, O. (2013). The doctor will swap with you now. Consumer reports on health, 25(8), 1.
Gandolfo, R. (2005). Bartering. Journal of Aggression, Maltreatment & Trauma, 11(1/2), 241-248. DOI: 10.1300/J146v11n01•15.
Woody, R.H. (1998). Bartering for psychological services. Professional Psychology: Research & Practice, 29(2), 174-178
Giving and Receiving Clients’ Gifts
Blanco, P.J. & Sheely-Moore, A.I. (2012). Gift giving and receiving in child-centered play therapy: An ethical response. Journal of Humanistic Counseling, 51(1), 66-77.
Brown, C. & Trangsrud, H.B. (2008) Factors associated with acceptance and decline of client gift giving. Professional Psychology: Research & Practice, 39(5), 505-511. DOI: 10.1037/0735-7028.39.5.505.
Gerig, M. (2004). Receiving gifts from clients: Ethical and therapeutic issues. Journal of Mental Health Counseling, 26(3), 199-210.
Knox, S.W., Nuttcli, E., Hess, S.A. & Hill, C.E. (2003). “Here’s a little something for you”: How therapists respond to clients gifts Journal of Counseling Psychology, 50(2), 199-210.
Ootes, S., Pols, A., Tonkens, E. & Willems, D. (2013) Opening the gift: Social inclusion, professional codes and gift giving in long-term mental healthcare. Culture, Medicine & Psychiatry, 37(1), 131-147. DOI: 10.1007/s11013-012-9293-8.
Willingham, B. & Boyle M. (2010). “Not a neutral event”: Clinical psychologists’ experiences in gifts in therapeutic relationships, Psychology and Psychotherapy: Theory, Research and Practice, 84(2), 170-183. DOI: 10.1348/147608310X514523.
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