As mental health professionals, most of us have attended risk management or ethics workshops where we hear the central message and dire warning that all or most multiple relationships are unethical, prohibited, harmful, and should be avoided. It is shocking for me to hear how so-called experts and ethicists can be so uninformed. This is its own kind of unethical behavior: instructors and ethicists, like all clinicians, have a duty to be well informed. While some relationships, such as sexual and exploitative dual relationships, are clearly unethical and illegal, some multiple relationships are unavoidable and at times mandated. This Clinical Update focuses on unavoidable multiple or dual relationships.
Multiple Relationships are Standard, Mandated and Unavoidable in the Following Settings:
- Military settings, where military psychologists have multi-loyalties–to the Department of Defense, to the fighting unit, and to the individual soldier-patient. Even though these multiple relationships can create a conflict of interests, they are often mandated and required by the military.
- Prison, jails and detention settings where, at times, forensic psychologists are required to provide reports regarding their psychotherapy patients’ competency or fitness to stand trial and may also be mandated to provide sanity reports. They also have primary loyalty and legal responsibility to the institution above their loyalty to the patient-prisoner.
Dual Relationships are Common, Unavoidable and Standard in the Following Settings:
- Rural and small communities, where there are few available clinicians and multiple relationships are, in fact, a normal and healthy aspect of living and an important ingredient of how such communities survive and thrive.
- Rehabilitation and drug programs, such as AA or other 12-step programs, where many therapists are themselves in recovery and clients and therapists regularly meet in AA meetings and other recovery-oriented gatherings.
- Sport Psychology, where social dual relationships are an inherent part of the milieu such as when sport psychologists travel with the team (and their patients), spending long hours with them on buses and in airports, airplanes, dining halls, hotels, and … bars.
- Spiritual and Faith Communities, such as churches, synagogues, ashrams, temples, mosques, etc., which often involve primarily social multiple relationships between the therapists who belong to the congregations and fellow congregational clients who chose them to be their therapists because they knew them in the congregation. As a result, therapists and clients interact socially and in other ways with each other in many congregational activities and functions. Additional dual roles may exist with the spiritual leaders of faith communities who provide spiritual- or pastoral-based clinical counseling.
- Educational and Training Institutions, where therapists and clients may be involved in social and other types of activities on campus within the department or the educational institution.
- Isolated military bases or aircraft carriers, where military psychologists train, dine, play sports, are entertained and live alongside their patients.
- LinkedIn and Facebook: Modern day consumers expect transparency and connectivity. Having clients as followers on a therapist’s FB Page (not as friends on the therapist’s FB profile) is an important aspect of modern day marketing. Similarly, clients who are fellow mental health professionals will have professional dual relationships when they interact with their therapists on LI.
Multiple Roles in Supervision
Supervisory Relationships are unique situations which involve inherent multi roles, functions, and responsibilities. Tensions may exist between the supervisor’s ethical, legal, and gatekeeping roles, which include:
- enhancing supervisees’ growth and professional development;
- protecting their clients;
- protecting future clients who may be treated by the supervisees; and
- like most other psychotherapists, protecting the public in certain cases, such as those where there is a danger (i.e., Tarasoff) or child/elder abuse/neglect.
Unexpected Dual Relationships
Unexpected multiple relationships take place is situations where therapists surprisingly discover that two different clients are related or have intense relationships, as in the movie “Prime” where the therapist finds out that that the “boyfriend” her client was referring to was . . . her son.
The Codes of Ethics on Dual Relationships of all major professional associations are clear that not all dual relationships are unethical. For example, the APA code states: “Multiple relationships that would not reasonably be expected to cause impairment or risk exploitation or harm are not unethical.” The ACA’s code states that multiple relationships “may be potentially beneficial.” CAMFT’s code states that, “Not all dual relationships are unethical, and some dual relationships cannot be avoided” and NASW’s code states, “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.”