We have been repeatedly told in graduate school and CE ethics and risk management seminars never to touch beyond a handshake, avoid gifts, do not engage in bartering or leave the office with a client and, of course, avoid dual relationships like the plague. In our hearts most of us therapists know that a hug and supportive touch can often connect and heal more than words, and a gift may also speaks louder than words. We also know that a home visit can give us more clinical data than clients report to us. Those who live in small communities know that dual relationships are a normal part of the rich interwoven fabric of small communities, such as church, synagogue, college campus, rural or small town, gay and lesbian, ethnic minority communities, etc..
Regardless of what risk management or ethical experts tell us, there are NO ethical guidelines or state laws that prohibit non-sexual, clinically appropriate touch, appropriate gift exchange, clinically driven self-disclosure or non-exploitative dual relationships.
Therapeutic Boundaries — Recap:
- Boundaries in psychotherapy refer to issues of self-disclosure, physical touch, gifts, bartering, activities outside the office (home or hospital visits, attending clients’ weddings or school plays, lunch with anorectic client, adventure therapy, etc.), incidental encounters, social and other non-therapeutic contacts and various forms of dual relationships.
- Boundary crossings and boundary violations generally refer to any deviation from traditional, strict, ‘only in the office,’ emotionally distant forms of therapy. Basically, they may all be seen as a departure from the traditional psychoanalytic or risk management approaches.
- Boundary violations in therapy are different from boundary crossings. While boundary violations by therapists are harmful to their patients, boundary crossings can be clinically very helpful.
- Harmful boundary violations typically occur when therapists and patients are engaged in exploitative dual relationships, such as sexual contact with clients or exploitative business relationships.
- Helpful Boundary crossings can be an integral part of well-formulated treatment plans or evidence-based treatment plans. Examples are, giving a supportive hug to a grieving client, accepting a small termination gift, flying in an airplane with a patient who suffers from a fear of flying, bartering with a cash-poor farmer, lending a book or CD to a client, making a home visit to a bed-ridden patient, attending a wedding, confirmation or Bar Mitzvah, going to see a client performing in a show, going for a walk with a depressed patient or accompanying a patient to a dreaded but important doctor’s appointment.
- Ethics codes of all major psychotherapy professional associations (e.g., APA, NASW, ACA, CAMFT, NBCC) do NOT prohibit boundary crossings, only boundary violations.
- Therapeutic orientations, such as humanistic, behavioral, cognitive, family systems, feminist or group therapy, often endorse boundary crossings as part of effective treatment.
- Different cultures have different expectations, customs and values and therefore judge the appropriateness of boundary crossings differently. Communally oriented cultures, such as Latino, Native American or Jewish, are more likely to frown upon the rigid implementation of boundaries in therapy.
- Not all boundary crossings constitute dual relationships. Making a home visit, going on a hike, attending a client’s wedding and many other ‘out-of-office’ experiences are boundary crossings, which do not necessarily constitute dual relationships.
- There is a prevalent and unfounded belief about the ‘slippery slope,’ which claims that minor boundary crossings inevitably lead to boundary violations and sexual relationships. This illogical approach is based on the ‘snow ball’ effect. It falsely predicts that the giving of a simple gift likely ends up in a business relationship, therapist’s self-disclosure becomes an intricate social relationship and a non-sexual hug turns into a sexual relationship.
Dual Relationships in Psychotherapy
- Dual relationships, or multiple relationships, in psychotherapy refer to any situation where multiple roles exist between a therapist and a client. Examples are when the client is also a student, friend, family member, employee or business associate of the therapist.
- Non-sexual and non-exploitative dual relationships are neither unethical nor illegal nor below the standard of care.
- Sexual dual relationships with current or recently terminated clients are always unethical and often illegal.
- Dual relationships are often unavoidable in rural and small communities, the military, forensic settings, church communities and among gays and lesbians, the deaf, people with AIDS, Hispanic, African American and many other minorities.
- Non-sexual dual relationships do not necessarily lead to exploitation, sex or harm. The opposite is often true. Appropriate and healthy dual relationships can prevent exploitation & sex rather than lead to it.
- None of the major ethical guidelines mandate a blanket avoidance of dual relationships. All guidelines do is to prohibit sexual dual relationships with current or recently terminated clients, as well as prohibit exploitation and harm of clients.
- There are several types of dual relationships: Social, business, professional, communal, etc. Dual relationships can also be concurrent or sequential, avoidable, unavoidable or mandated, and can be simple or complex or intricate.
Clinical and Ethical Recommendations
- The appropriate meaning and applicability of boundaries can only be understood within the context in which therapy takes place. The context of therapy consists of the following four components: Client factors (e.g., culture, age, gender, history of trauma or abuse, presenting problem); Setting factors (e.g., outpatient vs. inpatient, solo practice vs. group practice, home office vs medical building, rural vs urban); Therapy factors (e.g., individual vs. family vs. group therapy, psychoanalysis vs. humanistic vs. body psychotherapy); Therapeutic relationship factors (i.e., nature of therapeutic alliance; phase in therapy); Therapist factors (e.g., culture, age, gender, clinical experience, training).
- Develop a clear treatment plan, which is based on client’s problems, needs, personality, situation, venue, environment and culture. Intervene with your clients according to their needs and not according to any dogma.
- Some treatment plans may necessitate boundary crossings; however, in other situations they should be ruled out. Make sure you know the difference.
- Conduct a risk benefit analysis before crossing boundaries. Remember that inaction, such as rigid avoidance of boundary crossing, may also have significant drawbacks for clients and the therapeutic process.
- In planning to cross a boundary or enter into 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.
- 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.
- Remember that you are being paid to provide help, not to practice risk management.
- Do not enter into sexual relations with a current or recently terminated client.
- Consult with informed and open minded experts in complex cases and document the consultations.
- Attend to and be aware of your own needs and biases through consultations, peer supervision, therapy, etc.
- Discuss with your clients the complexity, richness, potential benefits, drawbacks and likely risks that may arise due to boundary crossings and dual relationships. When appropriate, share with them your risk benefit analysis.
- Boundary crossings with certain clients, such as those with borderline personality disorders or those who are acutely paranoid, are not usually recommended as they more often benefit from a structured and well-defined therapeutic environment.
- Make sure that, when appropriate, your office policies include the risks & benefits of boundary crossings and dual relationships, and that they are explained, read and signed by your clients prior to treatment.
- Make sure your clinical records document includes consultations, substantiation of your conclusions, potential risks and benefits of specific interventions and the discussion of these issues with your client.
- At the heart of all ethical guidelines is the mandate that you act on your client’s behalf and avoid harm. That means you must do what is helpful including, when appropriate, crossing boundaries and engaging in dual relationships.
Review and order Dr. Zur’s book, Boundaries in Psychotherapy