By Ofer Zur, Ph.D. and Arnold A. Lazarus, Ph.D., ABPP
Adapted from: Lazarus, A. A. and Zur, O. (Eds.) Dual Relationships and Psychotherapy, New York: Springer. Chapter 1, pp. 3-24.
Printed with permission.
Table Of Contents
The Origin of the Opposition to Dual Relationships
Arguments Against Dual Relationships and Rebuttals
The Concern with Boundaries
The ‘Slippery Slope’ Argument
Power and Exploitation
Familiarity and Issues Pertaining to Transference
Incidental Encounters and Other Interactions Outside the Office
The Origin of the Opposition to Dual Relationships
Dual relationships between psychotherapists and clients have been frowned upon and denounced by the majority of therapists, ethicists, courts, licensing boards, ethics committees and educators. The main reasons given for this proscription are that clients must be protected from exploitative and harmful therapists and that dual relationships, according to some, are not only harmful to clients but also compromise the integrity of the therapeutic process.
Issues of exploitation in general and sexual or business exploitation in particular are appropriately at the forefront of consumer advocates’ agendas. The valid concern is that service professionals, such as psychotherapists, physicians, pastors, or attorneys, can easily exploit their clients by using their positions of authority or power for personal gain. Clients seeking help with mental health are often in crisis and likely to be highly vulnerable and suggestible. Many regard trust in and vulnerability to the therapist as an inherent part of the healing process (Barnett, 1996; Canter, Bennett, Jones, & Nagy, 1994; Caudill & Pope, 1995; Corey, Corey, & Callahan 1984; Koocher & Keith-Spiegel, 1998; Zur, 2000b).
In view of clients’ potential vulnerability and the numerous reports of harm inflicted on them by sexual dual relationships, the attempt to curtail exploitation and protect consumers from damage is reasonable and essential (Borys & Pope, 1989; Herlihy & Corey, 1992; Pope, 1988; Williams, 1997). Accordingly, most ethical guidelines for licensed mental health care providers include warnings against any exploitation and harm of patients by therapists, and a specific caution against sexual relationships with clients (e.g., American Association for Marriage and Family Therapists, 2001; American Psychological Association, 1992; National Association of Social Workers, 1999). (For a verbatim account of the Codes of Ethics on dual relationships, see chapter 6 in this volume.) Most states have developed civil and penal codes that, similar to professional ethical codes, aim to discourage therapists from entering into sexual relationships with clients. Practitioners who are reported for having violated these rules, especially those who inflict damage on their clients, are duly punished (Caudill & Pope, 1995).
The Arguments Against Dual Relationships and Rebuttals
The traditional reasons for imposing negative sanctions on dual relationships stem from theoretical, ethical, and pragmatic reasoning. This chapter provides details of the principal arguments used by advocates for the prohibition of dual relationships:
- The concern with boundaries
- The slippery slope
- Power and exploitation
- Familiarity and issues pertaining to transference
- Risk management
- Leaving the office and incidental encounters
Each of the above six segments offers a description of the argument against dual relationships and a rebuttal. Following the critique of each predication, the reader is referred to relevant book chapters for further reading on the topic.
1. The Concern with Boundaries
The Argument Against Dual Relationships:
At the heart of the opposition to dual relationships is an argument that places immense importance on clear boundaries in therapy. Accordingly, supporters of this line of reasoning view any deviation from these boundaries as a threat to the therapeutic process and regard such transgressions as potential if not inevitable precursors to harm, exploitation and sexual relationships between therapists and clients (Borys, 1994; Brown, 1994; Katherine, 1993; Koocher & Keith-Spiegel, 1998; Pope, 1989; Pope & Vasquez, 1998; Sonne, 1989; Strasburger, Jorgenson, & Sutherland, 1992). Gutheil & Gabbard (1993) describe the critical areas relevant to boundary issues: time, place, space, money, gifts, services, clothing, language, self-disclosure and physical contact.
The effect of dual relationships on the therapeutic frame is a major concern for almost all psychoanalysts and psychoanalytically oriented therapists. Many conceive this effect to be intrinsically negative and hence believe that they invariably interfere with and undermine clinical work (Epstein & Simon, 1990; Langs, 1976; Simon, 1992). Accordingly, they view all dual relationships as inherently harmful and advocate their complete avoidance. Psychoanalytic theory emphasizes the importance of boundaries and the neutral stance of the analyst. According to traditional analysts, effective management of transference and other therapeutic work requires clear and consistent boundaries that enable the therapist to preserve the analytic frame of therapy (Langs, 1988). Transgressions that detract from therapists’ neutrality are said to contaminate the transference and hence are a detriment to analysis. Langs (1976), is an avid supporter of tight boundaries as a necessity for therapeutic progress. His work has been widely quoted by ethicists and those who view dual relationships as harmful. He testifies that “poor boundary management” impedes transference work and has other serious ramifications, such as the dilution of the therapist’s influence. He also maintains that boundary variations, such as dual relationships, that deviate from the traditional practice of analysts are serious mistakes with a significant negative impact on the therapeutic process. Simon (1995) operates from a similar perspective and has numerous publications that epitomize the case against boundary crossings or dual relationships. Adhering to traditional analytic principles, his main guidelines state:
Maintain therapist neutrality. Foster psychological separateness of the patient. Obtain informed consent for treatment and procedures. Interact only verbally with clients. Ensure no previous, current, or future personal relationships with patients. Minimize physical contact. Preserve relative anonymity of the therapist. (Simon, 1994, p. 514)
The concern with boundaries is not limited to analytically oriented therapists. Most texts advocate rigid adherence to strict boundaries. Koocher and Keith-Spiegel (1998) claim in their widely use ethics text, “. . . we are convinced that lax professional boundaries are often a precursor of exploitation, confusion and loss of objectivity” (p. 171). Similarly, Borys & Pope (1989), Brown (1985), Kagle & Geibelhausen (1994), Katherine (1993), Kitchener (1988), Pope and Vasquez (1998), Simon (1995), Sonne (1994) and many others view dual relationships as a detrimental boundary violation. They all view professional distance between therapist and client as essential, indeed as a sine qua non for effective clinical work.
In discussing boundaries it is imperative that boundary crossings are distinguished from boundary violations. Boundary violations refer to actions on the part of the therapist that are harmful, exploitative and in direct conflict with the preservation of clients’ dignity and the integrity of the therapeutic process. Examples of boundary violations are sexual or financial exploitation of clients. A boundary crossing is a benign, and often beneficial departure from traditional therapeutic settings or constraints. Examples of boundary crossings are making home visits to a bedridden sick client; taking a plane ride with a client who has a fear of flying; attending a client’s wedding, barmitvah, or other function; or conducting therapy while walking on a trail with a person who requests it and seems to benefit from it. Boundary crossings that also constitute dual relationships, such as socializing with clients or bartering, are the focus of this book.
Rigid boundaries often conflict with acting in a manner that is clinically helpful to clients. Rigidity, distance and coldness are incompatible with healing. Lambert (1992) and many others affirm, through outcome research, the importance of rapport and warmth for effective therapy. Boundary crossings are likely to increase familiarity, understanding and connection and hence increase the likelihood of success for the clinical work. Whitfield (1993) also describes how the most serviceable boundaries are those that are flexible, as opposed to those that are implemented in such a rigid manner as to cause harm through excessive and inappropriate distance.
We contend that exclusive reliance on analytic theory, which results in the eschewal of virtually all boundary crossings, has been detrimental to the overall impact of psychotherapy. Behavioral, cognitive-behavioral, humanistic, group, family and existential therapeutic orientations are the most practiced orientations today. These treatment approaches tend to endorse what are considered clear boundary violations by most ethicists, psychoanalysts and risk management advocates (Williams, 1997). In fact, feminist, humanistic and existential orientations view the tearing down of artificial boundaries as essential for therapeutic effectiveness and healing (Greenspan, 1995).
As this book documents extensively (e.g. see chapter 5) the maintenance of rigid boundaries between therapists and patients in many close-knit communities is unrealistic and impossible. These communities include the military (Hines, Ader, Chang, & Rundell, 1998; Johnson, 1995; Staal & King, 2000), rural (Hargrove, 1986; Jennings, 1992; Schank & Skovholt, 1997), religious (Geyer, 1994; Montgomery & DeBell, 1997), feminist (Greenspan, 1995; Lerman & Porter, 1990; Stockman, 1990), gay (Brown, 1991; Smith, 1990), and ethnic minorities (Sears, 1990). Social norms in these communities include flexible and permeable boundaries and often favor mutuality between professionals, including therapists, and their customers.
Interventions and the treatment plans, including the nature of boundaries, should be constructed according to the client’s idiosyncratic situation, condition, problems, personality, culture and history. It is preferable to base treatment plans on empirical research when available. The unduly restrictive analytic risk-management emphasis on clear, rigid and inflexible boundaries interferes with sound clinical judgment, which ought to be flexible and personally tailored to clients’ needs rather than to therapists’ dogma or fear.
Throughout this book, the reader will discover many arguments of when boundary extensions and crossings increase therapeutic effectiveness. See for example in Section 3, 5, 6 and 7.
2. The ‘Slippery Slope’ Argument
The Argument Against Dual Relationships:
The term ‘slippery slope’ refers to the idea that failure to adhere to rigid standards, most commonly based on analytic and risk-management approaches, will undeniably foster relationships that are sexual or otherwise exploitative and harmful. This process is described by Gabbard (1994) as follows: ” . . . the crossing of one boundary without obvious catastrophic results (making) it easier to cross the next boundary” (p. 284). Pope (1990), whose endorsement of the slippery slope idea has significantly contributed to its popularity, expresses a similar opinion: ” . . . non-sexual dual relationships, while not unethical and harmful per se, foster sexual dual relationships” (p. 688). Strasburger et al. (1992) conclude, “Obviously, the best advice to therapists is not to start (down) the slippery slope, and to avoid boundary violations or dual relationships with patients.” (p. 547-548). Also in agreement is Simon (1991), who decrees that: “The boundary violation precursors of therapist-patient sex can be as psychologically damaging as the actual sexual involvement itself” (p. 614). This poignant statement summarizes the opinion that the chance for exploitation and harm is reduced or nullified only by refraining from engaging in any dual relationship or boundary crossing. Many writers describe a long list of therapists’ behaviors (e. g. self-disclosure, hugs, home visits, socializing, longer sessions, lunching, exchanging gifts, walks, playing in recreational leagues) that they believe to be precursors to sexual dual relationships (Borys & Pope, 1989; Craig, 1991; Keith-Spiegel & Koocher, 1985; Lakin, 1991; Pope, 1991; Pope & Vasquez, 1998; Rutter, 1989; St. Germaine, 1996). It was along these lines that Epstein & Simon (1990) developed the ‘Exploitation Index,’ which has since become a frequently quoted reference in the field.
Sonne (1994) discusses how a therapist and client who are sports teammates can easily move their relationship to encompass activities, such as carpooling or drinking. She concludes that “With the blurring of the expected functions and responsibilities of the therapist and client comes the breakdown of the boundaries of the professional relationship itself” (p. 338). Similarly, Woody (1998) asserts “In order to minimize the risk of sexual conduct, policies must prohibit a practitioner from having any contact with the client outside the treatment context and must preclude any type of dual relationships” (p. 188). The ‘slippery slope’ argument is even more pronounced in the work of Evans (1997), who contends that from an ethical, legal and clinical perspective, non-sexual and sexual dual relationships are absolutely equal and ought to be dealt with in the same manner.
The slippery slope argument is grounded primarily in the assumption that any boundary crossing, however trivial it may be, inevitably leads to boundary violations. To assert that self-disclosure, a hug, a home visit, or accepting a gift are actions likely to lead to sex is like saying that doctors’ visits cause death because most people see a doctor before they die (Zur, 2000a). Lazarus calls this thinking “an extreme form of syllogistic reasoning” (1994, p. 257). We learn in school that sequential statistical relationships (correlations) cannot simply be translated into causal connections. The fear that any boundary crossing will end up with sex is described by Dineen (1996) as part of the more inclusive problem of psychotherapists’ sexualizing of all boundaries.
It is important to reiterate that whereas the analytic contingent underscores that crossing boundaries will nullify therapeutic effectiveness and hence cause harm, many other orientations have a different viewpoint. Behavioral, humanistic, group, family, existential, feminist or gestalt therapies at times stress the importance of tearing down interpersonal boundaries and strongly dispute that this will lead to exploitation and harm (Greenspan, 1995, Williams, 1997; Zur, 2000a, b, 2001a).
Contrary to popular expectations, dual relationships and familiarity with clients tend to reduce the probability of exploitation and do not increase it. The power differential in a more egalitarian relationship becomes attenuated so that the client is more likely to forestall any improprieties that may arise. (This is also amplified in the next section.) As concluded in studies of cults, exploitation flourishes in isolation (Singer & Lalich, 1995). Those who vigorously propound the “only in the office” policy and the isolation it imposes on the therapeutic encounter are more likely to foster exploitation and sexual misconduct (Zur, 2000a, 2001b). When implemented with care and integrity, dual relationships with clients and the familiarity that follows are more likely to curb exploitation and harm than encourage them.
3. Power and Exploitation
The Argument Against Dual Relationships:
The primary rationale for the argument to abstain from all dual relationships is that therapists may misuse their power to influence and exploit clients for their own benefit and to the clients’ detriment (Bersoff, 1999; Borys, 1992; Herlihy & Corey, 1992; Koocher & Keith-Spiegel, 1998; Pope, 1991; Pope & Vasquez, 1998). The argument is that the power differential enables and encourages therapists to exploit and harm their clients upon entering into dual relationships, that to venture beyond the threshold of the purely professional therapeutic hour inevitably fosters exploitation by the more authoritative clinician or counselor (Austin, 1998; Woody, 1998).
Kitchener (1988) describes the power differential between therapists and clients as one of the three most important factors in determining the risk of harm to clients engaged in dual relationships with their therapists. Similarly, Gottlieb (1993) lists power differentials as the first dimension in the decision-making model for avoiding exploitative dual relationships in therapy. Pope (Pope & Vasquez, 1998), like his many followers, maintains that because of the power differential, the client is vulnerable and incapable of free choice and hence exploitation is likely and therapeutic benefits are significantly compromised.
The concern with therapists’ power is important and valid, as the power differential is true for many, if not most therapist-client relationships. This is because therapists are generally hired for their expertise, which in most cases gives them at least some measure of an expert-based power advantage over their clients.
Power differential has almost become interchangeable with exploitation and harm in the ethics literature. However, when dealing with issues of power, one must remember that many relationships with a significant differential of power, such as parent-child, teacher-student or coach-athlete, are not inherently exploitative (Zur, 2000a). Parental power facilitates children’s growth, teachers’ authority enables students to learn, and coaches’ influence helps athletes to achieve their full athletic potential. Few, if any, marriage, business, friendship, or therapy relationships are truly equal. Therapists’ power, like that of parents, teachers, coaches, politicians, policemen, attorneys or physicians, can be used or abused. The Hippocratic Oath of ‘first do no harm’ attends exactly to such dangers. The problem of abusive or exploitative power in therapy does not lie within dual relationships, but in the therapist’s propensity to abuse his or her power for selfish gain. Tomm (1993) adds “It is not the power itself that corrupts, it is the disposition to corruption (or lack of personal responsibility) that is amplified by the power” (p. 11).
In this argument, patients are portrayed as malleable, weak, and defenseless in the hands of their powerful, dominant, compelling therapists. The disparity in power is regarded as extreme, which is disempowering to the client. It is possible that many therapists who cling to the false ideals of the segregated therapy session and avoid dual relationships because it increases their professional status (Dineen, 1996; Zur, 2000b, 2001a), are thereby imbuing themselves with undue power that can all too easily be translated into exploitation. Many therapists work with clients who are much more powerful than them. Some clients are CEO’s of large corporations, judges, powerhouse attorneys, master mediators or successful entrepreneurs. Often, these clients do not regard their therapists as particularly powerful or persuasive, and their therapists experience them as the more powerful and successful half of the dyad. Such cases are a prime example of when therapists have to work hard at cultivating an aura of power so as to appear credible.
Many of America’s businesses are family-operated, wherein the members experience the complexities of dual relationships, power differentials and the balancing of blood and money. Similarly, a therapist working professionally with clients who they also know outside the office experience richness, various challenges and creative difficulties, but this certainly does not inevitably lead to exploitation (Zur, 2000a)
As alluded to in the previous section, contrary to the general belief that dual relationships encourage exploitative behavior by therapists, it has been argued that the opportunity for exploitation is proportional to the amount of isolation in a given therapeutic relationship. The absence of relationships other than those developed in the traditional therapeutic session results in increased isolation. A therapist’s power is increased in isolation because clients tend to idealize and idolize them. Most instances of exploitation occur in isolation, including spousal and child abuse (Walker, 1994). Sexual exploitation is less likely to occur if the therapist is also working with the client’s spouse, friend and parent or has another community connection with the client, either directly or through the client’s family and friends. Therapists are less inclined to exploit those with whom they have a long-term or significant relationship outside of therapy (Tomm, 1993).
4. Familiarity and Issues Pertaining to Transference
The Argument Against Dual Relationships:
The traditional urban analytic risk-management model of therapy interprets familiarity with clients outside the consulting room as inimical to therapy (Epstein & Simon, 1990; Faulkner and Faulkner, 1997; Langs, 1976; Pepper, 1991; Pope & Vasquez, 1998). According to this argument, familiarity contaminates the therapeutic exchange. Faulkner and Faulkner (1997) advocate that even in rural settings, therapists should avoid becoming familiar with current or prospective clients. They maintain that an ethical rural therapist must “avoid engaging in behaviors with a client that lead to the development of familiarity” (p. 232). Thus, they veto all dual relationships and boundary crossings.
The fundamental proposition behind this prohibition assumes that therapists of all persuasions require a level of anonymity so that their clients can hold them in high esteem. They fear that familiarity may breed contempt if clients gain the opportunity to see some of their therapists’ shortcomings or frailties. Hence it is deemed essential to afford the client little (if any) opportunity to discover any shortcomings, weaknesses, or failings in their therapists.
Among psychoanalysts, the injunction to avoid familiarity or self-disclosure is even more stringent because it is held that veridical knowledge about the analyst, as a person will compromise the projections necessary for the analysis of transference. The original analytic concern stems from the initial belief and theory about the management of the transference and “securing the frame” of analysis (Lewis, 1959). Analytically oriented writers, such as Borys (1994), Epstein (Epstein & Simon, 1990), Lakin (1991), Langs (1976), Pepper (1991) and Simon (1989) are in agreement that dual relationships and familiarity nullify clinical effectiveness because the purity of the transference is negated and the very fabric of the analysis is undermined.
Contrary to the recommendations of therapist anonymity that stem from the urban-based model, there are some communities in which this is not feasible or desirable. The unique bond between therapists and clients in small communities is described by Hargrove (1986), Lazarus (1998, 2001), Schank & Skovholt (1997) and Zur (2000a, 2001a, b), as abundant with commitment, care and trust that, in turn, promote significant increases in therapeutic effectiveness.
Communities in which this manner of relating to clients is closer to the standard than the exception include rural (Hargrove, 1986; Jennings, 1992; Schank & Skovholt, 1997), religious (Geyer, 1994; Montgomery & DeBell, 1997), feminist (Greenspan, 1995; Lerman & Porter, 1990; Stockman, 1990), gay (Brown, 1991; Smith, 1990), and ethnic minorities (Sears, 1990). Social norms in these communities include the unavoidable overlap of relationships, professional and otherwise.
In small and close-knit communities, such as those cited above, clinical effectiveness is increased by familiarity and dual relationships. Familiarity is closely associated with beneficial therapeutic relationships. They are linked positively mainly because therapeutic relationships have been one of the best predictors of clinical effectiveness (e. g., Frank, 1973; Lambert, 1992; Bergin & Garfield, 1994; Miller, Duncan, & Hubble, 1997). Clients frequently emphasize the benefits that accrue when therapists interact with them in the community, outside the office. This fuller picture of clients’ history, family and interactions within the community gives context to clients’ accounts of their lives. For many cases, to commence therapy without utilizing the supplementary knowledge available would slow or halt therapeutic progress and fail to serve the client, particularly in cases where clients have a distorted view of themselves and their surroundings (Zur, 2000a).
ompatibility of lifestyle, values and spiritual orientation between therapist and client are known to positively affect the outcome of therapy (Lerman & Porter, 1990). Clients who select their therapists based on prior knowledge and familiarity are more likely to feel connected to their way of life. The trust that is vital for therapeutic progress is already in place for many clients who choose their therapists because of prior knowledge (i.e., familiarity). In small communities, therapists are chosen in much the same way that a minister, physician, or babysitter is selected. The findings of a study by Gruenbaum (1986) oppose the previously described stance of Faulkner & Faulkner (1997). The items most frequently cited as harmful were rigidity, coldness and distance on the part of the therapist.
The overriding emphasis that psychoanalysis places on therapist neutrality and distance to preserve the purity of transference work should not be seen as a model or frame of reference for the entire edifice of psychotherapy. Most therapists do not practice psychoanalysis or devote extensive time to the analysis of the “transference” (Lazarus, 1994; Zur, 2001b), yet the bulk of the therapeutic community is often expected to follow its standards (Williams, 1997). It is preposterous to hold therapists to the ideology of an orientation that they do not practice or believe in (Lazarus, 1994; Zur, 2000a).
5. Risk Management
The Argument Against Dual Relationships:
Risk management is the course by which therapists refrain from practicing certain behaviors or interventions because they may be misinterpreted and questioned by boards, ethics committees, and courts (Gutheil & Gabbard, 1993; Lazarus, 1994, 1998; Williams, 1997, 2000). Given the litigious climate in which we live, it has been argued that the fewer risks a therapist takes, the better. It is safer to adhere to a strict code of ethics, to cross no boundaries, and to avoid any transaction that might be viewed askance by licensing boards, ethics committees, or in a court of law. According to this argument, entering into a dual relationship with a client is a high risk enterprise. It opens the door for inquiries into and suspicions about the therapist’s conscious or unconscious motives. This vulnerability renders therapists susceptible to a host of accusations pertaining to proper treatment and the avoidance of exploitation. With many clients, it is all too easy for them to read nefarious motives into the therapist’s behavior in any extra-therapeutic setting or situation.
Risk management advocates advise against any controversial interventions, regardless of their ethical or legal standing. Accordingly, bartering, hiking, or socializing with clients are high on the risk management list of unadvisable actions. Gutheil and Gabbard (1993) claim that “From the viewpoint of current risk-management principles, a handshake is about the limit of social physical contact at this time” (p. 195). As the culture has become more litigious in the late nineteen-nineties, a whole industry of post-graduate seminars and texts have developed around the concept of risk management. In his book, Danger for Therapists: How to Reduce Your Risk, Austin (1998) equates dual relationships with exploitation and accordingly advises “Avoid any dual relationship with a client or former client” (p.55). Woody has published several books on risk management, one of which is Fifty Ways to Avoid Malpractice, where he advocates the practice of “healthy defensiveness” (1998, p. 123).
While it sounds reasonable at face value, risk management results in practices that are based on fear of attorneys and boards rather than clinical considerations. Around the issue of dual relationships much fear has been planted in therapists of board investigations (Ebert, 1997; Peterson, 2001; Saunders, 2001; Williams, 2001). Clarkson (1994) states, “An unrealistic attempt to avoid all dual relationships in psychotherapy may be defensively phobic or repressive” (p. 32). Therapists are hired to provide services that include the best possible care for clients, not the implementation of defensive practices. As described by Lazarus (1994), “One of the worst professional or ethical violations is that of permitting current risk-management principles to take precedence over human interventions” (p. 260).
This fear of board investigations inspires therapists to take protective measures. Schank and Skovholt (1997) discuss the repercussions of this fear in rural areas, one of which is that therapists refrain from seeking consultation about unavoidable dual relationships, which lowers the quality of care for the client.
Relevant factors for the implementation of clinical interventions include the client’s personality, situation, gender, history, culture, and degree of functionality. Treatment plans based on these considerations and available empirical research will far better serve the client than clinical decisions based on the advice of attorneys and the fear or terror of licensing boards. Accurate clinical records, well-documented consultations and clearly articulated and clinically sound treatment plans are probably the best means of assuaging risk management fears and insuring that clients derive significant therapeutic benefits.
6. Incidental Encounters and Other Interactions Outside the Office
The Argument Against Dual Relationships:
Interacting with clients outside the office is often discouraged for legal (Bennett, Bricklin, & VandeCreek, 1994; Kitchener, 1988), ethical (Gottlieb, 1993; Pope & Vasquez, 1991) and clinical (Borys & Pope, 1989; Epstein & Simon, 1990; Simon, 1991) reasons. The main reason for this is that leaving the office is considered a boundary violation or boundary transgression (Gutheil & Gabbard 1993; Kitchener, 1988; Koocher & Keith-Spiegel, 1998). “Seventy three percent of therapists were distressed about the fact that outside the safety of the office walls, they “have little control over whether or not something is revealed about themselves or their lifestyle during these moments. . .” (Sharkin & Birky, 1992 p. 327). It is widely assumed that experience with clients outside the office leads to disruption of therapy, exploitation, harm, or sexual relationships. Common advice from consumer advocates includes a warning against leaving the office in order to discourage damaging behavior by exploitative therapists (Barnett, 1996).
The concern over incidental encounters with clients outside the office has received substantial attention by ethicists (Sharkin & Birky, 1992; Grayson, 1986; Spiegel, 1990). Analytically and psychodynamically oriented therapists are also extremely concerned about out of office encounters (Glover, 1940; Gody, 1996; Langs, 1988; May, 1988; Tarnower, 1966). The general message is for therapists to avoid all out of office encounters. Even rural therapists have been advised to avoid such encounters (Faulkner & Faulkner, 1997).
As previously discussed, the sensitivity of psychoanalysts to the issue of chance or incidental encounters is based on the concern that it contaminates the transference and hence interferes with clinical work. They also speculate that clients and therapists alike wish to avoid such encounters so that clients’ view of their therapists as omnipotent is not disrupted. Avoidance of such out of office encounters seems to also be justified also in order to defend the therapists from them experiencing anxiety (Strean, 1981). Strean’s concern is that extra-therapeutic encounters are likely to provoke the type of transference and countertransference fantasies that evoke oedipal desires and sadistic urges, and significantly interfere with the analysis.
From an ethical point of view, the primary argument against incidental encounters is to avoid the invasion of a client’s privacy or any breech in confidentiality. Sixty percent of respondents in Sharkin and Birky’s survey reported “being concerned about the violation of confidentiality during incidental encounters” (1992, p. 327). Privacy and confidentiality have been known to contribute to trust in psychotherapy. In many instances, the private and insulated office setting provides an extremely important milieu in helping clients reveal meaningful clinical material that is essential for effective therapy. Privacy in therapy allows clients to be honest and have a sense of safety and security in the therapeutic exchange, and accordingly is associated with positive clinical outcomes (Lambert, 1991). Thus, the concern about dual relationships and other interactions outside the clinical setting most often raised by therapists and ethicists pertains to issues of confidentiality. According to this apprehension, being seen with a client in public, or even acknowledging a client by saying a simple “hello” may constitute a violation of the confidential therapeutic ethic.
There appears to be a widespread belief that “privacy” and “confidentiality” are synonymous. While they are connected, they are not identical. This was underscored by Lazarus in the January/February 2001 issue of The National Psychologist after being assailed by a critic who claimed that the very act of socializing with a client is a breech of confidentiality. Lazarus responded as follows: “When I am sitting at a lunch counter and socializing with a patient at his request, how does this violate his privacy or confidentiality? I get the feeling that [my critic] believes that I may be overcome by the urge to turn to the person alongside me and blurt out, ‘This is Tim Smith, a patient I am treating for guilt over his extramarital affairs,'” (p. 10).
In discussing situations in which therapists interact with their clients outside the office one must differentiate between three types of out-of-office experiences. As Zur (2001a) illustrates, the first type is where the out of office experience is part of a thought-out, carefully constructed, research-based treatment plan, such as eating lunch with an anorexic patient, taking an airplane ride with a client who has a fear of flying, or going to the local market with an agoraphobic client. The second is where the out-of-office experience is geared towards enhancing therapeutic effectiveness, such as attending a play to see a client who had overcame a fear of public speaking playing a role, or visiting a client’s new art exhibit. The third type is comprised of encounters that constitute dual relationships, or what have been referred to as overlapping relationships (Schoener, 1997). These are relationships that naturally occur as part of normal living in rural, military, deaf or other small communities. Examples of this include attending church, socializing, or playing in a recreational league with a client. All three types are boundary crossings, but not boundary violations.
Interacting with clients outside the office may not only be ethical but may actually be clinically desirable in certain situations and often consistent with Behavioral, Systems, Humanistic, Cognitive-Behavioral, Multimodal, and other non-analytic orientations (Williams, 1997). Lazarus (1994) states, “I have partied and socialized with some clients, played tennis with others, taken long walks with some . . .” (p.257). Jourard, a humanistically oriented therapist, states “I do not hesitate to play a game of handball with a seeker or visit him in his home-if this unfolds in the dialogue” (cited in Williams, 1997, p. 242). Therapists’ being known by their clients for the their strengths and weakness can “humanize” the process and thus enhance the therapeutic relationship and the healing process.
Zur (2001a), in his article “Out of Office Experience” describes numerous instances where he interacts daily with clients outside the consulting room in the small community in which he resides. These interactions occur because these clients are also parents at the school which his children attend, clerks at the stores he frequents, or players at the recreational league in which he participates. Zur (2001b) also claims that out of office encounter do not, necessarily, interfere with so-called “transference work.” In his words, “it is all grist to the transference mill” (p. 203).
It is possible to manage incidental or chance encounters outside the office in professionally and ethically. The first step is to discuss the possibility of meeting outside the office with clients early on in treatment. Then the prudent therapist ought to ask the clients for their preferred way of handling it. While some clients prefer the therapist not to acknowledge them in public others are quite open about the therapeutic relationship (Zur, 2001a). Clients with borderline, paranoid or narcissistic personality disorders may have a strong reaction that must be anticipated and taken into account. It is also important to discuss any incidental encounter after it happens, at least for the first time in order to make sure that clients’ concerns are aired and clients are comfortable with the exchange. In complex situations or when chance encounters occur frequently, consultation with an expert colleague may be called for.
For a more comprehensive response to the concern with dual relationships and encountering clients outside the office, see Section1 and 2 of this volume.
This chapter outlines six of the main arguments against non-sexual dual relationships in psychotherapy and offers rebuttals to these points. For a more comprehensive exploration of the complexities involved in each argument, the reader is encouraged to peruse the specific book chapters cited at the end of each rebuttal.
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