By Ofer Zur, Ph.D.
Reproduced by permission of the Division of Psychologists in Independent Practice of the American Psychological Association.
Original publication in PDF-printable format
Updated Extensive Bibliography on Dual & Multiple Relationships in Psychotherapy and Counseling
In Celebration Of Dual Relationships
1. On being an oceanographer in the wine country:
Jack and I have played basketball for several years in our local recreational league. His wife, Janet, and I chaperone our children on field trips together and are on the same educational committee. When they called me seeking help to save their marriage, I delivered my sermon about dual relationships, objectivity, and ethical guidelines.
In short, I was not the man for the job. I had taught ethics, research and clinical courses at the graduate and post-graduate level for over a decade, and my sermon was polished and substantiated with quotes, references and court cases. To my surprise Jack and Janet were outraged rather than being understanding. “We have known you for a long time,” they said, “we know your values and how you treat your wife, your children and your friends. We know of several marriages you have helped put on the right path. We choose you because we know you and because you know us well. Besides, we have already tried several other counselors to no avail, we are on the brink of divorce and do not have the time to tell our stories once again to another stranger.”
Moving to a serene, small town in the Northern California wine country was significantly less serene than I had anticipated, regarding my private practice. Psychodynamically oriented and cognitively trained, I had immense difficulty dealing with the lack of customary professional boundaries between my clients and myself. It was a shocking realization that people were choosing me as their therapist because they knew me and I knew them. Everything I had learned from graduate school, my supervisors or had absorbed from the professional literature led me to believe this was perilous.
Alarmed, I consulted with attorneys, supervisors, experts on ethics, and experienced therapists regarding my dilemma. How, I asked them, could I work with people who are part of my community? We discussed the ethical, legal, and clinical implications of such relationships on transference, countertransference, therapeutic alliance, boundaries, conflict of interest, objectivity, standard of care, power, freedom of choice, etc. We also analyzed in detail the potential clinical risks and benefits of entering into therapy with these people. The near consensus seemed to be that what I was doing was clinically, legally, and ethically inappropriate, and even dangerous. Though all my clients were fully informed about the complexities of dual relationships through my office policies, verbal explanations and through receiving an actual copy of the APA Ethics Code, and I was neither engaged in sexual or business interactions with them, nor exploited or harmed them in any way, I was warned that I was walking into a mine field.
Despairingly, I started looking for a job in my former profession of oceanography and deep sea diving. To my dismay I found no ads in the local paper stating: “A local winery is looking for an experienced deep sea diver.”
2. Playing Russian Roulette with the soul.
Some clients’ systematic search for a therapist-consultant is as sensible as it is rare. One client of mine, a physician, spent a couple of years observing me, reading my publications, meeting my wife and children and following up closely on cases he referred to me. All this, admittedly, for the purpose of checking me out as a potential therapist for himself. When people contact me through the Yellow Pages or from the list provided by my psychological association, I am shocked at the callousness of the lottery-type approach they are taking in the care of their psyches. In fact they are playing Russian roulette with their souls.
3. The Original Prohibition
“Dual relationship” refers to any situation where multiple roles exist between a therapist and a client. Besides having sex with a client, other examples of dual relationships are, engaging in therapy with a student, friend, or business associate.
The original prohibition on dual relationships in therapy emerged from two sources. Professional, federal, and state regulatory agencies developed the prohibition in an attempt to prevent therapists from exploiting and harming clients. Traditional psychoanalysis developed such prohibition for theoretical-analytic and clinical-transferential reasons.
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 helping professionals, especially psychotherapists, can easily exploit their clients by using their positions of power for personal gain. Hence, the effort to curtail exploitation and to protect consumers from harm is indeed essential.
4. Going Too Far in the Right Direction: The Demonization of Dual Relationship
Professional organizations, consumer protection agencies, and legislators use the therapist-client sexual prohibition and the concern with exploitation as the basis for all their protective policies and guidelines. The original intent of the regulatory agencies to protect the welfare of clients by putting forth a straightforward ban on sexual relationships between therapists and clients (Ebert, 1997) has become a massively broad prohibition of all dual relationships. As a result, the absolute avoidance of dual relationships is raised as a magical amulet against any and all possible harm to patients involved in therapeutic treatment. Consequently, the term “dual relationship” has been used interchangeably in the professional literature with “exploitation,” “harm,” “abuse,” “damage,” and “sexual abuse.”
As we are repeatedly reminded, the primary rationale for the avoid-all-dual-relationships argument is that therapists may misuse their power, and influence and exploit clients for their own benefit and to the clients’ detriment. A Power issue is certainly a valid concern. But is it reasonable to view the dual relationship as the sole source of exploitative interaction? Such unilateral responsibility can only be bestowed through a belief in the domino theory or snowball effect of dual relationships; one thing inevitably leads to another. An initially innocent hug will inevitably progress to sexual intercourse and a gift will inevitably lead to a business relationship.
Kenneth Pope, a leading expert in ethical matters, makes a claim that has become a strict standard of therapeutic ethics and law: “ . . . non-sexual dual relationships, while not unethical and harmful per se, foster sexual dual relationships” (1990, p. 688). Simon (1991) agrees that “The boundary violation precursors of therapist-patient sex can be as psychologically damaging as the actual sexual involvement itself” (p. 614). These chilling words epitomize the notion that by avoiding any semblance of dual relationships we necessarily avoid all forms of exploitation and harm.
To assert that self disclosure, a hug, a home visit, or accepting a gift is likely to lead to sex is like saying doctors’ visits cause death because most people see a doctor before they die. One of the few master therapists who brings refreshing critical thinking to the field of ethics is Dr. Arnold Lazarus, the founder of Multimodal therapy who calls this thinking “an extreme form of syllogistic reasoning.” (1994, p. 257). Sequential statistical relationships, as my undergraduate research professor emphasized, cannot simply be translated to causal ones.
5. When fear overrides clinical judgment
The tyrannical fear of lawsuits, combined with nineteenth century analytical dogma and many hyper-vigilant regulatory and consumer protection agencies, has created much dread and trepidation for therapists. As a result, courses and publications on risk management have become big business. “Risk Management” may sound like practical advice, but often, it is a misnomer for a practice where fear and attorneys determine the course of therapy.
6. If Dual Relationships aren’t Unethical, why isn’t the Prohibition Dead?
Due to the concern of rural and military therapists that dual relationships are unavoidable in such small and interwoven communities, most professional associations, among them the American Psychological Association (APA) have revised their ethical guidelines regarding dual relationships. Discarding the traditional strict prohibition on dual relationships.
The revised APA Ethical Guidelines of 1992, in section 1.17 is simply states:
In many communities and situations, it may not be feasible or reasonable for psychologists to avoid social or other nonprofessional contacts with persons such as patients . . .A psychologist refrains from entering into or promising another personal, scientific, professional, financial, or other relationship with such persons if it appears likely that such a relationship reasonably might impair the psychologist’s objectivity or otherwise interfere with the psychologist’s effectively performing his or her functions as a psychologist, or might harm or exploit the other party.
To most readers it will come as a surprise that the 1992 Revised Ethics Code does not consider dual relationships unethical. However, the changes in ethics codes have not put a dent in the professional and public opinions regarding the evils of dual relationship. Even today, this erroneous prohibition is assumed and implemented by most professional organizations, licensing boards, ethical committees and the courts.
Even the more relaxed 1992 version has been challenged for it’s constitutionality, surprisingly, by Ebert (1997), a psychologist, attorney and former Chairman of the California Board of Psychology. He challenges the constitutionality of the prohibition due to the vagueness and the excessive breadth of the prohibition and how it may violate the constitutional right for privacy and association.
7. On being the flasher in Alaska
Flying with a client who has a fear of flying is a mandated exposure-intervention to the behavioral therapist, but is a boundary violation to the psychoanalyst and most ethicists. Seeing a wife and husband in joint and individual therapy simultaneously can be part of well-articulated systems based therapy, but constitutes a severe boundary crossing to the psychodynamic therapist. A walk on a trail might be part of a strategically planned intervention for the humanistically based therapist, but a transgression to the interpersonal practitioner.
Staying in the office regardless of the presented problem may seem right to analysts, ethicists or attorneys, but may not help those who suffer from agoraphobia, social phobia or fear of flying. They require leaving the office and going to open places, mixing with the crowd, or getting on an airplane. Practicing risk management by staying in the office cold, aloof and detached is like the story about the flasher in Alaska where it is too cold to flash, so he just describes it. It neither works for the flasher nor for our clients.
8. In Praise of dual relationships
Familiarity and Therapy: Unlike the common myth that familiarity is an obstacle to therapy I have found it to be extremely helpful. Relying on a neurotic or psychotic clients’ distorted reports is futile and a set up for failure. Also, clients’ familiarity with my spiritual beliefs and personal ethics help them trust me more readily and realistically. Familiarity often shortens the length of therapy and increases it’s effectiveness.
Transference and Dual Relationships: There is an unsubstantiated myth that familiarity and dual relationships interfere with the transference analysis. Transference occurs anywhere and anytime not only when facing a “blank wall.” Whether or not I know the people or they know me outside of therapy, transference and counter-transference take place and if the clinician is so inclined the analysis can take place.
Isolation, Power, Duality and Exploitation: While privacy is often an important component in increasing psychotherapeutic effectiveness, it can also be a double-edged sword when it is used as an excuse for isolation. The privacy-secrecy argument also has been used to justify many therapists’ attempts to hide, assert power inappropriately or exploit. Sexual exploitation is less likely to occur if the therapist is also working with the spouse of a client, or has an outside connection to the family, perhaps through church. In other words, sexual and other forms of exploitation are less likely to occur in therapy if dual relationships exist. Similarly, isolating clients in therapy gives the therapist undue power and an easier opportunity to exploit clients.
Isolation and the “Resistance” Excuse: In the isolation of the office without dual relationships, therapists can easily blame the clients for their own ineffectiveness by using the famous “resistance” charge. The prohibition of dual relationships enables incompetent therapists to be unaccountable for long periods of time while they charge, exploit and harm clients by continuing therapy even when clients do not get better. So, we not only falsely charge them for services rendered, but, far more detrimental, we give them the sense that they are permanently and hopelessly damaged.
Exploiting Therapists Will Exploit: The problem of exploitation and harm lies not within the dual relationship, but in the therapist’s propensity to exploit and harm. Therapists who tend to exploit will exploit clients with or without dual relationships. The Ethics Code must ban harm and exploitation not dual relationships.
Dual Relationships in a Healthy Society: In a healthy society, unlike our modern culture, people celebrate their reliance on each other. The more multiple the relationships, the richer and more profound the individual and cultural experience. The witch doctor, the wise elder, and the practical neighbor all contribute advice, guidance and physical and spiritual support. In ministering to the needs of the members of the community, therefore, the healers, rabbis, priests, or therapists don’t shun dual relationships, but rather rely on them for the insight and intimate knowledge that such relationships provide.
On Power Differential: One must remember that neither dual relationships nor any relationship with a differential of power (i.e., parent-child, teacher-student) are inherently exploitative. While unpleasant to contemplate, it is altogether possible that many therapists cling to the false ideals of the segregated therapy session because it increases their professional status, imbuing them with undue power, which can all too easily be translated into exploitation.
Dual Relationships are Normal and Complex: More than half of America’s businesses are family run, in which people experience the complexities of dual relationships, balancing blood and money. Similarly, working professionally with people I know outside of the office adds richness and unavoidable complexities to our lives.
9. Conclusion:
The ban and demonization of dual relationships has come from an attempt to protect the public from exploiting therapists. Regretfully, it has emerged as a simplistic solution to a wide and complex problem. Even worse, the ban on dual relationships and the isolation it imposes on the therapeutic encounter tends to increase the chance of exploitation and decrease the effectiveness of treatment. It enables incompetent therapists, to wield their power without witnesses and accountability. In addition it buys into the general cultural trend towards isolation and disconnection. We have been frightened into accepting the ban, but now it is time to think critically, be courageous and dare to be known by our clients. If we dare to cultivate multiple, non-sexual and non- exploitive relationships with our clients when appropriate, we can be better, more effective therapists.
References
American Psychological Association. (1992). Ethical principles for psychologists. Washington, D.C.: American Psychological Association.
Ebert, W. B. (1977). Dual-relationship prohibition: A concept whose time never should have come. Applied & Prevention Psychology, 6: 137-156.
Lazarus, A. A. (1994). How certain boundaries and ethics diminish therapeutic effectiveness. Ethics & Behavior, 4, 255-261.
Pope, K. S. (1990). Therapist-patient sexual contact: Clinical, legal, and ethical implications. In E .A. Margenau, The encyclopedia handbook of private practice. pp. 687-696. New York: Gardner Press, Inc.
Simon, R. I. (1991). Psychological injury caused by boundary violation precursors to therapist-patient sex, Psychiatric Annals, 21, 614-619
Tomm, K. (1993). The ethics of dual relationships. The California Therapists, Jan./Feb., 7-19.
Zur, O. (1994). Psychotherapists and their families: The effect of clinical practice on individual and family dynamics. Psychotherapy in Private Practice 13, 69-75.
Zur, O. (1999). The demonization of dual relationships. Independent Thinking Review, Critical Thinking About Psychology Series, monograph #2 (26 pages). Oakland, CA: Published by Resources for Independent Thinking (RIT).
Extensive Bibliography on Dual & Multiple Relationships in Psychotherapy and Counseling