By Ofer Zur, Ph.D.
Following are annotated direct quotes from various professional associations’ codes of ethics in regard to dual or multiple relationships. Each quote is not only annotated, but also critiqued for its validity and usefulness, as well as how realistic and update to date it is.
Table Of Contents
1. American Association of Christian Counselors (AACC)
2. American Association of Marriage and Family Therapists (AAMFT)
3. American Board of Examiners in Clinical Social Work (ABE)
4. American Counseling Association (ACA)
5. American Mental Health Counselors Association (AMHCA)
6. American Psychological Association (APA)
7. Association of State And Provincial Psychology Boards (ASPPB)
8. Australian Ethics Codes for Psychologists, Social Workers
9. California Association of Marriage and Family Therapists (CAMFT)
10. Canadian Counselling and Psychotherapy Association (CCPA)
11. Canadian Psychological Association (CPA)
12. Center for Clinical Social Work (CCSW)
13. National Association for Addiction Professionals (NAADAC)
14. National Association of Social Workers (NASW)
15. National Board for Certified Counselors (NBCC)
The codes of ethics of psychotherapists’ professional associations have evolved through the years to suit the increasing awareness and knowledge of the field in regard to dual relationships and other relevant issues. Most codes during the mid-twentieth century and ensuing decades (i.e., APA, 1953) concentrated on the general points of promoting client welfare and discouraging abuse of power by therapists. The concerns with therapeutic boundaries came to the forefront of the field after Gestalt therapy, with Frederick Perls at the helm, became enormously popular during the sexual revolution of the 1960s. In response to the sexually and other permissive attitudes of the 1960s and 1970s, there was pressure on psychology and counseling to articulate and provide more specific guidelines regarding therapists’ conduct vis-á-vis their clients. As a result, consumer protection agencies, licensing boards, and legislators joined ethicists and psychotherapists in establishing clear restrictions with regard to therapist-client sexual dual relationships. Therapists were instructed not only to resolutely avoid sexual relationships but also to make every effort to avoid any kind of boundary crossing and dual relationship because, as the (unfounded) myth went, it starts them on the slippery slope towards sexual dual relationships and harm.
The increasingly litigious culture of the 1980s and thereafter as well as the increased focus on risk management in medicine, led to more spoken and unspoken injunctions against any deviation from hands-off, only-in-the-office, “no self-disclosure” therapy. Dual relationships, like bartering, gifts, nonsexual touch, and dual were generally viewed as hazards from a risk management standpoint and the first step in the slippery slope towards sexual relationships. The early 1990s witnessed a growing acknowledgment that nonsexual dual relationships were unavoidable under some circumstances, such as in rural areas, small towns, military settings, and among constituents of distinct individual communities, such as churches, the deaf, gay men and lesbians, and other minorities. Partly in response to this growing awareness, several professional associations (i.e., APA, ACA, NASW) revised their codes of ethics, particularly with regard to dual relationships.
A few years into the 21st century we have seen even more profound changes. Many professional associations, such as APA, ACA and ASPPB published codes of ethics that present a non-rigid, flexible and context based approach towards boundaries. As with this document, almost all current major organizations’ codes of ethics clearly acknowledge that sexual relationships with current clients are always unethical, not all (non-sexual) dual relationships are unethical and some dual relationships are not avoidable. Regretfully, there is still a widespread false impression among psychotherapists, ethics committees, “experts,” judges and licensing boards that dual relationships are essentially unethical and harmful.
To circumvent the possibility of contributing to the confusion surrounding the codes of ethics, the next section is composed of exact-direct quotes about dual relationships, lifted verbatim from the codes of ethics of the major professional associations. Because sexual dual relationships with current clients have always been unethical in the codes of ethics of all psychotherapists’ professional associations, the passages that follow contain primarily those principles that directly relate to non-sexual dual relationships.
American Association of Christian Counselors (AACC) Code of Ethics
1-140: Dual and Multiple Relationships: Dual relationships involve the breakdown of proper professional or ministerial boundaries. A dual relationship exists when two or more roles are mixed in a manner that can harm the counseling relationship and/or the therapeutic process. This includes counseling, as well as personal, fraternal, business, financial, or sexual and romantic relationships. Not all dual relationships are necessarily unethical—it is client exploitation that is wrong, not the dual relationship in and of itself. However, it remains the responsibility of the counselor to monitor and evaluate any potential harm to clients.
1-140-a: The Rule of Dual Relationships: While in a counseling relationship, or when counseling relationships become imminent, or for an appropriate time after the termination of counseling, Christian counselors do not engage in dual relationships with clients. Some dual relationships are always avoided—sexual or romantic relations, and counseling close friends, family members, employees, business partners/associates or supervisees. Other dual relationships should be presumed as potentially troublesome and avoided wherever possible.
1-140-b: Proving an Exception to the Rule: Christian counselors have the primary burden of proof for a justified dual relationship by showing: (1) informed consent, including discussion of how the counseling relationship might be harmed as other aspects of the relationship proceed; and (2) lack of harm or exploitation to the client. As a general rule, all close relationships are unethical if they become counselor-client or formal lay helping relationships. Dual relationships may be allowable, requiring justification by the foregoing rule, if the client is an arms-length acquaintance and/or the relationship is not a close one.
1-140-c: Counseling with Family, Friends, and Acquaintances: Christian counselors do not provide counseling to family members or close friends, as dual relationships with other family members, acquaintances, and fraternal, club, association, or group members, are potentially troublesome and best avoided, otherwise requiring justification.
1-140-d: Business and Economic Relations: Christian counselors avoid partnerships, employment relationships, and close business associations with clients. Barter relationships in exchange for rendered therapeutic services should be avoided as potentially troublesome, and require justification; therefore if done, barter should be considered a rare and uncommon occurrence. Unless justified by compelling necessity, customer relationships with clients are normally avoided.
1-140-e: Receiving Gifts: Christian counselors recognize that sometimes and for certain cultures, a gift, when it is given, is a token of respect and a way of showing gratitude to a counselor. Prior to accepting a gift, counselors consider the cultural narrative of the client, the monetary value of the gift, and any therapeutic implications.
1-140-f: Counseling with Fellow Church Members: Christian counselors do not provide counseling to fellow church members with whom they have close personal, business, or shared ministry relations. Dual relationships with any other church members who are clients are potentially troublesome and best avoided, otherwise requiring justification. Pastors and church staff helpers should take all reasonable precautions to limit the adverse impact of any dual relationships.
1-140-g: Termination to Engage in Dual Relations Prohibited: Christian counselors do not terminate counseling for the purpose of engaging in dual relationships of any kind. Some counselors and their former clients may agree that any future counseling will be done by another provider if, after legitimate termination and no identified risks of potential harm to the client, they decide to pursue another form of relationship.
[Dr. Zur’s comments: AACC code provides unusual, confusing, and conflicting messages and definitions of dual relationships. On one hand, it defines dual relationships in a negative way: “Dual relationships involve the breakdown of proper professional or ministerial boundaries. A dual relationship exists when two or more roles are mixed in a manner that can harm the counseling relationship and/or the therapeutic process.” It then contradicts itself saying: “Not all dual relationships are necessarily unethical” and then goes further to add (again correctly): “It is client exploitation that is wrong, not the dual relationship in and of itself.” The contradictions continue when in section 1-140-a the code states: “While in a counseling relationship, or when counseling relationships become imminent, or for an appropriate time after the termination of counseling, Christian counselors do not engage in dual relationships with clients.” But in section 1-140-b it announces: “Christian counselors have the primary burden of proof for a justified dual relationship by showing. . ..”]
American Association of Marriage and Family Therapists (AAMFT) Code of Ethics
Section 1.3, states: Marriage and family therapists are aware of their influential positions with respect to clients, and they avoid exploiting the trust and dependency of such persons. Therapists, therefore, make every effort to avoid conditions and multiple relationships with clients that could impair professional judgment or increase the risk of exploitation. Such relationships include, but are not limited to, business or close personal relationships with a client or the client’s immediate family. When the risk of impairment or exploitation exists due to conditions or multiple roles, therapists document the appropriate precautions taken.
American Board of Examiners in Clinical Social Work (ABE) Ethics Code (2006)
Section 1.5. States:
5. Clinical social workers do not use clients for self-interest, do not socialize with clients in a manner detrimental to treatment, and do not exploit clients or engage in sexual harassment or sexual relationships with supervisees, students, employees, research subjects, or current and former clients. The clinician carries the burden of determining that a relationship is appropriate, not detrimental, and does not violate boundaries of roles.
[Dr. Zur’s comments: Like many other professional organizations, ABE does not seem to recognize that dual relationships can be unavoidable and mandatory is certain setting (i.e., military, corrections) and unavoidable in small communities (i.e., rural, LGBT, church, deaf)]
American Counseling Association (ACA) Code of Ethics and Standards for Practice (2014)
A.1.d. Support Network Involvement
Counselors recognize that support networks hold various meanings in the lives of clients and consider enlisting the support, understanding, and involvement of others (e.g., religious/spiritual/community leaders, family members, friends) as positive resources, when appropriate, with client consent.
A.5.a. Sexual and/or Romantic RelationshipsProhibited
Sexual and/or romantic counselor–client interactions or relationships with current clients, their romantic partners, or their family members are prohibited. This prohibition applies to both in-person and electronic interactions or relationships.
A.5.b. Previous Sexual and/orRomantic Relationships
Counselors are prohibited from engaging in counseling relationships with persons with whom they have had a previous sexual and/or romantic relationship.
A.5.c. Sexual and/or RomanticRelationships With Former Clients
Sexual and/or romantic counselor–client interactions or relationships with former clients, their romantic partners, or their family members are prohibited for a period of 5 years following the last professional contact. This prohibition applies to both in-person and electronic interactions or relationships. Counselors, before engaging in sexual and/or romantic interactions or relationships with former clients, their romantic partners, or their family members, demonstrate forethought and document (in written form) whether the interaction or relationship can be viewed as exploitive in any way and/or whether there is still potential to harm the former client; in cases of potential exploitation and/or harm, the counselor avoids entering into such an interaction or relationship.
A.5.d. Friends or Family Members
Counselors are prohibited from engaging in counseling relationships with friends or family members with whom they have an inability to remain objective.
A.5.e. Personal Virtual Relationships With Current Clients
Counselors are prohibited from engaging in a personal virtual relationship with individuals with whom they have a current counseling relationship (e.g., through social and other media).
A.6. Managing and Maintaining Boundaries and ProfessionalRelationships
A.6.b. Extending CounselingBoundaries
Counselors consider the risks and benefits of extending current counseling relationships beyond conventional parameters. Examples include attending a client’s formal ceremony (e.g., a wedding/commitment ceremony or graduation), purchasing a service or product provided by a client (excepting unrestricted bartering), and visiting a client’s ill family member in the hospital. In extending these boundaries, counselors take appropriate professional precautions such as informed consent, consultation, supervision, and documentation to ensure that judgment is not impaired and no harm occurs.
A.6.c. Documenting Boundary Extensions
If counselors extend boundaries as described in A.6.a. and A.6.b., they must officially document, prior to the interaction (when feasible), the rationale for such an interaction, the potential benefit, and anticipated consequences for the client or former client and other individuals significantly involved with the client or former client. When unintentional harm occurs to the client or former client, or to an individual significantly involved with the client or former client, the counselor must show evidence of an attempt to remedy such harm.
A.6.d. Role Changes in the Professional Relationship
When counselors change a role from the original or most recent contracted relationship, they obtain informed consent from the client and explain the client’s right to refuse services relatedto the change. Examples of role changes include, but are not limited to
- changing from individual to relationship or family counseling,or vice versa;
- changing from an evaluative role to a therapeutic role, or viceversa; and
- changing from a counselor to a mediator role, or vice versa. Clients must be fully informed of any anticipated consequences (e.g., financial, legal, personal, therapeutic) of counselor role changes.
A.6.e. Nonprofessional Interactions or Relationships (Other Than Sexual or Romantic Interactions or Relationships)
Counselors avoid entering into nonprofessional relationships with former clients, their romantic partners, or their family members when the interaction is potentially harmful to the client. This applies to both in-person and electronic interactions or relationships.
[Dr. Zur’s comments: In contrast to most codes of ethics ACA latest 2014 Ethical Standard A.6.b. (Extending Counseling Boundaries) does not refer to the term “multiple relationships” at all. Instead, the ACA uses the term “boundary extensions”. This term replaces the 2005 more permissive term “potentially beneficial interactions” that was used in an earlier edition of its ethics code. Implicit in these terms is the assumption that boundary extensions may be a part of counseling. The code includes examples, such as “attending a client’s formal ceremony (e.g., a wedding/commitment ceremony or graduation), purchasing a service or product provided by a client (excepting unrestricted bartering), and visiting a client’s ill family member in the hospital”. Such interactions, correctly noted by the code, are not inherently unethical, but rather are described as ethically justifiable extensions of the counseling relationship beyond its traditional boundaries.
Section A.5.e. Personal Virtual Relationships With Current Clients, which states that “Counselors are prohibited from engaging in a personal virtual relationship with individuals with whom they have a current counseling relationship (e.g., through social and other media).” is extremely vague and unclear in terms of what constitutes “personal virtual relationships” in the digital age. This section seems to be written by ‘uniformed digital immigrants‘ rather than by ‘informed digital natives.’ While the code seems to acknowledge that extending boundaries may be beneficial, it also mandates that counselors who are involved in such boundary crossing “ensure that judgment is not impaired and no harm occurs.” Obviously, counselors cannot ‘ensure’ that no harm occurs; they can only avoid boundary crossings that “could reasonably be expected to impair” (to use APA terminology) the counselors “objectivity, competence, or effectiveness.” Later on in the text the code does state correctly “When unintentional harm occurs” acknowledging that counselors cannot ‘ensure,’ but only do their best or do what is reasonable.
The Bartering section is highly appropriate as it acknowledges that bartering, especially within certain cultures, is ethical and appropriate.
For unclear reasons, the code states that sexual or romantic relationships with former clients are prohibited for a period of 5 years following the last professional contact, unlike the codes of APA and CAMFT, which have only 2 years of ‘cooling period’.]
American Mental Health Counselors Association (AMHCA) Codes of Ethics (2015)
Section 3. Dual/multiple Relationships
Mental health counselors are aware of their influential position with respect to their clients and avoid exploiting the trust and fostering dependency of the client.
a) Mental health counselors make every effort to avoid dual/multiple relationships with clients that could impair professional judgment or increase the risk of harm. Examples of such relationships may include, but are not limited to: familial, social, financial, business, or close personal relationships with the clients.
b) When deciding whether to enter a dual/multiple relationship with a client, former client or close relationship to the client, mental health counselors will seek consultation and adhere to a credible decision-making process prior to entering this relationship.
c) When a dual/multiple relationship cannot be avoided, mental health counselors take appropriate professional precautions such as informed consent, consultation, supervision and documentation to ensure that judgment is not impaired and no exploitation has occurred.
d) Mental health counselors do not accept as clients, individuals with whom they are involved in an administrative, supervisory or other relationship of an evaluative nature.
Section 4. Exploitive Relationships
Mental health counselors are aware of the intimacy and responsibilities inherent in the counseling relationship. They maintain respect for the client and avoid actions that seek to meet their personal needs at the expense of the client.
a) Romantic or sexual relationships with clients are strictly prohibited. Mental health counselors do not counsel persons with whom they have had a previous sexual relationship.
b) Mental health counselors are strongly discouraged from engaging in romantic or sexual relationships with former clients. Counselors may not enter into an intimate relationship until five years post termination or longer as specified by state regulations. Documentation of supervision or consultation for exploring the risk of exploitation is strongly encouraged.
c) Determining the risk of exploitive relationships includes but is not limited to factors such as duration of counseling, amount of time since counseling, termination circumstances, the client’s personal history and mental status, and the potential adverse impact on the former client.
d) Mental health counselors are aware of their own values, attitudes, beliefs and behaviors, as well as how these apply in a society with clients from diverse ethnic, social, cultural, religious, and economic backgrounds.
[Dr. Zur’s comments: The 2015 code is similar to the 2000 and 2010 codes and is generally reasonable as it acknowledges that some dual relationships cannot be avoided. It is odd that the code mandates that “. . . mental health counselors will seek consultation . . .” rather than leaving it to the practitioners to determine what is the best ethical decision making to follow. The 2015 code also imposes no sex with former clients for 5 years after termination, which is much longer than the APA’s 2 years. 5 years seem excessive if therapy lasted one, two or very few sessions.]
American Psychological Association (APA) [Section 3.05] Ethical Principles of Psychologists and Code of Conduct (2016)
3.05 Multiple Relationships
(a) A multiple relationship occurs when a psychologist is in a professional role with a person and (1) at the same time is in another role with the same person, (2) at the same time is in a relationship with a person closely associated with or related to the person with whom the psychologist has the professional relationship, or (3) promises to enter into another relationship in the future with the person or a person closely associated with or related to the person.
A psychologist refrains from entering into a multiple relationship if the multiple relationship could reasonably be expected to impair the psychologist’s objectivity, competence, or effectiveness in performing his or her functions as a psychologist, or otherwise risks exploitation or harm to the person with whom the professional relationship exists.
Multiple relationships that would not reasonably be expected to cause impairment or risk exploitation or harm are not unethical.
(b) If a psychologist finds that, due to unforeseen factors, a potentially harmful multiple relationship has arisen, the psychologist takes reasonable steps to resolve it with due regard for the best interests of the affected person and maximal compliance with the Ethics Code.
(c) When psychologists are required by law, institutional policy, or extraordinary circumstances to serve in more than one role in judicial or administrative proceedings, at the outset they clarify role expectations and the extent of confidentiality and thereafter as changes occur.
[Dr. Zur’s comments: The 2016 version of the APA code includes, like the former codes, the clear statement “Multiple relationships that would not reasonably be expected to cause impairment or risk exploitation or harm are not unethical.” Additionally, it is important to note that the code, like the former code, does not consider sequential, non-sexual dual relationships as dual relationships. This seems to mean that activities by therapists who become friends or start business relationships after termination of therapeutic relationships, as long as there was no promise of such relationships, are not covered by the code of ethics. This has significant ramifications as it counters the claim by many psychoanalytic and other scholars, risk management experts and attorneys who focus on the supposedly lasting impact of transference beyond the termination date. Like prior codes, the 2016 code acknowledges that there are settings where multiple relationships are not avoidable in some settings. This is often true for settings such as the military, prison or jails, educational institutions, rural areas, etc.
The Association of State and Provincial Psychology Boards (ASPPB) Code of Conduct (2018)
RULES OF CONDUCT. B. Multiple Relationships
- Definition of multiple relationships. Psychologists recognize that multiple relationships may occur because of the psychologist’s present or previous familial, social, emotional, financial, supervisory, political, administrative or legal relationship with the client or a relevant person associated with or related to the client. Psychologists take reasonable steps to ensure that if such a multiple relationship occurs, it is not exploitative of the client or a relevant person associated with or related to the client.
- Prohibited Multiple Relationships.
- A multiple relationship that is exploitative of the client or a relevant person associated with or related to the client is prohibited.
- Psychologists take all reasonable steps to ensure that any multiple relationships do not impair the psychologist’s professional judgment or objectivity or result in a conflict of interest with the client or a relevant person associated with or related to the client.
- Multiple relationships that would not reasonably be expected to impair a psychologist’s judgment or objectivity or risk harm to the client or relevant person associated with or related to the client are not expressly prohibited.
[Dr. Zur’s comments: Using similar language to that of APA and other recently modified codes, ASPPB “recognized’ that multiple relationships “may occur because of the psychologist’s present or previous familial, social, emotional, financial, supervisory, political, administrative or legal relationship with the client or a relevant person associated with or related to the client.” Appropriately, it qualifies that “Multiple relationships that would not reasonably be expected to impair a psychologist’s judgment or objectivity or risk harm to the client or relevant person associated with or related to the client are not expressly prohibited.”]
Australian Ethics Codes for Psychologists, Social Workers
The Australian Psychological Society (APS) Code of Ethics (2007), Principle B.7.b states: Psychologists who use interpreters take reasonable steps to ensure that the interpreter is not in a multiple relationship with the client that may impair the interpreter’s judgement. Principle C.3.1 states: Psychologists refrain from engaging in multiple relationships that may: (a) impair their competence, effectiveness, objectivity, or ability to render a psychological service; (b) harm clients or other parties to a psychological service; or (c) lead to the exploitation of clients or other parties to a psychological service. Principle C.3.3 states: When entering into a multiple relationship is unavoidable due to over-riding ethical considerations, organisational requirements, or by law, psychologists at the outset of the professional relationship, and thereafter when it is reasonably necessary, adhere to the provisions of standard A.3. (Informed consent).
Australian Association of Social Workers (AASW) Code of Ethics (2002) section 4.1.4 g. states: recognising that conflicts of interest can arise from engaging in dual or multiple relationships with clients, former clients, research participants, students, supervisees or colleagues, social workers will set and enforce explicit, appropriate professional boundaries to minimise the risk of conflict, exploitation or harm.
Australian Institute of Welfare and Community Workers (AIWCW) Code of Ethics (1999) does not mention specific prohibition of dual or multiple relationships. It simply outlines the general principles that appear in all other codes, of the mandate to treat clients with respect.
Psychotherapy and Counselling Federation of Australia (PACFA) Ethical Guidelines section on Exploitation states:
– Counsellors must not exploit clients, past or present, in financial, sexual, emotional or any other way.
– Counsellors should consider that the deeper the involvement with the client’s emotional life during Counselling, the less likely is the possibility of a subsequent equal relationship following termination of therapy. Counsellors must seek professional supervision should any attempt to build a relationship with a former client be considered.
[Dr. Zur’s comments: All the above four Australian professional associations’ codes of ethics provide the general mandate that therapists must avoid exploitation, sexually and otherwise and treat clients with respect and dignity.]
California Association of Marriage and Family Therapists (CAMFT)
Ethical Standards for Marriage and Family Therapists (2011)
Section 1.2 states:
DUAL RELATIONSHIPS-DEFINITION: Marriage and family therapists are aware of their influential position with respect to patients, and they avoid exploiting the trust and dependency of such persons. Marriage and family therapists therefore avoid dual relationships with patients that are reasonably likely to impair professional judgment or lead to exploitation. A dual relationship occurs when a therapist and his/her patient engage in a separate and distinct relationship either simultaneously with the therapeutic relationship, or during a reasonable period of time following the termination of the therapeutic relationship. Not all dual relationships are unethical, and some dual relationships cannot be avoided. When a concurrent or subsequent dual relationship occurs, marriage and family therapists take appropriate professional precautions to ensure that judgment is not impaired and that no exploitation occurs.
1.2.1 UNETHICAL DUAL RELATIONSHIPS: Other acts that would result in unethical dual relationships include, but are not limited to, borrowing money from a patient, hiring a patient, engaging in a business venture with a patient, or engaging in a close personal relationship with a patient. Such acts with a patient’s spouse, partner or family member may also be considered unethical dual relationships.
1.2.2 SEXUAL CONTACT: Sexual intercourse, sexual contact or sexual intimacy with a patient, or a patient’s spouse or partner, or a patient’s immediate family member, during the therapeutic relationship, or during the two years following the termination of the therapeutic relationship, is unethical. Should a marriage and family therapist engage in sexual intimacy with a former patient or a patient’s spouse or partner, or a patient’s immediate family member, following the two years after termination or last professional contact, the therapist shall consider the potential harm to or exploitation of the former patient or to the patient’s family.
1.2.3 PRIOR SEXUAL RELATIONSHIP: A marriage and family therapist does not enter into a therapeutic relationship with a person with whom he/she has had a sexual relationship or with a partner or the immediate family member of a person with whom he/she has had a sexual relationship.
Section 4.1 adds:
DUAL RELATIONSHIPS: Marriage and family therapists are aware of their influential position with respect to students and supervisees, and they avoid exploiting the trust and dependency of such persons. Marriage and family therapists therefore avoid dual relationships that are reasonably likely to impair professional judgment or lead to exploitation. Provision of therapy to students or supervisees is unethical. Provision of marriage and family therapy supervision to clients is unethical. Sexual intercourse, sexual contact or sexual intimacy and/or harassment of any kind with students or supervisees is unethical. Other acts which could result in unethical dual relationships include, but are not limited to, borrowing money from a supervisee, engaging in a business venture with a supervisee, or engaging in a close personal relationship with a supervisee. Such acts with a supervisee’s spouse, partner or family member may also be considered unethical dual relationships.
Section 6.3 adds:
DUAL RELATIONSHIPS WITH RESEARCH PARTICIPANTS: Researchers respect participants’ freedom to decline participation in or to withdraw from a research study at any time. This obligation requires special thought and consideration when researchers or other members of the research team are in positions of authority or influence over participants. Marriage and family therapists, therefore, make every effort to avoid dual relationships with research participants that could impair professional judgment or increase the risk of exploitation.
Section 8.4 adds:
DUAL ROLES: Marriage and family therapists avoid providing both treatment and evaluations for the same clients or treatment units in legal proceedings such as child custody, visitation, dependency, or guardianship proceedings.
The CAMFT code clearly and appropriately states that “Not all dual relationships are unethical, and some dual relationships cannot be avoided” its injunction against “borrowing money from a patient, hiring a patient, engaging in a business venture with a patient, or engaging in a close personal relationship with a patient” is probably one of the most extreme standards set by any professional organization. It is unrealistic and unreasonable to always avoid business and personal relationships in rural and small communities. It is definitely impossible to avoid “close personal relationships” in the military or on Native American Reservations or in any small, rural or isolated communities. This code may mean that MFTs are not likely to be able to practice effectively in small or isolated communities. Avoiding bartering for services (i.e., “hiring a patient”) may deprive many cash-poor but skill-rich clients from obtaining therapy. The absolute statement that borrowing money is unethical seems to criminalize simple action of a therapists who may borrow a couple of dollars for a bus fair from a client until the next session. To read more about bartering, go to https://www.zurinstitute.com/bartertherapy.html, about rural communities, go to https://www.zurinstitute.com/online/rural14.html and about appropriate dual relationships, see Zur, 2007]
It is interesting to note that at least one code of ethics, that is of CAMFT, is extremely restrictive and equally unrealistic and unreasonable when it comes to small, rural or isolated communities in regard to business ventures between psychotherapists and clients when its states “Other acts that would result in unethical dual relationships include, but are not limited to, borrowing money from a patient, hiring a patient, engaging in a business venture with a patient, or engaging in a close personal relationship with a patient. Such acts with a patient’s spouse, partner or family member may also be considered unethical dual relationships.” (2011, section 1.2.1. Unethical Dual Relationships). Such codes may means that many therapists cannot practice is such small isolated communities and that people is these communities are not likely to have the mental health services they need from MFTs.
Some people have asked me whether or not sequential business dual relationships with (former) clients are permissible under this code. A careful analysis reveals that the opening paragraph, 1.2, defines what dual relationships are, and states that dual relationships can be concurrent (i.e. relationships with current clients) as well as sequential (i.e. relationships with former clients). Then the code states that in contrast to 1.2.1 section which talks only about a ‘patient’ and not about a former patient, paragraph 1.2.2 talks about patients AND former patients. Based on this analysis, it is my understanding that sequential business dual relationships do not fall under “Unethical Dual Relationship” (paragraph 1.2.1) and are permissible as long as they are not “reasonably likely to impair professional judgment or lead to exploitation” as articulated in paragraph 1.2.
Canadian Counselling and Psychotherapy Association (CCPA) Code of Ethics (2007)
Section B, Counseling Relationships, subsection B8, Dual Relationships, states:
Counselors make every effort to avoid dual relationships with clients that could impair professional judgment or increase the risk of harm to clients. Examples of dual relationships include, but are not limited to, familial, social, financial, business, or close personal relationships. When a dual relationship can not be avoided, counselors take appropriate professional precautions such as informed consent, consultation, supervision, and documentation to ensure that judgment is not impaired and no exploitation occurs.
[Dr. Zur’s comments: Like the code of 1999, the 2007 code, appropriately, acknowledges that some “dual relationship cannot be avoided.]
Canadian Psychological Association (CPA) Code of Ethics for Psychologists (2000)
Section III.33, states:
Avoid dual or multiple relationships (e.g. with clients, research participants, employees, supervisees, students, or trainees) and other situations that might present a conflict of interest or that might reduce their ability to be objective and unbiased in their determinations of what might be in the best interests of others (Avoidance of Conflict of Interest Section, para. 3) (Emphasis added).
Section III.34, states:
Manage dual or multiple relationships that are unavoidable due to cultural norms or other circumstances in such a manner that bias, lack of objectivity, and risk of exploitation are minimized. This might include obtaining ongoing supervision or consultation for the duration of the dual or multiple relationship, or involving a third party in obtaining consent (e.g., approaching a client or employee about becoming a research participant). (Avoidance of Conflict of Interest section, para. 4)
Center for Clinical Social Work (CCSW) Ethics Code
Section 1.5. States:
Clinical social workers do not use clients for self-interest, do not socialize with clients in a manner detrimental to treatment, and do not exploit clients or engage in sexual harassment or sexual relationships with supervisees, students, employees, research subjects, or current and former clients. The clinician carries the burden of determining that a relationship is appropriate, not detrimental, and does not violate boundaries of roles.
[Dr. Zur’s comments: Like many other professional organizations, ABE does not seem to recognize that dual relationships can be unavoidable and mandatory is certain setting (i.e., military, corrections) and unavoidable in small communities (i.e., rural, LGBT, church, deaf)]
National Association for Addiction Professionals (NAADAC)
Code of Ethics (2011)
Standard 3: Dual Relationships, states:
The addiction professional understands that the goal of treatment services is to nurture and support the development of a relationship of equals of individuals to ensure protection and fairness of all parties.
Addiction professionals will provide services to clients only in the context of a professional setting. In rural settings and in small communities, dual relationships are evaluated carefully and avoided as much as possible.
- Because a relationship begins with a power differential, the addiction professional will not exploit relationships with current or former clients, current or former supervisees or colleagues for personal gain, including social or business relationships.
- The addiction professional avoids situations that might appear to be or could be interpreted as a conflict of interest. Gifts from clients, other treatment organizations or the providers of materials or services used in the addiction professional’s practice will not be accepted, except when refusal of such gift would cause irreparable harm to the client relationship. Gifts of value over $25 will not be accepted under any circumstances.
- The addiction professional will not engage in professional relationships or commitments that conflict with family members, friends, close associates or others whose welfare might be jeopardized by such a dual relationship.
- The addiction professional will not, under any circumstances, engage in sexual behavior with current or former clients.
- The addiction professional will not accept as clients anyone with whom they have engaged in romantic or sexual relationships.
- The addiction professional makes no request of clients that does not directly pertain to treatment (giving testimonials about the program or participating in interviews with reporters or students).
- The addiction professional recognizes that there are situations in which dual relationships are difficult to avoid. Rural areas, small communities and other situations necessitate discussion of the counseling relationship and take steps to distinguish the counseling relationship from other interactions.
- When the addiction professional works for an agency such as department of corrections, military, an HMO or as an employee of the client’s employer, the obligations to external individuals and organizations are disclosed prior to delivering any services.
- The addiction professional recognizes the challenges resulting from increased role of the criminal justice system in making referrals for addiction treatment. Consequently he/she strives to remove coercive elements of such referrals as quickly as possible to encourage engagement in the treatment and recovery process.
- The addiction professional encourages self-sufficiency among clients in making daily choices related to the recovery process and self care.
- The addiction professional shall avoid any action that might appear to impose on others’ acceptance of their religious/spiritual, political or other personal beliefs while also encouraging and supporting participation in recovery support groups.
[Dr. Zur’s comments: NAADAC statement that therapists cannot have sexual relationships with former clients does not give any time limit. It is absurd to think that if an Alcohol and Drug abuse counselor sees a client for one session and twenty years later meets the ex-client in a party, they cannot have sexual relationships if they choose to.]
The National Association of Social Workers (NASW) Code of Ethics (2017)
1.06 Conflicts of Interest:
(a) Social workers should be alert to and avoid conflicts of interest that interfere with the exercise of professional discretion and impartial judgment. Social workers should inform clients when a real or potential conflict of interest arises and take reasonable steps to resolve the issue in a manner that makes the clients’ interests primary and protects clients’ interests to the greatest extent possible. In some cases, protecting clients’ interests may require termination of the professional relationship with proper referral of the client.
(b) Social workers should not take unfair advantage of any professional relationship or exploit others to further their personal, religious, political, or business interests.
(c) Social workers should not engage in dual or multiple relationships with clients or former clients in which there is a risk of exploitation or potential harm to the client. 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. (Dual or multiple relationships occur when social workers relate to clients in more than one relationship, whether professional, social, or business. Dual or multiple relationships can occur simultaneously or consecutively.)
(d) When social workers provide services to two or more people who have a relationship with each other (for example, couples, family members), social workers should clarify with all parties which individuals will be considered clients and the nature of social workers’ professional obligations to the various individuals who are receiving services. Social workers who anticipate a conflict of interest among the individuals receiving services or who anticipate having to perform in potentially conflicting roles (for example, when a social worker is asked to testify in a child custody dispute or divorce proceedings involving clients) should clarify their role with the parties involved and take appropriate action to minimize any conflict of interest.
(e) Social workers should avoid communication with clients using technology (such as social networking sites, online chat, e-mail, text messages, telephone, and video) for personal or non-work-related purposes.
(f) Social workers should be aware that posting personal information on professional Web sites or other media might cause boundary confusion, inappropriate dual relationships, or harm to clients.
(g) Social workers should be aware that personal affiliations may increase the likelihood that clients may discover the social worker’s presence on Web sites, social media, and other forms of technology. Social workers should be aware that involvement in electronic communication with groups based on race, ethnicity, language, sexual orientation, gender identity or expression, mental or physical ability, religion, immigration status, and other personal affiliations may affect their ability to work effectively with particular clients.
(h) Social workers should avoid accepting requests from or engaging in personal relationships with clients on social networking sites or other electronic media to prevent boundary confusion, inappropriate dual relationships, or harm to clients.
1.09 Sexual Relationships:
(a) Social workers should under no circumstances engage in sexual activities or sexual contact with current clients, whether such contact is consensual or forced.
(b) Social workers should not engage in sexual activities or sexual contact with clients’ relatives or other individuals with whom clients maintain a close personal relationship when there is a risk of exploitation or potential harm to the client. Sexual activity or sexual contact with clients’ relatives or other individuals with whom clients maintain a personal relationship has the potential to be harmful to the client and may make it difficult for the social worker and client to maintain appropriate professional boundaries. Social workers—not their clients, their clients’ relatives, or other individuals with whom the client maintains a personal relationship—assume the full burden for setting clear, appropriate, and culturally sensitive boundaries.
(c) Social workers should not engage in sexual activities or sexual contact with former clients because of the potential for harm to the client. If social workers engage in conduct contrary to this prohibition or claim that an exception to this prohibition is warranted because of extraordinary circumstances, it is social workers—not their clients—who assume the full burden of demonstrating that the former client has not been exploited, coerced, or manipulated, intentionally or unintentionally.
(d) Social workers should not provide clinical services to individuals with whom they have had a prior sexual relationship. Providing clinical services to a former sexual partner has the potential to be harmful to the individual and is likely to make it difficult for the social worker and individual to maintain appropriate professional boundaries.
[Dr. Zur’s comments: The position taken by NASW in section 1.09c is somewhat different than most other major codes of ethics regarding sex with former clients. It neither gives a fixed ‘cool-off’ period of 2 or 5 years nor does it mandate an absolute ban on therapists having sex with former clients. It mentions an undefined term, such as “extraordinary circumstances,” which leaves it open to diverse interpretations. The 2017 code adds restrictions of therapists communicating with clients for personal and non-personal purposes via electronic means. Probably written by a ‘digital immigrant’ and not by ‘digital native’, it puts the bar pretty high (some may argue unrealistically high) when it instructs “Social workers should avoid communication with clients using technology (such as social networking sites, online chat, e-mail, text messages, telephone, and video) for personal or non-work-related purposes.” Along these lines, the code also adds restrictions, such as “Social workers should avoid accepting requests from or engaging in personal relationships with clients on social networking sites or other electronic media to prevent boundary confusion, inappropriate dual relationships, or harm to clients.”
National Board for Certified Counselors (NBCC) Code of Ethics (2016)
5. NCCs shall not engage in harmful multiple relationships with clients. In the event that a harmful multiple relationship develops in an unforeseen manner, the NCC shall discuss the potential effects with the client and shall take reasonable steps to resolve the situation, including the provision of referrals. This discussion shall be documented in the client’s record.
14. NCCs who provide clinical supervision services shall not have multiple relationships with supervisees that may interfere with supervisors’ professional judgment or exploit supervisees. Supervisors shall not supervise relatives.
19. NCCs shall recognize the potential harm of informal uses of social media and other related technology with clients, former clients and their families and personal friends. After carefully considering all of the ethical implications, including confidentiality, privacy and multiple relationships, NCCs shall develop written practice procedures in regard to social media and digital technology, and these shall be incorporated with the information provided to clients before or during the initial session. At a minimum, these social media procedures shall specify that personal accounts will be separate and isolated from any used for professional counseling purposes including those used with prospective or current clients. These procedures shall also address “friending” and responding to material posted.
21. NCCs who use digital technology (e.g., social media) for professional purposes shall limit information posted to that which does not create multiple relationships or which may threaten client confidentiality.
84. NCCs shall carefully consider ethical implications, including confidentiality and multiple relationships, prior to conducting research with students, supervisees or clients. NCCs shall not convey that participation is required or will otherwise negatively affect academic standing, supervision or counseling services.
The Ethics Codes in Solidarity
There are unified principles among the codes of ethics of all major professional organizations concerning dual relationships in psychotherapy. Once the hindering factors of misinformation and prejudice are discarded, the platform of these codes is clear:
- Sexual dual relationships with present clients are always unethical.
- Non-sexual dual relationships are not always avoidable.
- Non-sexual dual relationships are not always unethical.
- Therapists must avoid only the dual relationships that might:
* Impair their judgment and objectivity.
* Interfere with performing therapy or supervision effectively.
* Harm or exploit patients.
Summary
In contrast to the widespread belief that non-sexual dual relationships are inherently unethical, the codes of ethics of all major professional organizations place no ban on non-sexual dual relationships and in fact acknowledge dual relationships as sometimes unavoidable. Instead of supporting the opinion that dual relationships are unethical under any circumstances, the codes dictate that only those relationships likely to impair judgment and objectivity, interfere with the therapeutic work, or harm or exploit patients ought to be avoided.
Understanding the ethics codes is imperative in order to make informed decisions about dual relationships. Blind trust in other practitioners’ interpretations of these codes does not constitute a thorough process of gathering information. Therapists familiar with the ethics codes will realize that non-sexual dual relationships are neither always unethical nor always avoidable, and thus will be better prepared to make choices about dual relationships that attend to the needs of the client. When the propensity to practice based on fear of litigation or licensing boards is set aside and replaced by first-hand knowledge of the ethics codes themselves, dual relationships can be accurately regarded as yet another opportunity to help clients.
Description/Order Book Dual Relationships and Psychotherapy
Guidelines and Online Articles on Dual Relationships
Online Home Study for CE on Dual Relationships
Workshops on Dual Relationships
Ethical-Legal-Expert Witness Consultations