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Boundary and Dual Relationships: Ethical Issues

by Frederic G. Reamer, Ph.D..


6 Credit Hours - $99
Last revised: 06/22/2015

Course content © Copyright 2015 - 2017 by Frederic G. Reamer, Ph.D.. All rights reserved.



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Course Outline

 

Introduction

Learning Objectives

Case Illustrations

A Typology of Boundary Issues and Dual Relationships: A Brief Overview

Intimate Relationships

Personal Benefit

Emotional and Dependency Needs

Altruistic Gestures

Unanticipated Circumstances

A Typology of Boundary Issues: An In-Depth Look

Intimacy Issues

Sexual Relationships with Clients

The Nature of Sexual Misconduct

Causal Factors

Clinical and Professional Consequences

Risk Management Strategy

Rehabilitation Efforts

Emotional and Dependency Needs

Friendships with clients

Unconventional Interventions

Self-disclosure

Affectionate Communications

Community Based Contact with Clients

Personal Benefit

Barter for Services

Business and Financial Relationships

Advice and Services

Favors and Gifts

Conflicts of Interest

Altruism

Giving Gifts to Clients

Meeting Clients in Social or Community Settings

Offering Clients Favors

Accommodating Clients

Self-disclosing to Clients

Unavoidable and Unanticipated Circumstances

Geographic Proximity

Conflicts of Interest

Professional Encounters

Social Encounters

Protecting Clients and Managing Risk

Further Reading

References

 

Introduction

 

I would like to welcome you to this unique opportunity to use distance learning to explore a wide range of challenging issues related to boundaries and dual relationships in behavioral health. There is no question that interest in ethical issues in behavioral health (in the professions of social work, psychology, psychiatry, marriage and family counseling, counseling, pastoral counseling, and psychiatric nursing) – and, more generally, professional ethics – has burgeoned in recent years.

 

I recognize that practitioners enroll in ethics continuing education courses for diverse reasons and with different levels of enthusiasm.  Some practitioners are keenly interested in the subject because of their direct experience with difficult ethical challenges or because of their general fascination with moral dilemmas.  Other practitioners enroll in ethics continuing education classes with some misgivings or reluctance – sometimes fearing that the material will be dry and mundane – and primarily because their state licensing board mandates ethics education.

 

Whatever your reasons for enrolling in this ethics course on boundaries sponsored by BehavioralHealthCE, and whatever your level of enthusiasm, my goal is to present you with engaging material that you find useful.  My hope is that by the end of this experience you have a keener appreciation of the complexity of ethical issues in behavioral health, greater understanding of both the daunting and more routine ethical issues that arise in the field, a solid grasp of helpful resources, and concrete information to help you protect clients and yourselves. Portions of this course content draw on the author’s work found in the following:

 

Frederic G. Reamer, Social Work Ethics Casebook: Cases and Commentary. Washington, DC: NASW Press, 2009

 

Frederic G. Reamer, Social Work Malpractice and Liability: Strategies for Prevention, 2nd ed. (New York: Columbia University Press, 2003)

 

Frederic G. Reamer, Social Work Values and Ethics, 3rd ed. (New York: Columbia University Press, 2006)

 

Frederic G. Reamer, Ethical Standards in Social Work: A Review of the NASW Code of Ethics, 2nd ed.  (Washington, DC: NASW Press, 2006)

 

Frederic G. Reamer, The Social Work Ethics Audit: A Risk-management Tool (Washington, DC: NASW Press, 2001)

 

Frederic G. Reamer, Tangled Relationships: Managing Boundaries in the Human Services (New York: Columbia University Press, 2001)

 

Frederic G. Reamer, Ethics Education in Social Work (Alexandria, VA: Council on Social Work Education, 2001)

 

LEARNING OBJECTIVES

     List 5 major risk areas related to boundaries and dual relationships

 

     Explain the typology of boundary issues

 

     Discuss intimacy issues within the context of boundary violations

 

     Discuss boundary problems related to Emotional and Dependency Needs, Altruism, Personal Benefit, and Unavoidable and Unanticipated Circumstances

 

     Explain a strategy for protecting clients related to boundary issues and dual relationships

 

Some Case Illustrations

 

I would like to begin the course by placing the topics of boundaries and dual relationships in a broader context.  As you may be aware, in recent years human service professionals have been paying a great deal of attention to ethical issues.  Staff development and continuing education programs now routinely address a wide range of complex ethical issues encountered in the profession.  Key examples include issues related to:

 

 

Table 1. Example Ethical Issues

 

 

Confidentiality, privacy, and privileged communication: Under what circumstances are practitioners permitted or required to disclose confidential information, without clients’ consent, to protect third parties?  Do parents have the right to know that their adolescent children are receiving drug or alcohol counseling?  Do parents have the right to see counselors’ case notes concerning their children, even though the children haven’t consented to the disclosure?  Are counselors obligated to share confidential information with law enforcement officials who are investigating a very serious crime involving one’s client?  Do deceased clients have confidentiality rights?

 

Client self-determination:  To what extent do clients have the right to engage in self-harming or self-destructive behavior without interference?  Should practitioners protect clients from themselves (known by ethicists as “paternalism”)?

 

Informed Consent:  How does one handle clients who are illiterate, mentally incompetent, or under the influence at the time a release or consent form needs to be signed?  How much detail does one need to put in the “purpose” section of the consent form for the consent to be truly informed consent?  How long can releases remain in force before being updated?  Is it important to provide clients with verbal explanations, or is a signed form sufficient?

 

Service delivery:  Under what circumstances can practitioners use experimental or “novel” treatment techniques?  What kind of training, education, supervision, consultation, and license should practitioners have?  Are certain treatment approaches considered unethical?

 

Termination of services:  Under what circumstances is it permissible to terminate services to clients who miss appointments or fail to comply with treatment protocols or recommendations?  What steps should counselors take to protect clients and themselves from allegations that they “abandoned” clients?

 

Whistle-blowing:  To what extent do practitioners have an obligation to disclose wrongdoing engaged in by colleagues and their agencies, particularly if doing so could jeopardize the practitioners’ own career?  What criteria should practitioners use when deciding whether or not to blow the whistle on unethical conduct?

 

Impaired practitioners:  To what extent do professionals have an obligation to approach or report a colleague who appears to be impaired as a result of mental health or substance abuse problems?  What ethical standards exist concerning impaired professionals’ obligations to address their own issues?

 

 

The broad field of professional ethics has burgeoned in recent years.  In contrast to the early years in the behavioral health professions, today’s practitioners are introduced to a wide range of ethical issues and ethical decision-making frameworks and protocols.  In addition, ethical standards – primarily in the form of codes of ethics – have evolved and become much more comprehensive, detailed, and substantial.

 

Without question, one of the topics that come up very frequently in my ethics teaching and discussions is that of boundaries and dual relationships.  Over the years I have encountered many cases where there are troubling and, often, complicated boundaries issues.  For this course, I will argue that boundary issues occur when practitioners relate to clients (and clients’ family members, colleagues, and so on) in more than one relationship, whether (1) professional, (2) social, or (3) business.  Such “dual” or “multiple” relationships can occur simultaneously or consecutively. 

 

Let me say at the outset of the course that I do not think that all dual or multiple relationships are unethical.  In my opinion, some are and some are not.  Some boundary issues are straightforward and relatively uncomplicated, and some are extraordinarily complicated and controversial.  For example, there is consensus in the profession that practitioners should not become sexually involved with clients.  Although it is true that a relatively small percentage of practitioners violate this widely held maxim, the concept itself is clear.  Similarly, practitioners generally agree that they should not become business partners with clients, because of the conflict of interest.  Agency supervisors know that they should not become intimately involved with the staff they supervise.  These are examples of “easy” cases.

       

However, in many other instances, I find that behavioral health professionals disagree about boundaries issue and voice different opinions about how to handle the relevant circumstances.  Here are several examples of cases I have encountered where thoughtful, principled, and dedicated professionals have disagreed (all case examples are disguised unless they are a matter of public record):

 

 

Case Examples

 

 

     Althea R., a counselor employed in a community mental health center, provides services to clients with chronic mental illness.  One of her clients, who is being treated for clinical depression, has been abusing alcohol and cocaine.  Althea encouraged the client to begin attending 12-step meetings.  The client decides to attend a local meeting that she chose from a long list of area meetings.  At the meeting the client encountered Althea, who has been in recovery for nearly 15 years.  Althea was shocked to see her client at the meeting and had to decide whether to stay in the meeting and whether to speak at the meeting in front of her client.

 

     Sandra K. was a counselor at a family service agency.  She developed a very good working relationship with a client, Theresa B., who was referred to the agency after Theresa was released from prison on parole.  Theresa deeply appreciated the help she received from Sandra and decided to give Sandra a gift – a bracelet worth about $20.00.  Sandra had to decide whether to keep the gift.  One concern she had was that Theresa would be offended if Sandra returned the gift.  However, Sandra’s agency had a policy that prohibited staff from accepting gifts from clients.

 

     Lance M. was a counselor in private practice.  One of his clients, Daphne F., a very religious woman, asked Lance to please spend time with her reading passages from the Bible.  Lance was not particularly religious but thought it may be therapeutically helpful to Daphne to read the Bible with her.  Lance wasn’t sure whether it would be appropriate for him to study the Bible with Daphne.

 

     Eunice W. was a social worker at an outpatient counseling program for adolescents.  One of Eunice’s clients, Melanie, age 16, struggled with issues of depression and marijuana abuse.  Over time, Eunice and Melanie developed a strong therapeutic alliance.  During one clinical session, Melanie asked Eunice whether she had smoked marijuana as a teenager and whether Eunice had ever gotten “high.”  Eunice was unsure about whether to respond candidly about her own drug use as a teenager.

 

     Malcolm C. was a counselor in a group private practice.  Malcolm provided counseling services to a young man, Justin L., who was struggling with anxiety.  Justin worked hard in treatment and terminated after about seven months.  Malcolm and Justin had an excellent therapeutic relationship.  Nearly four years later Malcolm and Justin encountered each other, entirely by coincidence, at a mutual acquaintance’s holiday party.  Malcolm and Justin thoroughly enjoyed reconnecting.  Malcolm and Justin enjoyed each other’s company so much that they talked about getting together again socially.  A couple of colleagues in Malcolm’s peer consultation group expressed concern about entering into a relationship with a former client.

 

These case examples illustrate some of the complex ethical issues that arise in the behavioral health professions related to boundaries and dual relationships.  Only recently, relatively speaking, have boundary issues become an explicit topic of conversation among human service professionals. 

 

 

Clearly, ethical issues related to professional boundaries are among the most problematic and challenging.  Briefly, boundary issues occur when practitioners establish more than one relationship with clients, whether professional, social, or business.  Boundary issues arise when behavioral health professionals encounter actual or potential conflicts between their professional duties and their social, sexual, religious, or business relationships.  My principal goal in this course is to explore the range of boundary issues and dual relationships, develop criteria to help professionals distinguish boundary issues that are and are not problematic, and present guidelines to help practitioners manage boundary issues and risks that arise in practice.

 

My primary aim in this course is to enhance practitioners’ ability to protect clients from harm that might arise out of problematic dual and multiple relationships.  After all, ethical practitioners should be motivated primarily by their wish to protect clients.  In addition, I would like to share information that can enhance practitioners’ ability to protect themselves from licensing board complaints, ethics complaints, and litigation that alleges that they mishandled a boundaries-related issue. 

 

Behavioral health professionals often encounter circumstances that pose actual or potential boundary issues.  Dual relationships occur primarily between professionals and their current or former clients and, as well, between professionals and their colleagues (including supervisees, trainees, and students). 

 

Historically, human service professionals have not generated clear guidelines regarding many boundary issues encountered in practice.  Understandably, much of the available literature on the subject focuses on dual relationships that are exploitative in nature, such as the sexual involvement of practitioners with clients.  Certainly, these are important and compelling issues.  However, many boundary issues – such as those reflected in the opening examples – are much more subtle than these egregious forms of ethical misconduct.  Research evidence suggests that there is considerable disagreement among practitioners concerning the appropriateness of behaviors such as developing friendships with former clients, attending life-course rituals when invited by clients (such as weddings and graduations), serving on community boards with clients, providing clients with one’s home telephone number, accepting goods and services from clients instead of money, and self disclosing personal information to clients (Jayaratne et al., 1997). 

 

To achieve a more finely tuned understanding of boundary issues, we must broaden our analysis and examine dual relationships through several conceptual lenses.  First, behavioral health practitioners should distinguish between boundary violations and boundary crossings (Gutheil et al., 1993).  A boundary violation occurs when a practitioner engages in a dual relationship with a client or colleague that is exploitative, manipulative, deceptive, or coercive.  Examples include professionals who become sexually involved with current clients, recruit and collude with clients to fraudulently bill insurance companies, or influence terminally ill clients to include their therapist in their will.

 

One key feature of boundary violations is a conflict of interest that harms clients or colleagues.  Conflicts of interest occur when professionals find themselves in a relationship that could prejudice or give the appearance of prejudicing their decision making.  Thus a clinician who provides services to a client with whom he would like to develop a sexual relationship faces a conflict of interest; the professional’s personal interests clash with his professional duty to avoid harming his client.  Similarly, a practitioner who invests money in a client’s business is embedded in a conflict of interest; the professional’s financial interests may clash with her duty to the client (for example, if the professional’s relationship with the client becomes strained because they disagree about some aspect of their shared business venture). 

 

The National Association of Social Workers (NASW) Code of Ethics is an example of a prominent code that explicitly addresses the concept of conflict of interest:

 

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. (standard 1.06[a])

 

The code goes on to say that "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" (standard 1.06[c]). 

 

Some conflicts of interest involve what lawyers call undue influence. Undue influence occurs when a practitioner inappropri­ately pressures or exercises authority over a susceptible client in a manner that benefits the practitioner and may not be in the client's best interest. In legal terminology, undue influence involves the "exertion of improper influence and submission to the domination of the influencing party.... In such a case, the influencing party is said to have an unfair advantage over the other based, among other things, on real or apparent authority, knowledge of necessity or distress, or a fiduciary or confidential relation­ship" (Gifis, 1991).

 

In contrast to boundary violations, a boundary crossing occurs when a professional is involved in a dual relationship with a client or colleague in a manner that is not exploitative, manipulative, deceptive, or coercive.  Boundary crossings are not inherently unethical; they often involve boundary "bending" as opposed to boundary "breaking."  In principle, the consequences of boundary crossings may be harmful, salutary, or neutral.  Boundary crossings are harmful when the dual relationship has negative consequences for the practitioner's client or col­league and, potentially, the practitioner him- or herself.  For example, a pro­fessional who discloses to a client personal, intimate details about her own life, ostensibly to be helpful to the client, ultimately may confuse the client and compromise the client's mental health because of complicated transfer­ence issues produced by the practitioner's self-disclosure.  A psychology or social work educator who accepts a student's dinner invitation may inadvertently harm the student by confusing him about nature of the educator's relationship with the student. 

 

Alternatively, some boundary crossings may be helpful to clients and col­leagues. Some professionals argue that, handled judiciously, a practitioner's modest self-disclosure or decision to accept an invitation to attend a client's graduation ceremony may prove, in some special circumstances, to be ther­apeutically useful to a client.  A practitioner who worships, coincidentally, at the same church, mosque, or synagogue as one of his clients may help the client "normalize" the professional-client relationship.  An educator in the human services who hires a student to serve as a research assistant may boost the student's self-confidence in a way that greatly enriches the student's educational experience. 

 

Yet other boundary crossings produce mixed results. A practitioner's self-disclosure about personal challenges may be both helpful and harmful to the same client-helpful in that the client feels more connected to the practitioner and harmful in that the self-disclosure undermines the client's confidence in the practitioner. The human service administrator who hires a former client initially may elevate the former client's self-confidence, but boundary problems will arise if the employee subsequently wants to resume his status as an active client in order to address some new issues in his life. 

 

Practitioners should also be aware of the conceptual distinction in the terms impropriety and appearance of impropriety.  An impropriety occurs when a practitioner violates a client's boundaries or engages in inappropriate dual relationships in a manner that violates prevailing ethical standards.  Engaging in a sexual relationship with a client and borrowing money from a client are clear examples of impropriety.  In contrast, an appearance of impropriety occurs when a practitioner engages in conduct that appears to be improper but in fact may not be. 

 

Let me illustrate this with a personal example.  A number of years ago, I had a leave of absence from my academic position and served as a senior policy advisor to the governor in my state.  In that position, I helped formulate public policy related to a number of human services issues.  I worked di­rectly with the governor when important issues arose, such as when relevant bills were pending in the state legislature. After several years, I resigned that position to return to my academic duties; shortly thereafter, the governor concluded his term in office.  The new governor then appointed me to the state parole board, which entails conducting hearings for prison inmates eligible for parole.  After I began serving in that position, the former governor – my former employer – was indicted and charged in criminal court with committing offenses while in office (among other issues, this complex case involved financial transactions among the governor, his political campaign staff, and building contractors and other parties who sought state contracts).  The former governor was sub­sequently convicted and sentenced to prison.  When he became eligible for parole and was scheduled to appear before me, I had to decide whether to participate in his hearing or recuse myself.  I knew in my heart that I would be able to render a fair decision; the former governor was not a personal friend and I had no knowledge of the events that led to his criminal court conviction.  However, I also knew that I needed to be sensitive to the appearance of impropriety.  I could not expect the general public to believe that I could be impartial, in light of my relationship with the man when he had been in office.  No matter how certain I was of my ability to be fair and impartial, I had to concede that, at the very least, it would appear that I was involved in an inappropriate dual relationship. Be­cause of the likely appearance of impropriety, I decided to recuse myself.  Thus, although engaging in behaviors that only appear to be improper may not be unethical, human service practitioners should be sensitive to the effect that such appearances may have on their reputation and the integrity of their profession.

A Typology of Boundary Issues and Dual Relationships: A Brief Overview

 

Given the great range of boundary issues in the behavioral health profes­sions, practitioners need a conceptual framework to help them identify and manage dual relationships they encounter.  What follows is a brief overview of a typology I have developed of boundary issues, based on several data sources: in­surance industry statistics summarizing malpractice and negligence claims; empirical surveys of human service professionals about boundary issues; legal literature and court opinions in litigation involving boundaries; and my experience as chair of a statewide ethics adju­dication committee and expert witness in a large number of legal cases throughout the U.S. involving boundary issues.  Following this brief overview I will explore the elements of this typology in greater depth.

 

Boundary issues in the behavioral health professions fall into five conceptual categories: intimate relationships, pursuit of personal benefit, how profes­sionals respond to their own emotional needs, altruistic gestures, and responses to unanticipated circumstances.

 

Intimate Relationships 

 

Many dual relationships in behavioral health involve some form of intimacy. Typically, these relationships entail a sexual relationship or physi­cal contact, although they may also entail other, more subtle, intimate gestures, such as gift giving, friendship, and affectionate communication.

 

Sexual relationships.  A distressingly significant portion of intimate dual relationships involves sexual contact.  Although behavioral health professionals agree that sexual relationships with current clients are inappropriate, they are not so unanimous regarding sexual relationships with former clients.

 

Professionals must also be aware of other potentially prob­lematic sexual relationships that may involve a client indirectly.  For example, current ethical standards in most human service professions prohibit sexual relationships between practitioners and a client's relatives or other individ­uals with whom a client maintains a close personal relationship.  Typical is the NASW Code of Ethics standard on this issue: 

 

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. (standard 1.09[b])

 

Other potentially problematic sexual relationships can occur between educators, supervisors, or trainers in the human service professions and their students, supervisees, or trainees.

 

Physical contact.  Not all physical contact between a practitioner and a client is sexual in nature. Physical contact in a number of circumstances may be asexual and appropriate – for example, a brief hug at the termination of long-term treatment or placing an arm around a client in a residential program who just received bad family news and is distraught.  Such brief, limited physical contact may not be harmful; many clients would find such physical contact comforting and therapeutic, although other clients may be upset by it (perhaps because of their personal trauma history or their cultural or ethnic norms related to touching). 

 

Some forms of physical contact have greater potential for psychological harm. In these circumstances, physical touch may exacerbate a client's trans­ference in destructive ways and may suggest that the practitioner is interested in more than a professional relationship.  For example, a clinician provided counseling to a twenty-eight-year-old woman who had been sexually abused as a child.  As an adult, the client sought counseling to help her understand the effects of the early victimization, especially pertaining to her intimate relationships.  As part of the therapy the practitioner, aiming to comfort the client, would occasionally dim the office lights, turn on soft music, and sit on the floor while cradling and talking with the client.  The client was thus retraumatized because this physical contact with the clinician exacerbated the client's confusion about intimacy and boundaries with important people in her life. 

 

The NASW Code of Ethics includes a standard pertaining specif­ically to the concept of physical touch: "Social workers should not engage in physical contact with clients when there is a possibility of psychological harm to the client as a result of the contact (such as cradling or caressing clients). Social workers who engage in appropriate physical contact with clients are responsible for setting clear, appropriate, and culturally sensitive boundaries that govern such physical contact" (standard 1.09[d]). 

 

Counseling a former lover.  Providing clinical services to someone with whom a practitioner was once intimately, romantically, or sexually involved also constitutes a dual relationship.  The relationship history is likely to make it difficult for the practitioner and the client to interact with each other solely as professional and client; inevitably, the dynamics of the prior rela­tionship will influence the professional-client relationship – how the parties view and respond to each other – perhaps in ways that are detrimental to the client's best interests. 

 

Intimate gestures. Boundary issues can also emerge when practitioners and clients engage in other intimate gestures, such as gift giving and ex­pressions of friendship (including sending affectionate notes, for example, on the practitioner's personal stationery).  It is not unusual for a client to give a clinician or case manager a modest gift.  Certainly, in many instances a client's gift represents nothing more than an appreciative gesture. In some instances, however, a client's gift may carry great meaning. For example, the gift may reflect the client's fantasies about a friendship or more intimate relationship with the practitioner.  Thus it behooves the professional to care­fully consider the meaning of a client's gift and establish prudent guidelines governing the acceptance of gifts.  Many social service agencies do not permit staff members to accept gifts because of the potential conflict of interest or appearance of impropriety, or they permit gifts of only modest value.  Some agencies permit staff to accept gifts only with the understanding – which is conveyed to clients – that the gifts represent a contribution to the agency, not to the individual professional. 

 

The human service professions agree that friendships with current clients constitute inappropriate dual relationships.  There is less clarity, however, about friendships between professionals and former clients.  Although pro­fessionals generally understand the risk involved in befriending a former client – the possibility of confused boundaries – some professionals argue that friendships with former clients are not inherently unethical and reflect a more egalitarian, nonhierarchical approach to practice. These profession­als typically claim that emotionally mature practitioners and former clients are quite capable of entering into new kinds of relationships after termina­tion of the professional-client relationship and that such new relationships often are, in fact, evidence of the former client's substantial therapeutic progress.  Later I will explore this complex debate more thoroughly.

 

Personal Benefit 

 

Beyond these various manifestations of intimacy, behavioral health profes­sionals can become involved in dual relationships that produce other forms of personal benefit, including monetary gain, goods, services, or useful in­formation. 

 

Monetary gain. In some situations, a practitioner stands to benefit financially as a result of a dual relationship.  In one case, a counselor's former client decided to change careers and become a therapist.  After completing graduate school, the client contacted her former therapist and asked to become the former therapist's supervisee (supervision was re­quired for a state license).  The counselor was tempted to take on the supervision for a fee, in part because he enjoyed their relationship and in part because of the financial benefit.  But the counselor also recognized that the shift from the counselor-client relationship to a collegial relationship would introduce a number of boundary issues. 

 

In another case, a client named a counselor in his will.  After the client's death and probate of the will, the client's family accused the counselor of undue influence (the family alleged that the counselor had encouraged the client to bequeath a portion of the estate to the counselor). 

 

Goods and services.  On occasion, human service professionals receive goods or services, rather than money, as payment for their professional services.  This occurs especially in some rural communities, where barter is a commonly accepted form of payment.  In one case, a rural practitioner's client lost his mental health insurance coverage yet still needed counseling services.  The client, a house painter, offered to paint the counselor's home in exchange for clinical services.  The counselor decided not to enter into the barter arrangement; after consulting with colleagues, she realized that the client's interests could be undermined should some problem emerge with the paint job that would require some remedy or negotiation (for ex­ample, if the paint job proved to be inferior in some way).  In another case, a social worker received several paintings from a client, an artist, as pay­ment for services rendered.  This social worker reasoned that accepting goods of this sort was not likely to undermine the clinical relationship, whereas accepting a service might. 

 

The NASW Code of Ethics is an example of a prominent code that includes a specific standard on barter. The NASW Code of Ethics Revision Committee, which I chaired, struggled to decide whether to prohibit or merely discourage all forms of barter.  On the one hand, bartering entails potential conflicts of interest; on the other hand, bartering is an accepted practice in some communities.  Ultimately, the committee decided to strongly discourage barter because of the risks involved while recognizing that barter is not inherently uneth­ical.  Further, the code establishes strict standards for the use of barter by social workers:

 

Social workers should avoid accepting goods or services from clients as payment for professional services. Bartering arrangements, particu­larly involving services, create the potential for conflicts of interest, exploitation, and inappropriate boundaries in social workers' relation­ships with clients. Social workers should explore and may participate in bartering only in very limited circumstances when it can be dem­onstrated that such arrangements are an accepted practice among pro­fessionals in the local community, considered to be essential for the provision of services, negotiated without coercion, and entered into at the client's initiative and with the client's informed consent. Social workers who accept goods or services from clients as payment for pro­fessional services assume the full burden of demonstrating that this arrangement will not be detrimental to the client or the professional relationship. (standard 1.13[b]; emphasis added) 

 

The American Counseling Association (ACA) ethics code (standard A.10.d) and the American Association for Marriage and Family Therapy ethics code (standard 7.5) include somewhat similar standards. 

 

Useful information.  A behavioral health professional occasionally has an opportunity to benefit from a client's unique knowledge.  A counselor with a complex health problem may be tempted to consult her client who is a physician and who happens to specialize in the area relevant to the coun­selor's chronic illness.  A psychologist who is interested in adopting a child, and whose client is an obstetrics and gynecology nurse who works is a teen pregnancy clinic, may be tempted to talk to his client about adoption opportunities through the client's clinic.  An agency administrator who is an active stock-market investor may be tempted to consult a client who happens to be a stockbroker.  A social worker with automobile problems may be tempted to consult a client who happens to be a mechanic. These situations entail the clear potential for an inappropriate dual relationship because the professional uses a portion of the client's therapeutic hour for the practitioner's own purposes, and the practitioner's judgment and services may be shaped and influenced by access to a client's specialized knowledge.  The client's transference also may be adversely affected.  Conversely, relatively brief, casual, and nonexploitative conversation with a client concerning a topic on which the client is an expert may empower the client, facilitate therapeutic progress, and challenge the traditionally hierarchical relationship between professional and client. 

 

Emotional and Dependency Needs 

 

A number of boundary issues arise from practitioners' efforts to address their own emotional needs. Many of these issues are subtle, although some are more glaring and egregious. Among the more egregious are the following examples on which I have consulted: 

 

 

Case Examples

 

 

     The administrator of a state child welfare agency that serves abused and neglected children was having difficulty coping with his failing marriage. He was feeling isolated and depressed. The administrator was arrested based on evidence that he had developed a sexual re­lationship with a sixteen-year-old boy who was in the department's custody and that he used illegal drugs with the boy.

 

     A psychologist in a private psychiatric hospital provided counseling to a resident who was diagnosed with paranoid schizophrenia. The psychologist, who was religiously observant, began to read biblical passages to his client in the context of counseling sessions. The client was not religiously observant and complained to other hospital staff about the psychologist's conduct.

 

     A psychiatric nurse in private practice provided psychotherapy ser­vices to a forty-two-year-old woman who had been sexually abused as a child. During the course of their relationship, the nurse invited the client to her home for several candlelight dinners, went on a camping trip with the client, gave the client several expensive gifts, and wrote the client several very affectionately worded notes on per­sonal stationery.

 

     A social worker in a public child welfare agency was responsible for licensing foster homes. The social worker, who was recently di­vorced, became friendly with a couple who had applied to be foster parents. The social worker also became very involved in the foster parents' church. The social worker, who approved the couple's ap­plication and was responsible for monitoring foster home place­ments in their home, moved with her son into a trailer on the foster parents' large farm.

 

 

Other boundary issues are more subtle.  Examples include professionals whose clients invite them to attend important life-cycle events (such as a wedding or graduation, or a key religious ceremony), professionals who con­duct home visits as a meal is being served and whose clients invite them to sit down to eat, and professionals who themselves are in recovery and en­counter a client at an Alcoholics or a Narcotics Anonymous meeting.  Professionals sometimes disagree about the most appropriate way to handle such boundary issues.  For example, some professionals are adamantly opposed to attending a client's life-cycle event because of poten­tial boundary problems (for example, the possibility that the client might interpret the gesture as a sign of the practitioner's interest in a social rela­tionship or friendship); others, however, believe that attending such events can be ethically appropriate and, in fact, therapeutically helpful, so long as the clinical dynamics are handled skillfully. Further, some professionals be­lieve that practitioners in recovery should never attend or participate in AA or NA meetings that a client might attend, because of the difficulty that clients may have reconciling the practitioner's professional role and per­sonal life.  Others, however, argue that recovering practitioners have a right to meet their own needs and can serve as compelling role models to clients in recovery.

 

Altruistic Gestures 

 

Some boundary issues and dual relationships arise from professionals' genuine efforts to be helpful. Unlike a professional's involvement in a sexual relationship or a dual relationship that is intentionally self-serving, altruistic gestures are benevolently motivated.  Although these dual relationships are not always inherently unethical, they do require skillful handling, as in the following examples:

 

 

Case Examples

 

 

     A psychiatrist in private practice was contacted by an acquaintance – not a close friend – who was in the midst of a marital crisis.  The acquaintance told the psychiatrist that she and her husband "really trusted" the psychiatrist and wanted the psychiatrist's professional help.  The psychiatrist agreed to see the couple professionally but later realized that being objective was very difficult. 

 

     A social worker in a family service agency provided casework services to a client who had a substance abuse problem.  The client asked the social worker if she would like to purchase wrapping paper that the client's daughter was selling as a school fund-raiser. 

 

     A counselor in a community mental health center provided psy­chotherapy services for many years to a young man with a history of clinical depression.  The client asked the counselor if she would say a few words during the ceremony at the client's upcoming wedding. 

 

     A psychiatric nurse in a small rural community provided counsel­ing to a ten-year-old boy who struggled with self-esteem issues.  In his spare time, the nurse coached the community's only youth basketball team, which played in a regional league.  The nurse be­lieved that the boy would benefit from joining the basketball team (for example, by developing social skills and new relation­ships).

 

 

Unanticipated Circumstances 

 

The final category of boundary issues involves situations that behavioral health professionals do not anticipate and over which they have little or no initial control.  The challenge for the professional in these circumstances is to manage the boundary issues in ways that minimize any harm to a client or colleague.  Consider the following examples:

 

 

Case Examples

 

 

     A social worker in private practice attended a family holiday gath­ering.  The social worker's sister introduced him to her new boy­friend, who is the social worker's former client. 

 

     The client of a psychotherapist in a rural community was a grade school teacher. Because of an unexpected administrative decision, the client became the teacher in the classroom in which the psy­chotherapist's child was a student.

 

     A psychologist in a community mental health center joined a local physical-fitness club.  During a visit to the club, the psychologist learned that an active client also was a member. 

 

 

This concludes my introduction to, and initial overview of, boundary and dual relationship issues in the behavioral health professions.  Now we will begin to explore these issues, and the elements of my typology, in greater depth.

 

A Typology of Boundary Issues: An In-depth Look

 

Now we will begin to explore the components of my typology of boundary issues in greater depth.  To reiterate, I maintain that boundary and dual relationships can be organized along five key dimensions: issues of intimacy; emotional and dependency needs; personal benefit; altruism; and unanticipated and unavoidable circumstances.

 

Intimacy Issues

 

Many boundary issues involve some form of intimate rela­tionship. Some issues are glaring, such as those involving sexual contact between a therapist and a current client.  Other issues, however, are more subtle, such as those involving seemingly innocent affectionate gestures.  

 

I will examine a wide range of boundary issues involving intimacy.  They include sexual relationships between professionals and their current or for­mer clients; sexual relationships between professionals and clients' relatives or acquaintances; sexual relationships between professionals who are super­visors or educators and their supervisees, students, trainees, or other col­leagues over whom they exercise professional authority; providing profes­sional services to a former lover; and physical contact between professionals and clients. 

 

Sexual Relationships with clients.  Here is a typical case involving sex-related boundary issues.

 

 

Case Example

 

 

Dr. Alfred S. was a counselor in private practice. For many years, Dr. S. provided clinical services to children and families.  He specialized in child behavior management problems and family therapy.

 

Dr. S. had been providing services to a nine-year-old child, Sam K., and his single mother, Judy K.  A school counselor referred Ms. K. and her son to Dr. S.; the faculty had been concerned about Sam's "acting out" and aggressive behavior in school.  Dr. S. met with Sam and his mother weekly for about eight months. 

 

For several months, Dr. S. felt attracted to Ms. K. He found himself thinking about Ms. K. outside working hours.  Dr. S. went out of his way to spend extra time with Ms. K. during their counseling sessions; he scheduled their sessions at the end of the day so that no other client's appointment would force them to end their session after precisely fifty minutes.  Toward the end of one session, Dr. S. asked Ms. K. if she would like to spend a little time with him outside the office "so we can get to know each other a little better."  Dr. S. went on to explain to Ms. K. that he was feeling attracted to her and wanted to know if she was feeling something toward him, which is what he sensed.  Dr. S. was careful to explain to Ms. K. that he wouldn't want to do anything to harm her or her son's progress in treatment. Within four weeks, Dr. S. and Ms. K. were involved sex­ually. 

 

 

As I noted earlier, a substantial portion of intimate dual relationships entered into by behavioral health professionals involve sexual contact. As Brodsky notes, 

 

A sexual intimacy between patient and therapist is one example of a dual relationship.  Dual relationships involve more than one purpose of relating.  A therapy relationship is meant to be exclusive and uni­dimensional.  The therapist is the expert, the patient the consumer of that expertise.  Once a patient accepts an individual as a therapist, that individual cannot, without undue influence, relate to that pa­tient in any other role.  Relating to the patient as an employer, busi­ness partner, lover, spouse, relative, professor or student would con­taminate the therapeutic goal.  The contamination is much more intense in a psychotherapy relationship than it would be in the re­lationship between a client and a professional in any other field for example, between a client and an internist, a dentist, a lawyer, or an accountant (Brodsky, 1986).

 

The nature of sexual misconduct.  Inappropriate sexual contact and sexualized behavior with clients can take several forms.  These include touching body parts (for example, shoul­der, arm, hand, leg, knee, face, hair, neck), hugging, holding hands, holding a client on one's lap, engaging in sexual humor, making suggestive remarks or gestures, kissing, exposing one's genitals, touching breasts, engaging in oral sex, and engaging in sexual intercourse.  One useful typology, based on self-reports of sexual contact and behavior by a large sample of licensed psychologists, categorizes these various behaviors into three conceptual groups. The first includes overt sexual behavior, such as sexual intercourse, oral sex, fondling the genital area, touching the breasts, genital exposure, and kissing.  The second group of behaviors includes touch­ing behavior, such as touching body parts (for example, shoulders, arm, hand, leg, knee, face, hair, or neck), hugging, holding hands, and holding the client on one's lap.  The third group includes suggestive behavior, such as using sexual humor and making suggestive remarks or glances.  State laws typically define sexual activity more narrowly as intercourse, rape, the touch­ing of breasts and genitals, cunnilingus, fellatio, sodomy, and inappropriate or unnecessary examinations and procedures performed for sexual gratifi­cation (Simon, 1999). 

 

A series of empirical studies demonstrates the seriousness and magnitude of boundary violations and inappropriate dual relationships involving pro­fessionals' sexual contact with clients.  During a twenty-year period, nearly one in five lawsuits (18.5 percent) against social workers insured through the malpractice insurance program sponsored by the NASW (National Association of Social Workers) Insur­ance Trust alleged some form of sexual impropriety, and more than two-fifths (41.3 percent) of insurance payments were the result of claims con­cerning sexual misconduct (Reamer, 1995).  In a pioneering study, Schoener and colleagues (1989) estimate that 15 to 16 percent of male and 2 to 3 percent of female therapists admit erotic contact with clients (Schoener et al., 1989). Other national data suggest that 8 to 12 percent of male counselors or psychotherapists, and 1.7 to 3 percent of female counselors or psychotherapists, admit having had sexual relationships with a current or former client.  According to Simon, the reported rate of sexual contact between therapists and clients is generally in the range of 7 percent to 10 percent.  Simon cautions that the actual rates are probably higher, because self-report data are known to un­derestimate actual incidence.  Stake and Oliver (1991) provide a general overview of the data: 

 

In most surveys of therapist sexual misconduct, between 5% and 10% of psychologists (Holroyd & Brodsky, 1977; Pope, Keith-Spiegel & Ta­bachnick, 1986, 2003; Pope, et al., 1979) and psychiatrists (Herman, Gartrell, Olarte, Feldstein & Localio, 1987; Kardener, Fuller and Mensh, 1973) have acknowledged erotic contact with one or more of their clients.  The incidence rate was lower in a survey of social workers.  Gechtman (1989) found 3.8% of male social workers and no female social workers in her sample reported erotic contact with clients.  Rates for male psychologists have generally been in the range of 5% to 12%, in contrast to rates of 1% to 3% for female psychologists (Bouhoutsos, et al., 1983; Gartrell, et al., 1987; Holroyd & Brodsky, 1977; Pope, et al., 1979; Pope, et al., 1986). 

 

In a major study, Pope reports on the frequency of successful malpractice claims filed against psychologists during a ten-year period.  Although the time period covered by Pope is shorter than the period described for my studies of social workers, the similarities are clear.  As with social workers, the most frequent claims categories for psychologists during the ten-year period were sexual contact (psychologists, 18.5 percent of claims; social workers, 18.5 percent of claims) and treatment error (psychologists, 15.2 percent of claims; social workers, 18.6 percent of claims).  Approximately 45 percent of dollars spent in response to claims against psychologists resulted from claims of sexual contact, compared with 41 percent of dollars spent in response to claims against social workers for claims of sexual misconduct.  Olarte provides a succinct profile of the offending therapist: 

 

The composite profile that most frequently emerges from the treat­ment or consultation with offenders is that the therapist is a middle-aged man who is undergoing some type of personal distress, is isolated professionally, and overvalues his healing capacities.  His therapeutic methods tend to be unorthodox; he frequently particularizes the ther­apeutic relationship by disclosing personal information not pertinent to the treatment, which fosters confusion of the therapeutic bound­aries. He is generally well trained, having completed at least an ap­proved training program and at times formal psychoanalytic training.

 

Brodsky's overview of offending therapists contains a number of strikingly similar attributes: 

 

The following characteristics constitute a prototype of the therapist being sued: The therapist is male, middle aged, involved in unsatis­factory relationships in his own life, perhaps in the process of going through a divorce.  His patient caseload is primarily female.  He be­comes involved with more than one patient sexually, those selected being on the average 16 years younger than he is.  He confides his personal life to the patient, implying to her that he needs her, and he spends therapy sessions soliciting her help with his personal problems.  The therapist is a lonely man, and even if he works in a group practice, he is somewhat isolated professionally, not sharing in close consulta­tion with his peers.  He may have a good reputation in the psycholog­ical or psychiatric community, having been in practice for many years.  He tends to take cases through referral only.  He is not necessarily physically attractive, but there is an aura of power or charisma about him.  His lovemaking often leaves much to be desired, but he is quite convincing to the patient that it is he above all others with whom she needs to be making love. 

 

Brodsky also describes other sexually abusive therapists, including those who tend to be inexperienced and in love with one particular client, and therapists with a personality disorder (typically antisocial personality disorder and/or narcissistic personality disorder) who manipulate clients into believing that they – the therapists – should be trusted and they have the clients' best interest at heart. A small number of therapists named in ethics complaints and lawsuits try to defend their sexual contact with clients. One argument they sometimes advance is that the sexual contact was an essential, construc­tive, and legitimate component of therapy.  The therapist typically claims that he was merely trying to be helpful to the client. 

 

Another defense is that the sexual relationship was conducted indepen­dently of the therapeutic relationship. In these instances, the defendant ­therapist usually argues that he and the client were able to separate their sexual involvement from their professional relationship.  As Schutz suggests, however, this argument "has not been a very successful defense, since courts are reluctant to accept such a compartmentalized view of hu­man relationships. A therapist attempting to prove the legitimacy of sexual relations between himself and a patient by establishing that two coterminous-­in-time but utterly parallel relations existed has a difficult task" (Schutz, 1982). 

 

The list that follows (Table 2) is a mere sample, a diverse cross-section of a large number of court cases and professional disciplinary hearings involving al­legations of sexual misconduct (Reamer, 2001). 

 

 

Table 2. Legal Examples

 

 

     A Pennsylvania court upheld the state licensing board's revocation of a psychologist's license to practice because of substantial evidence that he had had sexual relations with a patient before termination of the therapeutic relationship.  The psychologist had neither formally terminated nor even discussed termination of the therapeutic rela­tionship before he had sexual relations with the client.  He stopped billing the client for therapy sessions around the time they started their sexual relationship, but a psychologist cannot terminate a pa­tient relationship merely by ceasing to bill the patient. 
 

     Two weeks after a social worker took a job as an outpatient mental health program, management observed him socializing with patients while on breaks from therapy sessions.  The social worker induced a client – who had been diagnosed with bipolar disorder and alcohol­ism – to meet him outside the treatment program's facilities. The client testified that the social worker often had recited biblical quo­tations and she thought he was a good Christian man who could help her by going for long walks and talking. After meeting the social worker off the program's premises, the client entered into a sexual relationship with him.  After the second meeting, the client felt tre­mendous remorse and guilt and had a relapse with alcohol.  The jury awarded damages of $123,500 against the social worker and the pro­gram. 
 

     A Florida appeals court upheld the constitutionality of a state statute that was used to convict a psychotherapist for criminal sexual misconduct.  In counseling a client with low self-esteem, a licensed psychologist had raised issues involving the client's sexuality, digi­tally penetrated her, tried to kiss her, and lowered his pants in front of her.  The appeals court found ample evidence in the record that the psychologist had committed the misconduct by means of a therapeutic deception, meaning "a representation to the client that sexual contact by the psychotherapist is consistent with or part of the treatment of the client."  The client met with the psychologist while wearing a wire, and the police obtained a tape-recording of the psychologist admitting that he had offered to have sex with her as an incentive for her to had happened was hurtful but that it helped build her self-esteem.  Evidence of similar misconduct with another former client was admitted into evidence. 
 

     A thirty-seven-year-old woman, who complained of discontent in her life and failure to meet her family's expectations, sought help from a psychiatrist.  She claimed that the psychiatrist had committed mal­practice during the psychotherapy relationship when, after counsel­ing her for six months, he told her their relationship was going to change and told her to sit on his lap.  He then lifted her blouse and kissed her breast.  The patient sat there and watched the psychiatrist because she was too stunned to react.  He told her that he would kiss her other breast on the next visit.  The psychiatrist admitted that the incident had occurred, but contended that it did not constitute mal­practice and the patient was not harmed by his actions.  The psychi­atrist also claimed that the patient had actually seduced him.  The jury awarded damages of $142,371. 
 

     A nineteen-year-old woman received treatment from a psychologist at a mental health center.  The therapeutic relationship continued for about ten years.  After about one year, the psychologist began having sex with the woman.  She had been abused as a child and did not have a father figure in her life.  The client alleged that the psy­chologist had responded to this disclosure by viewing her as a friend, a daughter figure, and a lover.  The client claimed that she has poor social skills as a result of the abuse and will never get married or be able to have a normal relationship with a man.  She received $425,000 in a pretrial settlement. 
 

     A woman sought mental health treatment from a counselor, who was a lesbian, to address issues related to a sexual problem she was having with her female roommate and occasional lover.  The client believed that the counselor's own sexual orientation would help her deal with the clinical issues.  During the course of treatment, the client invited the counselor to have dinner with her and three other women.  The counselor and client became sexually involved while the counselor was still providing the woman with counseling ser­vices.  The state licensing board ruled the counselor was grossly negligent and revoked her license. 
 

     A psychiatrist hospitalized a thirty-year-old housewife and had sex­ual contact with her in the hospital and subsequently during office visits.  The client also accused a psychologist involved in the case of having encouraged her to have sexual relations with the psychi­atrist.  The psychiatrist did not deny the sexual contact, but claimed that he was in love with the patient.  The psychologist argued that she did not encourage their relationship.  The client received $275,000 in a pretrial settlement.

 

Causal Factors.  A large percentage of clinical practitioners report having felt attracted to their clients, although most do not act on this attraction.  In one major survey of practicing psychotherapists, 96 percent of men and 76 percent of women acknowledged attraction to one or more clients.  A relatively small percentage of this particular sample – 9.4 percent of the men and 2.5 percent of the women – reported having had sexual relations with their clients (Pope et al., 2003).  More than half (52.4 percent) of a state­wide sample of clinical social workers, two-thirds of whom were women, reported having felt sexually attracted to a client Jayaratne et al., 1997).  In a survey of trainees, 86 percent of men and 52 percent of women acknowledged sexual attraction to one or more clients (Gartrell et al., 1986). There are diverse theories about the causes of, and factors as­sociated with, practitioner sexual misconduct.  Here is a summary of major themes and speculation (Table 3):

 

 

Table 3.  Causal Factors in Boundary Issues

 

 

Boundary violations are a function of the nature of the client (the client's clinical issues), the type of treatment, the status of the thera­peutic alliance (whether it is strong or weak, functional or dysfunctional), and the personality of the therapist, combined with his or her training and experience. 

 

From a psychodynamic perspective, a clinician violates a client's bound­aries because of the therapist's difficulty in handling countertransference phenomena – that is, the therapist's transference reaction toward the client (countertransference involves unconsciously feeling toward a client the same feelings the clinician originally had toward someone else).  According to Simon, one common countertransference trap occurs when 

 

the therapist subconsciously overidentifies with a patient who he or she then tries to rescue.  The therapist is usually struggling with con­flicts or has experienced traumatic life events that are also observable in the patient.  The patient is treated like a favorite child, with increas­ing exceptions made to the maintenance of treatment boundaries.  As the therapist becomes more deeply immersed in the patient's life, the patient's demands become greater on the therapist. Eventually, the therapist abrogates the role of therapist and enters into a personal, sexual relationship with the patient.  Although the therapist becomes aware of increasing boundary violations, he or she feels "powerless" to restore the treatment situation.  This scenario is akin to therapists who become sexually involved with patients through "masochistic surren­der," one of a variety of countertransference developments in sexual misconduct cases.  

 

Many clients enter treatment with the subconscious wish that a loving, nurturing relationship with the therapist will gratify all needs and repair all hurts. According to Simon  

 

The ministrations of the therapist are often perceived by patients as acts of love.  For this and a myriad of other conscious and subconscious reasons, patients regularly "fall in love" with their therapists.  Some therapists exploit these love feelings for therapist-patient sex.  Other therapists mistake these feelings as "true love" and respond to their own needs by establishing a sexual relationship with the patient.  Even well-trained therapists may rationalize their behavior by telling them­selves that this relationship with the patient is very special and "truly an exception" to the prohibition against sexual involvement with pa­tients. In fact, "love transference" can be extremely capricious, often hiding a destructive hate transference that frighteningly erupts and engulfs the therapist and patient.

 

Boundary violations primarily are manifestations of clinicians' "undue influence" on clients.  That is, the therapist breaches the client's fiduciary trust. 

 

 

Several authors believe that practitioners who engage in sexual miscon­duct can be categorized conceptually.  Schoener’s classification scheme includes a broad range of offending therapists based on empirical evidence gathered from psychological and psychi­atric examinations of sexually exploitative therapists (Schoener, 1995).  These clinical clusters include (Table 4): 

 

 

Table 4. Characteristics of Sexually Exploitative Therapists

 

 

Psychotic and severe borderline disorders. While few in number, these professionals have difficulties with boundaries because of problems with both impulse control and thinking.  They are often aware of current ethical standards but have difficulty adhering to them because of their poor reality testing and judgment. 

 

Sociopaths and severe narcissistic personality disorders.  These are self-centered exploiters who cross various boundaries when it suits them.  They tend to be calculating and deliberate in their abuse of their clients.

 

Impulse control disorders. This includes practitioners with a wide range of paraphilias (sexual disorders in which unusual fantasies or bizarre acts are necessary for sexual arousal) and other impulse control disorders.  These professionals often have impulse control problems in other areas of their lives. They are typically aware of current ethical standards, but these do not serve as a deterrent.  These practitioners often fail to acknowledge the harm that their behavior does to their victims and show little remorse. 

 

Chronic neurotic and isolated.  These practitioners are emotionally needy on a chronic basis and meet many needs through their relationships with clients.  They may suffer from long-standing problems with depression, low self-esteem, social isolation, and lack of confidence.  At times, these practitioners disclose personal information to clients inappropriately.  Typi­cally, they deny engaging in misconduct or justify the unethical behavior as their "therapeutic" technique designed to enhance their suffering client's self-esteem.  They may also blame the client's claims on the client's pathol­ogy.  Such practitioners are often repeat offenders. 

 

Situational offenders.  These therapists are generally healthy with a good practice history and free of boundary problems, but a situational breakdown in judgment or control has occurred in response to some life crisis or loss.  These practitioners are generally aware of current ethical standards.

 

Naive.  In the absence of pathology, these therapists have difficulty understanding and operating within professional boundaries because they suffer from deficits in social judgment.  Their difficulties stem in part from their lack of knowledge of current ethical standards and their confusion about the need to separate personal and professional relationships. 

 

 

In contrast to this framework Simon offers a typology that includes somewhat different clinical dimensions.  Simon places vulnerable therapists in five categories (Table 5): 

 

 

Table 5. Therapists Vulnerable to being Sexually Exploitative

 

 

Character disordered.  Therapists diagnosed with symptoms of bor­derline, narcissistic, or antisocial personality disorder.

 

Sexually disordered.  Therapists diagnosed with frotteurism (recurrent intense sexual urges and sexually arousing fantasies in regard to a nonconsenting person), pedophilia, or sexual sadism. 

 

Incompetent.  Therapists who are poorly trained or have persistent boundary blind spots. 

 

Impaired.  Therapists who have serious problems with alcohol, drugs, or mental illness. 

 

Situational reactors.  Therapists who are experiencing marital dis­cord, loss of important relationships, or a professional crisis. 

 

 

Drawing on the concept of transference, Simon highlights several themes in therapist-client sexual relationship – for example, clients who idealize their therapist or regard the therapist as a savior or as omniscient.  Simon classifies these themes, reflecting clients' perceptions of their thera­pists, as follows (Table 6):

 

 

Table 6. Themes in Therapist-Client Sexual Relationships

 

 

Dr. Perfect. The client idealizes the therapist's attributes.

 

Dr. Prince. The client idolizes the therapist romantically, hoping the therapist will "rescue" him or her. 

 

Dr. Good Parent. The client experiences the therapist as a nurturing parent and may use therapy for "reparenting" purposes. 

 

Dr. Magical Healer. The client regards the therapist as his or her savior. 

 

Dr. Beneficent. The client regards the therapist as the devoted care­taker, akin to a nanny or first doctor. 

 

Dr. Indispensable. The client believes that only this therapist is able to cure. 

 

Dr. Omniscient. The client believes that the therapist knows and understands all. 

 

 

Based on his extensive experience with vulnerable and offending thera­pists, Simon argues that boundary violations are often progressive and follow a sequence, or "natural history," that leads ultimately to a therapist-­client sexual relationship (Simon, 1995). The sequence includes (Table 7):

 

 

Table 7.  Progression of the Therapist-Client Sexual Relationship

 

 

Gradual erosion of the therapist's neutrality.  The therapist begins to take special interest in the client's issues and life circumstances.  

 

Boundary violations begin "between the chair and the door."  As the client is leaving the office and both client and worker are standing, the therapist and client may discuss personal issues that are not part of the more formal therapeutic conversation.  

 

Socialization of therapy.  More time is spent discussing "nontherapy" issues. 

 

Disclosure of confidential information about other clients.  The ther­apist begins to confide in the client, communicating to the client that she is special.  

 

Therapist self-disclosure begins.  The therapist shares information about his own life, perhaps concerning marital or relationship prob­lems. 

 

Physical contact begins (for example, touching, hugs, kisses).  Casual physical gestures convey to the client that the therapist has very warm and affectionate feelings toward her.  

 

Therapist gains control over client.  The client begins to feel more and more dependent on the therapist, and the therapist exerts more and more influence in the client's life. 

 

Extra-therapeutic contacts occur.  The therapist and client may meet for lunch or for a drink.  

 

Therapy sessions are longer.  The customary fifty-minute session is extended because of the special relationship.  

 

Therapy sessions rescheduled for end of day.  To avoid conflict with other clients' appointments, the therapist arranges to see the client as the day’s final appointment.

 

Therapist stops billing client.  The emerging intimacy makes it difficult for the therapist to charge the client for the time they spend together.

 

Dating begins.  The therapist and client begin to schedule times when they can be together socially.

 

Therapist-client sex occurs.

                

 

Clinical and professional consequences.  Sexual misconduct typically has devastating consequences.  For victim­ized clients, common consequences include destroyed self-esteem, destruc­tive dependency, mistrust of the opposite sex, distrust of therapists, difficulty in subsequent intimate relationships, impaired sexual relationships, guilt, self-blame, suicidal ideation, substance abuse, loss of confidence, cognitive dysfunction, increased anxiety, identity disturbances, sexual confusion, mood lability, suppressed rage, depression, psychosomatic disorders, and feelings of anger, rejection, isolation, and abandonment.

 

Although we must be concerned primarily with the detrimental conse­quences of sexual misconduct for victimized clients, we should not ignore the effect on the therapists who are involved in these relationships, primarily in the form of evoked guilt, confusion, and anxiety.  

 

Risk management strategy. Practitioners can take various steps to protect clients and to minimize the likelihood of ethics complaints and lawsuits associated with sexual miscon­duct. Simon highlights five useful basic principles underlying con­structive boundary guidelines (Table 8):

 

 

Table 8. Sexual Misconduct Risk Management

 

 

1. Rule of abstinence: Practitioners should strive, above all else, to avoid sexual involvement with clients and to resist acting on sexual attraction toward clients.

 

2. Duty of neutrality: Practitioners should seek to relate to clients as neutrally as possible.  Neutrality entails the absence of favoritism, preferential consideration, and special treatment.

 

3. Patient autonomy and self-determination:  Practitioners should re­spect clients' right to self- determination, which means avoiding any manipulative behaviors or behaviors that might promote cli­ents' dependence or constitute "undue influence."

 

4. Fiduciary relationship:  Fiduciary relationships are based on trust.  Clients must be able to trust their therapists and to assume that their therapists would not engage in manipulative, exploitative, or seductive behaviors for self-interested purposes. 

 

5. Respect for human dignity:  Practitioners must maintain deep-seated respect for their clients, act only in a caring and compassionate manner, and avoid engaging in destructive behaviors.

 

 

More concretely, Simon argues, practitioners should adhere to a number of guidelines to protect clients and minimize risks associated with sexual attraction (Table 9): 

 

 

Table 9. Avoiding Sexual Misconduct

 

 

     Maintain relative therapist neutrality (the absence of favoritism) 

 

     Foster psychological separateness of the client 

 

     Protect client confidentiality

 

     Obtain informed consent for treatments and procedures 

 

     Interact with clients verbally 

 

     Ensure no previous, current, or future personal relationship with the client 

 

     Minimize physical contact

 

     Preserve relative anonymity of the therapist 

 

     Establish a stable fee policy

 

     Provide a consistent, private, and professional setting for treatment 

 

     Define the time and length of the treatment session 

 

 

Beyond these broad guidelines, therapists should pay special attention to clients' unique clinical issues that may complicate boundary phenomena.  For example, if a therapist senses that a client is feeling attracted to him or her, the therapist might avoid scheduling the client at times when no one else is in the office suite.  Therapists in solo private practice must be especially careful because of professional isolation and the absence of institutional or collegial oversight and restraints.  Further, therapists who sense potential boundary issues involving sexual attraction should avoid out-of-the-office contact with clients.

 

Boundary violations can also arise from seemingly innocent gestures, such as offering a stranded client a ride home after a counseling session.  Clinically relevant discussion may continue during the ride and while the therapist and client are parked in front of the client's home.  Conducting sensitive discussion in the context of the therapist's personal space can lead to boundary ambiguity, confusion, and, ultimately, violation. 

 

Simon urges practitioners to conduct an "instant spot check" to identify whether the therapist has committed or is at risk of committing a boundary violation.  Using this approach, the first question to ask is whether the treatment is for the benefit of the therapist or for the sake of the client's therapy.  Second, is the treatment part of a series of progressive steps in the direction of boundary violations (for example, inviting the client to have lunch after a counseling session in order to continue discussion of "compelling" clinical issues)?  Simon argues that a yes answer to either question should put the therapist on notice to desist immediately and take correction action. 

 

Practitioners should also be alert to certain gender-specific issues.  That most cases of sexual misconduct involve male clinicians and female clients is compelling.  This pattern reflects long-standing, enduring cultural patterns involving male dominance in heterosexual relationships.  Therapists of both genders need to be aware of the effect of their deep-seated sex-related interaction styles and patterns.  For instance, a male clinician who has little insight into his tendency to act in a somewhat controlling and authoritative manner may encourage his female client's dependency, passivity, and compliance, which may serve as precur­sors to boundary violations involving sexual misconduct. 

 

The overarching concept to keep in mind is prevention.  Practitioners must anticipate the possibility of boundary complications and take assertive steps to prevent problems.

 

Rehabilitation efforts.  Relatively little research has been conducted on the effectiveness of efforts to rehabilitate impaired professionals who engage in ethical misconduct.  Many investigations have serious methodological limitations; few studies control adequately for extraneous factors that may account for changes over time in practitioners' attitudes and behavior. 

 

In recent years, several organized efforts have tried to identify and address the problems of impaired professionals and ethical misconduct.  The con­sensus is growing that a model strategy for addressing impairment among professionals should include several components.  First, we need adequate means for identifying impaired professionals. Pro­fessionals must be willing to assume responsibility for acknowledging im­pairment among colleagues.  It certainly would help to develop reasonably objective measures of what con­stitutes failure to live up to professional standards, incompetent skills, and impaired professional functioning. 

 

Second, a professional who spots a colleague who may be impaired should first speculate about the causes and then proceed with what Sonnenstuhl describes as "constructive confrontation."(Sonnenstuhl, 1989).  Third, once a practitioner decides who (typically, a professional colleague) shall confront the exploitative colleague, the practitioner must decide whether to help the impaired colleague identify ways to seek help voluntarily or to refer the colleague to a supervisor or local regulatory body (such as a licensing board or professional association's ethics adjudication committee).

 

Assuming the data are sufficient to support a rehabilitation plan, the im­paired practitioner's colleague, supervisor, or local regulatory body should make specific recommendations.  The possibilities include close supervision, personal psychotherapy, or other appropriate treatment (for example, sub­stance abuse treatment).  In some cases, a local regulatory body or profes­sional association may need to impose some type of sanction such as censure, limitations on the practitioner's practice (for example, concerning type of clientele served or practice setting), termination of employment, suspension or expulsion from a professional association, or license revocation. 

 

With specific regard to treatment that follows the filing and processing of a formal complaint, Schoener (1995) argues that, ideally, a comprehen­sive assessment of the practitioner would be conducted by a licensing or regulatory body and would involve several steps, including (Table 10):

 

 

Table 10.  Evaluation of Practitioner in Sexual Misconduct

 

 

     Gathering data about the practitioner's professional training, profes­sional work history, and personal history (including noteworthy "ups" and "downs"), and the nature of the practice-related complaint (boundary violation)

 

     Generating hypotheses about causal factors that may be involved in the boundary violation 

 

     Formulating a rehabilitation plan, when feasible 

 

     Coordinating the rehabilitation plan with the licensing board, pro­fessional association, and practitioner's employer 

 

     Implementing the corrective action (for example, psychotherapy, su­pervision, consultation, continuing  education) and, when necessary, appropriate sanctions (for example, license suspension or revocation, expulsion from professional association) 

 

     Evaluating the practitioner's progress in regard to the possibility of allowing him to reenter practice and the profession 

 

 

Schoener (1995) believes that a formal assessment of an exploitative prac­titioner should not be conducted, or a rehabilitation plan developed, unless

 

(1) the practitioner admits wrongdoing and understands that the client suf­fered harm;

 

 (2) the practitioner believes that he or she has a problem that requires rehabilitation;

 

(3) the practitioner is willing to agree to the assess­ment and realizes that its outcome may not be favorable; and

 

(4) the essential facts of the case are not in dispute.

 

Once the practitioner has completed the rehabilitation plan, those responsible for overseeing it must be able to answer yes to two questions: "To a reasonable degree of psychiatric or psychological certainty, have the problems you were treating been fixed or resolved?" and "Would you have any qualms whatsoever if your spouse or child went to see this person for individual therapy?" 

 

In addition to prohibiting sexual relationships with current clients, codes of ethics in the behavioral health professions gen­erally prohibit sexual activities or sexual contact with former clients.  However, it is important to note that the codes differ with regard to the extent of this prohibition.  For example, the ethical standards for psychiatrists and social workers generally prohibit sexual relationships with former clients.  The NASW Code of Ethics acknowledges that there may be extraordinary exceptions to this prohibition, and that the burden rests with the social worker in instances when a practitioner believes that an exception is warranted:

 

“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” (standard 1.09[c]). 

 

In contrast, the standards for psychologists (APA), mental health counselors (AMHCA), and marriage and family therapists (AAMFT) prohibit sexual relationships with former clients within the two-year period following termination of the professional-client relationship (these organizations stress that practitioners who become sexually involved with clients more than two years after termination of the professional-client relationship bear the burden of demonstrating that there was no exploitation or injury to the client).  The standards for counselors adopted by the American Counseling Association prohibit sexual relationships with former clients within the five-year period following termination of the professional-client relationship. 

 

Emotional and Dependency Needs

 

Boundary problems arising from a practitioner’s personal issues can take many other forms in addition to inappropriate intimate relationships with clients.  Some manifestations amount to boundary violations, by which clients and others are exploited or harmed.  Others constitute boundary crossings, introducing complex issues that do not rise to the level of actual violations but must be managed carefully nonetheless.

 

What many of these phenomena have in common is that they are rooted in the practitioner’s emotional and dependency needs, such as those stemming from childhood experiences, marital issues, aging, career frustrations, or financial and legal problems.  Emotional distress among professionals generally falls into two categories: environmental stress, which is a function of employment conditions (actual working conditions and the broader culture’s lack of support or appreciation of the human service mission), and professional training and personal stress, caused by problems with marriage, relationships, emotional and physical health, and finances.  Of course, these two types of stress are often interrelated. 

 

Over the years I have observed a number of boundaries problems that take the form of questionable relationships with clients (or former clients), practitioners’ use of unconventional interventions, inappropriate self-disclosure to clients and colleagues, and affectionate communications to clients.  For example, practitioners who are struggling in their personal lives and are lonely may become involved in inappropriate friendships with clients with whom they have special rapport.  Counselors who are preoccupied with meeting their own emotional needs in their work with clients may use controversial interventions that entail spending considerable amounts of time with clients out of the office.  Clinicians who are very “needy” because of personal struggles may find themselves disclosing too much personal information to clients and colleagues (for example, about their own recovery efforts or marital struggles).  Here are several actual case examples from my experience:  

 

 

Case examples

 

 

     Mark L. was a counselor at an outpatient clinic that provides clinical services to armed forces veterans.  One of Mr. L’s clients was Sam T., fifty-seven, who was being treated for anxiety symptoms and alcohol abuse associated with post-traumatic stress disorder.

 

Mr. L was also a veteran, and he had grown disillusioned with his career.  He had been turned down for promotions several times and was feeling alienated from his colleagues.  Also, Mr. L.’s twenty-three year marriage had recently ended, and he was estranged from his two children.  Mr. L. was very lonely and isolated and started drinking heavily (he was a recovering alcoholic).  Mr. L. was feeling burned out. 

 

During their work together, Mr. L. and Mr. T. learned they had a number of interests in common.  They were both divorced and felt jaded about their jobs.  Both felt eager for a fresh start – new relationships, new jobs, and a change of scenery. 

 

As their professional work together began to wind down, Mr. L. mentioned to Mr. T. that they might enjoy spending some time together socially.  Mr. T responded enthusiastically, and the two first arranged to go to a local football game together.  Before long, Mr. L. and Mr. T. were spending considerable social time together, having dinner, going to movies, fishing, and taking day trips to local attractions.

 

     Mildred D. was a counselor in a family service agency.  Most of her clients were referred by the personnel office of the local city government in conjunction with its employee assistance program.  City employees who were having job-related problems that might be addressed through counseling – for example, declining job performance associated with an employee’s alcohol abuse or marital difficulties – were referred to Mildred D. or one of her colleagues.

 

One of Ms. D.’s clients was a midlevel administrator in the city’s parks and recreation department.  The client, Barbara S., was referred by her supervisor because of the supervisor’s concerns about Ms. S.’s frequent absences and deterioration in the quality of her work.  Ms. S. acknowledged to Ms. D. that indeed she was having some serious problems in her life, associated primarily with her recent divorce and child custody dispute with her former husband.  Ms. S. also reported an ongoing and troubling conflict she was having with one of her co-workers, Melanie N.  It happens that Melanie N. was also a client of Ms. D., having been referred to the employee assistance program by her supervisor because of her problem with alcoholism. 

 

Ms. D. helped Ms. S. identify counseling goals that might help her function more productively in her personal and professional life.  They met weekly for about three months and accomplished a great deal.  Ms. S. and Ms. D. then terminated their working relationship; Ms. D. wrote a favorable report to Ms. S.’s supervisor. 

 

By the end of their work together, Ms. S. and Ms. D. had developed a close relationship.  In fact, Ms. D. told Ms. S. during their last session that she would truly miss their meetings, and that Ms. S., had become one of Ms. D.’s “special” clients.  For months after the termination of their professional-client relationship, Ms. D. found herself thinking about Ms. S. and fantasizing about having a friendship with her.  About six months after their working relationship terminated, Ms. D. decided to write Ms. S. a casual note on informal stationery, mainly to say hello and to wish Ms. S. well.  At the end of the note, Ms. D. wrote: “So, I hope this note finds you well and that you’re as content as you were when we last saw each other.  I have great faith in your ability to manage life’s challenges.  You really are very special to me.  I hope, somehow, we will be able to share time together in the future.  P.S.  Last week I saw Melanie.  I guess you know she’s having big problems again.  I gather she may have relapsed.  I hope this doesn’t affect you.”

 

 

Boundary issues arising from a practitioner’s emotional and dependency needs assume a variety of forms, including forming friendships with clients or former clients, engaging in personal self-disclosure to clients, communicating with clients affectionately, and deliberately interacting with clients in the context of community-based groups (for example, religious, cultural, or ethnic groups) or activities.

 

Friendships with clients. Occasionally, human service professionals establish such special rapport with clients that they enter into friendships with them.  Sometimes these friendships meet practitioners’ deep-seated emotional needs; they may be lonely or in the midst of a personal crisis, and the friendship with a “special” client may provide solace and important support.

 

As with sexual relationships between practitioners and clients, friendships between professionals and clients can be harmful.  Former clients who become a practitioner’s friend may wish to resume counseling to address new or reemerging issues in their lives.  The friendship between the parties likely would interfere with the practitioner’s ability to provide truly professional, unbiased, and impartial service.  Having to locate and initiate counseling with a new practitioner – starting all over again – again could be costly to the client both financially and emotionally.  Even practitioners with the best of intentions, and whose motives are beyond reproach, risk harming clients by confusing the boundaries with a friendship. 

 

Unconventional interventions.  A significant number of ethics complaints and lawsuits filed against behavioral health professionals allege boundary violations arising from a practitioner’s use of intervention approaches that are variously described as unconventional, nontraditional, and unorthodox.  In substantiated cases, evidence often shows that the practitioner introduced the unethical or negligent intervention in part to meet her or his own emotional needs. 

 

Problems potentially associated with interventions take two forms.  The first involves practitioners who have difficulty skillfully administering accepted or traditional innovation – issues of competence.  For example, practitioners who have not obtained formal training, certification, or supervision in the use of widely accepted clinical innovation – such as dialectical behavior therapy, narrative therapy, hypnosis, art therapy, or wilderness therapy – may exacerbate clients’ emotional conditions because of their unskilled use of these approaches.

 

The second form of high-risk interventions in behavioral health involves practitioners’ use of nontraditional or unorthodox clinical approaches that are not widely endorsed by the profession, are not based on solid empirically-based or other research evidence, and which may pose significant risks to clients.  Nontraditional interventions are those that do not conform to the long-established or inherited way of thinking or acting; unorthodox interventions are those that do not conform to the approved forms of practice in the profession. 

 

Practitioners’ use of nontraditional and unorthodox interventions often entails ambiguous or inappropriate boundaries and dual relationships.  Here are several examples:

 

Case examples

 

 

     Donald S. was a therapist in independent practice.  In his private life Donald S. was especially involved in spiritual pursuits, specifically the use of what he described as “spiritual guides and masters” who provide people with guidance in their personal lives.  In his clinical practice, Donald S. introduced the concept of spiritual guides and masters to one of his clients, Ted M., who was struggling with marital issues.  During the course of therapy, Donald S. assigned Ted M. a new spiritual name and arranged for Ted M. to accompany him to several out-of-town spiritual retreats.  Shortly after the pair terminated their professional-client relationship, Ted M. filed a lawsuit against Donald S. alleging that the clinical intervention harmed him emotionally.

 

     Nancy L. was a clinical director of a center that provided services to women.  She provided counseling services to Sally B., who struggled for many years with symptoms of major depression.  Sally B. had no family, was very isolated, and had little social contact.  She was sexually abused as a child and teenager by her stepfather.  During the course of their counseling relationship, Nancy L. invited Sally B. to her home for several dinners, gave Sally B. a number of moderately expensive gifts (e.g., scarves, costume jewelry), shared a motel room with Sally B. while the two of them attended a conference on trauma issues, and invited Sally B. to join her on a camping trip.  Several months after their professional-client relationship ended, Sally B. filed a complaint with the state licensing board alleging that Nancy L. engaged in unethical, harmful, clinical practice.  Nancy L. defended her clinical approach as being a legitimate form of “re-parenting therapy.”

 

     Leana T. was a clinician who specialized in the treatment of individuals with histories of major trauma such as sexual assault and domestic violence.  Leana T. also believed that physically cradling clients during therapeutic conversations could have “profound healing powers.”  During several counseling sessions, Leana T. cradled her client, Melinda B., as they talked about Melinda B.’s traumatic experiences in her family of origin.  Melinda B. later reported that she became confused about her relationship with Leana T. and had begun having romantic fantasies about her.  Melinda B. filed a lawsuit and an ethics complaint against Leana T. for negligent and unethical practice.

 

     Victor R. and Marla K. had a joint private practice in which they specialized in the treatment of children with reactive attachment symptoms.  Victor R. and Marla K. attended workshops to develop skills in the use of “rebirthing therapy,” which involves having the child and parent reenact and simulate the child’s birth in an effort to strengthen their bond.  Techniques included videotaping the “rebirth” that involves covering the child in blankets and pillows, meant to simulate the womb, and encouraging the child to push his or her way out. 

 

 

Several codes of ethics address practitioners’ use of novel, nontraditional, and high-risk interventions.  Here are relevant standards in the NASW Code of Ethics:

 

Social workers should provide services in substantive areas or use intervention techniques or approaches that are new to them only after engaging in appropriate study, training, consultation, and supervision from people who are competent in those interventions or techniques.  (standard 1.04[b])

 

When generally recognized standards do not exist with respect to an emerging area of practice, social workers should exercise careful judgment and take responsible steps (including appropriate education, research, training, consultation, and supervision) to ensure the competence of their work and to protect clients from harm.  (standard 1.04[c])

 

Self-disclosure.  When I conduct workshops related to boundary and other ethical issues, I often ask the audience of human service professionals how many of them have disclosed to clients personal information about themselves.  Typically, the majority raise their hands.  What the subsequent discussion reveals, inevitably, is that despite this common practice, professionals have widely varying opinions about the circumstances under which self-disclosure is appropriate, the extent to which personal details should be shared with clients, the content of appropriate self-disclosures, and the clinical ramifications.

 

In principle, self-disclosure may occur for a variety of reasons.  In some cases, practitioners may self-disclose in an effort to be helpful – for example, when a clinician attempts to empathize with a grieving client whose parent has just died by making a reference to his own experience when his parent died.  A clinician may believe sincerely that the client would benefit from the clinician’s carefully constructed and handled disclosure. 

 

In other circumstances, however, self-disclosure may occur inappropriately because of the practitioner’s own deep-seated emotional or dependency needs.  This may happen because of the clinician’s (perhaps unconscious) wish to establish a personal relationship with the client; sharing personal details may be a way to set this process in motion. 

 

In some instances a clinician may be so absorbed or overwhelmed by his or her own personal issues, perhaps as a result of problematic countertransference, that the clinician leaks personal information and details without recognizing that the leak is occurring or without a sense of its inappropriateness. 

 

Practitioner self-disclosure is clearly inappropriate in some instance and, handled judiciously and circumspectly, may be appropriate in others.  Realistically, some circumstances will always fall in a middle range that is difficult to assess; these are the cases in which thoughtful and reasonable practitioners may disagree, in part because of their different training and ideological orientations. 

 

Affectionate communications.  I have encountered a number of instances when a clinician decides to send a client or former client a warm, affectionate note.  Typically these messages are sent on personal stationery, not on professional letterhead.  In addition, the notes are usually handwritten rather than typed.  The practitioner’s choice of this informal style of communication in itself often sends a signal that the message is more personal than professional. 

 

Affectionate communications can occur for a variety of reasons, some of which seem quite appropriate and ethical and some of which do not.  Sending a client (or former client) a condolence note following the death of someone close to the client is an example of a warm, informal message that most practitioners would consider appropriate.  Sending such a message on agency letterhead may be unnecessarily and insensitively cold and stiff.

 

In other instances, however, warmly and affectionately worded notes on personal stationery may communicate to a client that the practitioner is interested in something other than a professional-client relationship.  Even a gesture as seemingly innocuous as sending a client a holiday card can be problematic.  On the surface, it may appear that the card is sent as a reflection of social custom.  However, some clients may interpret from this message – particularly if the return address reveals that the card was sent from the practitioner’s home – that the practitioner is treating the client as special and is interested in more than a professional relationship.  In fact, in some cases this is an accurate conclusion on the client’s part.  The holiday card may be an indirect and relatively subtle – and not always conscious – way for the clinician to address his or her emotional needs and wish to connect with a particular client on more than a professional level. 

 

Community-based contact with clients.  Human service professionals often encounter clients in the community.  This may occur by happenstance – for example, when a practitioner and a client encounter each other unexpectedly in the supermarket aisle or at a local athletic event – or, more predictably, for example, when practitioners and clients learn that they are members of the same community-based group or religious community and can expect to run into each other at social events. 

 

Certainly, it is reasonable for practitioners to want to pursue their personal community activities without being constrained by their relationships with clients.  Ideally, practitioners’ and clients’ personal worlds would not intersect.  Realistically, however, we know that for most practitioners community-based encounters with clients are inevitable, particularly in smaller communities. Although such encounters may not occur frequently, they can be laden with meaning and potential repercussions.  At times it may be necessary for practitioners to protect clients and avoid inappropriate dual relationships by referring clients, when feasible, to other providers. 

Practitioners can also protect clients by talking with them, early in the relationship, about how they must maintain clear boundaries and how they can manage inadvertent or inevitable social encounters.  Although these steps do not provide a simple, guaranteed solution to all complicated circumstances, the process can help minimize harm and help practitioners comply with prevailing ethical standards.

 

Practitioners embark on dual relationships for various reasons.  Some boundary problems reflect clear exploitation and manipulation to satisfy the practitioner’s self-centered and prurient interests.  Others reflect a practitioner’s more subtle emotional and dependency needs, which produce dual relationships characterized by, for example, forming friendships with clients or former clients, interacting inappropriately with clients in the context of community-based groups or activities, engaging in excessive personal self-disclosure to clients, and sending clients affectionate written communications.

 

Preventing boundary problems associated with a practitioner’s emotional and dependency needs requires diligent and sustained efforts by the practitioner to constantly examine her or his motives and intentions when behaving in ways that are not consistent with prevailing clinical and ethical standards.  Practitioners must be willing and able to examine their actions in a constructively critical way and be open to feedback from colleagues and supervisors.  To use the language of the trade, practitioners must be exceedingly skilled in their “use of self.”

 

Personal Benefit

 

Some boundary and dual relationship issues emerge because of pragmatic concerns, specifically, the possibility that the practitioner’s relationship with the client could produce tangible, material benefits or favors for the practitioner beyond simple monetary payment for services rendered.  Some such dual relationships arise from relatively benign motives – for example, when a client with specialized knowledge or expertise offers to help a practitioner with a personal challenge (perhaps related to a health problem or automobile repair) – and some arise from more sinister motives – for example, when a practitioner attempts to exploit a client for material gain.           

 

Specific examples of dual relationships that have a personal benefit theme involve bartering for services, entering into business and financial relationships with clients, seeking advice or services from clients, accepting favors or gifts from a client (including client bequests), and engaging in self-interested conflicts of interest (for example, paying for referrals and soliciting clients).  Here are illustrative case examples: 

 

 

Case examples

 

 

     Donna N. was the director of an outpatient substance abuse counseling program.  Most of the agency’s clients did not have health care insurance to pay for their treatment.  For many years Ms. N. had successfully applied for foundation and government-agency grants to subsidize the cost of services for these clients.  Unfortunately, most of these funds had dried up and Ms. N. was finding it more and more difficult to serve low-income clients.  Ms. N. designed a new bartering program in an effort to provide substance abuse treatment services to people who cannot afford to pay for services.  Under the terms of the program, participants can perform concrete services for the agency – such as raking leaves, building maintenance, washing windows, and various clerical tasks – in exchange for clinical services.
 

     Martin F. was the program director of a residential drug and alcohol treatment facility.  Mr. F. believed that it is important to employ some staffers who are in recovery, in an effort to provide clients with helpful role models and with staff who can empathize with clients’ experiences.  Mr. F. hired two of the agency’s former clients to work as case managers.  He was delighted that he did not need to conduct a comprehensive search outside the agency, which would have been very time consuming.  One of the former clients had been a resident at the facility about eighteen months before being hired.  The second former client had been a resident at the facility about a year before being hired.  Both employees met or exceeded the posted job requirements.
 

     Diane P. was a counselor in a small group practice.  One of Ms. P.’s clients was a fifty-two-year-old man, Allen F., who was coping with what he described as “your all-purpose, predictable midlife crisis.”  Mr. F. explained to Ms. P. that he was “just plain tired of getting up in the morning and repeating the rhythm of yesterday, and the day before, and the day before, and . . . oh, you get the idea.  I really need a fresh challenge, something that would make me want to jump out of bed in the morning.”  During counseling sessions, Mr. F. and Ms. P. spent time talking about what was holding Mr. F. back from pursuing his dream of a major change.  After several months of exploration, Mr. F. reported to Ms. P. that he had finally settled on a new and exciting venture: Mr. F. was planning to work with a local consultant he had met to design and inaugurate an Internet-based business that makes texts available to college students electronically.  Mr. F. described how excited he was and the terrific financial returns he expected from this cutting-edge venture.  Mr. F. explained that he would need to spend several months recruiting a handful of investors who would likely enjoy a remarkable return on their initial minimum investment of $25,000.  Mr. F. then paused and asked whether Ms. P. might be interested in “getting in on this wonderful opportunity at the front end.”  Ms. P. said that she would like to take some time to think about the offer.  In fact, Ms. P. had become quite interested recently in investing some of her money outside the traditional stock market.

 

 

As noted earlier, many of the boundary challenges that arise because of the possibility of personal benefit for the practitioner involve bartering for professional services, entering into business and financial relationships with clients, seeking advice or services from clients, accepting favors or gifts from a client, and engaging in self-interested conflicts of interest. 

 

Barter for services.  The majority of clients (or their insurance providers) pay fees for social services, but in a relatively small number of cases a practitioner participates in a barter arrangement when a client is unable to pay for services and offers goods or services as a substitute.  Bartering also occurs in some communities that have established norms involving such nonmonetary exchange of goods and services.

 

On the surface, barter may not seem to pose ethical problems if the parties participate willingly.  In actuality, though, barter may lead to troubling ethical questions (not to mention complicated issues when independent practitioners file their tax returns).  Negotiations about the fair market value of the goods or services to be exchanged and, in particular, about the handling of defects in a product or service can interfere with the professional-client relationship in a way that is harmful to the client.  In addition, the services the practitioner provides may be determined in whole or in part by the market value of the goods or services provided by the client rather than by the client’s clinical needs.  Especially because the client may be dependent on the practitioner, and because of the unequal power in their relationship, the client may be vulnerable to exploitation, conflicts of interest, and coercion. 

 

Practitioners are in some disagreement about the extent to which barter arrangements in the human services should be permitted.  Some practitioners are clearly opposed to barter.  Other practitioners, however, argue that barter is ethical, particularly in communities where it is an accepted practice (for example, where farmers in rural areas exchange produce for plumbing or electrician services). 

 

Professional ethics codes provide some guidance on this issue.  For example after much discussion the NASW Code of Ethics Revision Committee concluded that categorically prohibiting barter arrangements between social workers and clients would be inappropriate.  Rather, the committee took the position that social workers should avoid bartering and that they should accept goods or services from clients as payment for professional services only in limited circumstances:

 

Social workers should avoid accepting goods or services from clients as payment for professional services.  Bartering arrangements, particularly involving services, create the potential for conflicts of interest, exploitation, and inappropriate boundaries in social workers' relationships with clients.  Social workers should explore and may participate in bartering only in very limited circumstances when it can be demonstrated that such arrangements are an accepted practice among professionals in the local community, considered to be essential for the provision of services, negotiated without coercion, and entered into at the client's initiative and with the client's informed consent.  Social workers who accept goods or services from clients as payment for professional services assume the full burden of demonstrating that this arrangement will not be detrimental to the client or the professional relationship. (standard 1.13[b])

 

Practitioners who are considering barter arrangements should carefully address several questions.  First, to what extent are such arrangements an accepted practice among professionals in the local community?  The widespread local use of barter can strengthen a practitioner’s contention that this was an appropriate practice in a particular case.  Second, to what extent is barter essential for the provision of services?  Is it used merely because it is the most expedient and convenient form of payment available, or is it the only reasonable way for the client to obtain needed services?  As a general rule, barter should be a last resort, used only when more conventional forms of payment have been ruled out and only when it is essential for the provision of services. 

 

Third, is the barter arrangement negotiated without coercion?  Practitioners should not pressure clients to agree to barter.  For example, a client may agree reluctantly to give a practitioner a valuable jewelry item that the client’s business manufactures primarily because the practitioner has commented on how much he or she would like to own such an item; in this situation, the client may feel pressured.  Clients who agree to participate in a barter arrangement must do so freely and willingly, without any direct or indirect coercion from the practitioner.  Fourth, was the barter arrangement entered into at the client’s initiative and with the client’s truly informed consent?  To avoid coercing clients or the appearance of impropriety, practitioners should not take the initiative to suggest barter as an option.  Such suggestions should come from clients.  Practitioners who decide to barter should explain the nature and terms of the arrangement in clear and understandable language and discussion potential risks associated with barter (for example, how the professional-client relationship could be adversely affected, particularly if the goods or services provided by the client in exchange for the professional’s services prove to be defective), reasonable alternatives for payment (for example, a reduced monthly payment rather than a single payment in full), the client’s right to refuse or withdraw consent, and the time frame covered by the consent. 

 

Business and financial relationships.  In a relatively small percentage of cases, human service professionals are accused of entering into inappropriate business and financial relationships with clients.  This can occur in several ways.  First, clients sometimes raise issues in counseling about their own financial conditions and futures.  Some clients are in financial distress and send out signals that they are eager for assistance.  For a practitioner to respond instantaneously with the offer of a loan would be highly unusual, but practitioners who have crossed boundaries with a client for other reasons or in other way – for example, to pursue a friendship or romantic relationship – may end up lending a client money as part of the broader dual relationship. 

 

In other situations, a practitioner may encounter a client who is in counseling to think through a midlife career change that involves establishing a new business that requires venture capital.  From this conversation may come a client’s invitation for the counselor, for whom the client feels great appreciation, to invest in this new opportunity.  Finally, on occasion practitioners who are experiencing their own personal financial problems have disclosed this fact (inappropriately) to clients of means, hoping – perhaps unconsciously – that the client would offer to help the practitioner out financially. 

 

What these various scenarios have in common is the blurring of boundaries and the possibility of client exploitation.  Introducing financial transactions into the professional-client relationship has great potential to distract both practitioners and clients from the social service agenda with which they began their work, compromise clients’ interests, and introduce conflicts of interest (where the practitioner’s judgment and behavior are affected by the business and financial concerns).  Such transactions can also expose practitioners to legal risk – for example, when a client files an ethics complaint against the clinician with a disciplinary board or sues the practitioner, alleging that the professional unduly influenced or manipulated the client for self-interested purposes. 

 

Advice and services.  Professionals sometimes provide services to clients who have expertise from which the professionals themselves might benefit.  This can happen under two sets of circumstances.  The first occurs when a practitioner faces personal problems and challenges that might be addressed by using a client’s expertise (for example, when a client is a physical therapist, plumber, or architect who may be able to help the practitioner resolve a problem).  The second circumstance occurs when a practitioner is eager to draw on a client’s expertise, not so much to address a problem but to enhance the quality of the practitioner’s life (for example, when a client who is a financial advisor offers to provide the counselor with retirement planning advice). 

 

Accepting advice or services from clients has the potential to create boundary confusion.  Over time, human service professionals may begin to feel indebted to their clients or eager for specialized treatment from them; this may cloud the practitioner’s judgment and, ultimately, lead to the perception of compromised care, actual compromised care, conflicts of interest, exploitation, and other forms of ethical misconduct and negligence. 

 

Favors and gifts.  Unique boundary issues sometimes emerge when clients offer gifts or special favors to human service professionals.  A client’s presentation of a gift to a practitioner is a particularly complex issue. Clearly, some clients offer practitioners gift –often modest in value – as genuine expressions of appreciation, with no ulterior motive or hidden agenda.  Examples include clients who give the practitioner a plate of home-baked cookies at holiday time, an infant’s outfit when the counselor has had a baby, or a handmade coffee mug at the conclusion of treatment.  Typically, these gifts represent tokens of appreciation – nothing more and nothing less.  The client would likely feel wounded or insulted if the professional rejected such a gift on ethical grounds.  In contrast, however, are more complicated situations, involving clients who offer practitioners gifts of considerable value or gifts that represent a more complex practitioner-client relationship (sometimes from the client’s view, sometimes from the practitioner’s, and sometimes from both). 

 

Most practitioners agree that in many instances – when there is no evidence of ulterior motives that might lead to egregious boundary violations – human service professionals may keep gifts of modest value.  Some social service agencies permit staff to do so, although they may stipulate that staff members must thank the clients on behalf of the agency.  That is making it clear that the gift will be shared with the agency’s staff at large can defuse the interpersonal dynamic and potential boundary confusion between the client and practitioner; this depersonalization of the transaction may help staff members to avoid complicated boundary issues.

 

Practitioners face unique challenges when they receive gifts that appear to have no ulterior motive but could introduce complex boundary issues.  Sometimes clients may not be consciously aware of the emotional meaning and significance – and the mixed messages and complications – that may be attached to a gift.  Practitioners sometimes face double-edged swords in these situations: a decision to reject a gift can have significant clinical repercussions – because the client may feel hurt, wounded, humiliated, or guilty – and a decision to accept a gift may trigger boundary issues that complicate and reverberate throughout the clinical relationship.  In such circumstances, practitioners are wise to obtain sound consultation and supervision to think through how best to handle the client’s gesture, including assessing the apparent (and perhaps not so apparent) meaning behind the gift, the ethical and clinical implications, the potential responses and related consequences, and any risk-management issues (related to potential ethics complaints and lawsuits).

 

The AAMFT ethics code includes a specific standard on the issue of accepting gifts:  “Marriage and family therapists do not give to or receive from clients (a) gifts of substantial value or (b) gifts that impair the integrity or efficacy of the therapeutic relationship” (standard 3.10).   The ACA code is more explicit: “Counselors understand the challenges of accepting gifts from clients and recognize that in some cultures, small gifts are a token of respect and showing gratitude. When determining whether or not to accept a gift from clients, counselors take into account the therapeutic relationship, the monetary value of the gift, a client's motivation for giving the gift, and the counselor's motivation for wanting or declining the gift” (standard A.10.e).

 

Similar issues can arise when clients offer meals to practitioners who provide in-home services.  Typical examples include practitioners employed by home health care agencies and programs that provide in-home services for high-risk families (for example, family preservation programs that provide intensive in-home services for families following allegations of child abuse or neglect).  It is not unusual in these situations for practitioners to visit a home at mealtime and to be invited to join the family at the table.  In many cultures, however, sharing a meal – breaking bread – is a socially significant and somewhat intimate event.  Some family members may view the sharing of a meal as a signal that their relationship with the practitioner has moved to a new plane, one that entails social as well as professional purposes.  The dynamics can be especially complicated when the family belongs to a particular ethnic or cultural group that attaches great meaning and symbolic significance to such invitations.  Members of some cultural groups may be hesitant to trust a practitioner who is unwilling to break bread with the family; the practitioner’s willingness to eat with family members may be an important signal that the practitioner accepts them.  A practitioner who (presumably politely and diplomatically) rejects the family’s meal invitation risks insulting the family, hurting its members’ feelings, and so on.  Here, too, discussion with colleagues and staff in advance and in anticipation of such invitations can provide critically important preventative maintenance.  Role playing such scenarios as part of agency in-service training can be valuable.  In one family preservation program, for example, staff members concluded that in some instances they could finesse the situation by saying they were not particularly hungry but would be happy to have a cup of tea or coffee, a gesture that tends to be far less culturally significant but that may help establish and preserve comfortable relationships with clients.  With families that are more insistent, practitioners may need to explain that their employer or their profession’s ethical standards prohibit this kind of activity.

 

In some contexts, sharing a meal with a client may be entirely acceptable.  This would occur in programs where staffers are expected, as part of their intervention approach, to provide services to people outside a formal office setting, perhaps at a residential facility or in a program that provides at-risk teens with independent living skills.  In these instances, widely accepted standards and practices in the human services would permit sharing meals with clients.

 

Sometimes practitioners offer clients intangible favors, as opposed to tangible gifts.  Examples include an invitation for the practitioner to attend the client’s holiday party or to contact the client’s relative who specializes in repairing the kind of automobile transmission trouble that the practitioner mentioned when he or she was late for a scheduled appointment.  The clinical and ethical issues are similar, with one significant exception: tangible gifts that the practitioner and her or his colleagues are inclined to accept – because of the negative clinical ramifications their refusal might entail – can be accepted by the agency instead, to minimize boundary complications between the client and the individual practitioner.  This is not possible with offers that involve intangible benefits.

 

As in any case in which a client offers a practitioner a gift or favor, professionals must carefully examine the potential for significant boundary problems, in the form of either boundary violations or boundary crossings.  Most practitioners are likely to agree that if a client offers to get his cousin to provide the practitioner with a “special deal” on his automobile repair, the practitioner should thank the client and explain that he or she has a regular mechanic who will address the problem (assuming that is true).  If the client persists, the practitioner might consider explaining why his or her profession discourages practitioners from doing business with clients’ relatives or close acquaintances; many clients can understand the concept of boundaries, particularly if the practitioner explains it clearly.  As with barter arrangements, practitioners who conduct business transactions with clients’ relatives or close acquaintances open the door for boundary problems, particularly if any dispute arises in regard to the goods or services involved in the transaction.  Most clients will accept these responses and explanations. 

 

Similarly, practitioners expose themselves to considerable risk if they accept a client’s invitation to attend a social event or to use a client’s personal property for vacation or other social purposes.  Although in rare instances a practitioner’s attendance at a social event may offer therapeutic benefits for the client, in general practitioners are likely to introduce significant boundary complications if they accept.  A client can easily misconstrue the practitioner’s attendance. 

 

Whenever a practitioner seriously considers accepting a gift or favor from a client – of whatever value or tangibility – the practitioner should consult with thoughtful colleagues and supervisors and critically examine the clinical and ethical implications (including current ethical standards and agency policy), the client’s and practitioner’s motives, any alternatives, and so on.  The practitioner should carefully document in the case record the client’s offers, the process the practitioner used to make the decision (for example, collegial consultation and review of ethical standards), the nature of the decision, and the rationale.  This documentation can prove to be enormously helpful if the client or some other party raises questions about the appropriateness of the professional’s decision.

 

Conflicts of interest.  One principal risk associated with dual and multiple relationships concerns conflicts of interest from which practitioners may benefit.  Conflicts of interest occur when a professional’s services to or relationship with a client (or former client or other pertinent party) are compromised, or might be compromised, because of decisions or actions in relation to another client, a colleague, the professional, or some other third party. 

 

Conflicts of interest in behavioral health can take several forms.  They may occur in the context of practitioners’ relationships with clients or in their role as supervisors, consultants, or administrators.  Practitioners must be careful to avoid conflicts of interest that might harm clients because of their decisions or actions involving other clients, colleagues, themselves, or third parties.  Examples include practitioners who are named in a client’s will, have a financial interest in other service providers to which they refer clients, pay referral fees to colleagues, accept a referral fee, sell goods to clients, and solicit clients. 

 

As with most ethical issues, no single standard provides clear-cut guidance.  In some instances, conflicts of interest are so blatant that they leave little or no room for discussion – for example, when practitioners refer clients to colleagues based on financial incentives offered by these colleagues, encourage clients to purchase profitable products from them, or extend treatment beyond what is clinically necessary in order to enhance their income from clients or third-party payers.  Other instances leave room for legitimate debate – for example, whether practitioners employed in an agency should be permitted to establish a part-time private practice within the same city or county, and to what extent it is appropriate for practitioners to rely on clients for research that is not likely to benefit the clients themselves. 

 

Professional codes of ethics also comment on conflict-of-interest issues involving solicitation of clients.  According to the NASW Code of Ethics, “social workers should not engage in uninvited solicitation of potential clients who, because of their circumstances, are vulnerable to undue influence, manipulation, or coercion” (standard 4.07[a]).  According to the APA Code of Ethics, “If it becomes apparent that psychologists may be called on to perform potentially conflicting roles (such as family therapist and then witness for one party in divorce proceedings), psychologists take reasonable steps to clarify and modify, or withdraw from, roles appropriately” (standard 10.02[b]).   The issue is also addressed in the AAMFT code: “Marriage and family therapists do not provide services that create a conflict of interest that may impair work performance or clinical judgment” (standard 3.3).

 

In summary, when potential conflicts of interest arise, professionals have an obligation to be alert to and avoid actual or potential conflicts that might interfere with the exercise of their professional judgment.  Practitioners should resolve the conflict in a manner that makes the client’s (or potential client’s) interests primary and protects the client’s interests to the greatest extent possible.

 

Altruism

 

A number of boundary issues arise because of practitioners’ genuinely altruistic instincts and gestures.  The vast majority of human service professionals are caring, dedicated, and honorable people who would never knowingly take advantage of clients.  Ironically, practitioners who are remarkably generous and giving may unwittingly foster dual and multiple relationships that are counterproductive and harmful to the parties involved.  In my experience, the most common boundary issues related to altruism involve giving gifts to clients, meeting clients in social or community settings, offering clients favors, accommodating clients’ unique needs and circumstances, and disclosing personal information to clients.  Here are examples: 

 

 

Case examples

 

 

     Allison P., seventeen, was a client in a residential program for youths and in the custody of the county child welfare department.  Allison was placed in the program after her single mother was sentenced to a long prison sentence for selling drugs.  Allison did not have other relatives with whom she could live.  The program was designed to provide youths in similar circumstances with a variety of educational and social services, including preparation for independent living.

 

After ten months in the program, Allison was ready to move into her own subsidized apartment.  Staff members had worked diligently with her so that she would have the knowledge and skills to live on her own.  Allison was proud of her accomplishments; she invited her primary counselor at the program, Melanie N., to come to her new apartment during the open house Allison had scheduled for the following weekend.  Ms. N. very much wanted to go to Allison’s new home but was unsure whether such a visit would be appropriate.  In addition, Ms. N. was unsure whether she should give Allison a modest housewarming gift (for example, a scented candle or kitchen utensil) if she did attend.  

 

     Tessa L., a counselor in private practice, provided therapy to a college student who reported feeling depressed after the death of her parents in a plane crash.  The counseling lasted for about sixteen months while the client was in college.  Following her graduation, the former client accepted a position as a case manager at a local domestic violence shelter.  One year later, the client applied to graduate school in social work and eventually received her master’s degree.  Shortly thereafter, the former client contacted her former therapist, Ms. L., and asked whether she would be willing to provide the weekly supervision that the former client needed as she worked toward obtaining her license as a clinical social worker. 

 

     Eric C., a counselor in a grade school, provided counseling services to a 12-year-old sixth grader.  The boy’s teacher referred him to Mr. C. because the boy seemed withdrawn and socially isolated.  Mr. C. spent time working with the student on self-esteem issues and relationship skills.  The young boy was also beginning to experiment with drugs.  In his spare time, Mr. C. volunteered as a Boy Scout troop leader.  Mr. C. considered inviting his client join the troop, in an effort to help the boy make friends and have a positive social experience. 

 

 

 

Giving gifts to clients.  At first blush, it may appear that behavioral health professionals should not give clients gifts under any circumstances, even with the most altruistic of motives.  After all, clients may easily misinterpret even a modest gift as a message that are in some special, perhaps exalted, relationship with the practitioner that entails some nonprofessional dimension.  Gifts often imply friendship and, at times, intimacy.  Gifts can lead to confusion about the nature of the client-professional relationship.  In some instances a practitioner may give a client a gift as a way to communicate the practitioner’s interest in developing an intimate relationship.  In other instances, gifts from a practitioner to a client may reflect the practitioner’s inappropriate emotional dependency on the client.

 

A practitioner may, however, encounter occasional circumstances where a modest gift seems appropriate, perhaps as a humane gesture in response to a client’s illness or a major life-altering event that was addressed in treatment.  In such situations, especially when the client may be relatively alone in the world, a modest get-well card or socially appropriate gift may seem innocuous. 

 

Even though many altruistic gestures in the form of a modest gift are completely benign on the surface, practitioners should always consider potential negative ramifications, particularly with respect to the possibility that the client will misinterpret the gift’s meaning.  When practitioners sense confusion could arise, they should seek collegial consultation and supervision and consider constructive risk-management strategies designed to protect both client and practitioner.  Simple risk-management steps can prevent negative outcomes.  For example, the practitioner should document in the client’s record any consultation with colleagues or supervisors and the rationale for giving the gift.  In a program that teaches high-risk adolescents how to live independently, a practitioner may consider giving a client a modest gift (a set of basic kitchen utensils, for instance) when the client graduates from the program and moves into his first apartment.  The gift card can indicate that the gift is from the program’s staffers or the agency, rather than the individual practitioner; this can help to prevent misunderstanding surrounding the client’s relationship with the individual practitioner.  This kind of gift may seem appropriate in light of the program’s unique mission and the client’s noteworthy rite of passage in relation to program goals.

 

Meeting clients in social or community settings.  Earlier I discussed how human service professionals might become involved in dual relationships with clients in community settings and social circumstances as a result of their emotional and dependency needs.  These situations involve issues that arise when practitioners have difficulty separating their professional duties from their personal relationship needs and wishes (for example, when practitioners accept a client’s invitation to a social event because the event fills a void in the practitioner’s personal life or provides the practitioner with an opportunity to pursue a personal relationship with the client).

 

In contrast, practitioners are sometimes inclined to have contact with clients in social or community settings for more genuinely altruistic reasons.  In these situations – for example, when a clinician wants to accept a client’s invitation to attend the client’s wedding or graduation in order to be emotionally supportive – the practitioner’s motivation is a sincere wish to be helpful and supportive to the client.  Yet this admirable altruism may trigger complicated boundary issues.  Skillful handling of these circumstances is necessary to avoid harming the client and exposing the practitioner to ethical and liability risks.  This phenomenon is highlighted in the ACA ethics code:

 

Counselor–client nonprofessional relationships with clients, former clients, their romantic partners, or their family members should be avoided, except when the interaction is potentially beneficial to the client.  (standard A.5.c)

 

When a counselor–client nonprofessional interaction with a client or former client may be potentially beneficial to the client or former client, the counselor must document in case records, 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. Such interactions should be initiated with appropriate client consent. Where unintentional harm occurs to the client or former client, or to an individual significantly involved with the client or former client, due to the nonprofessional interaction, the counselor must show evidence of an attempt to remedy such harm. . . . (standard A.5.d)

 

I have found that boundary issues that emerge because of practitioners’ altruistic instincts are especially likely in programs that provide home-based services.  Examples include intensive home-based intervention programs for families facing crises (for instance, as a result of substance abuse or allegations of child neglect) as well as those provided by hospices and visiting nurses.  In these situations, practitioners must be careful to avoid boundary problems and inappropriate dual relationships, because they are working with clients in very personal, private, casual, somewhat intimate, and informal surroundings.  Although formal office settings may have some drawbacks, they do convey to clients that what takes place within the office walls has a professional purpose, and this can help to reduce boundary violations and crossings.  Home settings, however, do not automatically convey that message.  In fact, the informality and intimacy of these settings can be the incubator for boundary confusion and problems.  Some clients may experience some interactions in their homes as personal rather than professional.

 

Imagine, for example, a clinician who provides intensive home-based counseling services to a family.  One day the clinician arrived at the family’s home at noon on a Saturday, just as the family was about to have lunch.  The father invited the clinician to join them.  When the clinician hesitated, the father politely insisted that the clinician take a few minutes to eat with the family before they got down to their work together.

 

In this situation, the practitioner may be tempted to accept the family’s invitation to dine, not because the clinician is hungry (which may be true) but because he does not want to offend the family and wants to respond to the warm offer in a courteous way that signifies his regard for the family.  Ultimately, the clinician may think, this will strengthen the therapeutic relationship and the effectiveness of his intervention approach, particularly since the family has been hesitant to collaborate with the clinician.  In fact, the invitation to join the family for the meal may be clinically and culturally significant, a signal that the family is ready to engage with the clinician. 

 

At the same time, sitting with a family and breaking bread may communicate to the family that its relationship with the practitioner has moved to a new plane, one that involves a social as well as a professional relationship.  This may be particularly problematic because the practitioner’s report and recommendations about the family’s progress in treatment will have a direct bearing on the parents’ ability to maintain custody of their children.  Confusion about boundaries in this set of circumstances can be especially consequential, because the family may be upset with the practitioner’s recommendations.  Family members may feel particularly betrayed if they had begun to sense that the practitioner was their “friend,” in part because the practitioner socialized with the family during lunch.  This is another example of a situation in which the practitioner may need to use great finesse to avoid insulting the family and avoid boundary confusion.  One possibility would be for the practitioner to explain that he just ate or is not particularly hungry, assuming this is true.  Accepting a cup of coffee may be a way to defuse the situation.

 

Offering clients favors.  Now let’s extend this example to make an additional point about the untoward consequences of altruistic actions that can result when practitioners offer clients favors.  Let’s suppose that about fifteen minutes before the practitioner’s planned departure from the home, the mother takes a telephone call and finds out that her employer is insisting that she immediately come to work at her job at a nearby hospital to fill in for a colleague who called in sick.  The family does not have a working car and, aware that the practitioner is planning to head back to his agency, which happens to be located two blocks from the hospital, the mother asks the practitioner whether he would be willing to give her a ride.  The practitioner wants to be helpful, yet he is also uncomfortable about establishing a precedent that involves spending informal time with a client outside the treatment context.  The practitioner is concerned that the mother – and perhaps other family members – will interpret this altruistic gesture as a sign that the practitioner has a special relationship, resembling a friendship, with the family.  Given the circumstances, the practitioner is not in a position to consult with colleagues or a supervisor.  He has to make a spontaneous decision.

 

Clearly, refusing the woman’s request could be awkward and, in fact, doing so could ultimately undermine the practitioner’s therapeutic relationship with the family.  In addition, the practitioner’s agency may prohibit staff members from transporting clients, which would provide the practitioner with a convenient way out.  Absent this convenient explanation and weighing all the competing factors, the practitioner may feel the need to provide the woman with the ride.  To prevent misunderstanding and to protect himself, however, the practitioner should talk with the client about how this is an unusual situation and not a precedent.  The practitioner consider entering a note along these lines in the case record as well, so his motives and reasons for offering the client a ride are clear.

 

Some altruistic gestures toward clients are unlikely to create significant or problematic boundary problems.  For example, the clinician who decides to purchase a roll of wrapping paper from her client who is raising money for her church is not likely to stir up complex boundary issues that would harm the client or lead to an inappropriate dual relationship.  Formulating an ambitious risk-management strategy in this situation would be gratuitous.  In contrast, however, several of these situations are much more likely to lead to boundary problems.  A counselor who agrees to be in his client’s wedding party, a social worker who permits a former client to live in his home temporarily while the client searches for permanent housing, a psychologist who agrees to counsel an acquaintance who is a former neighbor, and a social worker who agrees to actively help her client explore the social worker’s religion are practitioners who are – perhaps inadvertently – creating greenhouse-like conditions for what could well become complex boundary problems.  We can anticipate that the clients in these scenarios could easily become confused about the nature of their relationship with their practitioner.  The line between professional and friend or social acquaintance is likely to seem blurry to both client and practitioner.  In turn, this confusion could undermine the practitioner’s ability to provide competent care and the client’s ability to benefit maximally from the professional’s services.  Clients in these circumstances are likely to perceive and relate to their practitioners differently because of the extraprofessional contact.  The former client who lives in the practitioner’s home may see sides of the practitioner that are unnerving or disturbingly inconsistent with the client’s earlier perception of the practitioner – for example, if the client were to observe the practitioner having difficulty handling conflict with his spouse or children.  The social worker who counsels an acquaintance may unwittingly harm the client because of the social worker’s reluctance to constructively confront the acquaintance on an important issue related to the therapy.  The counselor who joins his client’s wedding party may stimulate all manner of counterproductive fantasies in the client about their budding friendship.

 

Although some altruistic gestures are clearly benign or harmful, others are ambiguous.  Practitioners may disagree, for example, about the appropriateness of a marriage therapist’s decision to visit his hospitalized client, a psychiatrist’s decision to meet briefly and informally with a former patient who stopped by his office to “reconnect,” and a social worker’s decision to provide supervision to a former client who is now a colleague.  Some would argue, for example, that a brief visit to a hospitalized client, or a brief encounter in the office with a former client, could have profoundly beneficial therapeutic consequences that far outweigh any associated risks.  At the same time, others would argue that these apparently innocuous, altruistic gestures could be harmful.  In these more ambiguous circumstances, practitioners should think carefully about the factors that may increase the risk of misunderstanding, such as the client’s clinical profile, the client’s ability to handle boundary issues, the practitioner’s personality, the strength of the therapeutic alliance, and the practitioner’s experience.

 

Accommodating clients.  In some instances, human service professionals encounter boundary issues because of their earnest attempt to accommodate a client’s unique request or circumstances.  These accommodations typically take the form of providing extraordinary service to the client (or former client) in an effort to be helpful. 

 

As with offering clients favors, efforts to accommodate a client’s unique circumstances require that human service professionals critically examine whether doing so is advisable.  Some accommodations are clearly inappropriate, and some are relatively benign.  For example, most practitioners would not object if a colleague agreed to provide a terminally ill, bedridden client with counseling in the client’s home, even though all previous counseling sessions had occurred in the professional’s office.  This accommodation seems reasonable in light of the client’s unfortunate circumstances.  In contrast, providing clinical services to acquaintances and members of the practitioner’s husband’s church, where he serves as minister, could very well lead to harmful boundary issues.  Circumstances may arise where the practitioner and her husband are unsure whether to share with each other critically relevant confidential information about the client – for instance, if the client shares information with the wife about illegal activities taking place in the church’s business office.  Also, clients who share deeply personal information with the minister’s spouse may feel overexposed and worried about whether their minister will learn of these sensitive details.

 

Similarly, a young client who plays on the basketball team coached by his social worker in a small community may encounter boundary problems.  For example, suppose the boy and the coach’s son, who also plays on the team, become friendly, and the coach’s son – who is not aware that his new friend is his father’s client – invites the client to sleep over at his house.  The social worker may end up in a situation in which one of his clients spends considerable social time at the social worker’s home and participates in family events.  This scenario is likely to confuse the client about the nature of his relationship with the social worker and could undermine his counseling experience.  One might also wonder whether detrimental consequences might result if, for instance, the basketball team is playing well and the coach (the social worker) benches his client “for the good of the team.”  The boy could be deeply wounded by being pulled out of the starting lineup and may experience this as a form of rejection by his social worker.  Clearly, these situations can produce conflicts of interest for the parties involved.

 

Unique issues can also arise in relation to accommodating former clients.  One particularly challenging case I encountered involved debate among community mental health center staff members about whether to hire former clients who applied for jobs in their agency as case aides.  The agency’s administration asked me to facilitate their meeting and to help guide their discussion about the ethical dimensions of their internal disagreement about what policy made the most sense.  This experience provided me with an opportunity to explore for myself the pertinent boundary issues and the arguments for and against hiring former clients.  The process the staff and I went through provides a good example of the benefits of sound procedures and decision making.  At the beginning of the meeting, the staff was almost evenly divided on the issue – half were opposed to hiring former clients, largely because of potential boundary problems, and half favored hiring former clients, mainly because of the agency’s empowerment approach to the delivery of mental health services.  In an effort to address this issue thoroughly and comprehensively, I acquainted staffers with the concept of dual relationships and prevailing ethical standards.  I then helped them identify arguments in favor of hiring former clients.  First, as mentioned earlier, hiring former clients is a way to empower clients with mental illness and acknowledge the unique and valuable contributions they can make to others who are coping with somewhat similar issues; after all, who can better understand what current clients are experiencing in their efforts to cope with mental illness?  Also, recognizing clients as “equals” is a less elitist, paternalistic, and hierarchical way to provide mental health services and is more likely to promote client growth, self-esteem, and self-confidence than some traditional processes.  In addition, hiring former clients can provide current clients with valuable role models – that is constructive examples of colleagues who have struggled and coped well with their mental illness.  Finally, staffers could not ignore the implications of the Americans with Disabilities Act, which prohibits discrimination in the workplace; certainly staff members would not want to refuse to hire former clients in a way that violated their legal rights. 

 

The mental health agency staff and I then turned our collective attention to a variety of concerns associated with hiring former clients, related primarily to potential – although admittedly not inevitable – dual relationship and boundary problems.  For example, staffers wondered whether former clients might encounter problematic transference issues as they attempted to relate to former treatment providers who are now colleagues.  Would it be difficult for the former clients to relate to their former treatment providers as genuine colleagues, in light of their previous professional-client relationships?  Of course, staff members might experience a comparable challenge, finding it difficult to relate to former clients as colleagues and, for instance, being unsure how candid they should be when expressing their views in staff meetings.  Also, what would it mean for former clients to learn, as a result of their new employment status in the agency, that some staff members, including their former treatment providers, are not well respected or are involved in complex political feuds within the agency – that is, that the agency idealized by the clients is flawed in some important respects?  Might this undermine the former clients’ confidence in the services they had received?  Also, what if personnel issues involving the former clients emerge that warrant critical feedback or discipline?  What would it mean for the

former clients to be “chastised” by their former treatment providers?

 

Further, what would happen if former clients who are now staff relapsed and wanted or needed to become active clients again?  How would they, and their treatment providers, handle the shift away from a collegial relationship back to a professional-client relationship?  Would the clients find this disconcerting and humiliating?  Would they have difficulty resuming the role of client, and would this interfere with their therapeutic progress?

 

In addition, the mental health center staff and I discussed in what ways hiring former clients could have a detrimental effect on other clients, who might be discouraged when they realize they were not “picked” to become staff members and perhaps conclude that they have not progressed as well clinically.  Current clients may also feel overexposed, fearing (perhaps unrealistically) that the former clients would have access to confidential information about them. 

 

By the end of this protracted discussion and analysis of potential dual relationship and boundary issues, staff opinion clearly had shifted.  Nearly all the staff had concluded that the potential risks outweighed any benefits from hiring former clients.  Although all staff members embraced the virtues of empowering former clients, they concluded that the potential harm to them and to the agency’s smooth functioning was a risk not worth taking.  Instead, the staffers realized, they could accomplish much the same goal by working assertively with other social service agencies in the area in an effort to find comparable jobs for their former clients.  In the staffers’ opinion, finding jobs in other agencies for former clients would reduce the likelihood of boundary problems while achieving all the benefits associated with hiring former clients to work with active clients.

 

One other unique circumstance involves accommodating the wishes of relatives or acquaintances of deceased clients.  In one unusual case on which I consulted, the parents of a deceased client asked the social worker to deliver a eulogy at the client’s funeral.  The parents understood how important the social worker had been to their son.  After giving the parents’ request considerable thought, the social worker was inclined to deliver the eulogy.  The social worker consulted with her supervisor and several colleagues, all of whom supported her inclination; all the parties agreed, however, that the social worker should deliver the eulogy in a way that did not disclose the nature of her relationship with the deceased client.  In addition, the social worker decided to obtain a signed, formal release form authorizing her to speak at the funeral; in this instance, the deceased client’s parents had the legal authority to sign the release as the client’s personal representatives.  The social worker also documented the parents’ request, the social worker’s consultation with colleagues, and the reasons for the social worker’s decision to deliver the eulogy. 

 

As always, the most challenging circumstances involving dual relationships are those that are ambiguous, where practitioners can advance reasonable arguments both for and against accommodating clients’ unique circumstances or requests.  As with all ambiguous boundary issues, practitioners must weigh the competing arguments, being mindful of their ultimate responsibility to protect clients from harm.

 

Self-disclosing to clients.  Earlier I discussed how a practitioner’s inappropriate self-disclosure to a client often reflects the practitioner’s unresolved emotional and dependency needs.  In these situations, self-disclosure is often associated with the practitioner’s unethical and harmful efforts to cultivate intimate relationships or friendships with clients. 

 

In other circumstances, practitioners may self-disclose for more altruistic purposes, deliberately and judiciously choosing to share personal details – usually modest in scope – in an effort to empathize with clients, offer clients support, align with clients, and provide a constructive role model that clients may use in their efforts to address their own issues.  Further, in some cultural or ethnic groups, a client may view the practitioner’s self-disclosure as an important sign that the practitioner accepts the client and will not be patronizing. 

 

Self-disclosure by practitioners who are in recovery for an addiction is a particularly challenging and useful example of complex boundary issues.  Clearly, professionals in the substance abuse field disagree about the wisdom and appropriateness of self-disclosure that occurs when practitioners who are in recovery attend AA, NA, or other 12-step meetings that clients also attend.  One side argues that a practitioner’s self-disclosure in this form provides a remarkably valuable service to clients who have substance abuse problems.  The clients can view their counselors as role models who practice what they preach about the need to be earnest about recovery, attend 12-step meetings, and so forth.  In addition, practitioners who disclose their recovery status to their clients may establish instant credibility, particularly among clients who might be skeptical of counselors who have not experienced substance abuse and the challenges of recovery first hand.

 

In contrast are those who argue with equal passion that the blending of the personal struggles of practitioners with those of their clients – in the context of 12-step meetings, for example – is likely to have profoundly detrimental consequences.  Clients may have difficulty separating their practitioner’s professional and personal roles.  In addition, some clients may lose confidence in practitioners who display their own vulnerabilities, personal struggles, and personal failures; the result may be an undermining of the practitioner’s authority and influence.  Further, practitioners in recovery – like all people in recovery – run the risk of relapsing, at least in principle.  Should relapse occur, the practitioner’s clients may be devastated, disheartened, and disappointed, and this could jeopardize their recovery efforts. 

 

In the end, the debate about practitioners’ self-disclosure to clients in recovery for altruistic purposes illustrates the difficulty of reaching consensus about some boundary and dual relationship issues.  Because of the legitimate and complex debate that can arise – as this one issue demonstrates – practitioners would do well to grasp the critical importance of the process they should use to make sound decisions, recognizing that in the end reasonable people may disagree.  This decision-making process should entail examination of conflicting professional obligations; identification of the individuals, groups, and organizations likely to be affected by the decision; identification of all viable courses of action and the participants involved in each, along with the potential benefits and risks for each; examination of the reasons in favor of and opposed to each course of action, considering relevant ethical principles and standards, practice theory and guidelines, and personal values; consultation with colleagues and appropriate experts (such as agency staff, supervisors, ethics committees); and appropriate documentation of these various steps. 

 

Unavoidable and Unanticipated Circumstances

 

The final category of dual relationship involves circumstances that practitioners cannot easily anticipate or prevent – circumstances that, in most respects, are unavoidable.  In these situations, practitioners encounter boundary crossings and dual relationships unexpectedly and need to manage the circumstances in a way that protects clients, colleagues, and practitioners to the greatest extent possible.  Common circumstances involve practitioners who encounter clients in small communities or 12-step meetings, former clients who become professional colleagues, and social encounters.  Here are examples:  

 

 

Case examples

 

 

     Dr. Lorna S., a family therapist, provided counseling to Janice and Bob P.  They were parents of 8-year-old twins and sought counseling to help them address chronic conflict in their relationship.  After nearly a year of on-again, off-again counseling, the couple decided to divorce.  Ms. P. was adamant that Mr. P. was emotionally unfit to parent their children.  Ms. P. alleged that Mr. P. was in denial about his alcohol abuse and was a neglectful and emotionally abusive parent.  Ms. P.’s lawyer subpoenaed Dr. S. and her records in an effort to produce evidence of Mr. P.’s emotional and psychological impairment.  Dr. S. felt uncomfortable because she was being forced to testify “for” one client and “against” the other.  

 

     Dr. Gary L. was a professor in a graduate program in social work.  He also served on the state parole board and several days per month conducted hearings for inmates eligible for parole. One hearing Dr. L. conducted was for an inmate who was serving a 7-year sentence for drug possession and sales.  Dr. L. and his colleagues voted to parole the inmate, a college graduate who had been an enthusiastic and earnest participant in the prison’s substance abuse treatment program. One year after the inmate’s parole, Dr. L. was surprised to find the man enrolled as a student in one of Dr. L.’s courses.  The former inmate told Dr. L., with pride, that he was now working in the substance abuse treatment field and was enrolled as a part-time graduate student in the social work program in which Dr. L. taught.  Because the former inmate was still on parole – and was technically under Dr. L.’s authority during this period – Dr. L. was uncomfortable having the student in his class.  Dr. L. talked with the student about transferring to another section of the course in order to avoid the dual relationship and potential conflict of interest.  

 

     Brenda V. was a counselor who provided services primarily to women struggling with domestic violence issues.  One of Ms. V.’s clients sought counseling to help her cope with the end of her lesbian relationship.  The therapy was very helpful to the client and they terminated the counseling relationship.  Nearly six months later, Ms. V., also a lesbian, began dating a woman she met at a neighborhood party.  Several months into the new relationship, Ms. V. discovered that her new partner was the woman with whom Ms. V.’s former client had been involved.  Ms. V. was unsure about how her former client might feel about Ms. V. becoming involved in a relationship with the former client’s former partner.  Ms. V. was also unsure about whether to reach out to her former client to discuss the awkward situation.

 

 

Geographic proximity.  The likelihood of unanticipated boundary issues increases in geographically small communities, especially in rural areas.   Behavioral health professionals in these settings often report how challenging it is when they encounter clients in, for instance, the local supermarket, community center, or house of worship.  Practitioners often describe how they walk through their day wondering when – not if – they will encounter clients outside their work settings.  They devote considerable effort to managing these encounters in a way that minimizes potential boundary confusion. 

 

Some unanticipated encounters in geographically small communities between practitioners and clients are innocuous and unlikely to pose significant problems.  For example, the practitioner whose client works for the local gas and electric company and visits her house to read her gas meter may feel awkward having her client in her home, and her client may feel awkward too; but, this brief, unplanned, and one-time encounter may not have significant, lasting repercussions.  In contrast, the practitioner whose child has become friendly with the practitioner’s client faces a more daunting challenge.

 

Behavioral health professionals who live and work on military bases often face special challenges, particularly bases that are located in remote areas.  These clinicians and their clients are likely to encounter each other in social and other informal contexts.  Further, clinicians who hold military rank (as opposed to civilian status) can have clients who outrank them and who, outside of the therapy office, have authority over the clinician. 

 

Dual relationships in small communities and rural areas take several forms, most commonly involving overlapping social relationships and overlapping business or professional relationships.  Schank and Skovholt formulated a set of useful guidelines to help human service professionals manage boundary issues in small communities and rural settings (Schank and Skovholt, 1997):

 

 

Table 11. Guidelines for Managing Boundaries in Small Communities

 

 

     Nonsexual overlapping relationships are not a matter of “if” as much as “when” in the daily lives of small-community mental health professionals.  Ethical codes or standards are necessary but not sufficient and are tempered by experience and context.  Although it may seem obvious, knowledge of these codes and of state laws is essential in framing the background for small-community application.  Continuing education in ethical issues adds to this framework.

 

     Clear expectations and boundaries, whenever possible, strengthen the therapeutic relationship.  This is especially important in situations where out-of-therapy contact cannot be closely controlled.  Obtaining informed consent, sticking to time limits, protecting confidentiality (and explaining its limits), and documenting case progress (including being explicit about any overlapping relationships) diminishes the risk of misunderstanding between client and practitioner.

 

     Ongoing consultation and discussion of cases, especially those involving dual roles, provide a context for practitioners to get additional perspectives and decrease the isolation that sometimes accompanies rural and small-community practice.  Each of us has blind spots – trusted colleagues can help us constructively examine them.

 

     Self-knowledge and having a life outside of work lessens the chances that practitioners will use, even unknowingly, clients for the practitioners’ own gratification.

 

 

Behavioral health professionals in small communities and rural areas would do well to anticipate the ways in which their professional lives may intersect with their personal and family lives and, where appropriate, talk with clients about how they might best handle these challenging circumstances.  In some instances, practitioners and their clients can come up with relatively straightforward ways to manage the boundary issues.  For example, a practitioner whose client works for the sole local plumber might talk about why it would be best for one of the client’s colleagues in the plumbing company to handle visits to the practitioner’s home.  A practitioner who has an opportunity to chaperone an overnight class trip that includes both the practitioner’s teenage child and the practitioner’s client (that is, a classmate of the practitioner’s child) can decide not to sign up to chaperone in order to avoid potential boundary confusion.  Also, practitioners can talk with clients ahead of time about how they – the practitioners – will not approach clients they encounter in local stores and other public settings in order to avoid boundary complications.

 

In contrast, however, are situations in which the potential or actual boundary issues are more difficult to manage.  The practitioner whose client is employed at the same company as the practitioner’s spouse may not be able to avoid encountering the client at a holiday party sponsored by the company for employees and their families.  The practitioner whose client moves into a house near the practitioner’s home cannot be expected to resolve the problem by moving to another location.  The practitioner whose client is the one automobile mechanic in town cannot be expected to drive thirty-five miles to another mechanic.  In these circumstances, it behooves the practitioner to broach the boundary issues with the client as early in their relationship as possible and discuss reasonable ways of handling potentially awkward circumstances in a manner that both find comfortable and in a way that protects the client’s interests to the greatest extent possible.  Practitioners should document these conversations to demonstrate their earnest efforts to handle these situations responsibly.  In some situations, practitioners may feel the need to consult colleagues for advice or refer clients to other providers – if they are available – in an effort to avoid inappropriate or harmful dual relationships.

 

Conflicts of interest.  A constant theme in discussions of dual relationships and boundary issues is the concept of conflicts of interest.  Some conflicts of interest arise when behavioral health professionals knowingly enter into dual relationships – for example, when a practitioner receives a fee from a colleague to whom the practitioner refers clients or when a practitioner receives professional assistance from a client (such as a doctor or lawyer) who has specialized expertise from which the practitioner can benefit.  However, in some instances conflicts of interest arise because of circumstances that are unavoidable or that practitioners could not have reasonably anticipated. 

 

In my experience, such conflicts of interest take two forms.  The first involves adversarial circumstances, in which practitioners unexpectedly find themselves caught between parties who are engaged in a dispute.  As I noted earlier, a common scenario with adversarial features involves practitioners who provide marital counseling.  In some situations, the couple is unable to resolve their differences and decide to divorce.  If the couple is not able to agree on child custody issues, the lawyer for one parent may subpoena the practitioner to testify about the emotional or psychiatric problems of the other parent that allegedly render the latter parent unfit.  That is, one parent’s lawyer may attempt to use the practitioner’s testimony to impeach the other parent.  Such practitioners, who would prefer to remain neutral and uninvolved in the legal dispute, then find themselves facing a subpoena that places them in a conflict-of-interest situation. 

 

Practitioners who provide couples or marital counseling should always anticipate the possibility (although not necessarily the probability) that the therapy will not resolve the couple’s problems, that a serious legal dispute may continue after or arise from the therapy, and that one or both parties may try to involve the practitioner in the dispute.  The practitioner should alert the clients to this possibility and of the practitioner’s wish to avoid a conflict of interest.  In fact, the NASW Code of Ethics highlights this specific phenomenon (Also see comparable standards in the ACA Code of Ethics A.5.e and A.7):

 

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. (standard 1.06[d])

 

Human service professionals sometimes receive subpoenas that place them in untenable conflicts of interest.  In these situations, practitioners must understand the nature of subpoenas and specific strategies they can use in their effort to extricate themselves from these conflicts.  Practitioners who are subpoenaed may face a special conflict-of-interest dilemma concerning the disclosure of confidential or privileged information.  If the professional practices in a state in which laws grant clients the right of privileged communication, avoiding compliance with the subpoena may be easier because the legislature has acknowledged the importance of the privilege.  Also, contrary to many practitioners’ understanding, a legitimate response to a subpoena is to argue that the requested information should not be disclosed or can be obtained from some other source.  A subpoena itself does not require a practitioner to disclose information.  Instead, a subpoena is essentially a request for information, and it may be without merit. 

 

Resisting disclosure of confidential information is appropriate, particularly when practitioners believe that the information is not essential or if they can argue that the information can be obtained from other sources.  More specifically, practitioners can take several concrete steps to manage conflict-of-interest situations involving disclosure of confidential information (Polowy and Gorenberg, 1997):

 

 

Table 12. Managing Conflict of Interest and Disclosure

 

 

     Prepare a letter to the requester advising that the information is confidential and privileged and that absent the client’s consent or a court order, the requested material cannot be released.  Copies of any correspondence should be maintained in the file and may be necessary to present in a hearing on the matter.

 

     File a motion to quash or objections to the subpoena based on the privileged nature of the communication between the client and practitioner.  A request for a protective order may also be filed seeking to limit access to the records.  The practitioner may want to seek legal consultation to help with these responses.

 

     After writing a letter to the relevant parties in the case advising that the requested materials are confidential and privileged, it may be necessary to follow such a letter with written objections that would be filed with the court or with a motion for a protective order that asks the court to deny access to the file because it contains privileged client information.  Finally, a motion to quash the subpoena could also be filed.

 

 

Unanticipated conflicts of interest involving adversarial circumstances could also arise in nonclinical contexts.  Human service administrators, researchers, or community organizers can find themselves in complicated boundary situations.  Examples include administrators who discover that a valued employee is involved in ethical misconduct and managers who are subpoenaed to testify against their administrative superiors in a personnel-related lawsuit filed by a disgruntled former employee who was mistreated by the agency.  In these dual relationship scenarios, practitioners feel caught between their duty to disclose misconduct of some sort and their loyalty to their agencies.

 

The circumstances surrounding collegial misconduct and pertinent boundary issues are rarely clear-cut.  The evidence of wrongdoing may be questionable, the effect of the misconduct may be equivocal, and the likelihood of resolving the problem satisfactorily may be small.  Deciding whether to blow the whistle must be approached deliberately and cautiously.  Codes of ethics can provide some conceptual guidance when practitioners find themselves involved in the midst of dual relationships and ethical misconduct.  The NASW Code of Ethics includes standards germane to collegial misconduct (See also ACA Code of Ethics Standards C.2.g and AAMFT Code of Ethics Standard 3.3):

 

Social workers who believe that a colleague has acted unethically should seek resolution by discussing their concerns with the colleague when feasible and when such discussion is likely to be productive.  (standard 2.11[c])

 

When necessary, social workers who believe that a colleague has acted unethically should take action through appropriate formal channels (such as contacting a state licensing board or regulatory body, an NASW committee on inquiry, or other professional ethics committees). (standard 2.11[d])

 

Of course, not all dual relationships involving conflicts of interest contain adversarial dimensions.  Some conflict-of-interest situations involve people of goodwill who have only noble intentions, for example, when a clinical supervisor offers to counsel a colleague who is struggling with a complex, troubling personal issue. 

 

Whatever form unanticipated conflicts of interest take, behavioral health professionals must take steps to minimize harm.  Sometimes practitioners must be concerned about potential harm to colleagues and their employing organizations.  In such instances, practitioners must take steps to protect these parties to the greatest extent possible.  They should focus primarily on the need to protect their clients, whether the clients are individuals, couple, families, groups, communities, or organizations.  As the NASW Code of Ethics states,

 

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.  (standard 1.06[a])

 

Professional encounters.  Professional relationships sometimes produce overlapping, challenging, and complex relationships and boundary issues.  On occasion, practitioners who are involved in a professional relationship with a colleague will encounter that colleague unexpectedly in another professional relationship in a way that produces boundary issues.  Examples include a professor in a counseling program who discovers that a friend in the local community has applied to be a student in the professor’s program, or when a practitioner’s client, who is a professional in the community, joins a community organization’s board of directors on which the practitioner serves.   As with all dual relationships, practitioners must address the boundary issues in a manner designed to minimize potential harm. 

 

Social encounters.  One other form of unanticipated or unavoidable dual relationship involves social encounters with clients.  Earlier I discussed practitioners’ decisions when clients invite them to social events (such as a wedding, christening, graduation, confirmation, or bar mitzvah) or when practitioners can reasonably anticipate encountering clients at community-based social events (for example, when a lesbian therapist in a relatively small community fully expects she will encounter a lesbian client at local social events).

 

In addition to these circumstances, behavioral health professionals must also anticipate the possibility that they will encounter clients completely unexpectedly, in contexts in which neither party ever expected to encounter the other.  Recognizing the frequency with which such unanticipated and unavoidable encounters occur, practitioners should have in mind how they will respond.  In addition, practitioners would do well to raise the issue with clients in advance, in order to manage the situation as professionally and smoothly as possible, minimize harm that may result from the boundary crossing, and avoid bruising clients’ feelings.  Clearly, practitioners must do what they can to prevent and manage boundary issues in the most effective, ethical way possible.  This includes discussing with clients, toward the beginning of their working relationship, how they will handle unexpected or unavoidable social encounters in the community.  This approach does not guarantee satisfactory and uncomplicated outcomes, of course; however, a thoughtful, planned approach can substantially increase the likelihood that clients and other concerned parties will not be harmed.  

 

Protecting Clients and Managing Risk

 

I have examined a diverse array of dual relationship and boundary issues.  Some issues that arise in behavioral health are relatively uncomplicated and some are complex.  Some involve practitioners who are motivated primarily by altruism, and some involve practitioners who violate clients’ boundaries because of their own deep-seated impairment, emotional needs, or greed.  Some boundary crossings serve a constructive purpose, whereas boundary violations are uniformly destructive.

 

Despite this remarkable variety, dual relationship and boundary issues share several key features.  First, they contain the seeds for potential harm to others.  Although serious harm is not inevitable – except in the most egregious violations, such as sexual involvement with a client – it is an ever-present possibility.  Behavioral health professionals must be vigilant in their efforts to minimize potential and actual harm to others. 

 

Second, dual relationship and boundary issues pose risks to professionals themselves.  At one extreme, practitioners who violate clients’ boundaries and exploit their relationships with them run the very real risk of losing their license and destroying their career.  Although some boundary violations occur in and remain in the dark, many eventually come to light.  Even less egregious boundary crossings can sometimes trigger lawsuits and ethics complaints filed with licensing boards or other professional bodies, thus disrupting the careers of even the most noble practitioners.  Given these possibilities, it behooves human service professionals to understand and follow sound risk-management policies and protocols – primarily to protect clients but also to protect themselves. 

 

Effective risk management concerning dual relationships and boundary issues should provide both conceptual guidance and practical steps that enhance protection of all parties involved.  The following is a decision-making model, based on several available frameworks and protocols, that practitioners can use when they encounter potential or actual dual relationships and boundary issues (Corey and Herlihy, 1997; Gottlieb, 1995; Reamer, 2001).  This model incorporates various factors that I have highlighted throughout the discussion (Table 13):

 

 

Table 13. Summary of Risk Management Strategies

 

 

     Attempt to set unambiguous boundaries at the beginning of all professional relationships.  Broach the topic, when appropriate, early in the relationship in an effort to prevent problems.  Individuals who have not had much experience as clients may require more detail, discussion, and explanation of boundary issues and concepts.

 

     Evaluate possible dual relationships and boundary issues by considering

 

  • the amount of power the practitioner holds over the client;

 

  • the duration of the relationship;

 

  • the clarity of conditions surrounding planned or actual termination;

 

  • the client’s clinical profile; and

 

  • prevailing ethical standards.  How much power does the professional have over the client? 

 

     A counselor functioning as a parole officer or child welfare worker can exercise much more power over a client than can a private practitioner.  How long has the relationship lasted?  Typically, longer relationships provide more opportunity for boundaries complications than shorter relationships.  How likely is it that the client will return for additional services?  The greater the likelihood, the more important it is to maintain clear boundaries.  To what extent do the client’s clinical needs, issues, vulnerabilities, and symptoms increase the risk that the client will be harmed?  Some clients have more complex personal histories and challenges – for example, as a result of being victimized – that may exacerbate confusion about boundaries and vulnerability.  To what extent does the dual relationship, boundary crossing, or boundary violation breach prevailing ethical standards, as reflected in professional codes of ethics and licensing statutes and regulations?  In general, relationships that entail considerable practitioner power, are long lasting, do not involve clear-cut termination, involve clinical issues that render clients vulnerable, and are not consistent with pertinent ethical standards are especially troubling and risky.

 

     Based on these criteria, consider whether a dual relationship in any form is warranted or justifiable.  Recognize that gradations exist between the extreme options of a full-fledged dual relationship and no dual relationship.  For example, a practitioner may decide that attending a client’s graduation from a substance abuse treatment program is permissible but that attending the post-graduation party at the client’s home is not.  A practitioner may decide to disclose to a particular client that she is a new parent without disclosing intimate details concerning her struggle with infertility. 

 

     Pay special attention to potentially conflicting roles in the relationship.  For instance, a clinician should not agree to counsel his secretary.  An administrator should not supervise her spouse or partner.  Of course, sometimes professionals do not agree about the nature of conflicting roles.

 

     Whenever there is any degree of doubt about dual relationships or boundary issues, consult a thoughtful, principled, and trusted colleague.  It is important to consult with colleagues who understand one’s work, particularly in relation to services provided, clientele served, and relevant ethical standards.

 

     Discuss the relevant issues with all the parties involved, especially clients.  Clients should be actively and deliberately involved in these judgments, in part as a sign of respect and in part to promote informed consent.  Fully inform clients of any potential risks.

 

     Work under supervision whenever boundary issues are complex and the related risk is high. 

 

     If necessary, refer the client to another professional in order to minimize risk and prevent harm. 

 

     Document key aspects of the decision-making process, for example, colleagues consulted, documents reviewed (such as codes of ethics, agency policies, relevant statutes and regulations), and discussions with clients. 

 

 

In the end, human service professionals who face difficult and challenging boundary issues must draw on their finely honed ethical instincts.  Conceptual guidance is fine and important, but practitioners’ handling of daunting circumstances ultimately must depend on their genuine and passionate determination to make ethically sound judgments. 

 

Further Reading

 

Celenza, T. (2007). SEXUAL BOUNDARY VIOLATIONS: THERAPEUTIC, SUPERVISORY, AND ACADEMIC CONTEXTS. Lanham, MD: Roman and Littlefield.

 

Gabriel, L., SPEAKING THE UNSPEAKABLE: THE ETHICS OF DUAL RELATIONSHIPS IN COUNSELING AND PSYCHOTHERAPY.  New York: Routledge, 2005.

 

Gutheil, T. and Brodsky, A. (2008). PREVENTING BOUNDARY VIOLATIONS IN CLINICAL PRACTICE.  New York: Guilford Press.

 

Peterson, M. R., AT PERSONAL RISK: BOUNDARY VIOLATIONS IN PROFESSIONAL-CLIENT RELATIONSHIPS. New York: Norton, 1992.

 

Reamer, F. G., TANGLED RELATIONSHIPS: MANAGING BOUNDARY ISSUES IN THE HUMAN SERVICES. New York: Columbia University Press, 2001.

 

Syme, G., DUAL RELATIONSHIPS IN COUNSELLING AND PSYCHOTHERAPY: EXPLORING THE RELATIONSHIPS. London: Sage, 2003.

 

Zur, O., BOUNDARIES IN PSYCHOTHERAPY: ETHICAL AND CLINICAL EXPLORATIONS. Washington, DC: American Psychological Association, 2007.

 

References

Brodsky, A.M. (1986).  The Distressed Psychologist: Sexual Intimacies and Exploitation.  In R. Kilburg, Nathan, P. and Thoreson, R. (Eds.). Professionals n Distress: Issues, Syndromes, and Solutions in Psychology (p. 155).  Washington, DC: American Psychological Association.

 

Corey, G. and Herlihy, B. (1997).  Dual/Multiple Relationships: Toward a Consensus of Thinking. In The Hatherleigh Guide to Ethics in Therapy (p. 183-94), New York: Hatherleigh.

 

Gartrell, N. et al. (1986).  Psychiatrist-Patient Sexual Contact: Results of a National SurveyAmerican Journal of Psychiatry, 143, 1126-31.

 

Gifis, S.H. (1991).  Law Dictionary, 3rd ed. Hauppauge, NY: Barron’s.

 

Gottlieb, M. (1995).  Avoiding Exploitive Dual Relationships: A Decision-Making Model.  In D.N. Bersoff (ed.), Ethical Conflicts in Psychology (p. 242-43).  Washington, DC: American Psychological Association.

 

Gutheil, T. G. and Gabbard, G. O.(1993).The Concept of Boundaries in Clinical Practice: Theoretical and Risk-management Dimensions.  American Journal of Psychiatry, 150, 188-196.

 

Jayaratne, S., Croxton, T., and Mattison, D. (1997). Social Work Professional Standards: An Exploratory Study.  Social Work, 42, 187-199.

 

Olart, S.W. (1997). Sexual Boundary Violations. In The Hatherleigh Guide to Ethics in Therapy (p. 195-209). New York: Hatherleigh.

 

Polowy, P.I. and Gorenberg, C. (1997). Client Confidentiality and Privileged Communication: Office of General Counsel Law Notes. Washington, DC: National Association of Social Workers.

 

Pope, K. (1986).  New Trends in Malpractice Cases and Changes in APAs Liability Insurance.  Independent Practitioner, 6, 23-26.

 

Pope, K.S., Tabachnick, B.G., and Keith-Spiegel, P. (2003).  Ethics of Practice: The Beliefs and Behaviors of Psychologists and Therapists. In D.S. Bersoff (ed.). Ethical Conflicts in Psychology (Third Edition).  Washington, DC: American Psychological Association. 

 

Reamer, F.G. (1995).  Malpractice and Liability Claims Against Social Workers: First Facts.  Social Work, 40, 595-601.

 

Reamer, F.G.  (2001).  Tangled Relationships: Managing Boundary Issues in the Human Services. New York: Columbia University Press.

 

Reamer, F.G. (2001).  The Social Work Ethics Audit: A Risk-Management Tool.  Washington, DC: NASW Press.

 

Schank, J.A. and Skovholt, T.M. (1997).  Dual-Relationship Dilemmas of Rural and Small-Community Psychologists.  Professional Psychology: Research and Practice, 28, 44-49.

 

Schoener, G. (1995). Assessment of Professionals Who Have Engaged in Boundary Violations.  Psychiatric Annals, 25, 95-99.

 

Schoener, G.R., et al. (1989).  Psychotherapists’ Sexual Involvement with Clients: Intervention and Prevention. Minneapolis: Walk-In Counseling Center.

 

Schutz, B.M. (1982). Legal Liability in Psychotherapy. San Francisco: Jossey-Bass.

 

Simon, R. (1999). Therapist-Patient Sex: From Boundary Violations to Sexual Misconduct.  Forensic Psychiatry, 22, 31-47.

 

Simon, R. (1995).  The Natural History of Therapist Sexual Misconduct: Identification and Prevention.  Psychiatric Annals, 25, 90-94.

 

Sonnenstuhl, W.J. (1989).  Reaching the Impaired Professional: Applying Findings From Organizational and Occupational Research. Journal of Drug Issues, 19, 533-539.

 

Stake, J.E. and Oliver, J. (1991). Sexual Contact and Touching Between Therapist and Client: A Survey of Psychologists’ Attitudes and Behavior. Professional Psychology: Research and Practice, 22, 297-306.

 

 

 



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