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Ethical Issues in Multiple Relationships, Referrals and Self-Disclosure

by Pamela H Harmell, Ph.D..

6 Credit Hours - $99
Last revised: 09/08/2018

Course content © Copyright 2018 - 2020 by Pamela H Harmell, Ph.D.. All rights reserved.


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multiple relationships 




Section A. Introduction and Review
Section B. Boundary Violations
Section C. Multiple Relationships
Section D. Multiple Relationships in a Rural Practice
Section E. Ethics of Accepting Referrals
Section F. Therapist Self-Disclosure
Section G. Risk Management






This is an intermediate level course. Upon completion of this course, psychotherapists will be able to:


     List five behaviors which will minimize the risk of a malpractice suit

     Apply the Ethics Code to one clinical situation involving a multiple relationship

     List six steps to prevent potential boundary violations

     Discuss the pros and cons for therapist self-disclosure

     Describe record keeping procedures for risk management





Thank you for choosing to take this course! The material contained in this course is the professional and personal understanding of the course author’s interpretation of the experts that will be cited throughout the text. Should any person wish to use this material for any purpose other than basic continuing education as it is presented here, that person should seek the original sources for his or her personal understanding.


The authors cited are accepted and published experts in the fields of legal and ethical issues in psychology, social work (SW), and marriage and family therapy (MFT). Described herein are current opinions, case law when applicable, California statute, and interpretations of the APA Ethics Code (2017), the ethics codes related to social work including  National Association of Social Work – (NASW, 2017) and Clinical Social Work Association – (CSWA, 2016) and California Association of Marriage and Family Therapy (CAMFT, 2015).   


This is not in any way a legal document; it does not offer legal advice or interpretations other than those of the experts as cited. This material is not meant as a personal or clinical consultation, nor is it intended as a substitute for contact with an ethics committee, attorney, or professional consultant. Since this applies to each section of the course, it will only be stated this once.


For those of you who have taken courses prepared by this author, some of the introductory Section A will be repeat material. However, much of the material in this section is updated and new, including vignettes, examples, and citations. It is important for participants who are completely new to a course by this author to have the same foundation as those who are already familiar with topics such as elements of malpractice, and for them to receive an introduction to the use of Ethics Codes.  I hope you enjoy the journey!




Your professional organizations have established codes of ethics that provide guidelines for appropriate practice and behavior.  The ethics codes are necessarily broad in order for application to various situations and circumstances.  They are general rather than specific.  You own awareness and familiarity with the principles of your profession and your problem-solving skills will determine how you translate these guidelines into behavior and attitudes.  Welfel (2010) notes that ethics codes are not to be used in a cookbook fashion, but are to be one of many factors used in making decisions in challenging situations.  It is essential each psychotherapist remain aware of the limitations of the professional codes (Herlihy & Corey, 2010). Throughout the course, you will be asked to take brief quizzes that are aimed at helping you learn and retain the material. When applicable, the relevant ethics section(s) from the following APA Code of Ethics, NASW, CSWA, and CAMFT will be included for your perusal. Our American system of law is separated into two divisions, federal and state. In most cases, federal law supersedes state law, except in special situations. Can you think of one?



Question for Reflection



Federal law is superseded by state law:


a)   When someone who is not a U.S. citizen commits a felony

b)   In some cases where murder is the crime

c)   With HIPAA, when state law gives more protection to patient’s records


If you guessed (c), you are correct! With HIPAA laws, which are federal laws (which will be discussed in another section), state law supersedes federal law if the state law provides more protection for the patient’s records and to the patient in general. You may wish to record your answer for future review.





The complete title of the document is Ethical Principles of Psychologists & Code of Conduct (APA, 2002 along with 2010 and 2016 Amendents). The need for an ethics code arose after World War II when psychotherapists developed group tests to help the armed services quickly evaluate draft eligibility and to provide mental health services to returning soldiers. After numerous task force revisions and drafts approval by the membership, the first code was adopted by APA in 1952 and published in 1953. The purposes of the current ethics code are many, including 1) establishing the integrity of the profession, 2) providing a guide for proper and expectable professional behavior, 3) securing public trust, 4) self-monitoring, and 5) the ability to adjudicate (APA, 2002, 2010, 2016; Please see Fisher, 2003 for most recent interpretation of just the 2002 code). By adjudicate, the APA means to have the power to settle an ethics violation judicially by the ethics committee of the American Psychological Association.


There are five important reasons for having an ethics code:


·         To prevent government intrusion into the profession of psychology

·         To aid professional autonomy in the practice of psychology

·         To avoid undue interference into the profession from outside regulators

·         To assert self-regulation of psychology

·         To protect the profession from internal discord


In other words, without an ethics code, psychotherapists would be vulnerable to outside regulators who might use their powers of adjudication in cases of ethics violations. Worse still, outside regulators might use inappropriate standards to adjudicate ethics violations when those standards are not applicable to psychotherapists. It is always more appropriate for those within the profession to make decisions about fellow psychotherapists who violate the ethics of the profession rather than outside parties who are less familiar with the profession.  The current code was adopted in 2002, and took effect in June 2003. The current code will be used in this course.




There are two primary sections of the APA Ethics Code: Aspirational and Enforceable.  The Aspirational section is unenforceable and includes the Introduction, Preamble, General Principles and Sections A through E.  The Enforceable sections include the 82 numbered codes that are the actual standards (1.01 to 10.10).


The Aspirational & Unenforceable Sections


The Introduction section discusses the intent and organization of the code and provides guidance only. It is not a legal document. Even though some states adopted the 1992 Code as legal and binding (for example, Georgia adopted the 1992 code as a legal document), the creators did not have this in mind when they wrote it. The Ethics Code looks at “reasonable” prevailing current judgment and considers the dictates of one’s own conscience while strongly encouraging professional consultation with colleagues.


All through the text of the APA Ethics Code, the terms “patient” and “client” are combined. The combination refers to whom a psychotherapist is providing treatment, intervention, or assessment services. The term “organizational clients” or “organizations” or simply “clients” refers to organizations or representatives of organizations for which the psychotherapist may provide consultation, personnel evaluations, test development, or other psychological services (Fisher, 2003).


The Preamble section discusses psychotherapists’ commitment to science in the improvement of the lives of others. Psychotherapists have a lifelong effort to act ethically. The primary focus and goal of the Ethics Code is to protect and enhance the welfare of the client/patient along with protection of the individuals and groups with which psychotherapists work. This includes the education of the members of the APA, students of psychology, and the public in general.


The General Principles AE guide and inspire psychotherapists to act with the very highest ideals, considering patient welfare as the primary focus.




The 82 numbered standards are the only enforceable part of the Code. These can be used in adjudication proceedings of any local or state ethics committee or an APA ethics committee, and have been used in malpractice suits and licensing board violations.



Questions for Reflection



The APA Code of Ethics is a legal document:


a)   True

b)   False


Answer: (b) false. The document is NOT to be used as a legal document, but as a guideline and set of standards to follow for psychotherapists.


The Aspirational (Unenforceable) section of the code contains:


a)   Aspirations, guidelines, introduction

b)   Introduction, guidelines, aspirations

c)   Introduction, preamble, general principles A through E


Answer: (c) Introduction, Preamble, General Principles.





The complete title of the document is PART I: Ethical Standards for Marriage and Family Therapists and PART II: Procedures for Handling Complaints of Violations of the Code of Ethical Standards for Marriage and Family Therapists. The effective date of the current revision is May 1, 2002. Members of CAMFT are expected to not only abide by these Ethical Standards, but to be familiar with them and “applicable California laws and regulations governing the conduct of licensed marriage, and family therapists, interns and trainees” (CAMFT, 2011, p. 3).


The purposes of an ethics code for psychotherapists are many-facetted. They include: establishing the integrity of the profession, provision of a guide for proper and expectable professional behavior, securing public trust, self-monitoring, and the ability to adjudicate. Adjudicate refers to acting as judge when another MFT violates the ethics code.


There are five important reasons for having an ethics code in any profession:


·         To prevent government intrusion

·         To aid professional autonomy

·         To avoid undue interference from outside parties

·         To assert self regulation

·         To protect the profession from internal discord


In other words, marriage and family therapists, without an ethics code, would be vulnerable to outside regulators who might use their powers of adjudication in cases of ethics violations. Or worse still, outside regulators might use inappropriate standards to adjudicate when those standards are not applicable to marriage and family therapists.




There are two primary sections:  Part I is the Ethical Standards and Part II is Handling Complaints.


Part I: Ethical Standards


1. Responsibility to Patients

2. Confidentiality

3. Professional Competence & Integrity

4. Responsibility to Students & Supervisees

5. Responsibility to Colleagues

6. Responsibility to Research Participants

7. Responsibility to the Profession

8. Responsibility to the Legal System

9. Financial Arrangements

10. Advertising


Part II: Handling Complaints


I. Basics & Scope of Authority of the Ethics Committee

II. Membership & Meetings of the Committee

III. Initiation of Complaints

IV. Initial Action by Executive Director

V. Preliminary Determination by Chair of Ethics Committee with the Advice of Legal Counsel for the Association

VI. Investigation by Ethics Committee of Designees

VII. Action by the Full Ethics Committee

VIII. Procedures for Hearing Before Board of Directors

IX. Records & Disclosures of Information




The 92 numbered standards of Part I, are the only enforceable part of the Code, however, the Ethical Standards is NOT a legal document. Part I, Ethical Standards, and Part II, Handling Ethical Complaints, are only valid in California. However, many of the Ethical Standards are quite similar to the national code used by the American Association of Marriage and Family Therapists (AAMFT). To review the AAMFT Code of Ethics (2015) see AAMFT.ORG. The AAMFT Code of Ethics can be used in any state or ethics committee adjudication proceedings, and has been used in malpractice suits and licensing board violations. Normally, if there is a state set of codes, they will be used for any proceedings within that particular state, such as the CAMFT Ethical Standards in California.



Questions for Reflection



The CAMFT Ethical Standards is a legal document:


a)   TRUE

b)   FALSE


Marriage and Family Therapists may only see families or couples.


a)   TRUE

b)   FALSE


Question two of course is false (b), as mentioned earlier the document is NOT to be used as a legal document, but as a guideline and set of standards. Question three answer is (b) as explained above.





The national version of the ethics code NASW (2017) was originally approved by the delegate assembly in 1996 and revised in 2017.  It is intended to serve as a guide to social workers who may or may not be clinical social workers for everyday professional conduct.  It has four sections, the last of which includes 51 specific numbered standards that will be the focus of this course along with the Code of Ethics of the Clinical Social Work Federation (CSWF) for clinicians (to be discussed subsequently).  The four major sections of the Code are as follows:


·         Preamble.  Summarizes mission and core values.

·         Purpose of NASW Code – Overview of functions of the code.

·         Ethical Principles – Six specific core values to be followed.

·         Ethical Standards – Six major numbered code sections (51 specific standards)



The six major code sections including the Ethical Standards are as follows:


1.   Social Workers’ Ethical Responsibility to Clients - 16 Standards covering  everything from informed consent to sexual exploitation

2.   Social Workers’ Ethical Responsibilities to Colleagues - 11 Standards covering everything from confidentiality to incompetence

3.   Social Workers’ Ethical Responsibilities in Private Practice - 10 Standards covering everything from supervision to record-keeping

4.   Social Workers’ Ethical Responsibilities as Professionals - 8 Standards covering everything from competence to soliciting patients

5.   Social Workers’ Ethical Responsibilities to the SW Profession - 2 Standards covering integrity of profession and evaluation of research

6.   Social Workers’ Ethical Responsibilities to the Broader Society - 4 Standards covering public emergencies to political action


The material contained in this course is the author’s professional and personal understanding and interpretation of the experts that are cited throughout the text. Should any person wish to use this material for any purpose other than basic continuing education, that person should seek the original sources for his or her personal understanding.


In all cases, the authors cited are accepted and published experts in the field of legal and ethical issues in psychotherapy; however some of the seminal papers and books are also used to discuss the foundation of the topics being discussed.  Cited herein are current opinions, case law when applicable, California statute as examples of state statutes, and interpretations of the NASW Code of Ethics , approved in 1996 and revised in 2017. When discussing situations that are strictly clinical or more pertinent to ethics codes related to clinical issues, the Clinical Social Work Association (CSWA) Code of Ethics, approved in 1997, reviewed in 2006, and revised in 2016, is used in this course. You will find the website below for downloading or linking to both of these ethics codes.


In the Preamble of this document, CSWA states:


The principal objective of the profession of clinical social work is the enhancement of the mental health and the well-being of the individuals and families who seek services from its practitioners. The professional practice of clinical social workers is shaped by ethical principles which are rooted in the basic values of the social work profession. These core values include a commitment to the dignity, well-being, and self-determination of the individual; a commitment to professional practice characterized by competence and integrity, and a commitment to a society which offers opportunities to all its members in a just and non-discriminatory manner. (CSWA, 2016, p. 1)


The Code of Ethics of the CSWF are specific to clinical social work and will be quoted when relevant in this course.  The following describes the content of the CSWF Code of Ethics in more detail:



Explanation of objective of social work

I.   General Responsibilities of Clinical Social Workers

A-D CSW  maintain high standards

II.  Responsibility to Clients

1.  Informed Consent to Treatment

2.  Practice Mgmt & Termination

3.  Relationships with Clients

4.  Competence

III.  Confidentiality

A-E  CSW maintain confidentiality

IV.  Relationship with Colleagues

A-E  CSW act with integrity

V.  Fee Arrangements

A-E  CSW maintain honesty re fees

VI. CSW Are Responsible to the Community

A-C  CSW practice their profession within legal boundaries

VII. Research & Scholarly Activities

A-K  CSW maintain ethical practices in research and teaching

VIII. Public Statements

A-E Public statements are always honest and truthful


The purposes of an ethics code for psychotherapists are many-facetted, including establishing the integrity of the profession, provision of a guide for proper and expectable professional behavior, securing public trust, self-monitoring, and the ethics committee’s ability to adjudicate (to act as judge when another social worker violates an ethics code).  There are five important reasons for having an ethics code in any profession


·         To prevent government intrusion

·         To aid professional autonomy

·         To avoid undue interference from outside parties

·         To assert self regulation

·         To protect the profession from internal discord


In other words, LCSWs, without an ethics code, would be vulnerable to outside regulators who might use their powers of adjudication in cases of ethics violations.  Or worse still, outside regulators might use inappropriate standards to adjudicate (judge ethical violations) when those standards are not applicable to LCSWs.



Questions for Reflection



The NASW and CSWA ethics codes are legal documents:


a)   TRUE

b)   FALSE


Social workers can only work in hospitals or clinics and not in private practice settings:


a)   TRUE

b)   FALSE


The first question of course is false (b), as mentioned earlier the document is NOT to be used as a legal document, but as a guideline and set of standards.  The second question is false (b) as explained earlier as well.





There are four elements of a civil suit for malpractice. All four have to be believed to be satisfied in a court of law. In some cases, the difficulties of attempting to prove a civil suit, or defending against a complaint, are reflected in an out-of-court settlement. Sometimes the malpractice carrier advises that the expense—both emotionally and financially—is not worth the risk of going to court for the plaintiff.


A civil suit for malpractice is defined as “a lawsuit between two citizens where the issue is whether the psychotherapist has breached the standard of care.” (Black’s Law Dictionary, 1996) “Standard of care” will be defined below.


Duty of care. A Duty of Care arises when there has been an agreement between the psychotherapist and a current client that the pair will work together in a therapeutic relationship. In most cases, a therapist-patient relationship should be established within the first few sessions because, after two or three sessions, a patient does begin to develop an assumption that he has begun treatment. It is important to be completely clear from the start under what circumstances the patient is being seen. Is it merely a two-time evaluation for consideration of longer-term therapy? Is the work being done merely as an evaluation using assessment instruments? Was something said to the patient that indicated long-term therapy had begun? Or is the relationship based upon a brief 6-week behavioral model of treatment? If a civil suit should occur, and the parties had not decided whether they wished to work together by the third session or so, the court may decide for them that a “duty of care” had been established. Exchange of money alone does not establish a duty of care; however, if there is nothing else for the court to consider, it may look at any financial matters in an attempt to establish responsibility.


Standard of care. This broad term refers to the level of proficiency against which any other psychotherapist’s work will be measured or compared. In other words, what any other trained psychotherapist would do with reasonable experience. This is also known as the minimum below which a psychotherapist must not fall (Stromberg, et al., 988; Caudill & Pope, 1994).


Generally, the standard of care is defined by state statute (e.g., California Penal Code 11166, child abuse reporting law; California Welfare and Institutions Code 5150, involuntary hospitalization) and the current ethics code of the profession. Another factor that establishes the standard of care in a profession is something called “case law.” Case law is a “collection of reported cases that form the body of jurisprudence within a given jurisdiction.” (Black’s Law Dictionary, 1996, p. 84) This means that when judges adjudicate a case in an appeals court, it becomes precedent, and must be followed thereafter. Case law is just as powerful as statute, and must be followed just as closely as law that has progressed through the traditional legislative process.


Caudill & Pope (1995) define standard of care as “the minimum standard below which a practitioner cannot fall. It is based on the average competent professional, not the best or the brightest.” (p. 564). This is generally known as the “reasonable therapist doctrine.” These authors go on to explain that competent treatment can lead to unsuccessful results without meaning that the treatment was negligent. “Errors in judgment are not necessarily malpractice…instead if the requisite degree of skill and care is used, a judgment call that proves wrong is not actionable.” (p. 564)


Demonstrable harm. Can hurt or harm be shown to have occurred to the “victim”? If so, what are her damages? The idea is to return a harmed individual (client or patient) to the condition in which the person existed prior to the harm. This is done in only one possible way in a civil suit—a monetary judgment. In many cases of demonstrable harm with psychotherapist defendants, the damage claimed is psychological in nature. Therefore, it is much harder to prove and harder to approximate the financial award.


Proximate cause. Proving that the psychotherapist’s wrongful conduct caused the damage, and that it was the direct or proximate cause of the harm of the plaintiff’s injury, is probably the most difficult element to establish. However, attorneys will try to impose liability upon the psychotherapist for his acts that “caused” the damage to the client. The question is—Would the client have been damaged if the psychotherapist had done anything differently? Where injury is alleged to occur, the client must still prove that the alleged injury is caused by the psychotherapist’s breach of the standard of care. In 1991, the California Supreme Court adopted a definition of proximate cause easily understandable to lay people—the “substantial factor” element. Was the therapist’s action a “substantial factor” in causing the patient’s injury? (Caudill & Pope, 1995)




Case Example



Carol has been seeing Therapist Green for five months. She calls Therapist Green saying she is suicidal and “does not want to go on anymore.” Therapist Green tells Carol to “perk up” and to stop being so down. He tells her to “go to a club with her friends and start acting like someone her age instead of an old woman” so that she can have a good time and “be normal.”


Carol feels terrible after this conversation with Therapist Green. In a suicide attempt, she takes an entire bottle of her antidepressant medication in along with a bottle of alcohol. When she calls Therapist Green the next day feeling ill and depressed, he tells her, “Look, Carol, you aren’t my only client! I am too busy to spend all this time on the phone with you. I will see you at our next appointment. Now, just relax.”

Soon after, Carol takes the rest of her medication and winds up in the hospital. Her family consults an attorney who is considering filing a lawsuit based upon the four elements of a malpractice suit.



Questions for Reflection: The Case of Carol



Since Carol and Therapist Green had been seeing each other in a therapeutic environment, the first element of a malpractice suit has been met because there was:


a)   Duty of Care established

b)   A breach of the Standard of Care

c)   Demonstrable Harm evident

d)   Proximate Cause shown


Answer: (a) duty of care is established when a client-therapist relationship is developed or created.


Therapist Green was probably not adhering to the current Ethics Code for psychotherapists, the statutes of his state, or the recent case law. Therefore, he probably:


a)   Did not create a Duty of Care

b)   Breached the Standard of Care

c)   Created Demonstrable Harm

d)   Provided Proximate Cause


Answer: (b) breaching the standard of care of his profession by not adhering to the ethics code.


Since Carol wound up in the hospital after talking with Therapist Green, this probably is evidence of:


a)   Duty of Care

b)   Breach of Standard of Care

c)   Demonstrable Harm

d)   Proximate Cause


Answer: (c) demonstrable harm. Since his patient ended up in the hospital, harm was demonstrated.


If Carol would have been fine if her psychotherapist, Therapist Green, had treated her in a more appropriate manner, this is proof of:


a)   Duty of Care

b)   Breach of Standard of Care

c)   Demonstrable Harm

d)   Proximate Cause


Answer: If it could be proven (which would be very difficult to do) that the patient would not have suffered damages (or they would not have been as serious), had Therapist Green done anything differently, then (d) proximate cause can be claimed by the attorney of the patient.





Experts in legal and ethical matters agree on these methods of minimizing the risk of a malpractice suit (Caudill & Pope, 1995; Welfel, 2002; Clayton & Bongar, 1994; Cranston et al., 1988; Reamer, 2018).


Professional consultation (discussed later)

Personal therapy

Membership in professional associations

Continuing education

Familiarity with current treatment methods

Familiarity with current journals

Knowledge of the current standard of care

Proper referrals (e.g., hospitalization, medication, adjunctive treatment)

Proper documentation of patient care




There are numerous elements to be considered when a new client calls for an appointment for treatment. Regardless of who is seeking therapy or making a referral, there are five main factors that must be considered. These “five always” (which can be remembered by the shortcut, “CCARQ”) are:




What is the culture of the person seeking treatment with you? Lee and Richardson (1992) tell us that every therapy relationship is a “cross-cultural” relationship because everyone who enters a psychotherapist’s office is of a different culture from the psychotherapist. Additionally, it is not wise to “judge a book by its cover.” In other words, a potential client may look or sound one way, but live in a completely different multicultural family than what appears at the initial visit. For instance, a client may be an African-American with a Chinese domestic partner. Psychotherapists should never make assumptions about a client’s culture and cultural sensitivities, or those of a client’s family.




This means that every client must be considered for the possible impact she has, or may have, on the psychotherapist. The psychotherapist must be able to intelligently evaluate his condition, reactions, behavior, feelings, and ability to handle difficult situations in order to avoid the negative effect of counter-transference on the therapeutic relationship (e.g., premature termination, inappropriate behavior by the psychotherapist).


Area of Competence


All psychotherapists should be able to handle all the diagnoses in the DSM; however, this is not realistic. What this actually means is that psychotherapists must be able to identify their limitations—when they should refer a client due to lack of training, counter-transference, or inexperience. In actuality, psychotherapists are expected to know how to handle all diagnoses or know when to refer out due to lack of expertise, competence, or desire to treat or know when to get proper consultation when gaining new skills and competencies.


Rule Out General Medical Condition or Substance Abuse


It is mandatory to rule out any general medical condition or substance abuse that may reasonably be causing, or be related to, mental health symptoms. For example, a person who has panic attacks or any other “head-to-toe” symptoms of anxiety disorders may be suffering from a hormonal imbalance or thyroid dysfunction rather than an actual DSM diagnosis. A medical doctor must rule out general medical conditions (See Axis III in the DSM-IV-TR, APA, 2002) prior to treatment for a mental disorder, particularly one that includes physical symptoms. A psychotherapist cannot rule out a GMC or substance abuse in the blood stream (lab tests) because it is outside of his or her area of competence (medicine).


Question the Reporter


It is not uncommon for a new client to attribute his range of symptoms to another person close to him, such as a significant other or loved one. For example, we might hear, “My significant other is an alcoholic and I don’t know what to do,” when the caller or our primary patient is actually the person with a drinking problem.




There are four mechanisms holding psychotherapists accountable for our actions as mental health professionals. A brief description of each follows:


State licensing boards.  A state licensing board is the agency that “giveth and taketh away” the ability to practice psychology. It decides how many hours of continuing education must be taken to renew the license and continue practicing, it regulates penalties for improper practice behaviors, and it can take action if a psychotherapist fails to respond to its dictates.


Ethics committees.  This second mechanism sets guidelines of practice that are considered the standard of care in the profession. It can also take sanctions against the psychotherapist for improper behavior.


Civil suit for malpractice.  Mechanism 3 is a generally unpleasant factor of American society – when one citizen takes civil action against another citizen. In a civil suit, the only thing being claimed is financial damages, and the only remedy is money. However, punitive damages are also a possibility where the court awards extra financial damages as punishment in a particularly egregious situation. A psychotherapist does not want to be confronted by this element of accountability, as it is generally grindingly slow and complex, not to mention painfully expensive.


Criminal allegations (Attorney General Involvement).  Criminal allegations are the least likely of the four mechanisms holding a psychotherapist accountable for practice behavior. If there is an unfortunate outcome where the state attorney general goes after a psychotherapist’s license and prosecutes for criminal allegations, the psychotherapist who is found guilty can find herself spending time in a jail cell.



Accountability Case Vignette



Suppose you are hungry at your lunch hour and decide to enter a McBurger restaurant. You sit down quietly in a small booth, with your new Jonathan Kellerman mystery, hoping to get a minute of peace before a busy afternoon. The server comes by and gives you a menu.


When the server returns, you decide to order the chili with a diet cola. The server tells you he will be right back with your order. You read another chapter of your book and enjoy the time off.


A few minutes later, the server delivers a cola and the chili, telling you to “enjoy your meal.” It smells good.


As you take a sip of the cola, you begin to salt the chili. You cool off the chili by letting some cool air flow through the thick chili. You cannot believe what you see, so you look more closely… it looks like there is a FINGER on the spoon! It seems you have been served a bowl of chili with someone’s finger in it!



Questions for Reflection



The definition of Duty of Care is:


a)   what another reasonable therapist would do in your situation

b)   proof of damage

c)   an established relationship


Answer: (a) Duty of Care is defined as an “established relationship between the therapist and client.”


Did the McBurger server and the McBurger establishment have a “Duty of Care” with you?


a)   Yes, because they gave you a menu in preparation to serve you food

b)   No, because they were only doing an evaluation of you to decide if they wanted to serve you

c)   No, because no relationship is established until you pay


Answer: (a) As in a therapy relationship, once service is offered in the restaurant, via being given a menu, the relationship has been established. This is the same as offering service to a potential client without saying it is an evaluation.


The definition of Standard of Care is:


a)   What the most recent ethics code says

b)   What a judge says

c)   Reasonable therapist standard, statute, case law, ethics code


Answer: (c) Standard of care is four things: reasonable therapist standard, statutes, case law, and ethics codes.


Did McBurger practice the Standard of Care of the restaurant profession with the chili they served to you? Why, or why not?


a)   No, because it is the standard of care to serve FINGER-LESS chili!

b)   Yes, because it probably was not a finger anyhow


Answer: (a) The standard of care was not met because the chili had a foreign object in it that was unexpected and inappropriate.


The definition of demonstrable harm is:


a)   Was someone hurt physically?

b)   Was someone hurt psychically?

c)   Can harm be shown in a court setting?


Answer: (c) Demonstrable harm can be shown in a court setting.


Did you suffer demonstrable harm after this event?


a)   Yes, I can never eat chili again, I am anorexic and nauseous

b)   Yes, I can never eat in a restaurant again

c)   Yes, I now suffer from PTSD and cannot grocery shop


Answer: The issue here is that the “demonstrable harm” is anything that you and your lawyer claim (that is true). Any of these answers are possible. If this were a real case, and a psychotherapist were being sued for malpractice, the issues would certainly be different, yet the claims would be similar and the four elements would be identical.


The definition of proximate cause is:

a)   What is the cause of the demonstrable harm?

b)   Is the demonstrable harm something the defendant did or failed to do?

c)   Can the demonstrable harm be remedied with money?


Answer: (b) Is the demonstrable harm due to something the restaurant or chef or server or staff did or failed to do? This is relevant to any civil suit.


How can Proximate Cause be applied to the finger-in-the-chili situation?


a)   It does not apply

b)   It would have to be that the chef or someone at the restaurant made an error and actually put the finger in the chili

c)   Only the chef could have put in the finger for this element to apply


Answer: (b) In this case, the chef or someone else at the restaurant would have had to do something that caused the damages. The test is whether the damage would not have occurred If the person had not done the act.





Radden (2001) reports that the discussion of boundary violations is filled with confusion partially because the words describe a wide variety of behaviors. These include:


Physical contact between treater and patient (non-sexual touching, such as pats and hugs, as well as sexual intimacy)


Forms of self-disclosure on the part of the treater about personal matters, such as the insertion of aspects of the treater’s personal life into the therapeutic discussion


Breaches of confidentiality by the treater, what would otherwise be known as conflicts of interest (for instance when the treater initiates or permits a social or business relationship to exist at the same time as the therapeutic one, or when other gratification for the therapist);


An assortment of improprieties associated with the therapeutic engagement (fee-setting, gift-giving, and appointment times and places, for example). (2001, p. 320)


Radden considers this definition “misleadingly broad,” saying, “boundary violation seems to encompass almost any form of exploitation and/or any behavior likely to diminish the therapeutic effectiveness of the engagement.” (p. 310)




Multiple Relationships


In Harmell’s 1998 article “Multiple Multiple Relationships Relationships,” she noted that ethics committees and licensing boards have always had difficulty defining the terms dual and multiple relationships. This began with major figures in the field such as Freud and Jung, both of whom straddled the line with their patients, although the “line” had not yet been solidly set. (Since the article was written in 1998, the author did not have a chance to include the more recent definitions of sexual behavior credited to former President Clinton, who appeared to segregate oral sex from sexual behavior entirely, giving a new slant to sexual terminology). This is mentioned here to demonstrate the difficulty inherent in an open society such as that of the United States in coming to a consensus on sexual terminology.


Sonne (1994, p. 376) defines multiple relationships as “situations in which the psychotherapist functions in more than one professional relationship, as well as those in which the psychotherapist functions in a professional role and another definitive and intended role, as opposed to a limited and inconsequential role growing out of and limited to a chance encounter.” In other words, multiple roles can be concurrent, or follow each other. Either way, it is generally considered a boundary violation. Positive limit-setting is something all therapists must master by placing restrictions when responding to patient requests, and then reframing their response to therapeutically meet the patient’s legitimate need.


Despite Sonne’s excellent description of the term multiple relationship, it remains difficult to produce an exact and absolute definition that will cover all situations in all locations for all people involved.


Boundary Violations


Because patients discuss emotional and highly personal matters, intimacy is created. It is the psychotherapist who is responsible for maintaining proper limits, keeping the therapy focused, and handling counter-transference and needs for personal gratification without involving the patient inappropriately (Harmell, 1998). Some psychotherapists try to rationalize conducting a business relationship with a patient as well as a therapeutic one simultaneously or after the therapy is over. According to the earlier definition, this constitutes a multiple relationship and is unethical.


Adding to the confusion about boundary violations is the fact that the literature refers to boundaries that occur both internally and externally. These terms are often used freely in the language of psychology. Internal boundaries refer to psychic boundaries that enter into the psychodynamic realm of discourse. External boundaries are more likely to refer to a situation in which inappropriate actions on the behalf of the therapist overlap the external boundaries of the patient in some inappropriate way. To add to the confusion, it is often noted that those who inappropriately intrude upon the external or internal boundaries of a patient have weak or problematic internal boundaries of their own.


Conceptualization becomes difficult when we evaluate the breadth of the usage of these words. Further, judgments of boundary violation seem to be context sensitive. According to Gutheil and Gabbard (1998) it is always required to place the activity in “contextual framing” in order to determine if it is an innocuous boundary crossing or an unethical boundary violation. Context includes:


1.   The treater’s professional ideology

2.   The presence or nature of the informed consent by the patient

3.   The point of therapy in which the behavior occurs

4.   The respective cultures of the therapeutic dyad

5.   Such environmental factors as:

·         Whether therapy occurs in a small town or in an urban center

·         Whether public transportation is available or not


Gutheil and Gabbard point out that a therapist who decides to give a patient a ride home in his or her car during a blizzard could be looked upon differently depending upon where the therapy is taking place. If it is a small prairie town as opposed to a large city with a subway system, whether the patient feels forced to accept the ride, or other such elements are the contextual sensitivities of each situation. Thus, it becomes impossible to provide one definition to cover the entire class of behaviors and activities of boundary violations.



Question for Reflection



The primary reason it is difficult to develop a definition of “boundary violation” in psychotherapy is due to the concept of:


a)   Internal boundaries

b)   Contextual sensitivities

c)   External boundaries


Answer: (b) is the best answer, as contextual sensitivities must always be considered because they change the details and interpretation of the facts of the situation



Once again, context is the primary element that determines how to interpret whether there has been a boundary violation.  For example:


Appropriate Touching- Holding a client’s hand while she is crying during a session where her husband recently died.


Inappropriate Touching- Putting an arm around a client while she is crying during a session where she recently lost her job.


Brown (1994) wrote about the futility of trying to give a single definition, then trying to avoid all forms of potential boundary violations using this single definition. Brown proposed conceptual criteria for looking at boundary violations using four criteria that appeared in the literature:


1.   The client is objectified or treated like an object rather than a person

2.   The therapist gratifies his or her impulses through the behaviors

3.   The therapist’s needs become more important than the needs of the client

4.   The client feels violated


Although this model attempts to avoid the definitional difficulties and ambiguities of the Gutheil and Gabbard definition discussed earlier, all raise challenges in interpretation.


For example, it seems impossible to designate all behaviors that gratify the therapist’s impulses as boundary-violating (Brown’s Criterion 2). Behavior engaged in for some other well-considered and therapeutic purpose may also happen to gratify the therapist’s impulses as well. Indeed, if therapy was not gratifying for the therapist, few therapists would continue in the profession and it would cease to exist.


Brown’s Criterion 3, where the therapist’s needs become more important than the needs of the client, is a dangerous phenomenon. For example, sometimes therapists violate boundaries by becoming overly sympathetic, or dreaming about a client, or failing to take the time to seek proper consultation or help with the treatment plan. Although, one must consult and fully understand how to handle these possible counter-transference reactions in order to avoid improper boundary violations in advance, this criterion alone fails to properly define boundary violation.


Criterion 4, wherein the client feels violated, is also unsatisfactory, according to Radden (2001). An oversensitive or even paranoid client is likely to feel violated with no actual violation. Thus, Criterion 4 is not a good definition point for boundary violation because the client may feel his or her boundaries have been violated without a true violation having occurred.


Boundary violation discussions rely on two basic conceptual features that Brown does not include in his work on boundary violation. For example, Garfinkel, Dorian, Sadavoy, and Bagby (1997) focus on asking the questions:


(1) Is the behavior in question potentially exploitative, and

(2) Is the behavior in question potentially detrimental, or at least not conducive, to therapeutic success?


It is important to note that lack of empathy for a client, lack of momentum, and other more subtle issues may be potentially detrimental to the therapeutic success, but fail to violate a boundary. It is fairly easy to give several examples of exploitation and detrimental activities that jeopardize the therapeutic relationship and exploit the client without violating the therapeutic boundary. Other examples of detrimental treater behaviors that do not violate boundaries are:


·         improperly overcharging clients

·         providing unnecessary care

·         providing inadequate care


It remains a puzzle as we continue to try to define boundary violation (Radden, 2001).


Boundary Transgressions Defy Categories


Thinking in categories is helpful and useful in order to make difficult concepts more understandable. As we have seen already, it is impossible to give a simple definition to “boundary violation.” Having a definition or a clearly stated boundary can give a false sense of security in which therapists may visualize an invisible line that creates a boundary that can be stopped before crossing (McGuire, 1996). It is, however, not that simple. For example, many psychotherapists have clear boundaries and policies about accepting gifts from clients. However, cultural issues may enter into such decision-making. Additionally, where one’s practice is located—a large or small town (to be discussed later)—is also a factor in making a decision about accepting gifts.


Although making categories is helpful, it is important to remember most transgressions cross over into several areas, not just one area such as location or setting of practice, and merge into more than one category.  Attempts to categorize boundary transgressions include the following:


Physical Boundary Transgressions


·         Any type of touching besides accidental touching that is non-sexual

·         Hugging, kissing, fondling

·         Any type of sexual touching


Physical Boundary Transgressions do not always fit the usual and customary definitions mentioned above. For example:


1.   A new client comes into the office and sits in “your” chair.

2.   An intern you are supervising asks you to attend his wedding.

3.   A patient whose husband recently died reaches for your hand during a session.

4.   A student stays after class and asks for a ride home during a rainstorm.


Emotional Boundary Transgressions


·         Using clients to satisfy the emotional needs of the therapist

·         Misusing client information to satisfy emotional needs of the therapist


Emotional Boundary Transgressions may manifest in the following ways:


1.   The therapist uses the sessions to talk about himself rather than focusing on the client

2.   The therapist over- or under-charges a specific client for her own reasons that are not therapeutic but are personal

3.   The therapist loans the client money or other personal items

4.   The therapist invites the client to a party in the home of the therapist


Psychological Boundary Transgressions


·         Using psychological tools to humiliate or trick another or potential “victim”


One who uses Psychological Boundary Transgressions is generally conscious of what one is doing to another person. There is an attempt to control the situation, or to be the more powerful person. For example:


1.   Using an offensive term in a session in order to put a client on guard

2.   Shaming a client in front of others (e.g., “You aren’t doing well at work. Maybe you need more training.”)

3.   During a session, the therapist answers the phone several times

4.   The therapist consistently runs late or ends early for sessions with a specific client without discussion on the matter


Sexual Boundary Transgressions


·         Any type of inappropriate clothing in the office

·         Any type of inappropriate sexual behavior (touching or not) in the office

·         Any type of inappropriately sexual innuendo or language in the office with clients


Sexual Boundary Transgressions are easy to stop when they involve clothing or subtle behavior. However, inappropriately sexual language or innuendo is more difficult to track. For example:


1.   A therapist winks at a client during a session in a sexual manner

2.   A female therapist wears a skirt that is too short to properly cover her legs during a session

3.   A therapist, when listening to the sexual fantasies of a patient, begins to discuss his own sexual fantasies as well

4.   A therapist comments on how “sexy” the client looks during the session



Question for Reflection



Therapist Dean was in the middle of a messy divorce, so when his attractive, young client arrived for her session wearing a skimpy outfit, he was unsure what to do. He became so flustered that he told her he is getting a divorce, and he wished she were not his patient because he would like to go out with her because she really turns him on. Which form of Boundary Transgression is this?


a)   Physical Boundary Transgression

b)   Emotional Boundary Transgression

c)   Psychological Boundary Transgression

d)   Sexual Boundary Transgression


Answer: This question is a bit more complicated, as the best answer is (d), Sexual Boundary Transgression. He never touched her, so (a) is eliminated. Even though (b) Emotional Boundary Transgression does overlap here, it is not as good an answer as Sexual Boundary Transgression. There does not seem to be any deliberate attempt to outsmart the patient by Therapist Dean or to make her feel overpowered, so (c) Psychological Boundary Transgression is eliminated.





The following APA codes apply to multiple relationships.  For the complete APA Code of Ethics click here.  Each code includes a brief discussion.


APA 3.05 Multiple Relationships


This code specifically prohibits having a professional role simultaneously with:


a)   Another role with the same person


b)   Or is in a relationship with another person closely associated with, or related to, the person with whom the psychotherapist has the professional relationship


c)   Or promises to enter into another relationship in the future with the person or a person closely associated with or related to the person


The consideration here is to ask if the multiple relationship could reasonably be expected to impair objectivity, competence, or effectiveness.


This is the first time the code has formally noted that not all multiple relationships are unethical if they do not risk exploitation or harm or do not impair the clinician’s judgment.


APA10.05 Sexual Intimacies with Current Therapy Clients/Patients


This is never appropriate under any circumstances.


APA 10.06 Sexual Intimacies with Relatives or Significant Others of Current Therapy Clients/Patients


This is never appropriate under any circumstances, nor is it ever appropriate to terminate therapy to begin a sexual relationship under these circumstances.


APA 10.07 Therapy with Former Sexual Partners


This is never appropriate under any circumstances.


APA 10.08 Sexual Intimacies with Former Therapy Clients/Patients


APA adheres to the “almost never” rule here. However, if a psychotherapist does engage in such activity after the two-year prohibition, at the very least the following seven elements must be considered:


The amount of time that has passed since therapy terminated.  The time that has passed changes the context of the situation. If the amount of time that has passed is twenty-six months versus twenty-six years, it is more understandable that the pair might consider having a sexual relationship and that the therapeutic relationship may be more distanced than if it was only two or three years in the past.


The nature, duration and intensity of the therapy.  The difference between a therapist who was an intern who performed an intake as opposed to a licensed psychotherapist who participated in an eight-year analysis with the patient makes a significant difference in the decision whether to have a sexual relationship with the former patient.


The circumstances of termination. It is critical to consider the circumstances of the termination, whether it was valid and sincere, or simply for the purpose of starting a sexual relationship as soon as possible. For example, does the sexual relationship begin at the end of the second year (as soon as legally and “ethically” possible under the APA Code and state laws that apply), versus much later in their lives?


The client’s personal history.  The client who has a history of suing psychotherapists or others in the medical field may not be the best person to have a sexual relationship with after therapy ends, even after the two-year waiting period.


The client’s current mental status.  The patient’s mental health should also be considered along with family life and diagnosis. For example, if the client were diagnosed with Borderline Personality Disorder, the fact that the person might be considerably unstable would be a serious consideration.


Likelihood of adverse impact on client.  The APA added this to the language of the Code in order for psychotherapists to take the time to consider if a romantic relationship with a former patient would create further stimulation of past trauma.


Any statements or actions made by therapist inviting the possibility of a post termination sexual or romantic relationship with client.  For example, suggesting if the client were not a client, a relationship might be possible. Many clients report their therapists telling them “If you were not my client, I would like to date you!”



Questions for Reflection



What does it say in the APA Ethics Code that automatically makes the psychotherapist’s behavior unethical?


a)   All sessions with a psychotherapist are psychotherapy when dealing with a court appearance


b)   Sex with a patient prior to a two-year delay after a valid termination is not appropriate


c)   Leaving unsolicited messages with sexual content for a patient is unacceptable behavior


Answer: (b)—sex with a patient prior to a two-year delay after a valid termination is not ethical and, in some states, not legal. It is important for each professional to become familiar with the laws in his state regarding sex with patients.





STANDARD 1: Responsibility to Patients


STANDARD 1.2 - This is a general code that explains that MFTs avoid dual relationships that could impair professional judgment or lead to exploitation. A dual relationship exists when:


1.   The therapist and patient engage in a distinct and separate relationship either simultaneously with therapeutic relationship, or during a reasonable period of time following the termination of the therapeutic relationship


2.   Not all multiple relationships are unethical and some cannot be avoided


STANDARD 1.2.1 - Sexual activity during therapy or within two years of termination is unethical.


STANDARD 1.2.2 - Other acts that are unethical dual relationships are borrowing money from a patient, hiring a patient, doing business with a patient, having a close personal relationship with a patient, having close relations with a patient’s relative, etc. is unethical.


STANDARD 1.2.3 - MFTs do not enter therapy with sexual partners.




NASW Code of Ethics


Standard 1.09 – Sexual Relationships (a-d)


a)   Under no circumstances do SW have sexual activity with patients.


b)   SW do not engage in sexual activities or sexual contact with patient’s relatives or others who have a close personal relationship with the patient.  SW do not have sexual contact with relatives of their patients.  The SW maintains the entire burden for setting clear and appropriate boundaries, culturally and otherwise.


c)   SW do not engage in sexual activity with former patients except under the most extraordinary circumstances.


d)   SW do not provide services to those with whom they have had sexual relationships.


Standard 1.11 – Sexual Harassment


SW do not sexually harass clients which includes sexual advances, solicitation, requests for sexual favors.


CSWA Code of Ethics


Standard 3 – Relationships with Clients (a&b)


a)   CSW are responsible for setting clear boundaries about dual and multiple relationships.  The do not take chances where there is an opportunity for patient exploitation, especially when the CSW is seeing two or more patients who know each other.


b)   CSW do not engage in sexual activity with former patients except under the most extraordinary circumstances.  CSW do not provide services to those with whom they have had sexual relationships.




Multiple Relationships: A Continuum from Destructive to Therapeutic


Moleski and Kiselica (2005) make a case for the continuum model of multiple relationships ranging from destructive to therapeutic in nature, scope, and complexity. Therapists are constantly balancing their own values and needs with those of the patient along with the ethics codes of their profession and the regulations of their licenses. However, none of these provides more than guidelines with any absolute answers. “Consequently, practitioners must combine their understanding of ethical codes with sound judgment to serve the best interests of their clients.” (Moleski & Kiselica, 2005, p. 3)


Destructive Multiple Relationships: Sexual and Non-sexual


Sex with a current patient.  There is very little disagreement that a sexual relationship with current patient is considered the most destructive. Indeed, in survey research done by Borys and Pope (1989) 98% of the nearly 5,000 mental health professionals asked cited “sexual activity with a client before termination of therapy” as never ethical (p. 289).


Despite this attitude, survey research has found therapist respondents admitting to having sex with current patients in percentages up to 12% (Stake, 1999). More alarming still, research done by Pope and Bajt (1988) in which senior experts belonging to state ethics committees, authors of ethics texts, and diplomats of the American Board of Professional Psychology were surveyed, 9% indicated that they had engaged in sex with a client.


Sex with a former patient.  Sexual relations with a former patient is less universally as destructive as is sex with a current patient, as demonstrated by the decision to allow psychotherapists to have sexual relations with a patient after a normal and valid termination after the two-year period has elapsed. Many experts complain the two-year delay is an arbitrary time frame with no real reasoning behind it, and that it contradicts the therapists dictum to do no harm and to enable patient autonomy (Hartlaub, Martin, & Rhine, 1986; Gabbard, 1994; Gotlieb, 1993; Harmell, 1998).


Part of the problem is that rather than analyzing the transference and counter-transference phenomenon, the pair might ignore what is vital to the therapy and the patient’s health. The therapist becomes just another person, rather than one who can help the patient overcome hurdles and process issues.


A patient hoping to fulfill the attraction in the future will lose an important part of the therapeutic relationship, perhaps hiding from the clinician parts of himself in hopes of pursuing this secondary relationship. Clients may consciously or unconsciously sabotage their own therapeutic efforts (Moleski & Kiselica, 2005).


Non-sexual multiple relationships.  Most authors write that even non-sexual multiple relationships can be harmful to the primary therapeutic relationship because they have the possibility of overriding the therapy relationship. For example, should the patient and the therapist go into a business deal together (as discussed in Section B) and the deal fails, the therapy relationship is in jeopardy. Because the therapist often has influence over the patient, she is in a position to exploit the patient for her own benefit (Moleski & Kiselica, 2005).


A particularly interesting form of non-sexual multiple relationship occurs when a recovering therapist attends a recovery meeting which his patient is also attending. Doyle (1997) states that either or both parties may risk sobriety, along with anonymity as a person in recovery. Each deserves the freedom to practice his or her program without the other person as witness. It is up to the therapist to protect the well-being of both parties so that neither become a victim of a harmful multiple relationship.


Therapeutic Multiple Relationships 


On the other end of the continuum are the secondary relationships that some consider complementary to the primary therapeutic relationship. These relationships may enable and enhance the primary counseling relationship, not only in rural settings but in large, urban cities as well. Refusing therapy patients because of fear of this therapy overlap may prevent those in need from receiving services in rural settings (Doyle, 1997).


Cultural issues often require therapists to overlap certain areas of their practice styles that might not ordinarily overlap. For example, accepting a gift in order to enhance the patient’s receptiveness to therapy, or in order to show respect for one’s culture is not necessarily acceptable to Western-trained therapists. However, if not accepting the (reasonably priced) gift would thwart the alliance between the therapist and client or otherwise disturb the relationship, it would clearly be an appropriate and therapeutic “multiple relationship” to accept the gift.


As we all know, the history of psychology is fraught with famous therapists who had all manner of relationships with their patients (see Freud and Jung by Linda Donn). Freud analyzed his daughter Anna, as well as fed his clients meals. Melanie Klein invited a client to join her where she vacationed. She placed him on her hotel bed and analyzed him for two hours (Moleski & Kiselica, 2005).


Protection for Therapists


Corey et al. (1998) recommend the following guidelines when thinking through potential problem boundary areas before they have a chance to cause trouble:


1.   Set healthy boundaries from the outset

2.   Secure the informed consent of clients and discuss with them both the potential risks and benefits of dual relationships

3.   Remain willing to talk with clients about any unforeseen problems and conflicts that may arise

4.   Consult with other professionals to resolve any dilemmas

5.   Seek supervision when dual relationships become particularly problematic or when the risk for harm is high

6.   Document any dual relationship in clinical case notes

7.   Examine your own motivations for being involved in dual relationships

8.   When necessary, refer clients to another professional



Question for Reflection



What is meant by the “continuum model” of multiple relationships?


a)   Therapists should examine their own motives for being involved in a dual relationship with a former patient

b)   Having a sexual relationship with a past patient is not as destructive as having a sexual relationship with a current patient

c)   Multiple relationships with patients range from destructive for the patient to therapeutic for the patient


Answer: The answers above contain two distracters and one best answer. Answer (a), although true, is not the definition of the continuum model. Answer (b) is also true, but is not the correct answer as it is not a definition of continuum model. Thus, answer (c) is the correct answer as it does give the correct definition of the continuum model for multiple relationships.



Precursors to Therapist Sexual Misconduct


Attorneys, when asked, report that most therapists who have sexual relationships with their patients do not simply have a normal and routine psychotherapy relationship with the patient one day, and suddenly sail into a romantic relationship the next. Therapists who get into a sexual relationship with a patient are generally vulnerable due to a counter-transference problem leading up to the sexual violation. For example, some therapists unfortunately gain false confidence about their continuing sexual attractiveness during and after a divorce or separation from a significant other by using patients to fulfill roles that should be filled by non-patients.


For most therapists, the idea that one would desire a patient so intensely that he would risk a hard-earned license, family life, professional reputation, and financial security seems difficult to imagine. However, as reflected by enormously high malpractice premiums for psychotherapists, the entire profession pays the price for those who do not follow the prescribed and agreed upon standards.


Recent research has indicated that the motivation for sexual boundary transgressions most often involved “unconscious, denied, or compartmentalized conflicts about which the therapist had little insight.” (Celenza, 1998, p. 380) The author of the research goes on to say that the issues that had motivated these therapists to seek sexual relationships with their patients were usually related to “personal conflicts in the character of the therapist, rendering the therapist vulnerable to enactments when intolerable helplessness, loss of self-esteem, or rage were evoked.” (p. 381)


The convergence of results from seventeen subjects’ personal interviews, clinical observations, background information, the Rorschach and Thematic Apperception Tests of both therapists who had transgressed and, where possible and appropriate, the patient-victim, were used in Celenza’s procedures and analysis. The author stresses that this is not a controlled or prospective study at this point, but a way of shedding light on, and further educating the profession in, this vital area of boundary violation.


Six Precursors to Multiple Relationships


Celenza (1998) found six features that fell into the following categories:


Long-standing and Unresolved Narcissistic, Neediness, and Lifelong Struggles with Low Self-esteem. Each therapist in this study reported lifelong feelings of inadequacy, failure, and unworthiness. All therapists reported feeling this way all of their lives. In the therapy where the therapist committed the boundary violation, the therapist’s needs had gradually become the focus of the therapy. In some cases, this occurred more subtly by disclosing personal matters at first, then soliciting sympathy or soothing from the patient. The patient often reported feeling powerless and reluctant to confront the therapist who appeared to be an authority figure. Ninety-four percent of the therapists reported feeling a paradox of powerlessness in relation to the therapy. These patients reported feeling as if angry feelings toward the therapist were not allowed under any circumstances (Celenza, 1998).


Childhood History of Sexualized Pre-genital Needs. Celenza reported therapists in this survey study indicated they had no conscious awareness of “having been over-stimulated as a child.” (p. 382) Only one of them reported having been the victim of outright sexual abuse. The study did reveal, however, that the sexualization would take the form of covert seductiveness and over-stimulation “in the context of an emotionally depriving relationship with a parental figure.” (p.381) Additionally, the seductiveness that was done in a covert manner always occurred in the context of an emotionally repressed and sexually prohibitive environment within the therapist’s family. A few memories reported were:


Therapist recalled memories of a mother in a conservative and religious family undressing in an asexual manner (not intentionally seductive) and was not aware that this behavior had the potential to stimulate a child.


Therapist recalled his mother preventing him from hugging her or holding her hand. He did recall the mother encouraging him to tell her about his own multiple sexual exploits.


Therapist recalled mother being warm and loving to nine sisters while being unaffectionate and unpredictable toward him, the only son. Father was described as “enjoying his manhood” and pursuing typically male hobbies such as building cars and racing hotrods.


Therapist recalled both parents as “Edwardian, very formal, unaffectionate, and repressive” (pp. 382-383), and sleeping in different rooms and having little contact with each other. Slaps on the hand were the routine form of punishment for “naughty” behavior. He longed to be slapped more often because this was his only form of being touched by his parents. Everyone knew father had gay lovers visiting in the afternoon with which he showered; no one in the family openly acknowledged these visits.


These childhood experiences have the power to result in unresolved needs that can be replayed in the therapeutic relationship. (Twemlow & Gabbard, 1989; Gabbard, 1994a)


Restricted Awareness of Fantasy.  This was especially true of those therapists who had the most guilt and self-reproach over the boundary transgression. ”Because a restriction in the ability to use fantasy impedes the capacity to imagine multiple levels of meaning (e.g., to recognize or consider transference, counter-transference, and defense functions), feelings are taken at face value.” (Celenza, 1998, p. 383) Celenza asks the question, “What mechanism failed to prohibit the therapists from acting their counter-transference or fantasy feelings about their patients?” Some of the material that was revealed in the research was:


     Exploration of therapist’s feelings showed an inability to perceive aggression in themselves


     Exploration of therapist’s feelings showed an inability to perceive aggression in others


     Many therapists were unable to acknowledge the boundary transgression as a hostile act toward the patient


     These therapists had moralistic views


     Many of the therapists were self-depriving


     Therapists reported their conscious fantasies lacked aggressive play themes and other impulses considered by themselves to be repugnant or immoral


     Gabbard (1994b) observes this represents an impairment in fantasy functions


     “This accords with Freud’s [1911/1958] early discovery that consciousness plays a central role in the capacity to delay, that it is those impulses that are unconscious that are most likely to be acted out.” (Celenza, 1998, p. 384)


It was reported by one therapist that he thought his job was to eliminate his anger and he found it impossible to sustain any anger in relation to a difficult past. Another developed panic attack symptoms at the funeral of a high school athletic coach who had refused to accept him on to the team. In analysis as an adult, he learned he unconsciously believed his anger and frustration at the coach had caused the coach’s death. Other therapists realized in therapy that their “seething rage underneath a placid and good exterior” hid severely aggressive feelings from themselves and others. It seems these therapists were unaware of their responsibility in the event and often felt seduced by the patient-victim. Indeed, one therapist remarked after the boundary violation, “My body responded; I did not.” (Celenza, 1998, p. 384)


Ample Precedence in Family History of Therapist of Boundary Transgressions by Parental Figure.  It seems that boundary-violating therapists in this group often experienced and witnessed a parental figure gratify his or her own sexual needs with a partner outside the parental dyad. The child (now the adult therapist) reenacted the scene in a secret and forbidden context, mirroring the patient’s wish to have a sexual relationship with an equally forbidden object with which the therapist colludes. Both parties are caught in this reenactment (Gabbard, 1994c).


Intense and Unconscious Unresolved Anger toward Authority Figures.  In one survey, subject-therapists reported they thought the researchers were actually working with them to work against the licensing board that had taken action against the therapist’s license for the boundary violation, and that they were actually attempting to reverse the suspension. Another therapist who was also a pastoral counselor reported he got sexually involved with a patient in order to “f**k God and f**k the church.” (Celenza, 1998, pp. 385-386).


One element found in every subject, and the one the researcher reports as the most important, was an acute inability to tolerate any part of the negative transference expressed by his or her patients. This was true of all his or her patients, not only the one with which the sexual relationship occurred. One therapist denied that any of his patients ever had any hostile, negative, or devaluing projections toward him. Indeed, when deeper questioning took place, the patients with whom these therapists became involved were experienced as particularly angry and hostile.


Circumventing of Unconscious Counter-transference Hate through Misuse of Conscious Counter-transference “Love”.  When these therapists were particularly threatened by the possibility of being exposed to their own aggression, they used techniques such as overly gratifying the client, and becoming seductive and suggestive, and even manipulative. They had an intense need to be seen as caring and giving by the patient, perhaps to ward off the fear of being exposed to their own anger and rage, or the patient’s anger and rage. They displayed intolerance for counter-transference hate or negative feelings toward the patient and quickly adjusted these feelings into the opposite feelings of more tolerable counter-transference love.

Celenza reports the seduction of the patient often occurred at the time the therapist felt the least helpful and the therapy was at the worst impasse. The therapists tried to connect with the patient on some level. “I was reaching the end of my rope. I didn’t know how to help her. So I seduced her because I knew how to do that.” (Celenza, 1998, p. 388)


Psychotherapists and Sexual Boundary Violations


Three factors have been implicated by the research as influencing the occurrence and continuation of sexual and nonsexual multiple relationships:


The connection between sexual and non-sexual professional boundary crossing.  Authors report a relationship between sexual and non-sexual boundary-crossing, using the “slippery slope” analogy. It seems when there is an erosion of nonsexual boundaries, there is a very consistent deterioration to sexual transgressions (Lamb, Catanzaro, & Moorman 2003). Earlier research reported therapists who admitted actual sexual boundary transgressions had previously engaged in nonsexual boundary transgressions such as crying in front of a patient or disclosing personal information.


Difficulty in exacting a definition for dual or multiple relationships.  As previously noted, this is a recurrent theme among experts who author articles on the subject. Many experts ask how the American Psychological Association can deem nonsexual behaviors as unacceptable when definitions are vague and over-inclusive (Ebert, 1997; Lamb et al., 2003). Additionally, theoretical differences add to the confusion and differences in defining multiple relationships, causing many to disagree within the profession (Williams, 1997).


Therapist characteristics putting them at risk. Lamb et al. (2003) report mixed findings in previous research regarding characteristics that put therapists at risk for becoming vulnerable to sexual transgressions with patients. However, researchers have developed various methods of evaluating this factor. Therapists’ self-reports and reflections about issues in their lives that made them particularly vulnerable will be discussed later in this section.


Psychotherapist’s Talk about the Experience of Violating Boundaries


What life circumstances did psychotherapists who practiced the prohibited behavior with patients, supervisees, or students report they believed had an influence on the development of the prohibited sexual relationships? Lamb et al. (2003) identified two general types of circumstances in their research:


Type One - Factors related to dissatisfaction in their personal lives


  • Marital problems
  • Employment issues
  • Money issues
  • Loneliness
  • Insecurity
  • New baby
  • Parent died
  • New job


Type Two - Actual activities or interactions related to the other person


  • Social interactions brought familiarity
  • Continued contact after therapy ended
  • Dreamed and fantasized about the person
  • Continued seeing patient after therapy should have terminated


Of thirteen rationales offered to those surveyed, researchers identified three general types of reasons or circumstances that the psychotherapists chose most often:


Rationale 1: No harm, thus I proceeded – 40% of the responses.  Typical answers from the participants that fell into this category are:


·         An egalitarian relationship existed

·         I did not see the relationship as falling under an ethical violation

·         There was no harm to the other person

·         The therapy relationship was over so there was no dual role

·         The time since termination was sufficient


Here, it seems that these psychotherapists used the defense mechanisms of rationalization and denial to decide that no harm could be foreseen. Therefore, there is no real reason not to proceed with a sexual relationship with the patient, supervisee, or student. It is understood that this type of thinking and non-analysis of the situation does not serve the profession nor does it follow the goals of the profession where the welfare of patient is primary.


Rationale 2: Consulted and/or negotiated – 32% of the responses.  Typical answers from the participants that fell within this category are:


·         I clarified this through peer consultation then proceeded

·         We agreed that the formal therapy relationship would not occur again

·         The two relationships were kept separate through discussion with the patient


While consultation is the standard of care, without receiving a consultation from a qualified professional who has expertise in the area in question, the consultation could be deemed inadequate and may not protect the psychotherapist from liability. Consulting with a professional who merely agrees with the psychotherapist’s point of view is not a consultation, but merely a “meeting of the minds” that cannot be used to validate the standard of care when a practitioner is in question about a treatment plan or an activity within the profession. Thus, simply receiving a consultation does not fulfill the standard of care initiative.


Rationale 3: Continued although I knew the behavior was problematic and/or unethical – 28% of responses.  Typical answers from the participants that fell within this category are:


·         I saw the relationship as problematic but I continued

·         I knew I was violating ethical standards but I did it anyway


Worse still, approximately fifty percent of this group indicated they terminated the professional psychotherapy relationship with the patient to proceed with the romantic or sexual relationship (Lamb et al., 2003).


Collegial Involvement/Peer Consultation was sought at Some Point


The majority of the offending psychotherapists (80%) reported they sought peer consultation at some time during the ordeal. All appeared to view consultation positively. There seems to be a good deal of naiveté about how to deal with overtures from patients, how to seek and receive formal consultation in this area, how to break off the sexual relationship once it begins, and how to find written materials related to professional boundaries and vulnerabilities (Lamb et al., 2003). Researchers suggest that there be more required detailed and explicit discussions, role-play activities, and mandated workshops for graduate students in order to prepare them for future difficulties with boundary issues in their clinical work.


Overall Professional Implications Reported


Thirteen of the 368-subject pool admitted having at least one sexual boundary violation as a professional psychotherapist (3.5%). The following displays the recent, more specific findings from the Lamb et al. (2003) research:




With Student


With Client


With Supervisee



Researchers attempted, and failed, to find a significant connection between reported sexual boundary violations as a former client, supervisee, or student and as a practicing professional (Lamb & Catanzaro, 1998). Using different methodology, Jackson & Nuttall (2001) did find that therapists who reported severe childhood sexual abuse in their past may actually be at a greater risk for engaging in boundary violations of a sexual nature with their own clients.


Specific Implications for Practice and Prevention


In reviewing the reflections of psychotherapists who engaged in sexual relationships with clients, supervisees, or students (or permutations thereof), the researchers found six specific implications. The authors hope their findings “can provide helpful insight to those who are currently involved with (or about to enter into) sexual or problematic nonsexual relationships and to those who have become aware of such behavior in their colleagues.” (Lamb et al., 2003, p. 106). The six specific implications for practice and prevention are as follows (see Lamb et al., 2003, p. 106):

Dissatisfaction in therapist’s own life.  Professionals who had inappropriate sexual relationships with clients, supervisees, or students experienced dissatisfaction in their own lives that may serve as a cue to their increased risk of engaging in a sexual relationship. What this may suggest is that such cues, if actually known to the therapist, can be a signal the need to discuss the issue and may have the potential to serve as prevention.


Sexual relationships are generally brief.  The course of the relationships is not long nor are they always positive. Approximately one-half of the involved psychotherapists reflected that “all and all,” the relationship was not worth having. The idea is to provide vulnerable clinicians with this type of post hoc information that may prompt further self-reflection regarding the value of pursuing such a relationship.


Involvement affects professional work.  Importantly, the prohibited behavior was found to affect professional work with other clients, supervisees, and students. This finding supports the critical standard of care issue related to professional consultation and peer consultation as an accepted method of double-checking one’s own judgment and minimizing the chance of following through on the pursuit of an appropriate sexual relationship.


“It isn’t harmful!”.  Shockingly, forty percent (40%) of those questioned who violated sexual boundaries did not view this type of involvement with patients, supervisees, or students as harmful to the other individual. “This suggests a need for several possible educative actions.” (Lamb et al., 2003, p. 106) such as education about sexual transgressions given by licensing boards, APA Ethics Office, training facilities, state ethics committees, and graduate schools.


Increase clarity and decrease ambiguity regarding how to evaluate ethical propriety of engaging in relationships after the formal relationship has ended.  There is a broad range of actions that fall upon a continuum with regard to engaging in a multiple relationship. There are instances in which a therapist will dispense with a “normal” therapeutic relationship with a patient specifically to engage in a romantic or sexual relationship with him. This course of action is generally view by most psychotherapists as inappropriate in all situations and is never a way of justifying the development of such a sexual relationship (APA, 1988).


Peer consultation.  As mentioned earlier, peer consultation is a major source of support, education, clarification, and intervention, and can serve as a deterrent regarding these types of relationships. Sometimes consultation is not sought due to professional arrogance, discomfort, and perceived personal costs such as negative repercussions. Authors have commented on professional hesitance to seek consultation (Biaggio, Duffy, & Staffelback, 1998; Mahoney, 1997).




Most psychotherapists do not practice in rural communities. However, with the large population of Baby Boomers thinking about cutting back and/or retiring, it is something that is being discussed more and more by those who have never considered it. In addition, psychology professors report their students are considering rural communities as possible places to set up clinical practices and raise families.


Introduction to the Rural Community


Multiple relationships, or the holding of another relationship with a client, patient, supervisee, or student, along with the professional relationship, have long been considered problematic. A special intensity and complexity pervade every aspect of rural life that makes decision-making about multiple relationships with clients difficult (Erickson, 2001; Hargrove, 1986; Jennings, 1992; Welfel, 2010).


Erickson (2001) has chosen to focus on nonsexual multiple relationships due to the fact that virtually all ethics codes forbid sexual relationships with patients. Therefore, she uses nonsexual multiple relationships, which are not universally forbidden, so that the unique differences between urban cities and small towns may be openly compared.


Characteristics of Rural Communities


By virtue of the definition of a rural community, the population is limited, meaning that it is much more likely that residents know each other and share common experiences more often than do members of larger communities.


The 2000 United States Census described “rural community” as an area with a population density of less than 500 people per square mile (United States Census Bureau, 2002). Although rural communities may be similar in terms of population density, they certainly are just as varied with regard to individuality as their larger counterparts.


Campbell and Gordon (2003) have delineated several distinctive characteristics that may be helpful in understanding why multiple relationships are more prevalent in rural practice than in urban practice:


People are known in family, social, and historical contexts. In larger cities, people are often known by the work they do or where they live rather than by their family legacy in the community in which they live. In smaller communities, it is much more common to know a person as whose son, daughter, or grandchild they are. Rural mental health professionals often know details about their patients such as what type of car is driven, salary information, and the like, and may indeed worship at the same place as their patients (Campbell & Gordon, 2003).


Rural residents want to know details about their neighbors and want to be known by others in the community. Gathering places such as coffee shops, barbershops, and grocery stores serve as settings for hearing the latest news in the community and sharing one’s own new experiences. Where anonymity is carefully prized in larger cities, rural areas are much less interested in this option; this makes the establishment of clear boundaries for the psychotherapist practicing in small towns extremely difficult (Campbell & Gordon, 2003; Coyle, 1999). The rural therapist must be careful not to ignore his or her patient outside of the office (Coyle, 1999).


Diversity and change are minimized and controlled in rural communities. Through the control of change, stability and predictability are promoted. Therefore, new residents must accommodate to the local norms and the existing power structure. The therapist who enters this picture is a definite outsider. To be successful in a rural community, the new therapist must quickly learn to accommodate to the community norms in various areas of life.


Relationships among rural residents are generally long-term. Relational bonds tend to be long-term, as residents are less likely to leave for occupational or educational purposes. Access to public transportation decreases as residents do not have a need to leave, are less mobile, and more likely to remain continuously in one area.

Rural community members may collude in tolerating some behavior while denouncing other behavior. The psychotherapist new to the rural way of life must be prepared to accept tolerance for various forms of discrimination and acceptance for various forms of abuse. For example, there may be intolerance for differences in sexual orientation, while there is acceptance of drunkenness and domestic violence (Mulder & Chang, 1997).


Psychological problems are to be dealt with by members of the family, clergy, or the family medical doctor. Church plays a more core role in the lives of rural residents (Campbell & Gordon, 2003). The authors present this as the reason why family and clergy, rather than the professional psychological community, are the primary source of support in times of need. Family physicians are figures of authority, are trusted, and play a prominent role in most families.


Non-community members are distrusted and viewed with suspicion. Outsiders are generally a potential threat to the way of life of a rural community. Residents may have been hurt in the past by outsiders who have brought about harmful changes on a financial or personal level. Once accepted, the community therapist becomes a trusted ally. The residents will only turn to an outsider if she is thought of as a “superstar” or perhaps an emergency resource (Campbell & Gordon, 2003).


Multiple levels of relationship are expected and seen as “normal.” Since anonymity is not particularly valued, local residents expect to relate to others (including the therapist) at the filling station, the coffee shop, the drug store, the place of worship, and children’s events. The therapist must become involved in these activities in order to become accepted.


Clearly, multiple relationships are inevitable and expected; in fact, in rural communities, they are encouraged.


Characteristics of Rural Psychotherapists


Federal programs have been set up to financially encourage psychotherapists and other mental health practitioners to locate their psychotherapy practices in rural areas (Campbell & Gordon, 2003). However, Campbell and Gordon (2003), in their literature review, were unable to find data on the success of any of these programs in getting clinicians to continue living and practicing in rural communities after the financial incentive ended.


However, the authors found several characteristics in their own observations (not yet substantiated by empirical research) that could “serve as hypotheses for research on successful rural psychotherapists” (p. 432):


Rural psychotherapists are comfortable with the rural lifestyle and probably grew up in a similar area or environment. Clearly, it is much easier to integrate into a community when one knows the norms, standards, and expectations. Psychotherapists, just like any other people who make a change in lifestyle, must be comfortable with the new lifestyle and willing to make several changes. For psychotherapists, one of the changes is the most difficult of all—having multiple relationships that are not unethical, not exploitative, and do not harm clients in any way. In large cities, psychotherapists are not confronted with this decision-making process on a daily, perhaps hourly, basis. In the rural lifestyle, one must be comfortable with the loss of anonymity and privacy.


Rural psychotherapists take active steps to integrate directly into the community. Since suspicion is one of the problems in a rural community with which the psychotherapist must deal, the sooner he enters the community activities the better. Rural psychotherapists must learn to be active and visible members of service groups, places of worship, and other community organizations and agencies that facilitate their active commitment to the community. In sum, the rural psychotherapist must not only be willing to do these things, but must be comfortable doing these things.


Rural psychotherapists have broad and general practices and are not specialists. In most large cities, there is a specialist on every corner for every DSM-IV-TR diagnosis. Not so in rural communities. Because of the shortage of psychotherapists in rural settings, psychotherapists who choose to set up practice in smaller cities work with a broad range of diagnoses and ages, and must provide a large array of assessments and services.


Rural psychotherapists are comfortable with a relatively high profile in the community. Psychotherapists, once accepted, tend to be placed alongside physicians and clergy in that their opinions and insights are sought as local experts (Campbell & Gordon, 2003).


Rural psychotherapists have a higher tolerance for blurring of boundaries, both professional and personal. It is never completely comfortable for a psychotherapist to accept multiple relationships due to the strict prohibition against them, and the trained inclination to avoid such relationships in general. However, the rural psychotherapist comes to expect such a relationship to occur in some context outside of the office.


Teaching Self-Sufficiency for Rural Practice


Most clinical psychology programs fail to address the challenges unique to rural psychotherapists on the job (Kersting, 2003). Programs that want to respond to rural needs must pay greater attention to the idiosyncrasies of working with a rural population, according to an interview with rural psychologist Garret Evans, Psy.D. (Kersting, 2003, p. 1). Beth Hudnall Stamm, Ph.D., a self-described “rural girl,” is Deputy Director at the Institute for Rural Health at Idaho State University where students have a chance to participate in rural research, educational outreach, policy creation, and clinical activities. Dr. Stamm says, “We give [students] the extra training they need to foster a smooth transition into a rural professional life.” (Kersting, 2003, p. 2)


Recruiting promising undergraduates, and in some instances, high school students from rural areas and encouraging them to consider psychology is taking place more in order to bring the rural cultural perspective into the profession. Dr. Stamm tells Kersting, “Even the five years or so someone spends training at an urban university can change them and make it hard for the community to accept their care. So it’s helpful if we can keep them in [rural] communities part of the year through summer placements and practica.” (Kersting, 2003, p. 3)


Dr. Stamm notes a traineeship in rural psychology is not enough to assure that one is prepared for the rigors of a rural practice. One must be fluent in health policy issues and be able to perform outcome evaluations for government grants as well.


Finances.  In addition to finding grant money to fund services in clinical settings, rural therapists also need to know how to be their own money managers and be able to run a business without benefit of a group practice. Most rural therapists also supplement their income with contracts from schools and other agencies such as prison systems.


The Scope of the Difficulty with Rural Communities


Multiple relationships have been thought of as the primary unethical behavior one can engage in as a psychotherapist and something to be avoided at all costs. However, multiple relationships are truly a reality in those who practice in a rural environment (Younggren, 2002).


There are three primary difficulties inherent with multiple relationships in rural communities that have been recognized by numerous authors (Cohen & Cohen, 1999; Corey, Corey, & Callanan, 2007); Herlihy & Corey, 2010; Welfel, 2009). No matter how appealing the situation is to the professional, the responsibility for the final decision lies with the psychotherapist. Additionally, the clinician is obligated to use a formal decision-making procedure including consultation and documentation. The psychotherapist, by virtue of being the mental health professional, is in a power position, and is always the person to make the decision in the best interests of the client (Erickson, 2001).


In reviewing the literature on multiple relationships in rural communities, Erickson (2001) found several common elements that make deciding how to handle the multiple relationships troublesome. She specified three elements in particular:


·         They are difficult to recognize

·         They are sometimes unavoidable

·         They can be harmful

  (They are not always harmful, and in fact can be beneficial)


Once again, the question remains—how does the psychotherapist decide when it is appropriate to attend the wedding of a client, the baseball game of a child client, the graduation of a patient, or a musical performance of a client?


Guidelines for Decision Making with Multiple Relationships in Rural Areas


If the relationship is avoidable, then avoid it.  Avoiding the problem is the best option if it is possible to do. If the psychotherapist already has some sort of preexisting relationship with the potential client, it would be easier and less complicated to simply refer the potential client to another therapist to avoid any later problems. Even the smallest communities generally have options that will relieve the psychotherapist from engaging in an unethical multiple relationship.


If the second relationship is unavoidable, potential benefits and risks must be weighed. If there truly is no other resource available to the client, the careful exploration to determine the possible negative and/or positive effects of the relationship must be discussed with the client. The psychotherapist must weigh all possible benefits versus the risks for possible harm to the potential patient.


If the risks outweigh the benefits, the conflicting relationship should be declined. After a careful and thoughtful examination of potential for good and negative effects is conducted, and it is determined that the negative effects outweigh the positive, then the secondary relationship should be declined. The psychotherapist should take the proper time to explain his or her rationale to the client for referring him or her to another therapist and assist in finding alternative resources for the client.


For example:


·         if the potential patient is also the psychotherapist’s new next-door neighbor,

·         if the potential patient is already the business partner of the psychotherapist’s significant other’s brother, or

·         if the potential patient is your significant other’s supervisor


These are likely to present an uncomfortable situation for both parties in the future.


If the benefits outweigh the risks, precautions must be taken to protect both the client and the psychotherapist from undesired consequences. It is important to secure informed consent from the client should the psychotherapist in a rural environment decide to have a secondary relationship with a client. Some experts suggest making the client part of the decision-making process, but with the awareness that the need to protect the client from harm lies with the psychotherapist.


It is mandatory to maintain constant self-evaluation for conflict of interest and boundary violations that may become harmful or exploitative to the patient. Be sure to document all consultations and discussions with the patient regarding these issues.

Continue to seek consultation with colleagues that are totally unrelated to the situation and are detached and unemotional in their assessment of the situation. This may be even more difficult in a rural community where the chances are that more people are related to each other in some fashion. The idea is to avoid blind spots in both the treating therapist and the consultants (Erickson, 2001).


Ethics Codes that Apply


No psychotherapist is immune to the possibility of engaging in an inappropriate relationship with a client (Olarte, 1997). Sexual misconduct is considered one of the most serious ethical violations and is a very common allegation in malpractice suits. “Therapist-client sexual contact is arguably the most disruptive and potentially damaging boundary violation.” (Corey, Corey, & Callanan, 1998) Experts agree that when sexual activity begins, therapy as a helping process ends (Bouhoutsos, Holroyd, Lerman, Forer, & Greenberg, 1993). Some psychotherapists maintain, “Once a patient, always a patient”; however, the APA ethics committee and task force have declined to make a blanket prohibition against sexual intimacies regardless of the time that has passed since a normal termination. In this subject area, the controversy exists primarily between rural and large city psychotherapists.


APA takes special care with this topic.  One APA Ethics Code that was discussed earlier should be discussed once again in more detail at this point.


APA 3.05 Multiple Relationships


This code specifically prohibits having a professional role simultaneously with:


(a) Another role with the same person


(b) Or a relationship with another person closely associated with or related to the person with whom the psychotherapist has the professional relationship


(c) Or a promise to enter into another relationship in the future with the person or a person closely associated with or related to the person


Basically, the consideration here is—could the multiple relationship reasonably be expected to impair objectivity, competence, or effectiveness?


The portion that requires reintroduction here is the final sentence of the Code that says, “Multiple relationships that would not reasonably be expected to cause impairment or risk exploitation or harm are not unethical [modified for clarity].” (Fisher, 2009, p. 65) This segment is particularly significant because it explains in writing for the first time that not all multiple relationships are unethical. For example, Standard 3.05 does not prohibit attendance at a client’s, student’s, or supervisee’s family funeral, wedding, or graduation. “Similarly, psychologists can serve as clinical supervisors for students enrolled in one of their graduate classes because both supervision and teaching are educational roles.” (Fisher, 2003, p. 65)


Incidental encounters with clients, students, or supervisees at religious services, school events, eateries, health clubs, or similar places are certainly not unethical. However, most experts suggest keeping a record of such encounters. The primary question seems to be—can the secondary relationship possibly cause impaired judgment or harm of any sort to the client, supervisee, or student?


Post-termination Nonsexual Relationships


Standard 3.05 does not address this issue directly nor does it have an absolute prohibition against post-termination nonsexual relationships after a normal and valid termination. Naturally, the post-termination relationship should never be promised prior to the termination nor be a part of the termination process, or it deems the entire termination invalid.


Valid termination. It is never appropriate to terminate in order to benefit the psychotherapist rather than the client, unless the therapist is in danger due to threats coming from a disturbed or psychopathic patient and termination is therefore necessary. For example, terminating with a patient who is a publisher in order to submit one’s book to the former patient or publication is highly improper and unethical.


Legal Cases and Advice Regarding Multiple Relationships


Investigative Report – Arizona


The Board of Psychologist Examiners is threatening to take strong action against a psychologist licensed in Arizona for behavior apparently representing an inappropriate boundary transgression with a patient. It is reported that the psychologist left numerous messages on the voice mail of the female patient, sent love notes, and also gave her an expensive gift that he demanded she wear in his presence.


The psychologist was appointed by the county to help the patient prepare for trial regarding a DUI charge. The psychology board listened to voice messages that were recorded by the patient where the psychologist said:


“I haven’t seen you wear that damn necklace yet. I want to see that necklace on you – preferably with nothing else…”


“I haven’t seen you in awhile. I hope you got [psychologist’s name] deprivation.”


“I’m going into the psychiatric unit to see some lunatics. I’ll see you later sweetie. Bye-bye.”


The psychology board remarked:


“His actions at the very least raise serious concerns about boundary issues.


“He appears to have used his status as a psychologist to inappropriately enhance his status as a potential suitor.”


The psychologist’s attorney argued to the board that the client had ended her professional relationship with the psychologist prior to the phone calls. The attorney claimed that the psychologist’s services were not “mental health” in substance, but more “educative.” The outcome of this case has not been decided as of this time.


CAMFT Staff Attorney Defines Dual Relationship


The California chapter of the American Association of Marriage and Family Therapists (AAMFT)— the California Association of Marriage and Family Therapists (CAMFT)—employs a number a staff attorneys to research, review and inform the public through written articles about the standard of care, along with current case law regarding timely topics. David Jansen, JD, wrote a recent article, “So, What Exactly is a Dual Relationship?” in which he discussed the topic of multiple relationships at length (Jensen, 2005).


“A dual relationship is a separate and distinct relationship that occurs between the therapist and a patient, or a patient’s spouse, partner, or family member, either simultaneously with the therapeutic relationship, or during a reasonable period of time following the termination of the therapeutic relationship” (Jenson, 2005, p. 17, quoted directly from the CAMFT Ethics Code).


Therapists must avoid relationships that exploit or harm patients or clients or are likely to impair their professional judgment. Jensen focuses on three primary issues:


1.   The notion that a dual relationship is a distinct and separate relationship from the therapy relationship


This second “relationship” has nothing to do with the therapy relationship and can in fact spoil the therapy relationship. The APA Ethical Standards prohibit multiple relationships in general that can harm the client. These include money exchanges outside of payment for therapy, attending events together, and business ventures.


2.   The concept that a certain or reasonable amount of time must pass after termination


Most psychotherapists are aware of the “two-year rule” when it comes to sexual relations with a former patient after a valid termination. However, the more appropriate approach is to refrain from a sexual relationship with a former patient altogether. A valid termination is generally for the benefit of the patient, not for the benefit of the therapist, and never in order to begin a sexual relationship with the patient.


3.   The idea that the relationship is reasonably likely to lead to exploitation or impair the judgment of the therapist


It is mandatory to avoid dual relationships that are reasonably likely to impair professional judgment or to lead to exploitation of the patient. One is not expected to be able to read the future or to know every aspect of what may or may not occur in the future. However, therapists are judged by the reasonable therapist doctrine, meaning that psychotherapists are expected to behave in the same manner any other reasonably trained and experienced psychotherapist would behave. Primarily, reasonably trained and experienced psychotherapists would not do anything that would cause harm to a patient.


A Defense Attorney Gives Pointers


The well-known California defense attorney, Brandt Caudill, has written extensively about “licensing pitfalls for therapists,” and how to avoid becoming vulnerable to attack from patients and licensing boards. Included in his list of pitfalls are forms of boundary violations, sexual and non-sexual. Selected points from Mr. Caudill’s writings follow: (From Dr. Pope’s site here)


Excessive or inappropriate self-disclosure.  Certainly, therapists use self-disclosure in a session with a patient as a legitimate therapeutic treatment technique (see Section F for further discussion). However, licensing boards do receive complaints alleging improper or excessive self-disclosure by the therapist. There are two primary factors to consider in deciding whether a self-disclosure by the therapist is excessive or inappropriate:


Is the material being disclosed for the purpose of helping the patient or client gain insight or move forward in her treatment in some way, or is it being made with no clinical foundation, or out of unconscious counter-transference, selfishness, or sloppiness on the part of the therapist?


Is it appropriate to disclose such information to a patient with this particular diagnosis or mental status?


Examples would be sharing with a patient that the therapist has gotten a divorce in her past, or sharing the therapist’s sexual orientation. If either of these personal pieces of information is helpful to the patient’s work with the therapist, and sharing this information is not impulsive and has been thought through clinically, the psychotherapist is the best judge of whether or not to self-disclose, as she is the only person “in the room” with the patient. However, if the treating psychotherapist is uncertain, a professional consultation with full documentation is the most effective way in which to manage such a situation well in advance of the client asking personal questions. If the disclosure has no place in the therapeutic relationship, can in no way support change for the patient, and will only satisfy a need for the therapist, it is clearly inappropriate. Caudill asks the question, “How does the disclosure aid in the patient’s therapy?” One must be honest in asking this question, and honest in presenting it to the consultant as well.


Some disclosure about the therapist’s family and background are particularly inappropriate because they may lead the patient to feel “special” or believe he or she has the potential for a more personal relationship outside the office (Caudill, 2005). It is mandatory to seek the clinical reasons for questions the patient brings into the room in order to maintain the therapeutic boundaries.


Business relationships with patients.  Caudill reports no knowledge of success where therapists have entered into business relationships with current or former patients. “In fact, almost every time such a relationship is reported it is reported in the context of a lawsuit being filed or an administrative action being taken because of the business relationship.” (p. 3) He suggest no matter how lucrative a potential business deal may seem with a patient, it is not worth the potential destruction of one’s career.

Regardless of how the business deal is set up, or what legal language is used, entering into a business relationship with a former or current patient will be looked upon as an imbalance of power or a possible exploitation of the patient, with the burden of establishing lack of exploitation on the therapist. Caudill suggests the rule for entering into a business relationship with a former or current patient should be “almost never” (p. 3). Always consult and document the consultation in all situations where there is a question of impropriety.


Caudill briefly mentions that psychotherapists should use caution in selling items such as books, vitamins, food supplements, and educational tapes to the patient as it may constitute an unprofessional secondary business relationship. It is not difficult to posit a scenario where a patient becomes allergic to a food supplement or vitamin, holding the psychotherapist accountable. It would be unfortunate to have to be in a position to have to let the licensing board or ethics committee decide whether this is a multiple relationship.


Using techniques without proper training.  Therapists should never use techniques without proper training and experience. It is considered below the standard of care to use techniques after only one workshop or without being supervised or seeking consultation. Using new techniques without completion of training can lead to potential liability as well as licensing and ethics board complaints.


Using incorrect diagnosis deliberately. With managed care so involved in the lives of therapists, there has been an unfortunate tendency to “choose” an “insurance diagnosis” that the managed care company is sure to pay for rather than the accurate DSM diagnosis for the patient. For example, some insurance companies refuse to cover Axis II Personality Disorders due to the “long term” nature of the diagnostic criteria involved. Indeed, it is tempting to use an Axis I diagnosis (such as Generalized Anxiety Disorder or Dysthymic Disorder) rather than an Axis II disorder so that it will not be disputed by the insurance company in order to (1) be paid for one’s work, and (2) help the patient afford therapy for a longer term.


Additionally, some insurance companies refuse to recognize the worthiness of V-Code diagnoses (conditions that are the focus of treatment but are not mental disorders, such as Parent-Child Problem or Partner Relational Problem) and refuse to recognize them with payment. Once again, it becomes tempting for therapists to choose a diagnosis for which the insurance company will pay. No matter how much a therapist wants to help his or her client, this is insurance fraud, and is illegal.


Avoiding the medical model. Caudill reports that some therapists use the excuse that they do not believe in the medical model in order to dispense with using informed consent, standard of care, patient record keeping, and other patient care paperwork issues. They believe this should prevent them from being held to the requirement of the medical model. Caudill claims this is just as ineffective as claiming to the IRS that one does not believe in taxes.


The true love exception for sexual relationships.  Of course, there is no true love exception for damages caused by this type of boundary violation. One makes a choice between “true love” and maintaining one’s career.


Failure to obtain an adequate history. This issue is related to failure to take any notes at all. Licensing boards and civil suits expect psychotherapists to take a thorough history of a patient upon entry into therapy in order to get a full picture of the patient and place the patient in the appropriate context. A history should include:


Presenting symptoms

Prior therapy

History of mental illness in patient and patient’s family

Physical condition of patient contributing to diagnosis and condition

Medications taken

Educational history

Marital status, children

Duration of patient’s symptoms

Recent physical examination


Out of the office contact. Unless there is a specific therapeutic purpose, there are few reasons for out of the office contact between patient and therapist. If an out of office contact is called for, it should be well documented in the patient file, a consultation may take place as well, and it should be made certain it fits appropriately into the theoretical orientation being used in the treatment (e.g., systematic desensitization). Caudill suggests the therapist document the contact in advance as to its purpose and what is hoped to be achieved. A follow-up consult and documentation about what actually occurred should be noted in the file as well.


Failure to obtain peer consultation. Feedback on a regular basis is common standard of care according to most experts in ethics (Clayton & Bongar, 1994; Applebaum & Gutheil, 1991; Kapp, 1987; Stromberg, et al., 1988).




Along with the increase of Health Maintenance Organizations (HMOs), many psychotherapists saw their reimbursements from the insurance companies declining. It is more important than ever, both ethically and legally, to remain vigilant about the ways in which psychotherapists may compromise or contaminate the way clients are treated. It is necessary as always to consider whether to accept the new referral, but it is not necessary to “descend to a neurotic over-scrupulousness or self-righteousness.” (Shapiro & Ginzberg, 2003, p. 258; Bennett et al., 2006)


With every new referral comes a decision-making process that includes, among other things:


·         Source of referral

·         Financial considerations

·         Scheduling considerations

·         First impressions

·         Telephone impression

·         In-office impression

·         Therapist competency

·         Possible multiple relationship issues


The receiving psychotherapist must consider who is referring the new patient—a current or past patient, a colleague, or a referral source such as an insurance company or professional association. The research suggests that it is the relationship between the therapist and client that is the “primary curative component.” (Lambert & Barley, 2001, p. 359) Therefore, all efforts to protect the therapeutic dyad from disruption or bias are primary (Shapiro & Ginzberg, 2003).


Shapiro & Ginzberg (2003) recently noted a “relative absence of literature to which psychotherapists may turn to help them understand the impact and meaning of these kinds of decisions.” (p. 258) In other words, when faced with complicated decisions about taking referrals or not, most psychotherapists have little or no resources to turn to for guidance. As soon will be noted, much of the cited articles are not as recent as one would wish. Some psychotherapists consult and discuss the referral with peers and others make abrupt decisions with very little consideration or reflection.


Framework for Managing Referrals


All referrals, despite the referring source, involve at least three possible ethical conflicts:


Exploitation – is the psychotherapist accepting the referral for the right reasons? Does the patient’s problem fall within the psychotherapist’s area of competence, or can he receive consultation or proper supervision in the area to provide appropriate treatment? If not, then the therapist is taking the patient on for his own reasons that are not in the best interests of the patient (e.g., financial, personal, other ego-related reasons).


Multiple relationships – this problem is well-documented in the literature with regard to other areas of psychology, and accepting referrals is no exception to this complex area of consideration. Psychotherapists must be vigilant with respect to accepting referrals of friends or family members so as not to disrupt the relationship with the current patient. Similarly, it may turn out to be inappropriate to accept such a patient from a terminated former patient in order to protect all participants from a multiple relationship circumstance.


Confidentiality – should a psychotherapist, after careful consideration, opt to accept a referral that is known to a current or former patient, confidentiality presents particularly knotty problems (e.g., caution in maintaining confidential communications disclosed to the psychotherapist about the parties who know each other). It is particularly baffling when each knows that the other party is also a patient of the therapist and is most assuredly bringing discussions of the friendship into the therapy setting.


At this juncture, it becomes relevant to evaluate the APA Standards that apply to Confidentiality and to Referrals.


Ethics Codes that Apply to Confidentiality


APA 4.01 Maintaining Confidentiality


Psychotherapists have an obligation to protect clients’/patients’ confidential communications and information. They respect the privacy and dignity of those with whom they work by protecting their confidentiality. They are expected to take reasonable precautions to protect patient confidentiality. (See Fisher, 2002 for a full discussion and examples of maintaining confidentiality as a psychotherapist.)


APA Ethics Codes that Apply to Referrals


APA 6.07 Referrals and Fees


This code falls under the general standard of “record keeping and fees” (APA, 2002).


“When psychotherapists pay, receive payment from, or divide fees with another professional, other than in an employer-employee relationship, the payment to each is based on the services provided (clinical, consultative, administrative or other) and is not based on the referral itself” (APA, 2002, p. 1060).


This standard touches upon accepting and declining a referral in the following ways:


     Does the psychotherapist receiving the referral have the expertise required to properly treat the referred client?

     Is it appropriate for the psychotherapist who is given the referral to accept the new client?

     Could it create a multiple relationship?

     Could it exploit or harm the referred client?

     Could it exploit or harm the former client or the referring source?


General Dilemmas


Referrals from current or former patient. Some authors have suggested that deciding to take a referral from a former or current patient demonstrates an example of exploitation because the therapist receives more compensation than the original patient’s fee in the form of the referred patient’s fee (Epstein, Simon, & Kay, 1992; Epstein & Simon, 1990). Shapiro & Ginzberg (2003) sum up the issue by quoting the old dictum “Once a patient, always a patient.” They discuss the idea that psychotherapists retain their professional capacity long beyond the termination of the actual treatment and that this dictum certainly contributes to the doubts and confusion about whether to accept referrals from former and current patients.


Thus, in some circles, a referral is considered a type of “gift” to the therapist and something to accept rarely and cautiously, and only after much exploration (Shapiro & Ginzberg, 2002). “It is our opinion that when a patient makes a referral that is likely to impinge on his or her treatment (e.g. a spouse, family member, sexual partner, close friend, coworker, or roommate), it is in the patient’s best interest for the therapist to decline.” (Shapiro & Ginzberg, 2003, p. 259)


Primarily, Standard 6.07 ensures client referrals are based upon the expertise of the psychotherapist or other professional to whom the referral is being made along with the appropriateness and correctness of the service for the client, not based on the referral itself. In other words, the decision to accept a referred client should always be made upon what is best for the client, not what is best for the referring or receiving psychotherapist.


If a psychotherapist receives payment from a particular therapist for referrals, and does not receive payment from a second therapist for a referral, the therapist who pays for referrals may have an advantage in getting the referrals if money is the motivator. However, since the ethics code requires the welfare of the client to be the primary motivator, this action would be unethical in any event. Such payments put psychotherapists in a potential conflict of interest if the referral is based on financial remuneration rather than welfare of the client (see discussion of welfare of client in the APA Preamble in Section A).


Dilemmas related to the referral source. Beliefs and feelings about the person or agency that refers the new patient can create counter-transference feelings for the psychotherapist who accepts the new referral. Since counter-transference is by definition unconscious, it is the responsibility of the psychotherapist to remain vigilant for feelings about the referral source and the referred patient, particularly if the referral source is a current patient or a former patient who may return to therapy.


If the referral source is a “higher status” therapist such as a former supervisor, the therapist to which the new patient is referred may feel the need to impress the colleague, or may accept a patient with which she has no experience. It is important to receive appropriate supervision or consultation when taking on a client that has a diagnosis with which the therapist is less familiar. Indeed, if consultation is not possible at such a time due to expense or patient emergency, or one’s schedule is cramped, this is the time to make a referral to an appropriate colleague (Shapiro & Ginzberg, 2003).


Definition of Counter-transference


Kernberg (1965) defined counter-transference (CT) as “the analyst’s conscious and unconscious reactions to the patient in the treatment situation which are reactions to the patient’s reality as well as to his transference; and also to the analyst’s own reality needs as well as to his neurotic needs.” (p. 38) Heimann (1950) was one of the first to offer several revisions to the CT concept. She expanded the term CT to include all of the feelings the therapist has toward his or her patient. Fundamentally, CT is considered important because it can influence the therapy in a number of negative ways: premature termination, inappropriate therapist reactions, lack of therapist insight, and failure to treat the patient properly (Harmell, 1987). Thus, it is import for all therapists to make efforts to remain aware of their CT reactions to patients in order to reduce harmful attitudes and/or behaviors related to patients (Harmell, 1987).


Additionally, CT is a wonderful tool by which psychotherapists can gain insight into nonverbal messages from patients, become aware of their own visceral experiences related to patients, and have a useful tool of valuable feedback regarding the patient. Early on in the history of psychotherapy, many powerful influences helped to reduce therapist avoidance of their CT reactions by reframing the concept positively (Heimann, 1950; Grossman, 1965; Epstein & Feiner, 1979; Racker, 1953, 1968; Langs, 1982).


Harmell (1987) studied the relationship between CT and three variables (1) Level of Therapist Experience, (2) Theoretical Orientation, and (3) Therapist Self-awareness, both independently and as a predictive unit. It was found by using CT subscales that CT is best examined as clusters of specific attitudes and behaviors rather than a unidimensional global concept. Clearly, CT is a complex topic to study and evaluate.


APA Ethics Codes that Apply to Area of Counter-transference


APA 2.06 Personal Problems & Conflicts


Awareness of personal problems is mandatory. This code tells psychologists to avoid harming clients when they know or should know that their problems might harm their patients.


APA 10.10 Terminating Therapy


Psychologists are told here to terminate patients properly rather than risk harming them in any way (for example, due to the therapist’s CT or personal problems).

Ethics Codes that Apply to Area of Competence


APA 2.01 – Boundaries of Competence


This is one of the longest standards in the entire Code. It has six sections, all of which discuss how to judge and gain expertise when it is required. It also advises psychologists to provide services and conduct research for others where they have competence through education, training, supervised experience, receive consultation, study, and professional experience. Please read the entire code (sections a-f) for a thorough understanding of Boundaries of Competence and its application to work as a psychologist.


Some examples, adapted from Fisher (2003), of Boundaries of Competence are as follows:


     Psychologists who graduate from programs where they are taught only the practice of Industrial or Organizational psychology and how to work within the scope of a company decided to set up a private practice working with families and children.


     A psychologist who graduated from a school psychology program has decided to set up a neuropsychological assessment private practice.


     A psychologist who took one graduate course in law and ethics in order to graduate and had one 3-month traineeship with elder adults has begun giving “expert” workshops on elder abuse.


     Psychologists who never took training in job-related assessment are offering “executive coaching” services.


Determinations as to whether a psychologist has expertise in a particular area are not easily made and vary with each relevant field. However, the general rule is that one cannot call himself an expert without having expertise in that topic.


CAMFT Ethics Code that Apply to Counter-transference


Because CT and burnout are such critical topics, the CAMFT ethics code addresses the topics in several areas.


STANDARD 3 – Professional Competence and Integrity




This code reminds psychotherapists to practice within their area of competence, training, experience and education. Burnout is more likely when psychotherapists work beyond their competence and “freelance” rather than use tried and true methods. Freelancing is a term that refers to the failure to research the best and most effective methods of clinical practice for a particular diagnosis in favor of simply trial and error without a formal or thoughtful treatment plan that is relevant and effective.




Awareness of personal problems is mandatory. This code tells psychotherapists to avoid harming clients when they know or should know that their problems might harm their patients.


STANDARD 1: Responsibility to Patients




Psychotherapists are told here to terminate patients properly rather than risk harming them in any way (for example due to the therapist’s CT or personal problems).


Social Work Ethics Codes that Apply to Counter-transference


NASW Code of Ethics


Standard 2.09 – Impairment of Colleagues (a&b)


(a)  SW who know of another SW who is impaired due to personal problems, psychological distress, substance abuse, or mental health difficulties that interfere with practice effectiveness must approach that colleague when it seems feasible and attempt to assist the colleague in taking remedial action.


(b)  SW who believe a colleague is not taking steps to remediate his or her impairment should take action through appropriate channels established by various agencies or employers.


Standard 2.10 – Incompetence of Colleagues (a&b)


(a)  SW who are aware of a colleague’s incompetence should consult with that colleague and assist that person in getting remedial help.


(b)  SW who believe a colleague is not taking steps to remediate his or her impairment should take action through appropriate channels established by various agencies or employers.


CSWA Code of Ethics


Standard IV. – Relationships with Colleagues (e)


CSW act with integrity in their relationships with colleagues and members of other professions.  They know and take into account the traditions, practices, and areas f competence of other professionals and cooperate with them fully for the welfare of clients.


(e)  CSW who have knowledge of a colleague’s impairment misconduct, or incompetence attempt to bring about remediation through appropriate means through appropriate regulatory bodies.


Definition of Terms Related to Consultation


·         Competence – sufficient, adequate or capable in the area being discussed (Webster’s)


·         Specialist – one who specializes in a particular field of study (Webster’s)


·         Expert – having much training or knowledge in a particular field (Webster’s)


As you can see, with each level you stick your neck out further! The highest level of competence is expert. This means that the person has done research on, written about, and read the history of the topic, and/or speaks, lectures, or teaches on the topic. Thus, most psychotherapists are specialists in some areas (children, ADHD, depression, etc.), but may not reach the level of an expert.


Experts Define “Specialist”


The former California Association of Marriage and Family Therapists (CAMFT) attorney Zachary Pelchat cautions, “Keep in mind that by citing yourself as a specialist, you will likewise be held to the standard of care that would be appropriate for someone identifying him or herself as a specialist” (p. 25.). All are competent to practice by virtue of being licensed to practice. By using the term specialist, the clinician is implying he or she has more knowledge and is practicing a “higher standard of care when dealing in their specialty.…When by citing yourself as a specialist, you will likewise be held to the standard of care that would be appropriate for someone identifying him or herself as a specialist.” (Pelchat, 2001, p. 25)


APA Ethics Codes that Apply to Area of Consultation


APA 4.06 – Consultation


This code allows psychologists to get “professional consultation” without the consent of the individual if the demographics of the person are disguised carefully.

Psychologists maintain confidentiality when consulting with other professionals.


Who are good choices for professional consultants?  Consultants should be senior therapists or experts in their field such as attorneys, pharmacists, medical doctors, substance abuse experts, ethics committees, and experts in specific cultures and ethnic groups.


Unfortunately, many psychologists fail to seek consultation due to lack of finances or professional arrogance. Studies indicate that many psychologists fail to utilize consultation; this can be detrimental to their patients (Clayton & Bongar, 1994). Kapp (1987) Experts note that, “failure to consult when appropriate may lead to a legal finding of negligence in malpractice cases.” In fact, Applebaum and Gutheil (1991) found “consultation together with documentation to be the ‘twin pillars of liability.’” (p. 201)


Confidentiality after the Referral


Concerned referral sources often want and expect updates and collaboration from those to whom they refer. For example, when working with adolescents, children, and young adults, it is not unusual for several mental health professionals to work together, each expecting to collaborate and get information from the others. Another routine example is in the case when university faculty members refer students to the campus mental health center and then encounter the restrictions of confidentiality upheld by therapists working with the referred students (Birky, Sharkin, Marin, & Scappaticci, 1998).


College is a domain that creates potential difficulty because of the possible pressure university mental health therapists may experience from faculty members and other university personnel to “fill them in” on what is going on with a referred student and to otherwise breach confidentiality (Birky et al., 1998). University mental health providers are generally asked without the student’s or patient’s knowledge, and information is often given without the student’s or patient’s consent (Sherry, Teschendorf, Anderson, & Guzman, 1991). These inquiries come from caring and involved persons who originally referred the patient, and often include follow up requests to verify that the student actually contacted the therapist.


Sharkin, Scappaticci, and Birky (1995) found that referral sources commonly expect they will be given confidential information by psychotherapists to which they refer patients, and many believe they should be given access to confidential information when they inquire. Sharkin et al. (1998) report that unmet expectations can fuel dissatisfaction and conflict. Despite the fact that the requests for confidential information come from individuals who are well-meaning and interested for the right reasons, and the request may be totally understandable and valid, problems may ensue when the psychotherapist fails to discuss or even verify that the person is a current patient. Unless the client gives a release of information in written form allowing the psychotherapist to discuss the patient with another source, including the referring individual, it is a breach of confidentiality to do so. Indeed, the psychotherapist may neither confirm nor deny whether there has even been any contact with the potential patient.


APA Ethics Codes that Apply to Confidentiality


APA 4.01 Maintaining Confidentiality


As discussed previously, psychologists have an obligation to protect clients’/patients’ confidential communications and information. The nature of the specific precautions taken to protect confidentiality will differ depending upon the psychologist’s role, the purpose of the psychological activity involved, and the age and legal status of the patient. They respect the privacy and dignity of those with which they work by protecting their confidentiality. They are expected to take reasonable precautions to protect patient confidentiality. “Reasonable precautions” mean that the psychologist does her best to maintain confidentiality, allowing for legal and ethical exceptions such as Tarasoff and the reporting of child abuse (Fisher, 2003).


CAMFT Ethics Codes that apply to Confidentiality


STANDARD 2 – Confidentiality


Above is the website of the CAMFT Ethical Standards. Please peruse all of Ethical Standard 2: Confidentiality. The relevant sections will be summarized below.


Standard 2: Marriage and family therapists have a unique responsibility to clients and patients because the client or patient may be more than one person. Since it is within the scope of practice for the marriage and family therapist to work with the patient’s interpersonal relationships, it is likely that at some point more than one person will be in the consultation room at the same time. Therefore, the confidentiality issues are tricky. The overriding principle in Standard 2 is to respect the confidences of all patients.


Standard 2.1: This standard goes into detail about disclosures, noting that marriage and family therapists do not disclose confidential information without the consent of the patient unless (1) mandated by law, (b) permitted by law, (c) when the psychotherapist becomes a defendant in a legal suit, or (d) when the patient gives previous authorization. California law with regard to mandated or permitted to breach (such as child abuse, the suicidal or dangerous patient, or other abuses that come to the attention of the therapist) will be discussed in later sections.


Standard 2.2: If a subpoena requests, or a court order demands, testimony or records in a situation where the psychotherapist is seeing more than one person at a time, this Standard suggests all members of the family or couple must agree and sign releases before the marriage and family therapist will release the records. This is excellent in ethical theory, but the legal requirements may force a different decision (to be discussed in a later section).


Standard 2.3: Marriage and family therapists are cognizant of the hazards of technological changes and make reasonable attempts to maintain confidentiality when transmitting and receiving information via electronic means.


Standard 2.4: Storing, transferring, and disposing of records is done properly and with the utmost respect to patient confidentiality.


Standard 2.5: Marriage and family therapists teach their employees the importance of confidentiality and take appropriate steps to ensure confidentiality be maintained.


Standard 2.6: In teaching and lectures, marriage and family therapists disguise patient identities unless written authorization has been previously obtained in accordance with other Standards of the document.


Standard 2.7: This Standard reviews the concerns a marriage and family therapist must consider when working with group therapy. CAMFT suggests explaining to the group the importance of respecting each other’s confidentiality and encourages psychotherapists to obtain an agreement to do so from each participant.


Social Work Ethics Codes that Apply to Confidentiality


NASW Code of Ethics


Standard 1.07(a-r) – Privacy and Confidentiality


Since this is such a long code with eighteen sections, it is incumbent upon each individual social worker to take the time to review this standard him or herself. However, a brief summary is given below.


  1. SW do not solicit information from clients unless they wish to disclose such information
  2. SW need valid consent to disclose any private patient information
  3. SW may breach in cases of danger to patient, others, etc.
  4. SW should try to give informed consent regarding disclosures
  5. SW should discuss limitations to confidentiality prior to treatment
  6. SW are cognizant of the difficulties of confidentiality with multi-client situations (group, couple, family)
  7. SW inform patients about disclosures to referring employers
  8. SW do not disclose information to third party payers without permission
  9. SW do not discuss confidential information in public places
  10. SW protect confidential information in legal procedures
  11. SW protect confidential information in media settings.
  12. SW are careful using technology for record storage.
  13. SW are careful using technology for record transmittal.
  14. SW dispose of records properly.
  15. SW take care to protect patient’s records in case of the therapist’s termination, incapacitation, or death.
  16. SW protect patient information in teaching or training lectures.
  17. SW do not disclose identifying patient information when receiving consultation.
  18. SW protect confidences of deceased patients.


CSWA Code of Ethics


Standard III(b,c,e) – Confidentiality


(b) Mandatory reporting obligations may include, but are not limited to; the reporting of the abuse or neglect of children or of vulnerable adults; the duty to take steps to protect or warn a third party who may be endangered by the client(s); and, any duty to report the misconduct or impairment of another professional.


In specific relation to California Law: This confidentiality standard relates to disclosures that are (1) mandated by law (child, elder, dependent abuse, danger to self or other, gravely disabled), (b) permitted by law (suicidality), (c) when the psychotherapist becomes a defendant in a legal suit, or (d) when the patient gives previous authorization. California law with regard to mandated or permitted to breach (such as child abuse, the suicidal or dangerous patient, or other abuses that come to the attention of the therapist) will be discussed in later sections.


(c) - If a subpoena requests or a court order demands testimony or records in a situation where the psychotherapist is seeing more than one person at a time, this Standard suggests all members of the family or couple must agree and sign releases before the clinical social worker will release the records.  This is excellent in ethical theory, but the legal requirements may force a different decision (to be discussed in a later section). 


(e) -   Social Workers are cognizant of the hazards of technological changes and make reasonable attempts to maintain confidentiality when transmitting and receiving information via electronic means.  Storing, transferring, and disposing of records is done properly and with the utmost respect to patient confidentiality.


Dilemmas that Exist with Referrals


By the preservation of strict confidentiality restrictions, the ethics code is not violated, and the patient is respected and treated with dignity. Unfortunately, in some cases, the referral source may become angry and frustrated at not being given information. Referral sources report feeling alienated after the referral is made and then the treating psychotherapist does not provide information, especially if the source is not in the field of psychology and is not familiar with the legal and ethical dictates of confidentiality. By appropriately denying the referring person confidential patient information, the treating psychotherapist may risk being seen in a negative, withholding, unhelpful, or uncooperative manner. Such perceptions can strain the relationships with these referral sources (Malley, Gallagher, & Brown, 1992).


Some Remedies that May Help


Birky, Sharkin, Marin, & Scappaticci, (1998) suggest psychotherapists take active measures to secure permission from the referred patient to acknowledge to the referral source that she is attending sessions and/or has attended an evaluation session, unless it is contra-indicated. These authors also suggest that university mental health facilities produce a brief brochure with a statement that explains that faculty and concerned others may show an interest in persons they refer to the clinic, and may make later inquiries regarding their attendance and well-being. Some psychotherapists routinely request permission to acknowledge the referring source automatically as a part of the informed consent policy.


When the referring source is another mental health professional, it may be in the best interests of the patient for the two professionals to confer. When this happens, full consent or release of information must be arranged by both professionals, with written consent being given to both parties to discuss specific information agreed upon by the patient. In most states, a release of information is good for approximately 12 months. It is the responsibility of each psychotherapist to become familiar with the laws in his or her state with regard to this issue.


Prior to the student in a campus mental health facility attending the first evaluation session, the psychotherapist may wish to thank the professor, colleague, or other referral source for the referral then “briefly inform the person of the value and necessity of confidentiality and of the need to get permission to respond to specific questions. The conversation might conclude with an agreement to get back in touch with the referring person if the student or client is seen and agrees to or requests a release of information.” (Birky, Sharkin, Marin, & Scappaticci, 1998, p. 181)


A word of caution. Psychotherapists may be tempted to circumvent and avoid negative reactions from referral sources by giving information to the referral source that should remain confidential. It is important to note that, in the long run, the reputation and perceptions of the disclosing psychotherapist can be tainted for a long time to come if he fails to protect the confidential material and maintain an ethical position. It is best to develop the wherewithal to deal with the immediate discomfort of refusing to disclose and, in so doing, best serve the patient and create an environment of respect and professionalism.


Referral services. Psychotherapists who are members of legitimate referral agencies or services are not prohibited from paying a percentage of a referred client’s fee, or a flat rate, to a referral source to support the administrative costs of running the referral agency. However, it is unethical to pay a referral source a fee for each client referred to the psychotherapist. This practice is the same as paying the referral source for a specific patient, which is a violation of this Standard. Standard 6.07 dictates the psychotherapist must be paid for the actual “services provided” rather than “the referral patient itself.” (see APA 6.07 above)


Additionally, according to Fisher (2003), the referral agency or service may perform patient intakes if the staff adheres to specific policies including:


     The staff refers only to members of the referral list who have expertise appropriate to a client’s or patient’s specific treatment needs


     The costs of the administrative and professional services are spread out evenly over the entire membership such that no individual psychotherapist has a preferential position due to his financial contribution to the referral agency


Laws and regulations related to referrals. As always, it is the responsibility of each psychotherapist to become familiar with his or her state licensing board regulations regarding accepting referrals, kickbacks, and fee-splitting. It is also mandatory to know whether these activities are consistent with state law (Fisher, 2003).


Welfare of patient as primary focus. As discussed in Section A, welfare of client is the primary focus of the APA Ethics Code, which automatically calls for the welfare of the client to be the most important consideration for all psychotherapists, no matter what form of work they perform with clients or patients.




Definitions of Psychotherapist Self-Disclosure


The early view on therapist self-disclosure was stated by Freud, “The physician should be impenetrable to the patient, and like a mirror, reflect nothing but what is shown to him.” (1912/2000, p. 18) The use of self-disclosure in psychotherapy remains a hotly debated topic with few empirical studies. Psychotherapists hold vastly differing opinions, ranging from the traditional view that self-disclosure will contaminate the process and has no place in the relationship, to self-disclosure as a helpful aid in the therapeutic process (Peterson, 2002). A single definition of therapist self-disclosure is not actually possible. One thing is certain—avoiding therapist self-disclosure of all forms is impossible (Mahalik, van Ormer, & Simi, 2000). For example, how a psychotherapist dresses, decorates the office, his or her gender, and other activities in which the therapist is involved all expose information about the therapist and are forms of self-disclosure. “Therapist self-disclosure can be broadly defined as statements that reveal something personal about therapists.” (Hill & Knox, 2001, p. 413)


How Often Do Therapists Self-Disclose?


Several early studies where judges coded therapist verbal behavior from transcribed therapy sessions showed 1-13% (a mean of 3.5% across studies) of all therapy interventions were therapist self-disclosures (see Barkham & Shapiro, 1986; Elliot et al., 1987; Hill, 1987; Hill et al., 1988; Hill, Thames, & Rardin, 1979; Stiles, Shapiro, & Firth-Cozens, 1988). Thus, the therapists in these combined studies made infrequent self-disclosures.


Most articles about therapist self-disclosure focus on the clinical issues surrounding the self-disclose, not on the actual ethical issues involved, although all agree ethics are deeply embedded in the decision-making process. The decision whether to withhold or disclose personal information to a client has numerous clinical and ethical implications that deserve evaluation (Peterson, 2002).


APA Ethics Codes that Apply to Psychotherapist Self-Disclosure


APA 3.08 – Exploitative Relationships


This Standard prohibits psychotherapists from taking unfair advantage of, manipulating, or exploiting patients, clients, students, supervisees, or any others over whom they may have power for their own personal satisfaction. This includes inappropriate therapist self-disclosures during sessions for which the person is being charged a fee to get help (not to receive information about the therapist’s personal life). Therapists must be certain they are not self-disclosing for their own unfulfilled needs (Gutheil & Gabbard, 1995) or unconscious counter-transference (Lane & Hull, 1990).


What Types of Therapists Disclose?


Traditionally, psychoanalysts have been most opposed to the practice of self-disclosure due to the distortion of the transference relationship and the necessary resolution of the transference (Edwards & Murdock, 1994).


Humanistic-Experiential therapists reported more self-disclosures than did other theoretical orientations, and were also judged by experienced clinical psychotherapist raters as using a more self-disclosing style (Beutler & Mitchell, 1981). Because Humanistic psychotherapists emphasize genuineness and the ability of the therapist to be freely himself, self-disclosure is valued as a therapeutic tool (Goldstein, 1994; Weiner, 1983).


Dryden (1990) suggests that Rational Emotive Therapy uses the ABC technique in which an activating event leads to an irrational belief, which leads to unwanted consequences. She posits that when RET psychotherapists self-disclose their own experiences to clients as illustrations and demonstrations of how the ABC framework helps to solve problems, the self-disclosure can be very helpful. Here, Dryden would, “maintain that self-disclosure is not only ethical, it is necessary for successful therapy. On the basis of this view, a rational-emotive therapist who refrained from self-disclosure would be violating the ethical principle of beneficence,” (Peterson, 2001, p. 23)


It is interesting to note that no differences were reported between male and female therapists, or among therapists of differing racial/ethnic/cultural origins (Edwards & Murdock, 1994). However, this subject matter is ripe for further empirical research as several researchers have taken the time to point out various limitations of the empirical research available on self-disclosure and the inherent limitations in their own studies (see Hill & Knox, 2001; Peterson, 2002; Barrett & Berman, 2001).


Content of Therapist Self-Disclosure


One issue with which researchers have tried to deal has to do with distinguishing ethical from unethical self-disclosures. In 1994, Wells defined types of self-disclosures with each representing a different category of therapist disclosure content. Wells did not imply that self-disclosures within these categories are unethical, only that these disclosures fall easily into categories as can be seen below. Wells’ (1994) four categories are:


Category 1 – Professional Information - Here, the psychotherapist gives routine information about training, education, and practice issues. This category includes content about where the therapist earned his degree, his years of experience, and his values and beliefs about the therapy process.


Category 2 – Personal Life Circumstances - This category includes personal experiences and attitudes that provide information to the patient about the therapist’s marital status, sexual orientation, personal struggles, parenthood, or opinions about an issue in therapy.


Category 3 – Therapist Reactions to the Client or Patient - This category includes the therapist’s feelings about the patient/client, such as when a therapist discloses how he or she feels about a patient’s behavior in a session or sharing that the therapist likes or dislikes a patient/client. It is often a therapeutic intervention to disclose to a client when she performs some behavior of which the therapist disapproves (for example, repeatedly forgetting to pay the bill, repeatedly comes late to sessions, or forgetting appointments). However, this category may or may not go beyond the therapeutic boundaries of this type of self-disclosure.


Category 4 – Therapist Admission of Therapeutic Errors to Patient -This category includes admissions to the patient or client that the therapist said or did something inappropriate or insensitive. This category includes rushing a patient through a session, missing an important point, confusing a session date or time, forgetting a piece of information, or anything that might offend the patient.


Within Session Self-Disclosures versus Outside Session Self-Disclosures


Wachtel (1993) noted that for some therapists the distinction between disclosing reactions and information from within a session and disclosing material about other personal experiences from outside the session from the therapist’s life “virtually defines the boundary between disclosures that are acceptable and those that are not.” (p. 211) Peterson cites Wachtel in her 2001 article; Wachtel believes that when the therapist brings in outside material to disclose to the patient about her life outside of therapy, it can “introduce material that is a distraction from the client’s experience, which is the only issue of importance in therapy.” (Peterson, 2001, pp. 23-24) Peterson notes that Wachtel argues, “By bringing his or her experiences into therapy the therapist is acting in a selfish manner that undermines his or her empathy and appreciation for the client’s needs… and are exploitative, whereas self-disclosures about reactions to the client are beneficent.” (Peterson, 2002, pp. 23-24)


Positive Aspects of Therapist Self-Disclosure


Benefits of psychotherapist self-disclosure of personal experiences have been reported for several years (Knox et al., 1997; Derlega et al., 1991; Jourard, 1971; Kaiser, 1965). Additionally, several early authors found that when therapists made self-disclosures, clients saw the therapist as more friendly, more open, more helpful, and warm (Myers & Hayes, 2006, Knox & Hill, 2003, Dies, 1973; Feigenbaum, 1977; May & Thompson, 1973; Murphy & Strong, 1972).


Although several researchers found evidence that self-disclosure by therapists, when done properly, was effective and did enhance the relationship between the therapist and patient/client, it did not confirm the argument that self-disclosing therapists affect patients or clients to increase their level of self-disclosure as well. “The analyses failed to detect systematic differences in either the frequency or intimacy of client disclosures under conditions of greater or less therapist disclosure.” (Barrett & Berman, 2001, p. 602) Indeed, the number and intimacy level of patient and client self-disclosures were identical in both treatment situations.


Some clients reported the disclosures helped them gain insight and to view their particular problem from a new perspective. Some of these same clients mentioned being able to see their therapists as “more human” or more “imperfect.” (Peterson, 2002, 0p. 24) Peterson interprets this information to mean that the therapist self-disclosures helped the clients to “equalize the therapeutic relationship.” As mentioned previously in this section, this may be why psychoanalytic psychotherapists are the least likely to use self-disclosures as a therapeutic technique, according to research by Edwards and Murdock (1994) and other researchers mentioned above.


Negative Aspects of Therapist Self-Disclosure


It should be noted that in at least one study (Knox et al., 1997) where clients and patients clearly viewed therapist self-disclosures as an ethical and beneficent technique, subjects were asked only to consider helpful therapist self-disclosures and were not asked to discuss or think about unhelpful or harmful disclosures by therapists involving personal content. Thus, the results must—as always with research—be viewed with caution (Peterson, 2001).


In contrast, Epstein (1994) makes a much stronger case against therapist self-disclosure as a good therapeutic technique. Similar to Wells’ four categories of self-disclosure, Epstein specifically cautions against self-disclosure of personal or outside life issues, especially problems and life circumstances. Epstein is supported by numerous others who believe that frequent personal self-disclosures “are often a precursor to a therapist’s sexual involvement with his or her clients.” (Peterson, 2002, p. 24; Celenza, 1998) Of course self-disclosure is not a cause of sexual acting out with patients; it is a form of boundary violation that can begin a process of violating the patient and gradually blurring the line of a severe impairment in the therapist’s ability to understand and maintain the professional role (1994, p. 201).


Appropriate Uses for Therapist Self-Disclosure


Most authors and researchers write that the primary determinant as to whether therapist self-disclosure is ethical or not is the therapist’s motivation for sharing the information with the patient or client (Peterson, 2001). It is well known by the experts in this topic that it is exploitative for therapists to self-disclose personal information if the goal of the “confession” is to meet one’s own needs through the patient rather than to do something therapeutic for the patient (Gutheil & Gabbard, 1995).

Goldstein (1994) took a strong position that therapists must remain attuned in advance to the patient’s history, needs, and transference issues before disclosing any personal information because therapist personal information can be experienced as intrusive or manipulative by the patient. She reminds therapists to assess, at all times, one’s own needs versus when the self-disclosure is based upon empathy and a thoughtful treatment plan.


Additionally, experts in this area caution therapists not to participate in potentially dangerous and unfair “role reversals” and use the therapy hour selfishly (Brown & Walker, 1990; Goldstein, 1997). Therapists must be constantly aware of their own counter-transference reactions in order to use self-disclosure positively and helpfully.


Experts agreed upon a few specific examples of therapist self-disclosure as useful, positive, and successful if done carefully (Myers & Hayes, 2006,Goldstein, 1997; Curtis & Hodge, 1994; Mahalik et al., 2000; Mathews, 1988; Edwards & Murdock, 1994). Experts reviewed the literature and surveyed psychotherapists, and found the following were reasons why therapists used self-disclosure as a therapeutic technique with patients:


·         To establish bonds of trust and understanding

·         To normalize the client’s feelings and concerns

·         To provide examples of methods for handling difficult situations

·         To demonstrate effective ways of expressing emotion

·         Promoting feelings of universality

·         Increasing client self-disclosure (Mahalik et al., 2000)

o   This may be wishful thinking, as this has not been confirmed in the research thus far according to Barrett & Berman, 2001 (see below and previous discussion).

o   “The analyses failed to detect systematic differences in either the frequency or intimacy of client disclosures under conditions of greater or less therapist disclosure.” (Barrett & Berman, 2001, p. 602)

·         To acknowledge the importance of the therapist-patient relationship

·         To help clients see they are like others

·         To help clients recognize boundaries between what they think and feel and what others think and feel

·         To help the client feel more relaxed and comfortable in therapy

·         To model behavior

·         To increase the sense of similarity between themselves and their clients


Curtis and Hodge (1994) go so far as to argue that if therapists refuse to disclose any type of personal material at all, they could appear to their patients as if they have no feelings or problems; they believe this stance undermines part of the helpful aspects of the therapeutic relationship. When clients were asked why they thought their own therapists self-disclosed in a study by Knox et al. (1997), clients indicated that their therapists self-disclosed personal material in order to normalize the client’s experience inside and outside of therapy, to reassure the patient, and to help the client make constructive changes in their lives. Thus, answers from clients asked by these researchers reflected views that their therapists self-disclosed in order to aid the therapy process, rather than to aid the therapist. In other words, self-disclosures are not made in order to move the focus from the patient to the therapist inappropriately, to blur the boundaries, or to interfere with the client’s flow of material (Hill & Knox, 2001).


Patient Traits and Therapist Self-Disclosure


Perhaps the most important aspect of the ethics of therapist self-disclosure is how the client perceives the therapist’s reason for disclosing. If the client suspects that the therapist is behaving in an exploitative manner, regardless of the therapist’s intentions, self-disclosure is likely to cause harm. Epstein (1994) proposed two types of clients who may have a negative reaction, followed by harmful consequences, to therapist self-disclosure:


Type One – Accommodating Client

This type of client could respond to a therapist’s inappropriate self-disclosure by trying to take care of, or heal, the therapist.


Type Two – Impulsive Client

This type of client is impulsive with poor boundaries and may be diagnosed as a Borderline Personality Disorder, Axis II individual. According to Epstein, this person may act out by using therapist self-disclosures improperly by trying to get aggressive or act out sexually with the therapist.


The age of the client is another key factor that must be considered when a therapist is making a decision whether self-disclosure is ethical and helpful for the client. When working with children and adolescents, the situation is different from working with adults, as youngsters ask many personal questions that are aimed at identifying and understanding their own place in the world. Papoutsis (1990) stated that avoiding self-disclosures in response to these types of questions from children and adolescents could likely interfere with the younger client’s ability to connect with the therapist and even to master reality. Papouchis (1990) feels that appropriate self-disclosure enhances trust with child and adolescent clients, and cements the core relationship. He also observes that by self-disclosing, the therapist models authenticity and openness.


Greenberg (1990) makes the opposing point about working with the elderly population. She recommends not self-disclosing with older clients because many elderly clients are socially isolated, and therefore are looking for someone to fill the role of family member or close or intimate friend. Greenberg (1990) reminds therapists to remain cognizant of their role as therapist who helps the elderly client resolve issues, not as a friend with whom to chat or equally share personal stories.


Therapeutic Practices Related to Therapist Self-Disclosure


Clearly, therapist self-disclosures cross the threshold of anonymity in the therapist-client relationship. Since the experts all agree self-disclosure may have a powerful effect on clients, most suggest guidelines for using self-disclosure in the therapy setting (See Hill & Knox, 2001, p. 416):


1.   Generally, therapists should disclose infrequently

2.   The most appropriate topic for therapist self-disclosure involves professional background, whereas the least appropriate topics include sexual practices and beliefs

3.   Therapists should generally use disclosures to validate reality, normalize, model, strengthen the alliance, or offer alternative ways to think or act

4.   Therapists should avoid using disclosures that are for their own needs, remove the focus from the client, interfere with the flow of the session, burden or confuse the client, are intrusive, blur the boundaries, or over-stimulate the client

5.   Therapist self-disclosure in response to similar client self-disclosure seems to be particularly effective in eliciting client disclosure

6.   Therapists should observe carefully how clients respond to their disclosures, ask about client reactions, and use the information to conceptualize the clients and decide how to intervene next

7.   It may be especially important for therapists to disclose with clients who have difficulty forming relationships in the therapeutic setting


Results of Therapist Self-Disclosure


Even if the therapist takes everything into consideration, he still cannot predict the consequences of divulging personal information to a client. Peterson (2002) suggests taking into account, prior to the disclosure, the content of the disclosure along with the reasons for disclosing the information, the traits of the person who will be receiving the disclosed information, and any special circumstances surrounding the specific disclosure.

Taking into account that there are few studies researching therapist self-disclosure on the client (Peterson, 2002), the ones that have reported consequences have reported varying results, both positive and negative (see Peterson, 2002, pp. 29-30 for examples).


Considerations and Suggestions


Simi and Mahalik (1997) found that 60% of clients in their study reported that their therapists had shared personal information during therapy sessions. “Clearly therapists are acting as more than impenetrable mirrors. They are doing more than merely reflecting clients’ emotions, experiences, and thoughts.” (Peterson, 2002, p. 30) The research goes on to indicate that these self-disclosures are well thought out and ethical, or not thought out, and are perfectly ethical and in the best interests of the patient or client.


Despite how well thought out or not the self-disclosure may be, there is no way to be certain of the benefits or danger to the patient or if it is being used in an ethical manner. The literature on self-disclosure suggests that an ethical therapist might do well to consider the following questions prior to disclosing any personal information to a patient or client:


     Is the self-disclosure necessary to protect the client’s informed consent?

     Is the therapist’s purpose in the self-disclosure to benefit the client/patient or to benefit the therapist?

     Will this particular client or patient use this disclosed information in a way that is helpful?

     Will disclosing this personal information interfere with the therapeutic progress, such as by contaminating the client’s or patient’s therapeutic transference?


The primary ingredient here is the therapist’s ability to speculate about the potential consequences of self-disclosures. In general, the uncertainty in being able to determine whether self-disclosure is ethical requires time and energy to untangle. The backlash for making a faulty decision might precipitate a premature termination or other inappropriate therapeutic error.


Opportunities for therapist self-disclosures often arrive unexpectedly, and with very little time to speculate. It is important for therapists to give this issue thought and take a stance on self-disclosure prior to finding themselves in the position of having to make a decision without any previous consideration (Goldstein, 1997). Goldstein (1997) suggests that, because self-disclosure can occur spontaneously in any session, therapists think ahead with every patient as to what their beliefs are about the issue so the disclosure will not be thoughtless and will be less likely to be harmful.


It has long been known that it is the responsibility of the therapist to seek counseling for personal problems that arise in her life so that they do not interfere with her work as a psychotherapist (Myers & Hayes, 2006, Bram, 1995; Goldstein, 1997; Vamos, 1993). In order to avoid making therapeutic errors and harming patients, the psychotherapist needs to take proper care of him or herself during difficult times.


APA Ethics Codes that Apply to Self-Disclosure


APA 2.06a Personal Problems & Conflicts


Awareness of personal problems is mandatory. This code tells psychologists to avoid harming clients when they know or should know that their problems might harm their patients.


The research has always indicated that emotional, social, health-related, and other personal problems can interfere with the psychotherapist’s ability to use skills effectively. Many types of problems can stop psychologists from performing their work in a competent manner (O’Connor, 2001):


  • Mental disorders
  • Divorce or separation
  • Death of loved one
  • Drug use
  • Work-related stress
  • Burnout
  • Social isolation of private practice
  • Chronic or life threatening diseases


The possible consequences resulting from a psychotherapist who suffers from untended personal problems are patient abandonment, therapeutic errors, therapist misconduct, and public misperception of psychology (Fisher, 2009).


APA 2.06 also requires psychologists to refrain from starting any work-related activity when there is a substantial likelihood that their personal problems may impair their ability to perform their work competently. The words “refrain from beginning” and “substantial likelihood” indicate that the intent of this standard prohibits psychologists from taking on a scientific or professional role when their personal problems have the potential to impair their work. By the words “or should know” psychologists must consider in advance if they are suffering from any problems that would cause work-related impairment and whether they should avoid doing such work at this time (Fisher, 2003). In other words, is the psychologist so impaired that he or she is unable to be aware of the impairment?


APA 2.06b Personal Problems & Conflicts


Section b requires psychologists to take appropriate measures (e.g., obtaining consultation or psychotherapy), if they become aware that they may have personal problems that may interfere with their work-related activities. This applies to situations in which services are already being provided such as teaching, conducting research, or performing psychotherapy. The standard calls for the psychologist to take appropriate steps to remedy the problem (Fisher, 2003).


CAMFT Ethics Codes that apply to Self Disclosure


STANDARD 3 – Professional Competence and Integrity


STANDARD 3.4 - MFTs seek consultation and assistance for their personal problems or conflicts that impair their work or clinical judgment.


STANDARD 3.8 - MFTs remain abreast of developments in their field.


Social Work Ethics Codes that apply to Self Disclosure


NASW Code of Ethics


Standard 2.09 – Impairment of Colleagues (a&b)


(a)  SW who know of another SW who is impaired due to personal problems, psychological distress, substance abuse, or mental health difficulties that interfere with practice effectiveness must approach that colleague when it seems feasible and attempt to assist the colleague in taking remedial action.


(b)  SW who believe a colleague is not taking steps to remediate his or her impairment should take action through appropriate channels established by various agencies or employers.


CSWA Code of Ethics


Standard IV. – Relationships with Colleagues (e)


CSW act with integrity in their relationships with colleagues and members of other professions.  They know and take into account the traditions, practices, and areas f competence of other professionals and cooperate with them fully for the welfare of clients.


(e)  CSW who have knowledge of a colleague’s impairment misconduct, or incompetence attempt to bring about remediation through appropriate means through appropriate regulatory bodies.


General ethical issues related to counter-transference and staying out of trouble. It is important for psychotherapists to practice within their area of competence, training, experience and education.  Burnout is more likely when psychotherapists work beyond their competence and “freelance” rather than use tried and true methods.  Freelancing is a term that refers to the failure to research the best and most effective methods of clinical practice for a particular diagnosis in favor of simply trial and error without a formal or thoughtful treatment plan that is relevant and effective.




Most psychotherapists are not aware of how to practice risk management behaviors and how to avoid client complaints, short of never having sex with a patient or breaching confidentiality. Unfortunately, anyone can have a complaint lodged against him, and even an ethical psychotherapist can find herself in trouble if certain day-to-day practices are not strictly followed (Bennett, et al., 2006, Kennedy, Vandehey, Norman & Diekhoff, 2003).


There are a number of important reasons why psychotherapists must be concerned about risk management behaviors:


  • A malpractice suit is emotionally exhausting and stressful.


A civil suit for malpractice produces difficulties in both one’s professional and personal lives. Schoenfeld, Hatch, and Gonzalez (2001) found psychotherapists being sued suffered numerous problems such as depression, anxiety, anger, sleep disorders, sexual dysfunction, marital dysfunction, emergence of physical symptoms, medical problems, and interpersonal difficulties.


  • A malpractice suit or complaint is time-consuming (Montgomery, Cupit, & Wimberley, 1999).


Lawsuits can take from two to five years. The person being sued must have a good deal of patience and be able to devote plenty of time to researching and preparing for a fight.


  • If a complaint is filed, these authors (Schoenfeld, Hatch, &Gonzalez, 2001) report an ethics committee or a state board could require the licensee to be supervised, monitored, or restricted in practice.


My experience as past president of the California licensing board (Board of Psychology (BOP)) is that one’s license cannot be tampered with unless, and until, an ethics complaint, licensing complaint, or civil suit has been settled against the licensee. A complaint that has not been settled for or against the licensee is not sufficient to take action against the psychotherapist.


  • Depending upon what is covered by his malpractice insurance, the psychotherapist may have to pay for some part of the legal fees and the amount of the settlement.


It is important to review one’s own insurance to know what is and what is not covered.


  • If a psychotherapist is found guilty, or is sanctioned in some way, malpractice insurance will be raised, or he may lose insurance altogether (Schoenfeld, Hatch, &Gonzalez, 2001).


  • Potential income may be reduced.


Some disciplinary actions must be made public in order to “protect” the public. Thus, a thriving private practice can suffer losses and income can drop substantially. Managed care panels may remove the professional’s name from the list of available providers.


  • Psychotherapists may feel dissatisfied by the entire process (e.g., the state board’s handling of the case, ethics boards, civil court system).


Most psychotherapists feel as if they are being treated unfairly, punitively, or in an abusive manner. Psychotherapists report being treated as if they are guilty prior to going to court or being heard by the boards.


  • Most psychotherapists, according to Schoenfeld et al. (2001), are found not to be in violation of the boards’ rules and regulations.


Recommendations for Risk-Management Practices


Kennedy, Vandehey, Norman, and Diekhoff (2003) reviewed the practice literature and findings of a Texas statewide pilot study on the everyday risk-management practices of psychotherapists and identified overall recommendations:


Attend Risk-management seminars regularly. These workshops offer successful practice strategies, reviews of practice topics such as case law, and discuss areas of practice that have high levels of litigation, such as custody, hypnosis, and child abuse issues. Because case law and standard of care both change over time, law and ethics seminars should be taken on a regular basis.


Use treatment contracts. In actuality, the “informed consent” is usually so the patient becomes informed about office policies, such as cancellation policy and methods of treatment, then gives consent to begin or remain in treatment with the psychotherapist. These authors suggest all informed consent contracts contain a discussion of confidentiality (APA 4.01 and 4.02), reasons to breach confidentiality (APA 10.01a), fee and payment issues (APA 6.04), a policy on termination (APA 10.10), and the anticipated course of treatment (APA 10.01). This document should be reviewed with the client (APA 3.10b), and documented (APA 3.10d).


Develop policies and procedures for suicide assessment and incorporate them into each intake interview. These authors suggest doing an assessment of harm to self in every interview regardless of the presenting problem (Kennedy, Vandehey, Norman, and Diekhoff, 2003). No matter whether the client is actually actively suicidal, the client’s responses to a routine suicide assessment provide useful insights into problem-solving or coping skills.


Assign a DSM Diagnosis – Diagnoses are given based upon two basic features:


1. Duration of Symptoms

Duration of symptoms can either rule in or rule out specific diagnoses. For example, Dysthymic Disorder has a duration of 2 years for adults. Major Depressive Disorder has a duration of at least 2 weeks. It is especially easy to distinguish between these two diagnoses due to the time frames.


2. Severity of Symptoms

This feature is particularly helpful to aid in distinguishing between diagnoses. For example, Dysthymic Disorder has a severity of mild to moderate depression, as opposed to Major Depressive Disorder with severe or extreme depression.


Keep detailed and thorough notes. Documentation helps with risk-management as it permits an ethics committee or licensing board to assess how one conducts treatment and the results of treatment. APA Standard 6.01 requires psychotherapists to document professional and scientific work and to properly maintain records.


Fisher (2003) recounts the record keeping guidelines developed by the APA Committee on Professional Practice and Standards, Board of Professional Affairs, when she iterates minimal recommendation for the content of patient records. These records should include:


  • Identifying data
  • Dates of service
  • Types of services
  • Fees
  • Any assessments
  • Plan for intervention
  • Consultations
  • Summary reports
  • Testing reports
  • Any supporting data as may be appropriate
  • Any releases of information obtained


Review every client’s file often. When available, review past therapy records of the patient, especially when the patient currently is dangerous to self or others. This may help to ascertain what negatively stimulates the person, how she acts out negative impulses, and how rapidly the she recovers from the episode.

Reviewing notes on a routine basis reminds psychotherapists about themes and events on which to follow up from week to week.


Contact sudden terminations or no-shows. Clinicians should develop policies for clients who have been attending regular sessions, and then suddenly fail to come to a scheduled session. The primary issue is whether the client was “at risk” at the last contact with the psychotherapist. “At risk” refers to how safe the client is; for example, is she dangerous to self or others, or has something unusual recently occurred, such as a child abuse report? If the client was at risk in any way at the last contact, further action is required. If not, further action is up to the discretion of the psychotherapist; although one must be cautious not to harass a client for failing to attend a session when the client wants to end therapy for her own reasons.


Consult when one has a difficult client. Formalize the consultation by documenting the consultant’s name, the date, time, and issues discussed. Consultation with colleagues is the standard of care of the profession and is an expected part of clinical practice. It demonstrates to licensing boards and ethics committees that one is practicing the standard of care by seeking a second opinion.






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