How best can multiple relationship issues be resolved if they are unavoidable for therapists?

BY DR. STEPHEN BEHNKE APA Ethics Director

According to its preamble, the new APA Ethics Code "has as its goals the welfare and protection of the individuals and groups with whom psychologists work and the education of members, students and the public regarding ethical standards of the discipline." Standard 3.05, on multiple relationships, is an excellent example of how the code achieves these goals. To illustrate how it both protects and educates, Standard 3.05 can be broken down into five parts.

The first paragraph of the standard offers a definition that is new to the code. The definition states that a multiple relationship arises when a psychologist is in a professional role with an individual, and that, in addition to this professional role, one of three other conditions is met. Note the future aspect to the third condition--that the psychologist indicates that another relationship will occur at some later point in time.

STANDARD 3.05 MULTIPLE RELATIONSHIPS

(a) A multiple relationship occurs when a psychologist is in a professional role with a person and (1) at the same time is in another role with the same person, (2) at the same time is in a relationship with a person closely associated with or related to the person with whom the psychologist has the professional relationship, or (3) promises to enter into another relationship in the future with the person or a person closely associated with or related to the person.

The first paragraph of Standard 3.05 thus informs psychologists and the public what constitutes a multiple relationship.

One of the most frequent misconceptions I encounter in consulting with psychologists is that multiple relationships are, by definition, unethical. The second paragraph of Standard 3.05 makes it clear that simply meeting the definition does not speak to the ethics of the multiple relationship. In order to assess the ethical appropriateness of the relationship, the second paragraph sets forth a test:

A psychologist refrains from entering into a multiple relationship if the multiple relationship could reasonably be expected to impair the psychologist's objectivity, competence, or effectiveness in performing his or her functions as a psychologist, or otherwise risks exploitation or harm to the person with whom the professional relationship exists.

Note several things about this test. First, the test sets out criteria: an impairment in objectivity, competence or effectiveness, and a risk of exploitation or harm. In assessing whether the test is met, the psychologist will therefore consider the likelihood of impairment or the risk of exploitation or harm. Second, the phrase "reasonably expected" is central in determining what level of likelihood must be present: what a reasonable psychologist would expect to occur. Would a reasonable psychologist expect that the multiple relationship will cause impairment or risks exploitation or harm? If a reasonable psychologist would not, the test is not met.

Third, there must be a causal connection between the multiple relationship and the impairment or risk. In other words, something about the relationship must reasonably lead a psychologist to expect that the relationship will cause impairment or risks exploitation or harm. Thus, that a multiple relationship exists, in and of itself, does not meet the test--a reasonable psychologist must expect that the multiple relationship will lead somewhere problematic. The third paragraph in Standard 3.05 emphasizes this point:

Multiple relationships that would not reasonably be expected to cause impairment or risk exploitation or harm are not unethical.

The definition in Standard 3.05 educates psychologists and the public about when a multiple relationship is present. The test that follows protects those with whom psychologists work, and thereby promotes their welfare, by making a safe space available for the psychologist and client to proceed.

One of the very enjoyable aspects of my position directing the APA Ethics Office is that I have the opportunity to listen to psychologists discuss ethical aspects of their work. Discussions about Standard 3.05 are especially interesting because of the wide variety of multiple relationships that arise in our profession. Often, though, I find myself thinking that a discussion ostensibly about the ethics of multiple relationships is not really about ethics at all.

What I mean is that often such discussions pose a specific question: whether a multiple relationship will lead to impairment or risks exploitation or harm. All the participants agree that if the multiple relationship were likely to lead to impairment or such risks, the relationship should be avoided. Thus, the debate is not about values--protecting from harm and promoting welfare--but is rather about what effect a particular multiple relationship will have on a particular client. While the answer to this clinical question has profound ethical implications, the disagreement remains on clinical and technical grounds. As psychologists, we can agree upon and share the underlying values.

The APA Ethics Code recognizes that because of the many roles psychologists assume in their work, family, community and social lives, multiple relationships arise in unexpected ways. Some of these multiple relationships are potentially harmful. The fourth paragraph in Standard 3.05 addresses potentially harmful, unanticipated multiple relationships:

(b) If a psychologist finds that, due to unforeseen factors, a potentially harmful multiple relationship has arisen, the psychologist takes reasonable steps to resolve it with due regard for the best interests of the affected person and maximal compliance with the Ethics Code.

In its fifth and final paragraph, Standard 3.05 recognizes that psychologists are sometimes required to serve in more than one role in judicial or administrative proceedings, and so cannot always avoid or fully resolve a potentially harmful multiple relationship. When a psychologist encounters such a situation, the Ethics Code focuses the psychologist on informing those affected about the change in expectations. The reasoning behind the code's language is that if a psychologist must take on a potentially harmful multiple role, the best way to help protect those affected is to inform them of the change in circumstances:

(c) When psychologists are required by law, institutional policy, or extraordinary circumstances to serve in more than one role in judicial or administrative proceedings, at the outset they clarify role expectations and the extent of confidentiality and thereafter as changes occur. (See also Standards 3.04, Avoiding Harm, and 3.07, Third-Party Requests for Services.)

* Defines a multiple relationship.

* Provides a test for when psychologists refrain from entering into a multiple relationship.

* Indicates what psychologists do when an unanticipated and/or unavoidable multiple relationship arises in their professional lives.

The goal of Standard 3.05, like the goal of the code as a whole, set forth in the preamble, is "the welfare and protection of the individuals and groups with whom psychologists work and the education of members, students and the public regarding ethical standards of the discipline."

Standard 3.05 illustrates that an excellent way to protect our clients and promote their welfare is to educate the public about our profession's core values and to inform psychologists about how these values can be implemented in their everyday practice.

Please send questions or comments about this column or suggestions for future "Ethics Rounds" columns via e-mail.

In 1988, after practicing as a Psychological Assistant in Berkeley, California, for four years, Dr. Ofer Zur, a licensed psychologist and director of the Zur Institute, LLC, settled in the small community of Sonoma, California, where he immediately opened up his own private practice. And at first, things went smoothly. He established himself as an expert in his field and as an involved and well-respected member of his community. Still, as is wont to occur in a small town, the inevitable happened: a couple he socialized with on a regular basis asked for his professional guidance with their struggling marriage.

Based on what Zur had been taught from the very beginning of his days as a mental health professional, he informed the couple he was not the right man for the job because of his preexisting personal relationship with them. The couple was outraged. Feeling conflicted, Zur brought his dilemma to attorneys, supervisors, ethics experts, and experienced therapists, all of whom told him that taking this couple on as clients would be crossing a clear line.
Still, this across-the-board finger-wagging made Zur wonder: were these unequivocal ethical guidelines outdated? Were there instances in which entering into a dual relationship might benefit a client? Wouldn't his preexisting relationship with this couple increase their trust in him, and strengthen the therapeutic alliance?

Dual relationships (also known as "multiple relationships"), refer to a situation in which multiple roles exist between a therapist and a client. For example, when a client is also a friend or family member, it is considered a dual relationship. If a client is also an employee or business associate, it is considered a dual relationship. If a therapist regularly comes across a client in any setting outside of the therapist's office — a bowling league, a country club, a school setting, karaoke night — it's considered a dual relationship and, in most cases, is officially frowned upon.

The rules are so ingrained in the industry culture that it seems like a no-brainer. And when pushed to explain the rules, professionals generally explain that avoiding dual relationships is necessary because, otherwise, a therapist might misuse their power and influence and exploit clients for their own benefit. And in fact, this is what's stated in most professional organizations' code of ethics.

But when one looks more closely at the rules, one tends to find a lot of gray areas.

For example, in the National Association of Social Workers (NASW) Code of Ethics (2008), there is a line acknowledging that some multiple relationships are unavoidable, and which then states that "in instances when dual or multiple relationships are unavoidable, social workers should take steps to protect clients and are responsible for setting clear, appropriate, and culturally sensitive boundaries" (section 1.06). 

Similarly, the California Association of Marriage and Family Therapists (CAMFT) Code of Ethics (2011) states that "not all dual relationships are unethical, and some multiple relationships cannot be avoided" (p.10).

The American Psychological Association (APA) Code of Ethics of 2010 even states that "multiple relationships that would not reasonably be expected to cause impairment or risk exploitation or harm are not unethical" (p. 6).

But how is one to find the line between an unethical and ethical dual relationship? Especially considering the variety of situations that could lead to such a relationship?

For one thing, there are dual/multiple relationships that are actually mandated by law.

For example, military clinical psychologists or psychiatrists on active duty fulfill multiple roles. They act as both commissioned military officers and psychotherapists-clinicians. Because of this, the work they do can often seem at odds. As Zur describes is, part of the responsibility of military psychologists is to enhance the combat readiness of the unit, while also helping traumatized soldiers overcome their PTSD. Because of these conflicting responsibilities, a solder's mental health can play second fiddle to a unit's need to see that soldier in combat duty again, as quickly as possible. 

Other examples of mandated relationships include psychotherapists who work in prisons and jails, and who are also prison guards. Or forensic psychologists who must report their findings to a prison warden, leading to a loss of trust in the psychologist, by the client.

There are also unavoidable — though not necessarily mandated — dual relationships, such as those that occur within a small community, when it's a given that a therapist will cross paths with a client in multiple settings.
In cases like these, Zur believes that certain codes of ethics can prove to be "overly restrictive and unreasonable." In the Code of Ethics for CAMFT, for example, it's stated that, "Other acts that would result in unethical dual relationships include, but are not limited to, borrowing money from a patient, hiring a patient, engaging in a business venture with a patient, or engaging in a close personal relationship with a patient. Such acts with a patient's spouse, partner, or family member may also be considered unethical dual relationships" (2011, p. 6).

Zur preaches a more open-minded, less restrictive view of dual relationships, claiming that "the context within which multiple relationships take place is, without a doubt, one of the most important factors in determining their appropriateness." In fact, he believes that  — in certain instances — a purposeful dual relationship can prove helpful to a client's progress.

How? For one thing, Zur believes that a client's familiarity with his therapist's spiritual beliefs and personal ethics will only helps him trust his therapist more readily. By extension, he believes this level of familiarity can aid in shortening the length of therapy and increasing its effectiveness.

He also feels that the isolation of the strict therapist/client relationship might allow for incompetent therapists to remain unaccountable for long periods of time, enabling them to continue therapy even when the client does not get better.

He also feels it's possible for the avoidance of all dual relationships to only exacerbate the power dynamic within the therapist/client relationship, which can easily lead to exploitation.

And these are only a handful of the arguments Zur makes in support of considering dual relationships.

One must "go through a thoughtful, ethical, decision-making process to determine what ethical, legal, and clinically appropriate actions they can or cannot or should or should not pursue," says Zur.

Of course, not everyone within the field fully agrees with Zur's viewpoints. Michael Plaut, a licensed psychologist who has both served on and chaired Maryland's Board of Examiners of Psychologists, finds many of Zur's points valid. After all, he concedes, it's almost impossible to avoid running into a patient or client at a social event, in a supermarket, or at a religious venue.  But he's concerned, primarily, with the language Zur uses in his arguments. "His writing seems to focus on a justification of boundary crossings and dual relationships rather than a balanced, practical consideration of how decisions about dual relationships are best made," said Plaut.

So how is the decision-making process best approached when it comes to finding that sometimes thin line between ethical and unethical? Plaut has several suggestions.

One suggestion — which he's written about in the Handbook of Clinical Sexuality for Mental Health Professionals, for which he contributed a chapter on understanding and managing professional/client boundaries — is to go through the process of making a "progressive boundary analysis." What this means is that, if someone is considering crossing a boundary, they should ask themselves what the implications of doing so might be. Are further crossings more likely to happen if one boundary is crossed?

Another question Plaut believes professionals should ask themselves:

Are we really meeting the patient's needs or are we satisfying our own need to be needed? 

"An honest answer to this question is critical in crossing any boundary," he says.  He goes on to explain that professionals' roles "as parents, teachers, and therapists is hopefully to help our charges get to the point that they do not need us anymore in order to thrive on their own. By exploiting their dependency on us, we are ultimately not helping them at all to achieve that level of self-sufficiency. I am not my patient's friend and I am not my student's friend. Ultimately, our clients need to find personal support in other places. It is part of our job to help them do that, rather than to provide excessively for their needs."

Finally, Plaut suggests consulting with fellow professionals. He advises documenting everything and then, in times of uncertainty, consulting with a colleague you trust.

And in the end, his suggestions are not so very different from the ones Zur lists out in the Zur Institute's Guidelines For Non-Sexual Dual Relationships In Psychotherapy. Though two of his guidelines do stick out:

"2. Intervene with your clients according to their needs, as outlined in each of their treatment plans, and not according to any graduate school professor's or supervisor's dogma or even your own beloved theoretical orientation."

And:

"5. Do not let fear of lawsuits, licensing boards or attorneys determine your treatment plans or clinical interventions. Do not let dogmatic thinking affect your critical thinking. Act with competence and integrity while minimizing risk by following these guidelines."

In these guidelines, Zur encourages professionals to move beyond what they may have been taught in their training, and to apply additional critical thinking to the decision-making process.

Still, when it comes to both Zur and Plaut, the inclination seems to be to err on the side of caution. Sure, the codes of ethics in regards to dual relationships may seem very unambiguous. But the rules and the limits that are in place are there because of what might happen.

Plaut puts forth the following scenario: Suppose you accept an invitation to a patient's wedding. On the one hand, this could be considered a supportive gesture, and could prove beneficial to the therapeutic relationship. On the other hand, you may end up confronting another ethical issue: breach of confidentiality. In a case like this, it might be useful to discuss with the patient beforehand how each of you might respond if someone asked how you knew each other. Is the patient comfortable disclosing that? How should you respond as a therapist to such a question from someone you meet at the wedding? When you consider all the possibilities, making a clear decision about the efficacy of a dual relationship becomes even more complex.

Plaut also lays out an analogy, likening the laws of dual relationships to the act of following the speed limit. While we may understand on an intellectual level why the speed limits are the way they are, we often toe the line, going above the speed limit... but not so far we're likely to be pulled over.

Still, if we are pulled over, we don't try to talk our way out of a ticket by insisting we didn't hurt anyone.

Because we know that speed limits are set in response to the perceived risk of harm and we know that, even if no one else was hurt, we've still broken the law.  

Plaut, S.M. (2010). Understanding and managing professional-client boundaries. In Levine, S.B., Risen, C.B., & Althof, S.E. (Eds.). Handbook of Clinical Sexuality for Mental Health Professionals, 2nd Ed. New York: Routledge, pp. 21-38.

Zur, O. (Winter 2014). Not All Multiple Relationships Are Created Equal: Mapping the Maze of 26 Types of Multiple Relationships. Independent Practitioner. pp. 15 -22.

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