1. Ethics of Multiple Relationships
and
The Case of Pat

2. Codes of Ethics posted on   PsychotherapySaintLouis YahooGroups listserv.

3. ACA Code of Ethics 2005   Revised AAMFT Code of Ethics, effective July 1, 2001   APA Ethical Principles of Psychologists and Code of Conduct 2010 Amendments   Code of Ethics of the National Association of Social Workers Approved by the 1996 NASW Delegate Assembly and revised by the 2008 NASW Delegate Assembly

4. after being kicked out of marriage
The Case of Pat
Time frame:
almost 9 years ago, through this year.
Chris sought help
after being kicked out of marriage
(by Pat)
for having an affair

5. The Case of Pat Chris’s spouse, Pat, softened
Chris wanted Pat to attend
Subsequently, to start couple’s counseling

6. AAMFT 1.3 Marriage and family therapists
are aware of their influential positions
with respect to clients,
and they avoid exploiting
the trust and dependency of such persons.
Therapists, therefore, make every effort to avoid
conditions and multiple relationships with clients
that could impair professional judgment
or increase the risk of exploitation.

7. Such relationships include, but are not limited to,
business or close personal relationships
with a client or the client’s immediate family.
When the risk of impairment or exploitation exists
due to conditions or multiple roles,
therapists take appropriate precautions.

8. ACA
A.5.c. Nonprofessional Interactions or Relationships (Other Than Sexual or Romantic Interactions or Relationships)
Counselor–client nonprofessional relationships with clients, former clients, their romantic partners, or their family members
should be avoided,
except when the interaction is
potentially beneficial to the client.

9. A.5.d. Potentially Beneficial Interactions
.. the counselor must document in case records..
 ….Examples of potentially beneficial interactions
… attending a formal ceremony
(e.g., a wedding/commitment ceremony or graduation);
purchasing a service or product provided by a client or former client (excepting unrestricted bartering);
hospital visits to an ill family member;
mutual membership in a professional association,
organization, or community.

10. 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.
APA

11. 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.

12. Multiple relationships that would not reasonably be expected to cause impairment or risk exploitation or harm are not unethical. (b) If a psychologist finds that, due to unforeseen factors, a potentially harmful multiple relationship has arisen, the psychologist takes reasonable steps to resolve it with due regard for the best interests of the affected person and maximal compliance with the Ethics Code.

13. 10.02 Therapy Involving Couples or Families
(a) When psychologists agree to provide services
to several persons who have a relationship
(such as spouses, significant others, or parents and children),
they take reasonable steps to clarify at the outset
(1) which of the individuals are clients/patients and
(2) the relationship the psychologist will have with each person…
(b) If it becomes apparent that psychologists
may be called on to perform potentially conflicting roles
(such as family therapist and
then witness for one party in divorce proceedings),
psychologists take reasonable steps to
clarify and modify, or withdraw from, roles appropriately.

14. Standard 3.05 does not prohibit
Celia B. Fisher, Ph.D.; Multiple Relationships and the New APA Ethics Ethics Code
Standard 3.05 does not prohibit
attendance at a client’s/patient’s, student’s, employee’s, or employer’s family funeral, wedding, or graduation;
the participation of a psychologist’s child
in an athletic team coached by a client/patient;
gift giving or receiving with those
with whom one has a professional role;
or from entering into a social relationship with a colleague
as long as these relationships would not reasonably be expected
to lead to role impairment, exploitation, or harm.
Incidental encounters with clients/patients at religious services, school events, restaurants, health clubs,
or similar places are not unethical.

15. Nonetheless, psychologists should always consider
whether the particular nature of
a professional relationship might lead
to misperceptions regarding the encounter.
If so, it may be wise
to keep a record of such encounters.

16. NASW 1.06 Conflicts of Interest
(c) Social workers should not engage in dual or multiple relationships with clients or former clients
in which there is a risk of
exploitation or potential harm to the client.
In instances when dual or multiple relationships
are unavoidable,
social workers should take steps to protect clients
and are responsible for setting
clear, appropriate, and culturally sensitive boundaries.
(Dual or multiple relationships occur when social workers relate to clients in more than one relationship,
whether professional, social, or business.
Dual or multiple relationships can occur
simultaneously or consecutively.)

17. to two or more people who have a relationship with each other
(d) When social workers provide services
to two or more people who have a relationship with each other
(for example, couples, family members),
social workers should clarify with all parties
which individuals will be considered clients
and the nature of social workers’ professional obligations
to the various individuals who are receiving services.
Social workers who anticipate a conflict of interest
among the individuals receiving services
or who anticipate having to perform
in potentially conflicting roles
(for example, when a social worker is asked to testify
in a child custody dispute or divorce proceedings involving clients)
should clarify their role
with the parties involved and take appropriate action
to minimize any conflict of interest.

18. Issues of Sexual Intimacy
(Not pertinent to Case Study)

19. AAMFT …should not engage in sexual intimacy
1.4 Sexual intimacy with clients is prohibited.
1.5 Sexual intimacy with former clients … is … prohibited for two years following the termination …
…should not engage in sexual intimacy
with former clients after the two years …
Should therapists engage in
sexual intimacy with former clients …
burden shifts to the therapist to demonstrate
that there has been no exploitation or injury

20. ACA A.5.a. Current Clients A.5.b. Former Clients
Sexual or romantic counselor–client interactions or relationships with current clients, their romantic partners, or their family members
are prohibited.
A.5.b. Former Clients
Sexual or romantic counselor–client interactions or relationships with former clients, their romantic partners, or their family members
are prohibited for a period of 5 years following the last professional contact.

21. APA
10.05 Psychologists do not engage in sexual intimacies with current therapy clients/patients.
10.06 (or) with individuals they know to be
close relatives, guardians, or significant others
of current clients/patients. Psychologists do not terminate therapy to circumvent this standard.
10.07 Psychologists do not accept as therapy clients/patients persons with whom they have engaged in sexual intimacies.
10.08 (a) Psychologists do not engage in sexual intimacies with former clients/patients for at least two years after cessation or termination of therapy.

22. except in the most unusual circumstances.
(b) Psychologists do not engage in sexual intimacies with former clients/patients even after a two-year interval
except in the most unusual circumstances.
[and] bear the burden of demonstrating that there has been no exploitation, in light of all relevant factors, including
(1) the amount of time that has passed since therapy terminated;
(2) the nature, duration, and intensity of the therapy;
(3) the circumstances of termination;
(4) the client's/patient's personal history;
(5) the client's/patient's current mental status;
(6) the likelihood of adverse impact on the client/patient; and
(7) any statements or actions made by the therapist during the course of therapy suggesting or inviting the possibility of a posttermination sexual or romantic relationship with the client/patient.

23. NASW 1.09 Sexual Relationships
(a) Social workers should under no circumstances
engage in sexual activities or sexual contact
with current clients, whether such contact is consensual or forced.
(b) [or with] clients’ relatives or other individuals with whom clients maintain a close personal relationship when there is a risk of exploitation or potential harm to the client.
… Social workers—not their clients, their clients’ relatives, or other individuals with whom the client maintains a personal relationship
—assume the full burden for setting clear, appropriate, and culturally sensitive boundaries.

24. (c) Social workers should not engage in sexual activities or sexual contact with former clients because of the potential for harm to the client.
If social workers engage in conduct contrary to this prohibition or claim that an exception to this prohibition is warranted because of extraordinary circumstances,
it is social workers—not their clients— who assume the full burden of demonstrating that the former client has not been
exploited, coerced, or manipulated, intentionally or unintentionally.
(d) Social workers should not provide clinical services
to individuals with whom they have had
a prior sexual relationship. ….

25. The Case of Pat Pat and Chris reconciled.
Couples counseling recurred from time to time.
Pat and Chris also sought individual counseling
from time to time.

26. The Case of Pat
Pat works in family services field* and would occasionally refer individuals to me for counseling.
[*Family Services field: Attorneys, CASA’s, Counselors, Children’s Division workers, GAL’s, Judges, etc]

27. APA 3.07 Third-Party Requests for Services
When psychologists agree to provide services to a person or entity at the request of a third party, psychologists attempt to clarify at the outset of the service the nature of the relationship with all individuals or organizations involved. This clarification includes the role of the psychologist (e.g., therapist, consultant, diagnostician, or expert witness), an identification of who is the client, the probable uses of the services provided or the information obtained, and the fact that there may be limits to confidentiality.

28. The Case of Pat In recent case:
Pat is an issue discussed by counseling clients in session.
Conversations between Pat and me become subjects of conversation in client sessions.

29. The Case of Pat Pat requested client notes. I declined.
Client obtained order from Judge compelling me to release information.
I reluctantly comply.

30. ACA A.5.e. Role Changes in the Professional Relationship
When a counselor changes a role from the original or most recent contracted relationship, he or she obtains informed consent from the client …
Examples of role changes include  
1.        changing from individual to
relationship or family counseling, or vice versa;
2. changing from a nonforensic evaluative role
to a therapeutic role, or vice versa;
… Clients must be fully informed of any anticipated consequences
(e.g., financial, legal, personal, or therapeutic)

31. Dual Relationships, Multiple Relationships, & Boundary Decisions
Dual Relationships, Multiple Relationships, & Boundary Decisions

32. Ken Pope & Patricia Keith-Spiegel "A Practical Approach to Boundaries in Psychotherapy: Making Decisions, Bypassing Blunders, and Mending Fences" Journal of Clinical Psychology: In Session, 2008, vol. 64, #5, pages ):
"Nonsexual boundary crossings can enrich therapy, serve the treatment plan, and strengthen the therapist-client working relationship. They can also undermine the therapy, sever the therapist-patient alliance, and cause immediate or long-term harm to the client. Choices about whether to cross a boundary confront us daily, are often subtle and complex, and can sometimes influence whether therapy progresses, stalls, or ends…”

33. Is the dual relationship necessary?
Ethical Decision-making and Dual Relationships Jeffrey N. Younggren, Ph.D., ABPP
Is the dual relationship necessary?
Is the dual relationship exploitive?
Who does the dual relationship benefit?
Is there a risk that the dual relationship could damage the patient?
Is there a risk that the dual relationship could disrupt the therapeutic relationship?
Am I being objective in my evaluation of this matter?
Have I adequately documented the decision making process in the treatment records?
Did the client give informed consent regarding the risks to engaging in the dual relationship?

34. Debra S. Borys Kenneth S. Pope http://kspope.com/dual/research2.php
Dual Relationships between Therapist & Client:
A National Study of Psychologists, Psychiatrists, and Social Workers
Debra S. Borys Kenneth S. Pope
4,800
psychologists, psychiatrists, and social workers
were surveyed
(return rate = 49%)

35. Ethical? 1=never 2rarely 3 sometimes 4 mostly 5always NS Not sure NR no response 1 2 3 4 5 NS NR
Accepting a gift worth under $
Accepting a client's invitation to a special occasion Accepting a service or product as payment for therapy
 Becoming friends with a client after termination
Selling a product to a client
Accepting a gift worth over $
 Providing therapy to an employee
Engaging in sexual activity with a client after termination Disclosing details of current personal stresses to a client
Inviting clients to an office/clinic open house
Employing a client
Going out to eat with a client after a session
 Buying goods or services from a client
Engaging in sexual activity with a client
Inviting clients to a personal party or social event
 Providing indiv. therapy to client’s relative/friend/lover Providing therapy to a current student or supervisee Allowing a client to enroll in one's class for a grade

36. Accepted a gift worth under $10 14.0 56.5 11.3 5.9 11.5 0.8
1 = no clients 2 = few, 3 = some 4 =most 5 = all clients, NR = no response NR
Accepted a gift worth under $
Accepted a client's invitation to a special occasion
Accepted a service or product as payment for therapy
Became friends with a client after termination
Sold a product to a client
Accepted a gift worth over $ Provided therapy to an employee Engaged in sexual activity with a client after termination Borrowed less than $5 from a client Disclosed details of current personal stresses to a client
Borrowed over $20 from a client
Invited clients to an office/clinic open house Employed a client
Went out to eat with a client after a session Bought goods or services from a client Engaged in sexual activity with a current client
Invited clients to a personal party or social event Providing indiv. therapy to client’s relative/friend/lover Provided therapy to a then-current student or supervisee Allowed a client to enroll in one's class for a grade

37. Zur, O. (2011). http://www.zurinstitute.com/dualrelationships.html.
Dual Relationships, Multiple Relationships & Boundaries
 In Psychotherapy, Counseling & Mental Health. 

38. Types of Dual Relationships: Social Professional
Treatment Professional
Business
Communal
Institutional
Forensic
Supervisory
Sexual.
digital, online or internet ??

39. Voluntary-avoidable:
Dual relationships can be ..
Voluntary-avoidable:
Unavoidable:
Mandated:
Unexpected
concurrent
sequential
Level of Involvement can be ..
Low-minimal level
Medium level
Intense level

40. GUIDELINES FOR NON-SEXUAL DUAL RELATIONSHIPS IN PSYCHOTHERAPY Treatment plans:
Develop a clear treatment plan for clinical interventions which are based on the context of therapy….
Intervene with your clients according to their needs…
Some treatment plans may necessitate dual relationships however, in other situations dual relationships should be ruled out. Make sure you know the difference.
4. If planning on entering a dual relationship you must take into consideration the welfare of the client, effectiveness of treatment, avoidance of harm and exploitation, conflict of interest, and the impairment of clinical judgment. These are the paramount and appropriate concerns.

41. 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.
6.Incorporate dual relationships into your treatment plans only when they are not likely to impair your clinical judgment, or create a conflict of interest. 7.Do not enter into sexual relations with a client because it is likely to impair your judgment and nullify your clinical effectiveness.
8.Remember that treatment planning is an essential and irreplaceable part of your clinical records and your first line of defense.
9. Consult with clinical, ethical or legal experts in very complex cases and
document the consultations well.

42. Prior to and during therapy which includes dual relationships:
10.Study the clinical, ethical, legal and spiritual complexities and potential ramifications of entering into dual relationships.
11.Attend to and be aware of your own needs through personal therapy, consultations with colleagues, supervision or self-analysis. Awareness of your own conscious and unconscious needs and biases helps avoid cluttering the dual relationship.
12.Before entering into complex dual relationships, consult with well-informed and non-dogmatic peers, consultants, and supervisors.
13.When you consult with attorneys, ethics experts and other non-clinical consultants make sure that you use the information to educate and inform yourself rather than as clinical guidelines. Separate knowledge of law and ethics from care, integrity, decency and above all effectiveness. Remember you are paid to help and heal, not to protect yourself.
14.Discuss with your clients the complexity, richness, potential benefits, drawbacks and likely risks that may arise due to dual relationships.
15.Make sure that your office policies include the risks and benefits of dual relationships and
that they are fully explained, read and signed by your clients before you implement them.
Make sure your clinical records document clearly all consultations, substantiations of your conclusion, potential risks and benefits of intervention, theoretical and empirical support of your conclusion, when available, and the discussion of these issues with your client.

43. Clinical integrity and effectiveness:
16. Remember you are setting an example. Model civility, integrity, emotionality, humanity, courage, and, when appropriate, duality.
17. As a role model, telling your own stories can be an important part of therapy. Make sure that the stories are told in order to help the client and not to satisfy your own needs.
18. Remember that you are being paid to provide help. At the heart of all ethical guidelines is the mandate that you act on your clients' behalf and avoid harm. That means you must do what is helpful, including dual relationships when appropriate.
19. Answer clients' basic and legitimate questions about your values and beliefs, including your thoughts on dual relationships.
20. Continue to keep excellent written records throughout treatment. Keep records of all your clinical interventions, including dual relationships, additional consultations and your own and your clients' assessment of treatment and its progress.
21.Evaluate and update your approach, attitudes, treatment plans and above all effectiveness regularly.

44. If you find yourself in a dual relationship
which either is not benefiting the client
or is causing distress and harm,
or has unexpectedly brought about
conflict of interest,
consult and, if necessary, stop or ease out
of the dual relationship
in a way that preserves the client's welfare
in the best possible way.