1. Ethics: Boundaries and Multiple relationships
Southern Nazarene University
Philip R. Budd, Psy.D.

2. Definitions: (Zur, 2011)
Boundaries in Therapy: Work on establishing a “Therapeutic Frame”
Boundary Crossings: Any violation of strict in office contact with the client
Boundary Violations: When therapists exploit or violate their clients
Dual/Multiple Relationships: Refer to establishing multiple roles with a client (e.g. therapist/student, therapist/physician, therapist/mechanic, etc.)
Thoughts of boundaries always take us back to Father Freud… some analytic writers are extremely rigid in their writing about therapeutic boundaries… Robert Langs… the ultimate superego… everything could create an iatrogenic impact on the treatment…
At the same time, Freud analyzed Ferenczi while walking through the country and wrote a letter to him, “Dear Son”… he had at least one meal with him. He was known to share information about his family, gave gifts, loaned books… He analyzed his own daughter. Melanie Klein invited one patient to join her on vacation to continue his analysis and then did 2 hour sessions laying on her hotel bed.. Winnicott shared with Margaret Little considerable detail about his CT with a patien who committed suicide. He ended each session with coffee and biscuits.
That is not to say these are acceptable in todays world.

3. Explore
Discuss ways boundary crossings may benefit the client… How does a therapist decide whether to allow a boundary crossing? How should it be addressed within the therapeutic frame?

4. Explore
Boundary violations occur purposely or inadvertantly… Discuss examples of boundary violations and the impact on the client. How were these violations managed therapeutically?

5. Explore
Kenneth Pope contends that “….nonsexual dual relationships, while not unethical and harmful per se, foster sexual dual relationships” (1990, p. 688). Simon (1991) agress that The boundary violation precursors of therapist-patient sex can be as psychologically damaging as the actual sexual involvement itself” (p. 614) Do you agree? What wisdom is in their position? Where do you find problems with their perspective? How does fear of a lawsuit create a paranoia regarding dual relationships?

6. Boundary Crossings and Violations (Zur, 2011)
Any deviation from “office only” or more “distant forms of therapy” (self disclosure, length and place of sessions, physical touch, activities outside of office, gifts, social and other non therapeutic contact)
Boundary violations are harmful, while boundary crossings are not and may be helpful
Most boundary violations occur when therapists and patients are involved in expoitive dual relationships
Boundary crossings can be a part of well formulated treatment plans. (e.g., dlying w/ a client working on fear of flying; having lunch w/ anorexic patient, home visit to a bed ridden patient, going to a wedding, graduation, funeral, bar mitzvah
Boundary crossings are not unethical; boundary violations are unethical
Therapeutic orientations may view boundary crossings differently: harmful boundary violations within one frame, may be seen as unethical in an other.
Culture will view boundary crossings differently
Not all boundary crossings will be harmful dual relationsips

7. Explore
Boundary violations occur when the “role” of the therapist is not clear. Define what you think the role of the therapist is…
A middle-aged borderline patient, attempting to convey how deeply distressed she felt about her situation, leaped from her chair in the therapist's office and threw herself to her knees at the therapist's feet, clasping his hand in both of her own and crying, "Do you understand how awful it's been for me?" The therapist said gently, "You know, this is really interesting, what's happening here-but it isn't therapy; please go back to your chair." The patient did so, and the incident was explored verbally.
Kernberg reportedly had a pt whose session ended and as they tried the door for the pt to leave, it would not open. After calling to have someone come open the door, Kernberg sat at his desk and said to the pt., “Are we agreed that the session is over?” Then

8. Areas of Boundary Violations (pope, 1993)
Role
Time
Place and Space
Money
Gifts, Services
Clothing
Language
Self Disclosure
Physical Contact
Role Boundaries: Essential boundary issue. Is this what the therapist does? Subject to ideological variations:
Acting in… Wish to see therapist as ideal parent who fulfills all wishes
Abstinence must be a part of therapy
Talk rather than act out wishes
Libidinal demands vs. growth needs
Greenson talks about avoiding the neurotic and infantile wishes
Empathically understanding does not mean we can fulfill all parental needs not met in childhood
Time:
possibility for sexualizing… last appt…. Marathon sessions, etc.
If erotic transference occuring.. Better to see when lots of people are around
Phone calls…
Place and Space:
Office or hospital room
Weddings, funeral of child
Boundary violations can be reversed or undone with further discussion
Apologies may be necessary
Home visits
Sessions in cars… give a ride home Work with phobias w/ systematic desensitization
Money: business nature of the relationship… this is not love it is work
Only form of material gratification for the work
Role of pro bono…
What happens if there is unpaid debt?
Why would the therapist be indifferent to making a living?
Bartering… blurs payment and gift
Gifts and Services:
Cleaning the therapist office or home
Bringing coffee or food to the session
Role of manners and boundaries is difficult
Clothing:
Language:
Use of first names?
Tone: pt won a settlement in an allegation of sexual misconduct when the tape recording she made of a phone call from her therapist revewled his intimate seductive tone
Word choice: therapist, “What are u feeling now in your vagina”
Countertransference around sadistic fantasies may reveal contempt
Self Disclosure:
Motivations for the self disclosure
Many therapists have wish to be known by their patients as a “real person” especially as termination is near (Gorkin). Is this related to their own unfulfilled needs?
Certainly self disclosure of how the client is impacting them may be helpful, but disclosure of dreams, fantasies, specific vacation plans, etc, may be burdening the pt.
Physical Contact:
When is it appropriate?

9. Explore
From the previous list, discuss when boundary crossings related to one of the issues would be appropriate and why…. How does the boundary violation assist the client and how does it fit with your view of boundaries based on your theoretical view of therapy?

10. Treatment plan and Boundary Crossing
Explore the issue with your client
Explore the issue in supervision
Anticipate potential other ethical issues (confidentiality, privacy, etc)
Understand the impact on the ongoing therapeutic endeaver
Above all else… do no harm

11. Understand the Context of therapy
Client factors: culture, history, history of trauma, sexual and physical abuse, age, gender, presenting problem, mental status, diagnosis, SES, personality, sexual orientation, social support, religious and spiritual beliefs and practices, prior therapy experience
Setting factors: outpatient vs. inpaitent, solo vs. group practice, type of office (in home or in professional building), public vs. private practice, location of other office staff, rural vs. metro area, prison, etc.
Therapy Factors: modality, individual vs. couple vs family vs group, short term vs. long term, frequency of sessions, population (child, adolescent, adult), theoretical orientation (psychoanalytic, humanistic, CBT, Gestalt, etc)
Therapeutic Relationship: Therapeutic alliance, new vs. long term relationship, beginning vs middle vs end of therapy, any dual relationship
Therapist factors: culture, age, gender, sexual orientation, scope of practice, quality of therapist personal relationships

12. Non Sexual dual relationships
Non sexual dual relationships are not necessarily unethical or illegal. Only sexual dual relationships with current clients are ALWAYS unethical and sometimes illegal.
Non sexual dual realtionship do not necessarily lead to exploitation, sex or harm. Dual relationships may actually prevent exploitation and sex rather than lead to it.
Almost all ethical guidelines do not mandate a blanket avoidance of dual relationships. All guidelines prohibit exploitation and harm of clients.

13. Types of Dual Relationships
Social Dual Relationship: Therapist and client are also friends or have other type of social relationship. These can be in person or online. Facebook friends may be a social dual relationship. Social media relationships have inherent problems
Professional Dual Relationship: Colleagues, doing presentations together, coauthors, etc.
Treatment-Professional Dual Relationshp: therapy and selling Mary Kay…
Business Dual Relationship: Owning partnerships, business, employer-employee relationship
Communal Dual Relationship: Live in same small community, same church, same community organization
Institutional Dual Relationship: military, prison, police
Forensic Dual Relationship: treating client while giving expert testimony for them
Sexual Dual Relationship: Always unethical

14. Dual Relationships can be avoidable, unavoidable or mandated
Voluntary-avoidable: take place in lare cities where there are many therapists, many places to shop, worship, recreate
Unavoidable: often found in isolated rural areas, small minority groups, disabled groups or spiritual communities or any small community in big metro areas or training institutions. Also more unavoidable in sports psychology or spiritual counseling
Mandated: In military, prisons and police departments
Unexpected: Ex spouse of former client, person a client is having an affair with, co-worker of a spouse; client joins your church, book club, etc.

15. Dual Relationships Concurrent/sequential
Concurrent dual relationships take place at the same time as the therapy, while sequential dual relationships take place after the therapy has ended

16. Level of involvement
Low-minimal: Running into a client at store Medium: Share occasional encounters (kids in same school) Intense: Serve on committees toegether, in the same Sunday School class

17. Additional Issues
Are prohibitions of dual relationships an infringement on constitutional rights?
Exploitive therapists will exploit with or without dual relationships
Avoiding ALL dual relationships can keep therapist in unrealistic and inappropriate power positions… increasing the liklihood of exploitation
Prohibition of dual relationships leads to increased isolation of the therapist
Not all therapeutic approaches disparage dual relationships. CBT, Family, Group and Existential may see dual relationships as important integral part of the treatment plan
Graduate education instills fear of licensing agencies and lawsuits, but also fails to give adequate instruction in personal integrity, individual ethics and how to navigate complex therapeutic issues.
Dual relationships may facilitate better health and healing

18. Guidelines for Nonsexual Dual Relationships
Be intentional in your treatment plan… pay attention to context as described above.
Intervene with clients according to their needs as outlined in the treatment plan
Some treatment plans may incorporate dual relationships, other plans should avoid dual relationships.
If entering a dual relationship:
Welfare of client
Effectiveness of treatment
Avoidance of harm or exploitation
Conflict of interest
Impairment in clinical judgment
Don’t let fear determine treatment plan
No sexual relationship… will impair judgment and nullify clinical effectiveness
Consult when dealing with complex cases with dual relationships

19. Decision Making (Pope & Vasquez, 2007)
Ethical awareness is a continuous, active process… Need for constant questioning and personal responsibility.
Awareness of ethical codes and legal standards is essential to critical thinking about ethics and making decisions. Those standards inform, but do not determine ethical decisions
Awareness of research and theory in scientific and professional literature is related to ethical competence
Most therapists conscientious and committed to high ethical standards, but all of us are fallible
Many find it easier to question the ethics of others than our own behavior
We may limit questioning about where we are more sure, and only explore areas that are less well known
We may have dilemmas where needs of the patient are not clearly met.
Consultation is always helpful and sometimes crucial

20. Decisions about Boundaries (Pope and Vasquez, 2007)
Imagine the best possible outcome and the worst possible outcome from crossing the boundary. Are there significant risks for harm.. Short term or long term? Consider the research and literature Evaluate the ethical codes, legislation, case law, etc. Ask trusted colleague Pay attention to uneasy feelings or doubts Informed consent, both at the beginning and throughout treatment Have informed consent for planned boundary crossing Keep careful notes of any boundary crossing… process of evaluating it, discussion with pt. and any immediate results

21. Online guides for Boundary Decisions
Three online guides to assist you in your decision: Jeff Youngren's "Ethical Decision-making and Dual Relationships" available at Janet Sonne's "Nonsexual Multiple Relationships: A Practical Decision-Making Model for Clinicians" at Mike Gottlieb's "Avoiding Exploitive Dual Relationships: A Decision-making Model" available at

22. Prior to and during Therapy involving Dual relationships
Study the clinical, ethical, legal and spiritual complexities and potential ramifications of entering dual relationships
Attend to and be aware of your own needs through your personal therapy, consultations with colleagues, supervision or self-analysis. Awareness of your conscious and UCS needs and biases helps avoid cluttering the dual relationship
Before entering into complex dual relationships, consult with well informed and non dogmatic peers, consultants and supervisors
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, and effectiveness. You are paid for helping and healing not self protection.
Discuss with the client the complexity, richness, benefits, drawbacks and risks that may arise from dual relationships
Make certain office policies include the risks and benefits of dual relationships and that they are explained, read and signed by your clients before you implement them
Make certain clinical records clearly articulate the consultations and what substantiates your conclusion, potential risks and benefits of intervention, theoretical and empirical support of you conclusion and the discussion with your client

23. Ethical Decision making RE Dual relationships (Younggren, 2002)
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 harm 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 my decision making process in the treatment records?
Did the client give informed consent regarding the risks to engaging in the dual relationship?
Handout

24. References
Gutheil, T.G. & Gabbard, G.O. (1993). The concept of boundaries in clinical practice: Theoreticala nd risk- management dimensions. American Journal of Psychiatry, Vol. 150, pp Pope, K. S. (1990). Therapist-patient sexual contact: Clinical, legal, and ethical implications. In E .A. Margenau, The encyclopedia handbook of private practice. pp New York: Gardner Press, Inc. Pope, K. S., & Vasquez, M. J. T. (2007). Ethics in psychotherapy and counseling: A practical guide (3rd edition). San Francisco, CA: Jossey-Bass/John Wiley Simon, R. I. (1991). Psychological injury caused by boundary violation precursors to therapist-patient sex, Psychiatric Annals, 21, , Zur, O. (2000). In Celebration of Dual Relationships: How Prohibition of Non-Sexual Dual Relationships Increases the Chance of Exploitation and Harm. The Independent Practitioner, 20 (3), Zur, O. (2010). Dual Relationships, Multiple Relationships & Boundaries In Psychotherapy, Counseling & Mental Health. Retrieved 4/17/2011 from