Presentation on theme: "Ethics of Multiple Relationships"— Presentation transcript:
1 Ethics of Multiple Relationships andThe 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 PatTime frame:almost 9 years ago, through this year.Chris sought helpafter 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 attendSubsequently, to start couple’s counseling
6 AAMFT 1.3 Marriage and family therapists are aware of their influential positionswith respect to clients,and they avoid exploitingthe trust and dependency of such persons.Therapists, therefore, make every effort to avoidconditions and multiple relationships with clientsthat could impair professional judgmentor increase the risk of exploitation.
7 Such relationships include, but are not limited to, business or close personal relationshipswith a client or the client’s immediate family.When the risk of impairment or exploitation existsdue to conditions or multiple roles,therapists take appropriate precautions.
8 ACAA.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 membersshould be avoided,except when the interaction ispotentially 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 witha person closely associated with or related to the personwith whom the psychologist has the professional relationship,or (3) promises to enter into another relationshipin the futurewith 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 expectedto impair the psychologist'sobjectivity, competence, or effectivenessin performing his or her functions as a psychologist,or otherwise risks exploitation or harm to the personwith 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 servicesto 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 psychologistsmay be called on to perform potentially conflicting roles(such as family therapist andthen witness for one party in divorce proceedings),psychologists take reasonable steps toclarify 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 CodeStandard 3.05 does not prohibitattendance at a client’s/patient’s, student’s, employee’s, or employer’s family funeral, wedding, or graduation;the participation of a psychologist’s childin an athletic team coached by a client/patient;gift giving or receiving with thosewith whom one has a professional role;or from entering into a social relationship with a colleagueas long as these relationships would not reasonably be expectedto 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 ofa professional relationship might leadto misperceptions regarding the encounter.If so, it may be wiseto 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 clientsin which there is a risk ofexploitation or potential harm to the client.In instances when dual or multiple relationshipsare unavoidable,social workers should take steps to protect clientsand are responsible for settingclear, 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 occursimultaneously or consecutively.)
17 to two or more people who have a relationship with each other (d) When social workers provide servicesto two or more people who have a relationship with each other(for example, couples, family members),social workers should clarify with all partieswhich individuals will be considered clientsand the nature of social workers’ professional obligationsto the various individuals who are receiving services.Social workers who anticipate a conflict of interestamong the individuals receiving servicesor who anticipate having to performin potentially conflicting roles(for example, when a social worker is asked to testifyin a child custody dispute or divorce proceedings involving clients)should clarify their rolewith the parties involved and take appropriate actionto 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 intimacywith former clients after the two years …Should therapists engage insexual intimacy with former clients …burden shifts to the therapist to demonstratethat 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 membersare prohibited.A.5.b. Former ClientsSexual or romantic counselor–client interactions or relationships with former clients, their romantic partners, or their family membersare prohibited for a period of 5 years following the last professional contact.
21 APA10.05 Psychologists do not engage in sexual intimacies with current therapy clients/patients.10.06 (or) with individuals they know to beclose relatives, guardians, or significant othersof 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 intervalexcept 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 circumstancesengage in sexual activities or sexual contactwith 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 beenexploited, coerced, or manipulated, intentionally or unintentionally.(d) Social workers should not provide clinical servicesto individuals with whom they have hada 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 counselingfrom time to time.
26 The Case of PatPat 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 torelationship or family counseling, or vice versa;2. changing from a nonforensic evaluative roleto a therapeutic role, or vice versa;… Clients must be fully informed of any anticipated consequences(e.g., financial, legal, personal, or therapeutic)
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., ABPPIs 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 WorkersDebra S. Borys Kenneth S. Pope4,800psychologists, psychiatrists, and social workerswere 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 terminationSelling a product to a clientAccepting a gift worth over $ Providing therapy to an employeeEngaging in sexual activity with a client after termination Disclosing details of current personal stresses to a clientInviting clients to an office/clinic open houseEmploying a clientGoing out to eat with a client after a session Buying goods or services from a clientEngaging in sexual activity with a clientInviting 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 NRAccepted a gift worth under $Accepted a client's invitation to a special occasionAccepted a service or product as payment for therapyBecame friends with a client after terminationSold a product to a clientAccepted 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 clientBorrowed over $20 from a clientInvited clients to an office/clinic open house Employed a clientWent out to eat with a client after a session Bought goods or services from a client Engaged in sexual activity with a current clientInvited 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 ProfessionalBusinessCommunalInstitutionalForensicSupervisorySexual.digital, online or internet ??
39 Voluntary-avoidable: Dual relationships can be ..Voluntary-avoidable:Unavoidable:Mandated:UnexpectedconcurrentsequentialLevel of Involvement can be ..Low-minimal levelMedium levelIntense 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 anddocument 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 andthat 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 clientor is causing distress and harm,or has unexpectedly brought aboutconflict of interest,consult and, if necessary, stop or ease outof the dual relationshipin a way that preserves the client's welfarein the best possible way.