Relationships
Sexual Abuse: A Journal of Research and Treatment 23(3) 365 –380 © The Author(s) 2011 Reprints and permission: http://www. sagepub.com/journalsPermissions.nav DOI: 10.1177/1079063210381411 http://sax.sagepub.com
SAX381411 SAX
Corresponding Author: Steven Sawyer, PO Box 10631, White Bear Lake, MN 55110 E-mail: steve@sawyersolutions.org
Boundaries and Dual Relationships
Steven Sawyer and David Prescott
Abstract
Ethical standards are core components of practice standards and codes of conduct for mental health practitioners. Practice standards and ethics related to boundaries are generally based on historical review, study of mental health services, and the impact of boundary crossing or boundary violations on clients receiving services. This article explores some common standards of ethical practice related to boundaries and dual or multiple relationships between mental health professionals and clients. The underlying conceptual basis for these standards and examples of questions encountered in clinical practice with sexual offenders are explored.
Keywords
sexual offender treatment, professional boundaries, professional ethics, dual relation- ships
“Ethics is a skill.”
Marianne Jennings
Introduction The conduct of mental health professionals (e.g., social workers, psychologists, mar- riage and family therapists, licensed counselors) with clients receiving services is addressed in professional literature, in standards and ethics documents adopted by professional organizations (American Group Psychotherapy Association [AGPA], 2002; American Psychological Association [APA], 2010; Association for the Treatment of Sexual Abusers [ATSA], 2005; National Association of Social Workers
Article
366 Sexual Abuse: A Journal of Research and Treatment 23(3)
[NASW], 2008), and in statutes and rules of mental heath or behavioral health licensing boards (e.g., Association of Social Work Boards, 2008; Minnesota Board of Social Work, 2009). Twenty-five states include continuing education in ethics or boundaries as a requirement for annual or biannual social work license renewals (Association of Social Work Boards, 2008).
With so much attention to providing guidance for clinical decision making, one might think that professionals would encounter fewer ethical dilemmas. Unfortunately, this is far from the case. In fact, some observers (e.g., Glaser, 2010) note that numer- ous potential conflicts remain between the standards and ethics of mental health pro- fessions and the treatment of sexual offenders.
Professional ethics are founded on such underlying concepts as these: (a) Clients are vulnerable when receiving professional mental health services; (b) professionals have varying degrees of perceived or real power and authority, especially when cli- ents’ participation is “involuntary” (court ordered); and (c) there is a fundamental need for psychological and physical safety for clients receiving mental health services. Treatment of sexual offenders referred by the criminal justice system are generally considered involuntary clients where the treating clinician holds considerable power and authority with an obligation to protect the community that may at times override individual client rights (Prescott & Levenson, 2010). These circumstances bring ethi- cal challenges to the entire course of treatment, from intake to discharge from services. Balancing the essential therapeutic relationship with the need to protect vulnerable community members from future harm requires clarity regarding the boundaries of the treatment relationship. This article explores boundaries in professional practice and the particular boundary issue of multiple or dual relationships.
The Legal Foundation of Mental Health Ethics The basic rights of clients receiving mental health care services in the community or in facilities are provided for in some state statutes, and clients of psychotherapy ser- vices are considered emotionally dependent when considering the criteria for sexual exploitation by professionals. These client rights arise out of the need for protection resulting from the inherently unequal relationship between mental health professional and client and from the vulnerability of the client receiving services. This vulnerabil- ity has additional dimensions when clients are ordered by the courts to receive services and are thus “involuntary” recipients of services. These legal rights and protections are supported in professional codes of ethical conduct as well as behav- ioral health licensing statutes and rules. Licensing statutes and rules regulate the licensed behavioral health professional for the purpose of protecting the public. Codes of conduct publicly state the professional standards of practice and allow the profes- sion to “regulate” the members while also protecting the client.
It can be easy for mental health professionals to minimize the vulnerabilities of their clients, who often feel markedly conflicted about the change process (Miller & Rollnick, 2002; Prochaska & DiClemente, 1984). Meta-analyses of psychotherapy drop-out rates
Sawyer and Prescott 367
attest to the fact that treatment is rarely easy for those who enter it (Wierzbecki & Pekarik, 1993). Furthermore, controversies remain in the field of assessing and treating people who have sexually abused.
Some Common Elements of Ethical Practices A summary of some common elements of statutes and professional standards related to ethics and relationships with clients are shown in Table 1. Common elements include avoiding harm, which includes physical, emotional, sexual, financial, and medical harm. Informed consent is a fundamental standard requiring that information is given to clients in advance of any important decision, such as treatment or research, which is directly related to promoting client autonomy and the inherent vulnerability of the client. Sexual intimacy is not allowed with current clients or, in many cases, with a former client or family member of a client or former client. Multiple or dual relationships should be avoided to prevent situations in which the professional provid- ing mental health services also has another personal or professional relationship with the client such that the two relationships are in conflict or affect the objectivity of the professional.
By defining the actions of the mental health professional and the limitations of the professional relationship with the client, codes of conduct serve to protect the client and guide the practitioner. Because the mental health professional has an ethical obli- gation to the primacy of the relationship and the privacy of the client (with exceptions for community safety and child abuse as mandated by laws such as Duty to Warn and child abuse reporting), ethical codes provide practice parameters and limits or bound- aries of the professional–client relationship.
These codes of conduct and basic ethical concepts are applicable to treatment of sexual offenders across treatment venues and treatment models that range from psycho- educational approaches to more process-oriented groups and apply to all therapy meth- ods. However, when treating sexual offenders, concerns remain regarding the proper balance of beneficence, nonmalificence, client autonomy, and the need for community safety. For example, in a recent paper, Glaser (2010) has argued that current treatment models provide no choice of therapy to the offender and compromise the client’s auton- omy. Glaser contends that current ethical guidelines such as those of the ATSA breach “the ethical codes which traditionally guide mental health practitioners.” Glaser further states that a primary problem with the status quo is that clinicians working in these programs “cannot serve (the) two masters” of community safety and client interests. He adds that traditional ethical codes, such as those published by APA (2010) and NASW (1999), do little to guide therapists treating sexual offenders. Prescott and Levenson (2010) have argued that although some clinicians are more effective at attending to the competing needs of this work better than others, this is precisely why organizations such as ATSA, APA, and NASW enforce their ethical codes. Furthermore, balancing these seemingly competing demands is what most sexual offender treatment providers are expected to do every day.
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Sawyer and Prescott 369
Boundaries
The term “boundaries” describes structural (e.g., time of service, place of service, fees, and agreements) and interpersonal (e.g., physical contact, sexual contact, rela- tionship limits, and giving or receiving gifts) dimensions of the professional–client relationship. An underlying purpose of explicitly defined boundaries is to create and maintain clarity for the patient about the nature and limits of the professional relation- ship. Ultimately, the client should experience both connection within the therapeutic relationship and protection from harm. The mental health professional has the respon- sibility to establish and maintain boundaries. Most professional codes of ethics and state licensing boards use a “reasonable and prudent” standard to judge these actions by requiring that mental health professionals must not act or fail to act in a way that inappropriately encourages the client to relate to the therapist outside of the boundar- ies of the professional relationship, or in a way that compromises objectivity or inter- feres with the client’s ability to benefit from services.
In a review of the history and evolution of the concept of therapist–client boundar- ies in therapy practice, Smith and Fitzpatrick (1995) identified three principles that underlie the patient–therapist relationship and boundaries: abstinence, duty to neutral- ity, and the responsibility of the therapist to strive for the independence and autonomy of the client. In this framework abstinence means the clinician refrains from self- seeking and personal gratification from the therapeutic relationship beyond the profes- sional rewards of the role as the professional. Duty to neutrality refers to the focus on the client’s therapeutic agenda, to the exclusion of interfering in the personal affairs of the client outside the presenting issues brought by the client. Independence and auton- omy of the client preserves the client’s freedom of choice.
Currently accepted practices of appropriate boundaries in providing professional mental health services to clients have evolved over time as the understanding of the patient experience and therapy process has grown. Gutheil and Gabbard (1993) referred to early accounts of Freud’s analytic practice:
Freud, for example, used metaphors involving the opacity of a mirror and the dispassionate objectivity of a surgeon to describe the analyst’s role, but his own behavior in the analytic setting did not necessarily reflect the abstinence and anonymity that he advocated in his writings. He sent patients postcards, lent them books, gave them gifts, corrected them when they spoke in a misinformed manner about his family members, provided them with extensive financial sup- port in some cases, and on at least one occasion gave a patient a meal (8). (p. 2)
Gutheil and Gabbard (1993) defined professional boundaries in terms of role, time, place and space, money, gifts, clothing, language, self-disclosure, and physical contact. They use these dimensions to explore the many facets, and in some cases subtleties, of boundaries in professional practice. Time boundaries can be as simple as maintaining the planned beginning and ending of a therapy session, regardless of the content of the session as it comes to a close.
370 Sexual Abuse: A Journal of Research and Treatment 23(3)
Other types of boundary considerations typically include structural, interpersonal, and dual relationships. Structural boundaries include clarity and consistency regarding the time and place of the service, fees, and agreements regarding the service itself. These can become challenging, particularly in inpatient settings where a clinician may feel that it is in one client’s best interest to spend extra time with them on a living unit or convene a meeting with staff on their client’s behalf, and the same clinician may feel differently about providing the same service to another client. Dilemmas appear quickly: When a clinician (whether in community or inpatient settings) provides an extra service, whose needs are met? Under what circumstances would the clinician extend the same courtesy to others? In addition, if a client requests the counselor to attend a personal event or activity that is not related to the therapy, the therapist is obligated to maintain the professional boundary and avoid personal encounters that could obscure the professional role. These judgments may be purely based on the needs of the individual client but underscore the importance of clinical supervision.
Interpersonal boundaries such as physical contact and giving or receiving gifts can create questions in the psychotherapeutic endeavor. Residential programs serving ado- lescents who sexually abuse have historically had difficulty establishing appropriate policies for physical contact between staff and clients, (Schladale, 2007) due to the highly individualized nature of the clients they serve. While a warm pat or soothing gesture sometimes seems to be the right thing to do when clients are exhibiting dis- tress, physical touch can be easily misinterpreted by clients or be viewed as crossing the line of appropriate contact, even with adult clients.
Smith and Fitzpatrick (1995) differentiated boundary crossing and boundary violation in the following way:
Boundary crossing is a non-pejorative term that describes departures from com- monly accepted clinical practice that may or may not benefit the client. A bound- ary violation, on the other hand, is a departure from accepted practice that places the client or the therapeutic process at serious risk. (p. 500)
Boundary crossing can be examined across a continuum, ranging from acts that have less potential for significant harm to the client (e.g., extending the time of a session beyond the normal time frame) to more potentially complex acts such as receiving a significant gift. Interestingly, even extending a session beyond the structured time can be interpreted by the client as a willingness by the therapist to provide special treatment or that the client is in some way special. It can also be a form of indirect reinforcement of avoiding important issues until the end of the session. Boundary violations can also be examined across a continuum but are generally considered more significant and, therefore, have the potential for greater harm to the client. Boundary violations include dual relationships, physical contact, self-disclosure, and sexual contact with current and former patients or their family members.
Whether a boundary “crossing” or a “violation,” therapists engage in a cognitive decision making or awareness process—be it thoughtful, analytic but misinformed,
Sawyer and Prescott 371
selfish, or absent minded—any of which allows the potentially harmful action to occur. Pope and Keith-Spiegel (2008) identified seven cognitive errors by clinicians that contributed to boundary errors:
• Error 1: What happens outside the psychotherapy session has nothing to do with the therapy.
• Error 2: Crossing a boundary with a therapy client has the same meaning as doing the same thing with someone who is not a client.
• Error 3: Our understanding of a boundary crossing is also the client’s under- standing of the boundary crossing.
• Error 4: A boundary crossing that is therapeutic for one client will also be therapeutic for another client.
• Error 5: A boundary crossing is a static, isolated event. • Error 6: If we ourselves don’t see any self-interest, problems, conflicts of
interest, unintended consequences, major risks, or potential downsides to crossing a particular boundary, then there aren’t any.
• Error 7: Self-disclosure is, per se, always therapeutic because it shows authenticity, transparency, and trust.
Most clinicians have encountered an actual or potential boundary issue at some point in their practice where they feel pressure to allow the boundary crossing or boundary violation. For example, it is common that a client becomes deeply immersed in an important personal issue at the end of session and the therapist directly or indi- rectly continues the session beyond the specified time limit. It would be easy for the therapist to think, “This is important, I will only extend the session one time and the client will not notice or take advantage in the future.” Or in a session where the client is exploring sexual feelings the therapist offers a personal (countertransferential) self-disclosure about finding the client to be very attractive. In this context the self- disclosure was not made to further the therapeutic work of the client but was made to alleviate the therapist’s anxiety about the sexual feelings.
Boundary Issues With Sex Offenders How are these questions relevant to treatment of sexual offenders? One of the most significant issues is the fact that most sexual offenders are involuntary clients in struc- tured treatment programs, under a court order, and supervised by a probation or parole agent. Because of these conditions and external controls, mental health professionals can be drawn away from considering the “offender” as a client who is vulnerable and thus operate clinically with a perceived freedom and independence from the more traditional service model with the “vulnerable” private client. Therapy with a sexual offender is different due to the external controls, but the involuntary client is in many ways just as vulnerable as a voluntary client presenting with anxiety or depression. An example of a thought error with an involuntary client could be, “He is not a typical
372 Sexual Abuse: A Journal of Research and Treatment 23(3)
client; he is a sexual offender; he has lost his rights.” This thought process reflects a bias on the part of the therapist and a potential loss of neutrality.
Should clinicians who treat court-ordered individuals who have committed a sexual crime be any less attentive to boundaries than a clinician treating an emotionally vul- nerable adult or adolescent? Clinicians working with court-ordered clients have added responsibilities to the client and the community. Most individuals presenting for ther- apy after a criminal justice intervention have experienced fear, shame, loss of family and friends, loss of livelihood, and damaged or diminished self-concept. Under this type of stress typical defenses (e.g., denial, minimization, and suppression) serve to protect the client. With the added potential of a sexual disorder that has been denied, grief is another potential underlying phenomenon. For example, this is especially true for those who have denied a lifetime of sexual attraction to children and during treat- ment come to terms with the meaning of their diagnosis (e.g. pedophilia). Hence, the unique dynamics of the involuntary client, combined with the public scrutiny of the criminal justice system and pressure to be accountable to the court (and the commu- nity) require the clinical professional to attend to the need for clearly defined relation- ship boundaries as well as the care and protection of the client.
Examples of Ethical Standards in Professional Associations Because of the breadth of responsibilities of mental health professionals and the widely accepted basic boundary expectations, professional associations address boundaries and professional relationships in codes of conduct. The ATSA, NASW, the APA, and the AGPA all address sexual relationships.
Prohibition of sexual contact with a current client is universal. Some standards (such as NASW) take this prohibition further to prohibit sexual contact with former clients or relatives of clients and prohibit providing services to individuals with whom a prior sexual relationship occurred. The rationale is that sexual contact as a form of intimacy impairs the neutrality of the professional and violates the rule of abstinence (of self-gratification).
The ATSA Code of Ethics (2001) states that that sexual intimacy with clients or former clients is unethical: “A member shall not engage in a sexual relationship with any client who is receiving or has received professional services, regardless of whether payment for the services was involved” (p. 8). Likewise, the AGPA states that sexual intimacy with patients/clients is unethical (AGPA, 2002).
Clear boundaries protect the client from harm, ensure that the client interests are paramount, and promote the objectivity and neutrality of the professional. Boundary violations put the objectivity or neutrality of the professional at risk or creates a con- flict of interest. The client is at risk when the professional experiences impaired objec- tivity, as the judgment of the therapist may not be in the client’s best interest. When boundaries are violated there is, by definition, risk of harm to the client, which the professional is committed to protect.
Sawyer and Prescott 373
Dual or Multiple Relationships: What Is This and Why It Is an Issue?
Dual relationships (or multiple relationships) in therapy practice are identified as an ethical issue and a boundary violation. This is based in part on the concepts that the relationship is not equal, that the client is vulnerable, and that the primary responsibil- ity of the clinician is to make care of the client the first priority. A dual relationship poses the risk that the personal interests of the mental health professional or some other obligation could be more important than the needs and safety of the client. Multiple relationships are defined by the APA (2010):
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 relation- ship, 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. A psycholo- gist refrains from entering into a multiple relationship if the multiple relation- ship could reasonably be expected to impair the psychologist’s objectivity, competence, or effectiveness in performing his or her functions as a psycholo- gist, or otherwise risks exploitation or harm to the person with whom the profes- sional relationship exists. Multiple relationships that would not reasonably be expected to cause impairment or risk of exploitation or harm are not unethical.
The ATSA Code of Ethics (ATSA, 2001) states in part: “ii) Multiple relation- ships may impair professional judgment and pose a significant risk for client exploi- tation” (p. 9). The AGPA Code of Ethics (2002) states, “The group psychotherapist shall not use her/his professional relationship to advance personal or business interests” (sec 3.2, p. 2). Engaging in multiple relationships with a client receiving mental health services is widely accepted as having a potentially harmful impact on the client or the neutrality of the mental health professional. When professionals have multiple roles with clients, the primacy of the therapeutic relationship is compromised because the relationship is now viewed to be a mutual exchange in which the needs of both parties are paramount. A dual role impairs the ability of the practitioner to place the client’s needs above one’s own in the therapeutic encounter, and if problems occur in the alter- native relationship, they will carry over into the therapist–client relationship. Some multiple relationships are intentional while others occur and must be addressed or navigated (e.g., in small towns or rural areas where options for the client and the pro- fessional are limited; see Campbell & Gordon, 2003). In all cases it is accepted prac- tice that the burden of responsibility is on the professional to identify the situation and prevent the multiple relationships from occurring. If a multiple relationship does evolve, then it is incumbent on the professional to work to resolve the boundary issue and operate in the best interest of the client.
374 Sexual Abuse: A Journal of Research and Treatment 23(3)
Examples of Multiple Relationships in Practice
A practice scenario. An adult client presents for intake at an outpatient treatment program in the community. During the interview he reports that he owns an auto repair business near the therapist’s office. The therapist recognizes that she has taken her car to that repair shop many times. She does not recognize the owner and he does not say he recognizes her. How should she proceed? Should she tell the client? Is this a boundary crossing? Is this a multiple relationship?
A practice scenario. An outpatient sexual offender treatment program operates under a practice model where a licensed mental health professional facilitates a therapy group that includes a probation officer who cofacilitates a therapy group. The proba- tion officer is also responsible for court-ordered supervision of the clients in the group. The ATSA Practice Standards and Guidelines (ATSA, 2005) sections F 38 and 39 express caution regarding probation officers in treatment groups, in particular related to the need for informed consent and potential of dual relationships.
This scenario poses several issues about boundaries and roles of the cofacilitators. Four dimensions of this scenario will be briefly discussed: (1) the involuntary client, (2) cofacilitation, (3) dual role and interests of the client, and (4) informed consent.
Considerations
The ATSA Code of Ethics, 8 (c) (ATSA, 2001) states:
If a potentially harmful multiple relationship develops, due to unforeseen circumstances, the member shall attempt to resolve it as quickly as pos- sible, with due regard for the best interest of Clients, supervisees, and other persons relying upon the member in his or her professional capacity, and in keeping with the ATSA Code of Ethics.
The therapist should seek supervision or consultation to assess the potential impact on the client, the neutrality of the therapist, and possible courses of action. Is there real or potential client harm? In this case there appears to be no direct connection between the client and the therapist. Is the therapist neutrality compromised? Did she have bad experiences at the repair shop that left her angry at the owner she never met? Was she very well treated in an emergency to the extent that she feels indebted to the shop (and the owner)? Should she con- tinue to patronize the repair shop?
Sawyer and Prescott 375
To begin with, the mental health practitioner is ethically bound to standards requir- ing that the welfare of the client is their primary responsibility, with the exceptions of legal requirements related to safety of others and child abuse reporting. A probation officer is an officer of the court, and, therefore, the first responsibility is allegiance to the court and to the public. Therefore, by definition, the probation officer cannot have the client’s well-being as first priority. Mental health professional/sexual offender therapist’s primary professional responsibility is to the client (except in cases of risk to harm others). Thus, models for delivering services to sexual offenders must be evaluated by in relation to the client’s best interests.
Some would assert that the sex offender therapist has dual clients—the sexual offender and the community. The ATSA practice standards and guidelines assert that community safety is a primary concern when assessing or treating sexual offenders. The licensed therapist treating sexual offenders has an ethical responsibility to the cli- ent, a legal responsibility to the court, and an ethical/moral responsibility to the com- munity. Specifically, the therapist’s primary responsibility to the client’s welfare is checked in part by the standard of practice to share information with county/state cor- rections and/or the community as required by law or by contractual obligations or as needed to protect the community. This is done with informed consent from the client or as needed by law. Within these limits of confidentiality, however, the therapist’s focus is on the sexual offender client. This situation recognizes that the client is best served—and the public is best served—when the therapist and the client develop a therapist–client relationship that is separate from the sexual offender’s relationship with the probation officer and the court. In contrast, the probation officer’s primary responsibility is not to the client; rather the probation officer’s primary responsibility is to the court and the community. Thus, any therapeutic model that allows the proba- tion officer to be a cofacilitator will not, simply by the fact that the sexual offender is not the probation officer’s first client, be in the sexual offender’s best interests.
1. The involuntary client: The clients in this scenario are involuntary, as they are court ordered to treatment as a condition of probation or parole. (It is noted that some professionals would view these clients as voluntary because they agreed to the court sanction and the probation conditions.) Involuntary clients are more vulnerable to influence and to boundary violations due to the per- ceived and real loss of freedom as a result of criminal justice intervention and the requirements of the court. Involuntary clients are vulnerable to reluctance about freely expressing their needs or disagreement with recommendations. They are more vulnerable to withholding information, due to lack of trust. They might agree with feedback or recommendations even when those recom- mendations are not deeply integrated simply because they fear consequences of expressing disagreement.
2. Cofacilitation: When a probation officer participates in a therapy group for sexual offenders, a boundary dilemma is created by the following dynamics: (a) The relationship between the treating clinician and the probation officer
376 Sexual Abuse: A Journal of Research and Treatment 23(3)
may be viewed as coequal where power is shared and both are seen as authorities or power figures and in a relationship where information is shared equally. (b) When viewed from the client’s perspective, these two individual group leaders are viewed as having equal responsibility for the client’s psychological and emotional welfare when, in fact, the probation officer’s first responsibility is allegiance to the court and therefore to the public. (c) If a client sees the therapist as a collaborator with the court, then the trust that must be established with the therapist is compromised, and the therapist is at risk of being viewed as being in a dual relationship.
Compare this to being pulled over on the highway by an officer of the state highway patrol. If you were speeding and using alcohol, would you roll down your window and confess, admitting your actions to the officer before you were asked? Most drivers would avoid this kind of self-incrimination. Would you admit this to a therapist or treatment program? Hopefully you would. Why? You know the therapist has your best interest as a priority and you trust the therapist. The police officer has a duty to observe your behavior and arrest you if a crime is committed, but not to prosecute you, find you guilty, or treat you. Prosecution, determining guilt, and rehabilitation are the roles of others. That fundamental separation of roles underpins the system of rights in the United States.
3. Dual role and interests of the client: Allowing the probation officer to participate in the therapeutic process causes the therapist to change roles with respect to the client. In the probation officer’s presence, the therapist may be hesitant to use certain interventions with clients or to pursue a certain line of inquiry, due to the possibility that the client may disclose information that, while therapeutic, would not be beneficial in the rela- tionship between the probation officer and the sexual offender. Thus, the therapist’s effectiveness, and possibly their objectivity, can be negatively affected. Ultimately, the client has no privacy when the probation agent is in the group. Hence, there is no solution, only a compromise that sac- rifices the privacy of the client and the therapeutic relationship, which research shows is of vital importance to successful therapy (Lambert & Okishi, 1997).
4. Informed consent: A sexual offender may not be willing to participate in a therapeutic group process in which the probation officer serves as a cofa- cilitator. Given that a decision not to participate on these grounds may be considered valid, the vulnerable and involuntary client may not feel he or she has a legitimate freedom to chose to decline participation out of fear of judi- cial consequences or he or she may not be given an alternative. Therefore, informed consent cannot occur if refusing the treatment is not an option. In this scenario, it would be necessary to offer the client reasonable alternatives that meet the client’s therapeutic needs, at the same time meeting minimum acceptable standards of treatment.
Sawyer and Prescott 377
American Psychological Association
10.01 Informed Consent to Therapy
(a) When obtaining informed consent to therapy as required in Standard 3.10, Informed Consent, psychologists inform clients/patients as early as is feasible in the therapeutic relationship about the nature and anticipated course of therapy, fees, involvement of third parties, and limits of confidentiality and provide sufficient opportunity for the client/patient to ask questions and receive answers. (APA, 2010)
Similarly, the client needs to be informed of the concerns noted previously, such as limited confidentiality, when a client is directed to be part of a group that is cofa- cilitated by a probation officer. The concerns noted previously need to be explained to the client, and the client must understand these concerns fully before agreeing to participate in a therapy group that is cofacilitated by a probation officer.
What about the conflict of interest the probation officer enters into when he or she is a state or county employee of the same government entity that contracts with the provider? The agent is then in a dual role, both treatment provider and observer of the treatment quality, and is actually wearing three hats: group leader, contract agency representative, and court representative. It is impossible to fulfill all of these roles without conflict.
Considerations
1. A specific informed consent form is provided to the client that specifies the type of cofacilitated group, the professional roles and limits, and the option to attend a different group.
2. Since the probation officer is part of the group, the role of observing the treatment program for quality or contract compliance is managed by a probation officer who is not cofacilitating the group.
3. A probation officer may be only an observer in the group without clinical input or responsibility. All aspects of the therapy are controlled by and facili- tated by the therapist. All interaction is between therapist and group members.
4. The probation officer is in the group to answer questions about probation conditions, community safety, and to monitor progress of the clients. The men in the treatment group are clients of the therapist
5. The client also has individual sessions with the therapist (i.e., if a client has a question about community notification, the probation officer has expertise to address the limits and process of notification. If the client has treatment issues, the therapist deals with those.) A probation officer can observe a group only when the group is comprised entirely of clients who are supervised by that probation officer.
378 Sexual Abuse: A Journal of Research and Treatment 23(3)
One additional ethical dilemma is how to manage confidentiality. Central to the success of a therapist–client relationship is the expectation of privacy and confidenti- ality. Confidentiality is the basis of the trust relationship between the client and the therapist, which enables the client to share personal information fully and freely with the therapist. Subject to the limits of confidentiality prescribed by law and any permis- sion the client gives through informed consent, all information shared with the thera- pist is held in confidence.
A model that prescribes third parties, such as probation officers, to join the therapy relationship compromises this expectation of privacy and confidentiality with the ther- apist and could impact the success of the therapeutic relationship. The relationship between a probation officer and a sexual offender is entirely different than the desired relationship between a therapist and a sexual offender. The probation officer is obli- gated to the court and has a primary responsibility to monitor compliance with court- ordered conditions of probation. The therapist has ethical and legal obligations to the client and privacy, with exceptions for legal mandates to report abuse or potential harm. How this model affects therapist neutrality would need to be assessed. Furthermore, the impact on client autonomy is at risk of being violated.
Requiring the probation officer to participate in the therapeutic process may deter the sexual offender client from sharing all of the information that is necessary for a successful therapeutic intervention, as the sex offender no longer has an assurance that the information to be shared will be maintained as confidential information. The logi- cal consequence is that the sexual offender will not share personal information as long as the probation officer is present.
Furthermore, the sexual offender may rightly view the probation officer as having a different role than the therapist. Requiring the probation officer to be part of the therapeutic alliance can, in fact, be deceptive to the client as it encourages the client to trust the probation officer in the same way as the client is encouraged to trust the thera- pist. Allowing the probation officer to work with a client in this dual capacity (officer of the court and group cofacilitator/therapist to the same client) is confusing to the cli- ent and can be detrimental to the client’s therapy.
McGrath, Cumming, and Holt (2002) surveyed one half (N = 379) of the adult community–based sex offender treatment programs listed in the Safer Society data- base. The adjusted response rate was 53%, representing 190 practitioners from 45 states and Washington, D.C. One of the scenarios presented on the survey was “A licensed treatment provider co-leads sex offender treatment groups with a proba- tion officer. Some of the probationers or parolees that the probation officer supervises are members of the group.” Most respondents felt that this practice was inappropriate (i.e., inappropriate = 56.3%, somewhat inappropriate = 12.1%, not sure = 2.6%, somewhat appropriate = 6.8%, and appropriate =16.8%). Only 8.9% of respondents said they engage in this practice.
Professional debate about the “cofacilitated” model continues, and not all relevant questions have been answered. For example, what are the rules, guidelines, and limits
Sawyer and Prescott 379
of the model? Nor have systematic responses to the ethical dilemmas been codified. The equivalent treatment parameters do exist in the rules for licensed mental health practitioners and government/provider contracts. This illustrates how a dual role’s ethical dilemma is created in a model where an officer of the court and a mental health therapist cofacilitate a treatment group.
Conclusion There are some boundary and relationship absolutes that few professionals or organi- zations would disagree with: Sexual contact with a client is always prohibited, it is never acceptable to exploit a relationship with a client for self-interest, a business or personal relationship with a current client is not in the best interest of the client, and causing direct physical or emotional harm to client is unethical.
Most often questions about boundaries and multiple relationships occur on a con- tinuum that may be subtle, requiring analysis to clarify the situation and find appropri- ate resolution. There are situations where decisions need to be made and communicated, such as receiving gifts or unintentional multiple relationships. Unique issues with sexual offenders include involuntary client, public scrutiny, the need to collaborate with the court, and the need to address public safety.
Recommendations for practice include providing education about the basic rules and parameters of practice (e.g., prohibit gifts, establish time boundaries, obtain signed written agreements about fees when applicable, and use a written treatment plan that the client participates in and agrees to, etc.). With practice parameters established, boundary questions may still occur in the normal course of assessment or therapy. When these events do occur, seeking consultation, reexamination of the standards in light of individual situations, or direct conversation with the client when appropriate are usually prudent actions.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the authorship and/or publication of this article.
Funding
The author(s) received no financial support for the research and/or authorship of this article.
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