Unit 6.1 DB: Case Study

Chapter: 7 Managing Boundaries and Multiple Relationships Introduction The terms dual relationships and multiple relationships are used interchangeably in various professional codes of ethics, and the ACA (2014) uses the term nonprofes- sional relationships. In this chapter we use the broader term of multiple relationships to encompass both dual relationships and nonprofessional relationships. The APA (2010) ethics code defines a multiple relationship as one in which a practitioner is in a professional role with a person in addition to another role with that same individual, or with another person who is close to that individual. When clinicians blend their professional relationship with a nonprofessional relationship with a client, ethical concerns must be considered. In these situations, it is often difficult to determine what is in the best interests of the client. Multiple relationships occur when professionals assume two or more roles at the same time or sequentially with a client. This may involve assuming more than one professional role (such as instructor and therapist) or blending a professional and a nonprofessional relationship (such as counselor and friend or counselor and business partner). Multiple relationships also include providing therapy to a relative or a friend’s relative, socializing with clients, becoming emotionally or sexually involved with a client or former client, combining the roles of supervisor and therapist, having a business relationship with a client, borrowing money from a client, or loaning money to a client. Boundary crossings or multiple relation- ships increase the possibility that therapists may misuse their power to influence and exploit clients for their own benefit and to the clients’ detriment (Zur, 2007). Although some suggest that it is good practice to abstain from crossing boundaries or engaging in multiple relationships, this is not always possible. Mental health professionals must learn how to effectively and ethically man- age multiple relationships, including dealing with the power differential that is a part of most professional relationships, managing boundary issues, and striv- ing to avoid the misuse of power (Herlihy & Corey, 2015b). Although codes can provide some general guidelines, good judgment, the willingness to reflect on one’s practices, and being aware of one’s motivations are critical dimensions of an ethical practitioner. Mental health professionals can fail to heed warning signs in their relationships with clients. They may not pay sufficient attention to the potential problems involved in establishing and maintaining professional boundaries. Practitioners may be unaware of the implications of their actions and may not recognize when they are engaged in unprofessional or problematic conduct. The underlying theme of this chapter is the need for counselors to be honest and self-searching in determining the impact of their behavior on clients. In cases that are not clear-cut, it is especially important to make an honest appraisal of your behavior and its effect on clients and to consult with trusted colleagues. To us, behavior is unethical when it reflects a lack of awareness or concern about the impact of the behavior on clients. Some counselors may place their personal needs above the needs of their clients by engaging in more than one role with clients to meet their own financial, social, or emotional needs. This chapter focuses on boundary issues in professional practice, establishing appropriate boundaries, the difference between boundary crossings and bound- ary violations, multiple relationships, role blending, a variety of nonsexual mul- tiple relationships, and sexual issues in therapy. We also examine the more subtle aspects of sexuality in therapy, including sexual attractions and the misuse of power. Multiple relationship issues cannot be resolved with ethics codes alone; therapists must think through all of the ethical and clinical dimensions involved in a wide range of boundary concerns. LO1 The Ethics of Multiple Relationships The codes of ethics of most professional organizations warn of the potential prob- lems of multiple relationships (see the Ethics Codes box titled “Standards on Mul- tiple Relationships”). These codes caution professionals against any involvement with clients that might impair their judgment and objectivity, affect their ability to render effective services, or result in harm or exploitation of clients. Nonsex- ual multiple relationships are not inherently unethical, and most ethics codes acknowledge that some multiple relationships are unavoidable. However, when multiple relationships exploit clients, or have significant potential to harm clients, they are unethical. Managing boundaries and Multiple relationships / 257 Copyright 2019 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-202 Copyright 2019 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. ETHICS CODES: Standards on Multiple Relationships American Association for Marriage and Family Therapy (2015) Marriage and family therapists are aware of their influential position 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. 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 document the appropriate precautions taken. (1.3.) American Mental Health Counselors Association (2015) Mental health counselors are aware of their influential position with respect to their clients and avoid exploiting the trust and dependency of the client. (Principle 3.) National Association of Social Workers (2008) 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.) (1.06.c.) ETHICS CODES: Standards on Multiple Relationships continued Canadian Psychological Association (2015) Manage dual or multiple relationships or any other conflict-of-interest situation entered into in such a way that bias, lack of objectivity, and risk of exploitation or harm are minimized. This might include involving the affected party(ies) in clarification of boundaries and expectations, limiting the duration of the relationship, obtaining ongoing supervision or consultation for the duration of the dual or multiple relationship, or involving a third party in obtaining consent (e.g., approaching a primary client or employee about becoming a research participant). (3.34.) American School Counselor Association (2016) School counselors establish and maintain appropriate professional relationships with students at all times. School counselors consider the risks and benefits of extending current school counseling relationships beyond conventional parameters, such as attending a student’s distant athletic competition. In extending these boundaries, school counselors take appropriate professional precautions such as informed consent, consultation and supervision. School counselors document the nature of interactions that extend beyond conventional parameters, including the rationale for the interaction, the potential benefit and the possible positive and negative consequences for the student and school counselor. (A.5.b.) American Counseling Association (2014) Counselors are prohibited from engaging in counseling relationships with friends or family members with whom they have an inability to remain objective. (A.5.d.) Counselors are prohibited from engaging in a personal virtual relationship with individuals with whom they have a current counseling relationship (e.g., through social and other media). (A.5.e.) Counselors consider the risks and benefits of accepting as clients those with whom they have had a previous relationship. These potential clients include individuals with whom the counselor has had a casual, distant, or past relationship. Examples include mutual or past membership in a professional association, organization, or community. When counselors accept these clients, they take appropriate professional cautions such as informed consent, consultation, supervision, and documentation to ensure that judgment is not impaired and no exploitation occurs. (A.6.a.) American Psychological Association (2010) (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. 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. 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. (c) When psychologists are required by law, institutional policy, or extraordinary circumstances to serve in more than one role in judicial or administrative proceedings, at the outset they clarify role expectations and the extent of confidentiality and thereafter as changes occur. (3.0Differing Perspectives on Multiple Relationships LO2 There is a wide range of viewpoints on multiple relationships. As you work to clarify your position on this issue, you will encounter conflicting advice. Some writers focus on the problems inherent in multiple relationships, espe- cially the legal implications of entering into multiple relationships. If a client suffers harm or is exploited due to a multiple relationship, the client could file a malpractice lawsuit against the mental health provider. Others see the entire discussion of multiple relationships as subtle and complex, defying simplis- tic solutions or absolute answers. Despite certain clinical, ethical, and legal risks, in many situations some blending of roles is unavoidable For example, in military settings multiple relationships are common and can be a healthy part of communal life. These relationships can improve morale, decrease the stigma attached to seeking psychological assistance, and improve access to care (Johnson & Johnson, 2017). Although the codes of ethics of most professions caution against engag- ing in nonsexual multiple relationships, they are not necessarily problematic, and some are beneficial (Herlihy & Corey, 2015b). For example, “mentoring” involves blending roles, yet both mentors and learners can certainly benefit from this relationship. Casto, Caldwell, and Salazar (2005) point out that men- tors often balance a multiplicity of roles, some of which include teacher, coun- selor, role model, guide, and friend. They add that the mentoring relationship is a personal one, in which both mentor and mentee may benefit from knowing the other personally and professionally. Casto and colleagues emphasize the importance of maintaining boundaries between mentorship and friendship, which requires vigilance of the power differential and how it affects the mentee. They contend that the focus of mentoring is always on the mentee’s personal and professional development. After reviewing the literature on the topic of multiple relationships, Herlihy and Corey (2015b) conclude that there is no clear consensus regarding nonsex- ual multiple relationships in counseling. When considering such a relationship, practitioners must examine their motivations and consult with other profession- als to determine the appropriateness of the relationship. Practitioners should be cautious about entering into more than one role with a client unless there is sound clinical justification for doing so, and they must take measures to min- imize the likelihood of harm coming to the client. It is good practice to docu- ment precautions practitioners take to protect clients when such relationships are unavoidable. Factors to Consider Before Entering Into a Multiple Relationship LO3 Moleski and Kiselica (2005) believe multiple relationships range from the destruc- tive to the therapeutic. Although some multiple relationships are harmful, other secondary relationships complement, enable, and enhance the counseling rela- tionship. Moleski and Kiselica encourage counselors to examine the potential positive and negative consequences that a secondary relationship might have on Managing boundaries and Multipthe primary counseling relationship. They suggest that counselors consider form- ing multiple relationships only when it is clear that such relationships are in the best interests of the client. Younggren and Gottlieb (2004) suggest applying an ethical, risk-managed, decision-making model when practitioners are analyzing a situation involving the pros and cons of a multiple relationship. They “acknowledge that these types of relationships are not necessarily violations of the standards of professional conduct, and/or the law, but we know enough to recommend that they have to be actively and thoroughly analyzed and addressed, although not necessarily avoided” (p. 260). Younggren and Gottlieb recommend that practitioners address these questions to make sound decisions about multiple relationships: • Is entering into a relationship in addition to the professional one necessary, or should I avoid it? • Can the multiple relationship potentially cause harm to the client? • If harm seems unlikely, would the additional relationship prove beneficial? If it is beneficial, is the benefit focused more on the client, the counselor, or both? • Is there a risk that the multiple relationship could disrupt the therapeutic relationship? • Can I evaluate this matter objectively? (pp. 256–257) In answering these questions, practitioners must carefully assess the risk for con- flict of interests, loss of objectivity, and implications for the therapeutic relation- ship. It is good practice to discuss the potential problems involved in a multiple relationship with the client and to actively involve the client in the decision-making process. If the multiple relationship is judged to be appropriate and acceptable, the therapist should document the entire process, including having the client sign an informed consent form. In addition, therapists would do well to adopt a risk man- agement approach to the problem. This involves a careful review of various issues such as diagnosis, level of functioning, therapeutic orientation, community stan- dards and practices, and consultations with professionals who could support the decision. Younggren and Gottlieb conclude with this advice: “Only after having taken all these steps can the professional consider entering into the relationship, and he or she should then do so with the greatest of caution” (p. 260). Barnett (Barnett, Lazarus, et al., 2007) suggests some guidelines to increase the likelihood that a client’s best interests are being served: • The therapist is motivated by what the client needs rather than by his or her own needs. • The boundary crossing is consistent with a client’s treatment plan. • The client’s history, culture, values, and diagnosis have been considered. • The rationale for the boundary crossing is documented in the client’s record. • The boundary crossing is discussed with the client in advance to prevent misunderstandings. • Full recognition is given to the power differential, and the client’s trust is safeguarded. • Consultation with colleagues guides the therapist’s decisions. 260 / chapter 7 Copyright 2019 Cengage Learning. All Rights Reserved. May not be copied, scanned, or dBoundary Crossings Versus Boundary Violations LO4 Certain behaviors of professionals have the potential for creating a multiple rela- tionship, but they are not inherently considered to be multiple relationships. Examples of these behaviors include accepting a client’s invitation to a special event such as a graduation; bartering goods or services for professional services; accepting a small gift from a client; attending the same social, cultural, or religious activities as a client; or giving a supportive hug after a difficult session. Gutheil and Gabbard (1993) caution that engaging in boundary crossings paves the way to boundary violations and to becoming entangled in complex multiple relation- ships. They distinguish between boundary crossings (changes in role) and bound- ary violations (exploitation of the client at some level). A boundary crossing is a departure from commonly accepted practices that could potentially benefit clients; a boundary violation is a serious breach that results in harm to clients and is there- fore unethical. Gutheil and Gabbard note that not all boundary crossings should be considered boundary violations. Interpersonal boundaries are fluid; they may change over time and may be redefined as therapists and clients continue to work together. Yet behaviors that stretch boundaries can become problematic, and boundary crossings can lead to a pattern of blurring of professional roles. The key is to take measures to prevent boundary crossings from becoming boundary violations. Johnson and Johnson (2017) contend that military mental health providers must increase their tolerance for routine boundary crossings and contacts with clients outside the consulting room. If military therapists demonstrate calm accep- tance of their multiple roles and relationships, clients are likely to become calmer about these unavoidable multiple relationships. Military therapists need to be mindful of client confidentiality in interactions with clients outside of therapy and remain vigilant to possible adverse effects of multiple roles on clients or on the therapeutic relationship. A common type of boundary crossing is therapist self-disclosure. If a coun- selor engages in lengthy self-disclosure, a client might well wonder whether he or she is being heard in the therapy session. Many theoretical models encourage appropriate and timely disclosure on the therapist’s part, but such self-disclosure must be in the service of the client. Therapist self-disclosure should never burden the client or result in the client feeling a need to take care of the therapist. Coun- selors must consider a range of factors such as the client’s history, his or her pre- senting problem, cultural factors, the client’s comfort with disclosures on the part of the therapist, and a therapist’s comfort with disclosing. It is critical that thera- pists understand their motivations for sharing personal experiences or reactions to what is going on in a session. In examining ethical complaints and violations received by the Commission on Rehabilitation Counselor Certification from 2006 to 2013, Hartley and Cart- wright (2015) found that boundary violations were the most pervasive themes. Barnett (Barnett, Lazarus, et al., 2007) states that even for well-intentioned clini- cians, thoughtful reflection is required to determine when crossing a boundary results in a boundary violation. If a therapist’s actions result in harm to a cli- ent, it is a boundary violation. Failing to practice in accordance with prevailing community standards, as well as other variables such as the role of the client’s diagnosis, history, values, and culture, can result in a well-intentioned action being perceived as a boundary violation. Pope and Vasquez (2016) caution that crossing a boundary entails risks: “Done in the wrong situation, or at the wrong time, or with the wrong person it can knock the therapy off track, sabotage the treatment plan, and offend, exploit, or even harm the patient” (p. 253). Barnett (2017a) states that “one client’s boundary crossing may be another client’s boundary violation” (p. 27) and recommends that therapists openly discuss concerns regarding mul- tiple relationships with clients as part of the informed consent process. Barnett adds that crossing boundaries may be clinically relevant and appropriate in some cases, and that avoiding crossing some boundaries could work against the goals of the therapeutic relationship. Pope and Vasquez (2016) point out that refusing to engage in a boundary crossing may be a lost opportunity that can damage the therapeutic alliance. If a client gives her therapist a small painting she created as a token of gratitude and her therapist declines the gift, the client may feel rejected because she personally created the gift. She also may be offended if giving gifts is considered to be an important part of her cultural tradition. Consistent yet flexible boundaries are often therapeutic and can help clients develop trust in the therapy relationship. Smith (2011) recommends finding a balanced framework for the therapeutic relationship that is neither too tight nor too loose. Smith states that appropriate boundaries provide “both patient and therapist freedom to explore past and present, conscious and unconscious, fact and fantasy. Boundaries offer safety from the possibility of rule by impulse and desire” (p. 63). Setting Appropriate Boundaries in Home-Based Therapy Changes in mental health care laws and practice have increased the need for outreach psychother- apists in recent years (Rogers, 2014). Some clients may have difficulty getting to an office due to a lack of transportation or physical limitations. Others may be struggling with poverty and a host of problems that limit their access to office services. Offering therapy in a client’s home can aid in building a therapeutic rela- tionship and provides the clinician with the opportunity to observe the client’s experience firsthand. Despite the benefits of outreach psychotherapy, graduate programs continue to emphasize in-clinic training and are not adequately prepar- ing students for the challenges encountered when meeting clients in their homes or working in the community. Some training programs would like to provide outreach therapy experiences for students but cannot due to the limits of mal- practice insurance at their university. Rogers (2014) lists some concerns that may be encountered when serving clients at home: challenging mental health issues, safety concerns, distracting environment issues, a lack of collegial support and supervision in the field, role confusion, feelings of isolation, countertransference, and blurred boundaries. These concerns are unlike those experienced in an office setting, and it is likely that boundary crossing issues will need to be addressed in the home environment. Hartley and Cartwright (2015) describe an increasing trend toward providing rehabilitation counseling services in clients’ homes and natural environmentsOne of the challenges that accompany this trend is that the practitioner may be asked to take on tasks outside of the counseling role such as running errands or attending to visitors coming to client’s home. Hartley and Cartwright believe “there is a need for continued discussion toward how to sustain appropriate roles and relationships with clients when providing services to reduce the potential of nonsexual boundary violations” (p. 161). Zur (2008) also makes a case for taking professional relationships beyond the office walls. He writes about the advantages of out-of-office experiences, such as home visits, attending celebrations of a client, adventure or outdoor therapy, and other encounters with clients. For example, he describes how he accompanied a client to the gravesite of a child for whom she had not grieved. This intervention proved to be therapeutic for the woman who had been depressed for years prior to beginning her therapy with Zur. In some situations, out-of-office contact is required on a regular basis. Psy- chologists who work with athletes and coaches may travel with teams, attend practice sessions and competitions, eat meals with their clients (the athletes), and share hotel rooms with coaches (Moles, Petrie, & Watkins, 2016). Sport psy- chology consultants often engage in behaviors that cross boundaries typically associated with mental health settings. Developing trusting and credible rela- tionships requires sport psychologists to meet athletes where they practice their sport; these relationships are considered appropriate because of the context of the sport environment and the culture of sport (Haberl & Peterson, 2006; Moles et al., 2016). We recommend that therapists who make it a practice to venture outside of the office or engage in nontraditional activities with clients make this clear at the outset of therapy during the informed consent process. Furthermore, therapists might do well to consult with their insurance carrier about such practices as these activities may have implications for their liability exposure. A Cultural Perspective on Boundaries Speight (2012) argues for the need to reconsider boundaries in the therapeutic relationship and calls for a reexamination of the traditional perspective on understanding boundaries, boundary crossings, the counselor’s role, and the counseling relationship. She discovered that many African American clients expect a warm, reciprocal, and understanding relation- ship and perceive therapists’ objective detachment as uncaring and uninvolved. Speight proposes the concept of solidarity, rooted in the ties within a society that bind people together, as a culturally congruent way of understanding, defin- ing, and managing boundaries. “Solidarity between myself and my clients both allowed and required me to be myself, to give primacy to the real relationship, to establish close boundaries, and to act in clients’ best interests” (p. 147). By embrac- ing a broader understanding of boundaries, Speight was able to be genuine and close in her therapeutic relationships without being inappropriate and exploit- ative. “I was flexible with my boundaries, in a way that felt entirely consistent cul- turally but was inconsistent with my prior training and education. No longer was I a distant, detached professional, but I was an engaged and involved counseling psychologist, and this was just ‘the type of psychologist’ I wanted to be” (p. 141). Managing boundaries and Multiple relationships / 263 Copyright 2019 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-202 Copyright 2019 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove addcommunity standards, as well as other variables such as the role of the client’s diagnosis, history, values, and culture, can result in a well-intentioned action being perceived as a boundary violation. Pope and Vasquez (2016) caution that crossing a boundary entails risks: “Done in the wrong situation, or at the wrong time, or with the wrong person it can knock the therapy off track, sabotage the treatment plan, and offend, exploit, or even harm the patient” (p. 253). Barnett (2017a) states that “one client’s boundary crossing may be another client’s boundary violation” (p. 27) and recommends that therapists openly discuss concerns regarding mul- tiple relationships with clients as part of the informed consent process. Barnett adds that crossing boundaries may be clinically relevant and appropriate in some cases, and that avoiding crossing some boundaries could work against the goals of the therapeutic relationship. Pope and Vasquez (2016) point out that refusing to engage in a boundary crossing may be a lost opportunity that can damage the therapeutic alliance. If a client gives her therapist a small painting she created as a token of gratitude and her therapist declines the gift, the client may feel rejected because she personally created the gift. She also may be offended if giving gifts is considered to be an important part of her cultural tradition. Consistent yet flexible boundaries are often therapeutic and can help clients develop trust in the therapy relationship. Smith (2011) recommends finding a balanced framework for the therapeutic relationship that is neither too tight nor too loose. Smith states that appropriate boundaries provide “both patient and therapist freedom to explore past and present, conscious and unconscious, fact and fantasy. Boundaries offer safety from the possibility of rule by impulse and desire” (p. 63). Setting Appropriate Boundaries in Home-Based Therapy Changes in mental health care laws and practice have increased the need for outreach psychother- apists in recent years (Rogers, 2014). Some clients may have difficulty getting to an office due to a lack of transportation or physical limitations. Others may be struggling with poverty and a host of problems that limit their access to office services. Offering therapy in a client’s home can aid in building a therapeutic rela- tionship and provides the clinician with the opportunity to observe the client’s experience firsthand. Despite the benefits of outreach psychotherapy, graduate programs continue to emphasize in-clinic training and are not adequately prepar- ing students for the challenges encountered when meeting clients in their homes or working in the community. Some training programs would like to provide outreach therapy experiences for students but cannot due to the limits of mal- practice insurance at their university. Rogers (2014) lists some concerns that may be encountered when serving clients at home: challenging mental health issues, safety concerns, distracting environment issues, a lack of collegial support and supervision in the field, role confusion, feelings of isolation, countertransference, and blurred boundaries. These concerns are unlike those experienced in an office setting, and it is likely that boundary crossing issues will need to be addressed in the home environment. Hartley and Cartwright (2015) describe an increasing trend toward providing rehabilitation counseling services in clients’ homes and natural environments. One of the challenges that accompany this trend is that the practitioner may be asked to take on tasks outside of the counseling role such as running errands or attending to visitors coming to client’s home. Hartley and Cartwright believe “there is a need for continued discussion toward how to sustain appropriate roles and relationships with clients when providing services to reduce the potential of nonsexual boundary violations” (p. 161). Zur (2008) also makes a case for taking professional relationships beyond the office walls. He writes about the advantages of out-of-office experiences, such as home visits, attending celebrations of a client, adventure or outdoor therapy, and other encounters with clients. For example, he describes how he accompanied a client to the gravesite of a child for whom she had not grieved. This intervention proved to be therapeutic for the woman who had been depressed for years prior to beginning her therapy with Zur. In some situations, out-of-office contact is required on a regular basis. Psy- chologists who work with athletes and coaches may travel with teams, attend practice sessions and competitions, eat meals with their clients (the athletes), and share hotel rooms with coaches (Moles, Petrie, & Watkins, 2016). Sport psy- chology consultants often engage in behaviors that cross boundaries typically associated with mental health settings. Developing trusting and credible rela- tionships requires sport psychologists to meet athletes where they practice their sport; these relationships are considered appropriate because of the context of the sport environment and the culture of sport (Haberl & Peterson, 2006; Moles et al., 2016). We recommend that therapists who make it a practice to venture outside of the office or engage in nontraditional activities with clients make this clear at the outset of therapy during the informed consent process. Furthermore, therapists might do well to consult with their insurance carrier about such practices as these activities may have implications for their liability exposure. A Cultural Perspective on Boundaries Speight (2012) argues for the need to reconsider boundaries in the therapeutic relationship and calls for a reexamination of the traditional perspective on understanding boundaries, boundary crossings, the counselor’s role, and the counseling relationship. She discovered that many African American clients expect a warm, reciprocal, and understanding relation- ship and perceive therapists’ objective detachment as uncaring and uninvolved. Speight proposes the concept of solidarity, rooted in the ties within a society that bind people together, as a culturally congruent way of understanding, defin- ing, and managing boundaries. “Solidarity between myself and my clients both allowed and required me to be myself, to give primacy to the real relationship, to establish close boundaries, and to act in clients’ best interests” (p. 147). By embrac- ing a broader understanding of boundaries, Speight was able to be genuine and close in her therapeutic relationships without being inappropriate and exploit- ative. “I was flexible with my boundaries, in a way that felt entirely consistent cul- turally but was inconsistent with my prior training and education. No longer was I a distant, detached professional, but I was an engaged and involved counseling psychologist, and this was just ‘the type of psychologist’ I wanted to be” (p. 141) Speight advocates for learning how to tolerate complexity and for developing role flexibility in therapeutic situations. She encourages clinicians to be mindful of the fine line between boundaries that are too close and those that are too distant. Role Blending Some roles that professionals play involve an inherent multiplicity of roles. Role blending, or combining roles and responsibilities, is quite common in some professions. For example, counselor educators serve as instructors, but they sometimes act as therapeutic agents for their students’ personal develop- ment. At different times, counselor educators may function in the role of teacher, therapeutic agent, mentor, evaluator, or supervisor. School counselors must often function in multiple roles such as counselor, teacher, and chaperon. Role blending is not necessarily unethical, but it does call for vigilance on the part of the professional to ensure that exploitation does not occur. Herlihy and Corey (2015b) assert that role blending is inevitable in the process of educating and supervising counselor trainees and that it can present ethical dilemmas when there is a loss of objectivity or a conflict of interests. Functioning in more than one role involves thinking through potential problems before they occur and building safeguards into practice. Whenever a potential for negative outcomes exists, profes- sionals have a responsibility to design safeguards to reduce the potential for harm. Avoiding the Slippery Slope Professionals get into trouble when their bound- aries are poorly defined and when they attempt to blend roles that do not mix (such as professional and social roles). A gradual erosion of boundaries can lead to very problematic multiple relationships that harm clients. Gutheil and Gab- bard (1993) and Gabbard (1994) cite the slippery slope phenomenon as one of the strongest arguments for carefully monitoring boundaries in psychotherapy. Once a practitioner crosses a boundary, the tendency to engage in a series of increas- ingly serious boundary violations can lead to a progressive deterioration of ethical behavior. Furthermore, if professionals do not adhere to uncompromising stan- dards, their behavior may foster relationships that are harmful to clients. Many practitioners are critical of the slippery slope argument, stating that it tends to result in therapists practicing in an overly cautious manner that may harm clients (Lazarus & Zur, 2002; Pope & Vasquez, 2016; Speight, 2012; Zur, 2007). Gottlieb and Younggren (2009) believe the slippery slope does exist but that it is not as steep or as slippery as many fear. They state that most boundary crossings are done in a thoughtful manner that is appropriate to the therapeutic context and that entail minimal risks to clients. Gottlieb and Younggren conclude that the increased flexibility in maintaining boundaries is a healthy sign but that as relationships with clients become more complex, more careful management and thoughtful decision making are required. Managing multiple roles and relationships can be extremely complex, and sea- soned professionals are often challenged to follow the most ethical course when it comes to crossing boundaries. Managing multiple relationships can be even more challenging to students, trainees, and beginning professionals. Those with rela- tively little clinical experience might be well advised to avoid engaging in multiple relationships whenever possible. On the other hand, as Dallesasse (2010) points out, graduate students often serve in a number of positions during their course of study, for example, as student, instructor, counselor, researcher, and adviser. These advanced students may encounter dilemmas regarding nonsexual multiple relationships, and they need to have a framework for sorting through different courses of action. Consider these slippery slope scenarios and reflect on whether you could see yourself saying “yes” to some of these boundary crossings: • A client asks to “friend” you on Facebook or follow you on Instagram or Twitter • A client invites you to his or her graduation • A client asks if he or she can bring you lunch when you meet at noon • A client texts you photos of her children from time to time • A client asks what general practice doctor you use because he or she is looking for a good referral What reactions do you have to these scenarios? Do you find yourself leaning toward saying “yes” or “no” more often? How do your responses to these situa- tions reflect your counseling theory? Issues to Consider in Addressing Multiple Relationships In Boundary Issues in Counseling: Multiple Roles and Responsibilities, Herlihy and Corey (2015b) identify a number of key themes surrounding multiple roles in counseling, some of which follow: 1. Multiple relationship issues affect most mental health practitioners, regardless of their work setting or clientele. 2. Most professional codes of ethics caution practitioners about the potential exploitation in multiple relationships, and more recent codes acknowledge the complex nature of these relationships. 3. Not all multiple relationships (and boundary crossings) can be avoided, nor are they necessarily always harmful; they can be beneficial. 4. Multiple role relationships challenge us to monitor ourselves and to examine our motivations for our practices. 5. Whenever you consider becoming involved in a multiple relationship, seek consultation from trusted colleagues, a supervisor, or your professional orga- nization. It is a good idea to document the nature of this consultation. 6. Few absolute answers exist to neatly resolve multiple relationship dilemmas. 7. Being cautious about entering into multiple relationships should be for the benefit of our clients rather than to protect ourselves from censure. 8. In determining whether to proceed with a multiple relationship, consider whether the potential benefit outweighs the potential for harm. To the extent possible, include the client in making this decision. The Changing Perspectives on Nonsexual Multiple Relationships In his thoughtful book, Boundaries in Psychotherapy, Zur (2007) addresses the chang- ing perspectives on professional boundaries. Concerns about therapeutic bound- aries came to the forefront during the 1960s and 1970s, largely due to a widespread lack of any sense of boundaries on the part of many mental health professionals and the resulting exploitation of clients. There was pressure within the culture at large as well as in the mental health professions to provide specific guidelines for appropriate and ethical conduct in the practice of psychotherapy. The 1980s saw increased injunctions against boundary crossing and an increased emphasis on risk management practices. Most boundary crossings and dual relationships were viewed from a risk management perspective as hazards that should be avoided. In the 1990s, a shift in thinking about psychotherapeutic boundaries began to emerge. There was increased recognition that some boundary crossings, such as therapist self-disclosure and nonsexual touch, can be clinically valuable. Topics such as appropriate therapeutic boundaries, potential conflicts of interest, and ethical and effective ways of managing multiple relationships were addressed in some ethics codes. The absolute ban on multiple relationships has been replaced with cautions against taking advantage of the power differential in the therapeutic relationship and exploiting the client, while acknowledging that some boundary crossings can be beneficial. Many professionals now agree that flexible boundaries can be clini- cally helpful when applied ethically and that boundary crossings need to be eval- uated on a case-by-case basis (Herlihy & Corey, 2015b). Consider the circumstances in which you may decide upon flexible bound- aries. What multiple relationships might be unavoidable, and what can you do in these situations? What kinds of relationships place you in professional jeopardy? Consider, for example, how refusing to attend a social event of a client could com- plicate the therapeutic relationship. In struggling to determine what constitutes appropriate boundaries, you are likely to find that occasional role blending is inev- itable. Therefore, it is crucial to learn how to manage boundaries, how to prevent boundary crossings from turning into boundary violations, and how to develop safeguards that will prevent the exploitation of clients. LO5 Perspectives on Boundary Issues Arnold Lazarus (1998, 2001) has taken the position that a general proscription against dual and multiple relationships has led to unfair and inconsistent deci- sions by state licensing boards, brought sanctions against practitioners who have done no harm, and sometimes impeded a therapist’s ability to perform optimum work with a client. Lazarus contends that professionals who hide behind rigid boundaries often fail to be of genuine help to their clients. He argues for a non- dogmatic evaluation of boundary questions when deciding whether to enter into a secondary relationship. Lazarus sums up his perspective on ethics and boundaries in this way: To my way of thinking, here is what I regard as really important: develop rapport; earn your client’s trust; respect and honor confidentiality; display genuine warmth and caring; stringently avoid any form of disparagement, exploitation, abuse, harassment, inconsiderateness, and sexual contact. Above all, do no harm and always keep the best interests of the client in mind. (personal communication, April 6, 2013) Advantages of Boundary Crossings A rigid risk-avoidance application of boundaries can be harmful to clients by cre- ating a sterile relationship that works against establishing a positive therapeutic alliance (Barnett, 2017a). Examples of such rigidity include never touching a client under any circumstances, refusing every small gift, or refusing to extend a session for any reason. In many situations, it may be difficult for clinicians to readily dis- cern the difference between a positive boundary crossing and a boundary violation. There are advantages to crossing boundaries in certain circumstances. The counselor can do a lot to build a relationship with a student by attending a student’s school play, musical recital, or sports event. However, we recommend that school counselors ask these questions: “How will I respond if this client continues to ask me to participate in other activities?” “How will I respond to other students who make similar requests?” “How will I deal with these extra demands on my time?” Consider the client population with whom you are dealing. Not all clients are alike. Age, diagnosis, life experiences such as abuse, and culture are key ele- ments to consider when establishing boundaries. Another important element is the character of the therapist. In our opinion, the therapist’s character and values have more influence than training and orientation. Consider how boundaries were respected in your family of origin and how you manage boundaries in your own personal life. How sensitive are you to the boundaries of others in your personal life? If we establish and maintain appropriate boundaries in our personal lives, it is unlikely that we will be indifferent to boundaries in our professional lives, or unwittingly ignore them. Your Thinking on Crossing Boundaries Before you read about the various forms of multiple relationships therapists may encounter, clarify your thinking on these issues: • What are your reactions to the position that some multiple relationships and boundary crossings can enhance treatment outcomes? • Do you think nonsexual multiple relationships necessarily lead to exploitation, sex, or harm? What are your thoughts regarding the slippery slope argument? • Do you think the ethics codes of the various professional organizations are reasonable as they pertain to boundary issues, nonprofessional relationships, and multiple relationships? • What challenges, if any, do you face in establishing and maintaining bound- aries in your personal life? • Might certain multiple relationships alter the power differential between you and your client in such a manner as to facilitate better health and healing? • Would your fears of a malpractice suit alter the way you deal with boundaries with clients? If so, what are you doing now that could be viewed as being unethical? • What topics pertaining to managing boundaries, multiple roles, and multiple relationships would you want to address with your clients from the initial session? As you read the rest of this chapter, think of some challenges you might encounter in managing multiple relationships. Managing Multiple Relationships in a Small Community Learning to manage multiple relationships is essential for practitioners in small communities. Practitioners in rural settings often find themselves involved in multiple relationships (Barnett, 2017b) as they balance the roles of being a clini- cian, a neighbor, a friend, and perhaps even a spiritual leader. Other challenges include professional isolation, high visibility in the community, spending a great deal of time traveling between professional engagements, and coping with the inevitability of multiple relationships (Bray, 2016). Practitioners who work in small communities often have to blend their professional role with a variety of community-oriented roles, such as being a member of a religious group, a member on various boards, an educational consultant, or a sports coach (Bradley, Werth, & Hastings, 2012). Clinicians may attend the same church or community activities as the clients they serve. A therapist who is a recovering alcoholic and attends Alco- holics Anonymous meetings may meet a client at one of these meetings. In an iso- lated area, a clergy person may seek counseling for a personal crisis from the only counselor in the town—someone who also happens to be a parishioner. Managing boundaries and multiple relationships are realities faced by all therapists who live and practice in small communities. Coping With Challenges of Practice in Rural Communities Counselors who practice in a rural area clearly experience challenges, but Bray (2016) believes these challenges can best be met by being creative and willing to collaborate with clients and others in the community. “Rural counseling is any- thing but the neat-and-tidy model in which a practitioner sees each individual client one hour per week in a single office” (pp. 33–34). To protect client confi- dentiality in small, closely knit communities where therapists commonly need to balance multiple roles, potential concerns about boundary issues and how best to safeguard client privacy should be discussed at the beginning of the counseling relationship. Barnett (2017b) believes that the goal for rural therapists is not to avoid all multiple roles and relationships but to manage these relationships in an ethical and thoughtful manner. A counselor who worked in a community agency in a rural area described how he addressed confidentiality matters with one of his clients: One of my clients disclosed to me in our first session together that he was gay, but he did not want the director of the agency to know that about him because they attended the same church. My client was in the process of coming out to significant others in his life, and it was important to him to feel a sense of control over the disclosure of this information. Earlier in that session, as I was discussing informed consent with him, I had revealed that the director of the agency was my clinical supervisor and that it was customary for me to discuss all of my cases with him. After my client shared his con- cerns, we brainstormed how we could work together so that he would feel comfortable and I would have access to supervision. The client granted me permission to share with the director the basic dilemma without sharing the specific issue that he didn’t want me to reveal. The director was understanding and wanted to respect the client’s boundaries and confidentiality. He allowed me to seek supervision for this one case from another therapist on staff. The client was satisfied with this solution, and we had a productive therapeutic relationship. Another challenge in practicing therapy in a small community is illustrated by Henry’s case. Henry owned a farm supply store in a midwestern town. He was given an ultimatum by his wife to seek therapy or face a divorce, and Henry reluctantly agreed to meet with a local therapist to address his anger management issues. A major factor contributing to his stress and anger was that another farm supply store had recently opened in the community, which put a strain on his business. The therapist was familiar with the new farm supply store because her son had recently been hired at this store. The therapist decided to disclose that her son was working there. If she withheld this information from Henry and he later discovered it on his own, he would likely feel betrayed. Henry was worried about people knowing he was going to therapy, and the therapist and Henry spent time during the first session discussing how they could take precautions to protect his confidentiality. In addition to addressing the source of his anger and ways to manage it constructively, the therapist assisted Henry in identifying resources that support small businesses. She encouraged him to join a regional small business advocacy group that met monthly, and Henry found this group to be helpful. Practicing counseling in rural communities comes with both advantages and challenges. Advantages related to a rural lifestyle such as less traffic and crime and a slower pace draws practitioners to these communities, and Fifield and Oliver (2016) state that the “challenges of rural practice are well documented and tend to cluster around ethical issues regarding professional competence, ensuring confi- dentiality, and avoiding/managing multiple relationships” (p. 77). If practitioners isolate themselves from the surrounding community, they are likely to alienate potential clients and reduce their effectiveness. Practitioners must be prepared to face the ethical dilemmas unique to rural practice. For example, if a therapist shops for a new snow plow he risks violating the letter of the ethics code if the only person in town who sells snow plows happens to be a client. However, if the ther- apist were to buy a snow plow elsewhere, this could strain relationships within the community because of the value rural communities place on loyalty to local merchants. Or consider clients who wish to barter goods or services for counseling services. Some communities operate substantially on swaps rather than on a cash economy. This does not necessarily have to become problematic, yet the potential for conflict exists in the therapeutic relationship if the bartering agreements do not work well. Minimizing Risks of Practicing in Small Communities Practitioners in rural communities experience greater visibility than those in urban settings, which has a bearing on the way therapists take care of themselves and how they balance their personal and professional life. Schank (Schank, Helbok, ManaginHaldeman, & Gallardo, 2010) states that practitioners in small communities can minimize risk and practice ethically and professionally by following these steps: • Obtain informed consent • Document thoroughly • Set clear boundaries and expectations, both for yourself and with your clients • Pay attention to matters of confidentiality • Get involved in ongoing consultation or a peer supervision group Fifield and Oliver (2016) conducted a needs assessment to identify ways to increase the perceived competency of rural practitioners. Those who responded to the survey reported that training specific to rural counseling would be helpful in strengthening their perceived competence. In addition to workshops and confer- ences, survey participants cited online communities, online interest networks, and regional resource guides hosted on the websites of professional organizations as potential resources. A Case of a Multiple Relationship in a Small Community Millie, a therapist in a small community, experienced heart pain one day. the fire department was called, and the medic on the team turned out to be her client, andres. to administer proper medical care, andres had to remove Millie’s upper clothing. During subsequent sessions, neither andres nor Millie discussed the incident, but both exhibited a degree of discomfort with each other. after a few more sessions, andres discontinued his therapy with Millie. • can this case be considered an unavoidable dual relationship? Why or why not? • What might Millie have done to prevent this outcome? • should Millie have discussed her discomfort in the therapy session following the incident? Why or why not? • if you were in Millie’s situation, what would you have done? Commentary. this case illustrates how some roles can shift and how some multiple relation- ships are unavoidable, especially in small communities where therapists need to anticipate frequent boundary crossings with clients. in our view, Millie should have discussed with andres how he would like to handle chance encounters in the community during the informed con- sent process. even so, we doubt that Millie could have predicted this awkward boundary cross- ing with andres. clinically, Millie might have salvaged the therapy relationship by processing her own discomfort with a colleague, and then processing the event with andres. by allowing the discomfort to remain hidden, Millie failed to practice with the best interests of her client in mind. in this instance, neither Millie’s nor andres’s needs were being met in the therapeutic relationship. • Practicing Ethically in a Small Community I (Marianne Schneider Corey) practiced for many years as a marriage and family therapist in a small town. This situation presented a number of ethical consider- ations involving safeguarding the privacy of clients. Even in urban areas, thera- pists will occasionally encounter their clients in other situations. However, in a rural area such meetings are more likely to occur. 270 / chapter 7 Copyright 2019 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-202 Copyright 2019 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in wholI discussed with my clients the unique variables pertaining to confidential- ity in a small community. I informed them that I would not discuss professional concerns with them should we meet at the grocery store or the post office, and I respected their preferences regarding interactions away from the office. Knowing that they were aware that I saw many people from the town, I reassured them that I would not talk with anyone about who my clients were, even when I might be directly asked. Another example of protecting my clients’ privacy pertained to the manner of depositing checks at the local bank. Because the bank employees knew my profession, it would have been easy for them to identify my clients. Again, I talked with my clients about their preferences. If they had any discomfort about my depositing their checks in the local bank, I arranged to have them deposited elsewhere. Practicing in a small town inevitably meant that I would meet clients in many places. For example, the checker at the grocery store might be my client; the per- son standing in line before me at the store could be a client who wants to talk about his or her week; at church there may be clients or former clients in the same Bible study group; in restaurants a client’s family may be seated next to the table where my family is dining, or the food server could be a client; and on a hiking event I may discover that in the group is a client and his or her partner. As I was leaving the hairstyling salon in town one day, I encountered a former client of many years ago who enthusiastically greeted me. I stopped and acknowledged her, and she then went on in detail telling the hairstylist about her therapy with me. I did not ask her any pointed questions nor did I engage her in any counsel- ing issues. Instead, I kept the conversation general. Had I not acknowledged her, this most likely would have offended her. All of these examples present possi- ble problems for the therapist. Neither my clients nor I experienced problems in such situations because we had talked about the possibility of such meetings in advance. Being a practitioner in a small community demands flexibility, honesty, and sensitivity. In managing multiple roles and relationships, it is not very use- ful to rely on rigid rules and policies; you must be ready to creatively adapt to situations as they unfold. The examples I have given demonstrate that what might clearly not be advis- able in an urban area might just as clearly be unavoidable or perhaps mandatory in a rural area. This does not mean that rural mental health professionals are free do whatever they please. The task of managing boundaries is more challenging in rural areas, and practitioners often are called upon to examine what is in the best interests of their client. Now consider these questions: • What ethical dilemmas do you think you would encounter if you were to prac- tice in a rural area? • Are you comfortable discussing possible outside contacts with clients up front, and are you able to set guidelines with your clients? • What are some of the advantages and disadvantages of practicing in a small community? • Is there more room for flexibility in setting guidelines regarding social rela- tionships and outside business contacts with clients in a small community? Bartering for Professional Services When a client is unable to afford therapy, it is possible that he or she may offer a bartering arrangement, exchanging goods or services in lieu of a fee. For exam- ple, a mechanic might exchange work on a therapist’s car for counseling sessions. However, if the client was expected to provide several hours of work on the ther- apist’s car in exchange for one therapy session, this client might become resent- ful over the perceived imbalance of the exchange. If the therapist’s car was not repaired properly, the therapist might resent that client. This would damage the therapeutic relationship. In addition, problems of another sort can occur with dual relationships should clients clean houses, perform secretarial services, or do other personal work for the therapist. Clients can easily be put in a bind when they are in a position to learn personal material about their therapists. The client might feel taken advantage of by the therapist, which could damage his or her therapy. Cer- tainly, many problems can arise from these kinds of exchanges for both therapists and clients. Ethical Standards on Bartering Most ethics codes address the complexities of bartering (see the Ethics Codes box titled “Bartering”). We agree with the general tone of these standards, although we would add that bartering should be evaluated within a cultural context. In some cultures, and especially in rural communities, bartering is an accepted prac- tice and frequently conforms to prevailing community standards (Barnett, 2017b). The ethics codes of APA, NASW, AAMFT, AMHCA, and ACA currently take a realistic stance on bartering, and most professional organizations now provide guidelines for the ethical practice of bartering. 272 / chapter 7 Copyright 2019 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-202 Copyright 2019 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. ETHICS CODES: Bartering American Psychological Association (2010) Barter is the acceptance of goods, services, or other nonmonetary remuneration from clients/patients in return for psychological services. Psychologists may barter only if (1) it is not clinically contraindicated, and (2) the resulting arrangement is not exploitative. (6.05.) American Counseling Association (2014) Counselors may barter only if the bartering does not result in exploitation or harm, if the client requests it, and if such arrangements are an accepted practice among professionals in the community. Counselors consider the cultural implications of bartering and discuss relevant concerns with clients and document such agreements in a clear written contract. (A.10.e.) American Association for Marriage and Family Therapy (2015) Marriage and family therapists ordinarily refrain from accepting goods and services from clients in return for services rendered. Bartering for professional services may be conducted only if: (a) the supervisee or client requests it, (b) the relationship is not exploitative, (c) the professional relationship is not distorted, and (d) a clear written contract is established. (8.5.) ETHICS CODES: Bartering continued American Mental Health Counselors Association (2015) Mental health counselors usually refrain from accepting goods or services from clients in return for counseling services because such arrangements may create the potential for conflicts, exploitation and distortion of the professional relationship. However, bartering may occur if the client requests it, there is no exploitation, and the cultural implications and other concerns of such practice are discussed with the client and agreed upon in writing. (E.2.b.) National Association of Social Workers (2008) Social workers should avoid accepting goods or services from clients as payment for professional services. Bartering arrangements, particularly involving services, create the potential for conflicts of interest, exploitation, and inappropriate boundaries in social workers’ relationships with clients. Social workers should explore and may participate in bartering only in very limited circumstances when it can be demonstrated that such arrangements are an accepted practice among professionals in the local community, considered to be essential for the provision of services, negotiated without coercion, and entered into at the client’s initiative and with the client’s informed consent. Social workers who accept goods or services from clients as payment for professional services assume the full burden of demonstrating that this arrangement will not be detrimental to the client or the professional relationship. (1.13.b.) Before bartering is entered into, both parties need to talk about the arrange- ment, gain a clear understanding of the exchange, and come to an agreement. It is important that problems that might develop be discussed and that alternatives be examined. Using a sliding scale to determine fees or making a referral are two pos- sible alternatives that might have merit. Bartering is an example of a practice that we think allows some room for therapists, in collaboration with their clients, to use good judgment and consider the cultural context in the situation. Zur (2011a) maintains that bartering can be a dignified and honorable form of payment for those who are cash poor but talented in other ways. He adds that bartering is a healthy norm in many cultures. Bartering can be part of a clearly articulated treat- ment plan, and like other interventions, bartering must be considered in light of the client’s needs, desires, situation, and cultural background. If bartering is done thoughtfully and in a collaborative way, it can be beneficial for many clients and can enhance therapeutic outcomes. Barnett and Johnson (2008) and Koocher and Keith-Spiegel (2016) acknowledge that bartering arrangements with clients can be both a reasonable and a humani- tarian practice when people require psychological services but do not have insur- ance coverage and are in financial difficulty. Barnett and Johnson (2008) suggest that bartering arrangements can be a culturally sensitive and clinically indicated decision that may prove satisfactory to both parties. However, bartering entails risks, and they emphasize the importance of carefully assessing such arrange- ments prior to taking them on. Clinicians should seek consultation from a trusted colleague who can provide an objective evaluation of the proposed arrangement in terms of equity, clinical appropriateness, and the danger of potentially harmful multiple relationships. Both Holly Forester-Miller (2015) and Lawrence Thomas (2002) provide views on the benefits of bartering when clients cannot afford to pay for psy- chological services. Forester-Miller (2015) addresses the difficulties involved in avoiding overlapping relationships in rural communities and reminds coun- selors that values and beliefs may vary significantly between urban dwellers and their rural counterparts. She suggests that counselors need to ensure that they are not imposing values that come from a cultural perspective different from that of their clients. Bartering is one way of providing counseling services in some regions to individuals who could not otherwise afford counseling. Forester-Miller recounts her experience providing therapy in the Appalachian culture, where individuals pride themselves on being able to provide for them- selves and their loved ones. Forester-Miller once provided counseling for an adolescent girl whose single-parent mother could not afford her usual fee, nor could she afford to pay a reduced fee, as even a small amount would be a drain on this family’s resources. When Forester-Miller informed the mother that she would be willing to see her daughter for free, the mother stated that this would not be acceptable to her. However, she asked the counselor if she would accept a quilt she had made as payment for counseling the daughter. The mother and the counselor discussed the monetary value of the quilt and decided to use this as payment for a specified number of counseling sessions. Forester-Miller reports that this was a good solution because it enabled the adolescent girl to receive needed counseling services and gave the mother an opportunity to maintain her dignity in that she could pay her own way. Thomas (2002) believes bartering is a legitimate means of making psycho- logical services available to people of limited economic means. He maintains that bartering should not be ruled out simply because of the slight chance that a client might initiate a lawsuit against the therapist. His view is that if we are not willing to take some risks as psychotherapy professionals, then we are not worthy of our position. Thomas believes that venturing into a multiple relation- ship requires careful thought and judgment. In making decisions about barter- ing, the most salient issue is the “higher standard” of considering the welfare of the client. Thomas recommends a written contract that spells out in detail the nature of the agreement between therapist and client, which should be reviewed regularly. Documenting the arrangement can clarify agreements and can help professionals defend themselves if this becomes necessary. Thomas admits that bartering is a troublesome topic, yet he emphasizes that the role of our professional character is to focus on the higher standard—the best interests of the client. Making a Decision About Bartering Barnett and Johnson (2008) maintain that, as a general rule, it is unwise to engage in bartering practices with therapy clients. They add that accepting goods or services for professional services can open the door to misunderstandings, perceived or actual exploitation, boundary violations, and reduced effectiveness as a clinician. Although bartering is not prohibited by ethics or law, most legal experts frown on the practice. Woody (1998), both a psychologist and an attorney, argues against the use of bartering for psychological services. He suggests that it could be argued that bartering is below the minimum standard of practice. If you enter into a bartering agreement with your client, Woody states that you will have the burden of proof to demonstrate that (a) the bartering arrangement is in the best interests of your client; (b) is reasonable, equitable, and undertaken without undue influence; and (c) does not get in the way of providing quality psychological services to your cli- ent. Because bartering is so fraught with risks for both client and therapist, Woody believes prudence dictates that it should be the option of last resort. Zur (2011a) notes that many who are opposed to bartering view this practice as the first step on the slippery slope toward harming clients. Zur believes what is missing in the literature is a discussion of bartering that is done intentionally and deliberately for the benefit of the client. Rather than focusing on the “do no harm” approach, Zur focuses on “doing good,” or doing what is most likely to improve the client’s mental health. During an economic crisis therapists may be presented with more frequent requests for bartering. Here are a few guidelines for bartering arrangements: • Determine the value of the goods or services in a collaborative fashion with the client at the outset of the bartering arrangement. • Estimate the length of time for the barter arrangement. • Document the bartering arrangement, including the value of the goods or services and a date on which the arrangement will end. To these recommendations we add the importance of consulting with experienced colleagues, a supervisor, and especially your professional organization if you are considering some form of bartering in lieu of payment for therapy services. The client may not realize the potential conflicts and problems involved in bartering. It is the counselor’s responsibility to enumerate the potential prob- lems and risks in bartering. We highly recommend a straightforward discussion with your client about the pros and cons of bartering in your particular situa- tion, especially as it may apply to the standards of your community. It may be wise to consult with a third party regarding the value of a fair market exchange. We concur with Thomas (2002), who recommends creating a written contract that specifies hours spent by each party and all particulars of the agreement. If you still have doubts about the agreement, consult with a contract lawyer. Once poten- tial problems have been identified, consult with colleagues about alternatives you and your client may not have considered. Ongoing consultation and discussion of cases, especially in matters pertaining to boundaries and dual roles, provide a context for understanding the implications of certain practices. Needless to say, these consultations should be documented. Your Stance on Bartering Consider a situation in which you have a client who cannot afford to pay even a reduced fee. Would you be inclined to engage in bar- tering goods for your services? What kind of understanding would you need to work out with your client before you agreed to a bartering arrangement? Would your decision be dependent on whether you were practicing in a large urban area or a rural area? How would you take the cultural context into consideration when making your decision? Which services might you be willing to barter for with a client? Think about why you would or would not be comfortable in each situation. Answer “yes,” “no,” or “uncertain” regarding each of the following services: • Have my client clean my house or office • Have my client take care of my pets while I’m on vacation • Accept my client’s art work • Accept my client cutting my hair or providing manicures • Accept yoga lessons from my client • Have my client tutor my child What do your responses say about your personal and professional boundaries? Are there any cultural factors or contextual factors that might cause you to change your answers? Consider the following cases and apply the ethical standards we have sum- marized to your analysis. What ethical issues are involved in each case? What potential problems do you see emerging from these cases? What alternatives to bartering can you think of? The Case of Macy Macy is 20 years old and has been in therapy with sidney for over a year. she has developed respect and fondness for her therapist, whom she sees as a father figure. she tells him that she is thinking of discontinuing therapy because she has lost her job and simply has no way of paying for the sessions. she is obviously upset over the prospect of ending the relationship, but she sees no alternative. sidney informs her that he is willing to continue her therapy even if she is unable to pay. he suggests that as an exchange of services she can become the babysitter for his three children. she gratefully accepts this offer. after a few months, however, Macy finds that the situation is becoming difficult for her. eventually she writes a note to sidney telling him that she cannot handle her reactions to his wife and their children. it makes her think of all the things she missed in her own family. she writes that she has found this subject difficult to bring up in her sessions, so she is planning to quit both her services and her therapy. • What questions does this case raise for you? • how would you have dealt with this situation? • What are your thoughts concerning the therapist’s suggestion that Macy babysit for him? • Do you think sidney adequately considered the nature of the transference relationship with this client? Commentary. this case illustrates how a well-meaning therapist created a multiple relation- ship with his client that became problematic for her. in addition, sidney suggested a barter- ing arrangement that involved Macy performing personal services in exchange for therapy; it generally is not a good idea for a therapist to involve his significant others in barter exchanges with the client. sidney did not explore with Macy her transference feelings for him, nor did he predict potential difficulties with her taking care of his children. indeed, countertransference on sidney’s part may have led to the blurring of boundaries. the ethics codes of the aca (2014), apa (2010), nasW (2008), aMhca (2015), and aaMft (2015) all specify that bartering may be ethical under certain conditions: if the client requests it; if it is not clinically contraindicated; if it is not exploitative; and if the arrangement is entered into with full informed consent. none of these standards was met in this case. sidney should have explored other options such as working pro bono, reducing his fees, or a referral to another agency. • The Case of Thai thai is a massage therapist in her community. her services are sought by many professionals, including giovani, a local psychologist. in the course of a massage session, she confides in him that she is experiencing difficulties in her long-term relationship. she would like to discuss with him the possibility of exchanging professional services. she proposes that in return for couples therapy she will give both him and his partner massage treatments. an equitable arrangement based on their fee structures can be worked out. giovani might make any one of the following responses: response a: that’s fine with me, thai. it sounds like a good proposal. neither one of us will suffer financially because of it, and we can each benefit from our expertise. response b: Well, thai, i feel okay about the exchange, except i have concerns about the dual relationship. response c: even though our relationship is professional, thai, i do feel uncomfortable about seeing you as a client in couples therapy. i certainly could refer you to a competent relationship therapist. consider your thoughts about these response options. • Which do you consider to be ethical? unethical? • Do you think thai’s proposal is practical? • What are the ethical implications in this case? • Do you think thai’s suggestion for an exchange of services reflects her own culturally appro- priate standards? if so, how would that affect your response? • if you were in this situation, how would you respond to thai? Commentary. because of the physically intimate nature of massage work, we would discour- age any therapist from entering into this kind of exchange. We do not see any signs that thai and giovani adequately assessed the potential risks involved in exchanging these personal ser- vices. in addition, no indication of an inability to pay for counseling has been stated by thai. as with the previous case, other options besides bartering could have been considered. • The Case of Exchanging Services for Therapy vidar is a counselor in private practice who has been seeing a client for a few months. jana is hard working, dedicated to personal growth, and is making progress in treatment. at her last session she expressed concern about her ability to continue funding her sessions. jana suggested that vidar consider allowing her husband’s pool company to provide summer pool cleaning service for the months of May through august for vidar’s home pool in return for her continued sessions. the fees would be basically equitable, and vidar is seriously considering this agreement to assist jana in her ability to continue counseling. • Does this arrangement seem like a reasonable request to you? • What ethical issues related to this situation might cause you concern, if any? • Which ethical standards apply to this situation? Commentary. the case of vidar and jana is less clear-cut. it is important that the arrangement was suggested by jana and not by vidar. it would be beneficial for vidar to consider some consultation in reviewing the pros and cons of this proposal prior to making a decision. vidar should also consider whether bartering is a commonly accepted practice in his geographical Giving or Receiving Gifts The codes of ethics of the AAMFT, the AMHCA, and the ACA specifically address the topic of giving or receiving gifts in the therapeutic relationship. See the Eth- ics Codes box titled “Giving and Receiving Gifts” for specific standards of these organizations. Lavish gifts certainly present an ethical problem, yet we can go too far in the direction of trying to be ethical and, in so doing, actually damage the therapeutic relationship. Some therapists include a statement regarding gifts from clients in their informed consent document to make their policy clear. Rather than establish- ing a hard and fast rule, our preference is to evaluate each situation on a case-by- case basis. Let’s examine a few of these areas in more detail. • What is the monetary value of the gift? Most mental health professionals would agree that accepting a very expensive gift is problematic and potentially unethical. It would also be problematic if a client offered tickets to the theater or a sporting event and wanted you to accompany him or her to this event. In the novel Lying on the Couch (Yalom, 1997), a therapist is offered a $1,600 bonus by a wealthy cli- ent to show his appreciation for how a few therapy sessions changed his life. The therapist struggles as he declines this gift, stating that it is considered unethical to accept a monetary gift from a client. The client angrily protests, claiming that rejecting his gift could cancel some of the gains made during their work, and he insists that the score be evened. The therapist steadfastly responds that he cannot accept the gift and acknowledges that one topic they did not discuss in therapy was the client’s discomfort in accepting help. • Whataretheclinicalimplicationsofacceptingorrejectingthegift?Itisimportant to recognize when accepting a gift from a client is clinically contraindicated and that you be willing to explore this with your client. Certainly, knowing the motivation for a client’s overture is critical to making a decision. For example, a client may be seeking your approval, in which case the main motivation for giving you a gift is to please you. Accepting the gift without adequate dis- cussion would not be helping your client in the long run. Practitioners may want to inquire what meaning even small gifts have to the client. Zur (2011b) suggests that any gift must be understood and evaluated within the context in which it is given. He mentions that inappropriately expensive gifts or any gifts that create indebtedness, whether of the client or the therapist, are boundary violations. However, Zur (2011b) claims that appropriate gift-giving can be a healthy aspect of a therapist–client relationship and can enhance therapeutic effectiveness. • When in the therapy process is the offering of a gift occurring? Is it at the beginning of the therapy process? Is it at the termination of the professional relationship? It could be more problematic to accept a gift at an early stage of a counseling rela- tionship because doing so may be a forerunner to creating lax boundaries. A gift at the end of therapy may have cultural and symbolic value for clients. Therapists should assess whether accepting a gift from a client is appropriate. • What are your own motivations for accepting or rejecting a client’s gift? The giv- ing or receiving of gifts has layers of meaning that should be explored. You must be aware of whose needs are being served by receiving a gift. Some counselors will accept a gift simply because they do not want to hurt a client’s feelings, even though they are not personally comfortable doing so. Counselors may accept a gift because they are unable to establish firm and clear boundaries. Other counselors may accept a gift because they actually want what a client is offering. In appropri- ate circumstances, a gift may be helpful to therapy, but it is the therapist’s respon- sibility to consider the meaning of the gift. • What are the cultural implications of offering a gift? The cultural context plays a role in evaluating the appropriateness of accepting a gift from a client. Sue and Capodilupo (2015) point out that in Asian cultures gift-giving is a com- mon practice to show respect, gratitude, and to seal a relationship. Although such actions are culturally appropriate, Western-trained professionals may believe that accepting a gift would distort boundaries, change the relationship, and create a conflict of interest. However, if a practitioner were to refuse a cli- ent’s gift, it is likely that this person would feel insulted or humiliated, and the refusal could damage both the therapeutic relationship and the client. Zur (2011b) notes that most practitioners agree that rejecting appropriate gifts of small monetary value but of high relational value can be offensive to clients and negatively affect the therapeutic alliance. Neukrug and Milliken (2011) found that the value of the gift was important in counselors’ decisions. Of the counsel- ors they surveyed, 88.3% thought it was unethical to accept a gift from a client worth more than $25, and 94.7% believed it was unethical to give a gift to a client worth more than $25. If you are opposed to receiving gifts and view this as a boundary crossing, you may need to address this issue in your informed consent document. One of the reviewers of this book stated that students sometimes give school counselors gifts. Such gifts are usually inexpensive, if purchased, or are items made in an art or shop class. He indicates that he could accept the gift and display the gift in his office. If you were a school counselor, would you be inclined to accept inexpensive gifts? Would you display a gift in your office? How would you respond if other students (your clients) or teachers asked you who made the gift that is on display? Under what circumstances, if any, might you be inclined to give a student a gift? To what degree would you be com- fortable documenting and having your colleagues learn about a gift you have accepted? ETHICS CODES: Giving and Receiving Gifts American Association for Marriage and Family Therapy (2015) Marriage and family therapists attend to cultural norms when considering whether to accept gifts from or give gifts to clients. Marriage and family therapists consider the potential effects that receiving or giving gifts may have on clients and on the integrity and efficacy of the therapeutic relationship. (3.9) American Counseling Association (2014) Receiving Gifts. Counselors understand the challenges of accepting gifts from clients and recognize that in some cultures, small gifts are a token of respect and gratitude. When determining whether to accept a gift from clients, counselors take into account the therapeutic relationship, the monetary value of the gift, the client’s motivation for giving the gift, and the counselor’s motivation for wanting to accept or decline the gift. (A.10.f.) American Mental Health Counselors Association (2015) When accepting gifts, mental health counselors take into consideration the therapeutic relationship, motivation of giving, the counselor’s motivation for receiving or declining, cultural norms, and the value of the gift. (E.2.d.) The Case of Suki toward the end of her therapy, suki, a japanese client, presents an expensive piece of jewelry to her counselor, joaquin. suki says she is grateful for all that her counselor has done for her and that she really wants him to accept her gift, which has been in her family for many years. in a discussion with the counselor, suki claims that giving gifts is a part of the japanese culture. joaquin discusses his dilemma, telling suki that he would like to accept the gift but that he has a policy of not accepting gifts from clients. he reminds her of this policy, which was part of the informed consent document she signed at the beginning of the therapeutic relationship. suki is persistent and lets joaquin know that if he does not accept her gift she will feel rejected. she is extremely grateful for all joaquin has done for her, and this is her way of expressing her appreciation. joaquin recalls that suki had told him that in her culture gifts are given with the expectation of reciprocity. a few days after this session, joaquin received an invitation from suki to attend her daughter’s birthday party where her family would be present. put yourself in this situation with suki. What aspects would you want to explore with your client before accepting or not accepting her gift? • Do you see a difference between accepting a gift during therapy or toward the end of therapy? • Would it be important to consider your client’s cultural background in accepting or not accepting the gift? • how would you deal with suki if she insisted that you recognize her token of appreciation and accept her invitation to her daughter’s birthday party? • if you find that clients frequently want to give you gifts, would you need to reflect on what you might be doing to promote this pattern? explain. Social Relationships With Clients Do social relationships with clients necessarily interfere with therapeutic relation- ships? Some would say no, contending that counselors and clients are able to han- dle such relationships as long as the priorities are clear. They see social contacts as particularly appropriate with clients who are not deeply disturbed and who are seeking personal growth. Some peer counselors, for example, maintain that friendships before or during counseling are actually positive factors in establish- ing trust. Other practitioners take the position that counseling and friendship should not be mixed. They claim that attempting to manage a social and professional relationship simultaneously can have a negative effect on the therapeutic process, the friendship, or both. Here are some reasons for discouraging the practice of accepting friends as clients or of becoming socially involved with clients: (1) ther- apists may not be as challenging as they need to be with clients they know socially because of a need to be liked and accepted by the client; (2) counselors’ own needs may be enmeshed with those of their clients to the point that objectivity is lost; and (3) counselors are at greater risk of exploiting clients because of the power differ- ential in the therapeutic relationship. Cultural Considerations The cultural context can play a role in evaluating the appropriateness of dual rela- tionships that involve friendships in the therapy context. Parham and Caldwell (2015) question Western ethical standards that discourage dual and multiple rela- tionships and claim that such standards can prove to be an obstacle or hindrance in counseling African American clients. In an African context, therapy is not con- fined to a practitioner’s office for 50-minute sessions. Instead, therapy involves multiple activities that might include conversation, playful activities, laughter, shared meals and cooking experiences, travel, rituals and ceremony, singing or drumming, storytelling, writing, and touching. Parham and Caldwell view each of these activities as having the potential to bring a “healing focus” to the therapeutic experience. In a similar spirit, Sue and Capodilupo (2015) point out that some cultural groups may value multiple relationships with helping professionals. Consider these cultural differences in determining when multiple relationships might be acceptable: • In some Asian cultures it is believed that personal matters are best discussed with a relative or a friend. Self-disclosing to a stranger (the counselor) is consid- ered taboo and a violation of familial and cultural values. Some Asian clients may prefer to have the traditional counseling role evolve into a more personal one. • Clients from many cultural groups prefer to receive advice and suggestions from an expert. They perceive the counselor to be an expert, having higher sta- tus and possessing superior knowledge. To work effectively with these clients, the counselor may have to play a number of different roles, such as advocate, adviser, change agent, and facilitator of indigenous support systems. Yet counsel- ors may view playing more than one of these roles as engaging in dual or multiple relationships. Forming Social Relationships With Former Clients Mental health professionals are not legally or ethically prohibited from entering into a nonsexual relationship with a client after the termination of therapy. How- ever, forming friendships with former clients may pose difficulties for both the client and the therapist. For example, a former client might feel taken advantage of, which could result in a complaint against the therapist. Therapists need to know that it is their responsibility to evaluate the impact of entering into such relationships. Although forming friendships with former clients may not be unethical or illegal, the practice can lead to problems. The safest policy is probably to avoid developing social relationships with former clients. In the long run, former clients may need you more as a therapist at some future time than as a friend. If you develop a friendship with a former client, then he or she is not eligible to use your professional services in the future. Even in the social relationship, the imbalance of power may not change and you may still be seen as a therapist or you may behave as a therapist. Mental health practitioners should be aware of their own motiva- tions, as well as the motivations of their clients, when allowing a professional rela- tionship to evolve into a personal one, even after the termination of therapy. We question the motivation of helpers who rely on their professional position as a way to meet their social needs. Furthermore, therapists who are in the habit of develop- ing relationships with former clients may find themselves overextended and come to resent the relationships they sought out or to which they consented. Perhaps the crux of the situation involves the therapist being able to establish clear boundaries regarding what he or she is willing to do. Your Position on Socializing With Current or Former Clients There are many types of socializing, ranging from going to a social event with a client to having a cup of tea or coffee with a client. Social involvements initiated by a client are different from those initiated by a therapist. Another factor to consider is whether the social contact is ongoing or occasional. The degree of intimacy is also a factor; there is a difference between meeting a client for coffee or for a candlelight dinner. In thinking through your own position on establishing a dual relationship with a current client, consider the nature of the social function, the nature of your client’s problem, the client population, the setting where you work, the kind of therapy being employed, and your theoretical approach. For example, if you are psychoan- alytically oriented, you might adopt stricter boundaries and would be concerned about infecting the transference relationship should you blend any form of social- izing with therapy. Weigh the various factors and consider this matter from both the client’s and the therapist’s perspective. When professional and social relationships are blended, a great deal of hon- esty and self-awareness is required by the therapist. Ask yourself why you are considering a social relationship with a client or former client. No matter how clear the therapist is on boundaries, if the client cannot understand or cannot handle the social relationship, such a relationship should not be formed—with either current or former clients. When clear boundaries are not maintained, both the professional and the social relationship can sour. Clients may well become inhibited during therapy out of fear of alienating their therapist. They may fear losing the respect of a therapist with whom they have a friendship. They may censor their disclosures so that they do not threaten this social relationship. What are your thoughts on this topic? What are the therapist’s obligations to former clients? Under what circumstances might such relationships be inap- propriate or even unethical? When do you think these relationships might be considered ethical? When you are uncertain about how to proceed, consultation is a priority. Holroyd, 1993). Simply experiencing sexual attraction to a client, without acting on it, makes the majority of therapists feel guilty, anxious, and confused. Given these reactions, it is not surprising that many therapists want to hide these feel- ings rather than acknowledge and deal with sexual feelings by consulting a col- league or by bringing this to their own therapy. Although a majority of therapists report feeling sexually attracted to some clients, and most report discomfort with their feelings, adequate training in this area is relatively rare (Pope & Wedding, 2014). In a survey conducted by Neukrug and Milliken (2011), 10.3% of counselors thought it was ethical to reveal a sexual attraction to a client; 89.7% thought this was unethical. In the specialty area of sport psychology consulting, little is known about the extent to which practitioners are aware of, manage, or act on their sexual attrac- tions. This lack of knowledge inspired a group of researchers to examine this phe- nomenon. Moles and colleagues (2016) reported that the vast majority (78.3%) of sport psychology consultants (SPC) in their study received ethics training on this issue while in graduate school, and some also received training after earning their graduate degrees. Of the 275 SPCs surveyed, 112 (40.7%) claimed to have been sexually attracted to at least one client-athlete. The majority were attracted to 1–2 client-athletes, 28.6% were attracted to 3–5 client-athletes, 8.9% were attracted to 6–10 client-athletes, and 6.3% were attracted to 11 or more client-athletes. Of the 112 respondents who acknowledged experiencing sexual attractions, only 88 reported on whether they had engaged in sexual behaviors: 13.6% admitted to crossing sexual boundaries “primarily by discussing sexual matters unrelated to their work; no SPC reported kissing, dating, or having sexual intercourse with a client-athlete” (p. 93). There is a distinction between finding a client sexually attractive and being preoccupied with this attraction. The SPCs who sought supervision to discuss their sexual attraction issues found supervision to be embarrassing and slightly uncomfortable, but also helpful, enlightening, reassuring, supportive, engaging, therapeutic, empowering, and normalizing (Moles et al., 2016). If you find your- self sexually attracted to your clients, it is important to monitor your feelings. If you are frequently attracted, examine this issue in your own therapy and supervi- sion. We recommend Irvin Yalom’s (1997) book, Lying on the Couch: A Novel, for an interesting case and discourse on the slippery slope of sexual attraction between therapist and client. Educating Counselor Trainees Training programs have an ethical responsibility to help students identify and openly discuss their concerns pertaining to sexual dilemmas in counseling prac- tice. Prevention of sexual misconduct is a better path than remediation. Ignoring this subject in training sends a message to students that the subject should not be talked about, which will inhibit their willingness to seek consultation when they encounter sexual dilemmas in their practice. The findings from Harris and Harriger’s (2009) study on sexual attraction in conjoint therapy suggest that new marriage and family therapists are not confident about the course of action to take when faced with the issue of sexual attraction. These researchers claim that there is an urgent need to address this topic during a training program and equip ther- apists in training with the skills to manage sexual attraction in a range of settings. Pope, Sonne, and Holroyd (1993) believe that exploration of sexual feelings about clients is best done with the help, support, and encouragement of others. They maintain that practice, internships, and peer supervision groups are ideal places to talk about this issue but that this topic is rarely raised. It is a disservice to therapists and clients if training involving sexual ethics is limited to the injunc- tion to “never engage in sex with clients.” Young (2010) broadens this topic to include a host of delicate and complicated sexual matters such as sexual attrac- tion, sexual fantasy, sexual advances of clients, romantic relationships with for- mer clients, and sexual discussions in therapy. These topics should be included in training programs. Suggestions for Dealing With Sexual Attractions Trainees as well as experienced counselors need to ask themselves how they set boundaries when sexual attraction occurs. Practitioners who have difficulty establishing clear boundaries in their personal life are more likely to encounter problems defining appropriate boundaries with their clients. To prevent sexual feelings of therapists from interfering with therapy, it is important for thera- pists to recognize their countertransference reactions and deal with and manage them. Burwell-Pender and Halinski (2008) point out that “the potential for sex- ual impropriety and sexual misconduct is increased with unmanaged counter- transference” (p. 43). The vulnerability the client shows when revealing painful material is very powerful and appealing. The attention a caring therapist shows in response is also powerful and appealing. This environment creates the pos- sibility of mutual attraction. When these feelings are acknowledged in a safe setting with a supervisor or a trusted colleague, therapists are more likely to manage their feelings productively. Perhaps out of a fear of experiencing sexual attraction to clients, or even worse, the temptation to engage in sexual misconduct, some clinicians address the issue proactively by broaching the topic during the informed consent dis- cussion at the initial session. Knapp, Handelsman, Gottlieb, and Vandecreek (2013) point out that harm can be done by disproportionately emphasizing cer- tain rules such as this statement in one clinician’s informed consent document: “I recognize that I am here to see Dr. X for professional purposes and that I have no sexual interest in him and will not attempt to involve him in a sexual relationship or even fantasize about him” (p. 375). This practitioner’s manner “appeared to place the responsibility for sexual misconduct on the patient and to raise it to a level of importance that most patients would never have consid- ered. Such statements could also cause some patients to wonder if this psycholo- gist had issues with personal control over his own impulses” (p. 375). Behaving in the most honorable and ethical manner possible is important, but this quest should not lead us to make matters worse and detract from our effectiveness as professionals. A Case of Sexual Attraction Toward a Client you find yourself sexually attracted to one of your clients. you believe your client may have similar feelings toward you and might be willing to become involved with you. you often have difficulty paying attention during sessions because of your attraction. Which of the following options do you think is most ethical? Which of the following courses of action would you con- sider to be unethical? • i can ignore my feelings for the client and my client’s feelings toward me and focus on other aspects of the relationship. • i will tell my client of my feelings of attraction, discontinue the professional relationship, and then begin a personal relationship. • i will openly express my feelings toward my client by saying: “i’m flattered you find me an attractive person, and i’m attracted to you as well. but this relationship is not about our attraction for each other, and i’m sure that’s not why you came here.” • if there was no change in the intensity of my feelings toward my client, i would arrange for a referral to another therapist. • i would consult with a colleague or seek professional supervision. can you think of another direction in which you could proceed? What would you do and why? Commentary. some may argue that if you are sexually attracted to a client, he or she will be aware of this and it could easily impede the therapy process. as therapists, we need to control our emotional energy without getting frozen. it is a good practice to monitor ourselves by reflecting on the messages we are sending to a client. it is our responsibility to recognize and deal with our feelings toward a client in a way that does not burden the client. as fisher (2004) states, therapists have the responsibility to make sure that they take appropriate steps to man- age their feelings professionally and ethically. Koocher and Keith-spiegel (2016) advise therapists to discuss feelings of sexual attraction toward a client with another therapist, an experienced and trusted colleague, or an approach- able supervisor. Doing so can help therapists clarify the risk, become aware of their vulnera- bilities when it comes to sexual attraction, provide suggestions on how to proceed, and offer a fresh perspective on these situations. therapists are always responsible for managing their feelings toward clients; shifting blame or responsibility to the client is never an excuse for unprofessional or unethical conduct. We caution against sharing your feelings of attraction with your client directly; such disclosures often detract from the work of therapy and may be a confusing burden for the client. • The Case of Adriana adriana’s husband, a police officer, was killed in the line of duty, leaving her with three school- age boys. she seeks professional help from clint, the school social worker, and explores her grief and other issues pertaining to one son who is acting out at school. she seems to rely on the social worker as her partner in supporting her son. after 2 years the son is ready to move on to high school. she confesses to clint that she is finding it increasingly difficult to think of not seeing him anymore. she has grown to love him. she wonders if they could continue to see each other socially and romantically. at first clint is taken aback. but he also realizes that throughout the relationship he has come to admire and respect adriana, and he discloses his fondness for her. he explains to her that because of their professional relationship he is bound by ethical guidelines not to become nvolved with parents socially or romantically. he suggests to her that they not see each other for a year. if their feelings persist, he will then consider initiating a personal relationship. • What do you think of clint’s way of handling the situation? • What possible negative implications might there be for adriana and her son? • is clint making himself vulnerable to professional misconduct in any way? • if you were in a similar situation and did not want to pursue the relationship, how might you deal with your client’s disclosure? • What personal values or life experiences have you had that might influence the way you respond in this case? Commentary. We agree with clint’s decision to refuse to initiate a romantic relationship with adriana at this time. clint should carefully consider his ethical obligations bearing on romantic and sexual relationships with former clients or their family members. the aca (2014) code explicitly prohibits such relationships for a period of 5 years following the termination of ser- vices. the apa (2010) code specifies a moratorium of 2 years, and the aaMft (2015) code prohibits sexual intimacy with former clients regardless of time elapsed. if clint does commence a romantic relationship with adriana in the future, he will bear the burden of showing that this change in roles was not harmful to her. if their relationship were to end, clint would not be protected should adriana report him for professional misconduct. if the boundaries involved in the therapeutic relationship are identified in our informed con- sent document, situations such as this are likely to be less complicated. growing fond of each other is not an ethical violation, but how we act on our feelings toward our clients determines our degree of ethical and professional behavior. • LO11 Sexual Relationships in Therapy: Ethical and Legal Issues It is important to realize that the relationship between therapist and client can involve varying degrees of sexuality. Therapists may have sexual fantasies, they may behave seductively with their clients, they may influence clients to focus on sexual feelings toward them, or they may engage in physical contact that is pri- marily intended to satisfy their own needs. Sexual contact in therapy is not a sim- ple matter limited to having sex with a client. Practitioners need to differentiate between a sexual attraction and acting on this attraction. Sexual overtones can distort the therapeutic relationship and become the primary focus of the sessions. We need to be aware of the effects of our sex-related socialization patterns and how they may influence possible countertransference reactions. A number of studies have documented the harm that sexual relationships with clients can cause. Other research highlights the damage done to students and supervisees when educators and supervisors enter into sexual relationships with them (see Chapter 9). Later in this section we discuss the negative effects that typically occur when the client–therapist relationship becomes sexualized. Ethical Standards on Sexual Contact With Clients Sexual relationships between therapists and clients continue to receive consider- able attention in the professional literature. Sexual relationships with clients are clearly unethical, and all of the major professional ethics codes have specific pro- hibitions against them (see the Ethics Codes box titled “Sexual Contact and the Therapeutic Relationship”). In addition, most states have declared such relation- ships to be a violation of the law. If therapists have had a prior sexual relationship with a person, many of the ethics codes also specify that they are prohibited from accepting this person as a client. It is clear from the statements of the major mental health organizations that these principles go beyond merely condemning sexual relationships with clients. The existing codes are explicit with respect to sexual harassment and sexual relationships with clients, students, and supervisees. How- ever, they do not, and maybe they cannot, define some of the more subtle ways that sexuality can enter the professional relationship. 288 / chapter 7 Copyright 2019 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-202 Copyright 2019 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. ETHICS CODES: Sexual Contact and the Therapeutic Relationship American Association for Marriage and Family Therapy (2015) Sexual intimacy with current clients or with known members of the client’s family system is prohibited. (1.4.) American Counseling Association (2014) Sexual and/or romantic counselor–client interactions or relationships with current clients, their romantic partners, or their family members are prohibited. This prohibition applies to both in-person and electronic interactions or relationships. (A.5.a.) American Mental Health Counselors Association (2015) Romantic or sexual relationships with clients are strictly prohibited. Mental health counselors do not counsel persons with whom they have had a previous sexual relationship. (A.4.a.) American Psychological Association (2010) Psychologists do not engage in sexual intimacies with current clients/patients. (10.05.) Psychologists do not engage in sexual intimacies 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. (10.06.) Psychologists do not accept as therapy clients/patients persons with whom they have engaged in sexual intimacies. (10.07.) National Association of Social Workers (2008) Social workers should under no circumstances engage in sexual activities or sexual contact with current clients, whether such contact is consensual or forced. (1.09.a.) Social workers should not provide clinical services to individuals with whom they have had a prior sexual relationship. Providing clinical services to a former sexual partner has the potential to be harmful to the individual and is likely to make it difficult for the social worker and individual to maintain appropriate professional boundaries. (1.09.d.) American Psychiatric Association (2013b) The requirement that the physician conduct himself/herself with propriety in his or her profession and in all the actions of his or her life is especially important in the case of the psychiatrist because the patient tends to model his or her behavior after that of his or her psychiatrist by identification. Further, the necessary intensity of the treatment relationship may tend to activate sexual and other needs and fantasies on the part of both patient and psychiatrist, while weakening the objectivity necessary for control. Additionally, the inherent inequality in the doctor-patient relationship may lead to exploitation of the patient. Sexual activity with a current or former patient is unethical. (2.1.) Sexual misconduct is considered to be one of the more serious of all ethical violations for a therapist, and it is also one of the most common allegations in mal- practice suits (APA, 2003b). Grenyer and Lewis (2012) examined the prevalence of all forms of psychologist misconduct reported to the New South Wales Psycholo- gists Registration Board over a period of 4 years. Of the 9,489 registered psycholo- gists, complaints had been filed against 224 of them, resulting in 248 independent notifications of misconduct (some were recipients of more than one complaint). Of these complaints, 24 were related to boundary violations: 10 of the boundary vio- lation complaints involved sexual relationships, and 4 involved sexual behavior without a relationship. The Scope of the Problem Many professional journals review disciplinary actions taken against thera- pists who violate ethical and legal standards, and most of these cases involve sexual misconduct. Brief summaries of a few of these cases provide a picture of how therapists can manipulate clients to meet their own sexual or emo- tional needs. • Aclinicalsocialworkerengagedinunprofessionalconductwhenheexchanged a romantic kiss with a client. The clinician used his relationship with another client to further his own personal, religious, political, or business interests. He engaged in a sexual relationship with a former client, less than 3 years after termination of the professional relationship (California Association of Marriage and Family Ther- apists [CAMFT], 2004b, p. 49). • A licensed marriage and family therapist engaged in inappropriate discussions and sexual relationships with a client. The therapist discussed intimate aspects of his personal life with his client, engaged in multiple relationships with the client, watched a sexually explicit movie with her, and accepted a nude photograph of the client. He failed to schedule appointments with the client at appropriate times, scheduling them instead for the evening hours. He failed to refer her to another therapist (CAMFT, 2004c, p. 50). • A licensed marriage and family therapist was charged with committing sexual misconduct and gross negligence. When his client, a woman with a history of alco- hol dependency and psychologically abusive relationships with men, revealed her sexual attraction to him, this therapist disclosed his mutual attraction to her and did not attempt to redirect her feelings or discuss the transference issue. He talked about his sexual fantasies in their sessions and expressed disappointment that they were prevented from having sex. He revealed personal details about himself and talked to her on the phone at night and on weekends, sometimes in a flirtatious fashion. After talking with her Alcoholics Anonymous sponsor, the client began to understand that her therapist was harming her. The client shared her confusion about their relationship directly with her therapist, but he did not respond well, which left the client feeling distraught. The therapist made no attempts to counsel her or to refer her to a different therapist (CAMFT, 2010, pp. 55–57). • A licensed clinical social worker was accused of unprofessional conduct in the form of gross negligence. She moved in with a patient who had been under her direct care only 2 months earlier in a hospital setting. She reported feeling a spiritual connection with him and, upon further investigation, was found to be intimately dating him. Her former patient dropped out of two recovery pro- grams, and the social worker moved out of his residence after a few months. Her employment at the hospital was terminated, and she was subject to further disciplinary action for recklessly causing emotional harm to a client (CAMFT, 2011b, pp. 40–41). Harmful Effects of Sexual Contact With Clients Studies continue to demonstrate that clients who are the victims of sexual mis- conduct suffer dire consequences. Erotic contact is totally inappropriate, is always unethical, and is an exploitation of the relationship by the therapist. Therapist– client sexual contact is the most potentially damaging boundary violation. Mental health professionals cannot argue that their clients seduced them. Even if clients behave in seductive ways, it is clearly the professional’s responsibility to estab- lish and maintain appropriate boundaries. To blame the client in these cases is as inappropriate as blaming a victim in a rape case. Bouhoutsos and colleagues (1983), in a pioneering study of sexual contact in psychotherapy, assert that when sexual intercourse begins, therapy as a help- ing process ends. When sex is involved in a therapeutic relationship, the thera- pist loses control of the course of therapy. Of the 559 clients in their study who became sexually involved with their therapists, 90% were adversely affected. This harm ranged from mistrust of opposite-gender relationships to hospital- ization and, in some cases, suicide. Other effects of sexual intimacies on clients’ emotional, social, and sexual adjustment included negative feelings about the experience, a negative impact on their personality, and a deterioration of their sexual relationship with their primary partner. Bouhoutsos and her colleagues conclude that the harmfulness of sexual contact in therapy validates the ethics codes barring such conduct and provides a rationale for enacting legislation pro- hibiting it. Decades have passed since that pioneering research was conducted, but their findings remain relevant today. Eichenberg, Becker-Fischer, and Fischer (2010) state that the consequences of sexual misconduct with therapy patients “are con- sistent in all international literature: all empirical studies that are available to date show very negative consequences for the victims” (p. 1019). These researchers reported that 86.5% of their study participants experienced consequences as a result of the sexual contact they had with their therapists. Of these, 93.3% experi- enced problematic consequences such as isolation, stronger distrust, fear, depres- sion, feelings of shame and guilt, suicidal tendencies, anger, and posttraumatic stress disorder. Legal Sanctions Against Sexual Violators A number of states have enacted legal sanctions in cases of sexual misconduct in the therapeutic relationship, making it a criminal offense. Among the neg- ative consequences for therapists include being the target of a lawsuit, bein convicted of a felony, having their license revoked or suspended by the state, being expelled from professional organizations, losing their insurance cov- erage, and losing their jobs. Therapists may also be placed on probation, be required to undergo their own psychotherapy, be closely monitored if they are allowed to resume their practice, and be required to obtain supervised practice. In addition, their reputation is likely to suffer among their colleagues and other practitioners. Criminal liability is rarely associated with the practices of mental health pro- fessionals. However, some activities can result in arrest and incarceration, and the number of criminal prosecutions of mental health professionals is increasing. The two major causes of criminal liability are sex with clients (and former clients) and fraudulent billing practices (Reaves, 2003). In California, the law prohibiting sexual activity in therapy applies to two situations: (1) the therapist has sexual contact with a client during therapy, or (2) the therapist ends the professional relationship primarily to begin a sexual rela- tionship with a client. Therapists who have sex with clients are subject to both a prison sentence and fines. For a first offense with one victim, an offending ther- apist would probably be charged with a misdemeanor, with a penalty of a sen- tence up to 1 year in county jail and a fine up to $1,000. For second and following offenses, therapists may be charged with misdemeanors or felonies. For a felony charge, offenders face up to 3 years in prison, or up to $10,000 in fines, or both. In addition to criminal action, civil action can be taken against therapists who are guilty of sexual misconduct. Clients may file civil lawsuits to seek money for damages or injuries suffered and for the cost of future therapy sessions (California Department of Consumer Affairs, 2011). Assisting Victims in the Complaint Process Each of the mental health professional associations has specific policies and procedures for reporting and processing ethical and professional misconduct. (Chapter 1 lists these organizations and provides contact information.) Mental health professionals have an obligation to help increase public awareness about the nature and extent of sexual misconduct and to educate the public about pos- sible courses of action. The California Department of Consumer Affairs (2011) booklet, “Professional Therapy Never Includes Sex,” describes ethical, legal, and administrative options for individuals who have been victims of professional misconduct. Although the number of complaints of sexual misconduct against thera- pists has increased, individuals are still reluctant to file complaints for disci- plinary action against their therapists, educators, or supervisors. Eichenberg and colleagues (2010) report that two thirds of study respondents said they never thought about taking legal steps, and among those who did, many decided not to follow through and initiate legal action. Clients are often unaware that they can file a complaint, and they frequently do not know the avenues available to them to address sexual misconduct. Each of the following options has both advantages and disadvantages, and it is ultimately up to the client to decide the best course of action. Clients can file an ethics complaint with the therapist’s licensing board. The board reviews the case, and if the allegation is supported, the board has the power to discipline a therapist using the administrative law process. Depending on the violation, the board may revoke or suspend a license. When a license is revoked, the therapist cannot legally practice. When sexual misconduct is admitted or proven, most licensing boards will revoke the therapist’s license. The board’s action is often published in the journal of the therapist’s professional organization. Legal alternatives include civil suits or criminal actions. A malpractice suit on civil grounds seeks compensatory damages for the client for the cost of treatment and for the suffering involved. Criminal complaints are processed based on state and federal statutes. Sexual Relationships With Former Clients Most professional organizations prohibit their members from engaging in sexual relationships with former clients because of the potential for harm. Some organi- zations specify a time period, and others do not. Most of the organizations state that in the exceptional circumstance of sexual relationships with former clients— even after a 2- to 5-year interval—the burden of demonstrating that there has been no exploitation clearly rests with the therapist. (For guidelines for particular pro- fessional associations, refer to the Ethics Codes box titled “Sexual Relationships With Former Clients.”) 292 / chapter 7 Copyright 2019 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-202 Copyright 2019 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. ETHICS CODES: Sexual Relationships With Former Clients American Psychological Association (2010) (a) Psychologists do not engage in sexual intimacies with former clients/patients for at least two years after cessation or termination of therapy. (b) Psychologists do not engage in sexual intimacies with former clients/patients even after a two-year interval except in the most unusual circumstances. Psychologists who engage in such activity after the two years following cessation or termination of therapy and of having no sexual contact with the former client/patient 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. (10.08.) American Counseling Association (2014) Sexual or romantic counselor–client interactions or relationships with former clients or their family members are prohibited for a period of five years following the last professional contact. This prohibition applies to both in-person and electronic interactions or relationships. Counselors, before engaging in sexual and/or romantic interactions or relationships with former clients, their romantic partners, or their family members demonstrate forethought and document (in written form) whether the interaction or relationship can be viewed as exploitive in any way and/or whether there is still potential to harm the former client; in cases of potential exploitation and/or harm, the counselor avoids entering such an interaction or relationship. (A.5.c.) ETHICS CODES: Sexual Relationships With Former Clients continued American Mental Health Counseling Association (2015) Mental health counselors are strongly discouraged from engaging in romantic or sexual relationships with former clients. Counselors may not enter into an intimate relationship until five years post termination or longer as specified by state regulations. Documentation of supervision or consultation for exploring the risk of exploitation is strongly encouraged. (A.4.b.) Commission on Rehabilitation Counselor Certification (2010) Sexual or romantic rehabilitation counselor–client interactions or relationships with former clients, their romantic partners, or their immediate family members are prohibited for a period of five years following the last professional contact. Even after five years, rehabilitation counselors give careful consideration to the potential for sexual or romantic relationships to cause harm to former clients. In cases of potential exploitation and/or harm, rehabilitation counselors avoid entering such interactions or relationships. (A.5.b.) National Association of Social Workers (2008) 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. (1.09.c.) American Association for Marriage and Family Therapy (2015) Sexual intimacy with former clients or with known members of the client’s family system is prohibited. (1.5.) Transforming a Professional Relationship Into a Personal Relationship A therapist should seek consultation or personal therapy to explore his or her motivations and the possible ramifications of transforming a professional relation- ship into a personal one. When considering initiating such a relationship, many factors must be evaluated. These include the amount of time that has passed since termination of therapy, the nature and duration of therapy, the circumstances sur- rounding termination of the professional–client relationship, the client’s personal history, the client’s competence and mental status, the foreseeable likelihood of harm to the client or others, and any statements or actions by the therapist suggest- ing a plan to initiate a sexual relationship with the client after termination. Koocher and Keith-Spiegel (2016) state that sexual relationships with former clients involve such a high potential for a number of risks that they strongly discourage them, regardless of the lapse of time stipulated in ethics codes. Some counselors maintain, “Once a client, always a client.” Although a blan- ket prohibition on sexual intimacies, regardless of the time that has elapsed since termination, might clarify the issue, some contend that this measure is too extreme (Shavit & Bucky, 2004). Others point out the significant differences between an intense, long-term therapy relationship and a less intimate, brief-term one. A blan- ket prohibition ignores these distinctions. Reflecting the lack of consensus on this issue, 42.9% of the ACA members surveyed by Neukrug and Milliken (2011) hought it was ethical to become sexually involved with a former client at least 5 years after the counseling relationship ended; the other 57.1% viewed this as unethical behavior. Examine Your Position At this point, reflect on your own stance on the controver- sial issue of forming sexual relationships once therapy has ended. Consider these questions in clarifying your position: • Should counselors be free to formulate their own practices about developing sexual relationships with former clients? Give your reasons. • Does the length and quality of the therapy relationship have a bearing on the ethics involved in such a personal relationship? Would you apply the same standard to a long-term client and a brief therapy client who worked on per- sonal growth issues for 6 weeks? • Would you favor changing the ethics codes to include an absolute ban on post- termination sexual relationships regardless of the length of time elapsed? Why or why not? • What ethical guidelines would you suggest regarding intimate relationships with former clients? • Although it might not be illegal in your state, what are the potential conse- quences of engaging in sex with former clients? Explain. • React to the statement, “Once a client, always a client.” A Special Case: Nonerotic Touching With Clients LO12 We include the discussion of nonerotic touching in this chapter because it is perhaps one of the more controversial boundary crossings. Although some are concerned that nonsexual touching can eventually lead to sexual exploitation, nonerotic touching can be appropriate and can have significant therapeutic value. A therapist’s touch can be a genuine expression of caring and compas- sion; touch can be reassuring and a part of the healing process. Such touching also might be done primarily to gratify the therapist’s own needs, so thera- pists must carefully assess the appropriateness of touching clients (Koocher & Keith-Speigel, 2016). It is inappropriate to touch some clients under any circum- stances. Zur (2007) and Zur and Nordmarken (2009) write that touch needs to be evaluated in the context of client factors, the professional setting, the ther- apist’s theoretical orientation, and the quality of the therapeutic relationship. Client factors include gender, age, culture, class, personal history with touch, presenting problem, diagnosis, and personality. For some clients touching may be appropriate and therapeutic, whereas the same kind of touch may be inap- propriate and harmful for other clients. According to Zur and Nordmarken, a growing body of research indicates the potential clinical value of nonerotic touch as an adjunct to verbal therapy. Clinically appropriate touch can increase a client’s trust and ease with the therapist and can be effective in enhancing the therapeutic alliance. There is another side to the issue of nonerotic touching. Some clinicians warn of the dangers of physical contact; others oppose any form of physical contact between counselors and clients on the grounds that it can promote dependency, can interfere with the transference relationship, can be misread by clients, and can become sexualized. Pope and Wedding (2014) remark on other dangers: “When discordant with clinical needs, context, competence, or consent, even the most well-intentioned nonsexual physical contact may be experienced as aggressive, frightening, intimidating, demeaning, arrogant, unwanted, insensitive, threaten- ing, or intrusive” (p. 585). Gutheil and Brodsky (2008) contend that the question of touch in therapy must be approached with caution and clinical understanding. Stating that “there are virtually no circumstances in which it is appropriate for a therapist to initiate a hug with a patient,” Gutheil and Brodsky believe a therapist may accept a hug from a client in rare cases, such as from a client in profound grief who reaches out to a therapist or from a client at the conclusion of an extended course of therapy (p. 167). In our view, it is critical to determine whose needs are being met when it comes to touching. If it comes from the therapist alone, and not from the context of the therapeutic relationship, it should be avoided. If touching occurs, it should be a spontaneous, nonsexual, and honest expression of the therapist’s feelings and always done for the client’s benefit. It should not be done as a technique. It is unwise for therapists to touch clients if this behavior is not congruent with what they feel. A touch that is not genuine will most likely be detected by clients and could erode trust in the relationship. Touching is counterproductive when it distracts clients from experiencing what they are feeling, or when clients do not want to be touched. Some clients may interpret any physical contact based on their experience in other dysfunc- tional past relationships. The therapist must approach any contact with caution as the therapist cannot know how clients will interpret or react to touch. Clients from abusive backgrounds may confuse a therapeutic physical contact with an expression of dominance or as a way of inflicting harm. With these clients, any kind of touch may have sexual connotations (Gutheil & Brodsky, 2008). Physical contact with clients must be carefully considered in context because a touch given at the right moment can convey far more empathy than words can. Therapists need to be aware of their own motives and to be honest with themselves about the meaning of physical contact. They also need to be sensitive to factors such as the client’s readiness for physical closeness, the cli- ent’s cultural understanding of touching, the client’s reaction, the impact such contact is likely to have on the client, and the level of trust that they have built with the client. Ethical and Clinical Considerations of Nonsexual Touch in Therapy Practitioners need to formulate clear guidelines and consider appropriate bound- aries when it comes to touching. In Neukrug and Milliken’s study (2011), 83.9% of the counselors surveyed endorsed the idea that it was ethical to console clients using nonerotic touch, such as touching their shoulder, and 66.7% believed it was ethical to hug clients. Think about your position on the ethical implications of the practice of touching as part of the client–therapist relationship by answer- ing these questions: • What criteria could you use to determine whether touching your clients is therapeutic or countertherapeutic? • Do you give hugs routinely in your personal life? If not, what motivates you to give hugs as a professional? • To what degree do you think your professional training has prepared you to determine when touching is appropriate and therapeutic? • What factors should you consider in determining the appropriateness of touching clients? (Examples are age, gender, the type of client, the nature of the client’s problem, and the setting in which the therapy occurs.) • What would you do if your client wanted a hug but you were hesitant to do so? How would you explain your reservation to the client? Zur and Nordmarken (2009) note that touch in therapy is not inherently unethical and that none of the codes of ethics of professional organizations view touch as unethical. They also suggest that practicing risk management by rigidly avoiding touch may be unethical. They do suggest that therapists seek consulta- tion in using touch in complex and sensitive cases. Documentation of the type and frequency of touch, along with the clinical rationale for using touch, is an impor- tant aspect of ethical practice. Zur and Nordmarken identify the following ethical and clinical guidelines for nonsexual touch in therapy: • Touch should be employed only when it is likely to have a positive therapeutic effect. • Touch should be used in accordance with the therapist’s training and competence. • It is essential that therapists create a foundation of client safety and empower- ment before using touch. • In deciding to touch, it is important to thoughtfully consider the client’s poten- tial perception and interpretation of touch. • Special care is important in using touch with people who have experienced assault, neglect, attachment difficulties, rape, molestation, sexual addictions, or intimacy issues. • It is the responsibility of therapists to explore their personal issues regarding touch and to seek education and consultation regarding the appropriate use of touch in therapy. • Therapists should not avoid touch out of fear of licensing boards or the dread of litigation. • Clinically appropriate touch must be used with sensitivity to clients’ variables such as gender, culture, problems, situation, history, and diagnosis. Zur and Nordmarken emphasize that it is critical for therapists to be mindful of not abusing the trust and power they have in the therapeutic relationship. They remind us that power by itself does not corrupt; rather, it is the lack of personal integrity on the therapist’s part that corrupts The Case of Sienna austin is a warm and kindly counselor who routinely embraces his clients, both male and female. One of his clients, sienna, has had a hard life, has had no success in maintaining rela- tionships with men, is now approaching her 40th birthday, and has come to him because she is afraid that she will be alone forever. she misreads his friendly manner of greeting and assumes that he is giving her a personal message. at the end of one session when he gives his usual embrace, she holds onto him and does not let go right away. Looking at him, she says: “this is special, and i look forward to your hugs.” he is surprised and embarrassed. he explains to her that she has misunderstood his gesture, that this is the way he is with all of his clients, and that he is truly sorry if he has misled her. she is crestfallen and abruptly leaves the office. she cancels her next appointment. • What are your thoughts on this counselor’s manner of touching his clients? • if austin had asked for sienna’s permission to hug her at the end of a session, would that have been more acceptable? • Would you feel differently if sienna had been the one to initiate the hugs? • Was the manner in which he dealt with sienna’s embrace ethically sound? • Would you follow up with sienna about canceling her appointment? Commentary. in our opinion, this case is a good example of a situation in which the counselor was more concerned with the bind he was in than the bind his client was in. the nature of a therapist’s work is to take care of the client’s difficulty first. austin assumed that he correctly understood sienna’s message, and his response served his emotional needs rather than sien- na’s. had austin put his client’s needs first, he would have encouraged sienna to discuss the meaning for her of the embrace. austin also must be mindful of his own possible counter- transference and how this could be affecting the manner in which he interpreted sienna’s comments. counselors need to be cautious in applying “routine” practices without consid- ering their unique relationship with the client as well as the client’s particular concerns being addressed in counseling. touching should be approached with caution and with respect for the client’s boundaries. • Chapter Summary In this chapter we have tried to put ethical issues pertaining to multiple relationships into perspective. We have emphasized that dual and multiple relationships are nei- ther inherently unethical nor always problematic. Multiple relationships are unethi- cal, however, when they result in exploitation or harm to clients. We have attempted to avoid being prescriptive and have summarized a range of recommendations offered by others to reduce the risk of boundary crossings and boundary violations— recommendations we expect will increase the chances of protecting both the client and the therapist. Although ethics codes provide general guidance, you will need to weigh many specific variables in making decisions about what boundaries you need to establish in your professional relationships. The emphasis in this chapter has been on guidelines for making ethical decisions about nonsexual multiple relationships, which often tend to be complex and defy simplistic solutions. To promote the well-being of their clients, clinicians are challenged with balancing their own values and life experiences with ethics codes as they make choices regarding how to best help their clients (Moleski & Kiselica, 2005). Sexual relationships with clients are clearly unethical and detrimental to clients’ wel- fare. It is unwise, unprofessional, unethical, and in many states illegal to become sexually involved with clients. However, it is important not to overlook some of the more subtle and perhaps insidious behaviors of the therapist that may in the long run cause serious damage to clients. It is unrealistic for therapists to believe they will never be attracted to certain clients. You are imposing an unnecessary burden on yourself if you believe that you should not have such feelings for clients or if you try to convince yourself that you should not have more feeling toward one client than toward another. It is important to decide how you will deal with these feelings as they affect the therapeutic relationship. Referral to another therapist is not necessarily the best solution, unless it becomes clear that you can no longer be effective with a certain client. Instead, you may recognize a need for consultation or, at the very least, for an honest dialogue with your colleagues. If for some reason your feelings of attraction become known to the client, it is essential that the client be assured that they will not be acted upon. If this creates a problem for the client, a referral should be discussed. We want to stress the importance of reflecting on what you are doing and on whose needs are primary. A willingness to be honest in your self-examination is your greatest asset in becoming an ethical practitioner. As was mentioned earlier, it is always good to keep in mind whether you would act differently if your colleagues were observing you. Suggested Activities 1. Investigate the ethical and legal aspects of multiple relationships as they apply to your professional interests. Look for any trends, special problems, or alternatives. Once you have gathered materials and ideas, present your findings in class. 2. Some say that multiple relationships are inevitable, pervasive, and unavoidable and have the potential to be either beneficial or harmful. Form two teams and debate the core issues. Have one team focus on the potential benefits of multiple relationships and argue that they cannot be dealt with by simple legislative or ethical mandates. Have the other team argue the case that multiple relationships are unethical and provide reasons. 3. Write a brief paper on your position on multiple relationships in counseling. Take some small aspect of the problem, develop a definite position on the issue, and present your own views. 4. What are your views about bartering with clients? Discuss the circumstances under which you might agree to barter with a client as well as those under which you would not agree. What guidelines would you need to establish? What are the ethical issues involved? 5. Discuss in a small group the issue of a sexual attraction in counseling. Explore how you might react if you found yourself attracted to a client. How might you respond to a client who reveals an attraction to you?