Module 5
Boundaries
a. Introduction
The terms dual relationships and multiple relationships are used
interchangeably in various professional codes of ethics, and the ACA (2014) uses the
term nonprofessional relationships. In this 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 relationships 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
manage multiple relationships, including dealing with the power differential that is a
part of most professional relationships, managing boundary issues, and striving 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 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.
Focuses on boundary issues in professional practice, establishing appropriate
boundaries, the difference between boundary crossings and boundary violations,
multiple relationships, role blending, a variety of nonsexual multiple 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.
b. The Ethics of Multiple Relationships
The codes of ethics of most professional organizations warn of the potential
problems of multiple relationships (see the Ethics Codes box titled “Standards on
Multiple 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. Nonsexual
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.
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, especially 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 simplistic 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.
Although the codes of ethics of most professions caution against engaging 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 mentors often balance a multiplicity of
roles, some of which include teacher, counselor, 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 nonsexual multiple relationships in counseling. When considering such a
relationship, practitioners must examine their motivations and consult with other
professionals 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 minimize the
likelihood of harm coming to the client. It is good practice to document precautions
practitioners take to protect clients when such relationships are unavoidable.
Moleski and Kiselica (2005) believe multiple relationships range from the
destructive to the therapeutic. Although some multiple relationships are harmful, other
secondary relationships complement, enable, and enhance the counseling relationship.
Moleski and Kiselica encourage counselors to examine the potential positive and
negative consequences that a secondary relationship might have on the primary
counseling relationship.
They suggest that counselors consider forming 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”
In answering these questions, practitioners must carefully assess the risk for
conflict of interests, loss of objectivity, and implications for the therapeutic
relationship. 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 management approach to the problem. This involves a careful review of various
issues such as diagnosis, level of functioning, therapeutic orientation, community
standards 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”
Certain behaviors of professionals have the potential for creating a multiple
relationship, 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 relationships. They distinguish between
boundary crossings (changes in role) and boundary 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 therefore 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
acceptance 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
counselor 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. Counselors must
consider a range of factors such as the client’s history, his or her presenting 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 therapists 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 Cartwright
(2015) found that boundary violations were the most pervasive themes. Barnett
(Barnett, Lazarus, et al., 2007) states that even for well-intentioned clinicians,
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 client, 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 multiple 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.
Changes in mental health care laws and practice have increased the need for
outreach psychotherapists 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
relationship 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 preparing
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 malpractice 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.
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 relationship 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, defining, 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 embracing a broader understanding of boundaries, Speight was able to be
genuine and close in her therapeutic relationships without being inappropriate and
exploitative. “I was flexible with my boundaries, in a way that felt entirely consistent
culturally 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” 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.
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 development. 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, professionals have a responsibility to design safeguards to reduce the potential
for harm.
Professionals get into trouble when their boundaries 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 Gabbard (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 increasingly serious boundary violations can lead to
a progressive deterioration of ethical behavior. Furthermore, if professionals do not
adhere to uncompromising standards, 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. 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.
c. 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 decisions 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.
A rigid risk-avoidance application of boundaries can be harmful to clients by
creating 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 discern 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 elements 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.
d. 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 clinician, 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. Clinicians may attend the same church or
community activities as the clients they serve. A therapist who is a recovering
alcoholic and attends Alcoholics Anonymous meetings may meet a client at one of
these meetings. In an isolated 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.
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 anything
but the neat-and-tidy model in which a practitioner sees each individual client one
hour per week in a single office”. To protect client confidentiality 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.
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 confidentiality, 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 therapist 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.
I discussed with my clients the unique variables pertaining to confidentiality 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 person 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
counseling issues. Instead, I kept the conversation general. Had I not acknowledged
her, this most likely would have offended her. All of these examples present possible
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 useful to rely
on rigid rules and policies; you must be ready to creatively adapt to situations as they
unfold.
e. 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 example, 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 therapist’s car in
exchange for one therapy session, this client might become resentful 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. Certainly, many problems can arise
from these kinds of exchanges for both therapists and clients.
Before bartering is entered into, both parties need to talk about the
arrangement, 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
possible 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 treatment 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
humanitarian practice when people require psychological services but do not have
insurance 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 arrangements 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 psychological
services. Forester-Miller (2015) addresses the difficulties involved in avoiding
overlapping relationships in rural communities and reminds counselors 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 themselves 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
psychological 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 relationship requires careful
thought and judgment. In making decisions about bartering, 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.
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 client. 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.
The client may not realize the potential conflicts and problems involved in
bartering. It is the counselor’s responsibility to enumerate the potential problems and
risks in bartering. We highly recommend a straightforward discussion with your client
about the pros and cons of bartering in your particular situation, 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 potential 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.
f. 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
Ethics 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
establishing a hard and fast rule, our preference is to evaluate each situation on a case-
bycase 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
client 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.
What are the clinical implications of accepting or rejecting the gift? It is
important 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 discussion 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.
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 common 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 client’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 counselors 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.
g. Social Relationships With Clients
Do social relationships with clients necessarily interfere with therapeutic
relationships? Some would say no, contending that counselors and clients are able to
handle 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 establishing 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) therapists 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 differential in the therapeutic
relationship.
The cultural context can play a role in evaluating the appropriateness of dual
relationships that involve friendships in the therapy context. Parham and Caldwell
(2015) question Western ethical standards that discourage dual and multiple
relationships 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 confined 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.
Mental health professionals are not legally or ethically prohibited from
entering into a nonsexual relationship with a client after the termination of therapy.
However, 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
motivations, as well as the motivations of their clients, when allowing a professional
relationship 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 developing
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.
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 psychoanalytically
oriented, you might adopt stricter boundaries and would be concerned about infecting
the transference relationship should you blend any form of socializing 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 honesty
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
inappropriate 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.
h. Sexual Attractions in the Client–Therapist Relationship
Are sexual attractions to be expected in therapy? In a classic and pioneering
study, Pope, Keith-Spiegel, and Tabachnick (1986) addressed the lack of systematic
research into the sexual attraction of therapists to their clients. Pope and his
colleagues studied 585 respondents, and only 77 reported never having been attracted
to any client. The vast majority (82%) reported that they had never seriously
considered actual sexual involvement with a client. An even larger majority (93.5%)
reported never having had sexual relations with their clients. Therapists gave a
number of reasons for having refrained from acting out their attractions to clients,
including a need to uphold professional values, a concern about the welfare of the
client, and a desire to follow personal values. Fears of negative consequences were
mentioned, but they were less frequently cited than values pertaining to client welfare.
Those who had some graduate training in this area were more likely to have sought
consultation (66%) than those with no such training.
The tendency to treat sexual feelings as if they are taboo has made it difficult
for therapists to acknowledge and accept attractions to clients. 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 feelings rather than acknowledge and deal with sexual
feelings by consulting a colleague 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 attractions.
This lack of knowledge inspired a group of researchers to examine this phenomenon.
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”
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 yourself
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 supervision. 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.
Training programs have an ethical responsibility to help students identify and
openly discuss their concerns pertaining to sexual dilemmas in counseling practice.
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 therapists 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 injunction 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
attraction, sexual fantasy, sexual advances of clients, romantic relationships with
former clients, and sexual discussions in therapy. These topics should be included in
training programs.
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 therapists to
recognize their countertransference reactions and deal with and manage them.
Burwell-Pender and Halinski (2008) point out that “the potential for sexual
impropriety and sexual misconduct is increased with unmanaged countertransference”
(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 possibility 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 discussion at the
initial session. Knapp, Handelsman, Gottlieb, and Vandecreek (2013) point out that
harm can be done by disproportionately emphasizing certain 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 considered. Such statements could also cause some patients to
wonder if this psychologist 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.
i. 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 primarily
intended to satisfy their own needs. Sexual contact in therapy is not a simple 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. Later in this section we discuss the negative effects that
typically occur when the client–therapist relationship becomes sexualized.
Sexual relationships between therapists and clients continue to receive
considerable attention in the professional literature. Sexual relationships with clients
are clearly unethical, and all of the major professional ethics codes have specific
prohibitions against them (see the Ethics Codes box titled “Sexual Contact and the
Therapeutic Relationship”). In addition, most states have declared such relationships
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. However, they do not, and
maybe they cannot, define some of the more subtle ways that sexuality can enter the
professional relationship.
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
malpractice suits (APA, 2003b). Grenyer and Lewis (2012) examined the prevalence
of all forms of psychologist misconduct reported to the New South Wales
Psychologists Registration Board over a period of 4 years. Of the 9,489 registered
psychologists, 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 violation complaints involved sexual relationships, and 4 involved sexual
behavior without a relationship.
Many professional journals review disciplinary actions taken against therapists
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 emotional needs.
Studies continue to demonstrate that clients who are the victims of sexual
misconduct 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 establish 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 helping process ends. When sex is involved in a therapeutic relationship,
the therapist 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 hospitalization 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
prohibiting 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 consistent 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% experienced problematic
consequences such as isolation, stronger distrust, fear, depression, feelings of shame
and guilt, suicidal tendencies, anger, and posttraumatic stress disorder.
A number of states have enacted legal sanctions in cases of sexual misconduct
in the therapeutic relationship, making it a criminal offense. Among the negative
consequences for therapists include being the target of a lawsuit, being convicted of a
felony, having their license revoked or suspended by the state, being expelled from
professional organizations, losing their insurance coverage, 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 professionals. 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.
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 relationship
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 therapist would
probably be charged with a misdemeanor, with a penalty of a sentence 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.
Each of the mental health professional associations has specific policies and
procedures for reporting and processing ethical and professional misconduct. 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 possible
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
therapists has increased, individuals are still reluctant to file complaints for
disciplinary 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 is typically initiated to seek compensatory
damages for the client. These damages aim to cover the cost of treatment that was
either necessary to address the harm caused by the counselor's actions or that resulted
from the counselor's negligence. Additionally, these suits often seek to compensate for
the emotional and psychological suffering the client endured as a consequence of the
malpractice. The process involves a detailed assessment of the financial impact and
the non-economic damages, such as pain and suffering, emotional distress, and loss of
enjoyment of life.
On the other hand, criminal complaints against a counselor are handled
differently. These complaints are processed based on relevant state and federal statutes
that define criminal conduct and prescribe penalties. Unlike civil suits, which are
pursued by the client or their representative, criminal cases are prosecuted by the
state. The focus of these complaints is on determining whether the counselor's actions
constituted a violation of criminal law, which could result in penalties such as fines,
probation, or imprisonment. The standards of proof and the legal procedures in
criminal cases are also distinct, requiring the prosecution to establish the counselor's
guilt beyond a reasonable doubt, whereas civil cases typically require a preponderance
of the evidence.
