Dual Relationships and Psychotherapy

William F. Doverspike, PhD, ABPP

This article is an excerpt from Risk Management: Clinical, Ethical, and Legal Guidelines for Successful Practice (2008). The opinions expressed in this article are those of the author and do not reflect any official policy or opinion of the GPA Ethics Committee or the State Board of Examiners of Psychologists. This article is designed to be educational in nature and is not intended to provide legal advice. The reader is encouraged to contact an attorney for legal advice regarding state laws and administrative rules governing professional conduct.

Ethical problems often arise when therapists blend their professional relationship with other kind of relationships. Dual or multiple role relationships occur when a professional assumes two or more roles at the same time or sequentially with a client or with someone who has a significant relationship with the client. I prefer the use of the term dual relationships rather than the politically correct but the less accurate term multiple relationships. In reality, most boundary crossings involve a duality, rather than a multiplicity, of roles. Even when multiple roles are involved, there is always a dual role before there are multiple roles. In other words, there must be two roles before there can be three or more. There must be a primary role before there can be a secondary role, and there must be a secondary role before there can be a tertiary role, and so on. From the perspective of aspirational ethics, the clinician striving for excellence in boundary management pays attention to maintaining the integrity of boundaries in the primary professional role. If the primary role is managed appropriately, then secondary roles are less likely to develop in the first place. If secondary roles do develop, they are less likely to become problematic.

Dual roles defined
APA (2002, p. 1065) Ethical Standard 3.05 (Multiple Relationships) states the following:

(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 they have the professional relationship, or (3) promises to enter into another relationship in the future with the person or a person 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. (See also Standards 3.04, Avoiding Harm, and 3.07, Third-Party Requests for Services.)

 

Foreseeable and unforeseeable dual roles
Dual roles differ in terms of their predictability or foreseeability. Dual roles can be classified as either foreseeable or unforeseeable. Foreseeable (or contemplated) dual roles are those that the therapist has time to consider or contemplate before engaging in them. An example of a foreseeable dual role would involve considering whether or not to provide psychotherapy to someone with whom you have had a prior social or business relationship (such as one of the fitness trainers or members at your gym). Unforeseeable (unpredictable or random) dual roles are those that cannot be reasonably foreseen. Using the above examples, an unforeseeable rule role might involve joining a gym and later learning that one of the fitness instructors or gym members is one of your former clients. Of course, if you had prior knowledge that your psychotherapy client was also a fitness instructor or gym member, then the subsequent dual role may have been reasonably foreseeable. This framework of classifying dual roles along the dimension of foreseeability is not meant to imply that any of the above roles are ethical or unethical, but simply to clarify the different ways in which dual roles can develop.

In the case of foreseeable or contemplated dual relationships, APA (2002) Ethical Standard 3.05(a) contains a caution: "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" (p. 1065; italics added). In those dual relationships in which a client is eventually perceives harm or exploitation, the burden of proof will fall on the psychologist to demonstrate that the prospective relationship could not reasonably have been expected to result in harm. Adjudication of licensing board complaints is often determined partly by the way that disciplinary boards interpret the meaning of the phrase "could reasonably be expected." The word "reasonably" does not define itself. What is reasonable to one psychologist may not be reasonable to another. As defined in the APA Ethics Code, "the term reasonable means the prevailing professional judgment of psychologists engaged in similar activities in similar circumstances, given the knowledge the psychologist had or should have had at the time" (APA, 2002, p. 1062). In other words, reasonable decisions are based on prevailing professional judgment, which can be discovered through consultation with other professionals. Consultation with a colleague provides an operational definition of reasonable. These considerations highlight the importance of consulting with colleagues in situations involving dual roles or boundary crossings. Of course, the best way to stay out of deep water is to avoid the slippery slope in the first place.

Corey, Corey, and Callanan (2007, p. 275) suggest that counselors ask the simple question, "In what way is what I am contemplating in the best interest of the client?" Lazarus and Zur (2002) provide dozens of practical guidelines related to dual relationships, the first of which states, "Always do whatever it takes to help clients" (p. 473). With respect to contemplated post-therapeutic dual relationships, Gottlieb (1993) advises that the therapist consider three dimensions of the current professional relationship: (1) power differential, (2) duration of relationship, and (3) specificity of termination. The first step involves assessing the current relationship according to the three dimensions of power differential (low, mid-range, and high power), duration of relationship (brief, intermediate, long duration), and specificity of termination (specific, uncertain, and indefinite termination). From the perspective of the client, where does the relationship fall on each of these dimensions? The second step involves examining of the contemplated relationship along the three dimensions, as was done for the current relationship. The third step involves examining both relationships for role incompatibility if they fall within the mid-range or to the left side of the dimensions. The final step involves obtaining consultation from a colleague before proceeding with the contemplated secondary relationship.

 

In the case of unforeseeable dual relationships, APA (2002) Ethical Standard 3.05(b) states, "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" (p. 1065). Resolving the dilemma of duality may include several options such as discussing the matter with the client, consulting with a colleague, considering termination of the secondary role, considering termination of the primary professional role, and so forth. Regardless of the option, the ultimate ethics question is, "What is in the best interest of the client?"

 

Concurrent and consecutive dual roles
Dual roles can also be classified as either concurrent or consecutive in time. Concurrent (or simultaneous) dual roles exist when a therapist has two roles at the same time with the same client, or with a person who is in a significant relationship with the client. In other words, the two roles occur simultaneously. For example, a concurrent or simultaneous dual role might involve beginning family therapy and then later learning that one of the members of the family is currently on your child’s soccer team. Consecutive (or sequential) dual roles involve a prior relationship that involves either a professional or nonprofessional role followed by the development of a second relationship at a later point in time. An example of a consecutive or sequential dual role might involve joining a gym and later learning that one of the fitness instructors is one of your former clients, in which the professional relationship was primary and then the business or social role developed secondarily. Another example might involve a situation in which the social or business role came first, such as providing psychotherapy to someone with whom you have had a prior social or business relationship (such as one of the fitness trainers at the gym). This classification of dual roles along the dimension of time is not meant to suggest that any of the above roles are ethical or unethical, but simply to illustrate the different ways in which dual roles can develop.

Based on the two dimensions of foreseeability and time as described above, it is possible to conceptualize a matrix of the following four types of dual relationships: A foreseeable concurrent dual role might involve considering whether to provide therapy to your personal trainer or a member of the gym where you take an exercise class, whereas an unforeseeable concurrent dual relationship might involve learning that one of your psychotherapy clients is married to your personal trainer or a member of the gym where you take an exercise class. A foreseeable consecutive dual relationship might involve considering whether to provide psychotherapy to your former personal trainer or a former member of the gym where you take an exercise class, whereas an unforeseeable consecutive dual relationship might involve learning that your personal trainer or member of your gym is one of your former psychotherapy clients. Again, this framework of classifying dual relationships is not meant to imply that any of the above types of relationships is ethical or unethical, but simply to clarify the different ways in which dual roles can develop.

Conflicts of interest 
In plain English, dual relationships involve concepts that clients may more readily understand as conflicts of interest, a term that is often more easily used when discussing the potential problems of engaging in dual roles with clients. APA (2002) Ethical Standard 3.06 (Conflict of Interest) states, "Psychologists refrain from taking on a professional role when personal, scientific, professional, legal, financial, or other interests or relationships could reasonably be expected to (1) impair their objectivity, competence, or effectiveness in performing their functions as psychologists or (2) expose the person or organization with whom the professional relationship exists to harm or exploitation" (p. 1065).

 

In my professional practice and in my consultations with colleagues, I often use the simple test of a "conflicts check" to improve ethical vision by assessing whether a contemplated role change will pass the ethical test. Based on APA Ethical Standard 3.06, a conflicts check includes five basic questions, listed in order from the most sensitive to the least sensitive screening criteria. When you are operating in a professional role (e.g., psychotherapist, counselor, employer, supervisor, researcher, teacher) and you are contemplating a dual relationship with a patient, client, employee, supervisee, research participant, or student, consider asking yourself these five questions:

Is there a chance of loss of effectiveness of the professional? If yes, then stop. If no, then proceed to the next step.

Is there a chance of loss of objectivity of the professional? If yes, then stop. If no, then proceed to the next step.

Is there a chance of loss of competence of the professional? If yes, then stop. If no, then proceed to the next step.

Is there a chance of risk of exploitation of the client? If yes, then stop. If no, then proceed to the next step.

Is there a chance of risk of harm of the client? If yes, then stop. If no, then proceed with caution after consulting with a colleague to determine the client’s best interests and to identify any ethical blind spots on the part of the professional.

 

References

American Psychological Association. (2002). Ethical Principles of Psychologists and Code of Conduct. American Psychologist, 57(12), 1060-1073.

Corey, G., Corey, M. & Callanan, M. (2007). Issues and ethics in the helping professions (Seventh ed.). Pacific Grove, California: Brooks/ Cole.

Gottlieb, M. C. (1993). Avoiding exploitive dual relationships: A decision-making model. Psychotherapy, 30, 41-48.

Lazarus, A. A. and Zur, O. (2002). Dual relationships and psychotherapy. New York, NY: Springer Publishing Company.

 

 

APA citation for this article:

Doverspike, W. F. (2008). Dual relationships and psychotherapy. Georgia Psychologist, 62(3), 17.