Timulak, L. (2011). Ethical aspects of psychotherapy and counselling. In Developing your counselling and psychotherapy skills and practice (pp. 78-82). SAGE.
One of the main potential problems for therapy is the nature of multiple or dual relationships. The therapist engages in a dual relationship with a client if, during therapy, before it or after it, their relationship has more than a therapeutic function. The problem of such a relationship is that it undermines the therapeutic work, which depends to a significant degree on the therapeutic relationship. There are also other problems in dual relationships. By their nature, due to the client’s vulnerability, they are not equal relationships. This dynamic can be present even after therapy, if the therapist and the client engage in a further relationship.
The detrimental character of dual relationships is well documented in cases of romantic and sexual relationships between therapists and their clients. The empirical evidence suggests that about 80% of clients experienced such a relationship as harmful (Pope & Vetter, 1992), typically stating that the client’s experience, for example, impaired their ability to mist, led to guilt and confused roles and boundaries (Pope & Vasquez, 2007). Interestingly, male therapists are significantly more likely to be involved in such relationships, and the therapist’s prior boundary-surpassing, problematic behaviour is a much stronger predictor that such a contact will happen than the client’s behaviour (Pope & Vasquez, 2007).
Given the nature and consequences of dual relationships, it is not surprising that many codes of ethics explicitly prohibit such relationships, either for sonic time after the therapy is concluded or completely (Bond, 1993). This has clear relevance as many therapists, during their career, occasionally experience countertransferential attraction to their clients (in fact. this experience relates to more than 80% of therapists though it is more common in male therapists – see Pope, Keith-Spiegel, & Tahachnik, 1986). The way of dealing with this attraction therapeutically, without harming the client, needs further research (see Ladany et al., 1997), though many recommendations exist (Pope & Vasquez. 2007). Slightly less research attention has been devoted to studying dual relationships of a non-sexual nature. Pope and Vasquez (2007) summarise some interesting findings with regard to non-sexual dual relationships. For example:
- It seems that male therapists are more likely to engage in such relationships.
- There seems to be a relationship between non-sexual and sexual dual relationships, suggesting that sexual relationships are a culmination of other types of boundary transgression.
- A significant portion of therapists (up to 30%) had at least one client with whom they had other social contact
Studying the occurrence and the nature of dual relationships is important as it is clearly recognised that it is not always possible to avoid a dual relationship of a non-sexual nature. In many instances, especially in more rural communities, local contact may make such relationships unavoidable. In other instances, dual relationships may occur after therapy, when the therapist and the client meet in unexpected circumstances (e.g. as colleagues in an institution such as a university). For example, the Code of Ethics of the American Psychological Association admits that some dual relationships between clients and psychologists can be unavoidable. However, the code admonishes psychologists for entering into such relationships in case the psychologist’s objectivity is decreased or the relationship interferes with the psychologist’s professional effectiveness, with a possibility of harming the client (Kitchener & Anderson. 2000). Kitchener and Anderson point to the study of Borys and Pope (1989), who found that four examples of dual relationships were assessed as non-ethical by American psychologists, psychiatrists and social workers. These are:
- Financial involvement. e.g. selling a product or giving a gift to the client.
- Dual professional roles. e.g. providing therapy to a current employee.
- Sexual intimacy. e.g sexual intercourse with a client before, during or after therapy.
- Social involvement e.g, inviting the client to a private party or other social event
All these dual relationships have one common feature: there is a high risk of weakening the whole psychotherapy work by blurring the therapeutic contract and by partaking in a form of exploitation, as the client is in a vulnerable position that limits his or her choices. The main characteristic is that the therapist is following his or her own needs, and in doing so the therapist misuses his or her professional role.
There is also a problem with post-therapy relationships. Kitchener and Anderson (2000), considering the work of several authors, summarise eight reasons why post-therapy relationships should be avoided (as they are American authors, some of these reasons may he more relevant to the USA):
- The former client may want to return to therapy, which would be affected by the post-therapy relationship.
- The power differential may continue, which can make the client vulnerable.
- The clients experience strong emotions towards the therapist, which can lead to a lower level of objectivity in the relationship.
- The post-therapy relationships may not turn out well, which can decrease clients’ confidence in psychology.
- The public may perceive post-therapy relationships as unclear and unpredictable.
- The therapist’s objectivity in offering a potential future professional service may be compromised by the post-therapy relationship.
- Clients may suppress information because they assume that some post-therapy relationship will exist after therapy.
- In some states of the USA these relationships are illegal.
Anderson and Kitchener (1998), in their earlier work, presented a four-component guide that can he used in assessing the appropriateness of a post-therapy relationship (see Box 4.7). The model can serve as an example of how the therapist can reflect his or her own feelings when entering into such a relationship. Similar reasoning is also relevant for concurrent or pre-therapy relationships.
Box 4.7 A four-component model for assessing the appropriateness of a post-therapy relationship (Anderson & Kitchener. 1998: 93-96)
The therapist may assess
- The therapeutic contract and the parameters of the contracted relationship Examples of questions to consider include:
- Did we come to a formal or identifiable closure to our work together?
- Did the former client and I process the termination of our therapeutic relationship?
- Can I maintain the confidentiality of the therapeutic relationship in this post-therapy relationship if that is the client’s wish?
- Does the former client understand that entering a post-therapy relationship may limit the opportunity for us to work together again in therapy?
- The dynamics of the therapeutic relationship – emotions towards the therapist, the differential power dynamics. Examples of questions to consider include:
- What was the status of the power differential when termination occurred?
- In light of the power differential in the therapeutic relationship, to what extent is the former client’s decision free of controlling influences?
- Social role issues. Examples of questions to consider include:
- How similar or dissimilar are the role expectations and obligations of the new relationship from the role expectations and obligations of the therapeutic relationship?
- How might the knowledge gained in therapy influence my perceptions or judgements of the former client in the post-therapy relationship?
- How might the former client’s perceptions of me gained in therapy influence the client’s perceptions of me in the new role?
- The therapist’s motivation. Examples of questions to consider include:
- What are the personal and professional benefits for me if I enter into this relationship?
- is this post-therapy relationship avoidable, and, if it is, why am I considering entering into it? One year from now, will I be satisfied with my decision?
Dual relationships may also represent a specific problem in psychotherapy training. A relationship may involve the trainer and the trainee or the supervisor and the supervisee (including in research situations) or the personal therapist and the trainee. Especially in small countries, where practitioner communities are also small, the duality of relationships is a reality. Former trainees become colleagues whom you encounter in professional forums. The duality of relationships, or sometimes also the multiplicity of roles, has therefore to be reflected upon and monitored, so that the recipient, (i.e. the trainee) who is in a more vulnerable position, is not harmed.
Another ethical issue pertaining to everyday practice is the therapist’s responsibility to his or her own profession. In interacting with clients and other professionals, either privately or publicly, each therapist represents his or her own professional body. Thus therapists build trust in psychotherapy and in their own profession (e.g. psychology). The therapist’s responsibility also extends to witnessing how the profession is represented by other fellow professionals in public presentations or in the actual work with clients. The therapist should, therefore, respond to any misrepresentation or misconduct of colleagues that the therapist is aware of. However, this must be done respectfully and with clients’ welfare in mind. The therapist should also be willing to help colleagues, if they request help with regard to a clinical or ethical issue. Responsibility may also involve a willingness to participate in research because it further develops the discipline, or in a willingness to supervise trainees.
