Thursday, July 17, 2008

Dual Relationships in Therapy

It is generally unacceptable for a therapist to have a dual relationship with his or her client. What are the legal guidelines for dual relationships in California? Cite references.

The issue of dual relationships is a common concern in the counseling field, as these relationships are potentially very harmful to clients. The main types of dual relationships are sexual relationships, non-sexual social or professional relationships and financial-business relationships. Generally, all of these relationships are to be avoided, as they are dangerous for both the therapist and client. However, because this is a complex issue, some types of dual relationships are unavoidable, and, some argue, a few are potentially helpful.

Lamb and Moorman (2004) say that dual relationships with clients, supervisees and students appear to take on one more of these roles: “(a) sexual relationships (e.g., with clients, supervisees, students); (b) nonsexual social or professional relationships, such as having dinner with a former client or employing a current supervisee; and/or (c) financial-business relationships, particularly as they may occur in a rural practice and small communities.” The Ethical Principals of Psychologists and Code of Conduct (APA, 2002) adds to this definition by stating,
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 (Moleski, 2005).

In general, a dual or multiple relationship occurs when the counselor takes on or promises to take on a secondary role/relationship with a client, supervisee or student. Because these relationships add complexity and harm to the counseling relationship, the APA has mapped out the above guidelines so counselors and clients can be weary of such relationships developing.
Cottone and Tarvydas (2002) say that the term dual relationship is associated with “a misuse of therapist power or authority.” The Association for Marriage and Family Therapy’s (AAMFT, 1991) Code of Ethics says that therapists should “make every effort to avoid dual relationships with clients that could impair professional judgment or increase the risk of exploitation” (Cottone & Tarvydas, 2002). Because the therapist is the individual in a position of power, they must take great care to not abuse this power and exploit their clients, students or supervisees. Thus, the therapist must be the one to withhold any desire to enter into a dual relationship, and if they are solicited to do so, they must use their authority to refuse. Cottone and Tarydas (2002) state that “feelings may develop and may be uncontrollable, but there are controls on actions of professionals.” A professional individual recognizes that feelings and desires to enter into a dual relationship may exist, but actions must be resisted, and authority must be used in a responsible manner.

Dual relationships can come about in two different ways: by choice and by chance. If a dual relationship comes about by the counselor’s choice, then “he or she must examine the potential positive and negative consequences that the secondary relationship might have for the primary counseling relationship. The counselor should choose to enter into the dual relationship only when it is clear that such a relationship is in the client’s best interests” (Moleski & Kiselica, 2005). On the other hand, sometimes dual relationships may come about by chance, such as “in sparsely populated rural areas, a dual relationship between a practitioner and a client may be unavoidable.” An example of this would be if a counselor is in personal recovery from alcohol addiction and attends the only AA group available in the small town they reside in. They may have a few clients also attending the AA group, and thus a dual relationship came about by chance and would be unavoidable.

Undoubtedly, the most harmful type of dual relationship is a sexual dual relationship. Moleski and Kiselica (2005) says that sexual dual relationships can be considered abusive. “Sexual relationships, according to Coleman and Schaefer (1986), include either overt forms of sexual contact with clients (e.g., passionate kissing, fondling, sexual intercourse, oral or anal sex, and sexual penetration with objects) and/or other less obvious expressions of sexual behavior (e.g. sexual gazes and seductiveness).” Moleski and Kiselica say that most, if not all, counselors agree that sexual relationships between a counselor and client are the most harmful type of dual relationship. Borys and Pope (1989) examined the opinions and practices of 4,800 mental health professionals about dual relationships. 98% of those surveyed stated that sexual activity with a client before termination of therapy’ is never ethical (Moleski & Kiselica, 2005).

However, even though almost all of the therapists surveyed rated sexual activity with a client before termination to be unethical, over half of those surveyed by Stake and Oliver (1991) said they have treated clients who have had sexual contact with a past therapist. Houseman and Stake (1999) have also found shocking results in their surveys of psychologists. “The percentage of psychologists reporting sex with current clients has ranged from 3% to 12% among male therapists and from 0.5% to 3% among female therapists” (Moleski & Kiselica, 2005). It is clear from these findings that although almost all therapists believe it is unethical to have a sexual relationship with their clients, a good percentage of them still have engaged in this behavior.

As evidenced above, male counselors are far more likely to engage in sexual dual relationships than female counselors. It has also been found that females are far more likely than male clients to be involved in sexual dual relationships (Hoffman, 1995). Hoffman (1995) also states that the “most effective predictor of whether a therapist is likely to involve a client in a sexual relationship is whether the therapist has previously engaged in sex with a client. The client’s personal history or characteristics do not seem to be significant factors in predictability.” It does not matter how the client behaves, or if they admit to having a sexual attraction to their therapist. The biggest indicator of a therapist engaging in a sexual dual relationship is whether or not they have engaged in one previously. This further indicates that the responsibility of engaging in a dual relationship lies on the therapist, as they have the authority in the client/patient relationship.

Gottlieb (1993) notes the American Psychological Association’s stance on sexual dual relationships. They state that because sexual behavior is “so frequently harmful… and undermines public confidence,” it is specifically prohibited for two years after termination, and it remains prohibited even after two years “except in the most unusual circumstances.” If sexual behavior between and therapist and past client does occur, the therapist must demonstrate that there has been no exploitation involved. The issue of sexual dual relationships is so harmful, that APA has developed a code with seven factors that must be considered if a sexual relationship can occur two years after termination. These seven factors are “the time since termination, the nature and duration of therapy, the circumstances of termination, the patient’s personal history, the patient’s current mental status, the likelihood of adverse impact and any statement made by the psychologist during therapy suggesting or inviting a post-termination relationship (Gottlieb, 1993).” It is exceptionally clear that a therapist should never engage in a sexual dual relationship with a current client, and should only engage in a sexual relationship with a past client after 2-5 years, in the most unusual of circumstances.

A second type of dual relationship is a nonsexual social or professional relationship. Moleski and Kiselica (2005) note the various types of nonsexual social or professional relationships that exist. Some examples are
personal or friendship relationships, social interactions and events, business or financial relationships, collegial or professional relationships, supervisory or evaluative relationships, religious affiliation relationships, collegial or professional relationships plus social relationships, and workplace relationships.

Such types of dual relationships, although not as harmful as sexual relationships, can be harmful to the therapeutic experience. These types of dual relationships blur the boundaries of therapy, and the therapist becomes more a friend than counselor. The client gains insight into the persona of the therapist in these types of relationships, and the focus can be placed on both the therapist and client, whereas the focus in therapy should rest mainly on the client.
Lamb (2004) notes that although nonsexual social or professional dual relationships do not seem overtly harmful, they may lead to sexual dual relationships. He states, “there is some evidence that certain activities within the professional relationship itself (e.g., nonsexual touching, self-disclosure by the psychologist) are associated with and may, depending on the circumstances and context of such activities, increase the likelihood of the development of an explicitly sexual MR.” While they may seem harmless at the time, nonsexual social or professional dual relationships have been shown to be a precursor to sexual dual relationships- yet another reason why they should be avoided.

A last type of dual relationship is a financial-business relationship, or, in other words, bartering. This type of relationship occurs when a therapist accepts goods or services in exchange for counseling. Woody (1998) sites the American Psychological Association’s ethics code, which states,
Psychologists ordinarily refrain from accepting goods, services, or other nonmonetary remuneration from patients or clients in return for psychological services because such arrangements create inherent potential for conflicts, exploitation, and distortion of the professional relationship. A psychologist may participate in bartering only if (1) it is not clinically contraindicated, and (2) the relationship is not exploitative (APA, 1992).
Woody notes that these types of relationships may be problematic for a few reasons. First off, if a client offers a service as trade, such as house painting, and the counselor is not satisfied with the end product, conflict can arise. Another issue is if a client performs a personal service for a counselor, such as housekeeping or babysitting, the client will have privy to personal information to the therapist’s home life. This becomes a boundary issue, as the client will know a great deal about the therapist’s life, and the emphasis may be taken off of the client in therapy sessions. Business and financial relationships can also lead to both negative and positive personal and/or sexual relationships, both creating conflict in the therapeutic relationship. A last reason why financial-business dual relationships are harmful is because the psychologist is always left with the liability, even if the client needs special financial arrangements (Woody, 1998).

Dual relationships are harmful because they disrupt the therapeutic relationship, creating a secondary relationship that can have highly negative repercussions. Pearson and Piazza (1997) note that the advantage of power and authority that therapists possess is the main culprit in creating harmful dual relationships. Keith-Spiegel and Koocher (1985) note that counselors can ‘hold an advantage of power over the people with whom they work, especially when they are psychotherapy clients or students. They occupy a position of trust and are expected to advocate the welfare of those who depend on them.’ Because they have a position of power, their client’s interests become subordinate to their own, which can create exploitation. Pearson and Piazza (1997) state that having a secondary relationship with a client makes it easier to abuse the power and authority a therapist has over their clients. Lastly, they note that dual relationships are not always abusive or exploitative.

Although dual relationships are generally not advisable, there are some cases where they are not harmful to clients, and can even be beneficial. Lamb and Moorman (2004) note that multiple relationships may not be considered unethical “depending on (a) the nature of the MR (e.g., sexual relationships with current clients are prohibited whereas other MRs are not), (b) the degree to which the MR may impair the psychologist's effectiveness, or (c) whether there is a risk of exploitation or harm to the person with whom the professional relationship exists.” The APA (2002) even states that “multiple relationships that would not reasonably be expected to cause impairment or risk exploitation or harm are not unethical.” Even though some types of dual relationships are not considered unethical, there is little consensus as to what these relationships may look like. More clarification is needed from the APA as to what types of dual relationships are ethical, as it is currently a gray and undefined area.

Cottone and Tarvydas (2002) state that a friendship that grows organically during the therapy or supervision process can be a positive dual relationship. They say, “As to whether there is danger of physical or emotional harm, a healthy friendship that develops during a formal counseling or supervisory relationship and lasts beyond the formal contracted services may not be considered harmful.” Although this is a gray area, and can lead to other types of unethical dual relationships, a positive friendship that develops in the course of therapy or supervision can have a great impact on both the therapist and client alike.

In conclusion, Moleski and Kiselica (2005) sum of the issue of dual relationships beautifully by stating, “Ethical decision making is an ongoing process with no easy answers. In order to promote the well-being of clients, counselors must constantly balance their own values and life experiences with professional codes of ethics as they make choices about how to help their clients effectively.” If counselors use their authority over their clients with great care and responsibility, they will naturally make the most ethical and beneficial choices regarding their relationships with their clients.


American Psychological Association (1992). Ethical principles of psychologists and
code of conduct. American Psychologist, 47, 1597-16111.

Cottone, R. R. & Tarvydas, V. M. (2002). Ethical and Professional Issues in
Counseling: Second Edition. Pearson Education, Inc.: New Jersey.

Gottlieb, M.C. (1993). Avoiding exploitive dual relationships: a decision-making model.
Psychotherapy: Theory, Research, Practice, Training, 30(1), 41-48.

Hoffman, R.M. (1995). Sexual dual relationships in counseling: confronting the issues.
Counseling and Values, 40(1), 15-23.

Keith-Spiegel, P. & Koocher, G.P. (1985). Ethics in psychology: professional standards
and cases. New York: McGraw-Hill.

Lamb, D.H., Catanzaro, S.J., Moorman, A.S. (2004). A preliminary look at how
psychologists identify, evaluate and proceed when faced with multiple
relationship dilemmas. Professional Psychology, 35(3), 248-254.

Moleski, S.M. & Kiselica, M.S. (2005). Dual relationships: a continuum ranging from
destructive to the therapeutic. Journal of Counseling and Development, 83 (1),

Pearson, B. & Piazza, N. (1997). Classification of dual relationships in the helping
professions. Counselor Education and Supervision, 37(2), 89-99.

Woody, R.H. (1998). Bartering for psychological services. Professional Psychology,
29(2), 174-178.

No comments: