Chapter 8

Question 1

Whenever mental health professionals have connections with a client in addition to the therapist–client relationship, a secondary relationship exists.

Answer 1

AKA dual relationships

Question 2

The counseling and psychology professions now use the term boundary extension or the designation multiple relationship for such an occurrence.

Question 3

Three other terms appear frequently in the mental health lexicon: boundary crossings, boundary extensions and boundary violations (Gutheil & Gabbard, 1993). These are grounded in the notion that there should be a division, a boundary, between the professional and personal lives of professional and client.

Answer 3

This division fosters a more productive therapeutic process by increasing the likelihood that the professional has the objectivity needed to understand and treat the client’s concerns and that the client has sufficient trust in the good will and altruistic motives of the therapist to share personal information and work through uncomfortable issues

Question 4

Boundaries provide structure for the process, safety for the client, and the required emotional distance for effective therapeutic work

Question 5

Boundary crossing to describe the kind of additional connection with a client that is grounded in the intent to help and has some credible evidence that benefit is likely to result.

Question 6

The term extension seems preferable to crossing since it acknowledges that a clear boundary still exists, just in a different place. It is important to note, though, that a professional’s ability to accurately predict whether an extension will really result in a good outcome is limited

Question 7

A boundary violation or boundary break is a departure from accepted practice that causes the client harm or is very likely to cause harm.

Answer 7

Boundary violations often occur when professionals are too compromised to function competently, too impulsive, or too self-interested to attend to the effects of violations on clients. Boundary violations are never ethical.

Question 8

The reality is that boundaries may be permeable in some circumstances—the challenge for the professional is to make responsible decisions about which circumstances merit relaxation of the usual parameters of the contact.

Question 9

Sonne (1994) clarifies that multiple relationships can be either concurrent with the professional relationship or consecutive. If consecutive, the therapeutic role may precede or follow the other role. Because counselors and therapists function in a variety of roles in their professional and personal lives, the possibility of a multiple relationship is always present.

Question 10

Essentially, the major risks of concurrent or consecutive multiple relationships are that the existence of the connection outside of therapy will compromise both the judgment of the professional and the response of the client to treatment.

Question 11

Three other factors have influenced the profession’s position on this issue:

Answer 11

• First, in some forms of boundary extensions the consumer stands to benefit substantially from the extension.
• Second, avoiding all boundary extensions would place a great burden on mental health professionals and those with whom they associate.
• Third, repudiating such actions is inconsistent with the right to free association of citizens in a democratic society.

Question 12

Still another circumstance that may make a boundary extension more ethical is the cultural background of the client. Clients from non-Western collectivist cultures may be confused and offended by rigid boundaries that fail to flex in ways typical in the client culture

Answer 12

For example, such a client may view a professional’s refusal to accept a sibling as an additional individual client as a hurtful and rejecting event rather than the establishment of a therapeutic boundary aimed at maintaining professional objectivity.

Question 13

The APA Code emphasizes the evaluation of the psychologist’s competence and objectivity, as well as the risk of exploitation in determining whether a multiple relationship is viable

Question 14

Ethics scholars have identified three underlying dynamics of the therapeutic relationship that can help practitioners evaluate the risk of any potential boundary extension. The professional has a duty to honor promises to the client, to be sensitive to their power over the client, and to be aware of the client’s emotional vulnerability during treatment. These dynamics affect the potential for client benefit in such relationships.

Question 15

Sonne (1994) focuses on the first dynamic, fiduciary relationship between a mental health professional and the client. The term derives from legal sources, and means that the professional’s primary obligation is to promote the client’s well-being.

Answer 15

One who fails in this responsibility is violating the most fundamental covenant with the client.

Question 16

duty to abstinence from gratifying self-interests in therapy. This duty means that the only acceptable profits from therapy are the fee paid and the satisfaction received from a client’s therapeutic gains.

Answer 16

The duty to abstinence is difficult to uphold when the temptations to serve self-interests are as strong as they will be for Alberto if he takes on the son of his wife’s boss as a client.

Question 17

the duty to neutrality. He postulates that a therapist is ethically bound to enhance the client’s autonomy and independence. Simon also asserts that because autonomy and independence are so fundamental to the achievement of the client’s therapeutic objectives, a professional should have no other agenda.

Answer 17

Another way to frame the duty to neutrality is to describe it as a duty to objectivity and disinterest in any particular aspect of the client’s life other than attaining therapeutic aims. Disinterest and objectivity should not be confused with a cold or uncaring attitude (Pope & Vasquez, 2011), but rather are highly compatible with a warm, empathic approach.

Question 18

The second dynamic that makes multiple relationships risky is the client’s emotional attachment to the therapist. The therapist becomes an important person in the life of the client, at least during their professional contact.

Answer 18

Client trust, confidence in the therapist’s expertise, clarity about the rules and boundaries of the relationship, and mutuality of expectations are all crucial features of successful therapy.

Question 19

When a professional has another role in a client’s life, the client’s emotional reaction is confused. Trust may be endangered, the rules for interaction may be obscured, and expectations may diverge.

Answer 19

In addition, sharing a very painful or embarrassing secret may be more difficult for a client who has multiple contacts with a professional.

Question 20

Theoretical orientation also plays a role in deciding whether nonprofessional contacts are advisable. Therapists who view transference as a central feature of counseling are particularly troubled by this dynamic. They contend that a client cannot work through a transference with a professional who plays another role in his or her life. Research shows that psychoanalytic therapists tend to view nonerotic multiple relationships as significantly less ethical than their cognitive or humanistic counterparts

Question 21

The third dynamic, the power differential between the professional and the client, was discussed at length as an important factor in sexual exploitation (Chapter 7). This imbalance may make clients acquiesce to the therapist’s wishes even when doing so is at odds with their own desires. This can happen not only in session but also in the second relationship.

Answer 21

A supervisee who is also a supervisor’s client may defer any disagreement with the therapist/supervisor because the risk of negative fallout is so great. Clients can also fear emotional abandonment (Sonne, 1994) if they offend the therapist in his or her other role. If clients refuse the therapist/friend’s social invitation, they may wonder if the therapist will retaliate by missing a session or even terminating therapy. The client’s autonomy may be jeopardized by the secondary relationship (Kitchener, 1988).

Question 22

The power difference also contributes to what has been called role slippage (Smith & Fitzpatrick, 1995). Role slippage means that the more powerful therapist may loosen the boundaries between the therapeutic relationship and the other relationship. A therapist might end a session with a conversation about a committee issue with a client who also serves on that body. Then, the therapist may suggest that they go out for a cup of coffee after a committee meeting to follow up on an unresolved issue. In this conversation, the therapist may disclose other information about himself to which the client does not know how to respond.

Question 23

Still another aspect of boundary extensions is troublesome: The confidentiality of services may be endangered. The chances that a professional may inadvertently reveal information disclosed in counseling are increased by the outside contact. In the situation described in the last paragraph, the therapist might accidentally repeat to another committee member something the client said within session.

Question 24

Given the potential for problems, many ethics scholars take a stronger stance than the codes do against boundary extensions, especially those in which one role is therapeutic. Kitchener (1988) and Sonne (1994) argue that mental health professionals cannot accurately predict the degree to which their capacity to practice competently will be compromised, or the harm that may come to a client as their relationship progresses. In light of this reality, they contend that most multiple relationships represent “undue risks” that should not be undertaken. Pope and Vasquez (2011) assert that mental health professionals who engage in many kinds of boundary extensions are frequently justifying their behavior with reasons that do not stand the test of logic or true commitment to the client’s well-being.

Answer 24

Using Simon’s terms (1991, 1992), close examination of these counselors’ motives sometimes reveals that they are acting without neutrality or abstinence. These practitioners seem to underestimate the conflict of interest or to overestimate their own skill. Simon also argues that a multiple relationship places the therapist at risk for other boundary violations, in a slippery slope analogy.

Essentially, these writers are basing their arguments on the principle of nonmaleficence. Because preventing harm is such an important professional value and because that harm cannot always be foreseen, prudence and devotion to the client’s welfare demand that counselors should regularly avoid multiple relationships.

Question 25

Other scholars take a more liberal stand (e.g., see Cottone, 2005; Herlihy & Corey, 2014; Lazarus & Zur, 2002; Moleski & Kiselica, 2005), suggesting that the ethics of a multiple relationship need to be examined on a case-by-case basis and need to give more weight to potential client benefits. They contend that professionals can make reasonable assessments when they know about the facts of a particular situation. These scholars also view a rigid posture about boundaries as impractical, because mental health professionals live in communities and are bound to have contacts with people who may at some point be clients.

Answer 25

They also point out the importance of the principle of beneficence and argue that prohibiting multiple relationships may diminish the professional’s opportunity to do good. Finally, they stress the role of community and cultural variables in determining whether a multiple relationship is ethical.Their views highlight the need to keep the focus in this debate on promoting the welfare of the client and not on protecting the professional from legal action or ethics complaints.

Question 26

All scholars seem to agree on at least one point. Regardless of the stance a professional takes on any particular boundary extension, if he or she observes a pattern of extensions that is more frequent than colleagues working in similar communities, that person should step back and reevaluate the dynamics underlying the behavior. Along with that reassessment should come careful supervision and consultation to unearth the underlying dynamics of the practice.

Answer 26

Client and consumer attitudes toward boundary extensions are also ambivalent. Claiborn et al. (1994) found that former psychotherapy clients expressed more reluctance about this situation than about confidentiality or informed consent issues. Pulakos (1994) reported contradictory findings, with her small sample seeking more reaction from their therapists when they encountered their therapists outside of sessions. In a qualitative study of clients who become friends with their therapists during or after therapy, Gibb (2005) reported that clients who experienced negative outcomes also rated the harm they suffered as “devastating,” and even those who did not regret establishing the friendship reported many negative reactions such as pain, confusion, awkwardness, and loss. Even this small and preliminary body of research underscores the need for professionals to use caution in entertaining boundary extensions; to consult extensively with clients and colleagues before their initiation; and to maintain those lines of communication during the nonprofessional contact.

Question 27

Occasionally, clients bring presents to sessions. The urge to give gifts can be motivated by a number of different factors. Some clients are driven by a belief that gifts may gain them special status in their counselors’ eyes or otherwise help maintain good service. For others, the action is connected to the very problems that sparked their decision to enter services. For instance, clients with low self-esteem may perceive gifts as the path to keep the professional interested in them, because they believe themselves to have little intrinsic value. A few clients may even attempt to use gifts as bribes for a positive report or a special favor. Still others wish to bestow a token of their appreciation for the gift that counseling has been to them or to ease the sadness of termination by leaving something from them with their counselor as they depart.

Answer 27

Consequently, the ethics of accepting a gift from a client depends substantially on the circumstances under which it was offered and on the attitude of and impact on its recipient. The language in the current ACA Code captures this complexity in Section A.10.f. The APA Code does not explicitly mention this topic, but its standards prohibiting exploitation and avoiding conflicts of interest indirectly address this issue. When gifts are a “quid pro quo” for better or special service, or are a manifestation of the client’s dysfunction, the professional probably should not accept them. However, when a present represents a token of appreciation for a successful therapeutic experience or a common cultural ritual (such as sharing holiday cookies in December), it may be ethical to receive it. Specifically, accepting a gift is more likely to be ethical if all the following criteria are met: It promotes rather than endangers the client’s welfare. It does not compromise the therapist’s objectivity or capacity to provide competent service in the future. It is a token of appreciation consistent with the client’s cultural norms and with a small monetary value. It is a rare event.

Question 28

In contrast, rural practitioners have dramatically different experiences because of both the demographics of their communities and their cultural norms. Their pool of potential clients is smaller; their referral sources more limited; and the chances of preexisting, concurrent, or subsequent connections with clients, significantly greater. A smaller population base from which to draw clients can mean that turning away clients may be a financial hardship for these professionals and for consumers. Competent referral sources are often distant and inaccessible by public transportation, so clients’ access to mental health care is more restricted when local practitioners decline to see them.

Answer 28

Unless rural practitioners refrain from joining any social, religious, or civic organizations and commute long distances to the workplace, they cannot easily avoid additional contacts with clients (Schank & Skovholt, 2006). Pearson and Piazza (1997) refer to these as circumstantial multiple relationships.

Question 29

Jennings offers additional guidelines to help the rural counselor act ethically. The first is to reject the notion that multiple relationships are avoidable in a rural setting. The price of rejecting all such contacts would be eliminating mental health services for many consumers. Traveling long distances to referral sources that the client is likely to distrust as “strangers” is not a viable option for most people

Answer 29

The decision about whether to accept a client must be made with the issue of accessibility of alternative services prominently in mind. Jennings recommends that those who work in rural settings make a real commitment to the fundamental ethical values of the profession and develop a generous capacity for tolerating ambiguity in their relationships.Both parties should understand what the other expects when they meet in another setting. This aspect is especially important given the public awareness of the counselor’s position

Question 30

When the prospective multiple relationship is closer or more intense, Jennings suggests that “the psychological intervention is limited in direct proportion to the intensity of the interpersonal relationship” (p. 100). In other words, Jennings’s view is that the rural mental health professional ought to offer only briefer, less intense services to those with stronger business, social, or community ties to the counselor and to reserve long-term counseling for people with whom outside connections are nonexistent or peripheral.

Answer 30

In short, the rural or small community practitioner should be especially sensitive to the ethics of multiple relationships. Jennings calls this a more demanding standard than applies to urban professionals. Counselors and therapists need to continually balance the obligation to serve the public’s mental health needs against the risk of harm and should seek out consultation to ensure that the difficult judgments necessitated by the environment are well founded.

Question 31

As with any other ethical issue, a practitioner should consult with other professionals and carefully scrutinize one’s own motivation before proceeding with a bartering arrangement. One should also scrupulously document that process, the informed consent procedures, and the progress of therapy. That document should include the details of the barter and an alternative to the barter should either party become dissatisfied with the agreement at a later point. The designation of a mediator for any disputes should also be included in that document. The issues just presented seem to lead to the conclusion that barter is simply not worth the trouble it can cause for both professional and client. That generalization is mostly true. However, there are two important reasons not to eliminate the possibility of bartering altogether. Barter can have value in making professional services accessible to those whose financial resources are limited.

Answer 31

Interestingly, counselors and psychologists seem divided on the issue of whether barter can be ethical. Research shows that psychologists tend to view the practice as rarely ethical (e.g., see Baer & Murdock, 1995), but counselors view it more positively. In fact, Neukrug and Milliken (2011) found that slightly more than half (53%) of the counselors they surveyed rated barter for services or goods ethically acceptable. The ACA Code permits bartering of both goods and services if it is not harmful, has been requested by the client, and is a regular community standard. The APA Code also identifies the risk of exploitation as a condition along with clinical considerations. One final reason makes this practice risky. The legal recourse typically available to parties dissatisfied with a business transaction is not easily available to either client or clinician. A professional who brought a client to small claims court would be violating confidentiality, and a client taking the same action would be risking disclosure of counseling information.