Dual relationships and boundary crossings are the most frequent counseling board ethics violations. But this is often not immediately apparent.
To illustrate, a board can receive ten patient complaints that all appear very different and all could be determined to be dual relationships violations and boundary issues.
The fundamental challenges of patient/therapist interactions in psychotherapy are universal. Therefore, it follows that counselor boundaries are also common problems for many other state mental health professional licensing boards.
Boundary Violations and Dual Relationships Are Closely Related.
A Boundary Violation
An effective way to illustrate this is through a hypothetical example:
John receives a letter from the LPC licensing board requesting he address an allegation of patient abandonment. John’s responds to the board with various details of his work with the patient and that he recently discovered she suffered with borderline personality disorder.
Let’s work backwards and find the boundary crossing/ violation.
X has been a patient of John’s for approximately two years. John admits to having limited experience with treating borderline personality disorder. He had felt uncomfortable working with the patient when he began treating her as he felt manipulated but did not want to abandon her.
He further stated in his response to the board that the patient expressed he was the only therapist who ever helped her and she was very persistent in continuing therapy with him. This was his justification to the board for continuing to treat her. John finally terminated therapy when the patient became upset and threatened a licensing board complaint after John finally convinced her he was not the best therapist for her. The board confirmed with John this was indeed the crux of the patient complaint.
Why is this a boundary crossing?
- If John had experience with borderline personality disorder, he would have had the expertise to identify borderline traits almost immediately after engaging her in therapy.
- Remember: the responsibility of managing the therapeutic relationship rests squarely on the counselor. John’s inexperience further resulted in his inability to assert himself with the client and draw a firm boundary.
- By not drawing a boundary, he crossed a boundary.
- It is very likely the complaint of abandonment would not have occurred had John referred this patient to another therapist two years earlier.
- As a side note, John consulted with peers who all agreed (probably erroneously) that since the patient threatened a board complaint he was not obligated to provide referrals to other therapists. So likely a third mistake was made.
We all know in theory we should work within our area of expertise, but this is a great practical example of how a series of clinical decisions resulted in a boundary crossing and licensing board complaint. It is also easy to see how this scenario could result in the patient filing a malpractice suit against the therapist.
Dual Relationships Are Not Created Equal.
Some dual relationships are boundary crossings. Some dual relationships create a boundary that must be managed, but not all boundary crossings are dual relationships.
When we engage in psychotherapy with patients or clients, we have created a client/therapist relationship. When a client chooses us as their therapist, a power differential is created. Managing this power differential is the therapist’ responsibility.
This power differential is created by:
- We are viewed as experts. We have advanced education, are knowledgeable in psychological matters and are licensed or sometimes doctors or PhD’s. Remember: there is ALWAYS a power differential.
- As a result of the above clients submit to vulnerability and are indeed vulnerable through this power relationship.
In short, a client /therapist relationship is characterized by an individual seeking mental and emotional help because we are believed to be expertly skilled in psychotherapy. Our singular role is to treat their mental distress through psychotherapy.
By sheer definition, we create a dual relationship when:
- we purchase an item they are selling because we want to assist them financially.
- we become an advocate for an agenda in their personal life that is not related to helping them with psychotherapy. For example, assisting in finding employment (unless one is solely–solely– a career counselor).
- Many other scenarios.
In both instances, the therapist has created two relationships. In the first example, they are therapist and customer of the client. In the second example, they are therapist and headhunter/job recruiter.