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.
Licensing boards often require licensees to complete continuing education in boundary management as a condition for reinstatement or contingent upon issuing a license.
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 -maybe incorrectly- 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 boundary crossing 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.
Bartering is an Unethical Dual Relationship
ACA: Counselors consider the risks and benefits of extending current counseling relationships beyond conventional parameters…commencement ceremony or graduation), purchasing a service or
product provided by a client (excepting unrestricted bartering).
AAMFT: Marriage and family therapists ordinarily refrain from accepting goods and services from clients in return for services rendered. Bartering for professional services may be conducted only if: (a) the supervisee or client requests it; (b) the relationship is not exploitative; (c) the professional relationship is not distorted; and (d) a clear written contract is established.
Let’s examine some of the terms in the above codes of ethics.
“beyond conventional parameters…client requests it…relationship is not distorted…ordinarily refrain”.
It is difficult to understand what these mean– “Distorted”?
Can we be confident that a bartering arrangement “benefits the client”?
“Ordinarily refrain” assumes we know when a situation is extraordinary.
Hence, the difficulty understanding how to abide by codes of ethics and the limitations of vague guidelines.
In reality, therapists create two relationships when they barter: buyer and seller.
Even if cash is not involved, two transactions occur. Yours and theirs.
One can envision any number of scenarios where the relationship could devolve into a dispute.
Clients understand when they seek therapy they purchase a specific service and we clearly define that transaction.
That’s not the case with products or other services that are not psychotherapy services.
Even considering culture or clients who don’t have money to pay for services, it is not possible to have a clear written agreement.
If a client trades a chicken for a therapy session, what happens if the chicken dies one day later and the client has no more chickens? This is equivalent to a client writing a bad check and saying they can’t cover the check because they don’t have money to pay you.
Attempts at written agreements on bartering create problems since there is already the psychotherapy agreement and counselors are responsible for that first.
Exchange of any item of any value could result in an adversarial client relationship.
It’s unwise to barter.
