Ethics of Multiple Relationships

1
Ethics of Multiple Relationships   and The
Case of Pat www.SteveFranklinMSW.com  
2
Codes of Ethics posted on  PsychotherapySaint
Louis YahooGroups listserv.
3
ACA Code of Ethics 2005 Revised AAMFT Code of
Ethics, effective July 1, 2001 APA Ethical
Principles of Psychologists andCode of Conduct
2010 Amendments Code of Ethics of the National
Association of Social WorkersApproved by the
1996 NASW Delegate Assembly and revised by the
2008 NASW Delegate Assembly
4
The Case of Pat

• Time frame
• almost 9 years ago, through this year.
• Chris sought help
• after being kicked out of marriage
• (by Pat)
• for having an affair

5
The Case of Pat

• Chriss spouse, Pat, softened
•  
• Chris wanted Pat to attend
•  
• Subsequently, to start couples counseling

6
AAMFT 1.3
Marriage and family therapists are aware of
their influential positions with respect to
clients, and they avoid exploiting the trust
and dependency of such persons. Therapists,
therefore, make every effort to avoid conditions
and multiple relationships with clients that
could impair professional judgment or increase
the risk of exploitation.
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• Such relationships include, but are not limited
  to,
• business or close personal relationships
• with a client or the clients immediate family.
• When the risk of impairment or exploitation
  exists
• due to conditions or multiple roles,
• therapists take appropriate precautions.

8
ACA

• A.5.c. Nonprofessional Interactions or
  Relationships (Other Than Sexual or Romantic
  Interactions or Relationships)
• Counselorclient nonprofessional relationships
  with clients, former clients, their romantic
  partners, or their family members
• should be avoided,
• except when the interaction is
• potentially beneficial to the client.
•  

9

• A.5.d. Potentially Beneficial Interactions
• .. the counselor must document in case records..
•  .Examples of potentially beneficial
  interactions
• attending a formal ceremony
• (e.g., a wedding/commitment ceremony or
  graduation)
• purchasing a service or product provided by a
  client or former client (excepting unrestricted
  bartering)
• hospital visits to an ill family member
• mutual membership in a professional association,
• organization, or community.

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APA

• 3.05 Multiple Relationships (a) 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.

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A psychologist refrains from entering into a
multiple relationship if the multiple
relationship could reasonably be expected to
impair the psychologist's objectivity,
competence, or effectiveness in performing his
or her functions as a psychologist, or otherwise
risks exploitation or harm to the person with
whom the professional relationship exists.
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Multiple relationships that would not reasonably
be expected to cause impairment or risk
exploitation or harm are not unethical. (b)
If a psychologist finds that, due to unforeseen
factors, a potentially harmful multiple
relationship has arisen, the psychologist takes
reasonable steps to resolve it with due regard
for the best interests of the affected person
and maximal compliance with the Ethics Code.
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10.02 Therapy Involving Couples or Families (a)
When psychologists agree to provide services to
several persons who have a relationship (such as
spouses, significant others, or parents and
children), they take reasonable steps to clarify
at the outset (1) which of the individuals are
clients/patients and (2) the relationship the
psychologist will have with each person (b) If
it becomes apparent that psychologists may be
called on to perform potentially conflicting
roles (such as family therapist and then
witness for one party in divorce proceedings),
psychologists take reasonable steps to clarify
and modify, or withdraw from, roles
appropriately.
14
http//www.division42.org/IPfiles/IPFall03/prof_pr
actice/multiple.html Celia B. Fisher, Ph.D.
Multiple Relationships and the New APA Ethics
Ethics Code

• Standard 3.05 does not prohibit
• attendance at a clients/patients, students,
  employees, or employers family funeral,
  wedding, or graduation
• the participation of a psychologists child
• in an athletic team coached by a
  client/patient
• gift giving or receiving with those
• with whom one has a professional role
• or from entering into a social relationship with
  a colleague
• as long as these relationships would not
  reasonably be expected
• to lead to role impairment, exploitation, or
  harm.
• Incidental encounters with clients/patients at
  religious services, school events, restaurants,
  health clubs,
• or similar places are not unethical.

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Nonetheless, psychologists should always consider
whether the particular nature of a professional
relationship might lead to misperceptions
regarding the encounter. If so, it may be wise
to keep a record of such encounters.
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NASW1.06 Conflicts of Interest

• (c) Social workers should not engage in dual or
  multiple relationships with clients or former
  clients
• in which there is a risk of
• exploitation or potential harm to the client.
• In instances when dual or multiple relationships
  
• are unavoidable,
• social workers should take steps to protect
  clients
• and are responsible for setting
• clear, appropriate, and culturally sensitive
  boundaries.
• (Dual or multiple relationships occur when
  social workers relate to clients in more than one
  relationship,
• whether professional, social, or business.
• Dual or multiple relationships can occur
• simultaneously or consecutively.)

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(d) When social workers provide services to two
or more people who have a relationship with each
other (for example, couples, family members),
social workers should clarify with all parties
which individuals will be considered clients and
the nature of social workers professional
obligations to the various individuals who are
receiving services. Social workers who
anticipate a conflict of interest among the
individuals receiving services or who anticipate
having to perform in potentially conflicting
roles (for example, when a social worker is
asked to testify in a child custody dispute or
divorce proceedings involving clients) should
clarify their role with the parties involved and
take appropriate action to minimize any conflict
of interest.
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 Issues of Sexual Intimacy 

• (Not pertinent to Case Study)

19
AAMFT

• 1.4 Sexual intimacy with clients is prohibited.
• 1.5 Sexual intimacy with former clients is
  prohibited for two years following the
  termination
• should not engage in sexual intimacy
• with former clients after the two years
• Should therapists engage in
• sexual intimacy with former clients
• burden shifts to the therapist to demonstrate
• that there has been no exploitation or injury

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ACA

• A.5.a. Current Clients
• Sexual or romantic counselorclient interactions
  or relationships with current clients, their
  romantic partners, or their family members
• are prohibited.
• A.5.b. Former Clients
• Sexual or romantic counselorclient interactions
  or relationships with former clients, their
  romantic partners, or their family members
• are prohibited for a period of 5 years
  following the last professional contact.

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APA

• 10.05 Psychologists do not engage in sexual
  intimacies with current therapy clients/patients.
• 10.06 (or) with individuals they know to be
• close relatives, guardians, or significant
  others
• of current clients/patients. Psychologists do
  not terminate therapy to circumvent this
  standard.
• 10.07 Psychologists do not accept as therapy
  clients/patients persons with whom they have
  engaged in sexual intimacies.
• 10.08 (a) Psychologists do not engage in sexual
  intimacies with former clients/patients for at
  least two years after cessation or termination of
  therapy.

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(b) Psychologists do not engage in sexual
intimacies with former clients/patients even
after a two-year interval except in the most
unusual circumstances. and bear the burden of
demonstrating that there has been no
exploitation, in light of all relevant factors,
including (1) the amount of time that has passed
since therapy terminated (2) the nature,
duration, and intensity of the therapy (3) the
circumstances of termination (4) the
client's/patient's personal history (5) the
client's/patient's current mental status (6) the
likelihood of adverse impact on the
client/patient and (7) any statements or
actions made by the therapist during the course
of therapy suggesting or inviting the possibility
of a posttermination sexual or romantic
relationship with the client/patient.
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NASW 1.09 Sexual Relationships

• (a) Social workers should under no circumstances
• engage in sexual activities or sexual contact
  
• with current clients, whether such contact is
  consensual or forced.
• (b) or with clients relatives or other
  individuals with whom clients maintain a close
  personal relationship when there is a risk of
  exploitation or potential harm to the client.
• Social workersnot their clients, their
  clients relatives, or other individuals with
  whom the client maintains a personal relationship
• assume the full burden for setting clear,
  appropriate, and culturally sensitive boundaries.

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(c) Social workers should not engage in sexual
activities or sexual contact with former clients
because of the potential for harm to the client.
If social workers engage in conduct contrary to
this prohibition or claim that an exception to
this prohibition is warranted because of
extraordinary circumstances, it is social
workersnot their clients who assume the full
burden of demonstrating that the former client
has not been exploited, coerced, or manipulated,
intentionally or unintentionally.   (d) Social
workers should not provide clinical services to
individuals with whom they have had a prior
sexual relationship. .
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The Case of Pat

• Pat and Chris reconciled.
• Couples counseling recurred from time to time.
• Pat and Chris also sought individual counseling
• from time to time.

26
The Case of Pat

• Pat works in family services field and would
  occasionally refer individuals to me for
  counseling.
•  
• Family Services field Attorneys, CASAs,
  Counselors, Childrens Division workers, GALs,
  Judges, etc

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APA 3.07 Third-Party Requests for Services

• When psychologists agree to provide services to a
  person or entity at the request of a third party,
  psychologists attempt to clarify at the outset of
  the service the nature of the relationship with
  all individuals or organizations involved. This
  clarification includes the role of the
  psychologist (e.g., therapist, consultant,
  diagnostician, or expert witness), an
  identification of who is the client, the probable
  uses of the services provided or the information
  obtained, and the fact that there may be limits
  to confidentiality.

28
The Case of Pat

• In recent case
• Pat is an issue discussed by counseling clients
  in session.
• Conversations between Pat and me become subjects
  of conversation in client sessions.

29
The Case of Pat

• Pat requested client notes.
• I declined.
• Client obtained order from Judge compelling me to
  release information.
• I reluctantly comply.

30
ACA A.5.e. Role Changes in the Professional
Relationship

• When a counselor changes a role from the original
  or most recent contracted relationship, he or she
  obtains informed consent from the client
• Examples of role changes include  
• 1.        changing from individual to
• relationship or family counseling, or vice versa
• 2. changing from a nonforensic evaluative role
• to a therapeutic role, or vice versa
• Clients must be fully informed of any
  anticipated consequences
• (e.g., financial, legal, personal, or
  therapeutic)

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http//kspope.com/dual/index.php

• Dual Relationships, Multiple Relationships,
  Boundary Decisions

32
Ken Pope Patricia Keith-Spiegel "A Practical
Approach to Boundaries in Psychotherapy Making
Decisions, Bypassing Blunders, and Mending
Fences" Journal of Clinical Psychology In
Session, 2008, vol. 64, 5, pages 638-652)

• "Nonsexual boundary crossings can enrich
  therapy, serve the treatment plan, and strengthen
  the therapist-client working relationship. They
  can also undermine the therapy, sever the
  therapist-patient alliance, and cause immediate
  or long-term harm to the client. Choices about
  whether to cross a boundary confront us daily,
  are often subtle and complex, and can sometimes
  influence whether therapy progresses, stalls, or
  ends

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Ethical Decision-making and Dual
RelationshipsJeffrey N. Younggren, Ph.D., ABPP
http//kspope.com/dual/youggren.php

• Is the dual relationship necessary?
• Is the dual relationship exploitive?
• Who does the dual relationship benefit?
• Is there a risk that the dual relationship could
  damage the patient?
• Is there a risk that the dual relationship could
  disrupt the therapeutic relationship?
• Am I being objective in my evaluation of this
  matter?
• Have I adequately documented the decision making
  process in the treatment records?
• Did the client give informed consent regarding
  the risks to engaging in the dual relationship?

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Dual Relationships between Therapist Client A
National Study of Psychologists, Psychiatrists,
and Social Workers Debra S. Borys
Kenneth S. Pope http//kspope.com/dua
l/research2.php 4,800 psychologists,
psychiatrists, and social workers were surveyed
(return rate 49)  
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Ethical? 1never 2rarely 3 sometimes 4 mostly
5always NS Not sure NR no response
1 2
3 4 5 NS NR Accepting a gift worth
under 10
3.0 13.0 38.4 40.1 5.0 0.4 0.2 Accepting a
client's invitation to a special occasion
6.3 26.3 41.0 20.8 4.6 0.8 0.1 Accepting a
service or product as payment for therapy
21.4 30.0 28.2 12.7 2.7 4.2 0.7  Becoming
friends with a client after termination
14.8 38.4 32.0 10.2 2.1 1.9 0.6 Selling a
product to a client
70.8 18.0 7.5 0.9 0.3 2.1
0.5 Accepting a gift worth over 50
44.9 37.0 13.1
1.4 0.8 2.3 0.5  Providing therapy to an
employee
57.9 26.2 10.9 2.1 0.2 2.4 0.4 Engaging in
sexual activity with a client after termination
68.4 23.2 4.2 0.6 0.3 2.6 0.7 Disclosing
details of current personal stresses to a client
26.0 39.3 29.5 2.9 1.3 0.5 0.5 Inviting
clients to an office/clinic open house
26.6 24.7 21.5 15.4 5.8 5.0 0.9
Employing a client
49.9 29.5 14.5
2.8 1.2 1.5 0.5 Going out to eat with a client
after a session 43.2 37.9
13.6 2.4 0.8 1.4 0.5  Buying goods or
services from a client
36.7 35.4 20.6 4.7 0.7 1.5 0.3 Engaging
in sexual activity with a client
98.3 0.5 0.0 0.1 0.6 0.4 0.0
Inviting clients to a personal party or social
event 63.5 29.2 4.6 0.7 0.5
1.2 0.2  Providing indiv. therapy to clients
relative/friend/lover 12.6 21.4 38.8 21.4
4.2 1.0 0.5 Providing therapy to a current
student or supervisee 44.4 31.0 16.0
5.4 1.0 2.0 0.4 Allowing a client to enroll in
one's class for a grade 39.0 28.0
18.0 7.6 1.9 5.2 0.4
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1 no clients 2 few, 3 some 4 most 5 all
clients, NR no response 1 2 3
4 5 NR Accepted a gift worth under 10
14.0
56.5 11.3 5.9 11.5 0.8 Accepted a client's
invitation to a special occasion
64.0 28.0 3.3 2.4 1.4 0.8 Accepted a
service or product as payment for therapy
82.6 13.9 2.8 0.2 0.1 0.8 Became
friends with a client after termination 69.0
26.5 3.2 0.2 0.3 0.7 Sold a product to a
client 97.1 1.4 0.7 0.0 0.1 0.7
Accepted a gift worth over 50 92.4 5.8
0.3 0.2 0.2 1.1 Provided therapy to an
employee 87.5 9.3 1.7 0.3 0.2 1.1
Engaged in sexual activity with a client after
termination 95.3 3.9 0.0 0.0 0.0 0.8
Borrowed less than 5 from a client 97.0 1.7
0.0 0.2 0.1 1.1 Disclosed details of
current personal stresses to a client 60.1 30.7
7.4 0.6 0.2 1.0 Borrowed over 20 from a
client 98.7 0.1 0.1 0.0 0.0 1.1
Invited clients to an office/clinic open house
88.7 3.7 3.5 1.1 2.0 0.9 Employed a
client 91.2 7.5 0.4 0.1 0.0 0.8
Went out to eat with a client after a session
87.4 10.5 0.9 0.2 0.0 1.1 Bought goods
or services from a client 77.6 20.5 1.1
0.1 0.0 0.8 Engaged in sexual activity with
a current client 98.7 0.4 0.1 0.0 0.0
0.8 Invited clients to a personal party or
social event 92.1 6.7 0.3 0.2 0.0
0.8 Providing indiv. therapy to clients
relative/friend/lover 38.0 36.0 21.6 2.1
1.4 0.8 Provided therapy to a then-current
student or supervisee 88.9 8.4 1.5 0.2
0.1 0.9 Allowed a client to enroll in one's
class for a grade 95.2 2.3 1.1 0.1 0.3
1.3
37
Zur, O. (2011).  Dual Relationships, Multiple
Relationships  Boundaries  In Psychotherapy,
Counseling Mental Health.  http//www.zurinstit
ute.com/dualrelationships.html.
38

• Types of Dual Relationships
• Social
• Professional
• Treatment Professional
• Business
• Communal
• Institutional
• Forensic
• Supervisory
• Sexual.
• digital, online or internet ??

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  Dual relationships can be .. Voluntary-avoidabl
e Unavoidable Mandated Unexpected Dual
relationships can be .. concurrent sequential
Level of Involvement can be .. Low-minimal level
Medium level Intense level
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GUIDELINES FOR NON-SEXUAL DUAL RELATIONSHIPS IN
PSYCHOTHERAPYTreatment plans

• Develop a clear treatment plan for clinical
  interventions which are based on the context of
  therapy.
• Intervene with your clients according to their
  needs
• Some treatment plans may necessitate dual
  relationships however, in other situations dual
  relationships should be ruled out. Make sure you
  know the difference.
• 4. If planning on entering a dual relationship
  you must take into consideration the welfare of
  the client, effectiveness of treatment, avoidance
  of harm and exploitation, conflict of interest,
  and the impairment of clinical judgment. These
  are the paramount and appropriate concerns.

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5.Do not let fear of lawsuits, licensing boards
or attorneys determine your treatment plans or
clinical interventions. Do not let dogmatic
thinking affect your critical thinking. Act with
competence and integrity while minimizing risk by
following these guidelines. 6.Incorporate dual
relationships into your treatment plans only when
they are not likely to impair your clinical
judgment, or create a conflict of interest. 7.Do
not enter into sexual relations with a client
because it is likely to impair your judgment and
nullify your clinical effectiveness. 8.Remember
that treatment planning is an essential and
irreplaceable part of your clinical records and
your first line of defense. 9. Consult
with clinical, ethical or legal experts in very
complex cases and document the
consultations well.
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Prior to and during therapy which includes dual
relationships 10.Study the clinical, ethical,
legal and spiritual complexities and potential
ramifications of entering into dual
relationships. 11.Attend to and be aware of your
own needs through personal therapy, consultations
with colleagues, supervision or self-analysis.
Awareness of your own conscious and unconscious
needs and biases helps avoid cluttering the dual
relationship. 12.Before entering into complex
dual relationships, consult with well-informed
and non-dogmatic peers, consultants, and
supervisors. 13.When you consult with attorneys,
ethics experts and other non-clinical consultants
make sure that you use the information to educate
and inform yourself rather than as clinical
guidelines. Separate knowledge of law and ethics
from care, integrity, decency and above all
effectiveness. Remember you are paid to help and
heal, not to protect yourself. 14.Discuss with
your clients the complexity, richness, potential
benefits, drawbacks and likely risks that may
arise due to dual relationships. 15.Make
sure that your office policies include the risks
and benefits of dual relationships and
that they are fully explained, read and signed by
your clients before you implement them. Make
sure your clinical records document clearly all
consultations, substantiations of your
conclusion, potential risks and benefits of
intervention, theoretical and empirical support
of your conclusion, when available, and the
discussion of these issues with your client.
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Clinical integrity and effectiveness 16.
Remember you are setting an example. Model
civility, integrity, emotionality, humanity,
courage, and, when appropriate, duality. 17. As
a role model, telling your own stories can be an
important part of therapy. Make sure that the
stories are told in order to help the client and
not to satisfy your own needs. 18. Remember that
you are being paid to provide help. At the heart
of all ethical guidelines is the mandate that you
act on your clients' behalf and avoid harm. That
means you must do what is helpful, including dual
relationships when appropriate. 19. Answer
clients' basic and legitimate questions about
your values and beliefs, including your thoughts
on dual relationships. 20. Continue to keep
excellent written records throughout treatment.
Keep records of all your clinical interventions,
including dual relationships, additional
consultations and your own and your clients'
assessment of treatment and its
progress. 21.Evaluate and update your approach,
attitudes, treatment plans and above all
effectiveness regularly.
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If you find yourself in a dual relationship
which either is not benefiting the client or is
causing distress and harm, or has unexpectedly
brought about conflict of interest, consult
and, if necessary, stop or ease out of the dual
relationship in a way that preserves the
client's welfare in the best possible way.