Boundaries in psychotherapy ethical and clinical explorations pdf

The therapist tried to explore fully the patient's perspective and experience. Sam was aware of wanting a relationship with a spiritual community and had chosen this church based on its community reputation. He was out of touch with any feelings, wishes, or conflicts symbolically expressed by his desire to join his therapist's church. The therapist wondered if Sam would like to be closer to the therapist and wished to know more about him but had been unable to ask. Perhaps it had been difficult to allow himself to be curious about the therapist, personally and professionally?

The therapist felt anxious and ineffective. Would they be able to negotiate this relationship crisis without a rupture in relatedness? Sam might be worried too. The therapist realized Sam might recast him in a negative light and leave treatment. Alternatively, the therapist wondered whether Sam's therapeutic achievements were more than he could bear in terms of affective tolerance and shifts in positive self-image.

Belonging to the same small congregation would significantly alter, perhaps in an untoward manner, the quality and nature of the therapeutic relationship. Was Sam destroying the treatment relationship to regain a familiar, albeit compromised, sense of self and internal affective climate? Perhaps Sam wondered what his therapist privately felt about him or if he was like the therapist.

Was Sam worthy of being in the same community as his therapist? Would the therapist allow or invite him to belong to his church? Was Sam capable of affecting his therapist in a deeply personal manner? Perhaps he was longing for an authentic, personal response. Sam's predominant experiences with relationships involved exploitation, betrayal, and abandonment. Was this request a reenactment of Sam's earlier abusive relationships, with Sam turning passive into active and assuming the role of abuser?

The therapist, feeling angry, wondered how much of this feeling was Sam's projected anger and how much was his own reaction to feeling intruded upon. Perhaps this was a test of the therapist's capacity to protect the treatment from Sam's self-sabotaging impulses and ultimately a test of containment and caring.

I know it doesn't feel this way to you but I am trying to protect the psychotherapy and our work together. One of the components that has worked well in this relationship is clarity about the limits and boundaries of our relationship and work together.

Why would we want to alter a system that has enabled you to move closer to a sense of self and life that you desire and, I believe, deserve? The therapist wondered whether Sam doubted he deserved his successes and was trying to undo his gains out of guilt or loyalty to old relationships.

The next Sunday the therapist, sitting in the front pews of the sanctuary with his wife and three children, heard a man wailing in tears behind him. He turned and saw his patient sobbing. The therapist felt intruded upon in a previously safe space. Although he did not fully understand his patient's motivation, it was clear to the therapist that the two of them belonging to the same church would not work therapeutically, at least for this therapist.

He wondered how his patient could begin in church a new chapter of relatedness with his painful history when it was contained in his therapist who was sitting before him. Sam, on the other hand, reported that the reason he was weeping in church was because he felt moved by the lovely organ music.

Although the therapist understood that Sam viewed this differently, he felt sharing the same church would be disruptive to the psychotherapy. It is part of who I am and how I work therapeutically. In order to be fully present and available to the treatment relationship and to respect your psychotherapy, I need to attend to my personal needs for privacy. After much careful thought about the experience and its effect on the patient, the therapist, and the psychotherapy, the therapist informed his patient that he felt they could not be co-congregants and continue the therapeutic work.

I understand you feel it is possible for you. I may be wrong, but I also don't believe it will be useful for your psychotherapy. I know you see this differently. Perhaps some therapists could see their way clear to do this. I can't do it. We may have to agree to disagree about this matter.

If he decided to attend the church, the therapist would terminate the psychotherapy and, if he wished, refer him elsewhere for treatment. Sam responded with a sense of betrayal and rage that threatened to destroy all he had achieved as well as the therapeutic relationship. Although angry and feeling betrayed, he decided to remain in treatment to understand his feelings and experience because he felt this relationship had been of great value to him and their work was not finished.

Holding firm to the boundaries allowed Sam to relive, not merely remember, the problematic past in relationship with the therapist. The therapist understood that the conversation was as important as any decision about where to set the boundary.

Power was mutually shared through the process of each participant deciding what he felt he could and could not do. The therapist offered Sam a new relational experience by acknowledging and owning his personal feelings, including what Sam might experience as limitations. Sam did have a choice here. As the boundaries were renegotiated, the therapist could see more of what his patient needed from him. Convinced that his therapist had reached an unambivalent decision, Sam was more open and willing to engage in the exploration of his deep sense of injury and rage.

The therapist offered himself as an authentic presence who was committed to understanding Sam's dilemmas and willing to tolerate his aggression in the service of protecting his treatment and his development. Sam needed to experience his therapist as failing him and betraying him. His therapist was able to tolerate the frustration, anger, and devaluing involved in assisting this man to differentiate his past relationships from his present ones and to have a different affective experience and outcome.

Sam's acceptance of his rage and sadism toward himself and others were crucial to his psychotherapy. Although disagreeing with his therapist's decision, Sam acknowledged the value of being enraged at an important other without the destruction or denigration of either participant.

Negotiating the intense affect and sense of betrayal while remaining in connection was a positive experience for Sam. This vignette is not intended as a prohibition against therapists and patients attending the same church. Often, particularly in rural communities, therapists discover that their professional and personal lives overlap with those of their patients. Such overlap may be handled in and out of the consulting room in a range of clinically useful ways.

The case of Sam illustrates the process of engaging patients in a sustained interpersonal and intrapsychic inquiry that leads to construction of affect, meaning, and deeper understandings. Such conversations and eventual understandings allow therapists to determine where to set boundaries in any particular treatment. Case 2. Emma, an attractive woman in her late thirties, began weekly psychotherapy almost against her better judgment.

In a state of chronic depression, rage, and anxiety, she worried about how little she understood about the effect she had on others and how greatly that blind spot affected her relationships. Furthermore, she struggled to control her anger, with very mixed results, and deeply worried that she was or would become the raging women her mother was. She reported a childhood history of severe emotional neglect and abuse with a rageful mother who always knew best.

She developed a close friendship, by uncanny coincidence, with a woman in a similar profession who was a group psychotherapy patient of her therapist. Emma began playing with thoughts of what she could ask for from her therapist. She initiated the conversation by bringing up information from her colleague's treatment relationship with the therapist. Emma wanted to be treated the same. The therapist felt Emma's determination to get her fair share at last.

Emma was unable to identify or express her personal wishes. She was not interested in discussing her experience of her therapist's particular manner of caring for her or how the therapist experienced or felt about her. She wanted treatment identical to her friend's.

Emma expressed sadness, frustration, and impotent rage at her inability to control her therapist or her colleague. The therapist commented that although Emma longed to be first, she wanted to punish someone for all the times she felt denigrated, marginalized, and not chosen.

Someone should make up for her heartache. Emma was committed to the feeling that she would be second best. Across the years of Emma's treatment, she had never asked her therapist about her personal vacation plans and had never been told. Now, Emma was curious and wanted the same treatment as her colleague. The therapist inquired about Emma's request, her feelings, and the meaning of knowing this information.

Emma was unable to identify her curiosity, longing, or sense of loss about her therapist and the vacation. The therapist felt Emma was replicating her painful childhood relationship with her mother. Emma was vacillating between recasting and inducting the therapist in the role of the abusive mother and assuming that role herself by bullying her therapist.

Although knowing Emma was anguished, the therapist felt predominantly bullied and mistreated and unsure of how to proceed. Informing patients about her vacation plans was not unusual when it had a relational and therapeutic purpose. However, in Emma's case the feelings of being coerced made her disinclined to share this information.

She and Emma seemed deadlocked and unable to move beyond feelings of insult and anger. Emma remained fixed on her angry, competitive feelings with her colleague and on her right to know. The therapist fantasized about Emma's unexpressed envy and jealous feelings toward her that were expressed through the colleague. This is about me. This applies to loans from therapists to clients or from clients to therapists. The loaning party may feel imposed on, taken for granted, or exploited; unhappy with how the loan was given or the terms of the gift-loan; or resent not being paid back on time.

When a therapist refers, introduces, or directs a client to a third party to receive a loan, this constitutes a business dual relationship if the therapist and the third party have a business relationship. Similarly, if a client refers a therapist to a third party for a loan, it may also constitute a business dual relationship if the client and the loaning party have a business relationship.

Either way, therapists are advised to be very cautious in such situations and make sure that they do not exploit, harm, or clutter up the therapeutic relationship by adding such complicated and potentially emotionally loaded transactions.

Buying goods from clients or selling goods to clients is another boundary consideration because it creates relationships secondary to the therapeutic one. This practice is very common among acupuncturists, chiropractors, nutritionists, and holistic health practitioners. As with any boundary crossing, borrowing from, lending to, buying from, or selling to clients must be conducted with sensitivity and great care that these practices are neither exploitative nor obstructive to the therapeutic process.

At all times the welfare of the client must be held paramount. Referrals Referrals are the lifeline of psychotherapists, whether they practice privately or as part of a clinic or even an institution. The referrals can be self-referred as well. Referrals that bear on the existing psychotherapeutic relationships by introducing new elements fall under the heading of boundary crossing.

Dual relationships may be established when the current client has a relationship with the new referral, which means that the therapist has dual loyalties to two associated clients. Referrals are sometimes similar to gifts. When it comes to referrals, the intent and the meaning of the individual making the referral as well as the therapist who receives the referral determines its appropriateness. If the referral creates indebtedness, the therapist may face a conflict of interest in which clinical decisions and the welfare of the client may become secondary to pleasing or fulfilling the expectations or even demands of the referral source.

If a therapist accepts a referral that is likely to lead to a conflict of interest or loss of objectivity, it is unethical and a boundary violation, unless the acceptance of the referral is mandatory. As with gifts, the intent and the meaning of the person making the referral, as well as the therapist who receives the referral, would determine a number of things. It would reveal the nature, quality, and magnitude of the impact of the referral, or secondary therapeutic relationship, on the original therapeutic relationship and between the referral source and the receiving therapist see chap.

Although most referrals by clients or their family members or friends are boundary crossings, boundary violations occur in situations in which therapists solicit referrals from clients that are clearly motivated by their need or greed, or put them in compromising conflict-of-interest positions that are likely to impair their clinical judgment and harm the original or new clients.

Among the richest resources for referrals in the private practice setting are referrals from satisfied current or former clients.

The satisfied customer may refer with the hope that the person referred will get the help that the client received. It may be driven by the hope that the therapist may help the client's spouse, partner, parent, or child and thereby help the client, too. If clients believe their therapists to be in financial need, they may give referrals to help them out. It can also be a way to show off their therapists to others. Or perhaps clients cannot draw healthy and appropriate boundaries with friends and relatives, and the referral becomes a power play to level the playing field and even create indebtedness.

Of course, the character of the relationship between the referring client and the newly referred one is very important in determining the propriety of seeing the referred client in therapy. For example, if a client has a stable, long-term relationship with the person he or she refers to his or her therapist, the referral may be appropriate. However, if the relationship between the referring client and referred person is volatile or conflict ridden, accepting the new referral is likely to interfere with the primary relationship.

In the latter case, it is inappropriate to accept the referred client because it is likely to create a conflict of interest or conflict of loyalty on behalf of the therapist. As with gifts, therapists and clients can discuss the intent, meaning, and potential impact of the referral. There are several concerns with referrals from clients. If the therapist accepts such referrals, the original client or the new one may later feel that the therapist favors one over the other.

If one client tells secrets about the other, the therapist may be caught in a triangle, which may then compromise confidentiality or quality of treatment. If the therapist feels indebted to the client, it may impair clinical judgment.

Shapiro and Ginzberg raised the concern that such referrals may result in ethical conflicts such as exploitation, dual relationships, and sacrifice of confidentiality. Similarly, Epstein and Simon suggested that taking a referral from a client is a form of exploitation in that the therapist receives more than just the fee in compensation for treating the client.

Bartering for client referrals is unethical, and most ethics codes bar therapists from "kickback"-type compensation for referrals. Colleagues and friends of therapists are another important source of referrals and, potentially, a flattering one that also creates a dual relationship situation. Therapists must be clear about the bounds of confidentiality and especially about what can be communicated to the referral source regarding the client.

The therapist must also watch for a sense of inappropriate indebtedness to the colleague or friend and whether the referral had a negative impact on their relationship. They also have to assess whether a conflict of interest arises, because therapy may reveal some unflattering or even dangerous aspect of the colleague's or friend's nature that could leave the therapist in an awkward position of dual loyalty.

Therapists referring a client to a spouse, family member, or anyone who is closely related to the therapist should be cautious. For example, if there are other options, it is ill advised to refer a client to a dentist or car mechanic who is also the spouse of the therapist because it is likely to create imprudent dual relationships and a conflict-of-interest situation Behnke, that may well constitute a boundary violation.

However, sometimes such referrals are unavoidable, as may be the case in a small, isolated community in which the referring therapist's spouse is the only nutritionist or chiropractor in the area. Generally, any referral by the therapist that can benefit him- or herself should be fully disclosed and discussed with the client and avoided if it is done primarily for the benefit of the therapist rather than the client.

Informing the client of the relationship to the therapist does not necessarily reduce the risk of exploitation and harm. Failure to inform the client of such relationships is a boundary violation and betrayal of trust. Self-referrals are another important source of clients.

Almost all advertisements are geared to tapping this source of clientele. As was discussed earlier, familiarity and self-referrals are unavoidable and a normal part of rural, ethnic, spiritual, disabled, and many other close-knit and interdependent communities. Therapists can find themselves in an uncomfortable situation if they realize, after therapy starts, that a self-referred client has an intimate, antagonistic, or otherwise complex relationship with another existing client.

The situation may be complicated, may often involve conflict of loyalties, and can be fraught with difficulties, loss of objectivity, or reduced clinical efficacy, whether only one or both of the clients are aware of the situation.

In this instance, the prudent practitioner should seek a consultation, go through a thorough and well-documented ethical decision-making process, and document the decision process.

Coauthors' or Collaborators" Dual Relationships A singular and rarely mentioned type of dual relationship occurs when therapists and clients write a book or an article, cocontribute to a project, or perform together. Similar collaborations have taken place when therapists and clients collaborate on a research project or are involved in any other artistic or other project together.

Ethics of Dual Relationships Unlike the general guidelines provided for most other boundary crossings, the APA Ethics Code and other such codes provide specific guidelines regarding dual relationships. In addition to the codes of ethics, other publications during the s and early s focused primarily on the risks of dual relationships and their association with sexual boundary violations e.

A shift took place in the mids that has continued through the early years of the 21st millennium. In the late s and s, there was growing awareness that nonsexual dual relationships were unavoidable under some circumstances such as in rural areas and the military. During the shift in the 20th century, mentioned previously, more publications have reviewed the inevitability and potential clinical utility of dual relationships e.

Thus, Younggren and Gottlieb wrote the following: Professional practice abounds with the potential for multiple relationships, and the circumstances under which these types of relationships occur are quite varied.

Although psychologists frequently choose to enter into these types of relationship, many may actually be unavoidable, and in some situations one can even conceptualize the avoidance of the dual relationship not only as unethical but as potentially destructive to treatment itself, p.

All these codes advised therapists to refrain from entering into a dual relationship if it could reasonably be expected to impair their objectivity or effectiveness or risk exploitation or harm to clients. The s and the early s were also marked by an intensification of the debate around dual relationships. The interlocutors were those who focused on consumer protection and risk management and those who asserted that some dual relationships are unavoidable, benign, a normal and healthy part of close-knit or small communities, and can be clinically beneficial.

As a result, the APA Ethics Code added the sentence, "Multiple relationships that would not reasonably be expected to cause impairment or risk exploitation or harm are not unethical" p. It then also took an important step to align the code of ethics with the standard of care by clarifying the term reasonable.

Also, the National Board of Certified Counselors a acknowledges that some dual relationships are unavoidable. Note to item d: Even beyond the 2-year minimum, therapists are advised to either avoid or be extremely cautious with regard to sexual relationships with former clients. Dual Relationships in the Context of Therapy The meaning and effect of dual relationships on the therapeutic process can only be understood within the context of therapy. The client's culture, maturity, and presenting problem are probably some of the most important factors determining the appropriateness of establishing a dual relationship with a client.

Also, clients with a long history of physical or sexual abuse, with sensitivity to boundary considerations, may be less likely to benefit from dual relations as they cross traditional boundaries and may be experienced as betrayal or violation. On the one hand, some clients from certain cultural or political backgrounds may even expect some level of duality, as may be the case with American Indian, Latino, feminist, or gay male and lesbian clients Gabriel, ; Zur, On the other hand, dual relationships with clients who tend to sexualize relationships or those who are paranoid, volatile, obsessively jealous, psychotic, or present borderline personality disorder features are clinically and ethically ill advised.

In addition to what was previously noted, there are numerous settings in which client-therapist interactions are mandated e. In contrast, dual relationships are less common in many private practices in metropolitan areas. The therapeutic modality is another highly relevant factor in determining the appropriateness of establishing dual relationships with clients. Humanistic psychotherapy emphasizes the importance of authentic and congruent relationships between clients and therapists and, therefore, is likely to endorse nonsexual and nonexploitative dual relationships because they are likely to enhance such authentic relationships Jourard, b.

The nature of the therapeutic alliance is another important determining factor in the decision of whether to engage in a dual relationship.

Obviously, trusting and positive therapeutic relationships between therapists and clients are more compatible with dual relationships than distrustful or hostile relationships. Similarly, a short-term relationship or when the therapist serves primarily as an educator is less likely to create unpredictable complexities in the "nonclinical" relationship than long-term therapy or therapy that focuses on transference analysis.

Therapists' factors also play a role in the decision of whether to engage in dual relationships. Generally, therapists who are more communally oriented or come from a highly communal culture e. Therapists' training and socializing into the profession are likely to affect their openness to such relationships.

Those whose training was analytically focused are less likely to view dual relationships as appropriate or beneficial than those whose training was humanistic, feminist, or cross-cultural. Similarly, therapists whose training emphasized risk management are more likely to avoid dual relationships, when possible, compared with therapists who were trained in rural areas or in more flexible, context-based ethics Williams, ; Zur, a.

If necessary, exit strategies should be discussed and agreed on. Obviously, each setting would require a different type of discussion and different type of consent.

In settings in which dual relationships are mandatory, unavoidable, or likely, the informed consent must be presented prior to the first session and should be discussed with clients before treatment gets under way. The following is a sample of an informed consent that is focused on small-town dual relationships. Dual relationships: Dual relationships or multiple relationships in psychotherapy refer to any situation in which therapists and clients have another relationship in addition to that of therapist-client, such as a social or business relationship.

Not all dual relationships are unethical or avoidable. Therapy never involves sexual or any other dual relationship that impairs Dr. XX's objectivity, clinical judgment, or therapeutic effectiveness or can be exploitative in nature. XX will assess carefully before entering into nonsexual and nonexploitative dual relationships with clients. XX is a small community in which many clients know each other and Dr.

Consequently, you may encounter someone you know in Dr. XX's waiting room or Dr. XX out in the community. Many clients chose Dr. Nevertheless, Dr. It is your responsibility to communicate to Dr. XX if the dual relationship becomes uncomfortable for you in any way. Most of these models focus primarily on power differential, potential for harm, and risk management considerations and imply that it may be best to avoid dual relationships, if and when possible. Additional, more flexible, and more applicable guidelines are provided by Barnett , Ebert , Herlihy and Corey , Moleski and Kiselica , Younggren and Gottlieb , and Lazarus and Zur Partly based on these models and guidelines, the following is a more inclusive approach to dual relationships that acknowledges that some dual relationships are unavoidable but also views dual relationships as a healthy aspect of certain small and interdependent communities and, as such, potentially able to enhance trust between therapists and clients, therapeutic alliance, and clinical outcome.

This approach comprises eight sets of questions. First, are the dual relationships avoidable-elective or mandated-unavoidable? Also, are they expected, normal dual relationships or rare and unique within the communal context in which they take place? Dual relationships in the military are unavoidable. They are common, expected, and difficult to avoid in small, rural communities but are less common and avoidable in large, metropolitan areas where there is a wide selection of available therapists.

Dual relationships in the gay male and lesbian or deaf communities, for instance, are avoidable but common and often expected. Dual relationships in the military are legally mandated.

Obviously, sexual relationships with clients are always unethical and are illegal in most states. Some codes of ethics, states' laws, and states' licensing boards limit the type of bartering therapists are allowed to engage in, whereas others define the parameters of dual relationships allowed in certain forensic situations.

Third, what is the nature, quality, and intensity or frequency of the dual relationship? Is it a personal, professional, or business dual relationship, and will the two parts of the relationship be implemented simultaneously or sequentially?

For example, a dual relationship with a fellow congregation member whom you see infrequently at a Sunday mass is considered a simultaneous, social, dual relationship of low level of engagement.

The fourth set of questions involves four closely related questions, which make up the risk-benefit analysis: a What are the potential risks of entering into a dual relationship? This step involves an analysis of the likely consequences of engaging in a dual relationship, as well as the likely consequences of not engaging in a dual relationship with this particular client at this particular time and in a certain setting.

The potential for conflict of interest, likely conflict of loyalties, and loss of objectivity must be seriously considered as this can have a significant negative impact on the therapeutic process. Also, it is very important, at this stage, to evaluate what might be the potential impact on the community.

Part of the analysis must look at the compatibility between the two roles—therapeutic and nontherapeutic—that therapists may play. Several types of dual relationship i.

Similarly, simultaneous versus sequential dual relationships should also be considered. Even mandatory dual relationships should be carefully assessed for their potential impact on the clinical work.

Obviously, the risk-benefit assessment must take into consideration the contexts of therapy i. The fifth set of questions involves the use of consultations: Does the complexity of the proposed dual relationship necessitate the use of a clinical, ethical, or legal consultation?

Therapists must differentiate between these three different domains and employ an expert consultant accordingly. Therapists should engage a consultant when there is a risk that they may not be able to sustain clinical objectivity or may enter into conflict-of-interest situations.

The sixth set of questions involves the clients: Has the client been fully informed of the risks and benefits entailed in engaging in dual relationships? Similarly, has the client given an informed consent to the dual relationship, and is the client aware of possible consequences and mentioned next exit strategies?

What are the client's reactions, responses, or input to the risks and benefits with which he or she was presented? The seventh set of questions is related to change of plans and exit strategies: If the dual relationship turns out to negatively affect the client or the therapeutic work, what are the exit strategies, and what are the likely consequences of using them?

Human relationships are often unpredictable, and dual relationships that seem initially to enhance the clinical process may affect it negatively later on. If a dual relationship proves harmful, an exit strategy must be constructed, discussed, and implemented. For example, seemingly benign and common social dual relationships in a tight lesbian community may turn competitive, possessive, fraught with jealousy, and highly disruptive to the therapeutic process. Therapists should weigh the options of disengaging from the social or the therapeutic relationships and discuss these options with the clients, including the possibility of referrals, before finalizing them.

Consultations with an expert when dual relationships go sour are highly advisable. Undoubtedly, eliciting a client's assessment of the situation is part of a therapist's determination of the appropriate application of the dual relationship.

Risk management has been central to dual relationship issues. This book takes the position that a thorough and well-documented decision-making process and treatment plan, clients' informed involvement in the decisionmaking process, and consultation, when necessary, is the best practice and thus the best risk management strategy. The process of deciding to engage in dual relationships should be documented and placed alongside the treatment plan in the client's records.

The records should reflect the client's participation in the decision-making process and, when necessary, should include a written and signed informed consent, a description of consultations, an exposition of the nature and type of the dual relationships, and, when applicable, referrals made. The decisionmaking process should show that the relevant client's factors, setting factors, therapy factors, and therapist's factors have been considered see chap.

For detailed steps on ethical decision making regarding dual relationships in psychotherapy, see Figure 1. Ultimately, the therapist must evaluate the actions she or he has decided on and ensure that they are consistent with the standard of care or with what should be expected from the average professional in the same or similar circumstances. However, periodical assessment and reassessment and corresponding adjustments of the course of treatment are also extremely important.

Thus, by not etching the course of action in stone and maintaining a certain fluidity, therapy and the client-therapist relationships can remain in balance. Do not engage in therapy; refer if necessary. Assess effectiveness of treatment, seeking consultation as needed.

Continue treatment, seeking consultation as needed. Continue therapy but discontinue dual relationships. Figure 1. Dual relationships decision tree: Seeking consultation can be done at any point in the process. Chapter 2 Reflections on Power, Exploitation, and Transference in Therapy nphis chapter discusses three of the most commonly raised and JL closely related points regarding boundaries in therapy.

The first one is that given the power differential between therapists and clients, crossing therapeutic boundaries can lead to exploitation and harm of clients by their therapists. The second is the "slippery slope" phenomenon, which is the basis for an assertion that minor, and seemingly harmless, boundary crossings are likely to lead to harmful boundary violations. The third is the premise that boundary crossings are likely to interfere with transference analysis and muddle the transferential relationships.

Power and Boundaries The major concern with boundary crossing in therapy is the power differential between therapists and clients and how therapists may use or abuse this power.

Therapists are hired for their professional expertise, which consequently gives them an expert-based power over their clients Frank, Therapists' seeming aura of wisdom also translates into a power advantage over their clients. Pope and Vasquez identified several types of power that pertain to therapists.

These include power conferred by the state, power to name and define, power of testimony, power of knowledge, and power of expectation.

This power differential has been described as one of the most important factors in determining the risk of harm to clients when therapists engage in boundary crossing Kitchener, It was also listed as the first dimension in the decision-making model for avoiding exploitative dual relationships in therapy Gottlieb, Whether it is power derived from the state as manifested through licensing or the power emanating from therapists' knowledge, education, and expertise, they all give therapists the power to influence clients.

As a result, therapists' suggestions, opinions, advice, or instructions are likely to be taken seriously by many clients, especially the ones who are more vulnerable to such influences. Such influence places the burden of responsibility not to abuse or exploit this power squarely on the therapist. As noted, the power differential enables therapists not only to help and assist but also to exploit and harm their clients. The concern with therapists' power has been focused on therapists' using boundary-crossing interventions or on entering into dual relationships.

Similar to the slippery slope idea, worries arise that an authoritative clinician or counselor who crosses boundaries and ventures beyond the threshold of only-in-the-office, hands-off therapy may foster sexual and other forms of exploitation. The proposed solution for the power differential problem is similar to the proposed solution for the slippery slope issue: avoidance, when possible, of all boundary crossing, and dual relationships, in particular. Some authors e.

In the power differential argument against boundary crossing, clients are often portrayed as passive and malleable, even defenseless, perceiving their therapists as strong and superior Lazarus, ; Tomm, ; Williams, ; Zur, Some clients are CEOs of large corporations, judges, powerhouse attorneys, master mediators, or successful entrepreneurs. Regardless of a client's power, the fiduciary relationship is the foundation of the therapist-client relationship and must be preserved at all times by the therapist.

Accordingly, a therapist must avoid any interventions that are likely to harm a client, such as a sexual relationship or financial exploitation.

Whenever possible, therapists must attempt to minimize potential harm. That is not to say that a therapist who touches a client in a nonsexual manner, accepts an appropriate gift, or crosses boundaries in other ways must anticipate and assure the prevention of all harm, which is not always possible. In fact, the view of the power differential changes with the angle of the viewer. With the rise of the humanist and feminist movements in the s and s, a different concept of power in therapy was introduced; both humanistic and feminist therapy strove to develop a more authentic and more egalitarian relationship between therapist and client than other therapeutic modalities Greenspan, Boundary crossing—primarily selfdisclosure, gifts, dual relationships, nonsexual touch, and a variety of out-of-office experiences—is deemed to permit some of the most effective ways to achieve the feminist and humanist goal of authentic and more egalitarian relationships Williams, Although the power differential is valid and real in many psychotherapeutic situations, it is still unfortunate that it has been used, at times, synonymously with exploitation and harm in the ethics literature.

Many relationships with a significant differential of power such as parent-child, teacher-student, or coachathlete, are not inherently exploitative Tomm, ; Zur, Parental power facilitates children's growth, teachers' authority enables students to learn, and coaches' influence helps athletes to achieve their full, athletic potential.

Therapists' power, like that of parents, teachers, coaches, politicians, policemen, attorneys, or physicians, can be used or abused. The Hippocratic Oath mandate to "first do no harm" attends exactly to such dangers. The problem of abusive or exploitative power in therapy does not lie within the boundary crossings or dual relationships but emanates from the therapist's propensity to abuse his or her power for selfish gain.

Tomm added, "It is not the power itself that corrupts, it is the disposition to corruption or lack of personal responsibility that is amplified by the power" p. When dealing with power issues in psychotherapy, it is important to note that therapists' power is not absolute; it also varies. Short-term therapy focusing on symptom reduction or specific, consultative services are less likely to yield a significant power differential compared with long-term or insight-oriented, psychodynamic therapy.

Similarly, family or group therapy, behavioral consultation, psychoeducation, and medication consultation are less likely to result in idealization and power differential compared with individual, transference-based therapy. Gonsiorek and Brown distinguished between therapy in which the transferential relationship plays a primary role and therapy that is short term and offers little opportunity for transferential relationships to develop.

Contrary to the belief that boundary crossing encourages exploitative behavior by therapists, it has been argued that the opportunity for exploitation is proportional to the amount of isolation in a given therapeutic relationship.

The absence of boundary crossing and relationships other than those developed in the traditional therapeutic session results in increased isolation. Although privacy is extremely important in psychotherapy, it has to be acknowledged that therapists' power is increased in isolation and when therapists do not disclose because clients tend then to idealize and idolize them. However, dual relationships, selfdisclosure, and incidental encounters, when conducted in a professional manner, can all promote a realistic rather than an idealized picture of the therapist.

It has been established that most instances of brainwashing and exploitation occur in isolation, including cult experiences and spousal and child abuse Zur, If a client sees her therapist in church every Sunday with his family, for example, she is going to have a more realistic view of him when she sees his wife and his sometimes misbehaving children. Then, when she sees him in the consulting room, and he is no longer an unknown, neutral, or blank-screen therapist, it is doubtful that he will be idealized in an extreme manner.

One might argue that sexual exploitation is less likely to occur if the therapist is also working with the client's spouse, friend, and parent or has another community connection with the client, either directly or indirectly through the client's family and friends Zur, b. Additionally, therapists are less inclined to exploit those with whom they have a long-term or significant relationship outside of therapy.

Along the same lines, Tomm wrote the following: Indeed, the additional human connectedness through a dual relationship is far more likely to be affirming, reassuring, and enriching, than exploitative.

To discourage all dual relationships in the field is to promote an artificial professional cleavage in the natural patterns that connect us as human beings.

It is a stance that is far more impoverishing than it is protective, p. On one hand, as has been widely acknowledged, it provides the necessary privacy and safety in which clients are more likely to reveal personal or shameful information to their therapists. Ongoing debate and research is valuable in contributing towards best practice and ethical education for therapists. In conclusion, more attention is needed specifically in researching insufficient closure.

Practical, specific ethical guidelines regarding its management should ideally be provided by professional bodies governing those who work in a therapeutic role. View all posts by Clinical Psychology Today. You are commenting using your WordPress. You are commenting using your Google account. You are commenting using your Twitter account. You are commenting using your Facebook account. Notify me of new comments via email. Notify me of new posts via email. Skip to content. Rachael Kelleher Abstract This paper will examine the ethical issues surrounding the management of boundaries in the therapeutic relationship both during therapy and outside the room.

Defining boundaries A key framework for practicing ethical client-therapist interactions both inside and outside the therapy room is the concept of boundaries. Difficulties in defining boundaries Much of the ethical literature emphasises the complex and nuanced definition of boundaries. Boundaries and supervision As the present article is focussed on client-therapist interactions, a discussion of boundaries within the supervisory relationship is outside the scope of the current article.

Discussion This article has examined the ethical issues related to managing boundaries in the therapeutic relationship. Non-sexual boundary crossings and boundary violations: The ethical dimension. Psychiatric Clinics of North America [Internet]. Code of Professional Ethics. Boundary Crossings and Violations in Clinical Settings. Indian Journal of Psychological Medicine [Internet]. Medknow; ;34 1 The concept of boundaries in clinical practice: Theoretical and risk-management dimensions.

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