COVID-19 Note: At the time of this writing, some opportunities to enter into unethical boundary crossings are less likely to present themselves. Currently, most therapy takes place online or on the phone. But we expect a return to up-close and in-person mask-free sessions in the not-too-distant future.

With the exception of boundary violations that clearly breach any standard of care, ethics codes cannot possibly give specific guidance when it comes to mandating appropriate ways to interact with counseling and psychotherapy clients across all possible situations. Many boundary crossings involve no ethical transgression and may even prove beneficial to the client. So much also depends on the setting and context in which the client is treated. A similar act may call for a different response if the client is in individual therapy, or in the military or police organizations, or in a recovery community or institution, or being supervised, and so on (Zur, 2017). However, as we will illustrate frequently, remaining vigilant regarding our own needs and vulnerabilities, as well as those of our clients, is fundamental to ethical practice. Whenever our needs take precedence, rationalization can inhibit sound professional judgment that too easily leads to unanticipated consequences for clients and even to the precipitous destruction of therapists’ careers.

What the therapist may deem as an acceptable, even helpful, boundary crossing may feel inappropriate or harmful to the client. Our main goal for this course is to make a strong case for vigilance and ongoing self-awareness when making decisions about boundary crossing with clients.

HOW RISKY ARE YOU IN PRACTICE?
10 EXAMPLES

If you were to ever have an ethics
complaint pressed against you by a current or former client, we can make an
educated guess as to the basis of the charge: an alleged boundary violation.
Ethics charges based on inappropriate role-blurring account for the majority of
ethics complaints and licensing board actions (Bader, 1994; Koocher &
Keith-Spiegel, 2016; Montgomery & Cupit, 1999; Neukrug, Milliken, &
Walden, 2001; Sonne, 1994; Note: In states having mandatory continuing
education requirements, failure to complete that requirement (when audited) has
become the most frequent licensing violation, with boundary violations the most
frequent complaint when clients are involved). Often, no one could have seen it
coming. Boundary issues can arise in ways that therapists may not initially
predict or even recognize. But, in too many cases therapists behaved in ways
that seem completely out of touch with the impact their decisions and actions
had on those with whom they had a professional relationship. Legal suits and
the cost of defending licensing board complaints cause professional liability
insurance rates to rise, thus harming all therapists. Sadly, the stigma and the
stress endured by the therapist if found guilty can be debilitating (Warren and
Douglas, 2012).

Among the most significant changes
in the ethics codes of professional organizations are those related to demarcating
appropriate boundaries between therapists and clients. Over the last three
decades, we have witnessed a relaxation of rigid restrictions. The reasoning
includes recognition that boundary crossing cannot be totally avoided, especially
in a relationship that involves personal, verbal interactions. And, as stated
earlier, under certain circumstances, role blending may even be helpful to the
client (or at least cause them no harm). Sometimes boundary crossings are actually
mandated (Barnett, 2017a).

On the surface, loosening boundary restrictions feels more
protective of therapists, allowing leeway as to how therapists and their
clients interact. At the same time, however, additional burdens are placed on
therapists because the rules are no longer firm. Decision-making can become
trickier and more challenging because one is at the mercy of one’s own judgment
and potentially unacknowledged biases.

Consider these scenarios:

• The police
  came to your client’s home this morning to arrest her 15-year-old son for
  assault. She feels extremely distraught. Should you allow this client an extra
  half hour in today’s session? And what if your next client with a serious
  anxiety disorder is in the waiting room now?

• You have
  completed your day’s work, and your car is in the shop. Your partner cannot
  pick you up for two hours, but your last client doesn’t live far from your
  apartment. Should you ask if your client would mind dropping you off on the way
  home?

• A new
  client has rheumatoid arthritis and struggles to unbutton her heavy coat.
  Do you rush over to help her?

• The small
  town in which you practice has suffered an economic decline. A client asks if
  he can pay you for therapy services by doing your yard work, as he
  does landscaping on the side. Your yard requires extensive maintenance, so
  should you accept?

• A long-term
  client owns your favorite bookstore in town. He has been letting you purchase merchandise
  at his cost. You purchase a couple of books every month and appreciate the deep
  discount. Should you continue this practice? After all the client is not losing
  anything.

These seemingly benign (or at least
low risk) situations did not turn out so well. The distraught mother scenario
illustrates a double boundary crossing. To offer the client extra time seems a
kind gesture but runs counter to the therapeutic agreement. In the future, this
actual client felt entitled to extra time and resented not getting it. In the
meantime, clients-in-waiting have an agreed upon appointment obligation
altered. One can feel sympathy for the distraught mother, but the matter does
not qualify as an emergency. In fact, the mother might more appropriately focus
on other actions (e.g., locating a lawyer). (Offering extra time would be
prudent in a true emergency situation.)

The client asked for a favor turned
into a bit of a fiasco. The client asked if they could stop on the way home and
have dinner together. The therapist refused politely, noting he had to get home
to his family. But now the client, who later became a stalker, knew where he
lived. This was a relatively new client with some issues that should have
signaled caution on the part of the therapist. His myopic focus on his own
convenience ended up costing him dearly.

Regarding the client struggling
with her winter coat, what seems like an obvious helpful gesture requires brief
reflection. This seemingly helpful act involves physical contact, and not all
clients will feel comfortable with that. Some may find it intrusiveness or
patronizing. Asking, “May I help you?” before acting is essential. (Case
adapted from Pope and Keith-Spiegel, 2008).

The economically strapped
landscaper provides a more complicated case, and we will have more to say about
bartering later. However, in such cases, taking someone up on what seems like a
good match can turn into an ordeal. In an actual similar case, the therapist
credited only a fraction of the therapy cost, requiring the landscaper to work
almost 10 hours to “pay” for one weekly therapy session. Ultimately, the client
successfully sued the therapist for exploitation.

The therapist who partook of the
client’s book offer probably never foresaw a problem. Therapy was progressing
well, and the client is coming out even. But when the therapeutic alliance
began to unravel due to a disagreement as to how therapy should proceed, the
client accused the therapist of “using him as a cheap bookstore.” The client
then quit therapy altogether. In the actual case the client wrote damming
comments about the therapist on a popular online review site. The therapist
experienced a decline in new clients

Let’s try a few more examples. See
if you can imagine what the actual outcome turned out to be.

• Your client
  starts bringing fancy coffee and pastries to every session. Her 10 a.m.
  appointment is just the right time for a coffee break, so you find yourself
  looking forward to it. Is this an innocent pleasure? Is it OK to continue
  this enjoyable tradition?

• The client
  who “Googled” you marvels at what a fascinating life you seem to have and tells
  you that he loves hearing you talk about yourself. You realize that you have
  disclosed a great deal about your personal life over several sessions. Should
  you pull back?

• You want to
  sell your car and have a sign on it out in the parking lot and another on your
  bulletin board in your therapy office hallway bulletin board. Your client
  decides to purchase your car. You believe it to be in excellent condition and a
  good buy. Should you go through with a deal?

• The client
  you have treated for depression over the last six months tells you that she
  plans to visit her sibling who lives across the country in a few weeks. She
  would like to take her dog with her and asks you to write a letter to the
  airline documenting her need for a “trained service animal.” That way she does
  not have to pay extra and avoids shipping the dog in the cargo hold.

• Finally, in
  walks a new client who takes your breath away. You have never seen such a
  gorgeous human being. The attraction feels electric. You have trouble
  concentrating on the session and hardly hear what the client is saying. Should
  you try to stick it out to see if you can gain composure or refer the client to
  someone else?

The client who brought coffee and pastries
to the 10 a.m. therapy session perceived the sessions to reveal a budding friendship.
She began to focus less on her own issues and more on the therapist as someone
with whom she could have a pleasant relationship outside of the office. The
therapist finally recognized what was going on and attempted, unsuccessfully,
to pull the relationship back to the business of therapy. The client
experienced the request to cease bringing coffee and sweets as both an insult
and a rejection. She never returned to therapy. Although this case did not
result in an ethics complaint, the therapist felt guilty over failing to better
perceive how meeting his own needs for what seemed like an innocent pleasure ultimately
caused pain for a client he very much liked working with. (Case adapted from
Pope and Keith-Spiegel, 2008).

The self-disclosing therapist soon
realized that the therapy hour was more about him than the client. He quit
talking about himself altogether, responding only briefly to the client’s
questions about his personal life. He became concerned when the client cancelled
sessions and then dropped out altogether, perhaps because the “pulling back”
felt like rejection. Self-disclosure can be appropriate, but it should always
be done based on clinical indicators and client welfare, as we shall discuss
further, rather than on the therapist’s desire to entertain or to engage in
self-promotion.

In the actual case involving the
sale of an automobile to a client, the therapist’s car failed to live up to the
client’s expectations, and she demanded the return of some of the sale price to
pay for multiple repairs. Unfortunately, the therapist became defensive and
told the client that she must have caused the damage. The therapeutic alliance
evaporated, and the client successfully sued the therapist in small claims
court.

Regarding the service animal
request, therapists may feel compelled to attempt to support their clients’ needs
without recognizing the legal implications (e.g., determining that one’s client
has a mental disability that meets the criteria for use of a support animal
under the Americans with Disabilities Act). Certifying the need for an emotional
support animal, as opposed to a trained service animal (e.g., Seeing Eye Dog)
has become a matter of growing concern among the airlines themselves. Many are
tightening the rules largely due to abuses, such as the array of unlikely
creatures brought onboard. Airlines now require a U.S.
Department of Transportation (DOT) Service Animal Air Transportation form
before any trip. Nevertheless, giving into client’s demands to circumvent
legitimate rules is not a wise boundary to cross. (See: Younggren, Boisvert
& Boness, 2016.)

Finally, in the actual case of the
stunningly attractive client, the moon-struck therapist decided he could not see
her professionally and referred her to another therapist. Then he openly
explained the situation to the client and invited her to dinner. Three months
later they married. Perhaps the story could have a happy ever-after ending.
But, alas, the marriage was short lived. After the enthralled therapist began
to see his then-client as a regular person and the client who had admired the
therapist as a professional began to see him as a regular person, there was too
little remaining to sustain a marital relationship.

THE BATTLE OVER BOUNDARIES:
WHAT IS AN ACCEPTABLE CROSSING?

Therapist/client boundaries occur in
many forms – from crisp to fuzzy – and exist in various influential contexts
(Gutheil & Gabbard, 1993; Knapp, VandeCreek, & Fingerhut, 2017; Zur,
2017). Crossing them has many potential effects. As Pope and Keith-Spiegel
(2008) note, “Nonsexual boundary crossings can enrich psychotherapy, serve the
treatment plan, and strengthen the therapist-client working relationship. They
can also undermine the therapy, disrupt the therapist-patient alliance, and
cause harm to clients.” (p. 638)

Our work as mental health
professionals is conducive to permeable role boundaries because so much of it
occurs in the context of establishing emotionally meaningful relationships,
often regarding intimate matters the client has not spoken of to anyone else.
Yet, mental health professionals continue to hold differing perceptions of role
mingling. These perceptions range from conscious efforts to sustain objectivity
by actively avoiding any interaction or discourse outside of therapeutic issues,
to loose policies whereby the distinction between therapist and best buddy
almost evaporates. However, even those who would stretch roles into other
domains would condemn conspicuous exploitation of clients.

Some therapists decry the concept
of professional boundaries, asserting that they treat psychotherapy as a
mechanical process rather than relating to clients as unique human beings. Such
rigid, cold, and seemingly aloof “cookbook” or “manualized” psychotherapy, the
critics of strict boundaries say, inhibits the formation of empathy and the
natural process of therapy. Instead, acting as a fully human therapist provides
the most constructive way to enhance personal connectedness and honesty in
therapeutic relationships (Hedges, 1993) and may actually improve professional
judgment (Tomm, 1993). Critics even contend that boundary violations have been
improperly inserted into ethics codes, training programs, and licensing and
malpractice litigation (Lazarus & Zur, 2002).

Those critical of setting firm
professional boundaries further assert that the overlapping of roles becomes
inevitable and attempting to control it by invoking authority (e.g., ethics
codes and licensing laws) oversimplifies the complexities inherent in the
therapy process and promotes a kind of defensive therapy (Bogrand, 1993;
Clarkson, 1994; Ryder & Hepworth, 1990). The answer, they say, involves
educating both clients and therapists about unavoidable breaks and disruptions
in boundaries and to ensure that therapists understand that exploitation is
always unethical, regardless of boundary issues.

As the scenarios at the onset of
this course reveal, however, exploitation is not the only harmful result of
boundary crossings. We believe that the therapist retains ultimate
responsibility for keeping the process focused. As Gabbard (1994) concludes,
“Because the needs of the psychotherapist often get in the way of the therapy,
the mental health professionals have established guidelines … that are designed
to minimize the opportunity for therapists to use their patients for their own
gratification.” (p. 283)

We see no reason why maintaining professional boundaries needs to
diminish a therapist’s warmth, empathy, and compassion. The correct task is to align
therapy style and technique with clients’ needs (Bennett, et al., 1994). This
requires a clear vision unencumbered by the therapist’s personal agendas and emotional
problems. Stress, for example, can spiral downward to distress, then
impairment, and finally improper behavior (APA Board of Professional Affairs
Advisory Committee on Colleague Assistance, n.d.). Furthermore, we believe that
lax professional boundaries can lead to exploitation, confusion, and loss of professional
objectivity.

We also understand that one cannot
possibly avoid all nonprofessional interactions with one’s clients. Military
psychologists and sports psychologists, for example, are thrust into levels of
multiple roles intrinsic to their jobs (Barnett, 2013; Watson,
Clement, Harris, Leffingwell, & Hurst, 2006). However, we also agree
with Pope’s (1991) contention that, “the professional therapeutic relationship
is secured within a reliable set of boundaries on which both therapist and
patient can depend.” (p. 23) Conflicts, which are more likely to arise when
boundaries blur, compromise the disinterest (as opposed to lack of interest)
prerequisite for sound professional judgment. As Borys (1994) contended, clear
and consistent boundaries provide a structured arena, and this may constitute a
curative factor in itself.

In short, the therapy relationship
should remain a safe sanctuary (Barnett, 2017) that allows clients to focus on
themselves and their needs while receiving clear, clean feedback and guidance. Candid
discussions about boundaries with clients during the initial informed consent
phase is also recommended. Cultural traditions, geography (e.g., small rural v.
large urban setting), age, and client personality and vulnerabilities are among
the factors that can guide such discussions.

WHAT DEFINES A MULTIPLE-ROLE RELATIONSHIP?

The ethics code of the American
Psychological Association (APA, 2010 with 2016 amendments) offers a clear
definition of multiple-role relationships. Multiple-role relationships occur
when a therapist already has a professional role with a
person and:

• Is also in
  another role with the same person, or
• Is also in
  a relationship with someone closely associated with or related to the person
  with whom the therapist has the professional relationship, or
• Makes
  promises to enter into another relationship in the future with the person or a
  person closely associated with or related to the person.

To qualify for the definition of
multiple-role relationship then, the initial relationship typically requires an
established connectedness between the parties. The primary role relationship is
usually with an ongoing therapy, counseling client, student, or supervisee.
Limited or inconsequential contacts that grow out of chance encounters would
not normally fall under the definition of a multiple-role relationship or cause
any ethical concerns.

Multiple-role relationships may occur via action, as when a
therapist hires a client as a housekeeper. Or they can take the form of a
proposal for the future while therapy remains ongoing, as when therapist and
client plan to go into business together or agree to start a sexual
relationship upon termination of therapy, thus altering the dynamics of the
ongoing professional relationship. Zur (2017) has categorized multiple-role
relationships by types. These include social/communal, professional, business,
instructional, forensic, sexual, and digital. These categories are illustrated
in the cases offered here.

Most nonsexual consecutive role
relationships with ex-clients do not fall under any specific
prohibitions in the APA code, unless some potential harms qualify as
foreseeable. However, based on post-therapy incidents described in this course,
we advise caution even after a natural termination of the professional
relationship. We have good evidence that certain types of complex
therapist-client interactions can later prove harmful (Bennett, Bricklin, &
VandeCreek, 1994; Smith & Fitzpatrick, 1995) and that duty to clients does
not necessarily end with therapy termination.

EVALUATING MULTIPLE-ROLE RELATIONSHIPS

Ethics codes of all major mental
health associations mandate that therapists refrain from entering a multiple-role
relationship if objectivity, competence, or effectiveness in performing
professional functions could become impaired, or if exploitation is a risk.
However, not all multiple-role relationships with clients are necessarily
unethical so long as no exploitation or risk of harm to the client or the
professional relationship can be reasonably expected.

We agree that careful consideration
should occur prior to softening the boundaries of any professional role, but we
also remain unconvinced that accurate outcome predictions involve a simple
exercise in judgment. If that were so, therapists would have the lowest divorce
rate of any professional group! Alas, no evidence of such foresight exists.
Indeed, the life of a therapist carries its own risks for burnout and stress
that negatively affect their relationships with others (Epstein & Bower,
2005).

We also contend that justification
for entering into some types of multiple-role relationships with persons in
active treatment does not exist. Sexual and business relationships, for
example, pose inherent risks regardless of who is involved. Neither can be
defended as reasonable dimensions to impose on a therapy relationship.

Finally, we will comment on how
easy it is to rationalize; to convince ourselves that an action is justifiable
in a particular situation. All therapists are vulnerable to self-delusion when
their own needs get in the way, even those who are competent and have been
scrupulously ethical in the past (Keith-Spiegel, 2014; Koocher &
Keith-Spiegel, 2016; Lowell, 2012; Merritt, Effron, & Monin, 2010; Monin
& Miller, 2011; Tenbrunsel & Messick, 2004).

Risk Assessment

Kitchener (1988) suggests assessing
the appropriateness of boundaries by using three guidelines to predict the
amount of damage that role blending might create. Role conflict occurs, she says,
when expectations in one role involve actions or behavior incompatible with
another role. First, as the expectations of professionals and those they serve
become more incompatible, the potential for harm increases. Second, as
obligations associated with the roles become increasingly divergent, the risks
of loss of objectivity and divided loyalties rise. Third, to the extent that the
power and prestige of the psychotherapist exceeds that of the client, the
potential for exploitation is heightened.

Gottlieb’s oft-cited (1993) model
for avoiding exploitative multiple relations tracks the level of the
therapist’s power (from interventions where little or no personal relationship
was established with a client to clear power differential with profound
influence) along with the duration (or expected duration) of the professional
relationship and the clarity of termination (defined as the level of mutual
satisfaction with the conclusion of therapy and the likelihood that the client
will have further professional contact). Thus, if after two years of intense
therapy and a tenuous termination whereby the client may need to return at any
time, no additional roles should be contemplated. However, after a Saturday
afternoon “self-empowerment workshop” that resulted in a mutually agreeable
one-time experience, the risk, if the therapist enters into another role with
an attendee, seems minimal. The success (or failure) of this new role
relationship would be more about what the parties do as consenting adults as
opposed to the brief professional experience.

Brown (1994) adds two additional
factors that, if present, heighten the risk of harm. First, “objectification”
can occur, with the therapist using the client as an “it” for the purpose of
providing entertainment or convenience. Second, boundary violations usually
arise from impulse rather than from carefully reasoned consideration of any
therapeutic indications. Thus, hugging a client is not unethical per se,
but an assessment of any potential hazards or misunderstandings should precede
such an act.

Risky Therapists

All therapists face some risk for
inappropriate role-blending (Keith-Spiegel, 2014). Those with underdeveloped
competencies or poor training may prove more prone to improperly blending roles
with clients. However, even those with excellent training and high levels of
competence may relate unacceptably with clients because of the failure of their
own boundaries. Some may feel a need for adoration, power, or social
connection. We must face the unfortunate reality that psychotherapy and
counseling services provide an almost ideal climate – a “perfect storm,” if you
will – for emotionally or morally precarious mental health professionals to
gratify their own personal needs. The settings are private and intimate. The
authority falls on the side of the therapist. Moreover, if things turn sour,
the therapist can simply eliminate the relationship by unilaterally terminating
the client and then denying that anything untoward occurred should a client
initiate a complaint.

Some evidence suggests that the
propensity to engage in boundary violations differs between men and women. The
extensive survey conducted by Dickeson, Roberts, and Smout (2020) reports that
boundary violation
propensity (BVP) was associated with nurturant interpersonal styles in women but
with dominant interpersonal styles in men. Their regression analysis revealed
unique BVP predictors for men: grandiose narcissism, vulnerable (or covert)
narcissism, self-centered interpersonal traits, and low levels of empathic
concern. For women, the authors found unique BVP predictors to be impulsivity,
childhood adversity, self‐sacrificing
interpersonal traits, and vulnerable narcissism.

Self-Disclosing Therapists

Most psychotherapists have engaged
in some measure of self-disclosure with their clients (Pope, Tabachnick, &
Keith-Spiegel, 1987; Yeh & Hayes, 2011), and many studies have examined the
role played by self-disclosure in the process of therapy (Barnett, 2011; Davis,
2002; Farber, Berano, & Capobianco, 2004; Kim, Hill, Gelso, et al., 2003;
Miller & McNaught, 2016; Peterson, 2002). Indeed, when a client walks
through the door, immediate clues about the therapist become apparent: the therapist’s
approximate age, dress style, decor preferences, certificates on the wall,
photographs on the desk, perhaps a wedding ring. Today’s clients probably
searched online to learn more about who they will be meeting.

Multiple authors have discussed the
advantages of self-disclosure. Done thoughtfully and judiciously, revealing
pertinent information about oneself can facilitate empathy, build trust, and
strengthen the therapeutic alliance (Kronner & Northcut, 2015; Levitt,
Minami, Greenspan, Puckett, et al., 2016; McBeath, 2015; Miller & McNaught,
2016).

However, those who engage in
considerable and revealing self-disclosure with clients stand at greater risk
for forming problematic relationships with them. Whereas well-considered
illustrations from the therapist’s life may help make a point or signal
empathy, the decision to use personal data as an intervention comes down to a
matter of professional judgment.

Mildred
Yappy, Ph.D., thought that disclosing her own experiences with weathering
extra-marital affairs would be helpful to her distraught client who recently
discovered that her husband was in a sexual relationship with a co-worker.
Instead, this client began to feel that the therapy environment was polluted
rather than safe and clean. She quit therapy feeling even more adrift.

It is difficult to know in advance
how a given client will respond to a self-disclosure, particularly when the
subject is in sensitive territory for the client. Dr. Yappy’s disclosures may
have solidified a trusting bond with a client who found shared misery
comforting. But client reactions are difficult to predict, even when therapists
pause to ask themselves, “What is the purpose of what I am about to share with
my client?”

Contextual issues are also
important; these include the therapist’s theoretical orientation and treatment
approaches as well as client factors such as culture, gender, mental health
history, current treatment needs, and agreed-on goals. However, even though
becoming too relaxed when sharing one’s personal life (or ignoring unexpected
client reactions to disclosures) may not result in a formal ethics charge,
effective psychotherapy can be compromised (Barnett, 2011).

Of course, clients may instigate
inquiries about their therapists’ personal lives. It seems reasonable to expect
that some clients would want to know as much as possible about the person in
whom they are placing so much trust. Therefore, we agree with Lazarus’s (1994)
contention that it feels demeaning to have a question dismissed and then answered
by another question, such as in, “Do you have children, Dr. Stone?” “Why do you
ask me that, Stanley?” Not all clients’ questions should be answered, of
course, and the wise therapist will explore the intent of a client who seems
too inquisitive. A skillful therapist can respond without demeaning the client
in the process.

At the same time, Internet searches
make considerable information on anyone readily available. Like any other
individual who prefers some modicum of privacy, therapists must understand that
information posted on personal and social sites will become known to curious
clients and may lead to unwanted inquiries or promote some other types of
boundary blurring. (Kolmes, 2017; Reamer, 2017)

Professional Isolation

Professional or personal isolation
can cloud therapists’ judgments. The next case involves an indignant response
to a fading career, compounded by an absence of close ties with family or
friends. Dr. Grandiose might elicit some sympathy were it not for her
ill-conceived approach to dealing with her own issues.

A
well-known and outspoken therapist, Panacea Grandiose, Ph.D., alienated the
professional community over the last several years with her personal attacks on
colleagues who criticized her and her theoretical foundation as outmoded.
However, Grandiose continued to maintain a successful practice, and her clients
became the focus of her life. She hosted frequent social events in her home and
invited herself along on clients’ vacations. Colleagues in the community became
concerned that Grandiose had developed a cult of sorts, made up of high-paying,
perennial clients who also provided her with adoration, loyalty, and “family.”

We have noted that many cases
involving boundary-blurring (including sexual ones) occur among therapists who
maintain solo practices, often in isolated offices away from other mental
health professionals. It seems that something about therapists either choosing
to work in isolation, or the isolating conditions themselves, foster the
potential clouding of professional standards of care. Or, perhaps some
therapists have experienced rejection by their colleagues, as with Dr.
Grandiose, and turn to inappropriate substitutes for support and validation.
Regardless of the reason, an insular practice with no provisions for ongoing
professional contact diffuses professional identity, thus putting appropriate
decision-making at risk.

Therapeutic Orientation and Specialty Practices

Some therapists practicing within
certain therapeutic orientations are probably more vulnerable to charges of
boundary violations. For example, Williams (1998) notes that humanistic therapy
and encounter group philosophies depend heavily on tearing down interpersonal
boundaries. Such therapists often disclose a great deal about themselves, hug their
clients, and insist on the use of first names. These therapists also become,
according to Williams, vulnerable to ethics charges even though their practice
is consistent with their training.

Some therapists who specialize in
working with a particular population or in certain settings may need to
exercise extra vigilance because the nature of the services or service settings
are conducive to (or even require) relaxed boundaries. Sports psychologists,
for example, often travel, eat, and “hang out” with a team, and may find
themselves called upon to fill water bottles and help out with whatever else
needs doing (Anderson, Van Raalte, & Brewer, 2001; Zur, 2017). An even more
complex relationship exists for mental health professionals embedded in military
units in close quarters, with an obligation, unlike embedded journalists, to
tend to the unit’s needs and even engage in combat (Johnson, Ralph, &
Johnson, 2005). In such instances, very fuzzy edges may constitute an inherent
element of practice rather than qualifying as inappropriate.

Pastoral counseling, wherein the
therapist may also function as the client’s religious guide, presents a
sensitive pre-existing dual role.

Mildred
Devine requested counseling for what she called a “spiritual crisis” from her
minister, Luther Pew, who also held a license in marriage and family
counseling. Ms. Devine experienced deep sadness, hopelessness, and questioned
her faith. At that time, Pew was dealing with his own troubles and struggling
to manage his large congregation. When Ms. Devine relayed her feelings, blaming
God for having forsaken her, Rev. Pew responded by pouring out details of his
own family problems, including the particulars of a drinking problem in his
youth. Pew hoped this intense session would prove helpful, figuring that Devine
would gain confidence from knowing that even he had to face and overcome
hardships. Devine, however, became upset by these revelations, passed them
along to other parishioners, and left the church.

Rev. Pew appears to have seriously
mismanaged his parishioner’s clinical depression by failing to recognize its
intensity and his own lack of competence to treat it. He also interjected too
much of his own life while failing to recognize that Ms. Devine asked Pew for
spiritual guidance only. Pew should have focused on his role as a pastor and
simultaneously referred Ms. Devine to someone competent to treat her
depression.

Therapists who belong to a
religious community as parishioners can also easily experience challenging
multiple roles. As Sanders (2017) points out, parishioners have common values
and gather together to share each other’s burdens. A therapist/
parishioner should, therefore, maintain some discretion when treating another
parishioner.

Risky Career Periods

No matter how long you have
practiced as a mental health professional, specific risks link to each career
development period. We will briefly describe those that can be associated with
early, mid-level, and later career stages.

Therapists who engage in
inappropriate role-blending often come from the ranks of the relatively
inexperienced. Many have graduated from programs where students developed
complex relationships with their educators and supervisors. Similarly, the
internship or residency period often involves role-blending, including social,
evaluative, and business-related activities (Slimp & Burian, 1994; Nanna,
2020). Not all supervisors are themselves good role models (Landany, Mori,
& Mehr, 2013; Strandberg, 2017). It may be that many therapists
new to functioning independently have had an insufficient opportunity to
observe professionals who have put appropriate boundaries in place, as
illustrated in the next case.

Kat Kopy,
LCSW, enjoyed her last supervisor because he was funny and flirty and took
her out for drinks after every session. She decided that her clients would
benefit from the same kind of relationship. Her client, Roger Rage,
misunderstood her affable demeanor and their after-session coffeehouse
excursions and assumed that she was attracted to him. When she recoiled as
Roger attempted a kiss on her lips, he felt humiliated and angry. He slapped
her face hard, breaking her glasses.

There are steps that should be
taken in educational programs to reduce confusion among trainees. Emphasizing an
ongoing “role awareness” program is recommended wherein staff makes decisions
about relationships with trainees and students (Reitz, Simmons, Runyun, et al.,
2013).

The mid-career period can pose
risks for those therapists whose professional or personal life has not panned
out according to their youthful aspirations. Divorce or other family-based
stresses involving teenagers, young adult children, or aging parents; onset of
chronic health issues; and apprehension about their own aging, as well as other
mid-career difficulties can impair professional judgment. Research findings
reveal that the majority of therapists who engage in sexual relationships with
their clients do so while middle-aged. The next cases illustrate how things can
go wrong.

Des Pondent, Ph.D., age 46, felt like a failure compared to his spouse’s
successful and still-rising career. When an attractive young client whose
self-esteem needed boosting showered praise on Des, that client’s sessions took
on a special priority. Therapy was often followed by coffee and soon more
extensive outings together, and eventually ended in a motel where the
proprietor did not expect guests to bring luggage or stay for more than a
couple of hours. Dr. Pondent thought it best to terminate therapy as the
relationship became more intimate, thinking that would provide a shield against
future criticism. Unfortunately, the now ex-client became insistent that they
see each other even more often and in nicer venues. Dr. Pondent, who had no
intention of leaving his spouse, then tried to call off the affair. The
ex-client was furious, felt abandoned and rejected, and contacted a licensing
board. The client’s evidence against Des consisted of emails, text messages,
and compromising photographs the client had surreptitiously taken with her smart
phone. (Story adapted from Keith-Spiegel, 2014.)

Recently
divorced Justin Singleman, Ph.D., was in a tight financial squeeze, what with
child support for his two young children and college tuition assistance for the
two older ones. He told his life story to one of his longer-term clients who
tried to console Dr. Singleman by offering him a free apartment to get through
a transition period. However, after a few months the client suggested that Dr.
Singleman should move on to his own place. Dr. Singleman became upset and
terminated the client. He also refused to move, forcing the client to go
through an ugly eviction process.

Dr. Pondent’s expectation that an
abrupt termination for the purpose of continuing a sexual relationship would
protect him from ethical scrutiny was a serious error. He was ultimately
expelled from his professional association and lost his license to practice.
Dr. Singleman appears to have become himself emotionally impaired, and his own
client was ultimately forced to bear the brunt of it.

Another elevated risk period can occur at the far end of the career cycle.
Sometimes older therapists have, perhaps without full awareness, come to see
themselves as “evolved” beyond questioning or as having earned some sort of
“senior pass” bequeathing the freedom to do things their own way. Pepper (1990)
discusses the psychodynamics of charismatic, grandiose, authoritarian senior
therapists who may harm clients by encouraging complicated multiple relationships.
We know of ethics cases involving therapists who have practiced for 40 or more
years who illustrate this phenomenon. Here is just one:

Alan
Groupie, Ph.D., age 73, went into business with a famous movie star who
suffered from severe depression. Groupie eventually became his manager and
moved in with the celebrity. He personally monitored all the celebrity’s
activities, charging his usual fee of $200 per hour, 24 hours a day, 7 days a
week. This arrangement lasted for more than a year until the celebrity’s
attorney stepped in and filed extortion charges against Groupie.

Risky Clients

Not every client can cope with
unintended effects of boundary crossings. Trust issues often lie at the heart
of the matter. Clients seen at social service and other out-patient community
agencies may become disenfranchised due to deficits in cognition, judgment,
self-care, and self-protection, as well as holding little social status and
power. Such clients are at greater risk for exploitation (Walker & Clark,
1999).

Clients who have experienced
victimization through violent attacks or abuse due to difficulties with trust
or ambivalence surrounding their caretakers also benefit from clear boundary
setting, despite their frequent testing of such boundaries (Borys, 1994).
Clients with self-esteem or individuation problems often depend on the constant
approval of others for confirmation. Therapists who weaken boundaries by
reassuring such clients that they are “special” by taking them to lunch, giving
them gifts, or disclosing excessive detail from their own lives may unwittingly
collude with this pattern, thereby reinforcing the pathology (Borys, 1994).

Clients who have suffered early
deprivations and have not fully mourned the finality of the past may still seek
to meet their residual needs by earning favor with those who were physically or
emotionally unavailable. Developing a therapeutic relationship often mobilizes
high hopes that the therapist will substitute for or replenish losses of the
past. If the therapist responds as a rescuer, a totally inappropriate cycle
becomes established, and the client will again experience the loss because a
therapist never can replace a parent or past relationship (Borys, 1994). In
this context, we gain considerable insight into the psychodynamics behind the
many charges of “abandonment” brought by clients involved in multiple-role
relationships with their therapists.

The technique of positive limit-setting
should be mastered by all therapists. It involves placing restrictions when
responding to a client’s request while, at the same time, reframing the
response in a way that meets a legitimate underlying need. Essentially, this
requires therapists to ask themselves whether or not their potential comments
or interventions will likely benefit their clients. Below is an example of
positive limit-setting.

An
emotionally needy child, who had witnessed domestic violence, asked his
therapist where he lived. When the therapist asked why the child wanted to know
he replied, “Maybe if my parents start fighting again, I could come to your
house.” The therapist replied, “I want you to be safe, but I’m not always home
and I would not want you to get lost.” The therapist suggested that if the violence
erupted at home, the child might go to the local fire station (a block from his
home) and ask the people on duty to help him, noting that there is always
someone there.

Here the therapist addressed the
client’s need with a problem-focused solution and rationale that did not leave
the child feeling patronized or without support.

More unusual types of risky clients
(through no fault of their own) are those who are special because of fame,
power, or fortune; The Very Important Patients, as Gainer and Cowan
(2019) calls them. Those therapists who want to get close to such clients for
their own reasons are prone to creating therapeutic blunders and role-mingling
that may come back to bite.

Making Role-Blending Decisions

We designed a table to help decide
whether a professional should even contemplate blending roles in a variety of
situations. We have adapted from Anderson and Kitchener (1998), Brown (1994),
Gottleib (1993), Kitchener (1988), and Younggren & Gottleib (2004), and
added our own observations and research. Of course, each situation that arises
has its own idiosyncrasies that must be reflected upon before acting.
Furthermore, most risks can be contemplated along a continuum as opposed to the
dichotomous scheme we present here. However, if an honest reflection results in
any feature of a possible new role tending toward the “more risky” column, we
advise considerable caution.

Evaluating Additional Roles with
Psychotherapy Clients

Our concern is that many people become
adept at avoiding what they don’t want to recognize in themselves, especially
if their own need-satisfaction is at issue. These people do not accurately
predict what problems could arise. The next section lists cautionary signals in
more concrete terms, making the decision less vulnerable to excuses.

Red Flag Alerts

Mental health professionals can be
helpful, caring, empathic human beings who maintain professional parameters
within which they effectively relate to their clients. We again acknowledge the
impossibility of setting firm boundaries appropriate for every client under
every circumstance. We remain concerned, however, that inappropriate crossings
are often rationalized as benevolent or therapeutic (Keith-Spiegel, 2014;
Koocher & Keith-Spiegel, 2016). Rationalizations can even include blaming
the client for untoward consequences.

Here we offer another personal
assessment in the form of some early warning signs of nonsexual boundary
crossings that could cause confusion and disadvantage clients. These signals,
some of which are adapted from Epstein and Simon (1990), Keith-Spiegel (2014),
Pope and Keith-Spiegel (2008), and Walker and Clark (1999), include the
following:

• Actively
  seeking opportunities to spend time with a client outside of a professional
  setting;

• Anticipating,
  with uncommon excitement, a certain client’s appointment;

• Expecting
  that certain clients should volunteer to do favors for you (e.g., getting you a
  better deal from her business);

• Viewing a
  client as in a position to advance your own position and fantasizing as to how
  that would play out;

• Wishing
  that a client were not a client and, instead, in some other type of
  relationship with you (e.g., your best friend or business partner);

• Disclosing
  considerable detail about your own life to a client and expecting interest or
  nurturing in return;

• Trying to
  influence a client’s hobbies, political or religious views, or other personal
  choices that have no direct therapeutic relevance;

• Allowing a
  client to take undue advantage without confronting him or her (e.g., allowing
  many missed appointments without calling to cancel);

• Relying on
  a client’s presence or praise to boost how you feel about yourself;

• Giving in to
  a client’s requests and perspectives on issues from fear that he or she will
  otherwise leave therapy;

• Feeling
  entitled to all of the credit when a client improves;

• Viewing one
  or more clients as among the central people in your life;

• Greatly
  resisting terminating a client despite indicators that termination would be
  appropriate;

• Believing
  that you are the only person who can help a particular client;

• Noticing
  that the pattern of interactions with a client is becoming increasingly
  irrelevant to the therapeutic goals;

• Feeling
  jealous or envious of a client’s other close relationships;

• Frequently
  allowing the therapy session to go overtime;

• Instigating
  communications with a client in between sessions for reasons that are contrived
  or irrelevant to the therapy issues;

• Finding
  yourself making extra efforts to impress a client about yourself and your
  achievements;

• A feeling
  of dread upon sensing that a client may decide to leave therapy; and finally,

• Feeling
  uncomfortable discussing the “red flags” that pertain to you with a trusted
  colleague because you are concerned that the colleague would be critical of your
  thinking or behavior.

Perhaps the most difficult message
for us to convey in writing is just how right it might
feel at the time to slip into a more complex role with those receiving our
services. Our brief case scenarios summarize situations that often unfold over
weeks or months. As a result, we may have failed to convey sufficiently the
perceptions and rationalizations that so often develop over time, often in baby
steps. Perhaps the brightest red flags should pop up any time you say to
yourself, “This person will be different,” or “This particular circumstance
doesn’t qualify as a role conflict.” Pause then to ask yourself, “How will
doing this help the client?”

Miscalculations are easy to make
when it comes to boundaries, especially if we are distracted, taken by
surprise, or focusing too much on our own needs. Pope and Keith-Spiegel (2008)
offer seven major errors in thinking that can occur:

• Error #1:
  What happens outside the psychotherapy session has nothing to do with the
  therapy.

• Error #2:
  Crossing a boundary with a therapy client has the same meaning as doing the
  same thing with someone other than a client.

• Error #3:
  Our understanding of a boundary crossing is also the client’s understanding of
  the boundary crossing.

• Error #4: A
  boundary crossing that proved therapeutic for one client will also therapeutically
  benefit another client.

• Error #5: A
  boundary crossing constitutes a static, isolated event.

• Error #6:
  If we ourselves do not see any self-interest, problems, conflicts of interest,
  unintended consequences, major risks, or potential downsides to crossing a
  particular boundary, then there aren’t any.

• Error #7
  Self-disclosure always qualifies as therapeutic because it shows authenticity,
  transparency, and trust.

If you begin to sense the
professional role stretching into any area unrelated to the purpose of the
professional relationship, pause immediately to evaluate the situation. Imagine
the worst-case scenario in terms of outcome should the present course continue
– often what seems like minor risk can end badly, as we have already
illustrated – and seek consultation with a peer. This makes good sense
considering that we can seldom fully predict harmful outcomes in advance.

Some invitations to blend roles can
prove so tempting that they blind the practitioner to pre-existing obligations
or cause damaging rationalizations.

Phil T.
Assessor, Ph.D., earned $1,500 in insurance reimbursement for conducting a
neuropsychological evaluation of Vic Tem, who suffered an injury in an automobile
accident, at the request of Mr. Tem’s neurologist. One of Dr. Assessor’s
conclusions suggested that Mr. Tem might have exaggerated his symptoms. Five
years later, a lawsuit involving the driver of the automobile that struck Mr.
Tem progressed to trial. The driver’s attorney retained Dr. Assessor at a fee
of more than $10,000 to rebut Mr. Tem’s claim of damages. When challenged on
his ethics, Dr. Assessor replied, “I only saw Mr. Tem on one occasion five
years ago, and he is no longer my client.”

In this instance, Dr. Assessor
blended the role of psychological evaluator with that of subsequent adverse expert witness. Although Dr. Assessor’s services to Mr. Tem had ended five
years earlier, Dr. Assessor still owed Mr. Tem a duty of care and protection from
harm. Despite the high compensation opportunity, Dr. Assessor should have
understood that blending in a role adverse to his client could not be
rationalized away.

Finally, Pope and Keith-Spiegel
(2008) suggest that when you do decide that a planned boundary crossing would
assist the client, engage in an informed consent process (e.g., before taking a
phobic client for a walk in the local mall to window shop). Then keep detailed
notes on any planned boundary crossing that describe why it did or will help the
client. Always confer with trusted colleagues if you have any doubts about your
decision.

BARTERING ARRANGEMENTS WITH CLIENTS

Bartering for mental health and
counseling services transformed from a forbidden practice to a nearly
incidental ethical matter. For example, the APA ethics code long discouraged
exchanging anything other than money for therapeutic services. However, APA has
nearly reversed itself in recent years, requiring only that the client not be
exploited and that the transaction not be clinically
contraindicated. The reason for the loosening of the no-bartering rule may be
the decrease of insurance coverage for mental health services and the general
economic downturn that has negatively impacted so many.

On the surface, allowing bartering
in hard economic times may seem like a win-win situation for clients who want
therapy and therapists who want clients, many of whom may have skills or
objects to trade. Lawrence (2002) even asserts that those who cannot pay for
therapy should be able to barter and that therapists unwilling to take any
attendant risks are not worthy of the job! We acknowledge that entering into
bartering agreements with clients appears reasonable and even a humanitarian
practice toward those who require mental health services but are uninsured and
strapped for cash. We also acknowledge that many bartering arrangements have proven
satisfactory to both parties. But, as we shall illustrate, things do not always
go as planned.

Exchanging Services

A gifted
seamstress agreed to make clothes in exchange for counseling. The client was
satisfied with the agreement because she needed counseling and had plenty of
time available to sew. The therapist’s elation was summarized by her giddy
remark at a cocktail party, “I am most assuredly the best-dressed shrink in
town.”

This case illustrates the potential
darker side of barter arrangements. Because the therapist openly acknowledged,
with delight, her dual relationship at a social gathering, she apparently never
considered any risk of exploitation. What will happen when an outfit does not
fit properly or does not meet the therapist’s expectations? What if the client
becomes displeased with the therapy or becomes too busy in her own life and she
begins to feel like a one-woman sweatshop? What if the therapist remains so
satisfied with the relationship that she creates within the client an
unnecessary dependency to match her own? These “what ifs” are not idle
speculation when one considers incidents of bartering that have already gone awry.

Kurt Court,
Esq. and Leonard Dump, Ph.D., met at a mutual friend’s home. Mr. Court’s law
practice was suffering because of what he described as “mild depression.” Dr.
Dump was about to embark on what promised to be a bitter divorce. They hit on
the idea of swapping professional services. Dr. Dump would see Mr. Court as a
psychotherapy client, and Mr. Court would represent Dr. Dump in his divorce.
Mr. Court proved to be far more depressed than Dr. Dump anticipated.
Furthermore, Court’s representation of Dump was erratic, and the likelihood of
a favorable outcome looked bleak. Yet, it was Mr. Court who brought charges
against Dr. Dump. Court charged that the therapy he received was inferior and
that Dump spent most of the time blaming him for not getting better faster.

This case illustrates not only the
unfortunate results that can occur when the follow-through phase of bartering
results in unhappy clients, but also the vulnerable position in which the
therapists place themselves.

Charges of exploitation become
heightened when the value placed on the therapist’s time and skills are set at
a higher rate than those of the client. Moreover, because the therapist’s
hourly rate will more likely exceed that of what one would pay for a client’s
skills, this risk probably exists in the majority of exchange agreements.

Elmo Brush
agreed to paint the rooms in the home of Paul Peelpaint, Ph.D., in exchange for
counseling Brush’s teenage daughter. Dr. Peelpaint saw the girl for six
sessions and terminated the counseling. Brush complained that his end of the
bargain would have brought $1,200 in a conventional deal. Thus, it was as
though he paid $200 a session for services for which Peelpaint’s other
full-paying clients paid $100. Dr. Peelpaint argued that he had satisfactorily
resolved the daughter’s problems, and the arrangement was valid because task
was traded for task, not dollar value for dollar value.

Trading a one-time service with a
known cost estimate – based on Brush’s own professional experience – with a
service that cannot be cost-estimated in advance, spells trouble from the
beginning. Brush’s daughter might have required 50 sessions, valued at $5,000,
if Dr. Peelpaint was willing to conduct as many sessions as therapeutically
necessary and had been collecting his usual fees. Dr. Peelpaint’s attitude also
reveals little regard for fairness toward Brush. Some of the ethical
complexities of Dr. Peelpaint’s case might have been avoided had he hired Brush
outright, leaving Brush free to make an independent decision about engaging
Peelpaint as his daughter’s therapist after the painting job was finished.

Sometimes, people who do not
understand the implications of their offer propose bartering arrangements.
Consider this actual posting to Craig’s List (spelling errors included):

Barter
counseling for bathroom repair “My husband
is a capible counselor, lisensed but not good at home repairs and construction.
I will trade his expertise for your time with him as a counselor if you can
help us with tub and tile repair and pluming. We had a termite problem that we
fixed but the place needs a new floor. If you or a loved one are struggling
with depression, or anger issues, or bipolar, he is your man. He is an
excellent counselor. We have our own non-profit and give to others without
charging so our financial situation is limited but looking to trade!”

Aside from the spelling errors, the
counselor’s spouse has no clue about the potential complications of her
solicitation. Does she really want an angry plumber in their bathroom?

Exchanging Services for Goods

So far, we have discussed
exchanging a service for a service. Here, we explore more fully the exchange of
professional services for tangible objects. It has been suggested that this
form of bartering is less problematic because a fair market price can be
established by an outside, objective source. However, the actual value of goods
often depends heavily on what buyers are willing to pay. This means that
determining the true value can prove challenging, and charges of exploitation
could easily arise. We know of instances of service-for-item bargaining that
turned out poorly. Therefore, we urge considerable caution when an object is
traded for professional services, and even when purchasing an item outright
from a client.

When Manifold Benz, Ph.D., learned that his financially strapped
client planned to sell his classic automobiles to pay outstanding therapy and
other bills, Dr. Benz expressed an interest in one of the cars. Benz said that he
had seen the same model at an auto show for $19,000, and that he would offer to
credit the client with 200 hours of therapy in exchange for the car. The client
stood 100 hours in arrears at the time.

Benz is exploiting his client by
committing him to a specific number of future therapy sessions that the client
may not need. Further, we do not know if the price Benz suggested represents
fair market value, and this may prove difficult to determine precisely given
the rarity of the item. (The fact that Benz had allowed a client to fall 100
hours in debt demonstrates another ethical problem.)

Flippy
Channel, Ph.D., allowed Penny Pinched to pay her past due therapy bill with a
television set that Penny described as “near new.” However, when Dr. Channel
set it up in her home, the colors were faded, and the picture flickered. She told
Penny that the television was not as she had represented it, and that she would
have to take it back and figure some other method of payment. Penny angrily
retorted that Dr. Channel must have broken it because it was fine when she
brought it to him. When Channel insisted that the TV was defective, Penny
terminated therapy and contacted an ethics committee. She charged that Dr.
Channel broke both a valid contractual agreement and her television set.

Dr. Channel found herself in a
no-win situation because of the television fiasco. A therapeutic relationship
was also destroyed in the process. Channel could have avoided a confrontation
and perhaps saved the relationship by junking the TV without mentioning it to
Ms. Pinched. Nevertheless, the therapeutic alliance might have suffered anyway
due to lingering resentment that might leak out toward her client. In the
actual case, the client was seeking therapy to deal with sexual abuse as a
child. Boundary crossings with clients who were badly betrayed are especially contraindicated
(Keith-Spiegel, 2014).

It is important to recognize two
points: First, therapists have the responsibility of assuring that they do not
take advantage of their clients. Second, therapists should normally not get
involved in helping clients sell their tangible property. If clients have
something of true value to sell, they can find many ready markets through
Internet sites, reaching thousands of potential buyers at little or no cost to
sellers.

Final Considerations Regarding Bartering

Because therapeutic services
typically involve a combination of trust, sensitive evaluations, social
influence, and the creation of some measure of dependency, the potential for
conflicts of interest and untoward consequences always exist with bartering
agreements (Gandolfo, 2005; Gutheil & Brodsky, 2008). We contend that it is
impossible to confidently ascertain which clients will be well-suited to a
nontraditional, negotiated payment system and which should be turned down,
especially near the outset of the therapeutic relationship. By definition,
bartering involves a negotiation process. Is a client in distress and in need
of professional services in a position to barter on an equal footing with the
therapist? Furthermore, even therapists feel attracted by a good deal. How does
this pervasive human motive play itself out in bartering situations with
clients?

When a client suggests a bartering
arrangement, therapists without a clearly stated “no-barter policy” can find
themselves in any of three situations that could cause discomfort for all
concerned. First, if a therapist is known to barter, especially probable in
small communities, turning down an unwanted proposal could feel like a
rejection, which could hamper some clients’ mental status. Second, must a
therapist accept something unneeded or unwanted? Imagine telling a client,
“Well, I sometimes accept goods for services, but I’m allergic to potatoes and
I don’t need a blender.” Third, how does a therapist react when one client with
whom you have a bartering arrangement refers someone who also wants to barter,
but the referral is clearly not clinically suited to such an arrangement? These
predicaments may not end up on ethics committee tables, but illustrate sticky
matters with the potential to cause the kinds of hassles that therapists
certainly would prefer to avoid.

A rarely discussed and serious
bartering complication involves restrictions typical in many professional
liability insurance policies that specifically exclude coverage
involving business relationships with clients (Canter, et al., 1994; Knapp,
Younggren, VandeCreek, Harris, & Martin, 2013). Liability insurance
carriers may interpret bartering arrangements as business relationships and
decline to defend covered therapists when bartering schemes go awry. To obscure
matters even further, recipients must declare the fair market value of bartered
goods or services as income on their tax returns. Failure to do so constitutes
tax evasion. The client may seek to deduct the cost of goods paid for mental
health services and will need proper receipts. To fully meet legal requirements
(and thereby behave in a fully honest and ethical manner) requires detailed
documentation, creating another type of interaction with the client. The
therapist who declared that there was nothing illegal about doing therapy for
free and nothing illegal about a client agreeing to work in the therapist’s
dress shop for free has set up both of them for charges of income tax fraud
and, for the therapist, labor law violations.

If one still decides to undertake a
bartering arrangement, we recommend preparation of a written contract that
judiciously protects the client’s welfare – one that the client clearly finds
agreeable.

We further recommend that
therapists avoid instigating a bartering relationship. To the
extent that the client sees the therapist as the more authoritative individual
in the relationship, or feels dependent on the therapist for emotional support,
it may prove difficult for a client to refuse the therapist’s proposal.

Finally, bartering organizations
capable of providing arm’s length relationships between clients and therapists
do exist. The use of such resources can defuse most of the ethical risks we
have discussed. However, the added concerns about client confidentiality,
screening clients for appropriateness, and the integrity of the bartering
organization remain as potentially sticky issues.

CROSSING BOUNDARIES WITH THOSE ONE ALREADY KNOWS

Providing Services to Close Friends and Family Members

Friends and family members of mental
health professionals frequently seek advice from them. When more than factual
information or casual advice is requested, a temptation may arise to enter into
professional or quasi-professional relationships with good friends or family
members. Therapists may reason that they can more easily provide especially
good counsel because trust already exists. Furthermore, therapists may express
a willingness to see these “clients” at bargain rates or at no cost whatsoever.

Despite the seeming advantages of
offering professional services to friends or family members, sustained therapy
relationships should be avoided. While both close relations and therapy exist
in the context of intimacy, striking differences exist between the purpose and
process of the two.

Successful personal relationships
cost nothing and aim for:

• Satisfaction
  of mutual needs
• Open,
  evolving agendas that are not necessarily goal-directed
• Longevity

Professional relationships, on the
other hand, normally involve payment to the therapist and aim for:

• Serving
  only the needs of the client
• Focusing on
  specific therapeutic goals
• Achieving
  therapeutic goals followed by a termination of the relationship

When we superimpose these two types
of relationships, the potential for adverse consequences to all concerned
increases substantially. Notice how the differences become oppositional,
meaning that expectations can clash and trust can more easily be broken.

Short-term support in times of
crisis may qualify as an exception. Responding to a frantic call from a friend
in the middle of the night is something friends do for each other. Should the
friend require more than temporary comforting, offer a referral. Otherwise, as
the following case illustrates, unexpected entanglements can occur, even when
therapists intend to be benevolent.

Weight-reduction
specialist, Stella Stern, L.M.H.C., agreed, after many requests, to work on a
professional basis with her good friend Zoftig Bluto. Progress was slow, and
most of Bluto’s weight returned shortly after she lost it. Dr. Stern became
impatient because Bluto did not seem to take the program seriously. Bluto
became annoyed with Dr. Stern’s irritation as well as the lack of progress.
Bluto expressed disappointment in Dr. Stern, whom she believed would be able to
help her lose weight quickly and effortlessly. The once close relationship
grew distant.

Dr. Stern’s friend could not commit
to the obligations of the professional alliance, but expected results anyway.

Faulty expectations, mixed
allegiances, role confusion, and misinterpretations of motives can lead to
disappointment, anger, and sometimes a total collapse of relationships.

To conclude, therapists are free to
be completely human in their friendship and family interactions and to
experience all of the attendant joys and heartaches. Their skills might prove
helpful by offering emotional support, information, or suggestions. When the
problems become more serious, however, the prudent course of action involves offering
help in finding appropriate alternative care.

Accepting Acquaintances as Clients

Another ready source of potential
clients flows through therapists’ circles of acquaintances. A member of the
same gym or church may request professional services. Disallowing casual
acquaintances as potential clients would, in general, qualify as unacceptable
to consumers as well as to therapists. This section illustrates cautions that
one should consider before taking on clients who base their request for your
services on the fact that they know you slightly from another context.

Felina
Breed, Ph.D., practiced psychotherapy and also raised pedigree cats. Many of
her therapy clients were the “cat people” she met at shows. The small talk
before and after treatment sessions usually involved cats. Clients also
occasionally expressed interest in purchasing kittens from Dr. Breed. She
agreed to sell them to her clients, which eventually came back to haunt her.
When the therapy process did not proceed as one client wished, he accused Dr.
Breed of using him as a way to sell high-priced kittens. Another client became
upset because Dr. Breed sold her a cat that never won a single show prize. This
client assumed that if the therapist raised “loser cats,” the trustworthiness
of her therapy skills also fell into question.

Dr. Breed did not adequately meet
her responsibility to suppress her acquaintance role while engaging in a
professional role. This disconnection can usually occur without untoward
consequences if the continuation of the former acquaintance role does not
require more than minimal energy or contact and avoids any conflicts of
interest. The risks and contingency plans for likely incidental contact with
clients should be discussed during the initial session. In Dr. Breed’s case,
that would have meant refraining from extended discussions of cats before or
after the therapy session and abstaining from selling cats to any ongoing
therapy client.

So, what differences exist between
a friend who one should not accept as a therapy client, and an
acquaintance who may appropriately become one? Making the distinction is not
clear-cut because sociability patterns among therapists themselves vary
considerably. Contextual issues, such the potential for frequent interactions
with the acquaintance in other settings, also demands consideration. You might
ask yourself questions such as: “Is the person seeking my services also a
person I would invite home for dinner, or who I would visit in the hospital
rather than just send a get well card, or with whom I would share more than
routine information about my personal life?” If your answer to these sorts of
questions is “yes,” then that person is more of a friend than an acquaintance.

A twist on the acquaintance peril
involves dealing appropriately with solicitations for services by someone who
also holds some influence or advantage over you. Examples include a request to
work with his alcoholic wife from the head of admissions of the local college
to which your daughter has applied, or a call for an appointment for marriage
counseling from the advisor who manages your financial portfolio. Unless
alternative services are unavailable, we encourage therapists placed in such
awkward positions to explain the dilemma to prospective clients and offer to
help find alternative resources.

Socializing with Current Clients

Psychotherapy has been referred to
as, among other things, “the purchase of friendship” (Schofield, 1964). As
already noted, we contend that it is precisely the differences between
psychotherapy and friendship that account for therapy’s potential
effectiveness. Friendships should ideally begin on an equal footing, with each
party capable of voluntarily agreeing to the relationship.

The various complications that can
arise when ongoing clients become friends are illustrated in the following
cases. Do take note of the therapists’ delayed awareness that anything was
amiss – a common phenomenon that creates unwelcome surprises.

Soon after
Patty Pal began counseling with Richard Chum, L.M.F.T., Patty invited Dr. Chum
and his wife to spend the weekend at her family’s beach house. The outing was
enjoyable for all. During the next few sessions, however, Ms. Pal became
increasingly reluctant to talk about her problems, insisting that things were
going well. Dr. Chum confronted Ms. Pal. She broke down and admitted that she
had been experiencing considerable distress but feared that if she revealed
more, Chum might choose to no longer socialize with her and her husband.

Patty Pal found herself in a double
bind. As Peterson (1992) observed about boundary violations in general, the
client is always faced with a conflict of interest; No matter what they do,
they risk losing something. Pal did not press ethics charges, but had she done
so, a committee would likely have found Dr. Chum guilty of exercising poor
professional judgment.

Will Crony,
Ph.D., had treated Buddy Flash for two years. They had also invited each other
to their homes. Flash gave especially elegant parties, often attended by many
influential community leaders, some of whom later became Crony’s clients.
During one such event where liquor flowed freely, Flash and Dr. Crony argued
over what, to Crony, seemed a trivial political disagreement. However, Flash
terminated therapy and wrote to an ethics committee, complaining that Dr. Crony
had kept him as a client for the sole purpose of capitalizing on his social
status.

An ethics committee found in favor
of Flash.

Becoming Friends with Clients After Therapy Ends

When can more intimate social
friendships be formed with former clients without the danger of multiple-role
complications? Conservative critics say, “Never.” An ex-client may want or need
to reenter therapy, and a clear pathway - including the beneficial effects of
continuing transference - should remain open for them.

The American Psychological
Association (2010) and the American Association of Marriage and Family
Therapists (2015) ethics codes do not specify prohibitions against nonsexual
post-termination friendships. The American Counseling Association (2014) and
National Association of Social Workers (2017) codes do include “former clients”
in their admonition to refrain from engaging in complicated roles without
ensuring that harm or exploitation are not at issue.

If a post-therapy friendship
disappoints or turns sour, elements of issues that came up during therapy may
resurface, raising new doubts in the client. The therapist a client believed he
or she knew so well may not completely resemble their professional persona in a
nonprofessional context and may fail to be an idealized friend.

Sue Nami,
Ph.D., and her ex-client Marsha Nullify fully expected that they would get
along exceptionally well because the therapy experience was extremely positive
for both of them. However, Nullify found Dr. Nami overbearing and controlling
in casual social situations, and Nullify’s other friends intensely disliked
Nami’s strident manner. Nullify began to doubt Nami’s overall competence and
distanced herself from the post-therapy friendship. She also began to suspect
that the previous therapy was probably inept. She felt exploited and lost, and
sought the counsel of another therapist who encouraged her to press ethics
charges against Nami.

Nullify’s charges against Dr. Nami
came before an ethics committee, but not because of the allegations that
Nullify brought forward. Proof of alleged incompetence failed to materialize,
but what became clear to both a surprised respondent and the complainant was
the finding of a multiple-role relationship violation. The investigation
revealed that during Nullify’s therapy, Nami had clearly planned their evolving
friendship and its longer-term continuation. Ironically, Nami herself provided
these facts as a defense against Nullify’s charges. This scenario also
illustrates how one can never count on a new, imposed role working out as well
as the first one. Nami’s authoritative personality worked well with this client
in therapy, but played out poorly away from the office.

So, can therapists ever safely
establish friendships with former clients? The findings in a critical incident
survey by Anderson and Kitchener (1996) suggest that nonsexual, nonromantic
relationships occur with some regularity among therapists and their previous
clients, but the judgments of the ethics of such relationships reveals little
consensus. The view that friendships with clients are always off limits might
deny opportunities for what could become productive, satisfying, long-term
relationships (Drogin, 2019). Gottlieb (1993, 1994), a strong supporter of
maintaining clear professional boundaries, also believes that social
relationships with some types of ex-clients may prove acceptable. Here is one
example from our files:

Mountain
bike enthusiast Wilber Wheel consulted Spike Speedo, Ph.D., whom he had
casually met at a biking exhibition. The therapeutic relationship went well and
terminated after 16 sessions. The two men found themselves in the same race a
few months later and realized that they enjoyed knowing each other on a
different basis. A close friendship endured for 25 years, and Speedo delivered
the eulogy at Wheel’s funeral.

The relationship between Wheel and
Speedo was not superimposed or even contemplated during active therapy and the
connection that drew the men together and sustained them was not based on
therapeutic issues.

EXCHANGING GIFTS WITH CLIENTS

Mental health professionals often receive words of sincere
appreciation from clients. Sometimes an expression of gratitude extends beyond
a verbal or written thank-you note. Holiday periods and the termination session
are the most likely times that some clients will bestow gifts (Amos &
Margison, 2006; Srivastava
& Grover, 2016).

How gifts are received requires
careful forethought and continual application due to how they might have an
impact on both treatment relationships and outcomes (Barnett & Shale, 2013).
Some clients may offer gifts in an attempt to equalize power within the
relationship (Knox, Hess, Williams, & Hill, 2003). Gifts should always be
understood and evaluated within the context in which they are given (Brown
& Trangsrud, 2008; Hundert, 1998; Zur, 2007).

Responding to gifts offered by
clients provides an excellent example of how relatively benign boundary
crossings must be differentiated from exploitative boundary violations
requiring careful forethought due to the potential impact on both treatment
relationships and treatment outcomes (Barnett & Shale, 2013; Brendel,
Chu, Radden, et al., 2007; Gabbard, Crisp-Han, & Hobday, 2015).
Accepting a small material token, such as homemade cookies or an appropriate
inexpensive item, typically poses no ethical problem. At times, however,
accepting certain types of gifts (e.g. a nude calendar, gift certificate
to Victoria’s Secret, a condom, or any other highly personal or
emotionally-laden item) would more appropriately require discussion about the client’s
meaning and motives, regardless of the cost.

As we all know, gift-giving may
reflect motives that have nothing to do with appreciation. Gifts have the power
to control, manipulate, or symbolize far more than the recipient can fully
understand. Some clients may even attempt to equalize power within the
relationship by bestowing a gift (Akerstrom, 2013; Knox, Hess, Williams, et
al., 2003; Zur, 2007). When a gift goes beyond a simple gesture of gratitude,
problems of ethics and competent professional judgment arise (Barnett, 2011).
The following cases demonstrate boundary-crossing with adverse consequences,
especially in the case of expensive gifts from clients.

Wealthy
Rich Motor gave his recently licensed therapist, Grad Freshly, Ph.D. a new car
for Christmas, accompanied by a card stating, “To the only person who ever
helped me.” Dr. Freshly felt flattered and excited. He convinced himself that
his services were worth the bonus because Motor recounted how he had
churned through many previous therapists with disappointing results. As a more
seasoned therapist would have predicted, Motor soon began to find fault with
Dr. Freshly and sued him for manipulating him into giving an expensive gift.

This actual case illustrates
naivete and inexperience, a frequent denominator among therapists who accept
gifts beyond the realm of small one-time or appropriate special occasion
tokens. Regardless of any other dynamics or considerations, a very valuable
gift should be refused. A person in a vulnerable situation can always charge
exploitation later, and such a charge may well have substance despite the
recipient’s rationalizations. Freshly’s case qualifies as unusual, but also
illustrates how blindly satisfying one’s own interests can lead to trouble
later (Barnett, 2011).

A grateful
elderly client with early onset Alzheimer’s Disease gave Salvador Time, M.A.
her father’s gold engraved watch. When the client’s son learned of the gift, he
pressed ethics charges. The son had wanted the watch all along, but never
pressured his mother, figuring he would inherit it after she passed. In his
defense, Mr. Time argued that the client, as an adult, had the right to decide
to give her possessions to whomever she wanted. Mr. Time also contended that
the client would have felt highly offended had he declined her gift.

The ethics committee did not find
Mr. Time’s reasoning acceptable. It concluded that Time knew that the client
had adult male children and male grandchildren. He should have recognized this
personal item as a family heirloom. However, they could not force Mr. Time to
return it to the client’s son, and Time chose to keep it.

We know of some instances when
declining a gift proved impossible.

Peter
Pensive, Psy.D. received a surprising call from an attorney representing the
estate of a client he had treated. Although he had not seen the client for two
years, and was even unaware that she had passed away, he was named as a
beneficiary of $5,000 in her will. The deceased client had no living relatives
and her estate had named several unrelated beneficiaries and charities as
inheritors.

Dr. Pensive had no idea that he might be included in the former
patient’s estate plan. Because he had not solicited the gift and had no way to
return it, he might have accepted the gift without violating any ethical codes.
After pondering the matter for some weeks Dr. Pensive re-directed the
inheritance to a local charity in memory of his deceased client.

The less-discussed
issue is whether therapists should offer gifts to their clients, creating an
instant multiple-role relationship of therapist and benefactor. Offering
clients gifts requires special forethought.

Many clients coming into therapy
feel ignored, abandoned, violated, or uncared for and may more easily
misinterpret the motivation of therapists who give them gifts. Beside the
potential complications and misunderstandings, there is an ever-present
possibility that the therapist’s own motives of benevolence are unconscious
rationalizations for self-serving intentions. In short, the therapist must ask,
“Do I just want to be liked?”

Benny
Nowalls, Ph.D., often gave clients little trinkets he thought they would enjoy.
The gifts included decorative key chains, figurines, and stuffed animals. He
also sent them cards when he went on vacation, hugged them often, worked out
alongside them at the gym, and met them for lunch. Eventually, several clients
complained about Dr. Nowalls for a variety of reasons, most dealing with
abandonment issues.

Dr. Nowalls felt stunned that some
of those to whom he had been, in his own mind, so kind and giving, turned on
him. He could never grasp how the multiple intrusions of his personal essence
into his clients’ lives initiated dependencies he could never ultimately
satisfy. From another perspective, seeking gratification by attempting to please
clients presents a serious problem, whereas helping clients to manage their
feelings toward the therapist, both positive and negative, can prove
beneficial. The question arises as to whether clients can feel free to address
negative feelings with a therapist who gives them gifts (Gabbard, 1994).

The therapist’s motives for gift-giving
are not necessarily unconscious or rationalized. The next case illustrates a
therapist who had a strategic purpose in mind.

Herman
Hustle, Ph.D., gave every client, current and past, expensive cheese baskets at
Christmas time. He confided to a colleague, “I want them to think about me as
this terrific guy and then pass my name along to their friends.”

Dr. Hustle wants to drum up
business and is attempting to enlist clients as his sales force. Clients will
not likely complain, and the tactic does not violate any ethical rule, but it
borders on the unprofessional. Some clients may also feel obligated to
reciprocate, which places an unwanted burden on them.

So, can therapists ever give their
clients gifts or do favors for them? We say “Yes, on occasion and after careful
consideration.” Offering a book to a client may prove helpful when
therapeutically indicated, especially if the client has a limited budget.
Therapists may also go out of their way to help clients locate other needed
resources relevant to improving their overall life situation. Small favors
based on situational needs and common sense, such as giving a client a quarter
for the parking meter, would raise no concerns. In these acceptable cases, no
ulterior motives pertain, and the scope either does not relate to the therapy
or is of a very specific and limited nature. A special situation can arise with
child clients. Here, at times, it may be appropriate to give a small gift
attending to the symbolic meaning that would advance the therapeutic function.
For example, an anxious child about to leave for three weeks of summer camp
might feel soothed and emboldened by the gift of a flashlight.

Finally, consider the generous
therapist who agrees to see a financially strapped client at no cost. This may
set up a gift-giving dilemma, at least in the client’s view. If a client no
longer has the ability to pay, and the therapist believes that continuation is
important to the client’s well-being, we suggest use of a reduced fee schedule
or sliding scale that makes the fee affordable. This also deflects the negative
impact on the proud client who would not welcome charity.

PROVIDING PSYCHOTHERAPY TO FORMER LOVERS

Avoiding soliciting or accepting an ex-lover as a client seems
like a no-brainer, but it does happen on occasion.

Jane Dumped
reluctantly accepted Casa Nova as a client when he showed up at her office six years
after Nova left her sitting alone in an expensive restaurant, a date to
celebrate her 33^rd birthday. Nova claimed that Dumped was the only
one who would understand his wayward ways with women. It wasn’t until the third
session that Dumped admitted to herself that she was focusing on feeling
vengeful and found herself eliciting and then delighting in Nova’s woes. She
told him she couldn’t help and sent him out the door. Nova felt ripped off and
pressed ethics charges, claiming that Dr. Dumped only wanted to humiliate him
for rejecting her years earlier.

Dumped tried unsuccessfully to use the defense that six years had
passed and the ethics code allows clients and their therapists to start a
sexual relationship several years after termination. She felt the flipside of
this principle should apply as well. The Ethics Committee rejected this
argument because it is explicitly forbidden in the ethics code and for good
reason; once one engages in sex with someone, the relationship dynamics are
forever altered. The National Association of Social Workers ethics
code addresses the matter directly: “Social workers should not provide clinical
services to individuals with whom they have had a prior sexual relationship.
Providing clinical services to a former sexual partner has the potential to be
harmful to the individual and is likely to make it difficult for the social
worker and individual to maintain appropriate professional boundaries.”
(1.09.d)

ACCEPTING CLIENTS’ REFERRALS OF THEIR CLOSE RELATIONS

In times of declining reimbursement
for the delivery of therapy services, it may feel tempting to relax the
criteria used for accepting clients and, in the process, compromise ethical
obligations (Shapiro & Ginzberg, 2003). Word of mouth from colleagues and
current or previous clients generates many referrals. However, care must be
taken when satisfied clients recommend you to their own close friends or close
relations. The potential for conflict of interest, unauthorized passing of
information shared in confidence, and compromises in the quality of
professional judgment constitute ever-present risks. Carefully considering what
could go wrong and estimating its likelihood may both save a therapeutic
alliance and avoid an ethics complaint.

Dum Tweedle
felt pleased with his individual therapy and asked Rip Divide, Ph.D., to
counsel his fiancee, Dee, in individual therapy. Dum eventually pressed ethics
charges against Dr. Divide for contributing to a breakup, a process that began,
Dum alleged, at the time Dee entered therapy. He contended that Dr. Divide
encouraged Dee to change in ways that proved detrimental to him and to their
relationship. Dr. Divide contended that it was his responsibility to facilitate
positive growth in each party as individuals, a responsibility he felt he had
upheld.

Dr. Divide ignored the invisible “third
client,” namely the relationship between the two clients and attempted the
improbable task of treating a couple as unconnected entities.

Sometimes warning signals appear,
even if in a somewhat off-handed way, that the unwary therapist might miss. The
next case, loosely adapted from a scenario provided by Shapiro and Ginzberg
(2003), illustrates one such situation.

Paris Jug
told her therapist, Ed Ipus, M.S.W., that she was recommending him to her
mother for counseling. Ipus was elated because these were self-paying clients.
So, when Paris then giggled and said, “You will see how much more loveable I am
than her,” he failed to recognize the subtle warning. Therapy with the mother
was difficult because her main complaints were about Paris, and Paris spent
much of her time attempting to manipulate Ipus into saying that she was sane
compared to her “crazy mother.” He decided to make things simpler by
terminating the mother, who then pressed ethics charges for abandonment and
emotional harm.

Mr. Ipus was highly remiss in
taking on the referral in the first place, knowing the intense emotional issues
between his ongoing client and her mother. He obviously should have told Paris
that he could not ethically treat her mother and maintain a professional
obligation to her.

One interesting challenge with
respect to accepting referrals of close acquaintances or current clients can
arise with cultural overtones. In some cultures, refusing to accept a referral
can cause a “loss of face” or humiliation. A friend, relative, or acquaintance
may feel disrespected if the therapist declines their request for services or
attempts to make a referral. There are many culturally acceptable ways to
handle such situations and avoid public disrespect to the referring or
requesting party, such as offering to make a better referral to a more
qualified person to help with the particular problem.

We do not suggest that accepting
referrals from current clients is necessarily inappropriate. Therapists must,
however, assess as thoroughly as possible the relationship between the
potential client and the referral source, the potential client and the context
in which the established client and the referral know each other, and the
motivations of the client in making the referral (Shapiro & Ginzberg,
2003). If things have the potential to become sticky, we advise referring the
potential client to a suitable colleague.

RURAL SETTINGS AND OTHER SMALL-WORLD HAZARDS

Role conflicts become nearly impossible
to avoid for mental health professionals working in small or isolated
communities. The goal is not to vigorously attempt to avoid all situations
where roles may be blended but to thoughtfully manage them (Barnett, 2017b).
More recently, welcome attention has been paid to training therapists in a culturally
informed way to work in rural and other underserved settings (Carter, 2019; Juntunen,
Quincer, & Unsworth, 2018; Whitley, 2020; Zimmerman, Barnett, &
Campbell, 2020).

As anyone who has lived in a rural
town can readily attest, face-to-face contacts with clients outside of the
office inevitably occur, sometimes on a daily basis. Clients likely belong to
some of the same groups or engage in some of the same activities as their
therapists. Sometimes in specific incidents, management requires some
creativity. One psychologist, who was the only mental health provider within a
60-mile radius, relayed to us the special care taken to ensure that he and his
client, the only sixth-grade teacher in town, could avoid difficulties that
might arise due to the presence of the psychologist’s rebellious 12-year-old
son in her class. Another small-town marriage counselor shared the burden of
scheduling neighbors so as to avoid unwelcome face-to-face meetings in the
waiting room.

Unfortunately, demand for services
in rural areas often exceeds resources (Barnett, 2017b; Benson, 2003; Schank
& Skovholt, 2006). The few therapists in town will know many of their
clients in other contexts, and the townspeople will also know a great deal
about the therapists and their families. Therefore, in small rural areas,
boundary guidelines demand consideration in relation to the sociocultural
contexts of the community (Roberts, Battaglia, and Epstein, 1999).

Attributes of small communities
further complicate ethical dilemmas in the context of delivering therapy
services. Information passes quickly, and standards of confidentiality among
professionals and community service agencies may become relaxed to the point
where information, originally shared in confidence, becomes widely known. In
smaller, isolated communities, gossip can be rampant, making it even more
difficult to ensure client confidentiality (Sleek, 1994).

Residents of small communities are
often more hesitant to seek professional counseling and do not quickly trust
outsiders, preferring to rely on their kinship ties, friends, and clergy for
emotional support. Because those who do seek therapy prefer someone known as a
contributing member in the community, it may not be possible to simply commute
from a neighboring town and expect to have much business. Ironically, then,
earning acceptance and trust means putting oneself in the position of
increasingly complicated relationships (Stockman, 1990; Campbell and Gordon,
2003). Consider, for example, what might happen when a client also works as a
salesperson at the local car dealership. When the therapist buys a new car, the
client may feel deeply offended if the therapist purchases it from someone else.
Yet, would the therapist have the same latitude to negotiate the price? Would
the client feel obligated to give the therapist a better deal than anyone else
would receive? And what if the car turns out to be a lemon? This is the kind of
dilemma that small town therapists must routinely manage, and perfect answers
are not always obvious.

Just because mental health
professionals in smaller communities cannot easily separate their lives
entirely from those of their clients does not mean that professional boundaries
become irrelevant. On the contrary, therapists must make deliberate efforts to
minimize possible confusion. For example, no matter how small the community, a
therapist and a client should never need to socialize only with
each other, such as meeting for dinner. Potentially risky acts over which
therapists always have complete control, regardless of community size, can
still be easily avoided. The therapist can maintain confidentiality and refrain
from chiming in during gossip sessions taking place outside of the office. The
therapist’s family may also need instruction on how to interact in certain
situations, while minimizing the details as to why.

The therapist in the next case
failed to attend to more than one ethical requirement, despite the more accepted
practice of bartering in rural communities.

Due to
stresses caused by economic hardships, the Peeps required more marriage
counseling sessions than originally estimated. The Peeps’ chicken farm income
was insufficient to pay their regular bills, let alone therapy. Ronald Rooster,
M.S.W., proposed that he would accept 2,000 chicks to continue counseling,
provided the therapy did not last beyond a year. Dr. Rooster’s wife had long
wanted to start a chicken farm, so this deal would also fulfill one of the
therapist’s needs. The Peeps reluctantly agreed to Rooster’s offer. Soon
thereafter, a lethal virus dangerous to humans and believed to be carried by
poultry resulted in the destruction of millions of chickens in Canada, driving
up the price of chickens from the Peeps’ non-flu area. The Roosters made a huge
profit, and, at the same time, found themselves in business competition with
the Peeps. The Peeps felt locked into a therapy situation that they felt very
uncomfortable with, and eventually successfully sued Dr. Rooster.

This case, adapted from Roberts,
Battaglia, and Epstein (1999), reveals the highly unethical role-blending that
can occur in rural settings where roles are often already blended. Taking an
exchange in advance for services that may not be needed is only the tip of the
iceberg. Bartering a vulnerable client’s assets to start a business that then
competes with the client was unconscionable.

Small communities also exist
outside rural areas or geographical isolation. Close-knit military, religious,
cultural, or ethnic communities existing within a much larger community can
pose similar dilemmas. Therapists working in huge metropolitan settings can
experience what amounts to small-world hazards, and the same need to view role
conflicts in a sociocultural context pertains. The primary advantage of working
in a heavily populated area is the availability of more alternatives. Yet
still, even when one cohesive population is embedded in a large city,
complications similar to those faced by rural therapists can arise. Gay,
bisexual, and transgender communities in urban settings provide one example
(Kessler & Wechsler, 2005).

Lisa Lorne,
Ph.D., specialized in counseling lesbian women. She accepted a client new to
the city into her therapy group, and during the second session, the new woman
announced that she had just met someone named Sandra Split and that they were
going to be seeing each other. Dr. Lorne was still devastated by Sandra Split’s
recent break-up up with her after 16 years together.

If Dr. Lorne’s own issues would
make it impossible to work with a specific client, arranging for some
alternative that keeps the client’s best interests in mind is well advised.
Furthermore, the new client is highly likely to learn of Split’s relationship
with Lorne sooner rather than later. Another less dramatic situation that may
cause complex interactions that require vigilance for gay, lesbian, bisexual,
or transgendered therapists involves frequent socialization venues, both
private and public.

Discoveries that may emerge during
therapy can often be handled by maintaining the professional role without
regard for the coincidences that link the therapist and client in other ways.
Things can, however, become more complicated, as illustrated in the next case.

Sid Fifer
consulted Ron Wrung, Ph.D., after Fifer’s offensive and antisocial behavior
caused increasing trouble in his family and at work. Early in therapy, Fifer
casually revealed that he and the therapist’s wife worked for the same large
company, though in different locations and different departments. Several weeks
later, Fifer was fired. He charged that Dr. Wrung must have told his wife what
he talked about in therapy, which she, in turn, shared with the company boss.
Wrung vehemently denied sharing material about Fifer or any other client with
his wife or anyone else.

Dr. Wrung was a casualty of the
type of circumstances that one could neither easily predict nor prevent.
Therapists will more likely be judged culpable when they recognize a
small-world hazard in advance and when other alternatives clearly existed.
Here, other treatment options did exist, but Wrung assumed that the remote
connection between the client and his wife would preclude any conflict.
Although Dr. Wrung was not found guilty, enduring an ethics investigation is
stressful. The matter might have been avoided had Wrung instigated a discussion
about confidentiality and how it related to this distant connection.

We have seen a large increase in
the use of telemetry-based therapy. Apart from concerns related to the COVID-19
pandemic, this type of service may ease the shortage of resources and relieve
some of the ethical problems inherent in rural communities and other
small-world situations when appropriate options are scarce (Bischoff, Hollist,
& Smith, 2004; Farrell & McKinnon, 2003). Of course, with teletherapy,
other ethical challenges beyond the scope of this course will apply.

NONTRADITIONAL THERAPY SETTINGS

Therapeutic goals can sometimes be
better achieved outside a professional office-style setting. Delivering therapy
in clients’ residences may forestall the need for hospitalization or alleviate
difficulties for clients who are physically frail or do not drive (Knapp &
Slattery, 2004). Action-oriented therapies, including crisis modalities, may
involve ecological involvements with clients. For example, a therapist might
accompany his “fear of flying group” on a flight from Chicago to Indianapolis
and back. A stress reduction group might hold a special weekend at a serene
lakeside lodge. A mental health professional, as part of an established eating
disorder clinic program, may go out to eat pizza or other “real food” with a
client to assist in addressing anxiety about eating in a realistic context.

Excursions beyond traditional
professional settings require careful forethought to preclude subsequent
charges of exploitation because of multiple-role or conflict-of-interest
overtones, confusion, or impairment of the therapists’ objectivity. When
employing an atypical setting or technique, it becomes critical to clarify the
therapeutic context and the activity.

Homa
Cloister feared crowds. Her therapist, Rip Vivo, Ph.D., suggested that they go
out to dinner at busy, fancy restaurants after therapy sessions as a way of
conditioning her to feel more comfortable around people. He did not charge an
additional fee for the after-hour activity, but did require her to pay the
dinner bill. The treatment proved ineffective and uncomfortable for this
client. Homa later charged that Dr. Vivo exploited her by disguising a free
meal ticket as psychotherapy.

Lynda Bones
broke both legs skiing and would not be able to drive for six weeks. Sarah Visit,
L.M.H.C., agreed to see Bones in her apartment until she could arrange
transportation to her office. Upon arriving, she found that Bones had prepared
lunch for the two of them, including wine. They chatted about politics and the
weather while eating. After three such sessions in Bones’ apartment, the
therapy sessions shifted in that Bones began to treat Ms. Visit as a friend
rather than as a therapist. Six weeks later, when sessions resumed in the
office, Ms. Visit attempted to get things back on track in a professional
setting. An affronted Bones decided to find another therapist.

Vivo’s technique with her homebound
client may have an appropriate therapeutic rationale, but she included the
trappings of a social event and structured the financial aspects poorly. Ms.
Visit settled too comfortably into the temporary therapy venue, and the
relationship shifted just enough to compromise it. Those who make home-based
visits or offer community-based treatment of those with serious mental problems
must remember that boundaries are challenged in ways that do not ordinarily
present themselves in professional office or hospital settings (Knapp and
Slattery, 2004; Perkins, Hudson, Gray, et al., 1998). Ms. Visit should have
anticipated the dynamics of a home-based setting and prepared her client with
the ground rules, which would not have included meals or alcohol.

Earning a living without leaving
one’s own house has become more of an option than ever before. One can easily
understand the increasing popularity of working from one’s home, both from
convenience and financial standpoints. While not inherently inappropriate or
codified as unethical, we do not advise conducting therapy in one’s home. If
one must conduct therapy in a private home, a separate room should be furnished
along the lines of a typical therapy office, and ideally have its own entrance.
Some clients, however, may find receiving therapy anywhere in the therapist’s
home (even in a dedicated home office or converted garage) confusing, and their
emotional status could become compromised by connotations attached to the
setting. The therapist who practices out of her own living quarters also risks
professional isolation, unless colleagues are actively sought out in other
venues. Some clients could potentially become burdens or pose risks to the
family if the client acts out in strange or frightening ways. Unless the
home-office therapist has another location available to screen new clients for
suitability, one cannot know in advance what level of pathology may walk
through the door

UNANTICIPATED ENCOUNTERS WITH CLIENTS

Every mental health professional is
at the mercy of coincidence, and a totally unexpected compounding of roles may
occur by chance (Barnett, 2017 b; Drogin, 2019). Although the appropriate
response may prove difficult to discern, therapists must actively attempt to
ameliorate the situation as best they can, trying to avoid devaluing or
diminishing anyone in the process. A therapist’s response, which must often
follow quickly, will depend on several factors. Confidentiality issues usually
pertain. Unless the therapist and client have discussed how to handle situations
when they encounter each other by chance, the therapist will not know how to
take the client’s preferred option into account. The urgency of the situation
can also become a factor.

When dealing with unforeseen encounters,
most of the time no lasting multiple-role relationship develops.
The nature of the encounter itself determines, in large measure, its impact.
Seeing each other in line at the post office sits at one end of the continuum,
meeting naked in the gym shower falls near the other. Most therapists who have
had unintended encounters with ongoing clients express surprise, uncertainly
about what to do, discomfort, anxiety, and embarrassment. Most also feel
concerned about confidentiality and boundary complications (Sharkin &
Birky, 1992).

Whereas fluke crossings will more
likely occur in smaller communities, unexpected situations can arise anywhere.
In fact, both incidents described in the next cases occurred in large
metropolitan areas.

During a New Year’s Eve event at a fashionable
restaurant with some friends, Eva Close, M.S.W., spots one of her clients at a
table across the room. This client is particularly sensitive about therapy and
constantly worries about anyone finding out that she even knows a therapist.
Mrs. Close and her husband had planned this evening for weeks and paid $200 in
advance. Mrs. Close thinks she may be able to stay in her corner of the dining
area, but as people begin to drink they also move around the room to chat with
others and make new friends. Mrs. Close’s husband and friends urge her to “get
out there and dance.”

Mrs. Close may have to figure out
how to keep a low profile at the New Year’s Eve event. She should not risk becoming
intoxicated. Given the client’s intense feelings, it would have been quite
appropriate for Close to have earlier attempted to ensure that important events
do not overlap with those of her client. In small communities, clients with
such intense concerns about discovery might better be referred to someone in an
adjacent city, or perhaps for Web-based counseling.

Fortuna
Yikes, Psy.D., agreed to have dinner with friends and a blind date that her
friends had arranged for her. When she arrived at the restaurant and peeked
inside, she recognized the man sitting with her friends as one of her clients.

In the real story, the therapist
was able to leave the restaurant before being seen. She called her friends in
the restaurant from her mobile phone, telling them that she had fallen ill.
Because such twists of fate do happen, and quick exits may not always be an
option, we suggest that therapists actively attempt to know in advance the
identities of people with whom they will be interacting in any intimate social
situation.

We also encourage mental health
professionals to raise the issue early on about chance meetings with their
clients outside therapy. Some clients will prefer to pretend that the two do
not know each other. Others may favor acting as though they are acquaintances
and want to exchange brief greetings.

We suggest that therapists not take
the lead during such chance encounters, and that the clients understand in
advance that the decision to interact with or ignore each other rests entirely with them. Clients should feel assured that their therapist will be comfortable
either way. We suggest discussing this with all clients early on. That way, the
therapist does not have to remember which reaction each client prefers (and
even these preferences could vary, depending on the circumstance). This
strategy poses no risk that the client will perceive the therapist as rejecting
because the client will know always to take the lead when the two notice each
other outside the office setting. With a pre-approved plan well in place,
common situations involving clients, such as finding oneself in the same line
at the grocery store, can be handled somewhat gracefully and without incurring
more than minimal discomfort. Pulakos (1994) surveyed clients who had already
experienced outside encounters with their therapists and found that 54% of
clients expressed that they would want a brief acknowledgement, 33% would want
a conversation, and only a small number would want to be ignored. Twenty-one
percent would want a different response than the one they received. These
results verify that no one size fits all.

MANDATED MULTIPLE RELATIONSHIPS WHICH MAY CATCH THERAPISTS IN THE MIDDLE

A number of work settings can pose
ethical challenges when the client is not the sole focus of concern. Therapists
working in prisons, the military, schools, hospitals, or as supervisors, or who
are court-appointed, are among those in settings where following policy may
pose conflicts (Johnson & Johnson, 2017; McCutcheon, 2017; Ward & Ward,
2017; Younggren & Gottlieb, 2017). For example, demands of the agencies
employing therapists may conflict with the needs and welfare of the agencies’
clients. Confidentiality may be forced to be compromised. This dilemma is
increasing as managed care takes over services which had previously been privately
contracted between therapists and clients.

Paul Plastique, Ph.D., provides psychotherapeutic care to children
with chronic medical conditions at Megahealth Memorial Hospital. For three
years, he has worked with eight-year-old Zachary Mug through several stressful
craniofacial surgical procedures to deal with malformations caused by Crouzon
Syndrome. Zack has experienced self-esteem and peer problems, school
disruption, and painful recoveries, but Zack and his parents feel that Dr.
Plastique understands him and his life experiences very well. The Mug family is
covered by Monolith Insurance through Mr. Mug’s employer. Monolith recently
"carved out" their mental health benefits and subcontracted these to
C.F.I. Care Services. Contract talks between C.F.I. Care and Megahealth
Memorial Hospital on a new contract for mental health services have broken
down. While Zack will still get medical and surgical care through Megahealth
Memorial, covered by Monolith, Dr. Plastique’s psychotherapeutic services will
no longer be covered. C.F.I. Care has referred Zack and his family to a
counselor in the community who has no familiarity with Crouzon Syndrome or
children with craniofacial abnormalities requiring surgical intervention.

The issues confronted by Dr.
Plastique and the Mug family have become all too common as third-party payers
continually strive for economic advantage using carved out contracts and
competitive pricing agreements. Coordinated continuous care in a single setting
by therapists with the most relevant training and experience has become
increasingly difficult to maintain. Perhaps Dr. Plastique and the Mug family
can make a special circumstances plea to C.F.I. Care or Monolith Insurance.
Perhaps Megahealth Memorial will offer some reduced fee to the Mug family in
the absence of coverage. Perhaps Dr. Plastique’s practice is such that he can
continue to treat Zack outside of the Megahealth system. More likely than not,
however, Dr. Plastique and his client will find themselves trapped in an arcane
world of contractual and fiscal constraints that allows little latitude to
consider the best interests of individual patients.

Government policy, legal requirements, or the welfare and safety
of society in general may sometimes clash with therapists’ judgments regarding
what constitutes the best interests of individuals with whom they work. The
identification of priorities and loyalties can cause acute stress and
conflict-of-interest dilemmas. The APA ethics code, for example, specifies that
psychologists should refrain from accepting a professional role when personal,
scientific, professional, legal, financial, or other interests or relationships
could reasonably be expected to impair their objectivity, competence, or
effectiveness, or expose an individual or an organization to any harm or
exploitation. Often, therapists are not in an objective position when acting
under such conditions because the more powerful of the conflict sources, such
as the legal system or the employer, may issue sanctions if the therapist’s
actions do not comport with the position of the more powerful party.

FINAL THOUGHTS

Today’s seemingly looser
restrictions on nonsexual multiple roles, as compared to three decades or so
ago, may well place unaware therapists at greater risk than earlier, stricter
ethics codes. Why? Because fewer specific prohibitions beyond
avoiding “exploitation” and “harm” remain. These are very general terms,
somewhat vague, and easily open to interpretation.

Here is our concern: Any client who
claims to have been “exploited” or “harmed” when roles became complicated could
be difficult to challenge and refute, and unpredictable ethics committees,
licensing boards, and juries will make their findings on a case-by-case basis.
Therefore, decisions to cross boundaries should be discussed with the client
and documented in case it ever becomes necessary to defend venturing into
territory other than the professional role with a client (Pope &
Keith-Spiegel, 2008; Younggren & Gottlieb, 2004).

Finally, complicated roles can lead
to an increased risk of engaging in sexual relationships with clients. Critics
of this slippery-slope argument suggest that this thinking is a holdover from
rigid psychoanalytic theory. However, data confirm that therapists with blurry
role margins do not necessarily stop with gift-giving, conducting sessions in
the park, inviting clients out to dinner, or a giving a quick kiss on the mouth.
Surveys have established a relationship between nonsexual and sexual boundary-crossing
(Borys, 1988; Borys & Pope, 1989; Lamb and Catanzaro, 1998). This
association should not come as any surprise, given that many forms of nonsexual
multiple-role behaviors are those also routinely associated with dating and
courtship rituals.

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