The therapeutic relationship is central to counselors’ work with clients. The therapeutic relationship is the association, rapport, and connection between a counselor and client. The establishment of the therapeutic relationship begins with the joining process, wherein the counselor and client get to know each other and clarify the need and purpose for counseling. The therapeutic relationship includes such things as unconditional regard for the client, placing the needs of the client first, engaging the client in a positive and collaborative manner, understanding the client and his or her context as it pertains to the presenting problem, mutually agreeing upon treatment goals and interventions, and empowering the client. In essence, the therapeutic relationship is the interaction, connection, and process between counselor and client in efforts to bring about the desired results in therapy.
Understanding the roles that a counselor plays and that the counselor may simultaneously engage in two or more of those roles is central to understanding the concept of dual or multiple relationships (the terms are used interchangeably). Counseling professionals function in a variety of professional roles, corresponding with their education, training, and experience. These include the roles of therapist, supervisor, researcher, employer, consultant, professional association officer, or expert witness. Simultaneously, therapists are functioning in other roles related to the personal, social, and business aspects of their lives (e.g., family member, friend, religious organization member, social acquaintance, sexual partner, business partner). A multiple relationship is defined as a situation in which the therapist functions in roles associated with a professional relationship with a client and also assumes another definitive and intended role that is not inconsequential or the result of a chance encounter. The multiple relationships may be concurrent or consecutive.
The concept of boundaries is critical to the discussion and understanding of multiple relationships. A professional boundary is conceptualized as a frame or limit that demarcates what is included or excluded from the therapeutic relationship. This includes the structure and content of therapy, as well as the professional responsibilities and behaviors that appropriately help clients. Critical areas relevant to boundary issues include time, place, space, money, gifts, services, clothing, language, self-disclosure, and physical contact. Meeting clients outside of the standard location for sessions or exchanging gifts with clients are examples of potential boundary violations.
Related to the construct of boundaries is the power a person has to influence another person or events. Power has the potential to be both helpful and harmful to those involved. This is particularly the case when there is unequal power between the parties involved and when one person has the ability to impose his or her will over others. Factors that contribute to power differences include such things as role, sex, education, and socioeconomic status. Therapists are considered to have greater power than clients in the therapeutic relationship. Therapists’ professional power is derived from four sources: societal ascription, expert knowledge, client expectations, and personal power. For example, in society, therapists occupy a position of authority and respect based on the work that they do and the potential influence that they have on people. When people (e.g., clients) come to them, the expectation is that therapists are experts within the field and that they have the knowledge and ability to help clients with the problems or challenges they face. Through the licensing process, society grants professionals the right to use their knowledge and power to benefit others.
Rationale for Avoiding Multiple Relationships
The inherent power differential in the therapeutic relationship raises the concern that professionals could use their power and authority to take advantage of client vulnerability and exploit clients for their personal gain. Knowledge of the potential for exploitive relationships has led to the prohibition of harmful multiple relationships by professional associations, therapists, licensing boards, ethics committees, and educators. The prohibition derives from the belief that engaging in additional relationships puts the therapeutic relationship and client at risk; that conflicting roles and boundary violations could precipitate impaired therapist judgment and exploitation of the client.
In her book about boundary violations in professional relationships, Marilyn R. Peterson described the roles of professionals and asserted that contemporary counseling professionals function as secular shamans. Intrinsic to the shaman perspective is that shamans act in the best of interest of those they help. Building upon this perspective, Peterson elaborated that society sets counseling professionals apart, elevating them to privileged positions of power and allowing them to influence and manage people’s lives. Because of this position of power and influence, it becomes even more critical that professionals respect the boundaries of their relationship with clients and not violate the trust and confidence bestowed upon them. This responsibility requires that professionals exercise restraint and vigilance to make sure that the client’s best interests come before their own. If therapists are acting in the client’s best interests, then they will exercise self-restraint and avoid situations that might tempt them to abandon the needs of the client and further their own interests.
Because trust in and vulnerability to the therapist and appropriate distance between therapist and client are inherent to the therapeutic process, many experts on ethics in the counseling profession advocate for therapists maintaining strict boundaries with clients. Clear boundaries are viewed as essential in therapy, and deviation from those boundaries presents a potential threat to the therapeutic process. Those who advocate for clear boundaries also consider crossing boundaries as a potential precursor to harming the client, varying in severity from harm to exploitation or even sexual relationships with clients.
Another concept discussed in the multiple relationship literature is that of the slippery slope. The term slippery slope refers to the notion that failure to adhere to rigid standards will gradually lead to relationships that are exploitative and harmful to the client. This process is thought to occur when one boundary is crossed without a clear damaging result, making it easier to cross future boundaries. The acceptance of the notion of a slippery slope has led to the generally accepted caution to avoid it by avoiding boundary violations or multiple relationships with clients. In the cautionary stance of risk management, therapists are admonished to avoid certain behaviors or practices because they might be misinterpreted and questioned by licensing board, ethics committees, and courts.
Problematic Aspects of Multiple Relationships
In the seminal article on what makes dual relationships so problematic, Karen S. Kitchener used role theory to explain the difficulties that arise in dual relationships when one person is involved, simultaneously or sequentially, with role categories that conflict or compete. She proposed that it is the conflicting or competing roles that become problematic and identified three specific guidelines for differentiating between dual relationships that have a high versus a low probability of leading to difficulty. The first guideline addresses the incompatibility of the expectations associated with multiple roles (e.g., therapist and friend). When role expectations are incompatible or compete, there is often confusion about how one should behave. When these expectations are unclear or conflict, there is greater potential for feelings of frustration, confusion, and anger, which in turn could lead to actions that could be harmful. The second guideline addresses the conflicting obligations associated with the roles (protecting the client’s welfare when functioning as a therapist, but reducing the client’s autonomy when giving advice as a friend). The problem in confusing these roles is that there may be confusion as to the underlying intentions. The final guideline addresses the power differential and notes as that differential increases, the potential for exploitation also increases. In the face of large power differences, clients may not be able to determine if they are being harmed.
Unavoidable Multiple Relationships
Another aspect of multiple relationships that makes them so problematic is that they are sometimes unavoidable. Avoiding multiple relationships is particularly difficult for therapists who practice in small, rural communities; in the military; and in definite communities with minority populations; or who are clergy and/or work in religious settings.
Unlike clinicians practicing in large urban areas where they are able to maintain anonymity, those working in rural and small communities face unique challenges. The literature related to rural and small communities reveals three characteristics that practitioners face: impact of greater distances and population scarcity, living and working in smaller communities with their formal and informal social and political units, and the multiple levels of personal and professional relationships.
For those living in rural areas, there is typically a greater physical distance between communities. As a result, members of these small communities are interdependent so that necessary services can be provided within the community. It is possible that the only choice for shopping will be a clients’ store, or that the therapist’s children will attend the same school or become friends with clients or clients’ children. Part of the difficulty is the fact that rural therapists have limited options for referring clients to other service providers. Additionally, the longer a therapist resides in the community, the more interaction the therapist has with community members, and the more difficult it becomes to separate professional and personal relationships. In rural communities, there is a cultural and social expectation of overlapping relationships and that “everybody knows everybody.”
For therapists who are members of small communities and/or minority groups, it may be difficult to avoid multiple relationships. Clients frequently choose therapists because they are a part of a shared community and are expected to be more sensitive to the clients’ issues. Small, shared communities include not only therapists from minority ethnic backgrounds but also gay and lesbian therapists. The ethical dilemma of being known and setting personal boundaries within these small communities can be especially complex and daunting for these therapists. All therapists, and particularly those within small communities, need to make sure that their social, emotional, and sexual needs are met through relationships with friends, colleagues, family, partners, or others and not through relationships with clients. It is important that therapists prepare for these unavoidable multiple relationships by increasing their awareness of their own needs, establishing their own guideline or model for managing unavoidable multiple relationships, having competent colleagues with whom to consult, and having outlets for personal fulfillment and satisfaction outside of the therapeutic setting. It is also essential that therapists who navigate unavoidable multiple relationships have frank and clear discussions with clients about how they will manage the complexities of the multiple relationships, including potential conflicts and how those conflicts will be addressed and resolved.
Sexual Relationships with Clients and Their Impact
Sexual relationships with clients are the most extreme form of multiple relationships. The American Psychological Association (APA) Code of Ethics and Standards of Practice clearly prohibits therapists from having sexual relationships with their current clients. Relationships with former clients (after a 2-year time period of no therapeutic contact) are not considered unethical, but are strongly discouraged. As a result of the ethical and legal prohibitions, therapists’ sexual involvement with current clients is rare. Depending on the survey, the frequency of therapist-reported sexual contact between therapist and client ranges from 0% to 3% for female therapists and from 3.8% to 13.7% for male therapists. There is little information pertaining to client reports of the frequency of sexual contact between therapist and client. The literature has shown that a sexual relationship between therapist and client is harmful to the client. This harm ranges from affecting the client’s emotional, social, and sexual adjustment, to negative feelings about the experience, a negative impact on his or her personality, and a negative impact on the client’s sexual relationship with his or her primary partner.
In describing the negative effects of therapist-client sexual involvement, Kenneth S. Pope reported that it commonly results in a distinct clinical syndrome, which he termed the therapist-patient sex syndrome. This syndrome has symptoms similar to those seen in sexual abuse, child abuse, posttraumatic stress disorder, battered spouse syndrome, and rape response syndrome. Just like in these other syndromes, in therapist-patient sex syndrome the appearance of adverse effects may be delayed. The 10 aspects identified as characteristic of this syndrome are ambivalence; feelings of guilt; a sense of emptiness and isolation; sexual confusion; impaired ability to trust; identity, boundary, and role confusion; emotional lability; suppressed rage; increased suicidal risk; and cognitive dysfunction. These adverse effects, and the severity of most of them, attest to the harm clients experience when their therapists are sexually involved with them.
Argument for Nonsexual Multiple Relationships
In addition to the fact that some multiple relationships are unavoidable, some therapists argue that the avoidance of nonsexual multiple relationships is, in fact, detrimental to clinical work with clients. Those in favor of multiple relationships emphasize the distinction between a boundary violation and a boundary crossing. A boundary violation is a departure from clinical practice that places the client or therapeutic process at risk. Boundary violations refer to actions on the part of the therapist that are harmful, exploitative, and in direct conflict with the preservation of the clients’ dignity and the integrity of the therapeutic process. Examples of boundary violations are sexual and financial exploitation of the clients. Boundary crossing is a nonpejorative term that indicates a departure from traditional therapeutic settings or constraints. Examples of boundary crossings are making home visits to a bedridden sick client; taking a plane ride with a client who has a fear of flying; attending a client’s wedding, child’s bar mitzvah, or other functions; or conducting therapy while walking on a trail with a person who requests it and seems to benefit from it. Not all boundary crossings are harmful, and therefore not all are violations. In addition to encouraging the distinction between boundary violations and boundary crossings, proponents of multiple relationships argue that rigid boundaries are contrary to being clinically helpful to clients.
The rationale for engaging in benign boundary crossing is based on research on the importance of rapport and warmth to the effectiveness of therapy. Proponents of this position describe boundary crossings as being a means for increasing familiarity, understanding, and connection and thereby increasing the likelihood of success for the clinical work. They further argue that the maintenance of rigid boundaries between therapists and patients in many small, close-knit communities is unrealistic and impossible. They cite the social norms within these communities of flexible and permeable boundaries and mutuality as requiring less rigid boundaries between professionals and their clients and argue that imposing such rigid boundaries on these communities is countertherapeutic.
Proponents of this view do not dismiss the importance of the power differential in the relationship, but suggest that power has become interchangeably associated with exploitation and harm in the ethics literature. They assert that it is not the power differential or multiple relationship that is problematic, but rather the therapists’ propensity to abuse their power for selfish gain. Supporters of multiple relationships also argue that using the power differential as a rationale to avoid multiple relationships is insulting and dismissive of the clients’ power and ability to navigate relationships and make decisions for themselves.
Guidelines for Decision Making With Multiple Relationships
Sexual relationships with clients are clearly defined as unethical and harmful to clients. Although there is little research regarding the effects or benefits of nonsexual multiple relationships with clients, the generally accepted stance in the field is that therapists should exercise caution in developing additional relationships with clients. While professional codes of ethics provide general guidelines, they do not provide clear and specific direction for every situation that may arise for therapists. It is up to the individual therapists to assess and evaluate clinical situations and choose behavior that they believe is the most ethical, legal, and beneficial to the client. This is part of the therapists’ professional responsibility. To this end, it is important that therapists either adopt an existing ethical decision-making model or formulate or adapt one of their own.
Building upon existing ethical decision-making models and K.S. Kitchener’s guidelines regarding role theory and relationships, Michael C. Gottlieb developed a model for avoiding exploitive multiple relationships. Gottlieb’s model is based on three critical dimensions of the ethical decision-making process: power, duration of the relationship, and clarity of termination. Power refers to the amount of power the therapist has in relation to the client. Duration of the relationship has to do with the time involved and is related to power in that power increases over time. Power is low when the relationship is brief, but increases as relationship continues. Clarity of termination refers to the client’s perspective of how long the professional relationship will continue. Gottlieb encouraged therapists to evaluate each of these dimensions from the client’s perspective, determine the risk of being perceived as exploitive, and then determine if they want to proceed with the additional relationship. If a therapist does choose to pursue another relationship in addition to the therapeutic relationship, the therapist should consult with a colleague and discuss it thoroughly with the client. The therapist should review the entire ethical decision-making process and the potential risks and/or adverse consequences so that, if the client chooses to engage in the additional relationship, it is done with informed consent.
The Responsibility of the Therapist
Therapists are expected to be responsible professionals and monitor themselves when it comes to multiple relationships. They must be aware of themselves (integrity, competence) and keep any of their personal issues or self-serving behaviors in check. They do this by making sure that they are appropriately connected to significant others, family, friends, and colleagues, and that their needs are being met through these interactions rather than through relationships with clients. When therapists find themselves vulnerable and at risk, they should seek appropriate support and guidance through consultation with colleagues, supervision, or personal therapy. This is critical to avoiding multiple relationships, but even more important in those instances when a therapist is already involved in an overlapping or multiple relationship. It is also essential that the therapist is self-aware so as to keep self-interest in check and to keep clients’ interests at the forefront. This self-monitoring is also critical in the area of boundaries in order to avoid boundary crossings that continue down the slippery slope to boundary violations. By engaging in careful self-awareness, therapists recognize multiple relationship issues and ethical dilemmas, use ethical decision-making models to plan for and facilitate ethical practice, and behave in ways that are in the best interest of clients.
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