Impact of Dual Relationships on Therapy Clients

Little research has been done that assesses, from the client’s perspective, the experience and outcome of client-therapist dual relationships, although the psychological literature and professional ethics codes reflect caution and generally advise against such relationships. It has long been the consensus of mental health care providers that dual relationships with clients are, on the whole, unethical and harmful, although surveys of practitioners (Pope et al. , 1987; Borys & Pope, 1989; Pope & Vetter, 1992) reveal that they are not uncommon.

This research based on the general population of therapy/counselling consumers poses the following questions: (a) explore current consumer attitudes towards dual relationships, (b) investigate the possibility that such relationships may have beneficial outcomes, and (c) identify what kind of dual role behaviours may relate to “good” and “bad” dual relationship outcomes. Additionally, research investigated whether or not there is a relationship between certain dual relationship behaviours and the impact of the dual relationship on the client.

Data for this project was obtained via a survey with adults who have experienced nonsexual dual relationships with their therapists or counsellors. The results of this research demonstrate, contrary to current opinion, that non-sexual dual relationships (or some elements of dual relationships) are not necessarily harmful to clients. The results of this survey challenge previous consensus in the literature as to the harm caused by dual relationship experiences.

The findings indicate that clients do not, generally, feel harmed by having dual relationships with their therapists: 59% of respondents experienced their dual relationship as a positive experience, and only 17% experienced it as negative. Introduction Overview All professions (e. g. , psychology, psychiatry, and social work) that promote therapy or counselling for treatment of psychological disorders have strict prescriptive standards regarding dual relationships between clients and therapists.

While these ethical standards may not strictly prohibit non-sexual dual relationships, they generally advise or imply that such relationships be formed very infrequently, and only when there is no risk of the client being hurt by the relationship. It is broadly acknowledged that dual relationships are a frequent cause of complaints filed with therapists’ ethics bodies and regulatory boards, and dual relationships (commonly reported in one combined sexual/ nonsexual category) are reported to be one of the most common ethical dilemmas encountered by psychologists and other mental health professionals (Mok, 2003).

Although the psychological literature reflects attitudes that caution against dual relationships and much has been speculated about the harm nonsexual dual relationships can cause, there is indication in more recent literature that some psychologists may be shifting their attitudes towards client-therapist relationships that occur outside the therapeutic hour. These new attitudes reflect the opinion that, perhaps, some dual relationship behaviours are not as objectionable or as harmful as has been believed …

and that some may even be helpful to clients. For the purposes of this study, the term ‘dual relationships’ refers strictly to nonsexual dual relationships. This research based on the general population of therapy/counselling consumers poses the following questions: (a) explore current consumer attitudes towards dual relationships, (b) investigate the possibility that such relationships may have beneficial outcomes, and (c) identify what kind of dual role behaviours may relate to “good” and “bad” dual relationship outcomes.

Additionally, research investigated whether or not there is a relationship between certain dual relationship behaviours and the impact of the dual relationship on the client. Data for this project was obtained via a survey with adults who have experienced nonsexual dual relationships with their therapists or counsellors. Statement of the Problem Little research has been done that assesses, from the client’s perspective, the experience and outcome of client-therapist dual relationships. Nerison (1992) surveyed 225 individuals who had been in dual relationship situations with their therapists or counsellors.

The participants indicated the kind of dual behaviours that they had experienced with their therapists and a subset of individuals from this group was selected for an additional telephone interview. This participant pool, however, was heavily inclusive of professional therapists, psychology students, and had other demographic inequities. Nerison (1992) noted herself that the cultural and socioeconomic similarities of those surveyed were not an accurate sample of the general population of therapy clients.

In 1993, Ramsdell & Ramsdell surveyed a group of former counselling clients who may, or may not, have had dual roles with their therapists. (It was not clear how many actually experienced dual relationships; they were asked about the “presumed” effect of the dual roles. ) This group was composed of clients who had participated in individual, group, family, and/or couple counselling, and who may have had sexual or nonsexual contact with their counsellors. The findings and limitations of these studies are discussed below.

Studies done with therapists suggest that it is not unusual for a dual relationship to be formed during or after the course of therapy and that some providers feel that post-therapy relationships are not necessarily harmful. In a study of 200 counsellors regarding post-termination friendships, 33% reported that they had engaged in post-termination friendships and 70% believed that a post-termination friendship with a client could be acceptable (Salisbury & Kinnier, 1996).

Most of the opinions expressed in the literature and the dominant tone in ethics textbooks, however, ranges from strict prohibition to a proceed-with-great-caution-approach to dual relationships. Indeed, in the only wide, comprehensive survey of nonsexual dual relationships, a majority of 4,800 psychologists, psychiatrists, and social workers reported that dual role behaviours were unethical under most conditions (Borys & Pope, 1989).

Limited contributions to the literature, in the past, and now, more recently, are encouraging a more permissive view of dual relationship behaviours. The purpose of this project was to study whether or not nonsexual dual relationships are harmful to clients. Clients who had experienced dual relationships with their therapists or counsellors were asked whether or not the dual relationship was a positive or a negative experience. They were asked if the dual relationship affected the quality or the progress of their therapy.

The survey data was studied to determine if a relationship between certain dual relationship behaviours and the impact of the dual relationship on the client could be determined. The survey data was studied to determine if a relationship could be demonstrated between clients’ therapy and the impact of the dual relationship on their well-being. Finally, in a series of open-ended questions, clients were asked to describe their experiences in their own words. These responses formed the basis for a narrative that articulated the participants’ experiences from their own perspectives.

Definition of Terms The existing literature in the subject area of this project alternates between the use of the phrases “dual relationship” and “multiple relationship” when describing extra-therapeutic relationships between clients and their therapists. For consistency, researcher has chosen to use the term “dual relationship” throughout this study. Only nonsexual relationships are referred to in this study. A dual relationship is a relationship between a client and his/her therapist that takes place outside of, and in addition to, the therapeutic hour.

Examples of dual relationships include social, financial, or professional interactions between client and therapist. Dual relationships can occur during or subsequent to the therapy and may be helpful or harmful. A helpful dual relationship is an experience that positively affects a client’s well being and contributes to progress in therapy. The client generally considers a helpful dual relationship an experience that is beneficial to his/her well-being and therapeutic experience. A harmful dual relationship is an experience that negatively affects a client’s well being and deters or damages progress in therapy.

The client generally considers a harmful dual relationship an experience that is damaging to his/her well-being and the therapeutic experience. Review of the Related Literature Defining the Dual Relationship Dual relationships are relationships between therapists and clients (or clinical supervisors and students) that occur outside of, and in addition to, the normal therapeutic role (or supervision relationship). Unlike sexual dual relationships, which have clearly defined characteristics and unambiguous ethical standards, nonsexual dual relationships do not enjoy the same level of ethical and descriptive clarity (Pritchett & Fall, 2001).

Sonne (1994) explains: “These other roles occur within the realms of personal, social, or business relationships (e. g. , social acquaintance, friend)… family member, business owner, or chief executive officer”. She continues to note that dual relationships “include those situations in which the psychologist functions in more than one professional relationship” in addition to “those in which the psychologist functions in a professional role and another definitive and intended role” (Sonne, 1994, p. 336).

Some examples of dual relationships include (a) combining the roles of teacher and counsellor, or supervisor and therapist; (b) providing therapy to a friend, an employee or a relative; (c) becoming sexually involved with a client; or (d) going into a business venture with a client (Corey & Herlihy, 1997). Kagle and Giebelhausen (1994) note that social workers engage in dual relationships when they become involved with a client as a friend, employer, teacher, business associate, family member, or sex partner.

Hiring a current or previous client is also thought of as a dual role. The creation of a dual role may be a gradual process that starts with an innocent gesture. Some practices that can create or lead to dual relationships include (a) bartering for goods or services, (b) selling a product to a client, (c) attending social events of a client, (d) inviting a client to a social event, and (e) accepting gifts from a client (Corey & Herlihy, 1997).

Epstein & Simon (1990) include permitting a first-name basis between therapist and patient and accepting referrals from present or former patients as breaches of appropriate boundaries (inflexible interpretations that most professionals today would challenge). Dual relationships may be formed during therapy, but can also be developed or continued after the client has left therapy. The most common manifestations of a post-termination dual relationship between therapist and client are employing a former client, going into business with a former client, and socially interacting with a former client (Welfel, 1998).

Post-termination friendships, at least in theory, have generally received endorsement in the profession. In the most comprehensive survey conducted of mental health professionals to date, Pope & Vetter (1989) discovered that most therapists surveyed believed that under certain circumstances, post-termination friendships could be useful (83%). Salisbury and Kinnier (1996) found that 70% of mental health counsellors surveyed thought that a post-termination friendship with a client could be acceptable.

Others, however, ascribe to the commonly-held “once a client, always a client” viewpoint, and consider all forms of post-termination relationships to be ethically risky, e. g. , It is my strong belief that once there is a therapeutic relationship, it is always extant to some degree. Thus, to enter into any other type of relationship would be unethical (Anderson & Kitchener, 1996, p. 60). Nonsexual Dual Relationship Much has been written about the incidence of sexual relationships between therapists and clients.

Less has been written about nonsexual dual relationship behaviours, even though dual roles are a widespread concern, and a fairly frequent occurrence among practitioners. A survey of counsellors at university counselling centres rated multiple roles (with students) as the most difficult ethical dilemma they faced (Hayman & Covert, 1986). In 1987, Pope, et al. found that of 456 psychologists surveyed, 1. 9% had entered a business relationship with a client, 8. 3% reported selling products to a client, 39. 9% had attended a client’s invitation to a social event, and .

3% had provided therapy to a friend. In 1989, a national study of 4,800 psychologists, psychiatrists, and social workers reported that the three professions did not differ among themselves in terms of having had dual professional roles, social involvements, or financial involvements with clients (Borys & Pope, 1989). In 1992, a survey of 1,319 members of the APA (Pope & Vetter) found that incidents of dual relationships were the second highest category of 23 “ethically challenging or troubling” incidents that were surveyed.

Nerison (1992) surveyed, for the first time, the experiences of individuals who had actually been in dual relationship situations with their therapists or counsellors. Nerison was able to hear in clients’ own words a description of what a dual relationship was like, and how it may have been helpful or harmful to their therapeutic experience. In general, literature that looks at the potential or real harm of dual relationships from the therapists’ point of view reveals a number of common concerns.

Sonne (1994) defines the dynamics that necessarily come into play in a therapeutic relationship as, primarily, 1) the existence of a fiduciary relationship, where the client’s needs and expectations are foremost; 2) the client’s emotional involvement in the relationship that comes from being cared for, listened to, and understood; 3) a power differential between therapist and client which is created by the therapist’s depth of personal knowledge about the client — their strengths, hopes, and personal fears — and which is necessarily unreciprocal. She says

A multiple relationship is likely to pose problems or conflicts when a secondary relationship is imposed on a professional relationship in such a manner as to adversely affect the dynamics just described (summarised, above)… A multiple relationship may result in a failure of relationship-related or role-related expectations or responsibilities. The professional relationship may no longer be fiduciary; the therapist’s welfare and best interests may begin to come to the fore and replace or even completely obscure those of the client (Sonne, 1994, pp. 209-210).

Others concur that when a dual relationship causes a redistribution in the balance of power between therapist and client, it isn’t necessarily in the client’s best interests to be on equal footing as the therapist. When the needs of the therapist come to the forefront in the form of a dual relationship and subordinates the client’s best interests to his or her own, it often leads to exploitation of the client (DeJulio & Berkman, 2003). Exploitation disrupts therapy by violating the sense of trust in the treatment relationship (Epstein & Simon, 1990).

According to Sonne (1994), “The risk for the client is that the power differential may foster exploitation of the client’s vulnerabilities to gratify the therapist’s emotional or other needs” (p. 338). Another outcome that may occur in dual relationships is that of role conflicts between client and therapist. Role conflicts arise when the expectations of one role are incompatible with the expectations of another role (Kitchener, 1986). Others have termed this situation as “role slippage” (Sonne, 1994).

Role issues may occur in situations such as becoming tennis or investment partners with one’s therapist, the possible result being a loss of the therapist’s objectivity in the therapeutic relationship. Means for clinicians to address multiple roles that may arise is available. Practitioners have produced typologies, measurement, and decision-making tools to assist with dual relationship issues as they arise in practice. Younggren and Gottlieb (2004) offer a risk-managed, decision-making model that could be helpful when dual roles develop.

Other guidelines include a conceptually-based typology of boundary issues to help manage dual relationships (Anderson & Kitchener, 1998), a classification system of dual relationships based on the nature of the relationship’s development (Pearson & Piazza, 1997), and a circular decision-making model for evaluating the potential for multiple/dual relationships (Gottlieb, 1993). An “Exploitation Index” provides a self-assessment questionnaire for therapists that is designed to serve as an early warning system for boundary violations (Epstein & Simon, 1992).

The literature also substantiates some changing and alternative thought on dual relationships. Some clinicians have recommended that the focus of study on dual relationships be towards the “multiple dimensions” of psychologists’ involvement with their clients (Rubin, 2000). That is, in Rubin’s opinion, it should be acknowledged that there is room for a dual relationship between client and therapist when an ethical balance is properly framed within current societal, therapist, and client mores.

Others recommend that mental health professionals change their thinking on dual relationships and move away from a concept of dual relationships as being inherently destructive in themselves (Lazarus & Zur, 2002). Rather, dual roles could be considered within a more individualised context that considers the likelihood of patient harm, exploitation, and the destructive impact of dual roles on treatment (Williams, 1997).

A more liberal interpretation of dual relationship standards has also been advocated, with the reasoning that the underlying moral and ethical rationale for prohibiting dual relationships may be outdated in the emergence of newer therapeutic models (such as briefer, shorter-term treatments), which make client exploitation less likely (Lazarus, 1994). It has been proposed that an unrealistic attempt to avoid all dual relationships in psychotherapy may be defensively phobic or repressive (Lazarus, 1994) and actually cause strain on the client-therapist relationship.

Published fairly recently, Lazarus & Zur (2002) have collected an entire series of essays by prominent psychologists who advocate for fewer rigid standards regarding dual/multiple relationships, and for more recognition of the beneficial aspects of certain dual relationships. A survey of the literature clearly suggests a variety of opinions on extra-therapeutic client-therapist relationships, but little empirical proof is offered concerning their potential for harm. As Nerison recommended as follow up to her 1992 work: This study should be replicated with a sample taken from the general population..

.should include men as well as women and persons from a broad range of socio-economic, ethnic, and vocational backgrounds… should exclude professional psychologists and other mental health service providers. Ideally, information about the therapist involved in the dual relationship would be obtained along with information about the client (p. 116). Ramsdell & Ramsdell (1993) note that differing norms and settings for client-counsellor contact be studied to determine whether or not the nature and the frequency of the interaction impacts the outcome of the therapeutic process.

Ramsdell and Ramsdell (1993) surveyed 67 former clients of a large metropolitan counselling agency on the frequency and nature of their experience with, and their opinions of, 13 dual behaviours that involved social contact. They asked respondents to indicate the impact on their therapy each behaviour had or would have had if it occurred. The three behaviours most highly-rated as beneficial were: (a) addressing a counsellor by first name, (b) a counsellor visiting a client in a hospital, and (c) a counsellor sharing information about his or her personal life during sessions.

Behaviours deemed to be most detrimental to therapy included (a) dating one’s counsellor and attending social events together, (b) a client visiting a counsellor at home, and (c) a counsellor employing a client. This study, however, is limited by its partly presumptive nature, rather than full reports of actual experiences and outcomes. The literature on client-therapist nonsexual dual relationships reflects that these relationships do occur and that a sizable number of therapists engage in extra-therapeutic relationships with their clients. Various dual relationship behaviours have been identified and surveyed in the literature.

The literature also reflects that a good proportion of therapists and counsellors believe that nonsexual dual relationships with clients, or former clients, are not inherently unethical. Unfortunately, the limitations of the literature are such that there is little direct knowledge about typical clients’ experiences of dual relationships. Nearly all of the studies done to date are based on attitudinal and self report surveys of the therapists and counsellors; hence, conclusions regarding dual relationships are based on the therapists’ experiences and beliefs.

The earliest previous specific study of clients’ experiences with dual relationships (Nerison, 1992) was limited primarily to female participants who were mental health care professionals themselves, hi her doctoral dissertation, Nerison surveyed attendees at a women’s psychology conference and members of a Presbyterian church congregation about their experiences with 18 nonsexual dual role behaviours and conducted interviews with a subsample of the survey participants. This survey produced results that were very close to the previous attitudinal studies by Borys & Pope (1989).

In Nerison’s study, clients most frequently endorsed therapist disclosure of personal problems (50%), acceptance of a gift worth under ? 10 (42%), providing therapy to a close friend or relative (35%), and becoming friends after termination (27%) as acceptable dual behaviours. A majority of Nerison’s participants rated 36% of the surveyed behaviours (therapy with a current employee or student, therapist’s invitation to a social event, therapist accepting an expensive gift, and therapist and client sharing a meal after therapy) as never acceptable.

(Nerison also surveyed participants’ attitudes towards the dual relationship behaviours thait were surveyed: 82% of the items received ratings as never, rarely, or only sometimes acceptable. ) While Nerison’s results were similar to previous survey outcomes, the participants’ professional training, academic settings, common gender, and knowledge of ethics were all confounding factors of the results.

An additional limitation of Nerison’s results is that most of the respondents were members of the same cultural and socio-economic groups, which limits the generalisation of results to more demographically diverse populations. Historically, licensing boards and professional ethics bodies’ actions take reasonably strict punitive measures when dual relationship behaviours are found. Sanctions at the Board level for unethical dual relationships frequently include loss of licensure or restrictions on practice.

Professional associations generally censure or expel members’ when harmful dual relationships are discovered. Despite the potential consequences, as evidenced in the literature, there is an ongoing and current body of psychologists and other mental health care providers (Lazarus & Zur, 2002) who are willing to explore and experience the beneficial aspects of dual relationships with their clients. This research, then, sought to learn more about the incidence and consequences of dual relationships from the consumers’ point of view.

A survey was completed by a group of individual clients with a variety of education and experience. Commonly-held questions concerning dual relationships were analysed from the perspective of clients’ actual experiences. Respondents identified specific behaviours that contributed to good and bad therapeutic experiences. They provided insight as to how or why these behaviours developed during therapy, and how they impacted their experiences of therapy.

Participants’ reported whether or not their opinion of their dual relationship experience had changed over the passage of time, and whether or not they had experienced dual roles with previous therapists. Methodology The purpose of this project was to attempt to determine whether or not clients perceive nonsexual dual relationships as harmful or helpful. Additionally, project investigated whether or not there is a relationship between certain dual relationship behaviours and the impact of the dual relationship on the client.

Data for this project was obtained via a survey with adults who have experienced nonsexual dual relationships with their therapists or counsellors. Description of the Research Design This was a descriptive study using quantitative and qualitative methods to explore survey results and individual responses to open-ended questions. Quantitative analysis of client responses to a survey of dual role behaviours was done to describe objective characteristics of dual relationships.

Then, participants’ responses to a series of open-ended questions were explored so that a sense of their feelings and subjective perceptions about dual relationships could be assessed. Definition of Variables For this study, a dual relationship was defined as a (nonsexual) social, financial, or professional relationship that occurs outside of, and in addition to, the therapeutic relationship, and that involves interpersonal contact between the client and the therapist outside of the normal therapeutic relationship. It may occur during or after therapy, or be part of both.

A dual relationship that the client considered a positive experience was considered a helpful dual relationship. A dual relationship that the client considered negatively was considered a harmful dual relationship. Materials and Instruments A survey questionnaire that included a series of open-ended questions was used to gather information in this research (Appendix B). A cover letter (Appendix A) preceded the first page of the survey and explained the purpose of the research and the confidentiality of the information that would be received.

The letter included contact information for the researcher in case of questions, instructions for returning the completed study (if done so by Postal Service), and provided information for those who wished to receive the results of the study. The questionnaire was divided into five sections. Section A established the fact that the participant had, indeed, engaged in a dual relationship with his/her counsellor/therapist. Section B listed 14 dual behaviours, ranked in order of severity.

The behaviours were selected from the list of behaviours previously and commonly surveyed by Nerison (1992), Pope & Tabachnik (1987) and Borys & Pope (1989) and updated slightly for relevancy (e. g. , the amounts of the “gift” behaviours were increased to reflect current economic standards and “addressing your therapist by first name”, which is now common and expected practice, was removed from the list). Section C presented a series of multiple-choice questions regarding the duration and impact of the dual relationship on the participant.

Section D covered demographic information about the participants. Section E listed open-ended questions intended to evoke subjective perceptions or opinions about the relationship experience. Participants All participants were informed of the confidential nature of the study and were specifically asked to not identify themselves on the survey. They were informed of the voluntary aspects of their participation, and told that they may decide to not return the survey if they change their minds about participating.

According to the Ethical Principles of Psychologists and Code of Conduct Standard 8. 05, (APA, 2002) such anonymous questionnaires do not require informed consent of the participants. This study met the criteria of ethical standards regarding “Research and Publication” in the American Psychological Association’s Ethical Principles of Psychologists and Code of Conduct (2002). Participants were recruited from a number of sources: 1. Classified advertising in the local newspapers; 2. Notices placed throughout the campus and within the student newspapers of University;

3. Notices placed on various bulletin boards at health clubs and coffee shops; 4. A mailing to clinical directors of mental health agencies who were asked to post the promotional flyer on patients’ bulletin boards. 5. Postings by the researcher to various mental health-oriented Internet chat rooms and classified listings. The advertisements, notices, and Internet postings directed potential participants to the survey’s URL address. The URL address opened to a cover letter (Appendix A), which explained the procedures and condition of the survey.

The cover letter was followed by the survey (Appendix B). Procedures The survey was posted on the Internet through an independent survey administrator. A total of 30 completed surveys were forwarded to the researcher via email; no identification of the participants was visible. An option to print the survey from the Internet and mail it to the researcher was used by two respondents. Although it was possible to respond to multiple Internet-posted surveys, there were no duplicates submitted and no indication that any reviewer had submitted more than one response.

Data Processing Descriptive statistics were used to summarise responses to the survey questions (Blaxter et al. , 2006). The 14 dual behaviour items were ranked in order of frequency and correlated with the evaluative (“quality of relationship”) responses. Percentages were calculated for the evaluative responses. The list of behaviours in Part B of the Questionnaire were presented in order of severity that which had been previously and commonly presented in the literature (Pope, Tabachnick, & Keith-Spiegel, 1987; Borys & Pope, 1989).

These behaviours were used to weight each participant’s responses to the Part B items as a measure of severity of the dual relationship experience. In addition to the statistical analyses of the questionnaire responses, information from the open-ended questions was used descriptively to explore the phenomenology of dual relationships. The open-ended responses were reviewed by the researcher for saliency and compared to the Part C responses for consistency in the report of the experience.

A representative sampling of participants’ responses was selected as descriptors of the experience of the dual relationship to supplement interpretations and conclusions derived from the statistical analyses of the questionnaire. Methodological Assumptions and Limitations The convenience sampling method used to recruit participants for the study may have resulted in a sample of therapy clients that is not representative of the overall population of individuals who experience dual relationships.

Unfortunately, it appears that demographics for this population are not available from prior research, so comparison with this study’s participants is not feasible. It was possible, though improbable, in the writer’s opinion, that more than one survey was returned per individual. The accuracy and reliability of responses to the survey items could have been reduced by carelessness or inattention, but could not be determined given the anonymous administration of the questionnaires. Results

Respondent Demographics and Responses to Survey Questions Of 34 surveys returned, one was blank and two did not meet the criteria for having had a dual relationship, leaving an N of 31 for most analyses. One respondent did not answer any of the demographic questions, and a few other questionnaires had scattered missing data. A majority (76%) of those responding to the survey were female. The participants were well educated: Except for one respondent, all participants had college education. Ni

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