Dual relationships refer to situations wherein a therapist, in addition to
providing psychological services, also engages in activities with the client
that go beyond their professional boundaries. Examples include therapists who
enter into a business relationship with a client, or those who are apt to
socialize with certain clients. The ultimate dual relationships comprise any
type of sexual intimacy.
The profession as a whole understandably prohibits sexual activity between
patient and therapist, but most ethics committees and state licensing boards
also frown upon non-sexual dual relationships. The ethical guidelines offered by
the American Psychological Association warn against entering into "multiple
relationships" for fear that professional, financial, scientific, personal
or other alliances might undermine the therapist's objectivity and impair his or
her capacity to fully help the client. The fundamental intent behind these
proscriptions is to protect clients from harm and exploitation - especially from
predatory therapists. This is admirable, but is it advisable and helpful to
impose a stringent form of prohibition? Will this truly deter predacious
clinicians from acting out and harming people who turn to them for help? I think
not.
There are documented cases in which impaired or predatory therapists have used
innocent boundary crossings as stepping-stones to a slippery slope that
culminated in coital unions. It has become quite apparent that there are
therapists with impaired reality testing, who display poor social judgment, and
even worse, who are sociopathic or have narcissistic or borderline personality
disorders. Consequently, there appears to be a widespread sense of mass hysteria
wherein numerous junior and senior clinicians, and many regulatory boards,
incorrectly believe that they can protect consumers by declaring all forms of
dual relations as synonyms for "exploitation" and "harm,"
and by asserting that most dual relationships inevitably lead to sex with a
client. It is absurd to consider non-sexual dual relationships ipso facto
unethical and harmful, and to contend that they inevitably foster sexual
intimacies. Zur (2000a) argues that this line of reasoning only creates an
ethical blur.
----------------------------------------------------------------
"Too many therapists see only a negative and hazardous side to all dual
relationships. They claim that harm is inevitable, faulty clinical judgments
will ensue, and in terms of risk-management, great dangers lurk behind every
corner."
----------------------------------------------------------------
The situation develops into a reductio ad absurdum when ethics committees and
licensing boards penalize therapists for such events as belonging to the same
church that a client attends, playing in the same recreational league as a
client; attending parties or conferences where a client is also present;
lunching with a client; or making regular purchases at a store where a client is
employed. Too many therapists see only a negative and hazardous side to all dual
relationships. They claim that harm is inevitable, faulty clinical judgments
will ensue, and in terms of risk-management, great dangers lurk behind every
corner. Zur (2000b) points out that the prohibition of non-sexual dual
relationships may increase the chance of exploitation and harm. If any and all
dual relationships are viewed as evil taboos, psychotherapists will fail to
realize that certain dual relationships tend to enhance treatment outcomes.
Before discussing how certain dual relationships can be beneficial, let me state
that in addition to forbidding sexual liaisons with clients, some non-sexual
dual relationships are also strongly ill advised. For example, teachers,
supervisors, or professors should not administer formal psychotherapy to
students enrolled in their classes (the conflict of interest is quite apparent
here). Likewise, employers should not also serve as therapists for their
employees. Elsewhere (Lazarus, 1994) I stressed that it is extremely unwise to
step outside the confines of strict professionalism with clients who are
seriously disturbed,--e.g., those who display-aggressive, histrionic,
borderline, paranoid, manipulative, or hostile tendencies. To my way of
thinking, client confidentiality is paramount; and there should never be even
the slightest hint of disparagement, exploitation, abuse, or harassment. And any
form of sexual contact with clients should be assiduously avoided. Outside of
the aforementioned considerations, I feel that most other limits and
proscriptions are negotiable. With some clients, a sense of camaraderie develops
when a therapist is willing to step outside the bounds of a sanctioned healer,
and positive treatment outcomes are facilitated.
Thus, a man I was treating for a post-divorce depression said that he'd very
much like to meet for lunch one day. I sensed that an issue of personal
validation lay behind his request. If I took the position that extra-therapeutic
activities of this kind violate certain ethical rules (no matter how kindly
stated) he would probably feel diminished. We met for lunch and he affirmed that
he was delighted I had not given him the brush off. Thereafter, coincidentally
or otherwise, his therapeutic progress was impressive. Occasionally, I have
partied and socialized with some clients, played tennis with others, taken long
walks with some, accepted small gifts, and given presents (usually books) to a
fair number. At times, I have learned more across a dining room table than might
ever have come to light in my office. I must reiterate that boundary crossings
must not be undertaken capriciously. A clear rationale is necessary, a
risk-benefit analysis may need to be factored in, roles and expectations should
be quite clear, and possible power differentials must be kept in mind.
Miriam Greenspan (1995) in an incisive essay underscores that whereas the ethic
of non-abuse is essential, she doubts if the admonition to avoid all dual
relationships achieves this objective. Elsewhere (Greenspan, 1994) she writes:
"The standard of care itself conspires against the genuine meeting of
persons that is the real sine qua non of healing. It keeps patient and
professional separate even when they don't wish to be. It makes authenticity
feel like a bad and dangerous thing" (pp. 199?200). She points out that the
rigidification of boundaries may produce more, no less, abuse in therapy.
Rather than instilling a fear of lawsuits in our students and terrorizing them
about the dangers of running afoul of licensing agencies, let us teach them how
to navigate the complex issues of duality, intimacy, boundaries, individual
ethics and personal integrity. Out of fear, too many therapists practice in a
bizarre and dehumanizing way. Some therapists create such highly sanitized
treatment environments that they lose sight of human and humane concerns.
Instead of producing frightened conformists, our training programs should focus
on turning out caring and enterprising helpers who have the confidence to think
for themselves.
References
Greenspan, M. (1994). On professionalism. In C. Heyward (Ed.), When
boundaries betray us. (pp. 193?205). San Francisco: Harper Collins.
Greenspan, M. (1995). Out of bounds. Common Boundary, July/August 1995, 51?54.
Lazarus, A. A. (1994). How certain boundaries and ethics diminish therapeutic
effectiveness. Ethics & Behavior, 4, 255?261.
Zur, O. (2000a). Going too far in the right direction: Reflections on the
mythic ban of dual relationships. California Psychologist, 23/4, 14?16.
Zur, O. (2000b). In celebration of dual relationships. The Independent
Practitioner, 20, 97?100.
-------
Arnold A. Lazarus, Ph.D., is a Distinguished Professor Emeritus of Psychology
at Rutgers University. He is the President of the Center for Multimodal
Psychological Services in Princeton, NJ. He has won many impressive awards and
has authored 16 books and over 250 articles. He may be reached on email at AALAZ@AOL.COM
