Not all ‘dual relationships’ are taboo; some tend to enhance treatment outcomes

By Arnold A. Lazarus, Ph.D., ABPP
January 1, 2001



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.

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“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.”

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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.

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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

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