While the primary role of a therapist is to provide counseling services, therapists often assume further professional roles related to their special knowledge and training. For example, they may be consultants, expert witnesses, supervisors, authors, or teachers. As private persons, therapists also assume nonprofessional roles. They may be parents, football coaches, consumers, members of the PTA, friends, sexual partners, and countless other things.
In their diverse professional and private capacities therapists can contribute much to the overall happiness of the communities in which they live and work. When a professional assumes at least one additional professional or personal role with respect to the same clients, the relationship thus formed is termed a dual or multiple role relationship. For example, a teacher may also be the supervisor of one of his students/interns, or a counselor may also be a customer of a client/proprietor. Dual role relationships may occur simultaneously or consecutively (NASW, 1997, 1. 6. c). For example, a therapist has a consecutive dual role relationship when she counsels a former sexual partner or a former student. While not all dual role relationships are unethical (have potential to cause significant harm to client or other), sometimes the blending of the counseling role with certain personal roles or with certain other professional roles can generate serious moral problems. Throughout this paper this learner will consider intricacies of problematic dual role relationships. The environment this learner will focus on is schools and universities.
Two case studies will be presented, one exploring some key issues of sexual relations with clients, the other exploring some key issues of non-sexual dual role relationships. This learner will also apply the ACA code of ethics throughout this paper. Four sets of standards regarding ethical management of dual role relationships will be adduced. Dual role relationships are morally problematic when they involve the therapist in a conflict of interest. According to Davis and Stark "a erson has a conflict of interest if he is in a relationship with one or more others requiring the exercise of judgment in the others' behalf but has a special interest tending to interfere with the proper exercise of judgment in that relationship. " For example, a therapist's ability to counsel a client may be adversely affected if the counselor is also the client's business partner. Insofar as a dual role relationship impairs the therapist's ability to make judgments promotive of client welfare, the therapist has a moral responsibility to avoid such a relationship or to take appropriate steps to safeguard client welfare.
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One possible manner of dealing with a dual role relationship involving a conflict of interest is to inform the client that the conflict exists. In this way, clients are treated as autonomous agents with the power to go elsewhere if and when they so choose. However, while such an approach will accord with candor and consideration for client autonomy, it may not alone resolve the moral problem. The potential for client harm may still persist in cases in which the client elects to stick with the relationship. Non-maleficence "first do no harm" should then take priority.
A further approach aiming at mitigating potential for client harm is to make full disclosure to the client and seek consultation and supervision in dealing with the conflict (Corey & Herlihy, 1997). According to Corey and Herlihy (1997), while this approach may be more "challenging" than avoiding dual role relationships altogether, "a willingness to grapple with the ethical complexities of day-to-day practice is a hallmark of professionalism. " However, the client's ability to "grapple" with the situation must also be taken into account.
In situations where the therapist seeks consultation and supervision to deal with a conflict of interest, candor requires that the therapist inform the client of such. Although different clients may respond differently to disclosure of this information, it should be considered what implications this arrangement may have from the client's perspective. If the therapist cannot trust himself (without supervision) to act in concert with client welfare, will this adversely effect the client's ability to trust the therapist in this or other situations?
The mere existence of the dual role relationship may itself present an obstacle for the client. For example, in a relationship in which the client barters for counseling services, the client may feel compelled to treat the therapist in a manner that exceeds ordinary customer expectations. The client's perception may then be more important than the reality. Even if the therapist succeeds in maintaining independence of judgment through consultation and supervision, this may not matter if the client does not perceive the situation this way or if the client is otherwise unable to maintain objectivity.
In some situations, dual role relationships may be unavoidable. For example, in a rural locality in which there is only one practicing therapist and one bank, the therapist's loan officer may also be the therapist's client. In situations where avoiding the dual role is not possible or not feasible, the therapist should then take precautions such as informed consent, consultation, supervision, and documentation to guard against impaired judgment and client exploitation (ACA, 1995, A. 6. a).
Viewed in this light, therapists practicing under conditions where unavoidable dual role relationships are likely (for example, in small rural towns), have additional warrant for making and keeping in contact with other competent professionals willing to provide consultation or supervision upon request. Morally problematic dual role relationships may be sexual or non-sexual in nature. Sexual dual role relationships include ones in which therapists engage in sexual relations with current clients or with former clients.
Non-sexual dual role relationships include (but are not limited to) ones in which the therapist is also the client's supervisor, business partner or associate, friend, employee, relative, or teacher. While these relationships are often avoidable, their problematic nature may go unnoticed. For example, in an effort to help a friend in need, a therapist may, with all good intentions, overlook potential for client harm. Professional and legal standards governing sexual relationships with current clients consistently forbid such relationships. Legal sanctions may include license revocation, civil suits, and criminal prosecution (Anderson, 1996).
According to The American Counseling Association Code of Ethics, "counselors do not have any type of sexual intimacies with clients and do not counsel persons with whom they have had a sexual relationship" (A. 7. a). The National Association of Social Workers Code of Ethics justifies its own prohibition against providing clinical services to former sexual partners on the grounds that such conduct "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" (NASW, 1997, 1. 9. d) The potential harm resulting from sexual activities with clients has been documented. For example, citing the research of Kenneth S. Pope (1988), Herlihy and Corey (1997) have noted that harm may resemble that akin to victims of rape, battery, child abuse, and post traumatic stress.
These effects include "ambivalence, guilt, emptiness and isolation, identity/boundary/role confusion, sexual confusion, impaired ability to trust, emotional liability, suppressed rage, cognitive dysfunction, and increased suicidal risk" (. The prohibition against sexual activities with current clients has also been extended to students and supervisees. For example, according to the American Psychological Association Ethical Standards, "psychologists do not engage in sexual relationships with students or supervisees in training over whom the psychologist has evaluative or direct authority, because such relationships are so likely to impair judgment or be exploitative .
There is, however, less consensus on the question of sex with former clients. Although some states unconditionally regard sex with former clients as sexual misconduct, other state statutes, as well as codes of ethics, make exceptions. For example, Standard 4. 07 of the American Psychological Association Ethical Standards asserts the following: Psychologists do not engage in sexual intimacies with a former therapy patient or client for at least two years after cessation or termination of professional services. Because sexual intimacies with a former therapy patient or client are so frequently harmful to the patient or client, and because such intimacies undermine public confidence in the psychology profession and thereby deter the public's use of needed services, psychologists do not engage in sexual intimacies with former therapy patients and clients even after a two-year interval except in the most unusual circumstances.
The psychologist who engages in such activities after the two years following cessation or termination of treatment bears the burden of demonstrating that there has been no exploitation, in light of all relevant factors, including the amount of time that has passed since therapy terminated,the nature and duration of therapy, the circumstances of termination,the patient's or client's personal history, the patient's or client's current mental status, the ikelihood of adverse impact on the patient or client and others, and any statements or actions made by the therapist during the course of therapy suggesting or inviting the possibility of a post-termination sexual or romantic relationship with the patient or client. The American Counseling Association has recently adopted a similar rule stipulating a minimum two year waiting period, and requiring counselors to "thoroughly examine and document that such relations did not have an exploitative nature" based upon similar criteria as those set forth in the above rule (ACA, Code, A. . b).
The American Association of Marriage and Family Counselors has also adopted a two year waiting period (AAMFT, 1991, 1. 12). Without stipulating a time period, the recent Code of Ethics of the National Association of Social Workers has provided that social workers should not engage in sexual activities or sexual conduct with former clients because of the potential for harm to the client. The latter also adds that if social workers act contrary to this prohibition or claim exceptional circumstances, then social workers, not their clients, "assume the full burden of demonstrating that the former client has not been exploited, coerced, or manipulated, intentionally or unintentionally" (NASW, 1997, 1. 09. c).
From a rule utilitarian perspective, a rule unconditionally forbidding sex with former clients may be warranted. First, as the above APA rule suggests, the circumstances of excusable sexual relationships with former clients are "most unusual. Second, therapists contemplating sexual relations with former clients may find it difficult to objectively examine and document that such relationships are not exploitative. Their "utilitarian calculations" may be biased. Third, insofar as sexual intimacies with former clients are frequently harmful to clients and tend to undermine public confidence in the profession and its services, permitting such relations risks a high measure of disutility. Accordingly, if therapists avoided sexual relationships with former clients without exception, then they would probably maximize overall happiness in the long run.
On the other hand, given discretionary standards such as those of the APA and ACA, it is important that therapists exercise such discretion wisely. The following case study is intended to shed light on confronting conflicts of interest when sexual interests become an issue. CASE 1 Sexual Dual Role Relationships: A Case of Mutual Sexual Attachment Crystal first met Dr. Walker, a thirty-eight-year-old psychologist, when she came to him for marital problems. Crystal, attractive, twenty-five-year-old women, had been married to her husband, Chris, for two years when she entered therapy.
Chris was a wealthy corporate CEO and at the time the couple met, Crystal was a fashion model working between jobs as a waiter in a popular nightclub. When the two were married, Chris insisted that Bethany give up her career goals and stay at home. Crystal cooperated with Chris, resigning from her job and severing all ties with her modeling agency. During the first few weeks of her marriage, after returning from a week-long honeymoon in Europe, she felt reasonably contented. However, as the weeks went on, she began to experience increasing dissatisfaction with her new life, which she subsequently described as "totally empty".
Although she was frequently visited by friends, she still felt very much alone. Chris was often away on business and the couple's relationship began to "feel strained" when the two were together. While they had previously enjoyed an active sex life, the couple gradually became sexually estranged. Crystal thought that their relationship might improve if she resumed her modeling career, but when Crystal tried to discuss the matter with Chris, he refused to listen to her, stating "I will not suffer the humiliation of having any wife of mine parading about like a piece of meat. When she suggested that they go to marriage counseling, Chris refused, saying that there was nothing that the two couldn't resolve on their own. However, a close friend convinced Crystal to seek counseling, even though her husband would not agree to come along. The friend recommended Dr. Walker. In therapy with Dr. Walker, Crystal often expressed a desire to leave her husband but also expressed fears of "being by herself" and of not "making it on her own" without guidance from her husband.
On the one hand, she complained of boredom, loneliness, and desperation; on the other, she expressed reluctance to give up what she now had to return to the precariousness of her former existence. It was a lot "easier and less risky," she said, "just to stay right where I am. " Dr. Walker knew from personal experience how difficult it could be to stand up to the fear of making changes in one's life without any guarantees. Having been through a divorce (three years ago) with a woman whom he had been married to for thirteen years, Dr. Walker felt a personal bond with Crystal. He too had struggled with similar issues and felt the force of inertia as he mustered up enough inner strength to leave a wife whom he had lived unhappily with for over a decade.
Hence, when Crystal began to make romantic overtures toward him (telling him that she found him extremely attractive, that she was falling in love with him, and asking him if he felt the same about her), Dr. Walker found himself in a more perplexing situation. In response to Crystal's query about his feelings toward her, Dr. Walker responded by stating query about his feelings toward her, Dr. Walker responded by stating "I think you are a very attractive woman but as your therapist it would be inappropriate and definitely not in your best interest if I were to become personally involved with you. "
Although he considered Crystal's overtures to be a result of transference, he began to question the appropriateness of counseling a women who awakened so much of his own personal turmoil, and he worried about the possibility of his own countertransference. Dr. Walker was indeed also sexually attracted to Crystal. While he was aware of other occasions in which he was sexually attracted to female clients whom he managed to successfully counsel, Dr. Walker felt less confident in the present case. Crystal had at this juncture been in therapy for six months. Although he believed that she had made significant progress in this period, he also believed that it would be in her best interest if she were referred to another therapist. He therefore decided to terminate therapy and to refer her. Dr. Walker explained to Crystal that he had personal problems of his own that made it inappropriate for him to continue as her therapist, and that it was in her best interest if she accepted his referral. Notwithstanding Crystal's repeated pleas to know more, Dr. Walker refused to comment on what exactly those personal problems were except to emphasize that they were his, not her, problems.
Crystal declined the referral and, in tears, left his office, neither seeking nor receiving therapy from anyone else again. Dr. Walker did not himself seek professional counseling for his personal problems. However. s a result of his experience with Crystal, he did subsequently avoid practicing marriage counseling, especially with young, attractive female clients. About two years after ending their professional relationship, Dr. Walker met Crystal while shopping at a supermarket and they began to talk. Crystal explained that she had divorced Chris a year ago and that she was presently trying to get back into fashion modeling but was finding it difficult to make headway. The two exchanged phone numbers. A week later Dr. Walker called Crystal and asked her out on a date. They subsequently began a sexual relationship.
As we have seen, the primary purpose of a therapist is to promote the welfare of the client. In the present case, Dr. Walker's decision to terminate Crystal's counseling was a rational response to the problem of how best to fulfill this primary counseling mission. Dr. Walker was aware that his personal emotions were potentially harmful to Crystal's continued therapeutic advancement. In particular, he was aware that his sexual attraction for this client coupled with his apparently unresolved feelings about his former marriage and divorce provided a climate for countertransference.
In this regard, Dr. Walker's decision to terminate was in concert with the Principle of Loyalty insofar as his personal conflict prevented him from maintaining independence of judgment in the provision of treatment. As provided by APA Standard 1. 13c, a therapist who becomes aware of a personal problem that has potential for interfering with the provision of professional services should take "appropriate measures," which may include terminating therapy. In making a referral upon termination, Dr. Walker further sought to safeguard client welfare. There was, of course, the risk that Crystal might refuse Dr. Walker's referral and never again seek counseling, a possibility that did in fact come to pass. Dr. Walker was accordingly confronted with the problem of deciding which option referral versus continued therapy ran the greatest chance of minimizing harm and maximizing welfare for this client. In making this "utilitarian" determination, Dr. Walker could not, however, mechanically and dispassionately calculate the risks of each available option. On the one hand, he had to try to transcend his own subjective feelings in order to rationally assess the situation.
Yet, on the other hand, he had to stay in touch with those very same feelings which he sought to transcend in the process of deciding. Were the emotions he was now experiencing more of an impediment to successful counseling than previous experiences he had when he chose not to refer? Was the present case really different than the previous ones? To answer these questions, Dr. Walker could not merely be an "impartial" and "objective" observer applying a rational standard as Kantian ethics. Nevertheless, while he had to live his feelings in order to adequately represent them, he also had to attain some measure of "rational" distance from them.
According to Martin (1997) such “professional distance" can be defined as a reasonable response in pursuing professional values by avoiding inappropriate personal involvements while maintaining a sense of personal engagement and responsibility. Under-distancing is the undesirable interference of personal values with professional standards. Over-distancing is the equally undesirable loss of personal involvement, whether in the form of denying one's responsibility for one's actions or in the form of lacking desirable forms of caring about clients and community.
How can a professional determine whether client engagement avoids the above extremes and is therefore "proper"? Such determination, according to Martin (1997), constitutes an "Aristotelian mean" between these extremes. As such it must rest with perception and sound judgment enlightened by experience. As a general rule, this mean appears to be reached in therapy when the therapist gets as close to the client's situation as possible without losing her ability to rationally assess it, for it is at this point that the therapist's powers of empathetic caring and understanding are at their highest rational level.
The point at which a therapist has attained this mean and has therefore stretched her rational capacities to their limits appears to be relative to both situation and individual therapist and May not always be attainable. Thus, while Dr. Walker has successfully treated clients to whom he was sexually attracted, at least some therapists might not be able to successfully work with such clients and had best refer them. On the other hand, Dr. Walker was not sanguine about his ability to work with Crystal without under-distancing himself. In deciding whether or not to refer, Dr. Walker needed to remain personally engaged yet detached enough to make a rational judgment about what would best promote his client's welfare. Paradoxically, he had to attain proper distance in order to decide whether, in counseling Crystal, he would be able to maintain proper distance. Martin (1997) claims that maintaining such distance within a professional relationship serves at least three important functions. First, it can help professionals to efficiently cope with difficult situations by keeping them from becoming emotionally overwhelmed.
Second, proper distance can help in promoting a professional's respect for clients' autonomy. Third, it can help a professional to maintain objectivity. Insofar as loss of professional distance militates against these three functions, serious potential for loss of proper professional distance in counseling Crystal would have afforded Dr. Walker sufficient reason for termination. In the first place, loss of professional distance, in particular under-distancing himself from Crystal, could have destroyed his ability to cope with Crystal’s crisis by resulting in countertransference. In such an instance, Dr. Walker’s inability to keep personal interests separate from those of client could well have clouded and distorted his professional judgment regarding client welfare and thereby preempted the provision of competent counseling services. With loss of proper professional distance, Dr. Walker would accordingly have also suffered loss of objectivity, that is”critical detachment, impartiality, the absence of distorting biases and blinders” (Martin (1997). Had Dr. Walker allowed his personal interests and emotions to seep into the professional relationship, his perception would have been biased and as such not objective.
For example, in overidentifying with Crystal’s plight as an extension of his own negative marital experience, he would no longer have been impartial. He would have had blinders on, interpreting Crystal’s circumstances in terms of his own values and interests, seeking resolution not of Crystal's crisis but of his own. In Dr. Walker’s case, loss of proper professional distance could also have affected client autonomy by impairing his powers of empathy. We have seen that empathy can be an important autonomy facilitating virtue.
This virtue, however, entails proper professional distance by requiring a therapist to feel as if he were in the client’s subjective world “without ever losing the `as if’ quality. ” Dr. Walker’s failure to keep his own subjectivity separate from that of his client would have precluded the possibility of his “accurately sensing the feelings and meanings being experienced by the client,” for these experiences would have been filtered through Dr. Walker’s own veil of self-interest and personal emotions. As a result Dr. Walker would not have been able to competently help his client accurately clarify the feelings and meanings she was sensing. It is, however, through such increased self-understanding that Crystal could reasonably hope to gain greater control over her own behavior and life circumstances. Given serious potential for loss of proper professional distance, any attempt by Dr. Walker to continue counseling Crystal might therefore have been carried out behind a veil of self-interest and misguided ideas, impeding client progress toward greater autonomy and well-being, countering the primary counseling mission.
Under such conditions, Crystal's own state of dependency would have rendered her vulnerable to the exploitation and manipulation that easily arises when a counselor does not clearly separate personal welfare, interests, or needs from that of the client. Dr. Walker's decision to terminate was accordingly in concert with his moral responsibility not to apply the power and authority of his professional role in a manner that might exploit client dependency and vulnerability.
In keeping with the Principle of Vulnerability, the heightened vulnerability of this client due to the therapist's diminished capacity for objectivity provided an occasion for exercising special care in guarding against infliction of client harm. This additional moral responsibility to take "special care" was discharged by Dr. Walker when, in consideration of his personal conflict, he decided to terminate. From a Kantian perspective, the rationale for termination is also apparent. As Crystal's therapist, Dr. Walker's role was to facilitate her increased personal autonomy.
However, by continuing therapy instead of terminating, he risked treating her as a "mere means" to the satisfaction of his own confused interests and desires rather than treating her as an autonomous agent. Dr. Walker’s motive for terminating Crystal's therapy, namely to safeguard her welfare, could also consistently be willed to be a universal law inasmuch as such a law would be consistent with and supportive of the primary counseling mission. It is noteworthy, however, that not all motives for termination could meet this Kantian standard. For example, had Dr. Walker terminated Crystal's therapy for the express purpose of beginning a sexual relationship with her, such a motive would not have been "universalizable. " This is because, if therapists consistently and universally sacrificed their clients' welfare whenever it suited their personal interests or needs, clients would not trust their therapists and therefore counseling would not effectively work. Furthermore, to consent to a universal law of such betrayal would be to consent to being treated as a “mere means” rather than as an autonomous agent, which no rational person would do.
It is thus apparent why the ACA now requires therapists who intend to have sexual relationships with former clients to ascertain that they did not terminate therapy as part of a plan to initiate a sexual relationship with the client (ACA, 1995, A. More generally the ACA also provides that counselors should "avoid actions that seek to meet their personal needs at the expense of clients" (ACA, 1995, A. 5. a). It might, however, be suggested that no violation of client autonomy occurs when a client consents to termination of therapy for purposes of beginning a sexual relationship.
After all, it might be said, is this not to respect the client's will rather than to engage in any form of betrayal? Thus, supposing that Crystal were willing to discontinue therapy for purposes of pursuing sex with Dr. Walker, would Dr. Walker not have respected her autonomy (self-determination) by obliging her? Crystal's attraction to Dr. Walker was a case of transference, carrying out a sexual relationship with her would have been to exploit and manipulate her dependency, not to foster her autonomy.
Given Crystal's vulnerable state of mind, it is far from clear, however, that her consent could have been considered "free" and "uncoerced". In the least, given Dr. Walker's own impaired capacity for objectivity, and the potential to cause serious client harm, such conduct would have been a blatant violation of Dr. Walker's moral responsibility to safeguard the welfare of a vulnerable client. In terminating the counseling relationship, should Dr. Walker have told Crystal why he was terminating her therapy? It is arguable that in not fully informing Crystal of the grounds of termination, Dr. Walker had failed to act in a manner befitting a candid and congruent therapist. In support of the Principle of Candor, the APA provides that "psychologists make reasonable efforts to answer patients' questions and to avoid apparent misunderstandings about therapy"(APA, 1992, 4. 01. d). In further support, the ACA provides that "whenever counseling is initiated, and throughout the counseling process as necessary, counselors inform clients of the purposes, goals, techniques, procedures, limitations, potential risks and benefits of services to be performed, and other pertinent information" (ACA, 1995, A. . a).
In still further support, the ACA provides that in terminating counseling, counselors should aim at "securing agreement when possible" (A. 11. c). Unfortunately, Crystal was not afforded the opportunity to provide informed consent to termination in a much as she was denied information material to termination, and which any client in similar circumstances would reasonably want to know. Thereby, she was not treated as an "end in herself," that is, as a self-determining agent. Additionally, Dr. Walker left Crystal in a state of frustration and bewilderment. Was she to blame for Dr. Walker's decision to terminate despite his insistence that it was due to "his problem"? Since Dr. Walker had already admitted that he found Crystal to be attractive, was termination a result of his feelings toward her? Did he really love her? On the other hand, was he just offended by her having "come on" to him? In refusing to disclose his grounds for termination, Dr. Walker failed to achieve adequate closure to therapy, and Crystal was simply left "hanging. "
While Dr. Walker did previously state that he found Crystal to be "a very attractive woman," this had been at Crystal's own prompting. As such, this statement of his could well have been construed by Crystal as merely an attempt to appease her. As far as Dr. Walker did not follow through with an explicit, candid disclosure as pertinent to termination, therapy ended on an inauthentic note. In failing to "own" his own feelings, Dr. Walker missed a final and hence important opportunity to model congruence and so to encourage Crystal to take similar responsibility for her own future life decisions.
What, then, might Dr. Walker have said to Crystal in response to her request for further information about why he was terminating and referring her? The truth as presented along the following lines would probably have been sufficient: "I have not completely worked through my own divorce, which, coupled with my own sexual attraction for you, has made it difficult for me to remain professionally objective and to provide you with the competent counseling services to which you are entitled.
In cases like this, it is my professional responsibility to refer you to someone who will afford you such services. " In making disclosure along these lines, Dr. Walker would have responded in a manner befitting a candid and congruent therapist, and accordingly in such a manner consistent with the primary counseling mission. Dr. Walker's experience with Crystal appropriately alerted him to the possibility that his own "unfinished business" surrounding his divorce justified refraining from accepting clients whose profiles were similar to Crystal's.
In this regard, in concert with the Principle of Loyalty, the APA (1992) provides that psychologists "refrain from undertaking an activity when they know or should know that their personal problems are likely to lead to harm to patent, client or other person to whom they may owe a professional or scientific obligation" (1. 13. a). Dr. Walker failed to have worked through his own marital issues affected his ability to provide competent counseling services, Dr. Walker also had a professional responsibility to obtain competent counseling for himself.
Thus, in concert with the Principle of Non-Maleficence, the ACA provides that "counselors refrain from offering or accepting professional services when their physical, mental or emotional problems are likely to harm a client or others. They are alert to the signs of impairment, seek assistance for problems, and, if necessary, limit, suspend, or terminate their professional responsibilities"(ACA, 1995, C. 2. g). In the present case neither Dr. Walker nor Crystal sought therapy for their personal problems after their professional relationship ceased.
It was under these circumstances, about two years later, that Dr. Walker and Crystal began a sexual relationship. It was therefore quite possible that Crystal's sexual attraction and willingness to begin a sexual relationship with Dr. Walker was a result of the same transference problem that led Dr. Walker to terminate therapy in the first place. Similarly, it is also quite possible that Dr. Walker's own sexual attraction and willingness to begin a sexual relationship with Crystal were themselves an actualization of his previously perceived tendency to countertransfer.
If so, then the possibility for client manipulation and harm which existed in therapy could be hypothesized to continue to exist in the personal relationship. Furthermore, since in his personal relationship with Crystal Dr. Walker was no longer expected to maintain professional distance or to be objective, the potential for even greater client manipulation and harm could be hypothesized to exist. In keeping with the Principle of Non-Maleficence, Dr. Walker had a professional responsibility to avoid harming others, which clearly included former clients.
Dr. Walker entry into a personal relationship with Crystal placed her at significant risk of harm and arguably at even greater risk than in their previous professional relationship Dr. Walker had a professional responsibility to avoid such a relationship with Crystal. In addition, since this potential for harm may be traced to the exercise of power and authority established in the therapeutic context, Dr. Walker may be viewed as having used his professional powers and authorities in a manner inconsistent with Crystal's welfare.
Furthermore, a rule of "once a client, always a client" would seem to derive force from the implausibility of supposing that a client's welfare matters only within the professional context but subsequently becomes expendable as soon as therapy is (formally) ended. Further, given that professional safeguards were no longer expected in the personal relationship, all knowledge previously acquired in the therapeutic context was no longer insulated from personal use. Thus, by virtue of his personal relation with Crystal, Dr. Walker was no longer expected to remain objective and professionally distanced, yet he was still privy to information previously protected by such professional responsibilities. Given the emotional dynamics of personal relationships, the potential for misuse of such knowledge will have accordingly increased. For example, in the throws of an emotionally heated disagreement, Dr. Walker might allow his perception to be colored by his intimate knowledge of Crystal's former marriage. This could in turn affect the manner of his own verbal, behavioral and emotional responses to Crystal.
Insofar as knowledge acquired under a bond of professional confidentiality, is subsequently used for personal purposes, the Principle of Discretion will also be breached. As the APA (1992) states, "Psychologists discuss confidential information obtained in clinical or consulting relationships only for appropriate professional and scientific purposes... " (5. 03. b); and it is clear use of private client information for personal, self-interested reasons falls outside the purview of such legitimate purposes. It is possible. of course, that Dr. Walker could manage to keep such private information out of his personal life.
Nevertheless, therapists are human beings who have emotions and do not always perform at their best. Therefore, expecting therapists to avoid at all times being influenced by prior clinical knowledge of a person with whom they are intimately relating may be asking too much of the most well-adjusted. In Dr. Walker's case, however, there were already reasons for supposing that he had unresolved problems that would make such expectations all the more unrealistic. Furthermore, maintaining such a stature is tantamount to expecting the therapist to fulfill his professional esponsibilities within the context of a personal relationship. Role expectations between professional and personal relationships, are however, notoriously inconsistent. Thus, in personal relationships, "there is an expectation that the needs of both parties will be met in a more or less reciprocal manner. It is difficult to consistently put the consumer's needs first if one is also invested in meeting one's own needs. " And, accordingly, "as the incompatibility of expectations increases between roles, so will the potential for misunderstanding and harm" (Kitchener, 1988).
On analysis, it is therefore clear that, in starting a sexual relation with a former client, Dr. Walker acted contrary to the primary counseling mission by taking substantial, unwarranted risks. Even though Dr. Walker waited two years before starting a sexual relation as some standards (for example, APA and ACA) require, there were strong reasons militating against starting the relationship. Furthermore, had Dr. Walker attempted to document that this relationship did not have an exploitative basis, it is questionable that Dr. Walker himself would have been in a situation to objectively assess the matter.
Under the circumstances, it would have been more fitting had he called in a consultant to help him to decide the matter (ACA, 1995, C. 2. e). Such unbiased ethics assessment would probably have been more reliable than Dr. Walker's own determination. It is evident that a two year waiting period is not itself a reliable index of warranted sexual relations with former clients. As the APA has suggested, warrant for sexual relations with former clients is "most unusual. " Had Dr. Walker seen Crystal on a single occasion without having established an ongoing professional relation with her, such warrant would have been arguable.
Here, however, there is still danger of the appearance of conflict of interest--or even worse, of exploitation of clients. A profession cannot afford to have its image tarnished. A therapist concerned for the welfare of prospective clients cannot afford to neglect professional image. A professional known to have had sex with former clients--no matter how well the relation might have been documented--does nothing to promote an image of a trustworthy and virtuous therapist in the public eye. Finally, legal requirements need not always be in harmony with professional standards.
While some causes may sometimes be morally compelling enough to override obedience to law, it is unlikely that violation of a state statute in order to engage in a sexual relation with a former client would qualify. If sexual relations with former clients were legally regarded as sexual misconduct in the state in which Dr. Walker practiced, there would have been further reason, an overriding and compelling reason, for his not engaging in such a relation with Crystal. In the absence of such a state statute, there would also have been a compelling case against it.
The following rules of dual role relationships may be gathered from the case study. While they are not intended to be exhaustive of all such possible rules, they are intended to supplement ones provided under Principles of Loyalty and Non-Maleficence. General Rules Regarding Dual Role Relationships: In considering whether a dual role relationship is morally problematic and should be avoided or terminated therapists considers the potential for loss of the client's independence of judgment as well as that of their own.
Therapists consider the adverse effects that pursuing certain types of dual role relationships (for instance, sexual relations with former clients) might have on the public image of their profession, and avoid apparent conflicts of interest as well as actual ones. Therapists avoid any dual role relationship in which a serious potential for misappropriation of confidential information exists (for instance, the use of such information for malicious or self-serving purposes).
Therapists who have institutional affiliations (for instance, teach at colleges or universities or work in agencies) avoid provision of therapy to other employees with whom they have or are likely to have working relations. Therapists establish and maintain contact with other qualified professionals available to render competent, independent ethics consultation or supervision in case conflicts of interest make the therapists' own judgment questionable.
GR's 1 through 4 are based upon the premise that therapists should take reasonable measures to avoid all dual role relationships for which there exists serious potential for loss of independence of judgment--the client's as well as the therapist's--and conflicts of interest--apparent and actual. The aforementioned rules provide some key considerations for avoiding such relationships. When therapists cannot feasibly avoid a conflict of interest, then they should fully inform the affected clients about the conflict, and, with the clients' consent, seek consultation and/or supervision from other qualified professionals . GR 5 has been advanced in support of the latter premise. In satisfying GR 5, therapists who work in agencies should establish and maintain contact with other competent professionals who practice outside their agencies and are therefore more likely to provide independent, nonbiased consultation or supervision. Therapists who practice in isolated rural areas have an especially compelling interest in establishing and maintaining such contacts.
As is true with respect to other rules, the present ones are intended to help in guiding therapists' decisions regarding dual role relationships, but are not intended as a substitute for careful ethical reflection. For instance, while avoidance of apparent conflicts of interest is important for maintaining professional image, GR 2 must be applied with regard for the welfare, interests, and needs of particular clients. For example, a therapist might justly tolerate public appearance of a conflict of interest in order to prevent serious harm to an identifiable client while such involvement purely for personal gain would be unacceptable.
GR 1 underscores that morally problematic dual role relationships can arise not only when the therapist encounters a conflict of interest but also when the client's independence of judgment is impaired. Since either case can result in ineffective or self-defeating therapy, a therapist may have compelling reason for avoiding or terminating a dual role relationship even when it is only the client's judgment that is adversely affected. The use of the term "qualified professional" in GR 5 refers to another competent therapist as well as to a competent professional in a related area such as a professional ethicist.
The term "working relations" in GR 4 means direct employee relations arising out of the cooperative performance of specific job-related tasks. Such tasks include secretarial, administrative, custodial, maintenance, committee, and departmental functions. Working relations must involve direct contact, which means exchange of information by face-to-face contact or other channels such as e-mail, phone or interoffice memo. In general, the more frequent and intimate the job-related ontact between therapist and client, the greater the potential for loss of independence of judgment by both parties. Thus, an occasional interoffice memo may not be as risky as on-going face-to-face contact. The term "working relation" does not apply simply because two individuals have the same employer. In a very large institution such as a state university, it is possible that two employees have no working relation, but this is less likely to be true in smaller institutions such as counseling agencies.
Rules Regarding Sexual Relations with Former Clients
Therapists do not engage in sexual relations with current clients and generally avoid sexual relations with former clients. In rare cases in which therapists are considering the warrant for sexual relations with former clients (for instance, in cases where no ongoing therapeutic relationship has been established), they consult with other competent, impartial professionals in documenting the non-exploitative nature of the considered relations.
SF 2 Therapists recognize that their former clients like current clients can still be vulnerable to sexual manipulation, and therefore avoid taking undue sexual advantage of these individuals Therapists do not assume that their former clients' agreement to enter into sexual relations with them constitutes freely given consent. SF 3 If the state in which a therapist practices regards all sexual relations with former clients as sexual misconduct, then therapists do not engage in any such relations even where warrant for the relation might otherwise exist.
In SF 2, the term "undue sexual advantage" refers to the exploitation of any client weakness related to the prior therapist-client relationship, for example, an unresolved client transference issue, persistent client dependency on the therapist, or the therapist's position of power and authority over the client. Insofar as such client weaknesses may persist after therapy has been terminated, the burden of proof resides with the therapist to show that the client's consent to a sexual relation with the therapist is not a result of such factors but rather constitutes the client's autonomous, uncoerced consent (NASW, 1997, 1. 9. c). In the rare cases in which this can be shown, SF 1 requires that documentation include the favorable outcome of consultation with at least one other independent, competent professional (as defined above) in addition to such documentation specified in other pertinent standards addressed in this chapter (APA, 1992, 4. 07; ACA, 1995, A. 7. b). While a virtuous therapist would ordinarily have regard for law, we have noted that some causes such as prevention of serious harm to a client may sometimes militate against compliance with law.
Rule SF 3, however, is intended to make clear that satisfaction of the therapist's sexual interests even when coupled with that of the former client does not warrant or mitigate the legal transgression. Rules Regarding Sexual Attraction to Clients: AC 1 Therapists are not disqualified from counseling clients to whom they are sexually attracted so long as they are able to provide these clients with competent, professional services.
However, if they have or, in the course of therapy, develop sexual attractions for clients which impair or are likely to impair the therapists' independence of judgment, then they terminate therapy and make appropriate referrals. AC 2 Therapists do not accept as clients individuals from certain populations (for instance, certain gender and age categories) for whom sexual feelings are likely to impair independence of judgment. In such cases therapists take appropriate steps to overcome their personal problems, such as seeking therapy for themselves, before taking on such individuals as clients.
AC 3 In cases where therapists terminate therapy due to mutual sexual attraction, therapists inform clients as to the nature of termination, and do not misrepresent or mislead clients as to the cause of termination. .AC 1 assumes that sexual attraction for at least some clients is frequent occurrence and is not in itself a reason for terminating therapy. AC 1 affords therapists the autonomy to decide whether such attraction is of such a quality as to impair professional judgment. Therapists' sexual attractions for clients may however sometimes be related to therapists' own "unfinished business. In such cases AC 2 recognizing the need to address such personal problems therapeutically before counseling groups of clients to whom the sexual attraction may be generalized. AC 3 is supported by both Principles of Honesty and Candor in requiring therapists with sexual attractions for clients to avoid deception in informing these clients of the grounds for termination.
Rules Regarding Therapy with Students
Therapists do not engage in therapy with current students or those with whom current students have intimate relationships. Consistent with client welfare, therapists may engage in therapy with former students. TS 2 while therapists may not solicit students for referrals, they may accept unsolicited referrals from students. If, during the course of therapy, therapists' clients also become their students, therapists take reasonable steps to terminate the ensuing dual role relationships, including terminating therapy and providing appropriate referrals. Therapists inform their clients of all significant risks related to maintaining such dual role relationships and, consistent with client welfare, decline to remain in both roles.
Therapists support and encourage their clients' own informed, autonomous choices in resolving the conflict. Therapists who ascertain that prospective clients are likely to become their students decline to accept such individuals as clients. As part of their clients' informed consent to therapy, therapists who teach inform potential students (clients whose profiles suggest that they might become students) of a professional responsibility not to engage in therapy with their students. In TS 1, the term "intimate relationships" includes family members such as parents, step parents, grandparents, and siblings.
The term also includes significant others such as boyfriends or girlfriends, fiancees, and sexual partners. While an individual may not have a close relationship with all family members, the probability that the family bond will implicate the student is substantial enough to justify a strict rule against counseling family members of students. Although TS 2 permits therapists to accept as clients the unsolicited referrals from students, it is noteworthy that, in concert with TS 1, such permissible, unsolicited referrals do not include individuals with whom students have intimate relationships.
TS 3 provides that therapists should take "reasonable measures" to terminate non-elective dual role relationships with students. In the context of therapy this means measures which are consistent with client welfare, and which accordingly promote client trust and autonomy. The rule provides that clients be afforded maximal autonomy in deciding how the dual role relationship will be resolved; for example, whether the student-teacher relationship will be preserved and the therapist-client relationship erminated, or conversely. TS 4 recognizes the utility of taking preventative measures to increase the likelihood that a non-elective dual role relationship with students is avoided before it is established by the student. It also conforms with the Principle of Candor in making clear, from the start, the Therapist's professional responsibility not to counsel students. In this way, the therapist's move to discontinue such a relationship (should one later be established) comes as no surprise to the client.
- American Association for Marriage and Family Therapy (1991). Code of ethics. Washington, DC: AAMFT
- American Association of University Professors (1990). Statement on professional ethics. AAUP Policy Documents and Reports, 75-76.
- American Counseling Association (1995). Code of ethics. Alexandria, VA: ACA. American Psychological Association (1992). Standards of ethics. Washington, DC: APA.
- Anderson, B. S. (1996). The counselor and the law. 4th Ed. Alexandria, VA: ACA. Davis, M. & A. Stark (in press). Conflict of interest and the professions. New York: Oxford University Press. Herlihy, B. &
- G. Corey (1997). Boundary issues in counseling: Multiple roles and responsibilities. Alexandria, VA: ACA.
- Kitchener, K. S. (1988). Dual role relationships: What makes them so problematic? Journal of counseling and development, 67, 217-221.
- Martin, M. W. (1997). Professional distance. International journal of applied philosophy. 12(1). National Association of Social Workers (1997). Code of ethics. Washington, DC: NASW.
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