Dual Relationships

In this week's episodes of In Treatment we saw two examples of dual relationships in psychotherapy and I have received emails asking to to say more about this.

It might seem that it would be easy to make a clear definition and prohibition against dual relationships, but in fact it is not and how they are viewed varies some by theoretical orientation. The more the relationship between therapist and patient is the primary vessel for the work, then the less likely that such a relationship would be benign, for the therapy.

The code of ethics for psychologists states:

American Psychological Association: Ethical Principles of Psychologists and Code of Conduct

 "A multiple relationship occurs when a psychologist is in a professional role with a person and (1) at the same time is in another role with the same person, (2) at the same time is in a relationship with a person closely associated with or related to the person with whom the psychologist has the professional relationship, or (3) promises to enter into another relationship in the future with the person or a person closely associated with or related to the person. A psychologist refrains from entering into a multiple relationship if the multiple relationship could reasonably be expected to impair the psychologist's objectivity, competence, or effectiveness in performing his or her functions as a psychologist, or otherwise risks exploitation or harm to the person with whom the professional relationship exists. Multiple relationships that would not reasonably be expected to cause impairment or risk exploitation or harm are not unethical. (b) If a psychologist finds that, due to unforeseen factors, a potentially harmful multiple relationship has arisen, the psychologist takes reasonable steps to resolve it with due regard for the best interests of the affected person and maximal compliance with the Ethics Code....Barter is the acceptance of goods, services, or other nonmonetary remuneration from clients/patients in return for psychological services. Psychologists may barter only if (1) it is not clinically contraindicated, and (2) the resulting arrangement is not exploitative."

The one unambiguous area of dual relationships is any sexual contact -- across the board this is seen as injurious to the patient and unethical. 

From there it becomes less clear. In a large urban area, it is possible for therapist and patient to have no contact or relationship of any kind outside of therapy. The more rural the area, the less possible this becomes. As an example, I live in a town of 6500 people. It is highly likely that I will know people who come to me or know people they are close to -- this is all but inevitable in a small population. What do we do about it? We talk about it and establish ground rules for the relationship.

It is also fairly clear that there shouldn't be any complicating financial relationship between patient and therapist. A patient could be a great accountant or plumber or attorney but should not be employed by the therapist for those skills. 

The primary consideration must always be the interests of the patient -- is the dual relationship in the best interests of the patient? And if it is not or there is doubt that it is, then it should be avoided.

In light of this, look at Paul and Mia. He knows as soon as he recognizes her that they would have a dual relationship if they proceed -- even if she did not return to see him in therapy, that that she was his patient remains the priority concern. And as they talk it becomes even clearer to him that she should not handle his case. Good decision.

Look at Gina and Paul. Their relationship is a tangled mess of personal and professional and the lines constantly shift and blur so that there has not been a clear therapeutic or supervisory contract. And though Paul asks to be in therapy with her, and Gina agrees, it is not in his best interests. He may not want to start again with someone new, but the issues between him and Gina make it highly unlikely that the therapy would be successful. And if it were to have even a chance of success, they would have to discuss the reality that their friendship needs to be set aside. Even were they able to do this, I am dubious about the outlook.

In order to have a solid container for the therapy, and for the particular kind of intimacy that can develop in a secure frame with good boundaries, sacrifice is needed on the part of both therapist and patient. No matter how much they may like each other and believe they could have a wonderful friendship, the sanctity of the therapy relationship must come first. It is sometimes very difficult to make this kind of sacrifice, but it is essential. These are feelings for the patient to put into words, and not to be acted out, by either patient or therapist.

© Cheryl Fuller, 2018. All  rights reserved.