Running head: DUAL RELATIONSHIPS 1

Dual Relationships: Forbidden, Avoided, Managed? Meagan Keashly University of Calgary

DUAL RELATIONSHIPS Dual Relationships: Forbidden, Avoided, Managed? Dual relationships are an important ethical consideration for psychologists. Notably, in 2007, 28% of cases that were opened by the American Psychological Association Ethics

Committee involved dual relationships (Gottlieb & Younggren, 2009). This paper will begin with a description of dual relationships. Second, will be an overview of a theory that contends dual relationships should be forbidden. Next will be a discussion of whether dual relationships should be avoided or managed, and what a psychologist needs to consider prior to engaging in these relationships. Following this will be a vignette of an ethical dilemma, which is resolved using a decision making model. This paper will conclude with a reflection on how my personal values interface with professional values. Dual relationships occur when a psychologist simultaneously or consecutively engages in two role categories (Gottlieb, 1993). Specifically this can occur when the psychologist undertakes more than one professional role (i.e., therapist and employer) or when professional and nonprofessional relationships are combined (i.e., counselor and business partner) (Moleski & Kiselica, 2005). Examples of these relationships include close personal, business, financial, social or familial relationships with clients (Moleski & Kiselica, 2005). Dual relationships can occur by chance, by choice or somewhere in between. Dual relationships by chance occur when fate blurs the boundaries between psychologists and their clients (e.g., having a clients sister as your next door neighbor) (Moleski & Kiselica, 2005). Dual relationships formed due to the psychologists choice require that the psychologist carefully examine the positive and negative consequences that the secondary relationship may have on the primary relationship. The in between area consists of instances where the psychologist has very limited choice regarding being involved in a dual relationship (e.g., psychologist in a rural setting) (Moleski & Kiselica, 2005). It is imperative that

DUAL RELATIONSHIPS psychologists consider the potential boundary violations that may occur as a result of dual relationships, and where they have choice in the matter consider their decision carefully. Boundary issues regularly pose complex challenges to clinicians. The effects of crossing commonly recognized boundaries range from significant therapeutic progress to serious, indelible harm (Moleski & Kiselica, 2005, p. 8).

There is not clear consensus on how psychologists should handle dual relationships. Some contend that boundary violations occur due to the slippery slope of psychotherapy (Gottlieb & Younggren, 2009, p. 564). Specifically, this requires psychologists to be apprehensive regarding departing from traditional practice in any way for fear it could lead to a slippery slope and ultimately a boundary violation (Gottlieb & Younggren, 2009). Gutheil and Gabbard (1993) use the term slippery slope to explain how a sexual relationship between practitioners and patients could occur. They believe it is a gradual process that involves a series of boundary crossings, which in and of themselves do not have negative outcomes. However, each boundary crossing results in a desensitizing effect making the next boundary easier to cross. Gutheil and Gabbard also imply that often the practitioner was unaware that this is occurring and eventually the momentum of the previous boundary crossings force the professional into boundary violations (Gottlieb & Younggren, 2009, p. 566). Therefore, as soon as the practitioner engages in boundary crossing, such as in the form of a dual relationship, this will likely escalate into a boundary violation (Gottlieb & Younggren, 2009). The only way to prevent a violation from occurring is to not engage in any boundary crossing whatsoever (Gutheil & Gabbard, 1993). Barnett, Lazarus, Vasquez, Moorehead-Slaughter, and Johnson (2007) contend that while avoiding all boundary crossings may prevent possible boundary violations, it is not practical or realistic and could result in an artificial or sterile psychologist-client relationship.

DUAL RELATIONSHIPS A perspective in the research that has more support than Gutheil and Gabbards (1993) view that dual relationships should be forbidden, is that they should be avoided or effectively managed. Whether dual relationships should be avoided or managed depends on the situation the psychologist is in. That is, those who practice within rural areas and small communities need to manage dual relationshipsrelationships, as they often cannot be avoided. While, those who do not practice within such a limited area or community should avoid dual relationships. Regardless of situation however, Moleski & Kiselica (2005) note there are two relevant moral principles that need to be considered in determining whether to engage in dual relationships: autonomy and nonmaleficence. Autonomy is the clients ability to decide upon his or her own direction and the psychologists responsibility to help this behavior progress. The degree to which potential negative or positive consequences may arrive is a function of the amount of autonomy the client loses or gains as a result of the additional relationship (Moleski & Kiselica, 2005). Nonmaleficence refers to the psychologists responsibility to avoid practices or behaviors that result in harm or could potentially result in harm. In deciding whether to engage in an additional relationship, the psychologist needs to weigh the potential for harm if they engage in the relationship compared to the potential for harm if they do not (Moleski & Kiselica, 2005). Decision-making models can be useful in helping to determine whether to engage in dual

relationships. Gottlieb (1993) suggests a three-dimension decision-making model. Power, the first dimension, is the amount of power a psychologist has in relation to the client. The second dimension, relationship duration, assumes that power increases with time. Therefore, brief relationships result in lower amounts of power. The final dimension is clarity of termination, which is the likelihood that the psychologist and client will have professional contact in the future (Gottlieb, 1993). The model also employs five steps in order for the psychologist to arrive at a

DUAL RELATIONSHIPS decision. First, the psychologist is to assess the current relationship with the client based on the

three dimensions. If the relationship is elevated on two or more of the dimensions (i.e., high power differential, long duration, and/or no agreement about when termination will occur) than no additional relationships are permissible. If the relationship scored in the low to mid-range on most of the dimensions, then the psychologist should proceed to the next step in the decision making model (Gottlieb, 1993). The second step is examination of the prospective secondary relationship in a similar manner to the examination of the primary relationship. If the relationship is elevated on the majority of the dimensions, a secondary relationship should not occur. If it is not, the psychologist should proceed to the third step of the model, which is to examine the primary and secondary relationships for role incompatibility. If the roles are very incompatible, then the secondary relationship should not occur. If they have low incompatibility then the psychologist may proceed to step four (Gottlieb, 1993). Step four is consulting a colleague regarding the relationship. If after consultation it is viewed to be acceptable to have the additional relationship, the final stage in the model is implemented. This occurs when the psychologist obtains informed consent by discussing the decision with client, including reviewing the basics of how the decision was determined, the ethical issues involved, possible alternatives and possible negative consequences. Only if the client is competent and decides to proceed with the secondary relationship, after being given sufficient time to consider the alternatives, may the psychologist may enter into the secondary relationship (Gottlieb, 1993). While this model can be useful for examining instances where the psychologist has full choice on whether to become involved in dual relationships, it does not do a good job explaining what a psychologist with very limited choice is to do. For example, in a small rural community a psychologist may be engaging in a primary relationship that is high on most of the dimensions (e.g., psychologist currently providing

DUAL RELATIONSHIPS individual therapy for clients depressive symptoms), but may need to engage in a secondary

relationship that is low on the majority of the dimensions in order to be an active member of a rural community (e.g., attending the same elementary school functions). Psychologists who practice in rural areas and small communities (e.g., deaf community) tend to encounter more issues with dual relationships than do psychologists who work in urban areas and/or those who serve more general populations (Schank & Skovholt, 1997). It becomes more difficult for these psychologists as they need to function within a variety of roles in the community instead of just being able to offer more traditional urban based services (Murray & Keller, 1991). According to Schank and Skovholt (1997) dual relationships are inevitable in rural and other small communities where community involvement lessens suspicion and increases approachability and where denying help to a potential client because of a preexisting relationships could mean that the person gets no help at all (p. 44). Within these communities, possible benefits to engaging in multiple relationships include demonstrating a stronger understanding the culture, or providing treatment in a locale where it would otherwise be unavailable. It is important to recognize that dual relationships need to be managed within rural and small-communities so safeguards should be implemented to minimize risk for boundary violations. Schank and Skovholt (1997) suggest rural area and small community psychologists employ four safeguards in order to manage dual relationships. First, recognize that nonsexual dual relationships are likely to occur for rural area and small community psychologists. Therefore, it is important to know the codes and provincial laws in order to understand how to apply them within a small community. Psychologists should also be involved in continuing education on ethical issues in order to lead to greater understanding. Second, acknowledge that clear boundaries and expectations, where possible, result in stronger therapeutic relationships. This includes protecting

DUAL RELATIONSHIPS confidentiality, documenting progress of cases and obtaining informed consent as these help to reduce potential psychologist-client misunderstandings (Schank & Skovholt, 1997). Third, it is important to engage in ongoing discussion and consultation of cases. This helps the psychologist get perspectives from others and reduces the isolation that may accompany rural and smallcommunity practice (Schank & Skovholt, 1997). Lastly, it is important to have a strong selfknowledge and engage in activities outside of work in order to reduce the chance that psychologists will use clients for their own gratification (Schank & Skovholt, 1997). Rural and small community psychologists face a different set of challenges compared to their urban counterparts due to professional isolation and a lack of anonymity and as such it is especially important for them to engage in safeguards to protect their practice (Schank & Skovholt, 1997). Barnett, Lazarus, Vasquez, Moorehead-Slaughter, and Johnson (2007) provide guidelines that can be considered by psychologists regardless of whether they practice in rural areas or small communities. Combining these with Gottliebs (1993) model and/or Schank and Skovholt (1997) safeguards may be beneficial in determining the most ethical solution to a dual relationship dilemma. Barnett et al.s (2007) primary guideline is identification of whether the boundary crossing is motivated by the clients needs or the psychologists needs. Additional relationships that solely benefit the psychologist should be avoided. Second, is consideration of whether the

dual relationship is sensitive to the clients history, diagnosis, culture and values. Third is ensuring that any additional relationships, along with the reasoning behind it, are documented in the clients record. This guideline is echoed by Younggren and Gottlieb (2004) who note that documentation of the decision making process is vital because inadequate documentation can negate the existence and value of the entire decision-making process regardless of how comprehensive and thoughtful it may have been (p. 258). Barnett et al.s fourth guideline is that where possible the

DUAL RELATIONSHIPS dual relationship should be discussed with the client prior to engaging in it in order to ensure the client is comfortable and decrease the chance of misunderstanding. Fifth is consideration of the psychologist-client power differential and ensuring not to exploit the clients trust. The final guideline is to ensure consulting with a respected colleague guides the ultimate decision. This is consistent with the recommendations of both Gottlieb (1993) and Schank and Skovholt (1997). Where psychologists have any choice in the matter, entering into a dual relationship is a decision that requires careful consideration. Ethical Dilemma The following vignette has ben adapted from Barnett et al. (2007). I will use the ethical decision-making process (Sinclair & Pettifor, 2001) to arrive at a decision.

I am a psychologist in a rural community who specializes in the assessment and treating of eating disorders. I receive a referral from a local physician. At the initial appointment, I am concerned to see that my new client is my childs third-grade teacher. Although I may wish to refer the client to another professional, I am the only health care professional within a 4-hour drive with this clinical expertise. I fear that if I do not provide the need treatment, the client will go untreated. (p. 404) Step One: Identification of the Individuals and Groups Potentially Affected by the Decision The client, her family, the school, the clients students and my competency as a psychologist could be affected by the decision I make. Step Two: Identification of Ethically Relevant Issues and Practices Utilizing the chart that outlines the Canadian Code of Ethics for Psychologists, there are a number of ethical values that are important to consider in this dilemma. Respect for the Dignity of Persons

DUAL RELATIONSHIPS It is important that I engage in general respect (I.1) by respecting the client and the referring physicians knowledge, insight and experience. It is also essential to obtain informed consent from the client (I.16, I.17, I.19, I.24). She should be a full and active participant in the

decisions that affect her, which include whether to engage in a dual relationship. The client should fully understand the purpose of the therapy, confidentiality and its limits, benefits and risks of engaging in therapy, alternatives, and consequences of not engaging in therapy. She also needs to understand that she may withdraw from therapy at any time. Freedom of consent (I.27) is also important to consider, as she should be able to freely choose whether to engage in therapy. It will be important to consider the privacy and confidentiality of the client (I.38, I.41, I.43, I.44, I.45) and maintaining these aspects whether or not she decides to continue with therapy. This includes only sharing the information with people the client gives permission for and obviously not sharing any information with my daughter or her school (unless given permission). Responsible Caring General caring (II.1, II.3) is an important consideration because I need to protect and promote the welfare of my client. I also need to be sure to accept responsibility for any consequences that may result from my decision regarding the dilemma. With respect to competence and self-knowledge (II.7, II.8, II.10), it is important that I do not refer the client to someone who is incompetent to carry out assessment and treatment. Further, if she remains my client I need to recognize if her needs go beyond my competence (e.g., through the course of therapy I may discover she displays symptoms of schizophrenia) and if they do I need to refer her to a more competent professional. It is also important to recognize how my own experiences, attitudes, beliefs, values, stresses and training can impact my interactions with her. In deciding on an outcome to the ethical dilemma, it is important that it maximizes benefits (II.21) and minimizes

DUAL RELATIONSHIPS harm (II.29, II.31). I need to decide whether the benefits of a dual relationship outweigh the

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potential harm to the client. Further, it is important that I strive to provide the best possible service for my client. If I am unable to provide it, I need to help her obtain this service (e.g., referral to another professional along with trying to find a way to get the professional to come to the rural area). Integrity in Relationships With respect to accuracy and honesty (III.2, III.5, III.8) it is important that I accurately represent myself, maintain competence within my area of specialty (i.e., eating disorders) and acknowledge my limitations. Considering objectivity and lack of bias (III.10) is also essential as I need to evaluate how my experiences with the client as my childs teacher may influence my thinking and strive to be objective in the therapy situation. I will need to engage in straightforward and open behavior (III.14, III.16) regarding all information that is needed to establish informed consent with my client, which includes possible conflicts, alternatives and possible outcomes. Once the decision has been made, I should also fully explain it to my client. Of significant importance in this dilemma is considering the value of avoidance of conflict of interest (III.31, III.33, III.34, III.35). This would entail not exploiting the psychologist-client relationship (e.g., expecting the client to raise my daughters grades in school). I will also need to consider whether this potential dual relationship needs to be avoided or managed based on what is in the best interest of the client. Additionally, I would need to consider whether a conflict of interest exists and if so, inform the client and act to resolve the situation in accordance with Principle I and Principle II. Responsibility to Society In considering the value of beneficial activities (IV.14) it is important that I only enter into a therapy agreement with the client if I am able to act in accordance with the principles and

DUAL RELATIONSHIPS standards of the Canadian Code of Ethics for Psychologists.

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Step Three: Consideration of How Personal Biases, Stresses, or Self-interest Might Influence the Development of or Choice Between Courses of Action My initial reaction was that I did not want to accept my childs third grade teacher for assessment and treatment because of added stress. I felt that having to navigate this dual relationship would add extra stress that I would not have if I were treating a client who did not have a close relationship to a member of my immediate family. Further, with regard to selfinterest, my schedule is already pretty full so I do not need to take on another client because that means more work for me. However, after consideration, I recognize that these are not ethically valid reasons for not accepting the client. Step Four: Development of Alternative Courses of Action Alternative One: Accept the Client for Assessment and Treatment As I am the only qualified practitioner in the area, I could accept the client for assessment and treatment. I would recognize that being in a rural setting significantly limits options for my client and myself. I would ensure that before assessment or treatment began that I was clear about the nature of the dual relationship that I explained alternatives, conflicts and possible outcomes, and that I had given her time to consider the factors involved before giving informed consent. Alternative Two: Refer the Client to Another Practitioner I could try to avoid the dual relationship and refer the client to another practitioner who is competent in assessment and treatment of eating disorders. I would explain to the client that I could not engage in therapy with her because it would represent a dual relationship, which I want to avoid. As her relationship with a member of my family is so close, I do not feel I can engage in an objective therapeutic relationship. I would explain to her that the nearest specialist in the area is

DUAL RELATIONSHIPS four hours away and I would do what I could to ensure she got the services she needs (e.g., try to

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arrange for the practitioner to come to our area to work with the client, or help the client in making arrangements to travel to the practitioner). Step Five: Analysis of Likely Short-term, Ongoing and Long-term Risks and Benefits Alternative One: Accept the Client for Assessment and Treatment The primary benefit to this alternative is that the client gets assessment and treatment by a competent practitioner within her community. She does not need to travel a far distance for treatment, which increases the likelihood she will attend the sessions and decreases the stress that may be associated with needing to travel such a distance. Ultimately, therapy could be successful and her symptoms would be reduced. The negative consequences could be that I am unable to remain objective during therapy due to the dual relationship, which compromises treatment. The client may also feel uncomfortable in the situation, resulting in her either not fully opening up or choosing to discontinue treatment. Ultimately, therapy could be unsuccessful with no symptom reduction. Alternative Two: Refer the Client to Another Practitioner The benefit of referring the client to another practitioner is that I will not enter a dual relationship with an individual who has such a close relationship with my daughter. Therefore, I do not need to consider the potential conflict of interest or lack of objectivity that could impact the assessment and/or treatment. The client may feel more comfortable in obtaining therapy from another practitioner to whom she does not have a secondary relationship. She may be more willing to fully disclose and discuss her issues and treatment may be more effective. The main negative consequence of referring the client to another practitioner is the feasibility of travel for therapy. As the nearest competent practitioner is four hours away, she will

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need to devote a considerable amount of time for travel. Plus, the added stress due to this situation may negatively impact her condition. The client may decide that it is too inconvenient to travel that distance and not go for therapy resulting in no reduction of symptoms. Step Six: Choice of Course of Action In carefully reviewing the alternatives, I believe that the first alternative, accepting the client for assessment and treatment would be the most appropriate course of action assuming the client provides informed consent. I prefer the first alternative because I think the amount of travel time required for the second alternative does not make it feasible and the likely consequence is that the client will either not engage in treatment or will discontinue treatment early. Further, I believe alternative one is the most appropriate course of action because it emphasizes the values in Principle II of responsible caring, maximizing benefits and minimizing harm. Step Seven: Action with a Commitment to Assume Responsibility for the Consequences I will carry out alternative one, which is what I believe to be the best course of action based on the circumstances. I will work within II.3 of the Canadian Code of Ethics for Psychologists and accept responsibility for the consequences of my actions. Step Eight: Evaluation of the Results of the Course of Action I need to evaluate whether the desired outcome has been achieved, whether further actions are needed and whether any negative consequences have resulted due to pursuing alternative one as the course of action. Step Nine: Assumption of Responsibility for the Consequences of Action Despite my careful consideration of the dilemma and alternative courses of action it is possible that what I intend to happen from my chosen course of action does not occur. For example, although the client was made aware of the risks, benefits and alternatives of the dual

DUAL RELATIONSHIPS relationship and provided informed consent, she may feel uncomfortable in the therapeutic

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situation. She may be very guarded for concern that I will not want her to teach my child and this could significantly impact the efficacy of treatment. If this occurs, I will re-engage in the decisionmaking process, including reexamining both alternative one and two. Step Ten: Appropriate Action to Prevent Future Occurrences of the Dilemma Due to my experience with this ethical dilemma, I have reflected on many ethical principles and values, especially ones surrounding dual relationships and the importance of informed consent. Primarily, in deciding in whether to engage in dual relationships, I need to consider that the psychologists primary purpose is to serve the best interests of the client (Sinclair & Pettifor, 2001, p. 260). Therefore I need to act is a way that recognizes that the welfare of my client is my main concern. I also am cognizant of the importance of clarifying my role as a psychologist at the beginning of a professional relationship, the value of undergoing and documenting the ethical decision making process, and how necessary it is to ensure the client is fully aware of the implications of choosing to enter into a dual relationship (if doing so is the most ethical decision). Further, through doing research on the topic, I am aware of the importance of collaboration with colleagues when facing an ethical dilemma. They provide an objective viewpoint on the situation and can help to ensure the best interests of the client are protected and promoted. Prior to determining a course of action for an ethical dilemma in the future, I will ensure I consult knowledgeable colleagues as part of the decision making process. In reflecting on how my personal values interface with the professional values, I primarily engage in what Gottlieb and Younggren (2009) term an assimilation strategy. This means that I tend to overidentify with professional standards resulting in the loss of my own personal values. I believe this is because the Canadian Code of Ethics is relatively new to me. I try to follow exactly

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what is written without consideration of my own values in determining an outcome. I would hope that as I become more familiar with ethical standards I would be able to utilize an integration strategy, which would be allow me to incorporate the ethical values of psychology while maintaining my personal values (Gottlieb & Younggren, 2009). In deciding upon a course of action for the ethical dilemma presented in this paper I did not find that the outcome selected presented a personal conflict for me. However, upon careful reflection, there may be personal conflict if alternative two would have been determined to be more ethically sound. The personal conflict arises in that I would want to provide services to those within the community in order to help them and feel I could be objective regardless of other relationships that may exist (with the exception of close personal ones). Therefore, when viewing the vignette I immediately thought the best course of action was to provide assessment and services to the client, and just ensure I remained objective and maintained confidentiality. However, I defer to professional values and am aware of the importance of working though the ethical decision making model. Working through this model, I recognize that there are negative consequences to alternative one and positive consequences to alternative two that I need to weigh in order to determine an outcome. Ultimately, it was a difficult decision to make. There were two issues that made the dilemma so challenging. First, the client was someone who had a current, close relationship with a member of my immediate family. Second, there was not another competent practitioner within a reasonable amount of travel time. If there were another competent practitioner in the community, the most ethical decision would be to refer to client. The decision on whether psychologists should engage in dual relationships is one without an easy answer. In some instances psychologists have very little choice in whether to engage in these relationships, such as in rural areas and small communities. In other instances, such as in

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urban centers, psychologists are afforded a lot of choice. In determining whether to engage in dual relationships psychologists should remember that serving the best interests of their clients is the most important consideration.

DUAL RELATIONSHIPS References Barnett, J. E., Lazarus, A. A., Vasquez, M. J. T., Moorehead-Slaughter, O., & Johnson, W. B. (2007). Boundary issues and multiple relationships: Fantasy and reality. Professional Psychology: Research and Practice, 38(4), 401-410. doi:10.1037/735-7028.38.4.401 Gottlieb, M. C. (1993). Avoiding exploitive dual relationships: A decision-making model. Psychotherapy, 30(1), 41-48. Retrieved from http://www.apa.org/pubs/journals /pst/index.aspx Gottlieb, M. C., & Younggren, J. N. (2009). Is there a slippery slope? Consideration regarding multiple relationships and risk management. Professional Psychology: Research and Practice, 40(6), 564-571. doi: 10.1037/a0017231 Gutheil, T. G., & Gabbard, G. O. (1993). The concept of boundaries in clinical practice: Theoretical and risk-management dimensions. American Journal of Psychiatry, 150, 188-196. Retrieved from http://ajp.psychiatryonline.org/ Moleski, S. M., & Kiselica, M. S. (2005). Dual relationships: A continuum ranging from the destructive to the therapeutic. Journal of Counseling and Development, 83(1), 3-12. Schank, J. A., & Skovholt, T. M. (1997). Dual relationship dilemmas of rural and

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small-community psychologists. Professional Psychology: Research and Practice, 28(1), 44-49. Retrieved from http://www.apa.org/pubs/journals/pro/index.aspx Sinclair, C., & Pettifor, J. (2001). Companion manual to the Canadian code of ethics for psychologists (3rd ed.). Ottawa, ON: Canadian Psychological Association. Younggren, J. N., & Gottlieb, M. (2004). Managing risk when contemplating multiple relationships. Professional Psychology: Research and Practice, 35(3), 255-260. doi:10.1037/0735-7028.35.3.255

DUAL RELATIONSHIPS Grading Criteria APA Style Running head & title Headings & quotations In-text citations & reference list 29/30 3/3 3/3 8/8 3/3 8/8 5/5

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State why the topic is important Demonstrate knowledge of relevant ethical principles and standards in addressing the topic Present one actual example of a dilemma (it will usually involve conflict between principles or between interests of different parties) Demonstrate how the issue you are addressing is reflected in the resolution of the dilemma, e.g., how you apply your knowledge and ethical decisionmaking skills. Describe how your personal values interface with the professional values and whether this presents any dissonance or personal conflict for you. What changes in the dilemma described could have made it easier, or more difficult, for you personally? Hi Meagan ~

Thank you for your paper, I enjoyed reading it. I can tell you really understand why dual relationships is an important topic for practicing Psychologists. I agree that this is something that all Psychologists need to be mindful of especially living in more rural areas. Although you did a good job using recent references, remember to only use literature that is no further than 10 years back at the most (i.e., 2001), unless there is a seminal article that you feel absolutely must be acknowledged (e.g., Gottlieb, 1993). This is especially important when discussing ethical issues, as older literature will not be as relevant to todays standards or practice. Congratulations on finishing the course. Sincerely, Sumerlee