Determine strategies for maintaining boundaries for interpersonal relationships with diverse clients in the correctional setting.  Must have citation and references along with speaker notes (not to m

Wk 3 - Inmate Manipulation and Boundaries Presentation [due Mon]

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Identify possible ways that inmates may try to use a personal traumatic experience you have had to manipulate you.

Create a scenario to describe one of these situations.

Create a 10- to 12-slide Microsoft® PowerPoint® Presentation including the following:

• Summarize the manipulation scenario.

• Develop a plan for how to maintain boundaries in this situation.

• Explain possible obstacles in setting and maintaining these boundaries.

• Identify ethical and legal consequences to not maintaining boundaries in this situation.

Include a minimum of two sources.

Format your presentation consistent with APA guidelines.

Submit your assignment.  

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Determine strategies for maintaining boundaries for interpersonal relationships with diverse clients in the correctional setting.

How can employees avoid being manipulated by an inmate? What changes do you think you would need to make in your life to make sure an inmate does not manipulate you?

Dual or multiple relationships occur when a professional assumes two or more roles simultaneously or sequentially with a person seeking his or her help. This may involve taking on more than one professional role (such as counselor and teacher) or combining professional and nonprofessional roles (such as counselor and friend or counselor and lover). Another way of stating this is that a helping professional enters into a dual or multiple relationship whenever the professional has another, significantly different relationship with a client, a student, or a supervisee.

Multiple relationship issues exist throughout our profession and affect virtually all counselors, regardless of their work setting or the client populations they serve. Relationship boundary issues have an impact on the work of helping professionals in diverse roles, including counselor educator, supervisor, agency counselor, private practitioner, school counselor, college or university student personnel specialist, rehabilitation counselor, and practitioner in other specialty areas. These issues affect the dyadic relationship between counselor and client, and they can also emerge in complex ways in tripartite relationships (such as client/supervisee/supervisor or client/consultee/consultant) and in family therapy and group work. No professional remains untouched by the potential difficulties inherent in dual or multiple relationships.

This book is a revision of our earlier editions, Dual Relationships in Counseling (Herlihy & Corey, 1992) and Boundary Issues in Counseling: Multiple Roles and Responsibilities (Herlihy & Corey, 1997, 2006b), but with an expanded focus. Since we last wrote together about this topic, helping professionals have continued to debate issues of multiple relationships, roles, and responsibilities; power; and boundaries in counseling.

Because of the complexities involved, the term multiple relationship is often more descriptive than dual relationship. Dual or multiple relationships occur when mental health practitioners interact with clients in more than one relationship, whether professional, social, or business. In the most recent versions of the ACA Code of Ethics(American Counseling Association [ACA], 2005, 2014), both of these terms have been replaced with the term nonprofessional interactions to indicate those additional relationships other than sexual or romantic ones. In this book, we continue to use the terms dual or multiple relationships to describe these nonprofessional relationships as well as dual professional relationships.

This revised edition is based on the assumption that counseling professionals must learn how to manage multiple roles and responsibilities (or nonprofessional interactions or relationships) effectively rather than learn how to avoid them. This entails managing the power differential inherent in counseling or training relationships, balancing boundary issues, addressing nonprofessional relationships, and striving to avoid using power in ways that might cause harm to clients, students, or supervisees. This book rests on the premise that we can develop ethical decision-making skills that will enable us to weigh the pros and cons of multiple roles and nonprofessional interactions or relationships.

Beginning in the 1980s, the counseling profession became increasingly concerned with the ethical issues inherent in entering into multiple relationships and establishing appropriate boundaries. Much has been written since then about the harm that results when counseling professionals enter into sexual relationships with their clients. Throughout the 1980s, sexual misconduct received a great deal of attention in the professional literature, and the dangers of sexual relationships between counselor and client, professor and student, and supervisor and supervisee have been well documented. Today there is clear and unanimous agreement that sexual relationships with clients, students, and supervisees are unethical, and prohibitions against them have been translated into ethics codes and law. Even those who have argued most forcefully against dual relationship prohibitions (e.g., Lazarus & Zur, 2002; Zur, 2007) agree that sexual dual relationships are never acceptable. We examine the issue of sexual dual relationships in detail in Chapter 2.

In the 1990s and until the turn of the century, nonsexual dual and multiple relationships received considerable attention in professional journals and counseling textbooks. The codes of ethics of the ACA 2014), the American School Counselor Association (ASCA; 2010), the American Psychological Association (APA; 2010), the National Association of Social Workers (NASW; 2008), and the American Association for Marriage and Family Therapy (AAMFT; 2012) have all dealt specifically and extensively with topics such as appropriate boundaries, recognizing potential conflicts of interest, and ethical means for dealing with dual or multiple relationships. Since this book was last revised in 2006, new articles on these topics have slowed to a trickle in the professional literature. There has been an increasing recognition and acceptance that dual or multiple relationships are often complex, which means that few simple and absolute answers can neatly resolve ethical dilemmas that arise. It is not always possible for counselors to play a singular role in their work, nor is this always desirable. From time to time we all will wrestle with how to balance multiple roles in our professional and nonprofessional relationships. Examples of problematic concerns associated with dual relationships include whether to barter with a client for goods or services, whether it is ever acceptable to counsel a friend of a friend or social acquaintance, whether to interact with clients outside the office, how a counselor educator might manage dual roles as educator and therapeutic agent with students, how to ethically conduct experiential groups as part of a group counseling course, and whether it is acceptable to develop social relationships with a former client.

In this chapter, we focus on nonsexual dual relationships that can arise in all settings. One of our guest contributors, Arnold Lazarus, makes a case for the potential benefits of transcending boundaries. He takes the position that benefits can accrue when therapists are willing to think and venture outside the proverbial box. The following questions will guide our discussion:

• What guidance do our codes of ethics offer about dual or multiple nonprofessional relationships?

• What makes dual or multiple relationships problematic?

• What factors create the potential for harm?

• What are the risks (and benefits) inherent in dual or multiple relationships, for all parties involved?

• What important but subtle distinctions should be considered?

• What safeguards can be built in to minimize risks?

The codes of ethics of all the major associations of mental health professionals address the issue of multiple relationships. To begin our discussion, consider these excerpts from the codes of ethics for mental health counselors, marriage and family therapists, social workers, school counselors, and psychologists.

The ACA Code of Ethics (ACA, 2014) provides several guidelines regarding nonprofessional interactions. Counselors are advised that:

Sexual and/or Romantic Relationships Prohibited

Sexual and/or romantic counselor–client interactions or relationships with current clients, their romantic partners, or their family members are prohibited. This prohibition applies to both in-person and electronic interactions or relationships. (Standard A.5.a.)

Previous Relationships

Counselors consider the risks and benefits of accepting as clients those with whom they have had a previous relationship. These potential clients may include individuals with whom the counselor has had a casual, distant, or past relationship. Examples include mutual or past membership in a professional association, organization, or community. When counselors accept these clients, they take appropriate professional precautions such as informed consent, consultation, supervision, and documentation to ensure that judgment is not impaired and no exploitation occurs. (Standard A.6.a.)

Extending Counseling Boundaries

Counselors consider the risks and benefits of extending current counseling relationships beyond conventional parameters. Examples include attending a client’s formal ceremony (e.g., a wedding/commitment ceremony or graduation), purchasing a service or product provided by a client (excepting unrestricted bartering), and visiting a client’s ill family member in the hospital. In extending these boundaries, counselors take appropriate professional precautions such as informed consent, consultation, supervision, and documentation to ensure that judgment is not impaired and no harm occurs. (Standard A.6.b.)

Documenting Boundary Extensions

If counselors extend boundaries as described in A.6.a. and A.6.b., they must officially document, prior to the interaction (when feasible), the rationale for such an interaction, the potential benefit, and anticipated consequences for the client or former client and other individuals significantly involved with the client or former client. When unintentional harm occurs to the client or former client, or to an individual significantly involved with the client or former client, the counselor must show evidence of an attempt to remedy such harm. (Standard A.6.c.)

The standard of the AAMFT Code of Ethics (AAMFT, 2012) dealing with dual relationships advises therapists to avoid such relationships due to the risk of exploitation:

Marriage and family therapists are aware of their influential position with respect to clients, and they avoid exploiting the trust and dependency of such persons. Therapists, therefore, make every effort to avoid conditions and multiple relationships with clients that could impair professional judgment or increase the risk of exploitation. Such relationships include, but are not limited to, business or close personal relationships with a client or the client’s immediate family. When the risk of impairment or exploitation exists due to conditions or multiple roles, therapists document the appropriate precautions taken. (1.3.)

The NASW (2008) code of ethics, using language similar to that of the AAMFT, focuses on the risk of exploitation or potential harm to clients:

Social workers should not engage in dual or multiple relationships with clients or former clients in which there is a risk of exploitation or potential harm to the client. In instances when dual or multiple relationships are unavoidable, social workers should take steps to protect clients and are responsible for setting clear, appropriate, and culturally sensitive boundaries. (Dual or multiple relationships occur when social workers relate to clients in more than one relationship, whether professional, social, or business. Dual or multiple relationships can occur simultaneously or consecutively.) (1.06.c.)

The Ethical Standards for School Counselors (ASCA, 2010) also advises that school counselors avoid dual relationships that carry a potential risk of harm and, like the ACA, suggests safeguards. The school counselors’ code is the only one, among those reviewed here, that addresses the burgeoning usage of social media and its potential for creating inappropriate relationships between students and professionals.

Professional school counselors:

Avoid dual relationships that might impair their objectivity and increase the risk of harm to the student (e.g., counseling one’s family members, close friends or associates). If a dual relationship is unavoidable, the school counselor is responsible for taking action to eliminate or reduce the potential for harm to the student through the use of safeguards, which might include informed consent, consultation, supervision and documentation. (A.4.a.)

Maintain appropriate professional distance with students at all times. (A.4.b.)

Avoid dual relationships with students through communication mediums such as social networking sites. (A.4.c.)

The APA (2010) code addresses multiple relationships quite extensively:

(a) 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.

(c) When psychologists are required by law, institutional policy, or extraordinary circumstances to serve in more than one role in judicial or administrative proceedings, at the outset they clarify role expectations and the extent of confidentiality and thereafter as changes occur. (3.05.)

As can be seen, the ethics codes for mental health professionals all take considerable care to address dual and multiple relationships. Ethical problems often arise when clinicians blend their professional relationships with other kinds of relationships with a client. The ethics codes of most professional organizations currently warn against crossing these boundaries when it is not in the best interests of the client. The emphasis is no longer on an outright prohibition of dual or multiple relationships; rather, the focus has shifted to avoiding the misuse of power and exploitation of the client. Also, it is increasingly acknowledged that some nonprofessional relationships are potentially beneficial.

Dual and multiple relationships are fraught with complexities and ambiguities that require counselors to make judgment calls and apply the codes of ethics carefully to specific situations. These relationships are problematic for a number of reasons:

• They can be difficult to recognize.

• They can be very harmful; but they are not always harmful, and some have argued that they can be beneficial.

• They are the subject of conflicting views.

• They are not always avoidable.

Dual or multiple relationships can evolve in subtle ways. Some counselors, counselor educators, or supervisors may somewhat innocently establish a form of nonprofessional relationship. They may go on a group outing with clients, students, or supervisees. A counselor may agree to play tennis with a client, go on a hike or a bike ride, or go jogging together when they meet by accident at the jogging trail. Initially, this nonprofessional interaction may seem to enhance the trust needed to establish a good working relationship in therapy. However, if such events continue to occur, eventually a client may want more nonprofessional interactions with the therapist. The client may want to become close friends with the counselor and feel let down when the counselor declines an invitation to a social event. If a friendship does begin to develop, the client may become cautious about what he or she reveals in counseling for fear of negatively affecting the friendship. At the same time, the counselor may avoid challenging the client out of reluctance to offend someone who has become a friend.

It can be particularly difficult to recognize potential problems when dual relationships are sequential rather than simultaneous. A host of questions present themselves: Can a former client eventually become a friend? How does the relationship between supervisor and supervisee evolve into a collegial relationship after the formal supervision is completed? What kinds of posttherapy relationships are ever acceptable? These questions are explored in later chapters.

A wide range of outcomes to dual or multiple relationships is possible, from harmful to beneficial. Some dual relationships are clearly exploitive and do serious harm to the client and to the professional involved. Others are benign; that is, no harm is done. In some instances, dual relating may strengthen the therapeutic relationship. Moleski and Kiselica (2005) provide a review of the literature regarding the nature, scope, and complexity of dual relationships ranging from the destructive to the therapeutic. They suggest that counselors who begin a dual relationship are not always destined for disaster. They describe some therapeutic dual relationships that complement and enhance the counseling relationship. For example, in counseling clients from diverse cultures, practitioners may find it necessary to engage in boundary crossings to establish the counseling relationship. Moleski and Kiselica maintain that the positive or negative value of the secondary relationship is determined by the degree to which it enhances the primary counseling relationship. Therapeutic dual relationships are characterized by the counselor’s commitment to doing what is in the best interest of the client.

Consider the following two examples. The first is a harmful dual relationship; the second could be described as benign or even therapeutic.

• A high school counselor enters into a sexual relationship with a 15-year-old student client.

• All professionals agree that this relationship is exploitive in the extreme. The roles of counselor and lover are never compatible, and the seriousness of the violation is greatly compounded by the fact that the client is a minor.

• A couple plans to renew their wedding vows and host a reception after the ceremony. The couple invites their counselor, who attends the ceremony, briefly appears at the reception to offer her best wishes to the couple, and leaves. The couple is pleased that the counselor came, especially because they credit the counseling process with helping to strengthen their marriage.

• Apparently, no harm has been done. In this case the counselor’s blending of a nonprofessional role with her professional role could be argued to be benign or even beneficial to the counseling relationship.

The topic of dual and multiple relationships has been hotly debated in the professional literature. A few writers argue for the potential benefits of nonsexual dual relationships, or nonprofessional relationships. Zur (2007) asserts that boundary crossings are not unethical and that they often embody the most caring, humane, and effective interventions. Other writers take a cautionary stance, focusing on the problems inherent in dual or multiple relationships and favoring a strict interpretation of ethical standards aimed at regulating professional boundaries. Persuasive arguments have been made for both points of view.

Welfel (2013) points out that many ethics scholars take a stronger stance against multiple relationships than that found in codes of ethics, especially those in which one role is therapeutic. Perhaps this is because their study of the issues has made them more keenly aware of the risks. Through their work on ethics committees, licensure boards, or as expert witnesses in court cases, they may have direct knowledge of harm that has occurred.

Even when practitioners have good intentions, they may unconsciously exploit or harm clients who are vulnerable in the relationship. If the professional boundaries become blurred, there is a strong possibility that confusion, disappointment, and disillusionment will result for both parties. For these reasons, some writers caution against entering into more than one role with a client because of the potential problems involved. They advise that it is generally a good idea to avoid multiple roles unless there is sound clinical justification for considering multiple roles.

Although dual relationships are not damaging to clients in all cases, St. Germaine (1993) believes counselors must be aware that the potential for harm is always present. She states that errors in judgment often occur when the counselor’s own interests become part of the equation. This loss of objectivity is one factor that increases the risk of harm.

Gabbard (1994) and Gutheil and Gabbard (1993) have warned of the dangers of the slippery slope. They caution that when counselors make one exception to their customary boundaries with clients, it becomes easier and easier to make more exceptions until an exception is made that causes harm. They argue that certain actions can lead to a progressive deterioration of ethical behavior. Furthermore, if professionals do not adhere to uncompromising standards, their behavior may foster relationships that are harmful to clients. Remley and Herlihy (2014) summarize this argument by stating, “The gradual erosion of the boundaries of the professional relationship can take counselors down an insidious path” (p. 206) that could even lead, ultimately, to a sexual relationship with a client.

Other writers are critical of this notion of the slippery slope, stating that it tends to result in therapists practicing in an overly cautious manner that may harm clients (Lazarus & Zur, 2002; Pope & Vasquez, 2011; Speight, 2012; Zur, 2007). Overlapping boundaries and crossing boundaries are not necessarily problematic; instead, they can be positive and beneficial within therapeutic relationships (Speight, 2012). G. Corey, Corey, Corey, and Callanan (2015) remind us that ethics codes are creations of humans, not divine decrees that contain universal truth. They do not believe dual or multiple relationships are always unethical, and they have challenged counselors to reflect honestly and think critically about the issues involved. They believe codes of ethics should be viewed as guidelines to practice rather than as rigid prescriptions and that professional judgment must play a crucial role.

Tomm (1993) has suggested that maintaining interpersonal distance focuses on the power differential and promotes an objectification of the therapeutic relationship. He suggested that dual relating invites greater authenticity and congruence from counselors and that counselors’ judgments may be improved rather than impaired by dual relationships, making it more difficult to use manipulation and deception or to hide behind the protection of a professional role.

Lazarus and Zur (2002) and Zur (2014) make the point that none of the codes of ethics of any of the various professions takes the position that nonsexual dual relationships are unethical per se. They believe that “dual relationships are neither always unethical nor do they necessarily lead to harm and exploitation, nor are they always avoidable. Dual relationships can be helpful and beneficial to clients if implemented intelligently, thoughtfully, and with integrity and care” (Lazarus & Zur, 2002, p. 472). They remind counselors that dual relationships are not, in and of themselves, illegal, unethical, unprofessional, or inappropriate. Instead, unethical dual relationships are those that are reasonably likely to exploit clients or impair professional judgment.

We agree that duality itself is not unethical; rather, the core of the problem lies in the potential for the counselor to exploit clients or misuse power. Simply avoiding multiple relationships does not prevent exploitation. Counselors might deceive themselves into thinking that they cannot possibly exploit their clients if they avoid occupying more than one professional role. In reality, counselors can misuse their therapeutic power and influence in many ways and can exploit clients without engaging in dual or multiple relationships.

It seems evident from the controversy over dual or multiple relationships that not all dual relationships can be avoided and that not all of these relationships are necessarily harmful or unethical. The APA (2010) states that “multiple relationships that would not reasonably be expected to cause impairment or risk exploitation or harm are not unethical” (3.05.a.). The key is to take steps to ensure that the practitioner’s judgment is not impaired and that no exploitation or harm to the client occurs.

Perhaps some of the clearest examples of situations in which dual relationships may be unavoidable occur in the lives of rural practitioners. In an isolated, rural community the local minister, merchant, banker, beautician, pharmacist, or mechanic might be clients of a particular counselor. In such a setting, the counselor may have to play several roles and is likely to find it more difficult to maintain clear boundaries than it is for colleagues who practice in more densely populated areas. It is worth noting that “small worlds” can exist in urban as well as in rural environments. In many close-knit communities, nonprofessional contacts and relationships are likely to occur because clients often seek out counselors who share their values and are familiar with their culture. These “small worlds” might include religious congregations, those in recovery from substance abuse, the gay/lesbian/bisexual/transgender community, some racial or ethnic minority groups, and the military.

The debate over dual or multiple relationships has been extensive, and much of it has been enlightening and thought provoking. At this point, we ask you to consider where you stand.

• What is your stance toward dual or multiple relationships?

• With which of the perspectives do you most agree?

• How did you arrive at this stance?

• What do you see as its risks and benefits?

Some behaviors in which professionals may engage from time to time have a potential for creating a problematic situation, but these behaviors are not, by themselves, dual relationships. Some examples might be accepting a small gift from a client, accepting a client’s invitation to a special event such as a wedding, going out for coffee or tea with a client, making home visits to clients who are ill, or hugging a client at the end of a particularly painful session. Similar types of interactions are listed in the ACA Code of Ethics(ACA, 2014) as examples of “extending counseling boundaries” (Standard A.6.b.)

Some writers (Gabbard, 1995; Gutheil & Gabbard, 1993; R. I. Simon, 1992; Smith & Fitzpatrick, 1995) have suggested that such interactions might be considered boundary crossings rather than boundary violations. A boundary violation is a serious breach that results in exploitation or harm to clients. In contrast, a boundary crossing is a departure from commonly accepted practice that might benefit the client. Crossings occur when the boundary is shifted to respond to the needs of a particular client at a particular moment. Boundary crossings may even result in clinically effective interventions (Zur, 2012).

Interpersonal boundaries are not static and may be redefined over time as counselors and clients work closely together. Zur and Lazarus (2002) take the position that rigid boundaries are not in the best interests of clients. They maintain that rigidity, distance, and aloofness are in direct conflict with doing what is therapeutically helpful for clients. We agree with Zur and Lazarus’s thoughts on rigid boundaries, but we also believe that even seemingly innocent behaviors can lead to dual relationship entanglements with the potential for exploitation and harm if they become part of a pattern of blurring professional boundaries.

Some roles that professionals play involve an inherent duality. One such role is that of supervisor. Supervisees often experience an emergence of earlier psychological wounds and discover some of their own unfinished business as they become involved in working with clients. Ethical supervisors do not abandon their supervisory responsibilities by becoming counselors to supervisees, but they can encourage their supervisees to view personal therapy with another professional as a way to become more effective as a counselor and as a person. At the same time, although the supervisor and therapist roles differ, personal issues arise in both relationships, and supervisors need to give careful thought as to when and how these issues should be addressed. As another example, counselor educators serve as teachers, as therapeutic agents for student growth and self-awareness, as supervisors, and as evaluators, either sequentially or simultaneously. This role blending can present ethical dilemmas involving conflicts of interest or impaired judgments.

None of these roles or behaviors actually constitutes an ongoing dual relationship of the type that is likely to lead to sanctions by an ethics committee. Nonetheless, each does involve two individuals whose power positions are not equal. Role blending is not necessarily unethical, but it does require vigilance on the part of the professional to ensure that no exploitation occurs. One of the major difficulties in dealing with dual relationship issues is the lack of clear-cut boundaries between roles. Where exactly is the boundary between a counseling relationship and a friendship? How does a counselor educator remain sensitive to the need to promote student self-understanding without inappropriately acquiring personal knowledge about the student? Can a supervisor work effectively without addressing the supervisee’s personal concerns that may be impeding the supervisee’s performance? These are difficult questions, and any answers must include a consideration of the potential harm to clients, students, or supervisees when a dual relationship is initiated.

Whatever the outcome of a dual or multiple relationship, a potential for harm almost always exists from the beginning of the relationship. To illustrate, let’s revisit the example given earlier of a behavior that was identified as benign or even therapeutic. No apparent harm was done when the marriage counselor attended the renewal of wedding vows ceremony and reception. But what might have happened if the counselor had simply accepted the invitation without discussing with the couple any potential problems that might arise? What if the counselor had been approached at the reception and asked how she knew the couple? Had the counselor answered honestly, she would have violated the privacy of the professional relationship. Had she lied or given an evasive answer, harm to the clients would have been avoided, but the counselor could hardly have felt good about herself as an honest and ethical person.

One of the major problems with multiple relationships is the possibility of exploiting the client (or student or supervisee). Kitchener and Harding (1990) contend that dual relationships lie along a continuum from those that are potentially very harmful to those with little potential for harm. They concluded that dual relationships should be entered into only when the risks of harm are small and when there are strong, offsetting ethical benefits for the client.

How does one assess the potential for harm? Kitchener and Harding identified three factors that counselors should consider: incompatibility of expectations on the part of the client, divergence of responsibilities for the counselor, and the power differential between the parties involved.

First, the greater the incompatibility of expectations in a dual role, the greater the risk of harm. For example, John, a supervisor, is also providing personal counseling to Suzanne, his supervisee. Although Suzanne understands that evaluation is part of the supervisory relationship, she places high value on the confidentiality of the counseling relationship. John is aware that her personal problems are impeding her performance as a counselor. In his supervisory role, he is expected to serve not only Suzanne’s interests but also those of the agency in which she is employed and of the public that she will eventually serve. When he shares his evaluations with her employer as his supervisory contract requires, and notes his reservations about her performance (without revealing the specific nature of her personal concerns), Suzanne feels hurt and betrayed. The supervisory behaviors to which she had agreed when she entered into supervision with John were in conflict with the expectations of confidentiality and acceptance that she had come to hold for John as her counselor.

Second, as the responsibilities associated with dual roles diverge, the potential for divided loyalties and loss of objectivity increases. When counselors also have personal, political, social, or business relationships with their clients, their self-interest may be involved and may compromise the client’s best interest. For example, Lynn is a counselor in private practice who has entered into a counseling relationship with Paula, even though she and Paula are partners in a small, part-time mail order business. In the counseling relationship, Paula reveals that she is considering returning to college, which means that she will have to give up her role in the business. Lynn is faced with divided loyalties because she does not want the business to fold and she does not have the time to take it over. As this example illustrates, it is difficult to put the client’s needs first when the counselor is also invested in meeting her own needs.

The third factor has to do with influence, power, and prestige. Clients, by virtue of their need for help, are in a dependent, less powerful, and more vulnerable position. For example, Darla is a counselor educator who is also counseling Joseph, a graduate student in the program. When a faculty committee meets to assess Joseph’s progress, Joseph is given probationary status because his work is marginal. Although Darla assures Joseph that she revealed nothing about his personal problems during the committee meeting, Joseph’s trust is destroyed. He is fearful of revealing his personal concerns in counseling with Darla because he knows that Darla will be involved in determining whether he will be allowed to continue his graduate studies at the end of his probationary period. He wants to switch to another counselor but is afraid of offending Darla. Counselor educators and counselors must be sensitive to the power and authority associated with their roles. They must resist using their power to manipulate students or clients. Because of the power differential, it is the professional’s responsibility to ensure that the more vulnerable individual in the relationship is not harmed.

The potential for harm can translate into risks to all parties involved in a dual relationship. These risks can even extend to others not directly involved in the relationship.

Of primary concern is the risk of harm to the consumer of counseling services. Clients who believe that they have been exploited in a dual relationship are bound to feel confused, hurt, and betrayed. This erosion of trust may have lasting consequences. These clients may be reluctant to seek help from other professionals in the future. Clients may be angry about being exploited but feel trapped in a dependence on the continuing relationship. Some clients, not clearly understanding the complex dynamics of a dual relationship, may feel guilty and wonder, “What did I do wrong?” Feelings of guilt and suppressed anger are potential outcomes when there is a power differential.

Students or supervisees, in particular, may be aware of the inappropriateness of their dual relationships yet feel that the risks are unacceptably high in confronting a professional who is also their professor or supervisor. Any of these feelings—hurt, confusion, betrayal, guilt, anger—if left unresolved could lead to depression and helplessness, the antitheses of desired counseling outcomes.

Risks to the professional who becomes involved in a dual relationship include damage to the therapeutic relationship and, if the relationship comes to light, loss of professional credibility, charges of violations of ethical standards, suspension or revocation of license or certification, and risk of malpractice litigation. Malpractice actions against therapists are a risk when dual relationships have caused harm to the client, and the chances of such a suit being successful increase if the therapist cannot provide sound clinical justification and demonstrate that such practices are within an accepted standard of care.

Many dual or multiple relationships go undetected or unreported and never become the subject of an inquiry by an ethics committee, licensure board, or court. Nonetheless, these relationships do have an effect on the professionals involved, causing them to question their competence and diminishing their sense of moral self-hood.

Dual or multiple relationships can create a ripple effect, affecting even those who are not directly involved in the relationship. This is particularly true in college counseling centers, schools, hospitals, counselor education programs, or any other relatively closed system in which other clients or students have opportunities to be aware of a dual relationship. Other clients might well resent that one client has been singled out for a special relationship. This same consideration is true in dual relationships with students and supervisees. Because a power differential is also built into the system, this resentment may be coupled with a reluctance to question the dual relationship openly for fear of reprisal. Even independent private practitioners can be subject to the ripple effect. Former clients are typically a major source of referrals. A client who has been involved in a dual relationship and who leaves that relationship feeling confused, hurt, or betrayed is not likely to recommend the counselor to friends, relatives, or colleagues.

Fellow professionals who are aware of a dual or multiple relationship are placed in a difficult position. Confronting a colleague is always uncomfortable, but it is equally uncomfortable to condone the behavior through silence. This creates a distressing dilemma that can undermine the morale of any agency, center, hospital, or other system in which it occurs. Paraprofessionals or others who work in the system and who are less familiar with professional codes of ethics may be misled and develop an unfortunate impression regarding the standards of the profession.

The counseling profession itself is damaged by the unethical conduct of its members. As professionals, we have an obligation both to avoid causing harm in dual relationships and to act to prevent others from doing harm. If we fail to assume these responsibilities, our professional credibility is eroded, regulatory agencies will intervene, potential clients will be reluctant to seek counseling assistance, and fewer competent and ethical individuals will enter counselor training programs. Conscientious professionals need to remain aware not only of the potential harm to consumers but also of the ripple effect that extends the potential for harm.

Whenever we as professionals are operating in more than one role, and when there is potential for negative consequences, it is our responsibility to develop safeguards and measures to reduce (if not eliminate) the potential for harm. These guidelines include the following:

• Set healthy boundaries from the outset. It is a good idea for counselors to have in their professional disclosure statements or informed consent documents a description of their policy pertaining to professional versus personal, social, or business relationships. This written statement can serve as a springboard for discussion and clarification.

• Involve the client in setting the boundaries of the professional or nonprofessional relationship. Although the ultimate responsibility for avoiding problematic dual relationships rests with the professional, clients can be active partners in discussing and clarifying the nature of the relationship. It is helpful to discuss with clients what you expect of them and what they might expect of you.

• Informed consent needs to occur at the beginning of and throughout the relationship. If potential dual relationship problems arise during the counseling relationship, these should be discussed in a frank and open manner. Clients have a right to be informed about any possible risks.

• Practitioners who are involved in unavoidable dual relationships or nonprofessional relationships need to keep in mind that, despite informed consent and discussion of potential risks at the outset, unforeseen problems and conflicts can arise. Discussion and clarification may need to be an ongoing process.

• Consultation with fellow professionals can be useful in getting an objective perspective and identifying unanticipated difficulties. We encourage periodic consultation as a routine practice for professionals who are engaged in dual relationships. We also want to emphasize the importance of consulting with colleagues who hold divergent views, not just those who tend to support our own perspectives.

• When dual or multiple relationships are particularly problematic, or when the risk for harm is high, practitioners are advised to work under supervision.

• Counselor educators and supervisors can talk with students and supervisees about balance of power issues, boundary concerns, appropriate limits, purposes of the relationship, potential for abusing power, and subtle ways that harm can result from engaging in different and sometimes conflicting roles.

• Professionals are wise to document any dual relationships in their clinical case notes, more as a legal than as an ethical precaution. In particular, it is a good idea to keep a record of any actions taken to minimize the risk of harm.

• If necessary, refer the client to another professional.

Although the ACA Code of Ethics (ACA, 2014) expressly forbids sexual or romantic relationships with clients or former clients, counseling close friends or family members, and engaging in personal virtual relationships with current clients, many “gray areas” remain. Do social relationships necessarily interfere with a therapeutic relationship? Some would say that counselors and clients can handle such relationships as long as the priorities are clear. For example, some peer counselors believe friendships before or during counseling are positive factors in building cohesion and trust. Others take the position that counseling and friendships do not mix well. They claim that attempting to manage a social and a professional relationship simultaneously can have a negative effect on the therapeutic process, the friendship, or both.

What about socializing with former clients, or developing a friendship with former clients? Although mental health professionals are not legally or ethically prohibited from entering into a nonsexual relationship with a client after the termination of therapy, the practice could lead to difficulties for both client and counselor. The imbalance of power may change very slowly, or not at all. Counselors should be aware of their own motivations, as well as the motivations of their clients, when allowing a professional relationship to eventually evolve into a personal one, even after termination. When all things are considered, it is probably wise to avoid socializing with former clients.

Another relationship-oriented question relates to the appropriate limits of counselor self-disclosure with clients. Although some therapist self-disclosure can facilitate the therapeutic process, excessive or inappropriate self-disclosure can have a negative effect.

A final related issue has to do with gifts. When is it appropriate or inappropriate to accept a gift that a client has offered? These questions are explored in the following sections.

Many writers have cautioned against counseling a friend, and the ACA Code of Ethics (ACA, 2014) expressly prohibits counseling close friends. Kitchener and Harding (1990) point out that counseling relationships and friendships differ in function and purpose. We agree that the roles of counselor and friend are incompatible. Friends do not pay their friends a fee for listening and caring. It will be difficult for a counselor who is also a friend to avoid crossing the line between empathy and sympathy. It hurts to see a friend in pain. Because a dual relationship is created, it is possible that one of the relationships—professional or personal—will be compromised. It may be difficult for the counselor to confront the client in therapy for fear of damaging the friendship. It is also problematic for clients, who may hesitate to talk about deeper struggles for fear that their counselor/friend will lose respect for them. Counselors who are tempted to enter into a counseling relationship with a friend would do well to ask themselves whether they are willing to risk losing the friendship.

A question remains, however, as to where to draw the line. Is it ethical to counsel a mere acquaintance? A friend of a friend? A relative of a friend? We think it is going to absurd lengths to insist that counselors have no other relationship, prior or simultaneous, with their clients. Often clients seek us out for the very reason that we are not complete strangers. A client may have been referred by a mutual friend or might have attended a seminar given by the counselor. A number of factors may enter into the decision as to whether to counsel someone we know only slightly or indirectly.

Borys (1988) found that male therapists, therapists who lived and worked in small towns, and therapists with 30 or more years of experience all rated remote dual professional roles (as in counseling a client’s friend, relative, or lover) as significantly more ethical than did a comparison group. Borys speculated that men and women receive different socialization regarding the appropriateness of intruding on or altering boundaries with the opposite sex: Men are given greater permission to take the initiative or otherwise become more socially intimate. In a rural environment or a small town, it is difficult to avoid other relationships with clients who are likely to be one’s banker, beautician, store clerk, or plumber. Perhaps more experienced therapists believe they have the professional maturity to handle dualities, or it could be that they received their training at a time when dual relationships were not the focus of much attention in counselor education programs. Whatever one’s gender, work setting, or experience level, these boundary questions will arise for counselors who conduct their business and social lives in the same community.

A good question to ask is whether the nonprofessional relationship is likely to interfere, at some point, with the professional relationship. Sound professional judgment is needed to assess whether objectivity can be maintained and role conflicts avoided. Yet we need to be careful not to place too much value on “objectivity.” Being objective does not imply a lack of personal caring or subjective involvement. Although it is true that we do not want to get lost in the client’s world, we do need to enter this world to be effective.

A special kind of dual relationship dilemma can arise when a counselor needs counseling. Therapists are people, too, and have their own problems. Many of us will want to talk to our friends, who might be therapists, to help us sort out our problems. Our friends can be present for us in times of need and provide compassion and caring, although not in a formal therapeutic way. We will not expect to obtain long-term therapy with a friend, nor should we put our friends in a difficult position by requesting such therapy.

A related boundary consideration is how to deal with clients who want to become our friends via the Internet. It is not unusual for a counselor to receive a “Friend Request” from a client or former client. For counselors who are considering using Facebook, a host of ethical concerns about boundaries, dual relationships, and privacy are raised. Spotts-De Lazzer (2012) claims that practitioners will have to translate and maintain traditional ethics when it comes to social media. Spotts-De Lazzer offers these recommendations to help counselors manage their presence on Facebook:

• Limit what is shared online.

• Include clear and thorough social networking policies as part of the informed consent process.

• Regularly update protective settings because Facebook options are constantly changing.

Zur and Zur (2011) have outlined a number of questions therapists should reflect on before agreeing to become involved as a friend on Facebook or some other form of social media. Some of these questions include:

• What is on the Facebook profile?

• What is the context of counseling?

• Who is the client, and what is the nature of the therapeutic relationship?

• Why did the client post the request?

• What is the meaning of the request?

• Where is the counseling taking place?

• What does being a “Friend” with this client mean for the therapist and for the client?

• What are the ramifications of accepting a Friend Request from a client for confidentiality, privacy, and record keeping?

• Does accepting a Friend Request from a client constitute a dual relationship?

• How will accepting the request affect treatment and the therapeutic relationship?

As is evident by considering this list of questions, the issue of whether or not to accept a client’s Friend Request is quite complex and requires careful reflection and consultation. To read more about this topic, visit the Zur Institute at http://www.zurinstitute.com/.

Socializing with current clients may be an example of a boundary crossing if it occurs inadvertently or infrequently or of an inappropriate dual relationship, depending on the nature of the socializing. A social relationship can easily complicate keeping a therapeutic relationship on course. Caution is recommended when it comes to establishing social relationships with former clients, and increased caution is needed before blending social and professional relationships with current clients. Among Borys’s (1988) findings were that 92% of respondents believed that it was never or only rarely ethical to invite clients to a personal party or social event; 81% gave these negative ratings to going out to eat with a client after a session. Respondents felt less strongly about inviting clients to an office or clinic open house (51% viewed this as never or rarely ethical) or accepting a client’s invitation to a special occasion (33%).

One important factor in determining how therapists perceive social relationships with clients may be their theoretical orientation. Borys found psychodynamic practitioners to be the most concerned about maintaining professional boundaries. One reason given for these practitioners’ opposition to dual role behaviors was that their training promotes greater awareness of the importance of clear, nonexploitive, and therapeutically oriented roles and boundaries. In the psychodynamic view, transference phenomena give additional meaning to alterations in boundaries for both client and therapist. A further explanation is that psychodynamic theory and supervision stress an informed and scrupulous awareness of the role the therapist plays in the psychological life of the client—namely, the importance of “maintaining the frame of therapy.”

A counselor’s stance toward socializing with clients appears to depend on several factors. One is the nature of the social function. It may be more acceptable to attend a client’s special event such as a wedding than to invite a client to a party at the counselor’s home. The orientation of the practitioner is also a factor to consider. Some relationship-oriented therapists might be willing to attend a client’s graduation party, for instance, but a psychoanalytic practitioner might feel uncomfortable accepting an invitation for any out of the office social function. This illustrates how difficult it is to come up with blanket policies to cover all situations.

• What are your views about socializing with current clients?

• Do you think your theoretical orientation influences your views?

• Under what circumstances might you have contact with a client out of the office?

Having considered the matter of socializing with current clients, we now look at posttermination social relationships between counselors and clients. Few professional codes specifically mention social relationships with former clients. An exception is the Canadian Counselling and Psychotherapy Association (2007) code of ethics:

Counsellors remain accountable for any relationships established with former clients. Those relationships could include, but are not limited to those of a friendship, social, financial, and business nature. Counsellors exercise caution about entering any such relationships and take into account whether or not the issues and relational dynamics present during the counselling have been fully resolved and properly terminated. In any case, counsellors seek consultation on such decisions. (B.11.)

In the first edition of this book, we noted that Kitchener (1992) described the nature of the relationship once the therapeutic contract has been terminated as one of the most confusing issues for counselors and their clients. Clients may fantasize that their counselors will somehow remain a significant part of their lives as surrogate parents or friends. Counselors are sometimes ambivalent about the possibility of continuing a relationship because they are aware of real attributes of clients that under other circumstances might make them desirable friends, colleagues, or peers.

Nonetheless, there are real risks that need to be considered. Studies have suggested that memories of the therapeutic relationship remain important to clients for extended periods after termination and that many clients consider reentering therapy with their former therapists (Vasquez, 1991). This reentry option is closed if other relationships have ensued. Kitchener (1992) maintains that the welfare of the former client and the gains that have been made in counseling are put at risk when new relationships are added to the former therapeutic one. Kitchener suggests that many of the same dynamics may be operating in nonsexual posttherapy relationships as in sexual ones, although not at the same level of emotional intensity. Her conclusion is that counselors should approach the question of posttherapy relationships with care and with awareness of their strong ethical responsibility to avoid undoing what they and their clients have worked so hard to accomplish.

Two studies reveal that there is little consensus among therapists regarding whether nonromantic relationships between therapists and former clients are ethical. The majority of the participants in a study by Anderson and Kitchener (1996) did not hold to the concept of “once a client, always a client” with respect to nonsexual posttherapy relationships. Some participants suggested that posttherapy relationships were ethical if a certain time period had elapsed. Others proposed that such relationships were ethical if the former client decided not to return to therapy with the former therapist and if the posttherapy relationship did not seem to hinder later therapy with different therapists.

Another study by Salisbury and Kinnier (1996) found similar results regarding counselors’ behaviors and attitudes regarding friendships with former clients. The major finding was that many counselors are engaged in posttermination friendships and believe that under certain circumstances such relationships are acceptable. Seventy percent of the counselors believed that posttermination friendships were ethical approximately 2 years after termination of the professional relationship. Although most codes of ethics now specify a minimum waiting period for sexual relationships with former clients, the codes do not address the issue of friendships with former clients.

In reviewing the codes of ethics of the various professional organizations, it appears that entering into social relationships with former clients is not considered unethical, yet the practice could become problematic. The safest policy is probably to avoid developing social relationships with former clients. Even after the termination of a therapeutic relationship, former clients may need or want our professional services at some future time, which would be ruled out if a social relationship has been established.

• What are your thoughts about social relationships with former clients?

• Do you think codes of ethics should specifically address nonromantic and nonsexual posttherapy relationships?

• Under what circumstances might such relationships be unethical?

• When might you consider them to be ethical?

Ed Neukrug presents a personal perspective on a study he and a colleague conducted in 2011 on counselors’ perceptions of ethical and unethical behaviors. Participants rated 77 behaviors, and many of these behaviors pertained to boundary issues.

Ed Neukrug

In 1993 Gibson and Pope published the results of a study that asked counselors to identify whether they believed 88 counselor behaviors were ethical or unethical. The questions highlighted the kinds of behaviors with which counselors struggle, and I included the results in two editions of my book The World of the Counselor (Neukrug, 2012). In 2011, with the fourth edition of the book ready to be written, I realized that a 1993 study was a bit old. Fascinated with the original research, I decided to update the study with a colleague of mine. In 2011 the new study was published, and soon after I added the results to the new edition of my book.

The updated version of the study identified 77 behaviors (see Neukrug & Milliken, 2011). Although we kept some of the original items from the Gibson and Pope study, we did not include items for which there had been close to 100% agreement by counselors in the original study. For instance, we did not ask if it was ethical to have sex with clients or to work while drunk. In the original study, just about every counselor felt strongly that those behaviors were unethical, and we knew from years of teaching that counselors had a clear understanding that behaviors such as these were unethical. We wanted to make sure the new survey reflected current codes. For instance, since 1993 the ACA Code of Ethics has twice been revised, with the latest Code replacing the term clear and eminent danger with serious and foreseeable harm; increasing restrictions on romantic and sexual relationships; including a statement on the permissibility of end-of-life counseling for terminally ill clients; increasing attention to social and cultural issues; allowing counselors to refrain from making a diagnosis; highlighting the importance of having a scientific basis for treatment; requiring counselors to have a transfer plan for clients; adding technology guidelines; including a statement about the right to confidentiality for deceased clients; and softening the permissibility of dual relationships, now often referred to as multiple relationships (ACA, 2005; Kaplan et al., 2009).

The new survey kept about one third of the original items, revised about one third of the original items, and included about one third new items that reflected changes since 1993. The new survey asked counselors to identify whether each of the 77 counselor behaviors were ethical or not ethical and to rate each counselor behavior on a 10-point Likert-type scale indicating how strongly they felt about their responses (1 = not very strongly, 10 = very strongly). In addition, the new survey asked counselors whether they had received ethics training in their program or elsewhere. Here we found some interesting results compared to the Gibson and Pope (1993) study.

Whereas Gibson and Pope found 73% of respondents had ethics training, a resounding 97.8% of counselors in our survey stated they had ethics training. Similarly, whereas 29% of counselors in the Gibson and Pope study reported taking a formal ethics course, this study found 60% had taken one ethics course, and 60% had taken more than one ethics course. In addition, a similar number stated that ethics training was infused throughout their program. The increase in ethics training demonstrates a major shift nationally and is likely the result of a number of changes. For instance, the increase in the number of programs accredited by the Council for Accreditation of Counseling and Related Educational Programs (CACREP) has undoubtedly affected these statistics because CACREP requires students to learn about ethics (CACREP, 2009; Urofsky & Sowa, 2004). This growth in ethics training is probably also the result of credentialing boards increasingly requiring ethics training when professionals obtain or renew their credentials (National Board for Certified Counselors, 2012). Also, as society has become increasingly litigious, the importance of ethics training to avoid malpractice lawsuits has become paramount (Neukrug, Milliken, & Walden, 2001; Remley & Herlihy, 2014; Saunders, Barros-Bailey, Rudman, Dew, & Garcia, 2007). Finally, this greater focus on ethics training has probably fostered a surge in scholarly materials (e.g., journal articles) that increase knowledge of ethics among professionals.

There is an expectation placed on counselors to maintain the sanctity of the counseling relationship by maintaining boundaries between themselves and the clients they serve (Remley & Herlihy, 2014). Our ethics codes tend to support this perspective, highlighting behaviors that should be avoided to protect our clients from injury. Our professional associations expect counselors to exhibit certain behaviors that respect boundaries between counselors and clients, and clients generally have a fairly good sense of what is “right and wrong” within the relationship regarding boundaries. Of course, it helps if clients have a clear understanding of these boundaries, and counselors can provide clients with an informed consent statement that addresses issues of boundaries in the relationship and the ethics code from the counselor’s professional association.

Despite expectations from our professional associations and dictates from our ethics codes, many boundary issues are complicated, and, as noted earlier in the chapter, sometimes an intentional and thoughtful boundary crossing can be helpful to the counseling relationship (G. Corey et al., 2015; Moleski & Kiselica, 2005; Zur, 2007). Although our survey examined counselors’ beliefs regarding a wide range of behaviors, a number of items specifically addressed boundary issues, the focus of this book. We have teased out those items and present them in Table 1.1. For the complete study results, see Neukrug and Milliken (2011).

Table 1.1 Counselors′ Perceptions Regarding Boundary Issues

In reviewing Table 1.1, it is clear that many counselors believe certain behaviors to be acceptable even though they will affect the boundary between counselor and client. For instance, more than 85% of counselors believed these behaviors are ethical: “breaking confidentiality if the client is threatening harm to self,” “having clients address you by your first name,” “using an interpreter when a client’s primary language is different from yours,” and “self-disclosing to a client.” However, even when the vast majority of counselors believe a behavior to be ethical, their actual responses may vary dramatically as a function of the context. For instance, a counselor doesn’t break confidentiality in all cases of potential “harm to self.” Rather, the decision depends on the seriousness of the thoughts, the likelihood of the action, and the means available to the client. Similarly, although many counselors may feel comfortable having clients address them by their first names, in some cases, depending on the professional style of the counselor or the issues of the client (a client who has boundary issues in his or her life), a counselor may decide it is important for a client to not address the counselor by his or her first name. Although it may be acceptable and even important to use an interpreter in a counseling relationship, a counselor must consider whether the interpreter is trustworthy and can keep the conversation confidential and how the use of an interpreter might affect the willingness of the client to discuss embarrassing or shameful material. It may be better to refer this client to a person who speaks the client’s language. Finally, although incidental self-disclosures such as “I’m so proud of you” or “I love your outfit today” can add to the working alliance, we are all aware that inappropriate self-disclosures that reveal too much about the counselor, or are done for the wrong reasons, can wreak havoc in the helping relationship.

Similarly, most counselors believe a number of behaviors are unethical most of the time and would negatively affect the boundary within the helping relationship if practiced. But even here context is everything, and a counselor might decide to exhibit the behavior in certain circumstances. Consider the following behaviors from Table 1.1 that most counselors view as unethical. Then look at the corresponding counselor situation in which exhibiting such a behavior might be acceptable.

1. Item 20: Trying to change your client’s values

   1. A counselor working with a client who uses corporal punishment suggests other ways that the client can parent, shows her “positive parenting” techniques, and points out the research regarding the effectiveness of positive parenting and the ineffectiveness of corporal punishment.

2. Item 21: Kissing a client as a friendly gesture (e.g., greeting)

   1. A counselor and client share a cultural heritage in which a kiss on the cheek is usual and expected.

3. Item 22: Accepting a gift worth more than $25 from a client

   1. A client who is terminating counseling after years of work with a counselor gives the counselor a $30 book as a thank-you for their work together.

4. Item 24: Engaging in a professional counseling relationship with a colleague who works with you

   1. The only counselor in an area practicing a neuroprocessing technique to relieve stress migraines is asked by a coworker to work with him for the three sessions needed to learn the process.

5. Item 25: Engaging in a dual relationship (e.g., your client is also your child’s teacher)

   1. A new client comes to counseling and the counselor realizes that the two of them are in the same exercise class. Together, they decide they can manage the dual relationship.

6. Item 26: Telling your client you are attracted to him or her

   1. Having worked with a depressed client for a while who has recently made some significant changes, a counselor says, “You have such an attractive smile when your depression lifts.”

7. Item 27: Giving a gift worth more than $25 to a client

   1. A client with whom you have worked has focused on improving her life. One area in which she has worked long and hard is obtaining her general equivalency diploma (GED). After 2 years of hard work, she obtains her GED. You decide to have her diploma framed as a reinforcement of her hard work.

Despite the fact that the behaviors just discussed were seen as mostly ethical (Items 1–5) or mostly unethical (Items 20–27) by the vast majority of counselors, responses can still vary as a function of context. In our survey, counselors had a fair amount of disagreement regarding whether some items were ethical or unethical (Items 5–19). These behaviors represent situations in which counselors might struggle. Keeping context in mind, review these behaviors and consider when you believe it might be appropriate or inappropriate to exhibit the behaviors. Finally, you might also want to tackle the last four items (Items 28–31) and consider whether there is ever a time when such behaviors might be ethical.

Ethical decision making around boundary issues can be a complex and difficult process, and responses may not always be as obvious as we might expect. Knowing your client, yourself, and the context of the particular ethical dilemma can help you make a wise decision in the client’s best interests.

Arnold A. Lazarus presents a provocative argument that strict boundary regulations may have a negative impact on therapeutic outcomes. He encourages therapists to avoid practicing defensively and to be willing to think and venture outside the proverbial box.

Arnold A. Lazarus

When I was an undergraduate student in South Africa (1951–1955), the dominant ethos was Freudian psychoanalysis. Most of the books and articles we read were authored by Freud or his followers. Practitioners endeavored to remain a “blank screen” to their patients or “analysands.” They avoided any self-disclosures, and all communications were strictly confined to the office or consulting room, which contained nothing personal—no diplomas, no family photos—and the only furniture was a couch, a desk, and some chairs. For the analyst to become the “screen” on which the patient projects fantasies and feelings during the transference process, he or she remains passive and neutral. This permits the patient to feel free to voice his or her private and innermost ideas and attitudes without interference by the personality of the analyst.

Some of the practitioners were so rigid that if they walked into a restaurant and saw one of their analysands they would leave immediately. Even when the field became more eclectic, many analytic proscriptions and prohibitions spilled over and were adopted by most therapists. Subsequently, when rules of ethics were first drawn up, any form of fraternization with a client was frowned upon, and dual relationships were considered taboo. During my internship in 1957 two of my peers were severely reprimanded: one for sharing tea and cookies with a client, and the other for helping a woman on with her coat.

As my orientation became behavioral and the theories and methods I applied differed significantly from psychoanalytic and psychodynamic approaches, I argued that there was no need to subscribe to their rules of client–therapist interaction. Far from being a “screen,” I was a fellow human being who considered it important to treat clients with dignity, respect, decency, and equality. Indeed, “breaking bread” with some clients fostered closer rapport, as did some out-of-office experiences such as driving a client to the train station on a cold rainy day. It always struck me as very impolite, if not insulting, to answer a question with a question instead of answering the question and then inquiring why that issue had been raised. One of my clients complained that when he asked his psychodynamic therapist a noninvasive and not too personal question she said, “We are not here to discuss me.” He said he felt demeaned and terminated the therapy soon thereafter.

To balance the playing field, it is necessary to remember that most rules have exceptions, and it is essential to observe certain caveats. There are clients with whom clear-cut boundaries are necessary. People who fit into certain diagnostic categories or evince certain behaviors require a definite structure and clear-cut boundaries: for example, those with psychoses, bipolar depression, borderline personalities, antisocial tendencies, substance abuse, histrionic personality disorders, character pathology, suicidal behaviors, eating disorders (especially anorexia nervosa), self-injurious behaviors, or criminal proclivities. A definite structure and clear-cut boundaries are not an invitation to mete out or exhibit nonempathic behavior, impolite comments, judgmental statements, or insulting remarks. The reason I am underscoring these issues is because many people have erroneously concluded that I am advocating a laissez-faire and capricious fraternization with all clients. It is necessary to be wary and well informed before deciding that it would be in the client’s best interests to stretch or cross certain boundaries. I am opposed to clinicians who treat all their clients in the same way and always go by the book. I reiterate that while deciding whether or not to traverse demarcated boundaries, if one has any misgivings, it is best to err on the side of caution.

A prevalent practice that tends to handicap therapists and often leads them to harm rather than to help certain clients or patients is therapists’ insistence on maintaining strict boundaries. They practice defensively, guided by their fear of licensing boards and attorneys rather than by clinical considerations. Risk management seminars typically warn therapists that if they cross boundaries severely negative consequences from licensing boards and ethics committees are likely to ensue. For example, they are warned not to fraternize or socialize with clients and are told to steer clear of any mutual business transactions (other than the fee for service). They are advised to avoid bartering and to avoid working with or seeing a client outside the office. Yet those therapists who transcend certain boundaries with selected clients often provide superior help. They rely on their own judgment and refuse to hide behind barriers or to function within a metaphorical straitjacket. Great benefits can accrue when therapists are willing to think and venture outside the proverbial box. Here is a case in point.

Paul, aged 17, required help for some potentially serious drug problems. His parents had tried to find a therapist who could treat and assist him, but to no avail. Paul had initial meetings with four different therapists over a 6-week interval but declared each one “a jerk” and refused to go back. He then reluctantly consulted a fifth therapist (who had been one of my recent postdoctoral students) who quickly sized up the situation. He realized that Paul would regard any formal meeting with a professional therapist as reminiscent of his uptight parents and strict teachers, so he would resist their ministrations. The therapist cleverly stepped out of role and invited Paul to shoot some baskets with him later that day at a nearby basketball court. It took several weeks of basketball playing and informal chatting before adequate rapport and trust were established, at which point Paul was willing to engage in formal office visits and seriously address his problems.

This innovative, free-thinking, and creative therapist was willing to take a risk and cross a boundary, and in so doing he gained the trust of a young man who was really hurting emotionally. This enabled Paul to respond to the therapist as a kind and accomplished big brother he could look up to and from whom he could learn a good deal.

Why have psychotherapists found it necessary to form ethics committees; establish a wide range of principled dos and don’ts; and police, discipline, and penalize those who cross the line? This is probably in response to the extreme laissez-faire climate of therapeutic interaction that prevailed in the 1950s and 1960s, when blatant boundary crossings were openly espoused. For example, at Esalen in California, where Frederick (Fritz) Perls and his associates established a training and therapy institute, therapists and clients often became playmates and even lovers. It is not far fetched to look upon many of their dealings as flagrant acts of malpractice. Concerned professionals became aware of the emotional damage that was being wrought in many settings and sought to establish a code of ethics and to lay down basic ground rules for practitioners. Terms like boundaries, boundary violation, and standard of care entered the vernacular.

Today, all therapists are expected to treat their clients with respect, dignity, and consideration and to adhere to the spoken and unspoken rules that make up our established standards of care. Many of these rules are necessary and sensible. For instance, it is essential for therapists to avoid any form of exploitation, harassment, harm, or discrimination, and it is understandable that a sexual relationship with a client is considered an ultimate taboo. Emphasis is placed on the significance of respect, integrity, confidentiality, and informed consent. Nevertheless, some elements of our ethics codes have become so needlessly stringent and rigid that they can undermine effective therapy. The pendulum has swung too far in the opposite direction from the era of negligent free-for-all indulgence.

One of my major concerns is that there is a widespread failure to grasp the critical difference between “boundary violations,” which can harm a client, and “boundary crossings,” which produce no harm and may even enhance the therapeutic connection. For example, what would be so appalling about a therapist saying to a client who has just been seen from 11 a.m. until noon: “We seem to be onto something important. Should we go and pick up some sandwiches at the local deli, and continue until 1 p.m. at no extra fee to you?” Strict boundary proponents would regard such behavior as unethical because it goes outside the therapeutic frame. However, strategic therapists would argue that rigid adherence to a particular frame and setting only exacerbates problems, especially in nonresponsive patients. For example, a patient of mine who had been resistant and rather hostile arrived early for his appointment. I was just finishing lunch and had some extra sandwiches on hand, so I offered him one. He accepted my offer as well as a glass of orange juice. Coincidentally or otherwise, thereafter our rapport was greatly enhanced, and he made significant progress. What became clear during our ensuing sessions was that the act of literally breaking bread led him to perceive me as humane and caring and facilitated his trust in me.

Over the past 40 years, I have seen thousands of clients and have selectively transcended boundaries on many occasions. For example, I engaged in barter with an auto mechanic, who tuned my car in exchange for three therapy sessions. I have accepted dinner invitations from some clients, have attended social functions with others, played tennis with several clients, and ended up becoming good friends with a few. Of course, I do not engage in such behaviors capriciously. Roles and expectations must be clear. Possible power differentials must be kept in mind. For my own protection as well as the client’s protection, I don’t engage in these behaviors with seriously disturbed people, especially those who are hostile, paranoid, aggressive, or manipulative. But the antiseptic obsession with “risk management” has led far too many therapists to practice their craft in a manner that is needlessly constraining and often countertherapeutic.

Those therapists who rigidly adhere to strict professional boundaries are apt to place risk management ahead of humane interventions. The manner in which they speak to their clients often leaves much to be desired. For example, I recently attended a clinical meeting at which a young psychiatrist was interviewing a woman who suffered from an eating disorder, bulimia nervosa. At one point the dialogue continued more or less as follows:

1. Patient: May I ask how old you are?

2. Therapist: Why is that important?

3. Patient: It’s no big deal. I was just curious.

4. Therapist: Why would you be curious about my age?

5. Patient: Well, you look around 30, and I was just wondering if I am correct.

6. Therapist: What impact would it have if you were not correct?

7. Patient: None that I can think of. It was just idle curiosity.

8. Therapist: Just idle curiosity?

As I watched these exchanges, I grew uncomfortable. It seemed to me that the patient wished she had never raised the issue in the first place and that she was feeling more and more uneasy. It did not seem that the dialogue was fostering warmth, trust, or rapport. On the contrary, it resembled a cross-examination in a courtroom and appeared adversarial.

In psychoanalysis it is deemed important for the analyst to remain neutral and nondisclosing so the patient can project his or her needs, wishes, and fantasies onto a “blank screen.” But it makes no sense for this to become a rule for all therapists to follow. It has always struck me as ill mannered and discourteous to treat people this way.

I recommend the following type of exchange in place of the aforementioned example:

1. Patient: How old are you?

2. Therapist: I just turned 30. Why do you ask?

3. Patient: I was just curious. It’s no big deal.

4. Therapist: Might you be more comfortable with or have greater confidence in someone younger or older?

5. Patient: No, not at all.

At this juncture, I would suggest that the topic be dropped. Notice the recommended format. First answer the question and then proceed with an inquiry if necessary. In this way, the patient is validated and not demeaned. Why am I dwelling on such a seemingly trivial issue? Because it is not a minor or frivolous point, and I have observed this type of interaction far too often, usually to the detriment of the therapeutic process. I see it as part and parcel of a dehumanizing penchant among the many rigid thinkers in our field who legislate against all boundary extensions. These are the members of our profession (and they are not a minority) who regard themselves as superior to patients and tend to infantilize and demean them in the process.

The purpose of this essay is to alert readers to an issue that is crucial in the field of psychotherapy. I have coedited a book (Lazarus & Zur, 2002) on the subject of boundaries and boundary crossings in which various contributors have addressed the topic from many viewpoints: nonanalytic practice procedures, feminist perspectives, military psychology, counseling centers, deaf communities, legal issues, gay communities, and rural settings (among others). It is generally agreed that the client–therapist relationship is at the core of treatment effectiveness. Yet by adhering to strict boundary regulations, many troublesome feelings are likely to arise and ruptures to emerge that destroy the necessary sense of trust and empathy. Greenspan (2002) aptly describes strict boundary adherence as a “distance model” that undermines the true healing potential of the work we do. I fully concur with her opinion that we need an approach of respectful compassion. Safe connection between therapist and client should be the overriding aim because this, not strict boundaries, will protect clients from abuse.

In this introductory chapter, we have examined what the codes of ethics of the major professional associations advise with respect to dual or multiple relationships. We have explored a number of factors that make such relationships problematic, as well as factors that create a potential for harm and the risks to parties directly or not directly involved in multiple relationships. Some strategies for reducing risks were described.

It is critical that counselors give careful thought to the potential complications before they become entangled in ethically questionable relationships. The importance of consultation in working through these issues cannot be overemphasized. As with any complex ethical issue, complete agreement may never be reached, nor is it necessarily desirable. However, as conscientious professionals, we need to strive to clarify our own stance and develop our own guidelines for practice within the limits of codes of ethics and current knowledge.

Sexual dual relationships with clients are among the most serious of all boundary violations because they involve an abuse of power and a betrayal of trust that can have devastating effects on clients. Later in this chapter we describe in some detail the harm to clients that such violations can cause. The consequences for counselors who engage in sexual misconduct with their clients also can be severe: They may have their license or certification revoked, be expelled from professional associations, be restricted in or lose their insurance coverage, be fired from their job, be sued in civil court for malpractice, or be convicted of a felony.

Sexual improprieties also undoubtedly have a negative impact on the profession. Publicity about such occurrences is likely to make potential consumers more reluctant to seek counseling services and certainly does not help mental health professionals to persuade legislators, government regulators, and health insurance companies of the value of our services (Welfel, 2013). Because sexual relationships with clients are such serious violations, they deserve careful attention. In this chapter we focus specifically on sexual dual relationships and address these questions:

• How do professional codes of ethics address sexual relationships with clients?

• What are the ethics of sexual relationships with former clients?

• How widespread is the practice of engaging in sex with current and former clients?

• Is there a “typical” offending therapist?

• What are the legal sanctions against these behaviors?

• What makes sexual dual relationships particularly harmful to clients?

• How can counselors deal appropriately with sexual attraction to clients?

• What are some appropriate and clinically useful ways to deal with a client’s attraction to the counselor?

• What steps can our profession take to increase awareness of problems involved in sexual misconduct and prevent this occurrence?

• What are some legal perspectives pertaining to sexual dual relationships?

To frame the discussion of topics to be explored in this chapter, we begin with Mary Hermann’s perspective on the legal issues surrounding dual relationships. She makes it clear that if clients can prove they were emotionally harmed because of a dual relationship, they could prevail in a malpractice lawsuit against the counselor.

Mary A. Hermann

Counselors’ legal liability related to dual relationships emanates from legal responsibilities associated with the counselor–client relationship. Courts have characterized the counselor–client relationship as fiduciary in nature (Douglass, 1994), a relationship in which one party places trust and confidence in another party who has power or influence (Garner & Black, 2004). As Wheeler and Bertram (2012) note, the “complexity, the power differential, and in some cases the vulnerability of counseling clients demand that we exercise extraordinary care to ensure that we are taking steps to define and respect the boundary between ourselves and our clients” (p. 135).

From a legal perspective, it is significant that dual relationships exist on a continuum ranging from boundary crossings for the benefit of the client to sexual dual relationships that can cause major trauma to the client. The legal implications of engaging in dual relationships vary, depending on the nature of the relationship and whether the client suffers harm. Thus the mere existence of a dual relationship does not, in itself, constitute malpractice. If a dual relationship is nonsexual and is managed effectively, it may have no negative impact on the counseling relationship, and no cause of action against the counselor would exist. However, if the client suffered harm because of a dual relationship such as that caused by sexual intimacy, the counselor could be sanctioned for violating legal and ethical standards.

Virtually all the professional codes of ethics prohibit sexual intimacies with current clients. Many of the codes also specify that if therapists have had a prior sexual relationship with a person, they must not accept this person as a client. Relevant ethical standards for counselors, psychologists, social workers, and marriage and family therapists include the following:

• Sexual and/or romantic counselor–client interactions or relationships with current clients, their romantic partners, or their family members are prohibited. This prohibition applies to both in-person and electronic interactions or relationships. (American Counseling Association [ACA], 2014, Standard A.5.a.)

• The requirement that the physician conduct himself/herself with propriety in his or her profession and in all the actions of his or her life is especially important in the case of the psychiatrist because the patient tends to model his or her behavior after that of his or her psychiatrist by identification. Further, the necessary intensity of the treatment relationship may tend to activate sexual and other needs and fantasies on the part of both patient and psychiatrist, while weakening the objectivity necessary for control. Additionally, the inherent inequality in the doctor-patient relationship may lead to exploitation of the patient. Sexual activity with a current or former patient is unethical. (American Psychiatric Association, 2013b, 2.1)

• Psychologists do not engage in sexual intimacies with current therapy clients/patients. (American Psychological Association [APA], 2010, 10.05.)

• Psychologists do not accept as therapy clients/patients persons with whom they have engaged in sexual intimacies. (APA, 2010, 10.07(a).)

• Social workers should under no circumstances engage in sexual activities or sexual contact with current clients, whether such contact is consensual or forced. (National Association of Social Workers [NASW], 2008, 1.09.a.)

• Social workers should not provide clinical services to individuals with whom they have had a prior sexual relationship. Providing clinical services to a former sexual partner 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, 2008, 1.09.d.)

• Sexual intimacy with current clients, or their spouses or partners is prohibited. Engaging in sexual intimacy with individuals who are known to be close relatives, guardians or significant others of current clients is prohibited. (American Association of Marriage and Family Therapists [AAMFT], 2012, 1.4.).

There is clear consensus among the professional associations that concurrent sexual and professional relationships are unethical, and many of the associations agree that a sexual relationship cannot later be converted into a therapeutic relationship. Is there similar consensus regarding the issue of converting a therapeutic relationship into a sexual one once the professional relationship has been terminated? This issue is examined next.

At one time, the codes of ethics of the professional associations were silent on the issue of whether sexual relationships with former clients are ever acceptable. That situation has changed. Today the various associations specifically address this topic:

Sexual and/or romantic counselor–client interactions or relationships with former clients, their romantic partners, or their family members are prohibited for a period of 5 years following the last professional contact. This prohibition applies to both in-person and electronic interactions or relationships. Counselors, before engaging in sexual and/or romantic interactions or relationships with former clients, their romantic partners, or their family members, demonstrate forethought and document (in written form) whether the interaction or relationship can be viewed as exploitive in any way and/or whether there is still potential to harm the former client; in cases of potential exploitation and/or harm, the counselor avoids entering into such an interaction or relationship. (ACA, 2014, Standard A.5.c.)

Counsellors avoid any type of sexual intimacies with clients and they do not counsel persons with whom they have had a sexual relationship. Counsellors do not engage in sexual intimacies with former clients within a minimum of three years after terminating the counselling relationship. This prohibition is not limited to the three year period but extends indefinitely if the client is clearly vulnerable, by reason of emotional or cognitive disorder, to exploitative influence by the counselor. Counsellors, in all such circumstances, clearly bear the burden to ensure that no such exploitative influence has occurred, and to seek consultative assistance. (Canadian Counselling and Psychotherapy Association [CCA], 2007, B12.)

(a) Psychologists do not engage in sexual intimacies with former clients/patients for at least two years after cessation or termination of therapy.

(b) Psychologists do not engage in sexual intimacies with former clients/patients even after a two-year interval except in the most unusual circumstances. Psychologists who engage in such activity after the two years following cessation or termination of therapy and of having no sexual contact with the former client/patient bear the burden of demonstrating that there has been no exploitation, in light of all relevant factors, including (1) the amount of time that has passed since therapy terminated; (2) the nature, duration, and intensity of the therapy; (3) the circumstances of termination; (4) the client’s/patient’s personal history; (5) the client’s/patient’s current mental status; (6) the likelihood of adverse impact on the client/patient; and (7) 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 client/patient. (APA, 2010, 10.08.)

Sexual or romantic rehabilitation counselor–client interactions or relationships with former clients, their romantic partners, or their immediate family members are prohibited for a period of five years following the last professional contact. Even after five years, rehabilitation counselors give careful consideration to the potential for sexual or romantic relationships to cause harm to former clients. In cases of potential exploitation and/or harm, rehabilitation counselors avoid entering such interactions or relationships. (Commission on Rehabilitation Counselor Certification [CRCC], 2010, A.5.b.)

Social workers should not engage in sexual activities or sexual contact with former clients because of the potential for harm to the client. If social workers engage in conduct contrary to this prohibition or claim that an exception to this prohibition is warranted because of extraordinary circumstances, it is social workers—not their clients—who assume the full burden of demonstrating that the former client has not been exploited, coerced, or manipulated, intentionally or unintentionally. (NASW, 2008, 1.09.c.)

Sexual intimacy with former clients, their spouses or partners, or individuals who are known to be close relatives, guardians or significant other of clients is likely to be harmful and is therefore prohibited for two years following the termination of therapy or last professional contact. After the two years following the last professional contact or termination, in an effort to avoid exploiting the trust and dependency of clients, marriage and family therapists should not engage in sexual intimacy with former clients, or their spouses or partners. If therapists engage in sexual intimacy with former clients, or their spouses or partners, more than two years after termination or last professional contact, the burden shifts to the therapist to demonstrate that there has been no exploitation or injury to the former client, or their spouse or partner. (AAMFT, 2012, 1.5.)

APA (2010) and AAMFT (2012) agree that sexual contact before 2 years after termination is unethical. CCA (2007) specifies a ban on sexual intimacies for a minimum of 3 years after termination of therapy. ACA (2014) and CRCC (2010) have a minimum waiting period of 5 years following termination. NASW (2008) prohibits its members from engaging in sexual relationships with former clients regardless of time elapsed. Most of the professional organizations state that in the exceptional circumstance of sexual relationships with former clients—even after a 2- to 5-year interval—the burden of demonstrating that there has been no exploitation clearly rests with the therapist. The factors that need to be considered include the amount of time that has passed since termination of therapy, the nature and duration of therapy, the circumstances surrounding termination of the professional–client relationship, the client’s personal history, the client’s competence and mental status, the foreseeable likelihood of harm to the client or others, and any statements or actions by the therapist suggesting a plan to initiate a sexual relationship with the client after termination.

Gary Schoener, interviewed for an article in Counseling Today (Foster, 1996), discussed some useful questions that practitioners can ask themselves when they are considering a posttermination romantic relationship:

• What was the length and level of therapeutic involvement?

• How much transference, dependency, or power inequity remains after termination?

• Was there any deception or coercion, intentional or unintentional, by the therapist indicating that sex is generally acceptable after termination of therapy?

• Was there an actual termination? Was the decision to terminate a mutual one? Did the therapist end the professional relationship to make it possible to enter into a romantic or sexual relationship?

• Who initiated posttermination contact?

• What kind of consultation, if any, took place?

Despite the consistency shown by the professional organizations, there remains disagreement among practitioners about whether a sexual relationship initiated after termination is ever ethical (Moleski & Kiselica, 2005). Some practitioners maintain that “once a client, always a client.” They contend that the transference elements of the therapeutic relationship persist forever; therefore, romantic relationships with former clients are always unethical. They also point out that a 2- or 5-year time limit is artificial and arbitrary and that it is nonsensical to assume that what was unethical for several years becomes ethical after a specific time period has elapsed. Furthermore, counselors often learn intimate details from clients during the counseling process, and that knowledge creates a power differential that has the potential to be abused in a future relationship (Moleski & Kiselica, 2005).

Whereas some take the position that sexual relationships with former clients are always unethical, others argue that a blanket prohibition of all sexual intimacies with former clients is too extreme. They contend that there is a real difference between an intense, long-term therapy relationship and a less intimate brief-term counseling relationship. What should be the appropriate response, for instance, by Ellen to Craig’s invitation in the following scenario?

Ellen served her counseling internship at her university’s counseling center. One of her clients was Craig, a graduate student who was a businessman returning to college for his master’s in business administration. Craig sought counseling because he was having second thoughts about committing himself to a lifelong career in the cutthroat competitive field he was in. During five counseling sessions with Ellen, he completed a series of inventories, weighed his values, and decided to switch majors. A little more than 2 years later, Craig and Ellen ran into each other at a social event. Craig asked her out on a date.

Assume that Ellen approaches you for consultation. She tells you that she does not want to be unethical, yet she also wants to accept Craig’s offer for a date. Because Ellen had only five sessions with him, because the focus was on career counseling, and because the counseling took place more than 2 years ago, Ellen does not think that accepting a date with Craig is unethical. However, she wants to get your opinion and wants to know if she is overlooking some important issues. What might you say to Ellen?

If Ellen consults with me, I will first ask her to state what she sees as the pros and cons of each decision. I will explore with her the reasons she is seeking consultation. Although she does not think accepting the date is unethical, she seems uncertain. Can she see potential problems in accepting? I will ask her if there is a pattern here. Has she dated other former clients? I will not flatly tell Ellen that accepting the date is either appropriate or inappropriate, although I will explore with her any possible consequences. I will ask her to consider carefully the factors listed by her professional association. My goals for the consultation are to have Ellen understand her reasons for choosing whatever course of action she may follow and be aware of and take responsibility for the possible consequences of her decision.

The counseling profession is clearer than it once was about sexual relationships with former clients. Still, whether sexual relationships with former clients are ever acceptable, even after more than 2 or 5 years, probably will be a subject of continuing discussion. On one hand, we need to remain aware of the harm that can result from sexual intimacies that occur after termination; of the aspects of the therapeutic process that continue after termination, including residual transference; and of the continuing power differential. On the other hand, it seems reasonable to consider the wide range of circumstances that could arise, especially the differences between long-term, intense, personal counseling relationships and brief, career-oriented, or other types of counseling.

Under the present codes, if a counselor does consider entering into a romantic relationship with a former client after 5 years have passed, some safeguards should be followed. These include consulting with a colleague, documenting carefully, and going for a therapy session conjointly with the former client to examine mutual transferences and expectations. As a general rule, Welfel (2013) states that counselors who consider entering into a sexual relationship with a former client, even many years after termination of the professional relationship, should be extraordinarily cautious about taking such a step. Careful consideration of the code and consultation with colleagues are critical. It is important to remain cognizant that because of the potential for exploitation in such a relationship, courts have found that posttermination relationships can violate the standard of care owed to clients (Shavit, 2005). Thus counselors are wise to refrain from posttermination sexual relationships except under the most unusual or exceptional circumstances.

It is difficult to determine the actual incidence of sexual intimacies between therapists and clients—or between counselor educators and students or supervisors and supervisees. Phelan (2007) reviewed ethics complaints from counseling, psychology, and social work organizations from 1996 through 2006 and found that dual relationships, particularly sexual dual relationships and sexual harassment, were the most common reasons for expulsion from professional organizations. Pope and Vasquez (2011) presented data indicating that sexual misconduct and unprofessional conduct are among the top five causes of disciplinary actions against psychologists.

Sexual dual relationships account for the largest share of formal complaints against psychologists, whether these complaints are filed with licensing boards, ethics committees, or civil courts. Kitson and Sperlinger (2007) compared attitudes of psychologists in the United Kingdom with attitudes of psychologists in the United States and found similarities. These researchers noted that the psychologists in both countries who were least likely to view dual relationships as appropriate were females, psychologists with the fewest years of experience, psychologists who experienced therapy as a client, and psychologists whose main theoretical orientation was psychodynamic. Kitson and Sperlinger found the most significant variable to be years of experience, potentially indicating that training has improved on this topic. In terms of the other variables, psychologists with a psychodynamic orientation may have an enhanced understanding of transference and countertransference and may be more likely to manage these issues effectively. Also, psychologists who have experienced personal therapy as a client may have more awareness of their vulnerabilities.

Hoffman (1995) reiterated that “the topic of sexual dual relationships encompasses complex, difficult, and controversial issues” (p. 21). Abbott (2003) found that constraints such as managed care and limited resources have shifted the therapeutic paradigm from psychoanalytic approaches and theorized that as mental health professionals have moved to more egalitarian relationships with clients, the nature of the relationship between therapists and clients has become more susceptible to intense emotional bonds. Furthermore, less emphasis placed in training on the psychoanalytic concepts of transference and countertransference has resulted in less understanding of these concepts. This lack of understanding could be contributing to inadvertent boundary violations. Strom-Gottfried (1999) concluded that violating professional boundaries may result from basic human vulnerability, erotic transference, and in some cases, misuse of power.

Previous research has suggested that male therapists are far more likely to engage in sexual relationships with clients than are female therapists. Considering research on the characteristics of therapists who engage in sexual dual relationships, one profile that emerges is that of a middle-aged male therapist who is burned out, professionally isolated, and currently experiencing some personal distress or midlife crisis (S. Simon, 1987; Smith & Fitzpatrick, 1995). This therapist often begins by sharing his own personal life and problems with a younger female client. This profile shares many of the characteristics of the impaired professional who has personal problems and attempts to meet his own needs through his clients.

Of course, not all therapists who engage in sexual dual relationships fit this profile, and other writers (e.g., Golden, in Schafer, 1990; Schoener & Gonsiorek, 1988) have suggested that there may be a wide range of types of professionals who become involved in sexual relationships with clients.

Historically, the legal system and the professional community were slow to respond to clients’ claims of sexual exploitation. When clients first began alleging that therapists were sexually exploiting them, many mental health professionals discounted the claims. In the 1960s and 1970s, some mental health professionals even defended sexual relationships with clients by alleging that they had therapeutic value (Welfel, 2013). In the landmark case of Roy v. Hartogs (1975), a court finally acknowledged that a psychiatrist caused harm by engaging in sexual intercourse with a client and that such action was not in accordance with acceptable professional procedures. The courage of victims in pursuing their legal claims and the persistence of scholars who demonstrated that sex with clients is harmful deserve credit for the resulting ban on sexual relationships with clients (Welfel, 2013).

Currently, the inappropriateness of engaging in sexual relationships with clients is universally recognized. Such behavior is considered unethical and illegal (G. Corey, Corey, Corey, & Callanan, 2015; Remley & Herlihy, 2014). Despite this consensus, one of the most common allegations in malpractice lawsuits against mental health professionals remains sexual misconduct (Pope & Vasquez, 2011).

In a malpractice case, the client has the burden of establishing by a preponderance of the evidence that the counselor had a duty to the client, the counselor breached the duty, and the client suffered harm. The client would have little difficulty establishing the duty element of malpractice because the very nature of a counseling relationship establishes a counselor’s fiduciary duty to clients.

The client also would have to show that the counselor breached his or her duty to the client by not adhering to the standard of care in the community. Meeting the standard of care can be described as acting like other similarly trained counselors would act under the circumstances. The standard of care would be established by expert testimony and reference to codes of ethics. A court would apply this standard of care to the case at bar to determine whether a counselor breached his or her professional duty to the client. In the case of sexual contact with clients, courts have little trouble finding that a counselor breached his or her duty to the client.

Finally, the client has to establish that the client suffered harm because the counselor breached the duty to the client. Emotional harm is a compensable injury in a malpractice case against a mental health professional. The emotional harm suffered by clients who had sexual relationships with their therapists is documented in the literature, which would support a client’s claim that his or her mental health was negatively affected by a sexual dual relationship.

However, clients who bring suit are placed in a difficult position. They may be able to demonstrate that they personally have been harmed only by providing their own subsequent treating therapists with a release to testify regarding that harm, thus robbing them of the privacy of sensitive, confidential material they have revealed.

Courts now recognize that clients are vulnerable in a counseling relationship. Courts have also acknowledged that clients are likely to suffer serious emotional distress when they have engaged in a sexual relationship with their therapist (G. Corey et al., 2015). Austin, Moline, and Williams (1990) reviewed relevant court cases and concluded that few, if any, arguments in defense of therapists who have sex with clients are likely to succeed in court. In particular, courts have rejected claims that the client consented, determining that consent was not voluntary or informed because it was affected by transference. Most clients alleging sexual misconduct against their therapists have based their lawsuits on counselors’ mishandling transference and countertransference reactions (Wheeler & Bertram, 2012). Courts have consistently held that counselors who mishandle transference and are involved in sexual relationships with their clients are negligent.

State legislatures are also addressing sexual dual relationships. Remley and Herlihy (2014) noted that some state legislatures have passed laws making sexual relationships with clients a case in negligence automatically. Thus the client would only have to prove he or she was physically, emotionally, and/or financially injured because of the therapist’s behavior. Remley and Herlihy also reported on a Wisconsin statute that forbids mental health professionals from entering into out-of-court settlements if the terms of the settlement include not reporting the incident to the public.

Malpractice suits are tried in civil court. Increasingly, charges of sexual misconduct against mental health professionals can also be brought in criminal court. Criminal sanctions for sexual intimacy between a counselor and client vary by state. Kane (1995) found that sexual intimacies between counselors and clients are a violation of criminal law in California, Colorado, Connecticut, Florida, Georgia, Iowa, Maine, Michigan, Minnesota, New Mexico, North Dakota, South Dakota, and Wisconsin. Remley and Herlihy (2014) noted that some states take even tougher positions, such as allowing prosecutors to file injunctions against counselors, forcing them to discontinue their practice even before they are found guilty of engaging in sexual relations with clients, if it can be proven that the practitioner presents a risk to clients by continuing to practice.

In addition to having criminal charges or malpractice lawsuits filed against them, counselors engaged in sexual dual relationships with clients can be expelled from professional organizations and lose their insurance coverage. Furthermore, clients can file complaints against counselors with their state licensure boards. Licensure boards are responsible for enforcing codes of ethics. These boards can impose sanctions or even have a counselor’s license to practice suspended or revoked if the counselor engages in inappropriate dual relationships. Many state licensure boards have revoked the licenses of mental health professionals who have had sex with clients (G. Corey et al., 2015).

As Bates and Brodsky (1989) have noted, problems in love relationships are frequently the impetus for clients to enter therapy. They contended that it is unforgivable for therapists to contaminate and deobjectify their role in helping to resolve these clients’ problems. Therapy is not “a mating game, or a place for lovers to meet” (p. 133).

Kenneth S. Pope has produced an impressive body of research into sexual dual relationships. He provides a clear and comprehensive picture of the harm that may be done to clients by sexual relationships with their therapists. Clients may have reactions similar to those of victims of rape, battering, incest, child abuse, or posttraumatic stress. According to Pope (1988, 1994), 10 general aspects commonly associated with the syndrome are ambivalence, guilt, emptiness and isolation, identity/boundary/role confusion, sexual confusion, impaired ability to trust, emotional lability, suppressed rage, cognitive dysfunction, and increased suicide risk. It is worth examining each of these indicators in more depth.

• Ambivalence. Clients who are sexually involved with their therapist may experience a sense of deep ambivalence, fearing separation or alienation from the therapist yet longing desperately to escape from the therapist’s power and influence. Loyalty to the therapist may prevent clients from acting to protect themselves (resisting sexual advances or reporting the abuse) for fear that their action could destroy the therapist’s personal or professional life. This ambivalence and misplaced loyalty help to explain why the behavior can go unreported completely or for a number of years.

• Guilt. Clients may feel guilty, as though they are somehow to blame for what has happened. Their reactions may be similar to those of incest victims. They may have a sense of guilt that they did not do more to stop the sexual activity or that they enjoyed the relationship or that they did something to invite such a relationship with a person they deeply trusted.

• Emptiness and isolation. Sexual activity between a therapist and client can seriously erode the client’s sense of self-worth. Clients may feel emotionally isolated, alone, and cut off from the world of “normal” human experience.

• Identity/boundary/role confusion. A phenomenon often involved in a patient–therapist sexual relationship is a reversal of roles. As the therapist becomes more self-disclosing, and as meeting the therapist’s needs becomes more important in the relationship, the client becomes responsible for taking care of the therapist. Clients become confused, not knowing where safe and appropriate boundaries lie, and this adds to the erosion of their sense of identity and worth.

• Sexual confusion. Many clients seem to manifest a profound confusion about their sexuality. Lingering outcomes can take two forms: Some clients will be threatened by any sexual activity, and others may be trapped into compulsive or self-destructive sexual encounters.

• Impaired ability to trust. Because therapy involves such a high degree of trust, violations can have lifelong consequences. When therapists abuse this trust, they are taking advantage of their clients in the most fundamental way. This is perhaps the core issue in sexual violations, and the consequences can extend far beyond the therapeutic relationship in question. Client victims are likely to mistrust other helping professionals, particularly therapists, and the damage may reverberate outward to other, less intense relationships.

• Emotional lability. This can be a long-term consequence. Clients who have been sexually involved with a therapist often feel overwhelmed by their emotions, both during the relationship and afterward. Even with subsequent therapy, victims may re-experience traumatic emotions when they become involved with a new and appropriate sexual partner. Counselors who work with these victims need to keep these setbacks in perspective so that clients will not lose hope.

• Suppressed rage. Victims may feel a justifiable, tremendous anger at the offending therapist. But this rage may be blocked from awareness or expression by feelings of ambivalence and guilt and by manipulative behaviors of the therapist. Offending therapists may use threats and intimidation to prevent clients from reporting the behavior and can be adept at eliciting compliance, hero worship, and dependency. As is true of feelings of guilt, this anger needs to be identified, expressed, and worked through in later therapy with another therapist. If the anger is bottled up, it is likely to affect clients’ relationships with significant others in their lives and with any other therapists from whom they might later seek treatment.

• Cognitive dysfunction. The trauma caused by sexual involvement with a therapist can be so severe that clients may experience cognitive dysfunction. Attention and concentration may be disrupted by flashbacks, nightmares, and intrusive thoughts.

• Increased suicide risk. Finally, suicide risk is increased for clients who feel hopelessly trapped in ambivalence, isolation, and confusion. These feelings, coupled with an impaired ability to trust, may prevent victims from reaching out for help.

It should be clearly understood that even if clients behave in seductive ways, it is always the therapist’s responsibility to maintain a professional distance in the relationship. Therapists can help clients to understand such behavior on their part as a manifestation of transference. The therapist, not the client, has the responsibility to evaluate the therapeutic situation and to monitor the boundaries of the relationship. Therapists who have trouble keeping clear boundaries in the professional relationship are often guilty of poor judgment in other areas of their practice. Clearly, the effects on clients can be profound and violate one of our most fundamental moral principles: to do no harm.

The following contributor’s perspective by Beth Christensen illustrates in a powerful way the harm that can come from a therapist’s exploitation and misuse of power. The case reinforces that it is always the therapist’s responsibility to maintain safe and therapeutic boundaries.

Beth Christensen

In every class or presentation regarding boundary issues in counseling, when the subject turns to sexual relationships with clients, the admonition is as clear and succinct as one can imagine: “Don’t!” Sexual boundary violations with current clients, or with partners or family members of clients, are absolutely and incontrovertibly forbidden. Counselors who violate this boundary with clients risk their careers, their licenses to practice, and their reputations. In some states, they may even risk criminal prosecution. Despite these serious risks to the counselor, sexual boundary violations continue to occur.

Sexual relationships with counselors and former counselors can cause serious harm to clients or former clients, harm that is manifested in virtually every area of their lives. There is some research on the effects of therapist–client sex in the professional literature, but there is not enough; the research that exists seldom goes deep into the subjective experience of the client/victim (Ben-Ari & Somer, 2004). Common consequences of therapist–client sex include low self-esteem; feelings of guilt, shame, and inadequacy; reluctance to speak to anyone about these experiences; and fear of entering into other therapeutic relationships. The harm imposed on victims of sexual boundary violations often resembles that suffered by incest survivors, whether or not the client/victim has suffered incest in the past. More qualitative, subject-centered research into the dynamics of the harm caused by therapist sexual abuse, and the mechanisms by which healing from such abuse takes place, is needed.

I am a licensed professional counselor and a survivor of a sexual boundary violation by a therapist, in my case a psychiatrist. I welcome opportunities to speak from the perspectives of both a survivor and a professional, and for me, doing so is an act of rejecting the inappropriate shame that is such a common struggle for victims of sexual abuse. I fully embrace the feminist/humanist values that consider the voice of the client to be a valid source of knowledge, and I have focused my studies and dissertation research on the dynamics and the effects of sexual abuse. I think it is important to add a flesh-and-blood dimension to what can otherwise be a somewhat distanced, abstract subject. It can be very hard to hear the reality of what someone who usurps and violates the role of therapist can do to a vulnerable client.

My own experience may be more extreme than many; however, it is by no means particularly rare. I was 14 years old when I first saw a psychiatrist. I had suffered sexual abuse earlier in my childhood, and I was acting out my confusion and anger in very destructive and dangerous ways. I was desperate for someone to listen to me, really hearme, and to understand my anger and feelings of alienation. At first I was nervous about going to see a psychiatrist, but my doctor seemed to be the answer to my prayers. He acted very “cool” with me; I could tell him anything, and he would not respond in a judgmental or scolding way. In my angry adolescent mindset of “me against the world,” I thought I had finally found an adult who was on my side. I had also found a loving father figure who listened to my every word and who seemed to think everything I said was important. When he looked at me, I thought that finally there was someone who truly saw me. What he saw, however, was a perfect victim.

The sexual advances began slowly and in subtle ways, so that I often wasn’t sure if the hugs he gave me at the end of each session were for me or for him. As the hugs evolved into kisses and touching, he told me over and over that I was special, that I was mature for my age, that I was beautiful and brilliant, and that he loved me. Like any (by this time) 15-year-old, I longed to hear those words. When the sexual activity finally reached the level of intercourse, I didn’t have any capacity to say no; I never thought of that as an option. I had lost any sense of who I was except for what he told me. He said that I was sexy and irresistible, that he had to “have” me. He said I was no longer a child but a woman. He said that what we were doing was wrong, but he couldn’t resist me (which was his way of telling me that this was really my fault—a common tactic among child sexual abusers).

The things he told me, and the weekly sexual contact, only intensified the confusion, anger, and depression that had brought me to him in the first place. I began living dual lives: the high school kid who was usually in trouble and, for one hour a week, the woman-child who was loved and desired. But this love was so confusing to me; I remember the sick feeling in my stomach when he would lock the double doors of his office (mine was always the last appointment of the day, after the secretary was gone), knowing that I would be his for the next hour. I remember taking the bus home in a daze after his appointments, as if I was moving through a fog. It didn’t feel right, and a lot of times I wanted it to stop, but I didn’t know how to make it stop. I also didn’t know what I would do if he stopped “loving” me. He had placed himself in the center of my life, and I began to lose any sense of who I was beyond what he told me I was.

As my depression, anxiety, and destructive behavior worsened, he began to prescribe drugs for me. I also learned, as I had done as a child, to mentally escape the sexual episodes by dissociating myself from what was happening. I remember staring up into the lightbulb in the lamp until the light in my eyes made everything else disappear, until it was over. I stopped spending time with friends; I stopped doing homework or going to the movies; I stopped doing everything that connected me with the world of being a teenager.

As I became more detached from myself, increasingly numb and automaton-like when I was with him, I also became more enraged and self-destructive in other aspects in my life. Shortly after I turned 17, after at least 2 years of weekly rapes (as I have since learned to properly name them), this same doctor diagnosed me as having schizophrenia, and I began what would be 2 years of hospitalizations, at least 30 electroconvulsive therapy (ECT) treatments, and ever-increasing doses of mind-numbing psychotropic medications (this was in the 1970s, the days of Thorazine). I lost any conscious memory of the rapes; maybe that was because of the ECT or the medications, but more likely it was because I simply did not have the ego strength, maturity, and coping skills to acknowledge the horror of what he had done to me.

My diagnosis of schizophrenia was, by accident or design, a perfect cover for the psychiatrist; posttraumatic stress disorder and dissociative responses to trauma had not yet made their way into mainstream psychiatry (even now people with these types of trauma-based disorders are frequently misdiagnosed). The flashbacks and body memories, horrific episodes of re-experiencing what he and others had done to me, were interpreted as manifestations of my alleged psychosis. Furthermore, had I remembered the sexual abuse and tried to tell someone about it, he had made sure, by certifying me as insane, that I wouldn’t be believed. He, at that point, fully owned me.

I did eventually go to another doctor, in another state, far away from my psychiatrist and other, earlier perpetrators, and I got better. The memory of the sexual abuse was stashed deep in some inaccessible place in my mind, and I began to assemble a life. In fact, it was a very successful life (at least on the surface), but I never, ever felt good enough, and I was always followed by a cloud of fear that this horrible disease of schizophrenia would come back and rip my life to shreds. It was not until about 25 years after the abuse ended that I began to remember what he had done and how it had affected me. I realized that I had never had schizophrenia; all of the “craziness” I had exhibited was in response to sexual abuse, and the most devastating abuse had come from the one who had been paid to help me. I realized that all of the developmental milestones that should have been part of my young adulthood—graduating from high school, going to college, even experiencing my first love—had been stolen from me, and I would never get them back. The memories of the rapes, which I experienced in sickening visceral sensations and very real and immediate terror, overwhelmed me, and it has taken years of painful and difficult therapy to work through the rage, humiliation, shame, and grief over what he did to me and what he stole from me. Although I have come a very, very long way, the work continues, and I expect that there are some wounds that will never fully heal.

My case is probably not “typical,” if there can be such a thing. But in my years of treatment, I have met and heard the stories of many women who were sexually abused by their therapists. Most of them were adults when the abuse happened. Most of them had suffered some amount of prior physical, emotional, or sexual abuse. Virtually all of the women expressed a feeling of “specialness” that had been communicated to them by the offending therapists, and they had a deep need in their lives to be seen as loveable and worthy of attention and affection. For some of them, the abuse recreated their earlier childhood sexual abuse, triggering a regressive response and a recreation of their feelings of helplessness, terror, and aloneness. All of them (including myself, despite my age at the time) believed, or had believed at the time, that they had consented. They believed they had had “affairs” with their therapists, and thus they shared equally in the blame. Ridding oneself of that shame and self-blaming is incredibly difficult. It can haunt survivors of therapist sexual abuse for a lifetime.

The imbalance of power between a therapist and a client makes true consent virtually impossible. When the client is a child, this inability to consent is obvious and, to most people, easy to recognize. When the client is a rebellious, angry adolescent, that inability might be called into question, as adolescent seductiveness and sexual promiscuity are sometimes a part of the acting-out behavior that brings them to treatment. When the client is an adult, many people would consider that she or he is fully capable of consent, so unless physical force is used, they would hesitate to call it rape.

In my experience, and my exposure to clients and peers who have been harmed by therapist sexual boundary violations, I have learned one central truth that I believe applies to all sexual encounters between a counselor or therapist and a client: It is always the responsibility of the counselor/therapist to set and maintain appropriate boundaries. It is never the client’s fault when inappropriate sexual contact takes place. It is not uncommon for the perpetrator to claim that the client was seductive and overwhelmed the perpetrator’s self-control. Mental health care providers who have that little self-control are probably in the wrong profession. At the very least, it is imperative that all mental health professionals learn to recognize risk factors for sexual boundary violations; maintain a keen awareness of their own feelings, needs, and potential weaknesses; and take appropriate action to protect themselves and, especially, their clients.

The existing codes are explicit with respect to sexual relationships with clients. However, they do not, and maybe they cannot, define some of the more subtle ways sexuality may be part of professional relationships. For example, sexual attractions between counselors and clients do occur, and it is not the attraction per se that is problematic. It is acting on the attraction that is inappropriate and becomes an ethical problem. It is not uncommon for clients to develop a sexual attraction to their counselor, and it may be inevitable that most counselors will at some time feel a sexual attraction to a client. Barbara, a counselor in private practice, related this anecdote:

The client was my prototype of the physically attractive man. He was tall, lean but muscular, and very good looking. As counseling progressed, it became apparent that he was sensitive to others, had a solid sense of personal integrity, and had a great sense of humor—all qualities that I admire. I realized that I found him attractive but wasn’t particularly concerned about it. After all, I had it in awareness and certainly didn’t intend to act on my feelings. Then, during one session he began to relate a lengthy story, and my attention wandered. I drifted off into a sexual fantasy about him, I don’t know for how long, probably only a few seconds. I snapped back to reality, and as I refocused on his words I realized he was now talking about sex. I nearly panicked: Had I somehow telegraphed my thoughts? I felt my face begin to redden, and compounded my discomfort by wondering if he saw me blushing and thought I was embarrassed about the subject of sex. With real effort I directed my concern away from myself and back to him and got through the rest of the session. I was so shaken by the incident that I immediately sought consultation.

Assume you are the person to whom Barbara turns for consultation. She wonders whether she should continue counseling this man or make a referral. Barbara tells you that she worries about the effect of her attraction on the counseling process. Yet she also wonders what she might tell him if she decided to suggest a referral to another professional. What might you suggest to Barbara? If you found yourself in a situation similar to hers, what course of action might you take?

Not only is it difficult to acknowledge sexual feelings toward a client, it is even more difficult to talk about these feelings with colleagues or in supervision (Pope, Sonne, & Holroyd, 1993). Despite the likelihood that sexual attraction is a common occurrence, there has been a lack of systematic research into the topic. Most practitioners reported that their graduate training and internships provided no coverage whatsoever about sexual attraction and characterize their graduate training on therapists’ sexual feelings as poor or virtually nonexistent (Pope, Keith-Spiegel, & Tabachnick, 1986; Pope & Tabachnick, 1993; Pope & Vasquez, 2011).

Pope and colleagues (1993) identified the conditions necessary for learning how to recognize and deal with feelings of attraction to a client. They believe that exploration of sexual feelings about clients is best done with the help, support, and encouragement of others. They maintain that practica, internships, and peer supervision groups are ideal places to raise this topic and list some common reactions to sexual feelings in therapy, which include surprise and shock; guilt; anxiety about unresolved personal problems; fear of losing control; fear of being criticized; frustration at not being able to speak openly or at not being able to make sexual contact; anger at the client’s sexuality; fear or discomfort at frustrating the client’s demands; and confusion about tasks, boundaries, roles, and actions.

The tendency to treat sexual feelings as if they are taboo has made it difficult for therapists to recognize, acknowledge, and accept attractions to clients. According to Pope and Wedding (2014), national studies have indicated that simply experiencing sexual attraction to a client, without acting on it, makes the majority of therapists feel guilty and anxious. It is not surprising, then, that many therapists want to avoid acknowledging and dealing with sexual feelings. Although a majority of therapists reported feeling sexually attracted to some clients, and most reported discomfort with their feelings, the studies revealed that adequate training in this area is relatively rare.

In light of these findings, we recommend that counselor education programs place more emphasis on the issue of sexual attraction. Prospective counselors need to be reassured that their feelings are a common manifestation of countertransference, that these feelings are natural, and that with awareness and preparedness they can still counsel effectively with clients to whom they feel attracted. The importance of consultation should also be emphasized, in both preservice and in-service education, to help prevent sexual attraction from crossing the boundary into an inappropriate dual relationship.

Although it is a good practice to discuss concerns regarding sexual attraction with colleagues and supervisors, it is not wise and is inappropriate for counselors to share with a client their feelings of sexual attraction. In their research on counselors’ perceptions of ethical behaviors, Neukrug and Milliken (2011) found that 89.7% of their sample of ACA members (N = 535) believed it to be unethical to inform clients about their attraction to them. Fisher (2004) discourages therapist self-disclosure of sexual feelings to clients and makes these suggestions regarding managing sexual feelings:

• Rather than making any explicit communication of sexual feelings for clients, therapists might consider acknowledging caring and warmth within the therapeutic relationship.

• Therapists do well to practice a risk management approach if they develop sexual feelings for a client. This would involve awareness of timing and the location of scheduled appointments, nonerotic touch, and general self-disclosure.

• Therapists should consider making use of supervision, consultation, and personal therapy throughout their careers, especially at those times when they are challenged.

Pope and Vasquez (2011) have summarized the issue of sexual attraction: “To feel attraction to a client is not unethical; to acknowledge and address the attraction promptly, carefully, and adequately is an important ethical responsibility” (p. 221). An excellent resource for further understanding is Sexual Feelings in Psychotherapy: Explorations for Therapists and Therapists-in-Training (Pope et al., 1993). Another valuable book is Lying on the Couch: A Novel (Yalom, 1997). Yalom’s book presents a discourse on the slippery slope of sexual attraction between therapist and client.

Amanda Connell

My first introduction to the counseling field was in substance abuse counseling. This began during my community college years, and we were not taught about boundary issues such as how to deal with sexual attractions. As a result, I often felt unprepared when these situations arose. To compound the issue, as a result of my own history, boundaries were challenging for me. My personal therapy has been enormously helpful in this area as well as many others. Supervision and consulting with colleagues have also been very useful.

In my experience, it is pretty common for clients struggling with addiction to have poor boundaries. I learned early on that it was important for me to model clear boundaries with clients. Over time, I learned to not take client behaviors personally. What was important was to teach clients about appropriate behaviors and boundaries. I found it helpful to come from a place of compassion and understanding for my clients, with the awareness that many of them grew up in homes with exceedingly poor boundaries and oftentimes even abuse.

Early in my career as a substance abuse counselor, I encountered a client who presented me with numerous opportunities for growth in learning about boundary issues. He exhibited poor impulse control and lacked appropriate social skills, in addition to his addiction. This became evident in the first group he attended, as he reached out and touched my hair, called all the females in the group “Babe” or “Honey” (myself included), and generally made sexualized comments to the women. Within a few weeks he had also discovered where I lived (I worked and lived in the same city) and proceeded to describe my house to me, which was unsettling given his stated attraction and demonstration of poor boundaries. One of the truly marvelous things about group counseling is that this can be the perfect environment to work on such matters. This is especially true when the group is as open, nurturing, and willing to work as was that particular group. Another key element is that this client recognized a need for change within a short time as we explored his loneliness and his inability to form meaningful intimate relationships. Over time, and with a lot of patience, diligence, and hard work on the part of all of us in the group, this client did make significant changes in his communication skills and boundaries. He also developed an increased respect for women. This was accomplished partly through clearly setting boundaries in the group by directly communicating what was and was not acceptable behavior and language. We took this further by working with the behaviors in the moment when they occurred, exploring his intentions and motivations, and then doing behavioral rehearsals so he could realistically practice the behaviors and language that would be both acceptable and welcomed by women and still convey his messages. We also helped him develop empathy and understanding for how his actions affected others, which was made possible by the other members’ willingness to be vulnerable and direct about feeling offended, violated, or disrespected. It turned out that this client had a very tender heart and feelings of inferiority, but he had learned poor boundaries and offensive communication in his family of origin. By the time he graduated from our program, he was one of our most actively engaged members, helping other newer members with their boundaries and communication skills.

Another interesting case occurred during one of my groups with a client who regularly pushed boundaries and the patience of all the counselors in that community agency. He had a full array of disruptive behaviors. In one of my groups, he made remarks about my appearance and asked me out. As I consulted with colleagues and a supervisor, it became clear that although at first it appeared that he had some sort of attraction to me, his remarks were instead his way of attempting to gain power, control, and attention in the group. This insight enabled me to work more effectively with him, although his behaviors varied and continued to be demanding for all of us.

Another challenging situation with attraction occurred just after the conclusion of a group. A group member who had just graduated from our program stayed after the group while waiting for his ride home. I was doing paperwork and was distracted, and he was making small talk. He asked me if I was married, and because I was not really paying attention, I answered absent-mindedly that I was not married. That was a therapeutic error that I regretted when he proceeded to ask me out on a date. That got my attention, and I felt surprised and ended up handling it badly. I believe that he ended up leaving with hurt feelings, and I regret not having the knowledge and confidence to handle it better. Although I still find these types of situations to be uncomfortable, I do feel better equipped these days to work through sexual attractions with clients when they arise. A much more effective way to handle that situation would have been to have been paying attention first of all. Instead of just answering the question, I would have explored with him the reason for this question. When a client expresses attraction for his counselor, it is not about the counselor. I would be direct about the sexual attraction, normalize the feelings, and have a discussion about ethics and boundaries surrounding the topic.

There was another instance when I felt attraction for one of the clients. The thoughts and feelings came about suddenly and unexpectedly, and to be very honest I was mortified. In my inexperience, I did not know much, but I did definitely know that it was a cardinal error to have any romantic relationship with a client. The feelings scared me, but luckily I had my own therapy appointment just after work that day. It was a fascinating experience. I was very aware and open about my feelings, and I successfully processed them with my therapist. I was such a driven person at that time that I was living life out of balance and had shut down the dating aspect of my life. Remarkably, and much to my relief, when I saw that client the following week, the feelings of attraction were gone. I learned that those feelings were not about him but were instead a subconscious way of getting my attention to the need to live a more balanced existence.

Sexual attractions in the counseling field will occur from time to time because it is a normal part of being human. The manner in which they are dealt with makes a difference. I have found it helpful to engage in my own counseling and to actively obtain supervision and consultations with colleagues in these instances. I have also found it helpful to practice these situations in role plays in classes. Avoidance and denial of attractions are problematic in multiple ways. Awareness and a willingness to help clients process their feelings of attraction are critical components of effective therapy.

Consider, for a moment, how this subject applies to you.

• Have you had to struggle with the matter of sexual attraction in counseling relationships?

• If so, how did you deal with your feelings and the feelings of your clients?

• What would you do if you found yourself attracted to a client, or a client to you?

• What do you want to see included in training programs about issues of sexual attraction?

Sexual dual relationships are one of the most harmful types of unethical behavior. We have seen how destructive they can be for clients, counselors, and the profession as a whole. Because violations are common—and probably occur more frequently than we realize—we need to make concerted efforts toward awareness and prevention. Steps that can be taken include consumer education, support for the victims, improved counselor training, and monitoring professional practice.

As professionals, we seem to be communicating well with one another regarding sexual dual relationships, as is evidenced by the large number of articles in our professional journals. However, it is equally important that we communicate clearly to consumers that they have the right to services that are free from sexual exploitation. Statements of client rights should include this information and be routinely distributed. An important step in prevention is to educate the public so that they have clear expectations about the counseling process and knowledge of the boundaries of the relationship.

Information about the ethical, administrative, and legal options available to clients who have had a sexual relationship with their counselors needs to be routinely shared with consumers. One excellent example of how this might be accomplished is the booklet titled Professional Therapy Never Includes Sex (California Department of Consumer Affairs, 2011), which was specifically designed to help victims of sexual exploitation by therapists. It describes warning signs of unprofessional behavior and presents the rights of clients. Another helpful resource for clients is a brochure titled If Sex Enters Into the Psychotherapy Relationship (American Psychological Association, 1987).

Many counselors may feel unprepared to help clients, students, or others who have had sexual relationships with their therapists. It is important to remember that clients who have been sexually exploited tend to be exceptionally vulnerable to revictimization when counselors fail to recognize their clinical needs (Pope & Vasquez, 2011). An abused client can be empowered by taking action against the offending therapist. Despite the potential for healing, it is extremely difficult for an abused client to pursue a complaint. In addition to the emotional toll that the process takes, it requires perseverance and some sophistication about the ethical complaint process and the legal system.

Counselors who work with these clients need to have a high degree of preparedness. They may need to deal with their own feelings of discomfort at being involved in a complaint against a colleague. They need to know all the possible avenues of redress and the advantages and disadvantages of each, so that these can be communicated accurately to the client. Finally, counselors need to keep in mind that the decisions—whether to pursue a complaint, what avenue(s) to take—rest with the client.

Women report great reluctance to file complaints that could lead to disciplinary action against their therapists or trainers (Gottlieb, 1990; Hotelling, 1988; Riger, 1991). These women often have ambivalent feelings about reporting their therapists, but they also encounter institutional barriers within the profession that contribute to their feelings of intimidation and deter them from following through with the complaint process. Gottlieb (1990) suggested that there is a need for an organizational structure within the profession that will reach out to these women and assist them in the complaint process.

Counselor education is discussed more fully in Chapter 5, but at this point we want to note some concerns specific to sexual dual relationships. We have the impression that, generally, counselor education programs are not giving much emphasis to the topic of sexual attractions between counselors and clients.

Pope and Vasquez (2011) reported that sexual attraction causes a great deal of discomfort among mental health practitioners, which may be the reason graduate programs and internships neglect educating students in how to identify and manage sexual attractions. Counselor education programs have a dual responsibility: to train prospective counselors and to protect the public whom they eventually will serve. Bartell and Rubin (1990) contend that education can play an important role in helping trainees first to recognize sexual attraction and then to take the necessary steps to avoid acting on the attraction. They suggest that the injunctions against sexual relationships be emphasized in training programs and be well publicized as a way to eliminate dangerous liaisons. Syme (2003) also recommended that graduate programs examine in detail the likelihood of erotic transference and countertransference in therapy and that they teach prospective therapists how to handle both of these phenomena.

On the matter of providing trainees with education on this subject, we think issues of attraction to clients ideally should be introduced in a beginning class in counseling, then dealt with in more depth in an ethics course, and further addressed in seminar sessions attached to students’ fieldwork or internship experiences. Students are bound to encounter attractions as a part of their fieldwork, and instructors can encourage them to bring up these concerns for discussion. Individual supervision sessions provide an excellent venue for exploring these issues.

The findings from Harris and Harriger’s (2009) study on sexual attraction in conjoint therapy suggested that new marriage and family therapists are not confident about the course of action to take when faced with the issue of sexual attraction. These researchers claim that there is an urgent need to address this topic during a training program and to equip therapists-in-training with the skills to manage sexual attraction in a range of settings. We agree with Syme’s (2003) observation that trainees may be very reluctant to publicly talk about feeling attracted to clients, but they will often do so privately in the safety of a supervision session. Some students may need to consider seeking therapy for themselves to explore their countertransferences and sexual attraction to clients.

Before attempting to educate others, instructors must gain their own clarity. Counselor educators who lack clarity will pass along their confusion to future generations of helping professionals, and counselor educators who behave in ethically questionable ways imply that those behaviors are acceptable. Counselor educators have a special obligation to be role models for what constitutes ethical behavior.

Thoreson, Shaughnessy, Heppner, and Cook (1993) suggest that issues of sexual contact between counselor educators and students and between supervisors and supervisees are more complex than issues of sex between client and therapist. Conflicting principles emerge, in that consenting adults have the right to establish consensual relationships, but because of the power differential involved, the notion of voluntary decision making is clouded with coercion. They recommended that education address the difficult issues of conflicting ethical principles, intimacy needs, the complexities of dual relationships, power inequities between “consenting adults,” and gender-role stereotypes.

Professionals have been reluctant to report their colleagues who engage in sexual relationships with clients, students, or supervisees. Tabachnick, Keith-Spiegel, and Pope (1991) reported that 79% of psychology faculty who responded to their survey had ignored unethical behavior by colleagues. There may be a combination of explanations for this reluctance. In large measure, our sense of professional identity depends on the interpersonal bonds we form with our colleagues. We may fear being criticized or ostracized by colleagues for speaking out against “one of our own.” The possibility of a defamation suit could also contribute to our hesitancy to take action. Many of us are reluctant to stand in judgment of others, particularly when we recognize our own fallibilities.

Consider what you might do in this situation: You become aware that a student intern in a counseling center has dated several of his clients. You and the student intern are in the same graduate program and are serving as interns in the same center. You approach him and inform him that you have heard from one of his former clients that they were involved in a sexual relationship. He tells you that he has no problem with this because both he and his client are consenting adults, and that because he is not a licensed professional he is not bound by a set of ethics codes. In essence, he informs you that you are interfering in his personal business. Where would you go from here?

It is difficult for professionals to take action against colleagues. However, despite our reluctance, we clearly have an ethical responsibility to act when we have reason to believe that a colleague has engaged, or is engaging, in sex with clients. As Syme (2003) has so aptly stated, “If a therapist does not report suspected sexual abuse of a client by a fellow therapist, this is false loyalty and a derogation of their duty of care to the general public” (p. 16). Keep in mind that it is not our role to investigate, judge, or punish. These responsibilities belong to ethics committees, licensing boards, and the courts.

It may also help to remember that, sometimes, sexually exploitive behavior may be a symptom of impairment (Emerson & Markos, 1996). Characteristics of counselors who have become sexually involved with their clients parallel in many ways the characteristics of the impaired professional. Here are some of the similarities:

• Fragile self-esteem, possibly manifested in a narcissistic style

• Difficulty establishing intimacy in one’s personal life

• Professional isolation

• A need to rescue clients

• A need for reassurance about one’s attractiveness or potency

• Abuse of alcohol or other drugs

Because one of the most common mechanisms of impairment is denial, responsibility for confronting the problem is likely to fall on the professional colleagues of an impaired counselor. One ethical course of action is to confront the counselor and to do so with sensitivity, respect, and preparedness (Herlihy, 1996). If the counselor is receptive, options such as seeking help, suspending or limiting practice, working under supervision, or self-reporting can be explored. If the impaired counselor denies, rationalizes, or justifies his or her behavior, there may be no other option than to report him or her to a supervisor, an ethics committee, or a licensing board. Although some offending therapists who are experiencing burnout or impairment can be restored to healthy functioning, there may be others who should not be allowed to practice. The high rate of recidivism and the difficulty of ensuring that an offender has been “cured” are factors that support this stance. The first and highest obligation must be to protect clients from harm.

Having a sexual relationship with a client is one of the most serious of all ethical violations. All codes of ethics of the professional associations prohibit sexual intimacies with current clients and with former clients until a specified amount of time has passed. The effects of sexual exploitation can be profound for the client, and the consequences can be severe for the counselor and for the profession. Sexual attraction to clients is not unethical, but acting on that attraction creates problems. This topic has not been fully addressed in counselor training programs and is deserving of more attention. The most productive future efforts will focus on prevention and remediation. The counseling profession needs to make a systematic effort to address sexual exploitation among its ranks and to educate clients about what they can rightfully expect from the professionals whose help they seek.

The beliefs and behaviors of mental health professionals regarding dual relationships have been extensively studied, but surprisingly little literature exists to describe the perspective or experiences of the client or consumer, particularly with respect to nonsexual dual relationships. We believe it is essential to consider the client’s perspective. In this chapter we discuss the few studies that have been conducted on consumer beliefs and attitudes toward dual relationships and present some anecdotes in which clients speak in their own words about their experiences. We raise questions about the implications of our profession’s focus on our own point of view. These questions frame our discussion:

• How do clients and potential clients view dual or multiple relationships?

• How do clients describe their experiences with dual relationships, both sexual and nonsexual?

• Do mental health professionals take a paternalistic approach to dealing with dual relationships? If so, how can we make clients active partners in the decision-making process?

Walden (1996) studied the general public’s knowledge of ethical counselor behavior, including nonsexual and sexual dual relationships. Her questionnaire was constructed from vignettes taken from the fifth edition of the ACA Ethical Standards Casebook (Herlihy & Corey, 1996). In one vignette participants were uncertain about the ethics of the behavior of a counselor who conducted business and social relationships with clients. Only 41.5% “thought” or “strongly believed” this behavior was unethical. A second vignette described a sexual dual relationship between a counselor and a former client slightly more than a year after termination of the professional relationship. Again, respondents were uncertain, with 41.5% judging it unethical. Walden also found that there was no significant relationship between experience as a client in counseling and knowledge of counselor ethics. Walden’s study was conducted nearly 20 years ago; contemporary consumers may be more educated about the professional ethics of therapists. Nonetheless, we believe her recommendations—that counselors work to educate the public about the ethical standards of our profession, and that we take steps to include the client’s perspective in formulating and adjudicating our codes—remain valid and valuable today.

Clients are often reluctant to take action against offending professionals (see Chapter 2). Even when boundary violations are sexual in nature, and when sexual advances are unwanted and sexual feelings are unreciprocated, reporting an offender can be a painful experience. Not all instances involve a client and a therapist. Other relationships involving a power differential, such as the relationship between student and professor, are potentially as harmful. Anonymous (1991) has written about her experiences with Professor X, a charismatic professor of counseling. Although Professor X singled out this student for special attention, praise, encouragement, and hugs, she trustingly failed to consider that he was “coming on to her” sexually until she learned that he had had affairs with other students. After much soul searching, she filed sexual harassment charges with the university and the ethics committees of professional associations. A lengthy process followed, filled with frustrations and disappointments for her, but in the end Professor X was found in violation and disciplined. Although this student successfully resisted the professor’s attempted seduction and her complaints were successfully resolved, the experience was traumatic for her, as is evident in the following passages:

I sat for hours, staring off into space, unable to focus. I saw Professor X as two images that refused to meld . . . his well-meaning, kind, and caring persona as opposed with a lustful and menacing one. I wondered if I had inadvertently given him some signal that I was approachable sexually. (p. 503)

My anger grew as the week wore on. It emanated from deep within me—I felt consumed by it, and I felt that I would not be able to stop myself from expressing it the next time I saw Professor X. I avoided having any contact with him. (p. 505)

I felt obsessed by the experience—it drew attention away from every area of my life. To keep myself going, I read about sexual harassment and about research regarding sexual intimacy between therapists and clients. . . . These activities helped me to combat the worst aspect of this problem—the loneliness. (p. 506)

It can be helpful for those who have been sexually exploited to read about experiences similar to their own. First-person accounts of sexual relationships with therapists include Betrayal (Freeman & Roy, 1976), A Killing Cure (Walker & Young, 1986), Sex in the Therapy Hour: A Case of Professional Incest (Bates & Brodsky, 1989), Therapist(Plaisel, 1985), and You Must Be Dreaming (Noel & Watterson, 1992).

Counselors are likely to be uncomfortable with the notion of practicing paternalistic relationships with their clients. Nonetheless, the position taken by professionals with respect to dual relationships, as reflected in our codes of ethics and our professional literature, has tended to be paternalistic. Mental health professionals seem to have assumed that it is up to the professional to determine the boundaries of the relationship.

Mental health professionals should not abdicate their responsibility to maintain therapeutic boundaries in the interests of avoiding paternalism. However, when we assume that we are in a better position than clients to know how to protect them from harmful dual relationships (Nerison, 1992), we diminish the autonomy of our clients. To us, this underscores the importance of involving the client in ongoing discussions about relationship boundaries and potential dual relationship problems. It is important that we strive to balance our responsibilities for maintaining appropriate boundaries with our commitment to making our clients active partners in the therapeutic relationship. From our perspective, practitioners are challenged to include clients in ethical decision making that affects them, but practitioners have the ultimate responsibility for the outcomes. This process takes time, and it should include consultation, not only with colleagues but also with our clients.

A number of theories of counseling emphasize including the client in the therapeutic process as a collaborative partner. Some of the theories that emphasize the collaborative nature of the therapeutic endeavor include Adlerian therapy, cognitive behavior therapy, narrative therapy, solution-focused brief therapy, and feminist therapy. In social constructionism, a viewpoint that is becoming increasingly popular, the therapist disavows the role of expert, preferring a more collaborative or consultative stance. Clients are viewed as experts about their own lives.

Adlerian therapists strive to establish an egalitarian therapeutic alliance with their clients. They consider an effective therapeutic relationship to be one between equals that is based on cooperation, mutual trust, respect, confidence, and alignment of goals. From the beginning of therapy, the relationship is collaborative, characterized by two persons working equally toward specific, agreed-upon goals.

Cognitive behavior therapy encourages clients to take an active role in the therapy process. Clients are expected to bring up topics to explore, identify the distortions in their thinking, summarize important points in the session, and collaboratively devise homework assignments that they agree to carry out. Cognitive therapists are continuously active and deliberately interactive with clients; they also strive to engage clients’ active participation and collaboration throughout all phases of therapy.

Narrative therapists place great importance on the qualities a therapist brings to the therapy venture. Some of these attitudes include optimism and respect, curiosity and persistence, valuing the client’s knowledge, and creating a special kind of relationship in which power is shared. Collaboration, compassion, reflection, and discovery characterize the therapeutic relationship. If counseling relationships are to be truly collaborative, therapists need to be aware of how power manifests itself in their professional practice. Therapists view clients as experts on their own lives.

Similarly, in solution-focused brief therapy, the emphasis is on creating collaborative therapeutic relationships. Although therapists have expertise in creating a context for change, clients are viewed as experts on their own lives, and they often have a good sense of what has or has not worked in the past, and what might work in the future. In short, collaborative and cooperative relationships tend to be more effective than hierarchical relationships in therapy.

Feminist therapists view the therapeutic relationship as being based on empowerment and egalitarianism. The very structure of the client–therapist relationship models how to identify and use power responsibly. Feminist therapists clearly state their values to reduce the chance of value imposition and to allow clients to choose whether to work with the therapist. Feminist therapists actively focus on the power clients have in the therapeutic relationship. They encourage clients to take charge of their lives and relationships by making choices that increase the possibility for experiencing mutuality in their relationships. Feminist therapists work to demystify the therapeutic relationship. They do this by sharing with the client their own perceptions about what is going on in the relationship, by making the client an active partner in determining any diagnosis, and by making use of appropriate self-disclosure.

Susan L. Walden addresses the feminist model for ethical decision making and the importance of including the client’s voice in ethical practice. She describes important therapeutic benefits that can result from inclusion of the client in the ethical decision-making process. She also offers some strategies for accomplishing this goal at both the organizational and the individual levels.

Susan L. Walden

Numerous studies have investigated the knowledge, judgment, and experiences of counselors, psychologists, and social workers with respect to dual relationships and other ethical issues (Borys & Pope, 1989; Gibson & Pope, 1993; Gottlieb, Sell, & Schoenfeld, 1988). We have data reflecting practitioners’ opinions on appropriate ethical actions as well as their self-reported practices when faced with ethical dilemmas. Although such studies certainly contribute greatly to our understanding, they tell only part of the story. The literature is scant concerning the other party in the counseling dyad—the client. Although it is true that both the professional and the field of counseling suffer when unethical practice occurs, in many cases the party who stands to incur the greatest harm is the client. Injury to clients resulting from dual relationships, especially sexual dual relationships, has been well investigated by Pope (1994) and others. The negative effects of dual relationships on clients have been documented.

Because of the potential for harm to clients, more attention must be given to understanding the client’s perspective and to educating and empowering clients. Inclusion of the client in ethical considerations is not an attempt to “victim blame” or to shift the responsibility for ethical practice onto the client—the professional always bears the onus for maintaining professionalism and ethical practice—rather, inclusion of the client can be a strong asset to the counselor in resolving ethical dilemmas and can be a source of empowerment for the client.

Why has so little attention been accorded to the client’s perspective? There are numerous possible responses to this question. First, perhaps tradition has dictated that we, as the professionals in counseling relationships, have the knowledge and training required to create and enforce the standards needed for best practice. Yet if we judge our clients as uninformed about the nature of counseling, we also deny them the potential for participation in the processes of understanding and resolving ethical dilemmas. Another potential explanation for the exclusion of the client perspective is the fear that telling a client too much about standards of practice might intimidate a client. For example, haven’t we all occasionally worried that explaining all the limits of confidentiality to a client might frighten the client into silence?

A third possible hesitation in involving the client in ethical considerations is that an educated consumer base might result in an increase in ethics complaints. We are charged with the responsibility of monitoring ourselves and our profession. Most of the time we do a good job, as evidenced by the fact that only a small percentage of mental health professionals are named in complaints to ethics boards. Perhaps we might do a better job, not by turning over the responsibility for monitoring practice to the consumers or by blaming the victims of unethical practice but by engaging the consumers of our services and empowering them in the process. We must remember that the client is the most important person in the counseling relationship.

Perhaps none of the aforementioned suggestions is accurate. It is possible that turning our focus to the client’s perspective is simply a paradigm shift of sorts. We have espoused a somewhat paternalistic model of practice in the profession of counseling and in the creation and enforcement of ethical standards. We, as the professionals, create a set of standards that we believe will protect the client’s welfare and best interests, yet we do this without the input or presence of the consumers of our services. I suggest that involving the client represents a natural step from a therapeutic benefits stance as well as a genuine move toward the aspirational level of ethical practice.

Potential therapeutic benefits may be derived from the inclusion of the consumer perspective in ethics. First, when we make decisions concerning a client for the client rather than with the client, we rob the client of power in the counseling relationship. Conversely, when we create collaboration between counselor and client, the client is empowered. The concept of collaboration emphasizes the importance and essential nature of both parties in the relationship. Although counselor and client each bring different contributions to the collaboration—the counselor’s training and professional experience and the client’s strengths, hard work, and life experiences—both contributions are essential for the success of the counseling endeavor.

Client empowerment through inclusion in ethical considerations is a good fit with current thinking in the mental health professions. Newer therapies, particularly social constructivism and solution-focused brief therapies, emphasize the collaboration between counselor and client. The aim is to work toward goals determined by the client, drawing on the successes and strengths of the client. Why not extend this way of thinking into the arena of ethics? Bringing the client into an ongoing dialogue regarding a potential dual relationship or other ethical concern should be a continuous process if we are truly to work within the client’s frame of reference, respecting the client’s views. We cannot pretend to understand fully the client’s view of a situation or gauge the potential ramifications of certain decisions for the life and well-being of the client accurately. What we may hope to communicate is a genuine regard for the impact of a situation on the client and respect for the client’s welfare in working to find the solution that best protects and respects the client. By soliciting the client’s perspective, we may ultimately achieve better counseling results and the best resolution for any ethical questions that arise.

Let’s examine the case of a client who presents with complaints of social isolation. She and the counselor work for several sessions reframing her sense of isolation, highlighting her strengths, and building strategies for connecting with others in social situations. When she invites the counselor to accompany her to a party, the counselor is concerned about the dual relationship implications but fears hurting the client. Rather than just turning down the client’s offer or making the excuse of previous plans, the counselor might engage the client in a discussion of the ramifications of such a venture, eliciting the client’s thoughts and feelings about potential situations that might occur, including the impact on the client and the counseling relationship. Some clients may be unable to see the potential risks involved in the situation, and in those cases the ultimate decision rests with the counselor. However, in many cases, counselor and client working together may arrive at a solution that enables the counselor to preserve the counseling relationship while helping the client feel a part of the decision-making process.

A second therapeutic benefit derived from the inclusion of the client perspective may be more culturally appropriate practice. The counseling profession is growing in its understanding of the demands of counseling in a culturally pluralistic society. Our codes of ethics may reflect primarily Western values and certain cultural biases, but they do not have to be applied in a culturally encapsulated manner. The ACA Code of Ethics (American Counseling Association [ACA], 2014) addresses culturally appropriate practice, for example, in the provisions made for bartering and the giving of gifts, which have important cultural implications for some clients. When the counselor has strict beliefs or policies regarding accepting gifts, misunderstandings may occur. However, if counselors are willing to understand the client’s perspective and share their own perspective, a solution may be reached by working together. Without such an exchange of views, the client may be offended by the counselor’s behavior. With an exchange, client empowerment and the selection of a solution more in keeping with the client’s cultural values are possible. Garcia, Cartwright, Winston, and Borzuchowska (2003) proposed integrating multicultural theory and competencies into the process of ethical decision making. They emphasized the significance of a client’s and counselor’s worldviews in influencing the resolution of ethical issues in counseling. We can be culturally inclusive in the application of ethical standards, and the inclusion of the client perspective may be an important step toward this goal.

Not only are there potential therapeutic benefits to be gained by including the client’s perspective in ethics, but such practices also speak to the attainment of the aspirational level of ethical practice. At the aspirational level, the practitioner is concerned with the spirit of the code and the moral principles on which the code rests (Remley & Herlihy, 2014). Functioning at the aspirational level of ethics means that the counselor’s concern is for the welfare of the client. The inclusion of the client’s voice in ethical matters speaks to this higher level of ethical functioning.

When a practitioner has decisions to make or ethical dilemmas to resolve, certainly the responsible professional consults the appropriate standards and is mindful of the impact of potential decisions on the welfare of the client. However, even the most well-meaning and skilled practitioner cannot fully understand the client’s perspective or investment in the situation without the input of that client. Although we may see a situation as being relatively low risk for a client, the client may view the situation differently. It is questionable whether it is truly possible to attain the aspirational level of ethical functioning without including the client in the decision-making process. In order fully to prize and value a client and represent what is in the client’s best interests, should we not involve the client in the process? Only by asking the client can we really know what a situation looks like through the client’s eyes.

The potential benefits of including the client perspective in ethics issues are many. Numerous therapeutic advantages may be gained, and a practitioner has moved closer to the aspirational level of ethical practice. Ultimately, such genuine regard for the client’s welfare may bring about benefits for the counselor, for the profession, and, most important, for the client.

With the rationale in place for the inclusion of the client perspective in ethics, the question becomes how to put this process into practice. Infusion of the client perspective begins on two major levels: the organizational level and the individual level. At the organizational level, professional counseling organizations can utilize several strategies to promote the client perspective. First, we must continue and strengthen our efforts at educating members of the public in general and our clients in particular regarding ethical practice. Frequent reference has been made in the literature to the benefits of educating consumers of counseling services regarding ethical considerations. In addition, most state licensure boards and other ethics bodies have begun to require that practitioners provide professional disclosure statements and utilize informed consent procedures. These developments are much needed and provide a useful source of information for our clients.

A second strategy for client inclusion at the organizational level involves client participation in the creation and adjudication of ethics codes. Rather than the paternalistic model currently in place in which we (the professionals) create and adjudicate our codes of ethics without the voice of the consumers, we might include representation by members of the general public. Although the American Psychological Association’s Ethics Committee has included a nonpsychologist member since 1987, ACA has not included a member of the general public on its ethics committee. Given the vast human resources we have in ACA, it does seem that the logistical aspects of appointing a consumer member to the ACA Ethics Committee could be managed if the membership and leadership of the organization supported such a move. By adding the voice and unique perspective offered by a consumer, we might be better able to formulate standards that protect our clients, better understand the implications of ethical and unethical practice for the client, and also indicate to the public that we as a profession are interested in protecting the rights and welfare of those who utilize our services.

A third component of client inclusion at the organizational level is to develop ethical decision-making models that include the client’s voice in the resolution of ethical dilemmas. Consultation with the client can be included at every stage of the decision-making process. An ethical decision-making model described in A Practitioner’s Guide to Ethical Decision Making (Forester-Miller & Davis, 1995) is a useful tool for the resolution of ethical dilemmas; however, the model does not call for consultation with the client as a part of the decision-making process. Hillerbrand and Stone (1986) suggest that the client is an integral part of the “ethical community of the counseling relationship,” capable of participating in determining appropriate actions in ethical dilemmas. The feminist model for ethical decision making (Hill, Glaser, & Harden, 1995) calls for consultation with the client at every stage of the decision-making process. More recent models for decision making have been proposed, including the social constructivism model (Cottone, 2001), which is based on the systemic-relational service models, and the collaborative model (Davis, 1997), which values inclusion and multiple perspectives and goals. Both models acknowledge that multiple parties are affected by practice and ethical decision making and emphasize a collaborative approach to the resolution of issues.

The transcultural integrative model (Garcia et al., 2003) rests on the essential influence of both client and counselor cultural perspectives. Herlihy and Watson (2006) proposed a paradigm for ethical decision making based on ethics, cultural identity development, and collaboration between counselor and client. This approach emphasizes the essential components of promoting social justice based on the client’s worldview, the understanding by the counselor of the influence of culture on the counseling process, and the value of the client’s participation in all aspects of the counseling relationship. These models all represent significant steps away from the individual perspective and influence common in earlier models.

Most ethical decision-making models share many common steps or procedures in the resolution process. The feminist model (Hill et al., 1995), which emphasizes the importance of including the client throughout the process, applies the following steps:

1. Recognize a problem

2. Define the problem (collaboration with the client is essential at this stage)

3. Develop solutions (with client)

4. Choose a solution

5. Review the process

6. Implement the solution and evaluate the result (with client)

7. Continued reflection

In the fifth step, which calls for consideration of the consequences of all options, readers are reminded to ponder the implications of each course of action for the client. The authors of the feminist model specifically state that consultation with the client “as fully as is possible and appropriate” is an essential step in ethical decision making (p. 27). The inclusion of the client in the decision-making process is a stated component of several steps of the feminist model. Ethical decision making from a feminist therapy perspective calls for involving the client at every stage of the therapeutic process, which is based on the feminist principle that power should be equalized in the therapeutic relationship (Brown, 2010). The decision-making model presented in the final chapter of this book provides an excellent model for the resolution of ethical dilemmas involving dual relationships, and the model includes consultation with the client.

A guide for ethical decision making published by the ACA Ethics Committee that reflects current thinking in the resolution of ethical dilemmas, with an emphasis on the inclusion of the client’s voice, would be welcomed at this juncture. Such a step at the organizational level certainly would both instruct practitioners about the importance of including the client perspective and give them concrete strategies to use. The support of such practices from the professional organization would surely impress upon the membership the importance of the client perspective and should ultimately lead to fewer misunderstandings and healthier relationships between counselors and their clients.

At the individual level, numerous strategies may be employed to involve the client in ethical matters. Informed consent is the process that most commonly includes the client in discussions of ethics, and practitioners can discuss potential dual relationship and other boundary issues at the outset. A good practitioner will revisit areas of informed consent periodically and especially as ethical concerns arise. Because informed consent by nature necessarily involves the client, perhaps reframing it as a process rather than an event will help counselors to be more inclusive of the client as the counseling relationship progresses. Another strategy for the individual practitioner involves utilizing a professional decision-making model when ethical dilemmas arise. This model should include consultation with the client at any and all possible stages during the process.

One final suggestion for infusing the client perspective involves the counselor educator. As counselor educators, we teach ethical principles to our students through our courses and through our deeds. If we teach students the process of informed consent and how to include the client in ethical decision making, we are equipping them from the beginning with a client-oriented philosophy and strategies. In addition, we can model these practices through our dealings with them in the teacher–student relationship.

The inclusion of the client’s voice in ethical matters may not be appropriate in all situations, and some clients may not be able to participate fully or objectively in the resolution of ethical dilemmas. Nonetheless, the client perspective is an essential component of sound ethical practice. There are therapeutic benefits to be gained in terms of client empowerment and culturally appropriate practice. We strive toward the aspirational level of ethical practice when we value the client’s perspective. There are few risks involved in bringing the client into ethical matters, and the benefits are many, not only for the professionals and for the profession but also, and primarily, for the client. When we value our clients, we do all that is possible to understand the world through their eyes. When we listen to our clients, we teach them that their voice is important and is heard. When we include our clients in the process of ethical decision making, we empower them. When we include our client’s perspective, we decrease the likelihood of harm to clients and increase the opportunities for positive results in counseling.

Ed Neukrug describes the postmodern and social constructionist perspective, in which the therapist disavows the role of expert, preferring a more collaborative or consultative stance. Certainly the therapist has expertise in bringing knowledge and skills to a client’s situation, but the client is viewed as the expert about his or her own life. The client is invited to become an active agent in the therapeutic process, and the voice of the client is given priority.

Ed Neukrug

The traditional manner of ethical decision making views the counselor as an expert who must, under the duress of a tough ethical dilemma, decide the “correct” path of action for both the counselor and the client (Geraghty, 2012). This notion of therapist as expert and final authority dates back to the beginning of counseling and psychotherapy.

The philosophical influences that led to the idea of the therapist as final authority and expert included the rise of structuralism and modernism during the late 19th and the 20th centuries (Hansen, 2010; Payne, 2006; Russell & Carey, 2004). These philosophies suggested that counselors, with their expert knowledge, techniques, and skills, could help clients uncover their problems and then help them find solutions. Aligning with the structural tradition, problems were seen as residing within clients, and if one could delve deep enough, analyze properly, or scientifically understand the person, problems could be revealed and understood and solutions found (Besley & Edwards, 2005).

Most major theories of counseling and psychotherapy have embraced the basic assumptions of modernism and structuralism (Hansen, 2006; Xu, 2010). For instance, psychodynamic therapists work with the unconscious in a manner that suggests an inherent structure drives behavior and only the expert analyst can help the “patient” understand it and make it conscious (Neukrug, 2011). Although behaviorists have a very different view that assumes individuals are wired to respond to environmental stimuli that shape their behavior, like the analyst, they too believe it is only through the knowledge base of the expert (in this case, the behavior therapist) that a person can come to understand his or her conditioning and begin a reconditioning process. Cognitive therapy brought forth the notion of cognitive “structures” (e.g., schemas and core beliefs) being responsible for a person’s well-being or lack thereof. And, once again, these theorists suggested that the expert (the cognitive therapist!) could help the client understand and change these structures. Finally, even existential humanists suggested there was an inherent structure, “the self,” that one must actualize in an effort to become congruent or real. In this case, it is the existential humanistic therapist that has attained the expert skills needed to provide an environment conducive to a search for the self (e.g., demonstrating empathy, unconditional positive regard, and genuineness).

Diagnosis reinforces the counselor’s role as expert and helps counselors objectify clients as it enables professionals to maintain a safe distance between themselves and their clients (Hansen, 2003). Using a diagnostic nomenclature supports the view that the actions of our clients are the result of their inherent personality structures. Perhaps they “have” a personality disorder, are major depressives, or have an anxiety disorder. In fact, we have so convinced ourselves that problems reside within our clients that we have created a book, the Diagnostic and Statistical Manual of Mental Disorders (DSM; American Psychiatric Association, 2013a), that reinforces this notion. Unfortunately, the DSM, at best, is a dictionary that offers a consensus of what individuals believe are diagnostic categories (Insel, 2013), and at worst, is a tool that ensures the continuation of the existing power structure that therapists hold over their clients (McLaughlin, 2006).

Because theory and diagnostic manuals have reinforced the notion of the counselor as an objectivist, somewhat removed expert, when it comes to ethical concerns, counselors and therapists who embrace modernism usually try to fix the problem—and our ethics codes reinforce that notion. For instance, counselors are encouraged to take action and “protect clients or identified others from serious and foreseeable harm or when legal requirements demand that confidential information must be revealed” (ACA, 2014, Standard B.2.a.). Or consider the flirtatious client. Because our ethics codes suggest that we have clear and appropriate boundaries with our clients, counselors characteristically move to set strong boundaries with flirtatious clients, assert their power as experts who need to control their client’s seductiveness, and often diagnose the client in a manner that places a safe amount of distance between them and their clients (e.g., the “histrionic” or “borderline” client).

But what if our modus operandi—our way of being as counselors and therapists—is largely a reflection of a structuralist and modernist worldview that has encouraged the belief that problems reside within the person and fostered the notion that counselors should act as the expert in a somewhat removed fashion? And what if these beliefs are just one manner of working with clients? Might there be a different way?

In more recent years, with the emergence of the philosophies of poststructuralism, postmodernism, and social constructionism, new therapeutic approaches have arisen that challenge the assumptions of structuralism and modernism and approach the helping relationship in new and profound ways that question the very core of the counselor as expert (Gergen, 2009; Guterman, 2013; Hansen, 2010; Payne, 2006; Winslade, Crocket, & Monk, 1997). These approaches suggest that how language is shared between and among people is a factor in the creation of reality. They go on to propose that the use of language by those in power can result in the oppression of others and the belief that others are the problem (e.g., parents holding power over children, dominant cultures holding power over nondominant ones, and, yes, even therapists holding power over their clients). Narrative therapy and solution-focused counseling propose that “problems” do not reside within the person but are a result of the milieu of conversations in which the person participated within his or her lifetime. Understanding the client from this perspective depathologizes the client, and the helping relationship is seen as a new and humanizing conversation that could potentially open up innovative views of the world (Dybicz, 2012). Here the therapist is no longer seen as the distant expert who is judging the client through a particular frame of reference. Instead, this counselor sees the counselor–client relationship in a collaborative manner, one in which the counselor and the client share their thoughts on the ethical decision-making process.

In considering ethical dilemmas, a postmodern, social constructionist approach suggests that clients have constructed their realities based on their discourses with others throughout their lives (Geraghty, 2012). Ethical dilemmas “brought to the counselor” are partly a function of these discourses and will continue to form as the discourse unravels with the counselor or therapist. Therefore, decisions about dilemmas will be made through ongoing discourse. The role ethics codes play in the ethical decision-making process is seen as somewhat of a mixed bag (Guterman & Rudes, 2008). Ethics codes can be seen as being a result of modernist and structuralist thinking developed to maintain the counselor’s power base in the relationship. However, from a social constructionist perspective, ethics codes are seen to have evolved over time as the conversation has changed about what is professionally right and wrong. Guterman and Rudes proposed that codes can be used from a postmodern, social constructionist perspective to help “inform the positions that counselors take” (p. 140), as opposed to the modernist approach, which fosters the notion that counselors should use ethics codes as a set of rules to which they must adhere.

Given the above understanding of how a counselor might work from a postmodern, social constructionist perspective when faced with ethical dilemmas, let’s contrast the modernist counselor with the postmodern, social constructionist counselor when dealing with a specific ethical dilemma.

Reanne is a 59-year-old mother of three adult children who has survived her only husband. She has just been diagnosed with terminal cancer. You have recently started seeing her as a client, and in the last session, she informs you of her diagnosis. She tells you that the doctors won’t give “timelines” but she is confident she has less than a year to live, perhaps only a few months. There is no treatment, she tells you. She then informs you that she has already devised a plan on how to kill herself, and she hopes to do so within the next month. She asks you not to interfere because she does not wish to live a long, drawn out, painful last few months of her life. What do you do?

When working with Reanne, the modernist counselor is hopeful that somehow his or her theory will set a direction for the counseling sessions. Perhaps this counselor will get advice on what to do next from a supervisor, and he or she is likely to refer to the ethics code and seek direction from it. Examining the Code, the counselor might see that the ACA (2014) suggests that counseling for end-of-life decisions is acceptable, so the counselor might consider whether this situation fits under that heading. Certainly the ethics code will also suggest that one must ensure that a client not harm him- or herself, and many counselors will want to act in some fashion to ensure that Reanne does not commit suicide. On the other hand, some might wonder what “harm” means. Does it include ending one’s life if one is in excruciating pain? In addition, some may seek “advice” from a variety of ethical decision-making models (Neukrug, 2012).

These are tough ethical decisions with which counselors might struggle, and all of the responses described are admirable and show an earnest desire to help the client. However, although these responses can be justified by today’s “standards” in counseling, they are all based on a modernist model of counselor as expert in which the counselor tries to somehow “fix” the problem from a somewhat aloof and objective perspective. What they do not do is include the client in the decision-making process.

In contrast, the postmodern, social constructionist counselor realizes that any theory is just one take on reality, as are the ethics codes, models of ethical decision making, and even the supervisor’s response to a dilemma. This counselor does not automatically run to theory, codes, ethical decision-making models, or to his or her supervisor but brings all of these points of view into the conversation with the client. The postmodern, social constructionist counselor offers such knowledge within the context of a shared, collaborative conversation, not as “I as expert.” In this context, the postmodern, social constructionist counselor might do the following:

1. Listen, use empathy, and try to understand the client’s current life story.

2. Be humble and respectful as the counselor realizes that the client’s decision is based on a lifelong series of discourses about family, illness, and suicide.

3. Asks questions to understand the client’s developed reality and how she came to make the choices she is currently making.

4. Actively attempt to not express a particular point of view that will make the client feel bad about herself, pathologize her, or push her toward taking a particular action.

5. Gently ask the client if there are other points of view that she has considered.

6. Gently ask the client if she would like to include others in her decision-making process—others who are important to her in the development of her life story.

7. Share with her the ethics code, legal requirements, personal counseling model, and other relevant thoughts and concerns the counselor might have about her situation, and ask the client what she thinks of them and how they might influence her decision-making process, if at all.

8. Consider whether to invite the supervisor to engage in conversation with the therapist and client. If so, ask the client how she might feel about the addition of the supervisor.

9. Engage in conversation with the client and others who might be jointly invited.

10. Listen to what the client ultimately wants, share thoughts about what the client says, and make a personal decision concerning whether the therapist can live with whatever her decision is. If not, go back to conversation with the client.

The above example contrasts the counselor who holds a modernist perspective with one who has a postmodern, social constructionist understanding of the world. Whereas the modernist counselor seeks advice and answers through outside experts and sources so that he or she can “act,” the postmodern, social constructionist counselor includes outside experts and sources as part of the conversation that will happen between the counselor and the client. Whereas the modernist counselor wants to actively find something to do to the client, the postmodern, social constructionist counselor wants to understand the client’s current reality and how she came to it. Whereas the modernist counselor is likely to act to prevent the client from doing something harmful to herself, the postmodern, social constructionist counselor wants to explore all of the client’s narratives to ensure that the client is making the right choice for herself. And finally, whereas the modernist counselor is concerned about adhering to the ethics code and the law, the postmodern, social constructionist counselor is concerned about bringing the ethics code and the law into the conversation and the decision-making process with the client.

When faced with thorny ethical decisions, counselors are ethically and legally bound to make decisions within the context of their ethics codes and the law. However, one can see how a postmodern, social constructionist approach can, on rare occasions, lead a counselor to a conversation with a client that considers actions that would violate the counselor’s ethics code and even the law. Ultimately, the counselor must make a decision that serves the client and the counselor best. Knowing the limits of the codes, the reach of the law, and the result of violating one’s code and the law, the counselor must think long and hard when faced with a difficult ethical dilemma that could result in a decision that violates the law or the counselor’s own ethics code. At that point, the counselor must decide on what action to take to preserve her or his own life story, and the counselor may want to share those concerns with the client. Then the conversation with the client can move forward, and this new conversation may become another decision point for the client. As the client hears the counselor’s dilemma, the client may change his or her understanding of what to do. If not, the counselor must decide what he or she wants to do.

This chapter on the client’s perspective concludes our introduction to dual or multiple relationships. In Chapter 1 we provided a foundation by defining dual relationships and discussing relationship boundary issues. We looked at risks and the potential for harm and offered some safeguards to minimize risk. In Chapter 2 we explored sexual dual relationship issues. In this chapter we focused on the client’s perspective and suggested a rationale and strategies for including clients in ethical decision making. In the next four chapters, we turn to multicultural and social justice perspectives on boundaries and highlight boundary issues in counselor education, supervision and consultation, and the education and training of group counselors.

In this chapter, we address boundary considerations from multicultural and social justice perspectives. Sue and Sue (2013) describe social justice counseling as an active philosophy and approach aimed at producing conditions that allow for equal access and opportunity. “Social justice counseling with marginalized groups in our society is most enhanced (a) when mental health professionals can understand how individual and systemic worldviews shape clinical practice and (b) when they are equipped with organizational and system knowledge, expertise, and skills” (pp. 108–109). From this perspective, the helper’s role is broadened beyond that of a traditional mental health provider. Traditional models and techniques need to be aligned to best suit the diverse worldviews of clients. The strong individualistic bias of contemporary theories and the lack of emphasis on broader social contexts, such as families, groups, and communities, may not provide a wide range of clients with what they most need. In many cultures, collectivism is valued and identity is not viewed as being separate from the group orientation. Counselors with a multicultural and social justice orientation will be challenged to redefine the boundaries of their professional roles and to modify the way they practice with clients. Becoming a multiculturally competent counselor entails a shift in thinking and demands a different way of acting and practicing that several guest contributors describe in this chapter.

A few of the questions we explore in this chapter are:

• Is it ethical to barter with clients for goods or services?

• Under what circumstances, if ever, should a counselor accept a gift from a client?

• What are the appropriate limits of self-disclosure, and how could overextending these limits create a dual relationship problem?

• What alternative roles do counselors need to assume to effectively serve a culturally and ethnically diverse population?

• How does the social justice orientation differ from traditional approaches to counseling?

The choices practitioners make regarding these issues are likely to either confound or clarify their attempts to practice aspirational ethics within an increasingly diverse world.

A basic theme that runs throughout this chapter is that the cultural context needs to be considered when determining appropriate therapeutic boundaries with clients. Eight guest contributors add their voices to this chapter:

• Fred Bemak and Rita Chi-Ying Chung present multicultural and social justice perspectives on boundaries with culturally diverse clients.

• Derald Wing Sue and Christina Capodilupo explore the cultural context of working with boundaries and present an Asian perspective on reconsidering some counseling practices.

• Thomas A. Parham and Leon D. Caldwell provide an African-centered perspective in rethinking the definition of appropriate boundaries.

• Raul Machuca describes boundary concerns with Latino clients.

• Mevlida Turkes-Habibovic explores boundaries in counseling Muslim clients.

In the most recent revisions of the ethics codes of mental health professionals, the standards pertaining to bartering have been refined, and bartering is more generally discouraged. Although bartering is not often practiced and is not encouraged, the codes of various professions do recognize that there are circumstances in which bartering may be acceptable and that it is important to take into consideration cultural factors and community standards.

Counselors may barter only if the bartering does not result in exploitation or harm, if the client requests it, and if such arrangements are an accepted practice among professionals in the community. Counselors consider the cultural implications of bartering and discuss relevant concerns with clients and document such agreements in a clear written contract. (American Counseling Association [ACA], 2014, Standard A.10.e.)

Marriage and family therapists ordinarily refrain from accepting goods and services from clients in return for services rendered. Bartering for professional services may be conducted only if: (a) the supervisee or client requests it, (b) the relationship is not exploitative, (c) the professional relationship is not distorted, and (d) a clear written contract is established. (American Association for Marriage and Family Therapy [AAMFT], 2012, 7.5.)

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. (American Psychological Association [APA], 2010, 6.05.)

Social workers should avoid accepting goods or services from clients as payment for professional services. Bartering arrangements, particularly involving services, create the potential for conflicts of interest, exploitation, and inappropriate boundaries in social workers’ relationships with clients. Social workers should explore and may participate in bartering only in very limited circumstances when it can be demonstrated that such arrangements are an accepted practice among professionals in the local community, considered to be essential for the provision of services, negotiated without coercion, and entered into at the client’s initiative and with the client’s informed consent. Social workers who accept goods or services from clients as payment for professional services assume the full burden of demonstrating that this arrangement will not be detrimental to the client or the professional relationship. (National Association of Social Workers [NASW], 2008, 1.13.b.)

Although the ethics codes do not prohibit bartering, they do offer cautions regarding the practice. There are potential problems with bartering, even though the practice may be motivated by an altruistic concern for the welfare of clients with limited financial resources. Kitchener and Harding (1990) pointed out that the services a client can offer are usually not as monetarily valuable as counseling. Thus, over time, clients could become trapped in a sort of indentured servitude as they fall further and further behind in the amount owed. Another potential problem concerns what criteria should be used to determine what goods or services are worth an hour of the therapist’s professional time.

The practice of bartering could open up more problems than it is worth. As an example, consider a client who pays for therapy by working on the counselor’s car. If the mechanical service is less than desirable, the chances are good that the counselor will begin to resent the client on several grounds: for having been taken advantage of, for being the recipient of inferior service, and for not being appreciated. The client, too, can begin to feel exploited and resentful if it takes many hours of work to pay for a 50-minute therapy session, or if the client believes the therapy is of poor quality. Feelings of resentment, whether they build up in the counselor or in the client, are bound to interfere with the therapeutic relationship.

Although bartering is not prohibited by ethics or law, most legal experts frown on the practice. Woody (1998), who is both a psychologist and an attorney, recommends against the use of bartering for psychological services because it could be argued that bartering is below the minimum standard of practice. If therapists enter into a bartering agreement with a client, Woody believes therapists have the burden of proof to demonstrate that the bartering arrangement (a) is in the best interests of the client; (b) is reasonable, equitable, and undertaken without undue influence; and (c) does not get in the way of providing quality psychological services to the client. Because bartering is so fraught with risks for both client and therapist, Woody believes prudence dictates that it should be the alternative of last resort. Even if bartering is monitored carefully to lessen the chance of exploitation, there is a high risk of allegations of misconduct.

Although we can see potential problems in bartering, we think it is a mistake to condemn this practice too quickly or in all cases. In some cultures or in some communities, bartering is a standard practice, and the problems just mentioned may not be as evident. For instance, rural environments may lend themselves more to barter arrangements. We know a practitioner who worked with farmers in rural Alabama who paid with a bushel of corn or apples. Within their cultural group, this was a normal way (and in some cases, the only possible way) of doing business. Many different kinds of barter arrangements could be agreed upon between counselor and client. There are also alternatives to bartering, such as using a sliding scale, doing pro bono work, or referring the client to another provider.

Before bartering is entered into, it is important that the client and the counselor talk about the arrangement, discuss problems that might develop along with alternatives that might be available, gain a clear understanding of the exchange, and come to an agreement in writing. Bartering is an example of a dual relationship that allows some room for practitioners, in collaboration with their clients, to use good judgment and consider the cultural context in the situation.

Barnett and Johnson (2008) and Koocher and Keith-Spiegel (2008) agree that bartering with clients can be both a reasonable and a humanitarian practice when people require psychological services but do not have insurance coverage and are in financial difficulty. They add that bartering arrangements can be a culturally sensitive and clinically indicated decision that may prove satisfactory to both parties. However, because of the risk involved in bartering practices, they recommend carefully assessing such arrangements prior to taking them on. This is an area in which counselors would do well to seek consultation from a colleague who can provide an objective assessment of the proposed bartering arrangements. Of course, all of these steps should be documented in the client’s clinical record.

Lawrence Thomas (2002), a clinical psychologist and a neuropsychologist, claimed that he never felt completely comfortable when he entered into a bartering arrangement, but each time he did so he believed bartering was the best alternative. Although bartering is a troublesome topic, it can be a legitimate means of helping out a person with financial difficulties. Thomas writes: “It can serve as a relatively dignified way for the patient to compensate the therapist for professional work” (p. 394). In his view, bartering should not be ruled out simply because of the slight chance that a client might initiate a lawsuit against the therapist. Thomas cautioned that venturing into any dual relationship requires careful thought and judgment and that the vast majority of professional work should be paid by the usual monetary means. When this is not possible due to a client’s economic situation, however, allowances should be made so that psychological services might be available. In short, bartering can be a way for the poor but needy client to obtain psychological services.

Thomas recommends a written contract, which should be reviewed regularly, that specifies the details of the agreement between therapist and client. Documenting the arrangement can clarify agreements and can also help professionals defend themselves if this becomes necessary.

• What is your own stance toward bartering?

• Do you see it as unacceptable in your own practice, or can you foresee instances when you might work out a barter arrangement that meets your professional code’s criteria for ethical practice?

• What cultural factors would you consider in deciding whether or not to barter?

• What standards within the community would you consider?

• What alternatives to bartering might you consider with your clients who are unable to pay your fee?

The cultural implications of gift-giving are recognized in the ACA Code of Ethics (ACA, 2014):

Counselors understand the challenges of accepting gifts from clients and recognize that in some cultures, small gifts are a token of respect and gratitude. When determining whether to accept a gift from clients, counselors take into account the therapeutic relationship, the monetary value of the gift, the client’s motivation for giving the gift, and the counselor’s motivation for wanting to accept or decline the gift. (Standard A.10.f.)

The AAMFT (2012) also has a guideline regarding gifts: “Marriage and family therapists do not give to or receive from clients (a) gifts of substantial value or (b) gifts that impair the integrity or efficacy of the therapeutic relationship” (3.10.).

Neukrug and Milliken (2011), in their survey of ACA members, found that approximately 89% of counselors believed it was unethical to accept a gift worth more than $25 from a client. In an earlier study, Borys (1988) found that only 16% of respondents believed that it was never or only rarely ethical to accept a gift worth less than $10, but the percentage of those who disapproved rose to 82% when the gift was worth more than $50. Apparently, the monetary value of gifts is a major factor for counselors in determining whether it is ethical to accept them. Although expensive gifts certainly present an ethical problem, it is possible to be overly cautious and, in so doing, damage the therapeutic relationship. Rather than establishing a hard and fast rule, our preference is to evaluate each situation individually.

Other factors also need to be examined. Counselors need to be sensitive to cultural differences. As Derald Wing Sue, Christina Capodilupo, and Raul Machuca point out later in the chapter, gift-giving has different meanings in different cultures. The motivation of the client also needs to be considered. If the offering of a gift is an attempt to win the favor of the counselor or is some other form of manipulation, it is best not to accept the gift. It may be unwise to accept a gift without first having a discussion with the client. Gutheil and Brodsky (2008) maintain that the giving or receiving of gifts has layers of meaning, for both the client and therapy, that call for careful exploration. They suggest that in appropriate circumstances a gift may be helpful to therapy. Koocher and Keith-Spiegel (2008) contend that accepting certain kinds of gifts (highly personal items) is inappropriate and would require exploring the client’s motivation. Counselors may want to inquire about the meaning to the client of even small gifts. According to Zur (2011), any gift must be understood and evaluated within the context in which it is given. Zur believes that expensive gifts or any gifts that create indebtedness, whether of the client or the therapist, are boundary violations. However, Zur claims that appropriate gift-giving can be a healthy aspect of a therapist–client relationship and can enhance therapeutic effectiveness.

The relationship that has developed between the counselor and the client should be considered. Offering a gift may be the client’s way of expressing appreciation. For example, a client might bring a potted plant to a termination session as a way of saying “thank you” for the work that the counselor and client have accomplished together. If the therapist were to simply say “I cannot accept your gift,” the client might feel hurt and rejected. Gutheil and Brodsky (2008) take the position that when clients offer a small gift at the end of therapy it is customary to accept the gift if it is appropriate and of insubstantial value. However, acceptance of other gifts might be improper. For example, a client who is a corporate executive might offer her counselor a stock tip based on her insider’s knowledge. The counselor needs to explain to the client why it is improper to profit financially from information gained through a counseling relationship, and this could lead to a productive discussion about why the client felt a need to make such an offer. As is true of so many ethical dilemmas, one possibility is for the therapist to discuss his or her reactions with the client about accepting a gift.

One way to avoid being put in the awkward position of having to refuse a gift is to include a mention of the policy in your professional disclosure statement. The statement could include the information that, although counseling sessions may be intimate and personal, the relationship is a professional one and does not allow you to accept gifts. Although being clear with clients at the outset of the relationship does prevent some later problems, there will be instances when small gifts are offered and might be received in the spirit in which they were offered. Rather than using a price tag or some other arbitrary criterion to determine the ethics of accepting gifts, the counselor might choose to have a full and open discussion with the client about the matter.

• In your own practice, would you ever accept a gift from a client? Why or why not?

• What criteria would you use in deciding whether to accept or refuse the gift?

• Would you ever be inclined to give a client a gift? If not, why not? If so, under what circumstances would you give a gift to a client?

Counselor self-disclosure has been an issue of ethical concern as a result of research such as that conducted by R. I. Simon (1991), who found that inappropriate self-disclosure is the type of boundary violation that is most likely to precede sexual intimacies. Nonetheless, Neukrug and Milliken (2011) found that nearly 87% of surveyed counselors rated self-disclosing to a client as “ethical.” Self-disclosure may be therapeutically beneficial or harmful, depending on a number of factors. The purpose of self-disclosure needs to be kept in mind. It is often relevant for a counselor to disclose his or her reactions to a client in the here-and-now of the therapy session, and this is more likely to have a therapeutic effect than disclosing details of one’s personal life to a client. As with other counseling interventions, self-disclosure must be a thought-out process. We must determine whether our self-disclosures are clinically sound therapeutic interventions or subtle boundary violations. When counselors disclose personal facts or experiences about their lives, the disclosures should be appropriate, timely, and done for the benefit of the client. Yalom (2003) acknowledged that the therapist’s practice of revealing aspects of his or her personal life can facilitate the therapeutic process, but he also suggests using caution.

If we find ourselves going into detail about our personal lives with our clients, we need to ask ourselves about our intentions and whose needs we are meeting. Clients are seeking our help for their problems, and they are not there to listen to our stories about our past or present struggles. Self-disclosure is a means to an end, not a goal in itself. If we lose sight of the appropriate professional boundaries with our clients, the focus of therapy might well shift from the therapist attending to the client to the client becoming concerned about taking care of the therapist.

A key ingredient in maintaining appropriate boundaries of self-disclosure is the mental health of the counselor. If we are not being listened to by our significant others, there is a danger that we might use our clients to satisfy our needs for attention. Our clients might become substitute parents, children, or friends, and this kind of reverse relationship is certainly not what our clients need. Instead, when we have conflicts or unresolved personal concerns, we need to address them with a colleague, a supervisor, or a therapist.

Fred Bemak and Rita Chi-Ying Chung present a multicultural and social justice approach to reconsidering boundaries in the therapeutic relationship. They develop the message that traditional models of counseling practice are grounded in assumptions that often are not effective when counseling people from diverse cultural backgrounds. They address a range of specific topics that call for adaptation to work from a multicultural and social justice framework. Some of the issues they address are community-based interventions, redefining self-disclosure, gift-giving, socializing with clients, the role of touch in counseling, bartering, and assuming alternate roles as helpers.

Fred Bemak and Rita Chi-Ying Chung

Collectively we (Fred and Rita) have been working in cross-cultural and multicultural settings for five decades. A continual challenge in doing this work has been defining and maintaining boundaries with culturally diverse clients while providing counseling oriented toward social justice. A recurrent question we have both asked is how to broaden counselor–client relationships to incorporate culturally appropriate boundaries when working with clients who do not fit the traditional Western counseling paradigm. I (Fred) began my career working in an antipoverty program with ethnically diverse clients, and traditional boundaries accepted by the mainstream counseling profession were not applicable. I (Rita) am from a traditional Chinese background and was not born nor did I grow up in the United States. I have always challenged counseling and psychology definitions of boundaries and multiple relationships because they are incongruent with my Asian cultural worldview. If you are a mental health provider working in a multicultural setting, it is not surprising to me that you find dealing with boundaries and multiple relationships challenging.

Our role as helping professionals is to assist our clients in times of growth, change, and vulnerability. We believe that the power imbalance presents significant challenges for mental health professionals and has the potential to create ambiguity about one’s professional role and responsibility. This belief was supported in a national survey of psychologists that found the second most challenging concern in their day-to-day practice was “blurred, dual, or conflictual relationships” (Pope & Vetter, 1992, p. 399).

Given the importance of professional boundaries and relationships, the major professional mental health organizations—ACA, APA, AAMFT, and NASW—all have codes of ethics that address the topic of boundaries and multiple relationships with an intent to define the role of the therapist that will lead to the best therapy for clients. However, the boundary definitions in these codes of ethics are based on Western cultural values (Barnett, Lazarus, Vasquez, Moorehead-Slaughter, & Johnson, 2007). We are concerned that counselors working in cross-cultural or multicultural environments who adhere strictly to the Western counseling-based codes of ethics are in danger of losing their credibility. This may lead to client mistrust, premature dropout, and termination of therapy.

To compound the challenge of defining boundaries and relationships that were historically developed from a Euro-American framework is the dramatic racial and ethnic change in U.S. demographics, with rapidly growing numbers of people of color throughout the United States (U.S. Census Bureau, 2010). If we follow the changing racial and ethnic composition of the U.S. population, we can imagine the proportionate expansion of clients of color. Therefore, embedded in the increased cultural and ethnic diversity in the United States is a need to redefine counselors’ roles and responsibilities to become better aligned with the expectations and understanding about the therapeutic relationship with clients of color. Traditional Eurocentric, individualistic theories define boundaries in counseling in ways that limit culturally responsive therapeutic relationships for diverse clientele, who may have different expectations about counseling and healing. This disparity in the definition of boundaries and multiple relationships between the mental health professionals and clients can have a negative effect on the therapeutic relationship (Chung & Bemak, 2012).

Adding to the complexity of culturally responsive counseling is the necessity for mental health professionals to be attentive to social justice concerns with their clients (Chung & Bemak, 2012). A danger in applying boundaries that are rooted in legality rather than culturally responsive or social justice orientations is reconstructing historical oppression, racism, discrimination, and shame that are experienced by clients of color (Vasquez, 2005), which may retraumatize clients. To move beyond the limitations of the traditional boundaries rooted in psychodynamic theory, counselors must at times become advocates and partners with clients, helping to change the inequities in the client’s world, and facilitating culturally appropriate and justice-related healing within the context of the client’s community (Bemak & Chung, 2005; Chung & Bemak, 2012). Taking on this advocacy role might involve counselors working with elders; spiritual, religious, and community leaders; or indigenous healers.

These multiple roles necessitate flexibility when interpreting current ethical standards and require that we create new ways of defining boundaries and relationships that are responsive to cultural healing methodologies that have often existed for centuries. This leaves counselors trying to figure out their role and position with clients in relation to both culture and social justice. Counselors may experience anxiety and confusion in deciding which boundary crossings are acceptable and appropriate and how to cultivate a therapeutic relationship that is in the best interest of the client. Although the Multicultural Counseling Competencies (Sue, Arredondo, & McDavis, 1992; Sue et al., 1998) were established as guidelines for counselors to be culturally competent when working with clients from culturally diverse backgrounds, they do not address boundaries and multiple relationships across cultures or the ethical responsibility of a mental health professional in addressing social injustices.

In this section we would like to help you think critically about the importance of culture and social justice as important multidimensional and complex issues when considering crossing boundaries in counseling. Some boundaries are universal even when conducting multicultural and social justice counseling, such as counselors avoiding the misuse of their power by exploiting, disparaging, abusing, undermining, or harassing a client, or engaging in inappropriate behaviors and sexual relationships (Barnett et al., 2007). Lazarus (in Barnett et al., 2007) contends that all other aspects of ethics and boundaries are open for discussion. We agree that the Western psychological framework regarding boundary crossings must be reconsidered as it relates to clients from different cultural backgrounds and from oppressive life situations. It is especially important to rethink this framework given the rapidly changing ethnic and racial demographics in the United States and the numerous injustices that disenfranchised clients and communities encounter.

It is critical to examine seven issues as we adapt our practice and attend to multicultural and social justice boundary relationships:

1. Community-based interventions. Many communities of color are close-knit and foster a social level of engagement that is antithetical to Euro-American individualistically oriented cultures. The boundaries around relationships, confidentiality, and privacy established within communities of color are oftentimes much more loosely structured and based more on the African premise that “It takes a village to raise a child.” Numerous times when we (Fred and Rita) have provided counseling in racial and ethnically diverse communities both in the United States and overseas, we have found there is much broader community involvement in a community member’s problem and expectations that the neighbors and friends will become highly involved in providing both formal and informal psychological support. This collective involvement necessitates a very different construction of boundaries that is oftentimes at odds with traditional Western ethics codes regarding confidentiality and privacy.

2. Redefining self-disclosure. In ethnically and racially diverse communities there are expectations that the relationship becomes more than a formal, in-the-office, 50-minute session. Self-disclosure can contribute to the commonality shared with a client and can foster a greater sense of genuineness. In many cultures there is an expectation that counselors will share aspects of their personal lives, which in turn cultivates trust and openness. Self-disclosure is appropriate only when it is helpful for the client and serves to facilitate the therapeutic process, but it is important to remember that self-disclosure has the potential to be a powerful tool in building a connection with marginalized clients who have a history of oppression or culturally different clients who may be distrustful of the therapeutic process. For counselors not to self-disclose may create mistrust, loss of counselor credibility, client feelings of being unsafe, potential harm to the client, and premature termination. In Asian cultures self-disclosure may enhance rapport and enrich the counseling process (Kim et al., 2003). It is essential to keep in mind that crossing boundaries with clients from different cultural backgrounds requires knowledge, skills, competencies, and experience about the cultural, historical, and sociopolitical background of clients.

3. Gift-giving. In some cultures, exchanging gifts represents the spirit of helping, and giving back is a demonstration of one’s appreciation and gratitude. For a mental health professional to reject a reasonable gift, or at times to withhold giving a gift, can be perceived as insulting and as a rejection of the client’s culture. The expense and appropriateness of the gift must be considered, but it is important to keep in mind the cultural norms and the importance of showing respect and thankfulness by and to the client through the gift. Counselors must utilize their common sense with regard to gift-giving. One example of appropriate gift-giving happened when we were facilitating a parent and caretaker’s counseling group in an urban African American community. There was a plan to celebrate a group member’s 70th birthday in the group. Unfortunately, the member’s granddaughter was ill the evening of the group meeting, so the grandmother couldn’t attend. Both of us, along with other group members, drove to her home, which was located in a close-knit nearby community, brought a birthday cake, and sat on her front porch in the neighborhood celebrating the birthday. Many neighbors joined us in an animated discussion about problems, life, and healing. The trust established from this visit carried through with all the group members for the duration of the group. Another example relates to my (Rita) culture, in which it is customary for clients to bring food as a way of saying thanks. To reject the specially cooked food would be highly insulting.

4. Socializing with clients. In communities of color, everyone important in the client’s life, including the counselor, is invited to join major social events. We have been asked to weddings, graduations, funerals, baptisms, birthdays, special cultural holidays, and community celebrations. Clients may perceive the rejection of these invitations as a lack of concern or care and, more important, a lack of a meaningful relationship. When we were invited by a client from Somalia to his mother’s funeral, it was important for us to show our support for his grief and loss. To reject his invitation would have been an affront and would have caused great strain on the client–counselor relationship. One of our Brazilian colleagues, a well-established and sought-after psychiatrist, has made numerous house calls with clients, sharing meals, drinks, and social time with family members before engaging in home-based therapy. Not socializing with these clients, he explained, would have created serious obstacles in the therapeutic relationship.

5. Touch is important and human. How did boundary concerns move us away from human contact? In many parts of the world where we travel, communities are far more receptive to appropriate physical contact and touch. How did we become so phobic about appropriate touching, and why do we let litigation become a driving force in defining healthy, culturally responsive healing practices? Reaching out and making suitable physical contact with someone who is feeling alone and depressed, a child who is crying or in deep pain, or an individual sobbing after loss of loved ones in an earthquake is normal in many cultures. Both of us have held a crying child or an adult who was in deep pain after the loss of a loved one through terminal illness, suicide, a fatal accident, civil conflict, or a natural disaster. It is critical that we reassess the Western cultural norm regarding physical contact and begin to understand the meaning of touch for our diverse client populations. We are convinced that we must redefine appropriate boundaries regarding touch so that they are healing with racially and ethnically diverse clients. It is our experience that multicultural and social justice–oriented counseling must incorporate appropriate touch and physical contact.

6. Bartering. Many cultures are built on a bartering foundation. In addition, these clients may not have adequate resources to pay for counseling services. To effectively reach out and work with those without the financial means to pay standard counseling rates, address economic inequities, and provide multicultural social justice counseling from a culturally responsive framework, bartering is an excellent alternative to the traditional form of payment. Bartering must be thoughtfully worked out, keeping in mind the cultural context and the specific situation of each client. For example, when I (Rita) worked with immigrants who had limited financial resources, the clients and I would discuss and agree on an exchange other than money as a form of payment. These clients visited an elderly person, helped out a person with disabilities, or tutored a newly arrived immigrant in return for counseling services. In other instances, both of us have worked out arrangements that were specific to clients, such as an exchange of home-baked goods by clients who were proud of their cooking skills, goods that were in turn shared with others and oftentimes donated to places such as homeless shelters, in return for counseling services.

7. Different roles create different boundaries. Attending to social justice issues and providing culturally responsive counseling requires us to take on different roles. At times we are advocates for our clients, at other times we are advisers, and sometimes we help generate social change in times of injustice or inequity. Still other times, mental health professionals find themselves being the liaison with culturally responsive healers such as elders and spiritual or religious healers. Each of these roles requires an expansion of traditional counseling responsibilities and functions from those based on the boundary definitions included in ethics codes. For example, we may become advocates to assist clients in gaining skills that would challenge discriminatory practices in their worksite, we may call on the Imam of the Mosque (mosque prayer leader) to speak with a client who is struggling with spiritual issues related to Islam, or we may become an adviser and provide directive interventions to a client coming from a culture where expectations are to receive explicit instructions from someone in an esteemed position like a counselor. Each of these singular roles requires a reconstitution of boundaries.

There is an inherent long-standing tension regarding boundaries and boundary crossings between the traditional psychodynamic model and the social justice approach of responding to racially and ethnically diverse clientele and oppressed populations. This tension mirrors much deeper divisions within the mental health field. It is imperative that we reexamine fundamental aspects of the counseling relationship that have a significant bearing on culture and social justice as a way to help us rethink the meaning, context, and practice of legality and humane practice that have bearing on social injustices and culture. As counselors we need to ask ourselves, “Whose boundaries are these?” “Do the boundaries help or hinder clients’ growth, development, and psychological well-being?” “If not, can we redefine the boundaries to more effectively respond to multicultural social justice issues facing clients?”

Counselors today, regardless of the setting in which they work, are likely to encounter challenges in meeting the needs of diverse client populations. Working effectively with culturally and ethnically diverse clients may entail a willingness to assume nontraditional roles and to adopt various roles at different stages in the helping process. Some of this role shifting may look like multiple relating and crossing boundaries that are traditionally marked; however, combining roles may be necessary to counsel effectively in a multicultural community.

Counselors who work with ethnically diverse clients may need to shift their thinking because sticking with a singular role may limit their ability to reach these clients. According to Atkinson, Thompson, and Grant (1993), practitioners are generally best trained to play the role of psychotherapist, but this is the role most frequently misapplied in working with racial or ethnic minority clients. Atkinson and his colleagues believe that the conventional role of psychotherapist is appropriate only for clients who are highly acculturated and want relief from an existing problem that has an internal etiology.

Sue and Sue (2013) have criticized conventional approaches to therapy that focus on a client’s intrapsychic conflicts and tend to place undue responsibility on clients for their plight. At the extreme, some interventions can be perceived as blaming client problems on the client rather than as examining real factors in the environment that may be contributing to the client’s problem. Many of the writers with a community orientation have emphasized the necessity for recognizing and dealing with environmental conditions that often create problems for diverse client groups rather than merely working to change an individual client’s behavior.

In selecting roles and strategies to use with diverse clients, Atkinson et al. (1993) believe it is useful to take into account the client’s level of acculturation, the locus of problem etiology, and the goal of counseling. These writers and Atkinson (2004) have suggested that several alternative roles—advocate, change agent, consultant, adviser, and facilitator of indigenous support systems—are appropriate for counselors who work in the community. These alternative counselor roles embody fundamental principles of social justice and activism that are aimed at client empowerment. Rita Chi-Ying Chung and Fred Bemak stated that at times they are advocates for their clients, at other times they are advisers, and sometimes they focus their efforts on social change to combat injustice or inequity. Each of these roles requires an expansion of traditional counseling responsibilities and functions.

Later in this chapter Derald Wing Sue and Christina Capodilupo describe the necessity for counselors to become competent carrying out nontraditional roles and reaching diverse members of a community. One of these roles is assuming the role of advocate when cultural groups are oppressed by the dominant society. Counselors can speak on behalf of clients who are low in acculturation and need help with problems that result from discrimination and oppression. Chung and Bemak (2012) contend that by adhering to traditional roles, mental health practitioners are maintaining and reinforcing the status quo, which results in politically supporting the social injustices, inequalities, and discriminatory treatment of certain groups of people. Chung and Bemak view becoming an advocate for empowerment as a central core of counseling that involves time and making a commitment to this goal. They take the position that advocacy is an ethical and moral obligation for becoming an effective counselor. The ACA Code of Ethics (ACA, 2014) acknowledges the importance of advocacy for clients whose problems result from discrimination and oppression (Standard A.7.), and the Codeincludes the promotion of social justice as a core value of the profession.

In the role of change agent, counselors can make use of political power to confront and bring about change within the system that creates or contributes to problems that clients face. In this role, counselors assist clients to recognize oppressive forces in the community as a source of their problems and teach clients strategies for dealing with these environmental problems. A change agent recognizes that healthy communities produce healthy people. In their role as change agent, counselors must at times educate organizations to change their culture to meet the needs of the community.

By operating as consultants, counselors often assume the role of teacher. They can encourage clients from various ethnic groups to learn skills they can use to interact successfully with various forces within their community. The client and the counselor work together collegially to address unhealthy forces within the system and to design prevention programs to reduce the negative impact of racism and oppression.

The counselor as adviser discusses with clients ways to deal with environmental problems that are contributing to their personal problems. This is much like a social work approach that considers the person-in-the-environment rather than addressing problems as residing solely within the individual. For example, recent immigrants may need advice on coping with problems they will face in the job market or that their children may encounter at school.

For many ethnically and culturally diverse clients, seeking help in the form of traditional counseling is foreign. Often they are more willing to turn to social support systems within their own community. By acting as facilitators of indigenous support systems, counselors can encourage clients to make full use of the resources in their communities, including community centers, extended families, neighborhood social networks, churches, and ethnic advocacy groups. Counselors need to learn what kinds of healing resources exist within a client’s culture. In many cultures, professional counselors have little hope of reaching individuals with problems because these individuals are likely to put their trust in folk healers, acupuncturists, and spiritual healers who are a part of their culture. At times, it may be difficult for counselors to adopt the worldview of their clients, and in such instances it could be helpful to make a referral to an indigenous healer. Counselors can then structure their activities to complement or augment the healing resources available for the client.

For counselors who hope to reach a diverse range of client populations, it is essential to be able to employ therapeutic strategies in flexible ways and to assume various roles in helping clients. Combining roles will be necessary to help many clients effectively. Counselors who assume a social justice orientation are not merely concerned with bringing about changes within the individual; rather, they are interested in instigating social change. Competent multicultural and social justice counseling calls for practitioners who are familiar with community resources, know the cultural background of their clients, have skills that can be used as needed by clients, and have the ability to balance various roles. For thoughtful discussions of case examples of social justice programs and re-envisioning the practice of counseling, we recommend Helping Beyond the 50-Minute Hour: Therapists Involved in Meaningful Social Action (Kottler, Englar-Carlson, & Carlson, 2013). For comprehensive discussions of social justice and systems changes as applied to working with diverse client populations, see Social Justice Counseling: The Next Steps Beyond Multiculturalism (Chung & Bemak, 2012).

Derald Wing Sue and Christina Capodilupo expand on some alternative roles in helping that may be implemented in various communities. They eloquently present an ethical framework for viewing dual or multiple relationships from a multicultural perspective. Their contribution shows how boundaries take on special meaning when working in the community.

Derald Wing Sue and Christina Capodilupo

Mental health professionals are increasingly being confronted with situations that challenge the standards of practice and codes of ethics developed by their professional associations (Sue & Sue, 2013). Such is the case with dual or multiple relationships. Once counselors have entered into a therapeutic relationship with a client, the role they play becomes relatively prescribed. Traditionally, that role has been defined as working for the “therapeutic good” of clients, avoiding undue influence, allowing clients to make decisions on their own, setting clear boundaries, and maintaining objectivity by preventing personal bias from entering counseling decisions. It is believed that such a therapeutic relationship is sacrosanct, and indeed ethics codes have arisen around it to protect clients from being “taken advantage of” or “harmed.”

Codes of ethics have clear guidelines that warn against multiple relationships because such relationships potentially compromise the therapeutic role. There is good reason for the existence of these standards, and some psychologists assert that relationship boundaries should remain rigid and well defined. Others have begun to raise questions and issues regarding the universal application of such standards to all situations, problems, and populations, suggesting that multiple relationships are not necessarily problematic, especially in the context of small communities (Schank & Skovholt, 2006; Sue, Ivey, & Pedersen, 1996). First, concepts of mental health, the therapeutic process, and the roles helping professionals play are grounded in modern Euro-American culture. Some cultural groups may value multiple relationships with the helping professional. Second, some dual or multiple relationships may be unavoidable. This is especially true in smaller towns and rural areas where there are very few mental health professionals (Campbell & Gordon, 2003; Schank & Skovholt, 2006). Finally, some mental health professionals believe that multiple relationships based on nontraditional helping roles may be more beneficial than harmful. For example, it has been suggested that multiple relationships may facilitate the use of mental health services among those in rural areas (Schank & Skovholt, 2006); communities of color (Pedersen, 1997); religious communities (Case, McMinn, & Meek, 1997); and the lesbian, gay, bisexual, and transgender (LGBT) communities (Graham & Liddle, 2009).

The multicultural counseling and therapy movement has sensitized many to the fact that standards of normality and abnormality, the counseling role, and what is considered therapy are culture bound (Parham, 2002; Santiago-Rivera, Arredondo, & Gallardo-Cooper, 2002; Sue & Sue, 2013). In Asian culture, for example, it is believed that intimate matters (self-disclosure) are most appropriately discussed with an intimate acquaintance (relative or friend). Self-disclosing to a stranger (counselor) is considered taboo and is a violation of familial and cultural values. Thus certain Asian cultures may encourage a “dual” or “multiple” relationship in which the helper is also a relative or close personal friend. An Asian client’s desire to have the traditional counseling role evolve into a more personal one is often perceived by a Euro-American–trained counselor as inappropriate and manipulative. In addition, gift-giving is a common practice in many Asian communities to show gratitude, respect, and the sealing of a relationship (Sue & Sue, 2013). Such actions are culturally appropriate, yet counselors unfamiliar with such practices may feel that it is inappropriate to accept a gift because it blurs boundaries, changes the relationship, and creates a conflict of interest. They may politely refuse the gift, not realizing the great insult and cultural meaning of their refusal for the giver. In direct recognition of this cultural consideration, the ACA Code of Ethics (ACA, 2014) specifies that “counselors . . . recognize that in some cultures, small gifts are a token of respect and gratitude” (Standard A.10.f.).

The multicultural counseling movement has also challenged the traditional roles played by counselors who work in the community. Most counselors are taught that therapy is conducted in an office environment, is directed toward remediation, and is a one-to-one process. They are taught that the counselor is relatively inactive and that clients must make the decisions and take responsibility for their own actions. Yet in many cultural groups, including among African Americans, Hispanic/Latino(a) Americans, and Asian Americans, clients prefer to receive advice and suggestions because they perceive the counselor to be an expert with higher status who possesses special knowledge and expertise. The roles they find helpful may not be the traditional counseling role but other, more active roles. Atkinson et al. (1993) and Atkinson (2004) have identified different helping roles that the professional needs to develop to become multiculturally competent and to work effectively in the community. These roles are associated with client needs and characteristics: internal versus external locus of the problem, level of acculturation/knowledge of the home culture, and whether the overall goal is one of remediation or prevention. Playing more than one of these roles implies the establishment of a dual or multiple relationship. Similarly, LGBT therapists often find themselves in overlapping relationships with LGBT clients who share their communities. It has been suggested that LGBT therapists need to maintain flexibility and constantly negotiate personal and professional boundaries in an effort to effectively manage these multiple relationships (L. E. Kessler & Waehler, 2005).

In smaller communities and in our historical past, it was not unusual for citizens to play multiple roles such as storekeeper, neighbor, teacher, and friend. With increasing urbanization, such cross-mixing of relationships has become rare in the cities. As Forester-Miller and Moody discuss later in this book (Chapter 11), a counselor or therapist in a smaller community may find it exceedingly difficult not to have other relationships with her or his clients. Similar assertions have been made for LGBT therapists (Graham & Liddle, 2009).

Our codes of ethics now recognize that multiple relationships may be unavoidable, that not all such relationships are harmful, and that under certain conditions they may even be therapeutically beneficial. A helpful distinction was made between boundary crossing and boundary violation by Zur and Lazarus (2002). A boundary crossing is a harmless and often helpful deviation from traditional clinical practice, whereas a boundary violation is a departure from accepted practice that is harmful and exploitive. These scholars argue that boundary crossings are likely to “increase familiarity, understanding, and connection and hence increase the likelihood of success for the clinical work” (p. 6). In general, the guidelines discouraging dual relationships are well intentioned and basically sound. However, they must not be rigidly applied to all situations. As we have seen, community characteristics (rural versus urban, small versus large, LGBT, and community acceptance of certain practices such as bartering), multicultural redefinitions of counseling roles, and cultural perceptions of helping practices must be considered. Given the fact that counselors may unavoidably find themselves in a dual relationship or faced with a potential one, what guidelines can be used to minimize harm? Here are a few suggestions to consider:

• Personal and professional integrity must be the guiding force behind a decision to enter a dual relationship or to maintain one. Counselors must consider the good of the client first and not allow personal or professional agendas to interfere with the therapeutic relationship. The decision must be based not solely on “good intentions” but on whether the relationship actually impairs or harms the therapeutic goals or whether the risks for harm are too great. Mental health professionals should assess whether they are using the power differential to exploit their client in any way.

• Counselors must be thoroughly knowledgeable about their profession’s code of ethics and the spirit in which it was developed. Written statements cannot cover all situations. Many, like the examples given earlier, are not covered by clear guidelines, and to stick to “the letter of the law” may harm clients. Adhering to a dichotomous definition of the therapeutic relationship may obscure subtleties in cultural expectations and prevent effective treatment (Glass, 2003).

• Counselors must educate themselves about cultural and community standards of practice. For example, if a counselor decides to accept a gift from a client or to accept barter as a means of exchange, the actions must be judged according to the client’s cultural context and by the community’s normative standards.

• If a counselor does not feel comfortable with a dual rela