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The codes of ethics of psychotherapists' professional associations have evolved through the years to suit the increasing awareness and knowledge of the field. Like other codes during the mid-twentieth century and ensuing decades, the code of ethics of the American Psychological Association (APA, 1953) concentrated on the general points of promoting client welfare and discouraging abuse of power by therapists. Years later, when the codes changed to provide more specific guidelines and restrictions, therapists were instructed to make every effort to avoid dual relationships (APA, 1977, 1981).
In the late Nineteen-Eighties, the realization began to spread that dual relationships were unavoidable in some circumstances, such as living in rural areas, the military and among constituents of definite individual communities, such as the deaf, gays, and other minorities. To reflect this fresh awareness about and acceptance of dual relationships, all major professional associations (e.g. ACA, 2005; APA, 1992; NASW, 1996) have revised their codes of ethics in recognition of the fact that dual relationships are neither always avoidable nor always unethical (Barnett & Yutrzenka, 1994; Ebert, 1997; Williams, 1997; Zur, 2000). This shift of recognition that dual relationships are unavoidable and can be ethical seems to have made little impression on the widespread opinion that dual relationships are inherently unethical and should be avoided (Hedges, 1993).
The common misapprehension about the ethics of non-sexual dual relationships results from lack of familiarity with, misunderstanding of, or a biased attitude towards the content of the codes themselves. These obstacles are inspired primarily by the analytic urban risk-management approach to therapy. Those still under the false impression that dual relationships are essentially unethical include the majority of therapists, judges, members of ethics committees, and attorneys. Notably, the most significant groups that demonstrate lack of clarity on this issue are scholars and ethicists, many of whom operate under the misinterpretation of dual relationships as innately unethical, exploitative, and harmful (Ebert, 1997; Hedges, 1993; Lazarus, 1994; Williams, 1997; Zur, 2001, 2007).
To circumvent the possibility of contributing to the confusion surrounding the codes of ethics, the next section is composed of exact quotes about dual relationships, lifted verbatim from the codes of ethics of the major professional associations. Because sexual dual relationships with current clients have always been unethical in the codes of ethics of all psychotherapists' professional associations, the passages that follow contain only those principles that directly relate to non-sexual dual relationships.
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The Current Codes of Ethics, Verbatim
- American Psychological Association (APA) Ethical Principles of Psychologists and Code of Conduct (The revised Code is Effective as of June 2002), Section 3.05 on Multiple Relationships offers a clearer than ever before an acknowledgement that dual relationships are not always unethical.
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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.
- 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.
- 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. (APA, 2002, Multiple Relationships section, para 1-4).
[Dr. Zur's comments: It is important to note that this 2002 code of ethics has added an important statement, "Multiple relationships that would not reasonably be expected to cause impairment or risk exploitation or harm are not unethical." Additionally, it is important to note that the code does not consider sequential, non-sexual dual relationships as dual relationships. This seems to mean that activities by therapists who become friends or start business relationships after termination of therapeutic relationships, as long as there was no promise of such relationships, are not covered by the code of ethics. This has significant ramifications as it counters the claim by many psychoanalytic and other scholars, risk management experts and attorneys who focus on the supposedly lasting impact of transference beyond the termination date. For more information on this issue, see Zur, 2007]
- American Psychiatric Association (ApA) Principles of Medical Ethics. With Annotations Especially Applicable to Psychiatry (2001) does not mention dual or multiple relationships. It simply outlines the general principles that appear in all other codes, of the mandate to avoid exploitation and harm to patients.
- American Association of Marriage and Family Therapists (AAMFT) Code of Ethics (2001), Section1.3, states:
Marriage and family therapists are aware of their influential positions 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 take appropriate precautions (Responsibility to Clients Section, para. 4)
- The National Association of Social Workers (NASW) Code of Ethics (1999), Standard 1.06.c, states:
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.) (Conflict of Interest Section, para. 3)
- American Counseling Association (ACA) Code of Ethics and Standards for Practice (2005).
A.1.d. Support Network Involvement
Counselors recognize that support networks hold various meanings in the lives of clients and consider enlisting the support, understanding, and involvement of others (e.g., religious/spiritual/community leaders, family members, friends) as positive resources, when appropriate, with client consent.
A.5.a. Current Clients
Sexual or romantic counselor–client
interactions or relationships with current
clients, their romantic partners, or
their family members are prohibited.
A.5.b. Former Clients
Sexual 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.
Counselors, before engaging in
sexual or romantic interactions or
relationships with clients, their romantic
partners, or client family
members after 5 years following the
last professional contact, demonstrate
forethought and document (in
written form) whether the interactions
or relationship can be viewed as
exploitive in some 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 such an interaction
or relationship.
A.5.c. Nonprofessional Interactions
or Relationships (Other Than
Sexual or Romantic
Interactions or Relationships)
Counselor–client nonprofessional
relationships with clients, former
clients, their romantic partners, or
their family members should be
avoided, except when the interaction
is potentially beneficial to the client.
(See A.5.d.)
A.5.d. Potentially Beneficial
Interactions
When a counselor–client nonprofessional
interaction with a client or
former client may be potentially
beneficial to the client or former
client, the counselor must document
in case records, 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. Such
interactions should be initiated with
appropriate client consent. Where
unintentional harm occurs to the
client or former client, or to an individual
significantly involved with
the client or former client, due to
the nonprofessional interaction,
the counselor must show evidence
of an attempt to remedy such
harm. Examples of potentially beneficial
interactions include, but are
not limited to, attending a formal ceremony
(e.g., a wedding/commitment
ceremony or graduation); purchasing
a service or product provided
by a client or former client (excepting
unrestricted bartering); hospital
visits to an ill family member; mutual
membership in a professional
association, organization, or community.
(See A.5.c.)
[Dr. Zur's comments: Undoubtedly, ACA code of 2005 has made significant positive change to stop the demonization of dual relationships and appropriately acknowledges that dual relationships can have positive clinical impact. However, it must be clear that "attending a formal ceremony (e.g., a wedding/commitment ceremony or graduation)" or making a "hospital visit to an ill family member" are not dual relationships. These are what I call out-of-office experiences. In contrast, bartering for services and "mutual membership in a professional association, organization, or community" constitute dual relationships. To read more about the differences between out-of-office experiences and dual relationships go to http://www.drzur.com/outofoffice.html and http://www.drzur.com/outofofficeexperiences.html. Finally, it is interesting to note the code no longer uses the term dual or multiple relationships. Substituted is the term "Nonprofessional Interactions or Relationships."]
A.5.e. Role Changes in the
Professional Relationship
When a counselor changes a role
from the original or most recent contracted
relationship, he or she obtains
informed consent from the client and
explains the right of the client to
refuse services related to the change.
Examples of role changes include
1. changing from individual to relationship
or family counseling, or
vice versa;
2. changing from a nonforensic
evaluative role to a therapeutic
role, or vice versa;
3. changing from a counselor to a
researcher role (i.e., enlisting
clients as research participants),
or vice versa; and
4. changing from a counselor to a
mediator role, or vice versa.
Clients must be fully informed of any
anticipated consequences (e.g., financial,
legal, personal, or therapeutic) of
counselor role changes.
- Feminist Therapy Institute (FTI) Feminist Therapy Code of Ethics (1999), Section III, Overlapping Relationships, states:
III. Overlapping Relationships
A. A feminist therapist recognizes the complexity and conflicting priorities inherent in multiple or overlapping relationships. The therapist accepts responsibility for monitoring such relationships to prevent potential abuse of or harm to the client.
B. A feminist therapist is actively involved in her community. As a result, she is aware of the need for confidentiality in all settings. Recognizing that her client's concerns and general well-being are primary, she self-monitors both public and private statements and comments. Situations may develop through community involvement where power dynamics shift, including a client having equal or more authority than the therapist. In all such situations a feminist therapist maintains accountability.
[Dr. Zur's comments: It is surprising that the Feminist Therapy Code of Ethics takes such a clear stance that ". . . client's concerns and general well-being are primary" This seems contrary to feminist philosophy about the importance of community and egalitarian relationships. The concern with confidentiality in regard dual relationships is unnecessary as detailed in my Out-Of-Office paper]
- Canadian Psychological Association (CPA) Code of Ethics for Psychologists (2000), Section III.33, states:
Avoid dual or multiple relationships (e.g. with clients, research participants, employees, supervisees, students, or trainees) and other situations that might present a conflict of interest or that might reduce their ability to be objective and unbiased in their determinations of what might be in the best interests of others (Avoidance of Conflict of Interest Section, para. 3) (Emphasis added).
Section III.34, states:
Manage dual or multiple relationships that are unavoidable due to cultural norms or other circumstances in such a manner that bias, lack of objectivity, and risk of exploitation are minimized. This might include obtaining ongoing supervision or consultation for the duration of the dual or multiple relationship, or involving a third party in obtaining consent (e.g., approaching a client or employee about becoming a research participant). (Avoidance of Conflict of Interest section, para. 4)
- National Association of Alcoholism and Drug Abuse Counselors (NAADAC) Ethical Standards (2004) Principle 7, Dual Relationships, states:
I understand that I must seek to nurture and support the development of a relationship of equals rather than to take unfair advantage of individuals who are vulnerable and exploitable.
- I shall not engage in professional relationships or commitments that conflict with family members, friends, close associates, or others whose welfare might be jeopardized by such a dual relationship.
- Because a relationship begins with a power differential, I shall not exploit relationships with current or former clients for personal gain, including social or business relationships.
- I shall not under any circumstances engage in sexual behavior with current or former clients.
- I shall not accept substantial gifts from clients, other treatment organizations, or the providers of materials or services used in my practice.
[Dr. Zur's comments: NAADAC statement that therapists cannot have sexual relationships with former clients does not give any time limit. It is absurd to think that if an Alcohol and Drug abuse counselor sees a client for one session and twenty years later meets the ex-client in a party, they cannot have sexual relationships if they choose to.]
- American Association of Pastoral Counselors (AAPC) Code of Ethics (1994), Section III.E, states:
"We avoid those dual relationships with clients (e.g., business or close personal relationships) which could impair our professional judgment, compromise the integrity of the treatment, and/or use the relationship for our own gain" (Client Relationships section, para. 5) (Emphasis added).
- Canadian Counseling Association (CCA) Code of Ethics (1999), Section B, Counseling Relationships, subsection B8, Dual Relationships, states:
Counselors make every effort to avoid dual relationships with clients that could impair professional judgment or increase the risk of harm to clients. Examples of dual relationships include, but are not limited to, familial, social, financial, business, or close personal relationships. When a dual relationship can not be avoided, counselors take appropriate professional precautions such as informed consent, consultation, supervision, and documentation to ensure that judgment is not impaired and no exploitation occurs.
- California Association of Marriage and Family Therapists (CAMFT) Ethical Standards for Marriage and Family Therapists (2002), Section 1.2 states:
Marriage and family therapists are aware of their influential position with respect to patients, and they avoid exploiting the trust and dependency of such persons. Marriage and family therapists therefore avoid dual relationships with patients that are reasonably likely to impair professional judgment or lead to exploitation. A dual relationship occurs when a therapist and his/her patient engage in a separate and distinct relationship either simultaneously with the therapeutic relationship, or during a reasonable period of time following the termination of the therapeutic relationship. Not all dual relationships are unethical, and some dual relationships cannot be avoided. When a dual relationship cannot be avoided, therapists take appropriate professional precautions to insure that judgment is not impaired and that no exploitation occurs.
Section 1.2.2 adds:
Other acts which would result in unethical dual relationships include, but are not limited to, borrowing money from a patient, hiring a patient, engaging in a business venture with a patient, or engaging in a close personal relationship with a patient. Such acts with a patient's spouse, partner or family member may also be considered unethical dual relationships. (Responsibility to Patients section, para. 2) (Emphasis added).
[Dr. Zur's comments: The CAMFT injunction against "borrowing money from a patient, hiring a patient, engaging in a business venture with a patient, or engaging in a close personal relationship with a patient" is probably one of the most extreme standards set by any professional organization. It is unrealistic to always avoid business and personal relationships in rural and small communities. It is definitely impossible to avoid "close personal relationships" in the military or on Native American Reservations. Avoiding bartering for services (i.e., "hiring a patient") may deprive many cash-poor but skill-rich clients from obtaining therapy. To read more about bartering, go to http://www.drzur.com/bartertherapy.html, about rural communities, go to http://www.drzur.com/online/rural14.html and about appropriate dual relationships, see Zur, 2007]
- National Board for Certified Counselors (NBCC) Code of Ethics (1997) does not mention specific prohibition of dual or multiple relationships. It simply outlines the general principles that appear in all other codes, of the mandate to avoid exploitation and harm to patients.
- Northamerica Association of Masters in Psychology (NAMP) Ethical Standards and Code of Conduct (2000), Standard 3.3 states:
"Master's Psychologists shall exercise all possible precautions regarding "dual-relations" of any kind, and should avoid social contact with individuals such as clients, students, and supervisees in order to avoid actual or apparent exploitation. When, due to unanticipated circumstances, the provider discovers that a dual-relationship[s] exist, the provider exercises all possible care within the guidelines set forth in these ethical principles."
[Dr. Zur's comments: The position taken by the Northamerica Association of Masters in Psychology (NAMP, 1997) of absolute avoidance of dual relationships contradicts the stance of all major professional organizations. Either it is a reflection of outdated, unrealistic thinking, or a significantly restrictive measure taken in an attempt to help masters-level psychologist-therapists gain equality with doctoral-level psychologists.]
- American Art Therapy Association (AATA), Ethical Principle for Art Therapists (2003), Standard 1.5 states:
Art therapists refrain from entering into a multiple relationship if the multiple relationship could reasonably be expected to impair the art therapist's competence or effectiveness in performing his or her functions as an art therapist, or otherwise risks exploitation or harm to the person with whom the professional relationship exists.
A multiple relationship occurs when an art therapist 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 art therapist 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.
Multiple relationships that would not reasonably be expected to cause impairment or risk exploitation or harm are not unethical.
[Dr. Zur's comments: Like many professional organizations, The American Association of Art Therapists (AATA, 2003), has replaced its old (1995) rigid, unreasonable and impossible guidelines regarding dual relationships with a more reasonable, appropriate and realistic guidelines.]
- United States Association for Body Psychotherapy (USABP) Ethical Guidelines (2007) states:
V Multiple Relationships
Body Psychotherapists avoid exploitive multiple relationships. A multiple relationship occurs when a Body Psychotherapist is in a psychotherapeutic relationship with a person and is at the same time, or sequentially, in another relationship with the same person. Body Psychotherapists make a distinction between normally occurring community interactions and multiple relationships. Body Psychotherapists do not accept as a client anyone with whom they have had a sexual, close personal. or financial relationship or family or relatives of such persons. The boundaries of the therapeutic relationship should be clearly defined otherwise they have the potential to impair judgment, cause damage and undermine the purpose of the therapy.
1. Considerations about potential exploitation include the: nature and intensity of the professional relationship and of the secondary relationship, stage of therapy, amount of transference, degree of the role conflict, level of communication skills, and existence of an evaluative role.
2. Body Psychotherapists are aware of the differences in power that may exist in their relationships with clients, students and supervisees. Body Psychotherapists will be sensitive to the real and ascribed differences in power, be responsible for bringing potential issues into the awareness of those involved, and be available for reasonable processing with those involved.
3. In some situations, for example in small geographical or modality communities, a multiple relationship that is non-exploitive may be undertaken. In these cases, the Body Psychotherapist takes precautions to protect the client from exploitation and damage. Such precautions may include, but are not limited to, acknowledgment of the multiple relationship and its inherent risk to the client, ongoing dialogue, informed consent, documentation, and case consultation and/or supervision.
4. In the event that a Body Psychotherapist is providing services to several persons who have a relationship (partners, parents and children, siblings, families) the therapist attempts to clarify at the onset of the therapy, the relationship they will have with each individual. At any time, if it becomes apparent that the Body Psychotherapist is in multiple relationships which compromise the treatment situation or threaten to impair the objectivity or judgment of the therapist in any way, they clarify, adjust or withdraw from conflicting roles.
5. Barter is the acceptance of goods or services from clients in return for psychological services. Body Psychotherapists do not barter (including work exchange) unless the bartering arrangements are appropriate in the context of the therapeutic relationship, indicated by the needs of the client, and for the welfare of the client. Where bartering is used, the therapist and client make agreements in writing related to the exchange of goods or services to ensure that both understand the scope and limitations of the agreement. Body Psychotherapists consult or obtain supervision to ensure that the bartering arrangement is not harmful to the client, that the client is being given fair value in the exchange, and that no exploitation of and/or damage to the client is involved.
6. As teachers, Body Psychotherapists acknowledge that their relationships with students and/or supervises include factors which often make avoiding multiple relationships difficult. They monitor their teaching and supervision relationships to ensure that they do not become exploitive and/or damaging. Body Psychotherapists do not have sexual relations with students or supervisees and do not subject them to sexual harassment.
[Dr. Zur's comments: This 2007 code of ethics has significantly revised the guidelines in regards to dual relationships compared to the last revision of 2001. It eliminated statements in the 2001 code, such as "Body psychotherapists avoid multiple relationships whenever possible" and "Body psychotherapists do not barter (including work exchange) for therapeutic services unless there is a compelling need to do so." Instead, the 2007 code appropriately and realistically states that "In some situations, for example in small geographical or modality communities, a multiple relationship that is non-exploitive may be undertaken" and "Body Psychotherapists do not barter (including work exchange) unless the bartering arrangements are appropriate in the context of the therapeutic relationship, indicated by the needs of the client, and for the welfare of the client."]
- Australian Ethics Codes for Psychologists, Social Workers
The Australian Psychological Society (APS) Code of Ethics (2003), principle B7 states: Members must avoid dual relationships that could impair their professional judgement or increase the risk of exploitation. Examples of such dual relationships include, but are not limited to, provision of psychological services to employees, students, supervisees, close friends or relatives
Australian Association of Social Workers (AASW) Code of Ethics (2002) section 4.1.4 g. states:
Recognising that conflicts of interest can arise from engaging in dual or multiple relationships
with clients, former clients, research participants, students, supervisees or colleagues,
social workers will set and enforce explicit, appropriate professional boundaries to minimise
the risk of conflict, exploitation or harm.
Australian Institute of Welfare and Community Workers (AIWCW) Code of Ethics (1999) does not mention specific prohibition of dual or multiple relationships. It simply outlines the general principles that appear in all other codes, of the mandate to treat clients with respect.
Psychotherapy and Counselling Federation of Australia (PACFA) Ethical Guidelines section on Exploitation states:
- Counsellors must not exploit clients, past or present, in financial, sexual, emotional or any other way.
- Counsellors should consider that the deeper the involvement with the client's emotional life during Counselling, the less likely is the possibility of a subsequent equal relationship following termination of therapy. Counsellors must seek professional supervision should any attempt to build a relationship with a former client be considered.
Reference: United States Association For Body Psychotherapy (USABP). (2007). Ethics Guidelines. Retrieved from USABP web site at http://www.usabp.org.
[Dr. Zur's comments: All the above four Australian professional associations' codes of ethics provide the general mandate that therapists must avoid exploitation, sexually and otherwise and treat clients with respect and dignity.]
The Ethics Codes in Solidarity
Among the codes of all major psychotherapists' organizations, there is no blanket prohibition of non-sexual dual relationships. The American Psychiatric Association (2001) and the National Board for Certified Counselors (1998) exclude dual and multiple relationships from their codes altogether. These codes appropriately concentrate on preventing harm and exploitation of patients by therapists, as opposed to dictating a uniform course of action for therapists about dual relationships.
There are unified principles among the codes of ethics of all major professional organizations concerning dual relationships in psychotherapy. Once the hindering factors of misinformation and prejudice are discarded, the platform of these codes is clear:
- Sexual dual relationships with present clients are always unethical.
- Non-sexual dual relationships are not always avoidable.
- Non-sexual dual relationships are not always unethical.
- Therapists must avoid only the dual relationships that might:
* Impair their judgment and objectivity.
* Interfere with performing therapy or supervision effectively.
* Harm or exploit patients.
Summary
In contrast to the widespread belief that non-sexual dual relationships are inherently unethical, the codes of ethics of all major professional organizations place no ban on non-sexual dual relationships and in fact acknowledge dual relationships as sometimes unavoidable. Instead of supporting the opinion that dual relationships are unethical under any circumstances, the codes dictate that only those relationships likely to impair judgment and objectivity, interfere with the therapeutic work, or harm or exploit patients ought to be avoided.
Understanding the ethics codes is imperative in order to make informed decisions about dual relationships. Blind trust in other practitioners' interpretations of these codes does not constitute a thorough process of gathering information. Therapists familiar with the ethics codes will realize that non-sexual dual relationships are neither always unethical nor always avoidable, and thus will be better prepared to make choices about dual relationships that attend to the needs of the client. When the propensity to practice based on fear of litigation or licensing boards is set aside and replaced by first-hand knowledge of the ethics codes themselves, dual relationships can be accurately regarded as yet another opportunity to help clients.
References
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Zur, O. (2000). In celebration of dual relationships: How prohibition of non-sexual dual relationships increases the chance of exploitation and harm. The Independent Practitioner, 20, 97-100.
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Zur, O. (2007). Boundaries in Psychotherapy: Ethical and Clinical Explorations. Washington, DC: American Psychological Association, APA Books
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