This online course makes a complex subject relatively easy to understand. Ethical issues concerning boundaries and dual relationships are among the most complex and difficult for the mental health professional. Other than explicit prohibitions concerning sexual contact with clients, many of the boundary situations which arise are not easy to assess ethically. What constitutes a boundary violation in one situation may be ethically acceptable in a similar situation.

The course guides mental health professionals in sorting through boundary crossings, boundary violations, and dual relationships in order to discern what constitutes not only the highest standards for ethical behavior, but the highest standards for practice. Ethical theory and principles are included, with particular attention to virtue ethics. Many case studies and realistic scenarios are presented. The author of this online course is Mary L. Caldwell, M.A.

Learning Objectives
Upon completion of this course participants will be able to:

• Understand ethical theory, ethical principles, and ethical process.



• Identify and understand an ethical dilemma.



• Define and explain boundary crossings and boundary violations.



• Articulate ethical principles regarding dual relationships (multiple relationships).



• Discuss “virtue theory” as applies to boundaries and dual relationships.

Introduction
I recently taught a session on ethics to a group of graduate nurses. They had many years of clinical experience in hospitals, clinics, or public health settings. Their professor had asked them, in advance of my coming, to describe an ethical dilemma they had encountered in their work. Most of them wrote about difficult and complex cases. One student, however, wrote: “I am fortunate that in my many years as a nurse, I have never encountered an ethical dilemma.”

Obviously this student had never been taught to recognize an ethical dilemma. Health care, in all its many forms, abounds with ethical dilemmas. There have been ethical dilemmas in caring for human beings since the dawn of time. We may need to learn what constitutes a dilemma and how to think carefully and clearly when we discuss ethics.

Certainly issues for mental health professionals around boundaries and dual relationships are among the most difficult ethical dilemmas. One reason these questions are particularly challenging is that many times there is no hard and fast rule about the appropriate ethical response. Aside from the question of sexual misconduct, which is absolutely prohibited, the myriad of other situations we encounter often leave us wondering if we are doing the right thing.

Is it acceptable for me to treat my receptionist’s husband? Is it okay for me to coach my son’s soccer team when the head coach was a client in my office last year? May I accept small gifts, such as homemade cookies, from a client? What about accepting a gift such as the use of a beach house for a week? Are there situations in which it might be ethically appropriate for me to barter therapy for other goods or services? What if I am the only therapist in my small town? How can I avoid running into clients, or their families, at church, at the grocery store, on the street?

These can be difficult questions, and there is no “one size fits all” answer.

Ethical Dilemmas
To begin thinking about how we best act in ethical ways, let’s review basic ethics.
         
Ethics concerns how we make decisions about what is right, and what is wrong; it is about moral decision-making. Many times we have no problem knowing the right thing to do. If an elderly person falls down as we are walking down the street, the right thing is to stop and help. If we are threatened by a crazed gunman, we act to protect ourselves. Many times we just know the right thing to do, without having to stop and ponder.
         
But there are times when we aren’t sure what to do. There are times in which there is no obvious right course of action. If we are faced with two or more choices, and we can’t easily know which is right, we are faced with an ethical dilemma. Each choice may have some positive elements as well as some drawbacks. Neither is immediately and clearly the only right way. Two professional colleagues may have conflicting ideas about which course of action is correct when facing a ethical dilemma.
         
Suppose you promised to take your teenaged daughter and her friends to the mall this weekend. Late Saturday morning you get a call that a client is suicidal, and this situation needs your immediate attention. You know you may be tied up at the hospital for several hours caring for this individual. You have made a promise to your daughter; you have a professional ethical obligation to care for your client. But under the circumstances you cannot do both. You must weigh the two choices and decide. There are two goods at stake: keeping a promise and caring for someone in need.

You might sort through the options and arrange for another parent to take the girls to the mall. While this may well be an acceptable solution, the fact remains that you are breaking a promise. Another option might be to enlist a colleague to care for your client. In either case, you are choosing not to honor an obligation. Of course the girls will be just as happy if someone else drives them to the mall, but your client may be very distressed to find a stranger meeting him at the hospital. So in deciding how to proceed, you weigh the benefits and burdens of each possible choice. And you make a decision which leaves you feeling not entirely satisfied, but knowing that sometimes, when facing ethical decisions, you simply do the best you can. You make a deliberate conscious choice between two competing moral claims.

How do we go about making these kinds of choices? Often we make these kinds of decisions intuitively. If we have been brought up with sound moral teachings about right and wrong (and most of us have), we may just go with what feels right, and very often that serves us well. Few of us spend hours pondering every dilemma of daily life.

But when we are dealing with professional issues, or concerns involving other persons, we may need to think more intentionally and carefully. In professional ethical dilemmas, we are accountable professionally as well as legally at times. We need ways to communicate, a common theoretical framework as well as common vocabulary so we can discuss issues and come to a morally acceptable resolution.

Ethical Theory
Understanding something of ethical theory helps us communicate with others. We often find ourselves in conversation around ethical issues with people whose background, training, and values differ from our own. Learning about ethical language, and theory, helps us find common ground to communicate clearly. There are four broad categories of ethical theory, each with many variations.

Consequentialist theories: This type of ethical thinking is called teleological; it concerns the result of an action or the consequences of a choice. Instead of examining the proposed action, we consider what happens as a result of that action. We look at the end result, rather than the action we take. Utilitarian theory is one type of consequentialism; it seeks to promote the most good for the most people.

An example of the usefulness of consequentialist theory might concern a client who is suicidal. You may be very concerned about her, and know that she will be quite angry if you take steps toward hospital commitment. However you know she will be safe in the hospital. You weigh the benefits of hospitalization (safety, treatment availability) with the burden (the client’s anger, your choice in disregarding her desire to stay home). You consider the value of honoring her wishes to be left alone vs. your concern for her well-being. You know that if your choice involves hospital commitment, you are not honoring her wishes. You must choose. As a consequentialist, you may choose hospitalization as bringing about the most good in the long run.

Rule-based ethics; Deontology: This theory examines the action you are considering. It is based on ideas about duties and rules. Some actions are always right; some are always wrong. For example, it is always wrong to lie, steal, or kill. It is my duty to choose, and act on, the good. I must always tell the truth, because I want to be able to rely on others to always tell the truth. At times truth-telling could lead to harm, but I must tell the truth nonetheless because it is my duty to do the right thing.

Strict interpretations of deontology are difficult to carry out. We can all think of times that telling the truth, that is honoring the duty to always tell the truth, may not be the best choice. Many people find telling a lie is justifiable under some circumstances, when the truth could cause harm. There are a number of philosophers who have interpreted deontological thinking in less strict ways to allow for circumstances which shape how we do our duty and keep important moral rules.

Agent-focused theories; Virtue ethics, Feminist ethics, Ethics of care:We will examine virtue ethics in more depth later. Basically these theories are among the broadly defined philosophical systems which focus on the person making the choice. In ancient Greece, Aristotle articulated a virtue ethic in which he cited the importance of virtues such as compassion and justice. These theories tend to take into account an extensive range of concerns and issues in considering a dilemma. There is attention to relationships, particular circumstances, and context.

Suppose, for example, that you are walking down a road beside a raging river. You see two persons about to drown, and you know that you can only rescue one of them. One is a famous scientist who is on the verge of a cure for cancer. The other is your father. Who should you save? Many people would say that their love for their father would lead them to rescue him, regardless of the important work the scientist is doing. A strict utilitarian would say that for the most people to benefit, you must save the scientist. A strict deontologist would say it must be a “toss of the coin” so to speak; one may not favor one person over another.

Agent-focused ethical theories encourage us to consider the kind of variables we all know exist in ethical dilemmas. It matters if we love our father; it matters that we know one person, and don’t know the other. We know that our life-long relationship with a loved one is a factor. We feel a special obligation to him.

Suppose, however, that your wife is suffering from cancer, and furthermore, you never got along well with your father. Your personal situation could, perhaps, lead you to save the scientist at the expense of your father. Ethical decision-making is rarely easy.

Principalism
Some philosophers include the notion of working with principles as a type of ethical theory. In medical ethics four basic principles serve well to provide a framework to think about balancing the concerns we encounter in an ethical dilemma. Briefly, the four principles are:

1. Autonomy
Respect for persons means that they be allowed to make their own decisions
about issues which affect them. There must not be undue influence;
the person must be capable of understanding the options; his or her choice
must be respected; and there is protection for persons unable to make
or communicate their own decisions. Respect for autonomy means that
we do not interfere if a person genuinely has the capacity to decide.

2. Beneficence
Promoting the welfare of another, acting in the best interest of another to promote
the well-being of persons.

3. Nonmaleficence
Do no harm, act in ways that avoid or prevent harm to persons.

4. Justice
There are a number of theories about justice, but essentially justice
concerns treating persons fairly and equally.

We will take another look at ethical principles later, examining how they apply to boundary issues.

Ethical Process
In order to think through an ethical dilemma, we need more than terms and theory. We need a process; a systematic way to proceed. There are a number of way we might approach sorting through the issues. Art Caplan, Director for the Center for Bioethics at the University of Pennsylvania teaches a simple process using five questions.

1. What are the facts?
2. What is the dilemma?
3. What principles apply?
4. What are the options for resolution?
5. What will it take to implement the decision?

We cannot begin ethical deliberations before we have gathered all the information we can collect. Often a single fact, or piece of the story, can drastically alter how we view things. We need as much information as possible. Suppose we are dealing with a client who has severe dementia. Knowing something of the wishes she might have expressed when she was able to think clearly may affect how we proceed with ethical decision-making.

Identifying the dilemma simply means naming the competing claims. What are the choices we face, and what are the benefits and burdens of each? Thinking in terms of principles helps us balance the various claims. Thinking in terms of the choice which promotes the well-being of the client (beneficence), or the choice which best honors her autonomy may help guide us toward resolution.

We may be able to identify only a few options which we can realistically implement. There may be choices which would be ideal, but we can see no way to actually carry them out. Our client suffering from dementia might be best served by having around the clock, in-home caregivers. But such a solution may be impossible for a variety of reasons, including financial considerations.

The process is designed to help us think clearly, communicate with others involved, and reach a reasonable moral choice which we can explain to others involved.


Case One
In order to “practice” our ethical decision-making skills, let’s examine a few cases. We will begin to look at cases involving boundaries and dual roles as a way of exploring how complex these issues can be.

You are a social worker practicing in a group setting. For several months you haves been seeing Clara and Tom Pettigrew. The Pettigrew’s youngest child left for college, and after years of raising children, being involved in their lives and activities, their “empty nest” has become the site of marital conflict. In therapy they are making good progress dealing with this major life transition. Your daughter comes home from college, and announces she has a new boyfriend, and his name is Tom Pettigrew, Jr. He is, indeed the son of your clients. How do you respond?

A. You call the Pettigrews and tell them you must discontinue therapy in light of the budding relationship between your daughter and their son.

B. You tell your daughter she has to break off this relationship; that she can’t date someone whose parents are clients of yours.

C. Since the young people are away at college, and rarely come home, you discuss the issue carefully and thoroughly with the Pettigrews at their next appointment, pointing out the potential for complications. You seek their input into how to proceed.

D. You call a colleague or supervisor to discuss how to proceed.

Response: This kind of case illustrates the complexities of issues around boundaries and dual relationships. There simply is not a good, clear answer. The first step should be to consult with a trusted colleague or supervisor. It may well be that the relationship between the young people will soon fizzle out with no hard feelings. Or is it possible that the relationship could become serious and long-lasting, in which case you would need to think carefully about continuing therapy with the young man’s parents. In any event, one must always honor confidentiality.

In any case, honest open conversation about the dangers and risks is called for. You may decide to adopt a “wait and see” stance. It may be that you can continue therapy, with the agreement that all those involved will continue to monitor the potential conflicts. If this is your decision, you may run the risk of hard feelings if the relationship becomes conflictual. Or if the young people become serious, your professional involvement with the parents could be a problem. The issues involved include the well-being of your clients (beneficence) and the potential to cause harm to them (nonmalficence). Their autonomy may well be compromised if they are not permitted to continue therapy.

Case Two
You work in a small private practice with two other therapists. Many of your clients are wealthy professionals in your small town. You have been seeing a single young attorney for several months to deal with a variety of issues, mostly around relationships. She has been fairly successful professionally, but recently has experienced a period of financial reverses. She is unable to afford your fee, and offers to trade her time-share week at an expensive resort for a few sessions of therapy.

A. You see no harm in an even barter. You calculate the monetary value of the therapy and the week at the resort to determine how many sessions will be covered. Then you make your vacation plans.

B. You explain that it is unethical to barter in this kind of circumstance. You offer to allow her to continue therapy, and pay the bill “when she can.”

C. Since she is not currently in acute distress, you suggest that you cease therapy for a time until she can better afford the fees.

D. You refer her to a colleague who you know often barters therapy for a variety of things.

Response: Bartering is discouraged in virtually all codes of ethics. We will look more closely at the codes later on. While there may be some situations in which bartering could be acceptable, the case described is certainly not an acceptable bartering situation. While it may be tempting for a therapist to enjoy a “free” week at the resort, the therapeutic relationship could well be compromised by this arrangement.

The issues include the client’s well-being (beneficence); is it really in her best interest for you to accept this offer? Are you at risk for exploiting her current situation if you accept her generosity? While her exercise of her autonomy certainly permits her to make the offer, the clinician is responsible for keeping boundaries clear.

Case Three
You attend a party at the local art gallery and discover that a former client is one of the artists exhibiting his work. You admire his work very much and plan to purchase a painting. As you talk with him, he is very friendly, and asks you to go with him for a drink later that evening. Since the therapy was ended some time ago, you are wondering if it is appropriate to accept his invitation.

A. You decide that there should never be any social contact with a former client, and decline the invitation.

B. You believe that strict rules about social contact with former clients is unnecessary, and furthermore is demeaning to the client. After all, he is a competent adult, capable of making decisions about who he wants to socialize with. To refuse his invitation is to continue to see him as a compromised individual.

C. You agree to go, giving little thought to ethical concerns.

D. You tell him you need to consult a colleague about the ethical issues, and you ask him to call you next week.

Response: This case represents one of the areas in which well-meaning, thoughtful therapists are in disagreement. Some say that it is best to avoid social contact. Others would set time limits on social contact (such as two years following the termination of therapy). Some say that social contact, as long as it does not involve sexual contact, is acceptable. Still others say that to prohibit contact between two adults is unfair to the former client who may have needed treatment in the past, but is functioning well in healthy ways now.

There is, therefore, no single right answer. Factors such as the reason he was in therapy, the nature and duration of the therapy, and the length of time which has passed come into play. The ethical principles involved include respecting the client’s autonomy, which may well mean that you do not continue to treat him as a “sick person” but relate to him as a competent adult.

Case Four
You have been going to the same hairdresser for years. She does an excellent job, and you like her work very much. You discover when you arrive at work, that the new client who has the first appointment is your hairdresser.

A. You call her right away and explain that you can’t be her client at the hair salon and see her for therapy. So she will have to choose whether to come for therapy, or lose a patron at the hair salon.

B. As part of your initial conversation with her, you point out the dual relationship, and discuss with her how that might be a problem. You seek her suggestions for handling issues that may arise. You agree that therapeutic issues will be discussed only in your office, or by phone.

C. You don’t mention that you know her elsewhere; you treat her as any new client.

D. You quickly consult with a colleague or supervisor by telephone before she arrives for her appointment.

Response: This type of dilemma can occur frequently in small towns or rural areas. If you live and work in such an area, dual relationships simply cannot be avoided completely. Nor should they always be shunned as unethical.

With careful conversation around the potential for problems, you and the hairdresser may well be able to negotiate any issues which the dual relationship might create. Consulting with a colleague or supervisor is often a good idea. Such conversation offers us a place to think through the questions with another person. The ethical principles include the well-being of the client (beneficence) as well as her autonomy, that is, in her right to choose her therapist. The potential for harm in the dual relationship raises the issue of nonmaleficence.


Defining Terms: Boundaries, Crossing or Violating
All of us occupy a number of different roles in our lives. For example I am a wife, daughter, and mother. At work I am a chaplain and an ethicist. At times I am a teacher, a writer, and any number of other roles. Each of these roles carries with it a set of expectations; a set of appropriate behaviors. There are, as well, limits to each role. When I am at work at the hospital, no one expects me to function in the role of nurse, taking vital signs, or giving medication. No one at the hospital expects me to go into the operating room and perform cardiac by-pass surgery. But if a patient or family member is experiencing distress, is in need of emotional or spiritual care, I am expected to provide such care.

Professional roles such as doctor, nurse, or chaplain carry not only specific sets of obligations, but specific responsibilities as well. Persons who occupy these roles are trained, qualified, and in most instances, legally authorized by licensing boards, to perform their tasks. There are specific legal restrictions concerning the scope of practice. For instance, nurses are not permitted to do surgery, nor are chaplains permitted to give medication to patients.

Mental health professionals, whether psychologists, social workers, school counselors, marriage and family therapists, or any of the particular roles that such persons are trained and qualified to perform, carry certain role expectations and restrictions. The line which surrounds the role is a kind of boundary. When I am functioning as a therapist, there are boundaries which define the role, which set limits on acceptable, or unacceptable behavior. It is always the responsibility of the therapist to keep the boundaries. As the professional in the client-therapist relationship, the therapist is legally, morally, and ethically bound to monitor and guard boundaries.

What kinds of boundaries might we mean? Judy Roberts suggests there are several areas in which we meet boundaries. This section is informed by Judy Roberts, “Boundaries in Clinical Practice” http:www.judyroberts.net/Boundaries-in-Clinical-Practice.htm. The first is time. Setting the limits of the session with a definite beginning and ending time provides structure for clients. Some clients may push these limits; it is the responsibility of the therapist to work to honor the schedule.

The place of therapy constitutes a boundary. The office of the therapist is the customary place, though there may be times when another place is acceptable. Under some circumstances the clinician may go with a client to court, or visit her in the hospital. It is important to document these visits carefully.

Money is another boundary; it defines the nature of the relationship as a business contract. Therapists’ time and effort and energy spent with clients is work; and it is appropriate to be compensated accordingly. There may be instances of providing care for a reduced fee, or on a pro bono basis, but these are the exception. Bartering may, in some instances, be acceptable, but most codes of ethics discourage bartering.

Favors constitute a boundary. Therapists should not accept, or perform favors, for clients such as providing lunch, running errands, offering discounts for goods or services, or anything which falls outside the therapeutic relationship.

Self-disclosure is an issue in boundaries. There are occasions when judicious self-disclosure on the part of the therapist may be beneficial to the client. However the therapist must use good judgment and caution, determining the purpose of the disclosure and its likely impact.
If self-disclosure may involve exploiting a client, it is best avoided.

Finally, physical contact constitutes an important boundary. Touching, hugging, and other forms of contact should be carefully limited. Again, it is difficult to set a firm kind of rule against all forms of contact, however the wise therapist will be extremely cautious in engaging in any form of physical contact with a client.

We can see that these boundaries are not always easy to discern. Just what constitutes these unseen lines we must not ethically cross? Are there times we can ethically cross the boundaries? Are we wise to stay as far as possible from the boundaries?

Dr. Thomas Gutheil, professor of psychiatry at Harvard Medical School, notes the difference between crossing boundaries and violating boundaries. “In a boundary crossing, the therapist steps out of the usual framework in some way, but this action neither exploits nor harms the patient; indeed, it may advance the therapeutic alliance of the therapy itself.” This section is informed by Thomas G Gutheil, MD, “Clinical Concerns in Boundary Issues” Psychiatric Times, August 1999, vol XVI, Issue 8, available at http://www.psychiatrictimes.com. Examples include helping a client who has fallen, offering a tissue to someone who is crying, disclosing instances from one’s own life that may be relevant to the therapy. Each of these examples involve contact or actions which could, under other circumstances be boundary violations.

One of the keys to distinguishing between boundary crossings and boundary violations lies in whether the client is subject to harm or exploitation. The therapist is responsible for such assessment, and for judging whether a potential action or contact is for the genuine benefit of the client. Clients may, and certainly will at times attempt to breach boundaries. Defining and maintaining boundaries is always the legal and ethical responsibility of the therapist.

Boundary violations are defined by their exploitative or harmful effects on the patient. During boundary violations, the therapist is taking advantage of the dynamics inherent in therapy: transference, intimacy, dependency, idealization, rapport, and empathy. Any time a therapist places his or her own needs above the well-being of the client, there is a boundary violation.

A Metaphor: the Importance of Boundaries
Judy Roberts provides an extended metaphor which offers an excellent illustration of the role and importance of boundaries in therapeutic work. Roberts suggests that the notion of boundaries may be likened to the path constructed through dense woods which will lead a traveler to a specific desired location. This passage is a summary of Judy Roberts, “Are We On the ‘Right Path’?” At http://www.judyroberts.net/Right-Path.htm.

When the path is clear, the hiker can enjoy the journey, the vistas, the quiet, the joy of moving through rugged terrain without fear of losing one’s way. The walk becomes risky when the path is unclear. If the path has not been used well, or kept clear it can be difficult to find one’s way. If darkness falls, or if there is stormy weather, the way may become obscured. Danger may occur when others have tried to create shortcuts and we can’t tell which is the original path, or which path may lead us into trouble. So, because of these factors concerning the nature of the path, we need to pay attention to that path.

While we may think we can use shortcuts, the path itself has been carefully planned by people who have gone before. Roberts states: “I would like to suggest that our role of being a therapist in relation to our clients is much like that path through the woods. With clear role boundaries we can enjoy the hike through the woods: enjoy the intimacy, the unknown and discovery, the exhilaration of learning to know someone at a profoundly deep level without having to worry about losing our way and getting lost in unknown territory in a way that might cause both our clients and ourselves harm.” When the path isn’t clear, when we don’t pay attention to where we are going, we can easily get off the path and become confused or lost. “Our professional role boundaries are the demarcations of our path.”

Roberts notes, in conclusion, that “boundary crossings are departures from commonly accepted practices that could potentially benefit clients, or are at the least, neutral in their impact.” On the other hand, boundary violations “are serious breaches of professional role boundaries that result in harm to clients. While not all boundary crossings are boundary violations, it is the responsibility of the therapist to discern between the two and always keep the path to the original destination not only in sight, but the guide to achieving that journey’s end.”.

Dual Relationships
Concerns about boundaries and dual relationships are related, but not identical. Dual relationships occur when a person occupies two roles at the same time in relation to the client. For instance a dual relationship exists when the clinician has another relationship with the client other than therapeutic. The client may be a friend, family member, student, business partner, teacher, or fulfill some other role. Are dual relationships inherently unethical? Certainly some such relationships are morally unacceptable, but the mere existence of a dual relationship is not automatically unethical. In fact, in some areas, such as small towns or rural communities, strict avoidance of dual relationships may be virtually impossible.

If you are the only therapist in a small town, your barber, your pastor’s wife, your child’s teacher, or your spouse’s business partner may have no other options for therapy. It may be very difficult for these people to travel long distances for care. While therapy may be available via a computer, there are good reasons to hesitate concerning on-line therapy. Consequently, some circumstances make it all but impossible to avoid dual relationships. The therapist should be aware that dual relationships hold the potential not only for boundary crossings but boundary violations as well. Jeffrey Younggren, PhD suggests several issues we need to consider when we are faced with the possibility of dual relationships. This section comes from Jeffrey N. Younggren, PhD, ABPP, “Ethical Decision-making and Dual Relationships”; found at http://kspope.com/dual/younggren.php.

Younggren asks that we consider the question: Is the dual relationship necessary? Indeed it may be necessary under some circumstances. If we deem that it is unavoidable, we need to examine whether it exploits the client and who benefits from the relationship. One would like to think that in therapeutic relationships the client is always the one who benefits, but sometimes the complex nature of dual relationships make assessment difficult.

If the only oncologist in town is your client, and he is treating your spouse for a serious illness, your relationship with him is beneficial, in some sense, to both parties. Assessing who benefits is not always easy.

The therapist must consider whether the dual relationship might be harmful to the patient. Is there some risk that the therapeutic relationship could be damaged? Assessing one’s own objectivity in these issues may be difficult. There are potential risks and benefits, harms or goods, which can result from a dual relationship. The capacity to think critically about one’s own motives and behavior are essential. Supervision may be wise.

Given the complex nature of dual relationships, careful documentation in treatment records is essential. The risk of professional misconduct or negligence may be thwarted by through documentation including the decision making process about entering into a dual relationship.

A dual relationship should only happen when a client has given informed consent. Early on in the process, there should be a frank and open discussion about the nature of the dual relationship, including mention of risks and possible problems which could arise. The client should be asked for input in the discussion so that potential difficulties can be discussed. For example, it should be made clear that no conversation about therapeutic issues may take place outside your office, or perhaps, by phone. A quick “check-in” at church or the local library is not permissible. A signed consent, with copies for both parties, is a good idea.

Distinguishing Between Boundary Crossings, Violations, or Dual Relationships
For each of the following situations, decide whether the scenario described is a
         A. boundary crossing
         B. boundary violation
         C. dual relationship
It is possible that some may represent more than one of the above.

1. As your session progresses, snow is beginning to fall. By the time the session is over, there are several inches of snow. You own a 4 wheeled drive vehicle. Your client, who lives 2 miles away, is afraid to drive home because she has slick tires on her car. You offer to take her home.

2. Your client has been very upset during the session dealing with her impending divorce. At the end of your time with her she begs you, “Please just hold me.”

3. Your son is involved in the local drama club. The drama coach comes to you for therapy.

4. Your client is a banker. In the initial chit-chat of your session, he offers advice concerning investments. He offers to manage your investments for you, free of charge.

5. Your client invites you to lunch at an exclusive restaurant, saying she wants to thank you for all you have done for her.

6. Your client is dropped off for her session by a friend. When the session is over, her friend fails to come to pick her up. She asks you to take her home.

7. Your client is dealing with her husband’s terminal illness. She is tearful during the session. You reach out to pat her arm gently as she departs.

8. You have just put your house on the market. Your realtor is very friendly, and promises you will make lots of money. The next week he shows up for therapy in your office.

9. Your live in a rural area, and there is only one attorney in town. You are thinking of having a will made, and the attorney is your client. He offers to give you a discount.

10. Your client comes to the office where you practice with 3 other therapists. It is to be her last appointment. She has done very well in therapy. She brings a plate of home made brownies.

These scenarios illustrate the subtle complexities of sorting through boundary and relationship issues.

Consider # 1 and # 6. In the first instance, given that snowy roads can be dangerous, and your client may be at risk if she drives, it may be prudent for you to drive her home. In this instance, such a practice would be a boundary crossing, but not necessarily a violation. However, in #6, your client can surely find another way home. In fact, one might wonder if this was a contrived situation of her attempting to violate boundaries. It is your responsibility to maintain the boundary.

Look at #2 and # 7. The client who asks you to hold her can be awkward to manage. However it is never appropriate to comply with such a request. This is a clear boundary violation, initiated by the client, as is often the case. An appropriate verbal response will remind her that she is cared for, but that holding her is inappropriate.          

In the second situation involving touch, #7, a gentle pat on the arm is far less intrusive than holding someone. In fact, such a gesture may offer a warm and compassionate response to the client’s pain concerning her impending loss. Provided there is no confusion about the meaning of the touch, this may well be a simple case of crossing a boundary.

#3 concerns the possibility of dual relationship, as does #8. There is, however, a difference in the nature and degree of the relationship. In #3 it is your son who is connected directly with the drama coach. You are not in the drama club, and while this degree of connection still constitutes a potential dual relationship, it is manageable. You may want to discuss this connection with the client to clarify the boundaries.
         
The realtor of #8 is coming in for therapy; hence he is in a position of a potentially direct dual relationship. Such a situation offers a great deal more opportunity for risk and for problems. Suppose your house doesn’t sell for months, or suppose the realtor mismanages the transaction. If he had handled real estate transactions for you in the past, the situation would be different. But simultaneous on-going real estate dealings, along with therapy, are probably unwise.

The banker of #4 surely means well. But his handling your money constitutes a dual relationship which is unacceptable. The risk for problems is too great. Suppose he mismanages your money and your suffer losses. The therapeutic relationship must take priority over your portfolio. A frank conversation with him should clarify this issue.

The attorney described in #9 is also suggesting an inappropriate arrangement. This kind of dual relationship is hard to avoid in small towns, but the offer of a discount is ethically problematic. You may need to use his services, but you should pay the standard rate, as he should pay you the standard rate for therapy.

Finally, the lavish lunch offered in #5 is a great deal different from the home made brownies made by the client in #10. Both are offers of free food. However having lunch in a restaurant is a boundary violation; accepting brownies you can share with the office staff is a boundary crossing.

We can see that similar situations can be ethically very different. A great deal of ethical discernment is needed to understand what actions constitute boundary crossings or boundary violations. Dual relationships run the risk of either boundary crossings or violations, and must be handled with a great deal of caution to maintain the highest ethical standards.


Introduction

“A code of ethics cannot guarantee ethical behavior. Moreover, a code of
ethics cannot resolve all ethical issues or disputes, or capture the richness
and complexity involved in striving to make responsible choices with a
moral community. Rather a code of ethics sets forth values, ethical principles,
and ethical standards to which professionals aspire and by which they
can be judged.”
(NASW Code of Ethics, 1996)

Codes of ethics provide guidelines for behavior for professionals. The roles which professional mental health providers occupy carry certain obligations, as well as responsibilities. Codes of ethics are designed to provide a moral framework for the practice of that particular profession, that is, for persons functioning in that particular role.

Codes of ethics usually contain standards of moral behavior specific to a particular profession. For example a nursing code of ethics differs from a code of ethics for engineers or attorneys because the purpose and nature of their respective roles differ. But most every code has certain common ideas and principles.

Many codes look to the four basic principles discussed above, that is, autonomy, beneficence, nonmaleficence, and justice. Most professional organizations promote the autonomy of the persons they seek to serve. Guidelines which affirm autonomy, and encourage respect for autonomy are commonplace. Likewise, the promotion of the well-being of the client are usually mentioned, as is the warning to do no harm. Codes of ethics often include topics such as truth-telling, maintaining confidentiality and fidelity.

Ethicists Tom Beauchamp and James Childress state: “No moral theorist or professional code of ethics has successfully presented a system of moral rules free of conflicts and exceptions, but this fact is not cause for either skepticism or alarm.” Tom Beauchamp and James Childress, Principles of Biomedical Ethics: Fifth Edition (Oxford: University Press, 2001), 15.                     

Codes of ethics are valuable guidelines; they help us make sure our practice is consistent with other clinicians; they offer us a set of standards for sorting through issues or problems. But codes can never provide answers to every possible dilemma encountered in professional life.

Nonetheless, examining codes of ethics for guidance on issues around boundaries and dual relationships is valuable. We will take an in-depth look at four representative codes under which mental health professionals practice. While there are other organizations and codes which may govern some professionals, these codes are representative of the ethical guidelines in mental health ethics.

The National Association of Social Workers Code of Ethics

“The primary mission of the social work profession is to enhance human well-being
and help meet the basic human needs of all people, with particular attention to
the needs and empowerment of people who are vulnerable, oppressed, and
living in poverty.”
(NASW Code, 1999)

The core values of social work include: “service, social justice, dignity and worth of the person, importance of human relationships, integrity, and competence.”(NASW Code, 1999)

The ethical mandate of these introductory statements in the Preamble hardly needs comment. Ethical goals underlie the very reason for social workers existence and work. Clearly the purpose for social workers is promoting autonomy and beneficence, as well as justice, for human beings. The value spell out the importance of respect for persons as well as justice.

The Code acknowledges, in the Purpose, the limits of codes, stating: “Ethical decision making is a process. There are many instances in social work where simple answers are not available to resolve complex ethical issues. Social workers should take into consideration all the values, principles, and standards in this Code that are relevant to any situation in which ethical judgment is warranted.” (NASW Code, 1999)

In addition to sections dealing with confidentiality, informed consent, and privacy, there are several passages which deal with boundaries and dual relationships.

Under “Conflicts of Interest” (1.06, c) we read:

"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)."
(NASW Code, 1999)

The responsibility for discerning dual relationships, for monitoring the potential for
harm, for protecting the client, and for setting boundaries lies with the social worker. The primary concern is ensuring the client is not at risk for harm or exploitation. Of course, the code cannot spell out the virtually infinite kinds of situations which constitute dual relationships, rather the burden of protecting the client falls squarely on the social worker.

The code speaks to the ever-present issue of sexual relationships in Section 1.09 (a-d)
and physical contact in 1.10.

1.09 Sexual Relationships

(a) Social workers should under no circumstances engage in sexual activities
or sexual contact with current clients, whether such contact is consensual
or forced.

(b) Social workers should not engage in sexual activities or sexual contact
with clients’ relatives or other individuals with whom clients maintain a close
personal relationship when there is a risk of exploitation or potential harm to
the client. Sexual activity or sexual contact with clients’ relatives or other
individuals with whom clients maintain a personal relationship has the
potential to be harmful to the client and may make it difficult for the social
worker and client to maintain appropriate professional boundaries. Social
workers–not their clients, their clients’ relatives, or other individuals with
whom the client maintains a personal relationship–assume the full burden
for setting clear, appropriate, and culturally sensitive boundaries.

(c) 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.

(d) 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.

1.10 Physical Contact

"Social workers should not engage in physical contact with clients when
there is a possibility of psychological harm to the client as a result of
the contact (such as cradling or caressing clients). Social workers who
engage in appropriate physical contact with clients are responsible for
setting clear, appropriate, and culturally sensitive boundaries that
govern such physical contact."
(NASW Code, 1999)

There are additional proscriptions concerning social workers’ relationships with colleagues, warning that those who function as supervisors or educators should not engage in sexual activities with those over whom they exercise authority, nor with colleagues if there is the possibility of a conflict of interest. (NASW Code, 1999: Section 2.07)

It is clear in the NASW Code, as well as other codes we will examine, that sexual contact is absolutely, strictly forbidden. We will discuss this important boundary violation in depth below. Notice, that beyond the strict prohibition concerning sexual contact, there is frequent use of terms such as “appropriate” “risk for harm” and “exploitation” are subject to interpretation.

And these kinds of case-by case interpretations are what makes ethical decision-making so challenging in these areas of practice. As noted in the exercise above, two very similar actions may have very different meanings, risk of harm, or potential for exploitation.

Hence it is incumbent upon every conscientious practitioner who seeks to strive for the highest ethical standard to become aware of the potential for dual relationships, boundary crossings, and boundary violations.

American Psychological Association Code of Ethics
The introduction to the APA Code of Ethics notes that the “application of an Ethical Standard may vary depending on the context.” Furthermore, there is explicit mention of the use of terms such as “reasonably” and “appropriate” noting that a set of rigid rules is not an acceptable way to do ethics.(APA Code, 2002). As with social workers, there is an acknowledgment that a code of ethics cannot, nor should it, attempt to provide answers for any or all possible dilemmas.

The APA code sets forth its general principles, including beneficence, nonmaleficence, fidelity, integrity, justice and respect. Promoting the welfare of human beings is at the heart of its purpose.

Section 3.05 deals with Multiple Relationships:
(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 who is 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 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 relations that would not reasonably be expected to cause impairment
or risk exploitation or harm are not unethical. (APA Code, 2002)

The APA code does not explicitly prohibit dual relationships. However, the psychologist bears the burden of assessing whether his or her capacity to do good work might be compromised. Furthermore, the psychologist is responsible for determining the potential for risk or harm to the client.
         
Making such assessments requires careful ethical discernment. It is no easy task to determine if a dual relationship which may be difficult to avoid at times, is in fact free from the possibility of harm or exploitation. Assessing one’s own objectivity is never easy. Supervision or consultation with a colleague may be helpful.

The APA code speaks to the issue of bartering:
         
6.05 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
financial arrangement is not exploitative. (APA code, 2002)

Assessing the potential for exploitation, as well as determining what constitutes a clinical contraindication, requires careful ethical analysis on the part of the psychologist. Bartering is certainly not encouraged, but it is, in some circumstances, permitted.

There are several sections dealing with sexual contact.

7.07 Sexual Relationships with Students and Supervisees
Psychologists do not engage in sexual relationships with students or
supervisees who are in their department, agency, or training center or over
whom psychologists have or are likely to have evaluative authority.

10.05 Sexual Intimacies with Current Therapy Clients/Patients
Psychologists do not engage in sexual intimacies with current therapy
clients/patients.

10.06 Sexual Intimacies with Relatives or Significant Others of Current Therapy
Clients/Patients
Psychologists do not engage in sexual intimacies with individuals they know
to be close relatives, guardians, or significant others of current clients/patients.
Psychologists do not terminate therapy to circumvent this standard.

10.07 Therapy with Former Sexual Partners
Psychologists do not accept as therapy clients/patients persons with whom
they have engaged in sexual intimacies.(APA Code, 2002)

Notice that the language use regarding sexual contact does not leave room for the clinician to interpret whether it is “appropriate” or “reasonable.” The ambiguity of the language concerning dual relationships or other possible boundary crossings is absent in the passages about sexual contact. It is strictly prohibited. Again, we will discuss this issue more fully below.

10.08 Sexual Intimacies with Former Therapy Clients/Patients

(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
current mental status; (5) the likelihood of adverse impact on the client/patient;
and (6) any statements or actions made by the therapist during the course
of therapy suggesting or inviting the possibility of a post termination
romantic relationship with the client/patient.(APA code, 2002)

While this code does permit sexual contact after a two year interval, the circumstances of such contact are carefully and thoroughly proscribed. Once again, the burden of ensuring that such relationships are ethical falls upon the psychologist, and it is a complex set of standards he or she must meet.

American Counseling Association Code of Ethics and Standards of Practice
Members of the American Counseling Association are “dedicated to the enhancement of human development throughout the lifespan. . . . . The primary responsibility of counselors is to respect the dignity and promote the welfare of clients.” (ACA Code, 1995)

Once again we find the very purpose for counseling couched in ethical terms. Professional counselors, like social workers and psychologists, seek to promote human well-being (beneficence). The code speaks to the issues under consideration.

A.6. Dual Relationships
(a.) Avoid When Possible. Counselors are aware of their influential positions
with respect to clients, and they avoid exploiting the trust and dependency
of clients. 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 such relationships include, but are not limited to, familiar, social
financial, business, or close personal relationships with clients.) When a dual
relationship cannot 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.
         
(b.) Superior/Subordinate Relationships. Counselors do not accept as clients
superiors or subordinates with whom they have administrative, supervisory,
or evaluative relationships.

A.7. Sexual Intimacies with Clients
(a.) Current Clients. Counselors do not have any type of sexual intimacies
with clients and do not counsel persons with whom they have had a
sexual relationship.

(b.) Former Clients. Counselors do not engage in sexual intimacies with
former clients within a minimum of 2 years after terminating the counseling
relationship. Counselors who engage in such relationship after 2 years
following termination have the responsibility to examine and document
throughly that such relations did not have an exploitative nature, based
on factors such as duration of counseling, amount of time since counseling,
termination circumstances, client’s personal history and mental status,
adverse impact on the client, and actions by the counselor suggesting
a plan to initiate a sexual relationship with the client after termination. (ACA code, 1995)

Once again, we find that sexual contact is permitted following a two year interval after the cessation of therapy. The burden of justifying the appropriate nature of the relationship falls on the counselor who must have the capacity to carefully examine all relevant factors and make a careful ethical determination.

A.10 Fees and Bartering
(c.) Bartering Discouraged. Counselors ordinarily refrain from accepting
goods or services from clients in return for counseling services because
such arrangements create inherent potential for conflicts, exploitation,
and distortion of the professional relationship. Counselors may participate
in bartering only if the relationship is not exploitative, if the client requests
it, if a clear written contract is established, and if such arrangements are
an accepted practice among professionals in the community.

And a further word about exploitation:

D.1. Relationships with Other Professionals
(k.) Exploitative Relationships. Counselors do not engage in exploitative
relationships with individuals over whom they have supervisory,
evaluative, or instructional control or authority. (ACA code, 1995)

The ethical concern for respect for persons provides a strong ethical injunction against any type of relationship in which the professional may exploit another person. Careful consideration of the potential ramifications of one’s actions can lead to good ethical decisions which respect persons.

American Association for Marriage and Family Therapy Code of Ethics
Like other codes we have examined, the American Association for Marriage and Family Therapy Code of ethics places the welfare of families and individuals at the center of concern.

We see in the passages below the AAMFT statements on dual relationship and boundary issues.

1.3 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.

1.4 Sexual intimacy with clients is prohibited.

1.5 Sexual intimacy with former clients is likely to be harmful and is
therefore prohibited for two years following the termination of therapy
or last professional contact. 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 after the two years following
termination or last professional contact. Should therapists engage in
sexual intimacy with former clients following 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 to the client’s immediate family.

4.3 Marriage and family therapists do not engage in sexual intimacy with
students or supervisees during the evaluative or training relationship
between the therapist and student or supervisee. Should a supervisor
engage in sexual activity with a former supervisee, the burden of proof
shifts to the supervisor to demonstrate that there has been no exploitation
or injury to the supervisee.

7.5 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
clients requests it, (b) the relationship is not exploitative, (c) the
professional relationship is not distorted, and (d) a clear written
contract is established.

The AAMFT code, like the others above, relies on the ethical discernment of the therapist in interpreting situations which may be ambiguous. Two very similar circumstances may in fact require ethically different responses.

Codes with Regard to Boundary Issues and Dual Relationships
We see, among the four codes cited, remarkable consistency regarding the issues under discussion. Concerning dual relationships, all codes caution that one should be careful, be aware of the potential for harm or the possibility of exploitation. Boundary issues, other than sexual contact (discussed below), are subject to interpretation. There is considerable latitude for the clinician to make determinations on a case by case basis.

There simply are no hard and fast rules regarding where the boundaries lie, or under what circumstances one has crossed a boundary, or violated a boundary. Likewise dual relationships require that the therapist have the capacity to be self-aware and be as objective as possible about the nature of multiple relationships. There may be a risk of exploitation, a risk to the integrity of the therapeutic relationship, or a risk of harm to the client.

The codes all refer, repeatedly, to terms such as “appropriate” “risk of exploitation” “risk of harm” and “potential for conflict.” Such language makes abundantly clear that the lack of rigid rules means there is latitude for the therapist to practice discerning, interpreting, and adhering to ethical standards. Just what does “appropriate behavior” look like? What actually constitutes “risk of harm” to a client? The same action in one situation may be harmless for one client, and in another situation, hold the potential for risk. A high degree of sensitivity to these issues is required to ensure consistently ethical practice. The therapist, in all instances, bears the responsibility for locating and maintaining boundaries.

Bartering is potentially connected to boundary violations as well as dual relationships. While not strictly prohibited, bartering for goods or services has the potential for blurring boundaries. Bartering for services performed directly by the client for the therapists may be particularly fraught with risk.

For example, if you decide to barter your services for a painting by a local artist, you can establish the monetary value of the therapy and the monetary value of the painting, which you have seen in a gallery and admired. Such a transaction should be initiated by the client. It would be wise to have a written contract spelling out the arrangement.

But if you are bartering therapy for someone to paint your house, the risk is much greater. There are several potential problems with this arrangement. First the client will be at your home, and this represents crossing a geographical boundary. Second, the client will likely be around your home for a number of days, and such proximity may lead to an over-familiar attitude. Third, there is the possibility that the client isn’t very good at painting houses, and you may be highly dissatisfied with his work. You have little recourse to correct problems in this kind of arrangement.

Hence, bartering for goods is probably a wiser choice than bartering for services to be performed by the client herself. The codes suggest that the therapist should never suggest a barter. If the client brings the idea to you, it may be worth consideration, but he should initiate the transaction.

There may be some geographical considerations around the ethical acceptability of bartering. In some locations it would be highly unusual. However in some areas, particularly rural areas, bartering for a variety of goods and services may be the norm. Attention to local custom will help the clinician determine if bartering is appropriate.


Let’s examine some cases to work on our skills at sorting through issues around boundary crossings, boundary violations, and dual relationships. In many of these scenarios, there will not always be a clear-cut “right” answer. Circumstances, and subtle nuances which are hard to capture in a few lines of script may mean that similar situations we might encounter in our work could lead to a different response.

Case One
You have been seeing a client for about two years, dealing with some very difficult and complex issues. She has worked hard, and done well. Now the time for termination of therapy is approaching. She repeatedly tells you how grateful she is, and at her last visit, brings you a gift certificate for $500 from a local jewelry store.

A. You see this as a boundary violation, and in spite of your discussion months ago in which you explained that accepting gifts is unethical, she wants so badly to show her gratitude. You know that she is very wealthy, and $500 is “small change” for her. You know that your wife’s birthday is coming up, and you sure could get her a nice gift with this gift certificate. So you explain that you are reluctant, and really shouldn’t, but you accept the gift.

B. You are irritated at her for ignoring your careful informed consent explaining that gifts may not be accepted. You tell her, in no uncertain terms that you cannot accept this gift. You suggest she make a contribution to the local animal shelter in honor of your practice, to show her gratitude.

C. You explain as gently as possible that as much as you appreciate her expression of gratitude, her good work and good progress are all the thanks you need. And furthermore it is simply unethical for you to accept a gift.

Response: This kind of situation can be so tempting that we may have trouble remembering where the boundary crossing ends, and the boundary violation ends. However a gift of this size is simply unacceptable, and you must, as gracefully as possible decline. Should she suggest making a charitable contribution in your honor, you may choose to permit this, especially if such things are commonly done in your community. C is the best response.

Case Two
You are working with a single mom, and she has a teenaged son who needs help with depression and a number of accompanying issues. The mom has no insurance, does not earn a lot of money, but she badly wants you to see her son. She offers to clean your house every week for as long as her son is in therapy.

A. You know that you won’t be at home when she comes to clean, and that her son really does need your help. Furthermore, this mom is trying to hard to deal with overwhelming problems. You are already paying an agency a lot of money to clean your house, and they don’t always do a good job. This seems like a good arrangement, which will benefit everyone.

B. As much as you want to help, you know that bartering therapy for housework is not a good idea. A client, or a client’s family member have no business coming into your home, and there is some risk that such an arrangement could be seen as exploiting the client. You gently explain to the mom that you cannot accept her offer, and suggest she go to a public mental health clinic.

C. You do a certain number of pro bono cases every year, and this looks like a good client for providing much-needed therapy gratis.

Response: Bartering therapy for housework in your home is indeed potentially exploitation; it is a boundary violation and is unacceptable ethically. You do, however, have other choices. You can refer to an agency which might provide some help for low income clients. Or you could choose to treat the young man pro bono. Good ethical practice states that giving to our communities in this fashion is commendable. B or C would be ethically acceptable choices.

Case Three
Your client has struggled for years, holding down a job and going to college at night. She has been in therapy off and on for several years, but you have seen her regularly for the past 6 months. Now she is about to graduate from college, and sends you an invitation to graduation. She also asks you at her last session to please attend her graduation as well as a party for her afterwards.

A. You explain that you are so pleased for her, and proud of her good work, but it would be unethical to attend her graduation.

B. You tell her you would be honored to attend, and you do indeed attend the graduation. But you tell her that you cannot make the party, offering no explanation.

C. You buy her a nice gift, attend graduation, and enjoy the party with her friends and family.

Response: Local custom may play some role here. If you live and work in a small town or rural community, you might feel more comfortable going to graduation than if you lived elsewhere. It is perfectly acceptable ethically to attend the graduation ceremony, which is a public event. However the party is another matter. You may decline the party invitation; and you do not have to provide a reason for not attending, any more than you have to explain why you can’t accept social invitations from other people. B is the best answer.

Case Four
After a week away from your office you return to find a new client scheduled for Monday morning. You do not recognize the name. It turns out that the client, Sue, is a sister-in-law of a man, Bernie, who has been in therapy with you for a few months. Not only have you heard him talk about this woman, his relationship with her has been a problem for him, and you know intimate details about her life. Sue does not realize that Bernie, her brother-in-law, is in therapy.

A. You keep your mouth shut. After all, maybe you can help this whole family if you are working with both of these individuals. You can gain information that will help both Sue and Bernie. And you certainly won’t tell either of them that the other is coming to see you.

B. You may not reveal the confidential information that her brother-in-law is a client. You simply tell her that for ethical reasons which you are not at liberty to explain, you cannot see her for therapy. You offer to refer her to 2 or 3 other therapists.

C. You explain that her brother-in-law, Bernie, is your client, therefore it is unethical for you to see her for therapy. You offer to refer.

Response: Seeing this woman is definitely a boundary violation. The prior therapeutic relationship with Bernie is at risk if you see Sue. There is a potential for harm to Bernie. You cannot, however, violate his confidentiality (a boundary violation) if you inform her why you cannot see her. You may not even tell her it is because of another client she may know. You explain kindly but firmly that you cannot see her; nor can you be explicit about the reason. B is the best response.

Case Five
You recently moved back to the area in which you grew up to practice. As you are getting your practice established, you discover that a new client is a friend from high school. Twenty years ago you and he were good buddies, but went to different colleges, and the friendship faded. Now he wants to see you for therapy.

A. You explain that ethical guidelines prevent him from seeing former friends for therapy, and while you would enjoy renewing the friendship you can’t be his therapist.

B. You know that seeing him could lead to a lot of referrals as he is a physician in town. So you happily welcome him as a client.

C. Codes of ethics do not permit therapy with persons with whom you have had a sexual relationship. However prior social relationships are not strictly prohibited. After a time span of 20 years, with no contact, it is ethically permissible to see this person as a client.

Response: Local custom may play a role in your decision. If you are in a rural area, and there are no other therapists for miles, you may be willing to interpret ethical guidelines more generously. Social contact is not, in fact, a prohibition against seeing a former friend. Had you been sexually involved with this person, that would be a different matter. But a former friend, with whom you had no contact for two decades, may indeed be a client. However you will want to be vigilant about the potential for harm or exploitation. Seeing a physician with the hope of generating referrals is unethical.

Case Six
Last year your son was involved with the Odyssey of the Mind program at his school His team did very well, and you enjoyed watching the competition. His coach was a parent volunteer. Now that parent wants to come to you for therapy.

A. As your son worked with this man for months, a close and friendly relationship developed. Your son speaks fondly of his coach. It would be wise to avoid therapy with this man for another year or so, giving your son time to move on and be less attached to the coach.

B. You had no direct contact with this man except when you saw him at competition time, which was not frequent. You had no occasions to speak to him by phone, to make plans for the team, or be involved in any other way. Hence, it is ethically acceptable for you to see him.

C. You explain to him that you cannot see him because he coached your son’s team.

Response: Given the brief duration (a few months) for your son’s involvement with the team, and the infrequent nature of competition events, your contact with this man has been minimal, and furthermore, it is in the past. There is no particular benefit from waiting a year or two to see this man in therapy. Of course you will maintain his confidentiality, as you do for all clients. It is ethically appropriate under these circumstances to see this man.

Case Seven
A client who has been seeing you for less than a year is coming in for her final visit. She is an elderly woman and you have grown very fond of her. She always asks about your spouse and children, expressing an interest in their lives. You have always been polite, but reticent, with information about your family. Now, at her last visit, she brings a cake telling you it is for your family’s dinner that night.

A. You thank her graciously, but tell her you can’t accept it for your family. You offer to accept it on behalf of the office staff, and then everyone there can enjoy it.

B. You tell her that as much as you hate to disappoint her, you cannot accept gifts; it is simply unethical.

C. You see no potential for harm or exploitation in accepting the cake, and you thank her and take it home for your family. In fact you know that she will take pleasure in giving you a token of her gratitude.

Response: A cake is not an expensive or lavish gift. This woman would likely be very hurt if you did not accept this gift, and take it to your family as she wishes. There seems minimal risk or harm or exploitation in accepting this gift. C is ethically acceptable.

Case Eight
Your client is a young man who has wrestled with relationship issues for a long time. Now he is about to get married, and he asks you to be his best man.

A. You accept as you always enjoy weddings; and furthermore you believe it is in his best interest to support his upcoming marriage.

B. You explain that you are honored, that you would enjoy attending the wedding, but it is ethically inappropriate for you to be his best man. There is indeed risk of harm or exploitation in this situation.

C. You explain that ethical codes prevent your participating in his upcoming wedding in any form.

Response: Certainly serving as best man violates the boundary in this case. However, attending his wedding is another matter; and, if you deem it therapeutically appropriate, you could attend the wedding without crossing ethical lines.

Case Nine
Your client owns a furniture store in town. You need new furniture for your office. He comes in, offering to barter therapy for furniture, dollar for dollar at retail value. You offer to draw up a written contract setting out these terms.

A. You see this as a win-win situation. Since the client brought up the issue, if you have a written contract, this may well be perfectly acceptable ethically.

B. You know that he will only pay wholesale price for the furniture, and you feel like you would be getting cheated. So you decline his offer.

C. You explain that bartering is unethical.

Response: Local custom regarding bartering may play a role in your decision. If you are, in fact, uncomfortable with bartering therapy for furniture, you should not agree to the plan. But if you are comfortable with the exchange, if the client brought it up, and if you have a written contract, this is ethically acceptable. Bartering for goods, rather than services (such as house cleaning), with a clear understanding, and a written contract, may be beneficial to all involved.

Case Ten
You attend the wedding of a distant cousin of your wife. When you get to the wedding you discover that he is marrying a client of yours. Though she had talked about her upcoming wedding, you had no idea that your client was about to marry your wife’s cousin. You don’t see this cousin often, no more than 3 or 4 times a year, at large family gatherings. However, you are uncertain about the ethical dimensions of continuing therapy.

A. You consult a supervisor for assistance in sorting through this dilemma.

B. You decide you must tell your client that therapy must be terminated in the best interest of all involved; that you are risking an ethical problem.

C. You do not mention the family connection to the client. You know she will figure it out, and you can deal with it when she brings it up.

Response: The therapist is always responsible for maintaining and monitoring boundaries. You cannot wait for the client to notice a problem and raise the issue. However, depending on the circumstances, you may find it ethically acceptable to continue therapy. Consulting a supervisor is a wise choice in determining how to proceed. A is the best choice.

Notice that there were differing, but similar issues in these cases. Both 1 and 7 dealt with accepting gifts. Both 2 and 9 concern bartering. 3 and 8 are about accepting invitations for important events in the lives of clients. 4 and 10 concern connections with family or social contacts. And 5 and 6 have to do with former relationships.

Ethical issues around boundaries and dual relationships are complex and subtle. One of the most important skills for the ethically conscious clinician is to discern the differences.


Sexual Contact with Clients
Sexual contact with clients remains one of the most difficult issues for mental health professionals. Sexual misconduct is one of the primary infractions leading to malpractice suits or reports to licensing boards. While virtually every authority on the topic agrees that sexual contact with clients is absolutely always unethical, the fact remains that such contact happens, and happens at a disturbing rate.

Bernstein and Hartsell note:

“The danger legally and ethically of dual relationships and boundary violations,
particularly those involving sexual misconduct, causes much grief, anxiety, and
concern for mental health professionals and the boards who enforce the rules.
Nevertheless, somewhere in the nation at any given time therapists are busily
engaging in such activities, whether they pursue a client sexually or intimately,
or a client pursues them and they cannot resist the temptation. Either way, it is
the mental health professional who ultimately loses. If caught, providers may be
dismissed from their national organizations, found guilty of a felony in some
states, and certainly risk having their licenses revoked for committing an
unethical act."
Barton E. Bernstein, JD, LMSW and Thomas L. Hartsell Jr., JD

The Portable Ethicist for Mental Health Professionals: An A-Z Guide to Responsible Practice (New York: John Wiley & Sons, Inc, 2000) 93.
We have seen that in all the codes above, as well as other codes governing the practice of mental health professionals, sexual contact with clients is always prohibited. There is zero tolerance for such practices. It is simply wrong. “There is nothing right about having sex with a client. Sexual misconduct with a client is ethically, legally, and criminally wrong.” Bernstein and Hartsell, p. 93.

Sexual misconduct is grounds for legal action in every state. Clients may sue for battery or malpractice. In some states sexual involvement is a felony. Additionally, in some states, terminating therapy to begin a sexual relationship with a client does not end the liability of the practitioner. Elaine P Congress, Social Work Values and Ethics: Identifying and Resolving Professional Dilemmas (Washington, DC: National Association of Social Workers, 1996) 106.

This is the issue about which ethicists agree. Regarding sexual contact with clients, there is an absolute hard and fast rule. There is no room for discernment or interpretation. It is always ethically, morally wrong to engage in sex with a client. And yet it continues to be a serious problem.

Sexual Misconduct Other Than With Clients
All the codes agree, and good ethical practice states that no mental health professional should ever engage in sex with persons over whom they have authority. Examples include students or interns the therapist might be supervising. Taking advantage of a position of authority is simply exploitative, and is not to be tolerated.
         
The mental health professional should not engage in sexual contact with any student or intern even if he is not the direct supervisor. “It is not an adequate defense to say that the sexual contact, sexual exploitation, or therapeutic deception with the person occurred with the person’s consent, outside the person’s professional counseling sessions, or off the premises regularly used by the provider for the professional counseling sessions.” Bernstein and Hartsell, p. 96.

Direct sexual contact is not the only form of inappropriate sexual misconduct. Verbal harassment, creating or tolerating a hostile environment, inappropriate facial expressions or gestures, physical gestures, suggestive comments or posturing are all forms of unacceptable sexual conduct. Note we are not calling these behaviors “inappropriate.” They are unacceptable.

Within the therapeutic setting asking for sexual information beyond what is truly necessary for therapeutic purposes can be construed as sexual misconduct. Sexual contact with those close to the client is ethically unacceptable. The therapist should never become involved sexually with the client’s family, close associates or friends.

Two years later
Some codes prohibit any sexual contact at any time between therapist and client. Other codes, including some of those cited above, permit contact between the therapist and the client after a two year period.

How we view, and relate to former clients is an ethical issue in itself. How we see persons; how we relate to them; how we treat them are ethical concerns. Many professionals believe that if we prohibit contact forever with former clients we do them a serious disservice. Placing former clients “off-limits” tends to keep them forever in the category of sick persons, persons who are not fully capable of functioning as competent adults able to make their own decisions about friendships or sexual relationships. Some say that forever forbidding relationships with former clients serves to continue to pathologize them.

Whatever your view concerning sexual contact with former clients, it is clear that the therapist bears the responsibility of monitoring boundary issues, and maintaining an appropriate ethical stance. The APA code offers excellent guidelines for relationships following a two year period following termination of therapy.

The APA code notes that such intimacies will occur only in “the most unusual circumstances.” It is the psychologist who has the burden of demonstrating that there is no exploitation. Factors to consider include the nature, duration, and intensity of the therapy. Obviously someone in therapy for a long period of time dealing with sexual abuse would be not be the most appropriate choice for a future relationship. The circumstances of termination are a factor. Did the therapist and client “complete” their work, and part on good terms? Or did the client simply “disappear” leaving unfinished therapeutic work?

What is the likelihood of harm resulting if the former client and therapist become involved? There must be an honest assessment of the potential risk to the client. As some states continue to hold therapists liable even after termination of therapy, there may be significant risk to the therapist if the relationship ends badly.

Were there any statements or remarks during the course of therapy suggesting the possibility of a relationship later on? If such ideas had been planted, the nature of the relationship which ensue could be called into question. (APA Code of Ethics, 2002)

Once again, we need to remember that if such a relationship develops, the therapist continues to bear the burden of maintaining the ethical boundaries.

Ethical Flash Points
Bernstein and Hartsell summarize their discussion about sexual issues for mental health professionals as follows:

Every mental health discipline prohibits sexual intimacy with clients.

Intimacy means anything that a client could interpret to be either sexual or intimate
The authors have had a client who wanted to file a complaint because the therapist
exhaled too hard, and the client thought he was panting with excitement over the
client.

Sexual intimacies are a common problem in the mental health field judging by the
number of complaints filed in this area. Malpractice insurance policies generally
limit coverage in this area because of the number of reported incidents. Most
policies contain specific monetary limits for sexual misconduct cases. Read your
policy.

Malpractice coverage for representation before a disciplinary board is even
more limited. Therapists are responsible for all fees incurred beyond their
deductible paid–usually no more than $5,000. Read your policy.

The “two years after termination” permissive language in some ethics codes
is usually drafted to shift the responsibility to the therapist to ensure that no
harm befalls the client.

Some guidelines require that therapists who discover or receive knowledge
of another therapist’s inappropriate sexual contact with a client are ethically
bound to report it or their own license is in danger.

Most disciplinary boards usually ignore convoluted explanations (sometimes
called fairy tales) to justify unethical sexual misconduct.

Sex with clients drifts between the top two or three major ethical infractions
committed by therapists of all disciplines.

When sex between a therapist and client takes place, the therapist has no
defense.

In a “he said” versus “she said” swearing match, the therapist is usually
discounted and the consumer of mental health services is believed unless there
are very unusual circumstances (e.g. the encounter could not have taken place
the way the consumer/client narrated the story; the consumer/client has
repeated the story several times, and each time there are significant
differences and sufficient inconsistencies to make the tale unbelievable).

Sex = exploitation. Bernstein and Hartsell, p. 97

Therapist Risk Factors
While it is unethical for therapists to become sexually involved with clients it occurs at an alarming rate. Good ethical practice means that we become aware of those factors which may put us at risk of such involvement occurring. These relationships rarely happen immediately. They usually develop over a period of time.

Norris, Gutheil, and Strasburger point to a number of factors which therapists need to become aware of as creating situations in which the risk rises. This passage is based on the work of Donna M. Norris, MD, Thomas G Gutheil, MD, and Larry Strasburger, MD, “This Couldn’t Happen to Me: Boundary Problems and Sexual Misconduct in the Psychotherapy Relationship,” Psychiatric Services at http://ps.psychiatryonline.org.

A life crisis, particularly midlife and late-life in the therapist’s development appears to be a risky time. While those practicing early in their careers are also vulnerable at times, those in mid or late life crisis periods are at risk, and may turn to a client for solace, gratification or excitement. A time of transition such as retirement, job loss or change, even a promotion, can make a therapist susceptible to boundary violations. Financial problems may also contribute to increased vulnerability. The therapists’ own illness may create situations in which he is tempted to turn to a patient for support or comfort.

Therapists are not immune from loneliness. The need to find someone to talk to, someone to share confidences about our personal lives such as marital problems, problems with children, or other personal issues may lead the therapist to turn to a client. Such role reversals may make the client feel important and needed. But it is a serious ethical breach to disclose such information about oneself.

There are, of course, times in which self-disclosure, practiced judiciously, can be therapeutically helpful. But there is empirical evidence that self-disclosure is often the final boundary violation before sexual relations.

Idealization and seeing a client as “special” should alert the therapist to countertransference issues. Some of the reasons the therapist may see the client as special include beauty, youth, intellect, artistic creativity, status in the community, or even therapeutic challenge.

At times pride, shame and envy may cloud one’s judgment such that he tells himself “This couldn’t happen to me” or “I have control, and I know what I’m doing.” If a therapist has problems setting limits, a sexually aggressive client may be too much to handle. Firm resolute maintenance of boundaries can be a challenge, but it remains the therapist’s responsibility.

Finally, therapists are not immune to denial. Early problematic situations can lead to serious problems, even with seasoned therapists. He may rationalize that the problem is not serious, and he can manage it. Norris, Gutheil, and Strasburger, as do a number of other authors, recommend that therapists seek supervision to deal with these issues. The objective assessment of another experienced therapist can be invaluable in helping therapists protect themselves from serious boundary violations which can lead to major trouble.

Consulting with colleagues can also be a wise move. The capacity to seek help, whether from a colleague or supervisor, is a significant ethical strength.

Summary
The therapist who chooses to engage in sexual contact with clients is running an enormous risk. He is acting unethically; he is exploiting the client; he is likely causing harm to the client. The therapeutic relationship is destroyed. Furthermore he is running risks legally and professionally. He may be reported to a licensing board and may lose his license to practice. He may be sued. The therapist who engages in sex with a client stands to lose a great deal.

If the therapist follows the “two year rule” the advisability of sexual contact remains dubious. Only under carefully assessed and monitored circumstances might such a relationship be considered ethical. And it is the therapist who is responsible for such assessment and monitoring.

The therapist who wishes to maintain high ethical standards needs to be able to examine his own behavior and look for clues to an increased risk. The willingness to turn to a colleague or supervisor for assistance is a significant ethical strength.
         

Introduction
In light of what we have seen regarding ethical issues around boundaries and dual relationships, it may be helpful to look, in more depth, at the relevant ethical principles and precepts. In order to develop and maintain a proactive stance around boundaries, it is important for mental health professionals to understand thoroughly the ethical basis for boundary guidelines as well as ethical implications of potential violations.

The therapist is always the one responsible for creating, maintaining, and monitoring boundaries. In fact, the client will often be the one who initiates crossings or violations.
Hence it is incumbent upon the professional person in the relationship, that is the therapist, to be fully informed and aware of ethical principles which inform standards concerning boundaries.

We have seen that these boundaries, and the limits to dual relationships, are not hard and fast. Other than sexual contact, almost every other potential boundary or dual relationship issue is less clear. We are in a broad “grey” area ethically. The therapist who wishes to maintain high ethical standards needs to be constantly vigilant, capable of exquisite ethical discernment, and willing to examine herself and her work at all times.

Autonomy
Autonomy, that is, the right of the patient or client to make her own decisions is a primary principle. We are enjoined, likewise, to respect the right of the client to function independently, to choose for herself what she believes to be in her best interest.

However the therapist-client relationship is not one of equality. The client comes to the therapist, acting out of her autonomy (usually, but not always), seeking help. The therapist is trained and qualified to offer help. Hence this relationship is, in a sense, unequal. Certainly the client may be “equal” to you financially, socially, educationally, and in other ways. But in your office, you are the one holding the power. You decide whether to accept the client, you decide the best course or type of therapy, you decide how much money to charge, and you decide how often you will see the client.

You are the expert. The role of expert carries certain rights as well as obligations. One of these obligations is to honor the autonomy of the client. You would never force her to follow a particular form of therapy, or violate her religious beliefs, or leave a bad marriage. You may certainly, and probably at times should, use powers of persuasion. But respecting her autonomy means you don’t force her to do anything.

In the therapist-client relationship, you have the responsibility to guard the client’s autonomy. The very nature of the kinds of problems we deal with in psychotherapy may compromise the client’s autonomy. The capacity to think clearly and make informed choices may be less than perfect. Hence, we bear a particular responsibility to assist clients in helping them maintain their autonomy to the greatest degree possible.

There will, of course, be times autonomy must be sacrificed in the best interest of the client. For example, hospital commitment for a client who is suicidal is usually carried out against her wishes. As such it is an explicit violation of autonomy. However, it is in her best interest, and when we weigh relative benefits and burdens we know that keeping her safe is more important than honoring her right to make her own decisions. In fact, one might argue that keeping her safe is the best way to maintain her future autonomy.
         
You respect her autonomy. You are in the role of expert. And you are the one who is responsible for monitoring the boundary between therapist and client. The fact that the relationship is unequal demands a significant degree of accountability for ethical standards on the part of the therapist.

Informed Consent
Informed consent is essential for autonomous decision-making. A potential client cannot know if she wishes to enter into a therapeutic relationship unless you provide some information regarding what is involved. She can’t make a decision if she doesn’t know what she is asked to decide about.

Bernstein and Hartsell state:

"The meaningful question is not whether informed consent should be obtained
but rather what constitutes informed consent. A client has the right to information
about many things in order to properly give consent for treatment. The more
information the client receives, the less likely there can be an allegation of
improper consent."
Bernstein and Hartsell, (p 59, further references or direct quotes will be
noted parenthetically.)

It is wise to document informed consent with an intake and consent form, written in clear and easy to understand language. “A signed, detailed intake and consent form, of which the client is given a copy, ensures there will be little controversy regarding the information provided to the client and the client’s consent to treatment. The form constitutes written evidence of the client’s consent to services and becomes part of the client’s permanent file.” (60)

What information should be included in such a consent form? First, information about the therapist or others involved in the client’s care and treatment should be provided. Educational background, licensing, training, are important. The client has the right to know the professional qualifications of those providing mental health care.

Information about fees should be clear. The rate per session, information about insurance, about who files, and about co-pay is essential. Charges for telephone consultation, missed appointments, and time the therapist may need to be in court need to be carefully and clearly spelled out. Confidentiality and its limitations must be made clear. (We will say more about this later). The legal exceptions to confidentiality should be spelled out, such as child abuse or threat to harm oneself or another. State laws vary, so you need to be familiar with requirements in your jurisdiction.

Clients should be advised of how or when the therapist’s office might contact them. As some persons may not wish to receive phone calls at home, it is important to have consent, and clear arrangements about contacting clients.

For a client to autonomously enter into a therapeutic arrangement, she has the right to know the initial goals, purposes, and techniques of therapy. If there are changes along the way, they should be documented. Information about alternative treatments should be provided, including disclosure about risks, benefits, and costs. The client should be informed that confidentiality survives the death or incompetence of the therapist as well as the client.

The consent form should speak to dual relationship or boundary issues. It should be clear that ethical conflicts may arise and the therapeutic relationship may be at risk. Specific prohibitions should be listed, such as gift giving, social interaction, personal relationships, or business relationships. “The form should further state that should the client attempt to draw the therapist into a dual relationship or boundary violation, termination of the therapy and referral to another provider will be the probable result.” (60-62)

Even though the therapist bears the responsibility for boundary violations, there may be times when a client repeatedly acts in flagrant violation of boundaries. There may be times the therapist is doing everything possible to maintain boundaries, and the client refuses to acknowledge or accept limits. Such times could lead to the termination of the therapy with referral.

When the client has been fully informed about boundaries, about dual relationships, it becomes much easier for the therapist to offer a gentle reminder when the client moves too close to the limit. Rather than introducing the issue of boundaries along the way, the therapist is wise to bring up the issue in the beginning.

There are, of course, times when you don’t need a detailed discussion of possible boundary violations. For instance, if your client is elderly, is brought to your office by nursing home staff in a wheel chair, the risk of boundary violations is much less. If your client is a college student, the warnings about business relationships may not be a serious issue. Your own good judgment about informed consent, with an eye to high ethical standards, will serve you well.

Confidentiality
In the best of all possible worlds we might be able to offer clients complete and absolute confidentiality. Certainly such a guarantee would enhance the client’s willingness to be honest and open in communication. However, there are legal as well as professional limits to confidentiality. There are times we have no choice but to tell someone what we have heard in therapy. There are times we must obey the law, and report certain facts. It is essential that we inform our clients, up front, about these circumstances.

Legal exceptions to confidentiality vary. You need to be familiar with laws in your area regarding requirements to report. Child abuse, elder abuse, and abuse of the mentally or physically disabled should be reported. In fact, if you know of such situations, and fail to report, you may be legally liable.

There may be a need to disclose information to third-party payers. While it is desirable to disclose no more than is absolutely necessary, some information may be required for reimbursement.

Most every mental health professional is aware of the famous Tarasoff case. In 1969 Prosenjit Poddar killed Tatiana Tarasoff. Poddar and Tarsoff were students at the University of California at Berkeley. Poddar was upset when Tatiana told him she wasn’t interested in a serious relationship. Friends convinced him to go to student health. During a therapy session he told the psychologist he was going to kill Tatiana. The psychologist informed campus police that Poddar was dangerous, but after questioning him, the campus police let him go. He promised to stay away from Tatiana. A few weeks later Poddar went to Tatiana’s house and stabbed her to death.

Tatiana’s parents brought suit. The California Supreme Court heard the case twice. The first time, in 1974, they found the police liable, but this was reversed in 1976. The therapist was held liable because of the “special relation that arises between and patient and his doctor or psychotherapist.” In spite of evidence that therapists are often unable to predict dangerous behavior, the court rules that there was a duty to warn.

Many states passed legislation concerning therapist’s duty to warn potential victims. Some states have rejected this idea. You need to be familiar with the laws in your state. These issues are by no means settled; there is a recent California case concerning a threat of danger which was communicated to the therapist by a family member of the client. The Ewing versus Goldstein case went to the California Supreme Court which upheld the Appeals Court decision which said that the therapist was liable for the death when the threat was communicated by a family member to the therapist. Other states are dealing with this issue as well. Once again, the ethical therapist needs to be fully aware of state laws.

Maintaining boundaries around confidentiality is not always easy. At times the laws about reporting make clear what is required. At other times, wise and careful discernment is necessary. The guiding ethical principles, in making such determination, should always be the best interest of the client.

Beneficence and Nonmaleficence
Doing good, and avoiding harm, are primary therapeutic as well as ethical goals. However, it is often difficult to know what constitutes good, and what makes for harm. There are times when a proposed course of action may contain some of both. Weighing the relative benefits (good) and burdens (harm) is at the heart of ethical decision-making.

Such discernment is at the heart of ethical thinking for the therapist, and no where is such sorting out more challenging than in boundary issues. So many factors can play into a situation such that a proposed action may, in one circumstance, be only a boundary crossing. On the other hand, a very similar action, in different circumstances, can become a serious boundary violation. A high degree of self-awareness, as well as ethical awareness will help the conscientious therapist navigate through these tricky situations.

The prudent therapist will always keep the well-being of the client in the forefront of her thinking. Any action which poses any risk to the client should be avoided. Any action which might exploit the client in any way should be avoided. Any action which threatens the integrity of the therapeutic relationship should be avoided. Any action with even the appearance of harm, or exploitation, should be avoided. It is always better to err on the side of staying well within boundaries, and avoiding dual relationships.

These kinds of judgments are particularly difficult for therapists living and working in rural areas. The millions of Americans who live in rural areas may experience significant obstacles in receiving mental health care. Roberts, Battaglia, and Epstein point out that isolated settings with limited resources are particularly fraught with ethical challenges concerning “overlapping relationships, conflicting roles, and altered therapeutic boundaries between caregivers, patients, and families.” Laura Weiss Roberts, MD, John Battaglia, MD, and Richard S. Epstein, MD “Frontier Ethics: Mental Health Care Needs and Ethical Dilemmas in Rural Communities” http://ps.psychiatryonline.org/cgi/content/full/50/4/497

At times serving the best interests of clients will necessarily involve moving across boundaries one might avoid in an urban setting. Dual relationships may simply be unavoidable if you are the only therapist for 200 miles. Bartering may be commonplace, both for goods and services. Personal relationships with relatives of clients may be difficult to avoid, particularly for a therapist who is involved in local community or church groups. Confidentiality can be hard to maintain in a setting where everyone sees who goes in your office.

Dealing with these situations demands constant awareness and vigilance. The well-being of the client must always come first, but balancing other factors can make this a real ethical challenge. Principles and guidelines which work well in urban settings are not always helpful in other places. The therapist always remains responsible for monitoring and guarding boundaries, and for refraining from risking harm to the client, or exploiting the client.


Introduction
Given the high degree of responsibility on the part of the therapist for maintaining boundaries, a closer examination of the theory of virtue ethics may be beneficial. While no one ethical theory need take precedence over others, boundary issues may be well served by attention to virtue ethics. Good ethical thinking will attend to duties and obligations, but how these are interpreted can be influenced by agent-focused ethics. Who we are as moral agents is the focus of virtue ethics.

Virtue ethics has its roots in ancient Greece. Aristotle taught that for human flourishing, one should have certain virtues such as wisdom and justice. He thought of moral virtues as dispositions to choose under the proper guidance of reason. One should strive to live in accordance with virtues. Moral virtues are what make a thing good; what enables people to live well. While the philosophical notion of virtue ethics has a rich and complex history, for our purposes, let’s think in terms of those virtues which serve us well to act as competent, caring, ethical care-givers.

Virtue ethics has to do with who we are as ethical decision-makers. It concerns the one making the choice rather than the results of the action, or the action itself. It is about the agent; the one assessing and choosing.

Pellegrino and Virtue Ethics
Edmund Pellegrino has written an important essay entitled “The Virtuous Physician and the Ethics of Medicine.” Edmund D. Pellegrino “The Virtuous Physician and the Ethics of Medicine,” Biomedical Ethics, Fifth Edition, ed. Thomas Mappes and David Degrazia, (New York: McGraw Hill, 2001), pp 68-71. Further references will be noted parenthetically with page number. While his article is written in terms of doctors practicing medicine, his ideas are important, and apply equally to mental health professionals practicing therapy.

Pellegrino notes: “The ancient Hippocratic Oath includes honoring duties such as keeping confidentiality and avoiding harm to the patient. The practitioner is enjoined to declare: “. . .in purity and holiness I will guard my life and my art.” This is not, of course, a religious declaration, rather it is an acknowledgment of the importance of acting in ways that are good and virtuous. Furthermore first century writer Scibonius Largus made humanitas (compassion) an essential virtue. (68)

Most modern professional codes of ethics include attention to duties and rights, as well as exhortations to virtue. There is a recognition that the well-being of the patient/client “cannot be fully protected by rights and duties.” There is room for, and a need for, attention to virtues.

The oft quoted Prayer of Maimonides has the physician/therapist asking “. . .may neither avarice nor miserliness, nor thirst for glory or for a great reputation engage my mind; for the enemies of truth and philanthropy may easily deceive me and make me forgetful of my lofty aim of doing good to thy children.” The call to virtuous practice is clear. (68)

Pellegrino’s analysis of obligations is keen. He proposes we think in terms of a three-tiered system of obligations. “In the ascending order of ethical sensitivity they are: observance of the laws of the land, then observance of rights and fulfillment of duties, and finally the practice of virtue.” The legally based ethic functions as the minimal requirements. These are based in laws such as those which protect persons; laws concerning licensing; and laws concerning torts and contracts.

Next are ethical systems based on rights and duties. These theories spell out obligations beyond what the law requires. Beneficence and nonmaleficence are more than legal requirements. There are no laws defining specifically what constitutes the good of the client. But ethical mandates concerning rights and duties demand that we respond to those we serve with compassion, kindness, truth-telling, and that we honor autonomy and confidentiality to the greatest extent possible.

Pellegrino says that “how sensitively these issues are confronted depends more on the physician’s (therapist’s) character than his capability at ethical discourse. . .”

Once again, Pellegrino:

"Virtue-based ethics goes beyond these first two levels. We expect the virtuous
person to do the right and the good even at the expense of personal sacrifice
and legitimate self-interest. Virtue ethics expands the notions of benevolence,
beneficence, conscientiousness, compassion, and fidelity well beyond what
strict duty might require.. . . . it calls for standards of ethical performance
that exceed those prevalent in the rest of society." (69)

Furthermore:

"The virtuous physician (therapist) does not act from unreasoned, uncritical
intuitions about what feels good. His dispositions are ordered in accord with
that ‘right reason’ which both Aristotle and Aquinas considered essential to          
virtue. . . . . . Virtue-based professional ethics distinguishes itself, therefore
less in the avoidance of overtly immoral practices than in avoidance of those
at the margin of moral responsibility."(69)

Pellegrino’s concern for virtuous practice in medicine applies equally to those practicing psychotherapy. In those grey areas where duties and rights are not clear, in those times and places we aren’t sure what is the right thing to do, who we are makes a difference. It is out of who we are, that we choose how to act. Pellegrino’s final reminder comes from Shakespeare in Hamlet:

"Assume the virtue if you have it not. . .
For use almost can change the stamp of nature." (71)

Five Focal Virtues
Beauchamp and Childress address the topic of virtue ethics at length, in a chapter entitled “Moral Character.” Beauchamp, Tom L. and James F. Childress. Principles of Biomedical Ethics: Fifth Edition, Oxford University Press, 2001. Specific references will be noted parenthetically.

They state:

"Often, what counts most in the moral life is not consistent adherence to
principles and rules, but reliable character, good moral sense, and emotional
responsiveness. . . .Our feelings and concerns for others lead us to actions
that cannot be reduced to instances of rule-following, and we all recognize
that morality would be a cold and uninspiring practice without various
emotional responses and heart-felt ideals that reach beyond principles and rules." (26)

Beauchamp and Childress emphasize five virtues which are of particular value in caring for persons.

Compassion “combines an attitude of active regard for another’s welfare with an imaginative awareness and emotional response of deep sympathy, tenderness, and discomfort at another’s misfortune or suffering” (32) Compassion focuses on our care for others. It is not about sentimental sympathy, but a genuine and abiding care for the well-being of others. We don’t even have to like those we care for to practice compassion.

Some philosophers have been concerned that compassion may make us unable to be impartial and act with reason. Spinoza and Kant have advocated a cautious approach to compassion.. At times we encounter language such as detached concern or compassionate detachment a way of reminding us that we are professionals and that our caring is not the same as the care we feel for close family or friends. We can be professional as well as compassionate.

“When compassion appropriately motivates and expresses good character it has a role in ethics alongside impartial reason and dispassionate judgment.” (34)

Discernment is of particular importance in the issues of boundaries and dual relationships. Beauchamp and Childress say that "the virtue of discernment brings sensitive insight, acute judgment, and understanding to action. Discernment involves the ability to make judgments and reach decisions without being unduly influenced by extraneous considerations, fears, personal attachments, and the like.” (34)

Discernment, akin to what Aristotle called practical wisdom, enables us to make decisions in those grey areas where we aren’t sure if a particular action will constitute a boundary crossing or a boundary violation. Discernment enables us to sort out what really is in the best interest of the client. Discernment guides us to acknowledge potential risk of harm to our client.

“The virtue of discernment thus involves understanding both that and how principles and rules are relevant in a variety of circumstances. It requires attention and sensitivity attuned to the demands of particular contexts” (34) Discernment understands grey areas, so to speak.

Trustworthiness is a virtue which enables our clients to know that we are morally responsible and reliable. It means that our clients can be confident that we will act in their best interest, and that we will not violate moral norms, including boundaries. Of course trust is basic to the integrity of the therapeutic relationship.

To maintain the best ethical as well as therapeutic environment, the therapist must have a relationship with a client in which trust is foundational. And one of the primary areas in which clients must trust is that the therapist will maintain boundaries.

Integrity is about who we are as moral agents. “In its most general sense, moral integrity means soundness, reliability, wholeness, and integration of moral character. In a more restricted sense, moral integrity means fidelity in adherence to moral norms.” (35-36)

Our integrity is compromised when we make decisions to act in ways other than what we know to be the right thing to do. An obvious example concerns sexual contact between therapist and client. Of course the therapist knows it is wrong, but acts nonetheless in ways that cause harm. Such actions are clearly a violation of his integrity.

Our integrity is maintained when we choose to act in the right way, even in circumstances that other courses of action may seem simpler, less trouble, or more emotionally appealing. It means simply that we know, and do, the right thing.

Conscientiousness, say Beauchamp and Childress, happens when an individual acts in ways “motivated to do what is right because it is right, has tried with due diligence to determine what is right, intends to do what is right, and exerts an appropriate level of effort to do so.” (37)

Once again we are considering a virtue which is particularly relevant to the issues around boundaries and dual relationships. When we aren’t sure what is the right thing, when we encounter a situation with no clear right path, the virtue of conscientiousness will help us sort through and decide. In fact it is the virtue which will guide our deciding. It is a virtue which provides the ability to be self-reflective; to examine our own motives and goals. “It is an internal sanction that comes into play through critical reflection.” (38)

We may, of course, include other virtues, such as fairness, hope, love, faithfulness and many more. However, these five we have discussed will serve us well in making the ethical decisions demanded by boundary and dual relationship questions. And, once again, Shakespeare reminds us that we can “assume the virtues” which may be a way of helping develop and enhance our virtuous behavior.

Summary
Attention to the law, attention to duties and obligations, to rights and rules are essential to good ethical practice. However even diligent attention to these aspects of ethics can leave us wondering, especially about boundary questions. The very nature of boundary issues as grounded in the particular situations and circumstances we face mean that we need more than duties and rules to guide us.

Virtue ethics offers us a theoretical framework in which to ponder and think about how to proceed. It is about who we are, as the agent deciding. It is about our character, our willingness and our capacity to be honest in thinking through the dilemmas we face. Virtue ethics isn’t about becoming “holier than thou,” rather it is about becoming a person who acts with good moral wisdom in making choices.

Virtuous character isn’t acquired all at once. Nor is it acquired by reading a book, or attending a workshop. Many thinkers, including Aristotle, believe that virtue can be learned. Virtuous character comes with practice, so to speak. It is something we choose to strive for, it is an ideal we seek to become. It is part of our own on-going growth and becoming as full human beings.

Becoming a virtuous person won’t make boundary decisions automatically easier. In fact, if anything, it may enable us to see complexities and subtleties we may have not been aware of. But high standards and a constant striving for virtuous action will lead us to good ethical decisions.


Case One
You have been treating a middle-aged woman named Kate for over two years for serious PTSD. She is progressing very well. You are invited to present at a workshop on PTSD for local clergy. Knowing that you will be addressing a specialized audience (as opposed to the general public) you are considering asking Kate if she will join you for an interview so that the group may learn from her experiences.

A. You fear that such an experience would constitute exploiting Kate, even though it would be a very effective presentation.

B. You discuss the possibility with Kate, and believing she is at a point in therapy where such an experience could be beneficial, you give her the option of participating.

C. You tell Kate about the invitation, tell her you think she should join you, and when she is hesitant, you urge her to come with you.

Response: As with so many of the cases about boundaries and dual relationships, this one requires the careful discernment of the therapist. Not only ethical issues, but therapeutic issues are at stake. If your best judgment is that such an experience would genuinely benefit the client, you may choose, if she agrees, B. However there may be good therapeutic reasons to choose A. The risk of exploiting her is very high in this kind of situation, and you should use great caution, and keen assessment to determine what is best for her.

Case Two
Your client, Hal, is HIV+ and you have been seeing him for several months to help him deal with this. While he is currently healthy, taking his medication, and in a stable relationship, his fears about his HIV status have been overwhelming. He is afraid that if people know, he will be ostracized and shunned. At the end of a session, he says, “Can I have a hug?”

A. You tell him that while you care about him, and empathize with his situation, it is unethical for you to touch him.

B. You give him a quick gentle hug, knowing that this kind of contact is a way of demonstrating to him that he is not “unclean” so to speak, and that you aren’t afraid to touch him.

C. You can’t imagine touching him, so you ignore the question, and head to the door.

Response: Normally physical contact is to be avoided as a boundary violation. However, the message that a hug can send has potential therapeutic value for the client. Hence, B is the best answer, and does not violate ethical boundaries. Should he ask for hugs repeatedly, you may wish to discuss his requests with him directly.

Case Three
Bob has recently been divorced and is quite despondent. He has begun taking medication for his depression, but he can’t imagine that his life will ever be good again. He comes in for a session, and tells you that he has bought a gun, and is thinking of “just ending it all.”

A. You tell him to stay in your office while you go tell the receptionist to call the police.

B. You talk with him, and inform him that his threat to harm himself constitutes a situation in which you are ethically and legally bound to act to protect him, hence you must take action to inform authorities.

C. You try to talk him out of hurting himself, reminding him of all the good times ahead.

Response: Of course the confidentiality of the therapeutic relationship is at risk, however, you are unquestionably bound, legally and ethically, to take action for Bob’s safety. Hence B is the best response.

Case Four
Ron is a new client, and owns the local car dealership. He is a jovial fellow, dealing with some marital issues. After a few sessions, he offers to get a really great deal for you on a new car. He isn’t asking to barter, just offering you a break.

A. You would love a new car at a good price, but you have to tell Ron that you cannot ethically accept his offer.

B. You take the deal, and buy the car for your wife, therefore you aren’t personally benefiting, only your wife is benefiting.

C. You think about it and realize that you would not be exploiting Ron; that he has made an offer which won’t actually cost him anything personally. In fact, it will boost his ego to enable him to help you as he is grateful for your help. So you take him up on the offer, thinking that you are helping him.

Response: This is not too complicated. You must refuse his offer. There is no way that such a deal is ethical.

Case Five
You are teaching a class in psychology at the local university as an adjunct instructor. One of the students is in her 30s, in college as part of a career change. She is very attractive, smart, and friendly after class. She invites you to dinner at her house.

A. As her teacher, you do not have a therapeutic relationship with her. She seems to be quite healthy and well-adjusted. So you tell her that after the term is over, you would love to come to dinner.

B. As her teacher, you are in a relationship with her which is unequal; therefore there is not a balance of power. She initiated the social contact, but you must refuse as long as she is your student. You use this as an opportunity to discuss the ethics of the situation with her.

C. You inform her right away that there cannot be any social contact between teacher and student. You hint that if she can wait two years, maybe you can get together.

Response: Both of you are competent, autonomous adults. However, the student-teacher relationship is not one of equality. Hence you must decline the invitation. B is the best response, as it includes an opportunity for you to explain your position.

Case Six
Your client George has died. You knew him for many years, and worked with him off and on over the years. One of the issues you and he had discussed concerned a long-time extra-marital affair. Now George has died, and his widow has made an appointment to see you. She is calm and composed, and says, “I need to know, for my own peace of mind, if he really was involved with that other woman all these years.”

A. George’s widow is experiencing distress because she doesn’t know what really went on in her husband’s life. She is seeking peace, and whether or not he had the affair seems less important than that she finally know the truth. So you gently tell her the truth.

B. You can see that if you tell her the truth she will be upset, disappointed in George, and leave your office believing all her years of marriage were a lie. So you simply tell her that George always loved her, and was always faithful to her. After all, the truth could cause harm to her.

C. In the kindest possible way, you explain that George’s death does not cancel your obligation to keep confidentiality. You talk with her about her question, offer good therapeutic counsel, but you cannot answer her question.

Response: This is difficult partly because we want to act in virtuous ways with George’s widow. We want to be kind and compassionate, and offer her some solace. However our duty, our obligation to keep confidentiality, even after death, must take precedence. Hence C is the best ethical response.

Case Seven
You live in a remote area of a large western state. The closest town only has 2000 residents. You are the only therapist for many miles. Your son’s teacher comes to you for help with serious personal problems. The only other alternative way for her to get help is to drive 4 hours to the nearest city, or try on-line therapy.

A. You tell her that as long as your son is in her class, you simply cannot assume the burden of this dual relationship, both her therapist, and a parent of her student. You recommend that she plan to take some days off and travel to the city for help.

B. You discuss the potential issues concerning the dual relationship. You inform her of the possible problems, and after a thorough discussion of the issue, you both agree that the therapy can proceed. You agree to continue to monitor the situation, and that you will not discuss therapeutic issues if you should run into one another around town.

C. You give her the names of some good inter-net therapists.

Response: Dual relationships are virtually unavoidable in remote areas. The standards which apply in urban settings are often of little use in rural areas. If you discuss the nature of the dual relationship with her, and you believe she understands, and is capable of keeping clear boundaries, then you may indeed proceed with therapy. B is the best response.

Case Eight
Your new client turns out to be your old college girlfriend. For two years you and she had a serious relationship, including abundant sexual contact. You lost touch with her after college, and didn’t recognize her married name on your appointment book.

A. Codes of ethics are clear about therapy with persons with whom the therapist had a sexual relationship in the past. Simple social contact might not be a problem, but in this case there is significant risk of harm to the client as old feelings may be aroused. There is risk of this relationship escalating in inappropriate ways. So you chat with her briefly, and in a kind way, explain that your past relationship precludes any possibility of therapy. You refer her to someone else.

B. She hadn’t realize that you were going to be the therapist, as yours is a fairly common name. She just moved here, and didn’t know you were a therapist here. She is delighted to see you, and when you explain the ethical dilemma, she tells you not to worry about it; there won’t be any problems.

C. You know that after all these years, you couldn’t possibly feel anything for her so you don’t even mention the possible ethical issues, and proceed with therapy.

Response: A is the only acceptable response. You are responsible for boundaries; you are responsible for making the call in this kind of situation.

Case Nine
A client repeatedly tells you about a neighbor who seems to be abusing her children. She reports to you that she hears screams, and that the neighbor sometimes appears to be drinking. The client tells you these stories several times. However you suspect her accounts are unreliable, as is some of what she tells you about herself.

A. You tell her she must call local authorities to report the potential child abuse.

B. You call local authorities and report what you have been told without revealing the precise source of your information.

C. You haven’t actually witnessed any abuse, and the client often tells you things that you know to be untrue, so you dismiss her accusations as fantasy.

Response: As a professional, you bear some moral responsibility, and in some situations, legal responsibility, to report these allegations. Even if they turn out to be untrue, the possibility of helping abused children is a greater good than the burden of a false report. The authorities should be the ones to make this determination regarding abuse. So B is the best response.

Case Ten
Your client is a young woman in her 30s. She is lonely, and isolated, with few friends or social contacts. Several times she has worn revealing clothing to her session, such as short skirts, or tight, revealing sweaters. While she hasn’t actually made overtly suggestive statements, her behavior is becoming more and more seductive. You are concerned with her behavior and fear that she is going to become overtly aggressive.

A. You ignore this behavior; she hasn’t actually crossed a boundary yet. She is just a flirt, and probably won’t do anything inappropriate.

B. You initiate a conversation about what you have noticed, and discuss with her the possible meaning of her behavior. You remind her that in your intake interview, you discussed boundaries and you are concerned she is moving close to a boundary.

C. Until she actually moves over a boundary, such as reaching out to touch you, or making specifically suggestive comments, you simply watch her behavior. You don’t want to give her the satisfaction of thinking she is affecting you. Until she becomes explicitly inappropriate, you act with great care.

Response: This is difficult, and the best response will depend on your intuitive assessment of this client. In some situations you may choose B or at times C will be the best choice. This is certainly one of those grey areas. Clearly there is a serious threat of a boundary violation, but it has not occurred, and not may occur. In some cases B will likely be the best choice, however you may decide that C is best. In either case, careful documentation is essential.


Ethical issues around boundaries, both crossing and violating, as well as dual relationships are among the most complex and challenging ethical dilemmas therapists encounter. The first step in good ethical practice is to simply become aware of the times and places such issues arise. It can be easy to not even think about possible ethical violations in many of these situations.

Becoming self-aware, becoming willing to examine one’s own motives and needs regarding many of these issues is essential to good ethical practice. This may not be easy or pleasant. Good sound knowledge about ethical principles and precepts provides the groundwork. However such knowledge is often insufficient to make the subtle distinctions needed in these issues.

Virtue ethics provides a channel for therapists to navigate the tricky paths through these areas. Virtue ethics promotes the use of our own good moral sense, applied with care and compassion, so that we have more than rules and obligations to guide us in sorting out the best ethical response.

But the final word remains: It is always the responsibility of the therapist to set, monitor, and maintain safe and appropriate boundaries, and to enter with great care into dual relationships.


On Line Resources
aamft.org

advocateweb.org

American Counseling Association.org

apa.org

amhca.org

4therapy.com

judyroberts.net

kspope.com

medicinenet.com
                                                   
psychiatrictimes.com

psychiatryonline.org

Print Resources
Abels, S. L. Ethics in Social Work Practice: Narratives for Professional Helping, Love Publishing, 2001.
                              
Ahia, C. Emmanuel. Legal and Ethical Dictionary for Mental Health Professionals, University Press of America, 2003

Beauchamp, Tom L. and James F. Childress. Principles of Biomedical Ethics: Fifth Edition, Oxford University Press, 2001.

Bernstein, Barton, JD LMSW and Thomas L Hartsell Jr., JD The Portable Ethicist for Mental Health Professionals: an A-Z Guide to Responsible Practice, Wiley and Sons, Inc. 2000.

Cohen, Randy. The Good, The Bad, and The Difference: How to Tell Right from Wrong in Everyday Situations, Doubleday, 2002

Congress, Elaine P. Social Work Values and Ethics: Identifying and Resolving Professional Dilemmas, Wadsworth, 1999

Edwards, Rem B. Ethics of Psychiatry: Insanity, Rational Autonomy and Mental Health Care, Prometheus Books, 1997

Epstein, Richard S. Keeping Boundaries: Maintaining Safety and Integrity in the Psychotherapeutic Process, American Psychiatric Press, 1994.
         
Ford, Gary George and Gary G Ford. Ethical Reasoning in the Mental Health Professions, CRC Press, 2000
                              
Green, Stephen A, MD, Richard L Goldberg, MD, David M. Goldstein, MD, and Ellen Leibenluft, MD. Limit Setting in Clinical Practice, American Psychiatric Press, 1988.

Haas, Leonard and John Malouf, Keeping Up the Good Work: A Practitioner’s Guide to Mental Health Ethics, Professional Resource Press, 1995

Lerman, Hannah and Natalie Porter, Ed Feminist Ethics in Psychotherapy, Springer Publishing Company, 1990

Mappes, Thomas A. and David Degrazia, Biomedical Ethics Fifth Edition, McGraw Hill 2001.

Lott, Deborah A. In Session: The Bond Between Women and Their Therapists, W.H. Freeman & Co, 1999                                                                        

Reynolds, Elizabeth Welfel and R. Elliott Ingersol, Ed. The Mental Health Desk Reference: A Practice-Based Guide to Diagnosis, Treatment, and Professional Ethics, Wiley, 2001

Roberts, Laura Weiss Concise Guide to Ethics in Mental Health Care, American Psychiatric Association, 2004


Copyright Mary L. Caldwell, M.A.

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