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Boundaries in Therapeutic Relationships

 

Entering treatment for numerous mental disorders 15 years ago, I gave little thought to the relationships I would be developing with the people who would help me bring order to, what at that point, was a chaotic and disorganized life.  It was only after more than a dozen years of therapy that the issue of post-therapeutic relationships first became an issue in my still-recovering, always-a-work-in-progress mind.  Though I initially felt shame for becoming emotionally attached to the people who helped me resolve issues that had plagued me my entire adult life. I soon came to realize that the feelings I had developed for my therapists were both normal and commonplace, but that maintaining a relationship with them would be complicated.

Few relationships are as intimate and personal as the relationship between client and therapist.  For some people, their relationships with their therapists may be among their longest-lasting, and most meaningful.  What differentiates these relationships from most other interpersonal relationships is that, at its base, the client/therapist relationship is a business transaction and subject to regulation by state and federal agencies.  Whether it remains as such during and after treatment is a source of controversy and debate, and professional ethical guidelines imposed by the American Psychological Association (APA) can be murky, allowing for discretion on the part of therapist and client alike.

According to the APA’s Ethical Principles of Psychologists and Code of Conduct, referred to as the Ethics Code for psychologists, boundaries are to be imposed on client/therapist relationships during the course of treatment and, in the case of sexual relationships, for two years following termination of treatment.  This is also true for many governing bodies on the state level, including the California Board of Psychology (CBOP).  If a client is treated by multiple therapists at a single clinic, the date of termination for all therapists he or she worked with is the last day of treatment at that clinic, regardless of when treatment ended with any specific therapist.

While the APA guidelines specifically prohibit sexual relationships after treatment has ceased, it has become a rule of thumb for many therapists to employ the two-year rule to all activities unrelated to treatment.  Once two years have passed following termination of treatment, it is up to the therapist and client to determine the nature of their relationship.  While a client may initiate personal relations with a former therapist, the therapist is discouraged from doing so, at least at the outset, as the client may be uncomfortable having personal contact with a person with whom he or she has shared such intimate information with on a professional level.  A therapist is discouraged from working with a former client in a therapeutic setting once a personal or business relationship has been established.

Many factors must be taken into consideration when determining what boundaries need to be utilized and to what degree in an active client/therapist relationship, including:

  • The state of the client’s overall mental health
  • The client’s points of vulnerability
  • The duration of treatment
  • The modality of treatment
  • What is being treated
  • Whether treatment might be resumed after initial cessation.

 

Additionally, practitioners of Cognitive Behavioral Therapy (CBT) and Dialectical Behavior Therapy (DBT) tend to be more liberal in crossing boundaries than those employing more traditional modalities, such as psychiatry, psychoanalysis, and psychodynamic therapy.  This is, in part, because CBT and DBT seek to influence the client’s thoughts and behaviors, where older models of therapy tend to focus on understanding the root causes of a client’s problems, requiring a more detached client/therapist relationship.  If there is a significant likelihood that treatment will have to be resumed at some point and a determination is made that it would be beneficial to the client to continue working with the same therapist or therapists, his or her therapist(s) may refrain from facilitating a non-therapeutic relationship.

Unethical boundary crossings are those that are determined to be non-consensual, conflict with the goals of treatment, involve harassment of the client, involve unfair discrimination against the client, or are exploitative of the client.  For example, sexual relationships with an active client are always considered unethical but are allowed two years after treatment has concluded on a case-by-case basis.  Only if it is determined that the therapist is not taking advantage of his or her former client would such a relationship be considered ethical.  A sexual relationship with a former client who is emotionally unstable or vulnerable is not acceptable under any circumstances.

Should a sexual relationship develop after the two years have passed, the burden of proof will be on the therapist to prove it is not an exploitative relationship.  Failure to do so may result in the suspension of the therapist’s license to practice psychology.  Sexual relationships with friends and family members of clients are also discouraged, as are sexual relationships between friends and family members of therapists and the clients they are treating.  It is in the best interest of clients that the people they’re working with remain outside of their social circles during treatment, so as to affirm the professional nature of their relationships and not compromise the therapist’s objectivity.  Getting to know the friends and family members being discussed intimately during therapy sessions on a personal level does not well serve the purpose of objectivity.

When therapists do forge bonds with clients outside of a clinical setting, these relationships are referred to as dual relationships, also known as multiple relationships.  Dual relationships, in short, occur when a client and therapist engage in multiple roles during the course of treatment.  These include socializing outside the clinical milieu, establishing family or business ties, and participating in charitable or religious activities not related to the treatment process.   Two types of dual relationships between clients and therapists that have been defined are:

  1. Concurrent dual relationships, in which multiple relationships exist simultaneously (for example, a therapist and client who engage in professional ventures during the course of therapy, such as co-authoring  a book or promoting mental health awareness)
  2. Sequential dual relationships, in which one type of relationship—the client/therapist relationship, for example— is replaced by a different type of relationship, such as a business or personal relationship

Both are allowed under most ethical doctrines, though concurrent dual relationships are generally considered to be more potentially problematic and subject to greater restrictions and scrutiny.

The rise of digital technology and social networking has served to further complicate the debate over ethical boundaries and their enforcement.  While the APA guidelines don’t explicitly address what is and is not allowed in this arena, it has become a rule of thumb that therapists ought not friend active clients at their Facebook accounts, particularly those that have privacy controls and content that is personal in nature.  While therapists often get to know their clients on a deeply personal level when working with them, blurring the lines between therapy and friendship brings with it the risk of confusing the client as to the nature of the therapeutic relationship, as well as hindering the judgment of the therapist.  Thus, any social networking therapists engage in outside the bounds of the professional sphere must be reserved for non-clients and former clients.

Maintaining a balance between trust and professionalism is essential to any healthy client/therapist relationship.  Though many clients come to think of their therapists as friends during the course of therapy, the job at hand requires an emotional distance on the part of the clinician that is very much atypical of personal relationships.  The ultimate goal for anyone in therapy is to leave treatment with a healthier state of mind and greater emotional stability, ready to face the challenges life offers in a way that is productive, rewarding, and life-affirming.  Once that has been accomplished, anything is possible.

 

Sources:

  1. Zur, Dr. Ofer.  “Dual Relationships, Multiple Relationships, Boundaries, Boundary Crossings & Boundary Violations in Psychotherapy, Counseling & Mental Health.”  Zur Institute.  na.  Web.  05 September 2012.
  2. “Codes of Ethics on Termination in Psychotherapy and Counseling.”  Zur Institute.  2012.  Web.  05 September 2012.
  3. “Ethical Principles of Psychologists and Code of Conduct Including 2010 Amendments.”  American Psychological Association.  na.  Web.  05 September 2012.
  4. “Laws and Regulations Related to the Practice of Psychology 2012.”  Board of Psychology.  Department of Consumer Affairs.  2012.  Web.  05 September 2012.

 

By Greg L.


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Filed under: Life, Recovery, Treatment · Tags: client therapist boundaries, crossing boundaries, relationships with therapists, therapist and client relationships