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References on Therapeutic Boundaries

 

  • Ahrentzen, S. B. (1990). Managing conflict by managing boundaries: How professional homeworkers cope with multiple roles at home. Environment and Behavior, 22(6), 723-752.
  • Ainsworth, M. (1978). Patterns of attachment: A psychological study of the strange situation. Hillsdale, NJ: Lawrence Erlbaum.
  • American Association for Marriage and Family Therapists. (2015). AAMFT code of ethics. Washington, DC: Author. Retrieved from https://www.aamft.org/Legal_Ethics/Code_of_Ethics.aspx.
  • American Counseling Association. (2014). Code of ethics and standards of practice. Alexandria, VA: Author.
  • American Indian Mental Health Advisory Council. (2004). Cultural competency guidelines for the provision of clinical mental health services to American Indians in the state of Minnesota. Retrieved from http://edocs.dhs.state.mn.us/lfserver/Legacy/DHS-4086-ENG.
  • American Psychiatric Association (ApA). (2013). Principles of medical ethics with annotations especially applicable to psychiatry. Washington, DC: Author. Retrieved from http://www.psych.org/MainMenu/PsychiatricPractice/Ethics/ResourcesStandards/ Principles-of-Medical-Ethics-2010-Edition.aspx?FT=.pdf.
  • American Psychological Association. (1953). Ethical standards of psychologists. Washington, DC: Author.
  • American Psychological Association (1992). Ethical principles of psychologists and code of conduct. American Psychologist, 47, 1597-1611.
  • American Psychological Association. (1997). Statement on services by telephone, teleconferencing, and Internet. Retrieved from http://www.apa.org/ethics/education/telephone-statement.aspx.
  • American Psychological Association. (2002). Ethical principles of psychologists and code of conduct. American Psychologist, 57, 1060-1073.
  • Anderson, M. B., Van Raalte, L. L., & Brewer, B. W. (2001). Sports psychology service delivery: Staying ethical while keeping loose. Professional Psychology: Research and Practice, 32, 12-18.
  • Anderson, S. K., & Kitchener, K. S. (1998). Nonsexual post-therapy relationships: A conceptual framework to assess ethical risks. Professional Psychology: Research and Practice, 29, 91-99.
  • Aponte, J. F., & Wohl, J. (2000). Psychological intervention and cultural diversity. Boston: Allyn & Bacon.
  • Appelbaum, P. S. (1991). Legal liabilities and managed care. American Psychologists, 48, 251-157.
  • Aron, L. (1991). The patient’s experience of the analyst’s subjectivity. Psychoanal. Dialogues, 1, 29-51.
  • Baer, B. E., & Murdock, N. L. (1995). Nonerotic dual relationships between therapist and clients: The effect of sex, theoretical orientation, and interpersonal boundaries. Ethics & Behavior, 5(2), 131-145.
  • Bailey, D. S. (2004) Approaching ethical dilemmas. Monitor On Psychology, 35(9), 62.
  • Banaka, W. H., & Young, D. W. (1985). Community coping skills enhanced by an adventure camp for adult chronic psychiatric patients. Hospital and Community Psychiatry, 36, 746-748.
  • Barnett, J. E. (1999). Multiple relationships: Ethical dilemmas and practical solutions. In L. VandeCreek, S. Knapp, & T. Jackson, (Eds.), Innovations in clinical practice: A source book, Vol. 17, (pp. 225-267). Sarasota, FL: Professional Resource Press.
  • Barnett, J. E. (1998). Should psychotherapists self-disclose? Clinical and ethical considerations. In L. VandeCreek, S. Knapp, & T. Jackson, (Eds.), Innovations in clinical practice: A source book, Vol. 16, (pp. 419-428). Sarasota, FL: Professional Resource Exchange.
  • Barnett, J. E., & Yutrzenka, B. A. (1994). Nonsexual dual relationships in professional practice, with special applications to rural and military communities. The Independent Practitioner, 14(5), 243-248.
  • Bennett, B. E., Bryant, B. K., VandenBos, G. R., & Greenwood, A. (1990). Professional liability and risk management. Washington, DC: American Psychological Association.
  • Berg, I. K. (1994). Family-based services: A solution-focused approach. New York: W.W. Norton.
  • Bernstein, A. C. (2000). Straight therapists working with lesbians and gays in family therapy. Journal of Marriage and Family Therapy, 26, 443-454.
  • Bersoff, D. (1999). Ethical conflicts in psychology. (2nd ed.). Washington, DC: American Psychological Association.
  • Blanton, S. (1971). Diary of my analysis with Sigmund Freud. New York: Hawthorn Books.
  • Borys, D. S. (1992). Nonsexual dual relationships. In L. Vandecreek, S. Knapp, & T. L. Jackson (Eds.), Innovations in clinical practice: A source book, Vol. 11 (pp. 443-454). Sarasota, FL: Professional Resource Exchange.
  • Borys, D. S., & Pope, K. S. (1989). Dual relationships between therapist and client: A national study of psychologists, psychiatrists, and social workers. Professional Psychology: Research and Practice, 20, 283-293.
  • Bowlby, J. (1969). Attachment, separation & loss, Vol. 1, New York: Basic Books.
  • Boyd-Franklin, N., & Bry, B. H. (2000). Reaching out in family therapy: Home-based, school, and community interventions. New York: The Guilford Press.
  • Bridges, N.A. (2001). Therapist’s self-disclosure: Expanding the comfort zone. Psychotherapy, 38, 21-30.
  • Brodsky, A. M. (1985). Sex between therapists and patients: Ethical gray areas. Psychotherapy in private practice, 3(1), 57-62.
  • Brown, L. S. (1984). The lesbian therapist in private practice and her community. Psychotherapy in Private Practice, 2 (4), 9-16.
  • Brown, L. S. (1985). Power, responsibility, boundaries: Ethical concerns for the lesbian feminist therapist. Lesbian Ethics, 1(3), 30-45.
  • Brown, L. S. (1994). Boundaries in feminist therapy: A conceptual formulation. In N. K. Gartrell (Ed.), Bringing ethics alive: Feminist ethics in psychotherapy practice (pp. 29-38). New York: The Haworth Press.
  • Bruce, M. L., & McNamara, R. (1992). Psychiatric status among the homebound elderly: An epidemiologic perspective. Journal of American Geriatric Society, 40, 561-566.
  • Bryce, M., & Lloyd, J. (Eds.). (1981). Treating families in the home: An alternative to placement. Springfield, IL: Charles C. Thomas.
  • Bugental, J. F. (1987). The Art of the psychotherapist. New York: W. W. Norton.
  • Burke, W. (1992). Countertransference disclosure and the asymmetry/mutuality dilemma. Psychoanalytic Dialogue, 2, 241-271.
  • Burns, D. D. (1990). The feeling good handbook. New York: Plume.
  • Bursten B. (1959) The expressive value of gifts. American Imago, 16(4), 437-446.
  • Campbell, C. D., & Gordon, M. C. (2003). Acknowledging the inevitable: Understanding multiple relationships in rural practice. Professional Psychology: Research and Practice, 34(4), 430-434.
  • Canter, M., Bennett, B., Jones, S., & Nagy, T. (1996). Ethics for psychologists. Washington, DC: American Psychological Association.
  • Caudill, C. O. (2004). Therapists under fire. Retrieved from https://www.cphins.com/DesktopDefault.aspx?tabid=39
  • Cherniss, C., & Herzog, E. (1996). Impact of home-based family therapy on maternal and child outcomes in disadvantaged adolescent mothers. Family Relations, 45, 72-79.
  • Clark, S. C. (2000). Work/family border theory: A new theory of work/family balance. Human Relations, 53(6), 747-770.
  • Cohen, S. S. (1987). The magic of touch. New York: Harper and Row.
  • Cooper, S. (1998). Countertransference disclosure and the conceptualization of analytic technique. Psychoanalytic Quarterly. LXVII, 128-154.
  • Corey, G., Corey, M. S., & Callahan, P. (2003). Issues and ethics in the helping professions. (6th Ed.). Pacific Grove, CA: Brooks/Cole.
  • Cornell, W. F. (1997). Touch and boundaries in Transactional Analysis: Ethical and transferential considerations. Transactional Analysis Journal, 37(1) 30-37.
  • Cortes, L. (2004). Home-based family therapy: A misunderstanding of the role and a new challenge for therapists. Family Journal, 12(2) 184-188.
  • Davis-Berman, J., & Berman, D. S. (1994). Wilderness therapy: Foundations, theory & research. Dubuque, IA: Kendall/Hunt.
  • Department of Health and Human Services . (1996). Health Insurance Portability and Accountability Act of 1996. (104th Congress. Public Law 104-191). Retrieved from http://aspe.hhs.gov/admnsimp/pl104191.htm.
  • Dineen, T. (1996). Manufacturing victims: What the psychology industry is doing to people. Westmount, Canada: Robert Davies.
  • Doverspike, W. F. (1999). Ethical risk management: Guidelines for practice, a practical ethics handbook. Sarasota, FL: Professional Resource Press.
  • Doverspike, W. F. (2004). Boundary violations and psychotherapy. APA Review of Books, 49(2) 209-211.
  • Downey, D. L. (2001). Therapeutic touch in psychotherapy. Psychotherapy, 36(1) 35-38.
  • Doyle, K. (1997). Substance abuse counselors in recovery: Implications for the ethical issues of dual relationships. Journal of Counseling and Development, 75, 428-432.
  • Dryden, W. (1990). Self-disclosure in rational emotive therapy. In G. Stricker & M. Fisher (Eds.), Self-disclosure in the therapeutic relationship (pp. 61-74). New York: Plenum.
  • Dunne, C., Bruggen, P., & O’Brien,C. (1982). Touch and action in group therapy of younger adolescents. Journal of Adolescents, 5, 31-38.
  • Durana, C. (1998). The use of touch in psychotherapy: Ethical and clinical guidelines. Psychotherapy, 35(2) 269-280.
  • Ebert, B. W. (1997). Dual-relationship prohibitions: A concept whose time never should have come. Applied & Preventative Psychology, 6, 137-156.
  • Epstein, R. S. (1994). Keeping boundaries: Maintaining safety and integrity in the psychotherapeutic process. Washington, DC: American Psychiatric Association.
  • Epstein, R. S., & Simon, R. I. (1990). The exploitation index: An early warning indicator of boundary violations in psychotherapy. Bulletin of the Menninger Clinic, 54(4), 450-465.
  • Epstein, R. S., Simon, R. I., & Kay, G. G. (1992). Assessing boundary violations in psychotherapy: Survey results with the exploitation index. Bulletin of the Menninger Clinic, 56, 150-166.
  • Erkolanhti, E., & Ilonen, T. (2004). A home-treatment system in child and adolescent psychiatry. Clinical Child Psychology and Psychiatry, 9(3), 427-436.
  • Ewert, A. (1987). Research in experiential education: An overview. The Journal of Experiential Education, 10(2), 4-7.
  • Faulkner, K. K., & Faulkner, T. A. (1997). Managing multiple relationships in rural communities: Neutrality and boundary violations. Clinical Psychology: Science and Practice 4(3), 225-234.
  • Faustman, W. O. (1982). Legal and ethical issues in debt collection strategies of professional psychologists. Professional Psychology, 13, 208-214.
  • Fay, A. (2002). The case against boundaries in psychotherapy. In A. A. Lazarus & O. Zur (Eds.), Dual relationships and psychotherapy. (pp. 146-166). New York: Springer.
  • Field, T. (1998) Massage therapy effects. American Psychologist, 53(12), 1270-1281.
  • Fisher, C. D. (2004). Ethical issues in therapy: Therapist self-disclosure of sexual feelings. Ethics & Behavior, 12(2), 105-121.
  • Feminist Therapy Institute. (1987). Feminist therapy code of ethics. Denver: Author.
  • Fosshage, J. L. (2000). The meanings of touch in psychoanalysis: A time for reassessment. Psychoanalytic Inquiry, 20(1). Retrieved from http://www.psychoanalyticinquiry.com/vol20no1.html.
  • Frank, J. D. (1973). Persuasion and healing: A comparative study of psychotherapy. Baltimore, MD: Johns Hopkins University Press.
  • Freeman, A., Fleming, B., & Pretzer, J. (1990). Clinical applications of cognitive therapy. New York, Plenum.
  • Gabbard, G. (1994). Teetering on the precipice: A commentary on Lazarus’s “How certain boundaries and ethics diminish therapeutic effectiveness.” Ethics and Behavior, 4, 283-286.
  • Gabbard, G. (Ed.). (1989). Sexual exploitation in professional relationships. Washington, DC: American Psychiatric Press.
  • Gabbard, G. O., & Lester, E. P. (1995). Boundaries & boundary violations in psychoanalysis. New York: Basic Books.
  • Gabbard, G. O., & Nadelson, C. (1995). Professional boundaries in the physician-patient relationship. Journal of the American Medical Association, 273(18), 1445-1449.
  • Gabbard, G. O., & Pope, K. S. (1989). Sexual intimacies after termination: Clinical, ethical, and legal aspects. In G. 0. Gabbard (Ed.), Sexual exploitation in professional relationships (pp. 115-127). Washington, DC: American Psychiatric Press.
  • Gallagher, R. P., Gill, A. M., & Sysco, H. M. (2000). National survey of counseling center directors 2000. Alexandria, VA: International Association of Counseling Service.
  • Gass, M. A. (1993). Adventure therapy: Therapeutic applications of adventure programming. Dubuque, IA: Kendall/Hunt.
  • Gerson, A., & Fox, D. D. (1999). Boundary violations: The gray area. American Journal of Forensic Psychology, 17(2), 57-61.
  • Geyer, M. C. (1994). Dual role relationships and Christian counseling. Journal of Psychology and Theology, 22(3), 187-195.
  • Knapp, M. L., & Hall, J. A. (1997). Nonverbal communication in human interaction. (4th ed.). Fort Worth, TX: Harcourt Brace.
  • Glass, J. S., & Shoffner, M. F. (2001). Adventure-based counseling in schools. Professional School Counseling, 5, 42-47.
  • Glover, E. (1940). An investigation of the technique of psychoanalysis. Baltimore: Williams & Wilkins.
  • Gody, D. S. (1996). Chance encounters: Unintentional therapist disclosure. Psychoanalytic Psychology, 13(4), 495-511.
  • Goldfried M. R., Burckell L. A., & Eubanks-Carter, C. (2003). Therapist self-disclosure in cognitive-behavior therapy. Journal of Clinical Psychology, 59(5), 555-68.
  • Goldstein, E. G. (1997). To tell or not to tell: the disclosure of events in the therapist’s life to the patient. Clinical Social Work Journal, 25, 41-58.
  • Gonsiorek, J. C., & Brown, L. S. (1989). Post therapy sexual relationships with clients. In G. R. Schoener, J. H. Milgrom, J. C. Gonsiorek, E. T. Luepker, & R. M. Conroe (Eds.), Intervention and Prevention. Minneapolis: Walk in Counseling Center.
  • Gottlieb, M. C. (1993). Avoiding exploitative dual relationships: A decision-making model. Psychotherapy, 30(1), 41-48.
  • Grayson, P. A. (1986). Mental health confidentiality on the small campus. Journal of American College Health, 34, 187-191.
  • Greenspan, M. (1986). Should therapists be personal? Self-disclosure and therapeutic distance in feminist therapy. In D. Howard (Ed.), The Dynamics of Feminist Therapy (pp. 5-17). New York: The Haworth Press.
  • Greenspan, M. (1995). Out of bounds. Common Boundary Magazine, July/August, 51-56.
  • Grohol, J. M. (1999). Best practices in e-therapy: Definition & scope of e-therapy. Retrieved from http://psychcentral.com/best/best3.htm.
  • Grosskurth, P. (1991). The secret ring: Freud’s inner circle and the politics of psychoanalysis. Toronto: Macfarlane Walter & Ross.
  • Gutheil, T. G. (1989). Patient-therapist sexual relations. The California Therapist, November/December, 29-39.
  • Gutheil, T. G. (1998). The psychiatrist as expert witness. Washington, DC: American Psychiatric Press.
  • Gutheil, T. G., & Gabbard, G. O. (1993). The concept of boundaries in clinical practice: Theoretical and risk-management dimensions. American Journal of Psychiatry, 150, 188-196.
  • Gutheil, T. G., & Gabbard, G. O. (1998). Misuses and misunderstandings of boundary theory in clinical and regulatory settings. American Journal of Psychiatry, 155(3), 409-414.
  • Guthmann, D., & Sandberg, K. A. (2002). Dual relationships in the deaf community: When dual relationships are unavoidable and essential. In A. A. Lazarus & O. Zur. (Eds.), Dual relationships and psychotherapy. (pp. 287-297). New York: Springer.
  • Haas, L. J., & Malouf, J. L. (1989). Keeping up the good work: A practitioner’s guide to mental health ethics. Sarasota, FL: Professional Resource Exchange.
  • Hahn, W. K. (1998). Gifts in psychotherapy: An intersubjective approach to patient gifts. Psychotherapy: Theory/Research/Practice/Training, 35(1), 78-86.
  • Halbrook, B., & Duplechin, R. (1994). Rethinking touch in psychotherapy: Guidelines for practitioners. Osychotherapy in Private Practice, 13(3), 43-53.
  • Hanson, J. E. (2003). Coming out: Therapist self-disclosure as a therapeutic technique, with specific application to sexual minority populations. [Online paper.] Retrieved from http://www.oise.utoronto.ca/depts/aecdcp/CMPConf/papers/Hanson.html.
  • Hargrove, D. S. (1986). Ethical issues in rural mental health practice. Professional Psychology: Research and Practice, 17, 20-23.
  • Harlow, H. (1971). Learning to love. New York: Albion.
  • Harris, S. R. (2002). Dual relationships and university counseling center environments. In A. A. Lazarus, & O. Zur (Eds.), Dual relationships and psychotherapy. (pp. 337-347). New York: Springer.
  • Hayman, P. M., & Cover, J. A. (1986). Ethical dilemmas in college counseling centers. Journal of Counseling and Development, 64, 318-320.
  • Heath, D. S. (2005). Home treatments for acute mental disorders: An alternative to hospitalization. New York: Routledge.
  • Hedges, L. E., Hilton, R., Hilton, V. W., & Caudill, O. B. (1997). Therapists at risk: Perils of the intimacy of the therapeutic relationships. New Jersey: Jason Aronson.
  • Helbok, C. M. (2003). The practice of psychology in rural communities: potential ethical dilemmas. Ethics & Behavior, 13(4), 367-384.
  • Heller, S. (1997). The Vital Touch . New York: Henry Holt and Company.
  • Herbert, J. T. (1996). Use of adventure-based counseling programs for persons with disabilities. Journal of Rehabilitation, 62, 3-9.
  • Herlihy, B., & Corey, G. (1997). Boundary issues in counseling: Multiple roles and responsibilities. Alexandria, VA: American Association for Counseling and Development..
  • Hernandez-Reif, M., Field, T., Krasnegor, J., Theakston, H., Hossain, Z., & Burman, I. (2000). High blood pressure and associated symptoms were reduced by massage therapy. Journal of Bodywork and Movement Therapies, 4, 31-38.
  • Hill, C. E., Mahalik, J. R., & Thompson, B. J. (1989). Therapist self-disclosure. Psychology, 26, 290-295.
  • Hill, M. (1999). Barter: Ethical considerations in psychotherapy. Women and Therapy, 22(3), 81-91.
  • Hines, A. H., Adler, D. N., Chang, A. S., & Rundell, J. R. (1998). Dual agency, dual relationships, boundary crossings, and associated boundary violations: A survey of military and civilian psychiatrists. Military Medicine, 163, 826-833.
  • Hollinger, L. (1986). Communicating with the elderly. Journal of Gerentological Nursing, 12(3), 8-13.
  • Holroyd, J. C., & Brodsky, A. (1980). Does touching patients lead to sexual intercourse? Professional Psychology, 11(5), 807-811.
  • Holub, E. A., & Lee, S. S. (1990). Therapists’ use of nonerotic physical contact: Ethical concerns. Professional Psychology Research & Practice, 21(2), 115-117.
  • Hunter, M., & Struve, J. (1998). The ethical use of touch in psychotherapy. Thousand Oaks, CA: Sage Publications.
  • Hyman, S. M. (2002). The shirtless jock therapist and the bikini-clad client: An exploration of chance extra-therapeutic encounters. In A. A. Lazarus, & O. Zur (Eds.), Dual relationships and psychotherapy. (pp. 348-359). New York: Springer.
  • Isaac, T. (2004). Ethical notes on disrupted frames and violated boundaries. Psychoanalytic Psychology, 21(4), 609-613.
  • Isay, R. A. (1996). Becoming gay: The journey to self-acceptance. New York: Henry Holt.
  • Johnston, S. H., & Farber, B. A. (1966). The maintenance of boundaries in psychotherapeutic practice. Psychotherapy, 33, 391-402.
  • Johnson, W. B. (1995). Perennial ethical quandaries in military psychology: Toward American Psychological Association and Department of Defense collaboration. Professional Psychology: Research and Practice, 26, 281-287.
  • Johnson, W. B., Ralph, J., & Johnson, S. J. (2005). Managing multiple roles in embedded environments: The case of aircraft carrier psychology. Professional Psychology: Research and Practice, 36 (1), 73-81.
  • Jones, E. (1957). The life and work of Sigmund Freud volume III: The last phase, 1919-1939. New York: Basic Books.
  • Jones, M., Botsko, M., & Gorman, B. S. (2003). Predictors of psychotherapeutic benefit of lesbian, gay, and bisexual clients: The effects of sexual orientation matching and other factors. Psychotherapy: Theory, Research, Practice, Training. 40(4), 289-301.
  • Younggren, J. N., & Gottlieb, M. C. (2004). Managing risk when contemplating multiple relationships. Professional Psychology: Research and Practice, 35(3), 255-260.
  • Jourard, S. M. (1971a) The transparent self. New York: Van Nostrand Reinhold.
  • Jourard, S. M. (1971b). Self-disclosure: An experimental analysis of the transparent self. New York: Wiley-Interscience.
  • Kanter, R. M. (1977). Work and family in the United States: A critical review and agenda for research and policy. New York: Russell Foundation.
  • Kerr, J. (1993). A most dangerous method. New York: Knopf.
  • Kertész, R. (2002). Dual relationships in psychotherapy in Latin America. In A. A. Lazarus, & O. Zur (Eds.), Dual relationships and psychotherapy. (pp. 329-334). New York: Springer.
  • Kessler, L .E., & Waehler, C.A. (2005). Ethical issues in professional practice: Addressing multiple relationships between clients and therapists in lesbian, gay, bisexual, and transgender communities. Professional Psychology: Research and Practice, 36(1), 66-72.
  • Kitchener, K. S. (1988). Dual role relationships: What makes them so problematic? Journal of Counseling and Development, 67, 217-221.
  • Knapp, S., & Slattery, J. M. (2004). Professional boundaries in nontraditional settings. Professional Psychology: Research and Practice, 14(5), 553-558.
  • Knox, S., Hess, S. A., Williams, E. N., & Hill, C. E. (2003). Here’s a little something for you: How therapists respond to clients’ gifts. Journal of Counseling Psychology, 50, 199-210.
  • Knox, S., Hess, S.A., Pedersen, D.A., & Hill, C.E. (1997). A qualitative analysis of client perceptions of the effects of helpful therapist self-disclosure in long-term therapy. Journal of Counselling Psychology, 44, 274-283.
  • Kohn, R., Phil, M., Goldsmith, E., & Sedgwick, T. W. (2002). Treatment of homebound mentally ill elderly patients: The multidisciplinary psychiatric mobile team. American Journal of Geriatric Psychiatry, 10, 469-475.
  • Koocher, G. P., & Keith-Spiegel, P. (1998). Ethics in psychology: Professional standards and cases. (2nd Ed.). New York: Oxford University Press.
  • Kossek, E. (2003). Setting boundaries between work and life helps families thrive. Retrieved from Michigan State University Newsroom Database.
  • Kritzberg, N. I. (1980). On patients’ gift-giving. Contemporary Psychoanalysis, 16, 98-118.
  • Lakin, M. (1991). Coping with ethical dilemmas in psychotherapy. New York: Pergamon Press.
  • Lamb, D. H., & Catanzaro, S. H. (1998). Sexual and nonsexual boundary violations involving psychologists, clients, supervisees, and students: Implications for professional practice. Professional Psychology: Research & Practice. 29(5), 498-503.
  • Lamb, D. H., Catanzaro, S. J., & Moorman, A. S. (2004). A preliminary look at how psychologists identify, evaluate, and proceed when faced with possible multiple relationship dilemmas. Professional Psychology: Research & Practice, 35(3), 248-254.
  • Lamb, M. E., Thompson, W., Gardner, & Charnov, E. L. (1985). Infant-mother attachment: The origins and developmental significance of individual differences in strange situation behavior. Hillside, NJ: Lawrence Erlbaum.
  • Lambert, M. J. (1991). Introduction to psychotherapy research. In L. E. Beutler & M. Cargo (Eds.), Psychotherapy research: An international review of programmatic studies. (pp. 1-11). Washington, DC: American Psychological Association.
  • Langs, R. (1982). Psychotherapy: A basic text. New York: Aronson.
  • Lawry, S. (1998). Touch and clients who have been sexually abused. In M. Hunter, & J. Struve (Eds.), The ethical use of touch in psychotherapy. New York: Guilford Press.
  • Lazarus, A. A. (1994). How certain boundaries and ethics diminish therapeutic effectiveness. Ethics and Behavior, 4, 255-261.
  • Lazarus, A. A. (1998). How do you like these boundaries? The Clinical Psychologist, 51, 22-25.
  • Lazarus, A. A., & Zur, O. (Eds.). (2002). Dual relationships and psychotherapy. New York: Springer.
  • Lemma, A. (1999). Humour on the couch: Exploring humour in psychotherapy and everyday life. London: Whurr.
  • Lerman, H., & Porter, N. (Eds.). (1990). Feminist ethics in psychotherapy. New York: Springer.
  • Lewis, P. (1959). A note on the private aspect of the psychoanalyst. The Bulletin of the Philadelphia Psychoanalytic Association, 9, 96-101.
  • Liddle, B.J. (1997). Gay and lesbian clients’ selection of therapists and utilization of therapy. Psychotherapy, 34, 11-18.
  • Little, M. I. (1990). Psychotic anxieties and containment: A personal record of an analysis with Winnicott. Northvale, NJ: Jason Aronson.
  • Llewellyn, R. (2002). Sanity and sanctity: The counselor and multiple relationships in the church. In A. A. Lazarus & O. Zur (Eds.), Dual relationships and psychotherapy. (pp. 298-314). New York: Springer.
  • Lowen, A. (1976). Bioenergetics. New York: Penquin.
  • Lowry, T. (1974). Camping therapy: Its uses in psychiatry and rehabilitation. Springfield, IL: Charles C. Thomas.
  • Maeder, T. (1989). Children of psychiatrists and other psychotherapists. New York: Harper & Row.
  • Mahalik, J. R., van Ormer, E. A., & Simi, N. L. (2000). Ethical issues in using self-disclosure in feminist therapy. In M. M. Brabeck (Ed.), Practicing feminist ethics in psychology. Washington: American Psychological Association.
  • Maheu, M., Whitten, P., & Allen, A. (2001). E-health, telehealth, and telemedicine : A guide to startup and success. New York: Jossey-Bass.
  • Mallow, A. J. (1998). Self-disclosure: Reconciling psychoanalytic psychotherapy and Alcoholics Anonymous philosophy. Journal of Substance Abuse Treatment, 15, 493-498.
  • Malouf, J. L. (1989). Keeping up the good work: A practitioner’s guide to mental health ethics. Sarasota, FL: Professional Resources Exchange.
  • McDermott, D., Tyndall, L., & Lichtenberg, J. W. (1989). Factors related to counselor preference among gays and lesbians. Journal of Counseling and Development, 68, 31-35.
  • Mehrabian, A. (1971). The silent language: Implicit communication of emotions and attitudes. Belmont, CA: Wadsworth.
  • Menikoff, A. (1999). Psychiatric home care: Clinical and economic dimensions. New York: Academic Press.
  • Minuchin, S. (1974). Families and family therapy. Cambridge, MA: Harvard University Press.
  • Moleski, S. M., & Kiselica, M. S. (2005). Dual relationships: A continuum ranging from destructive to therapeutic. Journal of Counseling & Development, 83, 3-11.
  • Montagu, A. (1971). Touching: The human significance of the skin. New York: Columbia University Press.
  • Montgomery, M. J., & DeBell, C. (1997). Dual relationships and pastoral counseling: Asset or liability? Counseling and Values, 42(1), 30-41.
  • Moore, Z. E. (2003). Ethical dilemmas in sport psychology: Discussion and recommendation for practice. Professional Psychology: Research and Practice, 34(6), 601-610.
  • Morris, J. (2003). The home visit in family therapy. Journal of Family Psychotherapy, 14(3), 95-99.
  • Nagy, T. F. (2005). Ethics in plain English: An illustrative casebook for psychologists. (2nd ed.). Washington, DC: American Psychological Association.
  • National Association of Social Workers. (1996). NASW Code of Ethics. Washington, DC: National Association of Social Workers.
  • National Association of Social Workers. (2017). Code of Ethics. Retrieved from http://www.naswdc.org/Code/ethics.htm.
  • National Board for Certified Counselors. (2016). National Board for Certified Counselors Code of Ethics. Greensboro, NC: Author.
  • Nickel, M. (2004). Professional boundaries: The dilemma of dual and multiple relationships in rural clinical practice. Consulting and Clinical Psychology Journal, 1(1), 17-22.
  • Norcross, J. C., & Goldfried, M. R. (Eds.). (1992). Handbook of psychotherapy integration. New York: Basic Books.
  • Nordmarken, N., & Zur, O. (2004). To touch or not to touch: Rethinking the prohibition on touch in psychotherapy and counseling: Clinical, ethical & legal considerations. Retrieved from https://www.zurinstitute.com/touchintherapy.html.
  • Nordmarken, N., & Zur, O. (2005). Home office: Ethical and clinical considerations. Retrieved from https://www.zurinstitute.com/homeoffice.html.
  • Older, J. (1982). Touching is healing. New York: Stein & Day
  • Pedersen, P. B., Draguns, J. G., Lonner, W. J., Trimble, J. E. (Eds.). (1996). Counseling across cultures. (4th ed.). Thousand Oaks, CA: Sage.
  • Pepper, R. S. (1990). When transference isn’t transference: Iatrogenesis of multiple role relations between practicing therapists. Journal of Contemporary Psychotherapy. 20(3), 141-153.
  • Pepper, R. S. (2003). Be it ever so humble: The controversial issue of psychotherapy groups in the home office setting. Groups, 27( 1), 41-52.
  • Perlmutter, M. S., & Hatfield, E. (1980). Intimacy, intentional metacommunication and second order change. American Journal of Family Therapy, 8, 17-23.
  • Pedersen, C. (2002). More than a mirror: The ethics of therapist self-disclosure. Psychotherapy: Theory, Research, Practice, Training, 19(1), 21-31.
  • Pedersen, C. (1996). Common problem areas and their causes resulting in disciplinary action. In L. J. Bass, S. T., DeMers, J. R. P., Ogloff, C., Peterson, J. L., Pettifor, R. P., Reaves, T., et al. (Eds.), Professional conduct and discipline in psychology, (pp. 71-89). Washington, DC: American Psychological Association.
  • Polster, D. S. (2001). Gifts. American Psychiatric Association Ethics Primer. DC: ApA.
  • Pope, K. S. (1989). Therapist-patient sex syndrome: A guide to assessing damage. In G. O. Gabbard (Ed.), Sexual exploitation in professional relationships. (pp. 39-55). Washington, DC: American Psychiatric Press.
  • Pope, K. S. (1990). Therapist-patient sex as sex abuse: Six scientific, professional, and practical dilemmas in addressing victimization and rehabilitation. Professional Psychology: Research and Practice, 21, 227-239.
  • Pope, K. S., Keith-Spiegel, P., & Tabachnick, B. G. (1986). Sexual attraction to clients: The human therapist and the (sometimes) inhuman training system. American Psychologist, 41(2), 147-15.
  • Pope, K. S., Sonne, J., & Holroyd, J. (1993). Sexual feelings in psychotherapy: Explorations for therapists and therapists in training. Washington, DC: American Psychological Association.
  • Pope, K. S., Tabachnick, B. G., & Keith-Spiegel, K. (1987). Ethics of practice: The beliefs and behaviors of psychologists as therapists. American Psychologist, 42(1), 993-1006.
  • Pope, K. S., & Vasquez, M. J. T. (1998). Ethics in psychotherapy and counseling: A practical guide. (2nd ed.). San Francisco: Jossey-Bass.
  • Fosshage, J. L., (2000) The meanings of touch in psychoanalysis: A time for reassessment. Psychoanalytic Inquiry, 20(1) [On-Line]. Retrieved from http://www.psychoanalyticinquiry.com/vol20no1.html
  • Psychopathology Committee of the Group for the Advancement of Psychiatry. (2001). Reexamination of therapist self-disclosure. Psychiatric Services, 52, 1489-1493.
  • Pulakos, J. (1994). Incidental encounters between therapists and clients: The client’s perspective. Professional Psychology, 25, 300-303.
  • Rappoport, S. P. (1983). Value for value psychotherapy: The economic and therapeutic barter. New York: Praeger.
  • Reich, W. (1972). Character analysis. New York: Simon & Schuster.
  • Reist, D., & VandeCreek, L. (2004). The pharmaceutical industry’s use of gifts and educational events to influence prescription practices: Ethical dilemmas and implications for psychologists. Professional Psychology: Research and Practice, 35(4), 329-335.
  • Renik, O. (1996). The ideal of the anonymous analyst and the problem of self-disclosure. Psychoanalytic Quarterly, 65, 681-682.
  • Rogers, C. (1970). Carl Rogers on encounter groups. New York: Harper & Row.
  • Rosie, J. S. (1974). The therapists’ self-disclosure in individual psychotherapy: Research and psychoanalytic theory. Journal of Consulting and Clinical Psychology, 42, 901-908.
  • Rueveni, U. (1979). Networking families in crisis: Intervention strategies with families and social networks. New York: Human Sciences Press.
  • Ramsdell, P. S., & Ramsdell, E. R. (1993). Dual relationships: Client perceptions of the effect of client-counselor relationship on the therapeutic process. Clinical Social Work Journal, 21(2), 195-21.
  • Rutter, P. (1989). Sex in the forbidden zone: When men in power–therapists, doctors, clergy, teachers, and others–betray women’s trust. New York: Fawcett Crest.
  • Saad, G., & Gill, T. (2003). An evolutionary psychology perspective on gift-giving among young adults. Psychology & Marketing, 20(9), 765-784.
  • Schacht, A. J., Tafoya, N., & Mirabla, K. (1989). Home-based therapy with American Indian families. American Indian and Alaska Native Mental Health Research, 3(2), 27-42.
  • Schank, A. J., & Skovholt, T. M. (1997). Dual-relationship dilemmas of rural and small-community psychologists. Professional Psychology: Research and Practice, 28(1), 44-49.
  • Schoel, J., Prouty, D., & Radcliffe, P. (1988). Islands of healing: A guide to adventure based counseling. Hamilton, MA: Project Adventure.
  • Schoener, G. R. (1997 September). Boundaries in professional relationships. Paper presented at the Norwegian Psychological Association, Oslo, Norway.
  • Schultz, LeRoy G. (1975). A survey of social workers’ attitudes and use of body and sex psychotherapies. Clinical Social Work Journal, 3(2) 90-99.
  • Sears, V. L. (1990). On being an “only” one. In H. Lerman , & N. Porter (Eds.), Feminist ethics in psychotherapy. (pp. 102-105). New York: Springer.
  • Shapiro, E. L., & Ginzberg, R. (2003). To accept or not to accept: Referrals and the maintenance of boundaries. Professional Psychology: Research and Practice, 34(3), 258-263.
  • Sharkin, B. (1995). Strains on confidentiality in college-student psychotherapy: Entangled therapeutic relationships, incidental encounters, and third-party inquiries. Professional Psychology: Research and Practice, 26, 184-189.
  • Sharkin, B. S., & Birky, I. (1992). Incidental encounters between therapists and their clients. Professional Psychology: Research & Practice, 23(4), 326-328.
  • Silber, A. (1969). A patient’s gift: Its meaning and function. International Journal of Psychoanalysis. 50(3), 335-41.
  • Simi, N. L., & Mahalik, J. R. (1997). Comparison of feminist versus psychoanalytic/dynamic and other therapists on self-disclosure. Psychology of Women Quarterly, 21, 465-483.
  • Simon, R. I. (1991). Psychological injury caused by boundary violation precursors to therapist-patient sex. Psychiatric Annals, 21, 614-619.
  • Simon, R. I. (1994). Transference in therapist-patient sex: The illusion of patient improvement and consent part 1. Psychiatric Annals, 24, 509-515.
  • Simon R. I., & Williams, I. C. (1999). Maintaining treatment boundaries in small communities and rural areas. Psychiatric Services, 50, 1440-1446.
  • Sleek, S. (1994). Ethical dilemmas plague rural practice. The APA Monitor, December, 25-26.
  • Smith, A. J. (1990). Working within the lesbian community: The dilemma of overlapping relationships. In H. Lerman, & N. Porter (Eds.), Feminist Ethics in Psychotherapy. (pp. 92-96). New York: Springer.
  • Smith, D., & Fitzpatrick, M. (1995). Patient-therapist boundary issues: An integrative review of theory and research. Professional Psychology: Research and Practice, 25(5), 499-506.
  • Smith, E., Clance, P .R., & Imes, S. (Eds.). (1998). Touch in Psychotherapy: Theory, Research and Practice. New York: Guilford Press.
  • Smolar, A. M. (2003). When we give more: Reflections on intangible gifts from therapist to patient. American Journal of Psychotherapy , 57(3), 300-323.
  • Sonne, J. L. (1994). Multiple relationships: Does the new ethics code answer the right questions? Professional Psychology: Research and Practice, 25(4), 331-343.
  • Sonne, J. L. (1989). An example of group therapy for victims of therapist-client sexual intimacy. In G. Gabbard (Ed.), Sexual exploitation in professional relationships. (pp. 101-114). Washington, DC: American Psychiatric Press.
  • Sonne, J. L., & Pope, K. S. (1991). Treating victims of therapist-patient involvement. Psychotherapy, 28, 174-187.
  • Spandler, H., Burman, E., Goldberg, B., Margison, F., & Amos, T. (2000). A double edged sword: Understanding gifts in psychotherapy. European Journal of Psychotherapy, Counseling and Health 3(1) 77-101.
  • St. Germaine, J. (1996). Dual relationships and certified alcohol and drug counselors: A national study of ethical beliefs and behaviors. Alcoholism Treatment Quarterly, 14(2), 29-45.
  • Staal, M. A., & King, R. E. (2000). Managing a multiple relationship environment: The ethics of military psychology. Professional Psychology: Research and Practice, 31(6), 698-705.
  • Stamm, B. H. (1998). Clinical applications of telehealth in mental health care. Professional Psychology: Research and Practice, 29(6), 536-542.
  • Stamm, B. H. (Ed.). (2003). Rural behavioral health care. Washington, DC: APA Books.
  • Stein, H. (1965). The gift in therapy. American Journal of Psychotherapy 19(3), 480-486.
  • Stein, L. (2002).Trade ya: The cash-free, tax-free culture of barter thrives online in hard times. Retrieved from http://www.metroactive.com/papers/metro/09.05.02/barter-0236.html.
  • Sterling, D. L. (1992). Practicing rural psychotherapy: Complexity of role and boundary. Psychotherapy in Private Practice, 10(3), 105-127.
  • Stockman, A. F. (1990). Dual relationships in rural mental health practice: An ethical dilemma. Journal of Rural Community Psychology, 11, 31-45.
  • Strasburger, L. H., Jorgenson, L., & Sutherland, P. (1992). The prevention of psychotherapist sexual misconduct: Avoiding the slippery slope. American Journal of Psychotherapy, 46(4), 544-555.
  • Strean, H. S. (1981). Extra-analytic contacts: Theoretical and clinical considerations. Psychoanalytic Quarterly, 56, 238-257.
  • Stricker, G. & Fisher, M. (Eds.). (1990). Self-disclosure in the therapeutic relationship. New York: Plenum.
  • Sue, D., & Sue, D. (2003). Counseling the culturally diverse: Theory and practice. (4th ed.). New York: John Wiley and Sons.
  • Syme, G. (2003). Dual relationships in counseling and psychotherapy: Exploring the limit. London: Sage.
  • Synder, W., & McCollum, E. E. (1999). Their home is their castle: Learning to do in-home family therapy. Family Process, 38, 229-242.
  • Tabachnick, B. G., Keith-Spiegel, P. C., & Pope, K. S. (1991). Ethics of teaching: Beliefs and behaviors of psychologists as educators. American Psychologist, 46, 506-515.
  • Talan, K. H. (1989), Gifts in psychoanalysis. Psychoanalytic Study of the Child, 44, 149-163.
  • Tantillo, Mary M. (2004). The therapist’s use of self-disclosure in a relational therapy approach for eating disorders. Eating Disorders, 12(1), 51-73.
  • Tarnower, W. (1966). Extra-analytic contacts between the psychoanalyst and the patient. Psychoanalytic Quarterly, 35, 399-413.
  • Taylor, S., & Thomas, E. (2003, December 15). Civil Wars. Newsweek, 43-51. Telehealth Improvement and Modernization Act of 2000. (May 4). S. 2505. Retrieved from http://thomas.loc.gov.
  • Tillman, J. G. (1998). Psychodynamic psychotherapy, religious beliefs, and self-disclosure. Journal of Psychotherapy, 52(3), 273-286.
  • Tirnauer, L., Smith, E., & Foster, P. (1996). The American Academy of Psychotherapists Research Committee Survey of Members. Voices, 32(2), 87-94.
  • Tomm, K. (1993). The ethics of dual relationships. California Therapist, 5(1), 7-19.
  • Trimble, J. E. (2002). Counseling across cultures. Thousand Oaks, CA: Sage.
  • United States Association for Body Psychotherapy. (2007). Ethics Guidelines. Bethesda, MD:Author. Retrieved from http://usabp.org/about-us/usabp-code-of-ethics/.
  • U.S. Department of Health and Human Services. (1999). Mental health: A report of the surgeon general-executive summary. Rockville, MD: Author.
  • Volker, T. (1999). Beyond the clinic: In-home therapy with Head Start families. Journal of Marital and Family Therapy, 25(2), 177-189.
  • Wakefield, J. (1996). Dual-role relationships in training. The C.G. Jung Page. Retrieved from http://www.cgjungpage.org/articles/jwake1.html.
  • Welfel, E. R. (2002). Ethics in counseling and psychotherapy: Standards, research, and emerging issues. (2nd ed.). Pacific Grove, CA: Brooks/Cole.
  • White, M., & Epston, D. (1990). Narrative means to therapeutic ends. New York: W. W. Norton.
  • Williams, M. H. (1997). Boundary violations: Do some contended standards of care fail to encompass commonplace procedures of Humanistic, Behavioral, and Eclectic Psychotherapies? Psychotherapy, 34(3), 238-249.
  • Williams, M. H. (2002). Multiple relationships: A malpractice plaintiffs’ litigation strategy. In A. A. Lazarus & O. Zur (Eds.), Dual relationships and psychotherapy. (pp. 228-238). New York: Springer.
  • Williams, M. H., (2003). The curse of risk management. The Independent Practitioner, 23(4), 202-205.
  • Woody, R. H. (1988a). Protecting your mental health practice: How to minimize legal and financial risk. San Francisco: Jossey-Bass.
  • Woody, R. H. (1998b). Bartering for psychological services. Professional Psychology: Research and Practice, 29(2), 174-178.
  • Woody R. H. (1999). Domestic violations of confidentiality. Professional Psychology: Research & Practice. 30(6), 607-610.
  • Yalom, I. D., & Elkin, G. (1990). Every day gets a little closer: A twice-told therapy. New York: Basic Books.
  • Yalom, I. D. (1975). The theory and practice of group psychotherapy. New York: Basic Books.
  • Younggren, J. N., & Gottlieb, M.C. (2004). Managing risk when contemplating multiple relationships. Professional Psychology: Research and Practice, 35(3), 255-260.
  • Zelig, M. (1988). Ethical dilemmas in police psychology. Professional Psychology: Research & Practice, 19(3), 336-338.
  • Zur, O. (2000). In celebration of dual relationships: How prohibition of non-sexual dual relationships increases the chance of exploitation and harm. The Independent Practitioner, 2(3), 97-100.
  • Zur, O. (2001a). Out-of-office experience: When crossing office boundaries and engaging in dual relationships are clinically beneficial and ethically sound. Independent Practitioner, 21(1), 96-100.
  • Zur, O. (2001b). On analysis, transference and dual relationships: A rejoinder to Dr. Pepper. The Independent Practitioner, 21(3), 201-204.
  • Zur, O. (2004a). To cross or not to cross: Do boundaries in therapy protect or harm. The Psychotherapy Bulletin, 39(3), 27-32.
  • Zur, O. (2004b). A chicken for a session: Bartering in therapy. Voices, 40(1), 75-80.
  • Zur, O. (2005). Dumbing down of psychology: Manufactured consent about the depravity of dual relationships in therapy. In R. H. Wright & N. A. Cummings (Eds.). (2005). Destructive trends in mental health: The well-intentioned road to harm. (pp. 253-282). New York: Brunner-Routledge.
  • Zur, O. (2006). Therapeutic Boundaries and Dual Relationships in Rural Practice:Ethical, Clinical and Standard of Care Considerations. Journal of Rural Community Psychology, V. E9/1.
  • Zur, O. (2007). Boundaries in Psychotherapy: Ethical and Clinical Explorations.  Washington, DC: APA Books
  • Zur, O. (2008). The Google Factor: Therapists’ Self-Disclosure In The Age Of The Internet: Discover what your clients can find out about you with a click of the mouse. The Independent Practitioner, 28/2, 82-85.
  • Zur, O. (2009). Psychotherapist Self-Disclosure and Transparency in the Internet Age. (Invited lead article to “Focus on Ethics” section) Professional Psychology: Research and Practice, 40,  22-26.
  • Zur, O. and Donnor, M. B. (2009). Google Factor: Therapists’ Transparency In The Era of Google and MySpace. California Psychologist, Jan./Feb.,  p. 23-24.
  • Zur, O., & Gonzalez, S. (2002). Multiple relationships in military psychology. In A. A. Lazarus, & O. Zur (Eds.), Dual relationships and psychotherapy. (pp. 315-328). New York: Springer.
  • Zur, O. & Nordmarken, N. (2004). To Touch Or Not To Touch: Rethinking The Prohibition On Touch In Psychotherapy And Counseling: Clinical, Ethical & Legal Considerations. Online publication. Retrieved from https://www.zurinstitute.com/touchintherapy.html on December 6, 2005.

I recently attended an ethics workshop were the presenter, an attorney, said, “All dual relationships are unethical or at least run the risk of getting you into trouble with your licensing board.” After shaking off my emotional reaction to hearing such a bold statement, I decided what I had just heard could not be further from the truth. In fact, professional practice throughout the country is fraught with various types of dual relationships many of which cannot be avoided and there are some situations where the avoidance of the dual relationship could even be thought of as unethical. For example, the solo practitioner who works out of a small town, is almost forced repeatedly into dual relationships by the very nature of his or her practice and to avoid so doing would remove psychological resources from the community altogether.

Thus, and contrary to what the attorney said in the workshop, it is not the mere existence of a dual relationship that makes in unethical. When a mental health professional is confronted with a choice as to whether one should enter into a dual relationship or not, many factors need to be carefully evaluated. Not only can these relationships run risk for the consumer of our services, but, as is well exemplified by the earlier comment, they may have great risk for the professional as well. I will not review the vast literature on this topic area as part of this paper since many authors, much more thorough than I, have already done so and these articles are easily available. What I will try to set out in this brief article is a decision making model that a professional can use to evaluate whether he or she should consider entering into a dual relationship with a patient. This model will not only focus on the welfare of the client but, in this world of professional risk, this model should be viewed as a risk management tool designed to also protect the welfare of the professional in this period of enhanced professional accountability

When addressing dual relationships one must be aware that the evaluation of boundary violations in professional practice are often outcome-driven determinations. Usually the determination of whether or not a professional committed a violation of professional practice is arrived at retrospectively when experts or ethics committees evaluate a case. Thus, and consistent with the risk management model of the APA Insurance Trust, when one chooses to enter into a dual relationship one is forced prospectively assess how these professionals might retrospectively view a specific case, potentially years after it occurred. So, when assessing whether or not to enter into a dual relationship, one is almost forced to predict future reactions to their conduct, something that is not at all easy to do. Hopefully, by answering the following questions in a step by step fashion a professional who is considering entering into a dual relationship will increase the likelihood that he or she will make the correct choice in the matter: a choice that is in the best interest of both the patient and the therapist.

Is the dual relationship necessary?

This is a very important question for the mental health professional to answer. Therapy by itself is complex and difficult to perform without the introduction of other factors. Thus, at the outset a professional must address whether he or she even needs to enter into a dual relationship. Simply put, unnecessary dual relationships can be fraught with unnecessary risk. As a rule, it is likely to be in the best interests of the professional, regardless of location, to avoid dual relationships if at all possible.

However, if the dual relationship is necessary, then the professional is forced to answer the next question.

Is the dual relationship exploitive?

This is an easy one. Exploitation of patients is unethical and if the proposed dual relationship is exploitive of the patient, then it is unacceptable. If exploitation is not evident or if it can be avoided, then the professional is forced to move on and answer the next question.

Who does the dual relationship benefit?

Since it is unethical to exploit patients, just whom does the relationship benefit? This is a dilemma often faced by those who work in small communities. Treating your minister’s wife in a small town would be a clear example of a dual relationship that benefited the client since, if you were the only therapist in this town, to avoid the dual relationship would prevent an individual in distress from getting service. However, not all dual relationships are as easy to assess as this small town dilemma. For example, what about purchasing a car from the local dealership in a small town when the owner of the dealership is your patient and when failure to do so would make people in the community wonder just why you did not buy the car locally? Benefit in this case is not as easy to assess. To purchase the car elsewhere would not only raise wonder in the community but also could impact your therapeutic alliance. The answer to this example only becomes more complex when trying to decide whether or not to negotiate the price of the vehicle with your patient? So, assessing just who benefits by the decision to enter into a dual relationship is not so easy to assess.

Is there a risk that the dual relationship could damage the patient?

This also is not an easy question to answer and it calls for a great amount of objectivity on the part of the professional. Consistent with the principles of biomedical ethics, interventions should not harm patients, or at least an attempt must be made to minimize the risk of harm. In that spirit, an additional relationship that is combined with therapy must be assessed for harm and its harmful effects must be controlled for and minimized. That is not to say that a professional entering into a dual relationship must completely prevent risk, but that each of us has a fiduciary obligation to be in touch with risk factors, to manage them and to minimize them.

Is there a risk that the dual relationship could disrupt the therapeutic relationship?

This question is one that not only requires consideration before entering into the dual relationship but also is one that must be asked throughout the treatment process. In the spirit of minimizing risk, the therapist who chooses to enter into a dual relationship with a client, or one who is even forced into the dual relationship, must manage the relationship in such away that the therapeutic component is not damaged by the secondary relationship. In this spirit, the therapist has an obligation to discuss this factor in detail with the patient prior to entering into the dual relationship and must also keep this topic and related issues at the forefront of treatment to avoid any damage to the therapeutic alliance.

Am I being objective in my evaluation of this matter?

This is a very difficult question to answer since it is arguable that no one is really objective. The answer to this question requires consultation with others, and not only those in the mental health field but also in related fields, like law. Personal needs are not things with which we are always in touch and given the inherent high level of risk that is associated with this type of conduct, one must not only answer the above questions by oneself, but should go through them with another individual to assure that the answers are as objective as they could be.

Once a therapist has addressed the above questions, he or she is now forced to move into what could be termed “risk management mode.” Since the decision to enter into a dual relationship has risk not only for the client, but also for the therapist, the therapist who chooses to enter into a dual relationship must engage in a risk management strategy that provides protection if charges of unprofessional conduct surface as a result of the choice to enter into the relationship. In that spirit, the mental health professional that has addressed the previous questions and has obtained a positive outcome, must now address the following.

Have I adequately documented the decision making process in the treatment records?

Since the spirit of the law is, “If it is not written down, it did not happen,” inadequate documentation can negate the existence and value of the whole decision making process. That is, if, while addressing all of the above questions, the mental health professional failed to document the process, then the protection afforded by having done so, becomes lost. Good record keeping can become a significant defense to allegations of professional misconduct and negligence on the part of a psychologist who chooses to engage in a dual relationship. If the record reflects a carefully thought out decision making process that led to the choice to engage in a dual relationship, it can lend great strength to the psychologist’s defense in these types of matters.

The records in these types of cases should reflect the process by which the choice was made to engage in the dual relationship and should, hopefully, lead the reader to the same conclusions. It should reflect all consultations made about the issue and logically explain to the reader why the mental health professional chose to engage in the secondary relationship. If the record fails to do this, it may leave the psychologist in a rather self serving position of possibly being the only witness who supports the choice that is in question – a rather self-serving and unenviable position in which to be. A good record, when a choice is called into question, lives almost like a second witness to what actually occurred and if this witness supports the psychologist’s choice, then in lends great strength to the argument that the choice was the right one.

Did the client give informed consent regarding the risks to engaging in the dual relationship?

While the patient or client is never in charge of choosing what a therapist does, when confronted by risky clinical situations, a professional is well advised to make sure that the client understands the issues at hand. That is, has the psychologists addressed all of the possible dilemmas and risks with the client and does the client understand them? If the answer to these questions is, yes, then the next question closely follows. Does the documentation reflect that the patients has been informed and consents to the relationship? This documentation could take the form of a signed document reflecting the agreement or could consist of a note in the patient’s chart. While a note is weaker evidence of informed consent, it still becomes strong evidence that something did, in fact, occur. It is important to point out, however, that patients can never give informed consent to something that poses severe risk to them and is a violation of an existing standard of care. A good example of this would be a consent to engage in a sexual relationship with a patient. Even if one chose to try to use informed consent as a defense is these types of cases the correctness of the choice, if you will, would be negated by the previous questions raised in this discussion.

Having addressed all of the issues addressed in this paper and having come up with positive answers to all of the questions it raise still does not remove the psychologist from risk. There is still risk in choosing to engage in dual relationship with clients since they clearly can complicate therapy. However, everything a professional chooses to do has some degree of risk in it and the goal of the professional is to make the right choices for a patient and with a patient while always trying to minimize that risk.

The decision to enter into a dual relationship with a client is not one that should be made casually or easily. Great risk exists in this area and, consequently, the professional who is confronted with this decision must take great care to protect all parties from risk. The previous questions and suggestions outline a risk management/decision-making model that should go a long way toward accomplishing this goal. It is only fair to say, however, that the psychologist who chooses to only answer some of the questions raised in this paper may still find him or herself making a good choice but, considering the risks to both parties, caution and care logically outweigh brevity and efficiency.

 
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