Dr. Kim is an experienced therapist with more than 15 years of practice. ?He is a quiet and reserved man. ?A new client, Susan, asked Dr. Kim for a hug at the

Chapter: 7 Managing Boundaries and Multiple Relationships Introduction The terms dual relationships and multiple relationships are used interchangeably in various professional codes of ethics, and the ACA (2014) uses the term nonprofes- sional relationships. In this chapter we use the broader term of multiple relationships to encompass both dual relationships and nonprofessional relationships. The APA (2010) ethics code defines a multiple relationship as one in which a practitioner is in a professional role with a person in addition to another role with that same individual, or with another person who is close to that individual. When clinicians blend their professional relationship with a nonprofessional relationship with a client, ethical concerns must be considered. In these situations, it is often difficult to determine what is in the best interests of the client. Multiple relationships occur when professionals assume two or more roles at the same time or sequentially with a client. This may involve assuming more than one professional role (such as instructor and therapist) or blending a professional and a nonprofessional relationship (such as counselor and friend or counselor and business partner). Multiple relationships also include providing therapy to a relative or a friend’s relative, socializing with clients, becoming emotionally or sexually involved with a client or former client, combining the roles of supervisor and therapist, having a business relationship with a client, borrowing money from a client, or loaning money to a client. Boundary crossings or multiple relation- ships increase the possibility that therapists may misuse their power to influence and exploit clients for their own benefit and to the clients’ detriment (Zur, 2007). Although some suggest that it is good practice to abstain from crossing boundaries or engaging in multiple relationships, this is not always possible. Mental health professionals must learn how to effectively and ethically man- age multiple relationships, including dealing with the power differential that is a part of most professional relationships, managing boundary issues, and striv- ing to avoid the misuse of power (Herlihy & Corey, 2015b). Although codes can provide some general guidelines, good judgment, the willingness to reflect on one’s practices, and being aware of one’s motivations are critical dimensions of an ethical practitioner. Mental health professionals can fail to heed warning signs in their relationships with clients. They may not pay sufficient attention to the potential problems involved in establishing and maintaining professional boundaries. Practitioners may be unaware of the implications of their actions and may not recognize when they are engaged in unprofessional or problematic conduct. The underlying theme of this chapter is the need for counselors to be honest and self-searching in determining the impact of their behavior on clients. In cases that are not clear-cut, it is especially important to make an honest appraisal of your behavior and its effect on clients and to consult with trusted colleagues. To us, behavior is unethical when it reflects a lack of awareness or concern about the impact of the behavior on clients. Some counselors may place their personal needs above the needs of their clients by engaging in more than one role with clients to meet their own financial, social, or emotional needs. This chapter focuses on boundary issues in professional practice, establishing appropriate boundaries, the difference between boundary crossings and bound- ary violations, multiple relationships, role blending, a variety of nonsexual mul- tiple relationships, and sexual issues in therapy. We also examine the more subtle aspects of sexuality in therapy, including sexual attractions and the misuse of power. Multiple relationship issues cannot be resolved with ethics codes alone; therapists must think through all of the ethical and clinical dimensions involved in a wide range of boundary concerns. LO1 The Ethics of Multiple Relationships The codes of ethics of most professional organizations warn of the potential prob- lems of multiple relationships (see the Ethics Codes box titled “Standards on Mul- tiple Relationships”). These codes caution professionals against any involvement with clients that might impair their judgment and objectivity, affect their ability to render effective services, or result in harm or exploitation of clients. Nonsex- ual multiple relationships are not inherently unethical, and most ethics codes acknowledge that some multiple relationships are unavoidable. However, when multiple relationships exploit clients, or have significant potential to harm clients, they are unethical. Managing boundaries and Multiple relationships / 257 Copyright 2019 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-202 Copyright 2019 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. ETHICS CODES: Standards on Multiple Relationships American Association for Marriage and Family Therapy (2015) Marriage and family therapists are aware of their influential position with respect to clients, and they avoid exploiting the trust and dependency of such persons. Therapists, therefore, make every effort to avoid conditions and multiple relationships with clients that could impair professional judgment or increase the risk of exploitation. Such relationships include, but are not limited to, business or close personal relationships with a client or the client’s immediate family. When the risk of impairment or exploitation exists due to conditions or multiple roles, therapists document the appropriate precautions taken. (1.3.) American Mental Health Counselors Association (2015) Mental health counselors are aware of their influential position with respect to their clients and avoid exploiting the trust and dependency of the client. (Principle 3.) National Association of Social Workers (2008) Social workers should not engage in dual or multiple relationships with clients or former clients in which there is a risk of exploitation or potential harm to the client. In instances when dual or multiple relationships are unavoidable, social workers should take steps to protect clients and are responsible for setting clear, appropriate, and culturally sensitive boundaries. (Dual or multiple relationships occur when social workers relate to clients in more than one relationship, whether professional, social, or business. Dual or multiple relationships can occur simultaneously or consecutively.) (1.06.c.) ETHICS CODES: Standards on Multiple Relationships continued Canadian Psychological Association (2015) Manage dual or multiple relationships or any other conflict-of-interest situation entered into in such a way that bias, lack of objectivity, and risk of exploitation or harm are minimized. This might include involving the affected party(ies) in clarification of boundaries and expectations, limiting the duration of the relationship, obtaining ongoing supervision or consultation for the duration of the dual or multiple relationship, or involving a third party in obtaining consent (e.g., approaching a primary client or employee about becoming a research participant). (3.34.) American School Counselor Association (2016) School counselors establish and maintain appropriate professional relationships with students at all times. School counselors consider the risks and benefits of extending current school counseling relationships beyond conventional parameters, such as attending a student’s distant athletic competition. In extending these boundaries, school counselors take appropriate professional precautions such as informed consent, consultation and supervision. School counselors document the nature of interactions that extend beyond conventional parameters, including the rationale for the interaction, the potential benefit and the possible positive and negative consequences for the student and school counselor. (A.5.b.) American Counseling Association (2014) Counselors are prohibited from engaging in counseling relationships with friends or family members with whom they have an inability to remain objective. (A.5.d.) Counselors are prohibited from engaging in a personal virtual relationship with individuals with whom they have a current counseling relationship (e.g., through social and other media). (A.5.e.) Counselors consider the risks and benefits of accepting as clients those with whom they have had a previous relationship. These potential clients include individuals with whom the counselor has had a casual, distant, or past relationship. Examples include mutual or past membership in a professional association, organization, or community. When counselors accept these clients, they take appropriate professional cautions such as informed consent, consultation, supervision, and documentation to ensure that judgment is not impaired and no exploitation occurs. (A.6.a.) American Psychological Association (2010) (a) A multiple relationship occurs when a psychologist is in a professional role with a person and (1) at the same time is in another role with the same person, (2) at the same time is in a relationship with a person closely associated with or related to the person with whom the psychologist has the professional relationship, or (3) promises to enter into another relationship in the future with the person or a person closely associated with or related to the person. A psychologist refrains from entering into a multiple relationship if the multiple relationship could reasonably be expected to impair the psychologist’s objectivity, competence, or effectiveness in performing his or her functions as a psychologist, or otherwise risks exploitation or harm to the person with whom the professional relationship exists. Multiple relationships that would not reasonably be expected to cause impairment or risk exploitation or harm are not unethical. (b) If a psychologist finds that, due to unforeseen factors, a potentially harmful multiple relationship has arisen, the psychologist takes reasonable steps to resolve it with due regard for the best interests of the affected person and maximal compliance with the Ethics Code. (c) When psychologists are required by law, institutional policy, or extraordinary circumstances to serve in more than one role in judicial or administrative proceedings, at the outset they clarify role expectations and the extent of confidentiality and thereafter as changes occur. (3.0Differing Perspectives on Multiple Relationships LO2 There is a wide range of viewpoints on multiple relationships. As you work to clarify your position on this issue, you will encounter conflicting advice. Some writers focus on the problems inherent in multiple relationships, espe- cially the legal implications of entering into multiple relationships. If a client suffers harm or is exploited due to a multiple relationship, the client could file a malpractice lawsuit against the mental health provider. Others see the entire discussion of multiple relationships as subtle and complex, defying simplis- tic solutions or absolute answers. Despite certain clinical, ethical, and legal risks, in many situations some blending of roles is unavoidable For example, in military settings multiple relationships are common and can be a healthy part of communal life. These relationships can improve morale, decrease the stigma attached to seeking psychological assistance, and improve access to care (Johnson & Johnson, 2017). Although the codes of ethics of most professions caution against engag- ing in nonsexual multiple relationships, they are not necessarily problematic, and some are beneficial (Herlihy & Corey, 2015b). For example, “mentoring” involves blending roles, yet both mentors and learners can certainly benefit from this relationship. Casto, Caldwell, and Salazar (2005) point out that men- tors often balance a multiplicity of roles, some of which include teacher, coun- selor, role model, guide, and friend. They add that the mentoring relationship is a personal one, in which both mentor and mentee may benefit from knowing the other personally and professionally. Casto and colleagues emphasize the importance of maintaining boundaries between mentorship and friendship, which requires vigilance of the power differential and how it affects the mentee. They contend that the focus of mentoring is always on the mentee’s personal and professional development. After reviewing the literature on the topic of multiple relationships, Herlihy and Corey (2015b) conclude that there is no clear consensus regarding nonsex- ual multiple relationships in counseling. When considering such a relationship, practitioners must examine their motivations and consult with other profession- als to determine the appropriateness of the relationship. Practitioners should be cautious about entering into more than one role with a client unless there is sound clinical justification for doing so, and they must take measures to min- imize the likelihood of harm coming to the client. It is good practice to docu- ment precautions practitioners take to protect clients when such relationships are unavoidable. Factors to Consider Before Entering Into a Multiple Relationship LO3 Moleski and Kiselica (2005) believe multiple relationships range from the destruc- tive to the therapeutic. Although some multiple relationships are harmful, other secondary relationships complement, enable, and enhance the counseling rela- tionship. Moleski and Kiselica encourage counselors to examine the potential positive and negative consequences that a secondary relationship might have on Managing boundaries and Multipthe primary counseling relationship. They suggest that counselors consider form- ing multiple relationships only when it is clear that such relationships are in the best interests of the client. Younggren and Gottlieb (2004) suggest applying an ethical, risk-managed, decision-making model when practitioners are analyzing a situation involving the pros and cons of a multiple relationship. They “acknowledge that these types of relationships are not necessarily violations of the standards of professional conduct, and/or the law, but we know enough to recommend that they have to be actively and thoroughly analyzed and addressed, although not necessarily avoided” (p. 260). Younggren and Gottlieb recommend that practitioners address these questions to make sound decisions about multiple relationships: • Is entering into a relationship in addition to the professional one necessary, or should I avoid it? • Can the multiple relationship potentially cause harm to the client? • If harm seems unlikely, would the additional relationship prove beneficial? If it is beneficial, is the benefit focused more on the client, the counselor, or both? • Is there a risk that the multiple relationship could disrupt the therapeutic relationship? • Can I evaluate this matter objectively? (pp. 256–257) In answering these questions, practitioners must carefully assess the risk for con- flict of interests, loss of objectivity, and implications for the therapeutic relation- ship. It is good practice to discuss the potential problems involved in a multiple relationship with the client and to actively involve the client in the decision-making process. If the multiple relationship is judged to be appropriate and acceptable, the therapist should document the entire process, including having the client sign an informed consent form. In addition, therapists would do well to adopt a risk man- agement approach to the problem. This involves a careful review of various issues such as diagnosis, level of functioning, therapeutic orientation, community stan- dards and practices, and consultations with professionals who could support the decision. Younggren and Gottlieb conclude with this advice: “Only after having taken all these steps can the professional consider entering into the relationship, and he or she should then do so with the greatest of caution” (p. 260). Barnett (Barnett, Lazarus, et al., 2007) suggests some guidelines to increase the likelihood that a client’s best interests are being served: • The therapist is motivated by what the client needs rather than by his or her own needs. • The boundary crossing is consistent with a client’s treatment plan. • The client’s history, culture, values, and diagnosis have been considered. • The rationale for the boundary crossing is documented in the client’s record. • The boundary crossing is discussed with the client in advance to prevent misunderstandings. • Full recognition is given to the power differential, and the client’s trust is safeguarded. • Consultation with colleagues guides the therapist’s decisions. 260 / chapter 7 Copyright 2019 Cengage Learning. All Rights Reserved. May not be copied, scanned, or dBoundary Crossings Versus Boundary Violations LO4 Certain behaviors of professionals have the potential for creating a multiple rela- tionship, but they are not inherently considered to be multiple relationships. Examples of these behaviors include accepting a client’s invitation to a special event such as a graduation; bartering goods or services for professional services; accepting a small gift from a client; attending the same social, cultural, or religious activities as a client; or giving a supportive hug after a difficult session. Gutheil and Gabbard (1993) caution that engaging in boundary crossings paves the way to boundary violations and to becoming entangled in complex multiple relation- ships. They distinguish between boundary crossings (changes in role) and bound- ary violations (exploitation of the client at some level). A boundary crossing is a departure from commonly accepted practices that could potentially benefit clients; a boundary violation is a serious breach that results in harm to clients and is there- fore unethical. Gutheil and Gabbard note that not all boundary crossings should be considered boundary violations. Interpersonal boundaries are fluid; they may change over time and may be redefined as therapists and clients continue to work together. Yet behaviors that stretch boundaries can become problematic, and boundary crossings can lead to a pattern of blurring of professional roles. The key is to take measures to prevent boundary crossings from becoming boundary violations. Johnson and Johnson (2017) contend that military mental health providers must increase their tolerance for routine boundary crossings and contacts with clients outside the consulting room. If military therapists demonstrate calm accep- tance of their multiple roles and relationships, clients are likely to become calmer about these unavoidable multiple relationships. Military therapists need to be mindful of client confidentiality in interactions with clients outside of therapy and remain vigilant to possible adverse effects of multiple roles on clients or on the therapeutic relationship. A common type of boundary crossing is therapist self-disclosure. If a coun- selor engages in lengthy self-disclosure, a client might well wonder whether he or she is being heard in the therapy session. Many theoretical models encourage appropriate and timely disclosure on the therapist’s part, but such self-disclosure must be in the service of the client. Therapist self-disclosure should never burden the client or result in the client feeling a need to take care of the therapist. Coun- selors must consider a range of factors such as the client’s history, his or her pre- senting problem, cultural factors, the client’s comfort with disclosures on the part of the therapist, and a therapist’s comfort with disclosing. It is critical that thera- pists understand their motivations for sharing personal experiences or reactions to what is going on in a session. In examining ethical complaints and violations received by the Commission on Rehabilitation Counselor Certification from 2006 to 2013, Hartley and Cart- wright (2015) found that boundary violations were the most pervasive themes. Barnett (Barnett, Lazarus, et al., 2007) states that even for well-intentioned clini- cians, thoughtful reflection is required to determine when crossing a boundary results in a boundary violation. If a therapist’s actions result in harm to a cli- ent, it is a boundary violation. Failing to practice in accordance with prevailing community standards, as well as other variables such as the role of the client’s diagnosis, history, values, and culture, can result in a well-intentioned action being perceived as a boundary violation. Pope and Vasquez (2016) caution that crossing a boundary entails risks: “Done in the wrong situation, or at the wrong time, or with the wrong person it can knock the therapy off track, sabotage the treatment plan, and offend, exploit, or even harm the patient” (p. 253). Barnett (2017a) states that “one client’s boundary crossing may be another client’s boundary violation” (p. 27) and recommends that therapists openly discuss concerns regarding mul- tiple relationships with clients as part of the informed consent process. Barnett adds that crossing boundaries may be clinically relevant and appropriate in some cases, and that avoiding crossing some boundaries could work against the goals of the therapeutic relationship. Pope and Vasquez (2016) point out that refusing to engage in a boundary crossing may be a lost opportunity that can damage the therapeutic alliance. If a client gives her therapist a small painting she created as a token of gratitude and her therapist declines the gift, the client may feel rejected because she personally created the gift. She also may be offended if giving gifts is considered to be an important part of her cultural tradition. Consistent yet flexible boundaries are often therapeutic and can help clients develop trust in the therapy relationship. Smith (2011) recommends finding a balanced framework for the therapeutic relationship that is neither too tight nor too loose. Smith states that appropriate boundaries provide “both patient and therapist freedom to explore past and present, conscious and unconscious, fact and fantasy. Boundaries offer safety from the possibility of rule by impulse and desire” (p. 63). Setting Appropriate Boundaries in Home-Based Therapy Changes in mental health care laws and practice have increased the need for outreach psychother- apists in recent years (Rogers, 2014). Some clients may have difficulty getting to an office due to a lack of transportation or physical limitations. Others may be struggling with poverty and a host of problems that limit their access to office services. Offering therapy in a client’s home can aid in building a therapeutic rela- tionship and provides the clinician with the opportunity to observe the client’s experience firsthand. Despite the benefits of outreach psychotherapy, graduate programs continue to emphasize in-clinic training and are not adequately prepar- ing students for the challenges encountered when meeting clients in their homes or working in the community. Some training programs would like to provide outreach therapy experiences for students but cannot due to the limits of mal- practice insurance at their university. Rogers (2014) lists some concerns that may be encountered when serving clients at home: challenging mental health issues, safety concerns, distracting environment issues, a lack of collegial support and supervision in the field, role confusion, feelings of isolation, countertransference, and blurred boundaries. These concerns are unlike those experienced in an office setting, and it is likely that boundary crossing issues will need to be addressed in the home environment. Hartley and Cartwright (2015) describe an increasing trend toward providing rehabilitation counseling services in clients’ homes and natural environmentsOne of the challenges that accompany this trend is that the practitioner may be asked to take on tasks outside of the counseling role such as running errands or attending to visitors coming to client’s home. Hartley and Cartwright believe “there is a need for continued discussion toward how to sustain appropriate roles and relationships with clients when providing services to reduce the potential of nonsexual boundary violations” (p. 161). Zur (2008) also makes a case for taking professional relationships beyond the office walls. He writes about the advantages of out-of-office experiences, such as home visits, attending celebrations of a client, adventure or outdoor therapy, and other encounters with clients. For example, he describes how he accompanied a client to the gravesite of a child for whom she had not grieved. This intervention proved to be therapeutic for the woman who had been depressed for years prior to beginning her therapy with Zur. In some situations, out-of-office contact is required on a regular basis. Psy- chologists who work with athletes and coaches may travel with teams, attend practice sessions and competitions, eat meals with their clients (the athletes), and share hotel rooms with coaches (Moles, Petrie, & Watkins, 2016). Sport psy- chology consultants often engage in behaviors that cross boundaries typically associated with mental health settings. Developing trusting and credible rela- tionships requires sport psychologists to meet athletes where they practice their sport; these relationships are considered appropriate because of the context of the sport environment and the culture of sport (Haberl & Peterson, 2006; Moles et al., 2016). We recommend that therapists who make it a practice to venture outside of the office or engage in nontraditional activities with clients make this clear at the outset of therapy during the informed consent process. Furthermore, therapists might do well to consult with their insurance carrier about such practices as these activities may have implications for their liability exposure. A Cultural Perspective on Boundaries Speight (2012) argues for the need to reconsider boundaries in the therapeutic relationship and calls for a reexamination of the traditional perspective on understanding boundaries, boundary crossings, the counselor’s role, and the counseling relationship. She discovered that many African American clients expect a warm, reciprocal, and understanding relation- ship and perceive therapists’ objective detachment as uncaring and uninvolved. Speight proposes the concept of solidarity, rooted in the ties within a society that bind people together, as a culturally congruent way of understanding, defin- ing, and managing boundaries. “Solidarity between myself and my clients both allowed and required me to be myself, to give primacy to the real relationship, to establish close boundaries, and to act in clients’ best interests” (p. 147). By embrac- ing a broader understanding of boundaries, Speight was able to be genuine and close in her therapeutic relationships without being inappropriate and exploit- ative. “I was flexible with my boundaries, in a way that felt entirely consistent cul- turally but was inconsistent with my prior training and education. No longer was I a distant, detached professional, but I was an engaged and involved counseling psychologist, and this was just ‘the type of psychologist’ I wanted to be” (p. 141). Managing boundaries and Multiple relationships / 263 Copyright 2019 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-202 Copyright 2019 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove addcommunity standards, as well as other variables such as the role of the client’s diagnosis, history, values, and culture, can result in a well-intentioned action being perceived as a boundary violation. Pope and Vasquez (2016) caution that crossing a boundary entails risks: “Done in the wrong situation, or at the wrong time, or with the wrong person it can knock the therapy off track, sabotage the treatment plan, and offend, exploit, or even harm the patient” (p. 253). Barnett (2017a) states that “one client’s boundary crossing may be another client’s boundary violation” (p. 27) and recommends that therapists openly discuss concerns regarding mul- tiple relationships with clients as part of the informed consent process. Barnett adds that crossing boundaries may be clinically relevant and appropriate in some cases, and that avoiding crossing some boundaries could work against the goals of the therapeutic relationship. Pope and Vasquez (2016) point out that refusing to engage in a boundary crossing may be a lost opportunity that can damage the therapeutic alliance. If a client gives her therapist a small painting she created as a token of gratitude and her therapist declines the gift, the client may feel rejected because she personally created the gift. She also may be offended if giving gifts is considered to be an important part of her cultural tradition. Consistent yet flexible boundaries are often therapeutic and can help clients develop trust in the therapy relationship. Smith (2011) recommends finding a balanced framework for the therapeutic relationship that is neither too tight nor too loose. Smith states that appropriate boundaries provide “both patient and therapist freedom to explore past and present, conscious and unconscious, fact and fantasy. Boundaries offer safety from the possibility of rule by impulse and desire” (p. 63). Setting Appropriate Boundaries in Home-Based Therapy Changes in mental health care laws and practice have increased the need for outreach psychother- apists in recent years (Rogers, 2014). Some clients may have difficulty getting to an office due to a lack of transportation or physical limitations. Others may be struggling with poverty and a host of problems that limit their access to office services. Offering therapy in a client’s home can aid in building a therapeutic rela- tionship and provides the clinician with the opportunity to observe the client’s experience firsthand. Despite the benefits of outreach psychotherapy, graduate programs continue to emphasize in-clinic training and are not adequately prepar- ing students for the challenges encountered when meeting clients in their homes or working in the community. Some training programs would like to provide outreach therapy experiences for students but cannot due to the limits of mal- practice insurance at their university. Rogers (2014) lists some concerns that may be encountered when serving clients at home: challenging mental health issues, safety concerns, distracting environment issues, a lack of collegial support and supervision in the field, role confusion, feelings of isolation, countertransference, and blurred boundaries. These concerns are unlike those experienced in an office setting, and it is likely that boundary crossing issues will need to be addressed in the home environment. Hartley and Cartwright (2015) describe an increasing trend toward providing rehabilitation counseling services in clients’ homes and natural environments. One of the challenges that accompany this trend is that the practitioner may be asked to take on tasks outside of the counseling role such as running errands or attending to visitors coming to client’s home. Hartley and Cartwright be

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