Double the pleasure, double the pain: dual relationships

Annals of the American Psychotherapy Association, Winter, 2005 by Bruce Gross

(This column is a continued examination of "Double Vision: An Objective View of Dual Relationships," published in the Annals Fall 2005 issue.)

Dual relationships exist when a therapist and client have two (or more) relationships, each with their own roles, obligations, and expectations. The prohibition against dual or multiple relationships arose from traditional psychoanalytic theory, became ingrained in professional codes of conduct, and has been enforced as a standard of practice by state and federal regulatory agencies appointed with the responsibility of protecting consumers from exploitation. Because certain dual relationships are undeniably harmful to clients, the safest course of action in terms of overseeing the well being of consumers of mental health services was to ban all secondary relationships. Yet in today's climate, with a research-based and fiscally reinforced trend toward cognitive, short-term therapies, the blind assumption that dual relationships must or should be prohibited is brought into question.

Looking for the Bright Side

The generally accepted reasoning behind the ban on dual relationships holds that once boundaries are loosened to develop the non-therapeutic relationship, the very crossing of boundaries inevitably leads to some form of client exploitation. The specific assumption is that dual relationships pave the way for sexual exploitation of clients, a belief that appears consistent with the nature of consumer complaints across time and agencies (Board of Psychology, 2005; Board of Behavioral Sciences, 2004). Viewed as syllogistic and fear-based reasoning, this "logic" has been equated with asserting the use of marijuana inevitably results in addiction to hard drugs (Lazarus & Zur, 2002). Certainly not everyone who experiments with marijuana develops an addiction to the drug, let alone goes on to use or abuse harder drugs. But just as certainly, there are more drug addicts than not who did start with a lesser substance like marijuana. Similarly, while not all dual relationships evolve into a sexual one, all client-therapist sexual relationships do have their inception in loosened boundaries.

There are practitioners who assert that multiple relationships can actually decrease the likelihood of clients being exploited (in particular, sexually exploited) by therapists (Lazarus & Zur, 2005). These practitioners contend exploitation requires isolation of the therapist-client relationship. When both parties are involved in an outside dual relationship, the privacy necessary for effective therapy is maintained while isolation is precluded.

With the uniform exception of those dual relationships involving sex, there appears to be agreement that some dual relationships can benefit the client and the therapeutic process. In fact, a pre-existing relationship may be the very tea son a person decides to enter treatment with a given therapist. It can often be a difficult process for clients to find the right match with a therapist, and knowing a therapist in advance may make the choice easier and better informed. The therapeutic process may benefit from an overlap of trust from the pre-existing relationship to the therapeutic, which in turn may allow the work of therapy to begin sooner, resulting in reduced length of and cost for treatment.

One of the most frequent and insidious ways therapists find themselves in dual relationships is as a result of the referral process; that is, when a current or past client refers a friend, family member, or co-worker for treatment. Word-of-mouth referrals are one of the most common and complementary forms of referrals. At the same time they pose a complexity of ethical challenges and risks that must be carefully considered from a therapeutic (versus business or financial) perspective.

Putting Things in Context

Whether a dual relationship is or becomes a constructive or destructive force in the therapeutic relationship appears to be dependent upon the context in which it develops. Directional determinants include at what point in the course of therapy the relationship became a dual relationship (before, during, or after; at a therapeutic turning-point or during a plateau), with what motivation (self- versus other-serving), by which party was the new relationship initiated (therapist or client), with what client diagnosis or presenting problem, in what setting (rural versus urban; including or excluding other persons), and with what new roles and obligations was the second relationship initiated. None of these variants are particularly novel. Given that therapists are ultimately responsible for their clients' well being, perhaps the most significant variable is when the therapist asks him or herself these questions. Ultimately, the questions should be asked before the consequences of the dual relationship have taken effect.

In terms of the setting, there are generally accepted environments or communities in which multiple relationships are virtually unavoidable. These include the military, rural towns, and communities that are isolated by choice (such as ethnic and other "culture-bound" minorities) or by disability (such as the hearing impaired). The challenge in these situations is to ensure that the dual relationship serves the needs of the client, confidentiality is maintained, and the client's comfort level is monitored.