Frederic G. Reamer, Social Work Malpractice and Liability: Explain a strategy for protecting clients related to boundary issues . Dual relationships occur primarily between professionals and their A boundary violation occurs when a practitioner engages in a dual relationship with a client or colleague. If therapists or counselors terminate the therapeutic relationship and then begin a board disciplinary action and liability in a civil lawsuit for money damages? before venturing into a relationship with a patient or former patient other than the Some definitions of dual or multiple relationships make clear that not all dual. Dual relationships between psychotherapists and clients have been frowned upon and Gutheil & Gabbard () describe the critical areas relevant to boundary . by refraining from engaging in any dual relationship or boundary crossing. .. books on risk management, one of which is Fifty Ways to Avoid Malpractice.
Is this an innocent pleasure? Case adapted from Pope and Keith-Spiegel, You realize that you have disclosed a great deal about your personal life over several sessions. Should you pull back? You want to sell your car, and have a sign on it out in the parking lot and another on your bulletin board in your therapy office waiting area. Your client decides to purchase it from you. You assure the client that it is in excellent condition and a good buy.
Should you go through with a deal? The client you have treated for depression over the last six months tells you that she plans to visit her sibling who lives across the country in a few weeks. With the exception of boundary violations that clearly violate any standard of care, ethics codes cannot possibly give specific guidance when it comes to mandating appropriate ways to socially interact with counseling and psychotherapy clients across all possible situations.
Many boundary crossings can involve no ethical transgressions and even prove beneficial to the client. However, as we will illustrate, remaining vigilant regarding our own needs and vulnerabilities as well as those of our clients is fundamental to ethical practice. As for our examples, not everything turned out well in the actual cases upon which they are based.
The distraught mother scenario illustrates a double boundary crossing. To offer the client extra time seems a kind gesture but runs counter to the therapeutic agreement. In the future, this actual client felt entitled to extra time and resented not getting it.
In the meantime, clients-in-waiting have an agreed upon appointment obligation altered. One can feel sympathy for the distraught mother, but the matter does not qualify as an emergency. In fact, the mother might more appropriately focus on other actions e.
Yet at other times, offering extra time would be prudent, such as in a true emergency situation. The client who was asked for a favor turned into a bit of a fiasco.
The client asked if they could stop on the way home and have dinner together. The therapist refused politely, noting he had to get home to his family. But now the client, who later became a stalker, knew where he lived. This was a fairly new client with some issues that should have signaled caution on the part of the therapist. His myopic focus on his own convenience ended up costing him dearly.
Regarding the client struggling with her winter coat, what seems like an obvious helpful gesture requires brief reflection. This seemingly helpful act involves physical contact, and not all clients will feel comfortable with that. Some may even feel it as intrusiveness. Asking before acting is essential. The client who brought coffee and sweets to the 10 a.
She began to focus less on her own issues and more on that therapist as someone with whom she could have a relationship with outside of the office. The therapist finally picked up on what was going on and attempted, unsuccessfully, to pull the relationship back to the business of therapy. The client experienced the request to cease bringing coffee and sweets as both an insult and a rejection.
She never returned to therapy. Although this case did not result in an ethics complaint, the therapist felt guilty over failing to better perceive how meeting his own needs for what seemed like an innocent pleasure caused pain for a client he liked.
Malpractice Pitfalls for Therapists
The economically strapped landscaper provides a more complicated case, and we will have more to say about bartering later. However, in such cases, taking someone up on what seems like a good match can turn into an ordeal. Ultimately, the client successfully sued the therapist for exploitation. Unfortunately, the therapist became defensive and told the client that the client must have caused the damage. The therapeutic alliance evaporated, and the client successfully sued the therapist in small claims court.
Finally, certifying the need for an emotional support animal, as opposed to a trained service animal e. Crossing them has many potential effects. The work of mental health professionals is conducive to permeable role boundaries because so much of it occurs in the context of establishing emotionally meaningful relationships, very often regarding intimate matters that the client has not spoken of to anyone else.
Yet, mental health professionals continue to hold differing perceptions of role mingling. These perceptions range from conscious efforts to sustain objectivity by actively avoiding any interaction or discourse outside of therapeutic issues to loose policies whereby the distinction between therapist and best buddy almost evaporates.
However, even those who would stretch roles into other domains would condemn conspicuous exploitation of clients. Some mental health professionals decry the concept of professional boundaries, asserting that they promote psychotherapy as a mechanical technique rather than relating to clients as unique human beings.
Instead, acting as a fully human therapist provides the most constructive way to enhance personal connectedness and honesty in therapeutic relationships Hedges, and may actually improve professional judgment Tomm, Those critical of setting firm professional boundaries further assert that role overlaps become inevitable and that attempting to control them by invoking authority e.
The answer, they say, involves educating both clients and therapists about unavoidable breaks and disruptions in boundaries and to ensure that therapists understand that exploitation is always unethical, regardless of boundary issues. As the scenarios at the onset of this course reveal, however, exploitation is not the only harmful result of boundary crossings.
We believe that the therapist retains ultimate responsibility for keeping the process focused. We see no reason why maintaining professional boundaries needs to diminish a therapist's warmth, empathy, and compassion. The correct task is to match therapy style and technique to a given client's needs Bennett et al.
Furthermore, we believe that lax professional boundaries can act as a precursor to exploitation, confusion, and loss of professional objectivity.
Conflicts, which are more likely to arise when boundaries blur, compromise the disinterest as opposed to lack of interest prerequisite for sound professional judgment. As Borys contended, clear and consistent boundaries provide a structured arena, and this may constitute a curative factor in itself. In short, the therapy relationship should remain a safe sanctuary Barnett, that allows clients to focus on themselves and their needs while receiving clear, clean feedback and guidance.
Frank discussions about boundaries with clients during the initial informed consent phase is also recommended. Cultural traditions, geography e. The ethics code of the American Psychological Association APA, offers a clear definition of multiple role relationships. Multiple role relationships occur when a therapist already has a professional role with a person and: Is also in another role with the same person, or Is also in a relationship with someone closely associated with or related to the person with whom the therapist has the professional relationship, or Makes promises to enter into another relationship in the future with the person or a person closely associated with or related to the person.
To qualify for the definition of multiple role relationship then, the initial relationship typically requires an established connectedness between the parties. The primary role relationship is usually with an ongoing therapy, counseling client, student, or supervisee. Limited or inconsequential contacts that grow out of chance encounters would not normally fall under the definition or cause for any ethical concerns.
Multiple role relationships may occur via action, as when a therapist hires a client as a housekeeper. Or they can take the form of a proposal for the future while therapy remains ongoing, as when a therapist and a client plan to go into business together or agree to start a sexual relationship upon termination of therapy, thus altering the dynamics of the ongoing professional relationship. Zur has categorized multiple role relationships by types. These categories are illustrated in the cases offered here.
Nonsexual consecutive role relationships with ex-clients do not fall under any specific prohibitions in the APA code APA, However, based on post-therapy incidents described in this course, we advise caution even after a natural termination of the professional relationship. However, not all multiple role relationships with clients are necessarily unethical so long as no exploitation or risk of harm to the client or the professional relationship can be reasonably expected.
We agree that careful consideration should occur prior to softening the boundaries of any professional role, and we also remain unconvinced that accurate outcome predictions involve a simple exercise in judgment.
If that were so, therapists would have the lowest divorce rate of any professional group! Alas, no evidence of such foresight exists. We also contend that justification for entering into some types of multiple role relationships with persons in active treatment does not exist.
Sexual and business relationships, for example, pose inherent risks regardless of who is involved. Neither can be defended as reasonable dimensions to impose on a therapy relationship. Finally, we will comment on how easy it is to rationalize, to convince ourselves that an action is justifiable in a particular situation.
Ethics & Malpractice
All therapists are vulnerable to self-delusion when their own needs get in the way, even those who are competent and have been scrupulously ethical in the past e. Risk Assessment Kitchener suggests assessing the appropriateness of boundaries by using three guidelines to predict the amount of damage that role blending might create.
Role conflict occurs, says Kitchener, when expectations in one role involve actions or behavior incompatible with another role. First, as the expectations of professionals and those they serve become more incompatible, the potential for harm increases. Second, as obligations associated with the roles become increasingly divergent, the risks of loss of objectivity and divided loyalties rise.
Third, to the extent that the power and prestige of the psychotherapist exceeds that of the client, the potential for exploitation is heightened.
Thus, if after two years of intense therapy and a tenuous termination whereby the client may need to return at any time, no additional roles should be contemplated. The success or failure of this new role relationship would be more about what the parties do as consenting adults as opposed to the brief professional experience.
Brown adds two additional factors that, if present, heighten the risks of harm. Second, boundary violations usually arise from impulse rather than from carefully reasoned consideration of any therapeutic indications. Thus, hugging a client is not unethical per se, but an assessment of any potential hazards or misunderstandings should precede such an act. Risky Therapists All therapists face some risk for inappropriate role blending Keith-Spiegel, Those with underdeveloped competencies or poor training may prove more prone to improperly blending roles with clients.
However, even those with excellent training and high levels of competence may relate unacceptably with those with whom they work because their own boundaries fail.Therapist to Therapist - Dual Relationships
Some may feel a need for adoration, power, or social connection. The settings are private and intimate. The authority falls on the side of the therapist. Moreover, if things turn sour, the therapist can simply eliminate the relationship by unilaterally terminating the client and can deny that anything untoward occurred should a complaint be initiated by a client.
Indeed, when a client walks through the door, immediate clues become apparent: Multiple authors have discussed the advantages of self-disclosure. Done thoughtfully and judiciously, revealing pertinent information about oneself can facilitate empathy, build trust, and strengthen the therapeutic alliance e. However, those who engage in considerable and revealing self-disclosure with clients stand at greater risk for forming problematic relationships with them.
Instead, this client began to feel that the therapy environment was polluted rather than safe and clean.
She quit therapy feeling even more adrift. It is difficult to know in advance how a given client will respond to a self-disclosure, particularly when the subject is in sensitive territory for the client. It seems reasonable to expect that some clients would want to know as much as possible about the person in whom they are placing so much trust.
A skillful therapist can respond without demeaning the client in the process. At the same time Internet searches make considerable information on anyone readily available. Like any other individual who prefers some modicum of privacy, psychotherapists must understand that information posted on personal and social sites will become known to curious clients and may lead to inquiries or promote some other types of boundary blurring.
Obviously if the business does not do well, the burden to prove that there was no exploitation is even greater. Unlike self disclosure, which is a common occurrence, the rule for entering into a business relationship with a present or former patient should be "almost never. Using Techniques Without Proper Training A recurrent issue over the last ten to fifteen years has been the use by therapists of treatment techniques which they are not well trained in.
An example of this is in a case from New Hampshire, Hungerford v. A key point in the decision of the Supreme Court in New Hampshire allowing the father to sue his daughter's therapist was that the therapist's only training in the area of repressed memories was one lecture on memory retrieval techniques that she attended at a weekend symposium. The therapist should not use any techniques without being thoroughly trained and experience in them.
It is probably below the standard of care per se to use a technique after only being trained in it one time. It is not uncommon with some treatment approaches such as EMDR or Bioenergetics for therapists to attempt to begin using the techniques before completing the entire training.
Using Incorrect Diagnosis Deliberately Over the last several years as managed care has become more a part of a practicing psychotherapist's life, there has also been a rise in allegations that therapists are deliberately reporting diagnosis to insurance companies that are not accurate to trigger coverage where it should not exist.
For example, it is not uncommon to have an allegation that a therapist failed to disclose an Axis II diagnosis because of an awareness that a particular insurance carrier in question would not cover any such condition. The general rule is that the diagnosis for treatment and diagnosis for insurance should be the same. The law does not recognize or permit the therapist to have one diagnosis for treatment purposes and one diagnosis for billing or insurance purposes.
In fact, the existence of two such diagnosis offers an opposing attorney a great opportunity to impugn the therapist's credibility. A patient should only be diagnosed with the accurate diagnosis. A typical scenario is for a therapist to report a less severe diagnosis, such as adjustment disorder, rather than a dissociative disorder, or if the patient has a borderline personality disorder.
When some dispute arises and the therapist wants to assert that the patient has the more severe diagnosis, that was not actually used in reports to insurance companies, the patient's attorney or the attorney for the licensing board will probably contend that the more severe diagnosis was made up after the dispute arose, because no preexisting record can be found.
Avoiding the Medical Model Faced with the complexities of informed consent, standard of care, note taking, etc. This has the same effectiveness as reporting to the Internal Revenue service that you do not believe that the tax laws are valid, and that you should not have to comply with them. While this may lead to making the acquaintance of interesting criminal defense and bankruptcy lawyers, it will not cause any change in the IRS's view of the applicability of the tax laws.
By the same token, for a psychotherapist to assert that he or she should not be subject to the medical model will be ineffective. The medical model will generally be imposed with or without your agreement. The True Love Exception for Sexual Relationships Over the years some therapists have sought to invoke the "true love" exception to actions for damages or by licensing boards arising from sexual relationships with present or former patients.
There is no true love exception, there never has been a true love exception, and, in all probability, there never will be a true love exception.
Sexual relationships with existing or former patients are unethical under most associations' ethical principles, illegal in some states such as Californiaand have career killing consequences.
It is almost axiomatic that what is seen as true love at the time the relationship begins is seen as mishandling of transference after the relationship ends. An example of this attitude is a survey of psychiatrists from The study involved over 1, psychiatrists, and approximately The issue of whether the relationship was due to "true love" was a factor for some of the respondents.
Under no circumstances should and therapist seriously consider a sexual relationship with a present or former patient regardless of how long the interval has been between the termination of the patient and the beginning of the relationship.
Generally a therapist who is choosing to engage in such a relationship with a patient is effectively choosing to discard his or her career.
While some experts may still say that there is a wide variance in the practice of therapists over keeping notes, the practical fact is that notes are essential for survival in this litigious age.
Notes should not only be accurate, but should be meaningful in terms of content. The notes should indicate what was said by the patient, as precisely as possible, and what the therapist did or said about the patient's communication.
It is not necessary that the notes be written in plain English, but the notes should be an accurate picture of what was discussed. A therapist should never agree to not take notes at a patient's request.
In fact, such a request from a patient should cause the therapist to seriously questions whether the patient has a secondary agenda. Failure to Obtain an Adequate History A related issue to failure to take notes is the failure to obtain an adequate history.
It is a common practice for licensing boards and civil plaintiffs to focus on the patient's history, to have the context of making an accurate diagnosis. The assertion that a therapist failed to obtain an adequate history is a common one, and in some instances is justified. Jeffrey Younggren, has commented that therapists, in addition to being required to comply with the standard of care, must utilize common sense in weighing what patients tell them.
The various cases that have dealt with repressed memory issues have articulated what amounts to a duty to utilize common sense or critical judgment, or a duty to be skeptical of a patient's implausible memories.
To uncritically accept implausible memories of sexual abuse has been found to be below the standard of care by the California Board of Psychology.