Dual Relationship and Boundaries in Clinical Practice
Boundary Decisions in Context
A Decision-Making Model
Application of Decision-Making Model
Case Study 1
Case Study 2
Discussion and conclusion
The issue of boundary and dual relationship has been a major subject of concern in psychological practice. Ethics complaints on dual relationship and boundary crossing continue to rise both in nature and variety. This paper examined and shed light on the complexities of dual relationship and boundary crossing in clinical psychology and explain the pertinent moral and clinical worries that clinical psychologist's face daily in their practice. The paper analysed three underlying themes: 1) using an empirical review of relevant literature to identify clinician’s attitudes toward risky and useful dual relationship and boundary crossing, 2) learn whether involving in dual relationships, negatively or positively influences therapeutic outcome, 3) using the decision making model to address the concept, challenges and variances associated with dual relationship in clinical psychology. Lastly, the paper comes up with strategies that help psychologists to make flawless ethical standards and offer moral guidance. Finally, study shows that, though, dual relationships sometimes enhanced therapy, aids the treatment strategy, and promotes the clinician-client working relationship; it also weakens the treatment process, hampers the clinician-client cooperation, and brings instant or lasting damage to the service user.
Key Words: Boundary crossing, dual relationship, ethical decision making,
The issue of boundary and dual relationship has been a major subject of concern in psychological practice. Of most concern is the fact that the issues has developed in the context of professionalization. In fact, no time in the history of the profession has the ethics of professional conduct being questioned or confronted with a wide range of contemporary ethical problems like it is today in our society. The profession has been besieged with clear messages about the immorality of dual relationship and boundary crossings to the extent that, the values and moral foundation of the psychology discipline was seriously challenged by both clients and consumers. From psychology course guidelines, to literatures on moral values, and clinical internships, it has been reported as inappropriate, for clinical psychologists to get involved in the following circumstances that face them daily in their professional duties: unofficial work or private relationship with clients, taken gifts offer, engage in physical contact and last but not the least, socialize with clients. This position is also accord with a large number of researchers, who one way or the other have made massive contributions to our understanding of the subject, particularly as regards boundary crossing and dual relationships in clinical practice (Corey 2009). Professional training continuously highlights that boundary crossing is likely to impacts on clients ‘right and also causes unjust sexual contacts. Although these acts are reported as immoral and often linked to abuse and harm, its continuous existence in clinical practice remains an issue of concern till date. The question is, how can we as psychologist blend our professional roles and personal needs without compromising our professional responsibilities?
Interestingly, each health professional association obligates their members to ethical standards and codes of conduct that guide, regulate and protect clients from experiencing bad practice. However, for clinical psychologist, navigating through ethical practice is a difficult mountain to climb. Psychologist and clients are regularly hindered by circumstances that allow a porous boundary between therapeutic and social relationships. Most research studies confirmed that a dual role relationships can either be harmful or helpful to clients and therapist (Edwards, 2007; Kitson & Sperlinger, 2007; Lazarus, Zur, & Doverspike, 2004; Pugh, 2007). Also, reports in the early 80s give special consideration to issues that are scientifically related to beliefs and behaviours about boundaries. Among the problems that emerged from numerous study include: therapist sexual category, career (psychiatrist, psychologist, social worker), knowledge, marital status, practice situation (private or public), locality, client sexual category, (such as solo or group private practice and outpatient clinics), practice area (size of the community), and last but not the least, theoretical belief. The corollary to this assertion is the religious and rural communities, who particularly stuck with the prospect of dual relationships, and view it as an inevitable reality of clinical practice (Catalano, 1997; Doyle, 1997; Sidell, 2007). However, work on boundary crossing continues to provide guidance to difficult issues that we came across in clinical practice as we make a judgement on certain boundary issues in our relationship with clients
Furthermore, it is of importance to note that most research on dual relationship focuses on role theory. Therefore, the issue of social roles that covers innate anticipations about how somebody in a specific role is to conduct him or herself, along with the rights and responsibilities that goes with the functions needed to be addressed. Thus, psychology profession uses ethical principles to advance moral code and moderate professional behaviour of their members (Beauchamp & Childress, 1994). To buttress this assertion, the American Psychological Association, ethical principles (APA, 1992) recognized "multiple dealings" in their code of conduct by stating that, in particular circumstances," it might not be possible or sensible, for psychologists to evade other non-professional interaction with their clients" (p. 1601). The code maintained that, one way or the other, going into such interactions might prejudice the psychologist's fairness, hinder his or her professional practice, or abuse the other party" (p. 1601). Besides, other health professionals also put into place, guidelines and principles that regulate and contain a prohibition of dual relationships. However, conflicts arise when the beliefs and expectations linked to one role call for conduct which is unsuited to that of another role (Kitchener, 1988). Dual role relationship happens when a particular person or an individual concurrently or successively partakes in double role (Kitchener, 1986). This is supported by Carroll, Schneider and Wesley (1985), where they established that, in addition to the professional rapport, the clinician created some other rapport with the person: colleague, relative, student or business partner. Therefore, the question remains: what and what should be prohibited or condoned when working with clients? Which boundary crossings were therapeutically helpful and harmful? And what therapeutic methods are acceptable or not acceptable for certain culture or communities? Despite all these challenges, a large number of research and literatures on boundary and dual relationship has aided and change our thoughts and knowledge, and therefore, shaping the base for what appears to be the main opinion of boundaries these days.
Though practitioners often miss the mark or fail to understand the possibility for dual relationships and how to cope with a specific relational dilemma, the issue still remain a major discuss in clinical psychology till date. This paper will examine and shed light on the complexities of dual relationship and boundary crossing in clinical psychology and explain the pertinent moral and clinical worries that clinical psychologist's face in their practice. The paper will also look at how the concepts influence the decision making process and make a distinction between the following: risky boundary violations, useful boundary crossings and inevitable or caring dual relationships. To realize this, the paper focuses on two underlying themes: 1) using an empirical review of relevant literature to identify clinician’s attitudes toward risky and useful dual relationship and boundary crossing, 2) learn whether involving in dual relationships, negatively or positively influences therapeutic outcome. Lastly, the paper uses the decision making model to address the concept, challenges and variances associated with dual relationship in clinical psychology and come up with strategies that help psychologists to make flawless ethical standards and offer moral guidance regarding dual relationships.
This paper analysed and reviewed empirical literature in order to investigates and check new empirical studies that highlights the complexities of dual relationship and boundary crossing in clinical psychology. The study collated and reviewed relevant articles, books, journals, and meta-analysis on dual relationship, boundary crossing and ethical decision making. Both the ERIC and PSYCHLIT databases were searched using the following key words: ethical decision making, boundary crossing, dual relationship and clinical psychology. This procedure initially reported about 1298 articles, journals, technical reports, paper presentation and book chapters covering more than 23 year period. Based on the abstracts retrieved from this initial 1298 plus articles and publications, the search was lessened to a relatively few hundred of studies that are pertinent and relevant to the theme of this paper. The contents of the remaining several hundred of articles cum journals were further scrutinised and only those that reported empirical findings were kept aside and used in this review, while others were left out of further consideration. This process shows that only a few studies documented empirical findings on boundary crossing and dual relationship in clinical psychology practice. To verify references, manual searches of relevant journals and articles related to the paper are performed.
Dual Relationship and Boundaries in Clinical Practice
As we all know, the major concern of psychology profession is to promote the well-being and welfare of others, however, this statement as well as it sound, has come to the utmost scrutiny in recent time. Clinical psychologist faces daily, how to handle the issue of dual relationships and boundary crossing without compromising their professional conduct and practice. Earlier research, particularly during the 80s and 90s established how hypothetical orientation, community size, psychoanalyst sexual characteristics, client sexual category, occupation, and other issues, impacts on the level that therapists involved in dual relationship or crossing several boundaries in their profession, particularly, feelings about the nature and suitability of borderline crossings. Besides, the period between the 1980s and 1990s also witnessed a practical outburst of healthy argument and considerate works on dual relationships, bartering, companionable touch, out of office consultation and other nonsexual boundary matters to mention a few, that faces health professionals. Also, there were thought-provoking and considerate literature that observed the constructive and undesirable aspects, the dangers and advantages of different boundaries and boundary crossings. A typical example of this is the article by American Psychologist in 1992 requesting for drastic changes in the ethics code.
Unfortunately, the literature reveals that many people have been victims of ethical issues for years. These problems have been linked to lack of clarity and awareness on when and how to engage with clients. For instance, the Committee on Ethics of the American Psychological Association in their report from 1990 to 1992 highlighted that around 40% to 50%of the complaints received during this period are on dual relationship issues. Also, Sonne (1994) complemented this statement by mentioned that, of all the problems facing APA members, the issue of dual relationship was the most common reason for their membership termination. On the contrary, research also sees boundary crossings as well-fashioned treatment strategies that increase the therapeutic success (Lazarus & Zur, 2002). Also the recent APA Code of Ethics of 2002offers a new insight into the issues by dropping the statement, “Psychologists ordinarily refrain from bartering”, that was in the 1992 code and incorporate a new sentence, “Multiple relationships that would not reasonably be expected to cause impairment or risk exploitation or harm are not unethical” (APA, 2002, section 3.05), to the multiple relationships unit. As a result of the ambiguity surrounding the concepts, it attracted serious litigation and other disciplinary cases such as ethics committee hearings, and complaints to professional boards of licensure.
Moreover, from the logical viewpoint, practically, not all boundary crossings are harmful to clinical work. Research maintains a distinction between boundary crossing and violations in clinical practice (Remley & Herlihy 2009). According to literature, boundary violations are more injurious to clients, whereas, some boundary crossing is beneficial (Knapp & Slattery 2004). Thus, professionals must endeavor to always differentiate between conducts that are boundary cross and those that are boundary violations. To support this, the new APA Code of Ethics of 2002 made some clarification that prevents the authorities, courts and ethics committees from employing the logical or community yardstick to evaluate non-logically oriented psychologist, who tactically embrace boundary crossing oriented interventions in societies where dual relationship and boundary crossing are inevitable. Additionally, some school of thought, i.e., behavioural, and humanistic, often embracenumerous forms of supportive boundary crossing that focus client’s wellbeing (Lazarus, 1994; Williams, 1997)as predicting therapeutic outcomes .Interestingly, a body of psychology literature ( Roth & Fonagy, 1996, Hubble et al; 1999) established the therapeutic implication of the clinician–client relationship. According to Roth and Fonagy (1996) and Hubble et al. (1999), client variables and extra-therapeutic elements are identified as responsible for 40 percent of progress made in therapy, while 30 percent are accounted for the therapeutic relationship. Thus, a dual relationship happens when there is a multiple roles or external relationship between a clinician and a client (Bleiberg and Skufca, 2005; Moleski & Kiselica, 2005; Ringstad, 2008). This can be business, social, communal, familial, sexual, and professional oriented to mention a few (Nigro, 2004). Research also classifies dual role relationships into two types: sexual and non-sexual (Corey, Corey & Callahan, 2007). Besides, Corey, Corey, and Callahan (2007) linked sexual dual-role relationships with negative outcomes in the client. They conclude that such relationship is the probable cause of harm to client wellbeing. These interactions are categorized as a little harmful to more deliberate double roles that have bigger potential for negative outcomes (Bleiberg & Baron, 2005; Kolbert, Morgan & Brendel, 2002; Reamer, 2003). Though, this is not made equal, they are structured this way in this paper in order to distinguish the degree of harm they bring to clients.
In addition, research on dual relationship emphasis more on a sexual misconduct between client-therapist (Gutheil, 1989, Corey, Corey & Callahan, 2007) and less on other complex boundary crossings, which to some extent, less noticeable but pose difficulties for clinicians. Though, most psychologist belief that they have a better understanding of boundary issues, using it when working with clients remains difficult. This is made more difficult by the propensity of the legal system, particularly complainants' lawyers, who see any act of boundary crossing as immoral, flawed, and injurious to their clients. Empirical research, advises that boundary violations often go along with or lead to sexual misconduct (Corey, Corey & Callahan, 2007, Gutheil & Gabbard, 1998), but the abuses themselves do not constantly institute misconduct or misdemeanours or even bad method. Moreover, many researchers consider this upshot to be inherently harmful and therefore seen as consistently inhibit or undermine clinical practice (Epstein & Simon, 1990; Simon, 1992). Thus, research advocates that all dual relationships are intrinsically dangerous and clinicians must endeavour to prevent it during practice.
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- dual relationships boundary critical issues clinical psychology practice