Dual Relationships in Therapy & Supervision

Multiple Relationships in Therapy and Supervision

• A dual relationship happens when two or more connections exist with the same person, either simultaneously or at different times.

Risks in Therapy

• Impaired judgment can arise from mixing roles, which compromises objectivity.
• Exploitation may occur when clients or supervisees feel pressured or manipulated because of power differences.
• Role confusion can blur boundaries, undermining trust and the main purpose of therapy or supervision.

Ethical Guidelines

• Most codes, including CAMFT and ACA, advise against dual relationships that are likely to harm or exploit clients or trainees.
• Some dual relationships are unavoidable, especially in small communities; professionals must document decision-making, get informed consent, and keep firm boundaries.

Protective Measures

• Protective measures include informed consent, consultation, and motive checks through self-reflection.

In Supervision

• Multiple relationships are common and sometimes unavoidable, clarification before trainees are asked to engage in multiple relationships is vital.
• Supervisors are at risk of exploitation and harm, especially in the context of a sexual relationship.

Boundary Errors: Crossings vs. Violations

• Crossings involve departures from commonly accepted practice that can potentially benefit clients.
  • Includes self-disclosure, multiple relationships, giving advice, or touch.
  • There is an increased possibility for therapist might misuse power, influence and exploit clients.
• Violations are major breaches that harm clients and are unethical and potentially illegal.
  • Examples include sexual contact or a relationship with client, or exploitation of the client

Consent vs. Assent vs. Dissent

• Assent is when counselors involve minors, who can't give consent, in decisions about their care and get their agreement to participate in counseling.
• Consent refers to an informed agreement to participate in treatment or services; the individual must understanding the risks, benefits, and alternatives beforehand.
• Dissent involves refusing therapy even when parents have given consent, and therapists must consider the client's wishes.

Bartering

• Bartering: Therapy is exchanged for goods or services instead of a fee. Ethical codes don't fully prohibit it, but stress caution.
• There is a risk of Exploitation. When therapists holds significant influence, there is a chance the arrangement might become unfair.
• In certain cultures, bartering is normal if acceptably structured after careful consideration
  • If you barter, clearly document the terms (Value of the goods/services, duration, and how any disputes will be resolved).
• Bartering for goods (produce, artwork, etc) is generally safer than services, since it can prevent potential ongoing role confusion.
• Consultation should be undertaken.

Supervision

• Supervision is an important part of acquiring competence for professional responsibilities.

Supervisor Roles

• Supervisors must provide training and experiences for ethical service delivery
• Supervisors must be competent in supervision and in the area of counseling being supervised
• Supervisors must have education on training and competence
• Supervisors must obtain 6 hours during each license renewal period (or within 60 days of starting supervising) is a must
• Supervises are ultimately responsible, both ethically and legally for the actions of their trainees.
• Must have a clearly developed framework for supervision and methods together employ

Responsibilities of Supervisees

• Supervisees must come prepared, participate, ask questions, seek, and critically evaluate feedback
• Establish healthy boundaries and discuss insecurities, and anxieties.
• Clients must be verbally and in writing told that supervisees are unlicensed and working under supervision, meeting regularly for Supervision
  • Cases may be discussed during supervision meetings and with other trainers, but without disclosing identity.

Methods of supervision/evaluations

• Self-report is commonly used, but not the best representation.
• Digital recordings can be helpful to review.
• Verbal exchange includes discussions of cases, ethical and legal issues, and personal development.
• Direct observation is also a tool for supervision,.

Informed Consent

• Informed consent involves incorporating clear material for supervisees, both orally and in writing.
• The rights of supervisees should be discussed at the start.
• Supervisees will achieve success when they learn expectations.

Supervision Contract

• Supervision Contract: It is an explicit agreement between supervisor and supervisee, to prevent problems.
  • Gold standard for best supervision practices.
• The contract may contains legal and ethical requirements, methods used in supervision, expectations, parameters for training experience, limits of confidentiality, etc.

Multicultural Competence and Social Justice

• Multicultural competence is an ongoing process of developing awareness, knowledge, and skills about different cultural backgrounds (e.g., race, ethnicity, gender, sexual orientation, ability, region, and socioeconomic status).
  • Competent practitioners examine their own biases, engage in respectful dialogue, and tailor interventions to meet clients' cultural contexts.
• Social Justice addresses societal power imbalances and systemic barriers, such as racism, sexism, ableism, classism, and homophobia.
  • Socially just counselors move beyond individual-level interventions to advocate in the community, shape policy, and empower marginalized groups.
• Ethical and professional standards should address these issues.

Ethical and Professional Standards

• Most major professional organizations (ACA, APA, CAMFT) mandate cultural responsiveness and non-discrimination.
• It's expected to continuously educate themselves on cultural humility and bias reduction.
• Ongoing self-reflection and recognizing personal prejudices and blind spots is also critical for preventing harm and ensuring ethical practice; supervisors or consultation is often sought around culturally sensitive cases.

Cultural Sensitivity in Practice

1. Awareness of your own cultural identity and values, including how they shape your worldview and potential biases.

   • Being Mindful of power differentials, such as those between a privileged therapist and marginalized client.

2. Knowledge of histories, practices, and experiences of diverse groups

   • Acknowledge how the socio-political climate affects people (Ex. discrimination, legislation, immigration issues).

3. Skills include

   • Adapting interventions to clients belief systems and communication styles.
   • Integrating culturally relevant healing practices and honoring family/community structures.

• Ethical imperatives:
  • No harm
  • Fidelity and Justice
  • Beneficence

Systems Theory in Family Therapy

• Systems theory views psychological and relational problems as arising from within the individuals present environment and the intergenerational family system.

Assessment vs. Diagnosis

• Assessment evaluates relevant factors in a client's life to identify themes for exploration.
• Diagnosis identifies a possible mental disorder based on a pattern of symptoms that matches a specific diagnosis described in the DSM.
• Psychological diagnosis is the process of identifying an emotional or behavioral problem and making a statement about the client's current status.
  • This may include DSM information but also identifies possible causes, leading to a treatment plan.
• Cultural factors are important, and differential diagnosis can distinguish one form of mental disorder from another.

Goal-Setting in Therapy

• Goal-setting, being one of the very first tasks in therapy, establishes direction for treatment and provides a framework for measuring progress.
• Collaborative process
  • Goals should be negotiated between therapist and client rather than imposed by the therapist.
  • Important to consider the client's unique needs, cultural context, and personal circumstances.
• Influences on Goal-Setting:

  • The therapist's theoretical orientation and personal values influence goal formation.

  • External factors (such as insurance requirements, workplace policies, or crisis situations) may also shape goals.

  • Goals should be adaptable, revisited, and refined as therapy progresses.

• You must articulate both short-term and long-term objectives clearly.
• Ensure goals are measurable and realistic, and discuss potential obstacles that may impact goal attainment.

Ethical Challenges in Working with Children, Couples, Families, and Groups

• Therapists often face dilemmas when working with multiple client systems, as interests may conflict between individuals.

• It is essential to work towards "the good of the relationship" or the system and safeguard each individual's well-being.

• Working with children demands the following:

  • Young clients require careful management of physical touch and boundaries.
  • Therapists must decide whether to reciprocate nonsexual gestures while maintaining professional limits.

• Couples and Families, balancing multiple interests should be taken into consideration

  • Dilemmas can arise when one member's interests conflict with another's.
  • Informed consent must cover the unique aspects of couples and family therapy (purpose, confidentiality limits, fee structure, and the option to withdraw).

• Managing disclosures, such as domestic violence, while respecting confidentiality and legal obligations, are special issues to observe.

• When working with groups

  • Confidentiality cannot be guaranteed; thus, thus it is crucial to educate members about its limits.
  • Informed Consent & Screening: Group members should understand the format, potential risks, and the process of terminating their participation.
  • Managing Dynamics: Group leaders must be adept at handling diverse personalities and ensuring that individual needs do not compromise group cohesion.

• One must establish and maintain competence in group work, family therapy, and couples therapy.

Competence

• Ongoing Training and Supervision: Supervision is crucial for professional development and ensuring ethical, effective practice through self-reports, direct observation, review of recordings, and online supervision.
• Regular feedback, self-reflection, and consultation with peers help maintain and enhance competence.
• Specialized Competencies is a must: Competence involves screening participants, managing informed consent, maintaining confidentiality, and navigating group dynamics.
• Family and Couples Therapy: Managing multiple relationships, balancing conflicting interests, and ensuring all members understand the therapeutic process is key.
• In addition, developing a framework for informed consent that addresses the unique challenges of working with more than one client at a time is also essential.
• Adherence to professional standards and guidelines and continuous education are also helpful to ensure that competence is maintained over time.

Reporting Ethical Violations

• Reporting ethical violations protects clients, maintains public trust, and upholds the integrity of the profession. It also prevents harm from continuing unethical practices and promotes accountability.
• Steps and Considerations:
  • The first step include identifying and documenting behaviors like boundary violations, dual relationships, exploitation, or any behavior that might compromise client welfare with a thorough and objective record.
  • The second step is Consultation
  • Before making a report, seek supervision or peer consultation to clarify the situation and ensure an accurate understanding of ethical standards.
  • Review the relevant professional ethics codes and legal guidelines.
• You must choose the right reporting channels
  • Internal avenues should be considered before reporting to external bodies .
• Legal and Ethical Implications of not doing so:
  • Failure to report may result in harm to clients and potential legal consequences for the therapist.
  • Reporting should be done in a timely and confidential manner, balancing legal and ethical requirements.

Couples Therapy Ethics

• Who the client is must be clarified
  • The “client” is typically the relationship itself rather than each partner separately. This shift helps the therapist maintain balance and avoid taking sides.
• Informed consent should be sought to implement "No Secrets" Policies
  • Content of Consent: what is the purpose of therapy, typical procedures, and possible benefits/risks
  • The fee structure and cancellation policies.
  • Confidentiality Limits: Unlike child abuse, domestic violence between adults typically doesn't trigger a mandatory report (unless children are also endangered).
  • There should be balance safety planning and prevent further harm, and balancing each partner's confidentiality.
• Managing Power Imbalances and Safety Concerns is important

  • If there is ongoing intimate partner violence, couples therapy may not be appropriate or safe for the victimized partner

  • Vigilance about signs of coercion or fear in sessions and deciding if separate, specialized interventions are needed is a must.

  • Voluntary participation: both partners must be willing participants. Any sense of coercion or intimidation undermines the therapeutic process and can impede on clinical problems.

• Individual sessions should be carefully taken into consideration
  • A couple's therapist may meet with one partner individually for clarity or crisis intervention.
  • Information disclose in individual sessions must be addressed when the couple reconvenes
  • Always maintain Consistency with the informed consent agreement is essential.
• Therapists should avoid simultaneously providing individual therapy to one partner and couples therapy to both, unless specifically trained and ethically prepared for overlapping roles. Even then, thorough documentation, informed consent, and consultation are critical.

Group Therapy Ethics

• Informed consent should be sought
  • Group format: explain the purpose of the group, how sessions are conducted, and the goals or structure. Stress confidentiality, members also bear responsibility, and no absolute guarantee can be made.
  • Disclose potential benefits (peer support, modeling) and possible risks (confrontation, group conflict).
• Screening and Member selection is also important
  • Appropriateness for group: not everyone is suited for a particular group; careful screening aligns each member's needs and interpersonal styles with the group's goals and culture.
  • When there are involuntary members (court ordered), the leader must clarify expectations and consent issues to facilitate group cohesion
• Confidentiality Nuances
  • Privileged communication is less clear in a group setting due to multiple witnesses, and is why we still have to mandate report anything.

Managing Group Dynamics

• Power differentials: Leaders must remain aware of subgrouping, scapegoating, or bullying.
• Multicultural sensitivity: Leaders must navigate different cultural values around disclosure, conflict, and emotional expresssion respectfully.
• Leader competence and boundaries require specialized training, leading to Co-leadership: Consistent communication is also important.

Termination and Follow-Up

• Closed groups: Review growth, provide aftercare/referrals.
• Open Groups: Process transitions and handle change in group dynamics.

Informed Consent Practices with Minors and Parents; Ages of Consent for Children

• General Rule: A parent or guardian provides informed consent for a minor's treatment.
• California Exception (12 and older): California law allows a minor 12 years or older to consent to their own outpatient mental health if the therapist deems them mature enough to participate intelligently if: treatment could lead to serious harm to self or others, or if the minor has been the alleged victim of incest or child abuse.

Other Exceptions

• Certain health services may allow minors to consent without parental involvement.
• Informing Parents vs. Protecting Confidentiality: High-Risk Behaviors are taken into consideration .
• Inform both parents and minors about confidentiality rules at intake.
• Know your local regulations and when to schedule a Consultation

Supervision Ethics

• Effective and ethical supervision balances protecting clients welfare and providing training for supervisees.
• Supervisors are ethically and legally responsible to monitor the quality of care clients receive and assist supervisees in therapeutic practice, by informed consent.
• It is important to ask for feedback from supervisees about and use this feedback to improve practices
• Liability of supervisors is important to observe. Direct liability (actions of supervisors cause harm) is as important as Vicarious liability (responsibilities supervisors must oversee the actions of their supervisees).
• Strict liability- clinical supervisors responsible without needing to establish negligence or carelessness

Diagnosis Use and Critique

• Framework For Treatment
  • Diagnoses provide a common language for clinicians and help in formulating treatment plans.
  • They facilitate risk assessment, determine insurance reimbursement, and offer a basis for research.
• Diagnosis can normalize client experiences and reduce feelings of isolation by placing individual symptoms within a broader context and assist in identifying areas for intervention and measuring treatment progress.
• There are limitations Potential Over-Pathologizing, reduced uniqueness of the client's experience.
• It is important to consider Cultural Sensitivity
  • The DSM is based on Western assumptions that may lead to misdiagnosis or stereotyping, and requires you to consider contextual factors.
• Critics argue that diagnosis can neglect the inherent capacities for self-healing and overlook the therapeutic relationship.
• Standardized approach outweigh the risk of minimizing the individual's unique narrative?