Therapeutic Boundaries & Ethics

Boundaries

• It's the therapist's responsibility to maintain relationship boundaries.
• Therapists assess the need for rigid versus permeable boundaries.
• Therapists explore the pros and cons of boundaries, considering the client's culture, diagnosis, needs, and treatment goals.
• Boundary crossings aren't always violations.
• Boundary violations include both legal (sexual contact) and ethical (dual relationships) breaches.

Ethics Codes

• CAMFT: Marriage and family therapists prioritize therapeutic benefits and protect clients from exploitation by establishing and maintaining professional boundaries, engaging in ethical multiple relationships cautiously and congruently with their therapeutic role.
• ACA: Counselors prioritize the counseling relationship and aspire to earn clients' trust by creating ongoing partnerships, establishing ethical boundaries, maintaining confidentiality, and communicating the parameters of confidentiality appropriately.

Dual/Multiple Relationships

• Defined as when a professional has two or more roles with a client, either simultaneously or sequentially.
• Exploitation risk increases.
• Eliminating/avoiding these relationships isn't always possible.
• While not always unethical/illegal, they may lead to unethical/illegal therapist behavior.
• The therapist always has the responsibility to uphold dual relationship standards.

CAMFT on Dual/Multiple Relationships

• Dual/multiple relationships occur when a therapist engages in separate, distinct relationships concurrently with a client.
• Not all dual/multiple relationships are unethical or avoidable, including those due to geographic proximity, diverse communities, certain MFT treatment models, community activities, or culturally congruent relationships.
• Marriage and family therapists understand their influential position and avoid relationships likely to exploit client trust/dependence or impair professional judgment.

ACA on Dual/Multiple Relationships

• Counselors weigh the risks/benefits of accepting prior relationship clients, including casual, distant, or past relationships.
• Examples involve mutual or past membership in professional associations/organizations/communities.
• When accepting such clients, counselors take precautions like informed consent, consultation, supervision, and documentation to ensure judgment isn't impaired and exploitation doesn't occur.

Dual Relationships

• Not always unethical.
• Dual relationships remain a possibility, as sometimes the roles of the therapist and community member can overlap.
• Ethics codes require assessment for:
  • Impairment of judgment/objectivity
  • Potential harm or client exploitation
• Dual relationships are an ethical issue that create potential for legal issues.

Possible Examples of Dual Relationships

• Small or rural communities may have limited or a single serving therapist.
• Clients may find it difficult or impossible to access the services they require because therapeutic services could be hundreds of miles distant
• Therapist and client may be involved in the same community activities, cultural or religious gatherings, or in similar educational settings.
• Referrals by your clients to future clients can cause dual relationships

Ethics Codes Review

• Ethics codes address various multiple relationships, including:
  • Unethical relationships (CAMFT 4.3, ACA A.6, & A.6.e)
  • Social relationships (CAMFT 4.4, ACA A.6.b)
  • Sexual relationships (CAMFT 4.5 & 4.6, ACA 5, A.5.a, A.5.b, A.5.c)
  • Non-therapist roles (CAMFT 4.8, ACA A.6.d)

Therapist Responsibilities

• Ethics codes state that therapists must assess the following when considering dual relationships or boundary extensions:
  • Relationship nature
  • Possible boundary violations
  • Possible exploitation
  • Documenting your decision

Social Relationships

• Post-therapy relationships aren't automatically illegal or unethical.
• Some considerations include:
  • If clients are always clients, is a social relationship wise/ If a client may return to therapy later.
  • What are the therapist's motivations to have a social relationship with a client?

Risks for Therapists who See Clients as Friends

• They may not challenge clients sufficiently.
• They may lose objectivity.
• They risk exploiting clients because of power differentials.

Sexual Misconduct

• It is a board requirement for the therapist to provide "Professional Therapy Never Includes Sex" to any client that reports any type of sexual relationship/contact with a pervious therapist.
• Failure to supply the brochure is punishable by the BBS with a minimum of one year probation.

Different Types of Sexual Misconduct

• Sexual contact with a client/former client
• Committing an act with a minor that is punishable as a sexual offense, regardless of whether it occurred prior to becoming a registrant/licensee.
• Committing an act punishable as a sexually related crime
• Sexual misconduct

Disciplinary Process

• Complaint
• Investigation
• Hearing
• Resolution

Sexual Contact

• Codes don't limit the types of sexual contact forbidden between therapist and client.
• Therapists are advised to avoid sexual contact with clients' family and friends.

Safe Guards for Avoiding Dual Relationships

• Provide informed Consent
• Performing a relationship evaluation
• Establish clear boundaries for yourself and the client.
• Pay close attention to confidentiality.
• Consult and document

Bartering

• Involves exchanging goods or services for therapy fees.
• Should be openly and honestly discussed.
• Requires a clear understanding and mutual agreement.
• Dignity, culture, and the client's ability to pay for services needs to be taken into account.
• It's important to always be focused on the client’s best interest.
• Consult other professionals.
• Document everything.

CAMFT on Bartering

• Marriage and family therapists usually refrain from accepting products or services from clients or patients in return for services rendered because of the possibility of conflicts, exploitation, and/or distortion of the professional relationship.
• Bartering should only be considered and carried out if the client or patient requests it, if the bartering is not otherwise exploitive or harmful to the therapeutic relationship, and if it is negotiated without coercion.
• Marriage and family therapists are responsible for ensuring that such arrangements are not exploitive and that a clear written agreement is created.
• Marriage and family therapists are encouraged to consider relevant social and/or cultural implications of bartering, including whether it is an accepted practice among professionals in the community.

ACA on Bartering

• Counselors may only barter if it does not result in exploitation or harm, and if it is requested by the client, and if such arrangements are an accepted practice among professionals in the community.
• Counselors consider the cultural implications of bartering and discuss relevant concerns with clients and document such agreements in a clear written contract.

Considerations for Bartering

• Therapist needs to make sure that any arrangement must be in the client’s best interest.
• Any bartering should be reasonable and equitable.
• Arrangements should not prevent the therapist from delivering a quality service.
• Potential risks associated with bartering arrangements should be discussed.

Gifts

• They can be an expression of many things in the therapeutic relationship (appreciation, transferences, etc.).
• The meaning of the gift must be explored.
  • The monetary value
  • Implications for accepting/rejecting
  • When is this happening in the process?
  • Therapist motivations for accepting/rejecting
  • Cultural implications

CAMFT on Gifts

• Marriage and family therapists carefully consider the clinical and cultural implications of giving and receiving gifts or tokens of appreciation.
• Marriage and family therapists consider the value of the gift, the effect on the therapeutic relationship, and the client/patient and the psychotherapist's motivation for giving, receiving, or declining the gift.

ACA on Gifts

• Counselors understand the problems caused by accepting gifts from clients and recognize that gifts can be a token of respect and gratitude in certain cultures.
• In consideration of whether to accept a gift, counselors take into consideration the therapeutic relationship, the monetary value of the gift, the client’s motivation for giving the gift, and the counselor’s motivation for wanting to accept or decline the gift.

Ethical issues in "Stutz"

• Jonah Hill creates a documentary-style movie to honor his psychiatrist Phil Stutz.
• Jonah Hill admits he had to lie about the progress of the film,.
• During the film, Stutz makes a sexualized comment about Jonah's mother, as they prepare to have a family session.
• Stutz reveals his own theories of pain, resilience, and grief journeys.
• Jonah and Stutz exchange "I love you".

Ethical issues for Sybil and Dr. Wilbur

• Sybil begins therapy with Dr. Wilbur to address past traumas.
• Sybil craves attention.
• Dr. Wilbur begins to believe that Sybil has Multiple Personality Disorder (MPD). Sybil presents to subsequent sessions with alters.
• Dr. Wilbur becomes fascinated by Sybil and increases the number of sessions conducted.
• Dr Wilbur gathers data to publish a book about MPD.
• Sybil says that she made up MPD in order to get more attention from Dr. Wilbur and Dr. Wilbur then dismisses this claim.
• Dr. Wilbur increases Sybil's sessions to 14-18 hours per week, because stopping their treatments would jeopardize his research.
• Dr. Wilbur begins buying Sybil food, clothing, and paying her rent in order to continue their work.
• Eventually the book gets released.
• Dr. Wilbur gains profits from the book and speaking engagements.