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This is a beginning to intermediate level course. Upon completion of this course, mental health professionals will be able to:
Authors’ Note: Almost all case scenarios presented in this course are adapted from actual incidents. We use improbable names throughout to enhance interest and ensure that identities of all parties are not discernible. It is not our intention to trivialize the seriousness of the issues. As part of our disguising process, we also randomly assign various professional designations, earned degrees and/or licensure status. Also, for ease of presentation, we use the term “therapist” throughout to refer to anyone delivering psychotherapy or counseling services to clients.
The materials in this course are based on current published ethical standards and the most accurate information available to the authors at the time of writing. Many ethical challenges arise based on highly variable and unpredictable contextual factors. This course material will equip clinicians to have a basic understanding of core ethical principles and standards related to the topics discussed and to ethical decision-making generally, but cannot cover every possible circumstance. When in doubt, we advise consultation with knowledgeable colleagues and/or professional association ethics committees.
One might assume that therapists found guilty of forming high-risk relationships with clients consist chiefly of poorly trained, obtuse, or psychopathic individuals. Amazingly, actual cases of serious infractions, from our personal experience serving on ethics committees, include more than one past president of a state psychological association, current and former members of state licensing boards, a professor at a major university who authored an article on professional ethics, and even the chair of a state psychological association ethics committee!
Although one can identify various types of high-risk therapists and situations, we must conclude that no one seems immune from temptation. Psychotherapeutic alliances have peculiar and significant features that require firm professional resolve and self-monitoring.
This course will offer examples of risky temptations and how to reflect on an appropriate response. But we start by offering the overarching concept underlying so many acts that result in unethical behavior: LACK OF SELF-AWARENESS. We have found that most cases we have adjudicated which resulted in an ethical violation were not due to the therapist not knowing better. Instead, they allowed rationalization, denials, and unbridled emotions to determine their actions.
We start with a list of “red flags” that signal a potential situation for risk-taking. It is important to note that not all red flags are unethical indicators in and of themselves. Nor does their existence automatically result in poor decision-making with regrettable results. Indeed, many are normal human reactions. But once a matter that signals potential risk becomes apparent, careful consideration of any necessary accommodations in one’s next steps are imperative. This assessment requires clear-minded self-awareness that can readily constrain incentives such as “What’s in it for me?” rather than, “What’s best for the client?” (Mulder, Rink, & Jordan, 2020).
The groupings below were originally adapted from Epstein and Simon (1990); Koocher and Keith-Spiegel (2016); Pope, Sonne, and Greene (2006); Pope and Vasquez (2011); and Walker and Clark (1999) and appear in Keith-Spiegel’s Red Flags in Psychotherapy: Stories of Ethics Complaints and Resolutions (2014).
This list is a mere skeleton. Memorizing the bones, however, is hardly a fool-proof method for avoiding potential traps. The material that follows, most of which are true incidents adapted from our case files, put meat on the bones by describing how some of these red flags can actually play out without early-on awareness of possible consequences.
Consider these examples:
How would you have responded to each scenario? And how did these real-life cases turn out?
The first incident represents the most frequently reported risky temptation. Therapists become dissatisfied with their personal lives and their professional self-awareness wanes. Along comes an attractive client who appears to hold out the prospect for removing (or at least masking) the therapist’s personal misery. In the actual case, a brief affair soon ensued and proved unsatisfactory to both parties. The therapist did not prove to be the amazing lover as the client had fantasized. The therapist attempted to blame the client after the client pressed charges, by saying “I learned the hard way why this client needed psychotherapy.” The therapist lost his license to practice.
That a therapist would be upset by a negative review, as illustrated in the second scenario, seems understandable. The therapist felt obligated to defend herself and did not also include the client’s last name. However, the client pressed ethics charges, claiming that he was publicly diagnosed, which caused him mental anguish because several of his friends knew he was consulting with this therapist. An ethics committee did find the therapist guilty of poor professional judgment and censured him.
The third scenario illustrates one of those situations that can so easily be perceived as a “great deal.” The two already experienced how well they worked together. However, the actual case resulted in calamity. The therapist invested more than he could afford in the client’s business and found the client to be a castigating and controlling boss. When the therapist said he wanted out and a return of his investment the client refused, noting that they had signed a valid contract. The client also spread the word around town that the “pushy therapist forced his way into my business.”
The fourth scenario seems more innocent, but the outcome in the actual case resulted in a sustained ethics charge of client exploitation. The therapist did purchase several items at the greatly reduced price from the new client’s boutique. Nevertheless, the therapeutic alliance did not progress smoothly. The client became increasingly defensive and resistant to the therapist’s advice, eventually stalking out and leaving an unpaid bill for three sessions. When the therapist attempted to be paid using a collection agency, the client pressed an ethics complaint charging that the therapist was only after her money and her merchandise.
The fifth scenario has a couple of unusual features in that the counselor did not know much about the client because the group focused solely on test-taking anxiety as opposed to the more sensitive issues that arise in individual psychotherapy. Yet, agreeing to meet in a very cozy setting with someone who had come for help, even in a carefully circumscribed way, always holds the potential of putting the therapist in an unexpected position. Once there, and after a few drinks, the therapist was totally unprepared for the client’s bold sexual advance. The therapist rejected it outright. “Know your client before crossing any professional boundaries” is a theme that will recur several times in this course. The client felt humiliated by the therapist’s rejection and later attempted to press ethics charges against the therapist for “getting him drunk.” The charge was not sustained, but the therapist had to endure a difficult inquiry by his peers, and his once-prized student turned against the therapist and was, himself, unnecessarily harmed. Had only the therapist paused to reflect and graciously refused the original invitation.
This course will focus on the pitfalls of giving in to a selection of risky temptations that can sneak up on therapists who are not paying sufficient attention to their professional responsibilities and management of their personal needs. We will illustrate the fallout from therapists giving in to their own vulnerabilities, failing to moderate their own needs or other personal issues, acting impulsively, rationalizing their actions as acceptable, overrating their competencies, crossing over a line after several seemingly innocent baby steps, or simply being caught off guard and failing to make an appropriate corrective decision. Most of these behaviors involve sexual, financial, or authority issues – the very same interpersonal issues that get people into trouble outside of our professional offices.
As we saw in one of the opening scenarios, all business partnerships are vulnerable to interpersonal conflict and financial risk. In the context of that potentiality, it seems surprising that mental health professionals have willfully undertaken risky business associations with their clients. There is no such thing as “strictly business” when one of the partners has a fiduciary duty to uphold the trust and ensure the personal welfare of the other. Other similar ventures that have gone awry illustrate the damage done to both therapists and their clients:
Leona Digital had been a client of Teki Grabbit, Psy.D., for almost two years. Dr. Grabbit was in awe of Digital’s astounding computer skills. During one session, Digital disclosed his aspiration to start a computer troubleshooting business. His plan was to cater to technically challenged people who needed help with their computer set-ups as no other such service existed in the immediate area. Grabbit encouraged Digital to pursue it and offered to serve as the business manager by doing the promotion and fielding appointments. She even volunteered to put up $5,000 of her own money to get the business off the ground. Unfortunately, things moved slowly and Digital did not always keep the business appointments that Grabbit arranged. Digital quit therapy because, as he later stated in his complaint to a state licensing board, “During our sessions, Dr. Grabbit focused almost exclusively on the business, demanded that I make certain changes that I didn’t feel comfortable with, and ignored the personal issues that I still needed to deal with. When I told her that I resented having to pay her to talk about the business, she said, ‘You owe it to me.’”
“You and I would make a great team,” declared cosmetic surgeon Marcel Sculpt, M.D., to his counselor Barbie Dip, L.M.H.C. “My patients often need counseling, and some of your clients may be interested in my services. We could share an office suite and call ourselves something like ‘Beautiful Inside and Out.’” Ms. Dip, whose client caseload was flagging, thought the idea a bit wacky. However, the more she considered the potential benefits, the more attracted she became. Dip did insist that Sculpt continue his therapy with someone else, figuring this would defuse any mixed role issues. However, the expected counseling clientele did not materialize, and Ms. Dip’s share of the lavish office expenses proved to be far more than she could afford. Her relationship with Sculpt soured, and, when they argued, she brought up content from his past counseling sessions to use against him. The partnership dissolved, leaving Ms. Dip deeply in debt. Dip blamed Sculpt for cajoling her into such a ridiculous venture and considered suing him.
No rational person goes into business unless the prospect of profiting in some way seems likely, which puts immediate and complicating expectations and pressures on a client with whom a secondary relationship role supplants a previous role. Greed played a large role in both Grabbit's and Dip’s cases, even though neither would likely admit it. They became entangled in business dealings to the detriment of their clients’ needs and ultimately to their own welfare. Each one should have reasonably foreseen that these deals could impair their objectivity and judgment. Grabbit ultimately did lose her entire investment and received a formal admonition from the licensing board.
Sculpt did complain to a licensing board about Dip’s using information shared in confidence against him. Ms. Dip believed that because Sculpt instigated the “Beautiful Inside and Out” partnership, and because she terminated the therapy with him, she had no responsibility for what ultimately transpired, but she should have foreseen potential hitches in such a plan. Terminating a client for the purpose of going into business constitutes unacceptable professional practice, even if Dip did assist Sculpt in finding a new therapist. Bringing up therapy during an argument is unjustifiable no matter how difficult the ex-client might be. If Dip files a complaint against Sculpt, she will find the tables turning on her.
The workplace breeds multiple role relationships. Many prove positive and enhance the quality of our lives. Employees and their supervisors are often friendly, care about each other's welfare, and attend some of the same social events. The workplace can also be rife with landmines – gossip, conflicts, incivility, competition for promotions and resources, and difficult co-workers – all of which contribute to the potential for volatility. Therefore, mental health professionals must remain vigilant to this ever-changing environment and should avoid, if at all possible, complicating it by willfully providing their services to those they work with. Employees almost always have reasonable external alternatives for needed psychotherapy or counseling.
Jan Excel worked as a records clerk for a community mental health agency. Helmut Honcho, Ph.D,. supervised her work. When Ms. Excel experienced some personal problems, she asked Dr. Honcho if he would counsel her. He agreed. Ms. Excel later issued an ethics complaint against Honcho, charging him with blocking her promotion based on assessments of her as a client instead of on her performance as an employee.
It may prove impossible to unravel the true basis for any job-related decision in such situations. Whether valid or not, Ms. Excel can always interpret any unpleasant reactions to what happens on the job as linked to the therapy, or vice-versa.
When a client is also an employee, the consequences of a multiple-role relationship gone awry can be especially devastating because of the potentially adverse career and economic ramifications for the client and sometimes for the employer if a complaint is sustained. In addition, some laws that apply in workplace relationships can complicate psychotherapeutic relationships. For example, clients can become unhappy with their therapists based on comments made by the therapist with legitimate therapeutic intent or due to a negative transference (i.e., developing negative emotions toward one’s therapist based on prior relationships with family members). If this happened in treatment with Dr. Honcho, Ms. Excel might decide she faces a “hostile work environment” and consider filing a complaint with the EEOC (Equal Employment Opportunity Commission).
Therapy clients who possess special skills may lead to the temptation to consider what these clients might have to offer as an employee. Moreover, many clients feel financially strapped in this difficult economy. Offering to employ them may seem like a good deed. However, as with business relationships, such alliances are fraught with risk that can obliterate the professional relationship and disperse additional emotional and financial debris in its wake.
Oscar Scatterbill, Ph.D., hired one of his clients, Thomas Clerk, as his personal secretary and bookkeeper. The relationship seemed to be working well until Clerk asked for a raise. Dr. Scatterbill refused, saying that Clerk already earned a good hourly wage. Clerk countered by reciting Scatterbill's monthly income and comparing it to his own. Dr. Scatterbill allegedly laughed, responding that a comparison between the two was ludicrous. An insulted Clerk quit his job as well as his therapy and wrote a disparaging Yelp review stating that Dr. Scatterbill had “ruined his life.”
Dr. Scatterbill should have known better than to employ an ongoing client, especially for such a responsible position that gave the client access to sensitive and confidential information. Different roles call for different protocols, and the roles of “therapist” and “boss'” often require opposing styles of interaction.
Client Click Shutter feared losing his new car because he was far behind in the payments. When Click offered to photograph the upcoming wedding of his counselor at a reduced price, Melvin Groom, L.M.F.T. agreed as a way of helping his client who suffered from a serious anxiety disorder. However, the bride found the photographs unacceptable (asserting that they made her “look old”) and insisted that Groom not pay Shutter. In the meantime, Shutter increased the agreed-upon price because the bride’s demands to photograph her from multiple angles caused him work and expense well beyond the original agreement. Groom paid for only for the originally negotiated fee. Shutter quit therapy, told everyone in town that Groom had married a witch, and successfully sued Groom in small claims court. Groom also suffered fallout at home.
That Shutter was saddled with payment on a car he could not afford was not a problem that was necessary for Groom to solve. Groom might have politely refused Shutter’s offer, noting that the couple had finalized their wedding plans. Even in situations where the task seems specific and time-limited, clear judgment must supersede giving in to what appears on the surface to be a reasonable arrangement.
Therapists who work in isolation, as compared to those in group practices or clinic/hospital settings, may find themselves more prone to look to clients to fulfill their own needs. Although we know of no large-scale study, your authors – who have served on several ethics committees, including that of the American Psychological Association – noticed that a disproportionate number of ethics charges were lodged against therapists practicing in relative isolation (e.g., working in a secluded office, an office building with no other practitioners close by, or a private home office). Most of these cases involved inappropriate and high-risk boundary violations.
Ivan Lonely, M.A. saw clients in a small office on an upper floor of a bank building. He admitted feeling cut off from collegial support when questioned by a licensing board regarding a teenage client whose condition deteriorated significantly under his care. The parents had charged Lonely with incompetence.
Perhaps, had Mr. Lonely worked in close contact with other mental health professionals, or was a member of a peer discussion group, he might have received sound ideas as to how best to proceed with this client. They may have persuaded him to refer the client to a more suitable colleague, thus avoiding harm to his client as well as to himself.
The increasing popularity of working out of one’s home is understandable from both convenience and financial standpoints. COVID-19 has caused some therapists with offices in the community to consider bringing clients to their homes, arguing that guidelines to prevent the spread are easier to follow. While not inherently inappropriate, even in normal times we do not advise conducting therapy or counseling in one’s home. For a good overview of issues related to “going it alone,” see Barnett and Corcoran (2018).
Chester Homebody, DSW did not anticipate the problems he would cause for his family by taking on Cling Blue in his remodeled garage home office. Blue was a depressed and needy client diagnosed as having a borderline personality disorder. After the first few sessions, Blue started showing up at the house almost every day, asking if he could help with the yard or walk the dog or play with Homebody’s children. Homebody’s wife felt extremely uncomfortable about Blue’s approaches to their children. Homebody’s attempts to gently dissuade Blue’s behavior resulted in only short-term compliance. He finally terminated Blue and told him he would have to get a restraining order if he ever came around again. Blue contacted a lawyer, which prolonged the ordeal for both client and therapist.
If one conducts therapy in a private home, the consulting room should have furnishings that mark it as a professional therapy office, with its own entrance. Some clients, however, may find receiving therapy anywhere in the therapist's home (even a dedicated home office) confusing, and their emotional status could become compromised by connotations attached to their therapist’s living conditions. Clients themselves may have strong views about the acceptability and comfort level of the setting in which therapy is conducted (Sinclair, 2020).
Some clients seen in private homes could even act out in frightening ways. We know of a case where a client’s boyfriend robbed the therapist’s home at gunpoint. Unless the home-office therapist has another location available to screen new clients for suitability, one cannot completely know in advance who will walk through the door.
In short, maintaining a professional office setting and easy access to colleagues establishes a solid professional identity that can preclude client confusion and avoid serious incidents.
Transparency is increasingly unavoidable for all people, leaving therapists facing the challenges of “small-world ethics” (Lannin & Scott, 2013). Those who fail to responsibly use new technologies and who blur professional and social boundaries can face embarrassment and other unwanted consequences (Devi, 2011; Gabbard, Roberts, Crisp-Han, et al., 2011). Many therapists “of a certain age” may deny the need to keep up with the rapid onset of technological advances. It is increasingly easy for “digital immigrants” (Zur & Zur, 2016) to feel overwhelmed and to rationalize that what they have always done is “good enough.” Whereas being technically savvy is not an ethical mandate, therapists cannot ignore the confidentially hazards that lurk on their smart phones, online, or “in the cloud.” If one feels unsure of how well your private communications and records are protected, engaging a consultant is highly recommended.
Keeping in mind that any e-mail message can be shared with anyone else may help avoid mishaps. Some of these blunders are of the therapist’s own making, even if they failed to perceive the consequences in advance.
Nathan Myopia, C.L.S.W., put the following on his Facebook page: “Having a bad day. My clients drive me nuts. Today was the worst because two of them I don’t really like.”
It did not take long in this small community for a client to hear of this post, and she made sure her friends knew how Myopia described his clients on social media. She also filed an ethics charge.
Whether a psychotherapist or counselor should maintain a Facebook, Instagram, or other publicly accessible social media page can be debated (Knox, Connelly, Rochlen, Clinton, Butler, & Lineback, 2020). But nothing is truly confidential, even when one restricts access to certain individuals. Mr. Myopia insulted his clients directly; however even if one’s Facebook commentary and photos are about oneself and seemingly “safe” topics and images, such disclosures can also be problematic.
Manny Stalk accessed his therapist’s (unrestricted) Facebook page and reviewed multiple photographs of the therapist’s new home. Stalk eventually located the address through the photos and unsettled the family by sitting in his car outside their home for an hour or more most evenings. The therapy alliance was destroyed, and the client faced legal consequences.
In the types of examples so far, the therapists could have been more protective of themselves by thinking before posting and minimizing access to their personal lives and opinions. Sometimes that is not possible, which creates an especially difficult challenge. Therapists can be blindsided by a negative online review that anyone can see, and such an assessment can result in the loss of potential business.
Online review sites allow clients to share experiences with their health providers, including counselors and therapists, with the public. Those who are justifiably aggrieved as well as the disgruntled can express themselves – often anonymously – with only a few restrictions on the content. Koocher and Keith-Spiegel (2016) offer examples of actual, shocking negative client reviews of therapists, leading us to wonder whether the therapist was really that bad or the client needed someone to blame. One can never tell.
An individual, going by the pseudonym “ghostwriter,” wrote the following on an online review site: “If you need psychotherapy, stay away from Fenster Snide, PhD. He does not listen to what you are trying to tell him, laughs at your problems, and is unprofessional in his billing practices. He charges way too much, and you get nothing for your money.”
A client wrote a negative comment about the “poor-quality” therapy he received from Upsetta Peeved, LCSW and posted it on Yelp along with awarding her one star. Ms. Peeved entered a scathing response about her ex-client’s personal issues, suggesting that the client was also delusional. The client wrote to an ethics committee claiming that Ms. Peeved violated his rights to confidentiality and made defamatory statements about his character.
Can such reviews be removed? It is more difficult than one might think. The First Amendment of our Constitution gives citizens considerable leeway in what they can say in public. Review sites such as Yelp contend that they are not in a position to judge the veracity of reviews posted on their sites and have statutory immunity. A review may be removed if they receive a court order to do so. That puts the therapist in an impossible situation – how can this statement be proven false and defaming? (Note: An effort by ex-President Trump to remove statutory immunity failed.)
A number of suggestions have been offered to help detract from bad reviews (See Kolmes, & Taube, 2019). These include bolstering your own profile on Yelp and other sites, creating more posts on Google to supersede a negative comment, apologizing to clients if identities can be ascertained (which seems appropriate given that the post authors do have the option of deleting their own reviews), and attracting more positive reviews from those with whom you have a non-confidential relationship. Asking clients to post positive reviews seems like the best fix but, of course, this creates new ethical problems (Lacroix, Dobson, & von Ranson 2018) and is therefore not advised.
The negative review problem is pervasive, resulting in several guides to assist professionals in managing their online reputations (e.g., Pho & Gay, 2013). The sad fact remains that people are drawn to critical reviews, and when other suitable therapists are available to those checking out their options, those with all positive reviews may get the call.
The obvious question is how to avoid bad reviews in the first place. After all, not everyone will be satisfied with their therapy, despite the competence and ethical sensitivity of their therapists. The best advice we can offer is to be extra sensitive to dissatisfied clients and attempt to work though their complaints, even if only to terminate on reasonably good terms.
We do not intend this course as a lesson on forensic mental health practice. Detailed ethical guidelines for forensic practitioners may be found elsewhere (APA, 2013). However, practitioners often step into difficulties when they unintentionally stumble or find themselves sucked into a role within the legal system. Such encounters with the legal system at some point in one’s career is practically inevitable (Bailey, 2013), and pose issues not only related to competence in the forensic arena but also to risky dual roles and confidentiality dilemmas (Connell, 2016; Ward and Rose, 2012). Consider the following examples.
Merilee Testing, Ph.D., undertook a learning disabilities assessment referral from a local school system. The 8-year-old child proved uncooperative, but his divorced mother commented, “He’s usually better behaved for his father. Can we schedule another appointment?” At the second appointment, the father brought in the boy and the child cooperated fully with the assessment procedures. In her report, Dr. Testing wrote a 12-page neuropsychological assessment report that included 18 recommendations for improving the child’s school performance. One of the recommendations dealt with the child’s frequent refusal to do homework. Dr. Testing suggested, “The child seems to attend to tasks better under his father’s influence, so perhaps the father should be involved in supervising more of the child’s homework.” Without consulting Dr. Testing, the father went to court arguing for more significant physical custody of his son based in part on her recommendation regarding homework. Dr. Testing vigorously asserted that she had not intended to make any recommendation about a change of custody, but after the mother complained, a state licensing board censured her for making a recommendation relative to such a change.
Wanda Wounded brought her four-year-old daughter, Wendy, to see Sara Sustenance, L.C.S.W., after noticing signs of emotional distress in the child. Ms. Sustenance suspected that Wendy might have been sexually abused based on some of the child’s comments. She reported her concerns to child protective services and an investigation led to criminal charges against an employee of the daycare program Wendy attended. Ms. Wounded kept Wendy in treatment with Ms. Sustenance who inquired about and pursued details of the events in question as a way to help Wendy “process the trauma and work it through,” even though Wendy had not raised it as a continuing issue. Later, at trial, Wendy’s testimony seemed far more detailed and serious than what she disclosed during her interview with child protective services. The defense attorney for the daycare employee accused Ms. Sustenance of witness-tampering by discussing and re-discussing the case with Wendy.
Carlos Danger, M.D., states expertise as a “trauma therapy expert.” Local attorneys frequently send their clients who have suffered automobile accidents, dog bites, and emotional distress in the workplace to Dr. Danger for treatment a few months ahead of filing lawsuits for civil damages. He invariably views such patients as deeply troubled and in need of long-term therapy for severe trauma. He often agrees to delay billing for his services until after the clients’ lawsuits are settled.
Each of these cases illustrates the potential incompatibility of therapeutic and investigative roles, particularly when legal issues may come into play. Whenever possible, the therapist needs to anticipate when a case may have legal implications and take care to avoid inadvertent or compromising role-shifting. This may require asking the question, “Who is the client?” and, “To whom do I owe professional responsibilities?”
Dr. Testing took on an assignment for a school system. It seemed a straight-forward learning disability assessment, but things went afoul when she failed to recognize that her recommendations might be used manipulatively by angry divorced parents, leaving her dragged into the legal system and facing a licensing board complaint. If she had known or recognized the custody contentiousness, she might have limited her recommendations to those aimed strictly at the classroom.
Ms. Sustenance may well believe that her treatment plan will benefit Wendy, but does this mean that she is free to proceed without considering the potential cost to Wendy and/or the accused? On one hand, this type of treatment could reduce Wendy’s credibility as she may be seen as having changed her story, and a guilty perpetrator may go free. On the other hand, it could mean that the defendant receives a more severe punishment than he otherwise might have gotten because of Wendy’s “enhanced” or more vivid post-therapy account of events and consequences.
Ms. Sustenance seems to have done the right thing in reporting suspected child abuse, and her wish to help her young client seems well-intentioned. However, a considerable body of literature addresses the biases that can influence therapists in ways that have the potential to alter children’s memories (Walker, 2002). When a criminal case is pending, conducting therapy with an alleged victim requires special sensitivity as described by Branaman and Gottlieb (2013).
Dr. Danger seems to be in the midst of several ethical role conflicts. Even if one assumes that his diagnoses and treatment plans are competent, he must recognize that his work will have forensic implications and that he should adhere to rigorous evidence-based assessment standards. He must also consider the expectations of clients and clarify them in advance. For example, suppose he treats a client and determines after a few sessions that no significant trauma damages exist. How will the client feel when his/her therapist fails to become their advocate at trial? This is one reason why therapists should always avoid agreeing to take on roles as forensic evaluators for their clients. In addition, by agreeing to defer billing until cases are settled, Dr. Danger recognizes that he has a role in the legal case, and at the same time seems blind to his financial interest in the outcome.
The practical message inherent in all such cases involves a role shift into the forensic arena. Attorneys seeking out the services of mental health professionals will generally have their own clients’ advocacy needs at the top of their agenda. Thus, practitioners should pause and enlist a consultation from a colleague skilled in forensic work whenever their role might involve a forensic facet or shift.
Touch is an intensely intimate, complex mode of communication that can convey support, consolation, empathy, caring, and sincere concern. Yet, touch has several faces. It can also signal sexuality, anxiety, aggression, and even fear. The relationship between the “toucher” and the “touchee,” and how each party experiences the other’s touch, can create complicated ethical dilemmas between client and therapist. The context in which touching occurs is also a significant factor in deciding its appropriateness or lack thereof (Bonitz, 2008; McGrane, 2019 Swade, 2020). According to Zur (2007), touch may be the most controversial of all boundary crossings, largely because both culturally and professionally touch, is associated with sex.
Historically, the “laying on of hands” has been an integral part of the healing process. Modern-day science has repeatedly demonstrated the calming and attendant physical benefits of supportive stroking (Reeve, Black, & Huang (2020). It would seem, then, that touching should be an integral procedure in mainstream psychotherapy. Touching clients, however, demands considerable caution, taking many factors into consideration, such as age, personal touch history, gender, therapeutic orientation, client presenting problem diagnosis and experience, culture and class, and context (Briggs, 2018; Celenza, 2011; Zur, 2007).
We have to consider that COVID-19 may preclude the problem of touch, not only in psychotherapy and counseling but in everyday life. It remains to be seen if handshakes will be replaced with other no-touch gestures. However, we will continue with the assumption that at some point touching will again be an acceptable form of human interaction in many circumstances.
When therapists have touched clients, the conditions most frequently listed as appropriate include expressions of emotional support and reassurance, as well as during the initial greeting or closing of sessions, what Westland (2011) refers to as “contactful touch.” Very brief non-erotic touching on the hand, back, and shoulders are the safest areas of touch while still conveying a caring, supportive message (Wilson, 1982).
Early surveys revealed that a majority of psychologists and psychiatrists never or rarely engaged in non-erotic touching (Holroyd & Brodsky, 1977; Kardener, Fuller, & Mensh, 1973). Subsequent surveys suggested that non-erotic touching of clients had begun to increase. Stake and Oliver (1991) reported reasonably high rates of touching of the shoulder, arm, and hand and hugging by both male and female therapists with both male and female clients. Average rates were highest for women therapists and their female clients and these touching behaviors were rarely viewed by the survey respondents as constituting misconduct. Similarly, the majority of respondents in a survey by Pope, Tabachnick, and Keith-Spiegel (1987) reported “sometimes” or “often” hugging clients or shaking their hands. The prevailing attitude seemed to be that both behaviors proved acceptable under most circumstances. Kissing clients on the lips or cheek occurred less often and would more likely qualify as inappropriate. Nevertheless, attitudes among professionals regarding attraction toward clients (along with flirting and harboring fantasies about clients) are far more variable (Martin, Godfrey, Meekums, et al., 2011).
There may be a return to greater caution regarding touching clients. Stenzel and Rupert (2004) found that 90% of their national survey sample never or only rarely touched clients. A handshake upon entering or exiting the session ranked as the most common tactile event. Successful lawsuits against therapists charged with sexually motivated touching and sexual harassment may have chilled any form of touching beyond traditional formalities.
At times, clients may unexpectedly initiate a desire for physical contact with their therapists and a decision to touch or not to touch must occur on the spot. Consider this dilemma, some version of which most therapists will face at some point:
Ivy Holdme, a divorced mother with custody of two difficult children experiencing serious troubles at school, had her car stolen the previous day. At the close of a dreary session, the mother said to the therapist, “I really need a great big hug.”
Although the nature of the already-established relationship will play a large role in the therapist's response, several questions will still come to mind. “Should I do it? Would it affect our therapeutic relationship? What kind of a hug should it be – short or long, tight or limp?” The therapist's level of comfort with touching and being touched will also come into play. Therapists who recognize their own physical attraction toward a client must exercise extra caution. If the client has already indicated clear signs of sexual attraction toward the therapist, engaging in any physical contact is ill-advised.
The following case illustrates how vastly differing perceptions of touch can lead to ethical charges.
Janet Demure complained to an ethics committee that her therapist, Pat Stroke, Psy.D., behaved in a sexually provocative manner which caused her considerable stress and embarrassment. He allegedly put his arm around her often, massaged her back and shoulders, and leered at her. Dr. Stroke felt shocked upon learning of the charges and vehemently denied any improper intentions. He claimed that he often put his hand briefly on his clients’ backs and patted or moved his hand with the intention of communicating warmth and acceptance. His customary constant eye contact was his way to communicate that clients had his full attention. He admitted that Demure seemed uneasy, but expected this would quickly pass as it did with others unaccustomed to expressions of caring.
Dr. Stroke’s training as a humanistically oriented practitioner disposed him toward non-erotic touching of clients (Durana, 1998). Regardless of therapeutic orientation, it is necessary to remain aware of individual clients’ special needs and issues, a sensitivity that may well require an alteration in one's usual demeanor. Cultural factors surrounding touching another must also be considered (Sommers-Flanagan, 2012).
Because touching issues may catch therapists completely off guard, wise practitioners will carefully consider these eventualities in advance. Not wanting to appear to be rejecting may overtake the moment, but a knee-jerk compliance with a request to hug or touch could have consequences, even if for only a small percentage of clients. For some clients, any form of touching under any circumstances can feel inappropriate.
Finally, we acknowledge that a “no touching policy” will not guide every situation. Deviations, however, should only occur when the following question can be answered in the affirmative – “If my colleagues knew what I had done, would they very likely agree that I served only the needs of my client?”
Based on surveys conducted over several decades, we feel confident in predicting that almost all therapists will face at some point in their careers eroticized stirrings in the context of executing professional responsibilities. The emergence of such feelings is a function of human nature; the way we manage those feelings lies at the heart of ethical professionalism. (See Barnett, 2014; Jacob & Prikhidko, 2020). Unfortunately, we don’t talk about it as much as we should in both training and professional discourse (Pope, Sonne, & Greene, 2006).
As with most typical human courtship rituals, sexual relationships between therapists and their clients often reveal similar progressive phases – feelings of attraction, mild flirtation, some friendly touching on “safe” body areas, a cup of coffee at the cafe across the street from the office, a switch in the client’s schedule to the last appointment of the day, hanging around afterward to talk about things in general, and hugging good-bye. Any sexual act often seems the culmination of a process occurring over time, starting with vague, uneasy feelings of excitement, but progressing in tidy, rationalized steps.
Feelings of sexual attraction toward a client requires neither physical expression nor disclosure. They can remain one's own little secret and may cause no real harm. So perhaps it surprised no one when the first published survey on sexual attraction in therapy discovered that therapists who reported they had never felt attracted to any of their clients fell in a distinct minority (Pope, Keith-Spiegel, & Tabachnick, 1986). Despite the high rates of attraction, however, a much lower percentage of psychologists (9.4% of the men and 2.5% of the women) reportedly allowed the attraction to escalate into sexual liaisons with their clients. Another survey (Rodolfa, Hall, Holms, et al., 1994) found that only 12% of their large sample of APA members reported never having felt attracted to a client, only a few had ever acted on these feelings, just less than half reported negative consequences, and more than half sought consultation. Pope and Tabachnick (1993) reported that almost half of the therapists responding to their national survey had experienced sexual arousal during a therapy session.
Under what conditions should feelings of attraction become cause for concern? How should one handle such feelings? If a therapist finds attraction occurring often, should one seek outside consultation? In an interview study with post-doctoral interns, most participants admitted to behaving in a more invested and attentive manner to those clients to which they felt attracted, but that the attraction also caused them to become more easily distracted and less objective (Ladany, O’Brien, Hill, et al., 1997). Because the therapy process may be compromised, it seems regrettable that only half of the sample in this study reported disclosing their feelings to their supervisors.
When therapists cannot bring their feelings under control or sense that they are having an adverse effect on how they treat their clients, and when consultation is sought but was ineffective, we recommend a sensitive termination and referral to protect all parties from complications, confusion, and harm. The therapist might say something like, “I would recommend that you work with someone more skilled than I am in addressing the issues of concern to you.”
Should one discuss such feelings with the client? Some have debated the issue, but after considering the available evidence, we do not recommend it. The client may not be able to deal with a frank admission of the therapist's attraction and may become confused, uncomfortable, and unclear about how to respond. In addition, such disclosure injects the therapist's own issues into the client's life in a way that constitutes poor professional practice. A client might perceive such revelations as harassing or even repulsive. Finally, the intrigued client may readily interpret the revelation as an invitation to follow the therapist's lead outside the office, which may not (and should not) be the therapist’s intent.
When professional vision becomes distorted, excuses to make moves that may later be deeply regretted seem to flow all too easily. We strongly advise therapists to discuss lingering feelings of attraction toward a client with someone, preferably another therapist, an experienced and trusted colleague, or an approachable supervisor.
Harboring sexually laden thoughts about their therapists is probably not uncommon among clients (Fabian, 2020). At first blush, client sexual attraction to therapists does not seem to belong in a high-risk category. However, as we shall illustrate, unless such client feelings are handled carefully, the result can be damaging to all concerned. That clients would be sexually attracted to their therapists comes as no surprise, given the emotionally intimate nature of counseling and psychotherapy (Lotterman, 2014). Rather than use the term transference, Parish and Eagle (2003) prefer the term “attachment” which manifests itself in clients perceiving therapists as emotionally responsive, admirable, a secure base, unique, and irreplaceable. Such powerful feelings can readily cause love – or something like it – to surface.
How should therapists respond to clients’ declarations of attraction? If a client openly and directly expresses erotic feelings, it is important to deal with these impulses in a way that both preserves professional boundaries and protects the client's self-esteem. Leaping into interpretations of unconscious issues may feel like the safe way to go, but could feel humiliating to the sincere client who has just who mustered up the courage to disclose their innermost feelings. A therapist's too-fast declaration that acting on any such feelings would be unethical and unprofessional may come across as an anxious overreaction. In addition, therapists must remember that when a client directly expresses erotic feelings, it does not necessarily mean that the client expects them to be acted upon. What the therapist interprets as seductive behavior could be, instead, an indicator of dependency.
We suggest that whenever a client makes any request or disclosure where reciprocation would be inappropriate, first ask that client how they see the fulfillment of the request as being helpful to him or her. Then, follow with a discussion about why granting the request would not be in their best interest. This way the focus remains solely on a caretaking orientation (Barstow, 2018). If a client becomes aggressively seductive, Gutheil and Gabbard (1992) suggest a more unyielding approach – tell the client that therapy is a “talking relationship,” and discuss why the client's behavior is inappropriate.
Rarely, a patient acting out exceptionally strong sexual or romantic interest may not be containable. This drastically limits the kinds of interventions available to that therapist (Ogden, 1999). In such circumstances, the best course of action is to refer the client to another therapist.
Edie Tsunami’s therapy with Tyler Engulfed, Ph.D., proceeded without incident for the first few sessions. Soon, however, Ms. Tsunami became belligerent, demanding that Engulfed hold her hand throughout the sessions and then wanting to sit on his lap during the entire therapy hour. She cried and flailed about uncontrollably whenever Engulfed attempted to get her back into a chair. The demands accelerated and became more bizarre, including insisting that Engulfed watch her masturbate and that he have sex with her to simulate a rape that she allegedly endured as a child.
Although the actual therapist on whom we base this case never engaged in sexual relations with his client, he endured a highly publicized licensing hearing resulting in sanctions for continuing to treat a client whose pathology fell well beyond his level of therapeutic competence.
Taking a client to dinner or for a drink at happy hour, or staying after hours in the office to chat while listening to music, do not qualify as “sexual intimacies.” Such activities, however, would, under normal circumstances, be a superimposition of inappropriate activities on a therapeutic relationship. Casual social excursions outside the office become especially risky because they typically involve more self-disclosure on the part of the therapist and other behaviors that could easily be perceived by clients or students as courtship/dating rituals. Even if therapists had no motivations beyond platonic pleasantries, clients could become confused.
Norman Breakup, L.M.F.T., felt lonely after a bitter divorce. He missed his teenage children and the companionship they provided. He began to single out several younger male and female clients on whom to shower extra attention, alternating among them for one-on-one experiences. Sometimes, he would sit and talk for up to three hours after a session. He often took them out to lunch and, sometimes, shopping afterward for gifts. Breakup felt shocked when one of the women complained to a licensing board that he “wined and then two-timed her.”
Whereas we may empathize with Mr. Breakup’s personal circumstances, he exercised extremely poor judgment in treating his clients as surrogate children. Using one's client base as a population of convenient intimacy is both unprofessional and unethical. The next case reveals a much more common scenario.
Simon Inchworm, Ph.D., felt attracted to Selma Receptive, his client of several months. Selma readily accepted what Inchworm believed at the time to be a professionally appropriate invitation to attend a lecture on eating disorders, given that Selma's sister had a history of anorexia nervosa. The lecture concluded at 5 P.M., so Inchworm invited Receptive to stop for a bite at a nearby deli. The next week, Dr. Inchworm accepted Receptive's gift of a book written by the speaker they had heard. The following week, Inchworm agreed to a reciprocal dinner at Receptive's place. Afterward, while enjoying a third glass of wine, they looked into each other’s eyes, embraced, kissed for a while, and retreated into the bedroom.
It does not take a rocket scientist to predict such an outcome. In this actual case, an affair persisted for a few weeks. In the meantime, “Dr. Inchworm” met someone else of more interest to him and terminated the affair. When “Ms. Receptive” became upset, he also terminated her therapy. The client sought and won a large damage award through a civil malpractice complaint.
We would note that these cautions differ from formal treatment or assessment activities conducted in real-world or simulated settings. Conducting therapeutic activities outside of a professional office can offer benefits in specific circumstances, such as desensitization or exposure techniques to treat certain phobias. However, such out-of-office therapeutic experiences require clear framing and client consent. The rapid advancement of computer-generated, augmented, and virtual reality simulations may ultimately eliminate the need for in vivo activities beyond the office walls (Anderson & Molloy, 2020).
Sexually exploitative therapists portrayed in films often seem dashing, debonair, and self-assured. These depictions hardly reflect the portrait emerging from the available information about real therapists who engage in sexual activity with their clients. Instead, we know that sexualized relationships with clients can not only cause substantial harm to the individuals but also to the relationships of those involved (Sonne, 2012).
Data about therapists who sexually exploit their clients lack the scientific rigor of a controlled experiment, yet available reports suggest that therapists who engage in sexual intimacies with clients have significant personal issues. These include general feelings of vulnerability; fear of intimacy; crises in their own personal sex, love, or family relationships; feelings of failure as professionals or as individuals; high needs for love or affection, positive regard, or power; poor impulse control; social isolation; overvaluation of their abilities to heal; isolation from peer support; sexual identity and other unresolved conflicts; depressive or bipolar disorders; and narcissistic, sadistic, and other character or predatory psychopathologies (Gabbard & Lester, 1995; Lamb, Salvatore, Catanzaro, & Moorman, 2003; Pope, 1990a; Solursh & Solursh, 1993). Offending therapists tend to excuse their behavior. They often work alone (Somer & Saadon, 1999). They often deny to themselves that their behavior has an adverse impact on clients (Holroyd & Bouhoutsos, 1985), and seem deficient in their ability to empathize (Regehr & Glancy, 2001). Most relationships apparently do not last long, and about half the time are later judged by the clients as not worth having (Lamb, Salvatore, Catanzaro, & Moorman, 2003).
Engaging in a sexual affair with a client is a frequent cause for disciplinary action. Sexual intimacies (usually implying intercourse but left open for other sexual physical acts) with ongoing therapy clients are forbidden in all current ethics codes issued by the primary mental health and counseling professional associations and can even lead to criminal prosecution for sexual assault in several states (Koocher & Keith-Spiegel, 2016).
Although data collection lacks the rigor demanded by traditional scientific methodology, available evidence confirms that sexual activity with clients will likely prove exploitative and harmful due to abuse of power, mishandling of the transference relationship, role confusion, and other factors. Ironically, therapists can suffer serious harm as well. The extent of the devastation – which can include loss of a job, license, spouse and family, financial security, and reputation – is typically far more pervasive and devastating than the fallout from committing most other types of ethical transgressions.
Although we may never know for sure, we suspect that intimate behavior with clients will decrease substantially so long as COVID-19 remains a public health menace. A reported downward trend already apparent in more recent self-report studies likely reflects a true shift and mirrors the influence of the absolute condemnation of sexual misconduct by the mental health professions. However, that same impact may also result in underreporting on surveys. Consumer complaints have increased, causing therapists to fear detection and litigation. Earlier, while professional communities mostly ignored the problem, clients may have felt too powerless to protest or, if they did complain, were discounted as delusional, subject to fantasy, and struggling with their transference neuroses.
Some clients may actively and knowingly contribute to the creation of a sexually tempting atmosphere. Those with borderline or histrionic personality disorders have been especially singled out as potentially seductive (Gutheil, 1989; Notman & Nadelson, 1994). In interviews by Somer and Saadon (1999), almost one quarter of clients who admitted to having sexual relations with their therapists also admitted that they initiated the first pass. Therapists, however, bear the responsibility to resist acting on their feelings of reciprocal attraction. Ethics committees and other hearing panels are unmoved when therapists whine that they are the ones who were lured and snared as defenseless victims of beguiling clients.
Hap Bowlover, Ph.D. wrote a letter in response to a state licensing board inquiry, insisting that he had become systematically “worn down by a client who showed up for therapy sessions wearing dresses with the neckline and the hem almost meeting and started flirting with me the minute she walked into my office.” He declared that she set a trap for him and that he was being used as a symbol for “all the men who had messed her up in the past.” He likened the client to a black widow spider and claimed to have contacted a lawyer for the purposes of suing her.
Such excuses are heard more often than you might think. Some commentators have expressed sympathy toward therapists, who, as Wright (1985) contended, find themselves enticed into lustful moments by unscrupulous clients seeking to exploit the vulnerability of therapists to their own economic advantage. Many clients who appear to encourage a sexual relationship with their therapists, however, may be repeating eroticized behaviors as learned remnants of sexual abuse from their childhoods. Such clients remain subject to re-victimization because they differ from others who may find the therapist sexy or develop an erotic transference (Kluft, 1989). Nevertheless, the bottom line remains – shifting blame or responsibility to the client, even if the client acts adeptly manipulative or seductive, never qualifies as an excuse for an incompetent and unprofessional response.
The available data on harm to clients do not represent all client-therapist sexual liaisons because they consist only of reported instances. The majority of disclosing clients assessed from these populations reported sex with therapists as damaging (e.g., Bates & Brodsky, 1989; Feldman-Summers, 1989; Pope 1990b, 2001; Pope & Vetter, 1991). Some clients may have viewed the experience as pleasurable at the time, but came to view it as exploitative later (Somer & Saadon, 1999).
While serving on ethics committees, we saw the manifestations of such feelings. The complainants typically expressed outrage, described the destructive impact on other relationships in their lives, expressed feelings of abandonment, exploitation, and hopelessness, questioned whether they could ever trust therapists or anyone else again, and often stated that charges were pressed chiefly to make sure that what happened to them would never happen to anyone else.
Although one can quibble about the quality of research and the generalizability of the findings, such debates obscure the basic point – sex with clients is unethical and lies far outside accepted standards of care. As Behnke (2006) observes, sexual involvement with clients renders psychotherapy impossible, and deriving this kind of gratification while conducting a fiduciary duty does not qualify as a legitimate professional service.
Should a therapist and a now ex-client feel “ethically free'” to commence a sexual relationship after therapy has concluded? Why should consenting adults in our democratic society not have the right to decide with whom they wish to consort? After all, client autonomy stands as a primary goal in therapy. On the other hand, do other potential perils lurk for an indefinite period after termination of the psychotherapy relationship?
Entering into sexual and even marital relationships with former clients is not that uncommon, at least according to earlier surveys. Taken together, available survey data indicate that between 3% and 10% of the respondents have sex with former clients (e.g., Borys & Pope, 1989; Lamb, Catanzaro, & Moorman, 2003; Lamb, Strand, Woodburn, et al., 1994; Pope, et al., 1987, as cited in Pope, 1993). Less than half of the psychologists in Akamatsu's (1988) survey judged sex with ex-clients as a serious ethical problem.
It took until the later years of the 20th century for professional associations to consider taking stands on these thorny questions, and, to date, their stands reveal some differences. All major professional mental health associations have mandated time lapses as part of their codes of ethics. They range from forever (American Psychiatric Association) to two to five years). Associations specifying a waiting period do offer considerations such as the client's current mental status and degree of autonomy, type of therapy, how termination occurred, time since termination, and what risks may still present themselves if a sexual relationship commenced.
Upon termination of four years of psychotherapy, Mattie Stringalong, Ph.D., suggested that she and Lenny Endure keep in touch. They started exchanging emails, spoke on the phone almost every week, and occasionally met for lunch. After 20 months, Dr. Stringalong informed Endure that their relationship could become sexual soon. They eventually married. Endure asked for a divorce a year later, also complaining to a state licensing board that Dr. Stringalong had been “lying in wait” so that she could get her hands on his substantial financial portfolio.
Here, the sexual activity occurred in the “correct” time frame, but the therapist kept an uninterrupted relationship afloat. Even if Dr. Stringalong was not guilty of plotting to gain financially, her active perpetuation of an emotionally charged relationship quickly after termination was unethical.
Does knowledge, on the part of the therapist or the client, that a post-termination sexual involvement is possible at some point, affect the service provided? Under what circumstances do post-termination sexual relationships result in harm? Are individuals able to exercise a truly autonomous choice to enter into sexual involvement with a former treating psychologist? (Behnke, 2004). Interviewees in a study by Shavit and Bucky (2004) agreed that the potential for harm resulting from sexual relationships with former clients is remarkably high.
We have doubts about the advisability of a “cool off” moratorium. Our main concern is that such stands on post-termination sex have the potential to alter the therapy relationship from the onset. If clients feel attracted to their therapists (a common occurrence) or therapists feel attracted to their clients (also common), and aspire to a different kind of relationship down the line, how likely are either clients or therapists to do or say anything that will put them in an unbecoming light during active therapy? Would what transpired during sessions constitute psychotherapy, or primarily a long-term investment in a potential future relationship?
We must also note that a therapist’s professional responsibilities do not conclude at termination. Continuing client rights to privacy, confidentiality, and privilege remain unaffected by therapy termination. The possibility of a subpoena of records and resulting court appearances also exists. As a result, clients could find themselves severely disadvantaged should they have need of professional services from a therapist who has become a lover (or ex-lover). Therapists need to remain responsible for any continuing duties and carry them out free from any conflict and role-confusion that sexual relationships impose.
Little has appeared in print specifically about sexual involvement by therapists with the sisters, brothers, guardians, adult children, parents, or close friends of ongoing psychotherapy clients. Most current ethics codes disallow members from entering into therapy with such known persons and forbid using termination of therapy as a way to circumvent compliance.
A client abruptly terminated therapy and complained to the state licensing board upon learning that Rob Cradle, Psy.D., has “slept with my baby girl.” Although the daughter was 25 years old, the parent-client felt betrayed by Dr. Cradle. The client assumed that Cradle had shared everything she'd said in therapy with her daughter, and maybe they even shared laughs at her expense after they made love.
In this case, the therapist knew at the onset of the romantic relationship that his current lover was the daughter of an active client. He erroneously reasoned that because the daughter did not have client status and because the two were consenting adults, no ethical obligation pertained. However, it should have been obvious to Dr. Cradle that the ethical edict admonishing therapists to refrain from entering any relationship if it appears that it could impair objectivity or interfere with effective therapy performance clearly applied to this situation.
Wadya Wannado, Ph.D., a clinical child psychologist, treated Billy Boyster on an outpatient basis. Billy, age 7, showed signs of an adjustment disorder in reaction to his parents' deteriorating marriage. Dr. Wannado saw Billy individually on a weekly basis for several months and met jointly and individually with his parents on three or four occasions to help them deal with Billy's problems. Soon after Billy's therapy was terminated, the relationship with Billy's mother became sexually intimate. The father filed a complaint against Dr. Wannado, who responded that she had done nothing wrong because she was no longer treating Billy and the mother was never a client.
When the client is a child, it becomes therapeutically and ethically critical to consider the family as the unit of treatment. Although Dr. Wannado's clinical attention focused on Billy, the parents had legally contracted with her for professional services. In addition, meeting with the parents in any professional capacity constitutes a therapist-client relationship. Dr. Wannado owes ethical obligations to Billy and to both parents equally.
The fact that Dr. Wannado had ended treatment with Billy does not end her professional obligations to the boy. Even after divorce, children harbor fantasies of parental reunion. Most likely, Billy will feel ambivalent, if not outright betrayed, by the invasion of the therapist into the relationship between his parents. Dr. Wannado's conduct is particularly reprehensible as it intrudes adversely into the relationships of three people undergoing a difficult transition, all of whom were owed duties of care. Slovenko (2006) notes that clients may even have a malpractice cause of action against a therapist for "undue familiarity" and infliction of mental distress in the event of sexual involvement with a member of the client’s family.
Most mental health professionals have the capacity to sustain appropriate professional boundaries upon which both client and therapist can always depend. Creating that safe place is the primary reason for keeping appropriate boundaries with one’s clients. However, sliding down a “slippery slope” is not always recognized until it is too late. Coupled with areas of dissatisfaction in one’s own life and rationalizations that excuse engaging in exceptions to what the violator usually knows to be competent practice, it is sad to note that some who have an otherwise solid track record of exemplary work end up losing everything.
Turmoil caused by the COVID-19 pandemic and political polarization have presented several risky conditions and challenges for those delivering therapy services (McBeath, du Plock, & Bager-Charleson, 2020). Interestingly, other temptations are rendered improbable. We’ve already pointed these out as related to touching and sexual involvement with clients.
Victims of the pandemic are not confined to those who contract the virus. The stress and depression caused by fear, isolation, and economic loss greatly increases the need for mental health services. The pandemic presents a major dilemma: Do we (1) accommodate safe face-to-face sessions, or (2) transition to teletherapy and its associated risks and challenges. We cannot provide a complete rundown of every consideration, but illustrate with a few examples.
Jina Housebound, M.A., suffers from COPD and offers her services from the small 9’ x 8’ room in her home rather than in the busy office complex in which she leases an office. She removes the bed and sets up a small desk and two chairs. She figures that if masks are worn and she wipes down the client’s chair after every visit, her husband and four children will be safe.
Despite giving in to the desire to move from her office to her home, Ms. Housebound’s setup is not ideal, especially given her personal risk and five other family members. It would be better to set up an adequate telehealth operation in her home. However, other ethical issues apply to offering therapy remotely, as we will cover briefly.
To be as safe as possible, the ideal accommodations for any office would include Plexiglas shields, a disinfectant regime after each client, taking the client’s temperature upon entry, mask-wearing, and ideally, an open window. (See Abrams, 2020, for space renovation needs.)
Given the unfortunate number of those who downplay the seriousness of COVID-19, a client may pose a problem.
Yolan Safeface, PhD, is blindsided by his emotionally fragile client, Karen AntiVaxxer, who arrives without a mask. When Safeface offers her one, she refuses, insisting that masks are unsafe. Dr. Safeface has worked with this client for almost a year and does not want to lose her. He decides to ask politely again, noting that he is diabetic. Antivaxxer still refuses, adding, “Don’t be silly. This isn’t any worse than a bad flu season.”
Dr. Safeface has a decision to make. Can he afford to put himself in potential peril to retain a rogue client?
The consequences of deep political splits currently upending our country can also seep into therapy sessions.
Adam Humanist, Ph.D., dreads client Q. Proudboy’s hateful ramblings about “a stolen election by fraud committed by Jews and Blacks.” During what would be their last session, Humanist calls Proudboy a “human stain who is his own worst enemy.”
Pushing back on disliked clients is rarely ethically defensible. However, therapists should not continue to treat clients who they dislike or disapprove of if their objectivity is compromised. Dr. Humanist might consider suggesting that he is not the best therapist to treat this client and gently terminate him.
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