Fluent Essays

Consider this scenario: You receive a hotline call at your mental health agency from a client requesting a same-day appointment. You are the only social worker available to work with clients at the time, as your coworker is out of town on vacation for 10 days. A 15-year-old boy struggling with depression (no suicidal ideation) and addiction calls asking for help. While you are gathering information over the phone, you realize that he happens to be the son of a friend. Do you continue the process, planning on providing him with services, or do you refer him to another mental health clinic that is over 30 miles away? Do you make him wait until your coworker returns? Do you contact his parents and tell them he called? In certain geographical areas there may be limited resources and in turn a lack of opportunities for clients to obtain assistance. In some rural or otherwise isolated areas there might be situations that make it difficult to maintain ideal boundaries due to dual-role relationships. Dual-role relationships exist when a professional fills multiple roles at the same time, a situation that may be unavoidable in certain circumstances. Understanding the significant impact of a dual-role relationship with a client is important in order to avoid harming the client. Further, recognizing the impact on the client and the relationship will assist in the creation of strong professional boundaries. In these situations, a social worker might feel his or her ability to maintain these boundaries is compromised or may even experience a value dilemma due to the existence of dual-role relationships. Consider the importance of boundaries in a therapeutic relationship. Think about ways a social worker might violate the NASW Code of Ethics as it pertains to dual-role relationships. Is there ever a situation in which dual-role relationships are acceptable, or even preferable? By Day 4 Post an explanation of how you might respond to the situation with the 15-year-old boy on the hotline. Include ways your decision may impact the client. Support your position with references to this week’s resources, professional experience, and additional research. How will you address a possible dual-role relationship? Dual Relations and Beyond: Understanding and Addressing Ethical Challenges for Rural Social Work Michael R. Daley, Ph.D. LCSW PIP, ACSW University of South Alabama [email protected] Sam Hickman, ACSW West Virginia Chapter of NASW [email protected] Journal of Social Work Values and Ethics, Volume 8, Number 1 (2011) Copyright 2011, White Hat Communications This text may be freely shared among individuals, but it may not be republished in any medium without express written consent from the authors and advance notification of White Hat Communications Note: An earlier version of this paper was published in the proceedings of the 33rd Annual National Institute on Social Work and Human Services in Rural Areas in Boise, ID as: Daley, M. R. and Hickman, S. (2009, July). Navigating the ethical landscape of rural practice. In Rodenheiser, R. W (Ed.) Proceedings form the 33 rd Annual National Institute on Social Work and Human Services in Rural Areas, (pp. 35-57). Boise, ID: Boise State University. Abstract Several authors have identified the special nature of ethical challenges faced by social workers who practice in rural areas. The authors discuss specific areas of ethical risk for rural social work such as dual relationships, confidentiality, anonymity & self-disclosure, and competence. Appropriate strategies for strengthening ethical practice and minimizing ethical risk are presented. 1. Introduction For many years social workers who practice in rural settings have been aware that a heightened sensitivity to some sections of NASW’s Code of Ethics (2008) is essential for maintaining ethical practice. Rural communities provide an environment in which the social worker is deeply involved in the community, professional expertise or supervision may not be present, individual social workers are widely known, confidentiality may be difficult to maintain, and relationships may be both complex and multiple (Burkemper, 2005; Daley and Avant 1999; Ginsberg, 1998; Ginsberg, 2005; Gumpert & Black, 2005; Miller, 1998; NASW, 2006). These ethical themes are also consistent with those raised by Green, (2003) with regard to rural social workers in Australia, and those identified for rural psychologists (Helbok, Marinelli, & Walls, 2006). The context of rural practice presents increased Journal of Social Work Values & Ethics, Vol. 8, No. 1, Spring 2011 http://www.socialworker.com/jswve mailto:[email protected] mailto:[email protected] ethical risks for rural social workers and requires advanced understanding of ethical responsibility and a need to strengthen and emphasize ethics training for rural practice (Daley & Doughty, 2006; NASW 2006). Although rural social workers have generally understood the importance of ethical risks they face for some time, increased attention has been paid to the ethics of rural practice since the early 1990s. Miller (1998) indicates that the 1993 revision to the NASW Code of Ethics that included principles on nonsexual dual relationships stimulated controversy because of the difficulty in avoiding these types of relationships in rural social work. The potential vulnerability and heightened risk for rural social workers that this revision highlighted mobilized the Rural Social Work Caucus to affect a change in the wording of the dual relationship standard in 1996 to better reflect the realities of rural practice. The social work profession’s experience with the Code of Ethics during the 1990’s generated an increased level of interest in ethical practices among rural social workers and has subsequently led to a growing body of literature on the subject. This article draws on the conceptual and empirical work that has been done on ethics for rural social workers over the last twelve years to review the major ethical issues that have been identified and suggest some strategies that may be used to strengthen ethical practice. Indeed the purpose of this article is to provide a review of prior work that coalesces current thinking on rural social work ethics that may prove useful to rural social workers and social work educators alike. 2. Ethical Issues for Rural Practice The Code of Ethics of the National Association of Social Workers (2008) is generally the accepted standard for ethical conduct for professional social work. NASW has 150,000 members and is the largest social work organization in the world (NASW, n.d.). Each member of NASW is required to adhere to the Code of Ethics as a guide to professional conduct (NASW, 2008) and the Council on Social Work Education identifies this code as the basis for teaching values and ethics in social work curricula (CSWE, 2003). Furthermore, almost one-half of the states reference the Code in regulating social worker behavior through their licensing regulations (Morgan & Carvino, 2006) and though not directly referenced, many more state regulations are strongly influenced by the Code. The Code of Ethics identifies general principles that apply to social workers in all types of settings. While specific principles in this code appear to present special challenges in application for rural social work, there is general agreement that these challenges are not sufficient to define a separate code of ethics for practice in rural communities (Boisen & Bosh, 2005; Daley & Doughty, 2006). As Ginsberg (2005) indicates, “social work with rural populations and in rural areas is, ideally, simply good social work that reflects and considers the environment in which practice takes place.” It is in the reflection on and consideration of the rural environment that social workers need to be knowledgeable in order to maintain a high standard of practice. The growing body of literature on rural ethics has called for the profession to focus on this interface between the practice environment and the Code (Burkemper, 2005; Daley & Doughty, 2006; Strom- Journal of Social Work Values & Ethics, Vol. 8, No. 1, Spring 2011 http://www.socialworker.com/jswve Gottfried, 2005). Consequently, the specific areas of the Code that may prove more challenging for rural social workers are an important topic for further discussion. 3. Ethical Challenges: A Review of the Literature The early discussions about ethical challenges for rural social work focused around the difficulty in avoiding dual relationships. More recently consideration has been given to additional areas of the NASW Code of Ethics where practitioners in rural areas may face ethical risks. The following section outlines the areas of ethical concern most appropriate for the rural environment including dual relationships, poor practice and competence, confidentiality, anonymity and self disclosure, and colleague related issues. 4. Dual Relationships Undoubtedly, the dual relationship is an ethical principle that has received the greatest attention in rural social work (Boisen & Bosch, 2005; Burkemper, 2005; Daley & Doughty, 2006; Galambos, Watt, Anderson, & Danis, 2005; Galbreath, 2005; Green, 2003; Gumpert & Black, 2005; Miller, 1998; Strom-Gottfried, 2005; Watkins, 2004). Helbok, Marinelli, & Walls (2006) also identify multiple relationships as a potential area of concern for psychologists who practice in rural communities. Ethical issues of this type fall under the general category of boundary violations that include both sexual and non-sexual relationships between social workers and clients (Strom-Gottfried, 2000). But it is the non-sexual dual relationship that is the primary area of focus for boundary violations in the rural literature. Sexual relationships are a specific type of dual relationship that is generally considered separately from dual relationships, likely because of the strong prohibitions against sexual contact in the Code and the perception that there are no circumstances in rural social work in which sexual relationships could be appropriately managed. Dual relationships with clients are addressed in the Code of Ethics in sections 1.06 (a), 106 (b), and 106 (c) (NASW, 2008) and generally consist of social, family, or business relationships and exchanges in which there is potential for harm or exploitation of the client (Galbreath, 2005; Strom-Gottfried, 2000). Exchanges with clients involving barter also create the risk of exploitation and dual relationships (Strom-Gottfried, 2000) and are addressed in section 1.13 (b) of the Code (NASW, 2008). This is an appropriate area of concern for rural social work. In a study of ethical violations reported to a social work licensing agency in a large state, Daley and Doughty (2006) report that boundary violations for rural social workers are alleged in nineteen and one-half percent of the reports. Allegations of boundary violations ranked second only to poor practice in frequency, although reports of boundary violations for rural social workers were slightly lower than those for social workers in urban practice. Fifty- two percent of the boundary violations for rural practitioners were for dual relationships (Daley & Doughty, 2006). Examples of dual relationships include inviting clients to family or social functions like weddings or dinners. They also include transacting business with clients or their close relatives. Journal of Social Work Values & Ethics, Vol. 8, No. 1, Spring 2011 http://www.socialworker.com/jswve Relationships of this type may easily create confusion about the nature of the worker- client interaction and in which actions the social worker is fulfilling the professional role. When confusion about the professional relationship between worker and client occurs, there is increased potential for either harm or exploitation of the client. Bartering becomes problematic in the sense that it is often difficult to establish fair value in the exchange. It is much easier to assess good, fair, or bad value when the unit of exchange is monetary and the use of money is impersonal. Barter or a swap for tangible goods or services creates greater difficulties in either fair value or impersonality. Thus when barter is used, there is potential for exploitation and role confusion. While the Code of Ethics does not prohibit either dual relationships or barter, it does place full responsibility on the social worker to prevent harm to clients (NASW, 2008) and the real challenge for the social worker in rural practice is how to manage the dual relationships that may not be avoidable. Martinez-Brawley (2000) points out rural communities do not permit the distance to develop the impersonality that may be common to social work in urban areas, and Reamer (1998) uses small or rural communities as examples of contexts in which dual or multiple relationships may be difficult to avoid. Rural social workers must relate to others in the community in fairly close terms, thereby making it more difficult for rural social workers to avoid dual relationships, presenting challenges for maintaining ethical practice. 5. Poor Practice and Competence Poor practice and/or competence of social workers are ethical concerns for rural social work that have been raised in the literature by several authors (Burkemper, 2005; Croxton, Jayratne, & Mattison, 2002; Daley & Doughty 2006; Strom- Gottfried, 2005). Poor practice refers to failures in meeting accepted standards for clients in areas like evaluation of progress, appropriate use of supervision, and making appropriate referrals. Some may use different terminology and refer to this as a competence issue, but in a general sense, both poor practice and competence refer to either significant substandard performance by the social worker or lack of adequate preparation for the method used. Poor practice may be an especially significant area of ethical risk. Daley & Doughy (2006), in their study of reports of ethical violations, identify poor practice as the area of greatest difference between rural and urban social workers. In this study, poor practice comprised 27.1% of the ethical complaints against rural social workers. Strom-Gottfried (2000) also found that thirty-eight percent of the NASW ethics violations in her study were for poor practice, most frequently the failure to use accepted treatment methods. For example, behaviors included in this category were misapplication of self- determination or boundaries, using techniques inappropriate to the age or condition of the client, misusing skills by yelling at or using derogatory language with a client, inappropriate termination or transfer procedures including premature termination, lacking insight or empathy for the effects of worker behavior on the client, failure to make appropriate referrals or case transfers, prolong care beyond what was needed, and failure to seek consultation and informed consent (Strom- Gottfried, 2000). Journal of Social Work Values & Ethics, Vol. 8, No. 1, Spring 2011 http://www.socialworker.com/jswve Poor social work practice is not an ethical violation per se, but when methods are used that violate generally accepted standards of practice, that do not conform to methods used by the profession, and where social workers lack appropriate training in the method or do not use supervision when needed, ethical violations may result. These are particularly thorny issues for rural social workers. Burkemper (2005), Croxton, Jayratne, & Mattison (2002), and Ginsberg (1998) all point to the independence in practice, broadened responsibilities, and the difficulties in obtaining supervision and continuing education in rural social work. Daley & Avant (1999) add that the rural social work labor force tends to have higher percentages of BSW educated workers and fewer MSWs with advanced credentials than in urban settings. All of this may result in social workers who are placed in situations for which they are not adequately prepared and appropriate supervision is not available (Daley & Doughty, 2006). The difficult dilemma they then face is to provide what service they can or to provide none at all (Croxton, Jayratne, & Mattison, 2002). Given these circumstances, it is small wonder that the rural social worker is at greater ethical risk for poor practice issues. 6. Confidentiality Rural communities are often small communities with close relationships and exchanges between members. People and their cars are readily recognized, and their relationships and business tend to be widely known (Carlton-LaNey, Edwards, & Reid, 1999). In these circumstances it is often difficult to keep things confidential, as when a client is experiencing martial problems, dealing with a substance abuse problem (Ginsberg, 1998) or even something as trivial as where one went to lunch or with whom. Given the close and personal nature of interactions in small communities, it is not surprising that a number of authors have identified potential difficulties for rural social workers in maintaining client confidentiality (Burkemper, 2005; Daley & Doughty, 2006; Galambos, Watt, Anderson, & Danis, 2005; Green, 2003; Gumpert & Black, 2005; Strom-Gottfried, 2005). Helbok, Marinelli, & Walls (2006) also raise confidentiality as a concern for rural psychologists. Confidentiality is addressed in section 1.07 of the Code of Ethics, and maintaining confidentiality is a complex issue requiring sophisticated practice judgments by the social worker. The primary concern for rural social work appears to be how the professional maintains confidentiality in this challenging environment in a way that is viewed as appropriate by both the social work profession and the rural community. Daley and Doughty (2006) suggest that rural social workers may already be finding ways to manage confidentiality appropriately. In their study they found that ten percent of the ethics complaints against rural social workers were for confidentiality violations and that this percentage was only slightly higher than that for urban social workers. Other authors identify strategies that rural social workers may be using to manage confidentiality effectively. Burkemper (2005) and Strom-Gottfried (2005) indicate that the use of informed consent may help to reduce the risk of confidentiality violations in rural practice. Strom-Gottfried (2005) adds that explicit understandings with family and clients about how to manage information may also Journal of Social Work Values & Ethics, Vol. 8, No. 1, Spring 2011 http://www.socialworker.com/jswve help to minimize ethical risk. Gumpert and Black (2005) discuss the application of a culturally sensitive approach for rural practice as an alternative to a strict rule based interpretation of the Code of Ethics. The culturally sensitive approach that they found used by a significant percentage of the social workers in their survey involved the use of boundary crossing but not violations to effectively work with their clients and local agencies. One example of this is for the social worker to acknowledge information already existent through the community grape vine while not violating client confidentiality as way of establishing working relationships in the community and with community agencies. 7. Anonymity and Self-Disclosure Strom-Gottfried (2005) identifies the tension generated between maintaining the impersonal professional self and the need to gain acceptance within the rural community in order to be effective. Both Ginsberg (1998) and Martinez-Brawley (2000) explain this in terms of the need for rural social workers to adapt to the norms of personal relationships in the rural community to gain the necessary acceptance to practice effectively. In the rural community there is an expectation that social workers be known as people in order to fit in to the community, because formal professional credentials are not as readily accepted as in urban practice. Failure to become known personally may result in a perception that the rural social worker some how feels better or superior to others. Once community members view the social worker in this way, it is likely that the level of cooperation will be limited, possibly affecting the social worker’s effectiveness. Unfortunately, personal disclosure is a double edged-sword for the social worker. Revealing too much or the wrong kind of information may also reduce the social worker’s efficacy. For example, when the social worker is seen as too different from the norm or as having too many personal issues of her or his own, community members may question the professional’s ability to understand their needs or provide help. In addition, when rural social workers need to seek help for personal or family needs, or exhibits some personal weakness (Green, 2003) this is often widely known because of the lack of anonymity within the community. Knowing this, a rural social worker may be reluctant to seek the help that is needed in order to maintain an image of professional competency. The result may be a conflict with the ethical provision of the Code (section 4.05 (b)) that requires social workers to seek help when problems or difficulties interfere with their performance and judgment (NASW, 2008; Strom- Gottfried, 2005). Once again the primary issue is not so much that these ethical challenges exist, but how to manage these challenges. If the social worker is not open enough, it potentially raises issues with either competence (Code section 4.01) or misrepresentation (Code section 4.06). But when the social worker is too open with self-disclosure, this may raise the question of private conduct versus professional conduct (Code section 4.03) or affect the worker’s level of competence (Code section 4.01). Similarly, familiarity with those in the community may inhibit the social worker from seeking help for personal or family problems lest such help seeking be widely known. Yet there is a clear responsibility for social workers to seek help when personal problems interfere Journal of Social Work Values & Ethics, Vol. 8, No. 1, Spring 2011 http://www.socialworker.com/jswve with the performance of their professional duties. Clear identification of these ethical dilemmas, assessment of the relative risks, and prudent action to manage these ethical dilemmas are clearly an important part of the rural social worker’s repertoire. 8. Ethical Issues with Colleagues While the complex, multiple, and overlapping relationships between social workers and clients in the rural community is frequently discussed, relatively little attention has been paid to the effects that the same kinds of relationships have on ethical practice with professional colleagues. As Martinez-Brawley (2000) indicates, close and personal relationships are necessary for survival in the rural community, but these relationships create a potential for ethical conflict between professionals in working with clients. Green (2003, p. 217) also points out that because of the relationships that rural social workers have with other members of the community the ability to develop trusting and open relationships with their supervisors may be compromised. This may be due to the fact that in a close knit rural community the worker has friends or relatives who have other kinds of connections with the supervisor and this may affect the worker’s ability to discuss sensitive material openly. Provisions of the NASW Code of Ethics that address social workers’ ethical responsibility to colleagues and practice setting responsibilities are found in Sections 2 and 3 of the Code. These sections emphasize the ethical obligation of the social worker to act in a professionally responsible manner. The Code is not prescriptive in this regard as it contains few dos and don’ts and leaves considerable discretion to the social worker in managing potentially troublesome situations. For the social worker in rural practice, this presents numerous ethical challenges. For example, section 2.01 (b) of the Code indicates that unwarranted negative criticism of colleagues should be avoided. While this may sound relatively easy to do, the lack of social distance and an overlapping network of relationships in a rural environment present numerous avenues in which a communication about a colleague may reach her/him directly or indirectly. As a result, rural social workers must be exceedingly careful about what they communicate about a colleague and think through the networks and avenues through which information may travel in order to minimize potential problems. Similar issues arise regarding the maintaining of confidential information shared by colleagues particularly in the course of seeking peer consultation (Code section 2.02). Given how easy it is for information to get back to people, and the overlapping personal, professional, and social relationships in the rural community, social workers must also be judicious in managing confidential information from colleagues. Another area of concern for practice is section 2.11 of the Code. This section deals with the ethical obligation for social workers to address the ethical conduct of colleagues, seek resolution, provide assistance, and take appropriate action through formal channels (NASW, 2008). This aspect of ethical responsibility is an important aspect of the social work profession’s efforts to improve the quality of practice and regulate incompetent or unscrupulous individuals. However, in the close knit rural community, social workers Journal of Social Work Values & Ethics, Vol. 8, No. 1, Spring 2011 http://www.socialworker.com/jswve usually understand that complying with expected behavior regarding the unethical conduct of colleagues may carry unpleasant consequences. These consequences may range from being placed in the uncomfortable position of having to see or interact with the offending social worker at work or in other social settings on a regular basis to attempts at retaliation through the local community or ethical counter complaints for lack of proper professional respect. Awareness of possible repercussions can make the rural social worker pause to think, to be reluctant, or even to fail to act. Similar issues may arise in a rural community regarding social workers who have responsibility for evaluating the performance of others or who serve as administrators (sections 3.01 (d), 3.03 and 3.07 of the Code). Evaluations that are perceived in a less than positive light may be subject to negative reactions from subordinates that invoke community rather than agency networks. Administrators may be reluctant to advocate too hard for client groups or to push for additional resources for fear of angering powerful factions in the community. 9. Dodging the Ethical Traps and Strengthening Rural Practice There appears to be consensus that characteristics of the social and professional networks in a rural community can create special ethical challenges for the social worker (Daley & Doughty, 2006; Galbreath, 2005; Ginsberg, 2005; Martinez-Brawley, 2000; NASW, 2006). Multiple types of relationships and increased client contacts in arenas outside of work are examples of factors that may increase risk in rural practice (Boisen and Bosh, 2005). But as Daley and Doughty (2006) argue, rural social workers appear to be finding a way to handle many of these challenges at least as well as their urban counterparts. So what kind of framework and practical guidelines may the social worker employ to avoid the ethical minefields of work in the small community and strengthen the quality of practice? There are several frameworks for ethical decision making presented in the social work literature. Examples include models developed by Congress’s (1997); Dolgoff, Loewenberg, and Harrington (2005); Reamer, (2006); and Strom-Gottfried. All of these models present an ethical screening mechanism assessing benefits and risks for the social worker and the client in terms of professional service delivery. These models present questions and criteria useful to the social worker for evaluating ethical issues in the course of practice. For example Strom-Gottfried (2007) suggests asking questions like “Who will be helpful?, and “Why am I selecting a particular course of action?”, whereas Dolgoff, Loewenberg, and Harrington (2005) suggest “To what extent will alternative actions be efficient, effective, and ethical?” and “Which alternative action will result in your doing the least harm possible?” The important question to be raised is to what extent these models and even part of the Code of Ethics are relevant for the context of rural practice. We would argue that the Current NASW Code of Ethics is broad enough and the existing frameworks are sufficiently inclusive for effective use in the rural context. However, it is in the application of the Code of Ethics and ethical decision making models that the social worker needs to be especially attentive to provide Journal of Social Work Values & Ethics, Vol. 8, No. 1, Spring 2011 http://www.socialworker.com/jswve both appropriate and ethically based services. In their research Boisen and Bosch (2005) found that rural social workers were not using a separate code of ethics with respect to dual relationships, and Daley and Doughty (2006) found that rural social workers were managing ethical dilemmas at least as well as their urban counterparts. Both of these findings speak effective use of the current code by social workers in rural settings. This should not be interpreted as meaning that in social work ethics one size fits all, especially with regard to rural practice. Clearly, given the literature on the subject, there are higher risks in some areas of the Code for rural social workers. Rather, it appears that it is in an overall perspective for applying and interpreting the Code that rural social workers should be especially attentive. Gumpert and Black (2005) indicate that rural social workers appear more likely to use a relativistic or culturally sensitive, rather than a rule based approach in resolving ethical dilemmas. The culturally sensitive approach is similar to what Dolgoff, Loewenberg, and Harrington (2005, pp. 42) identified as ethical relativism in which ethical decisions are made based on either the context or the consequences that could result. Whereas the rule based approach is similar to the concept of ethical absolutism Dolgoff, Loewenberg, and Harrington (2005). The rule based approach tends to result in the social worker applying a stricter, more literal interpretation of the Code. A culturally sensitive or relativistic approach to ethics appears reasonable for rural practice because it allows the social worker to make ethical decisions within the context of the rural community, whereas the more conservative rule based approach may be much more limiting or even counterproductive. For example, … NAVIGATING DUAL RELATIONSHIPS IN RURAL COMMUNITIES Jennifer L. J. Gonyea and David W. Wright The University of Georgia Terri Earl-Kulkosky Fort Valley State University The literature examining dual relationships in rural communities is limited, and existing ethi- cal guidelines lack guidelines about how to navigate these complex relationships. This study uses grounded theory to explore rural therapists’ perceptions of dual relationship issues, the perceived impact of minority and/or religious affiliation on the likelihood of dual relation- ships, and the ways rural therapists handle inevitable dual relationship situations. All of the therapists who participated in the study practiced in small communities and encountered dual relationship situations with regularity. The overarching theme that emerged from the data was that of using professional judgment in engaging in the relationship, despite the fact that impairment of professional judgment is the main objection to dual relationships. This overall theme contained three areas where participants felt they most needed to use their judgment: the level of benefit or detriment to the client, the context, and the nature of the dual relation- ship. Surprisingly, supervision and/or consultation were not mentioned by the participants as strategies for handling dual relationships. The results of this study are compared with estab- lished ethical decision-making models, and implications for the ethical guidelines and appro- priate ethical training are suggested. The authors’ collective experiences of practicing in small communities led us to question how therapists in these communities handle the inevitability of dual relationships. As we discussed anecdotes from our respective practices, it became apparent that tension exists between a client’s desire to have a familiar therapist and the ethical standards of our field. We turned to the American Association for Marriage and Family Therapy (AAMFT) Code of Ethics for answers about how to navigate these delicate situations. Couple and family therapists are admonished to “make every effort to avoid [dual relationships] at all costs” (AAMFT, 2001; p. 1); however, no mention is made of how to accomplish this in settings with limited alternatives. The issue of dual relationships in areas with limited alternatives is complicated by clients’ attempts to self-match. Self-matching occurs when clients select a therapist who shares their atti- tudes, race, education, social class, and/or religion (Jones, Botsco & Gorman, 2003; Whalley & Hyland, 2009; Willging, Salvador & Kano, 2006; Wintersteen, Mesinger & Diamond, 2005). Cli- ents feel more comfortable discussing their lives and presenting issues when they believe their ther- apist holds the same values or shared cultural experience. A large percentage of Americans living in small communities may be able to achieve this owing to homogeneity in small communities, but not without creating ethical challenges for the therapist. The ethical challenges for rural therapists are compounded when they also belong to a minor- ity group. In addition to the limited number of available therapists in a small community, there are Jennifer L. J. Gonyea, PhD, is a Lecturer and Undergraduate Coordinator, Department of Child and Family Development, The University of Georgia and in practice at Samaritan Counseling Center of Northeast Georgia, Athens Georgia; David W. Wright, PhD, is an Associate Professor, Department of Child & Family Development, The University of Georgia, Athens, Georgia; Terri Earl-Kulkosky, PhD, is an Assistant Professor, Department of Behavioral Sciences, Fort Valley State University, Fort Valley, Georgia. This research was made possible through consultation with Edwin Risler, PhD (Athens, GA) and the Georgia Association for Marriage and Family Therapy Board and members. Address correspondence to Jennifer L. J. Gonyea, Department of Child and Family Development, The University of Georgia, Dawson 123, Athens, Georgia 30602; E-mail: [email protected] January 2014 JOURNAL OF MARITAL AND FAMILY THERAPY 125 Journal of Marital and Family Therapy doi: 10.1111/j.1752-0606.2012.00335.x January 2014, Vol. 40, No. 1, 125–136 far fewer minority therapists in general (AAMFT, 2004). Therefore, when minority clients attempt to self-match, there is a strong likelihood that a dual relationship dilemma will be encountered. Thisstudyaimstoexploreareasnotpreviouslyconsideredintheethicsliterature,payingparticu- lar attention to how therapists practicing in rural areas navigate these complex relationships. The next section provides the foundation for this study by reviewing the unique set of circumstances and community variables that increase the likelihood of dual relationships in rural areas and the ways existingethical decision-makingmodels fail to considerthe challengesof rural practice. CHALLENGES OF RURAL PRACTICE Rural communities are partially defined by their isolation that forces residents to rely more heavily upon one another. Smaller communities have increased potential for dual relationships, in general, and those between clients and therapists in particular (Erickson, 2001). Although the lack of boundaries may seem natural and is often used as fodder for sitcoms set in small communities, in real-life, it sets the stage for dual relationship dilemmas. For many residents, this closeness is positive and helps build identity and sense of belonging to that community in terms of Us versus Them. Therefore, residents of rural areas are often hesi- tant to seek services from an outsider (Murry, Heflinger, Suiter & Brody, 2011) because they are not to be trusted, which can lead to multiple levels of personal and professional relationships. Fur- ther, persons from rural areas may resent an outsider offering assistance (Erickson, 2001; Jesse, Dolbier & Blanchard, 2008). Similarly, those who belong to a religious community or a minority group may prefer profes- sional services from someone within their group or at least from someone who may share familiar values. Research has found that people want a therapist and they believe to be like themselves (Jones et al., 2003; Wintersteen et al., 2005) and when clients’ ethnicity matches that of their thera- pist, they attend more sessions and have a greater likelihood of treatment completion (Erdur, Rude & Baron, 2003). Competing Ethical Principles The absence of attention to how therapists in rural settings navigate potential dual relation- ships is compounded by the ambiguous and vague discussion of dual relationships in the AAMFT Code of Ethics, which states: Marriage and family therapists are aware of their influential positions with respect to clients, and they avoid exploiting the trust and dependency of such persons. Therapists, therefore, make every effort to avoid conditions and multiple relationships with clients that could impair professional judgment or increase the risk of exploitation (American Association for Marriage & Family Therapy, 2001; p. 1). If one’s interpretation of the code is that when multiple relationship situations arise, MFTs should ensure that these relationships do not impair professional judgment or increase the risk of client exploitation, then the dilemma is not “how to avoid dual relationships,” but “how does one tell when multiple relationships will impair professional judgment” and “what is the obligation of the therapist in warning or explaining the dilemma to the client?” It quickly becomes clear that the real problem is how to address inevitable dual relationships, rather than how to avoid them. Some suggestions include openly discussing the inevitability and potential of out of session contacts between therapist and client (Faulkner & Faulkner, 1997) or having a preconceived plan to negotiate social contacts with clients and seek immediate consulta- tion if boundaries feel threatened (Jennings, 1992). Rural clinicians are likely to be professionally isolated, making it difficult to obtain supervi- sion or consultation. These clinicians may be secluded from the mainstream of their profession and may have limited colleagues from whom they can seek support, collaboration, or supervision. Rural therapists’ sense of isolation is also compounded by fewer opportunities for professional development, continuing education, and limited access to support services. These collegial issues also create a challenge to maintaining client confidentiality (Weigel & Baker, 2002). A client’s confidentiality can be compromised through the “grapevine” in small 126 JOURNAL OF MARITAL AND FAMILY THERAPY January 2014 communities when the client is seen leaving the therapist’s office, parked in front of it, or even while sitting in the waiting room. The few therapists in a rural area often have regular contact with one another, and informal conversations between providers can increase threats to client confidential- ity. Rural therapists rely on one another for professional development and resources. Withdrawing from such informal exchanges could alienate close colleagues and leave a rural therapist with even fewer resources. Rural therapists are left with the choice between increased threats to clients’ rights to privacy or alienation of a close colleague. Models of Ethical Decision-Making Many ethical decision-making models suggest the following for the resolution of ethical dilem- mas: (a) consulting the ethical guidelines of therapy professions; (b) seeking supervision or consul- tation with peers; (c) creating a pros and cons list to determine the possible consequences and/or alternative courses of action; or (d) some combination thereof (Corey, Corey & Callahan, 1998; Erickson, 2001; Forester-Miller & Davis, 1996; Smith & Smith, 2001; Steinman, Richardson & McEnroe, 1998; Tarvydas, 1998; Welfel, 1998). As noted previously, these guidelines may not pro- vide enlightenment because they are ambiguous and require interpretation, the very foundation of the original dilemma! Few existing models specifically refer to issues of power and maneuverability, that is, the roles and positions therapists take with clients. The professional guidelines assume therapists hold the position of power when interacting with clients. Yet, depending on the nature of the out-of-session contact, the client may occupy a powerful position in the relationship. In a unique acknowledg- ment of potential limitations to both sides of a dual relationship, Haas and Malouf (1995) suggest therapists ask themselves and their supervisors specific questions prior to engaging in a potential dual relationship. For example, how might engaging in the dual relationship inhibit clients’ ability to make autonomous decisions; how might the therapist acknowledge his or her privileged position in the relationship; will the dual relationship affect the therapist’s ability to intervene effectively and congruently. The suggested questions imply that the therapist is able to conceive a number of alternatives and have insight into multiple perspectives on the situation, yet the inability to do so when interacting with friends and relatives is precisely why dual relationships are discouraged. Most ethical decision-making models assume that therapists have equal access to professional resources across community types (rural compared to urban). In fact, models ignore the existence of barriers to obtaining supervision and consultation in rural areas even though the limited avail- ability of these in small communities has been well documented (Weigel & Baker, 2002). None of the models reviewed suggest alternatives to supervision or ways of navigating a dual relationship if, indeed, it is unavoidable. The potential consequences to seeking consultation with peers or feed- back from supervisors in rural communities are also not addressed in the ethical decision-making models reviewed for this study. Clearly, one model or set of ethical standards does not encompass all possible dual relation- ship dilemmas or all the factors contributing to it. Therefore, a more comprehensive exploration of the processes through which clinicians make ethical decisions is called for. To meet that goal, this study specifically examines (a) the ways rural therapists perceive dual relationships and the result- ing impact on clinical practice; (b) the strategies clinicians believe they employ to negotiate dual relationships; and (c) the perceived influence of minority or religious affiliation on dual relation- ship situations. METHOD Design of the Study This study used a naturalistic paradigm to explore the experiences of therapists in rural set- tings. Among Lincoln and Guba’s (1985) naturalistic paradigm axioms, several were relevant here: (a) realities are multiple, constructed, and holistic; (b) the knower and the known are inseparable; therefore, the participant and researcher influence one another; (c) generalization is only possible through the formulation of working hypotheses that are context and time specific; and (d) unlike traditional inquiry that is value-free, the naturalist paradigm states that inquiry is value-bound by the choice of the problem, theory, and context. January 2014 JOURNAL OF MARITAL AND FAMILY THERAPY 127 This study sought to explore how rural therapists interpreted the AAMFT ethical guidelines as they made decisions about whether to have dual relationships with the clients they served. Their experiences then constituted multiple realities and, while tied professionally to the ethical guide- lines, their interpretation of the guidelines allowed the therapist to construct their understanding and approaches to ethical dilemmas of dual relationships. This qualitative approach allowed for an emphasis on the participant’s view (Creswell, 1998) of their experience of dual relationships in rural areas and how they navigate such situations. Specifically, the present study questions how the experience of dual relationships decision-making is handled when the therapist’s professional supports are limited. Description of Participants and Selection Process Participants were Clinical and Associate members of an AAMFT Division in the Southeast practicing in rural areas. Rural areas were selected using the categories of urbanicity established by Bachtel (2004) at the county level: Urban, Suburban, Rural Growth, and Rural Decline. Approxi- mately, 50 members were in the pool of potential participants. Once the purposive sample was drawn from the current listing of active members of the Divi- sion, participants were contacted via telephone based on information provided in the Division directory. After providing verbal consent, telephone interviews were conducted. Multiple research- ers were involved in gathering the data through phone interviews, and this served as one of the forms of investigator triangulation (Denzin, 1978). Attempts to contact the 50 members were made, and six therapists participated in the phone interviews. Some participants expressed a desire to have more time to reflect on the questions. The researchers experience confirmed that additional data collection methods could provide more respondents and richer data. Therefore, researchers decided on an additional data collection method, which would be to collect data at the annual Division Spring Conference. Conference attendees self-selected to participate in the study after hearing it described and announced. An additional screening by the authors was used to ensure that participants met the criteria established at the outset of the study. Attendees were provided consent forms and study questions on the first day of the conference and asked to return both by noon on the last day. This ensured that participants were able to reflect on their experiences and practices to give as detailed explanations as possible. Participants provided information about the population size in their practicing area and completed survey forms where they provided demographic information such as age, race, type of practice, and length of practice. In addition, participants provided their perception of the degree to which their minority or religious affiliation influenced requests for therapeutic services from acquaintances in other settings, and how they make decisions in response to these requests. Between telephone interviews and the annual Division conference, fifteen therapists pro- vided data for this study. Of these, five self-identified as African American, one self-identified as racially mixed (Caucasian and Phillipina), and the remaining nine participants self-identified as Caucasian. Participant ages ranged from 29 to 60; however, most participants reported having been in practice for over 20 years. All practiced in areas designated as rural according to Bachtel (2004). Participants practiced in either private (N = 6) or public settings (N = 6), while three practiced in both types of settings. Seven participants practiced in catchment areas whose populations were 20,000–50,000, six practiced in catchment areas whose populations were 50,000–100,000, and two of the participant’s catchment areas were over 100,000 people. Some worked in communities that served more than one county, or in counties that served multiple cities. A detailed description of participant demographics is provided to illustrate several consider- ations regarding the results. First, the participants in this study represent very experienced clini- cians, the majority having practiced more than 20 years. The perception of one’s ability to navigate complex dual relationships may be related to a sense of clinical competency evident in an experienced sample. Second, how long clinicians had lived in their rural community is unknown, a factor that may influence the likelihood of dual relationships. And lastly, most of the participants worked at least part time in public settings where they may or may not have control over the decision to see the a client known in another setting. 128 JOURNAL OF MARITAL AND FAMILY THERAPY January 2014 Data Analysis An interview guide (see Appendix A) was developed with open-ended questions that invited the participants to convey their experiences with dual relationships in rural communities. This interview guide provided a common set of questions for all participants, and left room to explore new areas that might emerge. Data were analyzed using a sorting procedure that calls for searching for what Wolcott (1994) terms patterned regularities in the data. We looked for common themes and patterns of behavior that would give an understanding of the experiences of the participants. Participant responses were then compared with the suggested procedures for ethical decision- making reported earlier. Our analysis process was guided by grounded theory (Charmaz, 2002; Glaser & Strauss, 1967); a qualitative methodology used with the goal of finding new theory or emerging themes in phenomena studied. This method seemed most appropriate to the limited understanding of how dual relationship dilemmas are handled by clinicians when such dilemmas are frequent or inevita- ble. Consistent with a grounded theory approach, data collected from the first interview were compared with data from the second interview, and this process of comparison was repeated with each data collection (Strauss & Corbin, 1998). Each phone interview was transcribed by the research interviewer, and non-phone written interviews were reviewed. The interviewers (J.G. and T.K.) recorded notes immediately following the data collection. These process notes included clarification questions asked, information on the date and type of contact, insights, questions, and connections to other responses. The research investigators then carefully examined the data and completed the task of com- parison, developing new categories relative to the answers. Open coding methods (Charmaz, 2002) were used to organize the data, and initial categories were developed. Themes emerged from the categories and subcategories as data analysis continued. These themes are discussed in detail in the results section that follows. Trustworthiness and Credibility To ensure trustworthiness (Merriam, 1998) and credibility, qualitative terms that are similar to reliability and external validity, we used detailed descriptions of the research methods and credi- bility audits to review the research methods, interviews, and findings. A licensed marital and family therapy (MFT), who has practiced for more than 20 years, served as an internal auditor of the data to open code the data from the interviews and written responses. In addition, an external auditor (2nd author) reviewed all drafts of the results to verify that the categories and themes were consis- tent with the interviews. Transferability, the degree to which a study can be applied to other contexts by different researchers, was established by providing detailed information about the participants and contex- tual factors that may be relevant to future research efforts. For example, the Appendix A reports the guiding questions used and the demographic information, such as practice setting, catchment population, and years in practice are reported in the following section. RESULTS Although interviews varied somewhat, participant responses reflected the inevitability of dual relationships in rural areas, consistent with the existing literature. As expected, a common experience among participants was receiving referrals for persons that they knew in other settings on a frequent or occasional basis. Also as expected, participants received referrals based on religious and minority affiliation,althoughmostof these were basedonreligious as opposedto minority affiliation. Similar themes emerged across clinicians in terms of how they handled potential dual relation- ship situations. The therapists who participated in this study universally referred the potential client elsewhere when the referral was well known. Among those that made referrals to avoid the dual relationship, they took care to explain the dual relationship dilemma to clients in order to preserve the existing relationship and ease the transition to a trusted colleague. For example: The most common type of referral comes from my church. I usually refer them on and explain the problem inherent in dual relationships. Generally, people are clueless about January 2014 JOURNAL OF MARITAL AND FAMILY THERAPY 129 this [dual relationships] issue and appear disappointed but do okay once they get started with a colleague. Even among those who reported engaging in the relationship initially, all stressed the impor- tance of evaluation and assessment at the beginning of therapy. For example, several participants engaged in two to four sessions during which they assessed the clients’ needs, their own ability to meet those needs, and the likelihood that the therapeutic relationship might violate the ethical guidelines by potentially “exploiting the trust and dependency of such persons” or “impair profes- sional judgment or increase the risk of exploitation” (American Association for Marriage & Family Therapy, 2001; p. 1). One participant reported engaging in the relationship: depending on my conversation with the referral, for a 3 or 4 session evaluation with the clear understanding that I may make a referral, continue to see the client myself, or have a professional consultant in the fourth session to help us decide the appropriate next phase. Strategies for Handling Dual Relationships During the open coding procedure, responses developed into the overarching theme of profes- sional judgment which contained three areas where participants felt they most needed to use this judgment: (a) level of benefit or detriment to the client; (b) the context; and (c) the nature of the dual relationship. Professional judgment. Whether explicit or implied, participants’ approach suggested they had used professional guidelines as the source of their decision-making. One participant discussed the “limits of therapy,” while another came to an agreement that “boundaries will be kept” with the clients with whom he or she entered into a dual relationship. Elaborating on how boundaries were kept, one participant stated: NOT discussing client info with staff. When necessary for support, speak vaguely to the school counselor. Make it clear to students and any others I see in community that I do not/will not identify them seek them out in public social settings. I also make it clear that I do not/will not identify other clients—or talk about them any professional relationship to anyone. Clarity around boundaries is extremely important in maintaining them. Several participants appeared to use a strict interpretation of the AAMFT ethical guidelines concerning therapy with persons known from other contexts, unequivocally stating that they would refer the client elsewhere based on their understanding of “making every effort to avoid . . . multiple relationships” (American Association for Marriage & Family Therapy, 2001; p. 1). These participants did not disclose any conditions under which they would agree to conduct therapy with persons known from other contexts. Professional judgment is a broad category and precisely the aspect of navigating complex rela- tionships that this study was undertaken to explore. When prompted about how they used their pro- fessional judgment, participants elaborated on how they make the decision to refer the client or engage in the dual relationship. Participants were aware of the people or groups with whom they are mostexperiencedor thosethetherapist feltmostcompetent inhelpingand with whomtheyweremost likely to engage in therapy: one partipant reported, “I know I work best with couples, single adults of adolescents, not children and not addictive adults.” Several noted the client’s need for treatment, the severity of the presenting issue, intake information, or expertise in couples versus family work as issues to consider when deciding to take the case. For example, when participants felt that the client needed immediate intervention and making a referral might delay treatment, they were more willing to engage in a dual relationship. In this case, ensuring that the client received timely therapy was tem- porarilyprioritized over the admonishment to avoidadual relationship. The remaining three emergent themes reflect specific aspects of the dual relationships decision- making articulated by participants. Although participants used their professional judgment in each of these areas, they were specific enough to warrant separate elements. Level of benefit or detriment to client. Promoting clients’ well-being was a factor in most deci- sions therapists’ decision-making in their clinical practice. Specifically, they used their judgment 130 JOURNAL OF MARITAL AND FAMILY THERAPY January 2014 about the degree of benefit to the client when deciding whether or not to engage in a dual relationship: one stated “professional judgment and instinct regarding my ability to be helpful to the client.” In the words of one participant, he or she was aware of the potential “negative impact of a dual relationship” on the clients well-being and the existing relationship. Despite this senti- ment, many participants specifically mentioned that the dual relationship was a lesser concern than promoting client safety. For example, one therapist would “suggest another referral unless an emergency or crisis is presented.” Another aspect of benefit to the client used as a deciding factor in engaging in the dual rela- tionship was whether or not the client would not have sought therapy. A participant provided an example of such a circumstance: I have made one exception and accepted a client who told me she checked me out care- fully at church and would otherwise not go to another therapist. She disclosed a ritual abuse history and indicated a need to feel safe first since some of her abusers were trusted people in positions of authority. For this therapist, engaging in the relationship meant the particular client was able to receive services. Other participants’ responses suggest that they use their judgment about what the client needs and what they can offer at that time as means of determining whether or not to pursue the dual relationship. Context. Participants indicated concerns about the context within which they knew the potential client. One participant differentiated between contexts such as “church affiliate versus friend,” while another made the distinction between “whether I know them personally or profes- sionally” as influential factors in their decision to pursue a therapeutic relationship or refer a client to another therapist. Participants were more willing to conduct therapy with a professional associ- ate than with a personal associate. A few were very specific in their understanding of a need to keep personal and professional relationships separate, responding “I would not see someone with whom I have a personal relationship” or “I don’t see family members of friends or acquaintances.” Others made decisions based on a more graduated sense of the personal acquaintance. One participant considered taking the case of someone with whom he or she had a … Sexual Abuse: A Journal of Research and Treatment 23(3) 365 –380 © The Author(s) 2011 Reprints and permission: http://www. sagepub.com/journalsPermissions.nav DOI: 10.1177/1079063210381411 http://sax.sagepub.com SAX381411 SAX Corresponding Author: Steven Sawyer, PO Box 10631, White Bear Lake, MN 55110 E-mail: [email protected] Boundaries and Dual Relationships Steven Sawyer and David Prescott Abstract Ethical standards are core components of practice standards and codes of conduct for mental health practitioners. Practice standards and ethics related to boundaries are generally based on historical review, study of mental health services, and the impact of boundary crossing or boundary violations on clients receiving services. This article explores some common standards of ethical practice related to boundaries and dual or multiple relationships between mental health professionals and clients. The underlying conceptual basis for these standards and examples of questions encountered in clinical practice with sexual offenders are explored. Keywords sexual offender treatment, professional boundaries, professional ethics, dual relation- ships “Ethics is a skill.” Marianne Jennings Introduction The conduct of mental health professionals (e.g., social workers, psychologists, mar- riage and family therapists, licensed counselors) with clients receiving services is addressed in professional literature, in standards and ethics documents adopted by professional organizations (American Group Psychotherapy Association [AGPA], 2002; American Psychological Association [APA], 2010; Association for the Treatment of Sexual Abusers [ATSA], 2005; National Association of Social Workers Article http://crossmark.crossref.org/dialog/?doi=10.1177%2F1079063210381411&domain=pdf&date_stamp=2010-10-21 366 Sexual Abuse: A Journal of Research and Treatment 23(3) [NASW], 2008), and in statutes and rules of mental heath or behavioral health licensing boards (e.g., Association of Social Work Boards, 2008; Minnesota Board of Social Work, 2009). Twenty-five states include continuing education in ethics or boundaries as a requirement for annual or biannual social work license renewals (Association of Social Work Boards, 2008). With so much attention to providing guidance for clinical decision making, one might think that professionals would encounter fewer ethical dilemmas. Unfortunately, this is far from the case. In fact, some observers (e.g., Glaser, 2010) note that numer- ous potential conflicts remain between the standards and ethics of mental health pro- fessions and the treatment of sexual offenders. Professional ethics are founded on such underlying concepts as these: (a) Clients are vulnerable when receiving professional mental health services; (b) professionals have varying degrees of perceived or real power and authority, especially when cli- ents’ participation is “involuntary” (court ordered); and (c) there is a fundamental need for psychological and physical safety for clients receiving mental health services. Treatment of sexual offenders referred by the criminal justice system are generally considered involuntary clients where the treating clinician holds considerable power and authority with an obligation to protect the community that may at times override individual client rights (Prescott & Levenson, 2010). These circumstances bring ethi- cal challenges to the entire course of treatment, from intake to discharge from services. Balancing the essential therapeutic relationship with the need to protect vulnerable community members from future harm requires clarity regarding the boundaries of the treatment relationship. This article explores boundaries in professional practice and the particular boundary issue of multiple or dual relationships. The Legal Foundation of Mental Health Ethics The basic rights of clients receiving mental health care services in the community or in facilities are provided for in some state statutes, and clients of psychotherapy ser- vices are considered emotionally dependent when considering the criteria for sexual exploitation by professionals. These client rights arise out of the need for protection resulting from the inherently unequal relationship between mental health professional and client and from the vulnerability of the client receiving services. This vulnerabil- ity has additional dimensions when clients are ordered by the courts to receive services and are thus “involuntary” recipients of services. These legal rights and protections are supported in professional codes of ethical conduct as well as behav- ioral health licensing statutes and rules. Licensing statutes and rules regulate the licensed behavioral health professional for the purpose of protecting the public. Codes of conduct publicly state the professional standards of practice and allow the profes- sion to “regulate” the members while also protecting the client. It can be easy for mental health professionals to minimize the vulnerabilities of their clients, who often feel markedly conflicted about the change process (Miller & Rollnick, 2002; Prochaska & DiClemente, 1984). Meta-analyses of psychotherapy drop-out rates Sawyer and Prescott 367 attest to the fact that treatment is rarely easy for those who enter it (Wierzbecki & Pekarik, 1993). Furthermore, controversies remain in the field of assessing and treating people who have sexually abused. Some Common Elements of Ethical Practices A summary of some common elements of statutes and professional standards related to ethics and relationships with clients are shown in Table 1. Common elements include avoiding harm, which includes physical, emotional, sexual, financial, and medical harm. Informed consent is a fundamental standard requiring that information is given to clients in advance of any important decision, such as treatment or research, which is directly related to promoting client autonomy and the inherent vulnerability of the client. Sexual intimacy is not allowed with current clients or, in many cases, with a former client or family member of a client or former client. Multiple or dual relationships should be avoided to prevent situations in which the professional provid- ing mental health services also has another personal or professional relationship with the client such that the two relationships are in conflict or affect the objectivity of the professional. By defining the actions of the mental health professional and the limitations of the professional relationship with the client, codes of conduct serve to protect the client and guide the practitioner. Because the mental health professional has an ethical obli- gation to the primacy of the relationship and the privacy of the client (with exceptions for community safety and child abuse as mandated by laws such as Duty to Warn and child abuse reporting), ethical codes provide practice parameters and limits or bound- aries of the professional–client relationship. These codes of conduct and basic ethical concepts are applicable to treatment of sexual offenders across treatment venues and treatment models that range from psycho- educational approaches to more process-oriented groups and apply to all therapy meth- ods. However, when treating sexual offenders, concerns remain regarding the proper balance of beneficence, nonmalificence, client autonomy, and the need for community safety. For example, in a recent paper, Glaser (2010) has argued that current treatment models provide no choice of therapy to the offender and compromise the client’s auton- omy. Glaser contends that current ethical guidelines such as those of the ATSA breach “the ethical codes which traditionally guide mental health practitioners.” Glaser further states that a primary problem with the status quo is that clinicians working in these programs “cannot serve (the) two masters” of community safety and client interests. He adds that traditional ethical codes, such as those published by APA (2010) and NASW (1999), do little to guide therapists treating sexual offenders. Prescott and Levenson (2010) have argued that although some clinicians are more effective at attending to the competing needs of this work better than others, this is precisely why organizations such as ATSA, APA, and NASW enforce their ethical codes. Furthermore, balancing these seemingly competing demands is what most sexual offender treatment providers are expected to do every day. T a b le 1 . Ex am pl es o f Et hi cs a nd S ta nd ar ds in P ro fe ss io na l A ss o ci at io ns a nd S ta te L aw D ig ni ty o f th e pe rs o n/ no di sc ri m in at io n A vo id h ar m In fo rm ed co ns en t C o nf lic t o f in te re st M ul ti pl e o r du al re la ti o ns hi ps Se xu al re la ti o ns hi ps o r in ti m ac ie s Se xu al ha ra ss m en t Ph ys ic al co nt ac t Pr o te ct io n o f pr iv ac y N A SW x x x x x x x x x A PA x x x x x x x — x A G PA x x x x x — — x A T SA x x x x x x — x So ci al w o rk li ce ns in g bo ar da x x x x x x x — x M D H p at ie nt r ig ht sb x x x — — x x — x N o te : N A SW = N at io na l A ss o ci at io n o f So ci al W o rk er s; A PA = A m er ic an P sy ch o lo gi ca l A ss o ci at io n; A G PA = A m er ic an G ro up P sy ch o th er ap y A ss o ci at io n; A T SA = A ss o ci at io n fo r th e T re at m en t o f Se xu al A bu se rs ; M D H = M in ne so ta D ep ar tm en t o f H ea lt h. a. M in ne so ta B o ar d o f So ci al W o rk . b. M in ne so ta D ep ar tm en t o f H ea lt h, P at ie nt R ig ht s. 368 Sawyer and Prescott 369 Boundaries The term “boundaries” describes structural (e.g., time of service, place of service, fees, and agreements) and interpersonal (e.g., physical contact, sexual contact, rela- tionship limits, and giving or receiving gifts) dimensions of the professional–client relationship. An underlying purpose of explicitly defined boundaries is to create and maintain clarity for the patient about the nature and limits of the professional relation- ship. Ultimately, the client should experience both connection within the therapeutic relationship and protection from harm. The mental health professional has the respon- sibility to establish and maintain boundaries. Most professional codes of ethics and state licensing boards use a “reasonable and prudent” standard to judge these actions by requiring that mental health professionals must not act or fail to act in a way that inappropriately encourages the client to relate to the therapist outside of the boundar- ies of the professional relationship, or in a way that compromises objectivity or inter- feres with the client’s ability to benefit from services. In a review of the history and evolution of the concept of therapist–client boundar- ies in therapy practice, Smith and Fitzpatrick (1995) identified three principles that underlie the patient–therapist relationship and boundaries: abstinence, duty to neutral- ity, and the responsibility of the therapist to strive for the independence and autonomy of the client. In this framework abstinence means the clinician refrains from self- seeking and personal gratification from the therapeutic relationship beyond the profes- sional rewards of the role as the professional. Duty to neutrality refers to the focus on the client’s therapeutic agenda, to the exclusion of interfering in the personal affairs of the client outside the presenting issues brought by the client. Independence and auton- omy of the client preserves the client’s freedom of choice. Currently accepted practices of appropriate boundaries in providing professional mental health services to clients have evolved over time as the understanding of the patient experience and therapy process has grown. Gutheil and Gabbard (1993) referred to early accounts of Freud’s analytic practice: Freud, for example, used metaphors involving the opacity of a mirror and the dispassionate objectivity of a surgeon to describe the analyst’s role, but his own behavior in the analytic setting did not necessarily reflect the abstinence and anonymity that he advocated in his writings. He sent patients postcards, lent them books, gave them gifts, corrected them when they spoke in a misinformed manner about his family members, provided them with extensive financial sup- port in some cases, and on at least one occasion gave a patient a meal (8). (p. 2) Gutheil and Gabbard (1993) defined professional boundaries in terms of role, time, place and space, money, gifts, clothing, language, self-disclosure, and physical contact. They use these dimensions to explore the many facets, and in some cases subtleties, of boundaries in professional practice. Time boundaries can be as simple as maintaining the planned beginning and ending of a therapy session, regardless of the content of the session as it comes to a close. 370 Sexual Abuse: A Journal of Research and Treatment 23(3) Other types of boundary considerations typically include structural, interpersonal, and dual relationships. Structural boundaries include clarity and consistency regarding the time and place of the service, fees, and agreements regarding the service itself. These can become challenging, particularly in inpatient settings where a clinician may feel that it is in one client’s best interest to spend extra time with them on a living unit or convene a meeting with staff on their client’s behalf, and the same clinician may feel differently about providing the same service to another client. Dilemmas appear quickly: When a clinician (whether in community or inpatient settings) provides an extra service, whose needs are met? Under what circumstances would the clinician extend the same courtesy to others? In addition, if a client requests the counselor to attend a personal event or activity that is not related to the therapy, the therapist is obligated to maintain the professional boundary and avoid personal encounters that could obscure the professional role. These judgments may be purely based on the needs of the individual client but underscore the importance of clinical supervision. Interpersonal boundaries such as physical contact and giving or receiving gifts can create questions in the psychotherapeutic endeavor. Residential programs serving ado- lescents who sexually abuse have historically had difficulty establishing appropriate policies for physical contact between staff and clients, (Schladale, 2007) due to the highly individualized nature of the clients they serve. While a warm pat or soothing gesture sometimes seems to be the right thing to do when clients are exhibiting dis- tress, physical touch can be easily misinterpreted by clients or be viewed as crossing the line of appropriate contact, even with adult clients. Smith and Fitzpatrick (1995) differentiated boundary crossing and boundary violation in the following way: Boundary crossing is a non-pejorative term that describes departures from com- monly accepted clinical practice that may or may not benefit the client. A bound- ary violation, on the other hand, is a departure from accepted practice that places the client or the therapeutic process at serious risk. (p. 500) Boundary crossing can be examined across a continuum, ranging from acts that have less potential for significant harm to the client (e.g., extending the time of a session beyond the normal time frame) to more potentially complex acts such as receiving a significant gift. Interestingly, even extending a session beyond the structured time can be interpreted by the client as a willingness by the therapist to provide special treatment or that the client is in some way special. It can also be a form of indirect reinforcement of avoiding important issues until the end of the session. Boundary violations can also be examined across a continuum but are generally considered more significant and, therefore, have the potential for greater harm to the client. Boundary violations include dual relationships, physical contact, self-disclosure, and sexual contact with current and former patients or their family members. Whether a boundary “crossing” or a “violation,” therapists engage in a cognitive decision making or awareness process—be it thoughtful, analytic but misinformed, Sawyer and Prescott 371 selfish, or absent minded—any of which allows the potentially harmful action to occur. Pope and Keith-Spiegel (2008) identified seven cognitive errors by clinicians that contributed to boundary errors: • Error 1: What happens outside the psychotherapy session has nothing to do with the therapy. • Error 2: Crossing a boundary with a therapy client has the same meaning as doing the same thing with someone who is not a client. • Error 3: Our understanding of a boundary crossing is also the client’s under- standing of the boundary crossing. • Error 4: A boundary crossing that is therapeutic for one client will also be therapeutic for another client. • Error 5: A boundary crossing is a static, isolated event. • Error 6: If we ourselves don’t see any self-interest, problems, conflicts of interest, unintended consequences, major risks, or potential downsides to crossing a particular boundary, then there aren’t any. • Error 7: Self-disclosure is, per se, always therapeutic because it shows authenticity, transparency, and trust. Most clinicians have encountered an actual or potential boundary issue at some point in their practice where they feel pressure to allow the boundary crossing or boundary violation. For example, it is common that a client becomes deeply immersed in an important personal issue at the end of session and the therapist directly or indi- rectly continues the session beyond the specified time limit. It would be easy for the therapist to think, “This is important, I will only extend the session one time and the client will not notice or take advantage in the future.” Or in a session where the client is exploring sexual feelings the therapist offers a personal (countertransferential) self-disclosure about finding the client to be very attractive. In this context the self- disclosure was not made to further the therapeutic work of the client but was made to alleviate the therapist’s anxiety about the sexual feelings. Boundary Issues With Sex Offenders How are these questions relevant to treatment of sexual offenders? One of the most significant issues is the fact that most sexual offenders are involuntary clients in struc- tured treatment programs, under a court order, and supervised by a probation or parole agent. Because of these conditions and external controls, mental health professionals can be drawn away from considering the “offender” as a client who is vulnerable and thus operate clinically with a perceived freedom and independence from the more traditional service model with the “vulnerable” private client. Therapy with a sexual offender is different due to the external controls, but the involuntary client is in many ways just as vulnerable as a voluntary client presenting with anxiety or depression. An example of a thought error with an involuntary client could be, “He is not a typical 372 Sexual Abuse: A Journal of Research and Treatment 23(3) client; he is a sexual offender; he has lost his rights.” This thought process reflects a bias on the part of the therapist and a potential loss of neutrality. Should clinicians who treat court-ordered individuals who have committed a sexual crime be any less attentive to boundaries than a clinician treating an emotionally vul- nerable adult or adolescent? Clinicians working with court-ordered clients have added responsibilities to the client and the community. Most individuals presenting for ther- apy after a criminal justice intervention have experienced fear, shame, loss of family and friends, loss of livelihood, and damaged or diminished self-concept. Under this type of stress typical defenses (e.g., denial, minimization, and suppression) serve to protect the client. With the added potential of a sexual disorder that has been denied, grief is another potential underlying phenomenon. For example, this is especially true for those who have denied a lifetime of sexual attraction to children and during treat- ment come to terms with the meaning of their diagnosis (e.g. pedophilia). Hence, the unique dynamics of the involuntary client, combined with the public scrutiny of the criminal justice system and pressure to be accountable to the court (and the commu- nity) require the clinical professional to attend to the need for clearly defined relation- ship boundaries as well as the care and protection of the client. Examples of Ethical Standards in Professional Associations Because of the breadth of responsibilities of mental health professionals and the widely accepted basic boundary expectations, professional associations address boundaries and professional relationships in codes of conduct. The ATSA, NASW, the APA, and the AGPA all address sexual relationships. Prohibition of sexual contact with a current client is universal. Some standards (such as NASW) take this prohibition further to prohibit sexual contact with former clients or relatives of clients and prohibit providing services to individuals with whom a prior sexual relationship occurred. The rationale is that sexual contact as a form of intimacy impairs the neutrality of the professional and violates the rule of abstinence (of self-gratification). The ATSA Code of Ethics (2001) states that that sexual intimacy with clients or former clients is unethical: “A member shall not engage in a sexual relationship with any client who is receiving or has received professional services, regardless of whether payment for the services was involved” (p. 8). Likewise, the AGPA states that sexual intimacy with patients/clients is unethical (AGPA, 2002). Clear boundaries protect the client from harm, ensure that the client interests are paramount, and promote the objectivity and neutrality of the professional. Boundary violations put the objectivity or neutrality of the professional at risk or creates a con- flict of interest. The client is at risk when the professional experiences impaired objec- tivity, as the judgment of the therapist may not be in the client’s best interest. When boundaries are violated there is, by definition, risk of harm to the client, which the professional is committed to protect. Sawyer and Prescott 373 Dual or Multiple Relationships: What Is This and Why It Is an Issue? Dual relationships (or multiple relationships) in therapy practice are identified as an ethical issue and a boundary violation. This is based in part on the concepts that the relationship is not equal, that the client is vulnerable, and that the primary responsibil- ity of the clinician is to make care of the client the first priority. A dual relationship poses the risk that the personal interests of the mental health professional or some other obligation could be more important than the needs and safety of the client. Multiple relationships are defined by the APA (2010): A multiple relationship occurs when a psychologist is in a professional role with a person and (1) at the same time is in another role with the same person, (2) at the same time is in a relationship with a person closely associated with or related to the person with whom the psychologist has the professional relation- ship, or (3) promises to enter into another relationship in the future with the person or a person closely associated with or related to the person. A psycholo- gist refrains from entering into a multiple relationship if the multiple relation- ship could reasonably be expected to impair the psychologist’s objectivity, competence, or effectiveness in performing his or her functions as a psycholo- gist, or otherwise risks exploitation or harm to the person with whom the profes- sional relationship exists. Multiple relationships that would not reasonably be expected to cause impairment or risk of exploitation or harm are not unethical. The ATSA Code of Ethics (ATSA, 2001) states in part: “ii) Multiple relation- ships may impair professional judgment and pose a significant risk for client exploi- tation” (p. 9). The AGPA Code of Ethics (2002) states, “The group psychotherapist shall not use her/his professional relationship to advance personal or business interests” (sec 3.2, p. 2). Engaging in multiple relationships with a client receiving mental health services is widely accepted as having a potentially harmful impact on the client or the neutrality of the mental health professional. When professionals have multiple roles with clients, the primacy of the therapeutic relationship is compromised because the relationship is now viewed to be a mutual exchange in which the needs of both parties are paramount. A dual role impairs the ability of the practitioner to place the client’s needs above one’s own in the therapeutic encounter, and if problems occur in the alter- native relationship, they will carry over into the therapist–client relationship. Some multiple relationships are intentional while others occur and must be addressed or navigated (e.g., in small towns or rural areas where options for the client and the pro- fessional are limited; see Campbell & Gordon, 2003). In all cases it is accepted prac- tice that the burden of responsibility is on the professional to identify the situation and prevent the multiple relationships from occurring. If a multiple relationship does evolve, then it is incumbent on the professional to work to resolve the boundary issue and operate in the best interest of the client. 374 Sexual Abuse: A Journal of Research and Treatment 23(3) Examples of Multiple Relationships in Practice A practice scenario. An adult client presents for intake at an outpatient treatment program in the community. During the interview he reports that he owns an auto repair business near the therapist’s office. The therapist recognizes that she has taken her car to that repair shop many times. She does not recognize the owner and he does not say he recognizes her. How should she proceed? Should she tell the client? Is this a boundary crossing? Is this a multiple relationship? A practice scenario. An outpatient sexual offender treatment program operates under a practice model where a licensed mental health professional facilitates a therapy group that includes a probation officer who cofacilitates a therapy group. The proba- tion officer is also responsible for court-ordered supervision of the clients in the group. The ATSA Practice Standards and Guidelines (ATSA, 2005) sections F 38 and 39 express caution regarding probation officers in treatment groups, in particular related to the need for informed consent and potential of dual relationships. This scenario poses several issues about boundaries and roles of the cofacilitators. Four dimensions of this scenario will be briefly discussed: (1) the involuntary client, (2) cofacilitation, (3) dual role and interests of the client, and (4) informed consent. Considerations The ATSA Code of Ethics, 8 (c) (ATSA, 2001) states: If a potentially harmful multiple relationship develops, due to unforeseen circumstances, the member shall attempt to resolve it as quickly as pos- sible, with due regard for the best interest of Clients, supervisees, and other persons relying upon the member in his or her professional capacity, and in keeping with the ATSA Code of Ethics. The therapist should seek supervision or consultation to assess the potential impact on the client, the neutrality of the therapist, and possible courses of action. Is there real or potential client harm? In this case there appears to be no direct connection between the client and the therapist. Is the therapist neutrality compromised? Did she have bad experiences at the repair shop that left her angry at the owner she never met? Was she very well treated in an emergency to the extent that she feels indebted to the shop (and the owner)? Should she con- tinue to patronize the repair shop? Sawyer and Prescott 375 To begin with, the mental health practitioner is ethically bound to standards requir- ing that the welfare of the client is their primary responsibility, with the exceptions of legal requirements related to safety of others and child abuse reporting. A probation officer is an officer of the court, and, therefore, the first responsibility is allegiance to the court and to the public. Therefore, by definition, the probation officer cannot have the client’s well-being as first priority. Mental health professional/sexual offender therapist’s primary professional responsibility is to the client (except in cases of risk to harm others). Thus, models for delivering services to sexual offenders must be …