The process of psychotherapy is relationship based. As such, how psychotherapists conduct themselves in these relationships has significant clinical and ethical implications. The Ethical Principles of Psychologists and Code of Conduct (APA Ethics Code, APA, 2010) makes clear the ethical obligations relevant to boundaries and multiple relationships that are likely to be well known by psychotherapists (e.g., it is unethical to engage in sexual relations with your clients). Yet, the APA Ethics Code cannot provide strict rules to apply to every clinical situation that may arise in practice. Psychotherapists must apply their judgment in making decisions about the appropriateness of different actions and behaviors, hopefully utilizing the guidance provided by the Ethics Code, consultation with colleagues, and a decision-making process.
Boundaries in the Psychotherapy Relationship
In psychotherapy there is a need for rules and expectations to be discussed and agreed upon in order for the relationship to be acceptable and successful for all parties. Boundaries constitute the agreed upon rules and expectations that articulate the parameters of the relationship.
- “A therapeutic frame which defines a set of roles for the participants in the therapeutic process” (Smith and Fitzpatrick, 1995, p. 499)
- “a foundation for this relationship by fostering a sense of safety and the belief that the clinician will always act in the client’s best interest (Smith & Fitzpatrick, 1995, p. 500)
- a “distinction between the expectations and interactions that would be considered appropriate within the relationship and those that would be considered inappropriate within the relationship” (R. Sommers-Flanagan, Elliot, & J. Sommers-Flanagn, 1998, p. 38).
Six of the most common boundaries within the psychotherapy relationship include:
How each of these is addressed and managed in the psychotherapy relationship holds great implications for the client’s welfare as well as for achieving desired therapeutic outcomes.
Boundaries may be avoided, crossed, or violated. To avoid a boundary means that it is not traversed at all. For example, with regard to the boundary of touch, consider a psychotherapist treating a client who is a survivor of sexual assault or trauma. It may be inappropriate and unbeneficial for the psychotherapist to use touch with the client, and in fact may be harmful. Another example would be a male psychotherapist providing psychotherapy to a female Orthodox Jew for whom any touch by a man who is not her husband would be considered taboo.
Smith and Fitzpatrick (1995) defined boundary crossing as “a nonpejorative term that describes departures from commonly accepted clinical practice that may or may not benefit the client” (p. 500). Thus, traversing a boundary in a manner that is not harmful or exploitative to the client and that may in fact, be supportive of a strong therapeutic alliance and that may promote achieving treatment goals is considered a boundary crossing. Possible examples of boundary crossings include shaking a client’s extended hand upon first meeting or extending the time of a treatment session for a client who is in crisis.
In contrast, a boundary violation is “a departure from accepted practice that places the client or the therapeutic process at serious risk” (Smith & Fitzpatrick, 1995, p. 500). Boundary violations are likely to be harmful, exploitative, and not in the client’s best interest. Additionally, boundary violations are likely to take advantage of the client’s dependence and trust, and often are confusing to clients and inconsistent with their treatment needs. Examples of boundary violations include engaging in sexually intimate behaviors with a client and a psychotherapist disclosing her or his personal issues and life challenges with a client in an effort to receive emotional support from the client.
As was previously stated, boundaries should not always be avoided. In fact, a strict application of boundaries with clients may prove to be clinically ineffective and may create a cold or sterile environment that is contrary to the goals of a good working alliance (Zur & Lazarus, 2002). Flexibility with boundaries is recommended so that each client’s unique needs are met in the most appropriate manner possible.
It is likely that most psychotherapists are clear on those behaviors that are clearly ethical and those behaviors that are clearly unethical. It is the gray areas where there is no apparent right or wrong answer will likely prove most challenging to psychotherapists in determining the most appropriate course of action. When faced with these situations psychotherapists may benefit from engaging in a thoughtful decision-making process when deciding on the appropriateness of certain behaviors and in determining if a proposed action constitutes a boundary crossing or a boundary violation (Pope & Keith-Spiegel, 2008).
There are a number of factors that should be considered when engaging in a thoughtful decision-making process about boundaries.
- What are the motivations for taking the proposed action? Are they to meet the psychotherapist’s needs in some way or are they motivated by the client’s best interest?
- What is the likely effect or impact of the proposed action? Will it be of therapeutic value to the client or is it likely to be exploitative or harmful?
- Will the proposed action be welcomed by the client or viewed negatively? If this is not imminently clear, have you openly discussed the proposed action with the client to seek her or his input?
- Is the action under consideration consistent with widely accepted roles of psychotherapists and will taking this action risk jeopardizing the client’s, and the public’s, trust in the profession?
- Will the action under consideration promote the client’s autonomous functioning over time or is it more likely to create more dependence on the psychotherapist?
- Is the proposed action consistent with the agreed upon treatment plan and consistent with the client’s treatment goals?
- Are there any cultural factors or expectations, or other individual differences, that would impact the client’s needs and how the client might interpret or be impacted by the proposed action?
- Is the action under consideration consistent with your theoretical orientation?
- If unsure of any of the above, have you consulted with a colleague to receive input and feedback on your proposed course of action prior to taking it?
- Have you documented your decision-making process, the rationale for the decision you have made, and the impact of your action on the client?
As can be seen, there are a number of considerations that may be relevant for determining if a particular action or behavior would be considered a potentially helpful boundary crossing or a harmful boundary violation. Thus, a thoughtful decision-making process, at a minimum includes considerations of these questions, should occur in order to help ensure that the therapeutic relationship is preserved and that the client’s best interest is served.
To engage in a multiple relationship is to enter into a secondary relationship in addition to the primary psychotherapy relationship. Multiple relationships may be social, business or financial, or sexual in nature. The APA Ethics Code (APA, 2010) makes it very clear that all multiple relationships need not be avoided; only those that hold a significant potential for exploitation of, or harm to, the client, and those that are likely to lead to impaired objectivity and judgment for the psychotherapist, must be avoided. Of course, knowing this in advance may prove challenging. Thus, the use of a decision-making process and consultation with colleagues is recommended when the outcome and effects of an anticipated multiple relationship is unclear.
In addition to considering the questions listed above prior to entering into a multiple relationship with a client or other individuals associated with the client, there are ethical decision-making models that may prove helpful for making these decisions. Younggren and Gottlieb (2004) suggest that the psychotherapist consider the following questions when contemplating entering into a multiple relationship with a client:
- Is entering into a relationship in addition to the professional relationship necessary, or should I avoid it?
- Can the [multiple] relationship potentially cause harm to the patient?
- If harm seems unlikely or unavoidable, would the additional relationship prove beneficial?
- Is there a risk that the [multiple] relationship could disrupt the therapeutic relationship?
- Can I evaluate this matter objectively? (pp. 256-257)
In many settings the complete avoidance of multiple relationships may prove impossible. These may include being a member of a community who both lives and works in that community such as in a rural setting; a small or isolated community; a religious, ethnic, or LGBT community; and others. Often, it is because the psychotherapist has been active in the community and known to its members in a variety of roles, that the community members feel comfortable in seeking professional services from the psychotherapist. In addition, in these settings, options for making referrals to other clinicians may be quite limited, further impacting decisions about providing psychotherapy to individuals with whom the psychotherapist has pre-existing relationships (Hargrove, 1986).
In these settings the question is not “should I participate in multiple relationships?”, but “how should I best participate in multiple relationships so that my clients’ best interests are served?”. Curtin and Hargrove (2010) share the following representative example of life as a psychotherapist in a rural community: “my son’s third-grade teacher (a former client before I had children) also serves on the library board with my spouse and is a member of the Sunday school class that we attend. She shops at the same drug store and local discount house and eats at the same restaurants” (p. 550). But, as has been emphasized, not all multiple relationships are appropriate, and even in these settings, some multiple relationships will need to be avoided. How one makes these decisions, the factors one considers, when engaging in necessary multiple relationships is okay, and how they are managed is key.
In keeping with the information shared above, it is important to take a flexible approach to boundaries and multiple relationships that takes into consideration the many factors addressed above. Our clients’ best interest and the promotion of their treatment goals should always guide us. Further, it is important to consider the guidance provided by the APA Ethics Code (APA, 2010), to access the wisdom of colleagues when faced with dilemmas and unclear situations, and to utilize a decision-making process to assist us in making these decisions.