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Yesterday’s Ethics Vs. Today’s Realities - Page 3

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I was mortified. Great, I thought, now my client knows about the personal discussions between my son, his fiancee, my future in-laws, and me over who's paying for what. What other personal details did she know, I wondered? Now, I was the one not feeling safe.

Over the next few sessions, if anything, Louise's position hardened. She continued to tell me that I couldn't stop her, the catering plans were between her, my son, and his fiancee, and I was the one with a problem about it, not her. Furthermore, I was impinging on a business opportunity for her-a chance to break into an entirely new community with lots of new business.

At this point, some might well reason, "Oh for heaven's sake, this is really not such a big deal. This client isn't suffering from a mental illness. She seems well on the way to full recovery. You like and respect her. So why put a crimp in her professional life just to assuage your own hyperactive conscience? Maybe you are the one with the problem. Lighten up!" But not only was it an "official" ethical violation for Louise to cater the reception, it was an avoidable dual relationship. We didn't live in a small town, where there's only one caterer. I was convinced that allowing Louise to cater the wedding would compromise her therapy, subtly or not so subtly. I wasn't going to become another in the line of teachers, guides, or mentors who used her talents to benefit or satisfy themselves. Louise's pattern was to take care of others in order to feel good about herself-to sacrifice herself to meet others' needs and have them adore her as a result.

Furthermore, for my own well-being, I need to maintain a buffer between my professional and personal life. I don't want to have to worry about my client's thoughts and opinions about my personal life-my taste in friends, my relationships with family members, my behavior at high-profile personal occasions. This isn't a small matter because, as therapists, we're only as effective professionally as our own mental and emotional self-care allow us to be.

By now, my work with Louise seemed threatened by what felt like a classic power struggle. The more rounds we went on this, the more it seemed to me that this was a bona fide clinical issue that we needed to resolve to save the therapy. Louise wanted me to become like other authority figures in her life. One of my hypotheses was that we were coming close to the end of therapy and she wanted to find a way to make our relationship sustainable. She'd never had a relationship with someone in which the boundaries were clear and sustained. I felt that her core relationship issues were getting played out in this scenario, and we discussed all this. What felt deeply therapeutic was that we could argue about what was going on; this was a disagreement that we had to have. Finally, though, Louise said she was no longer willing to use her sessions to discuss my problem.

Luckily, I could call upon my consultation group, which I'd created years before to help me through just such clinical and ethical quandaries. Since I couldn't convince Louise that this was a clinical issue, my consultation group and I agreed that I'd offer to see her without charge to discuss the problem for two reasons. The first was that, since we'd already spent so much time early in the therapy creating a therapeutic context for safety and openly discussing the nature of and necessity for boundaries, this would all be familiar territory for her. And while no amount of preparatory conversation can prevent every ethical dilemma, it does establish a framework in which therapist and client can have the kind of free and open conversation that can resolve the issue.

Louise and I began methodically exploring both the positive and negative consequences of her catering or not catering the wedding. The pros of her catering: my son would have a fantastic event and she'd get great publicity, perhaps more clients, and a way to feel closer to me. The cons: there'd be a secret and some weirdness between us during every conversation and meeting, along with a degree of discomfort for me and for her, if she experienced me in a role other than as a therapist. Louise even admitted that she might be jealous that she wasn't going to be my daughter-in-law or that she might discover aspects of me that she didn't like. The pros to not catering: we'd continue on our therapeutic journey and might even get closer, having learned how to handle a difficult and confusing conflict together. Finally, there'd be someone in a position of intimacy and power who didn't use her or love her for what she could give to them. This was the most crucial point and the one that ultimately changed her mind about catering the wedding.

We also explored her personal history as it related to the current problem with a renewed immediacy. People in positions of hierarchy-her uncle, her teacher, her cantor-had all sexually abused her. Her first husband had physically abused her. In fact, throughout her life, too many people had crossed relational boundaries with her, confusing their needs with hers. I told her that if she catered the wedding, even though she consciously believed that I was in no way taking advantage of her, she might feel it on some level, given her history. I was deeply convinced that I simply couldn't take the risk of even inadvertently putting her, or any other client, into that predicament. As we spoke and she began to truly take in what I was saying, her eyes teared up. "I get it," she said softly. "This relationship has changed my life and I don't want to risk it. I'll find some way of canceling the job with your son and his fiancee." Then she smiled and said, "But, boy, would they have gotten one spectacular dinner!"

A day or so later, my son called and told me, with obvious disappointment in his voice, that Let's Have an Affair had cancelled. The owner had called to tell him that she'd mistakenly double-booked that day and was obliged to honor the first commitment. I inwardly breathed a sigh of relief as I consoled him. "I'm sure you'll find another wonderful caterer," I said.

The Good Old Slippery Slope

Ethical issues may seem obvious until you get embroiled in one. Most of what takes us, as therapists, close to the "no-go" line aren't the biggies (sex, expensive gifts, business partnerships, major confidentiality violations), but the less obvious ones, which make hard cases in the end. At the margins, many ethical issues are really judgment calls. It's not so easy in the thick of things to see a bright, shining line dividing the therapy relationship from some other relationship. While allowing Louise to cater my son's wedding is clearly a dual relationship, it might seem like a relatively benign one to many practitioners. Yet it seemed clear to me that it represented the slipperiest of slopes. In the end, two factors helped me work out a solution that she and I could accept. First, both of us had spent so much time discussing boundary issues and the peculiar nature of the therapy relationship early on that even though Louise challenged me mightily, she came around because she had, in effect, gone through the "Ethics 101" course that I give all my clients. She knew the language and could understand the issues.

Second, I had a consultation team on my side. To me, such a group is critical to helping any therapist think and make decisions about the kinds of thorny ethical issues that come up all the time in therapy. I like sports metaphors. As a therapist, you're something like an athlete, who must stay in shape to be ready for whatever comes at you during the game. You must have a coach and a team on your side who support you, challenge you, and tell you when you're in danger of screwing up. You can tell a good consultation group anything-"I've got a crush on a client," "My client wants to give me a pricey gift and will feel hurt and rejected if I say no," or even "My client has been hired to cater my son's wedding." The list goes on and on, and a consultation group will give you perspective on how to sort through it.

During good therapy, clients feel protected enough to let go of the defenses that shackle them to unhappy and unsuccessful patterns of living. In that environment, they can feel freer than ever before in their lives; they can allow themselves to be inspired and encouraged-empowered-to reenvision the world and the meaning of their lives. That therapy can do that is, in my opinion, due as much to the right understanding of boundaries as to any particular methodology. In fact, clients will forget all those brilliant interventions and masterful insights of ours, but they'll remember how we made them feel. Did we help them feel safe and secure enough to be bold, to look at the world with new eyes, to believe that within themselves they do have the wisdom and imagination to remake their lives? To me, therapy is genuinely a kind of sacred space-a sense that's been reinforced for me by many, many clients who've said the same thing. So, from my standpoint, the original Great Law of Good Therapy that we began with remains constant: remember thy boundaries, and keep them holy!

Mary Jo Barrett, M.S.W., the founder and director of the Center for Contextual Change, teaches at the University of Chicago. She's the coauthor of Systemic Treatment of Incest and coeditor of Treating Incest: A Multimodal Systems Perspective. Contact: mjb.ccc@att.net. Tell us what you think about this article by e-mail at letters@psychnetworker.org, or at www.psychother apynetworker.org. Log in and you'll find the comment section on every page of the online Magazine.

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3 comments

  • Comment Link Saturday, 04 August 2012 11:38 posted by daniel wolpert

    This is a great article, and it is clearly geared towards therapy in the big city. I'm a pastor with a previous career in psychotherapy and so I do a fair amount of pastoral counseling. My wife is a physician in the same town. Dual relationships are an inescapable fact of life in our context. If we didn't have other relationships with those we see in our office, we'd have to barricade ourselves in our house and starve to death. Interestingly, in historic healing/spiritual communities, dual relationships were also well recognized. In one of the most famous example of the 20th century, Thomas Merton was the spiritual director for his abbot, the man who had a great deal of power over his daily life. Having lived in the small town context for many years, I realize that the main essential boundary is confidentiality within the office. Of course many times people do 'get away' and see those outside the community for intimate services, and when they need this, people seem quite able to make this choice. However, I have come to believe that seeing each other in an array of community contexts actually adds to a sense of safety and well being rather than detracts from it.