As the status of the therapist has shifted from that of an oversized figure with Svengali-like powers to that of an overworked and underpaid service provider at the mercy of the client-consumer who might sue him or her for some infraction, what are we to make of our traditional ethical codes?
Traditionally, psychotherapists have thought of ethics as a kind of Old Testament list of "thou shalts" and "thou shalt nots":
Thou shalt have no connection with the client-emotional, sexual, occupational, financial, social, Facebook-except psychotherapy.
Thou shalt not breach confidentiality and loosen thy tongue about the client or what happens in therapy, even to your spouse or closest friends, particularly after a few glasses of wine.
Thou shalt not blab on about thyself or thy family or thy marital status or anything else without an ironclad clinical rationale for the therapeutic use of "self-disclosure."
Thou shalt forego dual relationships with clients; neither a borrower nor a lender be with them, nor engage in joint business ventures with them, nor hire them as nannies.
Thou shalt not exploit thy privileged position with the client to further thine own personal interests.
In sum, thou shalt remember thy boundaries and keep them holy.
Detailed ethics codes emerged in the new and somewhat amorphous profession of psychotherapy because its practitioners weren't exactly physicians, priests, or friends, but some amalgamation of these, requiring their own behavioral guidelines. The basic idea of the codes was to keep the therapist-a potentially revered and intimidating figure with a powerful emotional influence in the client's life-honorable, trustworthy, and discreet.
Through the years, as therapy became more widespread and society more informal, some of these guidelines have become increasingly ambiguous. As the general public has come to regard therapists as just another kind of service provider, rather than a potential Svengali, the relative power of therapist and client has shifted, as well as the role of ethics. In fact, if anybody needs protection today, it might be the overworked and underpaid therapist, who's at the mercy of clients who might bring suit for some peccadillo. Society has become more litigious, and nightmare scenarios-whether realistic or simply hyperbolic-of therapists being hauled into court and their careers ruined for some presumptive transgression have proliferated. Getting ethics CEs has become a grim requirement, not only for licensure, but as some small protection against the looming threat of aggrieved clients and their lawyers, like a wreath of garlic cloves to ward off legal vampires.
Presumably, the great majority of us recognize the importance of behaving ethically with our clients and wouldn't engage in unethical behavior, even if we could get away with it. As therapists, we intuitively know we can't do good therapy unless we're trustworthy and dependable, respect our clients' confidentiality, and maintain decent boundaries between ourselves and them. What's not as widely understood is that the way we share our ethical vision with our clients is as important to the practice of therapy-to the entire process of therapy-as any treatment model or clinical philosophy. An acute sensitivity to ethical issues doesn't just protect the client from overt harm or us from liability; it gives us the framework within which we can do clinical work. Our ethical stance isn't an add-on to therapy, or even merely a protective shield for the client, though it certainly is that: it's the foundation of therapy itself.
The Importance of Safety
The central ethical concern in therapy, the one around which all the others hinge, is boundaries. I began to understand this 21 years ago (a decade into my therapy career), when I began a regular program of exit interviews with terminating clients, systematically asking them what they thought had been most helpful about their experience in treatment. I asked about the intervention, the relationship, the practical advice offered, the office decor, the ease of parking, and for any other feedback they had. Thousands of interviews later, with similar input about clients from numerous other therapists and agencies, the answer was overwhelmingly clear: regardless of why these clients had sought treatment, what they valued and remembered most was feeling "safe" in therapy.
The essential factor for clients to benefit from therapy was the sense that they'd entered a secure haven, which provided a time and space set off from the tumult and emotional confusion of their "regular" lives. There they could concentrate on doing the reflective, difficult work they needed to do to make the changes they desired for themselves. They required a guide who was empathically on their side, hopeful about their future, and open to their free expression of thoughts and feelings, but detached enough not to be sucked into their emotional morass. They absolutely needed to believe that what happened in therapy would stay in therapy, and that included the therapist. This meant the therapist wouldn't regularly pop up in their daily life, and they might allow themselves the illusion that the therapist never left the office and was always there waiting for them when needed. In short, this therapeutic safe house was built on a foundation of unambiguous boundaries, confidentiality, and hopefulness, conveyed by a trustworthy expert in a collaborative engagement suspended from ordinary life. These features of the therapeutic process emerge precisely from those boring old ethical rules and regulations that were established with the specific purpose of safeguarding clients' interests.
Setting the Boundaries
We all know that the collaboration between therapist and client-the therapeutic alliance-is the keystone of therapy. What many therapists may not realize is how much clarifying boundary issues means in establishing and strengthening that collaboration. Boundaries are what make us all feel safe and grounded in a variety of situations; around a relationship in therapy, they create a secure perimeter, which makes possible the level of emotional freedom and authenticity that's critical to successful treatment.
I believe clients need to know up front what makes therapy different from all other relationships. As I've come to appreciate the importance of boundaries and safety to my clients, I've woven a clarification of those issues into the fabric of treatment from the very beginning of each case, sometimes from the first phone call. When clients call to make an appointment, I ask whether this is their first therapy experience. I then follow up during therapy sessions with questions like, "What do you think happens in therapy?" or "How do you think therapy works?" If they've already been in therapy, I ask what's worked for them in their past therapy experiences and, of course, what hasn't worked for them. I explore their opinion about what style of therapist they like and their overall expectations. I explain that I've learned that clients appreciate a collaborative, predictable structure and discuss how we can work together to make their therapy experience as transparent as possible.
I often say, "This is a unique relationship. I'll get to know you very, very well, and know the most intimate details about your life, but you'll never know me on that level. Although we may become best friends of sorts, I'll never hang out with you, and when things are going at their best, we'll probably begin to end the relationship." Often I'll take time to define with clients what makes them feel safe and what types of relationships they feel safe in. Then we'll explore how we can bring those ingredients into our work together.
Because of my focus on safety and collaboration early on, I talk directly about issues that might not occur to other therapists. For example, within the first few sessions, I make it a point to find out whether there may be potential overlap between my clients and me in our personal lives. If you live and practice in a small town, a commercially self-sufficient suburb of a large city, or even a city neighborhood, chances are you'll run into a client at least every now and then-at a party, a business you frequent, a PTA meeting, or perhaps in the shower of the local fitness center (this has happened to me). So I bring up the potential for confusing encounters early on, and discuss with clients how we might deal with possible meetings outside of therapy.
I routinely ask my clients, "If I see you out in public, how do you want to handle this? How should we acknowledge each other, if at all? What if we run into each other and you're with a friend?" Many clients look at me as though I'm crazy, asking if this isn't a bit excessive, and I tell them that it might be, but I've had lots of clients for whom this was a very big deal. Indeed, some clients have told me, "Let's pretend we don't know each other," which is fine with me. Many have no idea how they might handle a chance meeting, so I'll offer some suggestions. "We could just nod and smile, but not engage in conversation. If we met at a party, we could talk and have a ready-made story about how we know each other. At the other extreme, we could openly greet each other and you could just introduce me to all and sundry as your therapist." Most people prefer a little more discretion, since once the information is out, they've lost control of it and have no idea who might ultimately know. Many cautiously choose Option A: we'll nod and pass like ships in the night.
These conversations create an accepted etiquette that clarifies and smoothes over otherwise awkward situations, minimizing the amount of subsequent second-guessing. Particularly for clients new to therapy, unexpected encounters can loom large in their minds, causing days of rumination and requiring an hour of processing during the next session. We spend a good deal of time talking about what might be called the internal boundary issues of therapy: what clients can expect to happen in therapy and what I can do to make them feel secure during the process. If they've been in therapy before, I ask them what was helpful and what wasn't. One client, George, told me that he'd often felt during therapy that his previous therapist, a highly successful, much-published academic with a somewhat reserved manner, thought he was boring and kind of a loser. At that time, George was depressed, hated his job, and was worried about his own future. Whether or not his own lack of self-esteem made him unjustifiably anxious about his therapist's opinion, there was something about the latter's manner that made George afraid to ask him outright what he thought of him. "Besides, he probably wouldn't have told me the truth, anyway," he said. I asked George how we could best avoid the same situation, and he didn't exactly know. I told him a little about my own personal style, so he wouldn't have to spend hours pondering what I meant when I spoke or acted in a certain way. I said I often take long pauses during therapy or draw a deep breath to gather my thoughts before saying something: this is just thinking, not silent disapproval. "When either of those things happens," I said, "I'll share with you what's going on with me."
In addition, I told him I was just born a touchy person. "Sometimes, I automatically reach out and gesture toward someone, or even touch a client lightly, to make a point." Not only that, I tell people that when I have pronounced feelings or thoughts about something, my voice can be rather loud. Some people find this aggressive, even irritating. I tell clients that if I get too loud for them, not to be afraid to tell me to chill out. They won't be the first: I've had clients literally say to me "Whoa, calm down!" I lay out my "hugging policy": if they say they need a hug, I'll do it at the end of the session, but never without being asked. Since I have a small office, I tend to sit close to people. If this bothers a client, I'll back off. In fact, one client was so anxious that she asked me to leave the office door open for the first few sessions-and I did.
These may not seem like boundary issues as they're traditionally defined, but they make the client feel safe and contained like good boundaries are intended to do. What's impressed me repeatedly in talking with former clients is how often therapists (me included), unintentionally make clients feel violated. These are rarely the egregious violations, sexual or otherwise, that alarm ethics boards or end up in law courts. They're the small, sometimes careless, often unconscious acts that exacerbate clients' sense of vulnerability, powerlessness, and anxiety. Clients often say that they don't understand what the therapist was doing or why he or she wouldn't directly answer their questions, and they were put off by what seemed like high-handed behavior. One woman client once confided to me, "My first therapist was a kind man, who said he cared about me, yet he always seemed to be engaging in power plays. For example, he could cancel appointments less than 24 hours in advance, but if I did, I was charged. I asked him many times about his therapy methods, but he never really answered my questions, and it seemed to me he was defensive. I never had any idea what exactly was happening or what I was supposed to be doing or feeling. I'm not saying he ever did anything wrong or bad. But I just always felt off balance, one down, and without any control in therapy."
Clear structures and predictability are necessary to the healthy boundaries of the therapy process. The therapist's respectful and empathic demeanor can help clients build up a healthy sense of their own personal boundaries, which they may never have had the chance to develop before. Unfortunately, without meaning to, the therapist may replicate the abusive relationships in the client's past. We may be "nice people" and experts in our model of therapy; we may know the rules of ethics by heart, and still be completely unconscious of how our clients experience us. That's why it's necessary to make our intentions to keep therapy safe as transparent as possible.
Let's Have an Affair
Now, you might think that having spent so much time thinking and writing about my principles, as well as doing everything I can to follow them in my clinical practice, I'd seldom get caught in the insidious kinds of ethical binds so common in our field. You'd be wrong. Sometimes, the issues become so subtle and complex that we may alienate clients when we're trying our best to protect them. Regardless of how careful and painstaking we try to be, the vagaries of life, human temperament, and personal limitations can be counted on to prevent us from ever becoming proud of our own perfection. In short, stuff happens.
Louise, a caterer, had entered therapy with a history of childhood sexual abuse from several people close to her and a violent first marriage. A compulsive shopping addict who'd run up a great deal of credit-card debt, she had a pattern of wanting to be the favorite of teachers and other authority figures, who regularly took her into their confidence and told her she was their prize student. Throughout her life, many of these relationships had become sexual, although never turning into long-term, intimate connections. She didn't see them as abusive, yet she realized that, in the end, her needs weren't being met or even recognized. Although I regularly give my boundary and safety spiel to everyone in the beginning stages of therapy, it was clear that, with Louise, this discussion was crucial. I assured her, even though she never asked or seemed worried, that I wouldn't be a person in a position of power who'd use her as my prize. Early on, when we discussed the possibility of running into each other at an event she was catering, we decided that we'd only nod to each other if we met. She appreciated these discussions and said that there was "a transparency" she'd never thought of before to our therapy work. She proved to be an eager, intuitive, and likeable client and everything went swimmingly during our first few months of work.
Then one day, while I was at an out-of-state training, I got a call from my eldest son. "Mom," he said, obviously excited, "Marie [his fiancee] and I have found the perfect caterer for the wedding. She has a fantastic menu, she's reasonably priced, and she really seems to get what we're all about. We're so relieved! We want to have a tasting for both families in a couple of weeks, and I want you to look at your schedule and tell us some times when you can do it." Did I feel a warning tingle? Maybe, but I live in a pretty big town and there are lots of caterers around. I felt genuinely happy for my son and his bride to be, who'd spent months agonizing over this decision. "That's fabulous!" I said. "What's the caterer? I wonder if I've eaten their food." His response: "The name is Let's Have an Affair-do you know them?"
Yep, it was Louise's business, all right. I think I may have gasped. I know I stopped breathing and paused, but years of crisis-intervention training have made me quick on my feet. "Sweetie, that's just great. I'm really happy for you. Now, I'm due to begin my workshop, so I'll talk to you when I get back."
Now what? Clearly, I couldn't tell my son, "You can't use her: she's in therapy with me," without compromising her confidentiality. It seemed just as clear to me that I couldn't allow this dual relationship with Louise, because all the official rules and regulations forbade it, and my gut told me that for sure I didn't want to have a client putting my son's wedding reception together. I have a strict policy that, if invited, I'll attend clients' important transitional life ceremonies like weddings and funerals, since I'm already involved in the emotional and spiritual preparation for these ritual events, but I don't do parties, receptions, or wakes, which are purely social. However, I should add that if some transcendent Ethics Board in the Sky had thundered down an order to me that I had to invite one client to my son's wedding, Louise would have been the one. I felt great affection for her, and we had a mutually trusting, respectful clinical relationship. Now, just the thought of the "tasting"-the six of us, chit-chatting with Louise about the filet of beef or the red snapper-gave me hives. I had to have a conversation with her. Luckily, I thought, Louise and I had spent a lot of time discussing boundary issues, so we were both prepared for this discussion and it should go fairly smoothly. Silly me.
Louise walked into her next appointment with a huge smile on her face. Before even sitting down, she excitedly burst out, "Did your son tell you? Isn't this great?! I'll finally be able to give back to you in the most perfect of circumstances. I know I'll be paid for my services, and I'll give you the most beautiful, delicious wedding reception you could ever imagine!" Clearly, the ethical boundary issue had occurred to her, but she'd decided that being paid for her work, rather than doing it for free, mitigated any concern.
I explained to her that her catering the wedding not only violated my own personal sense of ethics, but it was a violation of the official ethical codes of social workers and family therapists. I said, "Louise, my profession has a code of ethics that states that I cannot engage in another professional relationship with you outside the confines of therapy."
She immediately became angry. "You don't need to show me anything. I'm not going to sue you. They want me to cater their wedding, I want to do it, and I don't think you can stop me. You can't tell your son and his fiancee that I'm your client, because then I could sue you!" At a later point in our exchange she said, "You wouldn't even be paying me. The kids have already told me what parts of the wedding you're paying for, and the catering isn't among them."
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!
Illustration © Art Valero
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