Therapists are expected, of course, to treat all clients with respect, dignity and consideration, and to adhere to the spoken and unspoken rules that make up our established standards of care. Many of these rules are necessary and sensible, but I believe that some elements of our ethical codes have become so needlessly stringent and rigid that they can undermine effective therapy. Take, for example, the almost universal taboo on "dual relationships," which discourages any connection outside the "boundaries" of the therapeutic relationship, such as lunching, socializing, bartering, errand-running or playing tennis. Naturally, sexual conduct falls into this forbidden category, and so do relationships involving conflicts of interest, such as a professors' serving as therapists to their own students.
But the blanket disapproval of "dual relationships" in some circles draws no distinction between "boundary violations," which can harm a client, and "boundary crossings," which produce no harm and may even enhance the therapeutic connection. For example, what would be so appalling if a therapist said to a client whom he has just seen from 11 a.m. until noon: "We seem to be onto something important. Should we go and pick up some sandwiches at the local deli, eat them here and continue until 1 at no extra fee to you?"
During the past 40 years, I have seen thousands of clients and have deliberately engaged in "dual relationships" with no more than 50. I have asked a client to drop off a package at a store that was not out of his way, engaged in barter with an auto mechanic who tuned my car in exchange for three therapy sessions and have gone to social functions and played tennis with some clients. Of course, I do not engage in such behaviors capriciously. Roles and expectations must be clear. Possible power differentials must be kept in mind. For my own protection as well as the client's, I don't chance things like this with seriously disturbed people, especially those who are hostile, paranoid, aggressive or manipulative.
But in our profession's antiseptic obsession with "risk management," there has been too little public discussion of whether the blanket rejection of dual relationships isn't, at least in some cases, needlessly constraining and perhaps even countertherapeutic. The following case is offered not as a blueprint or a path all therapists should follow, but as an unapologetic account of how and why I ignored a number of taboos. It is offered with the expectation that it will give many readers pause, perhaps even shock some, but also open up discussion of some long-neglected ethical issues in our field.Mark and Sally
About 20 years ago, a depressed, 56-year-old man named Mark came to see me, accompanied by his bright, vivacious, 47-year-old wife, Sally, who was quick to tell me that she had majored in psychology in college and considered herself "a bit of a psychologist."
Mark, it turned out, was a successful corporate vice-president who had suffered several bouts of depression. I liked him almost immediately. His intelligence, humor, charisma and even-tempered style (which had helped him to advance to a high professional level) shone through his current low mood. He told me that despite his business success, his lack of self-confidence had caused him considerable distress, and he was often criticized at work for being too tactful, too diplomatic and too much of a peacemaker. His CEO, he told me, had recently said to him, "Mark, I just wish you'd occasionally bang some heads together."
We covered a lot of territory in that first session. Mark and Sally told me about their respective family backgrounds and the somewhat strained relationship between Mark and Samantha, Sally's 9-year-old daughter from a previous marriage. We discussed situations in which Mark was apt to feel anxious and unconfident. When the hour was up, Sally turned to me and said; "If you could help Mark become less passive, I think this will be extremely beneficial."
I met with Mark alone after that, and once I had administered a battery of psychological tests and seen him for a couple of sessions, it was clear to me that his depressive episodes occurred when he overreacted to disappointments. Sally was correct in calling him too passive: he went out of his way to avoid confrontation, a trait that he attributed to a family upbringing that placed a high value on the old Biblical adage "Turn the other cheek."
A large part of our therapy consisted of role-plays, and for weeks Mark rehearsed assertive responses to various situations. At work, for example, he thought the accounting firm his company employed was inefficient and careless. Their lateness often resulted in needless bank penalties and irritated customers. Yet, he didn't want to make waves.
I pointed out that avoidance set him up for depression, especially when other irritations piled up. So, he and I rehearsed dialogues he might have with the company's chief financial officer, and I then encouraged him to act on them. I remember telling him, "You need to get rid of that 'Turn the other cheek' philosophy and replace it with TNC--Take No Crap!" After considerable hesitation and trepidation, he urged the company's top executive officers to fire the incompetent accounting firm, and his confidence and status within his company soared when a new group of accountants was brought in that performed far more effectively.
Over the months, Mark became more outspoken and learned to bounce back faster from disappointments (which were fewer), and his dark moods lifted. He proudly referred to this change as "testicular enhancement." Then, at the end of a session in which we discussed the need to schedule some final meetings to consolidate his gains, Mark said, out of the blue: "Would you and your wife be willing to come to our home for dinner some time?"
To this very day, I remember being struck by the fact that he had said, "to our home," rather than something like, "Would you come over for dinner?" I generally avoid mind reading, but I couldn't help feeling that he was really asking me something along the following lines: "After all I've told you about myself, do you trust me enough and regard me as worthy enough to enter my home with your wife and break bread with me?" This was not the first time I had received such a request. Other clients had extended social invitations of one kind or another, which I had accepted perhaps a dozen times in the past. With Mark, as in the other cases, I felt that to refuse his invitation would undermine the work we had done together. So I crossed the boundary and said that I'd very much like to accept.
At the dinner, Mark casually introduced me to the other guests as his "shrink." He and Sally were gracious hosts, the wine was excellent, as was the food, and the entire evening flowed effortlessly. My wife and Sally, who had never before met, struck up an instant friendship. Later, my wife and I talked about how comfortable the evening had been and agreed that Mark and Sally would enjoy meeting several of our other friends. So, in due course, we invited Mark and Sally to our home for dinner with two other couples. Again, we enjoyed ourselves immensely.
My wife and I soon found ourselves going out to dinner with Mark and Sally regularly, taking in movies, lectures and Broadway plays, playing tennis and even taking vacations together to Canada and the Caribbean. It turned out that Sally and my wife had many interests in common; they went to flower shows, art galleries, joined a women's discussion group and attended cooking classes.
Over the next several years, Mark became one of my closest friends and my wife and I saw him and Sally several times a month. When he and Sally began seeing a marriage counselor, he confided the news to me as one would to a good friend. But then, several months later, Mark called to tell me that they were unhappy with their counselor and asked if I would see Sally and him professionally. I said I'd really rather keep our relationship purely social and recommended several good therapists. When they insisted, I told them that seeing friends in therapy ran counter to the ethical codes of my profession and I could land in hot water. Mark, who apparently had learned his lessons well about speaking up for himself, quickly challenged my initial reluctance saying, "Coming from you, that sounds ridiculous. Since when do you bow to needless authority?" That took me aback.
I wrestled with the question of what to do for three or four days, discussed it with my wife and several colleagues and only acquiesced when a number of people convinced me that, with all my knowledge of both Mark and Sally and my comfort with our relationship, I was in a unique position to be helpful to them.Some Sticky Situations
Initially when we started working together, I found myself ill at ease asking the sort of penetrating questions I would normally ask a couple, some of which would be regarded as inappropriate within the domain of friendship. But then, I began to feel something even more disconcerting. All the affection, caring and fond memories that I had for Mark and Sally as friends were there, but as I focused with them on the difficulties in their connection to each other, it became clear that there was no strong underlying attachment between them. There were simply too many unresolvable resentments (especially Mark's unhappiness at the way Sally's intense bond with her demanding teenage daughter overshadowed her relationship with him and her unwillingness to try to change that balance in any way). They both admitted feeling less put upon when not in each other's company, and all attempts to resuscitate the vitality of their marriage--in-session coaching, homework assignments, improving communication skills--went nowhere. Yet, I felt that they each expected me to conjure up some magic that would infuse deep love and passion into their relationship.
At this point, I regretted that I had allowed myself to be talked into treating Mark and Sally. I felt a lot of pressure from the demands of having been their therapist, then becoming very close friends and again engaging in formal therapy with them. I could feel the pull of the implicit wishes and expectations that I simply could not fulfill. But I was too deeply committed and involved to back out.
It's one thing to tell the average client couple that their marriage seems to be dead, but it's far harder to advise friends to split up. I felt bad about letting Sally and Mark down, for failing to possess the magic wand that would transform their shaky relationship into a solid and satisfying marriage. Nevertheless, I gave them my professional opinion. They both thanked me for my candor. Even so, I felt uncomfortable and feared that it might spell the end of the friendship.
An amicable divorce followed. Mark bought a house, and Sally helped him furnish and decorate it. The four of us continued to play tennis and go out together. I was surprised and relieved at how easy it was to let go of the therapist role and become just a friend again. I was very pleased that the friendship had not been damaged. One evening, when my wife and I were driving home with Mark and Sally from New York, Mark whispered to me that he could take Sally in very small doses and that he was absolutely delighted that he would be dropping her off and then going on to his own home.
Sally and my wife have continued to be friendly, but the primary bond has always been between Mark and me. Mark remarried and his new wife also got on very well with us, and our friendship with them continued until they moved to California 4 years ago. It is now about 14 years since the therapy terminated. Mark and I still speak on the phone occasionally and often send e-mails to each other, but I still wish he lived close by.
While boundary crossings can have salutary effects, one should never underestimate the emotional complexities to be sorted out and, sometimes, the toll to be paid. Since my experience with Mark and Sally, I have entered into only one other triple boundary crossing (i.e., therapist--friend--therapist) and I will not venture into that territory again--it's just too demanding emotionally. Nevertheless, I continue to find that occasional extratherapeutic contacts with selected clients can enrich their lives and expedite our work together. After all my years in this field, it is clear to me that self-protectively distant or defensive therapists are more likely to injure than to help their clients. We must all be sure that mere risk management does not become more important than making our very best effort to serve our clients.
This article was originally published in the March/April 2002 edition of Psychotherapy Networker magazine.Want to read more articles like this? Subscribe to Psychotherapy Networker Today!>>