Ethics of the Greater Therapeutic Alliance

Do Dual Relationships Really Threaten Psychotherapy?

Arnold Lazarus

Therapists are expected, of course, to treat all clients with respect, dignity, and consideration, and to adhere to the spoken and unspoken ethical codes 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, and 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's 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?"

Of course, 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's 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.

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.

Mark, it turned out, was a successful corporate vice-president who'd 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."

A large part of our therapy consisted of role-plays, and for weeks Mark rehearsed assertive responses to various situations. Over the months, he became more outspoken and learned to bounce back faster from disappointments (which were fewer), and his dark mood lifted. 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?"

Other clients had extended social invitations of one kind or another, which I'd 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'd done together. So I crossed the boundary and said that I'd very much like to accept.

My wife and I soon found ourselves going out to dinner with Mark and Sally regularly, taking in movies, lectures and Broadway plays, and even vacationing 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 wrestled with the question of what to do for three or four days. I 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

At this point, I regretted that I'd 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 couldn't fulfill. But I was too deeply committed and involved to back out. Eventually, an amicable divorce followed.

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. Nevertheless, I continue to find that occasional extratherapeutic contacts with selected clients can enrich their lives and expedite our work together.

This blog is excerpted from “A Triple Boundary Crossing.” Read the full article here. >>

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Topic: Aging | Ethics

Tags: ethical issues | ACA | amicable divorce | counselor | depression | divorce | emotion | good therapists | marriage counselor | psychotherapy | rejection | sex | SPECT | success | TED | therapeutic ethics | therapist | therapists | therapy | therapy ethics

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