Tread Cautiously: Boundary Crossings and Dual Relationships
Written by Leslie S. Tsukroff, MSW, LCSW
Founder and Executive Director of Leslie S. Tsukroff, Inc.
While at the 2023 NASW-NJ conference, I had a lively discussion with a group of individuals who asked my opinion about working with more than one family member, either simultaneously (at the same time) or sequentially (after one service relationship has ended). Before sharing my thoughts, I reflected that they had posed a well-debated topic, and noted that clinicians often fall into one of two camps- “there’s nothing wrong with it” and “it’s an ethical, legal and clinical minefield”. For those who know me, you can guess which camp I’m in. For the rest of you, read on to find out.
As part of the informed consent process, at the outset of the service relationship, mental health professionals are tasked with explaining each person’s rights and responsibilities and an important piece of informed consent is clarifying what role each will play. When working with couples (or families and minors), determining who holds “client status”- is it the couple, one part of the couple or both individuals- is an important step and one that should not be overlooked. The NASW Code of Ethics states: “When social workers provide services to two or more people who have a relationship with each other (for example, couples, family members), social workers should clarify with all parties which individuals will be considered clients and the nature of social workers’ professional obligations to the various individuals who are receiving services.” (1.06 d).
Once client status is determined, other aspects of informed consent can be addressed. For example, when you know who the client is, you are able to advise clients (and collaterals) of your policies around privacy and confidentiality, access to the medical record, treatment planning, the nature and limits of the therapeutic relationship, and what happens when therapy ends.
Often overlooked, but a key aspect to your informed consent documents should be an explanation of the therapeutic relationship and the clinician’s professional requirements around managing conflicts of interests and entering into dual or multiple relationships with clients and/or their family members. A dual relationship exists when a mental health professional interacts with a client in more than one role or capacity including but not limited to professional, social or business. When each party’s role and responsibilities are clearly defined, clinicians are more likely to thoroughly weigh the pros and cons of entering into a dual relationship, consider the “what ifs” and make decisions based on the clients’ best interests. While entering into a dual relationship may not always be unethical or illegal, they have the potential to lead to a negative outcome for the clinician and/or their clients, create a rupture in the therapeutic alliance and in some cases, ethics and licensing complaints.
Oftentimes, well-meaning, skilled clinicians enter into dual relationships that unintentionally cause psychological distress to all involved. In fact, according to NASW, entering into a dual relationship is the most frequent ethical mistake made by social workers in private practice.
How can switching roles (sequentially or simultaneously) cause harm to clients?
Let’s take a quick look at this very common example (hypothetical of course).
A couple (the client) enters treatment for marital counseling, decides to separate and ends therapy. Party A starts treatment individually with the couples’ therapist. Then, Party B seeks individual treatment with the couples’ therapist. Our fictitious therapist now finds themselves right in the middle of a sticky ethical dilemma.
What are our hypothetical therapist’s options?
Accept Party B?
Keep Party A and refer out Party B, citing “conflict of interest”?
Keep Party A and accept Party B?
Terminate Party A and turn away Party B?
Some of you might be thinking, “Just tell Party B you are full and avoid the whole thing.”
How can this scenario go south?
Our fictitious therapist decides to maintain Party A as a client and refers out Party B. Party B is aware that Party A “got the therapist” in the divorce, Party B has a litigious nature and they file a complaint with the state licensing board alleging violations of the ethical/legal standards around client abandonment, conflicts of interest, and commitment to clients. Now our fictitious therapist must manage the complaint process which upends their life for years (yes, the system is broken), defend their actions and they are in a state of constant fear, worry, anger, frustration and despair.
Why is transitioning from the couples’ therapist (primary relationship) to Party A’s individual’s therapist (secondary relationship) problematic?
Because by engaging in a clinical relationship with two entities (the couple and Party A) who have a relationship with each other and whose interests may be in conflict, they created a dual relationship (Reamer 2009).
Before accepting Party A as a client, our fictitious therapist should have considered the potential ramifications of entering into a sequential relationship and switching roles from the couples’ therapist to an individual therapist for one or both parts of the couple.
As it is not uncommon or unreasonable for clients to return to treatment at some point after termination, ethics experts (and licensing boards) might assert that our fictitious clinician should have considered the possibility of Party B contacting them for services in the future. The clinician’s obligation to look into their crystal ball and assess for possible risks is supported by the NASW Code of Ethics which states, “Social workers should be alert to and avoid conflicts of interest” and to steer clear of dual relationships in which clients (or former clients) have the potential to suffer harm (1.06 a).
How does one assess the level of risk before engaging in a dual relationship?
When evaluating the potential pitfalls of engaging in sequential roles, it is important for the clinician to ask themselves the following:
Is there the possibility that my judgement or objectivity could be impaired because I worked with Party A as part of this couple?
Is there the potential, in this particular situation, with these specific clients (the couple, Party A and/or Party B) for anyone to experience harm if I become Party A’s individual therapist?
Since it is often hard to assess these situations on our own, whenever we are faced with a boundary crossing, conflict of interest or dual relationship, we should seek consultation or supervision from trusted colleagues who can help us brainstorm all of the possibilities, challenge our assumptions, consider and weigh any likely adverse effects, and develop an exit plan in the event that our actions lead to a negative outcome.
Boundary crossings are complex and require careful consideration of ethics, the law, the standard of care and the particular nuances of each situation, the client(s) and the clinician. As mental health professionals we must place our client’s interests at the forefront of most therapeutic decisions and should attempt to preserve the therapeutic relationship to the best of our ability. Therapists are tasked with protecting the integrity of the clinician-client relationship, as trust is a necessary component. We must strive to provide clients with a safe space, remain neutral, hold appropriate boundaries and ensure that treatment is not compromised due to our actions, inactions, or involvement with others. When faced with the possibility of engaging in a sequential dual relationship, we must ask ourselves if it is likely that we will be able to uphold all of these tenets. My advice- tread cautiously.
But wait. What should our fictitious clinician do?
Great question! Join me for my workshop “Warning: Boundary Crossing Ahead” for a review of ways to resolve this dilemma in a manner that minimizes harm to the clients, provides examples of viable exit strategies and offers risk management techniques. https://www.leslietsukroff.com/warning-boundary-crossing-ahead
© Leslie S. Tsukroff, Inc. 2023 (All Rights Reserved)
This article originally appeared in Leslie’s May 2023 Newsletter