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Boundary Issues and Dual Relationships in Behavioral Health

Written by Dr. Frederic Reamer

What do the following circumstances have in common?

  • A mental health counselor at an outpatient clinic is in recovery. She attends an Alcoholics Anonymous meeting in a local church and, coincidentally, encounters one of her clients who is also in recovery. The counselor must decide whether to stay at the meeting or leave.
  • A marriage and family therapist receives a Facebook “friend” request from a former client who terminated services about three years earlier. The therapist was unsure about ethical standards governing online social networking relationships with former clients.
  • A 32-year-old client of a clinical psychologist in private practice died by suicide. The client’s parents are devastated but deeply appreciate the psychologist’s efforts to help their son cope with chronic depression and PTSD. Shortly after the client’s death, the parents contact the psychologist and ask her to deliver a eulogy at the funeral.
  • A mental health counselor in private practice receives a text message from a former client. In the text message, the former client tells the counselor that she misses the counselor and wants to stop by the office briefly to say hello and give the counselor a “thank you” gift.
  • A clinical social worker in a residential treatment program for high-risk adolescents provides individual and group counseling. One of the residents met with the social worker individually and asked the social worker several questions about her personal life, including whether the social worker is partnered and has children, where the social worker lives, and whether the social worker ever tried drugs as an adolescent.
  • A mental health counselor in a residential facility for clients who struggle with mental illness helps one of his clients develop skills to enable her to move to a supervised apartment sponsored by another social service agency. Shortly after moving into the apartment, the client invites the counselor to visit her apartment on a Saturday evening to see her new residence and meet her roommates. The former client is proud of her achievements and independence and is eager for the counselor to see her new home.

Each of these situations involves what are commonly called boundary issues. Boundary issues occur when behavioral health practitioners establish multiple relationships with clients or former clients, whether professional, social, or business. These typically involve dual (or multiple) relationships.

Not all dual and multiple relationships are unethical. For example, many practitioners have had unanticipated or unavoidable contact with clients in supermarkets, sporting events, places of worship, or the local library; ordinarily, these encounters are brief and fleeting and do not pose any significant ethical challenge.

Some boundary issues, however, raise serious and troubling ethical questions. The most egregious circumstances involve some exploitation of clients, for example, when a practitioner becomes sexually involved with a client—a clear violation of prevailing ethical standards in the behavioral health professions.

Other circumstances involve more subtle and ambiguous boundary issues. For example, to what extent is it appropriate for practitioners to share selective personal information with clients? Would it be appropriate for a practitioner to serve with a client on a church committee they both joined coincidentally? How should a practitioner handle the news that a client—a teacher—has just been assigned as the new instructor in the practitioner’s son’s third-grade class (and this is the only third-grade class in the rural school district)?

Contemporary research on boundary issues suggests that practitioners face several major issues, including the following:

  • Intimate contact — Many dual relationships in behavioral health involve some element of intimacy. The most extreme cases involve sexual intimacy. However, there are other forms as well. Under what circumstances, for example, is it appropriate for practitioners to hug a client? Is there a distinction between a brief goodbye hug at the end of long-term treatment and a more sustained hug with a client who is distraught about a life crisis? Also, what about counseling a former lover who seeks the practitioner’s clinical expertise? Or, is it ever appropriate for a practitioner to give clients gifts (for example, when a client marries or delivers a baby) or accept gifts from clients.
  • Personal gain — Behavioral health practitioners occasionally become involved in dual relationships that produce personal benefits, such as a monetary gain from a business venture. This might involve practitioners who barter with clients for goods or services as payment for clinical services, refer clients to the practitioner’s relative for additional professional services, or seek useful information from clients.
  • Emotional and dependency issues — Some boundary issues arise from personal issues in practitioners’ lives. Many of these circumstances have in common that they are rooted in the practitioner’s emotional needs, such as those stemming from childhood experiences, marital or relationship issues, health problems, aging, career frustrations, or financial and legal problems. These stressors can impair practitioners’ judgment, leading to inappropriate dual or multiple relationships and boundary violations.
  • Altruistic instincts — Some boundary issues arise because of practitioners’ genuinely altruistic inclinations. Most behavioral health practitioners are dedicated, caring, and principled people who would never knowingly exploit clients. Ironically, extraordinarily kind and humane practitioners may unwittingly foster challenging dual and multiple relationships by doing favors for clients. Occasionally, such altruistic gestures may be misinterpreted by clients and trigger boundary confusion.
  • Unavoidable and unanticipated circumstances—In some instances, behavioral health professionals encounter complex boundary issues that are not easy to anticipate. This may occur when practitioners’ and clients’ lives intersect when they become neighbors in their relatively small community; a client is employed by the practitioner’s spouse or partner, or the client and practitioner join the same faith community. 

It is important to reiterate that not all dual and multiple relationships are unethical. Some are, and some are not. The challenge in behavioral health is to use good judgment, consistent with current ethical standards, to distinguish between the two. Register here for Dr. Reamer’s upcoming continuing education event that further discusses this topic! 

About the Author

Dr. Frederic Reamer is on the faculty of Rhode Island College School of Social Work. His teaching and research focus on professional ethics, criminal justice, mental health, health care, and public policy. Dr. Reamer received his Ph.D. from the University of Chicago and has served as a social worker in correctional and mental health settings. He chaired the national task force that wrote the Code of Ethics adopted by the National Association of Social Workers in 1996 and served on the code revision task force. Dr. Reamer also chaired the national task force sponsored by the National Association of Social Workers, Association of Social Work Boards, Council on Social Work Education, and Clinical Social Work Association, which developed technology standards for the profession.