One Client: Many Provider Roles - Dual Relationships in Human Service Settings
Debra Guthmann, Ed.D, Wendy Heines. LCSW, Marcia Kolvitz, M.S.
Unlike professionals who work with hearing consumers, those of us working with Deaf and Hard of Hearing individuals invariably will encounter our consumers outside of the work environment. Should professionals who work with Deaf and Hard of Hearing clients in vocational rehabilitation, social work, mental health, post-secondary settings or other human service agencies socialize with their clients? How should professionals deal with the number of dual relationship issues that arise on a regular basis? Is the significance of dual relationships different for hearing and Deaf professionals? Whenever we as professionals are operating in more than one role, and when there is potential for negative consequences, it is our responsibility to develop safeguards and measures to reduce (if not eliminate) the potential for harm.
Dual or multiple relationships are rarely a clear-cut matter. There is an ongoing debate over the risks and benefits of dual relationships. Some dual relationships are unavoidable and in these cases, professionals need to take appropriate precautions. Herlihy and Corey (1992) describe dual relationships as occurring when professionals assume two roles simultaneously or sequentially with a person seeking help. The dual relationship may exist at the beginning of the counseling relationship, it may occur during the time services are provided, or it may develop after the termination of counseling. Ethical codes vary in their statements about the length of time that must pass for another A significantly different@ relationship, especially a sexual one, to be permissible. Often, professionals need to make judgement calls and to apply the codes of ethics carefully to specific situations. Dual relationships are filled with complexities and ambiguities. Pope and Vasquez (1991) indicate that dual relationships are problematic because some dual relationships are clearly exploitative and do serious harm to the helper and professional involved, while others do not cause harm. Dual relationships are not always obvious. It can be difficult to anticipate situations which are not currently conflicts in role, but may become so at a later time. Dual relationships are also the subject of conflicting views and not always avoidable.
How does one assess the potential for harm? Kirtchener and Harding (1990) identified three factors that counselors should consider. First, there is a greater risk of harm when the expectations of client and counselor are incompatible. When clients have one set of assumptions about the ground rules of the relationship, and the professional has a dissimilar set of assumptions, there is an increased likelihood of vulnerability. Another principle is that when the responsibilities inherent in the dual roles are divergent, there is potential for divided loyalties and a concomitant loss of objectivity. Counselors who also have personal, political, social or business relationships with their clients, are at risk because their self-interest may be involved and thus compromise the client's best interest. Finally, by the very nature of the counselor/client relationship, clients are more dependent, have less authority and are vulnerable. Due to this power differential, it is the responsibility of the professional to ensure that the client in the relationship is not harmed..
Pope and Vasquez (1991) asserted that counselors who engage in dual relationships are often skillful at rationalizing their behavior thereby, evading their professional responsibility to find acceptable alternatives to dual relationships. Entering into dual relationships with clients, or even considering entering into them can drastically change the nature of therapy. Counselors could begin using their practices unconsciously to screen clients for their likelihood of meeting the counselor's social, financial or professionals needs. It can also distort the professional nature of the therapeutic relationship, which needs to rest on a reliable set of boundaries on which both client and counselor can depend. Dual relationships affect the cognitive processes that benefit clients during therapy and help them maintain these benefits after termination. Dual relationships create conflicts of interest, and thus compromise the objectivity needed for sound professional judgement. If a counselor were required to give testimony in court regarding a client, the integrity of the testimony would be suspect if a dual relationship existed.
There is clear consensus among the professional associations (counselors, psychologists, social workers, etc.) that concurrent sexual and professional relationships are unethical. Many of the associations agree that a sexual relationship cannot later be converted into a therapeutic relationship.
From a legal perspective, non-sexual dual relationships are less likely to produce sanctions than are sexual dual relationships. For instance Healy and Herlihy (1992) found that sexual dual relationships comprised 20% and other dual relationships comprised 7% of complaints made to state counselor licensure boards. However, in recent years state licensing boards seem to be addressing the issue of nonsexual dual relationships more vigorously.
Most ethical codes draw strong distinctions between sexual and non-sexual dual relationships. Ethical codes vary in their requirements about the length of time that must pass for another "significantly different" relationship, especially a sexual one, to be permissible (Herlihy & Corey, 1992, p.3). Although the codes considered here prohibit the counselor from having a sexual relationship with a current client, variation occurs in the prohibition of such a relationship with former clients and the length of time that must pass for such a relationship to be permissible (American Counseling Association, 1995; National Association of Alcoholism and Drug Abuse Counselors, 1995).
All the major professional associations agree that sexual contact less than two years after termination of the professional relationship is unethical. If a sexual relationship occurs after a two-year interval, the burden rests with the therapist to demonstrate that there has been no exploitation. Considerations include: amount of time that has passed since termination; nature and duration of therapy; circumstances surrounding termination; client's personal history; client's mental status; and any statements or actions by the therapist suggesting a romantic relationship after terminating the professional relationship.
There is disagreement among practitioners about whether a sexual relationship initiated after termination is ever ethical. Some maintain that "once a client, always a client." One must also consider that given the fact that there are so few professionals working in the Deaf community, chances are that former clients may have few, if any, other options, than to return to the same practitioner for services when the need arises again. The transference elements of the therapeutic relationship persist forever, and therefore, romantic relationships with former clients are considered unethical by many professionals.
The roles of friend and clinician are not compatible. Friends do not pay their friends a fee for listening and caring. It will be difficult for a counselor who is also a friend to avoid crossing the line between empathy and sympathy. Because a dual relationship will be created, there is always the possibility that one of the relationships -- professional or personal -- will be compromised. It may be difficult for the counselor to confront the client in therapy for fear of damaging the friendship. It will also be problematic for clients, who may hesitate to talk about deeper struggles for fear that their counselor/friend will lose respect for them. It can be very difficult when a professional has to report to authorities about a client who is homicidal or suicidal, or in regard to a child abuse/neglect report. Imagine the turmoil faced by a professional who is also friends with that client.
Is it ethical to counsel a mere acquaintance? A friend of a friend? A relative of a friend? It is going to extreme measures to insist that counselors should have no other relationship, prior or simultaneous, with their clients. Often clients seek us out for the very reason that we are not complete strangers. We need to ask ourselves if the nonprofessional relationship is likely to interfere, at some point, with the professional relationship.
For Deaf professionals working with Deaf clients, the issue of social relationships can frequently conflict with their professional roles. This may be impossible to avoid. For example, often Deaf professionals receive their elementary and high school educations in the same mainstream programs and residential schools as their Deaf clients. When former schoolmates become counselor and client, there are many potential conflicts. Some Deaf professionals choose to minimize this quandary by moving to a different state or at least a distance from where they spent their school years.
Deaf professionals, like humans everywhere, have their own social needs. It is natural to seek friendships with others who share the same language, culture and values as themselves... in other words, within the Deaf community. Even when one takes care not to accept friends, or former classmates into their caseload, conflicts may still occur. It is not only how the Deaf professional perceives the relationships he/she has with others, but how those relationships are perceived by others as well. Consider a situation in which Jack, who had been thinking about starting counseling, attends a Deaf event, and observes the Deaf counselor, Janet, chatting and laughing with Sue, from whom Jack has had a stormy and ugly divorce.
In addition, the partners of Deaf professionals often are Deaf as well. Clients frequently and understandably are concerned about what the spouses share with one another. Again, even when the counselor maintains scrupulous boundaries regarding confidentiality with their mate, how it is perceived by the client remains an issue. Morever, the partner's social relationships can sometimes cause a conflict with the counselor's professional relationships. As an example, a therapist begins counseling with a new client. During the third session, the client brings in photos of her new boyfriend. To the counselor's chagrin, she realizes that the new boyfriend is a close friend of her husband's. This presents a challenge that could develop when the counselor's husband wants to go out socially with his friend and his friend's new girlfriend. How will the counselor explain to her husband why she won't go out?
Hearing professionals working with the Deaf community, often feel discomfort when attempting to maintain a professional boundary which is meant to provide their clients with privacy and respect. Often, a hearing professional=s attempts to respect the Deaf community are misinterpreted as being aloof and the perception could be that they view themselves as better than the Deaf community member(s). For some, the perception is that the hearing professional is only working with the Deaf community as a means to fulfill their own needs whether financial or professional. The perceptions of some Deaf community members do not necessarily match the true intent of the hearing professional. Professional interpreters for the Deaf often identify the need to categorize their lives and actively avoid allowing the different arenas of their lives to overlap. Some interpreters may attempt to be friendly and supportive with clients, but do not get involved with most Deaf community social activities. This may help with dual relationship issues, but can be viewed negatively by some Deaf people. Interpreters try to socialize with those Deaf individuals who understand their role, but it may be difficult to determine who does and does not understand their role. Some individuals are often put in a position of crossing roles by uninformed hearing community members, but also by individuals from the Deaf community as well. Interpreters who interpret personal situations may also inadvertently find themselves in the role as a counselor, someone who helps hearing members of their families. At times, it is very difficult to block out information known about an individual, such as physical/sexual abuse , substance abuse problems, etc.
Hearing professionals need to establish trust and often do this through becoming actively involved in the Deaf community. People get to know these professionals and develop a comfort level with them. An individual may have been well trained in the field s/he is practicing in, received education on Deaf culture and interacted with Deaf students while in college or graduate school, actively participated in Deaf community activities while in school and developed fluent sign skills. If, however, when the individual moves from college to professional practice, the person remains apart from the Deaf community s/he is likely to be rejected by the very community in which s/he hopes to work. And yet, because of the close nature of the Deaf community, remaining active in this community can potentially violate the ethical standards set by the work environments
For both Deaf and hearing professionals, it is a common occurrence that a Deaf person at a social gathering will begin talking openly about what is normally considered confidential. This is commonly dealt with by quickly encouraging the client not to discuss personal issues with them outside the office. Another problem encountered is when a client invites the counselor to a social function such as their wedding. When asked, several professional=s indicated that if they had terminated with the client, they might attend. The nature of the social function is also an important consideration. It might be more acceptable to attend a client's wedding than to invite a client to a party at the counselor's home. A similar problem occurs when the clinician attends a wedding of a colleague, and a Deaf client is also attending the same event.
Professionals serving the Deaf community face a challenge in managing dual roles since it may not be feasible for professionals to avoid social or other non-professional contacts with persons such as patients, clients, students, supervisees or research participants. Within the Deaf community, particularly in more rural communities, professionals may play several roles and are likely to find it more difficult to maintain clear boundaries than do their colleagues who practice in urban or suburban areas. There are situations in which refusing to provide counseling to individuals with whom one has another relationship, would prevent people in need from receiving assistance, which would raise other ethical concerns. For example, a Deaf professional with whom you have occasional professional contact, requests your services because there are no other nearby professionals who are fluent in sign language. Situations occur in which professionals are asked to provide individual services to Deaf consumers who have close associations with each other (e.g. husband/wife, members of the same extended family, business associates, close friends or enemies) which could likely result in a conflict of roles. When there are no other referral sources with the necessary communication skills, sensitivity to and awareness of Deaf culture issues, professionals are faced with the dilemma of deciding between treating both, or deciding which client will be referred to a hearing professional via an interpreter. In certain communities, shortages of interpreters raise other difficult dilemmas for a clinician who is trying to set clear boundaries.
With the proliferation of the internet, e-mail, and instant messaging, there are other circumstances which are exposing professionals to boundary dilemmas. It has become a relatively simple matter for clients to obtain personal e-mail addresses. Clients may contact their counselors via e-mail on a variety of matters from the innocent Aforwards@ to emergency situations requiring immediate intervention. It is wise for counselors to set clear and consistent boundaries with clients regarding internet communication which takes into consideration not only the current situation, but anticipating how it could be abused as well. For example, a client may begin by sending Aforwards@ to you on Deaf community related issues. Then the client sends an e-mail to change an appointment after several days of playing phone tag. Finally the client sends an e-mail informing you that her husband gave her a black eye and asks you what to do because she doesn=t feel safe staying at home, and has no where to go. Some professionals feel comfortable with the forwards, but draw the line at two-way communication. However, even the innocent Aforwards@ may cause concern for the professional, from an off-color joke to forwards containing religious proselytization. Many agencies are beginning to develop policies with regard to using the internet, not only directly with consumers, but for sending client-related information within the agency. It may be sufficient to replace the clients name with a code or record number before sending confidential information. However, keep in mind that the Deaf community is small, and it may be possible for others to identify the client from the description given even with the name encoded.
Exploitation of Relationships
There is a danger of exploiting the client because the counselor holds a more powerful position since they are paid to provide a service. The greatest potential for harm from a dual relationship may result from the power held, or perceived as being held by the professional. Whereas the counseling relationship will eventually come to an end, the power differential may remain indefinitely, adversely affecting any future, non-therapeutic relationship between counselor and client (Haas & Malouf, 1989). Counselors may hold a great deal of power over clients that can potentially lead to exploitation. When exploitation appears in the personal interaction between counselor and client, serious dual relationship problems quickly arise.
Power issues between Deaf and hearing members of the Deaf community, or between Deaf clients and hearing therapists call for even more careful examination.
Another area that may cause potential exploitation involves bartering practices. In the most recent revisions of the ethics codes of mental health professionals, the standards pertaining to bartering have been refined and expanded. Although bartering practices are not encouraged, the codes do recognize that there are circumstances in which bartering may be acceptable, and that it is important to take into consideration cultural factors and community standards. Bartering can open up a number of problems. As an example, consider a client who pays for therapy by working on the counselor's car. If the mechanical service is less than desirable, the chances are good that the counselor will begin to resent the client for having been taken advantage of, for being the recipient of inferior service, and for not being appreciated. The client, too, can begin to feel exploited and resentful if it takes many hours of work to pay for a 50-minute therapy session, or if the client believes the therapy is of poor quality. In some cultures or communities, bartering is a standard practice, and the problems just mentioned may not be as evident. For instance, rural communities may lend themselves to barter arrangements such as with one practitioner who worked with farmers in rural Alabama who paid for services with a bushel of corn or apples. Within their cultural group, this was a normal way of doing business.
Dual Professional Relationships
Most professionals who work with Deaf and hard of hearing individuals have faced dilemmas related to dual relationships. Conflict has been evidenced on several fronts. Individuals often felt an obligation to interpret for consumers or Deaf friends when no interpreter is available and the need for an interpreter was crucial. Individuals try to do their best to define their role and limitations while assuring that those involved understood why they were choosing to accept the role of interpreter. These individuals also use this kind of opportunity to educate those who are unfamiliar working with Deaf individuals of the legal and preferred method of acquiring interpreting services. Professionals encounter times when it would be unethical to choose not to interpret.
Many professionals work in jobs that include multiple roles. Sometimes, people define and clarify their roles categorically and their constituents are able to understand when an individual is working in one role versus another. In a recent survey of professionals asked to respond to a number of ethical issues(Guthmann, 1999). One respondent indicated, "As a hearing professional working with Deaf people, one is often required to wear several different hats, i.e. administrator, counselor, interpreter. All have different roles, functions and responsibilities and keeping these hats straight is very challenging.@
Deaf professionals who have another position in the Deaf community (e.g. committee member of their state NAD chapter, A.A.A.D. team member for softball, basketball, bowling, etc.) face similar challenges. Does the Deaf professional have to resign their committee or team membership when a client joins? Under what circumstances should the professional remain?
Given that the Deaf community is so small, we may learn something about a client outside of the counseling setting. One example might be when a clinician sees a client at a Deaf event and s/he appears to be drinking alcohol. In the office, the individual reports continued sobriety. Another example might be a social worker who realizes that the client recently referred is in a relationship with an individual who s/he knew from another state and was rumored to be HIV positive. The dilemma is that since the information was not obtained within the agency, is it still confidential? Can the counselor confront the client and tell him he was observed at the Deaf event drinking?
Another challenge occurs when a Deaf individual shares a problem with a friend and also shares the fact that they are seeing a professional therapist. In these situations, the friend may say something to the effect of, "Oh, I know you are seeing Joe, and he said, >blah, blah, blah.@ What Joe told the person may or may not be true or could be misinterpreted or confused in some way. Professionals question if they should acknowledge "Yes, I am seeing Joe." Does the therapist attempt to provide an accurate interpretation of the facts? Most frequently professionals agree that they cannot engage in this conversation, but still the challenge is there and the risk for misinformation to be spread by silence could be imminent. Because the Deaf community is so small, it is important to make sure that roles are clear.
Current ethical standards do not include specific references to potentially difficult situations that face counselors, especially in the area of dual relationships. The standards do, however, give general guidelines that the counselor may use to draw conclusions about his or her particular situation or ethical dilemma. Whenever we as professionals are operating in more than one role, and when there is potential for negative consequences, it is our responsibility to develop safeguards and measures to reduce (if not eliminate) the potential for harm. These include the following:
1.) Set healthy boundaries from the onset. Have disclosure statements or informed consent documents that include a description of the agency's policy pertaining to professional versus personal, social or business relationships. This written statement can serve as a springboard for discussion and clarification. If your agency does not have a specific policy referring to dual relationships, it is suggested that supervisors and supervisees have a clear and shared understanding of the kind of professional boundaries expected from employees of the agency.
2.) Involve the client in setting the boundaries of the professional relationship. Although the ultimate responsibility for avoiding problematic dual relationships rests with the professional, clients can be active partners in discussing and clarifying the nature of the relationship. It is helpful to discuss with clients what you expect of them and what they might expect of you. Professionals working within the Deaf community must scrutinize their motivations when entering into dual relationships. It is not difficult to imagine that some clients may not object or may even be pleased to see their counselors in a setting outside of the office. Deaf and hard hearing professionals also enjoy membership in Deaf clubs, teams, and other organizations. It would be very easy to rationalize by thinking " It's okay with the client" or "I can keep my roles separate." The onus is on the Deaf professional to anticipate problem areas. One way to do this is by talking with other Deaf professionals in your region, who have more experience, to brainstorm areas of potential conflicts.
3.) Informed consent needs to occur at the beginning and throughout the relationship. If potential dual relationship problems arise during the counseling relationship, these should be discussed in a frank and open manner. Clients have a right to be informed about any possible risks. This is particularly important for Deaf and hard of hearing professionals. Clients should be encouraged to raise any concerns they might have about, for example, the professional's partner and other social or professional roles they may have outside of the counselor's role. Professionals are advised to react to such inquiries without defensiveness, which could short-circuit such openness. Many professionals prefer to maintain impermeable boundaries around their private lives. Therefore, they should consider how they will respond to common questions such as AWhere do you go to school?@ and AAre you married?@ When such information is being requested for the purpose of determining if a dual relationship exists, as opposed to just for the purpose of idle curiosity, professionals working with Deaf and hard of hearing people may have a greater obligation for self disclosure than professionals in other fields.
4.) Discussion and clarification may need to be an ongoing process. Practitioners who are involved in unavoidable dual relationships need to keep in mind that, despite informed consent and discussion of potential risks at the outset, unforeseen problems and conflicts can arise.
5.) Consultation from other professionals can be useful in getting an objective perspective and identifying unanticipated difficulties. We encourage periodic consultation as a routine practice for professionals who are engaged in dual relationships. We also want to emphasize the importance of consulting with colleagues who hold divergent views, not just those who tend to support our own perspectives.
6.) Practitioners should work under supervision. When working with Deaf and hard of hearing individuals in certain areas of the country, there may be a lack of trained personnel. When dual relationships are particularly problematic, or when the risk for harm is high, supervision is critical. Often, professionals working with Deaf and hard of hearing individuals, are working alone within a larger agency which is providing similar services to hearing people (e.g. a single vocational rehabilitation counselor serving the Deaf/Hard of Hearing community, while the rest of the staff in the office work with hearing people). The supervisor may be someone with limited experience and knowledge of the Deaf community, although s/he may have expertise regarding other professional issues. In these situations, counselors may want to consider seeking out other professionals working with Deaf/hard of hearing in their area, even if they work outside their discipline. Your agency could also utilize a paid consultant to provide supervision who has knowledge of issues related to the Deaf community. This consultant may come from outside your region, so supervision could be arranged on an as needed basis.
7.) Education and supervision is essential. Talk with students and supervisees about balance of power issues, boundary concerns, appropriate limits, purposes of the relationship, potential for abusing power, and subtle ways that harm can result from engaging in different and sometimes conflicting roles. Encourage your agency to have a policy that addresses these issues as it pertains to the Deaf and hard of hearing clients that you serve.
8.) Documentation is an important ethical precaution. It is a good idea to keep a record of any actions taken to minimize the risk of harm.
9.) If necessary (and an option), refer the client to another professional. When a dual relationship cannot be avoided, professionals take appropriate professional precautions such as informed consent, consultation, supervision, and documentation to ensure that judgment is not impaired and no exploitation occurs. This often creates a dilemma for professionals who work with Deaf and hard of hearing clients, since there aren't always appropriate individuals to refer a client to in all areas of the country. It is important to recognize your limitations, and provide the kinds of service for which you are qualified
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