Dual Relationship and boundary crossing: A clinical issue in clinical psychology practice

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Vol. 7(2), pp. 29-39, March 2015
DOI: 10.5897/IJPC2014.0287
Article Number: 327553050945
ISSN 1996-0816
Copyright © 2015
Author(s) retain the copyright of this article
http://www.academicjournals.org/IJPC
International Journal of Psychology and
Counselling
Full Length Research Paper
Dual relationships and boundary crossing: A critical
issues in clinical psychology practice
Olusegun Emmanuel Afolabi
Department of Educational Foundation, University of Botswana, Botswana.
Received 21 October 2014; Accepted 2 February, 2015
The issue of boundary and dual relationship has been a major subject of concern in psychological
practice. Ethics complaints on dual relationship and boundary crossing continue to rise both in nature
and variety. This paper examined and shed light on the complexities surrounding dual relationship and
boundary crossing in clinical psychology by explaining the pertinent moral and clinical worries that
clinical psychologist's face daily in their practice. To achieve the objectives, the paper analysed
underlying themes: 1) using empirical review of relevant literature to identify clinician’s attitudes toward
risky and useful dual relationship and boundary crossing in clinical practice, 2) to learn whether
involving in dual relationships negatively or positively influences therapeutic outcome, 3) analyze the
concept, challenges and differences associated with dual relationship in clinical practice using decision
making model, and 4) come up with strategies that help clinical psychologists to make flawless ethical
standards as well as offering of moral guidance. Finally, the study suggests that, though dual
relationship sometimes enhances therapy, aids treatment strategy, and promotes positive relationship
between clinician and client, it also weakens the treatment process, hampers the clinician-client
cooperation, and brings instant or lasting damage to the service user.
Key words: Boundary crossing, dual relationship, ethical decision making.
INTRODUCTION
The issue of boundary and dual relationship has been a
major subject of concern in psychological practice in
recent time. In fact, psychology and other mental health
professionals have grown increasingconcerned about
“dual relationship,” in clinical practice including the
boundary crossing and boundary violation. Of most
concern is that, the issue has developed in the context of
professionalization to say the least. No time in the history
of psychology profession has the ethics of professional
conduct being questioned or confronted with a wide
range of contemporary ethical problems like it is today in
our society. The profession has been besieged with clear
E-mail: afo13@yahoo.com.
Author agree that this article remain permanently open access under the terms of the Creative Commons
Attribution License 4.0 International License
30 Int. J. Psychol. Couns.
messages about the immorality and negativity of dual
relationship and boundary crossings, to the extent that
the values and moral foundation of the psychology
discipline was seriously challenged both by clients and
consumers.
For instance, from the psychology course guidelines, to
literatures on moral values, and clinical internships, it has
been labelled as inappropriate, if not unprofessional for
clinical psychologists to get involved in the following
circumstances: unofficial work or private relationship with
clients, taken gifts offer, engage in physical contact and
last but not the least, socialize with clients in their
practice. This position also received plaudit from large
number of researchers, who one way or the other have
made massive contributions in the area of study,
particularly as regard to boundary crossing and dual
relationships (Corey, 2009).
In fact, most evidence suggests that, in most cases,
client’s faces higher risk during treatment due to
negativity of dual relationship. Professional training also
highlighted that boundary crossing is likely toaffect clients
‘right and also causes unjust sexual contacts. Though
this is reported as immoral and often linked to abuse and
harm, its continuous existence in clinical practice remains
an issue of concern till date. Similarly, health professional
associations obligated their members to respect and
uphold ethical standards and codes of conduct that
guides, regulates and protect clients from experiencing
bad practices. Therefore, for a clinical psychologist,
navigating through an ethical practice is a difficult
mountain to climb.
Also, psychologist and clients are regularly hindered by
uncontrollable circumstances that prompt porous
boundary between therapeutic and social relationships.
Additionally, earlier reports gave special consideration
to issues that are scientifically related to beliefs and
behaviours about boundaries. Among the problems that
emerged from these studies include: therapist sexual
category, career (psychiatrist, psychologist, social
worker), knowledge, marital status, practice situation
(private or public), locality, client sexual category, (such
as solo or group private practice and outpatient clinics),
practice area (size of the community), and last but not the
least, theoretical belief.
Surprisingly, the corollary assertion is the religious and
communitybeliefs about the issue, particularlythe way
they stuckwith the prospect of relationships concept in
clinical practice (Catalano, 1997; Doyle, 1997; Sidell,
2007). Despite all the aforementioned challenges, it is
important to state that research on boundary crossing
continue to provide guidance to difficult issues that
clinicians come acrossas they make judgement on
certain ethical issues in clinical practice. The question is,
how can we as psychologist blend our professional roles
and personal needs without compromising our profes-
sional responsibilities?
Purpose
Clinicians often miss the mark or fail to understand the
possibility for dual relationships, particularly, how to cope
with relational dilemma in clinical practice. This problem
remains an issue in clinical practice till date. This paper
examines and sheds light on the complexities of dual
relationship and boundary crossing in clinical psychology
and explains the pertinent moral and clinical worries that
clinicians faces in their practice. The paper also looked at
how dual relationship influences decision making process
in clinical practice. To achieve this, the paper focuses on
five underlying themes: 1) makes a distinction between
the following factors: risky boundary violations, useful
boundary crossings and inevitable or caring dual relation-
ships, 2) used an empirical review of relevant literature
to identify clinician’s attitudes toward risky and useful
dual relationship and boundary crossing, 3) observed
whether involving in dual relationships during clinical
practice has any negative or positive influence on
therapeutic outcome, 4) used the decision making model
to address the concept, challenges and variances
associated with dual relationship in clinical psychology
and 5) come up with strategies that help psychologists to
make flawless ethical standards and offer moral guidance
regarding dual relationships.
LITERATURE REVIEW
Dual relationship and boundaries in clinical practice
As we all know, psychology profession strives to promote
the emotional well-being and social welfare of others.
However, events in recent time continue to point towards
its utmostscrutiny. Clinical psychologist faces daily
challenges by handling the issue of dual relationships
and boundary crossing without compromising their pro-
fessional conduct and practice. In facts, earlier research,
particularly in the 80s and 90s demonstrated how
hypothetical orientation, community size, psychoanalyst
sexual characteristics, client sexual category, occupation,
and other issues impact psychology profession,
particularly on the issue of nature and suitability of
borderline crossings in clinical practice. Besides, the
period between the 1980s and 1990s also witnessed a
practical outburst of healthy argument and considerable
works on dual relationships, bartering, companionable
touch, out of office consultation and other nonsexual
boundary matters to mention a few in clinical practices.
Also, thought-provoking and considerable literature on
dual relationship in clinical psychology observed a
constructive and undesirable aspect of boundaries and
boundary crossings. A typical example of this is the
article published by American Psychologist in 1992
requesting for drastic changes in the ethics code of the
profession. This publication further showed lack of clarity
and awareness on when and how clinicians should
engage with clients. To buttress this position, the
Committee on Ethics of the American Psychological
Association in their report suggested that around 40 to
50%of the complaints receivedduring the period of 1990
to 1992 are on dual relationship. Also, Sonne (1994)
reported that, of all the problems facing APA members,
the issue of dual relationship was the most common
reason for their membership termination. Unfortunately,
as a result of the ambiguity attracted, the concept
continues to face serious litigation and disciplinary cases,
such as ethics committee hearings, and complaints to
professional boards of licensure. Research sees
boundary crossings as a well-fashioned treatment
strategy that increasesthe therapeutic success (Lazarus
and Zur, 2002). For instance, the recent APACode of
Ethics of 2002 offered a new insight into the issue of
boundary crossing by stating that, “Psychologists
ordinarily refrain from bartering”, that was in the 1992
code,and incorporate a new sentence, “Multiple relation-
ships that would not rationally be expected to cause
impairment, risk exploitation or harm are not unethical”
(APA, 2002, section 3.05), to the multiple relationships
unit.
In addition, the dual relationship also focused on role
theory. That is, the issue of social roles that covers innate
anticipations about how somebody in a specific role
should conduct himself or herself, along with the rights
and responsibilities that go along with the functions
needed to be addressed. Psychology profession uses
ethical principles to advance moral code and moderate
professional behaviour of their members (Beauchamp
and Childress, 1994). To buttress this assertion, the code
of conduct of the American Psychological Association,
ethical principles (APA, 1992) recognized "multiple
dealings". According to the code of conduct, it is not
being possible or sensible in particular circumstances,
“for psychologists to evade other non-professional
interaction with their clients" (p. 1601). However, going
into such interactions might prejudice the psychologist's
fairness; hinder their professional practice or abuse the
other party" (p. 1601).
Moreover, other health professionals also incorporated
in their ethical guidelines, principles and practice that
regulated and contained dual relationships in clinical
practice. Yet, conflicts arise when the beliefs and
expectations linked to one role call for the conduct that is
unsuited of the other role (Kitchener, 1988). Dual role
relationship happens when a particular person or an
individual concurrently or successively partakes in double
role (Kitchener, 1986). This definition is supported by
Afolabi 31
Carroll et al. (1985), where they established that in
addition to the professional rapport, the clinician created
some other rapports with the person: colleague, relative,
student or business partner. Despite all these challenges,
further research and literatures on boundary and dual
relationship are needed to aid and change our thoughts
and knowledge about boundary crossing in clinical
psychology. Therefore, the question is: what and what
should be prohibited or condoned when working with
clients? Which of the boundary crossings were
therapeutically helpful and harmful? And what therapeutic
methods are acceptable or not acceptable for certain
culture or communities?
Boundary crossing and violations in clinical practice
Logically and practically, not all boundary crossings were
harmful to clinical work. Studies in Europe and the US
demonstrated that dual role relationships can be neither
harmful nor helpful to clients and therapist (Edwards,
2007; Kitson and Sperlinger, 2007; Lazarus et al., 2004;
Pugh, 2007). Research also maintained a distinction
between boundary crossing and violations in clinical prac-
tice (Remley and Herlihy, 2009). Literature on ethical
issue in clinical practice found that boundary violations
are more injurious to clients, whereas, some boundary
crossing is beneficial (Knapp and Slattery, 2004). As a
consequence, professionals must endeavor to always
differentiate between conducts that are boundary cross
and those that are boundary violations. Also, the APA
Code of Ethics of 2002 made some clarification that
prevents authorities, courts and ethics committees from
employing the logical or community yardstick to evaluate
non-logically oriented psychologist, who embraced
boundary crossing interventions in a society where dual
relationship and boundary crossing are inevitable. On the
other hand, some school of thought, such as the
behavioural, and humanistic, sees supportive boundary
crossing that is client’s focused oriented (Lazarus, 1994;
Williams, 1997) as predicting positive therapeutic out-
comes. In addition, a body of psychology literature (Roth
and Fonagy, 1996, Hubble et al., 1999) also suggested
positive therapeutic outcome as a correlation of clinician–
client relationship. For example, Roth and Fonagy (1996)
and Hubble et al. (1999) also found that client variables
and extra-therapeutic elements are responsible for the 40
percent of progress made in therapy, while 30 percent
are accounted for the therapeutic relationship.
Consequently, a dual relationship happens when there
were multiple roles or external relationship between a
clinician and a client (Bleiberg and Skufca, 2005; Moleski
and Kiselica, 2005; Ringstad, 2008). This include: busi-
ness, social, communal, familial, sexual, and professional
oriented to mention a few (Nigro, 2004). A dual role
32 Int. J. Psychol. Couns.
relationship is also classified into two types: sexual and
non-sexual (Corey et al., 2007). Corey et al. (2007) linked
sexual dual-role relationships with negative outcomes.
They found that such relationship is the probable cause
of harm to client’s emotional and social wellbeing. These
interactions are categorized as harmful and can lead to
bigger potential for negative outcomes (Bleiberg and
Baron, 2005; Kolbert et al., 2002; Reamer, 2003).
Though this is not made equal, they are structured this
way in this paper in order to distinguish the degree of
harm they bring to clients.
Similarly, research on dual relationship emphasized
more on sexual misconducts between client-therapist
(Gutheil, 1989, Corey et al., 2007) and less on other
complex boundary crossings that are less noticeable but
pose difficulties for clinicians. Empirical evidence on dual
relationship found that boundary violations often go along
with or lead to sexual misconduct (Corey et al., 2007;
Gutheil and Gabbard, 1998), It was also established that
abuses themselves do not constantly institute misconduct
or misdemeanours or even bad method. While most
psychologists believethey have a better understanding of
boundary issues, using it when working with clients
remains difficult. It was even worse when we look at the
difficultyposed by the legal system, particularly, the
complainants’ lawyers, who see any act of boundary
crossing as immoral, flawed, and injurious to their clients.
This upshot is considered to be inherently harmful and
consistently inhibit and undermine clinical practice
(Epstein and Simon, 1990; Simon, 1992). Therefore, dual
relationships are intrinsically dangerous and clinicians
must endeavour to prevent it during practice.
In addition, many definitions were used to explain dual
relationship in clinical practice. Some of these definitions
are recognized by functions (Doyle, 1997; Edwards,
2007; Kitson, 2007; Nigro, 2003), while some by inter-
personal closeness (Pugh, 2007). Functional interactions
are defined as a situation where clients have an outside
contact with a clinician in shared or professional means
like community or business affiliation. In this circum-
stance, dual relational role happens when service users
and clinicians developed external relationships or
connection that was outside professional practices. The
former can happen without the service users and
clinicians’ knowledge; while the latter grows with the
understanding of the clinician (Borys and Pope, 1989).
This, according to the American Associate for Marriage
and Family Therapy (2001), builds and promotes abuse.
Therefore, clinicians must look-for a way out by taking
safety measures when working with clients. In addition,
psychoanalytic theory highlights the significance of
boundaries and the unbiasedposition of the clinician.
According to the theory, active and proper manage-
ment of transference and other therapeutic process need
a flawless and reliable boundary that allows the clinicians
to sustain the analyticsetting of therapy (Langs, 1988).
Like many other ideas in clinical practice, i.e., "therapy,"
"transference," and "association," thisconcept is closely
linked when observed.
Of most importance is that, clinical psychologists must
strive to understand and take into cognisance the three
values that govern the relationship between boundaries,
boundary violations, boundary crossings, and sexual
misconduct. To start with, sexual misconduct starts with
slight boundary violations. This showed an upsurge
incursion into the patient's space and culminates to
sexual contact. Gabbard (1989) and Simon (1989) found
that the act of engaging in sexual misconduct takes the
following sequence: moving from calling each other the
last-name to the first-name; engaging in the personal or
private discussion that hampers professional duty,
involving in body contact i.e., pats on the shoulder,
massages, and hugging each other; outdoor outing;
sessions at lunch; having dinner together, going for
movies and any other social event together; and last but
not the least engaging in sexual intercourse. However,
not all the act of boundary crossings or violations
promotes or signifies sexual misconduct. An act of
boundary violation of one professional ideology may be a
normal professional practice for another. For instance, a
“Christian psychiatry movement" might encourage
clinicians to attend church service with one or more
clients, while some permit an inherent boundary violation
that supports employing clients in therapy by using them
for experiment treatment setting. Though, negative
training, messy practice, lapses of judgment, unconven-
tional treatment ideas, and social-cultural condition are all
revealed as promoting boundary violation in clinical
practice, they arenot necessarily predictors of sexual
misconduct or action that pushes professional away from
the principle and standard of care. Despite all this, the
fact still remains that professional ethics committee,
criminal juries, regulating boards, to mention a few, still
seeboundary violations or crossings as aprobable
evidence of sexual misconduct.
Lastly, from historical perspectives, some psychology
school of thought favoured an inflexibleboundary crossing
or violation. For instance, studies found that some
professional therapeutic leaning permitted inflexible
boundaries using Freud as an example. This school of
thought illustrated how Freud himself occasionally sent
cards to his clients, borrowed them books, gave out gifts,
discussed his personal life with clients, ate with them
while on vacation, carried out outdoor analysis and last
but not the least, analysed his own biological daughter.
This, according to Guthiel and Gabbard, formed the basis
for emerging research on “explorations," and develop-
mental framework on boundary crossings and violations,
and echoed its authentication in clinical practice. Guthiel
and Gabbard (1993) found that judgments must be based
on the following situation and specifics: If exploration is to
be beneficial, professionals should accept the resolution
that "boundary crossing" is a descriptive word, neither
admiring nor disapproving.
Therefore, judges should determine the effect of a
boundary crossing on individual basis with emphasis on
context and situational-facts like probableharmfulness of
the violation to the client. A violation, then, represents a
harmful crossing, a transgression, of a boundary (p. 190).
Gutheil and Gabbard (1993) also looked at boundary
crossing and violations from the context of role, time,
place and space, money, gifts, services, clothing, lan-
guage, self-disclosure, and physical contact to mention a
few. Though they underlined the fact that border crossing
sometimes is salutary, neutral, and harmful”, they also
concluded that the nature, clinical effectiveness, and
influence of a particular crossing "can be measured
through systematic consideration of the clinical environ-
ment" (pp. 188-189). This argument confirms that
psychology profession is still confronted with how to
handle and resolve boundary crossing and dual relation-
ship in clinical setting. It also takes into consideration,
both the theoretical orientation and contextual situation of
both the client and the clinician. Although this issue was
later addressed some years later by Gutheil and Gabbard
(1998) in their article titled "Misuses and misunder-
standings of boundary theory in clinical and regulatory
settings"
Boundary decisions in context
Although boundary decision is a weird and forbidding part
of clinical practice, it requires a specific guideline and
decision that is different from the general code of conduct
of clinical profession. The theoretical momentous
recorded in the literature provided a basis for clinical
psychologists to decide whether or not it is appropriate
for themto cross a particular boundary with client at a
particular time and for a specific purpose. This can be
achieved when we carefully observe and analyze the
following factors: the therapeutic context, the clinician,
and lastly the client to mention a few. But then, the
decision taken should be based on a holistic approach to
ethics. This sound very difficult, if we consider factors,
such as the intense focus, the historical arguments, and
the doubt and worry that follows the boundaries decision.
Although boundary decision is a weird and forbidding part
of clinical practice, it requires a specific guideline and
decision that is different from the general code of conduct
of clinical profession. Therefore, approach to boundaries
as professionals should base on our attitude to ethical
decision-making. Moreover, research shows that people,
sometime, do not perceive their actions as having nega-
tive implication on others (Rest, 1983). Thus, this paper
Afolabi 33
revised the following basic assumptions about the ethical
awareness and decision-making from ethics literature
(Koocher et al., 2008; Pope and Vasquez, 2007).
1. As a clinician, ethical consciousness is a
constant process that contains constant probing and
individual obligation. For instance, conflicts with managed
care companies, the intensity of clients' needs, the
likelihood of formal criticisms of clients or condemnation
by professional co-workers about boundary decision
taken, mind-deadening procedures undertaken in the
course of our duties, exhaustion, just to mention a few,
can have adverse effect on our individual awareness and
cloud our sense of personal obligation. These factors, if
not properly considered, can overpower, drain, divert and
lure professionals into ethical slumber. It also makes
professionals more vulnerable to the extent that people
around us will start questioning our ability and decision
making.
2. Consciousness of professional codes and ethics
is a vital feature of critical thinking and ethical decisions.
Our professional codes and values enlighten rather than
control our ethical judgments. As psychologists, we
cannot substitute this for our emotion and thinking when
we face ethical challenges. At the same time, they cannot
defend us from ethical tussles and doubt that confront us
daily as professionals. Besides, we should understand
and appreciate individual uniqueness, particularly among
clients and therapist, irrespective of their similarities. We
should also appreciate the fact that every situation is
unique and constantly evolves; In addition, we should
understand that our professional inclination coupled with
contextual factors such as community belief, client’s
orientation, and culture influences our perception of
ethical decision.
3. The knowledge about the emerging profession
and scientific theory and research is another vital feature
of ethical competence. Therefore the assertions and
conclusions from research should not be inactively
acknowledged or automatically applied irrespective of
their popularity and acceptability. We must receive
published statements and recommendation with active
and complete enquiring.
4. Though majority of psychologist and counsellors
are reliable, devoted, thoughtful individuals, and
dedicated to high ethical standards, none is infallible. As
humans, we are all prone to mistakes in our professional
duties. We sometimes overlook things that are important,
make wrong choices, work from limited viewpoint, make a
wrong conclusion, and have a strong view about things
that are unwise. To address these problems, profess-
sionals should endeavour to always examine and assess
their judgement, i.e., “What if I'm wrong about this? Is
there something I’m not seeing? Is there any other way to
approach this situation? Is there any other effective or
34 Int. J. Psychol. Couns.
creative way to answer?”
5. As psychologists, we often find it easier to query
the ethics of others -- particularly in a tough and
contentious area like boundaries, while placing our own
opinions, expectations, and actions out of bounds. For
us to query the other colleague’s ethical decision, we
must also question our own decision and conduct and be
ready for others to question us. That is, we must take it
as duties to challenge and question our self, as we
engage in pointing out weaknesses, flaws, mistakes and
ethical blindness observed in other colleagues. This
action will help us to be productive and awake to the new
challenges and possibilities in our profession.
6. Also, as psychologists, we tend to question our
ability in areas where we are unclear, while, we find it
harder to query our self about what we are more certain
of or beyond questioning. It will be more productive and
beneficial for us as professionals to ask questions about
what we know and follow it to the conclusion. While this
might take us to a new challenge, it will also make people
around us to see our action as "psychologically improper"
(Pope et al., 2006).
7. As psychologists, we frequently bump into ethical
problems devoured of clear and easy answers. This
mostly happens in boundary issues than any other
matter. We might be threatened with vast needs that are
unsurpassed by adequate resources, conflicting duties
that appear difficult to resolve, and other uncountable
problems that we face in our day to day actions as
clinicians who offer support for those who are desperate
and in need of care. Also, we make unnervingly difficult
decisions about boundaries "on the spot" due to clients
and colleague’s unforeseen statement or actions. As a
result, we cannot run away from ethical challenges, as
they are part of our professional call.
8. Last but not the least, as psychologists,
consultation is crucial and paramount in our day-to-day
dealing with clients. We sometimes cover our own
personal issues. So, turning to other trusted colleagues,
particularly those who are not involved in our situation
helps in building ourethical decision-making. Similarly,
valuable ideas that are not well-thought-out, particularly
unknown biases can be pointed out by colleagues.
Furthermore, as we take hard decisions under pressure,
we may inadvertently but reasonably become more
worried about how the action might affect our duties. For
instance, as professionals, we tend to contemplate
whether our action can cause us a misconduct suit or
accrediting complaint, or estrange us with our depen-
dable referral sources. We also think that our action can
cause us to lose our clients or client’s provider.
Therefore, engaging in consultation helps us to reflecton
our decision's outcomes consequences for those who are
affected.
A decision-making model
For us as psychologists to continueto emphasize the
significant implication of dual relationship and boundary
crossing in clinical practice, a variety of ethical issues
must be considered if professional standard is to be
maintained. Simon and Shuman (2007) in their contribu-
tion to ethical decision making, found that a psychologist
should always form the habit of upholding applicable
boundaries even in the face of working with tough clients
and boundary-testing. They argued that in a therapeutic
practice, there are neither faultless therapists nor perfect
treatment. This statement alone ought to inspire
psychologists to be acquainted with their boundaries. It
also makes their work easier. This paper used a decision
making model to analyze potential dual relationships and
the boundary issue in clinical psychology. The model has
three advantages that make it appropriate for analysing
ethical issues in clinical practice. Firstly, it is specifically
designed to address potential dual relationship and
ethical problems confronting professionals in clinical
practice. Secondly, the model is too broad, i.e., it
provides limited direction for professional and narrow,
i.e., explained how clinician should behave. Lastly, the
model contains all possible dual relationship issues that
might happen, irrespective of the situational context.
Assumptions
The decision making model is purposely designed to help
professional colleagues to manage their relationships
effectively and efficiently, if they realised that they cannot
avoid it. The model uses seven assumptions to analyse
relationship and boundaries in clinical psychology. As a
model that focuses on ethical decision making, it
embraces all professional relationships that we undertake
in clinical practice. The model is not only limited to
interactions with service users, learners, or supervises, it
also applicable to anyone who uses psychological
services, irrespective of the kind of support provided. The
model believes that as professionals, our social role
should be professionally oriented, irrespective of our
situation and relationship with clients. The model also
assumes that, our aspiration should be on how to avoid
any act of dual relationships inall our dealings (APA,
1990). This remains impossible in most situations, as we
are all confronted with multifaceted problems and
challenges. Similarly, Kieth-Spiegel and Koocher (1985)
and Haas and Malouf (1989) supported this assertion by
reporting that such interactions are not totally avoidable.
This supposition is also related to the APA Ethical
Principles (APA, 1992) and the concept of overlapping
interactions presented by the Feminist Therapy Institute's
Code of Ethics (1987).
Afolabi 35
Table 1.Dimensions for ethical decision-making.
Low power Mid-range power High power
Little or no personal relationship or persons consider each
other peers (may include elements of influence). Clear power differential present, but
the relationship is circumscribed. Clear power differential with
profound personal influence.
Brief Duration Intermediate Duration Long Duration
Single or few contacts over short period of time. Regular contact over a limited period
of time. Continuous or episodic contact
over a long period of time.
Specific Termination Uncertain Termination Indefinite Termination
Relationship is limited by time externally imposed or by prior
agreement of parties who are unlikely to see each other
again.
Professional function is completed but
further contact is not ruled out. No agreement regarding when or
if termination is to take place.
Thirdly the model assumes that, because of the high
inherent risk that clinical psychologists experience daily
with clients, any interactions with service users must
beassessed critically in order to evaluate possible harm.
The model assumes that all dual relationships are
oppressive and that engaging in dual relationships come
with little or no risk and sometime helpful. However, the
act must always be circumvented, if we realise it can lead
to harm. Fifthly, the model also educates professionals
on how to manage pertinent issues, and make
recommendations for action. The model assumes that
professional's problem arises when psychologists
anticipate adding additional relationship to the current
one. However, the model is not planned forlesser
relationships. Lastly, the model proposes that in clinical
practice, the dimension of any relationship must be
measured from thepoint of view of theservice user, and,
not that of professionals. While we do not have access to
the client's feelings in most circumstances, our decisions
must be conservatively done in order to ensure that
clients’ welfare are protected.
The model
The decision model is based on three dimensions
(Gottlieb, 1986). These dimensions are vital to the ethical
decision-making process in clinical practice. The first
dimension observed in this paper is power. This is
explained as the amount of power that psychologists
weld in their relationship with their clients. Although this is
widely varied, psychologists who give a talk during
community practice have relatively little control over
those in the gathering, compared to those that work with
clients over a long-term period. Secondly, the time of the
relationship, coupled with the aspect of power is relevant
in decision making. That is in therapist-client relationship,
power rises over time. This means that, the intensity of
power is limited in a brief relationship, such as a single
assessment session for referral, and increases as the
interactions progress, i.e., student and teacher. Thirdly,
the clarity of termination means that the client and the
clinician might engage in a further professional contact.
For instance, a psychological assessment with a job
seeker involves clear-cut termination, with little or no
additional contact. Conversely, a clinical psychologist
working with family, sometime believes he has a long-
term obligation to his client. The question is, how can we
terminate a professional relation in clinical practice? This
model indicates that, a professional relationship with
clients continues until the client thinks otherwise,
irrespective of the time or contact in the interim. As soon
as the psychologist realises he/she does not understand
how the client feels, the ethical choice is to accept that
the client has the right to recommence the professional
connection in the future (Table 1).
Application ofdecision-making model
Decision making model can be applied in clinical practice,
particularly, when a psychologist is consideringhaving an
additional relationship. This can be achieved through the
following process:
Firstly, psychologists need to appraise theirpresent
relationship with clientsby using the following dimensions:
from the client's angle, where do the relationship lies on
each? How pronounced is the power difference, for how
long is the relationship, and is it evidently over? If the
relationship takes the right side on two or three of the
scopes (i.e., upper power, lengthier period and no end),
the probability of danger is higher; therefore, the clinician
must avoid creating any other relationship apart from the
existing one. However, for family, group or individual
therapist, the circumstances are clear. For them, the
36 Int. J. Psychol. Couns.
power differential is boundless. This means that the
therapy session can be extensive; therefore, ending such
session is not explicit. Besides, the clients might believe it
is their right to come back for treatment any time they
want in the future. Also, some families may perceive a
psychologist the way they see a family physician by
thinking that he/she will always be accessible anytime
they need a service. In such circumstances, the general
belief that a professional-client relationship does not end
is correct. On the other hand, if the relationship lies on
the left flank of the three dimensions (i.e., less power,
fewer periods, and clearly ended), one can shiftor move
down to the subsequent level. But, in a situation where a
relationshiplies inthe middle of the three dimensions,
some kinds of extra relationships are allowed, so, the
psychologist can possibly move down to the subsequent
level.
Secondly, psychologists must observe the anticipated
relationship based on the three dimensions analysed in
the present interaction with clients. If the expected
relationship cascades to the right side of the scopes (i.e.,
leading to long and indeterminate end), then such
relationship must not be jettisoned, particularly, in a
situation where the present relationship also cascades to
the right. On the other hand, if the projected relationship
falls in between the middle and the left side of the
scopes, the rapport can be allowed and the psychologist
can proceed to step three.For instance, a psychologist
might ponder about going into a relationship with a family
‘client she has worked with before thatneeds no further
engagement. In this situation, the clinician has enormous
power that isshort-lived and last for a definite period, and
thus makes closing the professional rapport more explicit.
The new rapport, though, having unstated and unclear
length and termination, comprises little or no power
difference. In contrast, if the first relationship falls to the
left part of the dimensions, and the anticipated
relationship falls to the right side, the relationship can be
promoted and allowed, i.e., a psychologist could ponder
about assessing a child that he or she has previously
engaged with the parents.
Thirdly, psychologists must look at the relationship for
anyrole incongruity and see if they fall in-between the
middle or the left side of the dimensions. According to
Kitchener (1988), role incongruity rises as a result of the
following factors: higher differences in anticipations of the
two roles, greater divergence of the duties of the two
roles, and last but not the least an upsurge in the power
disparity. Whenever the two diverse roles look highly
unsuited, the clinician should endeavour to reject or
abandon the expected relationship. For instance, a
clinician must not take member of staff as a transitory
psychotherapy client. But, if the relationship falls in the
middle, or left side of the sizes, and the level of
unsuitability is small, the clinician can continue with the
relationship. For example, a psychologist might consider
one of his employees as a participant in an assessment
process he or she is supervising. A psychologist, who
worked with a drug addicted man before, might consider
working again with him and his spouse for conjugal
problems.
Fourthly, clinical psychologists must be ready to
engage other professional colleagues in consultation. In
line with the seventh assumption, the new relationship
must be measured from clients’ viewpoint, and
judgements must be done in a conservative manner.
Meeting with a professional colleague must be seen as
normal, when making judgements. A colleague who is
used to such situations, i.e., the service user, and the
decision-maker is the perfect choice for professional
consultation. For instance, an associate might view it ill-
advised that a recently divorced, troubled, male medical
training supervisor agreesfor a date from one of his
female interns.
Lastly, it is also imperative for psychologist to always
engage clients in decision making, if he or she decided to
continue with the extra relationship. The psychologist
must assess the following factors, such as the impo-
rtance of the decision-making model, its justification, the
relevant ethical questions, obtainable options, and lastly,
likely adverse implications as an element of informed
consent. If the client is capable, and decides to involve in
an additional relationship, the clinician can continue, once
the service user is given ample time to think about the
other options. If the service user/client fails to be aware of
the quandary or is reluctant to ruminate on the matters
before making a choice, he or she is seen as at risk, and
the anticipated relationship should be forbidden.
METHODOLOGY
This paper analysed and reviewed empirical literature in order to
investigate and check new empirical studies that highlight the
complexities of dual relationship and boundary crossing in clinical
psychology. The study collated and reviewed relevant articles,
books, journals, and meta-analysis on dual relationship, boundary
crossing and ethical decision making. Both the ERIC and
PSYCHLIT databases were searched using the following key
words: ethical decision making, boundary crossing, dual relation-
ship and clinical psychology. This procedure initially reported about
1298 articles, journals, technical reports, paper presentation and
book chapters covering more than 23 year period. Based on the
abstracts retrieved from this initial 1298 plus articles and
publications, the search was lessened to a relatively few hundred of
studies that are pertinent and relevant to the theme of this paper.
The contents of the remaining several hundred of articles cum
journals were further scrutinised and only those that reported
empirical findings were kept aside and used in this review, while
others were left out for further consideration. This process shows
that only a few studies documented empirical findings on boundary
crossing and dual relationship in clinical psychology practice. To
verify references, manual searches of relevant journals and articles
related to the paper are performed.
Case Study 1
Dr Badmus is a clinical psychologist working in a private
psychotherapy clinic. A young lady in her middle twenty was
referred to her for relationship issues. After working with her for 3
months, the client thinks that her problems are over and after
discussing with the psychologist, they both agreed to end the
therapy. Three years later the client and the psychologist,
coincidentally, met again at a get together party. They both had a
lengthy discussion and at the end of the day, they exchanged
address and the client asked the psychologist if they can meet
again. The clinician responded and quickly pointed out that he
would have loved to take her out, but due to their past professional
contact, he would not be able to do so. To buttress his point, he told
her that such relationship would affect any future professional
consultation she might need from him. She agreed with him, and
suggested that if there is any need for future consultation, she
would not mind him referring her to a professional colleague.
Though they went out together for quite some time, the relationship
did not last long. Two years after ending their social relationship,
she called the psychologist and requested for service. The clinician
declined the consultation by mentioning their last discussion at the
party and offered to refer her to a professional colleague. She
immediately gets annoyed with the suggestion and bangs the
phone. Since then, there has been no contact between them.
Case analysis
Many people would contend that Dr. Badmus took a good decision
the way he handled the situation. He was conscious of the danger
that may follow his friendship with a former client. Besides, he was
even aware of the informed consent processes in the hub of a
social event. But, if all his action is right, then, what is the problem?
By using the model to analysis the scenario, it shows that Dr.
Badmus had a rapport with high power of intermediate period and a
seemingly exact termination. The model also discloses the effect of
great role unsuitability when counsellors get involved in a social
relationship with former clients. Moreover, Dr. Badmus should have
considered the client's need in these circumstances. Though
agreed with her, the clinician failed to observe and analyse the
intended relationship from the client’s perspective. Additionally, the
model recommends a waiting period and discussion with a pro-
fessional colleague. Supposing Dr. Badmus, followed the principle
of the model to the end; he might have re-evaluated the situation.
Case Study 2
Dr. Titus is a private clinical psychologist practitioner; one day he
was having a psychotherapy session with a young lady who was
having a relationship problem. During the therapy session, the
young lady told the clinician about her problem in keeping a long
term relationship with the opposite sex. She told the psychologist
that since the death of her husband, she has not been able to hold
a relationship for a long period. Some weeks later the client called
Dr. Titus and reminded him of their conversation and asked if he
can recommend somebody for her. As a result of their conversation,
Dr Titus decided to consult a trusted professional colleague for
advice. After his consultation with a professional colleague, Dr Titus
called the client and declined further consultation with her.
Analysis
In analysing this scenario, some might think Dr. Titus action is
Afolabi 37
conservative. The client is a mature lady who has a right to make a
decision. The model demonstrates that the power differential was in
the middle, of unknown closure and perhaps of long period. Dr.
Titus recognized that as long as the power differential is sustained,
the inharmoniousness in the role would continue. The discussion
had shown additional information critical to his decision. Dr Titus
understood that if he went ahead and introduce someone to the
client and they start a relationship, she might feel indebted to him
and susceptible to potential manipulation. Had the relationship
failed, the client might displace or have hostile feelings towards
him, and this may have an impact on their future professional
conduct together. Moreover, Dr Titus followed the model recom-
mendation for a waiting period and discussion with a professional
colleague and this went a long way to help him make a positive
decision, which was eventually useful in his decision making.
DISCUSSION AND CONCLUSION
Though the American Psychological Association (APA)
came out with elaborate ethical values and principles that
guide the professional conduct of its members, there is
still lackof comprehensive, systematically gathered data
about the degree to which members believe in or comply
with these guidelines. Research has long identified lack
of broad and scientifically generated data on psycho-
logists' beliefs and compliance with ethical principles as
the bane of the profession. As important as they are,
such information, as important are not available to guide
individual clinical psychologistsin their decision making or
the APA in their efforts to review, improve, and spreadthe
code of practice. For instance, evidence till date, still
shows that little is known about the valuable experience
needed in regulating appropriate conduct in clinical
practice. As mentioned in most of the ethical literature,
the practicability of boundary issues remains unsolved in
clinical practice. Although the ethical principle offers
common guidelines for clinical psychologist, little or no
guideline is offered when it comes to decision making.
Nonetheless, there are a number of reasons why ethical
conducts continue to influence decision making process
in clinical practice. This paper describes the relevant
steps that psychologists must followin the course of
making a professional decision , and defines a decision-
making model that helps psychologists make
professional judgement. Though the model is relevant to
psychologists, thereare still some issues that need to be
solved if professionalism is to be sustained.
Also, the study demonstrated that power differential
remained even when it is evidently clear that a service
has ended. For instance, some clients strongly believe
that they can come back for further service despite the
fact that the session has ended. The question is, should
we engage former psychotherapy clients in social
relationship even withclear evidence to show that the
service has ended? If this arises, does making
relationship with such client untenable and unwise? This
38 Int. J. Psychol. Couns.
question continues to influence decision making in clinical
practice, thus hampers the success of the therapy. Also
psychologists face similar nettlesome conditions when
they had middle to long-term personal contact with clients
and interns. For instance, in the beginning of the
treatment, the power differential was pronounced, and
contacts may go on for ages, and then developed into
peer, friendly, companion-able or passionate ones. In this
case, it is advisable that psychologists take into
consideration the issue illustrated earlier, thatstate that
the scopes of the relationship must be viewed from the
client’s perspectives. So, it is not sufficient to conclude
that the approved professional rapport is reaching
termination. Finally, as good as a decision making model
is to clinical practice, it still lacked empirical validation.
Hence, for it to be properly applied in clinical practice, it
requires a subtle professional judgement as well as
careful and thorough reflection from a clinical psycho-
logist. Finally, it is worth mentioning that consultation is
an important ingredient in the decision-making process.
There is still no alternative to professional consultation of
trusted colleagues.
RECOMMENDATION
As the decisions whether or not to cross a borderline
threaten us every day, they are often subtle and influence
the progress recorded in the therapy. Although dual
relationships sometimes enhance therapy, aid the treat-
ment strategy, and promote the clinician-client working
relationship, they also weaken the treatment process,
hamper the clinician-client cooperation, and bring instant
or lasting damage to the service user. At the individual
level, psychologists should take cognisance of their
individual and professional needs and be self-care. They
should endeavour to achieve those needs without
allowing them having any bearing on their relationships
with clients. Based on these analyses, this paper
recommends that: 1) professionals should position
themselves and make sound choices by coming up with a
strategyon boundary crossings that focus on their general
attitude to ethics. 2) Efforts must be directed toward
staying up-to-date with the evolving law, ethical values,
research, concept, and practice procedures. 3) Before
taking any decision, a psychologist must take into
consideration the situational context of each client.4)
Clinical psychologist must involve incritical thinking
devoid of common cognitiveblunders that can affect
clinical duties. 5) Efforts should be directed toward
avoiding personal responsibility for our decisions and we
should justify our choices and conduct. When we realise
our mistake or notice that our boundary choices have led
to woe, we should apply accessiblemeans to come up
with the best solution to solve the problem.
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    ... 7. However, most schools of psychotherapy impose a clear boundary between therapist and client with the goal of maintaining mutual independence such that the therapeutic focus is on the client's and not the therapist's needs (Afolabi, 2015). It is viewed as unprofessional and unethical for therapists to focus on their own problems when interacting with clients. ...
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