The main concern as a counselor is creating and managing professional limits, which must always center on the best interests of the client. However, except for behaviors of an illegal nature, ethical concerns can negatively interfere with one’s work because there are no straightforward answers. The detrimental effect of sexual intimacies within a professional counseling relationship makes it apparent that it is always inappropriate to have a sexual relationship with a client. In the first part of this paper, a case study of a client who engaged in a sexual relationship with her former psychologist is illustrated. Main ethical concerns, application of specific ethical codes, techniques to address the issue, and an ethical decision-making process are analyzed to resolve the case. In the second part of this paper, an interview is conducted with a clinical psychologist, which highlights the issues relating to ethical standards and practices, transference, multicultural concerns, boundary violations, and supervision.
The structure within which a therapist and client relationship occurs is beneficial for adequate counseling. Healthy limits create a relationship that is proficient, trusting, and demonstrates an environment for competent psychological counseling. Therapists must know that ethical violations can relate to the gray areas between transference and countertransference (Redlich, 1990). Corey, Corey, & Callanan, (2011) state that sexual relationships between therapists and clients continue to receive substantial research in the professional literature. Sexual relationships with clients are undoubtedly unethical, and all of the main professional ethics codes have explicit prohibitions against these violations. Furthermore, such relationships are a violation of the law. The power imbalances may continue to sway the client well after the end of the counseling relationship, and professional standards forbid a therapist from engaging in any sexual relationship with a past client in which counseling service was provided in the past five years (Bouhoutsos & Greenberg, 1999). Therapists must know that any dating relationship is considered a form of inappropriate behavior that could fall within the classification of sexual abuse. The harmful effects of sexual abuse within the professional standards makes it obvious that it is inappropriate to have a sexual relationship with a client.
Rachel, a 24-year-old client, comes into her counselor’s office and states that she feels suicidal because she engaged in a sexual relationship with her former psychologist. Because the assessment and management of a suicidal client is extremely serious, the counselor addresses this issue immediately. As she approaches the suicide assessment, the counselor keeps three things in mind: consult with a colleague for another opinion, document the process, and evaluate the client’s risk for harming herself (Corey, Corey, & Callanan, 2011). The counselor asks Rachel to sign a no-suicide contract. In the contract, she agrees to avoid harming herself, but if she feels she cannot control herself, she would call 911, or another person who is close to her and she can trust. The counselor also asks her to talk with her family about her feelings. Rachel states that she disclosed to them that she is very depressed and is feeling suicidal.
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The counselor explains to Rachel at length about dual relationships. Usually when there is an ethical infringement such as a psychologist having a sexual relationship with a client, the relationship begins with a non-sexual relationship (Brown, 2002). Rachel says the relationship began in “good faith” and as time passed, the boundaries between her and the psychologist began to weaken. The risk of harm occurring to Rachel increased as the psychologist and client became more intimate, and there is a greater power differential just as there exists between men and women in general. The counselor explains about how these professionals may exploit and seduce female clients intentionally for their own satisfactions.
Rachel proceeds to tell her counselor about the symptoms and feelings she is experiencing: a sense of guilt; emptiness and isolation; sexual confusion; trust issues; role confusion in therapy; severe depression and acute anxiety; suppressed anger; and cognitive dysfunction involving flashbacks, nightmares, and intrusive thoughts. The counselor concludes that the client is indeed experiencing almost all of the symptoms described as Post Traumatic Stress Disorder.
Main Ethical Concerns
A professional counseling relationship, which involves sexual relations, is against the law. Sexual exploitation in a professional counseling relationship is described as, “sexual involvement or additional forms of physical relations between a practitioner and a client” (Brown, 2002, pg. 79). Situations involving sexual actions between a counselor and client are never acceptable. According to Moustacalis (1998), sexual activity between a client and counselor is always damaging to client well-being, despite of what reason or beliefs the counselor chooses to justify it. However, client consent and compliance to participate in a sexual relationship does not diminish the practitioner of his duties and responsibilities for adhering to ethical standards. Failure to take responsibility for the professional relationship and permitting a sexual relationship to develop is a mistreatment of authority and confidence, which are exclusive and fundamental to the therapist and client relationship.
In any professional counseling relationship, there is an innate power inequity. In this case study, the former therapist’s power arises through the client’s belief that the therapist has the proficiency to help with her problems, and the client’s confession of personal information, which is usually kept secret. The reality that counseling services cannot be successful unless clients are willing to open up does not change the main power imbalance (Moustacalis, 1998). Therefore, the psychologist has an important responsibility to take action, do no harm, and is ultimately liable for managing boundary issues if violations occur. Ironically, the former therapist in this case failed to maintain appropriate professional ethical standards and caused psychological damage to his client instead of promoting a trusting and healthy professional relationship. Because of the seriousness and complexity of these sexual boundary violations, Rachel currently suffers from suicidal thoughts, depression, anxiety, and post-traumatic stress disorder. The power difference that is in the therapist-client relationship causes Rachel to find it complicated to discuss boundaries or to recognize and defend herself against ethical violations. In addition, clients may at times prompt a sexual relationship and their behavior could promote violations (Marmor, 2000).
Application of Specific Ethical Codes & Techniques to Address Dilemma
According to the 2005 American Counseling Association’s (ACA) Code of Ethical Standards, “Sexual or romantic counselor-client interactions or relationships with current clients, their romantic partners, or their family members are prohibited” (A.5.a). Relating to former clients, “Sexual or romantic counselor-client interactions or relationships with former clients, their romantic partners, or their family members are prohibited for a period of 5 years following the last professional contact. Counselors, before engaging in sexual or romantic interactions or relationships with clients, their romantic partners, or client family members after 5 years following the last professional contact, demonstrate forethought and document (in written form) whether the interactions or relationship can be viewed as exploitive in some way and/or whether there is still potential to harm the former client; in cases of potential exploitation and/or harm, the counselor avoids entering such an interaction or relationship” (A.5.b). In this case, Rachel’s emotional intensity and stress generated due to difficult or conflicted personal relational situations may override her understanding of healthy therapeutic and relational processes. In addition, it suggests clients, such as Rachel, who possess little therapeutic knowledge relating to boundary violations, or with limited understanding of therapy, are particularly vulnerable (Marmor, 2000). The ACA Code of Ethical Standards also states that counselors act to avoid harming their clients (A.4.a). During their sexual relationship, Rachel’s former practitioner may assume she is responsible in the relationship and can sustain herself emotionally and psychologically. However, not all clients have this ability and look to their therapist for support. Engaging in a dual sexualized relationship is destructive to client welfare and is a dysfunctional means to offer ‘security’ to a vulnerable client (Robinson, & Reid, 2000).
Techniques to address this case are complex, yet imperative to consider. First, Rachel’s former therapist needs to be reported to the state licensing board for ethical complaints of sexual intimacies with a client (Hall, 2001). During this process, Rachel should know that a breach of client confidentiality will occur as a part of the reporting process. Next, Rachel must find a reputable attorney because there is a good possibility that the former therapist may deny the accusation or blame Rachel by saying she is making false claims. The former therapist could be the subject of a lawsuit. Malpractice is a serious legal concept involving the failure of a professional to provide the level of services or to implement the skill that is normally expected of other professionals (Hall, 2001). He risks having his license taken away or suspended as well as losing his insurance coverage and his credibility as a therapist. This ethical violation could have been avoided if the therapist carefully considered the dynamics of a healthy therapeutic relationship and put the client’s needs before his own.
The ethical decision making process used for the case of Rachel would be to first define the problem. Rachel is in search of counseling because she engaged in an intimate, sexual relationship with her former psychologist. Rachel currently feels guilty and resentful toward her former psychologist and is experiencing suicidal thoughts. The next vital step in ethical decision making is evaluating moral principles (Corey, Corey, & Callanan, 2011). In this case, the moral principle that would take priority is non-maleficence. Rachel expressed her need to talk with a counselor and feels she has a limited number of people she can trust. Since the former therapist violated the sense of non-maleficence, it may cause Rachel harm if the current therapist were to defy her trust because Rachel could panic and hurt herself if she feels she has no other option. Rachel must form a trusting relationship with her current counselor, and the counselor must maintain that sense of trust. The next step would be to talk with a supervisor or colleague to hear other perspectives or ideas. The fourth step is to make sure as her current therapist, decisions are not influenced by emotions (Corey, Corey, & Callanan, 2011). Having emotional awareness can ensure an accurate assessment of the situation. Therefore, encouraging Rachel and building up her sense of self-worth is essential. By creating a plan that includes psychological help along with legal action, Rachel will likely feel as though she has some control when assessing each option. The final step is implementation, and the therapist should help Rachel follow through with her plan.
Dr. Jennifer Lambert is a clinical psychologist and received her Psy.D from the University of Illinois. During the 45-minute interview, she provided thoughtful insight into the issues relating to ethical standards and practices, transference, multicultural concerns, boundary violations, and supervision. First, making ethical decisions involves developing an acceptance for dealing with gray areas and coping with uncertainty. Even though awareness of the ethical standards of one’s profession is significant, this knowledge is not enough. Ethical codes provide direction in assisting one in making the best informed-decisions for the benefit of clients and the practitioner. These standards may differ among agencies, and it is vital that every human service professional becomes aware of the exact policies of the agency.
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Secondly, Dr. Lambert discussed an example of transference. She is a supervisor for an adolescent mental health clinic and works with many great colleagues. One of her colleagues is an excellent therapist, but often she asks Dr. Lambert for marital advice. She does her best not to sway her colleague because Dr. Lambert knows the harm it could cause to their relationship. Instead, she encourages her colleague to inspect her own beliefs and values without imposing or giving direct advice. This story is an example of colleague transference and possible dependency if Dr. Lambert is not cautious when discussing these issues.
Next, Dr. Lambert spoke about multicultural concerns and boundary violations in therapy. As a therapist, it is key to know and appreciate one’s own cultural background, yet not push values onto clients. To be effective with diverse clients, therapists must accept and celebrate cultural differences and view them as a positive learning experience. By practicing acceptance while being curious, it will bring understanding between cultures and assist in expanding trust in the therapeutic relationship. Maintaining professional and personal boundaries is a necessity in the therapeutic process. If a therapist becomes emotionally over-involved with a client, counselors will likely lose their objectivity and ultimately cannot exercise proper judgment in the helping process. When counseling adolescents, maintaining appropriate boundaries can be complicated. Often, an adolescent sees the therapist as a friend to confide in, but if the young client becomes too dependent, relationship boundaries may be crossed. This can also violate boundaries if the therapist does not address the dependency.
Lastly, a vital element in the licensing process is supervision. Dr. Lambert believes the role played by the supervisor is important for the appropriate development of the trainee. The supervisee should be open to the ideas and leadership style of the supervisor. Above all, supervision was developed to help future therapists enhance their competency and during this process, the trainee will learn the necessary skills that will assist them in their entire professional career. One challenge to supervision is the continuous shortage of qualified professionals and the incapability to supply sufficient hours for proper competency development. When choosing a supervisor, an individual with a good moral and ethical approach is an area of concern. This factor would assist in developing a proper personal approach, and a supervisor must teach by example the importance of understanding transference/counter-transference, diversity, and rapport. Supervision is a support system, which gives the opportunity to present challenges that one may not be prepared to deal with when they occur.
Ethical decision making in the counseling field is a continuing assessment with no simple answers. In order to encourage the well-being of clients, counselors must always balance the professional ethical codes with their own life experiences and personal values to make critical decisions about how to assist their clients successfully (Redlich, 1990). Therefore, understanding the ethical codes and the effect of inadequate counseling practices are helpful for counselors as they maintain therapeutic relationships with clients. Nonetheless, even though professional codes of ethics offer guidelines for how counselors should act with clients, they do not give complete answers for how counselors must act in every circumstance. Ideally, counselors should integrate their knowledge of professional ethics with good judgment to facilitate the best interests of their clients. It is imperative for counselors to create personal and professional boundaries with their clients in order to avoid problems such as unethical counseling, favoritism, exploitation, harm, etc (Corey, Corey, & Callanan, 2011). Counselors must treat all clients respectfully, compassionately, and responsibly, while not compromising the professional relationship established with them.
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