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The Legal Department articles are not intended to serve as legal advice and are offered for educational purposes only. The information provided should not be used as a substitute for independent legal advice and it is not intended to address every situation that could potentially arise. Please be aware that laws, regulations and technical standards change over time. As a result, it is important to verify and update any reference or information that is provided in the article.
This article will review relevant ethical standards, the types of dual relationship and boundary violations that tend to prompt the Board of Behavioral Sciences (BBS) to take disciplinary action, ways to avoid liability, common exclusions in professional liability insurance policies, and potential consequences for inappropriate relationships with clients.
Sara Jasper, JD, CAE
Psychotherapists are constantly structuring, evaluating, and navigating ongoing relationships with their clients. Due to the potential for boundaries to become blurred, psychotherapists must be mindful of, and recognize, what constitutes a dual relationship. This article will review relevant ethical standards, the types of dual relationship and boundary violations that tend to prompt the Board of Behavioral Sciences (BBS) to take disciplinary action, ways to avoid liability, common exclusions in professional liability insurance policies, and potential consequences for inappropriate relationships with clients.
The following sections of CAMFT’s Code of Ethics offer direction for maintaining appropriate boundaries with clients:1
1.2 DUAL RELATIONSHIPSDEFINITION:
Marriage and family therapists are aware of their influential position with respect to patients, and they avoid exploiting the trust and dependency of such persons. Marriage and family therapists therefore avoid dual relationships with patients that are reasonably likely to impair professional judgment or lead to exploitation. A dual relationship occurs when a therapist and his/ her patient engage in a separate and distinct relationship either simultaneously with the therapeutic relationship, or during a reasonable period of time following the termination of the therapeutic relationship. Not all dual relationships are unethical, and some dual relationships cannot be avoided. When a concurrent or subsequent dual relationship occurs, marriage and family therapists take appropriate professional precautions to ensure that judgment is not impaired and that no exploitation occurs.
1.2.1 UNETHICAL DUAL RELATIONSHIPS:
Other acts that would result in unethical dual relationships include, but are not limited to, borrowing money from a patient, hiring a patient, engaging in a business venture with a patient, or engaging in a close personal relationship with a patient. Such acts with a patient’s spouse, partner or family member may also be considered unethical dual relationships.
1.2.2 SEXUAL CONTACT:
Sexual intercourse, sexual contact or sexual intimacy with a patient, or a patient’s spouse or partner, or a patient’s immediate family member, during the therapeutic relationship, or during the two years following the termination of the therapeutic relationship, is unethical. Should a marriage and family therapist engage in sexual intimacy with a former patient or a patient’s spouse or partner, or a patient’s immediate family member, following the two years after termination or last professional contact, the therapist shall consider the potential harm to or exploitation of the former patient or to the patient’s family.
Marriage and family therapists do not use their professional relationships with patients to further their own interests and do not exert undue influence on patients.
1.14 POTENTIAL CONFLICTS:
Marriage and family therapists carefully consider potential conflicts when providing concurrent or sequential individual, couple, family, and group treatment, and will take reasonable care to avoid or minimize such conflicts.
3.4 PROFESSIONAL ASSISTANCE:
Marriage and family therapists seek appropriate professional assistance for their personal problems or conflicts that impair work performance or clinical judgment.
3.8 HARASSMENT OR EXPLOITATION:
Marriage and family therapists do not engage in sexual or other harassment or exploitation of patients, students, supervisees, employees, or colleagues.
Examples of Dual Relationships/Boundary Violations
As cited in David Jensen’s article, “Unlawful and/or unethical Dual Relationship? A Word to the Wise,” the BBS tends to punish psychotherapists for dual relationships that are exploitative, that affect professional judgment, and fall in at least one of the following nine categories:
The first two categories of relationships are often viewed by the BBS as especially egregious because they compromise the integrity of the therapy and take advantage of clients who have put their trust and faith in the professionals they work with to guide them during the most vulnerable stages of their lives.
Strategies for Avoiding Liability
For the sake of consumer protection, the BBS requires licensees to earn a minimum of 6 continuing education credits in law and ethics during every renewal period. In order to protect the well-being of clients and avoid engaging in actions that may result in liability or a licensing complaint, therapists must first and foremost familiarize themselves with, and regularly revisit, the ethical standards for professional conduct that have been cited above. When forming relationships with clients, therapists also have a responsibility to establish clear boundaries that set the tone for appropriate therapist-client interactions. In addition to discussing information found in an informed consent, therapists should also consider discussing the following topics with new clients:
When there is potential for a dual relationship, therapists must take precautions to ensure judgment is not impaired and that clients are not exploited. Therapists who are concerned that a therapeutic relationship is headed in a dangerous direction can address those concerns by seeking consultation and/or supervision to determine whether they can continue to provide treatment that will be effective for the client and in the client’s best interest. Some situations may require therapists to terminate and refer out for the sake of avoiding harm to the client. Since therapists and clients benefit when treatment issues are addressed directly and promptly, therapists should not delay in seeking support from colleagues, supervisors or CAMFT when necessary.
Any potential dual relationship should be documented in a client’s file. The file should include information about how a situation with a client was handled, information about the consultation or supervision received, and the rationale for any decisions made. A welldocumented file will be helpful in the event a patient or third party files a complaint.
Engaging in a relationship with the patient after termination of therapy requires therapists to consider whether the subsequent relationship is exploitative of the client. The Code of Ethics requires therapists to wait a reasonable amount of time2 before entering into a subsequent relationship with a former client. A reasonable amount of time is not defined, and therefore, allows therapist to utilize best judgment when making such decisions. Even after time has passed, it is possible for a relationship with a former client to be exploitive. It is the responsibility of the therapist to demonstrate that the relationship with a former client does no harm.
There are, however, dual relationships that are unavoidable. For example, therapists who are living and working in rural communities may not be able to refer out cases where secondary concurrent relationships exist because they are the only care providers in their area. Likewise, a psychotherapist who is the only Vietnamese speaking behavioral health provider in a 60 mile-radius may have no choice but to offer services to those with whom he or she has a dual relationship. The Code of Ethics recognizes and accounts for these types of situations.
Professional Liability Exclusions
Most professional liability insurance policies do not apply to claims or suits for damages arising out of the following:
Professional liability carriers would generally only defend an insured who was accused of an inappropriate client relationship, such as harassment, molestation or sexual abuse, up until the point that the insured accepted or admitted guilt. Some insurance carriers offer vicarious sexual abuse and molestation coverage with a $1,000,000 limit that can be added to their policy. This type of policy would cover insureds vicariously in the event a professional was held liable for another person’s abuse conduct such as negligent supervision, reporting, employment, etc.
Potential Consequences for Dual Relationships or Boundary Violations
Dual relationships that impair professional judgment, exploit, and harm clients are illegal, unethical, considered unprofessional conduct, and may be grounds for revocation of a licensure or registration3.
Under California Business and Professions Code §4982.26(k), it is unlawful for therapists to engage in sexual contact with a client or former client if the therapeutic relationship terminated less than two years prior. The minimum penalty for such an offense is revocation or denial of a license or registration and cost recovery.
The minimum penalty for sexual misconduct4 with a client is 120 to 180 days actual suspension during which time the therapist would be required to undergo a psychological or psychiatric evaluation. The therapist would also be required to take and pass the licensure exam before being allowed to resume the practice of psychotherapy, be on probation for 7 years, and only be able to practice under supervision. The board would be able to recover the costs of administering probation (currently at $1,200 a year). The maximum penalty for sexual misconduct is revocation or denial of a license or registration and cost recovery.
A therapist who is found to have intentionally or recklessly caused emotional harm to a client5 would, at a minimum, undergo a 90- to 120-day suspension, five years probation, a psychological or psychiatric evaluation, psychotherapy, and could only practice if under supervision. The Board would have the discretion to revoke or deny a license or registration and impose cost recovery. For psychotherapists who are CAMFT members, these types of offenses may also result in an investigation by CAMFT’s Ethics Committee.
Reporting Other Psychotherapists for Inappropriate Relationships
In general, therapists are not mandated reporters of the illegal or unethical conduct of other psychotherapists, including colleagues. However, California Business & Professions Code §728 requires therapists to give clients who indicate they have had a sexual relationship with another therapist, a copy of the brochure titled “Professional Therapy Never Includes Sex.” This brochure can be downloaded from www.bbs.ca.gov. In addition to providing the brochure, the law also requires therapists to discuss the contents of the brochure with their clients.
Psychotherapists must use the utmost care in their relationships with their clients and refrain from crossing well-established ethical boundaries. Therapists who choose to disregard their ethical responsibilities are likely to face disciplinary action without the support of their malpractice insurance. For more information about dual relationships with clients, visit camft.org.
Sara Jasper, JD, CAE, is a staff attorney for CAMFT. Sara is available to answer member calls regarding legal, ethical, and licensure issues.
1 CAMFT’s Code of Ethics is under review by CAMFT’s Ethics Committee
2 CAMFT’s Code of Ethics does not define the term, “a reasonable amount of time,” but therapists should consider the facts related to the therapeutic relationship they had with the client, the length of time they worked in a therapeutic capacity with the client, and should get consultation around the subsequent relationship being formed with the former client.
3 Uniform Standards Related to Substance Abuse and Disciplinary Guidelines, State Department of California, Board of Behavioral Sciences, 2015.
4 Cal. Bus. and Professions Code §§4982(k); 4982.26
5 Cal. Bus. and Professions Code §4982(i)
This article is not intended to serve as legal advice and is offered for educational purposes only. The information provided should not be used as a substitute for independent legal advice and it is not intended to address every situation that could potentially arise. Please be aware that laws, regulations and technical standards change over time. As a result, it is important to verify and update any reference or information that is provided in this article.