So What Exactly is a Dual Relationship
The Therapist
July/August 2005
David Jensen, JD (Former CAMFT Staff Attorney)
Reviewed November, 2022 by Sara Jasper, JD, CAE (CAMFT Staff Attorney)

---

In the book The Poet of Tolstoy Park by Sonny Brewer, Henry Stuart is diagnosed with tuberculosis. Henry's physician suggests a change of climate to prolong Henry's life. So, Henry moves from Idaho to Alabama, presumably to die; however, in Alabama, Henry confronts his illness head-on and he learns a great deal about himself in the process. The Poet of Tolstoy Park is fictional, although Henry Stuart was a real human being who lived a remarkable, yet unconventional, life.

At a point late in the story, Henry's son, Thomas, asks Henry what wisdom Henry would leave with his family and friends if Henry knew that he was going to die that night? The following exchange then takes place.

"And what would I teach you, Thomas, if I knew that I would die tonight? Is that what you would like to know? If I could distill my years in these Alabama woods into a sermon, what would my message be?"

Thomas nodded.

"In your own way, learn to die in peace. That's what I think is important, Thomas. My own lessons for that have come from how I treat other people, from what things I give value, but mostly from understanding that in every instance fear is of my own making."

We make our own fear. What a profound thought.

My experience has been that licensees and associates create a lot of fear for themselves around the issue of dual relationships. Too many members "see" ghosts when there aren't any. This fear is somewhat irrational because the majority of practitioners have nothing to fear because they practice lawfully, meaning competently and ethically. Nevertheless, they fear that the Board of Behavioral Sciences (BBS) will swoop into their lives, like a bird of prey, and take away their license or associate registration because they ate at McDonalds at the same time a client did or because they shopped at Vons at the same time a client did. These chance encounters at McDonalds or Vons, or any other place for that matter, should not exploit patients or impair professional judgment so they are not, in and of themselves, illegal or unethical dual relationships. Moreover, these chance encounters are going to occur, especially if the community in which the therapist lives and practices is a small one. In such communities, these types of encounters, as well as more challenging types of dual relationships, i.e., patient as dentist or patient as plumber, are going to happen, most likely with regularity; the issue then becomes managing them through boundary enforcement, boundary maintenance, and on-going clinical consultation so that they do not mushroom into exploitive dual relationships or dual relationships that impair professional judgment.

But, back to one's fear of the BBS. It is not healthy or even realistic to view the BBS with so much fear. The BBS is not a bird of prey that swoops out of the sky to snatch those suspected of committing wrongdoing; it is a governmental agency that protects the public by regulating the conduct of associates and licensees. Certainly, much harm can result to patients from unscrupulous therapists. However, if you have not done anything wrong, the chance of someone filing a bogus complaint against you is low. Hence, by keeping your nose clean, so to speak, you should not fear the BBS. Take solace in that fact!

Rather than a fear-based relationship, the relationship between associates and licensees and the BBS should be respect-based. It is important to understand the role that the BBS plays in regulating the profession and to respect that role, but you do not have to fear the BBS if you practice lawfully. It is kind of like driving. If you are one of those drivers who never speeds, then you do not have to worry about being cited for speeding; conversely, if you always seem to be going 10 or 20 miles per hour over the posted speed limit, then you are likely to worry because the chance of an encounter with law enforcement is increased. A driver is able to regulate the speed of his or her vehicle by taking his or her foot off the accelerator; a therapist is able to regulate his or her conduct by learning what is expected of him or her as a professional and adhering to those standards. It is simply a matter of education and personal vigilance.

Education is the cornerstone of this understanding. By education, I mean that the therapist has a working knowledge about dual relationships and what makes them dangerous for practitioners. This knowledge comes primarily from two sources: the CAMFT Code of Ethics for Marriage and Family Therapists and the disciplinary actions taken by the BBS. The CAMFT Code of Ethics give us a working knowledge of important concepts; whereas, the disciplinary actions give us specific examples of things to avoid because the BBS has punished such conduct. In this article, we will focus on the CAMFT Code of Ethics regarding dual relationships. But, what does the law say about dual relationships? The law is basically silent on this issue. The law addresses dual relationship questions through the lens of "unprofessional conduct." For instance, section 4982(d) of the Business & Professions Code states that gross negligence, which is an extreme departure from the standard of care, constitutes unprofessional conduct and section 4982(i) of the Business & Professions Code states that intentionally or recklessly causing physical or emotional harm to a client constitutes unprofessional conduct. These concepts are left purposefully vague so that the BBS can "fill in the blanks" for enforcement purposes. Hence, the importance of studying the BBS' disciplinary decisions to determine what types of conduct it frowns upon. Dual relationship issues are a subset of the larger category of what is classified as unprofessional conduct. So, in terms of the law, when we are talking about illegal or unethical dual relationships, we are really talking about unprofessional conduct.

WHAT IS A DUAL RELATIONSHIP?

Marriage and family therapists are supposed to avoid dual relationships with patients that are reasonably likely to impair professional judgment or lead to exploitation. But, what exactly is a dual relationship? A dual relationship is a separate and distinct relationship that occurs between the therapist and a patient, or a patient's spouse, partner, or family member, either simultaneously with the therapeutic relationship, or during a reasonable period of time following the termination of the therapeutic relationship.²

Three concepts bear discussion: the idea of a dual relationship as a separate and distinct relationship; the concept of a reasonable amount of time; and, the concept of reasonably likely to lead to exploitation or impairment of judgment.

First, notice that a dual relationship is a "separate and distinct" relationship. This second relationship has nothing to do with therapy. In fact, such relationships often corrupt therapy. Sexual liaisons with patients, for example, because of the abuse of transference, have nothing to do with therapy. Every conceivable argument has been advanced to try and justify such conduct, but they have all been shot down. It is simply illegal, unethical, and unprofessional for a therapist to have a sexual relationship with a patient. Moreover, a therapist is prohibited from entering into a therapeutic relationship with someone with whom the therapist had a sexual relationship.³

The CAMFT Code of Ethics prohibit outright certain other secondary relationships: 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. These types of secondary relationships are inherently exploitive and capable of affecting professional judgment. Hence, they are prohibited outright.⁴ Why are these relationships singled out? Why are they inherently wrong? Keep in mind that a therapist has a "special relationship" with his or her patients.⁵ The hallmarks of this "special relationship" are vulnerability and dependence of the patient on the practitioner.⁶ When vulnerability and dependence are combined with money, a discrepancy in power, or a close personal friendship, the stage is being set for exploitation or impairment of judgment.

Prohibiting these relationships outright effectively serves to limit the establishment of them. But, what if the secondary relationship is with a member of the patient's family? Dual relationships with a patient's spouse, partner, or family member may also be considered unethical dual relationships.⁷ Notice the subtle difference in the language in the Ethical Standard, however. Whereas, borrowing money from patients, hiring patients, engaging in business ventures with patients, or engaging in close personal relationships with patients is prohibited outright,⁸ such things do not appear to be prohibited outright if done with a spouse, partner, or family member of a patient.⁹ The operative word in the Code of Ethics is the word "may." It is doubtful, however, that the word "may" is being used in a permissive sense so as to sanction or ratify this type of conduct; the better interpretation is that "may" means that the imposition of discipline for violating such provisions is possible. The use of the word "may" in terms of being permissive is a mirage. Secondary relationships that are reasonably likely to exploit or impair professional judgment should be avoided, whether with a patient or the patient's spouse, partner, or family member.

Conversely, accompanying an agoraphobic to a crowded shopping mall to observe the patient in hostile surroundings has a legitimate clinical purpose. It has much to do with therapy. It is not a social relationship; it is not a business relationship; it is not a close personal relationship. It is a continuation of the professional relationship because it advances the patient's therapy by increasing the therapist's knowledge of the patient and supporting the patient's treatment. Moreover, it does not exploit the patient, and it should not affect professional judgment. Hence, such conduct would not constitute an illegal or unethical dual relationship or a boundary violation.

Second, when analyzing dual relationship problems, the therapist must take into account the amount of time that has passed between the termination of the therapeutic relationship and the commencement of the second relationship. A therapist arguably may enter into a sexual relationship with a former patient if there has been a valid termination of the therapeutic relationship and at least two years have passed between such termination and the commencement of the sexual relationship.¹⁰ This is commonly referred to as "The Two- Year Rule," although the better approach may be to refrain from such activity with patients altogether. A valid termination is one that is in the patient's best interests; an invalid termination is one that is used to start the "Two-Year Clock" ticking, which is a termination that is in the therapist's best interests.

There is a different time period, however, for secondary relationships that are not sexual. A therapist may enter into a personal relationship, a financial relationship, a life-coaching relationship, or any other relationship for that matter, with a former patient, assuming there has been a valid termination and that a reasonable amount of time has passed from the termination and the commencement of the other relationship.¹¹ The concept of a "reasonable amount of time," however, is problematic. Crucial issues in the "reasonable time" equation are the depth of transference that has occurred, the autonomy or dependence of the patient on the therapist, the nature of the therapy, and the nature of the secondary relationship. The deeper the transference, the more the patient is still dependent upon the therapist, the more the therapy is about serious mental health problems as opposed to personal growth, and the more money is involved, the longer the "reasonable time" period will be. A prudent step in this analysis is getting clinical consultation regarding these issues, which, of course, should be documented in the client's file.

Third, therapists want to avoid dual relationships that are "reasonably likely" to impair professional judgment or lead to exploitation. This does not mean that you have to have a crystal ball or that you need to be able to divine the future. It seems to mean that the therapist's conduct will be measured, in an objective sense, against the conduct of a reasonably competent therapist, as opposed to being measured against the particular therapist's beliefs or expectations about the situation. Common sense and the realities of human nature will also factor into the equation. For instance, close personal friendships should be avoided because they are reasonably likely to affect the therapist's objectivity and judgment by aligning the therapist with the patient. Financial relationships should be avoided because they are reasonably likely to corrupt the therapeutic milieu because financial deals can turn sour or because unscrupulous practitioners can abuse patient transference and take advantage of patients. Or, the patient may later perceive he or she was taken advantage of.

ARE ALL DUAL RELATIONSHIPS UNETHICAL OR ILLEGAL?

No. Not all dual relationships are unethical, and some dual relationships cannot be avoided.¹² Associate MFTs and licensees should avoid dual relationships that are reasonably likely to impair professional judgment or lead to exploitation of the patient.¹³

If not all dual relationships are illegal or unethical, that leaves the possibility open for legal or ethical dual relationships. For example, a licensee in private practice may hire an associate. Such an action creates a dual relationship because the licensee is the associate's supervisor and employer. In fact, by law, the supervisor has to employ the associate. Assuming no exploitation of the associate by the supervisor/employer occurs and no compromise of supervisory judgment, such a relationship would be a legal and ethical dual relationship.

Moreover, a therapist and a patient may attend the same church. As long as they are co-parishioners, there is no exploitation of the patient and there should be no impairment of professional judgment. Hence, there is no illegal or unethical dual relationship.

With that said, the therapist definitely wants to keep the co-parishioner at arm's-length, figuratively, emotionally, and literally. They should not intentionally sit together in the same pew; they should not teach Sunday school together; they should not have family get-togethers after church, with all of these issues being thoroughly discussed with the patient in advance so that he or she understands why the therapist has to avoid these actions. The co-parishioner as patient problem creates on-going requirements for boundary maintenance and boundary enforcement. A co-parishioner who is also a patient may want to become "special" in the eyes of the therapist; or, the patient may try to encroach even further into the therapist's personal life. If the boundaries cannot be maintained, the therapist may have to terminate the therapy because such therapy is becoming ethically questionable.¹⁴

So, yes, the possibility is there for legal and ethical dual relationships, which, again, would be secondary relationships that are not reasonably likely to exploit patients or impair professional judgment. However, such relationships are the limited exception, not the general rule. Such relationships, by their nature, are few and far between, with them being more common in smaller communities.

WATCH OUT FOR THE PLOT TWIST!

The plot twist is a familiar device in mystery shows and novels. Just when you think you have figured out who the murderer is, there is a twist in the plot and the murderer turns out to be someone different than we thought it was going to be. In CAMFT's legal and ethical seminars, I've referred to this phenomenon as the Theme of Unintended Consequences or Changed Circumstances. Basically, something happens later that alters the nature of the relationship or the way the participants view the relationship. We often see this scenario in sexual misconduct cases. For example, therapist knows that he cannot engage in a romantic relationship with a client, but therapist believes that client is "the one," the light of his life, his dream girl. He likes her and she likes him and he really believes they will be together forever. During the course of the therapeutic relationship, they begin dating and socializing outside of therapy. He rationalizes the conduct by affirming to himself that she won't tell so no one will ever find out. They then end up living together and consummating their relationship, all the while believing that they are going to be together forever.

But, here comes the plot twist.

Forever turns out to last about six months, and as she is throwing his things out of the condominium they have been sharing, she reminds him that it is illegal for a therapist to be living with and having sex with a patient. The therapist did not account for the possibility of the relationship failing; he assumed they would be together forever. This twist in the plot has dramatically altered the nature and characterization of the second relationship. At the start of it, the therapist and the patient saw true love; for whatever reason, at the end of the relationship the love was gone, dried up like a rose left in the desert. Of course, the BBS, viewing the situation through the lens of unprofessional conduct, will see the relationship for what it is: a therapist having sex with a patient.

CONCLUSIONS

The CAMFT Code of Ethics were drafted to give therapists a working knowledge of the conduct that is expected of them in dual relationship situations. They serve as guideposts for the professional conduct of diligent and ethical therapists. The Code of Ethics indicate that a dual relationship is a separate and distinct relationship that a therapist has with a patient or the spouse, partner, or family member of a patient, whether during the course of the therapy or for a reasonable period of time thereafter, that is reasonably likely to exploit a patient or impair professional judgment. The Code of Ethics allow for legal and ethical dual relationships, although such relationships create on-going boundary enforcement and boundary maintenance obligations for therapists. Moreover, if a dual relationship cannot be avoided, the Code of Ethics place an affirmative duty upon the therapist to take professional precautions to ensure that exploitation or impairment of professional judgment does not occur. When wrestling with dual relationship questions, therapists are well served by obtaining clinical consultation from a trusted colleague and/or by consulting with an attorney who is knowledgeable about dual relationship issues.

These objective sets of eyes typically help keep therapists out of harm's way.

---

References 

¹ CAMFT Code of Ethics 4.1
² CAMFT Code of Ethics 4.1
³ CAMFT Code of Ethics 4.6
⁴ CAMFT Code of Ethics 4.3
⁵ Tarasoff v. Regents of the University of California (1976) 17 Cal. 3d 425, 435
⁶ Kockelman v. Segal (1998) 61 Cal. App. 4th 491, 499
⁷ CAMFT Code of Ethics 4.3
⁸ CAMFT Code of Ethics 4.3
⁹ CAMFT Code of Ethics 4.3
¹⁰ CAMFT Code of Ethics 4.5
¹¹ CAMFT Code of Ethics 4.1
¹² CAMFT Code of Ethics 4.1
¹³CAMFT Code of Ethics 4.1
¹⁴CAMFT Code of Ethics 4.2