Evidence brief: Navigating dual relationships in mental health care settings

What you need to know

  • Dual relationships can occur in any mental health setting and create ethical concerns for both the mental health professional and the client.
  • Service providers should avoid entering into dual relationships. In situations where this is not possible, service providers can use professional ethics to guide their behaviour.
  • The following approaches to navigating dual relationships can be helpful:
    • Consulting or establishing guidelines and frameworks.
    • Providing organizational support to mental health professionals.
    • Evaluating social media use and electronic communications.
  • Within each of these approaches, there are specific measures to be developed and implemented. These include educating and training peer support workers, making sure that dual relationships are well documented, and providing supervision and consultation to reflect on practice. Also recommended is the implementation of social media policies and use of privacy settings for social networking sites.
  • As dual relationships continue to be a reality and concern in mental health settings, more research will be needed to inform best practices to manage them.

Read the evidence brief below or download the PDF here.

What’s the problem?

In any mental health setting, the relationship between a client and their mental health professional (e.g., therapist) is based on a power imbalance. The client is the vulnerable party in the therapeutic relationship because they are seeking support and advice from the mental health professional.  Therefore, the mental health professional is in a position of power and influence, and is bound by professional duty (i.e., professional ethics codes) to protect the well-being of the client and not cause undue harm.1 When a relationship develops between a client and professional, separate from the therapeutic relationship, it is referred to as a dual—or multiple—relationship.*

The American Psychological Association (APA) Ethics Code defines “multiple relationships as follows:2

“A multiple relationship occurs when a psychologist is in a professional role with a person and (1) at the same time is in another role with the same person, (2) at the same time is in a relationship with a person closely associated with or related to the person with whom the psychologist has the professional relationship, or (3) promises to enter into another relationship in the future with the person or a person closely associated with or related to the person.”

As the APA definition suggests, dual relationships can create an ethical dilemma when established boundaries are blurred and the therapist loses their objectivity. In such cases, the therapeutic relationship can be jeopardized (e.g., the client doesn’t feel safe, no longer trusts the therapist, or is no longer receiving benefit from therapy), and the client can experience undue harm or negative consequence. Depending on the nature of the dual relationship, the mental health professional may feel conflicted by their own personal intentions or other commitments and their duty to provide appropriate care and a safe environment for their client.1

Despite the risks, it can be difficult—even impossible—to avoid dual relationships in certain settings.3,4,5 Peer support work is one specific setting where dual relationships are likely to arise with clients.6

The Centre for Innovation in Peer Support at Support & Housing-Halton, which provides system support for agencies that employ peer support staff, requested a literature review to determine what the literature says about guidelines or principles for navigating dual relationships in mental health. To answer this question, we conducted a rapid review, which will help inform the work of the Centre.

What did we do?

As a first step, an EENet knowledge broker conducted an initial search using Google Scholar to look for journal articles that mentioned guidelines or principles for navigating dual relationships in mental health settings, which was the research question. The search included different combinations of terms, including guideline, principle, best practice, dual relationship, and mental health. This search didn’t yield many results, and there were no articles found that spoke directly to the research question.

We then consulted a librarian at the Centre for Addiction and Mental Health (CAMH) who suggested that we conduct a broader search to capture relevant articles related to our question.

In a second search strategy, we searched Medline, PsychINFO, and CINAHL, combining terms related to dual relationships (e.g., boundaries professional ethic*, therapeutic alliance*) and mental health (e.g., therapeutic alliance*, mental*, psychiatr*, recovery, therap*) or peer support (e.g., peer support* or peer outreach* or peer mentor*). We went back as far as the year 2000. Within the literature, it’s common to see the terms dual relationships and multiple relationships used interchangeably, so for the purposes of this review, we considered them synonymous.

The initial search generated 379 articles. By scanning titles and abstracts, we found 38 articles that alluded to the research question, and retrieved them for a full text review. We then applied inclusion and exclusion criteria to the articles collected, as listed below.

Articles were included if they:

  • were published between 2009-2019
  • mentioned…† guidelines, principles, recommendations, or best practices in the abstract or title.

Articles were excluded if they:

  • didn’t focus on a mental health setting (e.g., mentorship programs of dental faculty/higher level students acting as mentors for first year students)
  • focused on correctional or forensic settings, where mental health professionals must try to balance the professional ethics and the well-being of their client against community safety.
  • addressed dual relationships without providing guidelines on how to navigate dual relationships.
  • focused on cases of misconduct that included dual relationship boundary crossing and articles on sanctioning by professional licensing board
  • focused on peer support work for incarcerated sexual offenders
  • were not peer-reviewed (e.g., we excluded articles from magazines and thesis dissertations)
  • were not available electronically (e.g., books and book chapters)
  • did not include an abstract.

Based on these inclusion and exclusion criteria, we identified nine relevant articles for review. In capturing guidelines, principles, recommendations, or best practices, we organized elements into themes for preparation of this brief.

What did we find?

Within the literature, dual relationships have been discussed in a variety of mental health settings, such as integrated primary care clinics, university counselling centers, church settings where pastors also provide mental health support, and small rural communities.3,4,5,7,8 In these settings, the core principles for navigating dual relationships fall under three main themes outline, as described below.

Consulting or establishing guidelines and frameworks

Given that mental health settings involve medical, psychological, and counselling practices, researchers have looked at the professional ethics codes of the relevant disciplines to guide them on how to navigate dual relationships.3,4

Although these ethics codes are intended to help mental health professionals navigate dual relationships, authors have identified gaps when applying them to specific situations. For example, professional ethics codes are inconsistent in addressing dual relationships that result from treating colleagues in integrated care settings.3,4

Ethics codes for social workers also don’t address dual relationships in remote communities (such as in the Canada’s North), where dual relationships are often inevitable. In these settings, there is a need, supported by international literature, for ethical guidelines that are not too prescriptive.5 Within academic settings, there is also a grey area for graduate students doing practicum placements, to guide their interactions with undergraduate students both inside and outside counselling centres.7

Professional codes of ethics address the potential harm that can result from dual relationships and emphasize that avoiding or limiting these relationships is the best approach.2 

Authors note that when this is not possible, the codes don’t provide sufficient guidance on how to reduce the risk of harm or how to ethically navigate these unavoidable relationships.3,4

With the increase in interdisciplinary practice, one recommendation is for the backbone professions (i.e., psychology, social work) to create more specific ethics guidelines for providers who work in these settings.4 These would help guide practitioners when dealing with dual relationships that may arise.4

Specific models and guidelines

Given the interdisciplinary nature of many mental health settings, specific and tailored ethics guidelines are necessary to help professionals navigate dual relationships.3,8 In particular, professional governing bodies, as well as organizations that provide mental health services, have a role to play in developing these guidelines. 

In addition to relying on professional codes, the literature points to using a problem-solving model to navigate ethical dilemmas in primary care.3 Using the following eight-step model, mental health professionals should consider the various components when approaching any ethical dilemma:3

  1. Consider your context.
  2. Consult your ethics code.
  3. Determine risks/benefits.
  4. Critically interpret/implement your code.
  5. Consider different perspectives.
  6. Identify others’ expectations.
  7. Clarify your role.
  8. Discuss your concerns.

The authors note that this model is flexible, as the steps don’t have to be followed in any specific order.

It can also be a good idea for the organization to establish ethics guidelines for situations or settings that fall outside the purview of professional ethics codes.8 Guidelines could include any of the following:8

  • Ethics guidance on which roles a professional can hold inside and outside their setting.
  • Limiting the professional’s responsibility to one role, even if they have different credentials that allow them to act in different roles (e.g., as a pastor and a therapist).
  • Avoiding sexual relationships.
  • Avoiding the disclosure of private information.
  • Having transparent accountability models, where professionals receive guidance from a supervisor or peer group, and can discuss concerns and advice on how to navigate multiple relationships. Regularly scheduled performance reviews are also recommended.
  • Making sure professionals are aware of the vulnerabilities of those they interact with and the influence they may have over them. They should also be humble and show integrity in their actions, while demonstrating dignity, respect, and compassion.
  • If issues or concerns arise that fall outside the professional’s scope of practice, they should help the client identify other community supports and provide referrals, where appropriate.

Providing organizational support to mental health professionals

Authors consistently discuss the importance of organizational support in helping professionals navigate dual relationships. This includes education, documentation, supervision, and mental health support.1,6,7,8 These are described below.

Education

One recommendation is to provide education to help professionals understand the potential harm and exploitation that may be involved in nonsexual dual relationships.7 Including case examples can stimulate reflective discussion and generate ideas for ways to navigate these relationships.7

Researchers who studied Northern social workers found they had difficulty avoiding dual relationships because of the remote settings in which they work.5 Their formal education had provided limited advice to guide them in this inevitable circumstance. In this study, many social workers indicated they isolated themselves from the rest of the community to prevent dual relationships from developing. Other social workers said they felt a deep sense of obligation to help extended family and close friends who were struggling, and that this in turn often emotionally drained them. In either case, their self-care was a concern since their job seemed to influence their other personal choices. Recommendations for these situations include specific training to develop skills for maintaining professional and personal boundaries, providing decision models to navigate the dual relationship, and approaches for ensuring the mental health professionals’ own self care is not sacrificed.5

Organizations can establish practice parameters and policies (e.g., when to accept gifts, setting time limits for sessions, and documenting treatment plans) and educate professionals so they will be able to use these practice parameters and policies when challenging situations arise.1 Recommended approaches to dealing with dual relationships include speaking with colleagues, reflecting on the situation in relation to the established guidelines, and, when all else fails, speaking directly with the client.1

Documentation

Thorough documentation is a key component of managing nonsexual multiple relationships, and includes the following information:7

  • any concerns about the relationship
  • what was done to avoid the problematic relationship
  • the decision-making process followed to address the multiple relationship.

Documentation goes hand in hand with having appropriate supervision and/or peer guidance in navigating ethical dilemmas.7,8

Mental health support

Finally, organizations have a duty to support peer workers’ mental health and well-being while keeping them engaged in the work6. It’s imperative that organizations consult their peer workers to tailor the supports that are offered and ensure optimal benefit for all involved.6

Evaluating social media use and electronic communications

Within a mental health setting, the use of social media and electronic communication (e.g., cell phones, email) with clients creates opportunities for dual relationships to develop.9,10 Therefore, the literature recommends establishing boundaries for use of social media and electronic communications in mental health settings. These include creating social media policies, establishing privacy settings for social networking sites, and establishing parameters around the use of cell phones and text messaging.

Social media policies and privacy

Creating an organizational social media/Internet policy is one approach to help set boundaries around the use of social media in psychological therapy.9 This policy can be included within the informed consent process, which takes place with clients before treatment commences. In doing so, it provides an opportunity to clarify expectations for social media and Internet use at the outset, while also preventing any potential boundary issues from taking root.9,10

Social media and Internet use can increase the risk that a client’s private or confidential information will be improperly used, or disclosed, by the client or their mental health professional.9 Therefore, mental health professionals need to be educated about the privacy limitations associated with social media and Internet use and need to educate and empower their clients to safeguard their own confidentiality.9

Technology, such as social media, is evolving at a fast pace, so organizations need to stay abreast of changes and update their policies to ensure both the private and confidential information of both professional staff and clients remains safe.9

Facebook and social networking sites

Psychologists who have a professional social media presence may find themselves in situations where they must address a client’s Facebook comments and Twitter posts. This brings up two primary recommendations around privacy and security:

1. Mental health professionals should educate themselves about the available privacy settings of the social networking sites they are using, and then actively manage these settings to suit their needs.9 For example, in Facebook, “users can locate their privacy settings, control how others contact them, what they want to share, what details others can share about them, and what contact information is listed on their profiles.”10 In controlling this, mental health professionals protect themselves against potential ethical issues.9 As Facebook frequently updates privacy settings, users should check for changes and update their settings as appropriate to the privacy level that suits their needs.10

2. When clients post on their mental health professional’s Facebook or Twitter page, they are sharing personal information. It is important for the professional to discuss potential risks with their clients and consult their organization’s social media policy (if one exists) or create a polity to prevent such scenarios from occurring.9

Internet security aside, mental health professionals need to think about their online behaviour and potential outcomes.10 By using a reflective practice, one can better ascertain the consequences of what they post.11 Some questions that are helpful in reflective practice are listed below:11

  • What are potential benefits and problems associated with posting this information?
  • How likely is it that this information might have a negative impact on clients or coworkers?
  • What impact might posting this information have on my professional reputation?
  • How might sharing this information impact perceptions of professional counselling in general?

Cell phone use and text messaging

Similar to social media, there is a risk of sharing personal information via email or text-messaging. Once again, the client’s confidentiality and privacy may be compromised if, for example, the therapist’s cell phone is lost or stolen. Clients may not be fully aware of this risk, and thus it’s the therapist’s responsibility to inform their clients.9

While it might be convenient to use a cell phone and text messaging to communicate with clients, it can also result in blurring of boundaries and development of dual relationships.9  There is also the risk that the client’s confidential information and privacy might be compromised.9 To prevent this problem from occurring, mental health professionals should have a cell phone and email address they use solely for work purposes, and should inform clients about these risks.9

If the client violates a previously established text messaging policy, the mental health professional should let the client know they will stop responding to text messages. If the client continues to violate the policy, the mental health professional should inform the client they might even stop providing services (and refer the client to other treatment options).9

What are the limitations in the studies reviewed?

Despite obtaining a large number of results overall, many articles discussed mental health professionals’ perceptions on dual relationships. Since our goal was to synthesize the evidence on this topic, we were limited by the lack of recommendations for how to navigate dual relationships. Thus, we did not include articles that did not provide concrete guidelines. As a result, we may have inadvertently left out relevant information to answer the research question.

Due to time and resource limitations, we also limited the articles to a ten-year cut off and did not include books, dissertations, or articles that were not available electronically. Therefore, we acknowledge that there may have been relevant information that might have been omitted.

We included articles that focused on some settings that might not be relevant to peer support workers. In integrated primary care, dual relationships occur in colleague to colleague interactions.3,4 In congregational settings, the dual relationships involved pastors and their religious community.8 These articles did fall within our search criteria, but the reader should keep their unique attributes in mind when considering this evidence.

It should also be noted that, through the literature review process, we identified the term “multiple relationships” to be interchangeable with dual relationships, something we were not aware of when we initiated this work.  Had our search also included the term “multiple relationships”, we might have found additional literature to inform this brief. 

Acknowledgements

The author of this rapid review is Lisa Ceroni, volunteer in EENet. The author would like to acknowledge Terry Rodak, CAMH Librarian, for assistance with the database search, Rebecca Phillips Konigs, Acting Assistant Manager for Special Projects, for mentorship and editing advice, as well as Jason Guriel, Assistant Manager for EENet, and Rossana Coriandoli, Communications Coordinator, for their editorial support.

References

  1. Sawyer, S. & Prescott, D. (2011). Boundaries and dual relationships. Sexual Abuse: A Journal of Research and Treatment, 23 (3), 365–380.
  2. American Psychological Association. (2017). Ethical Principles of Psychologists and Code of Conduct. Section 3: Human Relations. Retrieved from https://www.apa.org/ethics/code/
  3. Kanzler, K.E., Goodie, J. L. Hunter, C.L., Glotfelter M.A. & Bodart, J.J. (2013). From colleague to patient: Ethical challenges in integrated primary care. Families, Systems, & Health, 31 (1), 41–48.
  4. Dobmeyer, A. C. (2013). Primary care behavioural health: Ethical issues in military settings. Families, Systems, & Health, 31 (1), 60–68.
  5. Halverson, G. & Brownlee, K. (2010). Managing ethical considerations around dual relationships in small rural and remote Canadian communities. International Social Work, 53 (2), 247–260.
  6. Kilpatrick, E. & Keeney, S. (2017). Tokenistic or genuinely effective? Exploring the views of voluntary sector staff regarding the emerging peer support worker role in mental health. Journal of Psychiatric Mental Health, 24, 503–512.
  7. Dallesasse, S. L. (2010). Managing nonsexual multiple relationships in university counseling centers: Recommendations for Graduate Assistants and Practicum Students. Ethics & Behaviour, 20 (6), 419–428.
  8. Justice, J.A. & Garland, D.R. (2010). Dual relationships in congregational practice: Ethical guidelines for congregational social workers and pastors. Social Work & Christianity, 37 (4), 437–445.
  9. Van Allen, J., Seegan, P.L., Lancaster, B. & Gunstream-Sisomphou, D. (2018). Therapy with children and adolescent in an era of social media and instant electronic communication. In M.M. Leach & E.R. Welfel (Eds.). The Cambridge Handbook of Applied Psychological Ethics (pp. 616–636). Cambridge: Cambridge University Press.
  10. Yonan, J., Bardick, A.D. & Willment, J. H. (2011). Ethical decision making, therapeutic boundaries, and communicating using online technology and cellular phones. Canadian Journal of Counselling and Psychotherapy, 45 (4), 307–326.
  11. Lehavot, K. (2009). “MySpace” or yours? The ethical dilemma of graduate students' personal lives on the Internet. Ethics & Behaviour, 19 (2), 129-141. Cited in Yonan, J., Bardick, A.D.&  Willment, J. H. Ethical decision making, therapeutic boundaries, and communicating using online technology and cellular phones. Canadian Journal of Counselling and Psychotherapy, 45 (4) (2011), 307–326.