A couple that you know from a mutual organization asks you to provide treatment to their child.  You offer referrals to other providers but they really press you to work with their child.  What are your ethical obligations? (paraphrased from NASW – Florida Chapter Newsletter (May/June 2010)

It may be ill-advised to work with the family members of people you know.  Marriage and Family therapists are cautioned by their code of ethics to

“1.3 Marriage and family therapists . . .[should] make every effort to avoid conditions and multiple relationships with clients that could impair professional judgment or increase the risk of exploitation. Such relationships include, but are not limited to, business or close personal relationships with a client or the client’s immediate family. . .”

It is up to the clinician to take specific steps to protect the client or potential client from any possible exploitation.  In the case above, the parents of the adult child are likely to want to be informed of the progress their child is making.  They may believe that their acquaintance with the therapist would entitle them to information that must be held in confidence.  When a therapist is put into a situation where he or she must refuse to provide information a conflict might arise.  No matter what the extent of the prior relationship between the parents and the therapist was, there is the possibility that the adult child may be concerned that his or her confidentiality could be breached.  Also, that individual might not even understand the strength of the mandate upon us as clincians to uphold their confidence.

The state of Florida requires that all mental health professional registered interns, Licensed Clinical Social Workers, Mental Health Counselors, Marriage & Family Therapists and  Psychologists must have several years of post-licensed practice and complete a 16-hour course on supervision in order to be determined a “Qualified Supervisor”.  The course as described in Florida State Chapter 491 is expected to be didactic, live and interactional, not a home-study or book and test based learning experience. In fact, there are very specific guidelines for the course one must take. Below, are the state’s basic requirements of content that must be included in supervision courses and my approach to these requirements to the course curriculum.

First, the course is expected to present information on major models of supervision. Interestingly, this trainer found little to no professional literature reviewing models of supervision to help the trainers to present a concise summary of supervisory theories has been found to date. So this trainer, with her colleague Mary Jo Klingel, LCSW has developed a method of helping the participants to use their knowledge of practice theories, values, performance expectations and other factors  to guide participants thoughts about supervisory interventions. As a result of the exploration of models of supervision, the participants of the training are able to develop their own personal model of supervision, another objective required by the state.

Another objective of the course is to help the participants explore the “co-evolving relationship dynamics between the therapist-client dyad, and the triad of supervisor-therapist-client relationships”. New therapists are helped to understand the dynamics of their relationship with their clients. This is often accomplished with the supervisor’s guidance and support while exploring the relationship between the supervisor and supervisee.

The training course also allows participants to explore distinctive issues that arise in supervision. Some examples of issues that our participants have explored include: strategies for resolving conflicts before they become complaints, documentation of supervisory sessions, contracting with the supervisee, transference and counter-transference.

The Qualified Supervisor’s courses incorporate either as a separate section or as thread weaving through the two days of study contextual variables such as culture, gender, ethnicity, power and economics. Potential Qualified Supervisors must also become familiar with ethical, legal and regulatory issues in supervision. We have explored at length the moral/ethical obligations related to “duty-to-warn” versus the absence of a legal obligation in Florida to make such a warning. Many discussions have revolved around potential liability as well as responsibility of the supervisor for the omission or commission of wrong acts by the supervisee.  While the Florida 491 Board has never disciplined a Qualified Supervisor as a result of vicarious liability, the possibility of that action does exist and should be

Finally, participants are helped to understand the role and necessity of evaluative practices during the time of supervision. The supervisory process is one step in the nurturing of new clinical professionals. Evaluation of performance and professionalism need not be harsh or overly critical. However, the supervisor has an obligation to his or her profession to ensure that individuals who become licensed are properly prepared and competent for the work they have chosen to do.

Supervision can be an exciting and mutually rewarding process when approached in the proper way. Keep in mind, that you are furthering your education for the betterment of you as a therapist and the betterment of the lives of your patients and colleagues. New theories and information are consistently becoming available, allowing these courses and your experience to remain fresh and stimulating.

If you are already a supervisor and feel like your work has become a bit stale or concerns about liability have arisen consider taking our Practice Friendly Supervision course as a refresher or attend one of our advanced supervision workshops.

Mary Jo Klingel, ACSE, LCSW

Human beings need one another in ways that influence us profoundly.  We grow and find our greatest joys and challenges in relationships. In group therapy, the relationships with the other group members become part of the healing process. When an individual is ready to make real changes in their life, the process of this type of communal therapy becomes extremely enjoyable and rewarding.

As with any journey, it is good to know the territory and prepare for the experience, before you set out. In this case, the first step is internal. It involves taking the process of joining a group seriously. You are about to commit your time, effort and money to a process of growth and change. You are shifting the path of your life toward greater consciousness and opening yourself to a deeper understanding of yourself and your choices. This is a major undertaking. It is a way of saying to yourself, I am worth this.

Second, prepare by starting to identify your own issues. Ask yourself, and perhaps write about, such questions as: What has brought me to this place in my life? What are my current issues? What is happening in my life with family, love, work, friends, safety, spirituality, joy, my body, sexuality, and my overall physical and mental health? What causes me pain and what do I do about that pain? Who do I trust? What are my secrets? Am I where I want to be in my life? All these questions and more will begin the process of reflection that is the heart of the inner work that will take place in group.

Third, set specific goals for yourself. If you know what you want from group, it will be easier to hold that intention as the basis of your work.

Last, it is important to set realistic expectations. In groups, the patterns of working together cooperatively and developing trust take a while to emerge. Most people consider that spending a year in group therapy is the minimum necessary to gain what group has to offer, and many people stay longer. As people in recovery say, time takes time.

GROUP PREPARATION

The day or evening before group, spend some time in quiet reflection, asking yourself how the week has gone for you. This process is not about judging yourself, but about being aware. Notice what you have done to work on yourself this week, what challenges have come to you, what risks or new behaviors you have tried. This is simply time to see the work that is yet to be done, and to applaud all the efforts you have made. Then consider what you need to address in group this week.

MAXIMIZING GROUP POTENTIAL

When you come into group, take a moment and set your intention to be present. This approach helps to shape a field where the work of group can be done successfully.

Many people are socialized to give up their needs in favor of being good or taking care of others. That may make it difficult for you to ask for the groups time and attention, but make every effort to do so. Work in group as often as you can while being fair to others. Pay attention to the risks you need to take and know that the results are never as frightening as one assumes they will be. It is important to respect your own timing and need for safety, and not push beyond your readiness. While it is good to be gentle with yourself, remember that one of the richest rewards of group is to finally say the unspeakable and see only support and empathy on the faces looking back at you. Sometimes it is not easy to get the words out. You may have to challenge the internal voices that say that you will look stupid or nobody will care or they will not understand. It can change your world to learn that those harsh inner voices are not always accurate predictors of

how people will treat you. Perhaps on the other side of that risk is the support that you long for and deserve.

People in group sessions sometimes feel like they have to be clear and articulate before they speak; however, it is important to remember that the therapists are there to help you clarify the issues. Someone once said that they believe that therapy is the art of asking the right questions, and you have every right to ask the therapists for help in your process of moving toward clarity. The decision to ask for help may be part of learning to trust that you do not have to do your work all alone any more, and there will be help available when you need it.

There is also an art to working in groups when you do not have the floor. Begin by paying attention to yourself as someone else works. Notice any persistent feelings or reactions, any judgments or pain that comes up. It may be uncomfortable to notice your own irritability, intolerance, anger or jealousy or any of the not nice feelings, but they are a rich source of information about yourself. Remember that nobody makes you feel anything. Each feeling is your own, inside you. Each feeling is your teacher, showing you a part of yourself that you may not know well yet. Try to adopt a friendly and curious attitude toward each of your experiences. You can also report the feeling to the group and ask for help in discerning or fully owning it.

Group skills include learning how and, when to give feedback, and how and when to confront other group members. Give yourself permission to be a beginner at these skills, to practice and to ask the group leaders for help. In the safety of the group you can refine relationship skills and take them out into your life.

Most of all group is a place to speak your truth, moment by moment as you become aware of it. It is better to take the risk of speaking up, of not looking perfect, than to withhold and leave that group session feeling toxic or unfinished. It is difficult to speak up, to drop the mask of eternal niceness, to ask for help, but the rewards of all those risks are deep and long lasting.

GROUP REFLECTION

Once again try to find time for a little quiet reflection. You may want to review the group, noticing what happened and how it all felt to you. Consider how you could take what happened in the group out into your week. You may want to try out new behaviors in your life. Certainly you can practice that gentle curiosity about yourself that creates an internal atmosphere that supports your growth.

Being in a therapy group is a message to yourself that you are worth your own time and attention and care. Group is a great adventure in synchronicity, as what you need often comes in packages that you least expect to receive. With a little patience and openness, you will receive what you came for and much more.

Following up on my former post where I displayed relevant sections from each of the Codes of Ethics, I am presenting some situations (from a variety of sources) that relate to Dual Relationships:

A couple that you know from a mutual organization asks you to provide treatment to their child.  You offer referrals to other providers but they really press you to work with their child.  What are your ethical obligations? (paraphrased from NASW – Florida Chapter Newsletter (May/June 2010)

Your former client (services terminated over three years ago) who has completed his Master’s degree in Mental Health Counseling contacts you and asks to complete his Registered Internship in your agency/practice under your supervision.  What are your ethical obligations?  What if there were another Qualified Supervisor on staff who would be designated to be his supervisor? (Practice experience)

You have been in practice for a long time in your community and you have been invited to serve on the board of a small local social service program.  One of your current clients serves on the board and you wonder whether or not you can join the board and ethicall serve while maintaining both a non-professional relationship and therapeutic relationship with this person.  What factors (from the Codes or elsewhere) might influence your decision? (Practice exeperience)

Share your thoughts and questions.  Feel free to go back to the relevant sections of the Codes of Ethics to support or refute a position.

Earlier this year I had a number of colleagues contact me and ask questions about Dual Relationships.  As I gathered their questions, responses from a variety of knowledgeable people, and concerns into one file I realized that all of us would benefit from revisiting the concept “dual relationship”.  In this initial entry, we will see if there is some common definition that we could use.  Then in subsequent postings we can take a look at some relationships and consider whether or not some Dual-ity might exist.

Factors which might contribute to or constitute a Dual Relationship 

AAMFT (American Association for Marriage and Family Therapists) Code of Ethics . . .

Principle I – Responsibility to Clients . . .

1.3 Marriage and family therapists are aware of their influential positions with respect to clients, and they avoid exploiting the trust and dependency of such persons. Therapists, therefore, make every effort to avoid conditions and multiple relationships with clients that could impair professional judgment or increase the risk of exploitation. Such relationships include, but are not limited to, business or close personal relationships with a client or the client’s immediate family. When the risk of impairment or exploitation exists due to conditions or multiple roles, therapists take appropriate precautions. . .

Principle IV – Responsibility to Students and Supervisees . . .

4.1 Marriage and family therapists are aware of their influential positions with respect to students and supervisees, and they avoid exploiting the trust and dependency of such persons. Therapists, therefore, make every effort to avoid conditions and multiple relationships that could impair professional objectivity or increase the risk of exploitation. When the risk of impairment or exploitation exists due to conditions or multiple roles, therapists take appropriate precautions. . .

Principle V – Responsibility to Research Participants . . .

5.3 Investigators respect each participant’s freedom to decline participation in or to withdraw from a research study at any time. This obligation requires special thought and consideration when investigators or other members of the research team are in positions of authority or influence over participants. Marriage and family therapists, therefore, make every effort to avoid multiple relationships with research participants that could impair professional judgment or increase the risk of exploitation.

American Counseling Association’s  Code of Ethics addresses dual relationships (without using that terminology):

A.5.c. Nonprofessional Interactions or Relationships (Other Than Sexual or Romantic Interactions or Relationships)

Counselor–client nonprofessional relationships with clients, former clients, their romantic partners, or their family members should be avoided, except when the interaction is potentially beneficial to the client. (See A.5.d.)

A.5.d. Potentially Beneficial Interactions

When a counselor–client nonprofessional interaction with a client or former client may be potentially beneficial to the client or former client, the counselor must document in case records, prior to the interaction (when feasible), the rationale for such an interaction, the potential benefit, and anticipated consequences for the client or former client and other individuals significantly involved with the client or former client. Such interactions should be initiated with appropriate client consent. Where unintentional harm occurs to the client or former client, or to an individual significantly involved with the client or former client, due to the nonprofessional interaction, the counselor must show evidence of an attempt to remedy such harm. Examples of potentially beneficial interactions include, but are not limited to, attending a formal ceremony (e.g., a wedding/commitment ceremony or graduation); purchasing a service or product provided by a client or former client (excepting unrestricted bartering); hospital visits to an ill family member; mutual membership in a professional association, organization, or community. (See A.5.c.)

A.10.d. Bartering

Counselors may barter only if the relationship is not exploitive or harmful and does not place the counselor in an unfair advantage, if the client requests it, and if such arrangements are an accepted practice among professionals in the community.  Counselors consider the cultural implications of bartering and discuss relevant concerns with clients and document such agreements in a clear written contract.

 A.10.e. Receiving Gifts

Counselors understand the challenges of accepting gifts from clients and recognize that in some cultures, small gifts are a token of respect and showing gratitude. When determining whether or not to accept a gift from clients, counselors take into account the therapeutic relationship, the monetary value of the gift, a client’s motivation for giving the gift, and the counselor’s motivation for wanting or declining the gift.

 Florida Chapter 64B4 (relating to clinical social workers, marriage and family therapists and mental health counselors) has a section related to the supervision of Registered Interns that begin to clue us into situations which might constitute or be related to Dual Relationships.

64B4-2.003 Conflict of Interest in Supervision.

Supervision provided by the applicant’s therapist, parents, spouse, former spouses, siblings, children, employees, or anyone sharing the same household, or any romantic, domestic or familial relationship shall not be acceptable toward fulfillment of licensure requirements. For the purposes of this section, a supervisor shall not be considered an employee of the applicant if the only compensation received by the supervisor consists of payment for actual supervisory hours.  Specific Authority 491.004(5) FS. Law Implemented 491.005(1)(c), (3)(c), (4)(c) FS. History–New 1-4- 90, Amended 2-13-91, 10-7-92, Formerly 21CC- 2.003, 61F4-2.003, 59P-2.003.

NASW (National Association of Social Workers) Code of Ethic

1.06 Conflicts of Interest

(a) Social workers should be alert to and avoid conflicts of interest that interfere with the exercise of professional discretion and impartial judgment. Social workers should inform clients when a real or potential conflict of interest arises and take reasonable steps to resolve the issue in a manner that makes the clients’ interests primary and protects clients’ interests to the greatest extent possible. In some cases, protecting clients’ interests may require termination of the professional relationship with proper referral of the client.

(b) Social workers should not take unfair advantage of any professional relationship or exploit others to further their personal, religious, political, or business interests.

(c) Social workers should not engage in dual or multiple relationships with clients or former clients  in which there is a risk of exploitation or potential harm to the client. In instances when dual or multiple relationships are unavoidable, social workers should take steps to protect clients and are responsible for setting clear, appropriate, and culturally sensitive boundaries. (Dual or multiple relationships occur when social workers relate to clients in more than one relationship, whether professional, social, or business. Dual or multiple relationships can occur simultaneously or consecutively.)

(d) When social workers provide services to two or more people who have a relationship with each other (for example, couples, family members), social workers should clarify with all parties which individuals will be considered clients and the nature of social workers’ professional obligations to the various individuals who are receiving services. Social workers who anticipate a conflict of interest among the individuals receiving services or who anticipate having to perform in potentially conflicting roles (for example, when a social worker is asked to testify in a child custody dispute or divorce proceedings involving clients) should clarify their role with the parties involved and take appropriate action to minimize any conflict of interest. . .

1.13 Payment for Services. . .

(b) Social workers should avoid accepting goods or services from clients as payment for professional services. Bartering arrangements, particularly involving services, create the potential for conflicts of interest, exploitation, and inappropriate boundaries in social workers’ relationships with clients. Social workers should explore and may participate in bartering only in very limited circumstances when it can be demonstrated that such arrangements are an accepted practice among professionals in the local community, considered to be essential for the provision of services, negotiated without coercion, and entered into at the client’s initiative and with the client’s informed consent. Social workers who accept goods or services from clients as payment for professional services assume the full burden of demonstrating that this arrangement will not be detrimental to the client or the professional relationship.

2.07 Sexual Relationships. . .

(b) Social workers should avoid engaging in sexual relationships with colleagues when there is potential for a conflict of interest. Social workers who become involved in, or anticipate becoming involved in, a sexual relationship with a colleague have a duty to transfer professional responsibilities, when necessary, to avoid a conflict of interest. . . .

3.01 Superivsion and Consultation. . .

(c) Social workers should not engage in any dual or multiple relationships with supervisees in which there is a risk of exploitation of or potential harm to the supervisee.

3.02 Education and Training. . .

(d) Social workers who function as educators or field instructors for students should not engage in any dual or multiple relationships with students in which there is a risk of exploitation or potential harm to the student. Social work educators and field instructors are responsible for setting clear, appropriate, and culturally sensitive boundaries. . .

5.02 Evaluation and Researc

(o) Social workers engaged in evaluation or research should be alert to and avoid conflicts of interst and dual relationships with partiicpatns, should inform participants when real or potential conflict of interest arises, adn should take steps to resolve the issue in a manner that makes participants’ interests primary. 

NBCC (National Board for Certified Counselors) Code of Ethics . . .

Section B: Counseling Relationship . . .

2. Certified counselors know and take into account the traditions and practices of other professional disciplines with whom they work and cooperate fully with such. If a person is receiving similar services from another professional, certified counselors do not offer their own services directly to such a person. If a certified counselor is contacted by a person who is already receiving similar services from another professional, the certified counselor carefully considers that professional relationship as well as the client’s welfare and proceeds with caution and sensitivity to the therapeutic issues. When certified counselors learn that their clients are in a professional relationship with another counselor or mental health professional, they request release from the clients to inform the other counselor or mental health professional of their relationship with the client and strive to establish positive and collaborative professional relationships that are in the best interest of the client. Certified counselors discuss these issues with clients and the counselor or professional so as to minimize the risk of confusion and conflict and encourage clients to inform other professionals of the new professional relationship.

3. Certified counselors may choose to consult with any other professionally competent person about a client and must notify clients of this right. Certified counselors avoid placing a consultant in a conflict-of-interest situation that would preclude the consultant serving as a proper party to the efforts of the certified counselor to help the client. . .

9. Certified counselors who have an administrative, supervisory and/or evaluative relationship with individuals seeking counseling services must not serve as the counselor and should refer the individuals to other professionals.  Exceptions are made only in instances where an individual’s situation warrants counseling intervention and another alternative is unavailable. Dual relationships that might impair the certified counselor’s objectivity and professional judgment must be avoided and/or the counseling relationship terminated through referral to a competent professional. . .

Section C: Counselor Supervision. . .

In addition, because supervision may result in a dual relationship between the supervisor and the supervisee, the supervisor is responsible for ensuring that any dual relationship is properly managed.

Summary and conclusions

From these professional standards of practice guidelines we can see that the following issues must be considered in our efforts to ensure that we “do no harm” while providing the best possible services to our clients.  Be Aware. . .Avoid situations and relationships. . .Act in client’s best interest

• With real or potential conflicts of interest, especially in which the client might be harmed
• Having a non-professional relationship with a client outside of the therapeutic relationship
• A relationship in which the psychotherapist/field instructor/supervisor
  • can or does exploit the client
  • objectivity and professional judgment is impaired
• Bartering is only allowed by some professions and only when no exploitation nor harm nor possibility of the psychotherapist having an unfair advantage over the client
• Sexual relationships with colleagues
• Sexual relationships with clients
• Relationships with research subject/participants beyond the research study

We will continue to explore Dual Relationships in future posts.  Please post your comments and questions.

The educational responses provided by Dr. Waltz do not constitute a legal opinion.  If legal advice is needed, it is recommended that contact be made with an attorney qualified in the jurisdiction in which you practice or is applicable to your case.  We recommend that you use your knowledge of the law and your code of ethics in conjunction with this information (and any others) when deciding upon your course of action.

Forgiveness: Letting Go of Anger is scheduled for February 4th, 2011 in Crystal Lake, Illinois AND on February 18th, 2011  in Fort Lauderdale. This 3 credit CEU course will replace the Domestic Violence workshop on that date only. Mr. Ron Hall will be your trainer for this workshop. You will want to register for this course right away to ensure your place. Please call 954-801-4101 to register as the online registration for this selection is not yet active. Florida early registration rate is $65 for Forgiveness. See http://www.drwaltz.com/training_schedule.shtml for more information regarding this workshop for Florida and Illinois.
Recent Illinois trainees in the Forgiveness workshop reported that they liked the open discussion as well as the interaction with the trainer and one another.

Supporting Growth: Process-based Supervision This NEW 8-hour continuing education workshop will take participants from the basic understanding of the difference between “content” and “process” to more effect use of the approach and interventions. The “Process-oriented” approach to supervision enhances your effectiveness in working with supervisees, clients, self and others. The expanded time frame allows many opportunities to observe and practice process skills. See http://www.drwaltz.com/training_schedule.shtml for the program description containing objectives. The workshop will be offered on Saturday, January 22nd , 2011 from 8:45AM to 5PM. Early registration rate is $120 if paid no less than one month before the workshop. Fee will be $140 after the one month prior date and for all payments received at the door. You will want to register for this course early to ensure your place. Please call 954-801-4101 as the online registration for this selection is not yet active.

Great News!  Our 2010-2011 Training Schedule and Registration Forms are now online.   Check our website http://www.drwaltz.com/training_schedule.shtml  for details, additions, and updates.  On the Training Schedule page you’ll find a link to a table showing the complete schedule through the early part of 2011.  

Who do you know that needs to become a Qualified Supervisor or get those required courses out of the way?  Pass on our information to your colleagues.  Register for workshops for yourself.  Do it now – why wait until next year?

We want to know!  What topics are you interested in us incorporating into our continuing education offerings?  Are there new workshops you would like to attend?  What content do you definitely want us to include in our current workshops?  What enticed you to open our Training Email Newsletter.  Let us know by posting your comments here on our Blog.

My Thoughts

By Ross McDonough M.S.W., L.C.S.W., C.A.P.

I knew Trent Cook.  He was a therapist in a group private practice in the Regency area.  We collaborated on a family together.  I was treating the mother in my practice and he was treating the teenage daughter in the group practice where he worked.  It was not the same person referenced in the article.  We spoke a few times by phone to coordinate our work but never met in person.  He left the group practice abruptly a few months ago and did not terminate with his clients.  I was extremely disappointed in him to say the least and even considered filing a formal complaint on him for abandoning his clients.  I tried to contact him to talk about it but was unable to find him.  He did not leave a forwarding address with his group practice.

It saddens my heart to hear this news this morning.  I feel for the family of this young girl and for what she must be going through.  She is the victim of the ultimate betrayal of our profession.  Where will the victim and her family turn for help in order to start the process of healing?  To the same profession that brought about this suffering?  I feel sick.  The ramifications of this betrayal will likely linger for years.

Licensed Clinical Social Workers are bound by a professional Code of Ethics.  We are also bound by State laws outlined in Chapter 491.  I urge the State Attorneys Office to charge Trent with having sex with a therapy client.  This is a felony in the State of Florida and should be added to his three charges of unlawful sexual activity with a minor.  He should lose his license to practice forever.  He should serve an appropriate prison sentence for these crimes.

I am outraged.  I am angry at Trent for what he did.  I am angry about what happened to this young girl.  The injustices here are multi-layered.  If you look at the blog comments posted on the Times Union web site under this article, you will see that our community is outraged as well.  They are not just outraged with Trent, they are outraged with all of us.  The community blames the profession rather than the individual therapist.

Is that fair?  Do we deserve to share part of this burden?  I certainly haven’t crossed any boundaries with any clients.  There are over 300 Licensed Clinical Social Workers practicing in Northeast Florida.  This is the first time that I remember hearing of a therapist in this area who got into this kind of trouble.  The rest of us are respecting our boundaries with our clients.  The rest of us are working to empower our clients and help them on their journey of healing.  Should we share this burden with Trent?

I think we should.  We failed Trent and we failed his client.  Our profession allowed for Trent to commit the ultimate betrayal of a vulnerable minor.  Hindsight might offer an opportunity to learn from this tragedy.  I hope that we will learn what we could have done differently as a profession in this instance.  I hope that as a profession, we learn something here that will prevent this from ever happening again in Northeast Florida.

When I went through Clinical Supervisor training with Dr. Catherine Waltz in Fort Lauderdale, the discussion of sexual contact with clients came up.  Dr. Waltz wanted to make sure that we equipped those we supervise with the safety nets necessary to prevent this kind of event from happening.  She encouraged us to boldly ask our supervisees about their sexual attraction to their clients.  She encouraged us to make sure that we discussed this important topic and warn our therapists in supervision of the pitfalls that often lead up to boundary violations with clients. 

I remember asking Dr. Waltz about the circumstances that lead up to a therapist sleeping with a client.  I proposed that these therapists were probably weirdos that operate on bizarre theoretical and practice orientations that involve touching or other sexual contact as a part of the healing process.  I have heard rumors of these professional deviants and always assumed that these were the people who slept with their clients.  Dr. Waltz’s response startled me.

She told us that these therapists who slept with their clients were people like me and you.  They are people that have allowed themselves to become detached and not self-aware.  They are people that are experiencing personal issues that are not being dealt with.  They are people that have allowed the safety nets of the profession to loosen.  They are people who allowed themselves to take small liberties with clients, one at a time, that grow into the kind of boundary crossing that we see here. 

I am sure that Trent did not directly go from being this client’s therapist to being her sexual victimizer.  It is likely that there were a dozen or more progressive boundary violations that led up to this victimization and ultimate boundary violation of sexual victimization.  The safety nets of our profession failed to recognize these progressive boundary violations that led up to a therapy client and her family being betrayed by someone that they likely went to for help in a time of crisis. 

Trent was licensed.  He was not required to be in clinical supervision.  I don’t know if he participated in group or individual consultation with colleagues.  I don’t know if he ever participated in his own long-term therapy.  I don’t know what his clinical supervision was like.  I don’t know if he was experiencing a personal crisis that left him clinically vulnerable.  I don’t know if he recognized the significance of the progressive boundary violations that led up to him victimizing a client.  Our profession should be asking all of these questions.

What else should we do?  I believe that we have to be vigilant within our own profession to recognize boundary violations in our colleagues.  I also believe that we should embrace the idea and create a culture of therapists going through their own long-term therapy.  We need to empower therapists to police themselves and we need to figure out how to help each other.  We need to be more transparent in our work.  We need to staff problematic cases.  We need to participate in our own therapy.  We also need to ask difficult questions of each other.  We need to act on our “third ear.”

Trent’s behavior does not just affect him, the victim and the victim’s family.  His behavior undermines our collective credibility.  Our profession was betrayed by Trent.  You are betrayed as well.  Ask yourself, “What will I do to make sure that I never betray my clients or my colleagues?  What will I do to make sure that other therapists never betray their clients?”  The community blames us all for this tragedy.  We all need to act to make sure that this never happens again.

If you would like to reply to this, please email me at newdaycounseling@comcast.net or go to my website: www.newdaycounselingonline.com

Ross McDonough M.S.W., L.C.S.W., C.A.P.

Dr. Cathy Waltz’s Response:

Ross,

   Thank you very much for sharing your Blog entry with me and agreeing to allow me to post it on Dr. Cathy Waltz’s Blog as well.  The news article seems so terse and unemotional – “just the facts, m’am” reporting.

   On the other hand, your eloquent response and questions clearly express the pain that many are just beginning to realize.  Some of “us” are not clear about boundaries and cross the line.  Your efforts to contact Mr. Cook after he dropped out of sight are a credit to your personal/professional ethics and, hopefully, a response to all of the training you have had.  You observed something out of bounds and attempted to address your concerns directly.  That is what the Social Work Code of Ethics tells us (social workers) to do.  Remember, too, that our other 491 Licensed colleagues’ Codes of Ethics do not directly instruct them to take the same action. 

   I appreciate your saying what many of us feel and do not express.  You “feel sick” when facing the reality that the boundary violation committed by Mr. Cook has impacted the future help-seeking options for all of the young woman’s family but especially her future contacts with psychotherapists.

   I, too, feel sick. . . because many of our colleagues don’t even know that this abuse of power occurred and those that do might just “duck and cover” because it is really difficult to face the idea that “Mr. Cook is just like me…I could violate boundaries, too.”

   Your express outrage, anger, frustration, and then denial.  I am with you on all those emotional fronts.  Sorry, though, I have to say it Ross, when you assert that the rest of the LCSWs in your area haven’t crossed any boundaries I have to say denial.  Boundary violations occur along a continuum.  I dare say that we and many of our colleagues are likely to have crossed boundaries somewhere on that imaginary line.  I wonder what boundary violations we all would be willing to own publicly on a Blog or even in a consultative-supervision group.  I do share some of my errors when I am providing training, but I am much more comfortable pointing out others’ errors as examples.  Yck, I don’t even like remembering where those conversations have necessarily gone in my past consultative-supervision experiences or considering where they might go now.   I know so much more now than I did before when I was young and “knew everything”.

   Here are some questions for all of us:  How did the profession fail Mr. Cook?  How did our profession allow him to commit the ultimate betrayal?  What solutions do you think could be implemented?  Should licensed therapists be required to continue their own personal therapy?  Stay in formal supervision or consultation?  Should the 491 Board take a more proactive approach to the development of new professionals by clarifying the quality of “qualified” supervision?  Should the law be changed to close the loop hole that keeps the Board focused on the Registered Intern’s responsibility while remaining silent on all those who are un-registered and practicing under the auspices of an agency where someone might eventually sign-off on the worker’s hours?  Whoa, that’s certainly enough thought provoking questions for now.  Ross, you ask some great questions.  I’ve added mine. 

   Readers,  what is your response?

This first post contains the first part of an email conversation I had in October 2008 with Frida,  one of my training participants from Sweden.  She attended a training seminar during which she learned about how to facilitate batterer intervention (non-violence education) classes and had some questions.  Her questions and comments are in black and mine are dark blue

Frida (in Sweden):  When we got back to Gävle and presented IDAP at a staff meeting this afternoon, we had to face some resistance from our coworkers. Most of this, I think, comes from the fact that we already have a therapy-group for battering men, and people here absolutely loves this group and the leaders of it, and believe that this kind of treatment is the answer.. I’m not sure exactly how they work in this group, all I know is that they work a lot with self-esteem, emotional support for the men and with separating a man from his behaviour. My believe is that the group is more based on psychodynamic theories, than cognitive/behavioural ones.   (Dr. Cathy): What do they consider success?  Are they working within a framework of safety for the battered woman?  Who is contacting their participants partners to ensure safety?  Is anyone evaluating the program for compliance, non-violence during and after the program or anything like that?  The IDAP program is operating within a strong framework of accountability and efficacy. 

Frida (in Sweden):   This group works nothing with the women, they have no contact with them. The leaders of the group tell me that they do not let the men “get away” from their responsibility for their violent behaviour, but when I listen to them talking, I hear an awful lot of things that could maybe be comprehended as excuses for the violence. “The men are dealing with a lot of guilt and shame” or ”What hurts the most; getting slapped or hearing that you are not the father of your children?” (A woman had told her husband this in some example they told me about.) 

It’s very hard for me to discuss this with my colleagues because I’m very keen on working with our educationally structured programs that are based on cognitive behavioural therapy, I believe strongly in these theories. I think I scared my colleagues with my description of how harsh this programme can be on the men. I myself really agree with this point of view not the least because it combines an empathetic approach with zero tolerance for violence.   I am not sure what you mean by “how harsh the program can be”.  Do you see that the expectation that the participants remain non-violent during the program and accept responsibility for their violence as being harsh?  If not that, then it would be helpful to me to know what you or your colleagues might have seen as harsh. 

It’s the focusing on the violence. The therapy-programme focuses much more on how the men feel, WHY they behave like this, which experiences they themselves have. Also IDAP has a structure that needs to be followed, which (I think) means that there’s not as much room for hugging and crying and talking about what the men needs to talk about right then and there. Of course, if one of the participants is going through something hard or has a need to talk about something, we aswell will offer to sit down with him after the session. But in the therapy-programme, everything circles around this. It’s focusing on the men who batters, not on the battering. The men will feel better about themselves and through that, stop with the battering. Compared to that, I believe that some would say that IDAP is harsh.

Now, I know this is difficult for you to have any opinion on when you know so little about our therapy-group, but I would still like to know your thoughts about therapy versus IDAP and cognitive behavioural theories versus psychodynamic theories, when it comes to treating these men. You said at the training that insight is all good, but it doesn’t make a person change. More thoughts like that, please! =)  I found no evidence in Domestic Violence research literature that insight leads to behavior change.  Therapy that focuses on insight seems likely to spend a lot of time looking for excuses for why a man was violent rather than framing his violence as a social problem and helping him to see alternatives to his control and abuse.  We do not see his violence as individual pathology.  We don’t see the participants as ‘sick’ or look for diagnosable conditions.  Therapy and treatment is for sick people who have a diagnosis, else why would we treat them? 

I agree, it seems quite logical to me that a person has to practice a new behaviour to be able to start using it in real life. I’m sure it can be helpful and comforting for us all to get some answers to why we feel, think and act the way we do, but to make a change, we have to focus on here and now. And practice!

Another question: Many of the batterers were battered themselves in their childhood. What are your reflections on the fact that some of them choose to batter their wives/children, and some of them choose not to? Are there any connection with the need of control that we talked so much about? Why do some of these men react with such a need of control? Or do they all have the same need but choose to handle it differently?  See above, our framework for understanding why men batter is because they can, society and socialization prepares men and women for traditional roles that are based on a power-over, hierarchical/patriarchical structure that justifies men’s violence against women and 

This is what makes this subject so incredibly interesting! You have been in Sweden a lot, do you see any big differences between the gender roles here and in the states? My prejudice is that the families in the U.S. in general are more traditional than they are in Sweden. Is it for example common that men stay at home with their kids for some time after they’re born? Is it taken for granted that women work, or is that still an issue? Do you see big differences in the different parts of the country?  

In Sweden, I believe, we think that we’re really advanced in this area, that men and women are equal. This is of course not true. We have the big things, like the fact that women make less money for the same job, that the fathers rarely stay at home with their children as much as the mothers do etc etc. And we can also see smaller things, that one may think are not very important, but which I think maybe are the most important ones. We talked about it a bit at the training: The different colours of clothes we put on our children, the different toys we give them to play with, how we talk to them and behave towards them. All the time, we tell them that they should be a certain way because they are girls/boys! And it’s not just oppressing and discriminating towards the girls! Of course, this is not easy for the boys either. To not be tought how to express your emotions, for example, must make your whole life more difficult.

I could go on and on about this… =)

And another one: Do you think that, by putting all the responsibility for the violence on the men, we sometimes make the woman more of a victim? Don’t get me wrong, of course she IS a victim. But does it make her feel more helpless, worthless and weak, do you think?  I believe that we should always work in ways that identify and acknowledge victim/survivors’ strengths.  By focusing on his violent and abuse behavior and ways to help him to change, I also believe that we reduce her reaction/belief that she has to find a way to prevent his violence.  Battered women frequently act in ways that suggest that she believes that she can modify or prevent his violence, despite the repetitious nature of his behavior no matter what she does. 

Right. So, through putting all the responsibility for the violence on the men, we tell their partners that it’s not up to them to do something. it’s up to their partners. That doesn’t neccessarily mean that they are helpless etc, it just means that it’s not their job. The ball is not in their corner, so to speak.