Dual Relationships

Dr. Rob,

As funny as Dr. John is, we all know that he has issues. Other than sexual relations, though, what constitutes a “dual relationship,” and why is it so bad?

Ricky


Yes, we all love Dr. John, despite his quirks and propensity to sleep with your mother, so let’s talk about other problematic arrangements in therapy. Consider a dual relationship to be any involvement between therapist and client that is not part of the traditionally understood treatment agreement. In other words, when you see a therapist, she is offering you a very specific service: treatment of a psychological/emotional difficulty in exchange for payment, via your health insurance or directly from you. Anything that occurs beyond or in addition to that is essentially a dual relationship. This is almost invariably bad, and it is ultimately the therapist’s responsibility to ensure that this does not occur.

Generally speaking, the worst kind of infraction occurs when the therapist asks the client to perform a specific act that is not part of the client’s treatment. This could range from something as seemingly benign as asking the client to bring her a cup of coffee from Starbucks to the more egregious sexual advances. As a recent example, a reader sent an email reporting that a therapist asks his clients to purchase marijuana for him. This is problematic on multiple levels. In this case, the therapist is asking clients to not only commit a crime (i.e., sell or distribute drugs) but commit one that directly serves the therapist’s personal interests. While none of us should be na├»ve enough to not realize that countless people use and sell pot to both friends and colleagues, the therapeutic relationship is a unique one. By asking clients to do this the therapy is compromised.

Clients are often very dependent on their treatment and their therapist, as therapy can involve experiencing and discussing very painful emotions. Some clients have told me that their psychological pain is far worse than any physical discomfort they’ve endured. In many cases, the therapist becomes a vital person in clients’ lives, helping them to navigate through this emotional pain. Imagine, then, that the client wants to reject a request an “out of bounds” question from this extremely important person, whether it be to buy coffee, drugs, or have sex. Now consider the thoughts that might run through the client’s head: If I say no, will my therapist be mad at me? Will he think poorly of me? Will I stop getting ‘good’ treatment? What if my therapist outright refuses to see me anymore if I don’t comply? Who will help me then?

Suppose, however, that the client doesn’t mind bringing the therapist a cup of coffee (or drugs or sex for that matter). Is he now obligated to bring it every week? What if he forgets? What if the therapist decides he wants coffee and a donut? Does the client have to comply with that too?

In essence, the therapist is creating a potential and unnecessary whirlwind of questions and emotions by asking this of his clients.

Therapist Rule: Do NOT solicit from clients. Ever. For anything.

During graduate training, we often videotaped our sessions with clients as part of our education. Clients were fully aware of this and agreed to it as part of being seen in a low-fee (and sometimes no-fee) setting. One student, a particularly pompous and arrogant woman in her final year of training, was doing particularly well as a therapist that year. Clients were reporting feeling significantly better in a very reasonable number of sessions with her, which made me secretly want to punch her in the neck for being better than me.

During one particular session, a client was saying how thankful she was for all of the student’s help so far. The therapist responded with “You are so welcome. Would you mind giving a testimonial for my business card? Something like, ‘__________ is the best therapist I’ve ever seen,’ maybe? That would really help me start off my practice.”

The client blanched. “Um, well sure, I guess I could say something along those lines.”

Our professor stopped the tape that he and about five students were watching. “Tell me…what the hell is the matter with you?”

“What? What’s wrong?” the student asked, clearly confused.

“You asked a client to give a written testimonial that you are the best therapist?”

“No,” she corrected, “just the best that she has personally seen. Is that wrong?”

“Yes it’s wrong!” the professor snapped. “Do you realize that you are putting this client in a horrible position? This person now has to write that you’re the best therapist she’s ever seen! How do you even know she thinks that?”

“Because she agreed to it,” countered the student.

“Maybe she agreed to it because she is so thankful for your help, maybe she’s afraid that you’ll withhold that help if she says no, maybe she doesn’t want to hurt your feelings. Do you see how many ‘maybes’ we can come up with?”

“I didn’t know it was wrong,” the student said, dejectedly.

“Well it is. And by the way, if you’re the best she’s ever met, she’s seen some bad therapists.”

I was later told that the student cried that night over some cheap scotch.

Feel free to comment on any experiences with dual relationships, or bring this piece to your next therapy session. Just so your therapist knows not to mess with you.

(Visited 110 times, 1 visits today)

10 Responses to “Dual Relationships”

  1. Foil says:

    Another great entry Rob, please don’t leave so long in between them though!

  2. kate says:

    i’m a master’s student currently in the process of preparing and submitting applications for clinical phd programs next fall. as you know, the clinical psych phd is the most competitive of all doctoral programs. at times during the application process (and it’s been a three year process getting everything together) i become overwhelmed and think it’ll never happen for me–that somehow people who actually get accepted into these programs are in some way *superior beings*…..thanks to stories like these i realize i have a chance, because apparently even complete assholes like the ones you describe can get accepted for the clinical phd.
    you’re the best, dr. rob!

  3. Silvyr says:

    Wow. I have to say, not only was that a stupid move on the part of that student, but I think it would also be incredibly stupid to put that on her business card! If I went to see a therapist who had, “_____ is the best therapist I’ve ever seen!” written on his/her card, I’d be a little put off…no, scratch that, a LOT put off. What kind of ego would a therapist have to put that on their business card? A plumber or electrician I can see, but for a service as personal as therapy, I wouldn’t trust that at all…
    …and now that I think about it, how would that work, anyway? Putting the client’s name on there could make other potential clients concerned about their confidentiality, and putting no name (or worse, “Joan* [* name changed to protect privacy]”) just looks phony.
    Yeesh. Seriously, what WAS she thinking?

  4. Robin says:

    Great one, Dr. Rob! Thanks for clarifying the dual relationship issue for me. When I started seeing my therapist, I really didn’t understand that she and I would never be friends. Now I get it.

  5. Drew says:

    Rob,
    I had a conversation with my girlfriend this morning about the phenomenon of ‘learned helplessness’, and I was wondering what your take on it is. We agreed that, with enough of the right kind of help, anyone can overcome this struggle, but many never get that help.
    Do you think it’s something someone can overcome on one’s own? Do you think it’s a valid description for what underlies depression, anxiety or despair?
    I know this isn’t a comment, and certainly isn’t relevant to this post; I just thought I’d throw it out there in the hope of stimulating a future post.
    Thanks for all the posts thus far – they’ve been really stellar.
    Cheers,
    Drew

  6. Jameson says:

    In case Dr. Rob doesn’t have time to answer your question: Yes, it is very possible to overcome depression, anxiety, and despair by yourself. In my experience your own hard work will be more effective. Just believe you can make the necessary changes.. then make them (with no excuses for setbacks).

  7. Amber says:

    We need more of your posts.
    I have shrink withdrawal when you miss a day.

  8. TengaRay says:

    My supervisor sat me down just last week for a very unsettling talk about “dual relationships.”
    I’m a therapist and my supervisor used to be my therapist… so that sucks.
    It was a surprise when she opened the door at my interview… we were both shocked and each walked apart silently.
    It took her NINE months to approach me with this conversation. I don’t know what triggered it but honestly, I’m more worried that she brought it up now than if it were never discussed at all…
    It’s not like I told her I murdered babies and fed them to kittens… but I am a total neurotic stress case with paralyzing anxiety via PTSD reactions. So, that blows… and I wonder if I seem symptomatic to her and that’s why she brought it up…
    Ironically, I was less stressed during the two weeks preceeding her conversation than I’d been during the whole 6 years prior… Poop.

  9. Sidney says:

    I realize this is an old post, but I remembered reading something about dual relationships and this issue has come up for me recently…
    …in the world of web2.0, and everyone and their mother showing up on facebook, I used the friendfind utility today and…found my therapist. My gut tells me I should ~not~ add her as a friend, and I am not planning on doing so, despite being on friendly terms, and despite the innate desire of of my generation to add EVERYONEIHAVEEVERKNOWNEVERINMYLIFE as a “friend” on facebook, I don’t want to be weird or make her feel like she cannot have a life outside of her job…but I’m wondering, how many people have encountered this issue? How are people dealing with keeping boundaries in a world where they are constantly blurring, a world that is constantly shrinking (no pun intended)?

  10. Keith says:

    Sidney, I came across a similar problem when I came across a nurse that was very good to me during a recent hospitalization on Facebook. I opted not to add her for exactly the same reason I would decline one of my former clients adding me (I work in an RTC): the therapeutic relationship ended when I left that hospital, and the only relationship we have is a therapeutic one.
    You aren’t your therapist’s friend, you’re his client. You can be friendly, and you can have a friendship, but he should always be your therapist and you should always be his client, and when that relationship ends, it’s over.

Leave a Reply