Dr. Donald Moss on Multiple Relationships
Updated: Mar 24
Maintaining a healthy therapeutic relationship characterized by trust and empathy is critical to success in all behavioral and healthcare treatments. Although biofeedback and neurofeedback may appear more technical than most behavioral interventions involving training physiological processes, a client's sense of comfort, trust, and safety in the therapeutic relationship remains critical for successful treatment. Violations of the trusting relationship in psychotherapy, counseling, and biofeedback are among the most frequent sources of ethical complaints in behavioral health treatment. In this post, we will explore boundaries and boundary violations in the therapeutic relationship. The information presented here relies on concepts from APA (2017), Nagy (2008), and Zur and Anderson (2006). Graphic © evrymmnt/Shutterstock.com.
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AAPB Book Recommendation
The text is partly adapted from Moss and Shaffer's (2022) A Primer of Biofeedback, which you
can purchase from AAPB in its member or non-member stores. The authors have donated their royalties to AAPB.
Dual Relationships or Multiple Relationships
The American Psychological Association (APA) has led the way in providing guidance on dual or multiple relationships (APA, 2017). The original concept of a dual relationship prohibited developing a romantic or sexual relationship with a current client. Over time, this ethical principle was broadened to include advice against entering into many forms of dual or multiple relationships with current clients and recent clients.
The therapist has an unequal relationship with clients. First, the therapist learns many intimate secrets about the client during therapy, and for the most part, the clients learn relatively little about the therapist as a person. Some therapist disclosure at critical moments is often beneficial in treatment, yet the relationship remains unequal. The therapeutic concept of transference expresses that the therapist becomes a projection screen, onto which the client projects both positive and negative emotions engendered in past relationships, especially parent-child relationships. Clients may adopt a blind trust in the professional, anticipating parent-like self-less support, or conversely may project emotions from past abusive relationships, expecting the therapist to harm the client, just as past trusted figures have abused them.
The therapy relationship is also a power relationship. The client enters therapy in a vulnerable state, hoping and expecting assistance in overcoming life problems and burdens. When a therapist uses the client for their own purposes, it exploits that power. Photo 165564906 © Prostockstudio | Dreamstime.com
This unequal relationship between therapist and client opens the potential for other relationships outside therapy with the client to be exploitative. This does not preclude ever having a multiple relationship.
For example, therapists in small-town situations will frequently find it unavoidable to interact with a client in other settings. A therapist in a small town may consider taking a social acquaintance into treatment when the relationship is quite casual, and no other professional with comparable expertise is available locally. Nevertheless, however justified, the unequal relationship raises a responsibility for the therapist/practitioner to assess carefully, on an ongoing basis, how this interaction may be or may seem harmful to the client.
Entering into a financial relationship with a client constitutes a dual relationship and can have adverse consequences. Starting a business with a client, hiring a client for services, or bartering to pay for services constitute dual relationships. The American Psychological Association now discourages entering a barter relationship with clients to pay for the therapy with labor. This author has observed past bartering relationships in therapy go sour because the client either did not fulfill the agreement or carried out poor work. Suddenly the therapist is seeking to enforce the work agreement with someone still in a relationship of vulnerable trust with the therapist. In this case, the therapist may also feel exploited, perceiving the client as taking advantage of the therapeutic trust to avoid providing the promised work.
The concept of multiple relationships also applies to behavioral health professionals, not in a treatment relationship with a client. Examples of multiple relationships beyond therapy include developing a sexual relationship with a student in an unequal relationship with an instructor; the instructor can pass or fail the student's work.
In past years, it was commonplace for instructors to engage in sexual relationships with students, yet today this an offense triggering discharge from university employment and opening liability for civil suits for damages. It was also common in past years for instructors in psychology and counseling departments to take on students as therapy clients, yet this puts the instructor in a position to evaluate and grade someone in a vulnerable therapeutic relationship expecting positive support.
Similarly, a biofeedback professional mentoring a potential biofeedback certificant should have second thoughts about accepting the mentee as a therapy client. That therapeutic relationship could create a potentially harmful conflict when the professional must provide an assessment of the mentee for BCIA or other certifying bodies. The administrator or supervisor in a work site has a similar relationship of power over subordinates, and the Me-Too movement highlights that exploiting this power relationship is unacceptable.
Biofeedback professionals must recognize that dual or multiple relationships can threaten their therapeutic relationship with those they serve and risk the exploitation of both parties. Biofeedback professionals are advised to avoid dual relationships with clients whenever possible and avoid exploiting clients, students, supervisees, employees, and research participants. For example, professionals should never treat their spouses, and supervisors should never treat their employees. When providers question their own objectivity, they should seek guidance from colleagues.