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.
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.
Sexual Involvement with Current and Former Clients
Sexual involvement is an especially destructive form of dual relationship. Sexual intimacy with current clients, trainees, supervisees, and research participants is prohibited under professional ethics guidelines; sexual activity with current and recent clients is a criminal offense in many states. Following the termination of a professional relationship, providers should follow applicable statutes and the rules of their professional associations regarding when sexual intimacy is permissible. The American Psychological Association, for example, absolutely prohibits any sexual contact in the first 2 years after termination of treatment (APA, 2017).
Even when it is within the written guidelines of professional codes of conduct, post-treatment sexual involvement removes the patient's option of benefitting from a possible return to treatment with an already trusted provider. It also risks that the unequal treatment relationship makes it difficult for the former patient to make a completely autonomous decision about entering a sexual relationship. Professionals should also remember that although the post-therapy relationship may seem mutually consensual at the beginning, the former client may, over time, feel exploited and file a complaint about an abuse of the previous power relationship.
Providers should consider the recommendation of the American Psychological Association that all intimacies are prohibited in the first 2 years post-treatment and that after that, the practitioner bears "the burden of demonstrating that there has been no exploitation, in light of all relevant factors" (Behnke, 2004).
In general, mental health professionals are discouraged from touching their clients. Many behavioral therapists engage only in handshakes with clients; others carefully engage in a cautious side-hug at moments that call for contact. Yet, biofeedback professionals must touch their clients frequently, applying and removing sensors. Skin conductance sensor graphic © BioSource Software.
This calls for clear guidelines and procedures to avoid actual or apparent violations of the client's modesty. Listen to Dr. Moss explain touch © Association for Applied Psychophysiology and Biofeedback.
Attaching Biofeedback Sensors
Providers take special precautions when attaching biofeedback sensors to a client since it invades personal space, often involves physical contact, and risks misinterpretation. It is helpful to explain the function of the sensors and how they are attached and ask permission to place them on the client's body. Practitioners can encourage clients to attach sensors to their own bodies whenever feasible. For example, when attaching a respiratory band for respiratory biofeedback, the practitioner can ask clients to place the band around the abdomen or chest, guide them verbally in the placement, and stand behind the patient to secure the band as it is handed back to the practitioner. This strategy minimizes physical contact with vulnerable body areas, treats the client as a respected partner, and can strengthen the therapeutic alliance.
It is wise to remember the high percentage of individuals in the general population, especially women, who have been molested, raped, or otherwise violated, often by a person of trust. One multi-state and territory study showed that 18.5% of women report a history of attempted or completed nonconsensual sex during their lifetime (Smith & Breiding, 2011). Further, women with histories of sexual violation experience higher rates of chronic illnesses and health risk factors such as smoking, excessive alcohol use, and elevated cholesterol and blood pressure (Santaularia et al., 2014; Smith & Breiding, 2011). This research suggests that biofeedback practitioners will also see a disproportionate number of women with histories of sexual violation.
Accordingly, biofeedback practitioners are responsible for conducting all procedures involving even seemingly trivial touch with caution and respect. Explaining the procedure and asking permission to place the sensor are good guidelines. In many cases, the client can position the sensor, reducing any sense of being passively violated.
Biofeedback practitioners do not touch sensitive body parts like breasts or genitals during biofeedback practice except as part of a medical examination or medical treatment essential for the patient's complaint and performed by a licensed medical practitioner.
Treatment Applications With More Intrusive Procedures
Biofeedback practitioners whose clinical specialization requires the use of more personally intrusive sensors and procedures have a special responsibility to protect the privacy and dignity of their clients. Practitioners utilizing pelvic floor muscle biofeedback may utilize sensors that require insertion in the vagina or anus. The graphic below is a TensCare Vaginal Sensor.
It is important to develop educational materials to inform clients about such sensors' purpose and to develop office procedures/routines supporting professionalism in pelvic floor practice. Many pelvic floor therapists educate clients to insert the sensor themselves, and frequently a same-sex nurse or technician is included in the patient orientation session to assure clients of the professionalism of this treatment.
In summary, the psychological dimensions of the treatment relationship are essential for treatment success. Part of maintaining the therapeutic relationship is creating a sense of comfort and safety, communicating that this is a place where the client can feel safe being vulnerable, knowing that this will not be exploited. Achieving a positive therapeutic relationship is also beneficial for the professional because when clients feel understood and supported by the professional, they will be less likely to file a complaint, even when therapy doesn't go smoothly for a time.
For the therapist, dedicating oneself fully to the therapeutic relationship by avoiding competing relationships is critical. When a therapist attempts to combine financial, supervisory, or sexual interactions alongside the therapy relationship, troubles will probably ensue.
Educating the patient about the purpose and therapeutic benefit of physiological monitoring and biofeedback for the client's current problems will enhance their investment in biofeedback sessions. Educating the patient about the sensor, the physiological signal being measured, and the relevance of the physiology to the client's symptoms will enhance their comfort with the sensors and their application.
BCIA: the Biofeedback Certification International Alliance.
dual relationships (also called multiple relationships): situations where a healthcare provider and patient share multiple roles. For example, when a client is also an employee.
American Psychological Association (2017). Ethical principles of psychologists and code of conduct, including 2010 and 2016 amendments. Available at http://www.apa.org/ethics/code/
Behnke, S. (2004). Sexual involvement with former clients: A delicate balance of core values. Monitor on Psychology, 35(11), 76. https://www.apa.org/monitor/dec04/ethics
Moss, D., & Shaffer, F. (2022). A primer of biofeedback. Association for Applied Psychophysiology and Biofeedback. Nagy, T. F. (2008). Ethics in plain English: An illustrative casebook for psychologists (2nd ed.). American Psychological Association.
Santaularia, J., Johnson, M., Hart, L., Haskett, L., Welsh, E., & Faseru, B. (2014). Relationships between sexual violence and chronic disease: A cross-sectional study. BMC Public Health, 14, 1286. https://doi.org/10.1186/1471-2458-14-1286
Smith, S. J., & Breiding, M. J. (2011). Chronic disease and health behaviours linked to experiences of non-consensual sex among women and men. Public Health, 125(9), 653–659. https://doi.org/10.1016/j.puhe.2011.06.006
Zur, O., & Anderson, S. K. (2006). In P. Williams & S. K. Anderson (Eds.), Law and ethics in coaching: How to solve – and avoid – difficulty problems in your practice. Wiley.