There is little doubt that psychotherapists at one time or another find themselves considering, or being asked to consider, taking a friend or family member as a client, particularly in a 'Small-World' environment such as a country town or close-knit community (Keith-Spiegel & Koocher, 1998). However, this constitutes a violation of set boundaries and a conflict between two significantly different roles. These individuals are no doubt on a first name basis, increase the potential for therapist self-disclosure, and may frequently initiate physical contact such as a hug at the end of each session (Gutheil & Gabbard, 1993, as cited in Bersoff, 1999). While some may perceive these factors as a beneficial indication that significant trust is already established with the client, they are misrepresentations of the therapeutic relationship and constitute a crossing of boundaries. This contamination of the therapeutic relationship affects not only the therapists professional life but their personal one as well since clientele are being drawn from the same pool of people who serve to identify the social world of the therapist outside the office. As Corey (1996) states, "the crux of the matter is to avoid exploiting clients". This potential for exploitation and/or client harm is acknowledged within the psychological community as being a lucid example of one of the pitfalls of a dual relationship. Dual (or multiple) relationships being when counselors assume two (or more) significantly different roles simultaneously or sequentially with a client, whether of a sexual or nonsexual nature. The Australian Psychological Society's (APS) Code of Ethics states that - "Psychologists must avoid dual relationships that could impair their professional judgment or increase the risk of exploitation..." - and lists close friends and relatives as examples of those to which one should avoid providing psychological services to.

As suggested by Pope and Vasquez (1998), and Pope (1991, as cited in Bersoff, 1999) it may be the fact that definitions seem so relatively simple and abstract that results in psychotherapists ignoring the diverse ways that dual relationships can occur. However, in considering the adoption of a family member or friend as a client - in comparison with the relative ambiguity in recognizing other examples of dual relationships in practice - therapists find themselves in the fortunate position of being able to recognize from the outset that two distinctly different roles are involved. That of friend or relative, and that of therapist or client. This is more likely to be a sequential rather than initially concurrent example of dual relationships (Pope, 1991, as cited in Bersoff, 1999). One would assume that such recognition would make the situation rather straight-forward, i.e. two different roles are acknowledged, so according to the Code of Ethics the therapeutic relationship is avoided. But the fact is that things are never so simple in practice, and the psychotherapist, often to their own professional detriment, is forced to make an impulsive rather than considered decision on their course of action. Gottlieb (1993, as cited in Bersoff, 1999) goes to the length of asserting that the goal of avoiding all dual relationships is in fact unrealistic in many circumstances. It would seem that, overall, the answer is not a universal prohibition of dual relationships. Rather, only those situations in which a clear conflict of roles and interests presents itself and the potential for client harm is considerably high.

Psychotherapy, friendships and family ties exist in the "context of complex, intimate relationships" (Keith-Spiegel & Koocher, 1998). Therefore, the potential for client harm is significantly increased if the therapist fails to make considered steps when dealing with them simultaneously. While both in the same realm of highly personal and intimate relationships, their goals are significantly different. Therapy is (hopefully) a short-term, goal-oriented venture which aspires to objectivity in attempting to fulfill particular therapeutic ends for the benefit of the client. The expectations of friendships and family relationships differ in that they are often (if not always) long-term affairs which are highly emotionally charged, a situation which would obviously begin to threaten the psychologists objective position. While these personal relationships seek to satisfy needs, these needs are usually mutual, if not reciprocal. Friendships and family relationships do not necessarily seek to fulfill specific criteria in seeking a particular goal or resolution, at least, not in the same manner as would be witnessed within the therapeutic relationship. Obviously a distinction exists between the expectations of the relationships in question, which would satisfy the criteria for a potentially harmful dual relationship.

Therefore, the two most evident dangers of a dual relationship include a loss of objectivity and the fear of exploitation. Certainly, there is the danger that subjectivity may impinge upon the therapeutic process, and one must acknowledge that this danger is especially prevalent when dealing with ones own family and friends. This is similar to the first consequence of dual relationships extrapolated by Pope and Vasquez (1998). They stipulate that a dual relationship can "erode and distort the professional nature of the therapeutic relationship" in that set boundaries upon which therapist and client could depend are now virtually nonexistent. Pope and Vasquez (1998) also point out that the use of the word 'professional' in describing the therapeutic relationship may imply a "cold, distant, unfeeling, uncaring [therapist]". A stereotype which is undoubtedly the result of actions on behalf of the "worst professionals". Such a stereotype would become especially relevant in the possible perception of the therapist by friends and family if a) the therapist declines a therapeutic relationship without explaining the situation to the friend/relative, or b) in an attempt to more clearly delineate the professional and personal relationships, the therapist intentionally acts in accordance with the stereotype (in adopting a cold, distant demeanor). Such behavior on the psychotherapists behalf may result from the ethical impasse experienced when the two worlds - personal and professional - collide. Keith-Spiegel and Koocher (1998) suggest the employment of 'positive limit setting' as a viable solution to this dilemma. "It involves placing restrictions when responding to the client's request while...reframing the response in a way that meets a legitimate underlying need."

This brings us to the second consequence of dual relationships suggested by Pope and Vasquez (1998) - a conflict of interest. One would assume that psychologists who find themselves treating family and/or friends would experience a conflict between the best interests of the client and their own social needs in respect to their personal relationship with them.

Phillips (1986) investigates another facet of 'role conflict' pertinent to Pope and Vasquez's (1998) notion of a conflict of interest in describing the life of the psychologist outside the office. Unfortunately, little research focuses on the repercussions of dual relationships upon the personal lives of psychotherapists. In discussing dual relationships with family and friends this becomes an extremely important concern as these are the very individuals with whom the psychologist has regular contact outside the therapeutic setting. This becomes one of the difficulties in assessing whether to take on a friend/relative as a client, as whatever decision is made has profound and extensive effects upon the life of the therapist. Even in considering adopting the friend or relative as a client the psychologist is suddenly plunged into the ethical swamp of dual relationships. Decisions concerning the proposed therapeutic relationship have demonstrable repercussions on an already powerful, long-term personal relationship.

Gottlieb's (1993, as cited in Bersoff, 1999) decision-making model for assessing and managing dual relationships focuses on the power, duration and clarity of termination for both the current and contemplated relationships. It is interesting to note that Gottlieb (1993, as cited in Bersoff, 1999) uses the term 'consumer'. His model is most definitely an attempt to provide an objective tool for assessing the repercussions of dual relationships on an essentially business-like arrangement. One of the best boundaries defining the business nature of the therapeutic relationship is money. As Gutheil and Gabbard (1993, as cited in Bersoff, 1999) point out, "[therapy] is not love, it's work". Trouble begins when the psychotherapist no longer considers the professional relationship as work. Keith-Spiegel and Koocher (1998) outline several 'warning signs' that indicate when a relationship has moved away from the therapeutic role, many of which are particularly relevant to the reception of friends and family into therapeutic practice. For example, expecting the client to do favors for you, seeing the client outside the professional setting, allowing the client to take advantage (e.g. not pay or defer payment) or greatly resisting the termination of the therapeutic relationship as their presence and praise boosts the therapists self-esteem. The fact that psychotherapists feel that it's often necessary to make an exception for friends and family in terms of payment is a significant indicator that our professional judgment has been impaired. While a therapist would never encourage the perception that they were 'only in it for the money', receiving no material reward at all would suggest that the professional boundary set by money has been violated. An aspiration to maintain this degree of professionalism is as slippery a task as politely rejecting a friend or relatives request for advice. The friendship or familial association with the prospective client is the preceding relationship to the therapeutic one, and has a considerable degree of power which has been compounded over time. Termination of this personal relationship is therefore (presumably) out of the question. Personal issues will seep into the decision-making process as assuredly as the professional mindedness which is assumed in psychological practice will seep into our personal lives. Returning to Phillips (1986) we acknowledge that the psychologist has a unique relationship to friends and family as they know that the psychologist is a person to whom they can turn to for educated, insightful advice on personal and/or intimate issues. The danger begins when therapists use this unique position to serve their own needs, particularly in respect to self-esteem. Our desire to have control over our friends and relatives is as volatile a component as the need to feel useful and significant in their lives (Corey, 1996). The dangers the APS advises psychologists to avoid are evident, but we still need to define the moral complications of dual relationships that make the decision to decline and refer friends and relatives less clear-cut than would be appreciated.

Corey (1996) cites Welfel and Kitchener (1992) and Kitchener (1984) in describing five basic moral principles which appear in professional codes of practice. Basically, these are: benefit others (beneficence); exercise caution to avoid harm (nonmaleficence); respect the client's independence (autonomy); provide equal and fair treatment (justice); and faithfully honor promises to encourage trust in an effective therapeutic relationship (fidelity). First and foremost, our desire as professionals and as human beings is obviously to care for and benefit our friends and relatives. However, in providing therapeutic services, we may not exercise the necessary caution in avoiding the potential harm to clients that arises from a conflict of interest, as detailed in Pope and Vasquez (1998) and Phillips (1986). In regards to autonomy and justice, the therapist can respect the decision of a friend or relative to seek them out for professional consultation. Psychotherapists may not want to dismiss the potential client because they're involved with them personally, but must realize that this personal relationship itself poses a significant threat to the independence of the client not only within the therapeutic setting but, more evidently, in further relations with the therapist outside the office. In this respect the treatment provided could not be fair treatment as we are in a position to make judgments based upon background material not always relevant to the therapeutic setting. Finally, fidelity may suggest that counseling family or friends is excellent as trust has already been firmly established, but the complications of the dual relationship do not encourage the client to seek their own solutions and increases the potential for deceit or exploitation to occur as professionals rationalize an evasion of professional responsibility - particularly through selective inattention (Pope & Vasquez, 1991).

While in dealing with friends and relatives we are in the fortunate position of being able to recognize different roles from the outset, this doesn't make the ethical decision to avoid them as potential clients any easier. As Corey (1996) most succinctly states "[therapists] accept the responsibility of searching for appropriate solutions", an opinion which he no doubt borrows from an earlier collaboration with Herlihy (1994, as cited in Corey, 1996) - "self-monitoring is a better route for professionals to take than being policed by an outside agency". Dual relationships are complex and multidimensional, and few answers to a speedy resolution will present themselves. Once again the responsibility for making an honest and accurate professional judgment in an area of ethical difficulty falls squarely upon the shoulders of the individual therapist. While organizations such as the APS can institute rules and guidelines pertaining to the preferred responses to ethical dilemmas, it is the psychotherapist's responsibility to adhere to them as best as possible in what is often a realm of ambiguity. Ironically, it would be a violation of 'client' autonomy if psychological organizations were to start strictly regulating its members. When dealing with friends and family, Keith-Spiegel and Koocher (1998) make the best suggestion in that the therapist should provide "short-term emergency support until a suitable referral can be located". While the therapist can and should provide emotional support, information or suggestions, the best option is a referral to another competent professional when the situation becomes more serious. If measures such as these will not suffice, the consensus seems to be that the therapist should seek consultation with peers (Corey, 1996; Lonsdale, 1997; Gottlieb, 1993, as cited in Bersoff, 1999). Others working in the field may be in the unique position to provide a more objective opinion on the best course of action. Not only this, but the therapist who finds him or herself facing a dual relationship will have been seen to have attempted to resolve a recognized ethical dilemma in adopting a 'supervisor'.

While the task of dealing with dual relationships is no doubt particularly troublesome in relation to the highly emotive and sensitive domain of family and friends, the psychotherapist can only consider themselves the wiser for the experience. As stated by Lonsdale (1997) - "Grappling with ethical complexities in day-to-day practice is a hallmark of professionalism". The solution is not to completely avoid dual relationships, but face them responsibly in the hope of finding a solution that's beneficial for all parties concerned.

References

Australian Psychological Society (APS) Ltd., The. (1997) Code of Ethics.
Bersoff, D. (1999) Ethical conflicts in psychology (2nd ed.) Washington DC: American Psychological Association. Ch.5.
Corey, G. (1996) Theory and practice of counseling and psychotherapy. Pacific Grove: Brooks/Cole Pub. Co. pp. 51-81.
Keith-Spiegel, P., & Koocher, G. P. (1998) Ethics in Psychology: Professional standards and cases (2nd ed.) New York: Oxford University Press.
Lonsdale, J. (1997) The Hatherleigh Guide to Ethics in Therapy. New York: Hatherleigh Press.
Phillips, C. D. (1986) The Psychologist as a Friend: The Ethics of the Psychologist in Nonprofessional Relationships. Professional Psychology: Research and Practice. 17(4) 293-294.
Pope, K. S., & Vasquez, M. J. T. (1991). Ethics in psychotherapy and counseling. San Francisco: Jossey-Bass.