It’s the Lack of Thought That Counts: Ethical Decision Making in Dual Relationships
Curt and Katie chat about dual relationships. We talk about the types of dual relationships, how often therapists get in trouble for these types of relationships, how to manage dual relationships, and the ethical decision making process to go through to decide whether to engage in a dual relationship. This is a law and ethics continuing education podcourse.
Click here to scroll to the podcast transcript.
Click here to scroll to the podcast transcript.
In this podcast episode we talk about ethical decision making to navigate dual relationships
We take a deeper dive into the complex relationships that we can have with our clients, our supervisors and our supervisees.
What are dual relationships?
- Therapists know a lot about a very specific dual relationship: having sex with your clients, which is not acceptable
- There are many different types of potential dual relationships (we talk about the definitions of each type)
- The different hats we may wear with clients and colleagues
How do you manage a dual relationship?
- Open conversations
- Outside neutral party facilitating the transition in the relationship
- The assessment of benefit or harm, whether there is coercion
- Exploring how culture interacts with these types of relationships
How often are therapists getting in trouble for dual relationships?
- About 1/3 of complaints are due to sexual relationships with clients
- Other types of complaints include conflict of interest, non-sexual, or not described
- Concerns in rural areas are actually less dual relationships than incompetence
- Most complaints happen after the relationships have ended
Why do therapists engage in harmful dual relationships?
“Oftentimes [in predatory dual relationships] there is a conspiratorial element of it – if the client knows (hey, we’re stepping across the line) or there is a very manipulative element if the therapist is framing it as this is good for you. And so, once there’s a rupture or an end to the relationship and you start talking about, oh, my therapist did this and people are like “what?!?!”, I think it’s that element of [realizing] I’ve been wronged by my therapist, and let me go and tell the world that they did this thing.” – Katie Vernoy, LMFT
- Boundary slips
- Manipulation, intellectualization
- Not a thoughtful process
- Not an examination of bias
- Therapists going through an intuitive process versus a formal decision-making process
What is a strong formal process for ethical decision making?
“One of the calls to action, as far as any other ethics professors: really reinforcing the importance of an ethical decision-making model, because that is what the licensing boards and the ethics committees want you to do. If you go through a good model, and even if you end up with slightly the wrong answer, if you’ve put good thought into it, it at least formalizes the process and gives people an insight into how you’re thinking about things.” – Curt Widhalm, LMFT
- Pope and Vasquez have a 17 Step Process for ethical decision making
- Deeply examining the question, the impact, and exploring any bias
- Identifying and understanding relevant laws and ethics
- Consultation, documentation, and evaluation
- We walk through a specific dual relationship question: what happens if your client refers a friend and colleague to you? How do you decide whether to take the client or not?
Our Generous Sponsor for this episode of the Modern Therapist’s Survival Guide:
Thrizer is a new modern billing platform for therapists that was built on the belief that therapy should be accessible AND clinicians should earn what they are worth. Their platform automatically gets clients reimbursed by their insurance after every session. Just by billing your clients through Thrizer, you can potentially save them hundreds every month, with no extra work on your end. Every time you bill a client through Thrizer, an insurance claim is automatically generated and sent directly to the client’s insurance. From there, Thrizer provides concierge support to ensure clients get their reimbursement quickly, directly into their bank account. By eliminating reimbursement by check, confusion around benefits, and obscurity with reimbursement status, they allow your clients to focus on what actually matters rather than worrying about their money. It is very quick to get set up and it works great in completement with EHR systems. Their team is super helpful and responsive, and the founder is actually a long-time therapy client who grew frustrated with his reimbursement times The best part is you don’t need to give up your rate. They charge a standard 3% payment processing fee!
Thrizer lets you become more accessible while remaining in complete control of your practice. A better experience for your clients during therapy means higher retention. Money won’t be the reason they quit on therapy. Sign up using bit.ly/moderntherapists if you want to test Thrizer completely risk free! Sign up for Thrizer with code ‘moderntherapists’ for 1 month of no credit card fees or payment processing fees! That’s right – you will get one month of no payment processing fees, meaning you earn 100% of your cash rate during that time.
Receive Continuing Education for this Episode of the Modern Therapist’s Survival Guide
Hey modern therapists, we’re so excited to offer the opportunity for 1 unit of continuing education for this podcast episode – Therapy Reimagined is bringing you the Modern Therapist Learning Community!
Once you’ve listened to this episode, to get CE credit you just need to go to moderntherapistcommunity.com/podcourse, register for your free profile, purchase this course, pass the post-test, and complete the evaluation! Once that’s all completed – you’ll get a CE certificate in your profile or you can download it for your records. For our current list of CE approvals, check out moderntherapistcommunity.com.
You can find this full course (including handouts and resources) here: https://moderntherapistcommunity.com/courses/its-the-lack-of-thought-that-counts-ethical-decision-making-in-dual-relationships
Continuing Education Approvals:
When we are airing this podcast episode, we have the following CE approval. Please check back as we add other approval bodies: Continuing Education Information
CAMFT CEPA: Therapy Reimagined is approved by the California Association of Marriage and Family Therapists to sponsor continuing education for LMFTs, LPCCs, LCSWs, and LEPs (CAMFT CEPA provider #132270). Therapy Reimagined maintains responsibility for this program and its content. Courses meet the qualifications for the listed hours of continuing education credit for LMFTs, LCSWs, LPCCs, and/or LEPs as required by the California Board of Behavioral Sciences. We are working on additional provider approvals, but solely are able to provide CAMFT CEs at this time. Please check with your licensing body to ensure that they will accept this as an equivalent learning credit.
Resources for Modern Therapists mentioned in this Podcast Episode:
We’ve pulled together resources mentioned in this episode and put together some handy-dandy links. Please note that some of the links below may be affiliate links, so if you purchase after clicking below, we may get a little bit of cash in our pockets. We thank you in advance!
Pope: Steps in Ethical Decision Making
California Association of Marriage and Family Therapists (CAMFT) Code of Ethics
References mentioned in this continuing education podcast:
Boland-Prom, K. Johnson, J. & Gunaganti, G. S. (2015) Sanctioning Patterns of Social Work Licensing Boards, 2000–2009, Journal of Human Behavior in the Social Environment, 25:2, 126-136, DOI: 10.1080/10911359.2014.947464
Brownlee, K., LeBlanc, H., Halverson, G., Piché, T., & Brazeau, J. (2019). Exploring self-reflection in dual relationship decision-making. Journal of Social Work, 19(5), 629–641. https://doi.org/10.1177/1468017318766423
Pearson, B., & Piazza, N. (1997). Classification of dual relationships in the helping professions. Counselor Education and Supervision, 37(2), 89-99.
Pope, K. S., Vasquez, M. J. T., Chavez-Dueñas, N. Y., & Adames, H. Y. (2021). Ethics in Psychotherapy and Counseling: A Practical Guide (6th ed.). Wiley.
Wilkinson, Tyler, Dannielle Smith, and Ramona Wimberly. “Trends in ethical complaints leading to professional counseling licensing boards disciplinary actions.” Journal of Counseling & Development 97.1 (2019): 98-104.
*The full reference list can be found in the course on our learning platform.
Relevant Episodes of MTSG Podcast:
Dual Relationships: Pros and Cons
Therapists Are Not Robots: How we can show humanity in the room
Therapy as a Political Act: An interview with Dr. Travis Heath
What You Should Know About Walk and Talk and Other Non-Traditional Counseling Settings Part 1 and Part 2
Therapy with an Audience: An interview with Doug Friedman, LCSW
Small Town Sex Therapist: An interview with Jeanette Tolson, LCSW, CASAC
Whole Person Therapist Episodes
Therapy for Executives and Emerging Leaders
Who we are:
Curt Widhalm, LMFT
Curt Widhalm is in private practice in the Los Angeles area. He is the cofounder of the Therapy Reimagined conference, an Adjunct Professor at Pepperdine University and CSUN, a former Subject Matter Expert for the California Board of Behavioral Sciences, former CFO of the California Association of Marriage and Family Therapists, and a loving husband and father. He is 1/2 great person, 1/2 provocateur, and 1/2 geek, in that order. He dabbles in the dark art of making “dad jokes” and usually has a half-empty cup of coffee somewhere nearby. Learn more at: http://www.curtwidhalm.com
Katie Vernoy, LMFT
Katie Vernoy is a Licensed Marriage and Family Therapist, coach, and consultant supporting leaders, visionaries, executives, and helping professionals to create sustainable careers. Katie, with Curt, has developed workshops and a conference, Therapy Reimagined, to support therapists navigating through the modern challenges of this profession. Katie is also a former President of the California Association of Marriage and Family Therapists. In her spare time, Katie is secretly siphoning off Curt’s youthful energy, so that she can take over the world. Learn more at: http://www.katievernoy.com
A Quick Note:
Our opinions are our own. We are only speaking for ourselves – except when we speak for each other, or over each other. We’re working on it.
Our guests are also only speaking for themselves and have their own opinions. We aren’t trying to take their voice, and no one speaks for us either. Mostly because they don’t want to, but hey.
Stay in Touch with Curt, Katie, and the whole Therapy Reimagined #TherapyMovement:
Consultation services with Curt Widhalm or Katie Vernoy:
Connect with the Modern Therapist Community:
Our Facebook Group – The Modern Therapists Group
Modern Therapist’s Survival Guide Creative Credits:
Voice Over by DW McCann https://www.facebook.com/McCannDW/
Music by Crystal Grooms Mangano https://groomsymusic.com/
Transcript for this episode of the Modern Therapist’s Survival Guide podcast (Autogenerated):
Curt Widhalm 0:00
This episode of the Modern Therapist’s Survival Guide is brought to you by Thrizer.
Katie Vernoy 0:03
Thrizer is a modern billing platform for private pay therapists. Their platform automatically gets clients reimbursed by their insurance after every session. Just by billing your clients through Thrizer you can potentially save them hundreds every month with no extra work on your end. The best part is you don’t have to give up your rates they charge a standard 3% processing fee.
Curt Widhalm 0:24
Listen at the end of the episode for more information on a special offer from Thrizer.
You’re listening to the Modern Therapist’s Survival Guide where therapists live, breathe and practice as human beings. To support you as a whole person and a therapist, here are your hosts, Curt Widhalm and Katie Vernoy.
Curt Widhalm 0:45
Hey, modern therapists, we’re so excited to offer the opportunity for one unit of continuing education for this podcast episode. Once you’ve listened to this episode, to get CE credit, you just need to go to modern therapistscommunity.com, register for your free profile, purchase this course, pass the post test and complete the evaluation. Once that’s all completed, you’ll get a CE certificate in your profile, or you can download it for your records. For a current list of our CE approvals, check out moderntherapistscommunity.com.
Katie Vernoy 1:17
Once again, hop over to moderntherapistscommunity.com For one CE once you’ve listened.
Curt Widhalm 1:22
Welcome back modern therapists. This is The Modern Therapist’s Survival Guide. I’m Curt Widhalm, Katie Vernoy. And this is the podcast for therapists where we talk about the things that affect our lives, our practices, our clients. And this is another one of our CE episodes that actually covers our lives, our practices and our clients as we are diving into the ethics and laws around dual relationships. And you know, it’s interesting, we’ve talked about dual relationships in the past, it’s come up in a number of our episodes, we’ll link to some of those in our show notes over at mtsgpodcast.com. We’re kind of have the opinion here that not all dual relationships are avoidable. And not all relationships are bad. Not all dual relationships are bad.
Katie Vernoy 2:11
Curt Widhalm 2:12
And we will reinforce that throughout today’s episode. But when we decided to make this a CE worthy episode, just rather than one of our normal, award winning content that happens in between episodes.
Katie Vernoy 2:28
Have you made our award yet, Curt? Because I think we actually have to have an award to call it award winning.
Curt Widhalm 2:33
My daughter says that this is the best podcast for therapists that she knows of. And that is award enough for me.
Katie Vernoy 2:39
All right. How old is she now?
Curt Widhalm 2:42
Katie Vernoy 2:44
All right. All right. So we are the best podcast for therapists from a seven year old.
Curt Widhalm 2:52
So in diving into some of the research to make this CE worthy, and looking at dual relationships, and a lot that’s been written about it over the last 40 plus years, I was kind of glad to be able to take maybe a more in depth perspective on this. I think, from the very beginning of our law and ethics classes, we are warned about dual relationships. We’re taught to identify them. I didn’t realize just how many people get in trouble for them. And that’s something that we’re gonna dive into here. But as I think we start a lot of our episodes, Katie, how were you first kind of taught about dual relationships as a young and up and coming therapist.
Katie Vernoy 3:40
I think like most folks, I had an interaction with professors and supervisors or trainee or practicum instructors. And I think the the simplicity of the statement was avoid them if possible. And there wasn’t a lot of nuance. I think there was also more of a blank slate, psychodynamic psychoanalytic take on it. So this idea of there being some reason to have a dual relationship didn’t really make a lot of sense, in the way that I was trained. Subsequent to that, when I was actually working in community mental health, when I was doing a lot of stuff where therapists were also case managers, therapists were also driving clients places, therapists were going camping with their clients, because it was a, you know, outdoor event kind of thing. I think I learned a lot more about the boundaries and the ways that we can address some of those things. And so I think over time, I became much more fluid in how I looked at those relationships. And, and also, and I think, well, I don’t know if we have full on episodes that talk about this, but there’s pieces of them, but I was able to figure out how do I act as a professional human in different settings. So even though it was potentially a dual relationship, it wasn’t actually some of these dual relationships that we’re going to talk about today. I think it’s it’s it oftentimes, from my perspective, and certainly correct me if I’m wrong, if I’m wrong, but I think that it’s taught so black and white, early on, because there’s so much liability if a new clinician kind of willy nilly goes out and has all these dual relationships with their clients, versus I think the actual nuance of practice. And so I’m excited to dig in too because I think that there’s a lot more to consider than, at least I was initially trained with.
Curt Widhalm 5:42
And I think that a lot of education for early career therapists tends to focus on the more safe side, when it comes to things like this. Because as we’re gonna dive into throughout this episode here today, a lot of what we’re gonna get into is nuance and a lot of contextual considerations that is very hard to teach people without starting to face some of these issues themselves.
Katie Vernoy 6:13
Curt Widhalm 6:13
It’s very easy to make some very clear lines, as far as things like: don’t have to or relationships by having sex with your clients. And in some of the classes that I’ve taught, and even here in 2022, when I’ve taught my law and ethics classes, some of the discussion that comes up is like, there seems to be a lot written in history about not sleeping with your clients. And that just seems like such a no brainer sort of thing. But what it does is it misses just kind of how groundbreaking, that kind of a transformation was within our ethics code when it came out in the 70s and 80s. As far as you know, what we should really delineate that sleeping with your clients is universally a bad idea.
Katie Vernoy 6:58
Yeah. Well, I think before that, it seemed like it was kind of the whole free love. It could be therapeutic, it’s, it’s, you know, there was lots of things that were happening in the therapy space that at this point, I don’t think most of us are really keen on.
Curt Widhalm 7:15
So it is really easy to set some very clear, like these kinds of dual relationships are bad. And that’s how we teach those ones, then we get into a whole host of words like exploitation, and words like beneficial and predatory and other ideas around what makes some kinds of dual relationships bad, what makes them good, what makes them beneficial to a client and what makes some kind of confusing. And I think that it really helps to look at that there are multiple types of dual relationships. This is outlined in a 1997 article in the Journal of Counselor Education and Supervision called ‘Classification of Dual Relationships in the Helping Professions,’ by Pearson and Piazza. And they outlined that there are different kinds of dual relationships. The first is circumstantial multiple relationships. And these are ones that occur out of pure coincidence. Examples would be like going to a store to return an item and the only cashier that’s available is your client. That these are people who are just out and about and you happen to bump into each other.
Katie Vernoy 8:37
Curt Widhalm 8:38
This is one that definitely falls under that not dual relationships are gonna be unavoidable. That…
Katie Vernoy 8:44
Sure. I mean, if you live in a city where other, where your clients live, there’s going to be, there are going to be times that you’re going to end up in the same place.
Curt Widhalm 8:53
Right. And the recommendation in this article of dealing with such situations is have an open discussion with the client about, you know, these roles, not necessarily in the store that they’re working in at that time…
Katie Vernoy 9:08
Curt Widhalm 9:08
…but go ahead and just openly talk about it as soon as reasonably possible and privately done.
Katie Vernoy 9:15
Well, and I think what I’ve experienced is, is if I have a client that is talking about working in customer service, or who frequents a place that I know that I have, no, you know, I can’t avoid going, for example. I’ll have that conversation ahead of time around this is what happens if we see each other out in public. Talk about confidentiality. Talk about how to address it if they would like to. You know, you can claim me as your therapist, you certainly don’t have to claim me as your therapist, you don’t even have to know me. I won’t know you unless you recognize me and come over. I will play along with kind of however you characterize this and this is kind of how we deal with those things. And then if we see each other, you know, let’s talk about it afterwards if there’s any weirdness, or even if there’s not weirdness just to make sure that there isn’t. And I’ve had conversations afterwards, that process what that was like. And usually it was weirder for me than the client.
Curt Widhalm 10:14
And I think that this is stuff that gets taught in all…
Katie Vernoy 10:18
Curt Widhalm 10:19
…you know, graduate program classes, and, you know, hang on with us, we are going to get into deeper stuff in this, but covering all of our bases here.
Katie Vernoy 10:28
Curt Widhalm 10:28
And so the next kind of dual relationships that they identify is structured multiple professional roles. And this can be where you have different professional roles with a client, or if we’re broadening out within our ethics codes, and talking about the multiple professional relationships that we have, can be with supervisees, as well.
Katie Vernoy 10:49
Curt Widhalm 10:49
And this can be something where working in an agency, a therapist who has worked with a client gets a promotion to now being a supervisor of a caseload where the fundamental professional roles has shifted. In supervisory relationships, this can be things like being the supervisor, and the employer of a associate trainee, pre-licensed person where there are separate and distinct roles that ended up happening that are professionally outlined here.
Katie Vernoy 11:21
Okay, the question I have around that is, I know, in a lot of agencies, you know, and I had this happen frequently, I became one of my friend’s supervisors. Because we were colleagues, we were friends. And then I moved into that supervisory role, that’s not quite a dual professional role, it’s just two different roles.
Curt Widhalm 11:38
Katie Vernoy 11:38
How’s that defined in this?
Curt Widhalm 11:40
That’s going to be a personal professional shift, and is somewhat related here. And with this comes a lot of potential benefits of being able to know somebody’s more, you know, therapeutic needs in that first example of shifting from therapist to kind of a case manager, or supervisor situation of being able to speak more specifically to the needs of that particular client.
Katie Vernoy 12:08
Curt Widhalm 12:08
It can also work in that way, in kind of this, you know, multiple professional roles within an agency sort of situation for a supervisor to have had some of that more contact, more in depth conversations with somebody in the past. But it does also bring with it a risk of now being put in a position kind of what you’re speaking to about now, supervising your friend, of being put into an evaluative role of somebody and potentially having to hold some boundaries against them being able to be promoted, or be able to access certain kinds of trainings or other resources that puts a rift or a conflict on that type of a relationship.
Katie Vernoy 12:57
Another relationship that comes up that falls in this is one that probably isn’t as common in non-agency settings. But I was working in the Welfare to Work program. And so there were some relationships where I was therapist and case manager or I was therapist and kind of employment coach, or when I moved up, I was therapist, you know, former therapist, and employer. And that was something where there was, that was a huge, you know, there was a huge ethical decision making process, which we’ll talk about later. But there were pros and cons to that for different folks who had, I had worked with who ended up in the employment of the agency. And then, you know, there was other things but like, there’s there’s whole agencies that have these built in dual relationships, where they are wellness centers, where the adults help manage the center and/or work for the business within the mental health organization, and they get therapy, and they get case management. And so it kind of is built into a treatment plan, but it is definitely a number of different relationships that are happening there. And, and I think oftentimes, they’re very beneficial, but they have that same risk with that you’re the therapy, you’re the therapist, and then you’re also interacting with their boss who’s evaluating them and and working in that setting. So I think it can get really complicated when we get into more innovative or holistic treatments. When we’re looking at, especially from the client perspective.
Curt Widhalm 14:27
All of our ethics codes guide us into knowing situations where that conflict, that role conflict ends up pointing to where it impairs the judgment of being able to hold those separate roles and be able to do that professionally. Now, part of the recommendations from Pearson and Piazza here is, once again have open conversations about some of these different roles as they may come up. And to be able to have a very open and adult kind of thought process made together. In my practice sometimes where I end up having this as I’ll have pre-licensees who say, you know, I really want to be able to do this kind of a thing. And I’ll say, as your supervisor, here’s how I see this. As your employer, here’s how I see this differently. As a mentor, here’s how I see this also being a different hat and a different viewpoint on this.
Katie Vernoy 15:25
That makes sense. I think the the more conversations and openness you have about it, the better. So just because I know we’re kind of talking all over the place. So the different types so far are multiple circumstantial. And there’s a multiple structured professional, did I miss one? Or are we just two in?
Curt Widhalm 15:43
That’s where we’re at now.
Katie Vernoy 15:45
Okay. Okay, what’s the next one?
Curt Widhalm 15:47
Shifts in professional roles. And this can happen within an organizational structure. This is where the friendship now being into a boss.
Katie Vernoy 15:58
Into a boss.
Curt Widhalm 15:58
Katie Vernoy 15:59
Curt Widhalm 16:00
And I think that a lot of therapists who are nice with each other in these kinds of situations believe that you’re everlasting Care Bear type friendship is going to help you to just never have any problems that arise in these situations. And if you just hold hands and have whatever is tattooed on your belly shine up towards the sky…
Katie Vernoy 16:25
The Care Bear Stare.
Curt Widhalm 16:25
…will absolve everything. Yes.
Katie Vernoy 16:27
And that’s not true. We know that. I think it’s, it is a very hard transition to go from colleague to supervisor. And I’ve actually had situations where the roles flipped, where my supervisor became my supervisee. You know, like, it can get very complicated. And that requires, in the same regard, that requires a lot of discussion and conversation around how you manage those pieces. I like the different hats that you talk about, like as your friend, this is what I’m saying, as your former supervisee this is what I’m going to tell you about your supervision style, and as your supervisor, this is what I need you to do.
Curt Widhalm 17:11
And so the the risks that come into this is kind of an avoidance of any sort of conflict sort of thing. And that can lead to inadequate supervision, it can lead to power struggles. And the recommendations from this article is until both people are used to the new relationship, and how that new relationship happens, that there should be some sort of outside neutral third party that helps to facilitate the role in the meantime. That open conversations about it in Carebear worlds is going to be great. In real world sort of situations, that’s one piece of it. But helping to remain objective by having an outside neutral third party is kind of the best way to help facilitate that.
Katie Vernoy 18:00
I think that makes a lot of sense. I think we can believe that we’re very objective, and that we can see situations very neutrally. I think that’s not always the case. And having that additional oversight and kind of this objective third party makes a lot of sense.
Curt Widhalm 18:19
Moving on. The next one is personal and professional role conflicts. And this is where dual relationships have a pre-existing professional relationship that is followed by a personal relationship, or…
Katie Vernoy 18:32
Including friends with your clients.
Curt Widhalm 18:33
Yes. And these don’t necessarily just means sexual relationships. This could be things like engaging in a hobby or an activity that now that your professional relationship has ended, you’ve both identified, hey, we have this common, you know, interest in participating in Care Bear conventions and or more realistically things like a pastime, such as being a part of like a running group or a cycling group or something like that.
Katie Vernoy 19:10
You show up to the same events.
Curt Widhalm 19:11
Katie Vernoy 19:12
It’s not like trained together.
Curt Widhalm 19:13
Right. Yeah. These things aren’t necessarily always coerced or forced, but they have the potential to be. If it’s coerced, it is bad. If it’s not coerced, then we really have to look at what our ethics guidelines tell us as far as is this something to be avoided? How beneficial it is. And part of the decision making that we’re going to talk about later in the episode here is how do we determine just how beneficial or how non-beneficial that this could be to a client to see us in the shifting role? Because once this role is shift, if there’s ever a need to go back to the professional relationship, that has fundamentally shifted how the two of you can work together.
Katie Vernoy 20:05
And I think this is another one that’s pretty common discussion in grad school, which is like, do you become friends with your clients two years after they’re done? Or whatever, you know, the local, legal and ethical codes have to say about it. And I think, by and large, I’ve heard most folks say they just don’t do it, typically, because a client is always your client, like, they’re that you always want to have that opportunity for them to go back.
Curt Widhalm 20:31
I’m gonna give that a ‘Yes, but…’ This comes from the bias of coming from a large urban area, whereas some of the more rural therapists out there might not have either the professional capability to have a bunch of other people to refer to. Some of that’s going away with the telehealth and being able to have more providers reach more areas. But those rural therapists also may have less opportunities to engage in their own just personal interests in town. If you’re working in a small town of, let’s say, 1500 people, you’re only going to have, you know, the grocery store to go to or the community activity to go to that ends up being just something where it’s a lot more nuanced than it is straightforward.
Katie Vernoy 21:26
And so I think to wrap that point up. I think it’s something where being able to identify: does this move from a professional to personal? Is it, is it worth it? And if this client were to need therapy again, could there be a resource? Or could you effectively move back into that other role, and dismiss this personal. Right? Like that, it seems like there’s, there’s nuance, but I think a lot of folks just say, if you’ve been my client, I’m not going to, I’m not going to engage in stuff with you. But as you said very eloquently, if you’re in a small space, a small town, small community, that just may not be possible for you to live your life and be able to be a therapist.
Curt Widhalm 22:12
The last type of multiple relationship, dual relationship, that is outlined here by Pearson and Piazza is the predatory professional. And they define this as when professionals exploit the relationship to meet personal needs, rather than client needs. And this is going to include all of the bad things that therapists do when it comes to multiple relationships: sleeping with clients, going into business with clients, anything that is there for the professional to just kind of take advantage of their relationship with the client, and do bad things with it.
Katie Vernoy 22:51
Does this include the kind of conflict of interest?
Curt Widhalm 22:54
Katie Vernoy 22:55
So maybe you can describe a little bit what conflict of interest is related to therapists here.
Curt Widhalm 23:00
This is where that logical reasoning ends up going into, I’m going to put my needs onto my client, but they’re really my needs and I’m taking advantage of that situation. So I’m recommending a client, do a particular thing, buy a certain product, because it benefits me. But I’m also going to convolute some sort of reason that it benefits them as well.
Katie Vernoy 23:26
It could also be something along the lines of you, your therapy, your therapy client is an executive and accompany and you know what’s gonna happen and you purchase stock, right?
Curt Widhalm 23:38
Katie Vernoy 23:38
I mean, that’s kind of a dual relationship, but it’s kind of just conflict of interest.
Curt Widhalm 23:39
Katie Vernoy 23:40
Curt Widhalm 23:40
So the advice on those ones is don’t do those.
Katie Vernoy 23:40
Just don’t do it. And, and it’s interesting, because when we were talking ahead of the episode, you were saying that these types of, these are the types of ones that typically there are sanctions for. And like about half are sex with with their clients. Right?
Curt Widhalm 24:06
Well, I think that there’s that. But I also want to point out that even within what we’re doing here, we’re just still defining what types of dual relationships are. And I think that this helps us to go through some of our process as far as why some dual relationships are okay and why some aren’t. And we’re just kind of that very introductory level to dual relationships that a lot of therapists are taught. That isn’t sufficient as far as being able to say, okay, there are universal ones that you don’t do. You don’t go and do.
Katie Vernoy 24:40
But people still do them.
Curt Widhalm 24:40
People still do them.
Katie Vernoy 24:44
So that’s what I was saying is like, yes, there’s a universal don’t do them. And yet people still do them.
Curt Widhalm 24:49
Katie Vernoy 24:51
So do we know how they go down that rabbit hole? Like do, are we going to talk about that today?
Curt Widhalm 24:55
I think we’re going to talk about it when we get to some of the deeper thinking about entering into dual relationships that seems to be missing from these situations.
Katie Vernoy 25:05
All right, all right. Okay, so let’s just sum up again, we’ve got multiple situational, structured professional, professional that goes to personal…
Curt Widhalm 25:19
Shifts in professional roles.
Katie Vernoy 25:20
Shifts in professional roles.
Curt Widhalm 25:22
Personal and professional role conflicts.
Katie Vernoy 25:24
Curt Widhalm 25:25
Katie Vernoy 25:27
Curt Widhalm 25:28
Now, one of the things that I want to point out at this point in the episode is that I think that our ethics codes, since this article. This article is 25 years old now. So our professional codes across, at least all of the American major mental health professional organizations have been updated since then. And I think that our professional codes are moving more and more towards understanding the role of culture when it comes into how we evaluate whether we participate in a dual relationship or not. And I think that this is important to look at that a lot of our ethics codes have been steeped in a lot of Western traditions and being able to, you know, have the therapist in kind of a one up power position. And I think that that’s a consideration that we need to continue to hold. But as we adopt a wider view of the types of clients who are participating in mental health services, that we also have to look at the roles that the interplay of culture ends up having between the mental health provider and the communities that they’re serving. And, for example, participating in things like working with indigenous populations, where there may be some sort of community event that would better be received in having a mental health professional participate in ways that go along with the traditional ways of healing from that community. Whether it’s a community accident that claims the lives of, let’s say, some teenagers in the community, or whether it’s even just participating in community days and community activities as somebody who’s there and living and working amongst the people that they are serving as one on one professional client sort of situations.
Katie Vernoy 27:25
The participation within a cultural group or an affinity group, I think that makes a lot of sense. And I think there’s potentially some guidance around showing up. When we were talking about this before hitting record, the element of this that I think is a little bit harder to parse through is interacting as a community member, and not being at your most professional or best self, so to speak. You’re deeply impacted by the loss in the community, you’re having a great time at the community event, and potentially are more boisterous than you might be in a therapy session. I think there’s, there are definitely ways to address that. And I don’t think that those things are necessarily avoidable or bad. But I think it is worth considering that, that in some ways, if you’re behaving within your role as a mental health professional in your community, that you may show up differently than you would as a another community member. Like you may already be coming with that professional armor on. Right?
Curt Widhalm 28:30
Right. And I think that that’s an important part of how we look at entering into these kinds of relationships. Because we may have that guard up. We may not be fully, you know, just jumping into things. We may, you know, come from an observational standpoint. But the participation in the activity may be something that for those clients that you are serving, may see as doing a better job of trying to understand some of the cultural aspects that, especially, you know, I’m speaking very much from being a white outsider in this situation, that shows at least a attempt to understand and know some of the things at a deeper level within the community.
Katie Vernoy 29:23
I see this also something that would be relevant to being part of a smaller cultural minority group where you might end up in the same places because the group and the affinity groups are small. And so I think there’s that element of determining how you show up there and what the expectations are. Because if you show up as a therapist within a community, that that’s not your role, that could also be problematic for you, for the clients. Like it becomes an interesting juxtaposition to try to determine how do I show up within my, my, my group of folks when I know that these some of these folks are, are my clients.
Curt Widhalm 30:03
I’m gonna shift here to Curt and Katie, why are you spending so much time talking about dual relationships? This is something we’re all taught from the very beginning of our careers. You’re you’re jumping to how to participate in this well, but how frequent is this actually happening? Are people making these bad decisions? Yeah, we read stories about therapists who are sleeping with clients. But do people actually get in trouble having dual relationships with clients? Okay, maybe I know some of the stories about how there’s that therapists who started a business with the client. But how often do you think that therapists actually get in trouble for this?
Katie Vernoy 30:48
I think it’s hard to know, like, compared to the times that happens, how many people get in trouble. But I think it the, the message I got from early supervisors is like, don’t sleep with your clients, don’t give them drugs, and otherwise, you’re fine. And I think that was clearly, you know, obviously, more a performance from one of my supervisors, but I think it’s that that element of you assume that most of these things are sleeping with your client. And that would be the only time you would really get in trouble. Or these super predatory things where, you know, I think there was, you know, a couple of different ones that I’ve seen where people either went into business with their clients, or they, like, lived with their client, or had their client watch their dog. I mean, like, there’s like, interesting things where there are some lines that seem pretty obvious have been crossed. But I think there’s folks that become their clients coach, or they want to sell them a course or, like, I think that there are a lot of things that more and more often that I think we’re, we’re exploring in the world. Like how do we actually manage this? But I don’t know how often people actually get in trouble for it. So you seem to have some research to share. So what are you understanding?
Curt Widhalm 32:19
So this is from a 2015 article in Journal of Human Behavior and the Social Environment by Boland-Prom, Johnson and Shankar Gunaganti titled ‘Sanctioning Patterns of Social Work Licensing Boards, 2000 to 2009.’ And what they did is they looked at social workers in the United States, over the course of this 10 year period, looking at what kinds of complaints were filed about them. And they did a good job of breaking out complaints that fall under the categories of dual relationships. As you mentioned earlier, in the episode, roughly half of these seemingly, your misremembering, would fall under that sexual category. It’s really more of 1/3 of the complaints, according to this article fall under dual relationships that include sexual contact, but nearly two thirds of them fall under non-sexual or not described or conflict of interest categories.
Katie Vernoy 33:28
Well, the not described could be sexual. Like, that’s where we get kinda.
Curt Widhalm 33:32
Katie Vernoy 33:33
And so it’s a little bit, it’s helpful, but also a little murky.
Curt Widhalm 33:37
Yeah. And one of the things that they posit in this article is where these dual relationship complaints may end up happening. That theoretically, and one of the things that we seem to be talking about here and as seems to be talked about in any lengthy dual relationships sort of conversation ends up being that we would expect that more of these dual relationship boundary violations would occur in smaller or rural communities. When in fact, the evidence seems to suggest just the opposite. That more of the dual relationship type things are going to be seen in more suburban and urban areas. Whereas the rural therapists or rural social workers in this case, seem to have more complaints about providing poor quality therapy or incompetent therapy. So coming back to and positing on some of the whys of the situation.
Katie Vernoy 34:37
Curt Widhalm 34:38
Why are people engaging in dual relationships that ended up in complaints?
Katie Vernoy 34:46
I, that is a good question that I posited earlier. Do we do we have something or are we going to just do some conjecture?
Curt Widhalm 34:58
So from this article they say that some of this seems to be based on what the licensing boards seem to be wanting to tell the licensees within their jurisdiction. That it’s not kind of an evenly distributed, you know, every state has about this percentage of these kinds of complaints. That some states tend to take a larger focus on dual relationship type things. Other states might shy away from it and leave dual relationship complaints more up to ethics boards, rather than the licensing boards themselves. So some of this seems to be within the priority of what the governing bodies end up doing.
Katie Vernoy 35:39
Well, that’s about people getting caught, though.
Curt Widhalm 35:42
Sure. And amongst the research that we’re looking at, is that most of the complaints about dual relationships come not during the therapeutic relationship. But once the personal relationships and the professional relationships are over. Which suggests that there’s people who have successful dual relationships with people. Editor’s Note here: we’re not encouraging you to go out and seek dual relationships with your clients. But this would suggest that people who are happily engaged in dual relationships that seem to follow ethical guidelines don’t make complaints and therapists don’t get in trouble for them.
Katie Vernoy 36:27
Sure, and I think there’s this element of stepping across into this, into a gray area even. But certainly into these these areas of very predatory relationships, self serving relationships, ones that are clearly outlined, like sexual relationships where you absolutely cannot do that. I think those things, oftentimes there is a conspiratorial element of it. If the client knows, hey, we’re stepping across the line, or there is a very manipulative element if the therapist is framing it as this is good for you. And so once there’s a rupture it, you know, or an end to the relationship and you start talking about, oh, my therapist did this and people were like “what?!?!”, I think it’s that element of now I’m been wronged by my therapist, and let me go and and tell the world that they did this thing. That’s my impression of it any way.
Curt Widhalm 37:28
And this is backed up in some other articles as well, looking at ‘Trends in ethical complaints leading to professional counseling licensing boards disciplinary actions’ by Wilkinson, Smith and Wimberly. This is from the American Counseling Association Journal of Counseling & Development, 2019. That these seem to be amongst the most common complaints that are filed with liability claims, and specifically, sexual relationships as being one of the most common and costly types of violations. In these trends and trying to parse out, you know, the what is happening and the frequency of what is happening. We’re trying to get to this understanding of we’re with all of this focus early on in education, things seem to fall apart as far as this. Because as professionals, we are being upheld to the public is having a large, worthy, large amount of trustworthiness. That’s part of what are licensed stands for. And if amongst the things that we end up doing is taking people’s trust, and especially within the very intimate relationships that already is psychotherapy, or is counseling or is social work, and blending that, you know, more and more boundary violations, more and more personal disclosures that aren’t for the benefit of the client that end up to kind of make things seem more like friendships can be looked at in anything from, you know, just kind of making therapy last forever, because clients are feeling obligated due to the closer bonds that you’re feeling with the therapist to some of the more egregious acts that we’ve talked about as far as business and sleeping with clients and that kind of stuff.
Katie Vernoy 39:26
Well, to me, it seems like there’s this element of being able to justify to yourself as a therapist, and this is whether you know it’s wrong, and you’re doing it anyway because it feels right. Or if you’ve truly have kind of self manipulated into this is in the best interest of the client. Right? Or this is this is the only way I can practice. I have to sell all my goods and services to my clients because they have to, you know, that’s the only way I can sustain a business and they need me as a therapist, so I’m going to sell them everything and make as much money as possible, right? Like, I think there’s there’s kind of intellectualization. I think there’s manipulation. I think there’s self self manipulation. But I think that that piece that really it comes down to is that there’s not a thoughtful process. There’s not an examination of bias. And there’s not an, there’s not a real decision making that happens. It seems like it’s a slippery slope that can happen where boundaries are crossed, disclosures happen, and things move along in this direction. Whether it seems predatory and therapist driven or just circumstantial. I think it’s something where the therapist is responsible in this situation and needs to figure it out.
Curt Widhalm 40:40
And I think that that’s part of what you’re speaking to here is, I don’t know people who go through graduate school, a couple of thousand hours of supervised training, licensing tests, with the intention of going out and being predatory.
Katie Vernoy 41:00
Curt Widhalm 41:00
I don’t think that they’re just people were like, I’m a predatory therapist, I think that there’s people…
Katie Vernoy 41:05
At least not a lot of them, right?
Curt Widhalm 41:07
I would hope so.
Katie Vernoy 41:09
I would hope that would be screened out in all this huge process that we go through.
Curt Widhalm 41:14
And maybe within a part of this is really just kind of that convoluted thinking that ends up leading people down that path. In a 2018 article in the Journal of Social Work called ‘Exploring self-reflection in dual relationship decision-making’ by Brownlee et all. And they cite a bunch of the same research as far as just how often these dual relationships including non-sexual dual relationships end up leading to complaints. And this is, you know, also exploring rural versus urban areas. It gets into, you know, how our ethics codes at the time of application kind of looked at things. And also looking at where the responsibilities end up being as far as how the therapists evaluate this. And the big takeaway in this article is that a lot of therapists go through more of an intuitive process as far as trying to look at what a dual relationship, what an okay dual relationship to engage in is. Rather than going through a formal decision making process. And this leads to all sorts of vulnerabilities as far as biases and not really thinking about the possible consequences of engaging in a relationship like this with your clients.
Katie Vernoy 42:44
So I think the strongest thing for us to do now is to really jump into this ethical decision making process. I think it makes sense to talk through how it works. And then maybe even if we have time walk through a tricky situation where potentially a lot of our therapists might be trying to make these decisions of themselves.
Curt Widhalm 43:06
And just talking to the the depths of this in this article, they cite that fewer than 20%, or approximately 20% of participants in their study used any formal decision making model. This is my words now, despite all of the ethics code saying, use a decision making model.
Katie Vernoy 43:28
Well, you’re an ethics nerd, though. Like you, you love thinking about this stuff. I think a lot of therapists believe that they are good people, and they’re gonna make good decisions. And they don’t necessarily believe Oh, I’ve got to go through this process in this formal way. Or they may not have the tools to do so.
Curt Widhalm 43:46
And that is one of the calls to action is far as any other ethics professors of really reinforcing the importance of using a ethical decision making model. Because that is what the licensing boards and the ethics committees want you to do, is…
Katie Vernoy 44:06
Curt Widhalm 44:06
…if you go through a good model, and even if you end up with slightly the wrong answer. If you’ve put good thought into it, it at least formalizes the process and gives people an insight into how you’re thinking about things. But instead, and as cited in this article, the people who are most at risk of making these kinds of mistakes, they’re looking mostly at social workers here, are therapists in their 40s. And this seems to be developmentally a time when people have been practicing for long enough to, quote unquote, know what the rules are, but not necessarily have had either the clinical experiences or kind of those one in a million type sort of situations where they’re accustomed to regularly going back to a formal process of deciding what their actions should and could be, and what the effects of those actions will be.
Katie Vernoy 44:07
My assumption too is that they’re not in supervision. So there’s no oversight. And there’s also I, depending on how long they’ve been in the practice, they may be burned out. They may be, you know, kind of have had so many kind of gray area situations that went okay that they are more likely to tell themselves like, yeah, what’s the worst thing that could happen? That this…
Curt Widhalm 45:30
I haven’t seen anybody get in trouble for this yet.
Katie Vernoy 45:33
Sure. Let’s see if I can get in trouble. No, but but as far as an ethical decision making process, I know, I think we’ve talked about this before, but but let’s what’s the one that you like to use? And let’s let’s dig into that one.
Curt Widhalm 45:49
So the model that I like to use is called ‘Steps in Ethical Decision-Making.’ Yeah, and it’s just that straightforward. It’s been a part of Kenneth Pope and Melba Vasquez’s books for quite a while, the one that it’s been most recently and is the one that I use in my law and ethics classes. It’s called ‘Ethics in Psychotherapy and Counseling: A Practical Guide.’ This is the sixth edition with Pope, Vasquez, Chavez-Dueñas and Adames. And it’s got a lot of depth to it that helps to answer a lot of the questions that like in the Brownlee article, people are just saying, Hey, go by intuition. But this actually helps to get into the depths of a lot of decision making when it comes to ethics. So that way, we can tease these things out and at least put thoughts down as far as how we’re deciding that we get to, whether or not we should participate in things like dual relationships.
Katie Vernoy 46:51
That makes sense. So it’s a 17 step process, though, like this is intense.
Curt Widhalm 47:00
Us ethics people don’t want this to be taken lightly. And so…
Katie Vernoy 47:06
I guess so.
Curt Widhalm 47:07
The reason that it’s 17 steps is because 16 steps wasn’t enough.
Katie Vernoy 47:14
Curt Widhalm 47:16
Katie Vernoy 47:16
…your the ethics nerd. Did you want to walk me through this? Should we should we try to do something here?
Curt Widhalm 47:24
So the first part of this process is state the question, dilemma, or concern as clearly as possible.
Katie Vernoy 47:31
So I’m gonna go with one that I’ve actually done a lot of, because I have a very particular specialty. I work with executives and folks who are in leadership roles in their, their careers. And not everybody does. So I oftentimes will have clients refer friends or colleagues to me. And I have to decide, do I want to take that client or not? And so if we want to get specific, let me think here. So I have a long standing client, who is an executive, works in a trusted profession. And he wants to refer his friend who also is in the same profession and who is struggling with similar things. Do I take this, this new client, who is a friend of the client that I am currently seeing? That is the question.
Curt Widhalm 48:27
Okay, so the second step of the process is anticipate who will be affected by the decision.
Katie Vernoy 48:34
So my ongoing client, I think he might be affected because he and I have a very strong relationship. And this is, this is someone that I’ve not heard about, but obviously someone he cares about, in some way, and is someone who is in his life. And so this is a close friend. This is someone who he talks to periodically, not every day. And so sharing a therapist is something that would impact him. The new referral would also be impacted because they would have a situation where their friend had, they wouldn’t know whether or not their friend had talked about them or not, and would be already starting out with a, in a place of sharing me as their therapist. I would certainly be affected because I would get income from a new client. And referrals are often really good matches, especially by clients who know me well and think that my style would fit for their friends.
Curt Widhalm 49:40
I like that you’re adding yourself into who’s affected here. I think that that’s sometimes a step that gets overlooked in some of these decisions.
Katie Vernoy 49:48
Well, thank you. I try to be very ethical Curt.
Curt Widhalm 49:54
Step three is figure out who if anyone is the client?
Katie Vernoy 50:00
So in this situation, the client, my ongoing client is the client and this referral could be the client,. But that that is not yet set. And so I guess just the referring client is the current client right now.
Curt Widhalm 50:15
Okay. Assess whether our areas of competence, and missing knowledge, skills, experience or expertise are a good fit for this situation.
Katie Vernoy 50:25
So this is where I always get kind of stuck. Here is a, the ongoing client, absolute ideal match. He’s an executive. He’s in a very trusted profession. He’s someone who I really have exactly the right skill sets. Oftentimes, when folks come to me and they’re in executive positions, and they want another therapist, I have trouble finding people who have actually been executives before who have that skill set. And so the fact that he’s referring his colleague, who is in a similar situation is, is something where I don’t know that I have a referral, and I have specific expertise for this client. And so so there’s, there’s the clinical expertise, where I think I’m the closest match at least given the description from the referring client and from the prospective client. But then there’s also navigating the dual relationships that would be kind of inherent in both of these relationships, and making sure that I had the skill set to maintain confidentiality, know who told me what, make sure that I’m not making it overly awkward or overly familiar with having two people who know each other. And so I think in that situation, I, I’ve definitely done that. I’ve had clients who were in group with me and individually with me, and you know, and I’ve, I’ve been able to maintain confidentiality and kind of track where things belong. So I think I do have it, but I think it’s something where I don’t know the new client. So I don’t know what that new client would need to be able to make sure they’re going to be cool with me, also being their friend’s therapist.
Curt Widhalm 52:07
Now, I see some people at this point in situations like you’re describing where it’s like, well, if their friend referred, and they’re calling, then they have to be okay with it. Right?
Katie Vernoy 52:20
I think that clients, my experience is that when I actually have the conversation with clients about them referring their friend, they haven’t thought about the implications of it. They just like, oh, I have a great therapist, you should see her. And when I talk with them, and I say, Okay, well, I really appreciate your referral. Let’s talk about this. And I actually talk to the referring client and explain what it means. I’ve had some clients then change their mind. They’ll be like, Oh, no, I really, I would rather keep you to myself or, Oh, I hadn’t thought about the confidentiality elements of it, or whatever it is. And then there’s some clients that actually come back and say, Yes, I am totally cool with it, I get it. I am in a highly trusted profession. I also have to, you know, keep confidentiality, privilege, whatever. And so I get it, I think this is fine. I think I can manage this with my friend or colleague. So but some folks have no idea. And they just think, oh, it’s like referring my doctor or Oh, it’s like referring my financial planner. And they don’t think about oh, yeah, it’s a different conversation you’re having with your therapist. It’s a different relationship you have with your therapist. You may not want to share that person, just depending on the relationship you have with the person you’re referring.
Curt Widhalm 53:37
Step five is review relevant formal ethical standards.
Katie Vernoy 53:42
Okay, so obviously, there’s the dual relationship one. Are there other ethical standards that I’m not thinking about?
Curt Widhalm 53:50
You being gay marriage and family therapists in California, the ethics code that we’re going to jump to is the one that matches you. And that is the California Association of Marriage and Family Therapists, which section 4 is all about dual relationships. Now, some of these don’t apply in what you’re describing so far. Mostly, what I’m referring to is the ones about sexual contact and that kind of stuff.
Katie Vernoy 54:16
Yeah. No sexual contact, involved or even considered.
Curt Widhalm 54:21
So the one that I’m going to jump to and highlight first from the CAMFT code is 4.2 Assessment regarding dual multiple relationships. And it says prior to engaging in dual multiple relationships, marriage and family therapist take appropriate professional precautions which may include but are not limited to the following: obtaining the informed consent of the client patient, consultation or supervision, documentation of relevant factors, appraisal of the benefits and risks involved in the context of the specific situation, determination of the feasibility of alternatives, and the setting of clear and appropriate therapeutic boundaries to avoid exploitation or harm. Now that sounds remarkably like what we are doing, right?
Katie Vernoy 55:05
It does. It does.
Curt Widhalm 55:07
That is what we’re doing. You are highlighting even just the living breathing aspects of an ethics code right here.
Katie Vernoy 55:14
Curt Widhalm 55:16
Now, some of the other ones that we would consider is things like 4.3, which is called unethical dual multiple relationships: acts that can result in unethical dual relationships includes but not limited to borrowing money from a client, hiring a client, or engaging in a business venture with a client or engaging in a close personal relationship with the client. Such acts with the client’s spouse, partner, or immediate family member are likely to be considered on ethical dual relationships.
Katie Vernoy 55:42
Curt Widhalm 55:44
Although it doesn’t say friend, doesn’t say colleague here, part of what you are weighing out so far, could be maybe a little bit of an extension of this, like, if these were…
Katie Vernoy 55:56
But it says personal relationship, right? It doesn’t say that you wouldn’t have a professional relationship with the family members, right?
Curt Widhalm 56:03
Yeah, we we take these ethics and we sit them out in a decanter, let them breathe for a little bit.
Katie Vernoy 56:09
And what happens when we decant them? When the air is added? What What else do we learn?
Curt Widhalm 56:17
We don’t just take these, literally, we take them in the spirit of them. And but what you are describing is that even in this relationship between the existing client and the potential client here, nothing sounds like it is such a close relationship, that taking on somebody very, very close, ends up being something where we would need to immediately refer out. This isn’t things like, siblings. This isn’t thing like seeing a husband and a wife as individual clients separately. That what you’re describing is some some distance here.
Katie Vernoy 56:58
Sure. But I mean, I know therapists who do choose to see siblings or do choose to see husbands and wives separately, in addition to couples counseling, are you saying…
Curt Widhalm 57:07
And I would hope that they go through this 17 step process in order to justify it.
Katie Vernoy 57:12
Okay, it but it’s not inherently unethical to see someone who’s close to another person. Like if this, if this, if this client was referring their best friend, would I automatically need to refer them out? If I am the strongest match? And there’s been this process? Or? Or is it something where I can go through this process and determine based on the unique case? Because I’m hearing you say that I wouldn’t like if I were to become friends with a client’s best friend. Okay, that’s not cool. But having a therapeutic relationship with them. You’re saying that’s, that’s pretty dicey? Is that what you’re telling me from from this ethics code?
Curt Widhalm 57:51
I’m telling you go through a 17 step process.
Katie Vernoy 57:54
All right. All right. So if I say right now, like, these folks are our friends and colleagues, so they they have they have dual relationships. They work together, and they are friends. But they are not close friends, then we’re okay on that one, because we’re going through the 17 stage process. And I’m not going to be friends with either one of these folks.
Curt Widhalm 58:16
Right. So it sounds like you’re you’re operating okay, here. So once once we look at the ethical standards, then we go to reviewing any relevant legal standards.
Katie Vernoy 58:27
Okay, so what are relevant legal standards here?
Curt Widhalm 58:30
I don’t know that there are any about seeing two people as clients who know each other.
Katie Vernoy 58:34
Okay. One thing that I’m thinking about that I did not mention before, but when we started talking about legal stuff I would wanted to mention, so in this hypothetical case, my client who I’ve been seeing for ever, is on a sliding scale. And so the new client, I would not necessarily, I would offer them full fee and potentially a sliding scale, if that was appropriate. But I don’t know like there’s that thing where they may be paying different amounts. What do you think about that?
Curt Widhalm 59:08
Well, that shoves us right back into reviewing relevant ethical standards.
Katie Vernoy 59:13
Ooh, okay. I figured that was legal not ethical. So what what are the ethical standards on that one?
Curt Widhalm 59:19
CAMFT 4.7 still, in this dual relationship sort of thing talks about exploitation. Marriage and family therapists do not use their professional relationships with clients to further their own interests, and do not exert undue influence on patients.
Katie Vernoy 59:33
Curt Widhalm 59:33
So this is probably the closest one it doesn’t necessarily have the exact verbiage towards what you’re talking about here. It’s the looser, you know, kind of connection that now that we’re bringing money in, is this going to affect the new client in a way where if they’re talking about how much your fees are, that they’re gonna feel exploited?
Katie Vernoy 59:57
That is a very good question. I think in my conversations with my therapy clients who are on a sliding scale, I do make it clear, this is my full fee. And you’re on a sliding scale. And periodically, I have them review for ability to pay. So they recognize that they are in that structure of ability to pay. And when they can pay full fee, I expect them and I check in with them to go up to full fee. If they need a sliding scale, I expect them to tell me. I think the challenge is with newer clients, I really don’t have sliding scale spots anymore. I just don’t take a lot of clients on sliding scale. And so in this situation, however, if this is someone who I felt was a very good match, that I was the best match. And there’s this, you know, kind of pre-vetting by this other client because they know how I work and they think that I would be a good match too apparently. I can, at times open up a sliding scale spot. But I don’t know if that gets into weirdness, because I’ve kind of closed that section and to reopen it suggests that I might be exploiting other clients, right like that I didn’t offer sliding scale to. So this, this is where it gets a little bit complicated. I mean, I could just offer them the same fee that the client’s paying, but that doesn’t go along with the rest of my money structure. Is this just making it too complicated here?
Curt Widhalm 1:01:26
So you are now, and this is part of that deeper thinking that goes along with this. Is it’s better to get in your head and start talking about these things now, rather than five or six sessions deep when your clients show up and are like, Yo, what gives?
Katie Vernoy 1:01:42
Yeah, yeah. So if I stick with my structure, my current clients who are on a sliding scale, know my full fee, and know that they’re on a sliding scale. And I go with the current structure. And I talked to the new client, and I say, This is my full fee. And they say, Oh, I was hoping for a sliding scale. And then I do this sliding scale. Does that resolve this particular issue? Or does it create another or…
Curt Widhalm 1:02:10
It creates another, creates another issue.
Katie Vernoy 1:02:13
It’s because I’m not doing a sliding scale for other folks. I mean, I’m, I just yeah, what would you recommend in this situation? Because I, you know, if I decide to take on this client, this theoretical client, how do I address this disparity in pay piece? And it may not even be a disparity. I mean, it could be that they are, you know, end up in the exact same spot, but I’m just not sure.
Curt Widhalm 1:02:38
So looking at the CAMFT code here. 12.3 is disclosure of fees. Prior to the commencement of treatment, marriage and family therapists disclose their fees and the basis upon which they are computed, including but not limited to charges for cancelled or missed appointments, any interest we charge an unpaid balances, and give reasonable notice of any changes in fees or other charges. So this does not say that you have to have the same fee for every client.
Katie Vernoy 1:03:06
Curt Widhalm 1:03:07
And what you are describing in how you’re bringing this up to your clients seems to fully fall within doing this the correct way. You’re wrestling with the potential conflict that may come up with each of these clients individually, or one or the other of these clients. If this seems to be applied differently between the two of them.
Katie Vernoy 1:03:32
Sure. So my thought process is if I do choose to take this client, I would approach it as my current fee for new clients is, which is correct. And if they come back and say, Oh, well, my friend referred me and they are paying Y is that possible? Then the client and I can have that conversation directly. If they say, Sure, great, and no problem, then they’ve already agreed that they’re paying the current fee, and they don’t have an expectation to be paid the same as their friend who’s been around for, you know, five years or whatever it is. Right? So I think as long as I make it clear, and I’m above board with it, I think that there’s, I think I’m okay in that regard. So that gets us through ethical standards. We don’t have legal standards on this anyway, at least, unless it’s unprofessional conduct. Right? Isn’t that one of the ones you said that I might fall into?
Curt Widhalm 1:04:28
Professional conduct is kind of most licensing boards catch all for like, hey, we never wrote something that specifically identifies what you’re doing is wrong, but it falls under this.
Katie Vernoy 1:04:40
So I’ve probably covered most of that. Okay.
Curt Widhalm 1:04:43
Step seven is review the relevant research and theory.
Katie Vernoy 1:04:47
Okay, so if I’m thinking about this, it would be, I mean, it’s just about having additional folks in treatment. Like it’s not really, it doesn’t, shouldn’t clinically impact either client, if I’m doing my job right. Right? So I don’t know what I don’t know what were what research I would be looking at here. What do you think?
Curt Widhalm 1:05:15
Well, part of this is we go to Dr. Google. And as just even as a starting point, you can also go into, if you’re looking for more specific research, any of the wonderful search places, even Google scholars a more academic related place, is I’m kind of looking at some of this stuff. You may be in a jurisdiction where charging different clients for the same kinds of services may end up being something that would fall under price gouging laws. You would need to look at your jurisdiction allows for that. If you are in network with insurance, or maybe language in your insurance contracts that look at something like that, but charging different fees to different clients seems to be a absence in a lot of counseling and therapy literature, because a lot of the research that is done just pretends that therapy is free.
Katie Vernoy 1:06:20
Well, and it’s I mean, I think charging people different amounts is a pretty standard practice, because a lot of us use sliding scales. I mean, we have to have a rationale for it. But but I think I mean, if we’ve resolved the price issue, I mean, I’m thinking clinically, and whether or not I see a client’s friend and colleague, I don’t think there’s research on tha. Is there?
Curt Widhalm 1:06:41
Katie Vernoy 1:06:42
Okay, so so if we move past that one, just for the essence of time, because we’re sure close to the end of the hour here.
Curt Widhalm 1:06:51
Number eight, consider whether personal feelings, biases or self interest might affect our ethical judgment.
Katie Vernoy 1:06:57
So here’s another one that I feel like is super important, because I can, I can see how my self importance and the belief I have that I am the right person for this client, especially in a, in a place like California, if I’m going to be doing it virtually. In a place like California, I’m sure there’s a lot of therapists that potentially could serve this client. I certainly would love to have a new client. I’d love to have a client that a current client who I’m really well matched with has chosen because it obviously is probably a good match. And so I think I’m probably going to lean towards, well, if this person thinks I’m the right person, let me, and I have the skill sets, and I don’t have a lot of good referrals, I should take this case. And it would be some money. And so I think for me, I think the biggest thing I want to make sure that I’m doing is actually determining that I am the right person. And that I have talked through the potential dual relationships, or I guess the actual dual relationships with both the referring and the referred, and the prospective client.
Curt Widhalm 1:08:13
And from Pope’s websites, part of the more in depth part of this step is being relentlessly honest with ourselves. And as you’re pointing out here, it’s yeah, you do stand to make money. You know, as as an ethics committee member, if I was looking at your thought process on this, I would say you know what, at least you’re being really honest about this is something that could pull you into making this decision. And it’s the rest of the factors that we’re going to look at that really helped to make this a more valid critique.
Katie Vernoy 1:08:51
Sure. Yeah, and I think, you know, as far as assessing, you know, my skills, and my bias toward me being the right person, I think, I think it’s worth looking to see if there’s additional referrals that I can find, but I’ve, I’ve looked, and you know, this particular thing that I do, it feels like it’s different. And the folks who are talking about the things that they say are aligned, are just not. So, so I can continue to look but until that time, if the both referring and the prospective client feel like they can navigate this with me and I do my job correctly, I think it should be okay.
Curt Widhalm 1:09:31
The next step is to consider whether social, cultural, religious or similar factors affect the situation and search for the best response.
Katie Vernoy 1:09:41
So there’s a couple of different social slash cultural factors or similar factors that I see here. One is age. Both of these folks are early 30s. And so with that, I think that there is a less of a stigma and less of a concern about in mental health treatment. And so they’re more likely to claim their therapist than, you know, folks in my age bracket up in the 40s, or 50s. And so there’s not that the bias against therapy and claiming your therapist seems to be more in my generation. And so my clients that are younger than me tend to be more open to this. And it seems to be an okay thing. They also think it’s weird that there’s a separation here. Like that, I would have a big concern about someone referring their friend to me. I think there’s also this other element of this trusted profession and the profession that they’re both in where finding someone who they feel really gets at is, is really important. And the level of confidentiality and privacy that goes around it, as far as the content and having someone that understanding that is much more important. Versus I’ve got, I’ve got 20 year olds who are referring their friends to me. And oftentimes, there’s not that special interest involved for that special kind of professional culture, I guess involved that requires a slightly different type of therapist. As far as kind of socio economic, both are kind of in similar arenas. And so I think that, you know, as far as the money thing, I think that’s probably going to be fairly close, as far as what they end up paying, and how they view therapy and how they align with therapy, it’s or you know, are able to access therapy. I am culturally different than both of them. And they’re different culturally from each other. And so I think there’s a mixture of factors that play in there. One is, is more of a collectivist culture and doesn’t understand why I would worry about anybody else being involved. Another one is kind of more of the expert therapist’s culture. And so there would be slightly different ways I might interact with them. But I don’t see anything that would prohibit me seeing both of them within their, their factors. Does that make sense?
Curt Widhalm 1:12:19
Katie Vernoy 1:12:20
Curt Widhalm 1:12:20
Step 10. Have you considered consultation?
Katie Vernoy 1:12:24
I did an hour.
Curt Widhalm 1:12:28
Step 11 is develop alternative courses of action. What are some possible ways of responding to the situation that you can imagine? And this will naturally lead you into step 12, which is thinking through the alternative courses of action and what they may end up in?
Katie Vernoy 1:12:45
So assuming that my clients are both up for it, or the prospective and the referring client are both up for it, an alternate causes me to saying no, I think it makes sense to refer out and, and providing, you know, referrals to other therapists who could potentially serve the prospective client well. As I mentioned, the problem is this specific level of expertise with executives, with folks in these, in these kinds of trusted professions where there’s an additional understanding, that’s been hard for me to find folks. But it’s not impossible, I could do a little bit more research, it’s probably important for me to try to do that, especially as I continue to have these types of referrals come my way. But right now, I don’t feel like I have good alternative therapists to offer. Maybe one. And so I could look to see if that person has availability, and potentially offer that it would just be, you know, kind of more: Is this person a match or not?
Curt Widhalm 1:13:46
Step 13, is try to adopt the perspective of each person who will be affected.
Katie Vernoy 1:13:53
So the referring client, given what I know about him, he will most likely feel very relieved that I’m on the case. And he potentially will need some guidance to not try to talk about it. And so I would want to make sure I was talking about, very clearly about the boundaries and how I would be interacting with both of them. And so he would feel confident. I’m on the case, not that I would confirm that, but he would probably know that from his colleague friend. And that but that he, his and my relationship would not shift and we would not be focusing attention on this colleague and friend. For the prospective client, I think they might, I would need to make sure that they’re not coming in assuming my knowledge around the person who referred them and so then they would, they would need kind of that that interaction around refocusing and making sure that I keep them on their own very focused treatment trajectory versus having conversations like Well, oh, you know, so and so, you know, he and I were talking the other day, and he thinks this right, like, you know, kind of shift that so it becomes very much the relationship between the two of us. And then for myself, I think I’m clearly affected because I’m making money. I’m also, you know, getting actual physical evidence here that at least one client really thinks I’m doing a good job because they’re referring me. So I think it’s, that feels good. And it also has that other piece of I will be making money. And so I think I need to just pay attention to the other elements to be able to stay very true to what’s happening there.
Curt Widhalm 1:15:38
Step 14: Decide what to do, review or reconsider it, and take action.
Katie Vernoy 1:15:44
So I think in our conversation, I think if the first step is to talk to both the referring and the prospective client to make sure they are cool with it. They’ve thought all the way through it. And then assuming that’s the case, then I think I can take this client and, and as I was talking about, you know, make sure that I’m keeping both clients focused on their own treatment, and not the relationship between the two of them as it relates to me as a therapist.
Curt Widhalm 1:16:11
Step 15, is document the process and assess the results.
Katie Vernoy 1:16:15
So that means that documenting our conversation and the previous 14 steps.
Curt Widhalm 1:16:20
Yes, and lucky for you, we have this wonderful software that transcribed our episodes. So you just download that.
Katie Vernoy 1:16:28
That sounds great, I really, that’s a reason to do Zoom with Otter.
Curt Widhalm 1:16:35
So step 16, and 17 is maybe a little bit further down the line than where you’re at right now. So this is assuming personal responsibility for the consequences and consider the implications for preparation, planning and prevention. And so this is kind of taking what you’ve described, seeing how it plays out, and then being able to go back and say, Oh, this worked out in this way are things that I hadn’t considered, should inform my future policies for these kinds of situations.
Katie Vernoy 1:17:05
Curt Widhalm 1:17:05
And clearly delineating those in case those things ever come up again.
Katie Vernoy 1:17:10
Yeah. And that makes a lot of sense. And I know in other situations where I chose to either not take a client or take a client based on a relationship to my current client. Some have worked out well, some have worked out not so well. And so I think some of the some of the conversation we had is based on learning from those previous experiences. And so I think actually documenting it makes really good sense.
Curt Widhalm 1:17:34
So is this a process that you’ve largely just intuited before?
Katie Vernoy 1:17:43
I think so. I think I mean, part of it is I consult with you when it really is dicey. And so I think you’re walking me through this process anyway.
Curt Widhalm 1:17:50
Yes. Practice makes better.
Katie Vernoy 1:17:53
Yes, yes. But I think even in, you know, some of the supervision I’ve done, and some of the things where I’ve either been the consultant or the consulte, I think this is a pretty intuitive process. I think some of it like some of the things are like, Well, step 14, and 15 are pretty much the same thing, right, or whatever it is, or 15, and 16, 17, like they run together. And so 17 steps is just to make it really, really clear. But it does feel like a pretty intuitive process. I like the reminders around, you know, kind of the both ethical and legal standards as well as the the research because I think some folks in other situations, there may be clinical implications that you really have to say like Is this truly best practice at this point?
Curt Widhalm 1:18:36
Sure. So we would love to hear your feedback on this process. We’re going to include some references for this whole thing over in our show notes at mtsgpodcast.com. And I know that going through a process like this does seem lengthy, but it is something that helps us on kind of these fringe type cases that helps us to better be able to make good ethical decisions. And especially in the context of this episode, especially when it comes around things like dual relationships. So we’d love to hear your thoughts on it. Give us a 17 step feedback. You can do that on our social media. You can join our Facebook group, the Modern Therapists group. If you want to find other ways to support us, you please consider becoming a patron and seeing some of the outtakes and other things that we do for our patron members. And some of the other cool resources that we give them or consider supporting us through buying us coffee or just send us buckets of money and…
Katie Vernoy 1:19:45
Is this exploitative? Should we check the ethics code on it?
Curt Widhalm 1:19:49
And in till next time, I’m Curt Widhalm, with Katie Vernoy.
Katie Vernoy 1:19:54
Thanks again to our sponsor, Thrizer.
Curt Widhalm 1:19:57
Thrizer is a new billing platform for therapists that was built on the belief that therapy should be accessible and clinician should earn what they are worth. Every time you build a client through Thrizer, an insurance claim is automatically generated and sent directly to the clients insurance. From there Thrizer provides concierge support to ensure clients get their reimbursement quickly and directly into their bank account. By eliminating reimbursement by cheque, confusion around benefits and obscurity with reimbursement status they allow your clients to focus on what actually matters rather than worrying about their money. It is very quick and easy to get set up and it works great with EHR systems.
Katie Vernoy 1:20:38
Their team is super helpful and responsive and the founder is actually a longtime therapy client who grew frustrated with his reimbursement times. Thrizer lets you become more accessible while remaining in complete control of your practice. Better experience for your clients during therapy means higher retention. Money won’t be the reason they quit on therapy. Sign up using bit.ly/moderntherapists and use the code ‘moderntherapists’ if you want to test Thrizer completely risk free. You will get one month of no payment processing fees meaning you will earn 100% of your cash rate during that time.
Curt Widhalm 1:21:13
Once again, sign up at bit.ly/moderntherapists and use the code ‘moderntherapists’ if you want to test Thrizer completely risk free.
Katie Vernoy 1:21:23
Just a quick reminder if you’d like one unit of continuing education for listening to this episode, go to moderntherapistscommunity.com, purchase this course and pass the post test. A CE certificate will appear in your profile once you’ve successfully completed the steps.
Curt Widhalm 1:21:38
Once again, that’s moderdtherapistscommunity.com
Thank you for listening to the Modern Therapist’s Survival Guide. Learn more about who we are and what we do and mtsgpodcast.com. You can also join us on Facebook and Twitter. And please don’t forget to subscribe so you don’t miss any of our episodes.
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