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Section 6
Ethical Considerations in Mental Health

Question 6 | Test | Table of Contents

Particularly since the early 1980s, mental health professionals have developed an increasingly mature grasp of ethical issues. During the past two decades, mental health's literature has expanded markedly with respect to identifying ethical conflicts and dilemmas in practice; developing conceptual frameworks and protocols for ethical decision making when professional duties conflict; and formulating risk management strategies to prevent ethics-related negligence and ethical misconduct (Berliner, 1989; Besharov, 1985; Levy, 1993; Linzer, 1999; Loewenberg & Dolgoff, 1996; Reamer, 1982, 1990, 1994, 1995a, 1998b, 1999; Rhodes, 1986).

As the mental health literature clearly demonstrates, ethical issues related to professional boundaries are among the most problematic and challenging (Congress, 1996; Jayaratne, Croxton, & Mattison, 1997; Kagle & Giebelhausen, 1994; Strom-Gottfried, 1999). Briefly, boundary issues involve circumstances in which mental health professionals encounter actual or potential conflicts between their professional duties and their social, sexual, religious, or business relationships. As explored more fully later, not all boundary issues are necessarily problematic or unethical, but many are. The primary purpose of this discussion is to identify--in the form of a typology--the range of boundary issues in mental health, develop criteria to help mental health professionals distinguish between problematic and nonproblematic boundary issues, and present guidelines to help practitioners manage boundary issues and risks that arise in practice.

Boundary Issues in Mental health
Mental health professionals--be they clinicians, community organizers, policymakers, supervisors, researchers, administrators, or educators--often encounter circumstances that pose actual or potential boundary issues. Boundary issues occur when mental health professionals face possible conflicts of interest in the form of what have become known as dual or multiple relationships. Dual or multiple relationships occur when professionals engage with clients or colleagues in more than one relationship, whether social, sexual, religious, or business (St. Germaine, 1993, 1996). According to Kagle and Giebelhausen (1994),

a professional enters into a dual relationship whenever he or she assumes a second role with a client, becoming mental health professional and friend, employer, teacher, business associate, family member, or sex partner. A practitioner can engage in a dual relationship whether the second relationship begins before, during, or after the mental health professional relationship. (p. 213)

Dual relationships occur primarily between mental health professionals and their current or former clients and between mental health professionals and their colleagues (including supervisees and students).

The mental health literature contains few in-depth discussions of boundary issues (Jayaratne et al., 1997; Kagle & Giebelhausen, 1994; Strom-Gottfried, 1999). Most discussions have focused on dual relationships that are exploitive in nature, such as mental health professionals' sexual involvement with clients. Certainly these are important and compelling issues. However, many boundary and dual relationship issues in mental health are subtler than these egregious forms of ethical misconduct. A recent empirical survey of a statewide sample of clinical mental health professionals uncovered substantial disagreement concerning the appropriateness of behaviors such as developing friendships with clients, participating in social activities with clients, serving on community boards with clients, providing clients with one's home telephone number, accepting goods and services from clients instead of money, and discussing one's religious beliefs with clients (Jayaratne et al, 1997; see also Borys & Pope, 1989; Brownlee, 1996; Gutheil & Gabbard, 1993; Pope, Tabachnick, & Keith-Spiegel, 1988; Smith, 1999; Smith & Fitzpatrick, 1995; Strom-Gottfried, 1999). As Corey and Herlihy (1997) noted:

The pendulum of controversy over dual relationships, which has produced extreme reactions on both sides, has slowed and now swings in a narrower arc. It is clear that not all dual relationships can be avoided, and it is equally clear that some types of dual relationships (such as sexual intimacies with clients) should always be avoided. In the middle range, it would be fruitful for professionals to continue to work to clarify the distinctions between dual relationships that we should try to avoid and those into which we might enter, with appropriate precautions. (p. 190)

To achieve a more fine-tuned understanding of boundary issues, mental health professionals must broaden their analysis and examine dual relationships through several conceptual lenses. First, mental health professionals should distinguish between boundary violations and boundary crossings (Gutheil & Gabbard, 1993; Smith & Fitzpatrick, 1995). A boundary violation occurs when a mental health professional engages in a dual relationship with a client or colleague that is exploitive, manipulative, deceptive, or coercive. Examples include mental health professionals who become sexually involved with current clients, recruit and collude with clients to bill insurance companies fraudulently, or influence terminally ill clients to include mental health professionals in clients' wills. Boundary violations are inherently unethical.

One key feature of boundary violations is a conflict of interest that harms clients or colleagues (Epstein, 1994; Kitchener, 1988; Kutchins, 1991; Pope, 1988, 1991). Conflicts of interest occur when professionals find themselves in "a situation in which regard for one duty leads to disregard of another or might reasonably be expected to do so" (Gifts, 1991, p. 88). Thus, a clinical mental health professional providing services to a client with whom he or she would like to develop a sexual relationship faces a potential conflict of interest; the mental health professional's personal interests clash with professional duty. Similarly, a community organizer who invests money in a client's business is embedded in a conflict of interest; the mental health professional's financial interests may clash with the mental health professional's professional duty to the client (for example, if the mental health professional's relationship with the client becomes strained because they disagree about some aspect of their shared business).
The concept of conflict of interest is addressed explicitly in the NASW Code of Ethics (2000):

Mental health professionals should be alert to and avoid conflicts of interest that interfere with the exercise of professional discretion and impartial judgment. Mental health professionals should inform clients when a real or potential conflict of interest arises and take reasonable steps to resolve the issue in a manner that makes the clients' interests primary and protects clients' interests to the greatest extent possible. In some cases, protecting clients' interests may require termination of the professional relationship with proper referral of the client. (Standard 1.06[a])

The Code goes on to say that "mental health professionals should not engage in dual or multiple relationships with clients or former clients in which there is a risk of exploitation or potential harm to the client" (Standard 1.06[c]).

Some conflicts of interest involve what lawyers call undue influence. Undue influence occurs when a mental health professional inappropriately pressures or exercises authority over a susceptible client in a manner that benefits the mental health professional and may not be in the client's best interest. In legal terminology, undue influence involves the exertion of improper influence and submission to the domination of the influencing party.... In such a case, the influencing party is said to have an unfair advantage over the other based, among other things, on real or apparent authority, knowledge of necessity or distress, or a fiduciary or confidential relationship. (Gifts, 1991, p. 508)

The NASW Code of Ethics also addresses the concept of undue influence: "Mental health professionals should not take unfair advantage of any professional relationship or exploit others to further their personal, religious, political, or business interests" (Standard 1.06[b]).

In contrast, a boundary crossing occurs when a mental health professional is involved in a dual relationship with a client or colleague in a manner that is not intentionally exploitive, manipulative, deceptive, or coercive. Boundary crossings are not inherently unethical. In principle, the consequences of boundary crossings may be harmful, salutary, or neutral (Gutheil & Gabbard, 1993). Boundary crossings are harmful when the dual relationship has negative consequences for the mental health professional's client or colleague and, possibly, for the mental health professional as well. For example, a clinical mental health professional who discloses to a client personal, intimate details about his or her own life, ostensibly to be helpful to the client, ultimately may confuse the client and compromise the client's mental health because of complicated transference issues produced by the mental health professional's self-disclosure. A mental health educator who accepts a student's dinner invitation may inadvertently harm the student by confusing the student about the nature of the mental health educator's relationship. A mental health administrator whose family vacations with an employee and his or her family may have difficulty managing future personnel problems involving that employee.

Alternatively, some boundary crossings may be helpful to clients and colleagues. Some mental health professionals argue that, handled judiciously, a clinical mental health professional's modest self-disclosure or decision to accept an invitation to attend a client's graduation ceremony may prove, in some special circumstances, to be therapeutically useful to a client (Anderson & Mandell, 1989; Chapman, 1997; Reamer, 1997, 1998a). A mental health professional at a community mental health center who worships, coincidentally, at the same church a client attends may help the client "normalize" the professional-client relationship. A mental health educator who hires a student to serve as a research assistant may boost the student's self-confidence in a way that greatly enriches the student's educational experience.

Yet, other boundary crossings produce mixed results. A mental health professional's self-disclosure about personal challenges may be both helpful and harmful to the same client--helpful in that the client feels more "connected" to the mental health professional and harmful in that the self-disclosure undermines the client's confidence in the mental health professional. The mental health administrator of a residential substance abuse treatment program who hires a former client may initially elevate the former client's self-confidence and create boundary problems when the former client subsequently wants to resume the status of an active client following a relapse.
- Reamer, Frederic; Boundary issues in social work: managing dual relationships; Social work; Jan 2003; Vol. 48; Issue 1.

Personal Reflection Exercise #2
The preceding section contained information about boundary issues in mental health.  Write three case study examples regarding how you might use the content of this section in your practice.

Ethical and Legal Issues in Psychotherapy

Avasthi, A., Grover, S., & Nischal, A. (2022). Ethical and Legal Issues in Psychotherapy. Indian journal of psychiatry, 64(Suppl 1), S47–S61.

Peer-Reviewed Journal Article References:
Fivecoat, H. C., Cos, T. A., & Possemato, K. (2017). Special ethical considerations for behavioral health consultants in the primary care setting. Professional Psychology: Research and Practice, 48(5), 335–342.

James, K., & Stewart, D. (2018). Blurred boundaries—A qualitative study of how acts of selfharm and attempted suicide are defined by mental health practitioners. Crisis: The Journal of Crisis Intervention and Suicide Prevention, 39(4), 247–254.

Lustgarten, S. D., & Elhai, J. D. (2018). Technology use in mental health practice and research: Legal and ethical risks. Clinical Psychology: Science and Practice, 25(2), Article e12234.

Muir, H. J., Coyne, A. E., Morrison, N. R., Boswell, J. F., & Constantino, M. J. (2019). Ethical implications of routine outcomes monitoring for patients, psychotherapists, and mental health care systems. Psychotherapy, 56(4), 459–469.

Some conflicts of interest involve what lawyers call undue influence. What is undue influence? To select and enter your answer go to Test.

Section 7
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