Demystifying Therapy: What are Dual and Multiple Roles?

Now and then, someone on the fringes of my social circle asks if they can come into my office for therapy. Other times, a member of a couple who I worked with previously may contact me to ask if they can come in and talk about individual issues. I have also had occasions when a client invites me to a special event in which we might have more of a social interaction. These situations all fall under the heading of dual and multiple relationships. I am going to explain both concepts and discuss why they are generally avoided and what some of the exceptions may be.

What is a Multiple Role?

A dual or multiple role is when a therapist is in a professional role with a client (or student/supervisee) while simultaneously in another role with that individual (or someone closely associated or related to that person).  It can also be if a therapist is in a professional role with a person and promises to enter into another relationship in the future with that person or someone closely related to the individual. Dual roles refer to two different roles and multiple roles are when more than two overlapping roles exist.

Some Examples of Multiple Roles

Dr. Jones has a close friend, Andrea, who talks a lot about issues with her husband, Mike, and their intimacy problems. Over time, the Andrea convinces Mike to seek therapy. Andrea asks Dr. Jones for referrals and the Dr. Jones says that finding a therapist can be difficult so she would be happy to save Andrea and Mike the trouble and she will be happy to treat Mike herself.

Dr. Smith is seeing a patient, Jim, for whom she feels a strong sexual attraction. Several months into treatment, she tells Jim that she is looking forward to the end of therapy because then they can become friends and possibly even lovers.

Dr. Nelson is seeing a patient who is an art dealer. During the course of treatment, the client talks about a piece she wants to sell by Dr. Nelson’s favorite artist. The next sessions focus more on the particular painting and during the therapy, Dr. Nelson arranges a deal through her patient to buy the artist’s work.

Why Are Multiple Roles Avoided?

The short version is this: the purpose of avoiding multiple roles is to avoid conflicts of interest in our work and to avoid exploiting or otherwise taking advantage of the power we may have over the people with whom we work.

What Does the APA Ethics Code Say About It?

Regarding multiple roles, The APA Ethics Code Standard 3.05 states that psychologists should refrain from entering into multiple relationships if the multiple relationship could reasonably be expected to impair the psychologist’s objectivity, competence, or effectiveness in performing his or her functions as a psychologist, or otherwise risks exploitation or harm to the person with whom the professional relationship exists.

The APA Ethics Code explicitly addresses some types of multiple roles, including prohibiting sexual intimacies with current therapy clients/patients in Standard 10.05, prohibiting sexual intimacies with relatives or significant others of current therapy clients/patients in Standard 10.06, and prohibiting therapy with former sexual partners in Standard 10.07. Regarding sexual intimacies with former patients, Standard 10.08 outlines the extremely rare circumstances in which it may be permissible for such a relationship to develop. It should be noted that the mere suggestion of a possible future sexual relationship during the course of treatment is in and of itself an ethical violation and would invalidate the legitimacy of such a union.

Bartering is a particular kind of multiple role which can come up with clients. The Ethics Code states in Standard 6.05 that the acceptance of goods, services, or other non monetary reimbursement from clients can be done only if it’s not clinically contraindicated and if it is not exploitative. The challenge here is that it’s not always easy to know at the outset if a bartering arrangement will be smooth or complicated. If one party decides down the line that they have a different opinion about the exchange value of the services provided, this arrangement could quickly go south. Lastly, Standard 3.06 outlines that therapist refrain from taking on professional roles when there are conflicts of interest including personal, scientific, professional, legal, financial, or other interests which could impair objectivity, competence, or effectiveness in the therapist’s primary function as a psychologist.

What Are Some Examples of Multiple Roles That Could Impair Therapist Objectivity or Exploit Clients?

Let’s use the example of Dr. Jones who has decided to see her pal Andrea’s husband, Mike, in therapy. Suppose that after Mike and Dr. Jones meet for several sessions, Andrea mentions at lunch with Dr. Jones that Mike has a chronic drug problem that she hopes he’s mentioned in therapy. Suppose Mike tells Dr. Jones that Andrea is physically abusing their child. Or, suppose Mike wants to bring up issues about his sexual relationship with Andrea in the therapy, but he feels he can’t share certain things with Dr. Jones because he fears negatively influencing his and her friendship with Andrea. This is an unfair burden for Mike to hold.

Clearly, in the above scenario, there are a number of role conflicts that could get complicated very quickly. This doesn’t even take into account the challenge of Dr. Jones having to hold confidential information that she hears from Mike that she cannot share with Andrea. While Dr. Jones may have very good boundaries around protecting confidential information, it can still be easy to slip up and forget who has shared what when she is hearing stories about the same events and relationship from two different people.

Here is a different scenario which provides an example of multiple roles leading to potential exploitation: Dr. Bloom meets with a new patient, Anthony, who wants to work on his social anxiety. After a few sessions, Dr. Bloom attends a dance class and discovers that Anthony attends the same class. They discuss this in the next therapy session and decide that it seems okay to continue both therapy and attending the same dance class. After a month, Anthony stops attending the dance class and starts coming late to sessions. He seems easily angered by the therapist. When Dr. Bloom tries to explore this with Anthony, he angrily accuses Dr. Bloom of using the dance class to monitor his progress on social anxiety issues and admits that his anxiety has worsened due to his feelings of being scrutinized by Dr. Bloom in public. Dr. Bloom may not have been aware of the effect his presence in the dance class was having on the Anthony, but it’s easy to see how the additional role overlap led Anthony to feel uncomfortable with the arrangement. It’s also easy to understand that given Anthony’s social anxiety, he may have found it difficult to assert himself and ask Dr. Bloom to consider attending another dance class.

The above examples illustrate how even with the best intentions, multiple roles can create an array of potential problems. Oftentimes, it is easier to avoid the potential conflicts rather than approaching the situations with over-confidence about one’s ability to manage the complexities.

What Does This Mean to Me (The Client)?

It’s not your job as a client to avoid dual roles or multiple relationships, although you certainly have a choice about whether to enter into a therapy relationship when you know a multiple relationship exists. One such example is when a close friend (or someone you’re dating) refers you to their therapist and you know that the issues you wish to discuss in treatment are related to your relationship with the person who referred you to therapy. This is a time in which it may be better to look for a therapist who is a bit more removed from the relationship. Ultimately, it’s the therapist’s job to assess potential dual role situations and to use her or his best judgment but it may be useful to you to better understand the reasoning behind why multiple roles can become complicated. And this may also help you to understand why some therapists make particular decisions to avoid such situations. Of course, not all multiple roles will be apparent to you or your therapist from the beginning.

Social Networking and Multiple Roles

Social networking is creating new opportunities for therapists and clients to encounter one another out-of-session, and one of the discoveries it may provide for both therapist and client is social overlap. You may uncover information via the internet that leads you to find you have friends (or other contacts) in common with your therapist. You may feel comfortable with this information as a client, or you may find that it makes you feel uncomfortable and makes you feel self-conscious knowing about connections that you’d have preferred not to know about. Many of these connections likely existed before, but new sites which list people’s contacts have made it easy to discover networks of friends which were once veiled. This can be magnified when you are a member of a minority group and are seeking a therapist who serves such minorities (or identifies as one). This can happen in ethnic, religious, disability, or sexual minority circles.

What if I Become Aware of Multiple Roles and I’m Not Sure my Therapist Knows?

Therapy is a place where you need to feel secure and comfortable. If you think your therapist has a significant relationship that may have an effect on your feelings of safety in therapy, then it is reasonable to bring this up with your therapist. Be aware that if the other person is an actual client of your therapist, your therapist will be unable to disclose or confirm this fact. But a competent therapist should be able to address your feelings around this and talk to you about it. In some situations, it can make sense to get a referral to another therapist, if the role conflict has could interfere with your therapy and your experience of safety as a client. It will also be your therapist’s job to accurately assess whether the multiple role could impair her or his judgment, and proceed accordingly, perhaps seeking consultation, if necessary.

Are There Times When It is Acceptable for a Therapist to Be in Multiple Roles?

The ethics code is explicit that sexual role conflicts are always unethical, but there are times when non-sexual multiple roles cannot be avoided or when they may not be harmful. Multiple relationships that cannot be expected to cause impairment, risk exploitation, or cause harm are not considered unethical. Different situations offer unique characteristics that need to be weighed on a case-by-case basis. For example, when practicing in small or rural communities in which it is difficult to find a therapist nearby, it may be more common to work with a therapist who you encounter in other social or professional settings. Similarly, if you are a member of a ethnic, cultural, or sexual minority group and you are seeking care from a therapist in that community, there may be some overlap of activities and social circles. Some therapists are comfortable accepting invitations to special occasions such as graduations, speeches, or sporting events, feeling that their presence can be incorporated into the therapy. A skilled therapist will be able to discuss with you the impact and meaning of the multiple roles on the therapy and your feelings about it, and he or she should also be able to discuss how you may interact in other settings when your paths cross.

Bear in mind that some therapists have different boundaries than others and this can also be influenced by their theoretical orientation or other cultural norms. While one therapist may be very conservative about not treating clients individually whom she has seen previously in couples treatment, others may feel more comfortable about mixing the treatment modalities. Some therapists have different boundaries when it comes to distinguishing when a client is no longer a client and this may allow for different types of social or professional relationships to develop at a later point in time. Others feel that once someone is a therapy client, they will always be a therapy client, since they may return at any point in the future to continue work begun with that therapist. Therapists who feel this way are unlikely to enter into other types of relationships with former clients, even if they stop therapy.

Conclusion and Further Reading

Hopefully this has helped to clarify what dual and multiple roles are and why therapists often make efforts to avoid them, as well as why some therapists may feel more comfortable entering into some types of dual roles. If you’re interested in reading more about multiple roles in the therapeutic relationship, Ken Pope offers some great resources on dual relationships, multiple relationships, and boundary decisions.