Therapy In Your Own Backyard

It's a Sunday evening in the dead of a Cleveland winter. The sky is grey, the air is sharp, and I'm at CVS for the fourth time this week. Donning an ancient Miller Lite beanie I won at a raffle in college and threadbare sweats, I scan the children's cold and flu aisle for an infant-appropriate remedy. A bag rustles to my left, breaking my intense focus. I look up wearily, and my bleary eyes meet the other patron's.

A client. Specifically, my first client of the day on Monday, smiling back at me with a pint of ice cream under one arm. They wave cheerfully. I nod back. We turn back to our respective tasks.

In smaller communities, it is not uncommon for therapists and clients to cross paths in mundane spaces like the drug store. Some therapists might be one of the only mental health providers in a town, making these rural run-ins unavoidable. Others might share common spaces or resources with their clients: faith communities, coffee shops, their children's schools.

What is the best way to handle these encounters outside of the therapy room? Can an unexpected meeting alter the course of treatment? Should we change our routines to prevent it from recurring?

In this blog, we will explore the ethics of a therapist's duty to their client, both in and out of session, and offer a reframed perspective on managing dual relationships.

Ethics, Dual Relationships, and Small Communities

The social work code of ethics plainly states that we should "not engage in dual or multiple relationships with clients or former clients where there is a risk of exploitation or potential harm to the client" (NASW). Other therapeutic professions, including clinical psychology, counseling, marriage and family therapy, and chemical dependency counseling follow the same ethical standard, but may use different language.

This standard exists for a reason: dual relationships have high potential to alter the therapeutic relationship, and to cause harm. If a therapist hires their client's company to do administrative work for their practice, for example, the employer/employee relationship could muddy the waters of professional boundaries. While this example is pretty egregious, some would argue that being neighbors with their client could do the same.

A conservative interpretation of this ethical standard would read as no dual relationships, under any circumstances. A therapist seeking to reduce all risk would carefully curate their time outside of the office to minimize potential run-ins. Maybe they would work in a community separate from where they live, or grocery shop in the next town over.

Maybe it's the OCD therapist in me, but I believe that everything we do in life includes some amount of risk. This applies to working in the same community that you live in. The risk-averse therapist could go to extreme lengths to protect the sanctity of the therapeutic relationship, and the unexpected could still happen. We can't pretend it won't happen… we have to be ready to deal with it when it does.

When Is It Unavoidable?

Sometimes dual relationships are unavoidable. If we can't eliminate the possibility of contact outside of therapy, we need to be armed with the skills to repair potential ruptures that may occur.

Should you forgo your favorite coffee shop after learning your client is a regular there? Or tell your child they can't play soccer because a client's child is on the same team?

While therapists carry an ethical responsibility to prioritize their clients' well-being, it does not need to come at the expense of our own, or our family's. We do not need to martyr ourselves to be ethical therapists. In fact, doing so could cause countertransference from the therapist, affecting the client relationship all the same.

The Code of Ethics gives us some guidance here: "in instances where dual or multiple relationships are unavoidable, social workers…are responsible for setting clear, appropriate, and culturally sensitive boundaries" (NASW).

Instead of becoming a recluse to shore up firm professional boundaries, or giving up meaningful community spaces, we can choose to name and explore this dynamic in our therapeutic work with clients. What is it like for your client to consciously choose to attend yoga classes at the studio in your neighborhood, even after seeing their therapist in the parking lot? Does the benefit of going outweigh the risk of potential awkwardness? Are there choices both of you can make to mitigate these run-ins? Maybe choosing different class times so as not to overlap, or agreeing on how both parties would like to handle the encounter.

For queer, trans, kinky, or polyamorous people, navigating the dual identities of therapist and community member present unique challenges. Clients often prefer working with a clinician who shares their lived experience. At the same time, safe and affirming spaces for these communities are few and far between, and both the client and therapist might feel protective of their right to occupy them. In the same way that selling your house or pulling your kids out of school are not reasonable responses to client run-ins, telling therapists to forgo needed community spaces is not reasonable either.

A Different Perspective on Dual Relationships

How we manage dual relationships depends on our therapeutic style. A somatic therapist might ask, what was it like for you when we ran into each other? Did you notice any emotions, or sensations in your body? How did you manage them?

A more psychoanalytical therapist could pose, how does this encounter change our relationship? What does knowing more about my life outside of therapy mean for you?

Regardless of theoretical orientation, all of us can benefit from co-creating a plan for how to address future encounters with our clients. This is a conversation I have with clients at the onset of therapy, and revisit again as needed. That way the next time my dog runs up to them in the park, we have agreed on how the client would like it to be handled, and we have a framework for how to address it at their next session.

As with most ethical dilemmas, there is no perfect answer – only our clinical judgment.

References

National Association of Social Workers. (n.d.). Code of Ethics: Social Workers' Ethical Responsibilities to Clients. https://www.socialworkers.org/About/Ethics/Code-of-Ethics/Code-of-Ethics-English/Social-Workers-Ethical-Responsibilities-to-Clients

About the Author