April 13, 2017
Works Cited
Nickel, M. (2004). Professional Boundaries:
The Dilemma of Dual & Multiple Relationships in Rural Clinical Practice.
Counseling and Clinical Psychology Journal, vol. 1, No. 1, pp. 17-22
Mary-Beth Nickel
addresses in her article the issue of dual and multiple relationships, which
clinicians who practice in rural or less population dense regions of the
country may find themselves participants of. Through the publication of her
paper, Nickel, wishes to increase awareness of the ethical dilemmas faced by
these small-town clinicians, and promote the discussion of their issues. Unlike
highly populated areas, those who live in small towns often depend on one
another for their livelihood. People from these communities are often not open
to outside individuals who have no ties to their respected communities. Because
of factors such as these, it is often not possible for a rural clinician to
access these populations without first becoming a friend, co-worker, or another
tie to that specific community. Nickel’s paper suggests, that this is an issue
which needs to be further investigated and outlined so practitioners who face
the inevitability of participating in such a relationship, can act in an
ethical manner. The paper is subdivided into three sections: The Current Debate
Regarding Duel Relationships, The Situation in Small or Rural Communities, and
Management of Multiple Relationships in Small and Rural Communities.
In the first
portion of her work, we are shown the present landscape of the field. Both
sides believe any relationship involving a sexual component is unethical, and
that any relationship has the potentiality for unethical behavior Not
surprisingly, opinions are rather split on the issue of multiple relationships
pertaining to a single individual. Some in the field believe, that this builds
the overall relationship leading to a more positive outcome in therapy. While
others say that relationships such as the ones stated, have the potential to
create just as much harm as good. For this reason, they recommend steering
clear of such potential problems. This is also the overwhelming view of many
ethics boards, and professional association boards. The author discusses the literature
briefly and sites references such as The American Counseling Association Code of Ethics and Standards of
Practice. Nickel criticizes of these codes however by stating, “In the face
of the current debate, many authors fault these guidelines as being too
simplistic and vaguely written to adequately capture the complexity of multiple
relationship issues and guide clinicians in ethical decision-making” (18).
The second portion
of Nickel’s paper, discusses a few common problems found by rural
practitioners. She starts off with the issue of Role Boundaries. As stated
above, in a small community anonymity is something that simply, does not exist
in “tight-knit” (19) towns. Those who you see in your practice, are also those
who you see at the high school football game on Friday nights, or when you go
to church. Another common problem she mentions is, “refusing to treat any
person with whom the practitioner may have non-clinical contact may eliminate
most of the potential client population, especially if the community is remote....
could mean that the person receives no help at all” (19). The last thing she briefly discusses in this
section of her paper is the “indigenous helper” (19). This was touched on above
in the opening; however, it is best explained using Nickel’s words: “Residents
typically resent strangers entering their community from the outside in order
to ‘rescue’ it.” (19).
In the final
section of the article, the author discusses how one should manage multiple
relations concerning an individual person. Nickel’s first point, is that when
considering whether to go down this path, it is import that the clinician
evaluates each potential relationship in a Case-by-Case evaluation. She then
provides an example of how one would evaluate if a relationship outside that of
the client-patient relationship could exist. Here she references to a decision-
making model that was used by Brownlee (1996). By using the three question
model she presents, it is important that the therapist evaluate both the risks
and benefits to any potential relationship. Using this model in conjunction
with maintaining sensitivity to the “community norms and expectations” (20),
allows for a practitioner to build a case for why or why not to engage with a
multiple relationship endeavor. The author also specifies that if a
relationship is to occur, it is necessary for the therapist to have
“self-knowledge... in order to accurately monitor the potential influence of
personal needs on the therapy process” (20).
Nickel concludes by emphasizing the importance for there to be open
dialog not only between therapists in the field, but also between the client
and the therapist. Being able to disuse the relationship openly is vital to the
management of needs, wants, and expectations of both parties involved.
In response to
Nickel’s article, I generally would have to disagree stating that therapist
should not hold multiple non-sexual relationships with their patients. However,
growing up in a small “tight-knitted” community, where everyone knows
everybody, I realize that it is simply impossible to not hold these kinds of
relationships in rural, non-densely populated areas. I would however recommend against doing so
purely on the ethical principle that conflict will arise and harm both the
patient and the clinician. Ultimately, if the clinician losses his license, this
hurts not just the one client, but all those who are and could have needed
help in the community. It is also important to note that
Nickel does not define to what extent the outside relationship would consist
of, other than non-sexual. There is a clear difference between going over to a
friend’s house for dinner every single weekend, and going over and visiting once
a year. How the friendship or relationship is structured is of great importance
if a client- therapist relationship is attempted outside of practice. Although
there are serious issues which could arise from relationships such as these, I
believe that the responsibility of one’s actions should rest directly on their
own shoulders. Therapist should have the ability to assess issues such as this
on a case to case basis and act as they will; however, actions do have consequences
which should be recognized.
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