When I’m working with you in individual counseling towards one goal, can you start couple’s counseling with me and your partner, towards a different goal? It seems like having only one therapist do both would be more convenient, but many therapists flat out refuse because of the complications that may ensue. Some believe it’s unethical, but is it right to send people away when you can help them? Moreover, making that decision for clients is patronizing. Wouldn’t it be better to treat clients as competent adults, discuss the pros and cons, and decide together on a case-by-case basis?

First, why do some believe it’s unethical? They’d point to provisions in most ethical codes, like the one New York State has for mental health counselors, that warn us to “avoid the dangers of dual relationships when relating to patients in more than one context…” In other words, it’s best to have only one relationship with a client at a time. If I already have a relationship with you in your individual therapy towards one goal, they say we would be adding a second if I also saw you in marriage counseling, to help you towards another. They say we would also be adding a second relationship if you were my server when I came to your restaurant, if I hired you to do my taxes, if our kids were on the same baseball team, or if you read one of my books. This rule can be taken to absurd lengths and, for therapists who live and work in a small town, it’s impossible to follow.

A dual relationship is obviously unethical when the therapist is doing something egregious like having a sexual relationship with a client or coercing clients to pay for extra services. That’s the kind of thing ethics codes are trying to address. But just where can we draw the line between the truly dangerous and the picayune?

I have a seventeen step process towards ethical decision making that should shift out frivolous considerations and show us the ones we should worry about. I got it from the sixth edition of Ethics in Psychotherapy and Counseling, by Pope, Vasquez, Chavez-Dueñas, and Adames. Let’s take one scenario and put it through the seventeen steps.

1.    State the question, dilemma, or concern as clearly as possible.

Mark (not his real name), who I’ve been seeing individually for a couple of months for his alcoholism, is having problems in his marriage and wants his wife, Suzy (also not a real name), to join us for marriage counseling to help them communicate better, while he continues to see me for his alcohol use. He’s skeptical that he would find another counselor he trusts, for he’s had problems with that in the past and assumes it would be better to have someone already familiar with him to address this second issue.

It’s very common to meet with partners in substance abuse treatment, with the focus on substance abuse. In marriage counseling, it’s very common to find one or more partners who abuse substances, when the focus is on improving communication. But can I be effective when the focus is on two goals?

2. Anticipate who will be affected by the decision.

Suzy will be meeting me for the first time, while Mark already knows me well. She may feel out of place in my office and assume I’d side with him. If I don’t, then Mark may feel betrayed by me.

There may also be a problem with confidentiality. My individual sessions with Mark need to be private for them to be effective. What if Mark discloses something he wants to keep from Suzy? The goal in marriage counseling is to open up communication. That hardly seems to jibe when Mark and I collude to withhold information from her.

Then there’s the problem of mission creep. Will we end up talking about Mark’s alcohol use in marriage counseling and communication issues in individual, where we are least likely to effectively address them?

3.    Figure out who, if anyone, is the client.

Up until now, Mark has been the client in his individual sessions. He pays for them and decides his treatment goals with me. The moment I meet Suzy, there’s a risk that her concerns may start to direct his individual therapy, making her the real client there, even if she’s not in the room.

In marriage counseling, neither Mark nor Suzy is the client alone. Their relationship is the client. Treatment goals should be decided together. Ideally, no one person would pay for it, set up appointments, or do most of the talking in sessions, but often one partner does it all, making the other person a client in name only.

4.    Assess whether my areas of competence—and of missing knowledge, skills, experience, or expertise—are a good fit for this situation.

Substance abuse treatment is well within my area of competence. I have special training in that field and decades of experience. I also have had special training in marriage and family therapy. I wrote a book on communication and another on reconciliation. While my experience with marriage counseling is not as extensive as it is with substance abuse, I still have more experience than most other therapists they would find.

If Mark had asked for something different, like providing therapy for his seven year old son, I wouldn’t be a good fit. Although I’ve had some training in it, it’s been a long time since I did therapy with a child.

5.    Review relevant formal ethical standards.

The most relevant ethical standard is the injunction to avoid dual relationships, as I’ve already discussed. But the argument could be made that being a marriage counselor and substance abuse counselor are not two different roles, but different parts of the same one. In that case, the relevant standards would be around treatment planning. The only thing the New York State Office of Professions says about treatment planning is that I should be appropriately trained to implement the treatment plan. The American Counseling Association (ACA) says more. It says I need to work jointly with my client to devise a plan that offers a reasonable promise of success, consistent with the abilities, temperament, developmental level, and circumstances of the client.

6.    Review relevant legal standards.

The ACA Code of Ethics is a good reference point, but it has no legal authority over me. Legally, I only need to worry about the standards set by the New York State Office of Professions. Both treatment for alcoholism and marriage counseling are within the scope of practice for licensed mental health counselors in New York State. Regulations also say I should avoid dual relationships. I could be sued or lose my license if I don’t, but it’s highly doubtful I would over any but the most egregious errors.

7.    Review the relevant research and theory.

There’s a large body of knowledge called systems theory which is relevant. One of its principles is that individual problems like alcoholism cannot be separated from marital issues, such as communication. Under systems theory I wouldn’t even try to treat someone solely by individual therapy or solely by marriage counseling or even to focus solely on addiction or solely on communication. Everything’s connected.

One evidence-based treatment model that comes out of systems theory is Integrative Behavioral Couple Therapy. IBCT explicitly integrates the symptom reduction work done in individual therapy with the opening up communication work of couples’ counseling.

8.    Consider whether personal feelings, biases, or self-interest might affect our ethical judgment.

My strongest bias is in favor of systems theory. I have an aversion to arbitrary distinctions. Before Mark and Suzy came along, I developed an innovative program that integrated mental health and substance abuse treatment, two types of treatment that are sometimes incompatible. Therefore, I’m predisposed to rising to the challenge of finding how things can fit together.

I’m also inclined to go with Mark’s proposal because I would like to please my client who’s asking me to do this. You could say it’s in my self-interest to keep all Mark’s counseling business to myself, but, believe me, I’ve got plenty of work. The counseling business is different from many others in that there’s a limit to how much you can take. 

Mark has a bias towards seeing me for marriage counseling because he’s learned to trust me and won’t have to repeat his whole story to a new therapist. We don’t know how Suzy feels about this arrangement, though. We’d need to fill her in on all the pros and cons and get her opinion.

9.    Consider whether social, cultural, religious, or similar factors affect the situation and the search for the best response.

It was hard for Mark to go to therapy at first. Talking about his feelings does not come naturally to him and he’s had some bad experiences. Therefore, it might be hard for him to start seeing a therapist he doesn’t know. While I don’t know much about Suzy’s culture or religious background, I do know she’s a woman. I might assume she’s more adaptable socially, as women often are. However, I should not take her for granted. That would not be a good start if I do work with her in any way.

10. Consider consultation

I have a number of colleagues I consult on ethical issues and have talked about the issue of combining treatment modalities with them. Some of them would not agree to this request if asked of them, either because they don’t think it’s ethical or they’re not qualified to do it. Others would agree to it, either because they’ve used something like the seventeen steps, or because they just do what feels right.

The idea of consultation is not to see if everyone agrees with me. The idea is to solicit multiple points of view, so I can consider things I haven’t thought of. The decision about what to do must always rest between the therapist and clients, not a committee that has never met them.

11. Develop alternative courses of action.

The alternatives are:

• Try marriage counseling as well as individual, just as Mark proposed.
• Have them see Suzy’s therapist for marriage counseling, if she has one.
• Have them find a whole new therapist for marriage counseling.
• Not do any marriage counseling at all.
• Pause Mark’s individual therapy while we address the communication issues.

12. Think through the alternative courses of action. What are the risks with each?

If we tried marriage counseling as well as individual – The worst that could happen would be for Mark to get offended by me and stop going to both. Suzy might not engage because she assumes I’m biased. We might allow the focus of treatment to drift.

If Mark and Suzy were to see Suzy’s therapist – They’d run the same risks with Suzy’s therapist as they do with me. I would not be able to fully integrate the addiction work with the communication work.

If they did not get any marriage counseling – They may continue to struggle with communication and Mark would relapse with his alcoholism to deal with the pain of a bad marriage or divorce.

If they go to a new therapist to do marriage counseling – There’s a greater chance that an unknown counselor would be a bad fit than a known one. I would not be able to fully integrate the addiction work with the communication work.

If we pause Mark’s individual therapy while we do marriage counseling – We might get distracted from Mark’s recovery, leading to relapse. Mark still might get offended by how differently I relate to him in marriage counseling and stop coming. Suzy still might not engage because she assumes I’m biased. However, Mark would have fewer appointments to keep each week and it would save him the expense.

13. Try to adopt the perspective of each person who will be affected

The person most affected would be Suzy, and she’s the one person who has not yet been part of the decision making. We obviously need to talk to her before doing anything.

14. Decide what to do, review or reconsider it, and take action.

In this case, we decided that I would see Suzy for an individual session to get to know her and give her a chance to see if she feels comfortable with working with me. She was, so I proposed to start marriage counseling with the understanding that I would still be seeing Mark individually for confidential sessions. I explained that I’d keep those confidences, not because I think it’s a great idea for couples to have secrets from one another, but because individuals need a safe place to process their feelings and make confessions before putting them out to anyone who might have a strong reaction. I gave Suzy the same access to seeing me for confidential individual sessions if she needed to. She agreed to this plan, but never asked for any more individual sessions.

If Mark objected to doubling the number of appointments he must make, I was prepared to suspend his substance abuse treatment with the understanding that we will need to resume it if he relapses. As it was, he never complained about having to meet twice as often.

If they had decided to see someone else for marriage counseling, I was prepared to urge them to give me permission to talk with that therapist so that we would not be at cross purposes and so Mark does not have to repeat his whole story.

15. Document the process and assess the results.

I asked Mark and Suzy to read and sign a contract for each type of treatment. I wrote summaries of each session, no matter what type, and sent them to whoever participated. I repeatedly asked for feedback on how they thought it was going, so that we could talk about any problems that might come up.

16. Assume personal responsibility for the consequences.

In this case, we went ahead with marriage counseling to improve communication, as well as individual counseling for Mark’s alcoholism. It was very hard to keep them separate because Mark’s alcoholism, and Suzy’s bitterness towards it, played a leading role in the communication issues. It was like alcoholism was a third party in their marriage, like a stepchild that Mark brought in, and Suzy never learned to relate to.

Just as alcoholism invaded the marriage counseling, communication problems invaded the individual sessions. I often found myself coaching Mark on how to relate to Suzy better. Suzy could have used some private coaching sessions, as well; but she thought the problem was Mark’s alcoholism, so he should handle it.

In the end, we never achieved the goals set for marriage counseling. They remained cold and distant to one another and lost the enthusiasm for coming. Mark kept up his individual sessions and successfully sustained sobriety. I’m not sorry we tried it, though. I don’t think the outcome would have been any different if they saw a different therapist for marriage counseling. The two sets of problems really needed to be addressed together and it’s almost impossible to do so between two therapists who aren’t in the same practice. If I had to change anything, I’d insist on seeing Suzy for individual therapy more, making it an even more complex arrangement, for she was bringing her own baggage we never got a chance to unpack.

17. Consider implications for preparation, planning, and prevention

This question of seeing individual clients for marriage counseling, comes up so frequently, I decided to write an article about it, so the seventeen step process would be there for clients and therapists to read before making a decision to do it. Your case may be different from Mark and Suzy’s, but you now have a general idea about how to make tough ethical decisions and learn from them.

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