What are the Risks of Dual (Professional) Roles in Therapy?
This post aims to discuss potential risks of professional dual roles in therapy with a focus on how patients may be adversely impacted. Even outside of therapy, professional dual roles often carry some element of risk: as an arbitrary hypothetical example, if someone is friends with their hairstylist, they might feel a social obligation to continue receiving haircuts from their friend even if they aren’t satisfied with the actual results of the haircut. However, the unique dynamics of therapy and the vulnerability of patients inside of therapy heighten some common risks and introduce some therapy-specific risks.
To provide a brief context into my own background on this topic: I am not a clinician myself, but have some experience with this topic from the patient side. More specifically, I saw a very kind clinician and, over the course of therapy, gradually developed a friendship with her as well as a mild professional overlap/dual role. The professional overlap in particular was positive in some ways but immensely stressful in others, and catalysed my fascination with clinical boundaries. While there are several excellent materials on clinical ethics and boundaries, my goal is to add a complementary perspective focused primarily on the potential impact a patient might experience in such a situation.
As a key disclaimer, this post is not designed to discourage all elements of dual roles– clinical ethics is a complex topic and there may be situations where elements of dual roles are unavoidable (e.g. small rural communities), cultural nuances, or situations where maintaining strict clinical boundaries may introduce its own form of risk.
Potential Risks
1. Gradually increasing overlap and risk of overlapping social/professional networks
In some cases, what is initially meant to be a small overlap may gradually “snowball” into a more substantial overlap. For example, a one-off professional collaboration on a small project may eventually become ongoing collaboration on a larger project. Similarly, professional overlaps may end up introducing other types of overlap– i.e. the patient and clinician may end up with mutual collaborators, an overlapping professional network, or overlap related to the patient providing professional services at the clinician’s residence or to the clinician’s family or friends. This can introduce a risk of triangulation if a mutual collaborator voices concerns about the therapist to the patient or vice versa. Additionally, in any situation involving professional or social overlap, the patient may be placed in a precarious situation of feeling they need to hide their therapeutic relationship in order to protect the therapist.
Finally, if a patient is providing specific types of professional services (bodywork, hairstyling, physical therapy, etc.); the nature of the services may involve touch being added to the therapeutic relationship, albeit outside of the setting of therapy.
2. Deepened attachment to therapist and/or confusion about roles
The patient might interpret increased overlap with the therapist as a sign that the therapeutic relationship is special or deeper than typical, and may additionally start to view the overall boundaries of the therapeutic relationship as being more porous (e.g. “if my therapist is willing to collaborate with me/values my professional ability regarding XYZ, maybe we could also be friends or start to see each other more frequently outside of therapy”.)
As such, there is a risk that professional dual roles may heighten attachment to the therapist in a way that is not beneficial to the patient – and that may even inhibit the patient’s ability to make connections outside of therapy (ie the more that the therapist occupies an oversized role in the patient’s life, the less there may be room for other connections or collaborations.)
Additionally, there can be a practical confusion about whether interactions are part of therapy or the professional overlap, or a risk that parts of therapy sessions end up veering towards discussing the professional role or collaboration.
3. Additional pressure on the patient (even if the therapist doesn’t intend for there to be pressure)
Patients may feel varying degrees of anxiety or pressure to perform well in their professional role in order to make their therapist happy, or may fear the possibility of making a mistake and potentially upsetting their therapist.
Relatedly, patients may worry that their therapist would no longer care for them as a patient (or would care less for them) if they ended or scaled back their professional relationship. Even if a therapist specifically says that this isn’t the case and that the patient doesn’t need to continue with the professional overlap, patients may still worry that their therapist would be disappointed in them if it actually came to pass (this may be particularly true if the patient has a history of being reassured of something, only for the reassurance to end up not being accurate.)
4. General asymmetry of professional dual roles
I believe this element is at the heart of the risk of dual roles. Anecdotally, from the few case studies I have come across, professional dual roles in therapy tend to amplify the power imbalance within therapy. For example, it is not uncommon to see patients overextending themselves (often in a way that increases with time)-- e.g. spending a large amount of time assisting, volunteering for, or otherwise professionally connecting with their therapist (and, in some cases, their therapist’s friends and family). Similarly, many professional relationships involve patients either volunteering for their therapist or offering services at a very low rate or significant discount. Finally, many examples I have come across involve an additional layer of professional power imbalance beyond the therapist-patient power imbalance: e.g. a patient may do administrative work for their therapist, work or volunteer at their therapist’s practice, or otherwise have a professional collaboration that is strongly dictated by the therapist’s needs and priorities in a way that the therapist essentially becomes the director or supervisor.
I think this points to a broader trend about how – even if the therapist does not consciously intend for the dual role to be exploitative– the power dynamics of therapy can easily lead to the situation becoming skewed, whether initially or over time. (And, in some cases, clinicians may intentionally take advantage of the power dynamic which is its own sad topic.)
5. The risk of dual professional relationships amplifying people pleasing tendencies or struggles with equating self-worth and productivity
This is more of a personal item based on my own experience, though I imagine it may potentially be true in some other cases also. If a patient struggles with feeling their self-worth is tied to their productivity (or that they need to provide tangible resources or assistance to others in order to deserve connection), there may be additional risks to a dual professional relationship. Paradoxically, it was this very quality that initially led me to be enthusiastic about the dual professional relationship– I care about my previous therapist as a person and had come to equate caring for someone with offering them resources or generally trying to be helpful. As such, when the dual relationship started, I felt quite happy about it as it felt like a familiar and comfortable dynamic to me.
However, over time, having a professional dynamic – albeit a relatively limited one– brought into therapy (one of few environments that theoretically is focused purely on the patient’s own needs, trauma, and healing) ended up amplifying my fear that I should be trying to be productive in all situations. Even now, while I am not in therapy, there is a sense of guilt in being in a clinical environment of any kind without offering something in return.
6. Why patient feedback may not fully mitigate risk
Extending the example above– a patient who feels grateful towards the therapist and perhaps feels they owe the therapist something in exchange may not initially realize that a professional overlap is detrimental to them, especially if it is allowing them to return to a more familiar dynamic in their life of people-pleasing.
Additionally, dual relationships may not always leave a singular impact on the patient: the patient may feel grateful, find the work meaningful, find it stressful, resent the sense of obligation, or any number of other emotions, and these conflicting emotions may in some cases delay the recognition of harm.
7. Conflicts of interest and a dual stream of information
Dual roles can often create a conflict of interest for the therapist. For example, therapists may find it harder to maintain appropriate clinical judgment if they have a strong feeling (gratitude, frustration, etc.) towards the patient based on how the professional overlap is going. This conflict of interest may also run in the other direction, where a therapist may find it challenging to address necessary issues in the professional overlap with the patient or provide critical feedback, for fear of jeapordising their therapeutic role.
Additionally, dual roles can create two separate streams of information. The therapist may now be learning about the patient through therapy, but also through their professional overlap (either directly, or indirectly through others who are involved or providing feedback on the collaboration). If a therapist comes across something clinically relevant about the patient in the professional overlap, that could create an ethical dilemma. For example, suppose a patient discloses something in therapy that is directly relevant to their ability to complete a professional project or initiative safely. The therapist may then struggle to respond appropriately in the professional relationship while honouring the patient’s confidentiality and vulnerability in the clinical relationship. And, while I have not personally had this situation, I would imagine that a patient in this situation may feel hurt if their vulnerability in therapy ended up backfiring on them professionally.
8. Complications when ending therapy
Just as some patients may fear that a mistake in the professional overlap could jeapordise their therapeutic relationship, there may also be a fear that ending the therapeutic relationship could jeapordise the professional one. In particular, if therapy ends in a complicated way or with a rupture, the patient may either struggle to navigate the professional dynamics or have to cope with the end of two relationships at once (therapeutic and professional). A patient whose professional initiative depended on the therapist in a key way (e.g. being supervised by the therapist, using resources provided by the therapist) may be particularly vulnerable to this challenge.
