Dual Relationships

To Cross Or Not To Cross:
Do Boundaries In Therapy Protect Or Harm?

跨不跨越:治疗中的边界是保护还是伤害?

By Ofer Zur, Ph.D.

Source: Zur, O. (2004). To Cross or Not to Cross: Do boundaries in therapy protect or harm. Psychotherapy Bulletin, 39 (3), 27-32. Posted by permission of Division 29 (psychotherapy) of APA.

Psychologists have been inundated with unequivocal messages about the depravity of boundary crossings and dual relationships in clinical practice. From graduate courses and texts on ethics, to continuing education workshops on “Risk Management”, to attorneys’ advice columns, we have been warned never to leave the office with a client, to be very careful about gifts, never to socialize with clients, to avoid bartering and to limit physical contact to a handshake or a pat on the back. We have also been cautioned that boundary crossings are likely to lead us down the slippery slope to exploitive sexual relationships. Boundary crossings and dual relationships have often been labeled unethical and often used synonymously with exploitation and harm.

在临床实践中,治疗师总是被清晰地告诫跨越边界或发生双重关系是很不道德的。从有关伦理的研究生课程和课文,到持续进行地有关“危机管理”的工作坊,再到律师的忠告事项,我们被警告绝不可以在咨询室单独留下来访者;特别关注礼物的问题;绝不可以与来访者建立社交关系;不能发生经济往来;尽量减少与来访者身体接触,如:握手或轻拍后背。我们也不断被提醒,跨越边界就像是把自己置于滑向对来访者性渔利关系的滑坡。跨越边界和双重关系经常被贴上缺乏职业道德的标签,并且常被视作渔利(来访者)和伤害的同义词。

This article will attempt to shed light on the complexities of boundary crossings and will clarify the relevant ethical and clinical concerns. It will distinguish between harmful boundary violations, beneficial boundary crossings and unavoidable or helpful dual relationships. Most importantly, it will suggest ways to increase clinical effectiveness by appropriately incorporating beneficial boundary crossing interventions into our clinical practices.

本文的意图是阐明跨越边界的复杂性,并且澄清有关伦理和临床方面的相关情况。本文将区分有害的侵犯边界和有益的跨越边界,以及不可避免的或有帮助的双重关系。最重要的是,本文对于在临床实践中,通过适当地使用有益地跨越边界进行干预,进而提升临床效果提供了建议。

Defining Boundaries 边界的界定

Boundary issues mostly refer to the therapist’s self-disclosure, touch, exchange of gifts, bartering and fees, length and location of sessions and contact outside the office (Guthiel & Gabbard, 1993). Boundary crossing in psychotherapy is an elusive term and refers to any deviation from traditional analytic and risk management practices, i.e., the strict, ‘only in the office,’ emotionally distant forms of therapy (Lazarus & Zur, 2002). Dual relationships refer to situations where two or more connections exist between a therapist and a client. Examples of dual relationships are when a client is also a student, friend, employee or business associate of the therapist.

边界的议题大部分关涉到治疗师的自我暴露、(身体)接触、交换礼物、经济往来和咨询费、治疗的时长和地点,以及咨询室以外的接触(Guthiel & Gabbard, 1993)。跨越边界在心理治疗中是个晦涩的术语,它关涉到任何在传统分析或风险管理实践中偏差。如:“仅在咨询室中”保持严格地情感疏离的治疗形式(Lazarus & Zur, 2002)。双重关系是涉及治疗师和来访者之间存在两种或多种关系联结的情况。双重关系的例子包括来访者是治疗师的学生、朋友、雇员或合作者。

While most analysts, ethicists, attorneys and “experts” may use a broad brush in describing boundary issues, it is important that psychologists differentiate between harmful boundary violations and helpful boundary crossings. A boundary violation occurs when a therapist crosses the line of decency and integrity and misuses his/her power to exploit a client for the therapist’s own benefit. Boundary violations usually involve exploitive business or sexual relationships. Boundary violations are always unethical and are likely to be illegal. However, boundary crossings are often part of well-constructed treatment plans and, as such, they can increase therapeutic effectiveness (Lazarus & Zur, 2002). While all dual relationships involve boundary crossing, exploitative dual relationships are boundary violations. Obviously, not all boundary crossings are dual relationships.

尽管大多数分析师、伦理学家、律师和“专家们”经常会粗略地谈论边界议题,但对心理治疗师而言,能够区分有害的侵犯边界和有益地跨越边界是非常重要的。侵犯边界发生在治疗师违反了尊重和诚实的底线,滥用自己的影响力渔利来访者,以满足自己的利益。侵犯边界常常牵涉渔利式的商业或性关系。同时也常常是不符合伦理,并可能是违法的。但是,跨越边界往往被用于建构更好的治疗方案,由此可以增进治疗的效果(Lazarus & Zur, 2002)。尽管所有的双重关系都包含着跨越边界,如:渔利式的双重关系就是侵犯边界。但明显的,不是所有跨越边界的行为都造成双重关系。

Beneficial Boundary Crossings 有益地跨越边界

While from the analytical point of view almost all boundary crossings are detrimental to the transference analysis and the clinical work, behavioral, cognitive-behavioral, Rational-Emotional, humanistic, existential, group, feminist, Ericksonian and family system psychotherapies often endorse many forms of helpful boundary crossings (Lazarus, 1994; Williams, 1997). Additionally, boundary crossing, when executed with the clients’ welfare in mind, is likely to enhance therapeutic alliance, the best predictor of therapeutic outcome.

尽管从分析的视角看,几乎所有跨越边界都是有害于移情分析,但是临床工作、行为治疗、认知行为治疗、理性情绪疗法、人本主义疗法、存在主义疗法、团体治疗、女权主义治疗、埃里克森派、家庭系统心理治疗常常容许一些形式有益地跨越边界(Lazarus, 1994; Williams, 1997)。此外,当始终惦记着提升来访者利益时,跨越边界很可能增进治疗同盟,从而成为产生疗效的最佳指标。

Following are examples of beneficial boundary crossings and, when appropriate, the orientations or settings that support such interventions are included (Note: None of the following interventions constitute dual relationships):

当恰当的取向和设置支持干预的情况下,以下就是有益地跨越边界的例证(注意:以下没有一种干预会构筑双重关系。):

  • Behavioral therapy endorses walking with an agoraphobic client to an open space outside the office or flying with a fear-of-flying client on an airplane as part of an exposure or in vivo intervention.
  • 行为治疗允许与广场恐惧症的来访者去咨询室以外的开放空间散步,或者与一位患有飞行恐惧的来访者同乘飞机,以此作为暴露治疗或积极干预的一部分。
  • Child psychologists, and other psychologists who work with children, routinely leave the office for walks with them and or perhaps attend school plays in which they are performing. They also regularly touch and hug, provide snacks and drinks, play cards and exchange small gifts and photos with their young clients.
  • 儿童心理学家,以及其他与儿童工作的心理学家通常离开咨询师与儿童一起散步,或者可能会去学校参与儿童正在参与的活动。他们通常也与他们的小来访者碰触和拥抱、提供点心和饮料、玩牌和交换小礼物、照片。
  • Albeit for different reasons, Cognitive, behavioral, cognitive-behavioral, feminist, group, humanistic, feminist and existential therapies all endorse self-disclosure as a way of modeling, offering an alternative perspective, exemplifying cognitive flexibility, creating authentic connections, increase therapeutic alliance or leveling the playing field.
  • 尽管原因不同,认知、行为、认知-行为、女权主义、团体、人本和存在主义疗法都允许将自我暴露作为一种示范,一种选择性的观点、一种弹性认知的例证、创造真实的联结、增进治疗联盟或标明场域。
  • Behavioral and family therapy support joining an anorexic or bulimic client for a lunch or for a family dinner.
  • 行为治疗和家庭治疗赞成与厌食症或贪食症的来犯者共进午餐或参加其家庭晚宴。
  • Humanistic therapies are apt to frown upon therapists who never self-disclose, touch, hold, or hug their clients.
  • 人本主义治疗倾向于反对治疗师从不对来访者自我敞开,触碰、抱持或拥抱他们的来访者。
  • Many adolescent psychologists would not hesitate to go for a walk with a resisting, reluctant or irresponsive adolescent in order to break the ice. We have seen how this concept of boundary crossing has already filtered into our entertainment culture. Robin Williams, playing the therapist in the movie, Good Will Hunting, had the right attitude regarding boundaries when he decided to effectively break the ice by taking the highly resistive and distrustful young client, played by Matt Damon, to the riverbank for a walk.
  • 许多青少年心理学家会毫不犹豫地与有阻抗的、不合作的或缺乏反应的青少年去散步,以此打破坚冰。我们可以看到跨越边界的概念是怎样进入我们的娱乐文化。在电影《心灵捕手》中Robin Williams扮演的治疗师,对于边界抱着正确的态度,当他决定有效地打破由Matt Damon所扮演非常阻抗和怀疑的年轻来访者之间的坚冰时,进行了一趟河岸散步。
  • Therapists who work with different cultures inevitably join their Native American clients in some of their sacred rituals, their Latin clients in weddings, their Catholic clients in confirmations, or their Jewish clients for Bar or Bat Mitzvahs. Refusing to do so in certain settings is likely to cause irreparable damage to the therapeutic alliance, nullify trust and render therapy ineffective.
  • 与不同文化来访者工作的治疗师不可避免地参与到他们美洲土著来访者的神圣仪式,拉丁来访者的婚礼,天主教来访者的坚信礼,犹太来访者的成人礼。在特殊情况下,拒绝去参加这些很可能导致治疗联盟不可挽回的损害,摧毁互信,以及给治疗带来反效果。
  • Psychologists who work in poor, rural communities are often engaged in bartering arrangements, which may be the only way for people there to access mental health services. Bartering with cash-poor and art-rich artists is also a common practice.
  • 面对贫穷和农村社群工作的心理治疗师常常要接受以货易货的安排,那可能是人们唯一能够获得心理健康服务的方式。与身无分文却艺术品有余的艺术家交换服务也是通常的方式。
  • If it is likely to benefit the client, therapists of many non-analytic orientations, will:
    • Go on a home visit to an ailing, bedridden or dying client. Such a visit also gives them a much better firsthand sense of the broader clinical context of their clients.
    • Take a depressed, medically non-compliant client on a vigorous walk.
    • Accompany a fearful client to a medically crucial but dreaded medical procedure.
    • Join a client-architect on a tour of her newest construction, a winery owner on a tour of his beloved winery or a proud sculptor to the opening of an exhibition of her work.
    • Escort a client to visit a gravesite or a place that held special meaning for the client and their deceased loved one in order to facilitate the grief process.
    • Join an addict at a first 12-step meeting.

假如可能有利于来访者,许多非分析取向的治疗师将:

去拜访生重病的、卧床不起或将死的来访者。这样的拜访将给予治疗师对于他的来访者超越临床背景下的更加真切的感受。

带着一位抑郁却不接受医疗的来访者去好好地散步。

参观一位建筑师来访者的最新落成的建筑,一位粮酒厂主最心爱的粮酒厂,或一位自豪的雕刻家的雕刻作品展。

陪同来访者去对他们而言有特殊意义或者他们丧失的重要爱人的墓地,以此促进哀悼的进程。

参加成瘾者来访者的最初12步会议。


Dual Relationships 双重关系

Dual relationships are subtypes of boundary crossing. Psychologists practicing in rural and small communities encounter numerous unavoidable dual relationships in the course of their daily lives. The person who bags groceries in the supermarket, pumps gas, works in a dentist’s office or chaperones children on school field trips may often also be the therapist’s client. Relationships in such small communities can get even more complex when people choose their therapists because they know them and not because they saw their ad in the Yellow Pages. A therapist’s fellow congregation member, teammate in a local sports league or car dealer may all choose their psychologist because they have come to know him or her personally and they share values, attitudes, morals and or spiritual values. Like many other boundary crossings, such unavoidable dual relationships are not limited to rural or small communities; they are the norm within numerous small populations in larger metropolitan areas, e.g., gay/lesbian, handicapped, various minorities, religious congregations, and other such distinct small societies. In fact, duality, mutual dependence and prior knowledge of each other are prerequisites for the development of trust and respect in these communities. Non-sexual, non-exploitative dual relationships and familiarity between therapists and clients are not only normal but, in fact, increase trust. This enhances the therapeutic alliance, which is recognized as the best indicator of therapeutic results (Lambert, 1991; Norcross & Goldfried, 1992). Another excellent example is the military where, whether on a ship or in an isolated and remote base on foreign soil, dual relationships are not only unavoidable, but, in fact, mandatory.

双重关系是跨越边界的子类型。在乡村或小型社区工作的心理学家在他们的日常生活中面临许多不可避免的双重关系。在超市里打包商品的店员、加油站的工人、牙科医院的医护人员,或者负责护送孩子上下学的保育员,都常常会成为治疗师的来访者。当人们选择治疗师是因为了解他,而非从电话黄页中看到他的广告,使得小型社区的咨访关系可能更加复杂。治疗师同材团体的成员、当地运动社团的伙伴,或者汽车销售商可能都会因为私下了解他或她而选择其作为治疗师,同时他们一起分享价值观、态度、道德或者精神价值。和其他的跨越边界相似,这种不可避免的双重关系不仅限于乡村或小型社区,它还发生在大城市中的少数群体中。如:同性恋者、残疾人士、少数民族、宗教团体,或者其他明显的小社群。实际上,在这些社群里,彼此或相互依存状态,以及事先了解彼此成为了发展信任和尊重的先决条件。在治疗师和来访者之间非性的和非渔利的双重关系与熟悉度不仅很正常,而且发展了互信。这增进了治疗联盟,而且已经被公认为是治疗效果的最佳指标(Lambert, 1991; Norcross & Goldfried, 1992)。另一个显著的例子在军队,不论是在舰艇上,还是在异国孤军深入或移动基地,双重关系不但是不可避免的,而且实际上也是强制的。

It is important to differentiate between boundary crossing and dual relationships. Making a home visit to a bedridden patient or accompanying an acrophobic client to an open space, like many other ‘out-of-office’ experiences are boundary crossings that do not necessarily constitute dual relationships (Zur, 2001). Similarly, exchanging gifts, self-disclosure, bartering of goods (not services) or extending the therapeutic hour when needed are also boundary crossings but not dual relationships.

区分跨越边界和双重关系是很重要的。对卧床的病人进行一次拜访,或陪同广场恐惧症的来访者去开阔的地方,就像许多“咨询室”以外的体验是跨越边界的,但是并不必要建立双重关系(Zur, 2001)。类似的,交换礼物、自我暴露、以物易物(不是服务),或者当需要的时候延长治疗时间,都是跨越边界,但不是双重关系。

While dual relationships may be sometimes unavoidable, psychologists must nevertheless pay attention to the harm that can arise from them, especially where there is a conflict of interest. Conflicts of interest are often present in situations where the client is also a student, employee, employer or business partner. Of course, sexual dual relationships are always unethical, counter-clinical and illegal in most states.

尽管双重关系可能在一些时候难以避免,但是心理学家必须关注它们可能带来的损害,特别是在有利益冲突的时候。利益冲突常常发生在当来访者也是学生、雇员、雇主或者商业伙伴的情况下。当然,涉性的双重关系始终是违背职业伦理、反临床和非法的。

The Ethics of Boundaries 边界的职业伦理

Despite the prevalent belief to the contrary, there are no ethics codes or guidelines, which specifically deal with boundary crossings. The APA’s and almost all other professional organizations’ codes of ethics do not regulate non-sexual touch, gifts, length of sessions or self-disclosure. Of course, they all have a mandate to avoid harm and exploitation and respect clients’ integrity and autonomy. The new APA Code of Ethics of 2002 has taken a positive step in regard to boundaries and dual relationships issues. It drops the sentence, “Psychologists ordinarily refrain from bartering”, that appeared in the 1992 code and adds the sentence, “Multiple relationships that would not reasonably be expected to cause impairment or risk exploitation or harm are not unethical” (APA, 2002, section 3.05), to the multiple relationships section. Just as important are clarifications that the new APA code provides in its Introduction and Applicability sections where it finally explains what some of the modifiers that are used in the Code (e.g., reasonably, appropriate, potentially) mean. More specifically it states: “As used in this Ethics Code, the term reasonable means the prevailing professional judgment of psychologists engaged in similar activities in similar circumstances, given the knowledge the psychologist had or should have had at the time” (APA, 2002, Introduction). The importance of this clarification is that hopefully it will stop the experts, courts and ethics committees from using the analytic or urban yard stick to judge non-analytically oriented psychologists who strategically employ boundary crossing type interventions or work in small or rural communities where boundary crossing and dual relationships are unavoidable.

然而与普遍的认识相反,在伦理规条和指导中,并没有专门处理跨越边界的条文。在美国心理协会(APA)和几乎所有其他专业组织的伦理条例中,并没有关于非性的接触、礼物、咨询时间和自我暴露的规定。当然,它们都要求避免伤害、渔利和尊重来访者的完整和自主。2002年新的美国心理协会伦理条例在对待边界和双重关系问题上有了积极的进步。其中写道,“心理学家通常要避免陷入交易”,这是1992年的条例中的句子,而之后又增添了,“如果并非不正当地侵害或带有危害性的渔利或伤害来访者的多重关系,不属违背伦理。”(APA, 2002, section 3.05)作为多重关系部分的补充。重要的是APA在其简介和适用性部分都对这些条款的说明,它解释了适用这些条款的一些可变情况(如:正当地、适当地、可能地)的含义。特别是它写道,“在伦理条款中,‘正当地’一词是指,鉴于当时心理学家掌握的或应该掌握的知识,在类似行为和类似情境下能够做出的最普遍的专业判断。” (APA, 2002, Introduction)。此说明的重要性在于,它有望制止仅使用分析取向或都市标准的专家、法院和伦理委员批判非分析取向的心理学家有策略地使用跨越边界进行干预,或者在小型或乡村社区工作而不可避免跨越边界和双重关系。

 

Boundary Crossings and the Standard of Care

跨越边界和关怀标准

The standard of care is defined as qualities and conditions that prevail or should prevail in a particular mental health service and that a reasonable and prudent practitioner follows. The standard is based on community and professional standards, as well as on state laws, case law, licensing boards’ regulations, a consensus of professionals, ethics codes of professional associations and a consensus in the community. The standard of care is not an objective yardstick to be found in any textbook. It is closely tied to a theoretical orientation. The examples of boundary crossings mentioned above clearly fall within the standard of care of behavioral, humanistic, family, and other non-analytic therapies. Regretfully, boards, courts and ethics committees too often confuse the standard of care with the analytic standards or with risk management guidelines (William, 1997). This confusion has caused tremendous injustice and immense suffering to therapists due to many boards’ and courts’ experts who routinely and mistakenly apply an analytic criterion and pronounce clinically appropriate boundary crossings and dual relationships, such as those mentioned above, to be below the standard of care.
关怀标准被定义为,在专门的心理健康服务当中具备的或理应具备的品质和条件,是作为一位明智和谨慎的从业者需要遵的。该标准的制定是基于社会和专业标准,即州宪法、案例法、执照管委会规定、专业上的一致意见、专业协会的伦理条例,以及社会范围的一致意见。关怀标准不是教科书里的客观标尺。它和理论取向密切相关。以上提到的跨越边界很明显属于行为主义、人本主义、家庭治疗和其他非分析取向治疗的关怀。遗憾的是,管委会、法院和伦理委员会总是以分析取向的标准或危险管理指导标准混淆关怀标准(William, 1997)。由于许多管委会和法院专家习惯性的错误应用分析取向的标准,并宣判临床适当的边界边界跨越和双重关系不属于关怀标准,正如上面提到的,致使这种混淆对许多治疗师造成了极大的不公和巨大的伤害。

The Slippery Slope Argument 滑坡争议

There is a prevalent and unfounded belief in the ‘slippery slope’ argument, which claims that boundary crossings inevitably lead to boundary violations. It refers to the idea that failure to adhere to rigid boundaries and an emotionally distant form of therapy will ultimately foster exploitive, harmful and sexual dual relationships (Guthiel & Gabbard, 1993, Pope, 1990). This paranoid approach is based on the ‘snowball’ dynamic that asserts that giving a simple gift is the precursor of an exploitive business relationship; a therapist’s self-disclosure inevitably becomes an unhealthy social relationship; and a non-sexual hug will quickly devolve into a harmful sexual relationship. To allege that self-disclosure, a hug, a home visit, or accepting a gift are likely to lead to sex and harm is, in Lazarus’ words “an extreme form of syllogistic reasoning” (1994, p. 257).
有一种关于“滑坡”的普遍而又缺乏依据的确信,那就是跨越边界将不可避免地侵犯边界。它认为,不能严格地坚持边界和疏忽情感的治疗形式都会最终导致渔利的、有害的和涉及性的双重关系(Guthiel & Gabbard, 1993, Pope, 1990)。这种偏执的视角是基于坚信“滚雪球”效应,认为送小礼物就是企图渔利的商业关系的前兆,治疗师自我暴露会不可避免发展为不健康的社交关系,以及非性的拥抱将很快转变为有害的性关系。宣称自我暴露、拥抱、家访,或接受礼物非常可能导致性关系和伤害,以拿撒路的话说,这就是“极端的三段论形式” (1994, p. 257)。

Sexualizing Boundaries 涉及性的边界

The rigid attitude toward boundary crossings stems in part from what Dineen (1996) called ‘sexualizing boundaries.” This is a skewed view that sees all boundary crossings as sexual in nature as illustrated in the slippery slope argument. Simon (1991), for example, decrees that: “The boundary violation precursors of therapist-patient sex can be as psychologically damaging as the actual sexual involvement itself” (p. 614). Similarly, Pope (1990) states ” . . . non-sexual dual relationships, while not unethical and harmful per se, foster sexual dual relationships” (p. 688). These unreasonable beliefs link any deviation from risk management or analytic guidelines to sexual exploitation.
对于跨越边界严格的态度根源于Dineen(1996)所谓的“涉及性的边界”。这是一种将所有形式的跨越边界都自然视为与性有关,并以滑坡理论阐释的有偏颇的观点。例如:Simon (1991)判定:“侵犯边界的咨询师-来访者性关系的前兆,可视为与真实发生性关系造成同样的心理伤害。”类似的,Pope (1990)说道:“虽然非性的双重关系本身并非不健康和有害,但会发展为涉及性的双重关系。” (p. 688)。这些不合理的信念都和对性渔利的风险管理或分析取向指导的歪曲紧密关联。

To Cross or Not to Cross 跨越还是不跨越

Intentional boundary crossings should be implemented with two things in mind: the welfare of the client and therapeutic effectiveness. Boundary crossing, like any other intervention, should be part of a well-constructed and clearly articulated treatment plan which takes into consideration the client’s problem, personality, situation, history, culture, etc. and the therapeutic setting and context. Boundary crossings with certain clients, such as those with Borderline Personality Disorders or those who are acutely paranoid are not usually recommended. Effective therapy with such clients often requires well-defined boundaries of time and space and a clearly structured therapeutic environment. Dual relationships, since they always entail boundary crossing, impose the same criteria on the therapist. Even when such relationships are unplanned and unavoidable, the welfare of the client and clinical effectiveness will always be the paramount concern.

有意图跨越边界必须好好考虑两件事:来访者的福祉和治疗效果。跨越边界,就像任何其他形式的干预一样,作为一个结构完好、关联清晰的治疗的一部分,应该考虑到来犯者的问题、人格特征、所处情境、历史、文化等,以及治疗的设置和背景。跨越边界对于某些来访者,如边缘性人格障碍患者或严重偏执妄想患者,通常不推荐使用。对于此类来访者而言,有效的治疗通常需要界定完整的时间和场所边界,以及结构明确的疗愈环境。双重关系,因其总是带有跨越边界的特征,对咨询师而言也需要执行同样的标准。哪怕这种治疗关系是计划外或不可避免的,也总要将来访者的福祉和临床效果至于最高的关切。

Boundaries are like fences; they are man-made and are designed to separate. Their function is to “fence in” and “fence out”, to include and exclude. Being man-made, they can be constructed or dismantled, heightened or lowered, and made more or less permeable. Psychotherapy boundaries are an inherent part of the therapeutic setting. They have been the focus of psychoanalysts for clinical-transferential reasons. Consumer protection agencies, boards and professional organizations have focused on the boundary issue in order to guard clients from exploitative therapists.

边界就像栅栏一样,它们是人为的,为了形成区隔。它们的功能是产生“围进来”和“挡出去”,为了形成包含和逐出。既然是人为的,它们就能被结构或拆除,凸显或减低,牢固或松动。心理治疗的边界是治疗设置固有的一部分。它们被心理分析视为临床转化因素而被关注。消费者保护组织、委员会和专业性组织关注边界问题,为了指导来访者规避企图渔利的治疗师。

The Concern with Rigid Boundaries 对严格边界的关注

As to whether psychotherapy boundaries serve the protective purpose for which they were erected, I have two major concerns:

关于心理治疗边界是否可以起到它们被寄予的保护作用,我有两个主要关注点:

Firstly, I am concerned that rigid implementation of such boundaries decreases therapeutic effectiveness. As outlined above, there are numerous proven clinical and evidence-based interventions that fall under the heading of boundary crossings. These theoretically sound interventions are often not utilized due to therapists’ fears and their rigid adherence to risk management principles. As a result of this apprehension, many clients receive sub-standard care. Lazarus (1994) underscored that: “One of the worst professional or ethical violations is that of permitting current risk-management principles to take precedence over human interventions” (p. 260). Additionally, outcome research has documented the importance of rapport and warmth for effective therapy, and that rigidity, distance, and coldness are incompatible with healing. Appropriate boundary crossings and dual relationships are likely to increase familiarity, understanding, and connection hence, increasing clinical effectiveness (Lambert, 1991; Lazarus & Zur, 2002, Norcross & Goldfried, 1992).

首先,我关注的是一丝不苟地执行这些边界降低了治疗的效果。正如以上论及的,大量的证明了临床的和实证下的干预被置于跨越界限之下。由于治疗师的担忧和他们风险管理条例的严格遵从,这些理论上可行的干预通常无法被运用。如此担忧的结果就是许多来访者接收到的是次等的关怀。Lazarus (1994)强调,“最严重的专业和伦理违规之一就是将执行现行的奉献管理条例至于人性化干预之上的首要位置。”(p. 260) 此外,效果研究明确记载着,亲密的关系和温暖的体验对于有效治疗的重要性,同时刻板、疏远和冷淡是疗愈的阻碍。适当的跨越边界和双重关系可能提升熟悉度、理解和联结,进而增进临床效果(Lambert, 1991; Lazarus & Zur, 2002, Norcross & Goldfried, 1992)。

Secondly, I am concerned that the isolation imposed by rigid boundaries increases the likelihood of exploitation of, and harm to, clients. Exploitation, as a rule, happens in isolation (i.e., child abuse, domestic violence, cults). As with any kind of abuse and exploitation, it is easier for predatory therapists to take advantage of their clients in the ‘darkness’ of isolation. In fact, many of our clients’ early life abuse and neglect was made possible due to the isolation of their families. The boundaries, which are supposed to protect clients from exploitation, also increase the therapists’ power and, therefore, increase the chance of a client being exploited (Zur, 2001).

其次,我关注的是严苛的界限造成的孤立会给来访者增添类似于被渔利的伤害。通常,孤立会带来被渔利(比如:儿童虐待、家庭暴力、极端宗教)。伴随着任何形式的虐待和渔利,有企图心的治疗师能够更简单地从他们那些陷入孤立“黑暗中”的来访者身上渔利。实际上,许多早年遭受虐待和忽视的来访者,由于被家庭成员孤立而有被渔利的可能。边界本应防止来访者被渔利,却增强了治疗师的影响力,反而增加了来访者被渔利的可能性(Zur, 2001)。

Summary 摘要

Boundary crossing in psychotherapy has usually referred to any deviation from traditional analytic and risk management practices, i.e., strict, ‘only in the office,’ emotionally distant forms of therapy. They refer primarily to issues of self-disclosure, gifts, touch, bartering and home visits. Dual relationships, a sub-type of boundary crossing, refer to situations where multiple connections exist between a therapist and a client. Boundary crossings are different from harmful boundary violations and, appropriately employed, can increase clinical effectiveness and therapeutic outcome. Dual relationships and other forms of boundary crossing are unavoidable in many small and interdependent communities, such as rural, military, minority, church, university campus, and among gays, the deaf, etc. Unlike harmful boundary violations and sexual or exploitative dual relationships, neither boundary crossing nor dual relationships are unethical or below the standard of care. Behavioral, cognitive-behavioral, family, group, and existential therapeutic orientations are the most practiced orientations today. These approaches tend to endorse many types of boundary crossings that are considered clear boundary violations by many psychoanalysts and risk management advocates. In fact, feminist, humanistic, and existential orientations view the tearing down of artificial and rigid boundaries as essential for therapeutic effectiveness and healing. Boundary crossings should be implemented according to the client’s unique situation, condition, problems, personality, culture, and history and the setting in which therapy takes place. The rationale of boundary crossing, like any therapeutic intervention, should be articulated (in writing) in the treatment plan and consultations with experts are advised in complex cases. The unduly restrictive analytic risk-management emphasis on clearly defined, rigid, and inflexible boundaries often interferes with sound clinical judgment, which ought to be flexible and personally tailored to clients’ needs rather than to therapists’ dogmas or fears.

跨越边界在心理治疗中通常是关于任何与传统的分析取向和奉献管理实践,如:严格地、“只在咨询室中”,避免情感的治疗……相违背的情况。它们主要关涉到自我暴露、礼物、接触、交换和家庭访问的议题。双重关系作为跨越边界的一种形式,是关于咨询师和来访者之间存在多种形式的关系。跨越边界和有害的侵犯边界不同,适当地被使用有助于临床的效果和治疗成果。双重关系及其他形式的跨越边界在许多小型和互相依存的社群中是不可避免的,如:乡村、军队、少数民族、教会、大学校园、同性恋者、聋哑人等等。不同于有害的侵犯界限和涉性的、渔利的双重关系,不论是跨越边界,还是双重关系都并非是违反伦理和降低关怀品质的。行为取向、认知行为取向、家庭治疗、团体治疗和存在主义治疗取向都是当今主要的治疗取向。这些治疗倾向于使用许多跨越边界的方式,而这些方式被心理分析师和奉献管理支持者视为明显的侵犯边界。实际上,女性主义、人本主义和存在主义取向将打破人为和僵化的边界视为治疗效果和疗愈的要素。跨越边界的应用必须根据来访者独特的情境、条件、问题、人格、文化、历史,以及治疗中发生的情况而定。合理的跨越界限,就像其他任何治疗干预,必须明确关联于治疗方案和在复杂情况下专家的建议。过度严苛的分析式风险管理所强调的明确定义的、严格的和没有弹性的界限常常干扰了有效的临床判断,考虑那些本应该弹性的、对来访者量体裁衣的需要,而非治疗师的教条和担忧。

Six Arguments Against Dual Relationships And Their Rebuttals对双重关系的六个批驳及其反驳

By Ofer Zur, Ph.D. and Arnold A. Lazarus, Ph.D., ABPP

Adapted from: Lazarus, A. A. and Zur, O. (Eds.) (2002).
Dual Relationships and Psychotherapy, New York: Springer. Chapter 1, pp. 3-24.
Printed with permission.

The Origin of the Opposition to Dual Relationships 反对双重关系的根源

Dual relationships between psychotherapists and clients have been frowned upon and denounced by the majority of therapists, ethicists, courts, licensing boards, ethics committees and educators. The main reasons given for this proscription are that clients must be protected from exploitative and harmful therapists and that dual relationships, according to some, are not only harmful to clients but also compromise the integrity of the therapeutic process.

心理咨询师和来访者之间的双重关系会遭受绝大部分治疗师、伦理学家、法院、执照委员会、伦理委员会和教育者的否定和谴责。导致这种情形的主要原因在于保护来访者不受渔利性和伤害性的治疗师的侵害,而且双重关系不但会令来访者受侵害,也会令治疗过程的完整性打折扣。

Issues of exploitation in general and sexual or business exploitation in particular are appropriately at the forefront of consumer advocates’ agendas. The valid concern is that service professionals, such as psychotherapists, physicians, pastors, or attorneys, can easily exploit their clients by using their positions of authority or power for personal gain. Clients seeking help with mental health are often in crisis and likely to be highly vulnerable and suggestible. Many regard trust in and vulnerability to the therapist as an inherent part of the healing process (Barnett, 1996; Canter, Bennett, Jones, & Nagy, 1994; Caudill & Pope, 1995; Corey, Corey, & Callahan 1984; Koocher & Keith-Spiegel, 1998; Zur, 2000b).

一般性的渔利问题,以及特别在性和商业方面的渔利顺理成章地成为消费者的主要诉求点。对此合理的关注点是专业服务者,如心理治疗师、医生、牧师,或者律师,能够凭借他们的权威地位和专业影响力轻而易举地渔利他们的顾客。寻求精神健康帮助的来访者通常陷入危机之中,可能很脆弱且容易被影响。许多人认为面对治疗师时的信赖和脆弱性是疗愈过程的少不了的部分。 (Barnett, 1996; Canter, Bennett, Jones, & Nagy, 1994; Caudill & Pope, 1995; Corey, Corey, & Callahan 1984; Koocher & Keith-Spiegel, 1998; Zur, 2000b)

In view of clients’ potential vulnerability and the numerous reports of harm inflicted on them by sexual dual relationships, the attempt to curtail exploitation and protect consumers from damage is reasonable and essential (Borys & Pope, 1989; Herlihy & Corey, 1992; Pope, 1988; Williams, 1997). Accordingly, most ethical guidelines for licensed mental health care providers include warnings against any exploitation and harm of patients by therapists, and a specific caution against sexual relationships with clients (e.g., American Association for Marriage and Family Therapists, 2001; American Psychological Association, 1992; National Association of Social Workers, 1999). (For a verbatim account of the Codes of Ethics on dual relationships, see chapter 6 in this volume.) Most states have developed civil and penal codes that, similar to professional ethical codes, aim to discourage therapists from entering into sexual relationships with clients. Practitioners who are reported for having violated these rules, especially those who inflict damage on their clients, are duly punished (Caudill & Pope, 1995).

从来访者潜在的弱势和大量遇过他们在涉性的双重关系中遭受伤害的报告来看,减少被渔利和保护消费者免受伤害的意图是合理和必须的。(Borys & Pope, 1989; Herlihy & Corey, 1992; Pope, 1988; Williams, 1997)据此,大部分对于执照精神健康关怀提供者的伦理指导中都包含对任何形式的渔利,以及由治疗师伤害病人的警告,另外特别警示与来访者发生性关系(例如:美国婚姻与家庭治疗协会,2001;美国心理协会,1992;国家社工协会,1999)。(伦理条款中关于双重关系的逐句解释参见本文第六章)许多州都在民法和刑法中增加了类似专业伦理条款的法规,旨在劝阻治疗师与来访者发展出性关系。被报告违反这些法规,尤其是对其来访者造成伤害的治疗师都受到了合理处罚(Caudill & Pope, 1995)。


The Arguments Against Dual Relationships and Rebuttals

对双重关系的六个批驳及其反驳

The traditional reasons for imposing negative sanctions on dual relationships stem from theoretical, ethical, and pragmatic reasoning. This chapter provides details of the principal arguments used by advocates for the prohibition of dual relationships:

传统上,对于双重关系持有负面惩罚的态度源于理论、伦理及语用推理。本章将介绍用以支持惩罚双重关系的具体条款的细节:

  • The concern with boundaries
  • The slippery slope
  • Power and exploitation
  • Familiarity and issues pertaining to transference
  • Risk management
  • Leaving the office and incidental encounters

·        对边界的考量·        滑坡陷阱·        影响力与渔利·        熟悉度和关涉移情的议题·        风险管控·        咨询室以外和突然相遇

 

Each of the above six segments offers a description of the argument against dual relationships and a rebuttal. Following the critique of each predication, the reader is referred to relevant book chapters for further reading on the topic.

以上六个部分都提供了对双重关系的批驳以及反驳。读者可以顺着每个主题的评论,对这些主题的相关书目章节有更深入的阅读。

  1. The Concern with Boundaries

对边界的关注

The Argument Against Dual Relationships: 反对双重关系的论据
At the heart of the opposition to dual relationships is an argument that places immense importance on clear boundaries in therapy. Accordingly, supporters of this line of reasoning view any deviation from these boundaries as a threat to the therapeutic process and regard such transgressions as potential if not inevitable precursors to harm, exploitation and sexual relationships between therapists and clients (Borys, 1994; Brown, 1994; Katherine, 1993; Koocher & Keith-Spiegel, 1998; Pope, 1989; Pope & Vasquez, 1998; Sonne, 1989; Strasburger, Jorgenson, & Sutherland, 1992). Gutheil & Gabbard (1993) describe the critical areas relevant to boundary issues: time, place, space, money, gifts, services, clothing, language, self-disclosure and physical contact.

反对双重关系的核心争议点在于治疗时设置清晰边界的极端重要性。据此,支持次观点的人会将任何偏离界限的状况视作对治疗进程的威胁,并且认为此类偏差是导致伤害、渔利,以及治疗师与来访者之间性关系的隐患(Borys, 1994; Brown, 1994; Katherine, 1993; Koocher & Keith-Spiegel, 1998; Pope, 1989; Pope & Vasquez, 1998; Sonne, 1989; Strasburger, Jorgenson, & Sutherland, 1992)。Gutheil & Gabbard (1993)描述了有关边界问题的重要领域:时间、地点、空间、钱、礼物、服务、衣着、语言、自我暴露和身体接触。

The effect of dual relationships on the therapeutic frame is a major concern for almost all psychoanalysts and psychoanalytically oriented therapists. Many conceive this effect to be intrinsically negative and hence believe that they invariably interfere with and undermine clinical work (Epstein & Simon, 1990; Langs, 1976; Simon, 1992). Accordingly, they view all dual relationships as inherently harmful and advocate their complete avoidance. Psychoanalytic theory emphasizes the importance of boundaries and the neutral stance of the analyst. According to traditional analysts, effective management of transference and other therapeutic work requires clear and consistent boundaries that enable the therapist to preserve the analytic frame of therapy (Langs, 1988). Transgressions that detract from therapists’ neutrality are said to contaminate the transference and hence are a detriment to analysis. Langs (1976), is an avid supporter of tight boundaries as a necessity for therapeutic progress. His work has been widely quoted by ethicists and those who view dual relationships as harmful. He testifies that “poor boundary management” impedes transference work and has other serious ramifications, such as the dilution of the therapist’s influence. He also maintains that boundary variations, such as dual relationships, that deviate from the traditional practice of analysts are serious mistakes with a significant negative impact on the therapeutic process. Simon (1995) operates from a similar perspective and has numerous publications that epitomize the case against boundary crossings or dual relationships. Adhering to traditional analytic principles, his main guidelines state:

双重关系对于治疗架构的影响几乎是所有心理分析师和心理分析取向治疗师都重点关注的问题。他们中的许多人相信这种影响必然是负面的,并且相信它们总是妨碍和破坏临床工作(Epstein & Simon, 1990; Langs, 1976; Simon, 1992)。因此,他们将所有的双重关系都视为本身具有伤害性,并主张要坚决避免。精神分析理论强调边界的重要性和分析师的中立立场。根据传统的精神分析,有效地管理移情和其他治疗工作需要明确而不变的边界,如此能使治疗师保持治疗的分析架构(Langs, 1988)。偏离界限会影响治疗师的中立从而被称为污染了移情,因而对分析是不利的。Langs (1976)是将严格边界视为治疗进程必要条件的极力支持者。他的工作被伦理学家和视双重关系有害者广泛引用。他论证了“低劣的边界管理”妨碍移情的工作,并且具有其他糟糕的影响,如:减弱了治疗师的影响力。他也主张,边界的改变,如双重关系,是脱离了传统的分析实践,是会对治疗进程造成严重负面影响重大错误。Simon (1995) 提出相似的观点,发表了许多文章,以案例摘要反对跨越边界或双重关系。根据传统分析的原则,他的主要观点声明:

Maintain therapist neutrality. Foster psychological separateness of the patient. Obtain informed consent for treatment and procedures. Interact only verbally with clients. Ensure no previous, current, or future personal relationships with patients. Minimize physical contact. Preserve relative anonymity of the therapist. (Simon, 1994, p. 514)

维持治疗师中立。创造与患者的心理距离。对治疗和进程的达成一致。仅仅与来访者口语互动。保证与患者在过去、现在和将来不建立个人关系。杜绝肢体接触。保证治疗师相对匿名。(Simon, 1994, p. 514)

The concern with boundaries is not limited to analytically oriented therapists. Most texts advocate rigid adherence to strict boundaries. Koocher and Keith-Spiegel (1998) claim in their widely use ethics text, “. . . we are convinced that lax professional boundaries are often a precursor of exploitation, confusion and loss of objectivity” (p. 171). Similarly, Borys & Pope (1989), Brown (1985), Kagle & Geibelhausen (1994), Katherine (1993), Kitchener (1988), Pope and Vasquez (1998), Simon (1995), Sonne (1994) and many others view dual relationships as a detrimental boundary violation. They all view professional distance between therapist and client as essential, indeed as a sine qua non for effective clinical work.

对边界的关注不仅限制分析取向的治疗师,许多课本非常坚决地主张严格的边界。Koocher and Keith-Spiegel (1998)声称在他们最广泛使用的伦理课本中,“……我们可以确信,松散的职业边界通常是渔利、混乱和缺乏客观的先兆。” (p. 171)类似的,Borys & Pope (1989), Brown (1985), Kagle & Geibelhausen (1994), Katherine (1993), Kitchener (1988), Pope and Vasquez (1998), Simon (1995), Sonne (1994)以及许多其他学者将双重边界视为有害的侵犯边界。他们都将治疗师和来访者之间保持专业距离视为必要的,是有效临床工作的必要条件。

Rebuttal:  反对方:
In discussing boundaries it is imperative that boundary crossings are distinguished from boundary violations. Boundary violations refer to actions on the part of the therapist that are harmful, exploitative and in direct conflict with the preservation of clients’ dignity and the integrity of the therapeutic process. Examples of boundary violations are sexual or financial exploitation of clients. A boundary crossing is a benign, and often beneficial departure from traditional therapeutic settings or constraints. Examples of boundary crossings are making home visits to a bedridden sick client; taking a plane ride with a client who has a fear of flying; attending a client’s wedding, barmitvah, or other function; or conducting therapy while walking on a trail with a person who requests it and seems to benefit from it.

在讨论边界时,非常有必要区分跨越边界和有害的侵犯边界。侵犯边界是关于部分治疗师的有害的、渔利的、直接与保护来访者尊严相违背和影响治疗进程完整性的行为。涉性的或经济方面的渔利来访者是侵犯边界的例证。跨越边界是良性的,通常由于脱离传统的治疗设置或约束而获得有益的效果。跨越边界的例证包括,对卧床生病的来访者进行家访;与一位恐惧飞行的来访者一同乘机;参加来访者的婚礼、成人礼或者其他仪式;或者一边散步一边对有此要求的来访者进行治疗,并且产生有益的效果。

Rigid boundaries often conflict with acting in a manner that is clinically helpful to clients. Rigidity, distance and coldness are incompatible with healing. Lambert (1992) and many others affirm, through outcome research, the importance of rapport and warmth for effective therapy. Boundary crossings are likely to increase familiarity, understanding and connection and hence increase the likelihood of success for the clinical work. Whitfield (1993) also describes how the most serviceable boundaries are those that are flexible, as opposed to those that are implemented in such a rigid manner as to cause harm through excessive and inappropriate distance.

严苛的边界通常在某种程度上与对来访者临床有帮助的行为发生冲突。严苛、距离和冷漠是与疗愈不相符的。Lambert (1992)和其他许多学者声称,通过成效研究发现,亲密和温暖对有效治疗而言很重要。跨越边界可能增进熟悉度、了解和联结,进而增加临床工作成功的可能性。Whitfield (1993)也描述道,最有效的边界是那些有弹性的,与那些造成过度的和不恰当的距离感的严苛的规矩相反的应用。

We contend that exclusive reliance on analytic theory, which results in the eschewal of virtually all boundary crossings, has been detrimental to the overall impact of psychotherapy. Behavioral, cognitive-behavioral, humanistic, group, family and existential therapeutic orientations are the most practiced orientations today. These treatment approaches tend to endorse what are considered clear boundary violations by most ethicists, psychoanalysts and risk management advocates (Williams, 1997). In fact, feminist, humanistic and existential orientations view the tearing down of artificial boundaries as essential for therapeutic effectiveness and healing (Greenspan, 1995).

我们反对对分析理论排他性地坚信,其结果是拒绝了一切形式的跨越边界,从而对心理治疗产生了有害的影响。行为主义、认知行为、人本主义、团体治疗、家庭治疗和存在主义治疗取向是当今广泛使用的治疗方法。这些治疗取向倾向于认同那些被大多数伦理学家、精神分析师和风险管理支持者所认为是明显的侵犯边界的行为。实际上,女权主义、人本主义和存在主义取向将拆毁人为的边界视为治疗有效性和疗愈的必要因素(Greenspan, 1995)。

As this book documents extensively (e.g. see chapter 5) the maintenance of rigid boundaries between therapists and patients in many close-knit communities is unrealistic and impossible. These communities include the military (Hines, Ader, Chang, & Rundell, 1998; Johnson, 1995; Staal & King, 2000), rural (Hargrove, 1986; Jennings, 1992; Schank & Skovholt, 1997), religious (Geyer, 1994; Montgomery & DeBell, 1997), feminist (Greenspan, 1995; Lerman & Porter, 1990; Stockman, 1990), gay (Brown, 1991; Smith, 1990), and ethnic minorities (Sears, 1990). Social norms in these communities include flexible and permeable boundaries and often favor mutuality between professionals, including therapists, and their customers.

正如本书大量记载(例如,见第5章)维持治疗师和患者之间严格的边界在许多结构紧密的社群是不现实和不可能的。这些社群包括军队(Hines, Ader, Chang, & Rundell, 1998; Johnson, 1995; Staal & King, 2000)、乡村(Hargrove, 1986; Jennings, 1992; Schank & Skovholt, 1997)、宗教社团(Geyer, 1994; Montgomery & DeBell, 1997)、女权社群(Greenspan, 1995; Lerman & Porter, 1990; Stockman, 1990)、同性恋社群(Brown, 1991; Smith, 1990)和少数人种(Sears, 1990)。这些社群中的社会标准包含了弹性的和相互渗透性的边界,以及专业者,包括治疗师和他们的咨客之间的互助互利。

Interventions and the treatment plans, including the nature of boundaries, should be constructed according to the client’s idiosyncratic situation, condition, problems, personality, culture and history. It is preferable to base treatment plans on empirical research when available. The unduly restrictive analytic risk-management emphasis on clear, rigid and inflexible boundaries interferes with sound clinical judgment, which ought to be flexible and personally tailored to clients’ needs rather than to therapists’ dogma or fear.

干预和治疗计划,包括边界的属性,必须依照来访者特有的境况、条件、问题、人格、文化和历史来规划。更好的做法是以现有的经验研究为基础制定治疗计划。不当的约束性分析风险管理强调清晰的、严格的和毫无弹性的边界干扰了有益的临床判断,应该依照来访者的需要弹性的和量身定制的处理,而非治疗师的教条和恐惧。

  1. The ‘Slippery Slope’ Argument 对“滑坡”的争议

The Argument Against Dual Relationships: 反对双重关系的论据

The term ‘slippery slope’ refers to the idea that failure to adhere to rigid standards, most commonly based on analytic and risk-management approaches, will undeniably foster relationships that are sexual or otherwise exploitative and harmful. This process is described by Gabbard (1994) as follows: ” . . . the crossing of one boundary without obvious catastrophic results (making) it easier to cross the next boundary” (p. 284). Pope (1990), whose endorsement of the slippery slope idea has significantly contributed to its popularity, expresses a similar opinion: ” . . . non-sexual dual relationships, while not unethical and harmful per se, foster sexual dual relationships” (p. 688). Strasburger et al. (1992) conclude, “Obviously, the best advice to therapists is not to start (down) the slippery slope, and to avoid boundary violations or dual relationships with patients.” (p. 547-548). Also in agreement is Simon (1991), who decrees that: “The boundary violation precursors of therapist-patient sex can be as psychologically damaging as the actual sexual involvement itself” (p. 614). This poignant statement summarizes the opinion that the chance for exploitation and harm is reduced or nullified only by refraining from engaging in any dual relationship or boundary crossing. Many writers describe a long list of therapists’ behaviors (e. g. self-disclosure, hugs, home visits, socializing, longer sessions, lunching, exchanging gifts, walks, playing in recreational leagues) that they believe to be precursors to sexual dual relationships (Borys & Pope, 1989; Craig, 1991; Keith-Spiegel & Koocher, 1985; Lakin, 1991; Pope, 1991; Pope & Vasquez, 1998; Rutter, 1989; St. Germaine, 1996).

根据大多数基于分析和奉献管理的取向,“滑坡”一词通常表示不能坚持严格的标准,而这将不可避免地滋生涉性或者渔利、伤害性的关系。Gabbard (1994)曾对该过程有如下描述:“……一种没有明显严重问题的跨越边界很容易造成之后的跨越边界” (p. 284)。Pope (1990)支持“滑坡”的想法并对此进行广泛地推广,他也表达了相似的观念:“……非涉性的双重关系即便本身并非违背伦理或者有害,但是仍然会滋长涉性的双重关系。” (p. 688)。Strasburger及其他学者(1992)总结到,“很明显,对于治疗师最好的建议就是不要踏上‘滑坡’,以避免与患者发生边界侵犯或双重关系。” (p. 547-548)。Simon (1991)也论述道,“治疗师和来访者之间性关系的边界侵犯的起初影响造成的心理损害可以与实际发生了性关系等而视之。”(p. 614)。这一尖锐的论述可以总结为,造成渔利和伤害的可能性只有通过完全避免参与任何双重关系或跨越边界才能得以减少或消除。许多作者对治疗师行为例举了很长的细目(例如:自我暴露、拥抱、家访、社交、延长面谈时间、共进午餐、交换礼物、散步、一起消遣娱乐。),并以此认为这些就是发生涉性的双重关系的前兆(Borys & Pope, 1989; Craig, 1991; Keith-Spiegel & Koocher, 1985; Lakin, 1991; Pope, 1991; Pope & Vasquez, 1998; Rutter, 1989; St. Germaine, 1996)。

Sonne (1994) discusses how a therapist and client who are sports teammates can easily move their relationship to encompass activities, such as carpooling or drinking. She concludes that “With the blurring of the expected functions and responsibilities of the therapist and client comes the breakdown of the boundaries of the professional relationship itself” (p. 338). Similarly, Woody (1998) asserts “In order to minimize the risk of sexual conduct, policies must prohibit a practitioner from having any contact with the client outside the treatment context and must preclude any type of dual relationships” (p. 188). The ‘slippery slope’ argument is even more pronounced in the work of Evans (1997), who contends that from an ethical, legal and clinical perspective, non-sexual and sexual dual relationships are absolutely equal and ought to be dealt with in the same manner.

Sonne (1994)讨论了作为队友参与运动的治疗师和来访者是如何轻易地通过他们的共同活动进展关系,例如:一起搭车或喝酒。她总结到,“随着这些可预料的活动和责任变得模糊,治疗师和来访者的专业边界开始瓦解。”(p. 338)。Similarly, Woody (1998)坚称:“为了减少涉性的风险,伦理守则必须禁止执业者与来访者在咨询室外的任何接触,并且必须阻止任何形式的双重关系。”(p. 188)。Evans (1997)在他的工作中更多地提到“滑坡”,他声称从伦理、法律和临床的角度,非涉性的和涉性的床冲关系是完全同等的,并且应该被视作同等行为来处理。

Rebuttal: 反对方:
The slippery slope argument is grounded primarily in the assumption that any boundary crossing, however trivial it may be, inevitably leads to boundary violations. To assert that self-disclosure, a hug, a home visit, or accepting a gift are actions likely to lead to sex is like saying that doctors’ visits cause death because most people see a doctor before they die (Zur, 2000a). Lazarus calls this thinking “an extreme form of syllogistic reasoning” (1994, p. 257). We learn in school that sequential statistical relationships (correlations) cannot simply be translated into causal connections. The fear that any boundary crossing will end up with sex is described by Dineen (1996) as part of the more inclusive problem of psychotherapists’ sexualizing of all boundaries.

“滑坡”观点是主要是基于将预设任何的跨越边界,不论有多么微笑,都视为是不可避免的侵犯边界。声称自我暴露、拥抱、家访或者接受礼物都是很可能导致发生性关系的行为,这就好像是说看医生导致了死亡,因为许多病人是在看过医生后死亡的(Zur, 2000a)。Lazarus称这种想法为“极端的三段论”(1994, p. 257)。我们在学校学过,相继的统计关系(相关性分析),不能简单地被确定为因果关联。那种对以性关系告终的任何跨越边界的担忧被Dineen (1996)描述为,属于精神治疗师性化所有边界的问题的一部分。

It is important to reiterate that whereas the analytic contingent underscores that crossing boundaries will nullify therapeutic effectiveness and hence cause harm, many other orientations have a different viewpoint. Behavioral, humanistic, group, family, existential, feminist or gestalt therapies at times stress the importance of tearing down interpersonal boundaries and strongly dispute that this will lead to exploitation and harm (Greenspan, 1995, Williams, 1997; Zur, 2000a, b, 2001a).

重要的是重申,即便分析取向不同程度地强调跨越边界将使治疗无效并会造成伤害,但是许多其他取向却拥有不同的观点。行为主义、人本主义、团体治疗、家庭治疗、存在主义、女权主义或格式塔治疗有时会强调打破人际边界的重要性,并且强烈地驳斥这样会造成渔利和伤害(Greenspan, 1995, Williams, 1997; Zur, 2000a, b, 2001a)。

Contrary to popular expectations, dual relationships and familiarity with clients tend to reduce the probability of exploitation and do not increase it. The power differential in a more egalitarian relationship becomes attenuated so that the client is more likely to forestall any improprieties that may arise. (This is also amplified in the next section.) As concluded in studies of cults, exploitation flourishes in isolation (Singer & Lalich, 1995). Those who vigorously propound the “only in the office” policy and the isolation it imposes on the therapeutic encounter are more likely to foster exploitation and sexual misconduct (Zur, 2000a, 2001b). When implemented with care and integrity, dual relationships with clients and the familiarity that follows are more likely to curb exploitation and harm than encourage them.

与主流的预期相反,双重关系和与来访者保持亲密倾向于减少渔利的可能性而非增加了。权力的差别在更加平等的关系中被弱化了,如此来访者更可能预防在治疗中发生的不当行为。对于宗教狂热的研究也相应地发现,当处于孤立无援的状态时,容易被人渔利(Zur, 2000a, 2001b)。在保持关注和完整性的应用时,与来访者的双重关系和亲密联结将更可能控制渔利和伤害而非助长它们。

  1. Power and Exploitation 权力和渔利

The Argument Against Dual Relationships:  反对双重关系的论据
The primary rationale for the argument to abstain from all dual relationships is that therapists may misuse their power to influence and exploit clients for their own benefit and to the clients’ detriment (Bersoff, 1999; Borys, 1992; Herlihy & Corey, 1992; Koocher & Keith-Spiegel, 1998; Pope, 1991; Pope & Vasquez, 1998). The argument is that the power differential enables and encourages therapists to exploit and harm their clients upon entering into dual relationships, that to venture beyond the threshold of the purely professional therapeutic hour inevitably fosters exploitation by the more authoritative clinician or counselor (Austin, 1998; Woody, 1998).

该论点的首要依据就是规避所有的双重关系,以防止治疗师为了自己的利益,滥用权力来影响和渔利来访者,并造成损伤(Bersoff, 1999; Borys, 1992; Herlihy & Corey, 1992; Koocher & Keith-Spiegel, 1998; Pope, 1991; Pope & Vasquez, 1998)。该论点认为权力的差异将导致和激励治疗师进入双重关系来渔利和伤害他们的来访者。更多权威性的临床工作者或咨询师将冒险尝试跨越纯粹的专业治疗的门槛,从而不可避免的滋生渔利的现象(Austin, 1998; Woody, 1998)。

Kitchener (1988) describes the power differential between therapists and clients as one of the three most important factors in determining the risk of harm to clients engaged in dual relationships with their therapists. Similarly, Gottlieb (1993) lists power differentials as the first dimension in the decision-making model for avoiding exploitative dual relationships in therapy. Pope (Pope & Vasquez, 1998), like his many followers, maintains that because of the power differential, the client is vulnerable and incapable of free choice and hence exploitation is likely and therapeutic benefits are significantly compromised.

Kitchener (1988)将治疗师和来访者之间的权力差异描述为决定了来访者陷入与治疗师双重关系从而带来受损害风险的三个最重要的因素之一。类似的,Gottlieb (1993)将权力差异列为避免咨询中渔利性双重关系的决定模式的第一维度。Pope (Pope & Vasquez, 1998)像他的其他同行一样,坚持认为权力差异导致来访者的弱势和无力自由选择,因此渔利变得更有可能,而治疗获益也明显降低。

Rebuttal:  反对方
The concern with therapists’ power is important and valid, as the power differential is true for many, if not most therapist-client relationships. This is because therapists are generally hired for their expertise, which in most cases gives them at least some measure of an expert-based power advantage over their clients.

对治疗师权力的关注是重要且合理的,因为权力差异在大多数情况下是真实的,尤其是在咨访关系中。这是因为治疗师普遍享有专业优势,在大多数的案例中可以给予他们至少凌驾于来访者之上的某些程度的专家优势。

Power differential has almost become interchangeable with exploitation and harm in the ethics literature. However, when dealing with issues of power, one must remember that many relationships with a significant differential of power, such as parent-child, teacher-student or coach-athlete, are not inherently exploitative (Zur, 2000a). Parental power facilitates children’s growth, teachers’ authority enables students to learn, and coaches’ influence helps athletes to achieve their full athletic potential. Few, if any, marriage, business, friendship, or therapy relationships are truly equal. Therapists’ power, like that of parents, teachers, coaches, politicians, policemen, attorneys or physicians, can be used or abused. The Hippocratic Oath of ‘first do no harm’ attends exactly to such dangers. The problem of abusive or exploitative power in therapy does not lie within dual relationships, but in the therapist’s propensity to abuse his or her power for selfish gain. Tomm (1993) adds “It is not the power itself that corrupts, it is the disposition to corruption (or lack of personal responsibility) that is amplified by the power” (p. 11).

权力差异基本上已经成为伦理条款中渔利和伤害的同义词了。但是,当处理权力议题时,需要记得其实许多关系中都存在着权力差异,例如:亲子关系、师生关系或教练和运动员的关系,但是这些却是不构成渔利的(Zur, 2000a)。父母的权力促进儿童成长,老师的权威激励学生学习,教练的影响力帮助运动员充分发挥他们的潜能。此外,婚姻、商业、有意或咨询关系也是鲜有完全平等的。治疗师的权力,就像父母、老师、教练、政治家、警察、律师、医生等都是可以使用或滥用的。希波可拉底的训诫,“首先应避免伤害”正是针对这种危险。在治疗中,滥用权力去渔利的问题并不只存在于双重关系中,而是在于治疗师对滥用权力谋取私利的倾向。Tomm (1993)补充到,“不是权力带来腐败,而是腐败的倾向(或者缺乏个人责任感)被权力放大了。” (p. 11)

In this argument, patients are portrayed as malleable, weak, and defenseless in the hands of their powerful, dominant, compelling therapists. The disparity in power is regarded as extreme, which is disempowering to the client. It is possible that many therapists who cling to the false ideals of the segregated therapy session and avoid dual relationships because it increases their professional status (Dineen, 1996; Zur, 2000b, 2001a), are thereby imbuing themselves with undue power that can all too easily be translated into exploitation. Many therapists work with clients who are much more powerful than them. Some clients are CEO’s of large corporations, judges, powerhouse attorneys, master mediators or successful entrepreneurs. Often, these clients do not regard their therapists as particularly powerful or persuasive, and their therapists experience them as the more powerful and successful half of the dyad. Such cases are a prime example of when therapists have to work hard at cultivating an aura of power so as to appear credible.

在次观点之下,病人在有力地、掌控的和强迫的治疗师手中被描绘成是可欺的、弱小的和毫无防备的。这样不对等的权力被认为是极端情况,从而令来访者失去权力。很可能许多治疗师之所以坚持封闭性的治疗过程和避免双重关系的错误观念,是因为他们妄图凸显他们的专业身份 (Dineen, 1996; Zur, 2000b, 2001a)。由此对滥用权力的情况也都很容易被理解为渔利举动。其实,许多治疗师也与比他们更有权力的来访者工作。一些来访者本身是大公司的CEO、法官、有影响的律师、知名媒体人或成功企业家。通常,这些来访者不认为他们的治疗师拥有特殊的权力或有很强的说服力,而治疗师也认为他们的来访者更有权力和成就。这类的案例可以作为治疗师需要努力地经营他们的影响力以显得可被相信的典型例证。

Many of America’s businesses are family-operated, wherein the members experience the complexities of dual relationships, power differentials and the balancing of blood and money. Similarly, a therapist working professionally with clients who they also know outside the office experience richness, various challenges and creative difficulties, but this certainly does not inevitably lead to exploitation (Zur, 2000a)

美国许多的公司是家族经营的,其中的成员经常性地体验到复杂的双重关系、权力差异,以及金钱与血统的制衡。相似的,一位治疗师与来访者进行专业性的工作,即便他们也了解在咨询室以外治疗师有丰富的体验、各种挑战和随时出现的困难,但这也绝不会必然导致渔利状况的发生(Zur, 2000a)。

As alluded to in the previous section, contrary to the general belief that dual relationships encourage exploitative behavior by therapists, it has been argued that the opportunity for exploitation is proportional to the amount of isolation in a given therapeutic relationship. The absence of relationships other than those developed in the traditional therapeutic session results in increased isolation. A therapist’s power is increased in isolation because clients tend to idealize and idolize them. Most instances of exploitation occur in isolation, including spousal and child abuse (Walker, 1994). Sexual exploitation is less likely to occur if the therapist is also working with the client’s spouse, friend and parent or has another community connection with the client, either directly or through the client’s family and friends. Therapists are less inclined to exploit those with whom they have a long-term or significant relationship outside of therapy (Tomm, 1993).

正如前文谈到,与认为双重关系是鼓励治疗师渔利性为的普遍信念相反,已经证明被渔利的可能性和来访者在治疗关系中体验到的受孤立程度是成正比的。传统治疗方法中的缺乏关系感导致了孤独感的增加。治疗师的权力在来访者孤立的情况下变得更加明显,因为来访者倾向理想化他们。许多被渔利的案例就是在孤立的状态下发生的,包括婚姻中的虐待和儿童虐待(Walker, 1994)。涉性的渔利事件很少发生在治疗师同时也给来访者的配偶、朋友、父母或其他与来访者有关系的人做咨询的时候,不论是直接的,还是通过来访者的家庭或朋友。治疗师也更少地倾向渔利那些与他们在治疗以外有长期或重要关系的来访者(Tomm, 1993)。

  1. Familiarity and Issues Pertaining to Transference 亲近和关于移情的问题

The Argument Against Dual Relationships:  反对双重关系的观点
The traditional urban analytic risk-management model of therapy interprets familiarity with clients outside the consulting room as inimical to therapy (Epstein & Simon, 1990; Faulkner and Faulkner, 1997; Langs, 1976; Pepper, 1991; Pope & Vasquez, 1998). According to this argument, familiarity contaminates the therapeutic exchange. Faulkner and Faulkner (1997) advocate that even in rural settings, therapists should avoid becoming familiar with current or prospective clients. They maintain that an ethical rural therapist must “avoid engaging in behaviors with a client that lead to the development of familiarity” (p. 232). Thus, they veto all dual relationships and boundary crossings.

传统的都市分析性风险管理治疗模式认定与来访者在治疗室以外的亲近行为是对治疗有害的(Epstein & Simon, 1990; Faulkner and Faulkner, 1997; Langs, 1976; Pepper, 1991; Pope & Vasquez, 1998)。据此观点,亲近会污染治疗性的互动。Faulkner and Faulkner (1997)宣称在乡村背景下,治疗师需要防止与现在和可能性的来访者避免亲近。他们认为守伦理的乡村治疗师必须“避免参与来访者有关的活动以避免走近” (p. 232)。因此,他们禁止一切的双重关系和跨越边界。

The fundamental proposition behind this prohibition assumes that therapists of all persuasions require a level of anonymity so that their clients can hold them in high esteem. They fear that familiarity may breed contempt if clients gain the opportunity to see some of their therapists’ shortcomings or frailties. Hence it is deemed essential to afford the client little (if any) opportunity to discover any shortcomings, weaknesses, or failings in their therapists.

在此禁令之下的基本命题是,假定了所有流派的治疗师都需要一定程度的匿名,以便他们的来访者可对对他们保持高度的尊敬。他们担心亲近可能会导致来访者有机会发现他们治疗师的一些短处或弱点后而产生轻视的态度。因此,有必要让来访者更少(如果可以,一个都不要)的机会去发现他们治疗师的短板、弱点和缺点。

Among psychoanalysts, the injunction to avoid familiarity or self-disclosure is even more stringent because it is held that veridical knowledge about the analyst, as a person will compromise the projections necessary for the analysis of transference. The original analytic concern stems from the initial belief and theory about the management of the transference and “securing the frame” of analysis (Lewis, 1959). Analytically oriented writers, such as Borys (1994), Epstein (Epstein & Simon, 1990), Lakin (1991), Langs (1976), Pepper (1991) and Simon (1989) are in agreement that dual relationships and familiarity nullify clinical effectiveness because the purity of the transference is negated and the very fabric of the analysis is undermined.

在精神分析师中,对避免亲近或自我暴露的告诫甚至更加的严格。因为它们被当成分析师所持的真理,因为一旦咨询中发生了移情,作为个人的分析师会必然会产生投射。精神分析对此的关注源于对移情管理的最初的相信和理论,以及对“维护分析架构”的顾忌(Lewis, 1959)。分析取向的作家,如Borys (1994), Epstein (Epstein & Simon, 1990), Lakin (1991), Langs (1976), Pepper (1991) and Simon (1989)都一致认为,双重关系和亲近会破坏临床效果,因为会无法对移情保持纯净,从而破坏了分析的精妙结构。

Rebuttal:  反对方
Contrary to the recommendations of therapist anonymity that stem from the urban-based model, there are some communities in which this is not feasible or desirable. The unique bond between therapists and clients in small communities is described by Hargrove (1986), Lazarus (1998, 2001), Schank & Skovholt (1997) and Zur (2000a, 2001a, b), as abundant with commitment, care and trust that, in turn, promote significant increases in therapeutic effectiveness.

对源自都市治疗模式推荐治疗师匿名持反对态度的意见来自于一些不具备相应条件的社群。Hargrove (1986), Lazarus (1998, 2001), Schank & Skovholt (1997) and Zur (2000a, 2001a, b)描述到在小型社群,治疗师与来访者建立富有担当的、关怀的和信任的特殊关系反而可以极大地促进治疗的效果。

Communities in which this manner of relating to clients is closer to the standard than the exception include rural (Hargrove, 1986; Jennings, 1992; Schank & Skovholt, 1997), religious (Geyer, 1994; Montgomery & DeBell, 1997), feminist (Greenspan, 1995; Lerman & Porter, 1990; Stockman, 1990), gay (Brown, 1991; Smith, 1990), and ethnic minorities (Sears, 1990). Social norms in these communities include the unavoidable overlap of relationships, professional and otherwise.

在包括乡村(Hargrove, 1986; Jennings, 1992; Schank & Skovholt, 1997),宗教团体(Geyer, 1994; Montgomery & DeBell, 1997),女权团体(Greenspan, 1995; Lerman & Porter, 1990; Stockman, 1990), 同性恋团体(Brown, 1991; Smith, 1990), 和少数民族(Sears, 1990)这样的社群中,这种建立关系的方式对来访者而言更容易理解为亲近而非渔利。在这些社群中社交规范中已经包含了不可避免的关系、专业和其他身份的交叠。

In small and close-knit communities, such as those cited above, clinical effectiveness is increased by familiarity and dual relationships. Familiarity is closely associated with beneficial therapeutic relationships. They are linked positively mainly because therapeutic relationships have been one of the best predictors of clinical effectiveness (e. g., Frank, 1973; Lambert, 1992; Bergin & Garfield, 1994; Miller, Duncan, & Hubble, 1997). Clients frequently emphasize the benefits that accrue when therapists interact with them in the community, outside the office. This fuller picture of clients’ history, family and interactions within the community gives context to clients’ accounts of their lives. For many cases, to commence therapy without utilizing the supplementary knowledge available would slow or halt therapeutic progress and fail to serve the client, particularly in cases where clients have a distorted view of themselves and their surroundings (Zur, 2000a).

在小型和关系紧密的社群,正如以上所述,临床效果因为亲近和双重关系而得到增强。亲近与有益的治疗关系密切相关。它们积极地关联在一起,主要是因为治疗关系已经成为对临床效果最好的预测指标(e. g., Frank, 1973; Lambert, 1992; Bergin & Garfield, 1994; Miller, Duncan, & Hubble, 1997)。来访者常常强调当他们在治疗室以外的社群中与治疗师互动而带来的益处。这样对来访者的历史、家庭和社群中互动模式的全面图景给予来访者思考人生的丰富参考。在许多案例中,不能使用现有的背景信息就着手治疗常导致对来访者治疗进程的缓慢和受阻,甚至失败,尤其是在来访者对其自己和环境有扭曲的认知时(Zur, 2000a)。

Compatibility of lifestyle, values and spiritual orientation between therapist and client are known to positively affect the outcome of therapy (Lerman & Porter, 1990). Clients who select their therapists based on prior knowledge and familiarity are more likely to feel connected to their way of life. The trust that is vital for therapeutic progress is already in place for many clients who choose their therapists because of prior knowledge (i.e., familiarity). In small communities, therapists are chosen in much the same way that a minister, physician, or babysitter is selected. The findings of a study by Gruenbaum (1986) oppose the previously described stance of Faulkner & Faulkner (1997). The items most frequently cited as harmful were rigidity, coldness and distance on the part of the therapist.

治疗师和来访者相互调和生活风格、价值观和精神取向已经被认为会对治疗结果有积极的作用(Lerman & Porter, 1990)。基于先前的认识和亲近度来选择治疗师的来访者可以更能感受到与其生活方式的联结。对许多基于先前认知(或亲近度)而选择治疗师的来访者,那些对治疗过程而言至关重要的信任早已存在了。在小型社群,治疗师就像牧师、医生和保姆一样被选择。Gruenbaum (1986)的研究发现反驳了Faulkner & Faulkner (1997)先前描述的状态。对治疗师而言,严苛、能摸和疏离才是经常被引述为最有害的状态。

The overriding emphasis that psychoanalysis places on therapist neutrality and distance to preserve the purity of transference work should not be seen as a model or frame of reference for the entire edifice of psychotherapy. Most therapists do not practice psychoanalysis or devote extensive time to the analysis of the “transference” (Lazarus, 1994; Zur, 2001b), yet the bulk of the therapeutic community is often expected to follow its standards (Williams, 1997). It is preposterous to hold therapists to the ideology of an orientation that they do not practice or believe in (Lazarus, 1994; Zur, 2000a).

多度地强调精神分析是基于治疗师的中立和保持一定的距离以保证对移情的纯净状态已经不再被视为一切心理治疗必须接受的模式和框架。许多治疗师不从事精神分析,或者花更多的时间对“移情”进行分析(Lazarus, 1994; Zur, 2001b),但是大多数的治疗者还是经常被期望依的标准(Williams, 1997)。如此以一种他们不从事或不相信的治疗取向来强制治疗师的意识形态实在是可笑的(Lazarus, 1994; Zur, 2000a)。

  1. Risk Management 风险管理

The Argument Against Dual Relationships:  反对双重关系的论点
Risk management is the course by which therapists refrain from practicing certain behaviors or interventions because they may be misinterpreted and questioned by boards, ethics committees, and courts (Gutheil & Gabbard, 1993; Lazarus, 1994, 1998; Williams, 1997, 2000). Given the litigious climate in which we live, it has been argued that the fewer risks a therapist takes, the better. It is safer to adhere to a strict code of ethics, to cross no boundaries, and to avoid any transaction that might be viewed askance by licensing boards, ethics committees, or in a court of law. According to this argument, entering into a dual relationship with a client is a high risk enterprise. It opens the door for inquiries into and suspicions about the therapist’s conscious or unconscious motives. This vulnerability renders therapists susceptible to a host of accusations pertaining to proper treatment and the avoidance of exploitation. With many clients, it is all too easy for them to read nefarious motives into the therapist’s behavior in any extra-therapeutic setting or situation.

风险管理是限制治疗师进行某些行为或干预的课题,因为他们可能因此引起管理局、伦理委员会或者法院误解或质询(Gutheil & Gabbard, 1993; Lazarus, 1994, 1998; Williams, 1997, 2000)。我们的生活中充满了诉讼,有观点认为治疗师承担越小的风险越好。比较安全的做法是,坚持严格的伦理守则、不跨越任何边界、避免任何可能被执照管理局、伦理委员会和法院质疑的互动行为。奉献管理为询问和质疑治疗师有意识或无意识的动机打开了大门。这一弱点使得治疗师在面对关于适当的治疗和避免渔利的指控上显得被动。对许多来访者而言,太容易使其从治疗师超越治疗设置或情况的行为中屈解治疗师有不轨的意图。

Risk management advocates advise against any controversial interventions, regardless of their ethical or legal standing. Accordingly, bartering, hiking, or socializing with clients are high on the risk management list of unadvisable actions. Gutheil and Gabbard (1993) claim that “From the viewpoint of current risk-management principles, a handshake is about the limit of social physical contact at this time” (p. 195). As the culture has become more litigious in the late nineteen-nineties, a whole industry of post-graduate seminars and texts have developed around the concept of risk management. In his book, Danger for Therapists: How to Reduce Your Risk, Austin (1998) equates dual relationships with exploitation and accordingly advises “Avoid any dual relationship with a client or former client” (p.55). Woody has published several books on risk management, one of which is Fifty Ways to Avoid Malpractice, where he advocates the practice of “healthy defensiveness” (1998, p. 123).

风险管理提倡者们反对任何有争议的干预,和不顾伦理与法律的立场。相应地,与来访者的交换、远足或交往都被列为高风险的不宜行为。Gutheil and Gabbard (1993)认为“从现行的风险管理原则来看,握手已经是目前身体接触的极限了。” (p. 195)。因为在十九世纪90年代末诉讼风气盛行,整个专业的研究生研讨会和课本都是围绕风险管理的概念来发展的。Austin (1998)在他的书《治疗师的危险:如何降低奉献》中将双重关系和渔利行为等通话,并据此建议“避免与来访者或之前的来访者发展任何双重关系” (p.55)。Woody出版了好几本关于风险管理的书,其中一本是《五十种避免治疗不当的方法》,他提倡在实践中发展“健康的防御”(1998, p. 123)。

Rebuttal: 反对方:

While it sounds reasonable at face value, risk management results in practices that are based on fear of attorneys and boards rather than clinical considerations. Around the issue of dual relationships much fear has been planted in therapists of board investigations (Ebert, 1997; Peterson, 2001; Saunders, 2001; Williams, 2001). Clarkson (1994) states, “An unrealistic attempt to avoid all dual relationships in psychotherapy may be defensively phobic or repressive” (p. 32). Therapists are hired to provide services that include the best possible care for clients, not the implementation of defensive practices. As described by Lazarus (1994), “One of the worst professional or ethical violations is that of permitting current risk-management principles to take precedence over human interventions” (p. 260).

从表面价值看上述论点听起来很合理,但是风险管理的操作是对律师和管理局的恐惧带来的结果,而非出于临床的考虑。围绕双重关系的议题,管理局调查给治疗师们植入了过多的恐惧(Ebert, 1997; Peterson, 2001; Saunders, 2001; Williams, 2001)。Clarkson (1994)认为,“不切实际地躲避一切双重关系的企图可能是一种过度防御的病态恐惧或压抑。” (p. 32)。治疗师被雇佣提供的服务应该包括给予来访者能力所及的最好的关怀,而非自我防御式的服务。Lazarus (1994)描述道,“违反专业和伦理最糟糕的行为之一莫过于将现行的风险管理原则凌驾于对来访者的干预之上。” (p. 260)

Relevant factors for the implementation of clinical interventions include the client’s personality, situation, gender, history, culture, and degree of functionality. Treatment plans based on these considerations and available empirical research will far better serve the client than clinical decisions based on the advice of attorneys and the fear or terror of licensing boards. Accurate clinical records, well-documented consultations and clearly articulated and clinically sound treatment plans are probably the best means of assuaging risk management fears and insuring that clients derive significant therapeutic benefits.

在临床干预的操作中,相关的因素包括来访者的人格、处境、性别、历史、文化和功能性程度。根据这些因素的考虑和当下的经验研究所做出的治疗计划要远远好过基于律师的忠告和对执照管理局的恐惧而做出的临床决定。准确的临床记录、详实的咨询文献、清晰的衔接和良好的临床治疗计划可能是最好的降低风险管理的恐惧和确保来访者获得最大治疗益处的方法。

 

  1. Incidental Encounters and Other Interactions Outside the Office

偶然的相遇和其他在治疗室外的的互动

The Argument Against Dual Relationships:  反对双重关系的论点
Interacting with clients outside the office is often discouraged for legal (Bennett, Bricklin, & VandeCreek, 1994; Kitchener, 1988), ethical (Gottlieb, 1993; Pope & Vasquez, 1991) and clinical (Borys & Pope, 1989; Epstein & Simon, 1990; Simon, 1991) reasons. The main reason for this is that leaving the office is considered a boundary violation or boundary transgression (Gutheil & Gabbard 1993; Kitchener, 1988; Koocher & Keith-Spiegel, 1998). “Seventy three percent of therapists were distressed about the fact that outside the safety of the office walls, they “have little control over whether or not something is revealed about themselves or their lifestyle during these moments. . .” (Sharkin & Birky, 1992 p. 327). It is widely assumed that experience with clients outside the office leads to disruption of therapy, exploitation, harm, or sexual relationships. Common advice from consumer advocates includes a warning against leaving the office in order to discourage damaging behavior by exploitative therapists (Barnett, 1996).

与来访者在治疗室外的互动常常因法律上(Bennett, Bricklin, & VandeCreek, 1994; Kitchener, 1988)、伦理上(Gottlieb, 1993; Pope & Vasquez, 1991)和临床上(Borys & Pope, 1989; Epstein & Simon, 1990; Simon, 1991)的原因被劝阻。主要原因是治疗室之外的接触被认为是侵犯边界或破坏边界的(Gutheil & Gabbard 1993; Kitchener, 1988; Koocher & Keith-Spiegel, 1998)。“73%的治疗师都遭受过在安全的治疗室以外相遇的苦恼”,他们很难管控在这种时候,他们自己或生活方式的某些部分被泄露了(Sharkin & Birky, 1992 p. 327)。普遍的假设是,在治疗室外遇见来访者的情况将导致治疗的破坏、渔利行为、伤害或发生性关系。来自消费者的普遍建议是提倡反对离开治疗室,以便阻断造成损害的行为和有渔利倾向的治疗师(Barnett, 1996)。

The concern over incidental encounters with clients outside the office has received substantial attention by ethicists (Sharkin & Birky, 1992; Grayson, 1986; Spiegel, 1990). Analytically and psychodynamically oriented therapists are also extremely concerned about out of office encounters (Glover, 1940; Gody, 1996; Langs, 1988; May, 1988; Tarnower, 1966). The general message is for therapists to avoid all out of office encounters. Even rural therapists have been advised to avoid such encounters (Faulkner & Faulkner, 1997).

伦理学家对治疗师在治疗室以外与来访者的偶然相遇给予了广泛的重视(Sharkin & Birky, 1992; Grayson, 1986; Spiegel, 1990)。分析和心理动力取向的治疗师也格外地关注治疗室外的相遇(Glover, 1940; Gody, 1996; Langs, 1988; May, 1988; Tarnower, 1966)。普遍的看法是治疗师应该避免一切治疗室外的相遇。即便是乡村的治疗师也被建议躲避类似的相遇(Faulkner & Faulkner, 1997)。

As previously discussed, the sensitivity of psychoanalysts to the issue of chance or incidental encounters is based on the concern that it contaminates the transference and hence interferes with clinical work. They also speculate that clients and therapists alike wish to avoid such encounters so that clients’ view of their therapists as omnipotent is not disrupted. Avoidance of such out of office encounters seems to also be justified also in order to defend the therapists from them experiencing anxiety (Strean, 1981). Strean’s concern is that extra-therapeutic encounters are likely to provoke the type of transference and countertransference fantasies that evoke oedipal desires and sadistic urges, and significantly interfere with the analysis.

正如先前的讨论,精神分析师对偶然相遇的敏感性是基于对污染移情进而影响临床工作的顾虑。他们也推测来访者也有与治疗师类似的愿望,通过避免相遇使得来访者对治疗师全能的感觉不被打破。避免在治疗室以外的相遇也被视为理所当然地帮助治疗师有效地防御了焦虑体验(Strean, 1981)。Strean关注的是治疗室外的相遇可能造成移情和反移情的幻象,包括恋母情结、嗜虐的冲动,以及对分析严重的干扰。

From an ethical point of view, the primary argument against incidental encounters is to avoid the invasion of a client’s privacy or any breech in confidentiality. Sixty percent of respondents in Sharkin and Birky’s survey reported “being concerned about the violation of confidentiality during incidental encounters” (1992, p. 327). Privacy and confidentiality have been known to contribute to trust in psychotherapy. In many instances, the private and insulated office setting provides an extremely important milieu in helping clients reveal meaningful clinical material that is essential for effective therapy. Privacy in therapy allows clients to be honest and have a sense of safety and security in the therapeutic exchange, and accordingly is associated with positive clinical outcomes (Lambert, 1991). Thus, the concern about dual relationships and other interactions outside the clinical setting most often raised by therapists and ethicists pertains to issues of confidentiality. According to this apprehension, being seen with a client in public, or even acknowledging a client by saying a simple “hello” may constitute a violation of the confidential therapeutic ethic.

从伦理的视角,这种反对偶然相遇的观点主要是为了避免对来访者的隐私或隐藏秘密的干犯。在Sharkin and Birky’s的调查中60%的受访者报告说,“很关注在偶然相遇时的干犯隐私” (1992, p. 327)。隐私和秘密被认为在心理治疗中构建了信任。在许多案例中,保密和与世隔绝的治疗室设定提供了极其重要的环境,帮助来访者慢慢揭露具有临床意义的信息,这些是治疗成效的必要因素。保密可以是来访者在咨询中保持诚实和安全感,并且在治疗交流时感到放心,由此这关系到临床治疗的积极成果(Lambert, 1991)。所以对双重关系和治疗室外相遇的关注常常引起治疗师和伦理学家联想到隐私的议题上。基于这样的理解,在公共场合遇见来访者,或者只是对来访者简单地道一声“你好”,就可能构成治疗伦理上对隐私的侵犯。

Rebuttal:  反对方

There appears to be a widespread belief that “privacy” and “confidentiality” are synonymous. While they are connected, they are not identical. This was underscored by Lazarus in the January/February 2001 issue of The National Psychologist after being assailed by a critic who claimed that the very act of socializing with a client is a breech of confidentiality. Lazarus responded as follows: “When I am sitting at a lunch counter and socializing with a patient at his request, how does this violate his privacy or confidentiality? I get the feeling that [my critic] believes that I may be overcome by the urge to turn to the person alongside me and blurt out, ‘This is Tim Smith, a patient I am treating for guilt over his extramarital affairs,'” (p. 10).

很明显,大家普遍相信“隐私”和“秘密”是同义词。它们虽然有关联,但绝不是一回事。Lazarus在其2001年的《国家心理学家》中刊文遭到一位评论家后如此强调。该评论家认为与来访者的不当接触就是在打探来访者的机密。Lazarus回应道,“当我应一位来访者的邀请坐在他的对面与其共进午餐,这又怎么说明是在侵犯他的隐私或秘密?我能感受到,那位评论家相信我很可能会抑制不住冲动,对着身边的其他人不加思考的喊出‘这是Tim Smith,一位由我在帮助处理因为出轨而内疚的来访者’。” (p. 10)

In discussing situations in which therapists interact with their clients outside the office one must differentiate between three types of out-of-office experiences. As Zur (2001a) illustrates, the first type is where the out of office experience is part of a thought-out, carefully constructed, research-based treatment plan, such as eating lunch with an anorexic patient, taking an airplane ride with a client who has a fear of flying, or going to the local market with an agoraphobic client. The second is where the out-of-office experience is geared towards enhancing therapeutic effectiveness, such as attending a play to see a client who had overcame a fear of public speaking playing a role, or visiting a client’s new art exhibit. The third type is comprised of encounters that constitute dual relationships, or what have been referred to as overlapping relationships (Schoener, 1997). These are relationships that naturally occur as part of normal living in rural, military, deaf or other small communities. Examples of this include attending church, socializing, or playing in a recreational league with a client. All three types are boundary crossings, but not boundary violations.

当讨论治疗师在治疗室之外与来访者发生互动的情况时,必须区分三种情况的咨询室以外的体验。正如Zur (2001a)的解释,第一种情况是咨询室以外的体验是经过慎重思考、细心设计和基于研究的治疗计划的一部分。例如:和焦虑症患者共进午餐,和飞行恐惧症患者共乘飞机,或者与广场恐惧症患者一起去当地的超市。第二种情况是可以提升治疗效果的治疗室外的接触。例如:参加一位需要克服公开表演恐惧的来访者的演出,或者参加一位来访者的最新艺术展览。第三种情况是,带来双重关系以及和交叠关系相关的接触(Schoener, 1997)。这样的关系会很自然地发生在乡村、军队、聋哑人或者小型社群的生活之中。这样的例子包括:去教堂、社交、或者和来访者一起参加娱乐消遣的团体。所有这三种都是跨越边界,但没有侵犯边界的行为。

Interacting with clients outside the office may not only be ethical but may actually be clinically desirable in certain situations and often consistent with Behavioral, Systems, Humanistic, Cognitive-Behavioral, Multimodal, and other non-analytic orientations (Williams, 1997). Lazarus (1994) states, “I have partied and socialized with some clients, played tennis with others, taken long walks with some . . .” (p.257). Jourard, a humanistically oriented therapist, states “I do not hesitate to play a game of handball with a seeker or visit him in his home-if this unfolds in the dialogue” (cited in Williams, 1997, p. 242). Therapists’ being known by their clients for the their strengths and weakness can “humanize” the process and thus enhance the therapeutic relationship and the healing process.

与来访者在治疗师之外的互动可能不仅是符合伦理的,而且在某些情况下是符合临床期望的。这方面常常得到行为主义、系统治疗、人本主义、认知行为、整合模式和其他非分析取向的一致认同(Williams, 1997)。Lazarus (1994)表示:“我和一些来访者有所交往,一起打网球,一起散步……” (p.257)。Jourard是一位人本主义取向的治疗师,他说到“加入在交流中涉及到,我会毫不犹豫地和寻求者一起玩手球或者去他家拜访。” (cited in Williams, 1997, p. 242)。来访者了解治疗师的“长处”和“短板”能够更人性化治疗过程,从而促进治疗关系和治愈进程。

Zur (2001a), in his article “Out of Office Experience” describes numerous instances where he interacts daily with clients outside the consulting room in the small community in which he resides. These interactions occur because these clients are also parents at the school which his children attend, clerks at the stores he frequents, or players at the recreational league in which he participates. Zur (2001b) also claims that out of office encounter do not, necessarily, interfere with so-called “transference work.” In his words, “it is all grist to the transference mill” (p. 203).

Zur (2001a)在他的文章中写道,大量“治疗室外的经历”的例子。在他居住的小型社群每天都会和来访者在治疗室外互动。之所以发生互动是因为这些来访者也是他孩子所在学校的父母,是他经常光顾的商店的店员,或者是休闲消遣团体的参加者。Zur (2001b)也主张,治疗室之外的相遇不一定会干扰所谓的“移情工作”。以他的话来说,“它是移情这个磨坊的谷物”。

It is possible to manage incidental or chance encounters outside the office in professionally and ethically. The first step is to discuss the possibility of meeting outside the office with clients early on in treatment. Then the prudent therapist ought to ask the clients for their preferred way of handling it. While some clients prefer the therapist not to acknowledge them in public others are quite open about the therapeutic relationship (Zur, 2001a). Clients with borderline, paranoid or narcissistic personality disorders may have a strong reaction that must be anticipated and taken into account. It is also important to discuss any incidental encounter after it happens, at least for the first time in order to make sure that clients’ concerns are aired and clients are comfortable with the exchange. In complex situations or when chance encounters occur frequently, consultation with an expert colleague may be called for.

对在治疗室之外的相遇进行专业上和伦理上的管理是可能的。第一步是在治疗时尽早和来访者讨论在治疗室以外遇见的可能性。谨慎的治疗师应该询问来访者他们比较青睐的处理方式。一些来访者会倾向治疗师在公开场合不要和他们打招呼,另一些却相对治疗关系比较开放(Zur, 2001a)。患有边缘型、偏执型、自恋型人格障碍的来访者可能会有的强烈反应需要能被预期和考虑到。当偶然的相遇发生后,需要被讨论也是很重要的。至少在第一次时要确保来访者的顾虑可以表达,并且可以舒服的交流。在复杂的情况下,或者经常遇见,需要寻求专家团的咨询。

For a more comprehensive response to the concern with dual relationships and encountering clients outside the office, see Section1 and 2 of this volume.

想要获知有关双重关系和在治疗室之外与来访者相遇的更综合性地反馈,请参见本章的第一、二节内容。