Word of mouth is the source for many of my referrals. The best compliment you can give me and the work I do is a referral. However, sometimes I cannot work with someone, especially if the person is in the same family or a close friend of a current or former patient. The question I often get asked is, “why?” My kids have the same pediatrician. My best friend and I go to the same dermatologist. I totally get it. However, most professionals have a code of conduct and ethical guidelines to follow.
When I say I cannot accept that referral, I am following that code. I am not saying other professionals are being unethical- I don’t know their codes, regulations, or the circumstances of why they are seeing who they are.
Ethical codes are not laws. Their use is to help guide the practice of that profession/professional and have a minimum set of standards. However, ethical codes are not something I just consider. I consider and follow them each day.
For psychologists, our ethical codes are provided by the American Psychological Association and the state(s) in which we are licensed to practice. In many ethical code guidelines, there is a section regarding dual or multiple relationships. According to APA’s ethical code on multiple relationships (3.05):
(a) A multiple relationship occurs when a psychologist is in a professional role with a person and (1) at the same time is in another role with the same person, (2) at the same time is in a relationship with a person closely associated with or related to the person with whom the psychologist has the professional relationship, or (3) promises to enter into another relationship in the future with the person or a person closely associated with or related to the person.
A psychologist refrains from entering into a multiple relationship if the multiple relationship could reasonably be expected to impair the psychologist's objectivity, competence, or effectiveness in performing his or her functions as a psychologist, or otherwise risks exploitation or harm to the person with whom the professional relationship exists.
Multiple relationships that would not reasonably be expected to cause impairment or risk exploitation or harm are not unethical.
(b) If a psychologist finds that, due to unforeseen factors, a potentially harmful multiple relationship has arisen, the psychologist takes reasonable steps to resolve it with due regard for the best interests of the affected person and maximal compliance with the Ethics Code.
(c) When psychologists are required by law, institutional policy, or extraordinary circumstances to serve in more than one role in judicial or administrative proceedings, at the outset they clarify role expectations and the extent of confidentiality and thereafter as changes occur. (See also Standards 3.04, Avoiding Harm, and 3.07, Third-Party Requests for Services.)
The APA further identifies conflicts of interest (3.06):
Psychologists refrain from taking on a professional role when personal, scientific, professional, legal, financial, or other interests or relationships could reasonably be expected to (1) impair their objectivity, competence, or effectiveness in performing their functions as psychologists or (2) expose the person or organization with whom the professional relationship exists to harm or exploitation.
If I know that a multiple relationship may occur, I know in advance not to accept the referral. I can tell the person referring this new person to me that I am thankful for the referral, but I cannot accept it and provide additional referral sources to them. If the new referral already reaches out, I can say there is a conflict of interest. However, sometimes multiple relationships are unavoidable. I once went several years seeing friends within a close friend group without knowing. Neither of them ever mentioned the other person’s name and ironically enough, their stories about the same events were not similar at all.
One important piece of information I always like to convey is that your confidentiality is still maintained! I don’t say, “Hey! Yes, Mary told me that you were her best friend and would be calling,” or “I can’t see you because I already see your brother-in-law, Mark.” I can say that there is a conflict of interest and provide appropriate referral sources and go on my way. Sometimes, I am not even the appropriate referral for this new person, multiple relationships aside!
To be honest, even if dual and multiple relationships weren’t part of my ethical code, I would avoid them. I don’t want Mary from above thinking that I have additional information about her weekend getaway in Vegas that her best friend told me about. I don’t want Mark worrying about his disclosure about his brother being unhappy in his marriage and now I am going to tell his sister-in-law. Thay sibling that I see? I don’t want the older sibling to think I am siding with the younger sibling. My job is to remain unbiased, which can be difficult to do when I have additional information about a patient that was not provided by the patient. This is why therapists aren’t supposed to look up their patients on the internet. However, that might be saved for another blog post in the future.
When providing services in a small town, dual and multiple relationships might be unavoidable and part of the job. If you are the only provider within a 50-mile radius, that is a different story. One could argue some form of therapy, even if there is a possible dual relationship, is better than no form of therapy. However, I don’t work in a small town. Thankfully, there are ample providers whose contact information I can give as referral sources.
So, thank you for the referral and for thinking of me. Thank you for valuing our time together and trusting me with your information and the possibility of a loved one’s information. However, dual and multiple relationships are why I can’t provide therapy services to the mechanic who works on my car, a family friend, the child of someone I went to high school with, and my patient’s sister.