Ethics and the Ideal Helping Relationship: Response to Hill and Mamalakis

• DOI: http://doi.org/10.1111/j.1741-3729.2001.00209.x
• Published date: 01 July 2001
• Author: Mark H. Butler,Brandt C. Gardner
• Date: 01 July 2001

2001, Vol. 50, No. 3 209

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Ethics and the Ideal Helping Relationship:

Response to Hill and Mamalakis

Mark H. Butler*and Brandt C. Gardner

Ethics: A Guide to the Ideal Helping

Relationship

The essence of therapy is the helping relationship. Thus,

the goal of any clinical model, including a code of pro-

fessional ethics, is to describe as definitively as possible

the ideal helping relationship. Departures from ideal conditions

must be warranted by significant and highly probable benefit,

not outweighed by the possibility of countervailing harm. Some

departures from ideal clinical conditions are of such gravity that

they are expressly prohibited, as in the case of dual therapist-

sexual partner relationships. The prohibition of other departures

is not absolute, but decidedly cautionary. We agree with Hilland

Mamalakis that apparently unavoidable departures from ethical

guidelines—as in the case of a dual relationship (DR) within

religious, rural, or minority communities—must be cautiously

evaluated to avoid too casual dismissal of a prudent and con-

sensus-based ethical standard.

Code of Ethics: A ‘‘Constitutional,’’ Not Statutory

Standard

Avoiding premature dismissal of an ethical standard requires

perspective on the code of ethics itself. A code of ethics artic-

ulates professional consensus on ecological, relationship, and

practice conditions associated with the professional helping re-

lationship. Metaphorically speaking, codes of ethics provide a

constitutional framework for the practice of the profession. A

constitutional perspective dictates a far more conservative than

activist approach to interpretation and application and provides

for amendment, exception, or both, only on the basis of clear

warrant, agreed-upon protocol, and broad consensus.

We must remember also that the focus of a code of ethics

is resolved on those exact circumstances where a professional’s

independent judgment is most likely to be clouded and impaired.

Ethical codes provide guidance and rules for professional con-

duct in high-risk circumstances. They do not meticulously reg-

ulate the multitude of complex daily clinical decisions where

acute risk of impaired or self-interested judgment does not exist.

With this in mind, we should understand that any proposal in-

troducing or increasing independent and subjective judgment in

high-risk ethical situations initiates momentum exactly opposite

that intended by the code of ethics. Such a proposal must over-

come a strong presumption in favor of the ethical standard.

Indulging independent, subjective judgment in high-risk cir-

cumstances is like removing all signal lights and stop signs from

a four-lane intersection and relying on each individual driver

both to know the rules of the road and to follow them without

either inadvertent or intentional error. Thesignal light—although

inconvenient at times and seemingly unnecessary at others—

nonetheless moves traffic safely. We judge that a conservative

application of American Association for Marriage and Family

(Family Relations, 2001, 50, 209–214)

Therapy’s (AAMFT’s) code of ethics and an appropriately skep-

tical assessment of the case for exception/amendment does not

open the door for the decision-making latitude relative to DRs

recommended by Hill and Mamalakis. The inherent challenge

and associated risks to therapist, client(s), and therapy in assum-

ing multiple roles help explain the consensus prohibition of DRs

in most mental health professions (AAMFT, 1991; American

Psychological Association [APA], 1986, 1992; National Asso-

ciation of Social Workers [NASW], 1993). Avoidance of DRs

has long been considered a presumptive condition for the helping

relationship because the potential for muddling personal and pro-

fessional interests and roles, thoughts, feelings, and behavior is

all too clear in DRs (Craig, 1991; Humphrey, 1998; Kitchener,

1988; Ochroch, 1987).

Hill and Mamalakis express interest in opening ‘‘construc-

tive dialogue on the issues by organizing the various dimensions

of dual relationships into a cohesive framework, rather than [to

defend] a particular position’’ (p. 208). They affirm the impor-

tance of incorporating Kitchener’s (1984) catalogue of ethical

principles in a ‘‘thorough evaluation of dual relationshipissues.’’

However, ultimately, they recommend their more limited proto-

col as a ‘‘working model for practicing clinicians.’’ Further, the

clinical case study at the end of their article carries the therapist

through their model to the point where a DR was invoked. It

was not suggested or represented that prior to invoking their DR

additional essential steps needed to be undertaken. We presume,

therefore, that their maleficence-based decision-making protocol

is operationally complete and deemed sufficient to a DR deci-

sion. Other steps not undertaken are implicitly nonessential rec-

ommendations.

Sequential Analyses of Ethical Rules, Ethical

Principles, and Ethical Theory

Hill and Mamalakis anchor their ethical decision-making

model in Kitchener’s (1984) work. She proposed sequential ref-

erence to ethical rules, ethical principles, and ethical theory. The

first level of their model analyzes the DR decision relative to

ethical rules; the second level considers not ethics theory, as

Kitchener envisioned, but the therapist’s clinical theory as it re-

lates to DRs; the third level analyzes the DR in terms of ethical

principles and their focus is on maleficence-based considerations

alone. Thus, we note key differences and omissions from Kitch-

ener’s model: The analysis of ethics theory is dropped and re-

placed by an analysis (at the second level) of what the therapist’s

theory recommends about DRs. Ethical principles analysis is

shifted to the third level in their model and includes consider-

ations of maleficence only. Our critique parallels the proposed

model. We highlight risks of harm associated with DRs, broadly

categorized as risks to the client, the therapist, or therapy itself.

Our litany is representative, not exhaustive.

First Level: Ethical Rules Analysis and Decision

Making

Ethical rules include rules and practice standards articulated

in professional codes of ethics together with statutory regulations