By Mickey Skidmore, ACSW

Edited versions of this “perspective” have been published in the North Carolina Society for Clinical Hypnosis (NCSCH) Newsletter [Winter 1995, Vol. 26, No 1], and The Milton H. Erickson Foundation Newsletter [Fall 1995, Vol. 15, No. 3]. What follows is an expanded edition of these previously printed articles…

In recent years there appears to be a growing focus on the nature of dual-relationships — especially in the domain of mental health services. During this time, a growing number of articles and commentaries have appeared in various professional newsletters warning of the perils of dual relationships. The National Association of Social Workers (NASW) recently revised code of ethics, like many other professional organizations have taken a decisive position consistent with these warnings. While I generally believe that both parties are better served when dual relationships can be avoided, I am concerned with the emerging trend of these articles and positions which suggest dual relationships are tantamount to unethical conduct. Therefore, in response to these articles, I offer a differing viewpoint to this issue. Consider the following:

In the early 1960’s Milton Erickson, MD began treating a schizophrenic patient named John. Upon discovering that his family wanted little involvement with John, Erickson arranged for his family to establish a trust fund which enable him to be independent from them. As his symptoms were too severe for him to drive, Erickson assisted John in securing an apartment within walking distance of Erickson’s office so that he could continue treatment. Believing that pet ownership was a vehicle to advance many therapeutic learnings, Erickson suggested that he rescue a puppy from the local pound. When it became clear that John’s apartment complex did not allow pets, Erickson arranged for John’s dog, Barney to reside at the Erickson household, under the conditions that the Barney was John’s responsibility, and that he come to Erickson’s house twice a day to feed and care for Barney.

To ensure that Barney would not develop an attachment to Erickson, he would swat at him with a fly swatter and blow a loud horn whenever Barney approached him. Over time, Erickson stopped having “therapy sessions” with John, instead using his daily visits as informal treatment opportunities. Even though John’s “therapy sessions” had discontinued, Erickson wrote a series of letters allegedly from Barney describing events in the Erickson household and anecdotes about life in general.

Both Erickson and Barney died in 1980 after lengthy illnesses. Soon thereafter, Mrs. Erickson took John to the pound again, where they picked out a new puppy of the same breed that Barney had been. John continues to visit the Erickson house each night to watch TV with Mrs. Erickson and he looks after the house and the pets when Mrs. Erickson travels.

In another case, a 68 year old retired colleague sought help from Erickson because of a sexual dysfunction. Their shared interest in medicine, similarity in age, and his great respect for Erickson’s reputation were among the reasons he selected Erickson to help him with his personal problem. Needless to say, Erickson utilized all of these factors to facilitate therapeutic change during their consultation. Moreover, he concluded the therapeutic work by indirectly shifting the emphasis from the role of doctor-patient relationship to one of friendship as he invited him into his home to view Erickson’s personal collection of wood carvings.

Throughout his distinguished career Erickson used his personal self as much as possible to influence clients. He would persuade, cajole, joke, demand, threaten, make phone calls, or do whatever was necessary to achieve the therapeutic aim. Erickson thought it important for a therapist to be personally involved with a client. He did not think the therapist should be a blank screen or a neutral observer. It was his personal involvement that often induced the change he was seeking.

One can only wonder if NASW and other organizations are taking the position that such examples of Erickson’s treatment philosophies were unethical? Would any representative from the disciplines of medicine, dentistry, nursing, psychology, social work, or counseling wish to go on record declaring these approaches as violations of their professional code of ethics? If not, then how can the recent emphasis on an arbitrary and rigid interpretation on the nature of dual relationships be explained?

Without question, in each of these examples a dual relationship exists. At the risk of confusing the issue further consider the fact that not all professional disciplines have always agreed on the nature of dual relationships. Most disciplines have acknowledged there will be limitations on the other types of relationships we may have, but the only point of agreement in all professions is that under no circumstances shall we ever engage in sexual relationships. Beyond that, at least until this trend began emerging, the issue of dual relationships has been at best — unclear. Perhaps NASW’s recent revision of its code of ethics is an attempt to offer better clarity for such ambiguous circumstances. While my own belief is that the reader must determine for themselves whether or not these treatment approaches constitute unethical conduct, I am alarmed that a growing number of organizations and boards from professional disciplines seem intent on interpreting guidelines in increasingly rigid and absolute terms.

And then there is the contrast between urban and rural practice. In my years of practicing in rural settings, I am frequently approached by people for hypnotherapy in which I have relationships in other contexts. Some are social, some are professional, and some have even been friends. The one thing they all have in common however, is they sought me out because of these other relationships. My approach has been that this is a decision that is best determined openly together with the client before therapy begins. The fact that several potential clients have determined that this was not a good arrangement has only reinforced my belief that clients have a better sense of what they want and need than we sometimes give them credit for. Imagine how absurd it would be to hold Mayberry’s Sheriff Andy Taylor to this rigid standard of dual relationships. While this is a fictional example, these circumstances for many rural practitioners are quite real, and makes it virtually impossible to avoid dual relationships.

Regardless of one’s particular position on this issue, there is little doubt that the nature of dual relationships is ambiguous at best. And relying on Erickson’s work as a model for professional ethics may only serve to confuse the issue further. After all, Erickson was one of a kind. He lived and practiced in another time and era, considerably different from today’s social and political climate.

As practitioners search for answers to these very complex issues, trusting in the therapeutic process may be the best option. As stated earlier, clients often have a better sense of what they want (and need) than therapists give them credit for. If the nature of dual relationships were discussed openly with the prospective client before therapy begins, I maintain many would conclude that this is not a good arrangement. When (potential) clients are included in this process not only are other relationships honored, but the stage is set for the therapeutic relationship to take precedence.

I too challenge the ambiguous nature regarding the question of dual relationships. More importantly however, while it may politically incorrect by today’s standards, or even contrary to NASW’s revised code of ethics, I take issue with any group unwilling to allow reasonable flexibility for one to interpret their own professional ethics on the basis of their theoretical orientation. I submit that professional codes of ethics were intended to guide us through the ever increasing complexities of working with human behavior. They were never intended to be a set of predetermined or imposed responses for every conceivable entanglement throughout the range of human experience. In fact, the very process of discovering these solutions is what many would refer to as the art of therapy. The secret to ethics is not rigidity, but balance.

1) O’Hanlon & Hexum. An Uncommon Casebook:
The Complete Clinical Work of Milton H. Erickson, MD.
Norton, 1990.
2) Erickson & Rossi. Hypnotherapy: An Exploratory Casebook. Irvington, 1979.
3) Haley, Jay. Jay Haley on Milton Erickson. Brunner/Mazel, 1993.
4) Skidmore, Mickey. “Letter to the Editor” NCSCH Newsletter,
Winter 1995, Vol. 26, No 1.
5) Skidmore, Mickey. “Dual Relationships: An Ericksonian Perspective”,
The Milton H. Erickson Foundation Newsletter, Fall 1995, Vol. 15, No. 3.