Frustrations in the Gym

  Frustrations in the Gym

The purpose of this assignment is to examine ethical issues for professionals working in exercise psychology, rehabilitation, and in other professions related to physical activity as a means for maintaining individual health and well-being. Ethical principles and guidelines, previously discussed, will be applied to these various environments for critical analysis and discussion. Despite the differences in environments, the ethical situations exercise psychology professionals face, often, fall within the same parameters as those of other helping professions.

For this assignment, first, read the following article from the Argosy University online library resources:

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Pauline, J., Pauline, G., Johnson, S., & Gamble, K. (2006). Ethical issues in exercise psychology. Ethics & Behavior, 16(1), 61–76.

Now, answer the following questions: Are issues of competency and training more complex for exercise psychology professionals than for applied sport psychology professionals? What ethical dilemmas are unique to the relationship between a client and an exercise psychology professional? Are there distinct differences in this relationship compared to a relationship between a client and a sport psychology professional?

Answer each question in 200–300 words. Your response should be in Microsoft Word document format. Name the file SP6300_M4_A1_LastName_FirstInitial.doc and submit it to the appropriate Discussion Area by the due date assigned.

Through the end of the module, comment on the posts of two of your peers. In your reviews, check whether the answers given to the second question support their answers to the first one. Discuss any inconsistencies or similarities in your classmates’ answers. All written assignments and responses should follow APA rules for attributing sources.

Assignment 1 Grading CriteriaMaximum PointsIdentified and described the differences in competency and training issues for exercise psychology professionals as compared to applied sport psychology professionals.8Analyzed and described the ethical dilemmas unique to exercise psychology professionals.8Compared the relationship between a client and an exercise psychology professional with that of the relationship between a client and a sport psychology professional.8Reviewed the posts of at least two peers and pointed out any inconsistencies and similarities.8Wrote in a clear, concise, and organized manner; demonstrated ethical scholarship in accurate representation and attribution of sources, displayed accurate spelling, grammar, and punctuation.4Total:36 

Ethical Issues in Exercise Psychology

Jeffrey S. Pauline, Gina A. Pauline, Scott R. Johnson,

and Kelly M. Gamble

School of Physical Education, Sport, and Exercise Science

Ball State University

Exercise psychology encompasses the disciplines of psychiatry, clinical and counseling

psychology, health promotion, and themovement sciences. This emerging field involves

diverse mental health issues, theories, and general information related to physical

activity and exercise. Numerous research investigations across the past 20 years

have shown both physical and psychological benefits from physical activity and exercise.

Exercise psychology offersmany opportunities for growth while positively influencing

the mental and physical health of individuals, communities, and society.However,

the exercise psychology literature has not addressed ethical issues or dilemmas

faced by mental health professionals providing exercise psychology services. This initial

discussion of ethical issues in exercise psychology is an important step in continuing

tomove the fieldforward. Specifically, this article will address theemergenceof exercise

psychology and current health behaviors and offer an overview of ethics and

ethical issues, education/training and professional competency, cultural and ethnic diversity,

multiple-role relationships and conflicts of interest, dependency issues, confidentiality

and recording keeping, and advertisement and self-promotion.

Keywords: ethics, exercise psychology, sport psychology

The emerging field of exercise psychology consists of diverse mental health issues,

theories, and general information related to physical activity and exercise. Exercise

psychology encompasses approaches from the fields of psychiatry, clinical

and counseling psychology, health promotion, and the movement sciences (Buckworth

& Dishman, 2002a). The establishment of optimal mental health with

nonclinical, clinical, and population based settings is often the primary focal point

of exercise psychology practitioners. Physical activity is viewed as a treatment

ETHICS & BEHAVIOR, 16(1), 61–76

Copyright © 2006, Lawrence Erlbaum Associates, Inc.

Correspondence should be addressed to Jeffrey S. Pauline, School of Physical Education, Sport,

and Exercise Science, Ball State University, Muncie, IN 47306-0270. E-mail: [email protected]

modality for mood alteration, management of psychopathology and stress, and enhanced

self-worth. Exercise psychology practitioners also focus on factors related

to exercise program characteristics that influence exercise adoption and adherence

for individuals, groups, and communities (Berger, Pargman, & Weinberg, 2002).

The field of exercise psychology and consulting has many opportunities for

growth. Potential employment opportunities can be found in the areas of colleges

and universities, management of corporate fitness programs, counseling in physical

rehabilitation clinics, and individual consultation with a diverse clientele. The

effectiveness of exercise practitioners or consultants is often dependent on their

ability to develop a collaborative relationship with their clients and other

professionals.

When consulting with exercisers and/or incorporating exercise into a traditional

treatment plan, mental health practitioners may feel as if they are treading in uncharted

waters due to some of the unique consultation circumstances and settings

in the exercise environment. Until now, the literature has not directly addressed

ethical issues or dilemmas related to providing exercise adherence counseling services

or including exercise as a component of a traditional treatment plan. The

heightened media attention and rising mental health care costs have increased the

allocation of funding by federal agencies (i.e., National Institutes of Health) to enhance

physical activity patterns. Therefore, the need and opportunity for practitioners

to assist with exercise adoption and maintenance is only going to increase

over the next decade as we continue to search for alternative treatment options to

fight physical health problems (e.g., obesity) and mental health issues. With this

increased opportunity and demand, the need to provide proper guidance to practitioners

implementing exercise as a component of therapy must be examined.

Thus, the remainder of this article will focus on selected ethical issues and potential

ethical dilemmas facing mental health professionals who provide exercise

adherence consultations and/or include exercise as a component of counseling or

therapy. Specifically, this article will address the emergence of exercise psychology

and current health behaviors, an overviewof ethics and professional resources,

education/training and professional competency, cultural and ethnic diversity,

multiple-role relationships and conflicts of interest, dependency issues, confidentiality

and recording keeping, and advertisement and self-promotion. In conclusion,

future issues and opportunities related to the field of exercise psychology will

be presented.

EMERGENCE OF EXERCISE PSYCHOLOGY

AND CURRENT HEALTH BEHAVIORS

The emergence of exercise psychology is due to the decline in lifestyle and behavioral

choices. In America today, choosing desirable health behaviors such as regu-

62 PAULINE, PAULINE, JOHNSON, GAMBLE

lar physical activity and a healthy diet are not typically practiced to the degree they

should be. According to the U.S. Department of Health and Human Services

(USDHHS; 2000) Healthy People 2010 report, only 22% of adults in the United

States engage in moderate physical activity for 30 min five or more times a week,

whereas nearly 25% of the population is completely sedentary. Furthermore, when

people do attempt to modify a lifestyle behavior by, for example, increasing physical

activity, many are unable to maintain the adapted behavior. The physical activity

adherence research reports dropout rates up to 50% within the first 6 months of

the start of an exercise regimen (Dishman, 1988).

The cause for weight gain in Americans has been clearly identified. Simply put,

we are eating more and exercising less than ever before. Americans are eating

approximately 15% more calories than in previous years (Putnam, Kantor, &

Allshouse, 2000). Combine the increased caloric consumption with the previously

mentioned physical activity patterns and you have a formula for weight gain for a

large segment of our society.

Based on the aforementioned statistics and data regarding obesity, diet, and

physical inactivity, the outlook may appear bleak. However, there is hope due to

the development of effective behavioral and cognitively based intervention strategies

to assist individuals with the adoption and maintenance of more active lifestyles

(Buckworth & Dishman, 2002b). Currently, there is an abundance of literature

indicating that the adoption of a more active lifestyle will enhance mental

well-being (reduce depression and anxiety and enhance self-esteem) while decreasing

the likelihood of developing obesity and other risk factors (i.e., high blood

pressure and cholesterol) for chronic diseases such as cardiovascular disease and

cancer (USDHHS, 1996). Furthermore, the literature clearly indicates that an individual

does not have to be an athlete or exercise vigorously to engage in beneficial

exercise (Public Health Service, 2001). The American College of Sports Medicine

(ACSM; 2000) training guidelines for physical fitness and exercise performance

recommends for aerobic activities 3 to 5 days per week of moderate-intensity exercise

for 20 to 60 min (in at least 10-min sessions) and weight training that includes

one or more sets of 8 to 12 repetitions of 8 to 10 exercises at least 2 days a week.

Interestingly, many practitioners are utilizing exercise as a therapeutic modality

to improve traditional psychological services. Hays (1999) indicated that exercise

can be utilized to cope with clinical issues (e.g., depression, anxiety, and weight

management), issues of daily living, and improving self-care. Exercise psychology

research supports the use of exercise as a treatment modality for both clinical and

nonclinical clients (Buckworth & Dishman, 2002a). Based on the well documented

physical and psychological benefits of exercise, psychologists and counselors

need to be aware of the benefits that can be gained by adding exercise to a

traditional treatment plan. However, due to issues pertaining to ethical dilemmas

and/or competency, some practitioners may believe it is unethical to include exercise

as part of a treatment plan despite the literature supporting its use.

ETHICAL ISSUES IN EXERCISE PSYCHOLOGY 63

For most people physical activity poses minimal risks. However, it is important

that all clients, regardless of ethnic or cultural background, obtain physician approval

to begin an exercise regimen. In addition to the physician approval, conservative

therapists desiring to add exercise to treatment should also have their clients

complete the Physical Activity Readiness Questionnaire (PAR-Q; British

Columbia Ministry of Health, 1978). The PAR-Q is designed to identify adults

who may not be suited to participate in physical activity due to various physical

ailments.

ETHICS OVERVIEW AND PROFESSIONAL RESOURCES

The purpose of an ethics code is to provide guidance and governance for a profession’s

members in working settings. An ethics code provides integrity to a profession,

professional values and standards, and fosters public trust through the establishment

of high standards (Fisher, 2003). It should be noted that no code of

conduct or set of ethical guidelines can account for all possible situations or ethical

dilemmas. Ethical codes are developed from the current values and beliefs in society

as related to a profession. These values and beliefs, as well as common professional

practices, can and do change with the passing of time due to numerous factors,

making it necessary for ethical codes and standards to also change.

The American Psychological Association (APA; 2002) ethics code is a well developed

and ever-evolving document that provides ethical principles and codes of

conduct to govern and guide its membership. In contrast, the Association for the

Advancement of Applied Sport Psychology’s (AAASP; 1994) ethical code is derived

from the APA’s (1992) ethics code and has not been updated since its inception.

It is designed to address issues specific to sport and exercise psychology

work. There are differences between APA and AAASP ethical principles and

codes. Those differences will be discussed later as they relate to exercise consultations.

Whelan, Meyer, and Elkin (2002) provided a detailed discussion of the

AAASP principles and ethical standards and serve as a good reference for a sport

and exercise psychology practitioner preparing to be or currently involved with

sport psychology consulting or exercise adherence counseling. Fisher (2003) and

Bernstein and Hartsell (2004) also serve as good sources for both general practitioners

and exercise consultants.

The ACSM is recognized by health professionals throughout the world as the

leading organization and authority on health and fitness. The ACSM’s primary focus

is to advance health through science, medicine, and education. Furthermore,

the ACSM (2003) has established a code of ethics with the principal purpose of

“generation and dissemination of knowledge concerning all aspects of persons en-

64 PAULINE, PAULINE, JOHNSON, GAMBLE

gaged in exercise with the full respect for the dignity of people” (¶ 1). To achieve

its principal purpose, the ACSM (2003) established the following four sections:

1. Members should strive continuously to improve knowledge and skill and make available to

their colleagues and the public the benefits of their professional expertise.

2. Members should maintain high professional and scientific standards and should not voluntarily

collaborate professionally with anyone who violates this principle.

3. The College, and its members, should safeguard the public and itself against members who

are deficient in ethical conduct.

4. The ideals of the College imply that the responsibilities of each Fellow or member extend not

only to the individual, but also to society with the purpose of improving both the health and

well-being of the individual and the community. (¶ 1)

Therefore, the ACSM is an excellent resource for mental health professionals to

consult for guidance concerning issues related to exercise, health, and fitness.

EDUCATION/TRAINING AND PROFESSIONAL

COMPETENCY MAINTENANCE

The field of exercise psychology is a merger between psychology and exercise or

movement science. Individuals specializing in either of these areas will have different

competencies and thus the ability to practice with different populations.

Most professionals recognize the value of having individuals in the field from both

backgrounds due to the uniqueness of their training. The APA (2002) ethics code

specifies that in emerging areas such as exercise psychology practitioners should

“take reasonable steps to ensure the competence of their work and to protect clients/

patients, students, supervisees, research participants, organizational clients,

and others from harm” (p. 5).

The ideal training for exercise therapists or consultants is an ongoing debate.

The two primary sources of training for exercise practitioners are (a) psychology

(i.e., counseling or clinical psychology) and (b) the movement sciences (i.e.,

kinesiology or exercise physiology). As previously mentioned, psychology and

movement sciences have been meshed together to form the discipline of exercise

psychology. However, these two disciplines are indeed separate and pose a complex

issue concerning training. Training for exercise practitioners is complex due

to licensure. Clearly, to refer to oneself as a “psychologist,” an individual must satisfy

the state requirements for licensure within the state in which he or she works.

Most people trained in the movement sciences can specialize in exercise psychology

but will likely not be able to meet the requirements for psychology licensure.

Thus, practitioners can not ethically refer to themselves as “exercise psychologists”

because they will not be licensed as psychologists within their state of em-

ETHICAL ISSUES IN EXERCISE PSYCHOLOGY 65

ployment. Likewise, licensed psychologists with limited or no training in the

movement sciences should not ethically refer to themselves as “exercise psychologists”

because of a lack of proper training in exercise science.

Education and training from both exercise or movement science and psychology

is a necessity for scholar–practitioners in the field of exercise psychology. Due

to the interdisciplinary nature of exercise psychology, students will most likely

need to create an individualized plan of study suited to meet their future goals and

career objectives by combining courses from traditional psychology, sport sciences,

and sport and exercise psychology. In 1991, AAASP established certification

criteria for becoming a certified consultant of AAASP. The interdisciplinary

requirements of AAASP certification require coursework and practicum guidelines

for students who desire or specialize in applied sport or exercise psychology

(Sacks, Burke, & Schrader, 2001). The requirements appear adequate and are necessary

but reflect only minimal foundational training. AAASP certification requirements

should not be viewed as sufficient training to become an effective exercise

consultant. Furthermore, the attainment of AAASP certification requirements

does not permit an individual to ethically use the title “exercise psychologist.”

The following is a recommendation of minimal interdisciplinary coursework

based on most state licensure requirements and AAASP certification, to be competent

to do specialized consultation in exercise psychology. This recommendation is

not a comprehensive list intended to address every possible career aspiration

within exercise psychology, but it can provide some initial guidance. The interdisciplinary

coursework should focus on the areas of psychology, sport science, and

sport psychology. The exercise psychology curriculum should include

1. Traditional psychology courses such as human growth and development;

biological, social, and cultural bases of behavior; counseling skills;

psychopathology; individual and group behavior; psychological assessment;

cognitive–affective bases of behavior; professional ethics and standards;

statistics; and research design.

2. Sport science courses should incorporate biomechanical and physiological

bases of sport, motor development, motor learning, fitness assessment,

fundamentals of strength and conditioning, aerobic and weight training,

and sport nutrition.

3. Last, sport psychology, performance enhancement, exercise psychology,

health psychology, and social aspects of sport and physical activity should

be included.

In addition to formal coursework, practical experience (i.e., internships and/or

practicum) focused on the application of psychological principles, theories, and

practices in the exercise setting is also a necessity. The practical experience must

be supervised by a qualified specialist (e.g., licensed psychologist, licensed mental

66 PAULINE, PAULINE, JOHNSON, GAMBLE

health practitioner, or certified consultant of AAASP) within the field of exercise

psychology. The aforementioned curriculum and practical training seems to provide

the necessary education for mental health professionals regarding the physical

and psychological benefits of exercise.

Nevertheless, this initial, formal coursework and applied experience is not in

and of itself enough to allow one to practice ethically throughout his or her career.

Maintaining professional competence through continuing professional education

is extremely important in any field, including exercise psychology. The scientific

and professional knowledge base of psychology and exercise/movement science is

continually evolving, bringing with it new research methodologies, assessment

procedures, and forms of service delivery. Life-long learning is fundamental to ensure

that teaching, research, and practice have an ongoing positive impact on those

desiring services (Bickham, 1998). Both APA and AAASP provide a variety of opportunities

and methods for scholars and practitioners to maintain professional

competency. Some of these methods include independent study, continuing education

courses or workshops, supervision, and formal postdegree coursework.

Maintaining professional competency is also an important ethical requirement

that is valued highly by the APA, the AAASP, and the ACSM. Over 96% of

AAASP professionals recently surveyed by Etzel, Watson, and Zizzi (2004) believed

that it is important to maintain professional competency through continuing

education training. This very high percentage is a clear indication of the value

AAASP members place on maintaining professional competency. Maintaining

professional competence through continuing professional education ensures that

the scholars and practitioners in the field of exercise psychology are providing the

most current services to their clients.

CULTURAL AND ETHNIC DIVERSITY

The ethical standards of the APA (2002) and the AAASP (1994) clearly indicate

the importance of recognizing that human differences such as age, gender, and ethnicity

do exist and can significantly impact a practitioner’s work. The standards

emphasize the responsibility to develop the skills required to be competent to work

with a specific population or to be able to make an appropriate referral. The importance

of understanding the culture and background of a variety of populations is vitally

important in both exercise and therapeutic settings.

Research indicates high rates of obesity and inactivity among women and minority

groups. About 33.4% of all women are obese, compared to 27.5% of men

(Goldsmith, 2004). The age-adjusted prevalence of overweight and obesity in racial/

ethnic minorities, especially minority women, is generally higher than in

Whites in the United States (Flegal, Carroll, Ogden, & Johnson, 2002). More specifically,

among women, non-Hispanic White women have the lowest occurrence

ETHICAL ISSUES IN EXERCISE PSYCHOLOGY 67

(30.7%) of obesity, non-Hispanic Black women have the highest (49.0%), and

Mexican American women are in the middle (38.4%; Hedley et al., 2004).

The importance of cultural sensitivity and awareness is clearly underscored by

the aforementioned data. Barriers to exercise adherence are often directly or indirectly

related to personal and cultural factors. Therefore, when working in the area

of exercise consulting, a practitioner needs to consider the impact, positive and

negative, of factors associated with gender, ethnicity, socioeconomic status, and

other potentially relevant culturally based factors.

In traditional counseling and clinical settings, the impact of factors associated

with gender, ethnicity, and culture is also highly relevant for successful outcomes.

In 1972, the Association of Multicultural Counseling and Development (AMCD),

was established to assist with recognizing the assets of culture and ethnicity, and

other social identities and to address concerns about ethical practice (Arredondo&

Toporek, 2004, p. 45). These factors are also pertinent for practitioners who desire

to include exercise as a component of treatment. A series of essential questions to

address prior to prescribing exercise as a therapeutic modality include: Is exercise

valued in the culture and/or by the client? What is the prior exercise history of the

client? What types of social support are available to assist the client with exercise

adherence? Does the client’s culture create any additional barriers for adherence

for exercise and traditional treatment?

MULTIPLE-ROLE RELATIONSHIPS

AND CONFLICTS OF INTEREST

Multiple-role relationships are often viewed as occurring when the therapeutic

connection has moved toward a friendship relationship (Bernstein & Hartsell,

2004). Multiple-role conflicts in therapy and consultations for exercise adherence

may be encountered when clear boundaries have not been established. When the

relationship boundary between the professional and client becomes clouded, the

likelihood of multiple-role conflicts greatly increases. Every practitioner needs to

maintain ethically proper professional boundaries. Establishing and maintaining

such boundaries can be difficult due to the casual atmosphere that surrounds the

exercise environment. The casual environment is created by the type of clothing

worn during exercise, music being played, and the social atmosphere of many exercise

and rehabilitation facilities.

A first step in maintaining appropriate boundaries is to establish a common protocol

when communicating with all new clients. Instead of using first names,

which seems to be a more common custom, it might be helpful to be consistent

with the practice of referring to clients by last name and title (Miss, Ms., Mrs., and

Mr. Brown). This practice encourages clients to maintain a distance from the

therapist.

68 PAULINE, PAULINE, JOHNSON, GAMBLE

Maintaining this distance becomes even more difficult when exercising with

clients. Exercising together can be a great vehicle for building rapport and developing

communication between practitioner and client. Conversely, exercising with

clients may cloud the boundaries and thus cause some confusion or ambiguity regarding

the nature of the relationship between client and practitioner. There are no

current guidelines and/or laws relative to this specific situation. However, both the

APA (2002) and AAASP (1994) ethic codes indicate that multiple roles can be inappropriate

and unethical if handled in the wrong way and need to be maintained

with great caution. Clarifying the nature of the relationship during the intake and

informed consent process, prior to exercising with the client, is of primary importance.

It is the practitioner’s ethical responsibility to have a candid discussion with

the client that clearly defines a therapeutic relationship and the limitations concerning

nontherapeutic personal contact. For example, personal contacts such as

engaging in recreational or competitive athletic teams, attending sporting events,

and other general social functions together are in violation of maintaining therapeutic

boundaries. The practitioner should have a clear rationale for prescribing

exercise in a client’s treatment plan. In addition, the rationale for exercising together

(i.e., to develop rapport) should be clearly communicated and understood

between practitioner and client.

When exercising with clients, a common dilemma the practitioner faces is determining

what type of physical activity should be implemented. As previously

mentioned, research has found a variety of activities (aerobic and anaerobic) that

provide physical and psychological benefits (USDHHS, 1996). In regard to adherence,

it is vital to have clients’ input concerning activity selection. When clients

have input into the selection process, they will likely select/choose a physical activity

they enjoy. Enjoyment of the activity has been positively correlated to adhering

and maintaining an exercise regimen (Wankel, 1993).

Walking is one of the most commonly reported types of physical activity

(USDHHS, 1996). Walking is an excellent choice of physical activity for numerous

reasons. First and foremost, many people are able to walk. Furthermore, the

risks associated with walking are minimal due to the low to moderate intensity

level. Also, most people are able to walk and talk simultaneously, which is necessary

for therapeutic consultations. Last, walking can be performed inside or outside

and requires minimal equipment or modification of clothing. For clients who

are able to and desire a more intensive level of activity, jogging is a viable alternative

to walking. When selecting jogging, a major requirement is for the therapist

and client to have a high level of cardiovascular fitness. A high level of cardiovascular

fitness allows them to talk with each other while exercising.

Anaerobic activities such as strength training provide clients and therapists

with another viable option for activity selection. During strength training, there is

ample time for communication and discussion between practitioner and client.

However, there are a few limiting factors when choosing strength training. Most

ETHICAL ISSUES IN EXERCISE PSYCHOLOGY 69

strength training activities require specialized equipment and facilities and present

increased potential for risk of injury. In addition, a couple of potential ethical dilemmas

when including strength training are competency and confidentiality. The

therapist may not have the knowledge base and/or experience to supervise a

strength training program that would accomplish desirable health and therapeutic

objectives. It may also be difficult to maintain confidentiality due to other people

exercising in very close proximity.

The mental health practitioner should not assume the role of a physician, exercise

physiologist, or personal trainer in terms of providing or modifying an exercise

prescription. Furthermore, practitioners should be cognizant of their primary

role, which is to assist with exercise adherence and consultation. Exercise psychology

practitioners ethically need to be aware of their professional limitations and

competence boundaries vis-à-vis their education and training.

Maintaining an appropriate distance is sometimes useful in diverting inappropriate

attempts at amorous and other nonprofessional relationships. Sexualizing

the relationship with a client is clearly unethical as well as very unsound professional

practice that harms both the client and practitioner (APA, 2002; AAASP,

1994). Practitioners often hold an advantage of power over the people with whom

they work. Furthermore, practitioners occupy a position of trust and are expected

to advocate the welfare of those who depend on them.

Physical contact within the counseling and exercise setting is often ethically appropriate.

However, contact that is intended to express emotional support, reassurance,

or an initial greeting can be misinterpreted as an invitation for advances. The

social environment, revealing clothes, and close proximity that surround the exercise

setting can lead to inappropriate advances by clients or practitioners. Recognition

of signs, both in clients and in therapists, and dealing with these feelings immediately

and objectively is the best approach. The practitioner should discuss these

feelings with an experienced, respected, and trusted colleague. If the practitioner is

unable to control his or her feelings, termination and referral are recommended as a

method of protecting both the client and practitioner.However, on termination of the

relationship, thetwoindividuals are not ethically “free” to pursue amoresocial or intimate

relationship. It is strongly suggested to have a cooling off period (several

monthsto years) inwhichboth parties agree towait prior to pursuing a relationship at

a different level.Amore conservative approach suggested by Bernstein and Hartsell

(2004) is to followthe belief ofoncea client, always a client.With the adoption of this

approach, once a professional relationship is initiated it must always be maintained,

thus reducing the notion or intention of modifying any professional relationship.

DEPENDENCY ON THE THERAPIST

Another issue that must be discussed in collaboration with multiple-role relationships

is a client’s level of dependency on a thera