An example of a dual relationship is one where a social worker and client go on a date.

Dual Relationships between Therapist & Client:

A National Study of Psychologists, Psychiatrists, and Social Workers

ABSTRACT: 4,800 psychologists, psychiatrists, and social workers were surveyed (return rate = 49%) to examine attitudes and practices regarding dual professional roles, social involvements, financial involvements, and incidental involvements. Half of the participants rated the degree to which each behavior was ethical; the other half reported how often they engaged in each behavior. A majority believed dual role behaviors to be unethical under most conditions; most reported that they had rarely or never engaged in the behaviors. 10 factors (therapist gender, profession, age, experience, marital status, region of residence, client gender, practice setting, theoretical orientation, and practice locale) were examined for their relation to beliefs and behaviors. A higher proportion of male than of female therapists engaged in sexual and nonsexual dual relationships. The professions did not differ among themselves in terms of: (a) sexual involvements with clients before or after termination, (b) nonsexual dual professional roles, (c) social involvements, or (d) financial involvements with patients. 10 specific training implications are discussed in light of the potentially exploitive and clinically harmful nature of some dual relationships.

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The American Psychological Association (APA) has long recognized that harm and exploitation can result from some forms of dual relationship. The Ethical Principles of Psychologists require psychologists to act to avoid impairing their own professional judgment or increasing the risk of exploitation of their clients through unacceptable dual relationships. However, compliance with this principle has apparently been difficult for many psychologists: Sexual and nonsexual relationships form the major basis of financial losses in malpractice suits, licensing disciplinary actions, and ethics complaints against psychologists (Ethics Committee of the APA, 1988; Pope, 1989a, 1989c).

Our study represents an initial attempt to gather, from carefully selected national samples, data concerning previously unexamined aspects of behaviors and beliefs regarding dual relationships and incidental involvements. Three aspects were particularly important.

First, five national studies of psychologists have focused on sexualized dual relationships--that is, sexual relationships between psychologists, as teachers or as psychotherapists, and their students or clients (Glaser & Thorpe, 1986; Holroyd & Brodsky, 1977; Pope, Keith-Spiegel, & Tabachnick, 1986; Pope, Levenson, & Schover, 1979; Robinson & Reid, 1985). But no previous national study has focused exclusively on nonsexual dual relationships.

Second, in prior studies of sexual dual relationships, participants were asked to provide information about both their beliefs and behaviors, which created the possibility that responses regarding beliefs influence responses regarding behavior or vice versa.

Third, those studies, dating back over a decade, may have unjustly focused public and professional attention on the offenses of psychologists in comparison with those of other professionals. There has been only one national study of sexual involvements between social workers and their clients (Gechtman & Bouhoutsos, 1989)

Method

Sample Selection

Eight hundred male and 800 female clinicians were randomly selected from each of the current membership directories of the three major mental health professional organizations (i.e., the American Psychological Association, the American Psychiatric Association, and the National Association of Social Workers) to constitute a total sample of 4,800. An attempt to obtain a national, representative random sample of marriage and family counselors proved futile because this group does not have a well-organized national association with a membership list, and many states prohibit disclosure of licensed marriage and family counselors' names and addresses.

The population of interest was defined as those professionals who had completed both clinical training and licensure and either were currently practicing psychotherapy or had done so within the past 5 years. Because many of the dual role situations to be studied would not arise with child clients (e.g., borrowing over $20) or might have different implications with child clients (e.g., buying Girl Scout cookies from a child client vs. making an investment purchase from an adult client who is a stockbroker), this investigation focused on psychotherapy with adult clients.

Instruments

Two forms of the Therapeutic Practices Survey were developed. Each contained a list of behaviors representing both dual relationships and incidental involvements that may arise between a therapist and client. Some involved dual professional roles of the type that the Ethical Principles used to illustrate the prohibition against some dual relationships. Some involved social or financial arrangements that create a dual relationship between therapist and client, and some were incidental events: one-time, exceptional boundary alterations initiated by the client and accepted by the therapist, which, though not constituting dual relationships, might raise questions of potential conflict of interest (e.g., giving the therapist a gift worth more than $50 or inviting the therapist to a special occasion). Two additional items drawn from prior national studies were included to provide some assessment of social desirability response bias ("accepting a handshake offered by a client" and "feeling sexually attracted to a client"; Pope et al., 1986; Pope, Tabachnick, & Keith-Spiegel, 1987).

The "Ethics" form provided a scale (5 = always ethical and 1 = never ethical), and respondents indicated their beliefs regarding the degree to which each listed behavior was considered ethical. In a second section, respondents provided demographic information, including gender, age, marital status, professional discipline, involvement in provision of services, primary theoretical orientation(s), primary clinical setting, and practice locale.

The "Practices" form of the survey provided a frequency scale (5 = all clients and 1 = no clients), and respondents indicated the proportion of clients with whom they had engaged in each of the listed behaviors. Demographic questions identical to those of the "Ethics" form appeared on the back of the "Practices" form.

Procedure

Each of the 800 individuals within each of the six sample groups was randomly assigned to receive either the "Ethics" form on the "Practices" form. Each of the 4,800 individuals was sent (a) a one-page cover letter, (b) a one-page survey form, (c) a stamped, addressed envelope for returning the form, and (d) a postcard for requesting a summary of the results. We took a series of steps specified by Pope et al. (1979) to guarantee complete anonymity for participants. Ten weeks after the original mailing, approximately 50% of the forms had been returned, the additional forms were arriving at a very slow rate, and data collection was halted.

Results

Characteristics of the Respondents

Survey forms were returned by 2,332 of the 4,800 potential respondents. Thirty-six forms were undeliverable; thus the overall response rate was 49%. Of the returned forms, 8 were incomplete and unusable (4 were defaced by hostile comments). Only the responses of the 2,133 respondents who characterized themselves as "active" clinicians (i.e., they had provided psychotherapy within the past 5 years) were used for subsequent analyses.

Gender

The final sample was 52.4% female (n = 1,118) and 47.4% male (n = 1,012); 3 participants failed to indicate gender.

Profession

Psychologists (n = 904) made up 42.4%, psychiatrists (n = 570) 26.7%, and social workers (n = 658) 30.8% of the sample. One respondent did not indicate a profession.

Age

The mean age of respondents was 48 years; the range was 23 to 91 years. For the purpose of statistical analyses, respondents were divided into five age groups (21-34, 35-44, 45-54, 55-64, and 65 and over).

Experience

The average respondent reported 16 years of experience providing psychotherapy services; the range was 1 to 51 years. For statistical analyses, respondents were divided into four groups by the number of years' experience that they reported: 10 or fewer, 11-20, 21-30, and more than 30.

Region of Residence

Respondents were divided into five groups on the basis of their region of residence in the United States: Northeast (28.0%; n = 598), Midwest (20.1%; n = 429), South (22.8%; n = 486), West (23.9%; n = 510), and overseas (0.52%; n = 11). We could not classify 4.64% (n = 99) by region of residence because of illegible or missing postmarks.

Marital Status

More than 70% (n = 1,509) of the respondents were married; 13.0% (n = 277) were separated or divorced; 9.3% (n = 199) were single; 4.7% (n = 101) were cohabiting with a partner; and 1.5% (n = 33) were widowed. The remaining 0.7% (n = 14) did not indicate their marital status.

Theoretical Orientation

The survey form offered respondents six options for rating the influence of various theoretical orientations on their practice: behavioral, cognitive, existential, gestalt, psychodynamic, and "other" (with a request to label the "other"). Responses to the "other" option that fell within the purview of one of the five specified orientations were coded as such (e.g., ego-analytic was coded as psychodynamic). Also, because most respondents gave the same ranking to existential, gestalt, and other humanistic orientations, all orientations that traditionally are grouped within the humanistic-existential framework were collapsed into a single category for analysis.

The majority (58.0%; n = 1,238) of respondents ranked psychodynamic as their primary theoretical orientation; this was followed by cognitive (13.1%; n = 279), "other" (8.3%; n = 177), behavioral (7.9%; n = 169), humanistic (6.8%; n = 145), and eclectic (2.4%; n = 51). The remaining 3.5% (n = 74) did not state their orientations.

Practice Setting

Primary practice settings included solo private practice (45.7%; n = 975); outpatient clinics (22.7%; n = 485); group private practice (14.6%; n = 312); inpatient facilities (9.6%; n = 205); and other settings such as schools, day treatment programs, and community outreach programs (4.2%; n = 89). The remaining 3.1% (n = 67) did not indicate their practice setting.

Client Population

Most respondents (82.2%; n = 1,753) reported treating a greater proportion of adults than youths. In keeping with the fact that most psychotherapy clients are female, most of the respondents (68.3%; n = 1,457) reported a greater proportion of female than male clients in their practices.

Responses Regarding Beliefs

In Table 1 we present the degree to which the 1,108 participants in this part of the study considered each behavior to be ethical.

Table 1

Ratings codes: 1 = never ethical; 2 = ethical under rare conditions; 3 = ethical under some conditions; 4 = ethical under most conditions; 5 = always ethical; NS = not sure; NR = no response (i.e., missing data).

Note: Rows may not sum to 100% due to rounding.

Factor Analysis

Testing hypotheses about possible relationships between the ethical ratings for each dual role behavior and each of the clinician characteristics (such as age, gender, and profession) separately would have unacceptably inflated the probability of Type I error. To minimize Type I error and to permit conceptually meaningful statistical analysis, data were statistically abstracted by means of a principal-components factor analysis with Harris-Kaiser oblique (rather than orthogonal) rotation to accommodate correlations between factors. The eigenvalues, factor loadings, and conceptuallarity of the rotated factors determined the choice of the solution used in the subsequent statistical analyses.

Each factor chosen formed the basis of an index, which was developed by means of weighting participants' responses to the items loaded on that factor by their factor-score loadings and then summing the weighted items. Thus there were the same number of index scores for each participant as there were factors in the factor solution chosen. These factors and indices constituted the dependent variables for subsequent analyses.

Three items were excluded from this factor analysis: "Accepting a handshake offered by a client," "Feeling sexually attracted to a client," and "Engaging in sexual activity with a current client." The first two were excluded because they were used only as social desirability items for comparison with previous studies and did in fact show agreement with those studies. The third item (concerning sex with clients) was excluded because of the restricted range of responses obtained (i.e., more than 97% of the respondents rated the behavior as never ethical).

The remaining 17 items yielded three conceptually meaningful factors with eigenvalues over 1.0. In Table 2 we present the items constituting each factor and their factor loadings. Factor 1 (Incidental Involvements), accounting for 69.8% of the common variance, described three behaviors involving incidental, typically one-time events or special occasions in which therapeutic boundaries were altered at the initiation of the client. Factor 2 (Social/Financial Involvements), accounting for 17% of the common variance, described the involvement of the therapist and the client in extratherapeutic social, financial, or business activities. Factor 3 (Dual Professional Roles), accounted for 13.2% of the common variance. The ranges of possible values were 0 to 9.69 for the Incidental Involvements factor, 0 to 32.83 for the Social/Financial Involvements factor, and 0 to 13.10 for the Dual Professional Roles factor.

Relations Between Clinicians' Characteristics and Belief Factors

One-way analyses of variance (ANOVAS) between each of the 10 clinician characteristics and each of the three factors were conducted. Planned means contrasts followed initial ANOVAS for statistically significant results that had been anticipated. Selected two-way factorial ANOVAS (between the factors and pairs of clinicians' characteristics for which interaction seemed likely in light of both the initial findings and the frequency distributions of the clinician characteristics) were conducted. Surprisingly, no significant two-way interaction effects were found, which suggests that the clinicians' characteristics produced independent effects on beliefs and behavior.

In light of the number of analyses conducted, alpha was set at .01 for both main effects and planned contrasts to minimize Type I error. However, an alpha of .05 was used for post hoc Scheffé analyses, which included appropriate adjustments.

Factor 1: Incidental Involvements.

Respondents' ethical beliefs regarding incidental involvements with clients were found to vary significantly by profession, F (2, 1108) = 22.01, p < .0001; client population, F (5,1086) = 9.76, p < .0001; theoretical orientation, F (4, 1074) = 7.29, p < .0001; and practice setting, F (4, 1074) = 9.40, p < .0001.

Post hoc Scheffé analyses indicated, surprisingly, that psychologists (M = 5.43) viewed incidental involvements as significantly more ethical than did social workers (M = 4.83), F (1, 1108) = 3.00, p < .05; psychiatrists (M = 5.16), F (1, 1108) = 3.00, p < .05; and both of those professions combined (combined M = 4.98), F (1, 1108) = 30.98, p < .0001.

Planned contrasts showed that male respondents who reported a predominantly female client population viewed such involvements as significantly more ethical than did respondents in all other therapist-client gender pairings, F (1, 1086) = 15.76, p < .0001.

Post hoc Scheffé analyses showed that the main effect of theoretical orientation derived largely from two pairwise differences: Psychodynamic respondents (M = 5.01) rated incidental involvements as significantly less ethical than did humanistic (M = 5.64) or eclectic/"other" respondents (M = 5.45), F (1, 1074) = 2.38, p < .05.

Private practitioners (M = 5.32) rated incidental involvements as significantly more ethical than did respondents who work in other practice settings (M = 4.93), F (1, 1074) = 19.34, p < .0001. However, contrary to expectation, solo private practitioners (M = 5.27) did not differ significantly from the ratings of group private practitioners (M = 5.46).

Factor 2: Social/Financial Involvements.

Respondents' beliefs regarding social/financial dual relationships with clients varied significantly by profession, F (2, 1108) = 14.57, p < .0001; gender, F (1, 1107) = 22.03, p < .0001; theoretical orientation, F (4, 1074) = 27.68, p < .0001; practice setting, F (4, 1074) = 8.81, p < .0001; practice locale, F (3, 1097) = 10.95, p < .0001; years of experience, F (3, 1097) = 4.95, p < .005; and region of residence, F (3, 1057) = 6.56, p < .0005.

Post hoc Scheffé analyses showed that psychiatrists (M = 11.55) rated social/financial involvements with clients as significantly less ethical than did psychologists (M = 12.59) and social workers (M = 13.12), F (1, 1108) = 3.00, p < .05.

Female therapists (M = 11.98) viewed such involvements as significantly less ethical than did male therapists (M = 13.03).

Post hoc Scheffé tests revealed that psychodynamically oriented respondents rated social/financial involvements as significantly less ethical than did respondents of other orientations, F (1, 1074) = 2.38, p < .05.

Solo private practitioners (M = 11.79) rated social/financial involvements as significantly less ethical than did group private practitioners (M = 13.24), F (1, 1074) = 18.55, p < .0001. Post hoc Scheffé analyses showed that solo private practitioners also rated such involvements as less ethical than did practitioners in outpatient clinics (M = 13.15), F (1, 1074) = 2.38, p < .05.

Respondents who live and work in a single small town (M = 14.15) rated such involvements as significantly more ethical than respondents who live and work in the same suburban (M = 12.25) or urban area (M = 12.26) or live and work in different communities (M = 12.21), F (1, 1097) = 32.63, p < .0001.

Post hoc Scheffé analyses showed that the regional effect was attributable to the fact that respondents from the Northeast (M = 11.78) rated such involvements as significantly less ethical than did respondents from the South (M = 13.03) and the Midwest (M = 12.94), F (1, 1057) = 2.61, p < .05.

Factor 3: Dual Professional Roles.

Respondents' beliefs regarding dual professional roles with clients varied significantly by gender, F (1, 1107) = 25.97, p < .0001; theoretical orientation, F (4, 1074) = 8.01, p < .0001; practice locale, F (3, 1097) = 6.42, p < .0005; experience, F (3, 1097) = 3.55, p = .014; and region of residence, F (3, 1057) = 4.26, p < .006.

Female therapists (M = 5.02) viewed such involvements as significantly less ethical than did male therapists (M = 5.58).

Post hoc Scheffé analyses revealed that psychodynamically oriented respondents rated these involvements as less ethical (M = 5.04) than did respondents with all of the other orientations and as significantly less ethical than did respondents with the cognitive orientation (M = 5.75) and with the eclectic/"other" orientation (M = 5.59), F (1, 1074) = 2.38, p < .05.

A planned contrast showed that respondents who both live and work in the same small town rated dual professional roles as significantly more ethical (M = 5.86) than did respondents in other practice locales combined (combined M = 5.20), F (1, 1097) = 15.03, p < .0001.

Post hoc Scheffé analyses showed that respondents with 30 or more years of experience rated dual professional roles as significantly more ethical (M = 5.63) than did those with less than 10 years of experience (M = 5.11), F (1, 1097) = 2.61, p < .05.

Post hoc Scheffé analyses showed that respondents from the Northeast rated dual professional roles as less ethical (M = 4.99) than did respondents from the Midwest (M = 5.47) and the South (M = 5.45), F (1, 1057) = 2.61, p < .05.

Responses Regarding Behaviors

In Table 3 we present the frequencies with which the 1,021 clinicians in this part of the study reported engaging in each of the listed activities.

Table 3

Note: Rating codes for proportion of clients with whom clinician has engaged in the bahavior: 1 = no clients or no opportunity (combines both categories), 2 = few clients, 3 = some clients, 4 = most clients, 5 = all clients, NR = no response (i.e., missing data).

Note: Rows may not sum to 100% due to rounding.

Classification

Ratings on the "Practices" form were so heavily skewed toward never that the severely restricted variance prevented effective discrimination between variables. Thus factor analysis of these data was not a viable method of identifying conceptually meaningful factors. Consequently, four composite indices were constructed by means of grouping conceptually similar items and summing the ratings for those items for each participant. The four dimensions were those identified by the factor analysis of the "Ethics" form ratings: Incidental Involvements, Social Involvements, Financial Involvements, and Dual Professional Roles. The Social and Financial dimensions were separated for this measure because there was no statistical basis for grouping them. The two social desirability items were again excluded, but the item concerning sex with a client before termination of therapy was included in the Social Involvements index. The ranges of possible values were 0 to 15 for the Incidental Involvements index, 0 to 30 for the Social Involvements and Dual Roles indices, and 0 to 25 for the Financial Involvements index.

Relations Between Clinicians' Characteristics and Behavior Categories

Using the statistical procedures described previously, we analyzed the relations between each of the clinician characteristics and each of the four behavior categories. Potential interaction effects of the clinician characteristics were tested; none was statistically significant.

Category 1: Incidental Involvements.

The frequency of reported incidental involvements with clients varied significantly by profession, F (2, 1010) = 7.72, p < .0005; gender, F (1, 1019) = 6.94, p < .01; client population, F (2, 1002) = 6.10, p = .002; and practice setting, F (4, 983) = 3.53, p < .01.

Planned contrasts showed that psychologists (M = 5.32) reported having engaged in such involvements with a significantly greater proportion of clients than did members of the other two professions (combined M = 4.91), F (1, 1018) = 13.86, p < .0005.

Female therapists (M = 5.22) reported having engaged in such involvements with a significantly greater proportion of clients than did their male counterparts (M = 4.95).

Planned contrasts showed that private practitioners reported having engaged in such involvements with a significantly greater proportion of clients (M = 5.23) than did respondents from other settings combined (combined M = 4.89), F (1, 983) = 11.04, p < .001. A planned contrast showed that those in solo versus group private practice did not differ significantly in the frequency with which they reported engaging in incidental involvements.

Category 2: Social Involvements.

The frequency of reported Social Involvements with clients varied significantly by therapist's gender, F (1, 1019) = 8.73, p < .005, and theoretical orientation, F (4, 976) = 17.35, p < .0001.

Female therapists reported having engaged in such involvements with a significantly smaller proportion of clients (M = 7.27) than did their male counterparts (M = 7.58).

Post hoc Scheffé analyses indicated that the reported frequency was lower for psychodynamically oriented respondents than for respondents of any other orientation; this difference was statistically significant when psychodynamically oriented practitioners (M = 7.10) were compared with humanistic (M = 8.48), cognitive (M = 7.83), and eclectic/"other" respondents (M = 7.90), F (1, 976) = 2.38, p < .05. Behavioral therapists reported significantly fewer social involvements (M = 7.59) than did humanistic therapists, F (1, 976) = 2.38, p < .05.

Category 3: Financial Involvements.

The frequency of financial dual relationships with clients varied significantly by theoretical orientation, F (4, 976) = 6.80, p < .0001, and practice locale, F (3, 1010) = 4.08, p < .01.

Psychodynamically oriented therapists reported a significantly lower frequency of financial involvements (M = 5.46) than did humanistic therapists (M = 5.87), F (1, 976) = 2.38, p < .05, and cognitively oriented therapists, F (1, 976) = 2.38, p < .05.

Respondents who live and work in the same small town reported engaging in such involvements with a significantly greater proportion of clients than did respondents in other practice locales, F (1, 1010) = 7.31, p < .01. These respondents living and working in a single small town also had a significantly higher frequency of financial involvements than did respondents who live and work in different communities, F (1, 1010) = 2.61, p < .05.

Category 4: Dual Professional Roles.

The frequency of therapists' reported dual professional roles with clients varied significantly by gender, F (1, 1019) = 6.56, p = .0106, and theoretical orientation, F (4, 976) = 5.80, p < .0001.

Male therapists reported having engaged in dual professional roles with a greater proportion of clients (M = 7.59) than did their female counterparts (M = 7.36).

Psychodynamically oriented respondents reported engaging in such involvements with a smaller proportion of clients (M = 7.29) than did respondents of other orientations. However, post hoc Scheffé analyses indicated that the difference in frequency was statistically significant only in comparison with respondents of the cognitive orientation (M = 7.76), F (1, 976) = 2.38, p < .05. Humanistic therapists reported the highest frequency of involvements of this nature (M = 7.84).

Discussion

Validity and Interpretation Issues

Six issues are exceptionally important in interpreting these data. First, this is the only national study to date focusing on nonsexual dual relationships (although items concerning sexual dual relationships and incidental involvements were also included) and also the only cross-disciplinary study of ethical beliefs and behaviors that takes into account a full range of such factors as age, therapist's gender, client's gender, setting, geographic locale, and so on. It awaits attempts at replication.

Second, as Pope et al. (1987) emphasized, norms of beliefs or behaviors are not the equivalent of ethical standards: "In many situations, the formulation and dissemination of formal standards are intended to increase ethical awareness and to improve the behaviors of a professional association" (p. 993).

Third, unlike prior national ethics studies, cited earlier, that obtained information about both beliefs and behaviors from the same individuals, the participants in each subgroup of this study were randomly assigned to provide information about either beliefs or behaviors. Thus the potential cross-contamination of responses was avoided. When the relation between belief and behavior on items (e.g., engaging in sex with a current client or feeling sexual attraction to a client) that are identical or similar to those used by prior studies are examined, there is no evidence that the findings of the prior studies have been distorted through having the same individuals provide information about both belief and behavior.

Fourth, the clinical issues concerning each survey item are complex, and the systematic collection of a vast array of data provides a wide variety of perspectives on the findings. In light of space limitation, the discussion that follows is intended only to highlight a few major trends and patterns emerging from these initial data.

Fifth, there are of course strengths and weaknesses associated with any approach to gathering and interpreting data. As has often been observed, there is much that we do not know at this stage about the frequency, nature, and effects of actions that may harm patients; about treatment for patients who have been harmed through such actions; about therapists who repeatedly or intentionally engage in acts that may harm patients; and about effective prevention. For more detailed discussions of problems in sample selection, the potential similarities and differences between responders and nonresponders in survey studies, issues in scaling and statistical analysis, the qualified nature of inferences drawn from specific drawn from specific findings, and other research limitations, readers are referred to prior studies of sexual dual relationships, methodological critiques, and relevant critical reviews (e.g., Pope & Bouhoutsos, 1986).

Sixth, in any study of ethical beliefs and behaviors, there is the possibility that participants provide responses that are biased in terms of social desirability or similar influences. Analysis of the two items representing behaviors found to have a high level of reported prevalence in two previous studies did not show evidence of social desirability response bias ("accepting a handshake offered by a client" and "feeling sexually attracted to a client"; Pope et al., 1986, 1987).

In regard to one item alone could social desirability response bias be reasonably inferred from comparison with prior studies. In our study, only 0.2% of the women (n = 1) and 0.9% of the men (n = 4) reported engaging in sexual involvements with an ongoing client. These figures are lower than those reported for women (2.5%-3.1%) and for men (7.1%-12.1%) in any of the previously published national studies (Gartrell et al., 1987 ; Holroyd & Brodsky, 1977; Pope et al., 1986, 1979, 1987). There are three major possibilities, which are not mutually exclusive, for interpreting this discrepancy:

First, it may, of course, represent an actual decline in the rate of sexual involvements with clients. In the most recent previous study, Pope et al. (1987) found a significantly lower rate than in prior studies and discussed possible factors contributing to an actual decline. Our study may be charting a continuation of this trend.

Second, the discrepancy may be due to a decline in reporting--even on an anonymous survey--a behavior that is becoming recognized as a felony in an increasing number of states. No other item on the form concerns a behavior that constitutes a felony.

Third, the wording on this survey may have led to a misunderstanding among some participants. It is possible that participants may have interpreted "engaged in sexual activity with an ongoing client" as referring to sexual involvements with someone who was still a client at the time of this survey rather than sexual involvements with any client--past or present--before termination of therapy.

Ratings of the Beliefs About the Behaviors

The percentage of respondents viewing a behavior as ethical under most or all conditions was invariably less than the percentage viewing it as never ethical or ethical under only some or rare conditions. A majority of the 1,108 respondents rated five behaviors as never ethical: sexual activity with a client before termination of therapy (98.3%; n = 1,089), selling a product to a client (70.8%; n = 784), sexual activity with a client after termination of therapy (68.4%; n = 758), inviting clients to a personal party or social event (63.5%; n = 704), and providing therapy to an employee (57.9%; n = 641). In only two cases did fewer than 10% of the respondents rate a behavior as never ethical: accepting an invitation to a client's special occasion (6.3%; n = 70) and accepting a gift worth less than $10 (3.0%; n = 33). Fewer than 10% of the respondents were uncertain about the degree to which any particular item was ethical.

All behaviors in which the therapist assumed two roles (with the exception of providing individual treatment to the significant other of a client), all behaviors involving sexualized relationships, and all behaviors involving extra-fee financial arrangements with clients received lower ratings than behaviors involving incidental involvements, social involvements, and special fee arrangements.

Ratings of the Frequency of the Behaviors

For all behaviors, the percentage of respondents who had reportedly engaged in the behavior with few or no clients was greater than the percentage who had done so with some, most, or all clients. There were only two behaviors in which a majority of the 1,021 participants had engaged with at least one client: accepting a gift worth less than $10 (85.2%; n = 870) and providing concurrent individual therapy to a client's significant other (61.2%; n = 625). The behavior with the lowest reported frequency was sexual relations with a client before termination of therapy (0.5%; n = 5). Overall, these results suggest that the average respondent had engaged in most of the behaviors with few or no clients.

Behaviors and Beliefs as a Function of Profession

This study permits the first direct comparison of the behaviors of the three major mental health professions in terms of sexual and nonsexual dual relationships. Although psychologists tended to engage with greater frequency in incidental involvements, there was no significant difference among the professions in terms of (a) sexual involvements with clients before or after termination of therapy, (b) nonsexual dual professional roles, (c) social involvements, or (d) financial involvements with patients.

Psychiatrists tend, as a whole, to view nonsexual dual relationships as less ethical than do psychologists or social workers (but engaging in the behaviors, as noted earlier, does not differ by profession).

Behaviors and Beliefs as a Function of Theoretical Orientation

One of the most consistent findings was that to a significantly greater degree than their colleagues, psychodynamically oriented clinicians affirmed the unethical nature of dual professional, financial, and social involvements of the type that have been noted as a concern in, for example, the formal ethical policy of the APA, and they refused to engage in these activities. It is possible that training in psychodynamic therapy emphasizes greater awareness of the importance of clear, nonexploitive, and therapeutically oriented roles, boundaries, and tasks, as well as of the sometimes subtle but potentially far-reaching consequences that may result from violating these norms. For example, psychodynamic theory and supervision stresses an informed and scrupulous awareness of the role that the therapist can play in the psychological life of the client, the context of that role, and possible implications when that role is altered, blurred, or distorted. Furthermore, psychodynamic training, with its attention to the needs, motives, and desires of the therapist, may place greater emphasis on the need for practitioners to recognize and avoid exploitive relationships that advance the welfare or pleasure of the therapist at the expense of the client.

Gender Issues

Pope et al. (1979), in a report of research that both replicated and extended (to student-teacher interactions) the landmark research of Holroyd and Brodsky (1977), noted a clear trend:

When sexual contact occurs in the context of psychology training or psychotherapy, the predominant pattern is quite clear and simple: An older, higher status man becomes sexually active with a younger, subordinate woman. In each of the higher status professional roles (teacher, supervisor, administrator, therapist), a much higher percentage of men than women engage in sex with those students or clients for whom they have assumed professional responsibility. In the lower status role of student, a far greater proportion of women than men are sexually active with their teachers, administrators, and clinical supervisors. (p. 687)

Of importance is that the researchers took into account and statistically adjusted for the overall proportions of men and women serving in the various roles of therapists, teachers, supervisors, and administrators, as well as the gender proportions among clients, students, and supervisees.

The subsequent national studies to date, without exception, are consistent with the principle stated by Pope et al. (1979). This research extends that principle.

First, the significant gender difference (i.e., a greater proportion of male than of female psychologists) that characterizes sexualized dual relationships conducted by both therapists and educators (teachers, clinical supervisors, and administrators) also characterizes nonsexual dual relationships conducted by therapists in the areas of social/financial involvements and dual professional roles. Male respondents tended to rate social/financial involvements and dual professional roles as more ethical and reported engaging in these involvements with more clients than did female respondents.

Second, the data suggest that male therapists tend to engage in nonsexual dual relationships more with female clients than with male clients. Although the results of the ANOVAS only approached rather than achieved significance, male therapists with primarily female clients rated social/financial involvements (p = .024) and dual professional roles (p = .029) as more ethical than did respondents in any other therapist--client gender pairing; similarly, financial involvements (p = .08) and dual professional roles (p < .05) were more frequent among male therapists with primarily female clients than with any other pairing.

Third, these trends hold for psychologists, psychiatrists, and clinical social workers.

Implications for Education and Training

Graduate training programs, internships, teaching hospitals and clinics, organizations providing continuing education, and other providers of formal and informal learning opportunities can, through careful attention to program planning and evaluation, help to increase sensitivity to those dual relationships that are unethical and potentially harmful and to ethical issues more generally. The following 10 steps may be useful to help to ensure that clinicians do not collude in a process of denial regarding particular ethical issues and of tolerating and enabling the perpetuation of exploitive and clinically harmful behavior.

1) Programs need to present the research-based literature in which the nature, causes, and consequences of dual relationships are explored. A reading list of published studies and reviews of the consequences of sexualized dual relationships with clients before and after termination, for example, might include works by Durre (1980); Bouhoutsos, Holroyd, Lerman, Forer, and Greenberg (1983); Feldman-Summers and Jones (1984); Vinson (1984); Sonne, Meyer, Borys, and Marhsall (1985); Pope and Bouhoutsos (1986); Brown (1988); Gabbard and Pope (1989); and Pope (1988).

2) The ethical and clinical implications of both sexual and nonsexual dual relationships, as well as of incidental involvements, need to be reflected in virtually all clinical coursework, supervision, and other forms of education. Pope et al. (1986) emphasized that such issues must not be limited to a specialized lecture or course and neglected in the rest of the curriculum. Educators may find useful the data and review of published resources concerning dual relationships provided by the Ethics Committee of the American Psychological Association (1988) .

3) Departmental chairs, training directors, and others with administrative responsibilities must avoid shortcuts and negligence in following formal policies and procedures to select faculty and staff who are sensitive to ethical issues. When organizations fail to check faculty or staff applicants' history of ethics, licensing, or malpractice complaints and, as a result, those who have a clear and uncontested record of serious ethical violations that have resulted in significant harm to patients are hired and promoted as teachers or supervisors, what message is being sent to students, practicing clinicians, and the public (Pope, 1989c)?

4) There is a need for clear and explicit institutional standards regarding any forms of dual relationships between students and educators that the institution finds unacceptable (Pope, 1989b). For example, is it acceptable for a student to be a therapy patient of, a business partner of, or engaging in sex with that student's current classroom professor in one or more courses, clinical supervisor, departmental chair, or program director? Educators, students, and supervisees need and deserve an honest and unambiguous statement of the ethical and clinical values expressed and supported by the organization, and clear guidelines regarding any relationships that the institution finds unacceptable.

5) There is a need for written, operationally defined procedures for avoiding conflicts of interest in monitoring and enforcing the institutional standards regarding dual relationships. For example, if clearly unethical, illegal, or clinically destructive activities come to the attention of a program director, he or she might experience a human and very understandable impulse to minimize the damage (e.g., from civil suits, bad publicity, institutional strife, and perhaps even the director's being replaced) to the program and the organization. This impulse may be in genuine or apparent conflict with a desire to investigate thoroughly and objectively and to ensure that all matters are adequately addressed rather than hastily and superficially dispensed with. A negligent, cursory, or trivializing approach to violations involving unacceptable sexual or nonsexual dual relationships may place numerous future patients at risk for serious harm and can send a clear message that ethical values are not taken seriously.

6) The practical consequences for those (professionals, students, clients, and others) who report violations of the standards need to be candidly acknowledged and adequately addressed. Published resources, such as the classic article "The Psychologist as Whistle Blower" (Simon, 1978), can help to uncover ways in which systems discourage accountability and promote indifference to or complicity with unethical and clinically destructive behavior.

7) Beyond the formal standards, programs need to provide an authentically safe and supportive environment in which students and educators alike can acknowledge and examine the seemingly unacceptable impulses that might tempt them to enter into those dual relationships that would be unethical. Beginning and seasoned clinicians may feel sexually aroused by or attracted to a client or a clinical supervisee (Pope et al., 1986), may experience a desire to make a financial killing and therefore to take advantage of a wealthy therapy patient through a business partnerships or other lucrative arrangements, or may be uncomfortable setting appropriate boundaries or limits and thus find it difficult to refuse to provide psychotherapy to an employee supervised by the therapist, and so on. Students are unlikely to disclose their genuine impulses if they infer that discussing one's sexual impulses may be reflexively labeled "seductive" and may serve as the basis for a teacher's advances or departmental gossip, that disclosing an enthusiastic love of money will result in a less-than-glowing letter of recommendation, and that revealing an embarrassing reluctance to disappoint people may be diagnosed as a pathognomonic sign that one needs to make a different career choice.

8) Students and clinicians alike need to be able to recognize and appreciate the human dimensions of an abstract-sounding issue such as "dual relationships." The research methodologies and theoretical analyses of the published works cited earlier in Step 1 can make for dry reading if they are not connected to recognizable individuals and practical experience. First-person accounts by clients who have experienced sexualized dual relationships are provided in published works by Freeman and Roy (1976), Plaisil (1985), Walker and Young (1986), and Bates and Brodsky (1988). Actual or fictionalized scenarios of various forms of nonsexual dual relationships have been presented by Hall and Hare-Mustin (1983), Keith-Spiegel and Koocher (1985), and the American Psychological Association (1987). Unjustifiable and hurtful activities (not limited to certain forms of unethical dual relationships but including incest, rape, and hitting a spouse--activities that, like certain harmful forms of dual relationships, involve a disproportionately large number of male perpetrators and a disproportionately large number of female victims/survivors) that may prompt considerable rationalization, justification, denial, trivialization, humor, and other mechanisms of toleration and complicity frequently become serious and intolerable when experienced, actually or vicariously, through the viewpoint of the victim/survivor.

9) Training institutions must encourage, conduct, learn from, and disseminate the findings of systematic research and serious investigations into the gender implications of certain kinds of dual relationships. A disproportionately large percentage of male professionals approve of and engage in a range of certain nonsexual and sexual dual relationships. A disproportionately large proportion of female clients and students are the recipients of such behavior. Why is behavior such as therapist-patient sexual involvements that appears to systematically discriminate against women allowed to continue in psychology, psychiatry, and social work? To what extent, if at all, does it express and perpetuate not only unacknowledged and unjustifiable assumptions about women but also other forms of gender discrimination? Whom does it benefit? Does the fact it is predomionately (though not exclusively) men who engage in sexual and nonsexual dual relationships in the role of therapist and educator and it is predomonately (though not exclusively) women who experience sexual and nonsexual dual relationships in the role of patient and student play any role in the professions' allocation of attention and resources to the topic, to the evaluation of harm resulting from such relationships, or to the number and degree of seriousness of any efforts at prevention (Pope, 1987)? The age of clients may also be an important variable to acknowledge. In sexualized dual relationships, for example, clients tend to be significantly younger than the therapists (Pope & Bouhoutsos, 1986). Although we did not investigate the age of clients, the prevalence of sexualized dual relationships with minor clients--with some female clients as young as 3 years old--appears to be a serious problem (Bajt & Pope, 1989; Pope, 1989c).

10) Training institutions need to identify, through careful research, those factors that encourage ethical sensitivity and behavior in contrast with those that increase the likelihood that clinicians will act in ways that put their clients or others at risk for harm. Pope et al. (1979), for example, found that when educators engaged in sexual dual relationships with their students, those students were significantly more likely, when they became clinicians, to engage in sexual dual relationships with their clients.

Conclusion

Pope et al. (1987) divided the 83 behaviors that they surveyed into seven categories (five of which were drawn from the Hippocratic Oath) suggested by Redlich and Pope (1980) , each reflecting a specific ethical principle:

• Above all, do no harm.
• Practice only with competence.
• Do not exploit.
• Treat people with respect for their dignity as human beings.
• Protect confidentiality.
• Act, except in the most extreme instances, only after obtaining informed consent.
• Practice, insofar as possible, within the framework of social equity and justice.

The behaviors providing the focus of our study seem related to Principle 3: "Do not exploit." Many of the respondents' comments explaining their ratings reflected this principle. Their comments regarding steps that they had taken to reduce social isolation and other stresses demonstrated that they recognized how crucial it is to avoid using clients to meet their own needs--social, sexual, professional, or financial--through dual relationships that were exploitive and to avoid discounting or justifying the process as necessary, inevitable, or helpful to clients. The ways in which they had sought out other, more adaptive arrangements to meet their needs reflect thoughtfulness, resourcefulness, and creativity in maintaining ethical behavior and avoiding the denial, rationalization, or perpetuation of harmful and exploitive behaviors.

References

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