Ethics of Practice:
The Beliefs and Behaviors of Psychologists as Therapists
Abstract:There is an absence of comprehensive, systematically gathered data concerning psychologists' beliefs about and compliance with ethical principles, and we know little about which resources are valued as effective in guiding appropriate behavior. A national sample of psychologists provided data regarding the degree to which they engaged in each of 83 behaviors and the degree to which they considered each behavior to be ethical. Examples of the 83 behaviors are: treating homosexuality per se as pathological; accepting a client's decision to commit suicide; discussing clients (without names) with friends; engaging in sexual fantasies about a client; going into business with a client; breaking confidentiality if a client is suicidal; charging a client no fee; making a custody evaluation without seeing both parents; hugging a client; signing for hours a supervisee has not earned; filing an ethics complaint against a colleague; performing forensic work for a contingency fee; altering a diagnosis to meet insurance criteria; breaking confidentiality to report child abuse; inviting clients to a party or social event; accepting goods as payment; seeing a minor client without parental consent; telling a client "I'm sexually attracted to you"; terminating therapy if a client cannot pay; asking favors from clients; using a law suit to collect fees; lending money to a client; becoming sexually involved with a former client; and engaging in sex with clinical supervisees. Twelve of the behaviors were very difficult for participants to evaluate on the basis of ethics. Seven of the 83 behaviors were practiced by over 90% of the participants; 16 by fewer than 10%. Colleagues, the APA Ethical Principles, and internship training were rated as the most helpful resources in guiding behavior; state and federal laws, published research, and local ethics committees were rated least helpful.
CITATION & COPYRIGHT: This article was published in American Psychologist, vol. 42, #11, pages 993-1006. The American Psychological Association holds the copyright. The copy of record is available at http://dx.doi.org/10.1037/0003-066X.42.11.993
The American Psychological Association (APA) has developed elaborate ethical principles and standards of practice to guide the behavior of its membership. However, we still lack comprehensive, systematically gathered data about the degree to which members believe in or comply with these guidelines. Consequently, such data are not available to inform either the clinical decisions of individual practitioners or the attempts of the APA to revise, refine, and extend formal standards of practice.
No implication is intended that norms are 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. For example, many of the standards set forth in the ancient and still honored Hippocratic Oath were held by a minority of the physicians at the time. But those who are charged with developing, disseminating, and enforcing professional codes can function much more effectively if they are aware of the diverse dilemmas confronting the membership and of the membership's varied personal codes and behaviors.
A survey questionnaire, a cover letter, and a return envelope were sent to 1,000 psychologists (500 men and 500 women) randomly selected from the members of Division 29 (Psychotherapy).
The survey questionnaire was divided into three main parts. The first part consisted of a list of 83 behaviors. Participants were asked to rate each of the 83 behaviors in terms of three categories. First, to what extent had they engaged in the behavior in their practice? Participants either could indicate that the behavior was not applicable to their practice or they could rate the behavior's occurrence in their practice as never, rarely, sometimes, fairly often, or very often. Second, to what extent did they consider the practice ethical? In rating whether each behavior was ethical, participants could use five categories: unquestionably not, under rare circumstances, don't know/not sure, under any circumstances, and unquestionably yes.
The second part of the questionnaire presented 14 resources for guiding or regulating practice. Participants were asked to rate each resource in terms of "the effectiveness. . . in providing education, direction, sanctions, or support to regulate the practice of psychologists (i.e., to promote effective, appropriate, and ethical practice)." Five options were available for rating each of these resources: terrible, poor, adequate, good, and excellent.
The third part of the questionnaire asked participants to provide information about their own age, sex, primary work setting, and major theoretical orientation.
Demographic Characteristics of the Participants and Ratings of the 83 Behaviors
Questionnaires were returned by 456 respondents (45.6%). Table I presents descriptions of the respondents in terms of sex, age, and primary work setting.
|Age Group -||45 and under||230||50.4|
|Age Group -||Over 45||226||49.6|
|Primary Work Setting -||Private office||330||72.4|
|Primary Work Setting -||Clinic||35||7.7|
|Primary Work Setting -||Hospital||26||5.7|
|Primary Work Setting -||University||48||10.5|
|Primary Work Setting -||Other||14||3.1|
|Primary Work Setting -||No answer||3||0.7|
Table 2 presents the theoretical orientations of the respondents.
Table 3 presents the percentage of respondents' ratings for each of the 83 behaviors in terms of occurrence in their own practice and the degree to which they believe the behavior to be ethical.
Occurence in your practice? 1 = never; 2 = rarely; 3 = sometimes; 4 = fairly often; 5 = very often; NA=not applicable.
Ethical? 1 = unquestionably not; 2 = under rare circumstances; 3 = don't know/not sure; 4 = under many circumstances; 5 =unquestionably yes.
|Occurrence in your practice?||Ethical?|
|1.||Becoming social friends with a former client||42.1||45.2||9.2||1.8||1.1||0.7||6.4||51.1||13.4||21.9||6.8|
|2.||Charging a client no fee for therapy||33.3||47.4||15.8||1.1||1.8||2.9||4.6||25.2||14.5||24.8||29.6|
|3.||Providing therapy to one of your friends||70.4||25.2||2.2||0.2||0.7||2.2||47.6||40.1||2.9||4.4||3.7|
|4.||Advertising in newspapers or similar media||72.4||13.2||10.1||2.4||0.4||5.5||12.9||14.7||17.8||33.3||20.6|
|5.||Limiting treatment notes to name, date, and fee||48.2||18.4||13.8||6.6||12.1||1.5||18.6||22.4||21.7||20.8||14.7|
|6.||Filing an ethics complaint against a colleague||61.6||25.2||7.5||0.7||1.1||10.7||2.4||11.8||3.1||22.8||57.9|
|7.||Telling a client you are angry at him or her||9.6||45.0||36.8||5.7||2.2||0.7||3.1||26.8||8.3||35.5||25.4|
|8.||Using a computerized test interpretation service||39.0||21.7||20.8||7.9||7.5||13.2||2.0||9.0||12.9||39.3||34.9|
|9.||Hugging a client||13.4||44.5||29.8||7.7||4.2||0.2||4.6||41.2||8.3||35.5||9.2|
|10.||Terminating therapy if client cannot pay||36.2||36.2||20.0||3.7||2.0||5.3||12.1||27.4||15.4||32.7||11.0|
|11.||Accepting services from a client in lieu of fee||66.9||27.0||3.5||0.2||0.4||7.9||22.6||39.3||14.5||16.0||6.4|
|12.||Seeing a minor client without parental consent||65.8||22.4||5.5||0.2||0.7||14.0||23.5||45.6||13.4||11.6||3.7|
|13.||Having clients take tests (e.g., MMPI) at home||43.9||27.0||16.0||4.8||3.5||10.7||20.2||25.9||19.5||22.1||10.1|
|14.||Altering a diagnosis to meet insurance criteria||36.4||26.5||27.0||5.5||2.6||2.9||37.3||28.9||16.0||14.0||2.0|
|15.||Telling client: "I'm sexually attracted to you."||78.5||16.2||3.5||0.2||0.2||4.8||51.5||33.1||5.5||6.8||2.4|
|16.||Refusing to let clients read their chart notes||33.1||21.3||13.6||5.7||14.9||23.2||14.5||28.3||14.9||21.5||16.0|
|17.||Using a collection agency to collect late fees||48.0||21.9||19.7||5.9||1.8||8.6||5.0||15.1||15.6||35.5||27.4|
|18.||Breaking confidentiality if client is homicidal||15.6||9.6||6.6||24.6||17.3||35.7||1.1||5.0||3.5||18.9||69.1|
|19.||Performing forensic work for a contingency fee||67.3||7.0||6.8||0.9||0.7||42.1||35.5||11.0||29.8||7.0||10.3|
|20.||Using self-disclosure as a therapy technique||5.9||22.1||38.6||19.7||12.9||0.7||2.2||17.1||7.9||43.0||29.2|
|21.||Inviting clients to an office open house||76.3||9.6||5.0||0.7||2.0||19.3||28.9||25.7||23.2||12.1||8.3|
|22.||Accepting a client's gift worth at least $50||72.1||19.1||2.4||0.4||0.0||16.7||34.2||36.2||15.8||8.6||3.3|
|23.||Working when too distressed to be effective||38.8||48.5||10.5||0.4||0.2||5.3||46.7||38.4||8.6||4.4||1.3|
|24.||Accepting only male or female clients||83.8||3.7||2.4||0.2||1.1||18.2||11.0||16.2||18.6||16.9||34.6|
|25.||Not allowing client access to testing report||45.0||23.5||13.6||5.9||6.6||14.3||21.7||32.9||14.0||20.6||8.8|
|26.||Raising the fee during the course of therapy||27.6||23.9||29.4||11.8||5.7||3.5||8.3||15.8||13.2||32.5||28.9|
|27.||Breaking confidentiality if client is suicidal||16.2||24.6||25.0||9.6||19.3||11.8||2.0||10.1||5.5||23.5||57.5|
|28.||Not allowing clients access to raw test data||32.2||10.5||9.0||7.9||30.0||1.8||12.1||12.9||11.2||22.8||36.8|
|29.||Allowing a client to run up a large unpaid bill||12.5||44.1||34.4||5.7||1.5||2.9||7.2||35.3||22.8||16.9||16.4|
|30.||Accepting goods (rather than money) as payment||65.1||24.8||6.4||0.2||0.4||12.7||15.8||33.8||21.3||18.2||9.6|
|31.||Using sexual surrogates with clients||81.8||5.7||1.1||0.7||0.2||33.1||36.2||25.7||23.7||8.6||4.6|
|32.||Breaking confidentiality to report child abuse||25.0||16.2||15.1||8.3||22.6||29.4||1.3||4.4||5.3||20.8||64.9|
|33.||Inviting clients to a party or social event||82.9||13.2||2.2||0.2||0.4||4.6||50.0||34.0||8.1||6.1||1.5|
|34.||Addressing client by his or her first name||2.0||2.6||9.4||20.8||65.1||0||0.7||0.9||2.6||30.7||65.1|
|35.||Crying in the presence of a client||42.5||41.5||12.5||1.8||0.7||4.6||5.9||32.0||14.5||18.4||27.6|
|36.||Earning a salary which is a % of client's fee||46.3||4.4||10.1||3.5||5.3||41.0||12.1||8.1||34.2||16.0||16.4|
|37.||Asking favors (e.g., a ride home) from clients||60.5||35.7||2.4||0||0.2||5.0||27.0||45.2||12.3||10.1||4.4|
|38.||Making custody evaluation without seeing the child||76.8||7.2||1.3||0.2||0.2||36.0||64.0||22.8||5.3||2.4||0.9|
|39.||Accepting a client's decision to commit suicide||73.9||16.4||3.7||0.4||0||15.4||45.2||36.6||8.8||4.8||2.9|
|40.||Refusing to disclose a diagnosis to a client||49.8||30.9||10.1||4.6||2.4||4.2||21.5||43.2||13.2||13.4||6.8|
|41.||Leading nude group therapy or "growth" groups||88.6||2.2||0.9||0.2||0||24.3||59.6||16.4||14.9||3.9||2.9|
|42.||Telling clients of your disappointment in them||46.9||39.0||11.4||1.1||0.4||2.6||19.7||37.1||18.0||15.4||7.9|
|43.||Discussing clients (without names) with friends||22.8||46.3||22.4||5.7||2.0||0.9||32.9||38.6||13.8||9.4||4.6|
|44.||Providing therapy to your student or supervisee||63.8||22.4||6.8||0.9||0.9||12.3||45.8||33.6||6.1||8.8||4.2|
|45.||Giving gifts to those who refer clients to you||78.5||11.4||7.0||1.5||1.1||4.2||47.8||21.7||15.6||10.3||4.2|
|46.||Using a law suit to collect fees from clients||62.7||21.3||10.3||0.2||0.4||15.4||10.1||28.3||19.3||19.7||21.1|
|47.||Becoming sexually involved with a former client||88.2||10.5||0.4||0||0.2||7.5||50.2||34.4||7.2||3.9||3.3|
|48.||Avoiding certain clients for fear of being sued||48.9||30.3||13.4||1.3||0.9||13.8||7.9||23.0||23.7||23.9||19.7|
|49.||>Doing custody evaluation without seeing both parents||63.8||16.9||6.6||0.7||0.2||30.5||47.1||31.6||10.7||3.9||2.6|
|50.||Lending money to a client||73.7||23.9||1.5||0||0||4.4||40.6||38.8||10.7||5.9||3.3|
|51.||Providing therapy to one of your employees||79.6||12.9||2.0||0||0.7||15.6||55.0||31.1||6.8||2.9||2.4|
|52.||Having a client address you by your first name||3.5||10.5||21.9||21.9||41.9||0.4||1.3||3.3||7.9||23.5||63.6|
|53.||Sending holiday greeting cards to your clients||61.4||16.2||12.9||3.1||4.8||5.3||10.5||12.9||26.8||20.4||28.5|
|54.||Kissing a client||70.8||23.5||4.4||0.2||0.4||2.2||48.0||36.6||4.6||7.7||2.2|
|55.||Engaging in erotic activity with a client||97.1||2.4||0.2||0||0||3.9||95.0||3.5||0.4||0.4||0.4|
|56.||Giving a gift worth at least $50 to a client||95.0||3.7||0.4||0||0||4.6||69.7||16.0||8.1||2.9||2.6|
|57.||Accepting a client's invitation to a party||59.6||34.9||4.4||0.2||0.4||2.9||25.7||46.1||10.1||10.7||6.8|
|58.||Engaging in sex with a clinical supervisee||95.0||2.9||0.4||0||0||8.8||85.1||9.0||3.5||1.5||0.2|
|59.||Going to client's special event (e.g., wedding)||23.5||50.7||20.4||3.3||1.5||0.4||5.3||34.0||13.8||28.7||17.5|
|60.||Getting paid to refer clients to someone||98.0||0.4||0.2||0||0||7.2||88.4||7.2||3.3||0||0.2|
|61.||Going into business with a client||95.6||1.5||0.2||0||0.2||9.9||78.5||12.7||5.5||1.1||1.1|
|62.||Engaging in sexual contact with a client||97.8||1.5||0.4||0||0||4.2||96.1||2.6||0.2||0.7||0.2|
|63.||Utilizing involuntary hospitalization||30.5||42.1||16.7||2.4||1.1||17.1||3.1||28.9||8.8||24.3||31.8|
|64.||Selling goods to clients||90.6||5.9||2.0||0||0.4||7.5||71.1||18.4||.4||2.9||2.0|
|65.||Giving personal advice on radio, t.v., etc.||66.0||18.6||9.2||1.5||0.2||18.6||18.4||28.3||22.1||23.7||6.4|
|66.||Being sexually attracted to a client||9.2||38.8||43.9||5.5||1.3||1.1||11.2||11.0||19.5||19.1||33.3|
|67.||Unintentionally disclosing confidential data||36.0||58.6||3.3||0||0||2.9||75.2||14.3||4.6||1.8||1.8|
|68.||Allowing a client to disrobe||94.5||2.9||1.5||0||0||5.0||81.4||12.1||3.1||1.5||1.3|
|69.||Borrowing money from a client||97.1||1.8||0||0||0||4.4||86.2||10.7||1.1||0.4|
|70.||Discussing a client (by name) with friends||91.2||7.5||0.4||0.2||0||3.5||94.5||3.5||0.7||0.4||0.4|
|71.||Providing services outside areas of competence||74.8||22.8||1.8||0||0||2.0||80.7||16.9||0.2||0.9||0.7|
|72.||Signing for hours a supervisee has not earned||89.0||7.2||0.9||0||0||9.9||92.5||5.5||0.4||0.4||0.7|
|73.||Treating homosexuality per se as pathological||75.0||12.7||6.4||2.6||1.8||4.4||55.7||12.9||17.3||6.6||5.3|
|74.||Doing therapy while under influence of alcohol||92.8||5.7||0.2||0||0||3.5||89.5||7.7||1.1||0||0.9|
|75.||Engaging in sexual fantasy about a client||27.0||46.3||22.4||2.4||0.7||3.5||18.9||15.1||26.8||13.2||21.9|
|76.||Accepting a gift worth less than $5 from a client||8.6||31.8||45.0||9.4||3.7||0.7||5.0||20.0||16.2||36.4||20.2|
|77.||Offering or accepting a handshake from a client||1.3||3.3||17.5||28.1||48.2||1.1||0.7||1.1||3.3||21.7||71.9|
|78.||Disrobing in the presence of a client||97.8||0.9||0||0.2||0.2||4.6||94.7||3.3||0||0.2||0.7|
|79.||Charging for missed appointments||11.8||15.4||26.3||22.6||22.6||2.4||1.1||6.8||7.2||38.2||45.2|
|80.||Going into business with a former client||83.1||10.1||2.0||0||0.4||15.6||36.8||28.9||17.5||9.0||5.9|
|81.||Directly soliciting a person to be a client||89.3||8.6||0.9||0||0.2||4.4||67.5||22.6||5.7||1.8||1.5|
|82.||Being sexually attracted to a client||9.2||39.5||41.0||6.1||0.9||1.3||9.2||13.4||21.9||18.0||30.0|
|83.||Helping client file complaint re a colleague||52.9||19.4||9.4||1.1||1.1||20.0||6.4||22.6||14.9||29.2||25.2|
Resources for Regulating Psychology
Table 4 presents the respondents' ratings of each of the 14 resources for regulating psychology.
|Your graduate program||5.3||19.1||27.0||29.6||18.2|
|Agencies for which you've worked||5.0||16.2||31.4||30.7||12.9|
|State and federal laws||3.9||32.7||39.0||18.4||1.8|
|Court decisions (case law)||4.6||30.5||29.6||25.4||4.2|
|State licensing board||5.9||21.7||35.7||25.9||6.8|
|APA Ethical Principles||1.1||5.9||26.3||45.8||19.1|
|APA Ethics Commitee||2.0||11.4||32.9||36.8||12.9|
|State ethics committee||3.3||20.8||32.9||28.5||7.0|
|Local ethics committee||6.4||22.8||29.4||20.8||4.8|
|Published clinical and theoretical work||4.8||20.0||33.1||29.2||7.2|
|Continuing education programs||2.4||19.1||29.6||33.6||9.2|
|Colleagues (informal network)||1.1||6.6||18.9||43.4||28.1|
Note: Rows may not sum to 100% due to missing data or rounding.
A mixed between-between-within analysis of variance was performed on ratings of the 14 resources. Between-subjects factors were the two age groups and sex. The within-subjects factor was composed of the 14 resources. With a Huyn-Feldt adjustment for heterogeneity of covariance, a highly significant difference in ratings was found as a function of type of resource, F(13, 4316) = 55.24, p < .001. Type of resource accounted for 14% of the variance in ratings, using eta-squared. Because of the magnitude of design, an alternative form of eta squared was used in which the denominator is the sum of the effect being described and its error term. Schere-adjusted pairwise comparisons among the 14 means revealed that 48 of the 91 differences were and differences among those means appear in Table 5.
|4.||State and federal laws||2.84||.52*||.87*||.46*|
|6.||State licensing board||3.06||.30||.65*||.25||.22||.07|
|7.||APA Ethical Principles||3.77||.41*||.06||.46*||.93*||.79*||.71*|
|8.||APA Ethics Commitee||3.47||.11||.24||.17||.63*||.49*||.42*||.29|
|9.||State ethics committee||3.17||.19||.54*||.14||.33*||.18||.11||.60*||.31|
|10.||Local ethics committee||2.95||.41*||.76*||.36*||.11||.04||.11||.82*||.53*||.22|
|12.||Published clinical and theoretical work||3.10||.26||.61*||.21||.26||.11||.04||.67*||.38*||.07||.15||.26|
|13.||Continuing education programs||3.25||.11||.46*||.06||.41*||.26||.19||.52*||.23||.08||.30||.41*||.15|
*p<.01, Scheffé criterion
On the average, older clinical psychologists rated the resources higher (mean rating = 3.36) than those who were younger (mean rating = 3.17), F(1, 32) = 8.88, p < .01, eta-squared = .03. No statistically significant main effect of sex was found.
The interaction between age group and resource was reliable, F(13, 4316) = 2.29, p < .05, but of small magnitude, eta-squared < .01. Applying a Schefféé criterion at a = .01, differences between younger and older psychologists were statistically reliable for only three resources: state licensing board (older, M = 3.25; younger, M = 2.86), state ethics committee (older, M = 3.36; younger, M = 2.97), and local ethics committee (older, M = 3.12; younger, M = 2.77). None of the other interactions was statistically significant.
Behaviors Systematically Related to Sex of Psychologist
In order to assess the degree to which male and female psychologists might be differentially engaging in the 83 behaviors, chi-square analyses were performed on these data. To help eliminate seemingly significant findings actually due to chance-in light of the large number of analyses- a very strict significance level (p < .00 1) was used. Table 6 presents the items significantly related to sex, using this criterion.
|9.||Hugging a client||Female more likely||18.70||4|
|15.||Telling a client: "I'm sexually attracted to you."||Male more likely||16.29||2|
|52.||Having a client address you by your first name||Female more likely||20.00||4|
|73.||Treating homosexuality per se as pathological||Male more likely||19.26||4|
|75.||Engaging in sexual fantasy about a client||Male more likely||40.39||4|
|81.||Directly soliciting a person to be a client||Male more likely||11.24||1|
Validity and Interpretation Issues
Caution is essential in interpreting these data. First, this is an initial study, and it awaits attempts at replication. Second, it is unclear how the behaviors and beliefs of this sample of Division 29 members compare with those of the over 60,000 APA members, of the close to 50,000 individuals (both APA and non-APA members) who are licensed or certified by the states to practice psychology (Dörken, Stapp, & VandenBos, 1986), or of the approximately 63% of licensed, doctoral psychologists who identify clinical psychology as their current major field (Stapp, Tucker, & VandenBos, 1985). Third, the behavior of the majority may not reflect what the majority themselves believe to be ethical. For example, almost two thirds of the participants reported that they have disclosed confidential material unintentionally, yet three fourths identify this behavior as unethical. Fourth, specific ethical standards may not be reflected in majority belief. Most psychologists, for example, may be unfamiliar with the procedures, research, or complexities of such special areas as treating minors, performing forensic work, engaging in sex with former clients, or working with suicidal clients. As previously mentioned, the formulation and dissemination of formal ethical standards can represent attempts to improve ethical awareness and behavior. Empirical data about the behavior and beliefs of a general sample should inform-not determine-our ethical deliberations. Finally, most of the questionnaire items involve enormously complex issues. The following discussion is meant only to highlight some of the major themes, patterns, and dilemmas emerging from these initial data.
Relationship Between Behavior and Beliefs
The data suggest that the psychologists' behavior was generally in accordance with their ethical beliefs. This inference is based on the fact that for all but tour items, the frequency with which the respondents reported engaging in a behavior was less than the frequency of instances in which the behavior was ethical in their judgment. Of the four exceptions, three involved confidentiality: "discussing a client (by name) with friends," "discussing clients (without names) with friends," and "unintentionally disclosing confidential data." The fourth exception was "providing services outside areas of competence." *
Behaviors That Are Almost Universal
For 7 of the 83 items, at least 90% of the respondents indicated that they engaged in the behavior, at least on rare occasions (see Table 3). Two of these almost universal behaviors involved self-disclosure to the clients: "using self-disclosure as a therapy technique" and "telling a client that you are angry at him or her." Thus, it appears that the more extreme versions of the therapist as "blank screen" are exceedingly rare among psychologists. Similarly, the models of the therapist as a distant, almost standoffish authority figure-which, like the "blank screen" approach, are derived from the classical psychoanalytic tradition-are infrequently practiced. Fewer than 10% of the respondents indicated that they never engaged in "having a client address you by you first name" (as Table 6 shows, it is mainly male therapists who insist on being addressed by their last names), "addressing your client by his or her first name," "accepting a gift worth less than $5 from a client," and "offering or accepting a handshake from a client." Finally, only 9.2% of the respondents indicated that they had never been sexually attracted to a client. This finding may be compared to a national survey of psychologists in which 13% indicated that they had never been sexually attracted to a client (Pope, Keith-Spiegel, & Tabachnick, 1986).
Behaviors That Are Rare
One of the most surprising results was that only 1.9% of the respondents reported engaging in sexual contact with a client and that only 2.6% reported engaging in erotic activity (which may or may not involve actual contact) with a client. Previously, there have been three national surveys of sexual intimacies between psychologists and their patients. Holroyd and Brodsky (1977) reported 7.7% respondents "who answered positively any of the questions regarding erotic-contact behaviors or intercourse during treatment." Pope, Levenson, and Schover (1979) found that 7% of the therapists in their survey reported engaging in sexual contact with their clients. Pope et al. (1986) reported that 6.5% of their respondents acknowledged engaging in sexual intimacies with clients.
It is difficult to explain the discrepancy between the current findings and those of the previous three studies. It may be that respondents are now less willing to admit, even on anonymous survey, to a behavior that is a felony in some states, or it may be that these findings are reflective of random sampling error or bias in return rate rather than of a change in behavior.
However, the current findings may indicate an actual decrease in the percentage of psychologists engaging in sexual intimacies with their patients. The increasing publicity given to the consequences of therapist-patient sexual involvment (Bouhoutsos, Holroyd, Lerman, Forer, & Greenberg, 1983; Feldman-Summers & Jones, 1984; Pope & Bouhoutsos, 1986), as well as the vivid first-person accounts of patients who have been sexually involved with their therapists (Freeman & Roy, 1976; Plaisil, 1985; Walker & Young, 1986), may be significantly altering the behavior of psychologists who are tempted in this area. For additional information on this topic, see Pope, Sonne, and Holroyd, 1993; Pope, 1994, 2000.
Some other items concerning sexual behaviors- such as nudity as part of therapy or using sexual surrogates with clients-also had extremely low rates. Engaging in sex with a clinical supervisee was reported by only 3.4% of the respondents. This figure corresponds closely to the 4.0% in a prior survey of APA Division 29 members who reported engaging in sexual intimacies with their clinical supervisees (Pope et al., 1979).
Dishonesty in helping candidates to become degreed or licensed without the requisite supervised experience is relatively rare; it was reported by 8.1%.
A number of the rare practices concerned financial or business practices, such as borrowing money from a client, selling goods to clients, going into business with a client, or giving a gift worth at least $50 to a client. The most infrequently reported behavior was getting paid to refer clients to someone (0.6%). It is heartening to note that psychologists are not putting their judgment and influence up for sale.
Although over a fourth (26.1%) of the respondents advertise in newspapers and similar media, only 9.7% report directly soliciting a person to be a client. As Table 6 indicates, men were more likely than women to engage in this practice.
Few psychologists blatantly breach the confidentiality of their clients. However, 8.1% have discussed a client (by name) with friends.
Doing therapy while under the influence of alcohol is also rare (5.9%).
For the most part, psychologists are careful to interview the child when making a custody evaluation, although 8.9% fail to do so.
A gender-based criterion for admission to treatment is rare. Accepting only male or female clients was reported by 7.4%.
Although rare, some of these practices-such as discussing clients by name with friends or doing therapy while under the influence of alcohol-so clearly undermine the rights and welfare of patients that they need to be addressed much more forcefully and effectively by the profession.
We defined a difficult judgment as one in which at least 20% of the respondents indicated "don't know/not sure." There were 12 behaviors that posed difficult judgments in terms of whether they were ethical: "performing forensic work for a contingency fee," "accepting goods (rather than money) as payment," "using sexual surrogates with clients," "earning a salary which is a percentage of client fees," "avoiding certain clients for fear of being sued," "sending holiday greeting cards to your clients," "giving personal advice on radio, t.v., etc.," "engaging in sexual fantasy about a client," "being sexually attracted to a client," "limiting treatment notes to name, date, and fee," "inviting clients to an office open house," and "allowing a client to run up a large unpaid bill." It is interesting that one third of these directly concerned financial issues, and one fourth concerned sexual issues. The profession may need to develop practical guidelines in these areas.
Redlich and Pope (1980) suggested seven principles for meaningfully coordinating ethical guidelines with other standards of professional practice in a way that can be most useful to psychologists and psychiatrists attempting to carry out their professional tasks responsibly. These are (1) above all, do no harm; (2) practice only with competence; (3) do not exploit; (4) treat people with respect for their dignity as human beings; (5) protect confidentiality; (6) act, except in the most extreme instances, only after obtaining informed consent; and (7) practice, insofar as possible, within the framework of social equity and justice. The first five are ancient and are mentioned explicitly in the Hippocratic Oath. The sixth and seventh are of recent origin, express patients' rights, and have not yet been universally accepted. This seven-part framework organizes the following discussion of the questionnaire items.
1. Do No Harm
Lending money to a client. It is ironic that lending money to a client-an act that might seem to be generous and helpful-would be viewed as so harmful to the therapeutic enterprise as to be clearly unethical by 40.6% of the respondents and unethical under most circumstances by an additional 38.8%. Nevertheless, about one fourth of the respondents acknowledged that they had lent money to a client (23.9% rarely; 1.5% sometimes).
Signing for unearned hours. A clear majority (92.5%) believe that signing for hours that a supervisee has not earned is unethical. Producing graduates and licensees whose credentials were fraudulently obtained may subject numerous future clients to harm.
Filing ethics complaints. The injunction to do no harm can be construed to include the mandate not to remain passively acquiescent when fellow professionals are violating ethical principles and standards of practice. A surprising finding was that one fourth of the respondents reported that they had, on a rare basis, filed an ethics complaint against a colleague. An additional 9.3% reported that they did so more frequently.
The view that it is unethical always (2.4%) or under most circumstances (11.8%) to file an ethical complaint against a colleague may reflect the difficulties experienced by an association (the APA) charged with the task of promoting the profession when it also attempts to monitor and discipline the behavior of its members. Furthermore, the practical steps for effective peer monitoring may need to be more widely disseminated (see Keith-Spiegel & Koocher, 1985; Pope & Vasquez, 1999).
Helping a client file an ethics complaint was a behavior performed by over one third of the respondents on a rare (19.4%) or more frequent (11.6%) basis. Over one fourth believed that this action was unethical (6.4%) or unethical under most circumstances (22.6%).
2. Practice Only With Competence
Providing services outside areas of competence. Almost one fourth of the respondents indicated that they had practiced outside their area of competence either rarely (22.8%) or sometimes (1.8%).
Impaired performance. Psychology has turned increased attention to the impaired or distressed professional (Kilburg, Nathan, & Thoreson, 1986; Laliotis & Grayson, 1985; Pope & Tabachnick, 1994; Pope & Vasquez, 1999). The results of this survey suggest that those efforts are needed. Over half (59.6%) of the respondents acknowledged having worked-either rarely or more often-when too distressed to be effective. About 1 out of every 15 or 20 (5.7%) respondents acknowledged, on a rare basis, doing therapy while under the influence of alcohol.
Competence in carrying out assessments. In the area of assessment, what seem like efficient and competent short-cuts or innovative strategies to some may seem questionable to others (see Pope, Butcher & Seelen, 2000; Pope & Vasquez, 1999). Sending tests home with clients is said, by its advocates, to be more convenient and to allow clients to fill out the test in more familiar, less stressful surroundings. Critics of the practice argue that psychologists should monitor the administration of such tests- for example, to prevent clients from relying on the advice of friends and family about how to fill out the test. Furthermore, maintain the critics, should the test results become part of important legal proceedings, the psychologist would be unable to testify that the test responses were those of the client unaided by friends or family. The current study indicates that over half of the respondents send such tests home with clients either on a rare (27.0%) or more frequent (24.3%) basis. This practice is viewed as unethical by 20.2% and unethical in most circumstances by 25.9%.
The use of computerized psychological test interpretations has been harshly criticized (Matarazzo, 1986). The current findings indicate that a majority of the respondents have used such services either rarely (21.7%) or more often (36.2%). Few believe that they are unethical (2.0%) or unethical under most circumstances (9.0%).
Some literature in the field of child-custody conflicts indicates that a competent custody evaluation cannot be conducted without interviewing both parents. Shapiro (1984), for example, wrote that "under no cirumstances should a report on child custody be rendered to the court, based on the evaluation of only one party to the conflict" (p. 99). About half of the respondents agree that doing a custody evaluation without seeing both parents is unethical. Only 16.9% reported that they had done this rarely, 7.5% more frequently.
3. Do Not Exploit
Sexual issues and physical contact. As mentioned earlier, the rates of sexual contact and erotic activities with patients are significantly lower than in the previously reported national studies of psychologists. Over 95% of the respondents believed that both of these behaviors were unethical.
About half of the respondents believed that becoming sexually involved with a former client was unethical. (This figure may be compared to the 6.4% who believe that becoming friends with a former client is unethical.) These beliefs seem consistent with the harm that can be associated with these relationships (Pope & Bouhoutsos, 1986; Pope, 1994), with the awarding of general and punitive damages in malpractice suits in which the sexual intimacies occurred only after termination (e.g., Whitesell v. Green, 1973), and with a multiyear study of the adjudications of state licensing boards and state ethics committees (Sell, Gottlieb, & Schoenfeld, 1986). The study found "that psychologists asserting that a sexual relationship had occurred only after the termination of the therapeutic relationship were more likely to be found in violation than those not making that claim" (p. 504).
The focus on erotic contact in therapy has raised questions about the legitimacy and effects of ostensibly nonerotic physical contact (Geller, 1980; Holroyd & Brodsky, 1977, 1980; Pope, Sonne & Holroyd, 1993). Holroyd and Brodsky (1980) pointed out that it "is difficult to determine where 'non-erotic hugging, kissing, and affectionate touching' leave off and 'erotic contact' begins" (p. 810). About one fourth of our respondents reported kissing their clients, either rarely (23.5%) or more often (5.0%). About half viewed this practice as unethical. An additional 36.6% believed it to be unethical in most circumstances.
Hugging clients was practiced by 44.5% of the respondents on a rare basis, and by an additional 41.7% more frequently. Few (4.6%) believed the practice to be clearly unethical, but 4 1.2% believed it to be ethical only under rare circumstances.
The findings in the previous two categories may be compared to the results reported by Holroyd and Brodsky (1977) in which 27% of the therapists reported occasionally engaging in nonerotic hugging, kissing, or affectionate touching with opposite-sex patients, and 7% reported doing so frequently or always.
Almost all respondents offered or accepted a hand-shake from a client, either rarely (48.9%) or more frequently (48.2%). Very few found the behavior to be ethically questionable.
As mentioned earlier, using sexual surrogates with clients was a difficult ethical judgment for almost one fourth of the respondents. A little over one third believed that the behavior was unethical. An additional one fourth believed it was ethical only under rare circumstances.
A large majority (85.1%) believe that sexual intimacies with clinical supervisees are unethical, a finding consistent with published analyses of this practice (Pope & Bouhoutsos, 1986; Pope, Schover, & Levenson, 1980; Pope & Vasquez, 1999).
Over 1 out of every 10 respondents believed that simply "being sexually attracted to a client" was unethical. Approximately an additional one tenth believed that feeling such attraction was ethical under rare circumstances. These findings seem consistent with the results of a prior survey in which 63% of the respondents reported that experiencing sexual attraction to clients made them feel guilty, anxious, or confused (Pope et al., 1986; see also Bernsen, Tabachnick, & Pope, 1994 for a study comparing social workers to psychologists in regard to sexual attraction to clients).
Almost half (46.3%) of the respondents reported engaging in sexual fantasy about a client on a rare basis, an additional one fourth (25.5%) more frequently. These figures may be compared to the 28.7% of psychologists in a previous study who answered affirmatively the question, "While engaging in sexual activity with someone other than a client, have you ever had sexual fantasies about someone who is or was a client?" (Pope et al., 1986). Both the current and previous survey found that male psychologists were significantly more likely to engage in sexual fantasies about clients. This difference is consistent with research regarding sexual fantasizing in general, which shows higher rates for men (Pope, 1982).
Financial issues. The vulnerability, dependency, and sometimes confusion of so many who seek help from psychologists call for a strong ethic against financial exploitation, as well as extensive research to determine which financial arrangements work best for therapist and patient. Yet until the 1970s, the subject was virtually absent from the research literature. Volumes attempting comprehensive collection, review, and evaluation of research in psychotherapy (Bergin & Garfield, 1971; Rubinstein & Parloff, 1959; Shlien, 1968; Strupp & Luborsky, 1962) cited no research on financial arrangements, prompting one contributing author to comment: "As a footnote, I would like to remark that if a Martian read the volumes reporting the first two psychotherapy conferences and if he read all the papers of this conference it would never occur to him that psychotherapy is something done for money. Either therapists believe that money is not a worthwhile research variable or money is part of the new obscenity in which we talk more freely about sex but never mention money" (Colby, 1968, p. 539).
Mintz (1971) likewise labeled fees a "tabooed subject" and suggested that "a varied set of guidelines" concerning fee payment has "functioned to inhibit therapists from inquiring too closely into the financial side of psychotherapeutic practice and into the actual effects it may have on the therapeutic enterprise" (p. 3).
In more recent decades such factors as the increase in third-party payments have brought financial issues into the open. As the results of this study reveal, psychologists have developed a consensus of opinion about the acceptability of some-but by no means all-of the financial approaches to their work.
Over half of the respondents reported altering an insurance diagnosis to meet insurance criteria, either rarely (26.5%) or more frequently (35.1%). This action- which can be legally construed as insurance fraud-is viewed by slightly more than one third as unethical. An additional one fourth viewed it as ethical under rare circumstances. This widespread practice-in light of its legal implications and the use of dishonesty in the therapeutic endeavor-is in need of open discussion among professionals.
Charging for missed appointments seems an acceptable practice to virtually the entire psychological community. Raising a fee during the course of therapy 'also seems widely accepted.
About half (49.3%) of the respondents have used a collection agency to collect late fees, at least on a rare basis. Only 5% view this practice as unethical.
About one third (21.3% rarely; 10.9% more often) of the respondents have filed a lawsuit to collect fees. One out of 10 (10.1%) view this as unethical.
Accepting a salary that is a percentage of client fees- a practice sometimes known as "kick-backs" or "fee-splitting" (Keith-Spiegel & Koocher, 1985)-was reported by 23.3% of the respondents. It is viewed as unethical by 12.1%. This was the item with the lowest response rate by far, suggesting that many respondents may have been unsure of the meaning of the question.
In another area, forensic psychology, psychologists may be tempted to accept a contingency fee (Pope, Butcher, & Seelen, 2000). Standard texts have made clear statements concerning the unacceptability of such arrangements. "The psychologist should never accept a fee contingent upon the outcome of a case" (Blau, 1984, p. 336). "The expert witness should never, under any circumstances, accept a referral on a contingent fee basis" (Shapiro, 1984, p. 95). Only about 15% of the respondents report engaging in this practice either rarely (7.0%) or more often (8.4%).
About one fourth of the respondents reported that they had engaged in bartering, at least on a rare basis. Over half viewed the practice as either unethical or unethical under most circumstances.
Other dual relationships. Both sexual intimacy with clients and bartering for services may be considered by some as dual relationships. The current study inquired into three areas that might also be considered as dual relationships: therapy with employees, students/supervisees, and friends. The most frequent dual relationship involved students and supervisees (22.4% rarely; 8.6% more frequently), followed by friends (25.2% rarely; 3.1% more frequently) and employees (12.9% rarely; 2.7% more frequently).
Dual relationships can also be initiated once therapy begins, as happens when a therapist engages in sexual contact with a patient. According to the respondents, initiating business relationships with clients (1.5% rarely; 0.4% more frequently) and former clients (10.1% rarely; 2.4% more frequently) is not a widespread practice.
Advertising for and soliciting clients. About one fourth of the respondents report advertising in newspapers and similar media, either rarely (13.2%) or more frequently (12.9%).
Fewer than 10% of the respondents (generally male psychologists) directly solicit clients. At least two thirds view this practice as unethical.
4. Treat People With Respect for Their Dignity as Human Beings
To some extent, the history of psychotherapy has reflected the struggle to arrive at the most effective way in which to express respect. For example, Thompson (1950) discussed the ways in which, because of suspicions about countertransference, the feeling grew that even a genuine objective feeling of friendliness on his part was to be suspected. As a result many of Freud's pupils became afraid to be simply human and show the ordinary friendliness and interest a therapist customarily feels for a patient. In many cases, out of a fear of showing countertransference, the attitude of the analyst became stilted and unnatural. (p. 107)
In this study, we found that many of the walls that prevented therapists from engaging in simple human interactions-for example, therapists revealing their emotions-have come down, although therapists are still in a quandary about some of these issues.
An overwhelming majority of the respondents are on a first-name basis with their clients and do not view this as ethically questionable. Three fourths have attended a client's social event, such as a wedding, although only about one third have accepted an invitation to a party. About one fourth view accepting a party invitation as unethical. About the same percentage have invited clients to an office open house, but slightly more (28.9%) view this as unethical.
A large majority (93.3%) use self-disclosure. More specifically, over half tell clients that they are angry with them (89.7%), cry in the presence of a client (56.5%), and tell clients that they are disappointed in them (5 1.9%). The most questioned of these was telling clients of disappointment: 56.8% viewed it as unethical or unethical under most circumstances.
5. Protect Confidentiality
Breaking confidentiality to prevent harm. The results of this study suggest that psychologists have accepted the legitimacy of breaking confidentiality in order to prevent danger. Fewer than 10% view this action as unethical in cases involving homicide, suicide, or child abuse.
The data also indicate that such situations are a customary part of general practice for psychologists: 78.5% report having broken confidentiality in regard to suicidal clients, 62.2% in cases of child abuse, and 58.1% when the client was homicidal.
Informally or unintentionally breaking confidentiality. About three fourths discuss clients-without names-with friends. Only 8.1% discuss clients-with names-with friends. Surprisingly, over half (61.9%) have unintentionally disclosed confidential data.
Public psychology. When psychological services are performed in a public forum, of course, there is no confidentiality. Giving personal advice on radio, TV, and so forth, is a very difficult issue. More than one in five indicated that they did not know or were not sure if it was ethical.
Surprisingly, over one fourth of the respondents reported giving such advice in the media either rarely (18.6%) or more frequently (10.9%).
6. Acting Only With Informed Consent
Seeing a minor without parental consent. A major ethical, as well as legal, dilemma is faced by many psychologists when the client is not empowered to give adequate consent to treatment (Koocher, 1976; Melton, 1981; Morrison, Morrison, & Holdridge-Crane, 1979; Plotkin, 1981; Pope & Vasquez, 1999). Over one fourth of the respondents have elected to see a minor without parental consent either rarely (22.4%) or more frequently (6.4%). Over half of the respondents believe such treatment to be either unethical (23.5%) or unethical under most circumstances (45.6%).
Withholding access to data. Should the clients have full access to assessment and treatment data that concern them? On the one hand, access to data about the client's condition may be important to the client's reaching a truly informed decision about initiating or continuing treatment. For example, if clients are not honestly told the diagnosis, it may be hard for them to know whether they want to be treated without knowing what they are to be treated for. On the other hand, psychologists may feel that certain technical terms or raw data may actually exacerbate the client's condition.
About one in five believe that it is unethical to refuse to disclose the diagnosis (21.5%) or to refuse access to a test report (21.7%). Fewer believe that refusing to allow clients to read their chart notes (14.5%) or that denying clients access to raw test data (12.1%) is unethical. Around half of the respondents have denied their clients access to the diagnosis (48.0%), to the testing report (49.6%), to their chart notes (55.5%), or to raw test data (57.4%).
Access to chart notes may have differential meaning and usefulness depending on how much information is contained in the chart. Over half (50.9%) of the respondents indicated that they had, at least rarely, limited treatment notes to name, date, and fee. The General Guidelines for Providers of Psychological Services (APA, 1987) mandate that "accurate, current and pertinent records of essential psychological services are maintained" (p. 19). Lack of adequate documentation of assessment, interventions, and responses to interventions have contributed to successful malpractice actions by establishing lack of care. One court held:
The hospital record maintained by the State was about as inadequate a record as we have ever examined. We [the court] find that. . .the inadequacies in this record militated against proper and competent psychiatric care. . . . Therefore, to the extent that a hospital record develops information for subsequent treatment, it contributed to th inadequate treatment this claimant received. . .it was so inadequate that even a layman could determine that fact (Whitree v. State, 1968).
Interventions against the client's wishes. Some of the most difficult and painful judgments psychologists must make concern under what, if any, conditions informed consent can be waived. One area of such judgments involves involuntary hospitalization, an area filled with controversy. Over half of the respondents have utilized involuntary hospitalization, either rarely (42%) or more often (20%). Fewer than 5% view it as unethical.
Whether to accept a client's decision to commit suicide is likewise a difficult and painful dilemma for many psychologists. Some have argued that the informed consent of the patient to accept or to refuse treatment in such cases must be absolute (Szasz, 1986). Only about one in five of the respondents has accepted, either rarely (16%) or more frequently (4%), a client's decision to kill himself or herself. Almost half (45%) believe it to be unethical. An additional 37% believe it to be unethical under most circumstances.
7. Promoting Equity and Justice
Homosexuality. The profession's struggle to eliminate the stigma and pathologizing of homosexuality has been long, difficult, and not yet complete (Baer, 1981; Malyon, 1986a, 1986b). Slightly more than one in five of the respondents reported treating homosexuality per se as pathological, either rarely (12.7%) or more often (10.8%). However, over half (55.7%) viewed such a practice as unethical.
Sex of client. Whether to make access to one's practice dependent in any way upon the making of discriminations about a potential client's sex, race, religion, and so forth, is another of the very difficult judgments for many psychologists. On the one hand, discrimination as the term is customarily used is abhorrent. On the other hand, psychologists may wish to specialize, and such specialty areas may be founded in part upon such characteristics as sex, race, or religion. Fewer than 10% engaged in this practice either rarely (3.7%) or more often (3.7%).
Financial barriers. To what extent are people without sufficient funds denied access to needed psychological services? Ever since Freud's (1913/1958) statement that "the absence of the regulating effect offered by the payment of a fee makes itself very painfully felt" (pp. 131-132), there have been strong advocates for the therapeutic necessity of charging fees (e.g., Davids, 1964; Kubie, 1950; Menninger, 1961). Such claims have been made in the absence of empirical support, because systematic studies have found, in general, no therapeutic effect exerted by the fee and no harm to the therapy caused by an absence or lowering of the fee (Balch, Ireland, & Lewis, 1977; Pope, Geller, & Wilkinson, 1975; Turkington, 1984).
Almost half (47.4%) of the respondents report providing free therapy on a rare basis, an additional 18.7% more frequently.
Over half of the respondents had terminated therapy due to the client's inability to pay, either rarely (36.2%) or more often (25.7%).
Fear of being sued. Do certain clients whose condition may make therapists wary of being sued find access to therapy shut off? Avoiding certain clients for fear of being sued was acknowledged by 30.3% on a rare basis and by 15.6% more often. Fewer than 10% viewed this practice as unethical.
Resources for Regulating the Practice of Psychology
It is interesting that informal networks of colleagues are viewed as the most effective source of guidance, but it is heartening that both the Ethical Principles and the APA Ethics Committee are highly valued resources. The fact that both state and local ethics committees received significantly lower ratings suggests that state and local associations may need to devote increased time, financial backing, and program planning and evaluation to these efforts if they are to be judged as valuable by psychologists.
In light of psychology's identity as an empirically based discipline (Singer, 1980), the low ratings accorded to published research are troubling. It is possible that research too rarely addresses ethical concerns and standards of practice in a way that is useful for psychologists.
The lack of comprehensive normative data about the behaviors of psychologists and their relationship to ethical standards leaves psychologists without adequate guidelines to inform their choices.
These data would also be useful to psychology in the formulation of formal standards and in the deliberations of the APA Ethics Committee. In this age of increasing accountability, the formal means by which we psychologists hold ourselves accountable for our behavior is the APA Ethics Committee. Although the Committee participates in a variety of tasks, a major activity is the attempt to resolve complaints against APA members. If the Committee can adjudicate these complaints in a sensitive, fair, and informed manner and can demonstrate a legitimate system of accountability, four consequences are likely to follow.
First, those who file complaints may believe that the perceived wrongs have been corrected or at least seriously addressed. The relationship between the psychologist-complainee and the client or colleague may be reestablished on a more positive, constructive level. At a minimum, those who may have been harmed by the unethical actions of a psychologist may feel that they have been heard and respected.
Second, the psychologist-complainee may be at less risk for future unethical behavior and at less risk for harming others.
Third, the integrity of the profession is affirmed.
Fourth, if the profession can demonstrate a sound process of accountability, there will be less need for regulation by external agencies, such as the courts and legislatures, that are ill-equipped for such monitoring. The profession is willing to spend its time, money, and energy maintaining actual accountability to its own ethics rather than looking to others to control the behavior of its members. It recognizes that something can be legal--i.e., meeting the standards of civil, administrative (licensing), and criminal law--and yet still be unethical, and that this difference is important for the profession.
The integrity of psychology is contingent to a great degree on the extent to which we-both as a discipline or profession and as individuals-can regulate our own behavior, and view this self-regulation as worth the substantial time, money, and work that it involves. Our ability to engage in effective and ethical regulation, in turn, is contingent on our willingness to study our own behavior and our beliefs about that behavior.
[Note: Some references have been added and some wording changed to update this article since its original publication.]
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