National Study of Therapist-Client Sex

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Prior Therapist-Patient Sexual Involvement Among Patients Seen by Psychologists

ABSTRACT: A national survey of 1,320 psychologists found that half the respondents reported assessing or treating at least one patient who had been sexually intimate with a prior therapist; a total of 958 sexual intimacy cases were reported. Most cases involved female patients; most involved intimacies prior to termination; and most involved harm to the patient. Harm occurred in at least 80% of the instances in which therapists engaged in sex with a patient after termination. Respondents reported that in about 4% of the 1,000 cases in which the issue of sexual intimacies arose, the allegations were false.

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As the phenomenon of therapist-patient sexual involvement receives increasing acknowledgement as a problem for the mental health professions and the harm that may occur for patients becomes a focus of clinical inquiry (see, e.g., Bates & Brodsky, 1989; Brodsky, 1989; Brown, 1988; Feldman-Summers, 1989; Gabbard, 1989; Gilbert & Scher, 1989; Kluft, 1989; Lapierre & Valiquette, 1989; Pope, 1990a, Pope 1990b. Pope, 1990c, Pope, 1994, Pope, 2000; Pope & Bouhoutsos, 1986; Pope, Sonne, & Holroyd, 1993; Pope & Vasquez, 1998; Shopland & VandeCreek, 1991; Sonne, 1989; Sonne & Pope, 1991; Vasquez, 1991), it is important to know the extent to which psychologists are likely to encounter such patients in their practice.

The two earliest national prevalence studies based on anonymous surveys of psychologists (Holroyd & Brodsky, 1977; Pope, Levenson & Schover, 1979) suggest that perhaps as many as 12% of male therapists and 3% of female therapists engaged in sexual intimacies with at least one patient (for a review of research in the area of patient-therapist sex, see Pope, 1990c, 1994, 2000). It is crucial to note that the sole national study using the same instrument during the same time period with the three major mental health professionals found no significant diffiference among the rates at which psychiatrists, psychologists, and social workers acknowledged engaging in sex with their patients (Borys & Pope, 1989). Statistical analyses of the national studies likewise shows no significant differences among professions once other factors are held constant (Pope, 1994). There is no meaningful way to infer from such studies, however, how many patients who have been sexually intimate with a therapist subsequently seek professional services from other therapists.

There has been no national study investigating the degree to which psychologists encounter in their work patients who have been sexually intimate with a prior therapist. The pioneering study in this area was conducted by Bouhoutsos and her colleagues (1983). This creative, landmark research found that about 45% of the psychologists surveyed reported treating such patients. The findings, however, must be viewed cautiously because of at least three major factors: (1) the survey was limited to psychologists in only one state (California), (2) the return rate was exceptionally small (16%), and (3) there were no published attempts at replication. In addition, data on patients who became intimate with a therapist more than three months after termination and on patients who made false allegations were not collected.

The current research study was designed to collect representative data from a national sample of psychologists regarding their patients who had engaged (or made false allegations of engaging) in sexual involvement with a prior therapist. In light of the very small return rate of the 1983 California study [and also of a somewhat similar study on the reporting practices of psychiatrists (Gartrell et al., 1987) which achieved only a 26% return rate], the survey form was kept extremely brief (i.e., one page asking relatively few questions). Thus many questions concerning the respondents, the patients, and the prior therapists had to be omitted. Consequently, it is essential to emphasize that since no baseline data (e.g., the sum of patients seen during the respondent's career, the percentages of that sum who were victims of rape or incest) were elicited, no statistical inferences can be made regarding such questions as whether patients who are rape or incest victims are more or less likely to have been sexually involved with a prior therapist. The current study was designed to focus exclusively upon patients who are reported by psychologists to have actually engaged in or falsely alleged sexual involvement with a prior therapist.

METHOD

Sample Selection

Thirteen hundred and twenty psychologists who met three criteria were randomly selected from the membership directory of the American Psychological Association. The three criteria were that the member: (1) had earned a doctoral degree in the clinical or counseling area, (2) was currently licensed, and (3) appeared, according to the listing, to be currently providing clinical or counseling services to patients (e.g., was not retired).

Instrument

Participants were asked to indicate: (1) how many female patients they had seen professionally, over the course of their career, who had been sexually intimate with a therapist prior to termination, and (2) how many if any, suffered harm as a result. They were also asked to provide this information for female patients who had engaged in such intimacies only after termination. Data were collected in comparable categories for male patients who had engaged in sexual intimacies that were initiated before or after termination. The questionnaire did not enumerate the various possible forms of sexual intimacy and harm; whether either had occurred was to be based solely upon each respondent's professional assessment and opinion.

Participants were asked to indicate how many of all of these patients, if any: (a) were minors at the time of the intimacies, (b) married the therapist, (c) were victims of incest or other child sex abuse, (d) had experienced rape prior to intimacies with the therapist, (e) required hospitalization that, in the opinion of the survey respondent, was at least partially a result of the intimacies, (f) attempted suicide, (g) committed suicide, (h) achieved complete recovery from any negative effects of the intimacies, (i) were seen by the survey respondents pro bono or for a reduced fee, and (j) filed formal (e.g., licensing, malpractice, criminal) complaints. [Because participants were asked how many of all the sexually involved patients fell into each of these ten categories, no statistical analysis was possible relating these categories to such factors as whether the patients were male or female, or whether the intimacies were initiated before or after termination.]

The form asked how many patients participants had seen, over the course of their career, who made what was, in the participant's opinion, a false allegation about having engaged in sex with a prior therapist.

Finally, participants were asked to indicate whether their graduate school, internship, or continuing education programs provided adequate training regarding understanding, assessing, and treating patients who have been sexually intimate with a therapist.

Procedure

Each of the 1,320 psychologists was mailed: (1) a one-page cover letter, (2) the one-page survey form, and (3) a stamped, addressed envelope for returning the form. An effort was made to locate a more recent address when envelopes were returned by the postal service as undeliverable.

Results

Survey forms were returned by 654 of the 1,320 potential respondents, yielding a response rate of 50%. Seven respondents did not fill out the form, most of them indicating that they had not engaged in clinical or counseling practice (e.g., their work was exclusively research). Thus the final data base was provided by 647 respondents.

About half (n = 323) of the 647 respondents who had provided clinical or counseling services reported seeing professionally at least one patient who had been sexually intimate with a therapist. Respondents reported a total of 958 patients who had engaged in such intimacies.

A 2 X 2 X 2 frequency table was formed among patient gender, whether or not the patient was harmed, and whether sexual intimacies were initiated before or after termination. All first, second, and third order effects were statistically significant using tests of partial association for the 2-way analyses. Since the 2-way relationships are modified by the 3-way effect, only the highest and lowest order effects are interpreted. N = 958 patients for all analyses.

The 3-way association shows that female patients were more likely to experience harm if the intimacy was initiated before termination (95%) than after (80%), while male patients were not more likely to experience harm from intimacies initiated before termination (80%) than after (86%), chi-square(1) = 11.38, P < .01.

Table 1 - Characteristics of 958 patients who had engaged in sexual intimacies with a therapist
%	Characteristics
5%	Patient was a minor at the time of the intimacies¹
3%	Patient married the therapist
32%	Patient had experienced incest or other child sex abuse
10%	Patient had experienced rape prior to intimacies with therapist
11%	Patient required hospitalization considered to be at least partially a result of the intimacies
14%	Patient attempted suicide
1%	Patient committed suicide
17%	Patient achieved complete recovery from any harmful effects of intimacies²
20%	Patient seen pro bono or for reduced fee
12%	Patient filed formal (e.g., licensing, malpractice) complaint

Table notes:

¹ Although, as mentioned previously, the design of the questionnaire prevented linking the categories listed in Table 1 to such factors as gender, termination, or harm, there were instances in which a respondent reported only one patient (indicating whether the patient was male or female, whether the patient was harmed, and whether the intimacies were initiated before or after termination). Interestingly, there were three instances in which a respondent reported only one patient, reported that no harm resulted from the intimacies with the therapist, and reported that the intimacies occurred while the patient was a minor. In two such instances, the patient was male; in the third instance, the patient was female. In all three instances the sexual intimacies were reported to have been initiated prior to termination.

² 17% of the 866 patients who experienced harm

Thirty-three (5%) of the 647 respondents reported a total of 42 patients who, in the professional opinion of the respondent, made false allegations that they had engaged in sexual intimacies with a therapist. Thus, respondents encountered a total of 1,000 cases in which the issue of actual or falsely alleged sexual intimacies with a therapist arose. Forty-two (4%) of the 1,000 cases were reported to involve false allegations; 958 (96%) were reported to be cases of actual intimacies.

Discussion

It is impossible to overemphasize the need for care and caution in interpreting these data. Threats to validity are numerous (for a discussion of methodological issues, see Pope 1990b, 1990c, 1994). The study relies upon the candor, professional opinion, and memory of the respondents. As with any assessment or judgment a professional makes, these reports concerning whether allegations are true or false, whether a patient's dysfunction or distress is attributable in whole or in part to a specific event, or whether the respondent's training was adequate may be wrong for any number of reasons, including inadequate or misleading data provided by the patients or other sources, personal bias, or insufficient care in reaching a professional opinion. Holroyd and Bouhoutsos (1985), for example, found that therapists who had engaged in sexual intimacies with a patient exhibited a bias against finding any harm when evaluating patients who had been sexually intimate with other therapists. Furthermore, any harm that may result from therapist-patient sexual intimacies can, like harm from incest, be delayed, sometimes for a period of years (see Gabbard, 1989), a fact that the courts are beginning to affirm. In a recent case, for example, an appellate court overturned a summary judgment in favor of the defense while emphasizing that a delay may occur between the sexual intimacies and the resulting harm (thus affecting the statute of limitations):

Indeed what evidence there is in the record suggests [plaintiffs] injury did not occur at the time of the alleged sexual relations.... [Plaintiff's] description of delayed symptoms is consistent with the view of clinicians who have described the injury caused by patient-therapist sexual relations as "posttraumatic stress." (Mason v. Marriage and Family Center, 1991, p. 3071).

Yet another compelling factor warranting exceptional caution in interpreting these results is that in cases in which the patient has also been an incest or rape victim, it may be extremely difficult to determine what harm is attributable to the various potential sources. It is also necessary to emphasize, as stated previously in the introduction: this study focused exclusively on patients who sought services from a subsequent clinician (and who thus might differ substantially from patients who became sexually involved with a therapist but who do not seek subsequent services); and the brevity considered necessary to ensure an adequate return rate precluded collection of baseline data necessary for various methods of statistical inference.

Nevertheless, this is the first national study of three important topics: (1) the likelihood that psychologists will encounter in their work patients with a history of sexual intimacies with a therapist, (2) patients who have engaged in sexual intimacies with a therapist only after termination, and (3) patients who make false allegations regarding sexual intimacies with a prior therapist. Several findings or implications are worth highlighting.

First, the findings provide qualified evidence that a significant number of psychologists encounter patients who have been sexually involved with a therapist or who falsely allege such involvement. Half of the 647 respondents reported seeing professionally at least one patient who had been sexually intimate with a therapist. About 5% of the respondents reported encountering at least one patient who made false allegations regarding sexual involvement.

Second, the findings strongly suggest that psychologists need to be adequately prepared to assess whether sexual involvement harmed the patient (see Bates & Brodsky 1989; Feldman-Summers & Jones, 1984; Pope 1988, 1994)--as the respondents judged to have occurred in 90% of the instances in this study-and to render appropriate treatment (see Gabbard, 1989; Pope, 1994; Pope & Bouhoutsos, 1986; Sonne, 1987, 1989; Sonne et al., 1985; Sonne & Pope, 1991). In some instances, the assessment of possible harm from sexual involvement with a therapist must be considered in the context of a patient's history of rape (10%) or incest and other forms of child sex abuse (32%); moreover, in about 5% of the instances, the sexual involvement with the therapist occurred while the patient was a minor, further complicating assessment issues (see Bajt & Pope, 1989). The treatment, likewise, may be complex; 14% of the patients attempted suicide, 11% required hospitalization (the same percentage that were reported to have required hospitalization in the pioneering California study by Bouhoutsos and her colleagues [1983]), and only 17% of those who were harmed were reported to have recovered completely, at least by the time of this study. To render adequate assessment and treatment to this population and to practice within their area of competence as required by the "Ethical Principles," psychologists need adequate training both in their graduate education and in continuing education courses; yet only 15% of the respondents reported that their training adequately prepared them to assess and treat such patients.

Third, psychologists can take justifiable pride in the fact that they provide services to a considerable portion of these patients, who presumably could not otherwise afford them, at no or low cost. One out of every five of the 958 patients was receiving professional services pro bono or at a reduced fee.

Fourth, about 12% of patients who had been sexually involved with a therapist and who received subsequent treatment from a different therapist filed formal complaints with licensing boards, malpractice courts, ethics committees, or other regulatory offices. [The 112 patients who filed formal complaints represent 12% of all 958 patients who were reported to have been sexually involved with a therapist and 13% of the 866 patients reported to have been harmed by such involvement. It is possible that patients who are sufficiently willing and able to seek help from a subsequent therapist are also more willing and able (than patients who don't or can't seek further help) to file a formal complaint. Subsequent therapists may also, in many cases, provide necessary information and support to patients who are considering filing a complaint. Thus, there is a possibility that a far higher percentage of patients who obtain help from a subsequent therapist (than those who never again enter the mental health system) may file a formal complaint.] Prior research has suggested that patients may not file complaints regarding sexual intimacies with a therapist, despite their belief that they have been harmed, because of such factors as patients' lack of awareness that therapist- patient sex is prohibited by formal standards (Vinson, 1984), patients' difficulty locating the appropriate regulatory agency (Center for Public Interest Law, 1989), patients' belief that regulatory bodies will be unresponsive (Bouhoutsos et al., 1983), and influence by subsequent therapists who are reluctant to see their colleagues exposed (Gartrell et al., 1987). Comprehensive research is needed to explore and clarify the factors promoting or discouraging patients from filing formal complaints with each of the various professional, judicial, or administrative agencies as well as the consequences for the patient, the offending therapist, and the possible prevention or deterrence of therapist-patient sexual involvement.

Fifth, the analysis of the relationship among gender, harm, and termination provided intriguing findings which invite subsequent research. It is not surprising that subsequent therapists report that 87% of the patients who had been sexually involved with a prior therapist were female; prevalence research regarding sexual involvement between patients and therapists from a spectrum of mental health disciplines has tended to find a much higher proportion of female patients than male patients to be involved in such intimacies (see Brodsky, 1989; Gartrell et al., 1986, 1989; Gechtman, 1989; Holroyd & Brodsky, 1977; Pope, 1994).

However, it is surprising that female patients seen by subsequent psychologists were more likely to have been harmed by sexual intimacies that were initiated prior to termination, whereas the male patients were not more likely to have been harmed by intimacies that were initiated only after termination. These puzzling findings appear to have no easy explanation and may, of course, be the misleading result of any of the numerous possible sampling or design artifacts, but they warrant investigation in more detailed research to see if they recur and, if so, how we may best understand them. It is important to note that harm was judged to occur to at least 80% of patients, male or female, who engaged in sex with a therapist only after termination.

Although, as previously emphasized, there are numerous cautions in interpreting these data, the possibility that there may be a percentage of patients who engage in sex with a therapist prior to termination and a percentage who engage in sex only after termination whom a subsequent therapist does not judge to have been harmed by the experience can prompt a reexamination of an absolute prohibition against sex with patients prior to termination and/or an absolute prohibition against sex with patients after termination. In addressing the latter prohibition it is important to note that although there appear to be numerous theoretical, research-based, professional, and other considerations in support of the prohibition (see Brown, 1988; Dyer, 1988; Ethics Committee of the American Psychological Association, 1988; Gabbard & Pope, 1989; Shopland & VandeCreek, 1991; Vasquez, 1991), the actuarial data alone, suggesting that a substantial percentage of patients appear to be harmed by posttermination involvements, can support the prohibition against therapists engaging in sex with their clients after termination as follows: Even when systematic investigations suggest that an act is often harmless (perhaps even most of the time), a reasonable policy can prohibit an act that places a third party at risk for serious injury and can direct sanctions for violating the prohibition. The increasingly strict laws prohibiting drunk driving are in no way invalidated, undermined, or contradicted by research indicating that only a relatively small percentage of the instances in which one drives while intoxicated result in actual damage to people or property.

Sixth, the finding that so many of us are encountering patients, most of them female, who appear to have been harmed by our colleagues may prompt a careful reexamination of our institutional and organizational responses, especially as they are embodied in our formal and informal policies (see Bouhoutsos, 1985). For example, we need to reexamine the ways in which our response to victims on the policy level may be influenced by such factors as the tendency for victims to be female and perpetrators to be male (Pope, 1990b) and the potential conflict of interest between concern for victims and concern for keeping insurance premiums low (i.e., the rationale that some may hold that if we tend to minimize therapists' offenses and their consequences for victims, courts may tend to give smaller amounts to victims who sue, therefore decreasing the incentive to sue and the overall losses for the carrier to whom we pay premiums). A former president of the American Psychiatric Association and current professor of law and psychiatry at Harvard, for example, wrote that "we should all realize that there is a serious conflict of interest between APA's [American Psychiatric Association's] professional concerns for the victims of sexual exploitation in therapy and its financial concerns when the associations' economic interests are at serious risk" (Stone, 1990, p. 26). In noting the de facto gender discrimination in capping or excluding professional liability coverage specifically for therapist-patient sexual involvement, he observed that

each of us contributes by paying liability insurance to a fund that has two functions: to protect us and to compensate those who are unfortunate victims of our negligence. With this in mind, the policy decision to exclude victims of sexual exploitation, who are typically women, from participation in our victim compensation fund is difficult to defend. If we are concerned about them, why should they be "victimized" by this exclusion? (p. 25)

Seventh, we need also to reexamine the ways in which our responses to offenders may be influenced by the same sort of factors mentioned above, and to reflect upon the consequences of our responses. For example, if we were to discover perfect and infallible methods for rehabilitating offenders so that we could be 100% certain that they would never offend again, what would be the policy implications of enabling an offender to return to practice as a psychotherapist (Pope, 1990b; 1991)? To what extent do we view it as important to attempt to sustain the values of inviolable trust and integrity for this aspect of our profession? As described elsewhere (see Pope, 1990b; Pope & Vasquez, 1998), a judge might allow a bribe to influence his or her decision. If the offense were discovered, the judge might pay whatever debt were due society, undergo rehabilitation, and emerge as a model citizen. Yet the judge would not be allowed to return to the bench, though of course he or she might pursue other activities (e.g., writing, consulting, teaching, lecturing) within the legal field. Similarly, a teacher running a preschool might be discovered to have molested one or more of the children. Again, despite apparent complete rehabilitation, that individual would never knowingly be granted another license to run a preschool, although again, other activities within the field of education might be open. To allow individuals who accepted bribes or sexually exploited children to resume the positions of trust that they had violated would be to change profoundly the meaning that those positions have for us as a society and for individuals who are inherently vulnerable to those holding the positions.

Violation of a clearly understood prohibition against such a grave abuse of power and trust precludes further opportunity to hold these special positions in the legal or educational professions, although numerous other opportunities in law or education ... remain available to the rehabilitated perpetrator.

Psychology must answer the question of whether psychotherapy involves, requires, and deserves the same level of inviolable trust (both from society and from those who are directly affected by the therapist) and integrity as judiciary and teaching roles within the legal and educational professions. The exceptional privacy and intensity of most psychotherapy relationships should not be overlooked when one confronts this question. (Pope, 1990b, p. 234)

A reexamination of alternatives for offenders may be worthwhile. The director of the Menninger Hospital, for example, notes that an approach sometimes used "in Topeka is to have the offending therapist work in a purely administrative position in which there is no contact with patients or clients" (G. Gabbard, personal communication, January, 1991).A distinctly different but related consequence of enabling perpetrators to return to practice affects victims (see Sonne & Pope, 1991). For example, research has indicated that offenders are significantly more likely than nonoffenders to serve as therapists for patients who have been exploited by a prior therapist. The national study conducted by Gartrell and her colleagues (1987) found that

a comparison of repeaters, one-time offenders, and nonoffenders on this variable revealed highly significant differences, with repeat offenders the most likely to have treated previously involved patients and nonoffenders the least. (p. 289)

Setting aside the psychological effects for victims of therapist- patient sex who discover that their subsequent treating therapist is an offender who has been enabled to return to practice, there may be, as outlined in item 6 above, significant financial savings for the profession that come at the expense of victims. One woman who had been a victim of therapist-patient sex decided to reenter therapy with a new therapist. She subsequently filed suit against the original therapist. Prior to a deposition in which he would be giving testimony under oath, the subsequent treating therapist disclosed to the woman's attorney something he had not revealed to the woman who was his patient: that he himself had been a perpetrator. How such situations affect women's chances in court are not difficult to imagine. What is much more difficult is to acknowledge and confront the conflicts of interest and similar factors (Pope, 1990b, 1994) that may be influencing our policies.

Eighth, to the extent that we make a formal or de facto policy decision that sexual offenders should--if they can be adequately rehabilitated--be allowed to resume functioning as therapists, we need to reexamine the forms and procedures used by individual clinicians, licensing boards, and others who have been trying out rehabilitative strategies. While carefully designed, independently conducted (because we are rarely disinterested judges of the effectiveness of our own work), and adequately replicated research studies are being carried out and prepared for publication in our scientific and professional journals, all patients subsequently treated by offenders passing through rehabilitation programs are being placed at risk for sexual exploitation despite supervision or monitoring which has been shown to be ineffective in ensuring patients' safety from exploitation (see Pope, 1990b; 1991, 1994; Sonne & Pope, 1991).

Unless all rehabilitation interventions that have been in development work perfectly from the very first (i.e., the intervention ensures without exception that no offender judged to be adequately rehabilitated offends again), thus surpassing in perfection virtually all other psychological interventions, then some patients have been or will be sexually exploited by supposedly rehabilitated offenders. An accurate estimate of the success rates of the various rehabilitation strategies can be determined only if these subsequent reoffenses are discovered, an extremely complex methodological challenge (Pope, 1990b; Pope, Butcher, & Seelen, 2000, pages 206-223). The patients who have been and will be subsequently treated by these offenders constitute an inherent part of the efforts to rehabilitate offenders. They are placed at substantial risk for the harm that can be caused by a sexually exploitive therapist. As Bates and Brodsky observed in their review of the research: "The best single predictor of exploitation in therapy is a therapist who has exploited another patient in the past" (p. 141). Such clients have an inherent and inviolable right to know that they are participating in a trial or experimental procedure that places them at risk for serious harm. This right, though questioned or discounted by some (see Pope & Vasquez, 1998), was affirmed in the Nuremburg Code, whose first principle is that the "voluntary consent" [to participate or withdraw] of those who are placed at risk by research or experimental procedures is "absolutely essential." Psychologists have a responsibility to respond vigorously and proactively to ensure that such human rights are not violated (Pope & Garcia-Peltoniemi, 1990; see also Pope, 2001; Pope & Vasquez, 1998).

None of us should adopt a stance of complicit inattentiveness, silence, or acceptance if there are any instances in which a patient has been placed at risk for serious harm as part of an offender's rehabilitation plan without that patient's informed awareness and freely given consent. We need to examine carefully the consent forms and procedures used by clinicians, licensing boards, and others who are developing, implementing, mandating (i.e., for reinstatement of license), supervising, or otherwise using rehabilitation interventions on a trial basis (i.e., prior to the publication of independently conducted, carefully controlled, adequately replicated research demonstrating the degree of effectiveness of the rehabilitative intervention) to ensure that patients who are placed at risk for harm as these methods are used on a trial or experimental basis are adequately informed of the risks and are accorded meaningful voluntary consent to participate or withdraw. Exceptional care and consideration are warranted in light of the tendency to discount issues of informed consent when those placed at risk are primarily women, people of color, or minority ethnic groups (Pope & Vasquez, 1998).

Ninth, we need to reexamine the sources of our attitudes and beliefs regarding the phenomenon of therapist- patient sexual involvement, its consequences, interventions, etc. Our investigations and methodologies should be no less creative, useful, rigorous, and diverse in this area than they are in any other area of psychological study, nor should we allow ourselves to engage in selective inattention to their results. To what extent, for example, are our policies and actions in tune with the research evidence published in our scientific and professional journals? As members of an empirically oriented profession, we seek to learn from formal research and careful, systematic explorations. The APA Council of Representatives has, in formal statements of policy, repeatedly emphasized that psychological interventions should be "based on the available scientific evidence of efficacy" (1989, p. 1024). A diversity of opinions, dogmas, expectations, assumptions, hopes, fears, and hunches are now tested within the framework of systematic investigation and empirical data (Pope, 1990c). Books, workshops, symposia, classroom discussions, policy deliberations, and informal dialogues benefit from, wrestle with, challenge, and explore information from systematic investigations that have met the fundamental though by no means foolproof criterion of publication in journals employing peer review, a process rooted in the scientific tradition and vital to the openness and skepticism of the scientific approach. This process of peer review, created to help ensure the reliability and integrity of scientific and professional findings, is important in avoiding what social psychologist Carol Tavris (1987), in her examination of a large-scale and extremely prominent and influential survey that avoided the peer-review process, labeled "social-science fiction." In examining "warning flags" for questionable data, Sommers and Sommers (1983) found that the "most prominent was the lack of publication in refereed sources" (p. 984). Attention to this warning flag might have enabled earlier detection of the apparently phantom nature of survey data regarding impaired professionals presented at an APA convention in an episode described by Bates and Brodsky (1989). As an increasing array of theories and findings have emerged from the rigorous process of peer review, we find ourselves better able not only to understand the phenomenon of therapist -patient sex but also to help those who have been injured by it. The very nature of the process, however, should also prompt us to subject even our most deeply held or long-standing certainties to continuing reexamination.

Tenth, we need to reexamine the opportunities for preventing sexual exploitation of patients. To some extent this may involve increased understanding of the tendency of most therapists to experience sexual attraction to patients (Pope, Keith-Spiegel & Tabachnick, 1986; Pope, Sonne, & Holroyd, 1993) and the phenomenon of engaging in sexual fantasies about patients (Pope et al., 1986; Pope, Tabachnick & Keith-Spiegel, 1987). It may also involve increased understanding of the sexualization of our teaching relationships and the ways in which training programs provide education and modeling regarding sexual issues (Glaser & Thorpe, 1986; Pope, Levenson & Schover, 1979; Robinson & Reid, 1985; Tabachnick, Keith-Spiegel & Pope, 1991). What seems likely, however, is that creating, implementing, and evaluating comprehensive and effective prevention efforts will not come easily for us as clinicians. As much as we may talk about the concept, it is hard to argue with Sarason's (1985) conclusion: "The fact is that in practice, and the ways clinicians are prepared for practice, the preventive stance is conspicuous by its absence" (p. 63). And yet as psychologists, we have a rich and growing legacy of theory, research, and experience in attempting to bring about the kind of sustained, systematic changes that might be part of an effective prevention program (e.g., Bronfenbrenner, 1974; Cowen, 1977; Kelly & Hess, 1987; Sarason, 1972, 1988; Trickett, 1990). As we consider the feasibility and desirability of various preventive strategies, it is important that we also consider carefully their ethical implications (Bond & Albee, 1990; Trickett & Levin, 1990).

Conclusion

The phenomenon of therapist-patient sexual involvement confronts us with pressing questions that have immediate consequences for our patients and far-reaching implications for our profession. After some initial, understandable resistance (see Brodsky, 1989; Pope, 1990b; 1994), psychology has begun to acknowledge and study the phenomenon of therapist- patient sexual involvement. We are working to overcome the tendencies-likely shared by all of us to some degree-to deny the problem, discount its implications, and rationalize our responses. Healthy controversies and vigorous debates have emerged. An empirical literature is developing in our scientific and professional journals. Our sharing in this process of critical reexamination of our beliefs, behaviors, policies, interventions, and responsibilities, our searching for relevant empirical data and subjecting our findings to the discipline of peer review, and our struggling to come to terms with the ways in which a trusted helping profession can betray trust and cause harm are aspects of our profession's increasing capability and maturity. That half of the respondents in this study reported seeing at least one patient who was sexually intimate with a prior therapist is a stark reminder that we have unfinished business in this area that urgently requires our attention. We have many questions to explore and much work to do.

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