BOUNDARIES IN SOCIAL WORK: THE ETHICAL DILEMMA OF SOCIAL WORKER-CLIENT SEXUAL RELATIONSHIPS

BOUNDARIES IN SOCIAL WORK: THE ETHICAL DILEMMA OF SOCIAL WORKER-CLIENT SEXUAL RELATIONSHIPS

Susan Hutchinson Mittendorf, Ph.D. and Julie Schroeder, Ph.D
Louisiana State University School of Social Work

Abstract

This article reports the results of an exploratory study examining social workers’ attitudes and beliefs about sexual involvement with clients and their knowledge of the prevalence of this behavior as reported to them by their clients. It also presents an historical perspective for discussing previous research documenting the incidence of this unethical behavior and offers policy implications that address prevention of social worker misconduct.
Key Words: Mental Health, Ethics, Sexual misconduct, Private practice, Psychotherapy

Introduction

The sexual exploitation of clients by their therapists continues to be a problem in social work and in the other mental health professions (Berkman, Turner, Cooper, Polnerow, & Swartz, 2000; Freud, & Krug, 2002). The National Association of Social Workers (NASW) identified sexual activity with clients as the most frequently cited infraction of the association’s Code of Ethics (NASW, 1996). Strom-Gottfried’s (2000) review of ethics complaints filed with NASW between 1986 and 1997 found that of the 267 cases with findings of ethics code violations, 55% (n=147) were related to boundary violations. Of these cases with findings of boundary violations, 37.4% (n=95) involved sexual activity with clients. Strom-Gottfried argues that these incidence estimates of misconduct must be used with caution because NASW receives fewer complaints against social workers than state licensing boards and malpractice insurers.

The picture becomes murkier when attempting to ascertain the prevalence of sexual misconduct by using statistics compiled by state social work licensing boards. These boards regularly receive complaints of ethics violations, including the sexual exploitation of clients by social workers, but many retain data only on fully adjudicated cases (Berliner, 1989, Dawes, 1988; Reamer, 1995). The absence of information on complaints of unethical behavior by social workers, regardless of outcome, hampers efforts to systematically and reliably measure the frequency with which clients allege sexual misconduct by their social workers. For example, a review of all disciplinary actions by the Louisiana State Board of Certified Social Work Examiners between 1975 and 1999 yielded a total of 13 fully adjudicated cases in which disciplinary action for sexual misconduct was taken. Because no records of complaints of sexual misconduct against social workers are kept by the Board, researchers are not able to compare the number of complaints with actual survey responses. The lack of uniformity across national and state systems that receive complaints of professional misconduct coupled with the methodology problems of survey research in this area (viz., response bias), hinders efforts to describe and understand the frequency with which social workers engage in sexual behavior with their clients.

This article reports the results of an exploratory-descriptive study examining social workers’ attitudes and beliefs about therapist-client sexual contact, as well as their knowledge of the prevalence of this behavior, as reported to them by their clients. It is a replication of an earlier study by Hutchinson (1991) conducted to confirm the presence of a group of clients in the earlier research who reported having been sexually abused by their therapist. We also offer an historical perspective to frame previous research examining the incidence of this unethical behavior, and we recommend practice, policy, and research measures to prevent social worker misconduct.

Getting Valid Answers to Sensitive Questions

Social work researchers contend that survey data gathered by social workers about worker-client sexual contact underestimate the actual occurrence of these incidents and these data are not consistent with the complaints of unethical behavior by reported other sources (Berkman et al., 2000; Jayaratne, Croxton, & Mattison, 1997). There is a discrepancy between the self-reported rates of unethical behavior published in the literature and those based on actual complaints of unethical behavior received by NASW, state licensing boards, and malpractice insurers. This discrepancy raises questions about the well being of clients of practitioners who are unaware of the problem of worker-client contact and who underestimate its prevalence. At the very least, it may be assumed that for every exploitive social worker, there is at least one sexually exploited client. Nearly half (46.3%) of the 147 responding social workers surveyed by Hutchinson (1991) reported that 177 clients had disclosed sexual involvement with a previous therapist. These clients reported that the majority of these therapists were psychiatrists (37.8%), followed by social workers (18.6%), psychologists (15.8%), clergy (13.5%), licensed professional counselors (7.3%), and other professions (6.7%). Sloan, Edmond, Rubin, and Doughty (1998) obtained similar results in their survey of 450 social workers. They found that during a twelve-month period, 75 (17%) of respondents provided clinical services to 123 clients who reported having been sexually exploited by a previous therapist.

A representative of the NASW Insurance Trust observed that sexual misbehavior continues to be a serious problem, and in 1999, it was a major cause of suits against social workers (L. Robinson, personal communication, January 11, 2000). The increasing number of claims against social workers for sexual misbehavior resulted in the NASW Insurance Trust limiting its coverage for social workers found guilty of sexual involvement with clients to $25,000 (Gechtman, 1989). The number of social workers who admit engaging in sexual misconduct with clients, combined with claims of sexual misconduct received by insurers, state licensing boards, and NASW, indicate that social workers are as much at risk for this type of unethical behavior as other mental health practitioners.

A Brief History

Researchers in the fields of medicine (Kardener, Fuller, & Mensch, 1973), psychiatry (Gartrell, Herman, Olarte, Feldstein, & Localio, 1986), and psychology (Holroyd & Brodsky, 1977) called attention to this issue by estimating the number of practitioners in these professions who engaged in sexual misconduct with patients. These early studies stimulated interest in this issue in the professions of psychiatry and psychology, generating an on-going discussion of therapist exploitation of clients that continues to the present time.

In social work, however, the sexual exploitation of clients by their therapists was not widely discussed in the literature prior to 1990. Articles in the social work literature published prior to 1990 (Brown, 1984; Gareffa & Neff, 1975; Holzman, 1984; Shor & Sanville, 1974) focused on treatment dynamics, and frequently addressed treatment issues such as therapeutic responses to seductive clients. Gechtman (1989) completed the first national survey of social workers that described practitioners’ sexual behavior with clients in 1985. This research was not embraced by major social work journals but was later published in a book edited by a psychiatrist (Gabbard, 1989).

The first article to appear in a social work journal specifically addressing social worker sexual misconduct as a professional problem was written by Berliner (1989). The number of publications focused on the issue of social worker sexual misconduct increased slowly within the profession during the next decade (e.g., Kagel & Giebelhausen, 1994; NASW, 1995; Reamer, 1992). This body of literature addressed the topic indirectly by incorporating it into more global discussions of practitioner impairment, boundaries, and ethical practice. More recent articles (Berkman et al., 2000; Jayaratne et al., 1997; Sloan et al., 1998) directly explored the topic of social worker sexual misbehavior with clients in more detail than was done in earlier articles.

As stated above, obtaining accurate estimates of the number of social workers who have engaged in sexual behavior with clients is difficult, primarily because obtaining information on intrusive issues raises complex methodological problems. Studies published in social work journals varied in design, sample size, and methodology, making generalizations across studies difficult. Although incidence rates varied, all of these studies yielded consistently low self-reported rates of social worker sexual involvement with clients (Gechtman, 1989; Hutchinson, 1991; Jayaratne et al., 1997; Sloan et al., 1998).

The effect of gender on the sexual exploitation of clients has been the subject of considerable speculation among researchers. Early studies (Gartrell et al., 1986; Holroyd & Brodsky, 1977; Kardener et al., 1973) indicated that the highest rates of sexual exploitation of clients involve male therapists and female clients. More recent research (Bernsen, Tabachnick, & Pope, 1994) confirms the importance of gender in any discussion of sexual impropriety. This research suggests that male therapists are more likely than female therapists to experience sexual attraction to clients and to become sexually involved with them. Fewer reports of social worker-client sexual contact may be due, in part, to the gender make-up of social work as compared with that of psychiatry and psychology, given that social work is a predominantly female profession, and the other two professions are predominantly male.

Although current research suggests that male therapists are more likely than female therapists to become sexually involved with their clients, the importance of same-sex contact as a factor in client sexual exploitation must be considered. Strom-Gottfried (1999) notes that little is known about same-sex involvement. She cautions, however, that it is important to explore the dynamics of gender and sexual orientation as they relate to the sexual abuse of clients in order to more fully understand this problem.

Method

This study investigated the attitudes of 144 social workers in private practice settings regarding therapist-client sexual contact. Using a 40-item questionnaire, the survey gathered information about the following characteristics of respondents: gender, previous psychotherapy, practice experience, knowledge regarding the NASW Code of Ethics, and MSW curriculum content on ethics. Respondents were also asked whether they had engaged in sex with a current or former client and whether they ever had a client who reported a sexual encounter or relationship with a previous therapist.

The study population was composed of all social workers in a southern state whose primary practice setting was identified by NASW as private practice. The population included 288 social workers, 216 females (75%) and 72 males (25%). A cover letter explaining the purpose of the study, the nature of the selection process, and the procedures for establishing confidentiality were mailed with the questionnaire and a stamped self-addressed envelope to all 288 social workers. Responses received in the four-week period following the initial mailing of the questionnaire were tabulated in the returns. Univariate statistics were used to summarize and describe the data. A nonparametric procedure, Chi square analysis, was used to detect the presence of a relationship between the therapist type and number of reports of sexual contact reported to subsequent therapists.

The questionnaire was originally developed by psychiatrists and psychologists and was used in similar studies of their members’ attitudes and practices regarding sexual involvement with clients (Gartrell et al., 1986; Holroyd & Brodsky, 1977). In an attempt to maintain consistent definitions across studies, the present study used the same definition of sexual contact as that used in these previous research studies.

Hutchinson (1991) adapted this questionnaire for use by social workers by adding items that more accurately reflected social work training and practice. Items added to the revised questionnaire included information about licensing, practice history, ethics training, concern about the prevalence of client-therapist sexual contact, assignment of responsibility for this behavior, and suggestions for handling erotic feelings that arise in therapy. The revised questionnaire contained 11 items measuring respondents’ demographic characteristics, 9 measuring their attitudes toward social worker-client sexual contact, and 20 items gathering information about their personal experiences with their own clients. Most questions required pre-coded, forced-choice responses (e.g., yes/no or always appropriate/sometimes appropriate/always inappropriate) or a numerical specification. Space was provided for additional comments.

Respondents were asked for their opinions about the appropriateness of social worker-client sexual contact. They were given an opportunity to describe circumstances in which they considered sexual contact with a client to be appropriate and their beliefs about how this type of sexual behavior affects clients. Social workers were questioned about their knowledge of NASW's policy on sexual behavior in therapy and their beliefs about NASW's position on this matter. Reliability and validity data for the revised questionnaire have not been established; however, the questionnaire used by Hutchinson (1991) in a similar study yielded comparable data.

Findings

Responses were received from 144 respondents, 75.6% females (n=109) and 24.3% males (n=35), establishing a response rate of 50%. This response rate compares favorably with the returns received in similar studies of social workers (Bernsen et al., 1994; Gechtman, 1989; Hutchinson, 1991; Jayaratne et al., 1997; Sloan et al., 1998).

The mean age of respondents was 52 (SD=8.20) with a range of 28 to 78 years. Sixty-five percent (n=93) reported having over 10 years of practice experience. Slightly less than half (49%, n=71) recalled participating in continuing education that included content on ethics over the last 3 years. When asked to recall the amount of ethics content offered in their master’s program, one fourth (n=34) reported no ethics-related course content and 64% (n=91) recalled content included as part of another course. Only 17 respondents (12%) had taken a course specifically related to ethics. When questioned further about their MSW program’s emphasis on ethics content, 28% (n=40) of respondents reported no emphasis in this area while 20% (n=29) reported that their MSW program placed strong emphasis on ethics content.

Attitudes about Sexual Contact with Clients

Erotic contact with clients. All respondents indicated that erotic contact between social worker and client is usually harmful to the client. In describing their level of concern about this issue, most (66.2%, n=94) said they were very concerned, just over one third (25.4%, n=36) were somewhat concerned, 7.7% (n=11) were not particularly concerned, and one respondent was unconcerned about this problem. When asked how frequently they believed this type of behavior occurred, 3.5% (n=5) of respondents said they thought it occurred frequently, about two-thirds (65%, n=93) responded sometimes, and fewer than one third (31.5%, n=45) said rarely. In assessing responsibility for the sexual contact, 91.7% (n=132) of the respondents believed that the social worker was always responsible when sexual contact occurred. When asked who usually initiates sexual contact, 34.8% (n=48) said the social worker usually initiates the contact, 13.8% (n=19) said the client, and 51.4% (n=71) said both social worker and client initiate the contact.

Respondents were asked to specify whether any of the following types of intimate client contact were appropriate during therapy: hugging, kissing, fondling, sitting on social worker’s lap, and genital contact (multiple responses were allowed for this item). The majority of respondents (92%, n=132) indicated that hugging is always inappropriate in therapy. Comments by some respondents pointed out that hugging is not necessarily a form of erotic or sexual contact. A smaller percentage of respondents (10.4%, n=15) believed that kissing and allowing the client to sit on the social worker's lap (4.1%, n=6) are always appropriate. Most respondents stated that kissing (88.8%, n=128), fondling (100%), sitting on the social worker’s lap (95.8%, n=138) are always inappropriate. All respondents agreed that genital contact with clients is always inappropriate in therapy.

When asked under which circumstances they would permit sexual relationships with clients, a few respondents (2.1%, n=3) indicated that they would allow a sexual relationship when the social worker is in love with the client or when the client is being treated for sexual dysfunction. Although most respondents indicated that sexual contact between social worker and client is prohibited even after the termination of therapy, a few respondents (6.3%, n=9) believed that the prohibition against erotic contact with a client ends with the termination of therapy.

Responsibility for reporting unethical behavior. When asked who should report social worker-client sexual contact, fewer than half (41.6%, n=57) of respondents indicated that the client should report a social worker's unethical behavior, 19.7% (n=27) indicated that reporting should be done by the subsequent social worker, and just over one third (38.7%, n=53) said reporting should be done by the client and subsequent social worker together.

Sexual Practices with Clients

Clients who reported having sex with a previous therapist. When asked if they ever had a client who reported having had sexual contact with a previous therapist, about half (54%, n=77) answered affirmatively. These respondents acknowledged having had a total of 245 clients who reported having sex with their previous therapist. These sexually exploited clients were 90.6% female and 9.4% male. In speculating about the effects of these sexual relationships on their clients’ well-being, most of the respondents (94.9%, n=75) believed the encounters were always harmful to the client, one respondent believed that these encounters had no effect, and one believed sexual contact was helpful in some cases. Respondents identified the professions of the exploitive therapists as social workers (21%, n=30), psychiatrists (21%, n=30), psychologists (21%, n=30), clergy (21%, n=31), licensed professional counselors (10%, n=14), and unspecified other professionals (6%, n=6). As a group, licensed professional counselors differed significantly in proportion from the number of other professions (c2=22.70, df=1, p<.001). Fewer than one third of the respondents (27.5%, n=22) reported the exploitive therapist to a licensing board or other authorities.

Other social workers believed to have had sex with clients. When asked if they knew of other social workers who had sexual contact with a client, over one third (38%, n=47) of respondents answered affirmatively, identifying 103 other social workers who they believed had initiated sex with from 1 to 4 clients. Among respondents who believed that one or more peers had initiated sexual contact with clients, only 15% (n=7) reported these ethics violations to an ethics committee or licensing board.

Respondents' sexual contact with their own therapists. Seven respondents (4.9%) reported having had previous sexual contact with their own therapists. All of these respondents were heterosexual female social workers ranging in age from 45 to 60. All described the sexual contact as ultimately inappropriate, exploitive, and harmful. None of these respondents described the sexual contact as therapeutic.

Sexual contact with clients. None of the respondents reported sexual contact with clients during therapy, however, two social workers acknowledged having had sexual contact with clients after termination. One respondent was a female social worker who became sexually involved with a former male client five years after termination of therapy. She reported that the client initiated the sexual contact, both she and the client had strong positive feelings for each other, and the relationship resulted in marriage. The second respondent, a male social worker, reported that he initiated sexual contact with two former female clients. He noted that at the time the contacts occurred, it was not considered unethical to have sexual relationships with former clients if there was a significant delay between termination of the professional relationship and the sexual encounter.

Discussion

There was almost no variation in the responses of social workers participating in the study concerning their attitudes toward sexual contact with clients and respondents’ actual behavior with clients. All respondents stated that they were opposed to sexual contact of any kind with clients, and no respondent acknowledged having had this type of contact with a client during treatment. These findings are inconsistent with the number of social workers disciplined by the Louisiana State Board of Certified Social Work Examiners for sexual misconduct and with a national survey of social workers’ attitudes and practices about erotic behavior with clients (Gechtman, 1989). This latter study estimated a 2.6% incidence rate of social worker-client sexual contact during therapy. While this rate is considerably less than the overall 7%-10% incidence rates reported in the professions of psychiatry and psychology, it is consistent with the lower rates of sexual involvement reported by female psychiatrists and psychologists who reported sexual contact with clients (Gartrell et al., 1986; Holroyd & Brodsky, 1977).

The majority of respondents expressed concern about the issue of worker-client sexual contact. Almost all believed that the social worker is responsible when sexual contact occurs, although half of these respondents suggested that these dual relationships are entered into by mutual decision. The majority of respondents also believed that the decision to report previous sexual contact with a therapist should be a joint decision made between the client and his/her subsequent therapist. Fewer than one fifth believed that the client’s current therapist should make a unilateral decision to report.

Perhaps the most interesting findings from this study point to the discrepancy between the number of social workers who admit having sexual contact with clients and the number of social workers whose clients reported having had sexual contact with previous therapists, many of whom were social workers. These data were gathered from social workers who practice in different areas of the state, suggesting that respondents were not repeatedly identifying the same few clients. These findings are consistent with those of Hutchinson (1991) and Sloan et al. (1998) whose research identified similar groups of clients exploited by their therapists. The presence of this group of exploited clients suggests that some therapists continue to exploit their clients. Although one must exercise caution when relying on second-hand self-reports from clients, these allegations are disturbing.

Coping with therapists’ sexual impulses and sexual fantasies toward clients has been a persistent problem experienced by mental health professionals ever since the development of psychotherapy (Strean, 1993). Social workers may be confused when they experience sexual feelings about clients, and unsure about how to process these feelings (Giovazolias & Davis, 2001). Sexual feelings are common by-products of therapy that should be explored in supervision or consultation. The use of supervision and consultation protects both the social worker and the client in situations when sexual feelings occur in therapy.

As with all exploratory studies, there are limitations to this work. In addition to limitations imposed by a small sample drawn from one state, the most obvious of these are measurement problems. The questions used to measure attitudes and behaviors rely on self-reported data. The sensitive nature of the study’s substantive focus may have encouraged socially desirable responses, a validity problem that plagues measurement of professional attitudes (Rubin & Babbie, 1997). Further, individuals who have engaged in unethical behavior may have underreported certain aspects of their behavior with clients out of fear of being identified.

In addition to sample size and methodological limitations, generalizability of study findings is limited by issues related to sample composition such as gender. Previous research indicates that therapist sexual misconduct primarily involves male practitioners who become involved with female clients (Brodsky, 1985; Gartrell et al., 1986; Gechtman, 1989). Although gender composition in this present study closely approximates the gender breakdown of NASW (i.e., a population that is 75% female and 25% male), gender differences could be more fully investigated with a larger male cohort. Constructing a sample for future research composed of equal numbers of male and female social workers, similar to the one used by Gechtman (1989), may provide more accurate estimates of social workers’ sexual involvement with clients.

Another limitation related to sample construction is the generalizability of the findings to social workers in practice settings other than private practice. Some studies suggest that private practitioners are most at risk for engaging in unethical behavior with clients (Berkman et al., 2000; Jayaratne et al., 1997) because of the lack of organizational support and oversight in this setting. Independent practice may also allow troubled or impaired professionals to escape notice because of the relative isolation in which they work (Kagel & Giebelhausen, 1994). Including a broader range of practice settings in future research may increase knowledge about the contexts in which worker-client sexual contact occurs.

Implications for Social Work Practice, Education, Policy, and Research

Social work practice with exploited clients. The social work profession is challenged to develop assessment tools and treatment procedures that respond to the needs of exploited clients. Social work education is the proper venue to outline the complicated roles of therapists who are working with clients who have been exploited by previous therapists. The social worker’s expertise when treating a previously exploited client is critical to the success of therapy because of the unique issues that must be processed and resolved, in addition to addressing the client’s initial presenting problems. Such issues include exploring the client’s thoughts and feelings about the relationship with the previous therapist, processing the client’s feelings about being exploited by a helping professional, and determining whether to report the client’s exploitation to a licensing board.

Social work education. Despite the integration of ethics content into the MSW curriculum and the availability of continuing education seminars on professional ethics, some social workers appear to be confused about appropriate boundaries in a therapist-client relationship. The majority of these respondents were not clear about their obligation to report ethics violations, and they were unsure about provisions in the NASW Code of Ethics that address dual relationships with clients. In a survey of attitudes of social work graduate students, Berkman et al. (2000) found relatively high level of approval of sexual contact between social workers and clients under certain circumstances. These authors concluded that the social work students who comprised this sample did not understand professional values and ethics, the power differential between social worker and client, and the possible harm to clients that such a relationship could cause.

Increasing awareness of unethical behavior is facilitated by open discussions of the problem in practice classes and field settings. As Berkman et al. (2000) cautions, inadequate exploration of worker-client sexual contact in social work education may imply that teachers and supervisors are uncomfortable with this content, or believe that this aspect of ethics training is unimportant. They also warn that inadequate discussion of this topic deprives students of the opportunity to identify and process sexual feelings toward clients, as well as learning how to behave ethically when sexual feelings are present in a therapeutic relationship.

Social Work Policy. The education of stakeholders such as consumers, public officials, and policymakers is a critical step in the prevention of unethical behavior by social workers (Strasburger, Jorgenson, & Sutherland, 1992). Formulating policies in all states to demystify client reporting of unethical behavior by social workers will assist licensing boards in identifying unethical practitioners. Clear procedures that guide social workers who are required to report the unethical behaviors of their colleagues need to be developed by state regulatory boards. Development of a client-rights handbook in all states that explains the complaint process will make it easier and less threatening for clients to report an unethical social worker.

In an informal survey, the authors contacted all state social work regulatory boards in 2003 to request information on documentation and reporting procedures for ethics violations. A review of information from the responding boards indicated that there is no consistent method of record keeping and reporting of ethics violations among the states. Some states document numbers of complaints by category of violation while others document information only for adjudicated cases. Regulating agencies also vary widely in the amount of information regarding ethics violations that they are willing to provide to researchers. Some posted this information on easily accessible web sites or responded via e-mail. Others required payment before initiating a query of their data base. The development of more consistent data management policies and procedures that allow for education and feedback about these data among state regulatory agencies would facilitate future research on ethics violations.

Requiring social workers to report ethics violations is a regulatory action implemented by many states. However, mandatory reporting raises complex issues of client confidentiality and client self-determination. Clinicians may avoid reporting a colleague’s unethical behavior because they lack well-documented evidence about the alleged violation. They may be concerned about derailing the therapeutic process by insisting that the client report previous exploitation. In most jurisdictions, mandatory reporting is the obligation of the social worker, not the client. Although clients are encouraged to report unethical behavior to the social worker’s licensing board, they are not required to make these reports.

Social Work Research. The identification of a cohort of clients that reported sexual involvement with a previous social worker during therapy underscores our obligation as a profession to directly address this problem and to develop systematic means of preventing worker-client sexual contact. While it is clear that some social workers in private practice continue to engage in sexual contact with their clients, the current research methodology is inadequate to capture the attitudes and behaviors of this subgroup of social workers. With this being the case, proper education on ethics and on the dynamics and dangers of dual relationships, as well as changes in policy are needed to protect clients from exploitation as a result of sexual relationships with their therapists. Practitioners and educators must not become complacent because state licensing boards prosecute relatively few social workers for the sexual exploitation of clients.

Acknowledgements

We thank Catherine Lemieux, Ph.D., Louisiana State University School of Social Work, for her expertise in the reviewing and editing this manuscript.


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