A Comparison of Psychologists Who Engage in

Nonsexual and Sexual Dual Relationships with Psychologists Who Do Not

Debra K. Ehlert

Dissertation submitted to the

College of Human Resources and Education
at West Virginia University
in partial fulfillment of the requirements
for the degree of

Doctor of Philosophy
in
Counseling Psychology

L. Sherilyn Cormier, Ph.D., Chair

Andrea Celenza, Ph.D.
Lynda Danley, Ph.D.
Robert Marinelli, Ph.D.
Jeffrey K. Messing, Ed.D.
Richard T. Walls, Ph.D.

Department of Counseling, Rehabilitation Counseling,

and Counseling Psychology

Morgantown, West Virginia

2002
Keywords: dual relationships, boundary violations, psychologist impairment,
therapist narcissism

Abstract
A Comparison of Psychologists Who Engage in
Nonsexual and Sexual Dual Relationships with Psychologists Who Do Not
Debra K. Ehlert
The purpose of this study was to examine and understand potential differences
between psychologists who have engaged in a nonsexual and sexual dual relationship and
psychologists who have not. Psychologists from across the United States (N = 59)
completed questionnaires concerning object relations, parentification, narcissistic injury,
self-esteem, and ethical judgment. Measures included a demographic questionnaire, the
Bell Object Relations Inventory (BORI) with four subscales of alienation, insecure
attachment, egocentricity, and social incompetence), the Parentification Questionnaire
(PQ), the Narcissistic Injury Scale (NIS), the Rosenberg Self-Esteem Scale (RSE), the
Ethical Judgment Scale (EJS), and four open-ended questions regarding the experience of
being sanctioned.
In regard to demographic characteristics, two significant differences were found
for the sanctioned groups. One, more males than females engaged in nonsexual and
sexual dual relationships and two, there were more female than male client victims.
Other notable demographic characteristics of the sanctioned groups include a mean age
range at the time of the ethical violation of 45.6 years, 77% of the participants worked in
private solo practice at the time of the ethical violation, and 25% of the nonsexual dual
relationship group and 53% of the sexual dual relationship group were experiencing the
loss of a significant relationship at the time of the ethical violation.
A multivariate analysis of variance revealed no significant differences between
group membership and the Bell Object Relations Inventory subscales. For these groups,
object relations did not appear to be impaired as their scores were not above the cutoff on
the Bell Object Relations Inventory. However, it is notable that the mean scores on each
subscale for the nonsexual and sexual dual relationship groups were higher than for the
control group, suggesting that participants in the dual relationship group reported more
problematic object relations than the control group, though not significantly different.
A multivariate analysis of variance revealed a significant main effect for group
membership and the remaining measures (PQ, NIS, RSE, EJS). Subsequent analyses of
variance revealed significant differences on the Narcissistic Injury Scale and Rosenberg
Self Esteem Scale. Post hoc tests revealed the nonsexual and sexual dual relationship
groups had significantly higher scores on the Narcissistic Injury Scale and significantly
lower scores on the Rosenberg Self Esteem Scale than the control group. Thus, the dual
relationship groups reported more narcissistic injury in childhood and lower self-esteem
than the control group.
Emotional, physical, and/or sexual abuse emerged as important predictors in the
multiple regression analyses for the dual relationship groups. For the nonsexual group,
the variables, emotional abuse and physical abuse were most potent. That is, emotional

abuse emerged as a predictor of parentification and narcissistic injury. The demographic

variables emotional abuse and physical abuse together predicted a significant amount of
variance on the Parentification Questionnaire. Analyses for the sexual dual relationship
group revealed that a history of emotional abuse is the most powerful predictor.
Emotional abuse predicted insecure attachment, social incompetence, and narcissistic
injury. Not surprisingly, the demographic sexual abuse emerged as a predictor of
alienation and the demographic physical abuse predicted a significant amount of variance
on the Parentification Questionnaire. Finally, the demographic age at the time of
violation emerged as a predictor of the Ethical Judgment Scale.
Multiple regression analyses for the control resulted in two significant findings.
Emotional abuse accounted for a significant amount of variance on the Parentification
Questionnaire, which was similar to the nonsexual dual relationship group, and physical
abuse predicted a significant amount of variance on the Ethical Judgment Scale.
Pearson product moment correlations were computed for each group to assess the
relationship between the measures. For the nonsexual dual relationship group, increases
in alienation and insecure attachment were related to increases in social incompetence
and narcissistic injury. Conversely, as insecure attachment, egocentricity, social
incompetence, and parentification, and narcissistic injury increased, self-esteem
decreased. For the sexual dual relationship group, insecure attachment correlated
significantly with egocentricity, social incompetence, parentification, and narcissistic
injury. Additionally, higher egocentricity was related to higher parentification. Higher
social incompetence and parentification were related to higher indices of narcissistic
injury. Finally, a higher score on the Narcissistic Injury Scale correlated with a lower
score on the Rosenberg Self Esteem Scale.
Correlational analyses for the control group revealed that an increase in alienation
was related to a decrease in egocentricity and narcissistic injury. While for the nonsexual
group, an increase in alienation was related to an increase in narcissistic injury. For both
the control group and the nonsexual dual relationship group, an increase in insecure
attachment was related to an increase in social incompetence. Additionally, for the
control group, an increase in parentification was related to an increase in narcissistic
injury.
Responses to the open-ended questions for the sanctioned groups were analyzed
for themes. In general, the groups used positive terms to describe themselves and their
competency as psychologists. In response to what was happening in their lives at the
time of the ethical violation, statements were elicited regarding stressful situational
variables, stable life variables, and the feeling of being overworked. In regard to the
sanctioning process, some participants described feelings of humiliation, others felt the
sanctioning process was difficult but positive, and some perceived maltreatment from the
sanctioning Board of Psychology. Some participants wrote responses indicating personal
and professional growth, blame of the client who filed the complaint, and blame of the
Board of Psychology who sanctioned them. Finally, recommendations are offered for
practice, training, licensing boards, and future research.

iv
Acknowledgments
With much trepidation about whether I would get participants, I began this research
project believing that those who have been sanctioned needed a voice. Were it not for those
individuals who agreed to participate, despite their feelings about the sanctioning process, I
would not have finished. To all the sanctioned psychologists, thank you, I hope I have accurately
represented your voice.
Over the course of my tenure as a doctoral student, I was blessed to come into contact
with a few strong, compassionate, and spirited women who served as role models for my personal
and professional development. My mentor, Sherry Cormier, has touched my life in ways Im not
sure even she realizes. Sherrys unwavering support and consistent encouragement through my
own growth will stay with me always. Thank you, Sherry, for providing the perfect balance of
support and challenge. As you say, The Universe knows what you need and will provide and it
certainly did in this case.
Thanks goes to Dr. Richard Walls for his statistical and research expertise, for his
willingness to meet with me at a moments notice, and for his sense of humor (I know where all
those cookies went!). Thanks, also, to Drs. Messing, Marinelli, Celenza, and Danley for their
input in making the project and final document better. You have been a wonderfully supportive
committee, and an invaluable resource.
Of course, my completing this project would not have been possible were it not for the
perseverance and strength I inherited from my Mother. Thanks Mom, youre the strongest
woman I know and I hope you know Im your biggest fan. Thanks also to my Father and Carolyn
for their unfaltering support.
A final thank you goes to my intended husband, Dr. Joseph Kachik. Thank you for being
willing to go through the Program a second time and for providing me with a solid foundation
on which to find myself. You gave me faith to believe in my dreams and myself. Soon, the
children and I will be home and well have our life back.

v
Table of Contents
Abstract

ii

Acknowledgments

iv

List of Tables

viii

Chapter 1: Introduction

Statement of the problem

16

Purpose of study

17

Definition of terms

18

Chapter 2: Literature review

23

Treatment boundaries in therapy

24

Definition of dual relationships

26

Nonsexual dual relationships

30

Sexual dual relationships

34

The evolution of sexual dual relationships

46

The misuse of countertransference in sexual dual relationships

49

Typologies of sexually offending psychologists

55

The psychodynamic characteristics of offending psychologists

59

The childhood histories of psychologists

64

Narcissistic injury to therapists

71

Summary of literature review

74

Summary of empirical and anecdotal findings

78

Conclusions and purpose of study

80

Research questions

81

Chapter 3: Method

82

vi

Participants

82

Procedure

82

Measures

87

Chapter 4: Results

97

Research Question 1

98

Research Question 2

111

Research Question 3

113

Research Question 4

115

Research Question 5

125

Analyses of open-ended questions

132

Additional analyses

134

Summary of Results

137

Chapter 5: Discussion

141

Research Question 1

142

Research Question 2

154

Research Question 3

158

Research Question 4

161

Research Question 5

164

Implications of the study

168

Suggestions for future research

173

Summary and conclusions

174

Limitations of the study

175

References

178

Appendices

191

vii

Appendix A: Letter of Introduction (Groups A, B)

192

Appendix B: Postcard for Groups A, B

194

Appendix C: Cover Letter (Groups A, B)

196

Appendix D: Information Form (Groups A, B)

198

Appendix E: Demographic Questionnaire (Groups A,B)

200

Appendix F: Follow-up Postcard

203

Appendix G: Parentification Questionnaire

205

Appendix H: Narcissistic Injury Scale

208

Appendix I: Rosenberg Self-Esteem Scale

211

Appendix J: Ethical Judgment Scale

213

Appendix K: Open-Ended Questions (Groups A, B)

216

Appendix L: Cover Letter, Group C

218

Appendix M: Information Form, Group C

220

Appendix N: Demographic Questionnaire, Group C

222

Curriculum Vitae

224

viii
List of Tables
Table 1. List of Sanctioned Subjects by State and Gender

84

Table 2. Packets of Materials for Groups A, B, C

85

Table 3. Reliabilities and Validities Reported for Standardized Instruments

Used in Present Research
Table 4. Means, Standard Deviations, and Ranges for Instruments

88
99

Table 5. Group Membership X Demographic Variables Contingency

Table

100

Table 6. Group Membership X Client Gender Contingency

Table

102

Table 7. Demographic Characteristics of the Participants

103

Table 8. Demographic Characteristics of Sanctioned Participants

105

Table 9. Gender and Diagnostic Impression(s) of Client Victims

107

Table 10. Means, Standard Deviations, and Multivariate Analyses

of Variance Results for BORI by Group

112

Table 11. Analyses of Variance and Multivariate Analyses of

Variance Results for Group Membership on the Four
Dependent Variables (NIS, PQ, RSE, EJS)

114

Table 12. Correlational Data for Research Instruments and Demographic

Variables

117

Table 13. Summary of Multiple Regression Analyses for Demographic

Variables on Dependent Variables (Group A)

119

Table 14. Summary of Multiple Regression Analyses for Demographic

Variables on Dependent Variables (Group B)

121

ix
Table 15. Summary of Multiple Regression Analyses for Demographic
Variables on Dependent Variables (Group C)

124

Table 16. Intercorrelations of Research Instruments (Group A)

126

Table 17. Intercorrelations of Research Instruments (Group B)

128

Table 18. Intercorrelations of Research Instruments (Group C)

131

Table 19. Matrix of Linkages Between Open-ended Questions and

Themes for Group A

133

Table 20. Matrix of Linkages Between Open-ended Questions and

Themes for Group B

135

CHAPTER I
Introduction
In their survey of licensed psychologists, Pope and Vetter (1992) noted that one of
the two most frequently reported ethical dilemmas is maintaining clear, reasonable,
therapeutic boundaries in relationship to a client. The practice of psychotherapy requires
the psychologist to balance empathy, caring, and support with emotional, mental, and
physical limits within the therapeutic relationship. In regard to this fluctuating boundary
separating the psychologist and client, the limits of intimacy are inevitably challenged.
But, how far is too far? How close is too close?
In 1998, despite ethical prohibitions against dual relationships, 58% of the cases
ending in loss of American Psychological Association (APA) membership and state
licensure involved psychologist-client sexual misconduct. Nineteen percent of the cases
with similar disciplinary outcomes involved nonsexual boundary violations (APA, 1998).
Furthermore, these percentages have not been reduced in the last six years from
publication of this article despite increased public consciousness and litigation (APA,
1998). Even more disturbing is that psychologist-client dual relationships, especially
those involving sexual misconduct, have almost universal negative consequences for
clients (Bouhoutsos, Holroyd, Lerman, Forer, & Greenberg, 1983; Feldman-Summers, &
Jones, 1984; Gutheil, 1991; Pope, Keith-Spiegel, & Tabachnick, 1986; Simon, 1991;
Somer & Saadon, 1999).
Considering the above information, boundary violations appear to underpin the
major ethical dilemma psychologists struggle with as members of the APA. Simply
stated, difficult ethical situations arise regularly in regard to the negotiation of boundaries

2
in therapy (Smith & Fitzpatrick, 1995). As the literature shows, too often, the blurring of
boundaries leads to some sort of dual relationship (e.g., social, sexual, financial, or
professional).
The American Psychological Association (APA) has addressed the issue of dual
relationships since the first publication of its ethical code in 1953 (APA, 1953). In this
first written ethical code, psychologists were reported to have a cardinal obligation
(APA, 1953, p. 4) to respect the integrity and welfare of the clients with whom they
served. The code admonishes psychologists to avoid entering into clinical relationships
with clients that their welfare might be jeopardized by the dual relationship (APA,
1953, p. 4).
A specific proscription against sexual intimacies with clients first appeared in the
1977 Ethical Code (APA, 1977). Principle 6a states, Sexual intimacies with clients are
unethical (APA, 1977, p. 22). Since 1977, efforts to address the problem of social and
sexual dual relationships were sparked by the increase in complaints from consumers
from 1982 to 1985 (Gottlieb, 1990). The 1989 Ethics Code (which was amended in
1990) included instructions for psychologists to make every effort to avoid dual
relationships that could impair their professional judgment (APA, 1990). Currently, the
1992 Ethics Code has attempted to define dual relationships and address post-therapy
dual relationships (APA, 1992).
What exactly is a dual or multiple relationship? APA Ethical Guideline 1.17
(1992) provides a definition and a warning:
In many communities and situations, it may not be feasible or reasonable
for psychologists to avoid social or other nonprofessional contacts with
persons such as clients, clients, students, supervisees, or research

3
participants. Psychologists must always be sensitive to the potential
harmful effects of other contacts on their work and on those persons with
whom they deal. A psychologist refrains from entering into or promising
another personal, scientific, professional, financial, or other relationship
with such persons if it appears likely that such a relationship reasonably
might impair the psychologists objectivity or otherwise interfere with the
psychologists effectively performing his or her functions as a
psychologist, or might harm or exploit the other party (p. 1601).
Additionally, APA Ethical Guidelines 4.05, 4.06, and 4.07 (1992) deal directly
with sexual dual relationships. Standard 4.05 states, psychologists do not engage in
sexual intimacies with current clients or clients, standard 4.06 states, psychologists do
not accept as therapy clients or clients persons with whom they have engaged in sexual
intimacies, and standard 4.07 states, psychologists do not engage in sexual intimacies
with a former therapy client or client for at least two years after cessation or termination
of professional services (APA, 1992, p. 1605). Although it appears clear that these
guidelines explicitly prohibit psychologists from engaging in dual or multiple relations
with current and past clients, this problem continues to plague the profession.
Some researchers (Pope & Vetter, 1992; Sonne, 1994) believe APA Ethical
Guideline 1.17 (1992) is not clear regarding exactly what behaviors constitute harm or
exploitation of the client. Perhaps one reason why boundary violations continue is
because what exactly constitutes a dual relationship is ambiguous. According to Sonne
(1994) the designation of many communities and situations (APA, 1992,
p. 1601) is too broad and general. Another problem Sonne (1994) identified is that the
psychologist is left to determine what kind of dual relationship will likely and

4
reasonably cause harm. Therefore, the unethical psychologist has a sizeable
loophole (p. 342) for potential conscious and unconscious misinterpretation (Sonne,
1994).
A related issue is the process of ethical judgment or how a therapist comes to
view potentially unethical behaviors. Empirical research has shown that two
demographic variables, age and years of practice experience, are related to the judgment
of behaviors as ethical or unethical (Borys & Pope, 1989; Epstein, Simon, & Kay, 1992;
Lamb, Woodburn, Lewis, Strand, Buchko, & Kang, 1994; Rodolfa, Hall, Holms, Davena,
Komatz, Antunez, & Hall, 1994; Stake & Oliver, 1991). Specifically, as age and years of
practice increase, prohibitive attitudes toward dual professional roles decrease.
Another perspective on this issue comes from literature and empirical research on
therapists who enter into dual relationships. Literature based on clinical experience states
that character flaws (i.e., mildly neurotic and personality disorders) and situational
variables (e.g., divorce or separation, loneliness) cause unfit therapists to transgress
ethical boundaries (Gabbard, 1994a; Olarte, 1991; Schoener & Gonsiorek, 1990; Simon,
1995; Somer & Saadon, 1999). Importantly, empirical research on sexual dual
relationships found that the most common profile is a middle aged male psychologist
who falls in love with a much younger female client because of separation, divorce,
loneliness, or loss of his significant other (Butler & Zelen, 1977; Pope, 1993; Somer &
Saadon, 1999). Most likely, a combination of these explanations may explain why some
psychologists cross boundaries that ultimately end in dual relationships. That is,
otherwise ethically minded professionals ignore the APA Ethical Guidelines (1992) and
get caught in a spiral of boundary crossings because they have long-standing emotional
problems (e.g., low self-esteem, interpersonal difficulties, impaired object relations,

5
childhood histories of abuse), are experiencing a personal crisis, or both (Celenza, 1998;
Gabbard, 1994b).
If the complexities of this phenomenon are to be understood, current research
must examine and extend information on the predisposing characteristics of psychologists
who engage in boundary violations that lead to dual relationships. Awareness of these
vulnerabilities can be used to inform supervisors and psychology educators. When the
focus of concern is the therapeutic skill level and personal development of the trainee or
student, appropriate interventions can prevent the evolution of a problematic dual
relationship. Given the above information on the incidence of unethical boundary
violations, our profession, and particularly psychology training programs, have a
significant responsibility to address the etiology of this phenomenon.
Treatment Boundaries
A treatment boundary is a therapeutic frame that defines a set of roles for the
participants in the therapeutic process (Smith & Fitzpatrick, 1995). This therapeutic
frame includes both structural elements (e.g., time, place, and money) and the content
(what actually transpires between therapist and client) of therapy. Consistent
management of session length and fees, appropriate work place, and minimal therapist
self- disclosure represent common treatment boundaries. Most importantly, therapeutic
boundaries support the psychologists efforts to provide a relationship based on integrity,
trust, and a working alliance (Simon, 1992). Said differently, treatment boundaries
define and secure the professional relationship, as well as encourage trust to promote
psychological healing.
The importance of maintaining treatment boundaries becomes apparent when one
considers the nature of the therapeutic relationship (Smith & Fitzpatrick, 1995). Inherent

6
in the treatment process is a power imbalance. Psychologists are encouraged to maintain
a sensitivity to the real and ascribed differences in power (APA, 1992, p. 1606). The
immediate power imbalance that occurs in the therapeutic relationship requires the
psychologist to act in good faith and to forego personal gratification (Strasburger,
Jorgenson, & Sutherland, 1992). In no other fiduciary relationship is the welfare of the
client more important than during therapy (Simon, 1992; 1999).
Simon (1992; 1999) delineated five principles that underlie treatment boundaries:
the rule of abstinence (avoid using the client for personal gratification), the duty of
neutrality (avoid non-therapeutic interference in the personal life of the client), client
autonomy and self-determination, the fiduciary relationship, and respect for human
dignity. When considering the regulation of boundaries in treatment, these principles can
help a psychologist be aware of the process of gradual and progressive boundary
violations (Simon, 1992). To this end, researchers have delineated between boundary
crossings and boundary violations (Gutheil & Gabbard, 1993; Smith & Fitzpatrick, 1995;
Twemlow, 1997).
Boundary crossings represent a departure from commonly accepted clinical
practice that may or may not benefit the client (Smith & Fitzpatrick, 1995; Twemlow,
1997). Accepting a gift from a client or hugging the client after a session are examples.
Boundary crossings that increase in frequency and intensity eventually may lead to a
boundary violation (Simon, 1992; 1999). A boundary violation, on the other hand, is a
clear departure from accepted practice that places the client or the therapeutic process at
serious risk (Gutheil & Gabbard, 1993). Retaining the client in treatment longer than
indicated, failing to set limits, the use of favors or services from the client for the benefit
of the psychologist, and excessive therapist self disclosure, are examples of boundary

7
violations (Gutheil & Gabbard, 1993; Twemlow, 1997).
Situations that test boundaries arise regularly in treatment. Some situations are
very clear, while others go unnoticed, and are influenced by ones gender and theoretical
orientation (Baer & Murdock, 1995; Borys & Pope, 1989; Lamb et al., 1994; Pope, 1990;
Simon, 1992). Research on boundary violations has shown that male psychologists are
more likely than female psychologists to engage in sexual and nonsexual dual
relationships and to view these boundary crossings as positive (Borys & Pope, 1989;
Bouhoutsos et al., 1983; Holroyd & Brodsky, 1977; Lamb et al., 1994; Pope, 1990). This
does not imply that male psychologists are the only perpetrators of dual relationships but
male psychologists engage in dual relationships more often than their female
counterparts.
Psychodynamically oriented therapists are less likely to engage in social,
financial, and dual professional roles with clients than their cognitive-behavioral or
humanistic counterparts (Baer & Murdock, 1995; Borys & Pope, 1989; Holroyd &
Brodsky, 1977; Pope & Bouhoutsos, 1986; Pope, Tabachnick, & Keith-Spiegel, 1987).
Interestingly, Borys and Pope (1989) showed that this finding was consistent across three
different groups of mental health practitioners (psychologists, psychiatrists, and social
workers).
Regardless of therapist gender or theoretical orientation, the important issue is
that boundary violations, including those that precede actual sexual involvement, have
been shown to be damaging to the client (Bouhoutsos et al., 1983; Feldman-Summers, &
Jones, 1984; Gutheil, 1991; Pope, Keith-Spiegel, & Tabachnick, 1986; Simon, 1991;
Somer & Saadon, 1999). Furthermore, therapists who commit nonsexual boundary
violations are more likely to become sexually involved with their clients and therefore,

8
are at an increased risk for exploiting the relationship (Holroyd & Brodsky, 1980;
Twemlow, 1997). Thus, the recognition of boundary crossings and the prevention of
boundary violations are essential for the ethical practice of therapy and the integrity of
the treatment process.
Types of Boundary Violations
Boundary crossings represent a continuum ranging from those that are not
harmful but in fact, may be helpful (e.g., appropriate therapist self-disclosure) to those
that put the client at risk for serious harm. Notably, therapists who commit nonsexual
boundary violations are more likely to cross sexual boundaries with clients (Holroyd &
Brodsky, 1980; Twemlow, 1997). Some common boundary crossings that may lead to
boundary violations include excessive therapist self-disclosure and non-erotic physical
contact.
Self disclosure. In certain circumstances, self-disclosure can be a powerful
intervention. However, it must be done for the clients benefit within the context of the
therapeutic process (Smith & Fitzpatrick, 1995). Therapist disclosures that are not
considered appropriate include current problems or stressors, personal fantasies about the
client, dreams, and social, sexual, or financial circumstances (Simon, 1991).
In appropriate self-disclosure is the most dangerous boundary to cross during
therapy because it may lead to therapist-client sexual contact (Simon, 1991; Somer &
Saadon, 1999). Most boundary crossings begin between the chair and the door (Gutheil
& Simon, 1995). That is, they begin insidiously with social informalities or seemingly
inconsequential self-disclosures, at the very beginning or end of a session. For example,
sessions become more social as therapist and client address each other by first name, the
session is extended or changed to later in the day, sessions end with a hug, and the

9
therapist begins to self-disclose personal problems or details until ultimately, the sexual
boundary violation occurs. As Simon (1989) noted, a sexual violation begins before it
happens (p. 104).
Physical contact (nonerotic). Physical contact with clients is a complex issue. A
gentle reassuring touch or hug can be the most appropriate therapeutic response at certain
times with some clients (Simon, 1992). However, the mindful therapist will consider the
clients interpretation of such an act. Afterall, there is a risk that the client may see touch
as a sexual advance. Cultural factors must also be taken into account (Smith &
Fitzpatrick, 1995). What may or may not carry an erotic overtone can vary among clients
of diverse cultural backgrounds.
Research in the area of physical touch during therapy has been sparse. Holroyd
and Brodsky (1977) researched the use of touch by psychologists from differing
theoretical perspectives. They found that humanistic therapists (30%) believed touch
could be beneficial to clients, whereas, psychodynamic therapists (6%) were less
enthusiastic about the benefits of touch in therapy.
Pope et al. (1987) reported the incidence of three kinds of physical touch between
psychologists and clients. Kissing a client was deemed least acceptable (85% reported it
was not ethical) and was rarely practiced (71% reported never practiced) by their group
of respondents. Hugging was categorized as ethical under many circumstances by 44%
of the subjects. Finally, handshakes were the most widely accepted (94%) and the most
practiced form of physical contact between therapist and client.
Extending the literature on physical contact with clients, Stake and Oliver (1991)
surveyed 320 licensed psychologists (207 men and 113 women) and found three
categories of therapist touching and sexual behaviors, overt sexual behavior (e.g., oral

10
sex, intercourse), touching (e.g., touching face, hair, or neck) and suggestive behavior
(e.g., sexual humor, suggestive looks or remarks). Stake and Olivers (1991) participants
rated overt sexual behaviors as always or almost always constituting misconduct,
touching behaviors as seldom constituting misconduct, and the suggestive behaviors as
frequently constituting misconduct. Stake and Oliver (1991) make the point that a simple
distinction between sexual and nonsexual behaviors is oversimplified, and greater
attention needs to be given to suggestive behaviors.
Holroyd and Brodsky (1977) studied sexually offending therapists and found they
engaged more often in touching behavior with opposite-sex clients. The issue here is that
while non-erotic physical touch may not be harmful in and of itself, therapists must
consider contextual variables when contemplating touch in the therapy hour. As stated
earlier, another related issue is the age of the therapist and years of practice. Ethical
judgment appears to become more flexible as age and years of practice increase.
Therapist-client sexual contact. Sexual misconduct is the most examined and
troublesome boundary violation. In most cases of sexual misconduct, there is a
predictable sequence of boundary violations beginning with nonsexual boundary
crossings leading to sexual contact. Interestingly, most psychologists experience sexual
attraction to a client at some point in their careers, struggle emotionally with these
feelings, and feel both their training and supervision were inadequate to help them deal
with these feelings (Lamb & Catanzaro, 1998; Pope et al., 1986; Rodolfa et al., 1994).
Suffice it to say that sexual feelings sometimes exist in the therapy hour but how these
feelings are managed appear to be the key to ethical versus unethical behavior.
Complicating the matter further, how these feelings are managed (i.e., ethical judgment)
appears to be related to the age and years of practice of the therapist.

11
Fortunately, most psychologists do not act on their sexual feelings toward clients.
Yet, survey results of licensed psychologists consistently show between 5% and 12% do
exploit their client(s) sexually (Lamb & Catanzaro, 1998; Lamb et al., 1994; Pope et al.,
1986; Rodolfa et al., 1994). Surprisingly, because survey data are known to
underestimate the actual incidence of psychologist-client sexual misconduct and
offending psychologists may tend to withhold such information, Pope et al. (1986)
estimated the actual figure may be close to 20%, while Simon (1989) estimated a rate of
25%, or 1 out of four psychologists.
Holroyd and Bouhoutsos (1985) examined biased reporting of therapist-client
sexual misconduct. In this study, information about the psychological affects of
therapist-client sexual misconduct was gathered. The researchers reported that
psychologists who claimed no harm was done as a result of the previous sexual
misconduct with another therapist were almost three times as likely to admit having
engaged in sexual misconduct with their own clients. Holroyd and Bouhoutsos (1985)
concluded that these participants were biased in their observations and reporting of sexual
misconduct.
Finally, graduate training programs and internships rarely address the issue of
therapist-client sexual attraction adequately, if at all (Hamilton & Spruill, 1999; Ladany,
et al., 1997; Pope & Feldman-Summers, 1992; Pope & Tabachnick, 1993). Pope and
Tabachnick (1993) reported a large percentage of their subjects rated their training with
regard to feeling anger, fear, and sexual arousal toward a client was nonexistent or poor
(41%, 50%, & 65%, respectively).
Hamilton and Spruill (1999) explain that the problem of sexual misconduct with
graduate trainees is not a matter of lack of exposure to the ethical standards, rather, it is

12
the failure on the part of the trainee to identify and deal effectively with ethical conflicts
when they arise in real-life situations. Hamilton and Spruill (1999) note that trainees may
recognize ethical dilemmas in laboratory studies but recognizing and handling ethical
dilemmas outside the laboratory is another issue. In short, graduate programs do well to
offer exposure to ethical dilemmas and ethical standards but fall short in helping trainees
apply these standards to ethical practice outside the classroom, especially in situations of
intense transference and countertransference reactions. A majority of subjects (N = 13)
in the Ladany et al. (1997) qualitative study reported sexual attraction to clients was not
addressed in their training program and felt it would be beneficial for the training to be
didactic as well as experiential to gain experience in handling such strong feelings.
Finally, Pope and Tabachnick (1993) add that due to a neglect of these issues in graduate
training, graduate psychology students may lack the support to develop knowledge,
resources, confidence, and skills to acknowledge, accept, and understand such feelings
when they occur in the therapists work. (p. 147).
Training on the issue of therapist-client sexual attraction may be one of the most
effective preventive measures. Hamilton and Spruill (1999) report that for training to be
effective in the prevention of sexual misconduct graduate training programs must address
issues of therapist-client sexual attraction explicitly and forcefully through class
discussion, role plays, and skills training; feelings of sexual attraction must be openly
discussed and normalized, and appropriate therapeutic boundaries must be explained (p.
324). These authors also comment on the importance of role modeling proper boundaries
between faculty and students to help prevent trainee-client boundary violations. Finally,
Gabbard (1996) states that a knowledge of the ethical code is important, however,
learning to be aware of and handling intense transference and countertransference

13
reactions, even if the students dont intend to practice dynamic psychotherapy, are
perhaps more effective in preventing boundary violations than just knowledge alone.
Evolution of Boundary Violations
The evolution of boundary violations often follows a predictable pattern
(Gabbard, 1996; Gutheil & Simon, 1995; Pope, Keith-Spiegel & Tabachnick, 1986;
Simon, 1991; 1995; 1999; Somer & Saddon, 1999). Most boundary violations are the
end result of a buildup of increasingly harmful boundary crossings that begin benignly in
everyday social situations (usually at the beginning or end of the therapy hour) (Gutheil
& Simon, 1995). The two most common boundary violations that precede sexual
involvement are therapist self-disclosure and nonsexual hugging (Gabbard, 1996; Simon,
1991; Somer & Saddon, 1999). A related issue that has been addressed by only one
empirical study (Saadon & Somer, 2001) is that of who initiates the physical boundary
violation, the psychologist or client. Potentially different profiles of offenders and clients
may arise based on who initiates physical contact.
Early stages of boundary violations begin with boundary inattention (Twemlow,
1997). Boundary inattention manifests in being unaware of the significance of a fantasy
or thought about a client. The second developmental stage occurs when boundary
inattention gives way to boundary crossings; a point at which some action occurred but
did not result in harm although there is the potential for harm. A boundary crossing may
begin as a therapeutic intervention and then progress to a boundary violation where the
therapists needs are clearly being met at the expense of the client.
Portrait of Offending Psychologists
Two recent studies (Celenza, 1998; Celenza & Hilsenroth, 1997) have examined
empirically the psychodynamic characteristics of therapists that may be seen as possible

14
precursors to sexualized boundary violations. In these studies, samples of mental health
practitioners who engaged in sexual relations with clients were given comprehensive
psychological examinations. Both studies found that offending psychologists commonly
experienced frequent misunderstandings of countertransference, long-standing and
unresolved problems with self-esteem, feelings of helplessness, depression, interpersonal
longing or object hunger, restricted awareness of fantasy, childhood boundary
transgressions by a parental figure, unresolved anger toward authority figures, and
intolerance of negative transference.
In effect, these offending therapists appeared to struggle with chronic low selfesteem and impaired object relations. As an explanation of this, Miller (1981) postulated
that therapists are likely to have been raised by a parent who used his or her children in
order to gratify unfilled needs. As a result, offending therapists use their clients to meet
unresolved narcissistic needs and need their clients to view them in a positive light
(Celenza, 1998), in effect constructing a reenactment of their early object relations
history with their parents.
Childhood Histories of Psychologists and Resulting Object Relations Issues
The childhood environment of some psychologists suggests that therapists are
often raised in dysfunctional families (Elliott & Guy, 1993; Pope, 1992; Racusin,
Abramowitz, & Winter, 1981). In all of these studies, over 50% of the therapist sample
reported incidents of childhood abuse resulting from physical or sexual abuse, parental
alcoholism, psychiatric hospitalization of a parent, or death of a family member. In these
families, the boundaries between parent and child became blurred.
Family systems theorists have identified the phenomenon of parentification, the
familial pattern whereby children, in effect, parent their parents (Boszormenyi-Nagy &

15
Spark, 1973; Mika, Bergner, & Baum, 1987). These roles frequently include caring for
younger siblings or dysfunctional parents; assuming roles such as consoler, confidante,
peacemaker or personal advisor to parents; and, taking on household responsibilities
normally handled by adults.
Research has shown that there may be a strong link between childhood
parentification and the adoption of care-taking roles or careers (e.g., therapist, nurse) in
adulthood (Valleau, Bergner, & Horton, 1995; West & Keller, 1991). As a result of
parentification, individuals tend to have trouble establishing and maintaining healthy
boundaries in relationships (Glickauf-Hughes & Mehlman, 1995). Perhaps some
therapists who have trouble maintaining clear, therapeutic boundaries have been
parentified as children. As a child their emotional needs were unmet which may have
resulted in a narcissistic injury. Narcissistic injuries of the therapist may contribute to
boundary violations with clients.
Narcissistic Injuries to Therapists
One area hypothesized to underlie boundary violations is the incidence of
narcissistic injury in the childhoods of adult therapists. Miller (1981) defined narcissistic
injury as the psychological damage that occurs when normal childhood narcissistic needs
for respect, understanding, and mirroring go unmet. Healthy development occurs when
the childs emotional needs are met adequately and reliably by caregivers. Unfortunately,
some therapists experienced a different reality in childhood and their emotional needs
went unacknowledged or unmet. Masterson (1981) suggested that many of the mothers
of individuals with narcissistic personality disorder were emotionally cold and exploitive.
These mothers ignored their childrens separation-individuation needs in order to mold
them into objects that justified their own perfectionistic and emotional needs. As a result,

16
the childs individuation needs suffered, as did their self-esteem, which ultimately led to
narcissism and underlying depression. Celenza and Hilsenroth (1997) observed in
offending therapists that, one of the most salient factors observed in these individuals is
the pervasive sense of unmet interpersonal longing and emotional deprivation in
relational contexts (p. 103). Such an emotionally harmful childhood may result in
impaired ethical judgment. For example, a therapist whose emotionally needs were
unmet in childhood may look to a client to fill those needs, thus viewing boundary
violations and dual relationships as more ethical.
Of importance in this study is the impact of object relations, incidence of
narcissistic injury and parentification in childhood, and resulting low self-esteem, as it
pertains to the etiology of impaired ethical judgment and management of treatment
boundaries.
Statement of the Problem
Boundary issues pose complex challenges to psychologists. Proper maintenance
of boundaries encourages the autonomy and independence of clients, while boundary
violations have the opposite effect (Smith & Fitzpatrick, 1995).
While most research in this area informs the field on the prevalence and
progression of boundary violations, there is little research that explores the underlying
psychodynamic characteristics of psychologists who cross treatment boundaries. To
understand the etiology of the phenomenon, inquiry must go beyond demographic and
incident reporting survey research. Specifically, investigation of offending and
nonoffending psychologists is needed that explores the impact of object relations,
evidence of narcissistic injury, the incidence and prevalence of parentification, and the
level of therapist self-esteem. In reviewing the literature, there is a lack of empirical

17
studies that examine and compare the psychodynamic characteristics of psychologists
who engage in nonsexual and sexual dual relationships with clients with those
psychologists who do not (Celenza, 1998).
Research has shown that most psychologists do feel sexually attracted to at least
one client at some point during their career (Pope et al., 1986; Pope & Tabachnick,
1993). While most psychologists dont act on such feelings, some do. What separates
these two groups of psychologists? Also, training programs may not be thoroughly
addressing this issue (Hamilton & Spruill, 1999; Pope, Keith-Spiegel & Tabachnick,
1986; Pope & Feldman-Summers, 1992; Pope & Tabachnick, 1993). More knowledge is
needed to inform supervisors and educators about this potentially costly violation and the
training issues surrounding it.
Purpose of the Study
This study will attempt to extend current research on psychodynamic
characteristics of psychologists who engage in nonsexual and sexual boundary violations
with clients. Of interest are variables that may influence a therapists decision to enter
into a dual relationship, such as, demographic variables, therapist object relations, history
of narcissistic injury, parentification, and self-esteem. The information obtained will be
useful to several groups of people including clinicians who treat offending psychologists,
supervisors and educators who train and supervise psychology students and
psychologists, and licensed psychologists who provide therapy.
The specific research questions of this study are: (1) are there significant
differences in demographic data between psychologists who engage in nonsexual
dual relationships, psychologists who engage in sexual dual relationships, and
non-sanctioned psychologists, (2) are there significant differences on measures of

18
object relations for psychologists who engage in nonsexual dual relationships,
psychologists who engage in sexual dual relationships, and non-sanctioned
psychologists, (3) are there significant differences on measures of parentification,
narcissistic injury, self-esteem, and ethical judgment for psychologists who
engage in nonsexual dual relationships, psychologists who engage in sexual dual
relationships, and non-sanctioned psychologists; (4) to what extent do the
demographics of academic training, theoretical orientation, history of childhood
abuse, practice setting and age at the time of the ethical violation predict scores on
object relations, parentification, narcissistic injury, self-esteem, and ethical
judgment; and (5) is there a relationship between measures of object relations,
parentification, narcissistic injury, self-esteem, and ethical judgment for each
group.
Definition of Terms
Boundary crossing:
A departure from commonly accepted clinical practice that may or may not
benefit the client (Smith & Fitzpatrick, 1995). For example, accepting a gift from a client
or hugging the client after a session. Boundary crossings that increase in frequency and
intensity eventually may lead to a boundary violation.
Boundary violation:
A departure from accepted practice that places the client or the therapeutic
process at serious risk (Gutheil & Gabbard, 1993). Clinical boundary violations include
retaining the client longer than indicated, failure to refer, failure to seek supervision or
consultation, failure to set limits, failure to create a treatment structure, the use of favors
or services from the client for the benefit of the psychologist, placing unidentified

19
obligations on a client, and therapists in appropriate self disclosure (Gutheil & Gabbard,
1993; Twemlow, 1997).
Countertransference:
The transference reaction of the therapist toward the client (Stone, 1994). As the
therapist tries to understand their own reactions to a client, understanding of the client is
deepened and consequently, the therapist can offer better, more helpful responses.
Countertransference is seen as a universal response and effective use of this phenomenon
can have a positive effect on treatment (Gelso & Carter, 1994).
Dual relationship:
According to the APA Ethical Guidelines (1992) a dual relationship occurs when
the therapist enters into another significantly different relationship (social, financial, or
professional) with a client. This definition excludes inconsequential roles that arise from
chance encounters. For the purpose of this study, it is assumed that the dual relationship
may have been sequential and/or concurrent as reported by the sanctioned participant. A
sequential dual relationship refers to a relationship that was terminated and, less than two
years later, a second relationship was initiated. For example, the psychologist was a
therapist to an individual and one year later (after terminating therapy) has agreed to be a
clinical supervisor to the same individual. A concurrent dual relationship refers to a
psychologist who maintains two or more roles at the same time with one individual. For
example, a psychologist was both a therapist and clinical supervisor of an individual.
Additionally, the term 'dual relationship' refers to both a single dual relationship with one
client and/or multiple clients.
Erotic countertransference:
Sexual excitement in the psychologist elicited by the client.

20
Fiduciary relationship:
A relationship involving trust or confidence.
Narcissistic injury:
A term coined by Alice Miller (1981) to refer to the psychological damage that
results when a childs narcissistic needs for respect, understanding, and mirroring go
unmet.
Offender:
A psychologist who engages in sexual misconduct (e.g., sexual activity between a
psychologist and client including intercourse, rape, the touching of breasts and genitals,
cunnilingus, fellatio, sodomy, and inappropriate or unnecessary examinations and
procedures performed for sexual gratification).
Parentification:
First defined by Boszormenyi-Nagy and Spark (1973) as the subjective distortion
[by an adult] of a relationship as if ones partner or even ones children were his parent.
Later defined by Mika, Bergner, and Baum (1987) as the familial interaction pattern
whereby children and adolescents are assigned roles and responsibilities normally the
province of adults in a given culture, but which parents in a particular family have
abdicated (p. 229).
Psychologist:
A person licensed by the state to apply knowledge of human behavior in a variety
of contexts including acting as administrator, consultant, diagnostician, educator,
evaluator, expert witness, supervisor, psychotherapist, researcher, and social
interventionist (APA, 1992).

21
Sexual dual relationship:
The psychologist develops a sexual relationship with a client. The relationship is
characterized by physical expressions of sexuality (e.g., any form of intimate sexual
contact including kissing, fondling, intercourse, or non-physical communications of
sexual intent or desire (Lamb et al., 1994).
Sexual misconduct:
Statutes generally define sexual activity as intercourse, rape, the touching of
breasts and genitals, cunnilingus, fellatio, sodomy, and inappropriate or unnecessary
examinations and procedures performed for sexual gratification. Statutory definitions of
sexual misconduct cannot encompass the wide variety of sexual activities that constitute
the abuse of clients by therapists (Simon, 1999). Therefore, sexual misconduct in this
study refers to sexual activity between a psychologist and client.
Therapist:
A psychologist licensed by the state and who performs therapy.
Transference:
The unconscious assignment to others of feelings and attitudes that were
originally associated with important figures (Stone, 1994). Transference is a repetition of
past conflicts onto present relationships. Feelings, attitudes, and behaviors that rightfully
should be associated with past significant figures are projected onto the therapist (Gelso
& Carter, 1994).
Transgressing psychologist:
Similar to offender, a psychologist who has committed an ethical violation
according to the American Psychological Associations ethical guidelines.

22
Treatment boundaries:
A therapeutic frame which defines a set of roles for the participants in the
therapeutic process (Smith & Fitzpatrick, 1995). This therapeutic frame includes both
structural elements (e.g., time, place, and money) and the content (what actually
transpires between therapist and client) of therapy. There is wide agreement that
therapists are solely responsible for constructing and maintaining treatment boundaries,
however, it is generally accepted that clients also contribute to its development (Gutheil
& Gabbard, 1993).

23
CHAPTER 2
Literature Review
Boundary violations that lead to dual relationships have emerged as an important
issue for psychologists. In the past decade, dual relationships have accounted for most of
the licensing disciplinary actions and financial losses due to malpractice suits, the loss of
licensure, and means of generating an income for psychologists (Borys & Pope, 1989;
Haspel, Jorgenson, Wincze, & Parsons, 1997; Pope, 1989). In addition, most ethics
complaints against psychologists have been a result of a dual relationship (Ethics
Committee of the APA, 1988; 1998). In response to this continuing problem, five states
(California, Illinois, Minnesota, Texas, and Wisconsin) have enacted civil statutes related
to sexual misconduct and 15 states have enacted criminal statutes prohibiting certain
behaviors by psychologists (Haspel et al., 1997). Additionally, some states have formed
walk-in clinics and self-help groups to assist victims (Haspel et al., 1997). Despite
increased public awareness, prohibitions by the APA Ethical Codes (1990; 1992), and
emerging research, the problem of boundary violations persists. The important question
is why do some psychologists continue to struggle with this issue despite training,
prohibitions, and increased public awareness?
In order to understand why some therapeutic relationships evolve into a dual
relationship, it is necessary to examine the nature of normal, therapeutic treatment
boundaries. The foundation of therapy rests on the conviction that psychologists are
expected to create therapeutic treatment boundaries via adherence to the APA Ethical
Principles (1992) of competence, integrity, respect of peoples rights and dignity, and
concern for others welfare. The assumption is that therapists who adhere to these

24
principles will create a therapeutic environment free of exploitation and foster a sense of
openness, trust, and safety in the relationship (Simon, 1992).
This review of the literature examines treatment boundaries in therapy, the broad
range of dual relationships (including nonsexual and sexual), the evolution of sexual dual
relationships, the misuse of countertransference in sexual dual relationships, typologies of
offenders, and the more recent research on the psychodynamic characteristics and
childhood histories of psychologists who engaged in sexual dual relationships with
clients.
Treatment Boundaries in Therapy
In the course of therapy the therapist is challenged continually to find the right
balance of empathy and limit-setting with clients. There is wide agreement among
researchers that the therapist is solely responsible for creating and maintaining proper
therapeutic boundaries (Gutheil & Gabbard, 1992; Pope, 1990; Simon, 1994).
Normal boundary behaviors are defined as those behaviors that mark the
parameters of appropriate, good, ethical practice (Simon, 1992; Smith & Fitzpatrick,
1995). That is, boundary behaviors encompass structural elements of the therapy
experience such as time, place, and money, as well as the content of therapy (Smith &
Fitzpatrick, 1995). For example, consistently starting and ending sessions on time,
performing therapy in the same office, and giving advance notice of fee changes are
examples of boundary behaviors.
A leading pioneer in the area of treatment boundaries is Robert I. Simon, M.D.
Although Dr. Simon has written specifically for psychiatrists, his views are applicable to
psychologists and other mental health professionals. Simon (1992) delineated basic
boundary guidelines for the establishment of a therapeutic relationship. These guidelines

25
are based on maintaining the integrity of the treatment process which, of course, is eroded
during the evolution of a dual relationship. The guidelines are to maintain relative
therapist neutrality, foster psychological separateness of client, protect confidentiality,
obtain informed consent for treatment, interact verbally with clients, ensure no previous,
current, or future personal relationship with the client, minimize physical contact, provide
consistent, private, and professional setting, and define time and length of sessions
(Simon, 1992).
Several principles underpin Simons (1992) boundary guidelines. The first
principle, the rule of abstinence, states that the therapist must refrain from obtaining
personal gratification at the expense of the client. Simon states that the therapists main
source of personal gratification arises from the professional gratification derived from the
therapeutic process. The second principle is the duty to maintain neutrality. This
therapeutic neutrality allows for the clients agenda to take precedence while therapist
self-disclosure is kept at a minimum. This allows for the therapist to limit interfering
with the personal lives of clients. The third principle, client autonomy and selfdetermination, refers to maintaining the clients separateness from the psychologist. One
way autonomy is demonstrated is by obtaining informed consent for procedures. Selfdetermination allows the client to determine the course of his or her life, without
interference from the therapist. The fourth principle, the fiduciary relationship, refers to
the inherent power differential in the client-psychologist relationship and requires the
psychologist not to use the client for personal advantage. The last principle, respect for
human dignity, refers to the moral, ethical, and professional standards that psychologists
use to treat their clients with respect and compassion. These principles are important to
keep in mind as this review analyzes the etiology of dual relationships.

26
Definition of Dual Relationships
The Ethical Principles and Code of Conduct (APA, 1992) provides a prohibition
against dual relationships under certain conditions in Standards 1.17 (a) and (b). The
code states:
(a) In many communities and situations, it may not be feasible or reasonable for
psychologists to avoid social or other nonprofessional contacts with persons such
as clients, clients, students, supervisees, or research participants. Psychologists
must always be sensitive to the potential harmful effects of other contacts on their
work and on those persons with whom they deal. A psychologist refrains from
entering into or promising another personal, scientific, professional, financial, or
other relationship with such persons if it appears likely that such a relationship
reasonably might impair the psychologists objectivity or otherwise interfere with
the psychologists effectively performing his or her functions as a psychologist, or
might harm or exploit the other party. (b) Likewise, whenever feasible, a
psychologist refrains from taking on professional or scientific obligations when
preexisting relationships would create a risk of such harm. (APA, 1992, p. 1601).
One of the first problems encountered when examining the etiology of dual
relationships is the APAs (1992) operational definition which has been described as both
simplistic and abstract (Gutheil & Simon, 1995; Pope, 1991). Without consideration of
the complexity of dual relationships, the Ethical Guidelines (APA, 1992) simply state that
psychologists are to refrain from entering into or promising another personal, scientific,
professional, financial, or other relationship (p. 1601). The question arises as to what
exactly constitutes a dual relationship? This admonishment is problematic because of the
subtle manner in which dual relationships evolve as a result of sequential boundary

27
violations of which psychologists are often unaware (Pope, 1991). Complicating the
matter further, the Ethical Principles and Code of Conduct (APA, 1992) acknowledges
that it is not feasible to avoid all dual relationships, especially for psychologists working
in rural areas (Brownlee, 1996; Schank & Skovholt, 1997).
Finally, researchers have noted that ethical judgment appears to change as the
therapist ages and gains more experience in practice (Borys & Pope, 1989; Epstein,
Simon, & Kay, 1992; Lamb, Woodburn, Lewis, Strand, Buchko, & Kang, 1994; Rodolfa,
Hall, Holms, Davena, Komatz, Antunez, & Hall, 1994). Epstein, Simon, and Kay (1992)
found that middle-aged (45-52 years) psychiatrists endorsed more exploitative behaviors
on the Exploitation Index than younger psychiatrists (age 27-36 years). Perhaps most
surprising are the results reported by Rodolfa et al. (1994) that older psychologists (age
44 years or more) were significantly more inclined to seriously consider sexual
involvement with a client than were younger psychologists (under age 44 years).
Borys and Pope (1989) found that participants with 30 or more years of practice
rated dual relationships as significantly more ethical than psychologists with less than 10
years of experience. Similarly, Stake and Oliver (1991) reported that women
psychologists and psychologists (both genders considered) with fewer years of practice
were more likely to rate sexually suggestive behaviors as misconduct. However, they
found no significant result between years of practice and permissive attitudes toward nonsexual dual relationships. Lamb et al. (1994) found that psychologists who engage in
post-termination dual relationships (sexual and business types) were older and reported
more years of experience.
Therapist age and years of practice appear to be related inversely to ethical
judgment. Some researchers have found evidence linking therapist age and years of

28
practice to ethical judgment and the endorsement of dual relationships (Borys & Pope,
1989; Epstein, et al., 1992; Lamb, et al., 1994; Rodolfa, Hall, Holms, Davena, Komatz,
Antunez, & Hall, 1994). While Stake and Oliver (1991) did not find this trend, there
appears to be more evidence that older therapists are more likely to relax their ethical
judgment and seek to engage in a dual relationship with a client.
Sonne (1994) speaks to the limitations of the 1992 Ethics Code stating that it
provides only limited guidance to psychologists regarding ethical conduct. Pope and
Vetter (1992) explain the need for the APA ethical guidelines to define clearly dual
relationships and to note with clarity if and when dual relationships are ever
therapeutically indicated or accepted. Suffice it to say, if left unexamined, all dual
relationships have the potential to be harmful (Anderson & Kitchener, 1996; 1998;
Kitchner, 1988).
While the 1992 Ethics Code may not clearly define a dual relationship, codes
4.05, 4.06, and 4.07 clearly admonish psychologists to avoid sexual relations with past
and present clients. Standard 4.05 states, psychologists do not engage in sexual
intimacies with current patients or clients, standard 4.06 states, psychologists do not
accept as therapy patients or clients persons with whom they have engaged in sexual
intimacies, and standard 4.07 states, psychologists do not engage in sexual intimacies
with a former therapy patient or client for at least two years after cessation or termination
of professional services (APA, 1992, pg. 1605). Additionally, the burden of
responsibility for proving that a relationship with a client after the two-year time limit is
not harmful falls on the psychologist. Standard 4.07 states this burden clearly:
(b) Because sexual intimacies with a former therapy client are so frequently
harmful to the client, and because such intimacies undermine public confidence in

29
the psychology profession and thereby deter the publics use of needed services,
psychologists do not engage in sexual intimacies with former therapy clients even
after a two-year interval except in the most unusual circumstances. The
psychologist who engages in such activity after the two years following cessation
or termination of treatment bears the burden of demonstrating that there has been
no exploitation, in light of all relevant factors, including (1) the amount of time
that has passed since therapy terminated, (2) the nature and duration of the
therapy, (3) the circumstances of termination, (4) the clients personal history, (5)
the clients current mental status, (6) the likelihood of adverse impact on the client
and others, and (7) any statements or actions made by the therapist during the
course of therapy suggesting or inviting the possibility of a post-termination
sexual or romantic relationship with the client (p. 1605).
As a result of identified limitations, some researchers have attempted to provide
psychologists with guidelines regarding how to identify and assess boundary violations
that may lead to dual relationships (Gottlieb, 1993; Gutheil & Gabbard, 1993; Smith &
Fitzpatrick, 1995; Sonne, 1994). For each relationship, Gottlieb (1993) suggests
contemplating the power differential between therapist and client, duration of
relationship, and clarity of termination before engaging in a dual relationship of any kind.
Gutheil and Gabbard (1993) and Smith and Fitzpatrick (1995) suggest two aspects of
boundary issues: boundary crossings and boundary violations. Boundary crossings refer
to deviations from commonly accepted clinical practice that may or may not harm the
client. Accepting a holiday gift from a client is an example. The question therapists
should ask themselves when contemplating a boundary crossing is how can my client
benefit? Boundary violations, on the other hand, are departures from professional

30
standards of practice that place the client or the therapeutic process at risk. Entering into
a business relationship with a former client is an example (Lamb et al., 1994).
There is empirical evidence that as a therapist ages and gains more practice
experience he or she may disregard previously held professional standards of practice and
may be more likely to engage in a dual relationship with a client (Borys & Pope, 1989;
Epstein et al., 1992; Lamb et al., 1994; Rodolfa et al., 1994).
Nonsexual Dual Relationships
Prevalence. There has been considerable research on sexual dual relationships,
however, few studies have examined nonsexual dual relationships between psychologists
and clients. The first empirical study to examine nonsexual dual relationships was an
unpublished manuscript by Tallman (1981, as cited in Pope, Keith-Speigel & Koocher,
1985). Nineteen male and 19 female psychotherapists were surveyed regarding their
involvement in social relationships with clients. The results of this survey indicated that
approximately 68% of the men had formed a social relationship with clients while none
of the women had formed such a relationship. This gender disparity for nonsexual dual
relationships is consistent with results of other published studies as well (Borys & Pope,
1989; Lamb et al., 1994).
Extending Tallmans research are two decades of empirical studies on the topic of
nonsexual dual relationships. Beginning with Pope et al. (1987), nonsexual dual
relationships appear to be the rule rather than the exception. Pope et al. (1987) found that
nearly 40% of psychologists surveyed had accepted a clients invitation to a party, 28.3%
had provided therapy to a friend, 16% had invited clients to a party or social event, and
12.1% had entered into a business relationship with a client. Lamb et al. (1994) reported
29% of their random survey of 1,000 psychologists reported entering into a business

31
relationship with a former client. Lamb et al. (1994) believe that their finding is more
reflective of the actual incidence of nonsexual dual relationships than what prior research
has reported because participants were identified as providing a minimum of 19 hours per
week of direct service and had been doing so for a mean number of 14 years. Therefore,
these researchers concluded that the participants were likely to have had ample
opportunities to engage in dual relationships. Additionally, characteristics of the sample
were noted to be similar to the actual population of APA members in terms of gender,
educational degree, and ethnic background.
In a comprehensive empirical study of three major mental health professions,
Borys and Pope (1989) conducted a mail survey (using respective membership directories)
with 4,800 psychologists, psychiatrists, and social workers examining their attitudes and
practice in regard to dual relationships. With a response rate of 49% (N = 2,133), three
findings appear to be relevant. First, the three groups did not differ in the extent to which
they engaged in nonsexual or sexual dual relationships. Psychologists, however, engaged
more frequently in incidental involvements initiated by the client (e.g., giving a therapist a
gift worth more than 50 dollars or inviting a therapist to a special occasion). Second,
psychodynamically oriented practitioners from each group engaged in dual relationships
less frequently and tended to view dual relationships as less ethical. Finally, gender
differences applied to all dual relationships regardless of group membership. That is,
males tended to engage in dual relationships more often and viewed them as more ethical
than their female counterparts.
Most recently, Anderson and Kitchener (1996) completed a nonrandom,
exploratory study of critical incidents of non-romantic, nonsexual relationships with
former clients. Participants (N = 63) were chosen and surveyed from Divisions 29

32
(Psychotherapy) and 42 (Psychologists in Independent Practice). Two important findings
emerged. First, some psychologists became involved with a variety of non-romantic,
nonsexual relationships. For example, some psychologists and former clients formed
friendships, participated in community activities, formed business or financial
relationships, formed collegial or professional relationships, and were affiliated with the
same religious group. Second, among this sample there was little consensus regarding
the ethics of non-romantic, nonsexual relationships. This finding seems to highlight the
issue that the APA Ethical Guidelines (1992) need to define nonsexual dual relationships
more clearly.
The disparate findings from the Borys and Pope (1989) and Anderson and
Kitchener (1996) studies illustrate the lack of consensus related to dual relationships.
Borys and Pope (1989) found that a majority of respondents (N = 1,089) described posttherapy relationships as never ethical or ethical under rare conditions. In contrast, a
majority of the participants in the Anderson and Kitchener (1996) study saw post-therapy
relationships as ethical. Anderson and Kitchener (1996) provided two interpretations of
this finding. One, psychologists who are involved in a dual relationship or who have
firsthand knowledge of a dual relationship may not evaluate post-therapy relationships as
unethical. Secondly, the results may have been influenced by a low response rate. That
is, psychologists who differ from the perceived norm may have invested the time to
respond.
Gender. Gender appears to be one of the most important risk factors for engaging
in nonsexual dual relationships. Previous empirical research has indicated that male
therapists engage in dual relationships more than female therapists (Borys & Pope, 1989;
Bouhoutsos et al., 1983; Holroyd & Brodsky, 1977). In the Borys and Pope (1989) study,

33
more male than female therapists engaged in nonsexual dual relationships, male
therapists engaged in nonsexual dual relationships with female clients, and male
therapists rated non-erotic behaviors (e.g., became friends with a client after termination
or borrowed over $20 from a client) as more ethical than female therapists.
Epstein, Simon, and Kay (1992) surveyed 2,500 psychiatrists regarding their
boundary behavior. Forty-three per cent of the participants (26% of the sample were
female, 74% were male) admitted to engaging in at least one potentially
counterproductive boundary behavior with clients, and male psychiatrists were
significantly more likely to fall into the highest decile of exploitative scores (the exact
percentage of gender and boundary behaviors were not provided but the authors did say
the prevalence of male sexual violators in their study was similar to the ten per cent
reported in earlier studies). Along this same line of inquiry, Lamb et al. (1994) found the
same gender difference; males engaged in dual relationships at a higher rate than female
participants. Specifically, Lamb et al. (1994) reported 62% of their male participants and
38% of their female participants engaged in a nonsexual dual relationship.
Theoretical orientation. Theoretical orientation appears to influence the degree to
which psychologists endorse and engage in nonsexual dual relationships. Empirical
research has documented that psychodynamic/analytic therapists endorse a greater variety
of boundary violations as unethical than their cognitive-behavioral or humanistic
colleagues (Baer & Murdock, 1995; Borys & Pope, 1989; Pope et al., 1987). Borys and
Pope (1989) suggest that this difference may be the result of training as psychodynamic
clinicians have a greater awareness of the importance of clear, non-exploitive, roles, and
boundaries (Borys & Pope, 1989, p. 290).

34
While gender and theoretical orientation play an important part in a
psychologists decision to enter into a nonsexual dual relationship, empirical research
also indicates that a psychologists attitude toward nonsexual physical contact is
predictive of his or her likelihood to engage in sexual contact with clients (Holroyd &
Brodsky, 1980; Twemlow, 1997). In other words, non-erotic physical contact with an
opposite-sex client may be a risk factor for future sexual contact with clients (Holroyd &
Brodsky, 1980). It is noteworthy here that non-erotic physical contact with an opposite
sex client may be associated with sexual misconduct, not physical touch per se, that is
potentially damaging. Said differently, contextual factors (i.e., gender, theoretical
orientation of the therapist, clinical setting) also influence the experience of sexual
feelings as a result of non-erotic physical contact. With this in mind, the field needs to
glean more information about potential offenders. Clearly, the complexities of nonsexual
dual relationships are illuminated by these studies and more information is needed to
understand characteristics of those psychologists who engage in nonsexual dual
relationships. Information is also needed that addresses ethical judgment and what
causes ethical judgment to change as the therapist ages and gains more professional
experience.
Sexual Dual Relationships
The 1992 APA Ethics Code addresses sexual dual relationships and provides four
standards prohibiting such behavior. Standard 4.05 states, psychologists do not engage
in sexual intimacies with current clients (APA, 1992, p. 1605). Standard 4.06 states,
psychologists do not accept as therapy clients persons with whom they have engaged in
sexual intimacies (APA, 1992, p. 1605). Standard 4.07 states, psychologists do not
engage in sexual intimacies with a former therapy client for at least two years after

35
cessation or termination of professional services (APA, 1992, p. 1605). With regard to
students, the ethical code states in standard 1.19, psychologists do not engage in sexual
relationships with students or supervises in training over whom the psychologist has
evaluative or direct authority, because such relationships are so likely to impair judgment
or be exploitative. These standards are explicitly clear and most psychologists who
engage in sexual dual relationships consciously know they are breaching the ethical code
(Celenza, 1991). Knowledge of the ethical code is not enough to prevent this damaging
behavior. What then motivates these offenders to breach this code and risk their entire
careers? While this question has been addressed in contemporary research, it is necessary
to review what past research has shown about this issue.
Prevalence. Early empirical research in this area was mostly demographic in
nature and merely reported the prevalence of sexual dual relationships. The prevalence
of reported therapist-client sexual misconduct has been markedly consistent. Earlier
studies found that 12% of male therapists and 3% of female therapists had engaged in a
sexual relationship with at least one client (Holroyd & Brodsky, 1977; Pope, Levenson,
& Schover, 1979). Later studies reported lower percentages ranging from .9% to 9.4%
for male therapists and from .2% to 3.1% for female therapists (Akamatsu, 1988; Borys
& Pope, 1989; Pope et al., 1986; Pope et al., 1987).
One empirical study surveyed 1,000 members of APA about sexual and nonsexual
boundary violations involving psychologists, clients, supervisees, and students (Lamb &
Catanzaro, 1998). With a 60% response rate (N = 596), 8% of the participants reported
that they had engaged in a sexual boundary violation as a psychologist, with males
engaging in the behavior significantly more often than women. Six per cent of the
sample reported a sexual boundary violation with a client, 1.5% with a supervisee, and

36
1.7% with a student (the authors noted that these percentages exceed 8% because some
individuals reported more than one type of boundary violation). Notably, 12% of their
sample reported at least one sexual boundary violation during his or her own therapy
(2%), supervision (6%), or education (8%) (again it was noted that the percentages
exceed 12% because of multiple reports of boundary violations) (Lamb & Catanzaro,
1998).
The most recent empirical survey done by Jackson and Nuttall (2001) reported
9% of their sample (N = 323) of mental health practitioners reported sexual boundary
violations with a client. Jackson and Nuttall (2001) reported men were nineteen times as
likely to engage in sexual misconduct than women. Another important finding reported
by these researchers is that 36% of the men who had been sexually abused by a relative
or caretaker reported having engaged in sexual misconduct with a client. In contrast, 7%
of the men sexually abused by a stranger reported having sexual relations with a client.
While the incidence of therapist-client sexual misconduct appears to have
declined in the last decade, researchers cannot be certain what has contributed to these
lower rates. Pope (1986; 1990b) purports the result of research, civil suits, efforts at
prevention, increased public awareness, as well as increased caution by clinicians are
some reasons for this decline. An alternative reason for lower rates of sexual misconduct
could be an actual decline in the rate of sexual misconduct (Borys & Pope, 1989; Holroyd
& Bouhoutsos, 1985). Another explanation is that some psychologists who sexually
exploit their clients believe no harm was done and as a result are biased in their reporting
of the incident and effects of sexual misconduct on clients (Holroyd & Bouhoutsos,
1985). Finally, Pope et al. (1987) contends that offending therapists are not reporting
their unethical boundary violations on surveys.

37
Addressing the issue of biased reporting of therapist-client sexual misconduct,
Holroyd and Bouhoutsos (1985) gathered secondhand information about the
psychological affects of therapist-client sexual misconduct. That is, 318 subsequent
treating psychologists of 559 clients, who had previously experienced therapist-client
sexual misconduct with another therapist, answered questions regarding the effect of the
sexual misconduct on the client. Holroyd and Bouhoutsos (1985) reported psychologists
who reported that no harm was done to the client who was the victim of therapist-client
sexual misconduct were almost three times as likely to admit having engaged in sexual
misconduct with their own clients. Holroyd and Bouhoutsos (1985) concluded that the
distorting effects of countertransference on observation of areas that have been
problematic for the therapist influenced the biased reporting (p. 708).
In an anecdotal paper, Pope (1990) described the issue of professional
accountability when dealing with therapist-client sexual misconduct. Pope (1990) framed
his discussion against the backdrop of the conflict between self-interests and
professional ethics that protect clients. One aspect of self-interest is the psychology
professions difficulty in responding effectively to the issue of sexual misconduct. Pope
(1990) stated that because the profession has been historically dominated by males, that
the male professionals sense of identification with the male perpetrator (intensified
because both roles involve being the more powerful member of a private dyad) may elicit
the professionals collusion in exonerating the perpetrators accountability for his acts
and/or enabling the perpetrator to continue the abuse (p. 229).
The psychology profession may never know the true prevalence of therapist-client
sexual misconduct. Regardless, with 45-65% of clients reporting to current therapists
that a previous therapist crossed a sexual boundary (Bouhoutsos et al., 1983; Pope &

38
Vetter, 1991; Stake & Oliver, 1991), this issue, indeed, remains contemporary and
worthy of attention.
Gender. One of the most notable demographic characteristics in the empirical
study of sexual dual relationships has been gender. An overwhelming consistent finding
is that typically it is a middle aged male therapist who engages in a sexual dual
relationship with a female client in her thirties (Borys & Pope, 1989; Bouhoutsos et al.,
1983; Butler & Zelen, 1977; Epstein et al., 1992; Jackson & Nuttall, 2001; Kluft, 1990;
Lamb & Catanzaro, 1998; Lamb et al., 1994; Pope et al., 1979; Pope & Bouhoutsos,
1986; Pope et al., 1987; Pope, 1990b; 1993). Three empirical studies highlight this
finding: Bouhoutsos et al. (1983), Pope (1993), and Jackson and Nuttall (2001).
Bouhoutsos et al. (1983) reported 96% of incidents of sexual misconduct involved a male
therapist (N = 559). Pope (1993) searched a large states records of psychology licensing
disciplinary actions for a 28 month period and found 95% of the cases involved a male
therapist. Jackson and Nuttall (2001) reported men were nineteen times more likely than
women to engage in sexual misconduct with a client (N = 323).
Only three studies have indicated no significant gender difference in sexual
miscontact (Akamatsu, 1988; Pope et al., 1987; Stake & Oliver, 1991). Pope et al. (1987)
suggest that an overall lower incidence rate of sexual misconduct and a decreased
likelihood that offenders will admit wrongdoing may explain why there are lower rates
for male respondents. Some offenders appear unable to accept responsibility for the harm
done to clients as a result of sexual misconduct (Holroyd & Bouhoutsos, 1985; Pope,
1990a). Thus some perpetrators may be motivated to preserve their social image.
While it is noted that men appear to be struggling with maintaining proper
therapeutic boundaries more than females, this does not imply that men are the only

39
offenders. As stated earlier, the prevalence rate for female offenders of sexual dual
relationships has been reported between .2% to 3% (Akamatsu, 1988; Borys & Pope,
1989; Pope et al., 1986; Pope, Tabachnick & Keith-Spiegel, 1987). Gabbard (1994a)
suggests that some female offending therapists are attracted to nonconforming male
clients and that this attraction is a key factor in their boundary violations. He also notes
that countertransference rescue themes are common in both offending male and female
therapists (Gabbard, 1994a).
Age. The second most common demographic variable present in sexual dual
relationships is age. Recall that it is most likely a male therapist in his early forties who
exploits a female client in her early thirties. Bouhoutsos et al. (1983) reported the
average age of the offender in their study was 42 years while the average age of the
victim was 30 years (N = 559). In a recent study done by Somer and Saadon (1999) the
average age of the offending therapist was 47.5 years and the average age of the victim
was 32.5 years. Therapist age is also related to ethical judgment. As stated earlier, the
older the therapist, the more likely he is to judge ethical delimmas involving dual
relationships as ethical (Borys & Pope, 1989; Epstein et al., 1992; Lamb et al., 1994;
Rodolfa et al., 1994; Stake & Oliver, 1991).
Theoretical orientation. Empirical research has documented that
psychodynamic/analytic therapists endorse a greater variety of boundary violations as
unethical than their cognitive-behavioral or humanistic colleagues (Baer & Murdock,
1995; Borys & Pope, 1989; Pope et al., 1987). In the most recent study, Jackson and
Nuttall (2001) report that their mental health practitioner participants were more likely to
endorse a psychosocial orientation, not a psychodynamic orientation. The authors
explain the discrepant finding by stating in the Borys and Pope (1989) study psychosocial

40
was not an option for theoretical orientation. Additionally, a psychosocial orientation
emphasizes the relationship aspect of the therapeutic process and is therefore very similar
to psychodynamic (Jackson and Nuttall, 2001).
Partner status. Butler and Zelen (1977) interviewed 20 sexually offending
psychologists and found that at the time of the sexual violation 90% reported feeling
vulnerable, needy, and lonely due to recent marital dissatisfaction, separation, or divorce
from a significant other. As a result of personal problems, therapists reported feeling a
high need for love, affection, and positive regard. Fifty-five percent reported feeling in
love with the client with whom they engaged in a sexual relationship. Butler and Zelen
(1977) also found that 60% of the participants perceived themselves in the relationship as
a father-figure and reported that the countertransference had been paternal in nature.
Finally, 55% of this group of offenders claimed they were frightened of intimacy. Butler
and Zelen (1977) interpret the psychologists use of sexual contact as a way to avoid the
fear of intimacy that was aroused as the client displayed emotional vulnerability.
Most recently, Celenza and Hilsenroth (1997) reported 50% of their sample of
sexually offending therapists reported experiencing the loss of a significant other at the
time of the transgression.
Private practice. Practitioners in solo private practice are at an increased risk for
sexually exploiting their clients. Bouhoutsos et al. (1983) and Somer and Saadon (1999)
reported nearly 80% of the therapists who crossed sexual boundaries with clients were
working alone in private practice. Epstein et al. (1992) found that psychologists with
practices located in a suburban area and those with solo private practices endorsed more
boundary violations.

41
Same-sex exploitation. Empirical research describing therapists who perpetrate
against same sex clients is nonexistent, however, Gonsiorek (1989) provides some insight
into possible risk factors and dilemmas associated with the problem. One especially
influential risk factor occurs when the therapist is in the throes of his or her own coming
out process. Gonsiorek (1989) reported that such therapists may project or act out their
own denial, ambivalence, and internalized homophobia onto clients. This poses a
particularly troublesome dynamic when the client is also struggling with confusion about
his or her own sexual orientation. Empirical research on the coming out process does
reveal that for some individuals, homosexual identity development may include identity
confusion, feelings of alienation and isolation, and feelings of ambivalence while
maintaining separate public and private images (Cass, 1979).
Gonsiorek (1989) states that therapists who are fearful of revealing their own
sexual orientation to others may unconsciously or consciously seduce clients. Similar to
heterosexual therapists, homosexual therapists with a stable sexual orientation may be
vulnerable to social isolation. Gonsiorek (1989) reports that sexual exploitation of clients
may arise out of situational variables or characterological issues. Regardless of the
cause, because of oppression and isolation, homosexual therapists may view gay or
lesbian clients as comrades or peers. As a result, the therapist may begin to use clients as
a personal support system.
Harm to clients who experience a sexual dual relationship. Research has shown
that a common rationale therapists use when confronted about their unethical sexual
behavior with clients is that the sexual dual relationship benefited the client (Pope, 1991).
In reality, the evidence for psychological damage done to clients as a result of therapistclient sexual misconduct is overwhelming. In an anecdotal paper, Pope (1988) provided

42
a listing of the most common damages resulting from therapist-client sexual contact. He
coined the term Therapist-Client Sex Syndrome to describe the constellation of
psychological harm done to clients by sexually offending therapists. For example,
ambivalence toward the exploitative therapist, feelings of guilt, a sense of emptiness and
isolation, sexual confusion, impaired ability to trust, identity, boundary and role
confusion, emotional lability, suppressed rage, increased suicidal risk, and cognitive
dysfunction are common reactions of victims of therapist-client sexual misconduct.
In an article written from personal experience in treating offending psychologists
and client victims, Simon (1991) noted that the psychological harm that results from
sexual contact with therapists begins before the actual sexual contact. As boundary
violations occur, the therapeutic aspect of the therapist-client relationship shifts. That is,
as the therapist begins to exploit the client, critical clinical information may be
overlooked, the client may be burdened with the therapists self-disclosure and increasing
boundary violations, and finally, the client does not receive proper treatment (Folman,
1991; Simon, 1991).
Actual empirical literature on the clients direct experience of a sexual dual
relationship with a psychologist is scant. Most papers written on the subject have been
thoughtful reviews by psychiatrists and psychologists that speak to the numerous adverse
consequences of therapist-client sexual misconduct (Folman, 1991; Gutheil, 1991;
Simon, 1991; 1994). Reasons for the dearth of empirically driven literature is that the
confidential nature of therapy makes subject recruitment difficult (Bouhoutsos et al.,
1983). Only about 4% of victims are likely to report the abuse, and therapist-client
sexual misconduct may have similar dynamics to that of an incest relationship (e.g., use
of power, lack of consent, characteristics of perpetrators) (Gabbard, 1991; Pope, 1988).

43
Empirical studies report that between 45% and 65% of therapists will encounter at
least one client who has been a victim of therapist sexual exploitation (Bouhoutsos et al.,
1983; Pope & Vetter, 1991; Stake & Oliver, 1991). One of the first studies to address the
experience of the victim was conducted by Bouhoutsos et al. (1983). Three hundred and
eighteen psychologists who treated 559 clients with histories of therapist-client sexual
relations were surveyed about clients who had sexual contact with a previous therapist.
Present therapists reported the symptom sequelae for these clients included increased
depression, impaired social adjustment, loss of motivation, significant emotional
disturbance, suicidal feelings or behavior, and increased drug or alcohol use. These
findings regarding the psychological symptoms of victims of therapist-client sexual
misconduct were mirrored by other researchers as well (Feldman-Summers & Jones,
1984; Pope, 1988; Sonne & Pope, 1991). A limitation of Bouhoutsos et al. (1983) study
was that information regarding the victims experience was gathered secondhand via the
surveyed therapists assessment of the clients experience with the perpetrating therapist.
In other words, the clients were not asked directly about their experience of therapistclient sexual misconduct.
Feldman-Summers and Jones (1984) presented firsthand accounts of victims
experiences by surveying women who had been sexually exploited via the therapist-client
relationship (N = 21). In addition to the previously listed symptoms, Feldman-Summers
and Jones (1984) found that their female respondents revealed a greater mistrust of and
anger toward men and therapists, and a greater number of psychosomatic symptoms
following termination. Other risk factors for psychological injury were the severity of
psychological problems prior to the sexual contact and the marital status of the therapist
(Feldman-Summers & Jones, 1984). The authors reported that clients who already had

44
severe problems were significantly impacted with additional problems once the sexual
relations began because the therapeutic process was diverted away from the clients
presenting problems. Additionally, if the offending therapist was married, victims
reported feelings of guilt for participating in an extramarital affair (Feldman-Summers &
Jones, 1984).
Lamb and Catanzaro (1998) reported the effects of engaging in a sexual dual
relationship differed according to the type of relationship. For example, sexual relations
with a therapist had the most negative impact. In contrast, ratings of sexual relations with
supervisors and educators were more often listed as positive. However, Lamb and
Catanzaro (1998) noted that among these latter instances there were incidents whereby
the emotional impact of the relationship was negative or becoming more negative over
time.
In the Lamb and Catanzaro (1998) study, only five individuals (less than one
percent) reported sexual boundary violations as both victims and offenders. This finding
contradicted the Pope et al. (1979) study that reported 23% of victims subsequently made
sexual advances to students while in the role of educator. Lamb and Catanzaro (1998)
cited increased professional attention to the negative impact of dual relationships,
increased litigation of this issue, and more positive role models as reasons why this
phenomenon is not being repeated as professionals. One criticism of the Lamb and
Catanzaro (1998) article is that the researchers did not define negative or positive
impact, thus the reader had to assume what was meant by those descriptors.
In a qualitative study, Somer and Saadon (1999) interviewed 27 women who had
been victims of therapist sexual misconduct. Thirty percent of the participants met the
criteria for post-traumatic stress disorder and 26% for major depressive disorder. They

45
also found that victims were more likely to be parentified as children, emotionally
neglected or abused, and sexually abused or exposed to other traumatizing events.
Hence, women who were sexually exploited by their therapist were more likely to have
been exploited in the past. Women involved in a therapist-client sexual relationship
reported contradictory feelings of pleasure, fulfillment, and excitement; and confusion,
disorientation, feeling of exploitation, humiliation, numbness, and dissociation. Women
that initially reported being pleased with the therapist-client sexual relationship later
changed their minds and subsequently reported feeling exploited. Most of the
respondents reported feeling anger toward their therapist, guilt and shame for having
engaged in the sexual relationship, and disappointment and disillusionment about their
therapeutic experience (Somer & Saadon, 1999).
Somer and Saadon (1999) further reported that 13 sexual liaisons (out of 27)
began during the course of therapy, nine began immediately after therapy ended, and five
began during the course of therapy but both the professional and sexual relationship
ended after the first sexual contact. Average length of the sexual relationship was 10.2
months.
Somer and Saadon (1999) found that 59% of the participants reported the gradual
erosion of boundaries began with therapist self-disclosure. Other research supports this
finding (Gabbard, 1996; Gutheil & Simon, 1995; Pope et al., 1986; Simon, 1991; 1995;
1999). Additionally, Somer and Saadon (1999) reported that physical contact (e.g.,
hugging, kissing, touching) was initiated by 22% of the client victims and was offered by
the therapist as a consolation due to a client crisis and usually preceded sexual contact.
Finally, twenty-two percent of respondents reported a change in session time that allowed
for greater privacy for sexual intimacies. A change in session time is a hallmark sign for

46
potential sexual boundary violations (Simon, 1995). Interestingly, Somer and Saddon
(1999) reported 22% of their participants admitted that they had initiated the physical
embrace that eventuated in sexual misconduct. To date, there is no empirical literature
that addresses who, psychologist or client, initiates physical contact.
By virtue of entering into a therapeutic relationship where there is an inherent
power differential (Gottlieb, 1993), every client is vulnerable to therapist exploitation.
Those individuals especially at risk for therapist sexual exploitation are clients diagnosed
with Borderline Personality Disorder (Gutheil, 1989; 1991; Simon, 1989; 1995).
Perhaps, this is because clients with this diagnosis tend to elicit the greatest
countertransference reactions from therapists (Simon, 1995), are likely to have a sexual
and physical abuse history (Herman, Perry, & van der Kolk, 1989), and may be
reenacting their past abuse in the present therapeutic relationship (Gutheil, 1991; Simon,
1995; Twemlow, 1997). Simon (1989) noted that clients with Borderline Personality
Disorder may not always be able to separate fantasy from reality and are therefore prone
to manipulate and challenge therapeutic boundaries. Including an analysis of client
characteristics in this review is an exercise in understanding the dynamics of the
therapist-client dyad and is in no way meant to blame the victim, as the therapist is solely
responsible for maintaining boundaries in therapy
The Evolution of Sexual Dual Relationships
The evolution of boundary violations that lead to sexual involvement has been
repeatedly established through anecdotal accounts from experts in the field and
empirically by researchers (Gabbard, 1996; Gutheil & Simon, 1995; Pope et al., 1986;
Simon, 1991; 1995; 1999; Somer & Saddon, 1999). Based on anecdotal account, most
boundary crossings begin between the chair and the door (Gutheil & Simon, 1995). That

47
is, they begin insidiously with social informalities, at the very beginning or end of a
session. Potential boundary crossing scenarios include sessions becoming more social as
therapist and client address each other by first name, the session extended or changed to
later in the day, sessions ending with a hug, and therapist inappropriate self-disclosure.
Empirical research has shown that two boundary violations commonly precede sexual
involvement, therapist self-disclosure and nonsexual hugging (Somer & Saddon, 1999).
Psychologists who engage in boundary crossings have a number of cognitive
strategies that makes such violations tolerable in the mind of the perpetrator. Based on
his experience treating offending psychologists, Pope (1991) outlined these strategies as
selective inattention, benefits, and prevalence. When the therapist blocks out awareness
of the dual relationship or splits the two relationships and refuses to acknowledge that
both relationships involve the same client, this is referred to as selective inattention. Left
unchecked, selective inattention could lead to negligence. For example, as a therapist
begins to engage in the slippery slope of boundary violations, uncomfortable feelings
arise that the therapist selectively keeps out of awareness. As a result, the therapist may
miss important clinical data and mismanage the relationship. Finally, Pope (1991) points
out that selective inattention also occurs between colleagues who ignore evidence of
therapist-client dual relationships in order to save the friendship or professional
relationship.
The second way a sexual dual relationship is justified is that the therapist claims
the dual relationship is beneficial to the client (Pope, 1991). Some defendants in
malpractice claims have stated that the sexual relationship was part of the treatment plan;
provided the client with a nurturing human being; provided an experience of acceptance;
provided a corrective sexual experience; and worked through overt transference. There

48
has been virtually no research evidence to support this claim that sexual dual
relationships benefit clients (Pope, 1991). Incidentally, psychologists who reported no
harm was done to clients who had a sexual relationship with a previous therapist were
almost three times as likely to engage in a sexual relationship with a present client than
the general population of psychologists (Holroyd & Bouhoutsos, 1985). As stated earlier,
some perpetrators of therapist-client sexual abuse may be motivated to present
themselves in a more favorable light by claiming no harm was done to victims of
therapist-client sexual misconduct.
A third way some therapists justify their actions is to claim that other therapists
also engage in sexual dual relationships (Pope, 1991). Some therapists will cite research
that notes a percentage of therapists enter into sexual dual relationships. This percentage
is then used to bolster their claim that at least a sizable minority engage in sexual dual
relationships (Pope, 1991, p. 31).
Gabbard (1996) maintained that errors in technique, judgment, and clinical
assessment occur along the way from the first minor nonsexual boundary crossing to the
sexual relationship. One such error Gabbard (1996) described is trying to love the client
back to health (p. 312). Some therapists harbor a conscious and unconscious rescue
fantasy to love the client in an attempt to compensate for a lack of parental love. Such an
attitude sets the stage for misunderstanding and misusing the countertransference.
Gabbard offered a clinical example of a male therapists conscious decision to hug a
client in order to demonstrate caring. Such a therapist may rationalize that because the
client had a childhood of neglect, he is providing healing nurturance. Unconsciously,
however, this decision may serve as a defense against the therapists own sexual feelings

49
or hostility toward the client (Celenza, 1991; 1995; Celenza & Hisenroth, 1997; Gabbard,
1996; Twemlow, 1997).
Twemlow (1997) used a developmental continuum to analyze the progression
toward sexual exploitation. Similar to Popes (1991) description of selective inattention,
the first stage of this phenomenon is described as boundary inattention. Boundary
inattention manifests in the therapist being unaware of the significance of a fantasy or
thought about a client. He suggests that a danger sign is when thoughts of a client
frequently enter the personal time or dream life of a therapist. The second developmental
stage occurs when boundary inattention gives way to boundary crossings. Used within
this context, a boundary crossing is a point at which some action occurred but did not
result in harm, although there is certainly the potential for harm. A boundary crossing
may begin as a therapeutic intervention and then progress to a boundary violation where
the therapists needs are clearly being met at the expense of the client.
The Misuse of Countertransference in Sexual Dual Relationships
The work that therapists do can sometimes be intense, complex, and stressful.
Countertransference is viewed in the present research as feelings, thoughts, and fantasies
that therapists may have toward clients which arise as a result of intrapersonal issues,
interpersonal issues, or past object relations (Bridges, 1994). The dynamics in cases of
sexual exploitation are often wrought with unconscious defensive operations during the
countertransference (Bridges, 1994; Celenza, 1991; 1998; Celenza & Hilsenroth, 1997;
Gabbard, 1994b; Twemlow, 1997). Celenza (1991) stated, the assumption of
intentionality in these cases is oversimplistic. For many therapists, the sexual
exploitation is largely unconsciously motivated and multidetermined. The power of these
unconscious factors can greatly outweigh conscious prohibitions (p. 502).

50
According to Gelso and Carter (1994), therapist countertransference to clients is
seen as universal regardless of theoretical orientation and can be beneficial or destructive
to the therapeutic relationship depending on how it is handled. However, simply having
awareness of countertransference and of ethical guidelines does not appear to prevent
psychologists from exploiting their clients.
Psychoanalytic writers have long recognized that during countertransference,
therapists sometimes feel love, hate, and sexual attraction toward clients (Coen, 1996;
Gabbard, 1994b; Twemlow, 1997). The frank acknowledgment of the therapists anger
and hatred toward a client was pioneered by Winnicott (1949). He courageously revealed
and explored his own anger and hatred toward his client(s) through his writing. Winnicott
(1949) wrote that therapists must not deny hate that really exists (p. 70) and believed
that the denial of hate led to therapy that is adapted to the needs of the therapist rather
than to the needs of the client (p. 74). Freud acknowledged his struggle with erotic
countertransference (McGuire, 1974; as cited in Gabbard, 1994b). In a letter to Jung
regarding his sexual feelings toward his analysand, Sabina Spielrein, he noted, I have
come very close to it a number of times and had a narrow escape (p. 230). Similarly,
contemporary psychologists also write of the struggle to acknowledge and deal openly
with love and hate in the countertransference (Celenza, 1991; 1998; Celenza & Hilsenroth,
1997; Pope & Tabachnick, 1993).
Certain feelings such as anger, hate, love, fear, and sexual attraction (Pope &
Tabachnick, 1993) cause many therapists to be uncomfortable and to respond by feeling
guilty, anxious, or confused (Pope et al., 1986). For some therapists, merely
acknowledging these feelings to self or others may be extremely difficult, especially if
their training and supervision have not encouraged them to do so (Pope & Tabachnick,

51
1993). For most psychologists sexual attraction to a client tends to be very problematic as
their training has inadequately prepared them for the eventuality of such a common human
experience (Celenza, 1995; Pope et al., 1986; Pope & Tabachnick, 1993). Consistent with
other studies (Pope et al., 1986; Pope et al., 1987), 87% of the respondents reported
feeling sexually attracted to clients on at least one occasion (Pope & Tabachnick, 1993).
Additionally, over half (57.9%) of the 285 participants in the Pope and Tabachnick (1993)
study reported experiencing sexual arousal while in the presence of a client. What
happens during treatment when a therapist is ill equipped to deal such powerful feelings
toward a client and they are unrecognized or ignored?
Several authors have noted that when sexual feelings and countertransference are
so intolerable to the therapist, they either may go unnoticed or are transformed into other
affects or behaviors (Bridges, 1994; Gabbard, 1996; Twemlow, 1997). For example,
unrecognized sexual feelings and countertransference can take the form of a particular
interest in clients sexual life and relationships (Bridges, 1994). Celenza, (1991; 1995)
and Celenza & Hilsenroth (1997) have shown empirically that the misuse of
countertransference feelings sometimes manifests into egregious behavior. Bridges
(1994) explained this transformation by stating, the vehicle for the affective symbolic
communication is sexuality, sexual feelings and countertransferences often defend
against and disguise other feelings, conflicts, and vulnerabilities that are more
intolerable (p. 426).
Twemlow (1997) postulated that erotic countertransference and a perverse
aggressive element is present in cases of therapist-client sexual exploitation. He stated, I
find that a dominance-submission pattern is present in all relationships between therapists
and clients, usually as a harmless, even motivating, background to the therapy. But hatred

52
and envy pathologizes and brings an unequal coercive power dialectic into the
foreground (p. 365). Against this backdrop of pathologized hate and envy, a reaction
formation against hatred of the client can allow a therapist to feel like a victim and
develop a martyrdom role. Further, he stated that such a therapist is very susceptible to
project identification and counteridentification with the client.
Twemlow (1997) suggested in many instances the sexual contact is unsatisfying
yet what is more satisfying is the perverse fantasy life of the therapist. Focusing on this
perverse fantasy, Twemlow (1997) reported the principal reason for the fantasy is to
undo childhood traumata, conflicts, and frustrations by converting them to triumphs (p.
366). Other reasons for the perverse fantasies are to avoid true intimacy, to dehumanize
the client, to transform pain into pleasure, and to keep an air of secrecy regarding the
sexual relationship that, in effect, stimulates erotic excitement. Twemlow does not
describe in detail how consciously aware these therapists are of their perverse fantasies.
An empirical study of sexually offending therapists. Celenza (1998) gathered data
on characteristics of sexually offending therapists (N = 20) from therapies, comprehensive
evaluations (including the Rorshach, Thematic Apperception Test, clinical interview,
background information, and clinical observation), and when possible, consultation with
the therapists supervisors, colleagues, spouse, therapist, and client-victim. Celenza
(1998) found that a majority of her participants had the inability to introspect and perceive
aggression in themselves or others, which led to the misuse of transference and
countertransference. These offending therapists had a concrete style of thinking and a
tendency to take feelings at face value. Therefore, the offenders in her study had a
restricted awareness of fantasy (Celenza, 1998). Celenzas (1998) study indicated that this
restricted awareness of fantasy is the mechanism that fails to prohibit sexual behavior in

53
offenders. Also, the fantasies this group did express were lacking in aggressive or other
impulses and instead were very moralistic and self-depriving thus setting the stage to act
out unconscious, libidinal, aggressive impulses (Celenza, 1998). Finally, Gabbard
(1994b) previously noted that clients with impaired fantasy functions (i.e., having narrow,
stereotypic fantasies) may be prone to action over reflection.
In addressing the countertransference phenomenon, Celenza (1995) wrote the
most salient finding in almost all of the difficulties with which these [offending] therapists
struggle involves some misunderstanding of, rationalization about, and/or unconscious
defensive transformation of love and/or hate in the countertransferenceon a conscious
level there are rationalizations that reflect an overvaluing of countertransference love with
an underlying intolerance of countertransference hate (p. 302).
Celenza (1995) suggested that some therapists can recognize they feel hateful
feelings toward their clients because countertransference hate is incompatible with the
warm, empathic therapeutic alliance needed to establish an atmosphere of trust and
safety. For those therapists who do recognize their hateful feelings, there may be a
tendency to withdraw defensively (Celenza, 1991). On the other hand, if therapists do
not acknowledge their hateful feelings they may be transformed into the opposite
(Gabbard, 1996). That is, because of being unable to tolerate their own aggressive
impulses, some therapists transform their hateful feelings into loving feelings because of
the need to be viewed as caring or giving (Celenza, 1998; Gabbard, 1996). The
sexualization of the relationship may be the therapists last-ditch effort to make the client
respond to their healing efforts (Gabbard, 1996). Virtually all of the offending therapists
in Celenzas (1998) empirical study could not tolerate negative transference from their
clients and consequently, the transgression often occurred at a therapeutic impasse. In

54
other words, the seduction of the client occurred when the client began to express
negative feelings toward or disappointment in the therapist (Celenza, 1998).
Many offending therapists view countertransference love as aspects of warmth
and empathy (Celenza, 1995). In fact, many boundary violations multiply out of the
erroneous efforts of therapists to love the client back to health (Gabbard, 1996). As
Celenza (1998) noted, therapists place themselves at risk when they attempt to provide
rather than to understand what the client needs. Gabbard (1996) reported that some
therapists confuse the roles of therapist and parent, thereby attempting to make up for lost
love in the clients childhood. This dynamic also may be reversed in that the therapist
who felt insufficiently loved during childhood may subsequently seek out idealization
and love from the client (Celenza, 1995, Celenza & Hilsenroth, 1997; Gabbard, 1991).
Some therapists have trouble handling countertransference/transference love and
hate, yet never engage in boundary crossings. Naturally, one is left to wonder what is
different about offending therapists compared to non-offending therapists. Interestingly,
many offending therapists admit to having awareness of transference issues and
knowledge that their behavior was unethical (Celenza, 1991). One is left to surmise that
conscious and unconscious processes are at work in these transgressed therapists.
Therefore, a closer examination of the psychodynamic characteristics unique to therapists
sanctioned for engaging in nonsexual and sexual dual relationships is warranted so that
the field can develop more effective preventive measures.
Presently, supervision or consultation is seen as the most important preventive
measure of sexual dual relationships (Gabbard, 1996; Hamilton & Spruill, 1999; Pope et
al., 1986; Simon, 1999). Yet, most psychology interns and professionals do not reveal
their sexual attraction to clients during supervision or consultation. Only about half of

55
psychologists surveyed who feel sexually attracted to their clients share their feelings
with a colleague or supervisor (Ladany, Hill, Corbett, & Nutt, 1996; Ladany, OBrien,
Hill, Melincoff, Knox, & Petersen, 1997; Pope et al., 1986). Celenza (1998) noted the
therapists who are most likely to need supervision or consultation around sexual
attraction issues are the least likely to utilize such a relationship.
Gabbard (1994b) and Pope (1987) reported erotic countertransference is
unavoidable and even potentially useful in therapy if addressed and analyzed
constructively. Thus, those psychologists who do not share their sexual attraction with a
supervisor or consultant are placing themselves and their clients at risk for exploitation.
Such psychologists may begin down the road of mishandling the
transference/countertransference relationship.
Typologies of Sexually Offending Psychologists
When thinking of the sexually offending psychologists, it is easy for one to
believe that offending psychologists are somehow severely neurotic, psychotic, or
otherwise unlike the majority of psychologists. However, this view is both naive and
inaccurate according to this warning by Pope (1990):
Sexually abusive psychotherapists cannot be dismissed as the most marginal
members of the profession. They are well represented among the most prominent
and respected mental health professionals. Cases involving therapists publicly
reported to have engaged in sexual behaviors with clients have included those
who have served as faculty at the most prestigious universities (including those
with APA-approved training programs), psychology licensing board chair, state
psychological association ethics committee chair, psychoanalytic training institute
director, state psychiatric association president, state association of marriage and

56
family therapists president, prominent media psychologist, chief psychiatrist at a
prominent psychiatric hospital, and chief psychiatrist at a state correctional
facility (APAs Ethics Procedures Upheld, 1985; Bass, 1989; Bloom, 1989;
Colorado State Board of Examiners, 1988; Jalon, 1985; Matheson, 1984, 1985;
Pugh, 1988; The Resignation of ____, 1990; Smith, 1984; as cited in Pope,
1990a) (p. 236).
It should not be surprising that some of the most prominent and successful
psychologists in the profession have acted in harmful ways toward clients. Afterall, some
of our most influential forefathers and foremothers modeled unethical behavior. For
example, Sigmund Freud analyzed his friend, Sandor Ferenczi, and his own daughter,
Anna; while on her vacation Melanie Klein analyzed a client for two hours a day on her
hotel bed; D.W. Winnicott took clients into his home as part of their treatment (Gutheil &
Gabbard, 1994) and; Jung entered into a long-term sexual relationship with his former
client, Sabina Spielrein (Lothane, 1999). Interestingly, Jung rationalized his ethical
breach of the doctor-client relationship by stating he prolonged the relationship to prevent
a relapse (Lothane, 1999). In a poignant statement regarding contemporary transgressed
therapists, Gabbard (1996) said, most striking is that the majority of the therapists I have
seen have had no previous history of ethical misconduct and are often even highly
respected and prominent members of the profession (p. 312).
Several researchers and authors have attempted to provide a typology of
psychologist offenders (Butler & Zelen, 1977; Gabbard, 1994a; Olarte, 1991; Pope, 1993;
Schoener & Gonsiorek, 1990). The most recent typology based on clinical experience
was done by Gabbard (1994a). He created four broad categories of psychologists who

57
sexually exploit their client(s): (a) psychotic disorders; (b) predatory psychopathy and
paraphilias; (c) lovesickness; and (d) masochistic surrender.
The first category, psychologists with psychotic disorders, constitute a very small
percentage of offenders. These therapists may be diagnosed with bipolar affective
disorder, paranoid psychosis, schizophrenia, and psychotic organic brain syndrome
(Gabbard, 1994a).
The second category, predatory psychopathy and paraphilias, includes therapists
with antisocial personality disorder and narcissistic personality disorder with prominent
antisocial features. Clients of these psychologists are seen as objects to be used for their
own sexual gratification. This group of offenders tend to prey on many victims and are
the hardest to rehabilitate. When caught, they may pretend to be remorseful and state that
they were in love with their client. Due to their antisocial traits, they manipulate the legal
system and may evade punishment. The childhood histories of these therapists include
profound abuse and neglect (Gabbard, 1994b).
Most therapists who engage in sexual relations with a client are lovesick
(Gabbard, 1994b; Twemlow & Gabbard, 1989). Twemlow and Gabbard (1989)
characterized the lovesick therapist as a therapist who develops an emotional dependence
on the client, experiences intrusive images or thoughts of the client, experiences physical
sensations in regard to the client, feels a sense of incompleteness when separated by the
client, feels an intense longing for the client which is exacerbated by social proscriptions,
and experiences altered states of consciousness when with the client which impairs
judgment. The lovesick therapist is likely to feel that he or she is in love with the client.
Feeling in love appears to be common: 65% of the psychiatrists who had been sexually
involved with a client felt they were in love (Gartell, Herman, Olarte, Feldstein, &

58
Localio, 1986). For the lovesick therapist, the client unconsciously represents the lost
parental object (Gabbard, 1994b). Consequently, narcissistic themes saturate the therapy
hour as the therapist uses ones clients to feel validated, loved, and idealized (Celenza &
Hilsenroth, 1997).
The most common scenario is a lovesick, middle aged, male therapist who
enters into a sexual dual relationship with a much younger female because of separation,
divorce, loneliness, or loss of a significant other (Butler & Zelen, 1977; Gabbard, 1994a;
Pope, 1993). Adding to this description, Somer and Saadon (1999) offerred the
emerging profile of a therapist-at-risk for sexual transgressions is one of a reputable,
middle-aged, mainstream, male clinical psychologist working alone in his private
practice (p. 507).
Finally, some therapists experience what Gabbard (1994b) described in the final
category as masochistic surrender. These therapists are self-destructive and allow
themselves to be intimidated, badgered, and controlled by their clients demands for love.
As client demands escalate for longer appointment hours, physical contact, and late night
phone calls, the therapist feels obliged. Often having trouble dealing with their own
aggression, these therapists feel they have no choice but to yield to the clients demands
as setting limits feels sadistic. As a result, reaction formation is used to defend against
growing rage. If the client confronts the therapist for setting a limit, he or she may
accuse the therapist of not caring. As a result, the therapist may feel guilty and acquiesce
to the clients demands. Like lovesick therapists, masochistic therapists may be
reenacting their own childhood abuse, however, unlike lovesick therapists, they typically
will not report feeling in love with the client (Gabbard, 1994b). Twemlow (1997)
concurred with Gabbard (1994b) in that such therapists appear to be reenacting childhood

59
abuse and cannot tolerate negative feelings and hatred being exposed by the client.
Recently, intolerance for negative transference has been identified as a characteristic of
offending psychologists in an empirical study (Celenza, 1998).
The Psychodynamic Characteristics of Offending Psychologists
Empirical studies. Most research examining the characteristics of psychologists
has been conducted to explore positive characteristics of therapists. When examining
characteristics of offending psychologists, the pendulum must swing to analyzing the
more troublesome aspects of these perpetrators. To date, two studies have attempted to
examine empirically psychodynamic characteristics of sexually offending therapists
(Celenza & Hilsenroth, 1997; Celenza, 1998).
Celenza and Hilsenroth (1997) and Celenza (1998) conducted empirical studies of
the psychodynamic characteristics of therapists who engaged in sexual misconduct.
Both studies had a small number of subjects (N = 20, 17, respectively). Data on
personality characteristics of offending therapists for both studies were derived from
projective measures and a five-hour interview.
In the Celenza and Hilsenroth (1997) study, measures included in the
examinations were the Wechsler Adult Intelligence Scale-Revised or the Shipley Institute
of Living Scale-Vocabulary and Analogies subtests, and the Rorschach. All subjects
were male (ages between 22 and 66 years), 19 were Caucasian and one was Hispanic.
Ninety percent were heterosexual and 50% were married at the time of the sexual dual
relationship. All subjects had achieved a postgraduate degree with 90% earning a
doctoral degree (mean IQ for the sample was in the superior range of 124). None of the
subjects had a history of mental illness although many had experienced personal therapy
or psychoanalysis. Two subjects reported a history of sexual abuse and all subjects

60
reported significant emotional abuse in their families of origin characterized by a lack of
affection or emotional deprivation (Celenza & Hilsenroth, 1997). As is common with
many offenders, 50% reported experiencing the loss of a significant other at the time of
the transgression.
Relying primarily on the Rorschach, Celenza and Hilsenroth (1997) examined
several different variables including, coping resources, affect, interpersonal relations,
ideation/mediation, cognitive style, self-perception, and psychopathology. Briefly, these
subjects displayed coping resources similar to the normative group, however, scores
revealed chronic distress associated with affective/object hunger and neediness (p.96).
Affective responsivity was normal although there was a tendency to withdraw from
stimulating or emotional situations. Measures of interpersonal contexts revealed these
participants have a discomfort with, or distance from interpersonal relations, and may feel
pessimistic about having their needs met by others. Additionally, these participants
produced responses that revealed body parts in isolation and were often associated with
primitive, morbid, or aggressive content (p. 98). Celenza and Hilsenroth (1997)
postulate that these data represent developmentally regressed part-object relations.
Continuing on, ideation/mediation scores did not reveal any gross reality
distortions but did reveal a tendency toward activity rather than fantasy use. These
participants appeared to have little ability to introspect and examine ideas from a
different perspective. The cognitive processing style for these participants were normal.
The self-perception scores reflected a preoccupation with body integrity, feelings of
damage, and vulnerability. Furthermore, these participants appeared to have the inability
to introspect without feeling worthless in the process. Finally, the contellations score

61
revealed no formal thought disorder, psychotic states or gross distortions of reality.
However, more than half the sample met the criteria for depression.
The second empirical study conducted by Celenza (1998) gathered information
from 17 offenders (14 male, 3 female) through comprehensive evaluations including an
extensive 5-hour clinical interview, a full psychological test battery (including the
Rorschach, Thematic Apperception Test, and Drawings), and when possible, consultation
with the therapists supervisors, colleagues, spouse, therapist, and client-victim. In this
group, all offenders were psychodynamically trained and considered themselves
competent and sensitive to transference/countertransference issues.
The preliminary findings reported by Celenza (1998) briefly include, longstanding and unresolved narcissistic neediness, lifelong struggles with low self-esteem, a
childhood history of sexualized pregenital needs, restricted awareness of fantasy, a family
history of boundary violations by a parental figure, intense and unconscious unresolved
anger toward authority figures, and the transformation of unconscious
countertransference hate into love.
Both studies (Celenza & Hilsenroth, 1997; Celenza, 1998) revealed the
impairment present in these two groups of offenders followed a pattern based on a poorly
developed sense of self and disturbed object relations. In other words, Celenza and
Hilsenroth (1997) and Celenza (1998) indicated that these mental health professionals
struggled with long standing low self-esteem, feelings of inadequacy, failure and
unworthiness, depression, chronic distress associated with interpersonal longing and
neediness, and object hunger. Additionally, Celenza (1998) reported all the offenders in
her study shared 73% of the following characteristics: long-standing and unresolved
problems with self esteem, boundary transgressions by a parental figure, restricted

62
awareness of fantasy, unresolved anger toward authority figures, intolerance of negative
transference, and misunderstandings of countertransference.
Low self-esteem. The common denominator in these offending therapists
appeared to be a poorly developed sense of self manifested in one manner via low selfesteem. For example, during the 5-hour interview, all the therapists studied by Celenza
(1998) described an intolerance of negative transference from clients and many reported
long standing low self-esteem. Without a healthy sense of self, these therapists used their
clients to meet unresolved narcissistic needs and required clients to view them in a
positive light (Celenza, 1998). There was often an unwritten rule that expression of anger
or negative transference from the client toward the therapist was taboo (Celenza, 1998).
Additionally, Celenza (1998) reported these therapists had an inability to view
themselves as depriving and thus depended on therapeutic techniques designed to elicit a
corrective emotional experience. Unfortunately, if the technique did not yield results, a
therapeutic impasse was experienced which likely led to the seduction of the client.
During this impasse the therapist appeared to have desperately attempted to connect with
the client to protect his or her self-esteem (Celenza, 1998). Finally, these therapists had a
tendency to transform countertransference hate into countertransference love (Celenza,
1998). That is, aggression was defensively transformed into love, empathy, caring, or
giving for the client in order to preserve the self-esteem of the therapist.
Impaired object relations. Equally as troublesome for these two groups of
offenders were their object relations (measured by the Rorschach, Thematic
Apperception Test, Drawings, the 5-hour interview). Impairment in these offending
therapists appeared to involve feelings of alienation, insecure attachment, social
incompetence, and egocentricity. Alienation has been described as indicating a lack of

63
trust in relationships, the inability to attain and maintain a stable, satisfying intimate
relationship, feelings of isolation, and a belief that others will fail them (Bell, Billington,
& Becker, 1986). Celenza and Hilsenroth (1997) hypothesized that these offenders have
a feeling of pessimism regarding having their needs met by others.
Analyzing object relations in these subjects revealed a discomfort with or distance
from interpersonal situations. Celenza and Hilsenroth (1997) stated, these individuals
appear acutely sensitive to, and deprived of, emotional sustenance derived from
interpersonal contact (p. 103). These two groups of subjects appeared to have insecure
attachments and to experience social incompetence. Individuals with insecure
attachments are likely to be very sensitive to the slights of others, have a neurotic need to
be liked and accepted, and a fear of object loss (Bell et al., 1986). Social incompetence
refers to shyness, nervousness, social isolation, uncertainty about how to act with the
opposite sex, and unsatisfactory sexual adjustment (Bell et al., 1986). These
characteristics are similar to what Celenza (1998) postulated leads to the misuse of
countertransference.
Celenza (1998) reported therapists in her study relied on their clients to meet their
own unresolved narcissistic needs by requiring that their clients always see them in a
positive manner. Celenza and Hilsenroth (1997) noted that the sexually offending
individuals in their study were capable of empathy and had a tendency to over-identify
with clients who present with similar needs. Therapist overidentification with a client
was the beginning of the evolution of boundary crossings that led to sexual involvement.
The sexualization of the relationship may be an attempt to establish a sense of selfcohesion, an interpersonal connection, or to confirm the male gender role (Celenza &
Hilsenroth, 1997). Celenza and Hilsenroth (1997) concluded, one of the most salient

64
factors observed in these individuals is the pervasive sense of unmet interpersonal
longing and emotional deprivation in relational contexts(p. 103). In the end, the
offenders in both studies appear to have had a sense of egocentricity in that their clients
were used to serve their own self-centered needs, however, the authors of both studies
note that the participants did not meet the DSM-IV criteria for narcissistic personality
disorder. Rather, these participants appeared to experience excessive narcissistic injuries
in childhood that led to low self-esteem, impaired object relations, and depression.
Celenza (1998) noted that the results of her study are preliminary and the findings
were not the result of a controlled study. The present study will improve on this
limitation by comparing sexually offending psychologists with nonsexually offending
psychologists and non-offending psychologists. Additionally, Celenza and Hilsenroth
(1997) and Celenza (1998) depended on projective measures and interview data for their
results. The Rorshach and Thematic Apperception Test are established and valuable
instruments to measure personality characteristics. However, the present study will
expand on this limitation by taking these preliminary findings regarding self-esteem and
object relations by using quantitative measures to address the salient personality
characteristics that appear to be present in some offending psychologists.
The Childhood Histories of Psychologists
For many psychologists, their childhood history appears to be wrought with
turmoil. In one of the earliest studies to look at psychologists, Racusin et al. (1981)
interviewed therapists (N = 14) regarding their families of origin. The researchers found
that 100% of their sample had at least one family member with physical or behavioral
problems due to psychogenic factors. Alcoholism, child abuse, or both were found in
50% of the families. Finally, half the sample reported their primary role in the family

65
was to provide parenting functions to their own parents and/or siblings. These authors
suggest the family histories of these therapists provided training grounds for sensitivity to
interpersonal stress, which later became a valuable tool in doing therapeutic work.
Additionally, they believe therapists may have sought out a career that affords them
emotional intimacy on a daily basis to compensate for parental deprivations experienced
from very early on (p. 276).
Celenza (1998) reported many of her subjects described a childhood history of
parental boundary violations mixed with covert seductiveness and overstimulation of the
child. These therapists described a family atmosphere that was emotionally repressed,
emotionally deprived, and sexually prohibited despite a theme of covert sexuality.
Celenza (1998) framed the childhood experience of her subjects as one that left them with
unresolved narcissistic needs that were reenacted in the therapist-client dyad, which
represented a sexual relationship with the forbidden object.
Pope (1992) and Elliott and Guy (1993) have researched the early life experiences
of psychologists. Popes (1992) national survey study of 500 clinical and counseling
psychologists found an astonishing 70% of the women and 33% of the men had
experienced some form of physical or sexual abuse in their lifetime. While
generalizability cannot be assumed, nonetheless, given that the population was
prominently licensed practitioners, these results are striking. Elliott and Guy (1993)
found similar results in female health professionals (N = 340). That is, 51% of the
subjects reported one or more incidence of physical abuse, sexual molestation, parental
alcoholism, hospitalization of a parent for mental illness, or the death of a parent or
sibling before the age of sixteen years (Elliott & Guy, 1993).

66
Most recently, Jackson and Nuttall (2001) presented findings from their national
survey (N = 323) of mental health practitioners (social workers, pediatricians,
psychiatrists, and psychologists) that identified specific factors that placed therapists at
risk for engaging in a sexual dual relationship with a client. The authors developed a
sexual boundary violations survey and the results indicated that a history of sexual abuse
places a therapist at risk for engaging in sexual behavior with a client. A second
important finding is that 36% of the men who had been sexually abused by a relative or
caretaker reported having engaged in sexual misconduct with a client. In contrast, only
7% of the men sexually abused by a stranger reported having sexual relations with a
client.
Although the sample size was small (n = 6, 21% subjects who had a childhood
history of sexual abuse and who subsequently crossed sexual boundaries with a client),
Jackson and Nuttall (2001) encourage high risk therapists to avoid the isolation of private
practice, monitor boundaries with clients carefully, obtain supervision, and seek personal
therapy to resolve abuse issues. Finally, the authors provided a caution against
profiling high risk therapists, clearly, not all therapists who have been sexually abused
as children sexually exploit their clients. Nor do all therapists who sexually violate their
clients trust have a history of sexual abuse (p. 203). The implication here is that while
most psychologists with abuse histories are competent, ethically minded individuals, an
abuse or trauma history (especially when perpetrated by a parent or caretaker) cannot be
ignored as a risk factor for impairment and subsequent unethical behavior.
Some authors (Celenza, 1998; Finell, 1985; Miller, 1981; Racusin, et al., 1981;
Wells & Jones, 2000) believe the propensity to become a therapist is set in motion very
early in life. As demonstrated by Celenza (1998), problems for some therapists begin in

67
childhood with poor object relations which ultimately leads to long-standing low selfesteem and narcissistic longings. The field of psychology affords many possibilities for
the gratification of narcissistic needs and emotional intimacy that are missed due to early
and chronic parental deprivations (Finell, 1985; Racusin, et al., 1981). Miller (1981)
purports that therapists are likely to have been raised by a parent who used his or her
children in order to gratify unfilled needs. Many therapists feel that their primary role in
the family had been to provide parenting for family members and to fulfill the needs of
others at the expense of their own needs (Racusin et al., 1981).
Parentification
Boszormenyi-Nagy and Spark (1973) were the first theorists to identify and
describe the phenomenon of parentification as the subjective distortion [by an adult] of a
relationship as if ones partner or even ones children were his parent (p.151). In effect,
there is a role reversal whereby the child assumes physical and/or emotional
responsibility for the parent who has abdicated their parental role. While some amount of
role reversal is normal, it becomes dysfunctional when the caretaking is not supported,
diffused, or reciprocated by parental figures (Goglia, Jurkovic, Burt, & Burge-Callaway,
1992). The result of parentification is a child who sacrifices his or her own needs to
accommodate and care for the logistical, emotional, and self-esteem needs of the parent
(Chase, Deming, & Wells, 1998).
Mika, Bergner, and Baum (1987) defined parentification as the familial
interaction pattern whereby children and adolescents are assigned roles and
responsibilities normally the province of adults in a given culture, but which parents in a
particular family have abdicated (p. 229). These roles frequently include caring for
younger siblings or dysfunctional parents; assuming roles such as consoler, confidante,

68
peacemaker or personal advisor to parents; and, the assumption of household
responsibilities such as cooking, cleaning, and laundry.
There appears to be two manifested constructs of parentification. Goglia et al.
(1992) described child as parent and child as mate as two distinct types of
parentification. In their empirical study (N = 120), Goglia et al. (1992), described the
child as parent role as one whereby the child carries out more of the logistic tasks such
as cooking meals, caring for and disciplining younger siblings or managing the family
budget. The child as mate role entails caring for the emotional well-being of the parent
or serving as a parental confidante, peacemaker, or mediator.
Parentification has numerous potentially destructive consequences. West and
Keller (1991) were the first authors to link childhood parentification with excessive caregiving as an adult. They hypothesized that the structure of the persons interaction with
the parent is carried forward into adulthood and serves as a template for negotiating
current relationships (p. 426). Specifically, West and Keller (1991) described
compulsive features that manifest in parentified individuals such as compulsive strivings
for perfection, shame over mistakes, and basic insecurity that underlies the motivation for
control via compulsive caretaking.
Other destructive consequences of parentification may include inadequate
opportunities to define self on major life goals and issues and thus differentiate
successfully from the family of origin, the development of an excessively care-taking
personal orientation, and proneness as an adult to seek relationships in which he or she is
exploited and/or subjugated (Mika et al., 1987). In clinical settings the parentified child
may present as symptomatic, infantilized, or unmanageably rebellious (Jones & Wells,
1996). However, Jones and Wells (1996) highlighted that a parentified child also may

69
appear overindulged, over-parented, or high achieving, especially when the parent
expects the child to live out their unfulfilled dreams and accomplishments. Long term
effects of parentification show that parentified children have difficulty with healthy
separation-individuation from parents and are unable to develop an authentic sense of self
(Chase et al., 1998; Jurkovic, Jessee, & Goglia, 1991). Thus, parentification appears to
undermine the healthy development of the true self. Parental failure in attunement and
mirroring results in the child feeling a lack of power and specialness (Kohut, 1971;
Miller, 1985; Glickhauf-Hughes & Wells, 1997). This leads to feeling ashamed of the
true self and a loss of awareness of ones true needs, values, and desires (Jones &Wells,
1996). In fact, parentification has been linked empirically to feelings of shame (N = 190)
by Wells and Jones (2000).
As the child begins to mold his or her personality around fulfilling the needs of
others, one of two distinct personality characteristics may emerge: masochistic or selfdefeating and overtly narcissistic (Jones & Wells, 1996). In an empirical study, Jones
and Wells (1996) examined undergraduates (N = 360) for the presence of these two
different but related manifestations of parentification. For example, parents may
encourage a masochistic parentification by needing the child to care directly for the
parents emotional or physical needs (e.g., by being a good listener or friend, by being
moms little helper or the little man of the family). Individuals with this type of
parentification may defend against feelings of shame by over-identifying with the role of
indispensable caretaker. Narcissistic parentification may be induced by needing the child
to become the parents idealized self-projection (e.g., living the parents dream of
becoming a doctor, lawyer, or successful businessperson). Individuals with this type of
parentification may defend against feelings of shame about the real self with a grandiose

70
false self, which equals the ego ideal projected onto him or her by the parent(s). Jones
and Wells (1996) note that children also may have personality traits that include both
types of parentification. Importantly, these researchers have linked childhood
parentification with the later manifestation of masochistic or narcissistic personality
characteristics.
Empirical evidence for the destructive nature of parentification can be found in
Valleau, Bergner, and Hortons (1995) study of parentified caregivers. These researchers
found that the incidence of childhood parentification positively correlates with current
excessive care-taking in female undergraduate students (N = 208). In effect, what these
caregivers learned very early was that their authentic needs will go unheeded and they are
responded to only when they meet the needs of others.
Are individuals with a history of parentification at risk for future unethical
behavior? Some authors believe the answer is yes (Glickauf-Hughes & Mehlman,
1995). Glickauf-Hughes and Mehlman (1995) state, individuals who are parentified and
highly attuned to the needs of others have difficulty setting limits and boundaries with
clients (p. 216). These authors explain that as a result of narcissistic injury and
parentification, these therapists are at risk for burnout, vicarious gratification of
dependency needs with clients, pathological perfectionism, low self-esteem, and feelings
of pretense. Additionally, McClure and McClendon (1989) list some common problems
associated with parentification: (a) believing that one is loved for what one does rather
than for who one is, (b) poor limit-setting, and (c) difficulty getting ones own needs met
directly. Clearly, parentification represents an extreme boundary violation and sets the
stage for later role-reversal (e.g., therapist-client sexual and nonsexual dual
relationships).

71
Of course, excessive caretaking does not in and of itself explain why some
therapist may cross treatment boundaries. The result of parentification has been shown
empirically to relate to narcissistic injury in childhood (Glickauf-Hughes & Mehlman,
1995; Jones & Wells, 1996). Therefore, to complete this complex analysis, a discussion
of narcissistic injury to therapists is needed.
Narcissistic Injury to Therapists
Narcissism has been reviewed and written about by many prominent authors
(Finell, 1985; Glickhauf-Hughes & Mehlman, 1995; Horner, 1984; Kohut & Wolf, 1978;
Miller, 1981). First, it is necessary to establish that a reasonable amount of narcissism is
normal (Kohut & Wolf, 1978). Kohut and Wolf (1978) proposed that the formation of a
grandiose self is developmentally normal and healthy. This study seeks to understand
the unhealthy formation of self and impaired object relations resultant from continued
narcissistic injuries in childhood. Noted here is the Celenza and Hilsenroth (1997) study
that reported that their participants did not meet the Diagnostic and Statistical Manual-IV
(American Psychological Association [APA], 1994) criteria for narcissistic personality
disorder but did reflect impairment in the narcissistic realm (p. 106).
To develop a healthy sense of self, one needs two things from the parents during
childhood: (a) appropriate mirroring and admiration, and (b) non-traumatic empathic
failures. In other words, a child needs to feel invulnerable and accepted unconditionally
most of the time. Occasional empathic failures help further develop a childs self-esteem
by forcing the child to draw on their own internal resources for comfort and soothing.
When development goes awry, Kohut and Wolf (1978) and Miller (1981) contend
it is because caregivers repeated failures to respond empathically to the internal
experiences and developmental needs of a young child. As a result, the childs ability to

72
form an integrated self-structure is compromised. In effect, the child experiences a
fragmentation of the self. Manifested symptoms of this fragmented self include
hypochondria, depression, hypersensitivity to slights, and lack of zest. Thus, as Kohut
and Wolf (1978) explained, pathological manifestations of grandiosity and idealization
represent an arrest in normal development and a continued yearning for the unfulfilled
narcissistic needs of early childhood. Celenza and Hilsenroth (1997) and Celenza (1998)
postulated that unmet narcissistic needs unconsciously motivate therapists to engage in
sexual dual relationships.
As shown earlier, childhood interactions with parents have a considerable
influence on an individuals developing self. Therapists appear to be especially
vulnerable, as can be seen in this poignant statement by Horner, I have been struck by
the prevalence of narcissistic mothers in the history of those clients who are themselves
therapists and have concluded that learning to sense and meet the needs of the narcissistic
parent constitutes an effective training ground for the future psychotherapist (Horner,
1984, p. 197).
Leading theorists in the study of narcissism contend that parents, for whom their
narcissistic needs were not met as children, are likely to feel compelled to gratify their
needs through their own children (Finell, 1985; Glickhauf-Hughes & Mehlman, 1995;
Horner, 1984; Kohut & Wolf, 1978; Miller, 1981). In effect, the child may develop a
heightened sensitivity to the parents psychological state and learn how to respond to the
parent by catering to his or her narcissistic needs. Eventually, the child may surrender
him or herself to the narcissistic needs of the parent and develops a false self. Miller
(1981) explained that a lack of authenticity, rooted in a narcissistic disturbance, leads to
depression, especially in gifted children. Further, although the parent may respond

73
positively to this false self, the child may not internalize these positive responses and
feelings of depression and futility often follow. This lack of authenticity may influence
offending therapists to present themselves in a positive light.
Lending further empirical support for the influence of parental feedback on the
development of narcissism, Watson et al. (1995) measured narcissism, self-esteem, and
parental nurturance (N = 459). These researchers suggest that narcissism falls on a
continuum and is related to early parental nurturance, which in turn influences positive
self-esteem. In other words, higher parental nurturance correlated with higher selfesteem. Greater parental nurturance and self-esteem correlated with lower incidence of
narcissism.
Brightman (1989) delineated several reasons why narcissistic issues in therapists
are important. First, the stereotype of the therapist as the all-knowing, allloving,
embodiment of the healer reveals ones own narcissistic aspirations. Second, the
professional self and the personal self are intimately linked in the field of therapy.
Therefore, unresolved narcissistic issues in one realm will inevitably influence the other
realm. Finally, at a developmental level, practicing therapy may be a reenactment of an
earlier situation whereby the child has been forced into caring for the narcissistic needs of
the parent. This notion is supported earlier in this text by the authors describing the
phenomenon of parentification.
Narcissistic perils exist in experienced therapists as well. As Finell (1985) stated,
analysts too, struggle with narcissism (p. 433). She elaborated that feelings of shame
lower self-esteem when the analyst is faced with defects in his or her idealized self.
Further, if the analyst does not process these feelings in analysis, the potential for
countertransference over and above a specific reaction to the clients narcissistic

74
transference is enormous. Said differently, idealization, grandiosity, devaluation, and
fear of dependency form an essential part of the narcissistic configuration. As these
feelings are often very painful, they may go unanalyzed in treatment. Therefore, the
potential for the practice of ineffective and/or unethical therapy is enhanced.
Importantly, according to Kernberg (1975), narcissistic problems often become painful
around the age of 48 years. This is congruent with therapists at risk for engaging in
sexual dual relationships (i.e., middle-aged males who exploit younger female clients).
Summary of Literature Review
As this literature review has shown, empirical literature on the characteristics of
therapists who engage in nonsexual and sexual dual relationships is limited. While there
are guidelines and ethical prohibitions to assist therapists in the establishment and
maintenance of boundaries, some psychologists continue to struggle with both types of
dual relationships (APA, 1992; Lamb & Cantanzaro, 1998; Simon, 1992).
Very few studies have examined nonsexual dual relationships. Research has
shown that psychologists become involved with a variety of non-romantic, nonsexual
relationships, view the ethics of these dual relationships differently, and cite a number of
different theoretical reasons for their stance (Anderson & Kitchener, 1996; Pope, 1989).
However, the trend overall appears to be that as a therapist ages and gains more
experience, ethical judgment falls below previously held standards (Borys & Pope, 1989;
Epstein et al., 1992; Lamb et al., 1994; Rodolfa et al., 1994; Stake & Oliver, 1991).
Furthermore, research indicates that a psychologists attitude toward nonsexual physical
contact is predictive of future likelihood to engage in sexual dual relationships (Holroyd &
Brodsky, 1980). Finally, males engage in nonsexual dual relationships at a greater rate
than females and psychodynamically oriented therapists tend to view dual relationships of

75
all kinds as less ethical (Baer & Murdock, 1995; Borys & Pope, 1989; Holroyd &
Brodsky, 1977; Lamb et al., 1994; Pope et al., 1987).
The focus of most existing research has been on sexual dual relationships.
Previous research, beginning in the 1970s has consistently reported that six to 12% of
psychologists engage in a sexual dual relationship (Akamatsu, 1988; Holroyd & Brodsky,
1977; Lamb & Catanzaro, 1998; Pope et al., 1987). While incidence rates have declined
in the past decade, the profession has no clear explanation for the decline. Pope et al.
(1987) suggested that an overall lower incidence rate of sexual misconduct and a
decreased likelihood that offenders will admit their wrongdoing may explain why there
are lower rates. The desire to save face and maintain the male privilege may be
buffering the actual incidence rate of therapist-client sexual misconduct (Pope, 1990b).
Three of the most notable demographic characteristics in the study of sexual dual
relationships have been gender, age, and practicing therapy in a solo private practice. An
overwhelming consistent finding is that typically it is a middle aged male therapist in solo
private practice who engages in a sexual dual relationship with a female client in her
thirties (Borys & Pope, 1989; Bouhoutsos et al., 1983; Butler & Zelen, 1977; Epstein et
al., 1992; Jackson & Nuttall, 2001; Lamb & Catanzaro, 1998; Lamb et al., 1994; Pope et
al., 1979; Pope et al., 1987; Pope, 1990b; 1993; Somer & Saadon, 1999).
The harm done to clients as a result of therapist-client sexual relations has been
established repeatedly (Feldman-Summers & Jones, 1984; Folman, 1991; Gabbard, 1991;
Gutheil, 1991; Pope, 1988; Simon, 1991; Somer & Saadon, 1999; Sonne & Pope, 1991).
Notably, Pope (1988) coined the term Therapist-Client Sex Syndrome to denote the
myriad of symptoms experienced by victims of therapist-client sexual dual relationships.
Interestingly, therapists who believe minimal damage is done to client victims of past

76
sexual misconduct have an almost threefold increase in the incidence of sexual
misconduct (Holroyd & Bouhoutsos, 1985).
The evolution of sexual dual relationships has been established as one that begins
with incidental boundary crossings usually at the beginning or end of a session and
moves toward outright boundary violations that seriously harm the client (Gabbard, 1996;
Gutheil & Simon, 1995; Pope et al., 1986; Simon, 1991; 1995; 1999; Somer & Saadon,
1999). Importantly, the two most common boundary violations that precede sexual
involvement are therapist self-disclosure and nonsexual physical contact (Gabbard, 1996;
Simon, 1991; Somer & Saddon, 1999). Similarly, researchers have noted that the age of
the therapist and years of practice experience influence the judgment of behaviors as
ethical or unethical. That is, as therapists age and gain more experience, they tend to
judge behaviors that previously may have been judged unethical, as ethical (Borys &
Pope, 1989; Epstein et al., 1992; Lamb et al., 1994; Rodolfa et al., 1994; Stake & Oliver,
1991).
Some researchers have analyzed the misuse of countertransference phenomenon
within the therapeutic relationship (Bridges, 1994; Celenza, 1991; 1995; 1998; Gabbard,
1994b; Pope & Tabachnick, 1993; Rodolfa et al., 1994; Stake & Oliver, 1991). Most
therapists experience anger, hate, love, fear, and sexual attraction toward a client at some
point in their careers and struggle with these feelings (Pope & Tabachnick, 1993).
Furthermore, while consultation and/or supervision are seen as important preventive
factors for sexual dual relationships, most psychologists do not seek out or utilize such a
relationship to deal with these issues (Hamilton & Spruill, 1999; Pope et al., 1986;
Rodolfa et al., 1994; Stake & Oliver, 1991). Gabbard (1996) and Celenza (1998)
reported that some therapists transform their hateful or aggressive impulses into loving

77
feelings because of the need to be continually seen by clients in a positive light.
Furthermore, the intolerance of negative transference has been shown as a possible
precursor to sexual involvement (Celenza, 1991; 1998). Finally, some common
psychodynamic characteristics of therapists who cross sexual boundaries include long
standing low self-esteem, depression, long-standing interpersonal problems and object
hunger, unresolved anger, restricted awareness of fantasy, and a childhood history of
boundary transgressions by a parent (Celenza, 1998; Celenza & Hilsenroth, 1997;
Gabbard, 1996).
The typology of sexually offending therapists has been reported by several
researchers (Butler & Zelen, 1977; Gabbard, 1994a; Olarte, 1991; Pope, 1993). The most
commonly cited categorical system was created by Gabbard (1994a). Gabbard (1994a)
delineated four categories based on his clinical work with offenders: psychotic, predatory
psychopathy, lovesick, and masochistic surrender. These categories have yielded
important clinical information in understanding the general characteristics of offending
psychologists, however, empirical studies exploring the underlying characteristics of nonoffenders and offenders have been lacking.
Two empirical studies have examined psychodynamic characteristics of sexually
offending therapists (Celenza & Hilsenroth, 1997; Celenza, 1998). Common
characteristics in these mental health professionals were long standing low self-esteem,
feelings of inadequacy, failure and unworthiness, depression, chronic distress associated
with interpersonal longing and neediness, and object hunger. Two themes appear to be
relevant, the prevalence of long standing low self esteem and impaired object relations.
Literature on childhood experiences of therapists reveals frequent histories of
abuse (Elliot & Guy, 1993; Pope, 1992; Racusin et al., 1981). Further evidence suggests

78
that some therapists may have been put into parentified roles or raised by caretakers with
narcissistic tendencies (Mika et al., 1987; Miller, 1981; Valleau et al., 1995; West &
Keller, 1991). As a result, therapists may adopt an over-functioning, care-taking style
that often results in boundary crossings and difficulty setting limits with clients
(Glickhauf-Hughes & Mehlman, 1995; Mika et al., 1987; Valleau et al., 1995; West &
Keller, 1991).
Childhood experiences of narcissistic injury (that is, failure by the parent to
respond empathetically to the internal experiences and developmental needs of a young
child) may place therapists at risk for boundary violations. Celenza and Hilsenroth
(1997) and Celenza (1998) postulated that unmet narcissistic needs unconsciously
motivate therapists to engage in sexual dual relationships.
Summary of Empirical and Anecdotal Findings
Knowledge regarding the risk factors and precursors to therapist-client sexual
misconduct falls into one of two camps: empirical and anecdotal. On the empirical side,
research has demonstrated the prevalence of misconduct (Jackson & Nuttall, 2001; Lamb
& Catanzaro, 1998; Pope et al., 1979; Pope et al., 1986; Pope et al., 1987), demographic
variables (Borys & Pope, 1989; Bouhoutsos et al., 1983; Butler & Zelen, 1977; Epstein et
al., 1992; Lamb & Catanzaro, 1998; Lamb et al., 1994; Pope et al., 1979; Pope et al.,
1987; Pope, 1990b; 1993; Somer & Saadon, 1999), the evolution of sexual dual
relationships (Pope et al., 1986; Somer & Saadon, 1999) and the damage done to clients
as a result of therapist-client sexual misconduct (Feldman-Summers & Jones, 1984;
Folman, 1991; Gabbard, 1991; Gutheil, 1991; Pope, 1988; Simon, 1991; Somer &
Saadon, 1999; Sonne & Pope, 1991). Additionally, empirical literature on childhood
experiences of therapists reveals frequent histories of abuse (Elliot & Guy, 1993; Jackson

79
& Nuttall, 2001; Pope, 1992; Racusin et al., 1981). Further empirical evidence suggests
that some therapists may have been put into parentified roles or raised by caretakers with
narcissistic tendencies (Mika et al., 1987; Valleau et al., 1995; West & Keller, 1991).
The most recent empirical research on this subject has provided the field with preliminary
data on the psychodynamic characteristics of sexually offending therapists (Celenza &
Hilsenroth, 1997; Celenza, 1998).
On the anecdotal side, authors who have extensive experience assessing and
treating therapist offenders have provided typologies of offenders (Gabbard, 1994a;
Olarte, 1991; Pope, 1993) and further clinical evidence for the evolution of sexual dual
relationships (Gabbard, 1996; Gutheil & Simon, 1995; Simon, 1991; 1995; 1999). Some
authors have noted that therapists who have been raised by caretakers with narcissistic
tendencies (Miller, 1981) may adopt an over-functioning, care-taking style that often
results in boundary crossings and difficulty setting limits with clients (Glickhauf-Hughes
& Mehlman, 1995). Finally, based on their empirical findings, Celenza and Hilsenroth
(1997) and Celenza (1998) postulated that unmet narcissistic needs unconsciously
motivate therapists to engage in sexual dual relationships.
Clearly, there are a myriad of factors that influence the evolution of a therapistclient sexual and nonsexual dual relationship. Bridges (1994) summarized the more
quotidian aspects of therapist-client sexual misconduct by stating, sexuality [on the part
of the therapist or client] may be a symbolic marker, distraction, or disguise for numerous
other affects and phenomenathe need for nurturing, admiration, or soothing; avoidance
of intimacy or grief; denial of dependency or passivity; and reenactment of traumatic
object relations (p. 430). All these factors may contribute by varying degrees to a

80
psychologist crossing the line into unethical behavior. This study is one attempt to
understand this complex and intriguing phenomenon.
Conclusions and Purpose of Study
Psychologists who have crossed the line of sexual misconduct have overstepped a
line that most professionals regard as uncrossable. As Gabbard (1995) noted, it is easy to
label these transgressed psychologists into stereotyped categories such as psychotic,
inhuman, mentally ill, and the like. Underlying these categorizations may be a deepseated anxiety connected with the thought that if it could happen to a respected colleague,
perhaps it could happen to me. Thus, there is a powerful defensive need to distance
oneself from transgressed psychologists (Gabbard, 1995). However, the psychological
profession must overcome the human tendency to categorize and ignore these colleagues.
Presently, research on this topic is needed. To date, no empirical studies have
compared psychodynamic characteristics of psychologists who engage in nonsexual and
sexual dual relationships with those psychologists who do not. Additionally, there is a
void in the dual relationship literature examining variables that may influence a
therapists decision to enter into a sexual dual relationship. Awareness of these
vulnerabilities can be used to inform supervisors and educators especially when the focus
of concern is the therapeutic skill level and personal development of the trainee. Finally,
previous studies have not directly assessed what demographic variables, if any, are
related to ethical judgment.
The present research is undertaken to examine the phenomenon of nonsexual and
sexual dual relationships and the psychodynamic characteristics of offending
psychologists that may contribute to the problem. This study will attempt to answer the
questions related to the unique childhood experiences of psychologists as they relate to

81
present day nonsexual and sexual boundary violations. This study also attempts to
broaden the understanding of the psychodynamic characteristics of sanctioned
psychologists by comparing them to nonsanctioned psychologists. The following
research questions will be explored in this study:
1. Are there significant differences on demographic measures for psychologists
who engage in nonsexual dual relationships, psychologists who engage in
sexual dual relationships, and non-sanctioned psychologists?
2. Are there significant differences on measures of object relations for
psychologists who engage in nonsexual dual relationships, psychologists who
engage in sexual dual relationships, and non-sanctioned psychologists?
3. Are there significant differences on measures of parentification, narcissistic
injury, self-esteem, and ethical judgment for psychologists who engage in
nonsexual dual relationships, psychologists who engage in sexual dual
relationships, and non-sanctioned psychologists?
4. To what extent do the demographics of academic training, theoretical
orientation, history of childhood abuse, practice setting, partner status, and age
at the time of ethical violation predict scores on measures of object relations,
parentification, narcissistic injury, self-esteem, and ethical judgment?
5. Is there a relationship between measures of object relations, parentification,
narcissistic injury, self-esteem, and ethical judgment for each group?

82
CHAPTER 3
Method
Participants
Three distinct groups of psychologists were recruited to participate in this
investigation: (Group A) 20 doctoral level psychologists who were sanctioned by their
respective state psychology licensing board for engaging in a nonsexual dual relationship
with a client(s), (Group B) 19 doctoral level psychologists who were sanctioned by their
respective state psychology licensing board for engaging in a sexual dual relationship
with a client(s), and (Group C) 20 doctoral level licensed psychologists who were not
sanctioned by their respective state psychology licensing board (control group). Names
and addresses of sanctioned psychologists (Groups A and B) were requested from state
licensing boards and also found on the world-wide-web. Names and addresses of 20 nonsanctioned psychologists (Group C) were provided from the American Psychological
Association Membership list.
Procedure
Data collection. Many state boards of psychology across the United States and
the National Register of Health Service Providers have posted lists of psychologists who
have been sanctioned for ethical violations on the world wide web. Through these
websites and written requests to all 50 state psychology boards, names and addresses of
psychologists who were sanctioned for engaging in nonsexual (Group A) and sexual dual
relationships (Group B) with a client(s) were secured. The American Psychological
Association (APA) provided a randomly selected group of 100 non-sanctioned
psychologists (Group C) from the APA membership list that served as the control group
in this study. Of the 100 packets sent to the control group, 54 were returned (indicating a

83
return rate of 54%). To make the number of subjects in each group more equal for
statistical purposes, the investigator used a table of random numbers to randomly select
20 packets out of the 54 that were returned. Thus, the control group included 20
participants. Total number of participants for this study equaled 59.
Six hundred and seventy-five names and addresses of sanctioned psychologists
(Groups A and B) were secured prior to the first mailing. These sanctioned psychologists
were sent a letter of introduction (see appendix A) and a stamped postcard (see appendix
B) to return indicating their willingness to participate in the present study. In all, 151
letters were returned undeliverable and a total of 116 sanctioned psychologists returned a
postcard (indicating a return rate of 22%). Approval of the preliminary mailing was
granted by the Institutional Review Board of West Virginia University prior to the
mailing.
A second mailing was conducted with the 116 sanctioned psychologists who
returned a postcard and to the control group of 100 non-sanctioned psychologists. Table
1 lists by state and gender those subjects from the two sanctioned groups who returned a
postcard indicating a willingness to participate. Approval of the research study by the
Institutional Review Board of West Virginia University was obtained prior to the second
mailing.
All participants in each of the three groups were mailed a packet of materials on
February, 15, 2000. Materials included in the packets for Groups A, B, and C can be
found in Table 2. Each packet included a cover letter, an information form, a
demographic questionnaire, and five self-report measures. Additionally, the sanctioned
groups received a separate sheet of paper with four open-ended questions. The cover

84
Table 1
List of Sanctioned Subjects by State and Gender Who Returned a Postcard Indicating a
Willingness to Participate
State

Arizona
California
Colorado
Connecticut
Florida
Georgia
Illinois
Indiana
Iowa
Kentucky
Maine
Michigan
Minnesota
Missouri
Nebraska
New Jersey
Nevada
New Mexico
New York
Ohio
Oregon
Pennsylvania
S. Carolina
Texas
Utah
Virginia
Washington
Wisconsin

03
12
05
03
01
02
03
04
03
01
09
11
01
03
04
04
01
02
04
11
03
08
01
03
01
09
01
03

Total

116

Gender
Female
Male

N
28
88

%
24
76

85
Table 2
Packets of Materials for Groups A, B, and C
Group
A and B

Content of Packets
Cover letter and information form (see Appendix C, D)
A demographic questionnaire (see Appendix E)
The Bell Object Relations Inventory-40 (BORI)
The Parentification Questionnaire (PQ) (see Appendix G)
The Narcissistic Injury Scale (NIS) (see Appendix H)
The Rosenberg Self-Esteem Scale (RSE) (see Appendix I)
Ethical Judgment Scale (EJS) (see Appendix J)
Four open-ended questions printed on a single sheet of paper (see
Appendix K)
A self-addressed stamped envelope

A cover letter and information form (see Appendix L, M)

A demographic questionnaire (see Appendix N)
The Bell Object Relations Inventory-40 (BORI)
The Parentification Questionnaire (PQ)
The Narcissistic Injury Scale (NIS)
The Rosenberg Self-Esteem Scale (RSE)
Ethical Judgment Scale (EJS)
One open-ended question (see Appendix N)
A self-addressed stamped envelope

86
letter, information form, and demographic questionnaire varied slightly between the
sanctioned groups (A and B) and non-sanctioned group (C). For the sanctioned groups
(A and B) the demographic questionnaire asked for age, gender, academic training,
theoretical orientation, childhood history of abuse, type of ethical violation; work setting,
partner status and age at the time of the ethical violation; gender, age and DSM-IV
diagnostic impression of the client(s) with whom the ethical violation occurred. The
demographic questionnaire for the non-sanctioned group (C) included age, gender,
academic training, theoretical orientation, childhood history of abuse, and the open-ended
question, have you even had any experience with the sanctioning process for
psychologists youd like to share?
Packets were counterbalanced by systematically varying the order of the five selfreport measures to control for ordering effects. For example, the first measure in the first
packet was the second measure in the second packet, the last measure in the first packet
was the first measure in the second packet, etc. Participants were asked to complete the
instruments and return them in a self-addressed stamped envelope. A follow-up postcard
reminder was mailed on March 9, 2001, three weeks after the secondary mailing to all
participants (see Appendix F).
Measures
There were seven measures used in this study: (a) two demographic
questionnaires constructed by the investigator (one for the sanctioned groups, one for the
control group), (b) four standardized measures, and (c) a measure of ethical judgment
constructed by the investigator comprised of vignettes selected from the literature.
Additionally, a separate sheet of four open-ended questions was included for the

87
sanctioned groups . A summary of the reliability and validity of the standardized
measures can be found in Table 3.
Demographic Questionnaires (see Appendix E, N). The demographic
questionnaire for the sanctioned groups consisted of 13 questions. Information gathered
consisted of age range by decades, gender, academic training, theoretical orientation,
childhood experiences of abuse, type of ethical violation for which the participant was
sanctioned, type of sanction(s) received, work setting at the time of the ethical violation,
partner status at the time of the ethical violation, age at the time of the ethical violation,
gender of the client-victim, age the of the client-victim, and DSM-IV diagnostic
impression of the client-victim.
The demographic questionnaire for the control group consisted of six questions.
Information was gathered regarding age range by decades, gender, academic training,
theoretical orientation, childhood experiences of abuse, and the optional question
regarding the participants experience with the sanctioning process.
Bell Object Relations and Reality Testing Inventory (BORI). The BORI consists
of 90 descriptive statements that participants respond to as true or false, depending
on their most recent experience (Bell, Billington, & Becker, 1986). There are seven
subscales, four that assess object relations and three that focus on reality testing. The four
object relations subscales were used (45 items total, no score ranges were provided). The
BORI was normed on eight subpopulations (N = 934) with a wide range of ego
functioning (Bell, 1995). Normative subpopulations included members of a voluntary
board of directors for a social service agency with no identified pathology,
undergraduates with no identified pathology, outpatients who met the DSM-III criteria

88
Table 3
Reliabilities and Validities Reported for the Four Standardized Instruments Used in the
Present Research

Instruments
Bell Object
Relations Inv.
(four scales)

Research
Bell, et al. (1986)

Parentification
Questionnaire

Sessions and
Jurkovic, (1986)
Burt (1986)

Reliability
Validity
Stability
Internal
Convergent
(test-retest)
Consistency
Spearman-Brown Burt (1986)
r = .73-.90
split half rel.
Goglia (1982)
(4 weeks)
.90-.78
Sessions and
r = .65-.81
(13 weeks)
Jurkovic, (1986)
Wolkin (1984)
r = .86
(two weeks)
Spearman-Brown
split-half r = .85

Wolkin (1984)

Coefficient Alpha
r = .83
Narcissistic
Injury Scale

Slyter, 1989

On 130 items:
Coefficient Alpha
r = .88
On 50 items:
Coefficient Alpha
r = .94

Rosenberg Self
Esteem Question.

Zamostny et al.
(1993)

r = .94

Rosenberg (1965)

reproducibility
.92
Coefficient Alpha
r = .72. ,80

Silber & Tippett,

(1965)

r = .85
(two weeks)

89
for personality disorder other than borderline, outpatients and inpatients who met DSMIII criteria for borderline personality disorder, inpatients diagnosed with schizophrenia,
schizoaffective disorder, and schizoaffective disorder with mixed features. Using norms
for the non-pathological groups (N = 60 board members, 874 students) subjects with a
subscale score above the 85th percentile were classified as pathological for that subscale.
Bell (1995) reported that an inconsistent responding (INC) scale enables clinicians to
detect inconsistent response patterns. For the four object relations scales, there are eight
item pairs that contribute to the INC scale. When contradictory responses are given to
four or more item pairs, the results should be interpreted with caution. Additionally, high
scores on the four object relations subscales are indicated if the subscale score is equal to
or greater than 60T.
The four object relations subscales are alienation (ALN), insecure attachment
(IA), egocentricity (EGC), and social incompetence (SI). The ALN items indicate a lack
of trust in relationships and the inability to attain and maintain a stable, satisfying
intimate relationship. High scorers (> 60T) on ALN subscale generally feel isolated,
believe that relationships are ungratifying, and that others will fail them. A sample item
for ALN is, It is my fate to live a lonely life. The IA subscale measures interpersonal
relations. High scorers are likely to be very sensitive to the slights of others, have a
neurotic need to be liked and accepted, and a fear of object loss. A sample item for IA is,
If someone dislikes me, I will always try harder to be nice to that person. The EGC
subscale measures three attitudes toward relationships: mistrust of others motivations;
others exist only in relation to oneself; and others are to serve ones own self-centered
aims. Bell et al. (1986) state, high scorers may have a self-protective and exploitive
attitude and be intrusive, coercive, and demanding (p. 739). A sample item of EGC is,

90
Sometimes I see only what I want to see. Elevated scores (> 60T) on ALN, IA, and
EGC suggest a lack of basic trust, painful interpersonal relations, and a tendency to
exploit others (Bell et al., 1986). The SI subscale measures shyness, nervousness,
uncertainty about how to act with the opposite sex, social isolation, and unsatisfactory
sexual adjustment. A sample item of SI is, I usually end up hurting those close to me.
Unusually low scores (< 40T) reflect gregarious and superficial confidence while
elevated scores (> 60T) may indicate an individual who is reluctant to engage
emotionally with others.
Subscales of the BORI (Bell, 1995; Bell et al., 1986) were determined through
factor analysis. Cronbachs Coefficient Alpha and Spearman-Brown split-half reliability
coefficients for each subscale respectively, were ALN = .90, .90; IA = .82, .81; EGC =
.78, .78; and SI = .79, .82. Test-retest reliability for 4 weeks and 13 weeks respectively,
for each subscale were ALN = .88, .81; IA = .73, .67; EGC = .90, .65; and SI = .58, .77.
Additionally, Bell et al. (1986) noted that Pearson correlations between the four object
relations subscales and the Marlowe-Crowne Social Desirability Scale (Crowne &
Marlowe, 1960) were nonsignificant. In other words, the BORI appears to be free of
social desirability response bias. However, Bell (1995) reports that although the BORI
has been shown to be free of favorable self-representation bias (Bell, et al., 1985; Crowne
& Marlowe, 1960), it is vulnerable to purposeful positive or negative self-report (p. 9).
For restricted copyright reasons, the BORI does not appear in an appendix. It is available
from Western Psychological Services at 310-478-2061 or www.wpspublish.com.
The Parentification Questionnaire (PQ) (see Appendix G). The PQ is a self-report
questionnaire measuring subjective patterns of care-taking responsibilities in childhood
(Sessions & Jurkovic, 1986). The PQ is comprised of 42 items (0-42 score range)

91
measuring care-taking of an emotional and physical nature (e.g., At times I was the only
one my mother/father could turn to, and I was frequently responsible for the physical
care of some member of my family, i.e., washing, feeding, dressing, etc.). Participants
are asked to choose true or false as each item pertains to them. Wolkin (1984)
reported an overall mean of 21.10 (SD = 6.95) for the normative sample (N = 359
undergraduates). Sessions and Jurkovic (1986) state the higher the score, the higher the
degree of parentification (no cutoff score was provided).
Wolkin (1984) found a Spearman-Brown split-half reliability of .85 and
Coefficient Alpha of .83 (N = 359). Test-retest reliability of .86 over a two-week period
was found with a group of undergraduates (N = 42) (Burt, 1986). Convergent validity for
the PQ indicates scores on this instrument are related to predicted variables such as lack
of differentiation from family of origin, choice of care-taking profession, features of
depression, and ambivalence about dependency needs (Burt, 1986; Goglia, 1982;
Sessions, 1986; Wolkin, 1984). Additionally, higher scores of parentification have been
found in children of alcoholics (Goglia et al., 1992).
The Narcissistic Injury Scale (NIS) (see Appendix H). The NIS is a self-report
measure designed to measure narcissistic injury. The NIS was developed by Slyter
(1989) and is designed to measure key aspects of narcissistic injury: restriction of affect,
grandiosity, depression, perceptions of parent-child relationship, and feelings about the
self. The instrument is scored by summing the ratings (possible 38-228); higher scores
indicate a higher incidence of narcissistic injury (no cutoff score was provided) (Slyter,
1989). Example items include I feel constricted, I have an amazing ability to perceive
the needs of others who are important to me, I suffer from depression at times, My
parents saw me as the person I really was, and I have the sense of what my needs are.

92
Slyter (1989) started with 130 items and used a 6-point Likert scale ranging from
definitely most uncharacteristic of you (1) to definitely most characteristic of you (6). A
pilot study using 130 items (N=99) yielded a coefficient alpha of .88. The item pool was
reduced to 50 items, 40 measuring the construct and 10 included to reduce response bias.
The final 50 items were chosen for their ability to discriminate the top and bottom 25% of
the total scores. Two of the final 40 items were eliminated because of multicollinearity.
Licht (1995) defined multicollinearity in the descriptive sense to indicate the degree to
which the predictors are intercorrelated (p. 45). It is assumed that Slyter (1989)
eliminated these two items because the intercorrelations were two high. The resulting
coefficient alpha using the resulting 38 items was .94. Finally, the NIS has been shown
to correlate positively with depression, grandiosity, and difficulties in coping and to
correlate negatively with self-esteem and parental bonding (Rios & Hill, 1993).
Zamostny, Slyter and Rios (1993) studied 250 undergraduates experience of past
trauma, psychological damage and adjustment to college. The mean score for this group of
subjects was 107.1 (SD = 28.6). A .94 coefficient alpha was reported for the 38-item NIS.
Factor loading of 38 items ranged of .28 to.75. Only four items loaded below .40.
Zamostny et al. (1993) concluded that the NIS reflects one general factor rather than
several underlying dimensions of narcissistic injury (p. 504). Additionally, the NIS
correlated with general psychopathology (r = .64).
The Rosenberg Self-Esteem Scale (RSE) (see Appendix I). The RSE is a well
known and utilized 10 item self-report questionnaire designed to measure self-esteem.
The RSE is scored on a 4 point (1-4) Likert scale from strongly agree to strongly
disagree. The range of scores is ten to 40. Scores are obtained by summing the
responses; higher scores indicate higher self-esteem (Rosenberg, 1965). Notably, the

93
author does not differentiate scores that indicate low, medium, or high self-esteem.
Sample items include: I feel that I have a number of good qualities, I wish I could
have more respect for myself, and at times I think I am no good at all.
The RSE was normed on 5,024 high school juniors and seniors from ten New
York schools. Rosenberg (1965) reported a coefficient of reproducibility of .92 and an
Coefficient Alpha of .80. Additionally, the RSE has a two-week test-retest reliability of
r = .85 (Silber & Tippett, 1965).
Ethical Judgment Scale (EJS) (see Appendix J). For this study, two vignettes
describing nonsexual dual relationships and two vignettes describing sexual dual
relationships were selected from the literature provided by leaders in this area of research.
Clinical vignettes one and two were provided by Simon (1999). Vignette number three
was found in Celenza (1991), and vignette four was provided by Pope (1991). Each
vignette was modified slightly to shorten the text. A five-point Likert rating scale was
devised indicating (1) completely ethical behavior, (2) somewhat ethical behavior, (3)
neither ethical nor unethical behavior, (4) somewhat unethical behavior, and (5)
completely unethical behavior. The range of scores is four to 20, with higher scores
indicating a higher cognitive recognition of ethical behavior. Respondents were
instructed to read the vignettes and rate the psychologist on a scale of 1 to 5 in regard to
the ethical nature of his or her behavior.
Rationale for the use of this instrument is twofold. One, these participants are
currently or previously licensed professional psychologists and are expected to be
instrument savvy. With a measure of ethical judgment, the researcher hoped to bypass
the motivation to present oneself in a positive light. Two, the EJS will provide a measure
of participants knowledge and application of the APA Ethical Code. Prior research

94
suggests that offending psychologists are aware of the ethical standards but choose to
ignore them, especially as they age and gain more years of professional practice (Borys &
Pope, 1989; Epstein et al., 1992; Hamilton & Spruill, 1999; Lamb et al., 1994; Rodolfa et
al., 1994; Stake & Oliver, 1991).
Open-ended questions (see Appendix K, N). At the end of the survey, Groups A
and B had a single sheet of paper with four open-ended questions (Appendix K).
Question one was, How would you describe yourself as a psychologist? Question two
was, Briefly describe what was happening in your life at the time of the ethical
violation. Question three was, What has the experience of being sanctioned been like
for you? Question four was, What would best help this researcher understand your
situation? Responses to these questions were separated into general themes. These
more personal written reactions added to the richness of the discussion section, and in the
spirit of investigation, helped to better understand the experience of being sanctioned for
an ethical violation. In addition, throughout chapter 5, anecdotal reports are offered.
At the end of the demographic questionnaire, Group C (control group) had one
optional question (Appendix N). The question was, Have you ever had any experience
with the sanctioning process for psychologists that youd like to share? Information
gained from this question was intended to screen the control group for being sanctioned
for an ethical violation and to provide another vantage point to the sanctioning process.

95
Research Questions and Statistical Analyses
Research question 1. Are there significant differences on demographic measures
for psychologists who engage in nonsexual dual relationships, psychologists who engage
in sexual dual relationships, and non-sanctioned psychologists? To assess the question,
Pearsons chi-square tests and frequency data were computed.
Research question 2. Are there significant differences on measures of object
relations (BORI, four subscales) for psychologists who engage in nonsexual dual
relationships, psychologists who engage in sexual dual relationships, and non-sanctioned
psychologists? To assess this question, a multivariate analysis of variance (MANOVA)
was computed.
Research question 3. Are there significant differences on measures of
parentification (PQ), narcissistic injury (NIS), self-esteem (RSE), and ethical judgment
(EJS) for psychologists who engage in nonsexual dual relationships, psychologists who
engage in sexual dual relationships, and non-sanctioned psychologists? To assess this
question, a multivariate analysis of variance (MANOVA) was computed.
Research question 4. To what extent do the demographic variables of cademic
training, theoretical orientation, history of childhood abuse, practice setting, partner status
and age at the time of the ethical violation predict scores on measures of object relations
(BORI, four subscales), parentification (PQ), narcissistic injury (NIS), self-esteem (RSE),
and ethical judgment (EJS)? To evaluate the contribution of the demographic variables
to the measures listed above, multiple linear regressions were conducted.
Research question 5. Is there a relationship between measures of object relations,
parentification, narcissistic injury, self-esteem, and ethical judgment for each group? To

96
address this question, Pearson product moment correlations were computed, one for each
group, using the variables BORI (four subscales, ALN, IA, EGC, SI), PQ, NIS, RSE, and
EJS.

97
CHAPTER 4
Results
The focus of this investigation was to compare the psychodynamic characteristics
present in psychologists who were sanctioned for engaging in nonsexual and sexual dual
relationships with clients with psychologists who have not been sanctioned. Additionally,
demographic variables that may contribute to the problem were examined. This study
attempted to answer the questions related to the unique childhood experiences of
therapists as they relate to nonsexual and sexual boundary violations.
The measures obtained of relevance to the research questions included two
demographic questionnaires, four standardized instruments, and a measure of ethical
judgment. Furthermore, the two groups of sanctioned psychologists received four openended questions, and the non-sanctioned psychologists (control group) received one
optional question. The qualitative open-ended questions and the optional question were
not included in the statistical analyses but were analyzed for general themes and used to
provide anecdotal evidence about the experience of the sanctioning process. The seven
instruments and their subscales were (a) a demographic questionnaire for the sanctioned
groups, (b) a demographic questionnaire for the control group, (c) the Bell Object
Relations Inventory (BORI), with four subscales: Alienation (ALN), Insecure Attachment
(IA), Egocentricity (EGC), Social Incompetence (SI), (d) the Parentification
Questionnaire (PQ), (e) the Narcissistic Injury Scale (NIS), (f) the Rosenberg SelfEsteem Scale (RSE), and (g) the Ethical Judgment Scale (EJS).

98
Research Question Results
The results of the five research questions are reported below and addressed
through the reported analyses using a .05 significance level. Means, standard deviations,
and ranges for research instruments are reported in Table 4. Of note, the Bell Object
Relations Inventory Inconsistent Responding Scale for all 59 participants indicated that
responses were given in a consistent manner.
Research Question 1. This question sought to determine if there are differences in
demographic characteristics of the participants. A set of Pearsons chi-square tests was
used to compare observed and expected frequencies of group membership (nonsexual
dual relationship group, sexual dual relationship group, control group) by each of the
demographic variables separately (participant gender, academic training, theoretical
orientation, emotional abuse, nonsexual physical abuse, sexual abuse). Findings from
these analyses revealed one significant association of group membership by gender, 2 (2,
N = 59) = 10.85, p < .01. Thus the distributions across gender were significantly
different. Specifically, in both sanctioned groups there were more males than females.
Total frequencies for the 3 (group membership) x 2 (gender) contingency table are shown
in Table 5. Of note, the gender distribution of the control group was similar but not
identical to the total American Psychological Association membership. That is, the
control consisted of 40% males and 60% females, whereas, the American Psychological
Association membership consists of 51% males and 49% females (A. Berger, personal
communication December 13, 2001).
A second set of Pearsons chi-square tests was used to compare observed and

99
Table 4
Means, Standard Deviations, and Ranges for Research Instruments
Nonsexual Dual Relationship Group

Sexual Dual Relationship Group

Control (nonsanctioned group)

SD

Range

SD

Range

SD

Range

Alienation

46.8

7.2

35 61

47.9

7.2

34 60

43.9

5.0

38 - 55

Insecure Attachment

43.6

6.9

30 - 59

43.4

8.1

30 61

38.6

5.9

30 - 48

Egocentricity

41.9

6.5

31 62

44.2

6.5

30 53

39.1

4.9

30 - 49

Social Incompetence

46.4

8.9

41 64

45.2

7.3

34 59

41.7

8.3

32 - 60

PQb

16.8

8.4

5 32

16.7

8.0

3 33

11.7

7.3

3 - 30

NISc

96.4

25.7

37 132

95.7

26.9

52 152

79.7

14.7

58 - 113

RSEd

35.5

3.5

27 40

34.4

4.3

22 40

38.8

1.6

35 - 40

EJSe

19.1

1.6

14 20

18.4

2.2

11 20

19.5

0.9

17 - 20

Measures
BORIa (T-scores)

Note1. aBORI = Bell Object Relations Inventory, bPQ = Parentification Questionnaire, cNIS = Narcissistic Injury Scale,
d

RSE = Rosenberg Self Esteem Scale, eEJS = Ethical Judgment Scale.

Note 2. On the BORI subscales, elevations > 60T suggest pathology. For the PQ, NIS, RSE, and EJS respective authors report higher scores
indicate higher levels of parentification, narcissistic injury, self-esteem, and ethical judgment. No further quantitative descriptors were
provided.

100
Table 5
Group Membership X Demographic Variable Contingency Table
Demographic

Group Membership
____________________________________________

Variable

Group Aa

Group Bb

Group Cc

Expected

13.2

12.6

13.2

Observed

14

17

08

Expected

6.8

6.4

6.8

Observed

06

02

12

Participant Genderd
Male

Female

Note. aGroup A = nonsexual dual relationship group, bGroup B = sexual dual

relationship group, cGroup C = control group.
d

gender = 2 (2, N = 59) = 10.85, p <.01.

101
expected frequencies of the sanctioned group members (nonsexual dual relationship and
sexual dual relationship groups) by each of the demographic variables (working setting,
partner status, client gender, DSM-IV diagnosis). Findings from these analyses revealed
one significant association of group membership by client gender, 2 (1, N = 39) = 4.23,
p < .05. Thus, the distributions across gender were significantly different. Specifically,
in both sanctioned groups there were more female client victims than male client victims.
Total frequencies for the 2 (sanctioned group membership) x 2 (client gender)
contingency table are shown in Table 6. Moreover, two significant associations were
found between group membership and the demographic variables listed above.
Descriptive statistics on the demographic characteristics common to all participants were
computed and are presented in Table 7. Descriptive statistics on the demographic
characteristics pertinent to the sanctioned psychologists are presented in Table 8.
Descriptive statistics on the demographic characteristics of client victims are presented in
Table 9.
As seen in Table 7, a total of 59 psychologists participated in the study. Of the
participants, 39 were male, and 20 were female. There were 14 males (70%) and 6
females (30%) in the nonsexual dual relationship group. There were 17 males (90%) and
2 females (10%) in the sexual dual relationship group. The control group had eight male
(40%) and 12 female (60%) participants.
Interestingly, 60% (n = 12) of the participants in the nonsexual dual relationship
group were sanctioned for boundary violations consisting of nonerotic physical contact
and excessive or inappropriate self-disclosure. Upon closer examination, males were
three times more likely than females to be sanctioned for nonerotic physical contact and
inappropriate or excessive self-disclosure.

102
Table 6
Group Membership X Client Gender Contingency Table
Demographic

Group Membership
____________________________________________
Group Aa

Group Bb

Expected

2.1

1.9

Observed

04

00

Expected

17.9

17.1

Observed

16

19

Variable
Client Genderc
Male

Female

Note. aGroup A = nonsexual dual relationship group, bGroup B = sexual dual

relationship group.
c

gender = 2 (1, N = 39) = 4.23, p < .05.

103
Table 7
Demographic Characteristics of the Participants (N = 59), by Group
Group A
(Nonsexual)

Group B
(Sexual)

Group C
(Control)

20-29 years

30-39 years

02

10

40-49 years

04

20

03

15.8

06

30

50-59 years

12

60

08

42.1

09

45

60+ years

04

20

08

42.1

03

15

Male

14

70

17

89.5

08

40

Female

06

30

02

10.5

12

60

Counseling

05

25

08

42.1

08

40

Clinical

14

70

11

57.9

12

60

Psy.D.

01

05

00

00

00

00

Characteristic
Current Age

Gender

Academic Training

(table continues)

104
Table 7 (continued)

Characteristic

Group A
(Nonsexual)

N
Theoretical Orientation

Group B
(Sexual)

Group C
(Control)

Psychoanalytic/
dynamic

07

35

05

26.3

03

15

Cognitive

05

25

03

15.8

05

25

Humanistic

04

20

01

05.3

01

05

Family Systems

00

00

02

10.5

02

10

Eclectic

04

20

08

42.1

09

45

Behavioral

00

00

00

00

00

00

Other

00

00

00

00

00

00

Childhood Abuse Experience

Emotional

06

30

09

47.4

08

40

Physical

02

10

05

26.3

01

05

Sexual

02

10

05

26.3

01

05

Note 1. Sanctioned participants age range at the time of the ethical violation was 40 to 65 years
with a mean of 45.6 years (SD = 6.5). Male client victims had an age range from 40 to 47 years
with a mean of 42 years (SD = 3.36). Female client victims had an age range from 15 to 50
years with a mean of 33.5 years of age (SD = 7.9).

105
Table 8
Demographic Characteristics Pertinent to Sanctioned Participants (N = 39)
Group A
(Nonsexual)

Group B
(Sexual)

Supervision

12

28.6

07

18.0

Probation

08

19.1

07

18.0

Loss of licensure

04

09.5

08

20.5

Education

06

14.3

05

13.0

Reprimand

06

14.3

01

02.5

Treatment

02

04.8

04

10.3

Psychological
Evaluation

01

02.3

04

10.3

Monetary fine

02

04.8

02

05.0

Censure

01

02.3

01

02.5

Stipulated
resignation

00

00

00

00

Cease/desist order

00

00

00

00

Private practice

15

75

15

78.9

Group practice

01

05

01

05.3

Characteristic

Type of Sanction(s) Received

Work Setting at the

time of violation

(table continues)

106
Table 8 (continued)
Group A
(Nonsexual)

Group B
(Sexual)

University
Counseling Ctr.

00

00

01

05.3

Faculty member

01

05

00

00

Community M.H.

00

00

01

05.3

Federal Prison

00

00

01

05.3

Veterans Hosp.

00

00

00

00

Other

03

15

00

00

Married/coupled

15

75

13

68.4

Single/divorced
/separated

05

25

06

31.6

Characteristic

Partner status at the

time of violation

107
Table 9
Gender and Diagnostic Impression(s) of Client Victims, by Group (N = 39)
Group A
(Nonsexual)

Group B
(Sexual)

Male

04

20

00

00

Female

16

80

19

100

Borderline PDa

11

55

10

52.6

Alcohol addiction

01

05

02

10.5

Paranoid PDa

02

10

00

00

Narcissistic PDa

02

10

00

00

PDa, NOS

01

05

01

5.3

Histrionic PDa

01

05

00

00

Post traumatic
stress disorder

01

05

00

00

Depression

00

00

01

5.3

Other

01

05

04

21.1

Characteristic

Gender of Client Victim

Diagnostic Impression
of Client Victim

Note 1. aPD = Personality Disorder

108
Current age of all 59 participants ranged from 30 to over 60 years (the exact age
was not measured). Exact age of the sanctioned participants at the time of the ethical
violation was measured and ranged from 35 to 65 years with a mean of 45.6 years (SD =
6.5). For the nonsexual dual relationship group, female participants age range at the
time of the ethical violation was 36 to 52 years with a mean of 44.1 years (SD = 6.3). In
the sexual dual relationship group, female participants age range at the time of the
ethical violation was 38 to 45 years with a mean of 41.5 years (SD = 4.9). Male
participants age range at the time of the ethical violation for the nonsexual dual
relationship group was 35 to 53 years with a mean of 44.4 years (SD = 4.5) and for the
sexual dual relationship group, was 38 to 65 years with a mean of 47.7 years (SD = 7.8).
All respondents (100%) possessed a doctoral degree. Of the sanctioned groups,
95% (n = 38) received their degrees in a clinical psychology (n = 25, 64%) or counseling
psychology program (n = 13, 33%). These percentages are similar to the ratio of current
American Psychological Association members who have received their degrees in
clinical psychology and counseling psychology. Currently, 68% of the members of the
American Psychological Association have their degrees in clinical psychology and 32%
have a degree in counseling psychology (A. Berger, personal communication, December
13, 2001). The control group reported 60% (n = 12) in clinical psychology and 40%
(n = 8) received their degrees in counseling psychology.
As may be noted in Table 7, over one-third of the participants (n = 7) in Group A
reported their theoretical orientation as psychodynamic with eclectic, family systems,
humanistic, and cognitive representing the other major theoretical orientations of the
participants. In Groups B and C, 42.1% and 45% respectively, endorsed eclecticism as
their theoretical orientation.

109
Close to 40% of the entire sample (n = 23) reported the experience of childhood
emotional abuse, six in the nonsexual dual relationship group, nine in the sexual dual
relationship group, and eight in the control group. Eight participants (14%) reported
childhood physical abuse, two in the nonsexual dual relationship group, five in the sexual
dual relationship group, and one in the control group. Eight participants (14%) reported
childhood sexual abuse, two from the nonsexual dual relationship group, five from the
sexual dual relationship group, and one from the control group. Broken down by groups,
40% of the nonsexual dual relationship participants, 53% of the sexual dual relationship
participants, and 40% of the control group participants reported some form of childhood
abuse. (Some participants endorsed more than one kind of childhood abuse.)
Analyzing these demographics further, it is noteworthy that for the nonsexual dual
relationship group, participants were equally as likely to have been emotionally abused
by their mother or mother figure as they were by their father or father figure. Of the two
participants in this group that reported nonsexual physical abuse, both reported the
perpetrator to be their father or father figure. Sexual abuse was reported to have been
perpetrated against two participants by a non-relative. Of those participants that reported
emotional and nonsexual physical abuse in the sexual dual relationship group, 100%
endorsed a parent or parent figure as the perpetrator. Specifically, for emotional abuse,
mother or mother figure was endorsed as the perpetrator in 64% of the cases. Nonsexual
physical abusers were about equally mother or mother figures and father or father figures
(n = 2 mother or mother figure, n = 3 father or father figure). Sexual abuse was
reported to be perpetrated against four participants by a non-relative and for one
participant by both another family member and a non-relative.

110
The participants in the two sanctioned groups received varying sanctions. As may
be noted in Table 8, in descending order of frequency, the sanctions were supervision,
probation, loss of licensure, education, reprimand, treatment, evaluation, monetary fine,
and censure. Almost one-fourth of the participants received the sanction of a supervision
requirement (n = 19, 23.5%). Interestingly, 20.5% (n = 8) of the psychologists
sanctioned for engaging in a sexual dual relationship lost their license, and almost as
many (n = 7) were put on probation. For the psychologists sanctioned for engaging in a
nonsexual dual relationship, supervision was the most common sanction
(n = 12, 28.6%).
At the time of the ethical violation, most of the sanctioned psychologists (77%)
worked exclusively in private practice, while other participants reported working in a
group practice, university counseling center, community mental health center, federal
prison, or as a university faculty member. At the time of the ethical violation most of the
sanctioned participants (n = 28, 71.8%) were married and ranged in age from 35 to 65
years with a mean of 45.6 years of age (SD = 6.5). Exploring this demographic further,
at the time of the ethical violation 75% of the nonsexual group were married, and 68% of
the sexual dual relationship group were married. However, in the second open-ended
question (Briefly describe what was happening in your life at the time of the ethical
violation), 25% of the participants in the nonsexual dual relationship group and 53% of
the sexual dual relationship group reported experiencing the loss of a significant
relationship at the time of the ethical violation.
As can be seen in Table 9, there were some male client victims (n = 4, 10.3%)
who, incidentally, were all victims of nonsexual dual relationships by female
psychologist offenders. Notably, all four of these female offending psychologists

111
described the male client with whom they violated nonsexual boundaries as character
disordered (e.g., narcissistic, paranoid, and borderline). The two female offenders who
engaged in a nonsexual dual relationship with a female reported both female client
victims as character disordered. While only one of these six participants was
experiencing a loss of a significant other at the time, three of the six did endorse
experiencing childhood emotional abuse perpetrated by their father or father-figure.
Not surprisingly, most client victims were female (n = 35, 89.7%). Male client
victims had an age range from 40 to 47 years with a mean of 42 years (SD = 3.36).
Female client victims had an age range from 15 to 50 years with a mean of 33.5 years of
age (SD = 7.9). The most common diagnostic impression given to these female clients
by the sanctioned psychologists was Borderline Personality Disorder (n = 21, 55.2%).
Research Question 2. Are there significant differences on measures of object
relations (BORI, four measures) for psychologists who engaged in nonsexual dual
relationships, psychologists who engaged in sexual dual relationships, and nonsanctioned psychologists? To assess this question, a multivariate analysis of variance
(MANOVA) was computed.
The independent variable was group membership (Group A = nonsexual dual
relationship, Group B = sexual dual relationship, and Group C = non-sanctioned
psychologists). The dependent variables were the BORI subscales, ALN, IA, EGC, and
SI. With regard to the BORI subscales (ALN, IA, EGC, SI), the MANOVA yielded a
nonsignificant Wilks Lambda, F(8, 106) = 1.69, p = .107. The means and standard
deviations of each subscale and the results for the multivariate analysis of variance are
reported in Table 10. These results indicated that participants in the nonsexual and
sexual

112
Table 10
Means, Standard Deviations, and Multivariate Analysis of Variance Results for the Bell
Object Relations Subscales (dependent variable) by Group Membership (independent
variable) (n = 59)
Dependent

NonSex DRa
__________

Sexual DRb
_________

Controlc
________

Variable

SD

SD

SD

BORId
ALNe

46.8

7.2

47.9

7.2

43.9

5.0

IAf

43.6

6.9

43.4

8.2

38.6

5.9

EGCg

41.9

6.6

44.2

6.5

39.1

4.9

SIh

46.4

8.9

45.3

7.3

41.7

8.3

Overall MANOVA: Wilks Lambda = .78, F(8, 106) = 1.69, p > .05
Note 1. an = 20, bn = 19, cn = 20, dBORI = Bell Object Relations Inventory, eALN =
Alienation, fIA = Insecure Attachment, gEGC = Egocentricity, and hIS = Social
Incompetence.
*p < .05. **p < .01.
Note 2. Bell (1995) reported a subscale score above the 85th percentile (60T) as
pathological for that subscale.

113
dual relationship and the control did not significantly differ on scores of object relations.
Specifically, the groups did not differ on indices of alienation, insecure attachment,
egocentricity, and social incompetence as measured by the BORI.
Research Question 3. Are there significant differences on measures of
parentification (PQ), narcissistic injury (NIS), self-esteem (RSE), and ethical judgment
(EJS) for psychologists who engage in nonsexual dual relationships, psychologists who
engaged in sexual dual relationships, and non-sanctioned psychologists? To assess this
question, a multivariate analysis of variance (MANOVA) was computed.
The independent variable was group membership (Group A = nonsexual dual
relationship, Group B = sexual dual relationship, and Group C = non-sanctioned
psychologists). The dependent variables were scores on the PQ, NIS, RSE, and EJS.
This MANOVA yielded a significant main effect for group membership, Wilks Lambda,
F(8, 106) = 2.92, p = .006. Component analyses of variance (ANOVAs) were computed
to determine which dependent measures contributed to this significant difference between
the three groups. The means, standard deviations, and results for theanalyses of variance
and multivariate analysis of variance are reported in Table 11. As may be noted there,
two of four component analyses yielded significant findings, the Narcissistic Injury Scale
(NIS), F(2, 56) = 3.34, p = .04 and the Rosenberg Self-Esteem Scale (RSE), F(2, 56) =
9.12, p < .001. Differences on the Parentification Scale (PQ) and Ethical Judgment Scale
(EJS) were nonsignificant. Post hoc analyses were conducted using the Fishers Least
Squared Differences (LSD) test to control for Type I error and to determine which groups
differed from one another.

114
Table 11
Analysis of Variance and Multivariate Analysis of Variance Results for Group
Membership (independent variable) on the Four Dependent Variables of Scores on the
NIS, PQ, RSE, and EJS (n = 59)
Dependent

NonSex DRa Sexual DRb

__________ _________

Controlc
________

Variable

SD

SD

SD

df

NISd

96.4

25.7

95.7

26.9

79.7

14.7

2, 56

3.34*

PQe

16.8

8.4

16.7

8.01 11.7

7.33

2, 56

2.75

RSEf

35.5

3.5

34.4

4.4

38.8

1.6

2, 56

9.12**

EJSg

19.0

1.6

18.4

2.3

19.5

.94

2, 56

1.82

Overall MANOVA: Wilks Lambda = .67, F(8, 106) = 2.92, p < .01
Note. aDR = Nonsexual Dual Relationship Group (n = 20), bDR = Sexual Dual
Relationship Group (n = 19), cControl = Control Group (n = 20), dNIS = Narcissistic
Injury Scale, ePQ = Parentification Questionnaire, fRSE = Rosenberg Self Esteem Scale,
and gEJS = Ethical Judgment Scale.
*p < .05. **p < .01.

115
For the significant finding for NIS (F(2, 56) = 3.34, p = .04), the LSD test indicated that
(a) the sexual and nonsexual dual relationship groups had higher scores on this
instrument than the control group (p < .05), and (b) the sexual and nonsexual dual
relationship group scores on this instrument did not differ from one another. For the
significant finding for RSE (F(2, 56) = 9.12, p < .001), the LSD test indicated that (a) the
sexual and nonsexual dual relationship groups had significantly lower scores on this
instrument than the control group (p < .05), and (b) the sexual and nonsexual dual
relationship group scores on this instrument did not differ from one another.
Thus, participants in the sexual and nonsexual dual relationship groups scored
higher on NIS and lower on RSE than the control group (there were no differences
between the sexual and nonsexual dual relationship groups on these two measures). For
these two groups, it appears that they experienced a greater amount of narcissistic injury
in childhood and have a lower level of self-esteem than the control group.
Research Question 4. To what extent do the demographic variables of academic
training, theoretical orientation, history of childhood abuse, practice setting, partner status
and age at the time of the ethical violation predict scores on measures of object relations
(BORI, four measures), parentification (PQ), narcissistic injury (NIS), self-esteem (RSE),
and ethical judgment (EJS)? To evaluate the contribution of the demographic variables
to the measures listed above, multiple linear regressions were conducted.
Prior to conducting the analyses for the sanctioned groups, only demographic
variables of relevance and interest were considered. Thus, predictor variables were split
into two groups of four. The first group of predictors included demographic variables
deemed relevant as predictors because of their correlation with the criterion variables:
emotional abuse (EA), nonsexual physical abuse (PA), sexual abuse (SA), and age at the

116
time of the ethical violation (AV). The second group of predictors was chosen because
prior research has suggesting several demographic variables may be of interest with
sanctioned psychologists: academic training (AT), theoretical orientation (TO), partner
status (PS), and work setting (WS). Client demographic variables were not considered
for analysis because the focus of this investigation is on sanctioned psychologists.
Correlations between the demographic variables of interest and all measures for the
sanctioned groups are presented in Table 12.
Multiple regression analyses examined which of the predictors or combination of
predictors contributed to the prediction and understanding of the eight criterion variables.
These eight criterion variables were scores on the BORI subscales (ALN, IA, EGC, SI),
PQ, NIS, RSE, and EJS.
In these regression analyses for the sanctioned groups, the predictor variables
were academic training (coded counseling psychology = 1, clinical psychology = 2,
as shown in Question 3 in Appendix E), theoretical orientation (coded psychodynamic
= 1, other = 2, as shown in Question 4 in Appendix E), childhood emotional abuse
(coded yes = 1, no = 2, as shown in Question 5 in Appendix E), childhood nonsexual
physical abuse (coded yes = 1, no = 2, as shown in Question 5 in Appendix E),
childhood sexual abuse (coded yes = 1, no = 2, as shown in Question 5 in Appendix
E), work setting at the time of the ethical violation (coded individual private practice =
1, other = 2, as shown in Question 8 in Appendix E), partner status at the time of the
ethical violation (coded single/divorce/separated = 1, married/coupled = 2, as shown
in Question 9 in Appendix E), actual age at the time of violation (as reported in Question
10 in Appendix E), and DSM-IV client diagnostic impression (coded Axis I diagnosis
= 1, Axis II diagnosis = 2, as shown in Question 13 in Appendix E).

117
Table 12
Correlational Data for Research Instruments/Subscales and Demographic Variables
For the Sanctioned Groups (n = 39)
Demographic Variables
Instruments

and scales

EA

PA

SA

AV

AT

TO

PS

WS

ALNb

.177

.00

-.407* .156

.035

-.047 .038

-.002

IAc

.372* .303

.013

.076

.079

-.007 .243

-.228

EGCd

.270

.337* .007

.094

-.086 .152

SIe

.529** .277

BORIa

-.073 -.221 .045

PQf

.635** .631** .168

NISg

.641** .296

RSEh

-.396* -.285 .135

.126

EJSi

.319* .291

-.400* .120

-.025 .280

-.197 -.070 -.025 .039

-.205 -.191 .093

.291

.029

.205

-.190 .234
.233

.091
-.045
.077
-.041

-.260 .032

-.178 -.258 .169

Note. aBORI = Bell Object Relations Inventory, bALN = Alienation, cIA = Insecure
Attachment, dEGC = Egocentricity, and eIS = Social Incompetence, fPQ = Parentification
Questionnaire, gNIS = Narcissistic Injury Scale, hRSE = Rosenberg Self Esteem Scale,
i

EJS = Ethical Judgment Scale

Abbreviations: EA = Emotional Abuse, PA = Nonsexual Physical Abuse, SA = Sexual

Abuse, AV = Age at Ethical Violation, AT = Academic Training, TO = Theoretical
Orientation, PS = Partner Status during Ethical Violation, WS = Work Setting
*p < .05. **p < .01.

118
Regression analyses for the control group included the predictor variables of
academic training (coded counseling psychology = 1, clinical psychology = 2, as
shown in Question 3 in Appendix N), theoretical orientation (coded psychodynamic =
1, other = 2, as shown in Question 4 in Appendix N), childhood emotional abuse
(coded yes = 1, no = 2, as shown in Question 5 in Appendix N), childhood nonsexual
physical abuse (coded yes = 1, no = 2, as shown in Question 5 in Appendix N), and
childhood sexual abuse (coded yes = 1, no = 2, as shown in Question 5 in
Appendix N).
The stepwise regression method was used for these analyses. The stepwise
method was chosen because the variable with the highest correlation with the criterion is
added first, and variables are removed that are no longer making a significant
contribution (Howell, 1992). This method was chosen because of the entry and removal
criteria and the authors intent to use predictors with the strongest relations to criterion
variables. Additionally, the stepwise regression method is considered as probably the
best regression method (Howell, 1992), and as the surest path to the best prediction
equation (Tabachnick & Fidell, 1996). Prior to computing the regression analyses,
demographic variables with minimal correlations with the dependent variables were
eliminated.
Nonsexual dual relationship group. Table 13 displays results of the multiple
regression analyses for both sets of predictors for the nonsexual dual relationship
group. For the first set of predictors (EA, PA, SA, and AV), multiple regression
analysis for Social Incompetence (SI) eliminated three independent variables (emotional
abuse, sexual abuse, and age at the time of violation) resulting in one model which

119
Table 13
Summary of Nonsexual Dual Relationship Groups Multiple Regression Analyses for
Demographic (Predictor) Variables on the Dependent (Criterion) Variables

Multiple Regression Analysis

Dependent Variable
and Predictor Variable

df

R2

BORI-SIa

4.60*

1, 18

.20

9.81

.451

12.66

.707

Emotional Abuse

11.06

.617

Physical Abuse

8.42

.410

31.64

.578

Physical Abuse
PQb

17.96**

1, 18

.50

Emotional Abuse
PQb

16.47**

NISc

9.03**

1, 18

1, 18

.66

.33

Emotional Abuse

Note. aBORI-SI = Bell Object Relations Inventory-Social Incompetence Subscale,

b

PQ = Parentification Questionnaire, cNIS = Narcissistic Injury Scale

*p < .05. **p < .01.

120
included nonsexual physical abuse (PA) as a significant predictor, R2 = .20, F(1, 18) =
4.60, p < .05. In this model, PA accounted for 20% of the variance in SI.
For Parentification (PQ), the multiple regression analysis produced two models
after elimination of two independent variables (sexual abuse and age at time of violation).
The first model included one predictor, emotional abuse (EA), R2 = .49, F(1, 18) = 17.96,
p < .01, which accounted for 49% of the variance in PQ. The second model included EA
and nonsexual physical abuse (PA), R2 = .66, F(1, 18) = 16.50, p < .01. These two
predictor variables (EA and PA) accounted for 66% of the variance in PQ. Multiple
regression analyses for criterion variables ALN, IA, and EGC with predictor variables
EA, PA, SA, and AV, yielded nonsignificant results. Likewise, multiple regression
analyses for criterion variables ALN, IA, EGC, SI, PQ, NIS, RSE, and EJS with the
second group of predictor variables, AT, TO, PS, and WS, yielded nonsignificant results.
The multiple regression analysis for Narcissistic Injury (NIS) resulted in the
elimination of three independent variables (nonsexual physical abuse, sexual abuse, and
age at the time of violation) resulting in one model that included emotional abuse (EA)
asa significant predictor, R2 = .33, F(1, 18) = 9.03, p < .01. Thus, EA accounted for 33%
of the variance in NIS. In summary, for the Nonsexual dual relationship group, multiple
regression analyses resulted in four models. The model for the BORI-SI included one
predictor, physical abuse. The model for the PQ included one predictor, emotional abuse.
A second model for the PQ included two predictors, emotional abuse and physical abuse.
Finally, the model for the NIS included one predictor, emotional abuse.
Sexual dual relationship group. Results for the multiple regression analyses for
both sets of predictors for the sexual dual relationship group can be seen in Table 14.

121
Table 14
Summary of Sexual Dual Relationship Groups Multiple Regression Analyses for
Demographic (Predictor) Variables on the Dependent (Criterion) Variables
Multiple Regression Analysis
Dependent Variable
and Predictor Variable

df

R2

BORI-ALNa

11.1**

1, 17

.40

Sexual Abuse
BORI-IAb

4.8*

1, 17

13.9**

1, 17

18.9**

1, 17

17.6**

1, 17

8.7**

1, 17

7.57

.470

9.69

.671

12.84

.725

37.89

.713

-.170

-.582

.50

Emotional Abuse
EJSf

-.629

.53

Physical Abuse
NISe

-9.97

.45

Emotional Abuse
PQd

.22

Emotional Abuse
BORI-SIc

.34

Age at the Time of

Violation

Note. aBORI-ALN = Bell Object Relations Inventory-Alienation Subscale, bBORI-IA =

Bell Object Relations Inventory-Insecure Attachment Subscale, cBORI-SI = Bell Object
Relations Inventory-Social Incompetence Subscale, dPQ = Parentification Questionnaire,
e

NIS = Narcissistic Injury Scale, fEJS = Ethical Judgment Scale

*p < .05. **p < .01.

122
Results of the multiple regression analysis for the first set of predictors (EA, PA, SA, and
AV) will be discussed first.
Multiple regression analysis for Alienation (ALN) produced one model and
yielded one predictor, sexual abuse (SA), R2 = .40, F(1, 17) = 11.10, p < .01. Sexual
Abuse (SA) accounted for 40% of the variance in ALN. As sexual abuse increases,
alienation decreases. Eliminated independent variables included nonsexual physical
abuse, emotional abuse, and age at the time of violation.
For Insecure Attachment (IA), multiple regression analysis produced one model
that yielded one predictor, emotional abuse (EA), R2 = .22, F(1, 17) = 4.82, p < .05).
Three independent variables were eliminated, nonsexual physical abuse, sexual abuse,
and age at time of violation. Emotional abuse accounted for 22% of the variance in IA.
One model was produced for Social Incompetence (SI) during the multiple
regression analyses. In this model, one predictor, emotional abuse (EA) (R2 = .45,
F(1, 17) = 13.9, p < .01), accounted for 45% of the variance in SI. Three independent
variables were eliminated during the analyses, nonsexual physical abuse, sexual abuse,
and age at time of violation.
The multiple regression analysis for Parentification (PQ) eliminated three
independent variables (nonsexual physical abuse, sexual abuse, and age at time of
violation) and produced one significant predictor, nonsexual physical abuse (PA),
R2 = .53, F(1, 17) = 18.90, p < .01. Thus, PA accounted for 53% of the variance in PQ.
The multiple regression analysis for Narcissistic Injury (NIS) produced one model
with one predictor, emotional abuse (EA) (R2 = .50, F(1, 17) = 17.60, p < .01. Three
independent variables were eliminated, nonsexual physical abuse, sexual abuse, and age
at time of violation. Thus, EA accounted for 50% of the variance in NIS.

123
Finally, multiple regression analysis for Ethical Judgment (EJS) eliminated three
independent variables (nonsexual physical abuse, emotional abuse, and sexual abuse) and
produced one model with one significant predictor, age at the time of violation (AV),
R2 = .34, F(1, 17) = 8.70, p < .01. Thus, 34% of the variance in EJS was accounted for
by AV. As age at the time of the ethical violation increases, scores on the ethical
judgment scale decrease.
Multiple regression analyses for criterion variables EGC and SE with predictor
variables PA, EA, SA, and AV, yielded nonsignificant results. Likewise, multiple
regression analyses for criterion variables ALN, IA, EGC, SI, NIS, PQ, RSE, and EJS
with the second set of predictor variables, AT, TO, PS, and WS, yielded nonsignificant
results.
In summary, for the Sexual dual relationship group, six multiple regression
analysis models emerged. The model for the BORI-ALN produced one predictor, sexual
abuse. The models for the BORI-IA, BORI-SI, and NIS all produced one predictor,
emotional abuse. The model for the PQ produced one predictor, physical abuse. Finally,
the model for the EJS produced one predictor, age at the time of violation.
Control group. Table 15 displays results of the multiple regression analyses for
the group of predictors for the control group. Multiple regression analysis for criterion
variables ALN, IA, EGC, SI, NIS, and SE were nonsignificant. Regression analyses for
PQ eliminated four independent variables (academic training, theoretical orientation,
nonsexual physical abuse, and sexual abuse) and produced one model with one
significant predictor, emotional abuse (EA), R2 = .26, F(1, 18) = 6.36, p < .05. Thus,
26% of the variance in PQ was accounted for by EA.

124

Table 15
Summary of Control Groups Multiple Regression Analyses for Demographic (Predictor)
Variables on the Dependent (Criterion) Variables
Multiple Regression Analysis
Dependent Variable
and Predictor Variable

df

R2

PQa

6.36*

1, 18

.26

Emotional Abuse
EJSb

10.70**
Physical Abuse

1, 18

7.46

.511

-2.60

-.611

.37

Note. aPQ = Parentification Questionnaire, bEJS = Ethical Judgment Scale

*p < .05. **p < .01.

125
One model was produced for the Ethical Judgment Scale (EJS) during the
multiple regression analyses. In this model, one predictor, nonsexual physical abuse
(PA) was significant, R2 = .37, F(1, 18) = 10.7, p < .01. In other words, PA accounted for
37% of the variance in EJS. Four independent variables were eliminated during the
analyses, academic training, theoretical orientation, emotional abuse, and sexual abuse.
Research Question 5. Is there a relation between measures of object relations,
parentification, narcissistic injury, self-esteem, and ethical judgment for each group? To
address this question, three sets of Pearson product moment correlations were computed,
one for each group, using the variables BORI (four subscales, ALN, IA, EGC, SI), PQ,
NIS, RSE, and EJS. Rationale for using three separate sets of correlations was founded
on a preliminary correlation analysis that combined all three groups together. These
correlations using all measures from all the groups resulted in virtually every instrument
yielding a significant correlation, thus no valuable information was gained.
Nonsexual dual relationship group. As shown in Table 16, the correlational
results of the aforementioned instruments and subscales for the nonsexual dual
relationship group yielded a significant relationship between ALN and SI, r(20) = .60,
p < .01 and ALN and NIS, r(20) = .62, p < .01. Thus, it appears that the greater the
experience of alienation, the greater the social incompetence and narcissistic injury.
For IA, two significant positive correlations and one significant negative
correlation were found. Specifically, a significant positive relationship occurred between
IA and SI, r(20) = .74, p < .01 and between IA and NIS, r (20) = .64, p < .01. Thus, it
appears that the greater the insecure attachment, the greater the experience of social
incompetence and narcissistic injury. A significant negative correlation occurred

126

Table 16
Intercorrelations of Research Instruments, Nonsexual Dual Relationship Group, N = 20
Measures

1. ALN

--

.44

.23

.60** .17

.62** -.33

--

.19

.74** .24

.64** -.55* -.02

--

.34

.33

.40

--

.41

.63** -.51* .20

--

.43

-.52* -.03

--

-.72** -.20

2. IA
3. EGC
4. SI
5. PQ
6. NIS
7. RSE
8. EJS

8
.06

-.60** -.08

--

.40
--

Note. 1 4 were scales from the Bell Object Relations Inventory; 5 was obtained from
the Parentification Questionnaire, 6 was obtained from the Narcissistic Injury Scale, 7
was obtained from the Rosenberg Self-Esteem Scale, and 8 was obtained from the Ethical
Judgment Scale
*p < .05. **p < .01.

127
between IA and RSE, r(20) = -.55, p < .01. It appears that the higher the insecure
attachment, the lower the self esteem.
For EGC, the correlational analysis yielded one significant negative correlation
with RSE, .r(20) = -.59, p < .01. Participants in the nonsexual dual relationship group
with greater egocentricity had lower self-esteem. Two significant correlations were
found with the SI subscale. There was a significant positive relationship between SI and
NIS, r(20) = .63, p < .01, and there was a significant negative relationship with SI and
RSE, r(20) = -.51, p < .05. Thus, higher social incompetence relates to high narcissistic
injury and lower self esteem. The PQ yielded a significant negative correlation with
RSE, r(20) = -.52, p < .05. It appears as the incidence of parentification increases, self
esteem decreases. Finally, the NIS also correlated negatively with RSE, r(20) = -.72, p <
.01. Similarly, as the incidence of narcissistic injury increases, self esteem decreases.
In summary, for the nonsexual dual relationship group, ALN and IA showed
significant positive correlations with SI and NIS. RSE was significantly negatively
correlated with IA, EGC, SI, PQ, and NIS. Thus, for this group, increases in alienation
and insecure attachment are related to increases in social incompetence and narcissistic
injury. Conversely, as insecure attachment, egocentricity, social incompetence,
parentification, and narcissistic injury increase, self esteem decreases.
Sexual dual relationship group. As shown in Table 17, for the sexual dual
relationship group, significant positive correlations were found for four variables in
relation to IA. These variables included EGC (r(19) = .50, p < .05), SI (r(19) = .64, p <
.01), PQ (r(19) = .48, p < .05), and NIS (r(19) = .68, p < .01). These correlations indicate
that increased insecure attachment was related to increased egocentricity, social
incompetence, parentification, and narcissistic injury.

128
Table 17
Intercorrelations of Research Instruments, Sexual Dual Relationship Group, N = 19
Measures

1. ALN

--

.16

.11

.44

-.14

.18

-.33

-.07

--

.50*

.64** .48*

.68** -.30

.05

--

.28

.55*

.18

-.10

--

.32

.63** -.38** .28

--

.56*

-.18

--

-.51* .30

2. IA
3. EGC
4. SI
5. PQ
6. NIS
7. RSE
8. EJS

-.08

--

.26

-.43
--

Note. 1 4 were scales from the Bell Object Relations Inventory; 5 was obtained from
the Parentification Questionnaire, 6 was obtained from the Narcissistic Injury Scale, 7
was obtained from the Rosenberg Self-Esteem Scale, and 8 was obtained from the Ethical
Judgment Scale
*p < .05. **p < .01.

129
The correlation performed on EGC showed a significantly positive relationship
with PQ, r(19) = .55, p < .05. Thus, as egocentricity increases, the rate of parentification
increases. For SI, the results yielded one significant positive correlation and one
significant negative correlation. SI was found to be significantly positively correlated
with NIS, r(19) = .63, p < .01. Specifically, as SI increased, NIS increased. Conversely,
SI was found to be negatively correlated with RSE, r(19) = -.38, p < .01. Thus, as SI
increased, RSE decreased. Said differently, as the rate of social incompetence increased,
the rate of narcissistic injury increased and the level of self esteem decreased.
PQ was found to be significantly positively correlated with NIS, r(19) = .56, p <
.05. Thus, for subjects who reported an increase of parentification, it appears they also
reported an increase of narcissistic injury. Finally, NIS was significantly negatively
correlated with RSE, r(19) = -.51, p < .05. This correlation reveals that as narcissistic
injury increases, self esteem decreases.
To summarize, for the sexual dual relationship group, insecure attachment
correlated significantly with egocentricity, social incompetence, parentification, and
narcissistic injury. Additionally, higher egocentricity was related to higher
parentification. Likewise, higher indices of social incompetence and parentification were
related to higher indices of narcissistic injury. Finally, a higher score on the narcissistic
injury scale correlated with a lower score on the self-esteem scale. Thus, for this group,
an increase in insecure attachment is related to increases in egocentricity, social
incompetence, parentification, and narcissistic injury. Similarly, increases in social
incompetence and parentification are related to an increase in narcissistic injury, and an
increase in narcissistic injury is related to a decrease in self esteem.

130
The control group. As shown in Table 18, four significant correlations occurred
between the aforementioned instruments for the control group of nonsanctioned
psychologists. ALN yielded two significant negative correlations. As ALN increased,
EGC and NIS decreased respectively (r(20) = -.51, p < .05, r(20) = -.51, p < .05). Thus, it
appears as the occurrence of alienation increases, egocentricity and narcissistic injury
decreases.
For IA, the correlation resulted in one significant positive relationship with SI
(r(20) = .74, p < .01). Said differently, the more insecurely attached, the more socially
incompetent the control group appeared to be. Finally, the correlation revealed a
significantly positive relationship between PQ and NIS (r(20) = .46, p < .05). Thus, as
parentification increases, so does narcissistic injury.
To summarize, the correlational analyses within the control group indices
revealed four significant relationships. An increase in alienation is related to a decrease
in egocentricity and narcissistic injury. Interestingly, recall that for the nonsexual dual
relationship group, an increase in alienation is related to an increase in narcissistic injury.
Thus, for the control group, higher scores on alienation were related to lower scores on
egocentricity and narcissistic injury, whereas, for the nonsexual dual relationship group, a
higher score on alienation was related to a higher score on narcissistic injury. Finally, for
the control group, an increase in insecure attachment is related to an increase in social
incompetence, and an increase in parentification is related to an increase in narcissistic
injury.

131
Table 18
Intercorrelations of Research Instruments, Control Group, N = 20
Measures

1. ALN

--

.07

-.51* .38

--

-.32
--

2. IA
3. EGC
4. SI
5. PQ
6. NIS
7. RSE
8. EJS

-.04

-.51* .28

-.19

.74** .07

.35

.02

-.19

-.40

.21

.20

.21

.38

--

.13

.07

-.002 -.16

--

.46*

.35

.21

--

.06

.02

--

.15
--

Note. 1 4 were scales from the Bell Object Relations Inventory; 5 was obtained from
the Parentification Questionnaire, 6 was obtained from the Narcissistic Injury Scale, 7
was obtained from the Rosenberg Self-Esteem Scale, and 8 was obtained from the Ethical
Judgment Scale.
*p < .05. **p < .01.

132
Analysis of open-ended questions. The sanctioned groups of psychologists
(Groups A and B) were given a separate sheet of paper in the questionnaire packet that
listed four open-ended questions. Those questions were, How would you describe
yourself as a psychologist; Briefly describe what was happening in your life at the time
of the ethical violation; What has the experience of being sanctioned been like for
you? and, What would best help this researcher understand your situation? There was
a 100% response rate for all four questions and responses were analyzed for recurrent
themes in the data. Specifically, the researcher taped each statement onto an index card
and sorted each statement according to content. As each similar statement was sorted,
themes began to emerge. The themes listed represent the categories with the most
responses.
As seen in Table 19, three themes for each question emerged from the data
provided by the nonsexual dual relationship group. Question one (How would you
describe yourself as a psychologist?) elicited three types of responses: positive selfstatements, statements regarding competency as a psychologist, and statements
describing their theoretical approach. Question two (Briefly describe what was
happening in your life at the time of the ethical violation.) revealed three common
themes: statements regarding stressful situational variables, statement reflecting stable
life variables, and the feeling of being overworked. Question three (What has the
experience of being sanctioned been like for you?) also evoked responses that could be
categorized into three themes: feelings of humiliation, feeling the sanctioning process
was difficult but positive, and descriptions of maltreatment from the Board of Psychology
who sanctioned them. Finally, question four (What would best help this researcher
understand your situation?) elicited three common response themes: an introspective

133
Table 19
Matrix of Linkages Between Open-ended Questions and Themes for the Nonsexual Dual
Relationship Group.
Themes
Question 1

Question 2

Question 3

Question 4

Positive Self statements:

caring, skilled, sensitive,
compassionate, verbal, insightful,
concerned, thoughtful, effective,
ethical, and competent
Situational Variables: At the time
my father had failing health and I
had remarried one year earlier;
my life had suddenly come apart
(my oldest daughter was
murdered and my wife developed
multiple sclerosis); I was in the
throes of coming out; my
husband had become increasingly
low functioning and abusive.
Humiliation: humiliating, it
undercut my trust in the
profession and in my clients; the
experience was nightmarish;
profoundly distressing and
shaming; more horrible than I can
describe; it was costly and
humiliating.

Introspective: my intense need to

help this patient seems to be
related to my narcissistic
identification in doing whatever
was necessary to helpmy
inability to say sorry, I cant help
you was highly activated; I
learned a great deal from the
experience; I was wrong, but
never bad; the education,
supervision, and therapy I
received during my probation
helped me significantly in this.

Competency: I always strive to be as

good a psychologist as I can be, I
rarely experience burnout; I aspire to
offer good psychological wisdom; I
am a better diagnostician than
therapist.
Stable Life Variables: I was
personally as happy and fulfilled as I
had ever been, married and happy
with the relationship, I was feeling
great having just graduated, the
practice was just beginning and we
were hiring part-time staff, I felt busy
all the time.
Difficult But Positive: it was difficult,
at first I was defensive and resistant
but once I accepted the process I felt
better and the process worked; I got
supervision for 2 years, it was
wonderful, I have stopped trying to
be helpful to so many people;
devastating (at first)Im more
aware of boundaries and uphold
them; humiliating, deeply troubling,
and yet an opportunity to figure out
what is my vulnerability; proved to
be a very meaningful and
empowering learning experience both
professionally and personally.
Blame the Client: I was set-up by a
sociopathic drug dealer and user who
had AIDS, understand that a
disgruntled ex-client can wreak havoc
with a professional practice when
they want revenge; the supervisee
was engaged in social gossipand
embellished her storythe Board
believed her; unless you have been
set-up, defamed, lied about by
perjurers, been a victim of a
malpractice insurance extortion scam
by a crooked lawyer and clients he
sent in to claim malpractice and
abuse, you couldnt begin to
understand what it has been like.

Theoretical Approach: I use

Gestalt Therapy, CBT, and
insight methods; I use a
developmental object-relations
approach, humanist, eclectic,
holistic (psyche + spirit + body).
Feeling Overworked: I was
raising 5 children with my wife
and had recently built a new
home, I was very busy and facing
challenges, I was professionally
isolated and working very hard,
emotionally over-committed and
edging into burn-out, I was CEO
of a clinic and working 80 hours a
week.
Maltreatment by the Board: the
reckless Board has defamed
methey denigrated me in every
possible wayand offered no
help, no guidance, and no
guidelines for rehabilitation; I
personally felt violated and
abandoned by the Board, who I
perceived was more interested in
the complainant than in fairness
to me; I experienced the behavior
of representatives of the Board as
insensitive, adversarial, and brutal
in nature; the Board did not
pursue the truth.
Blame the Board: the radical and
unquestioning consumer
advocate stance of the Board has
completely ruined my 20 year
reputation, when a complaint is
filed, you are guilty until proven
innocent; understand the desire of
various individuals to be punitive
in nature rather than constructive;
be aware that the Boards follow
administrative law not
constitutional law, the defendant
is guilty until proven innocent;
the Board never investigated me
in depth.

134
response indicating personal and professional growth, blame of the client who filed the
complaint, and blame of the Board of Psychology who sanctioned them.
As seen in Table 20, themes for each question emerged from the data provided by
the sexual dual relationship group. Question one (How would you describe yourself as a
psychologist?) elicited two types of responses: positive self-statements, statements
regarding competency as a psychologist. Question two (Briefly describe what was
happening in your life at the time of the ethical violation.) revealed three common
themes: statements regarding stressful situational variables, statements reflecting stable
life variables, and statements regarding personal problems. Question three (What has the
experience of being sanctioned been like for you?) also evoked responses that could be
categorized into three themes: feelings of devastation, feeling the sanctioning process was
difficult but positive, and descriptions of maltreatment from the Board of Psychology
who sanctioned them. Finally, question four (What would best help this researcher
understand your situation?) elicited three common response themes: a description of the
events that led to the violation, the emotional cost of being sanctioned, and descriptions
of maltreatment by the Board who sanctioned them.
Additional analyses. Responses to the four open-ended questions were
subcategorized by five-year increments. This was done to assess whether the overall tone
of the responses changed in any way with time. To the best judgment of the primary
researcher, no significant changes were noted. The only reference to how time may have
changed their views was in regard to their own self-worth. For example, at the time of
the sanction some participants described having low self-esteem versus presently

135
Table 20
Matrix of Linkages Between Open-ended Questions and Themes for the Sexual Dual
Relationship Group.
Themes
Question 1

Question 2

Question 3

Question 4

Positive Self statements:

caring, ethical, thoughtful;
mature, warm, caring, common
sense, good sense of humor;
experienced, bright, educated,
motivated to learn, accepting,
knowledgeable, empathic,
understanding and cautious in
todays litigious society.
Situational Variables: I was
having serious marital
difficulties; my father died and
my wife and son were in a serious
auto accident; my wife and I were
growing apart; my relationship
of 7 years ended; I lost my father,
experienced the death of my
mentor and my mother had
terminal cancer; my wife left me.
Devastation: it ended my career;
devastating over the course of its
9+ years duration; ten years of
anxiety, grief, and recurrent
depression; feeling a great
injustice, depression, pain in
every direction; hugely painful,
shameful, and humiliating; onset
of traumatic nightmare,
depression.

Descriptive Events: I entered

analysis after the clients
demands for specialness
accelerated, working through
narcissistic issues that allowed
me to violate boundaries; I lost
sight of how acquiescence would
be damaging to the client as well
as myself; we feel in love.

Competency: well trained, competent,

and very effective; excellent at
assessment, diagnosis, and treatment
planning; average as a therapist,
above average as a diagnostician,
assessment, and evalution; I still view
myself as well-trained and
knowledgeable; among the brightest
and best.
Stable Life Variables: I was very
busy, things were going well, my new
practice was growing; nothing special
or unusual, I was married for the first
time, no real problems on the job.

Difficult But Positive: it was

obviously an anxiety producing
experiencebut Ive grown from it; a
learning experience that changed my
focus in supervision and therapy; the
worst experience of my life, however,
it transformed my life and had a
tremendous impact on my
personalitythe adversity has had an
overall positive effect; gave me an
opportunity to be a much better
person, learned so much about me
and others; it was helpful, this was
handled quite well and the Board
members were sensitive and careful.
The Cost: my deepest regret lies in
the fact that I was ultimately
responsible for placing her in harms
way; I cant believe I could ever
really be forgiven; I have been unable
to obtain insurance despite being
licensed now (after 18years); my
error in professional judgment was
costly to everyone, I survived and am
forever changed.

Personal problems: I was

thinking with my emotions
rather than my head, I was acting
out personal issues with a client; I
didnt assume responsibility for
saying no; almost complete
focus on career; I would have to
say it was a combination of
stupidity, immaturity, role
confusion, and mid-life crisis.
Maltreatment by the Board:
sexually biased ultra-feminine
licensing board being non-caring,
non-understanding, and
manipulated by their own agendas
with total lack of regard for the
person; they were 100% punitive,
never asked anything that was not
prosecutory in nature; admitted
my wrongdoing and cooperated
and they turned around and used
information against me; I did not
receive justice from them; I had
no rights, I never got to tell my
version of what happened.
Maltreatment by the Board: there
simply was no due process, I
would have been better off if I
had committed a criminal act; the
Board never cared about me, the
client, or our child; my Board had
to be taught during the legal
process that borderlines
confabulate and grossly
exaggerate in their pathology; I
didnt feel the Board had any
sympathy or understanding that
they took away my livelihood.

136
experiencing positive self-esteem. In regard to experiencing the adjudication process,
some participants discussed how emotionally difficult it was initially but, as time passed,
they were able to regain a sense of self-esteem and see some value in the experience.
In summary, both sanctioned groups were similar in that the majority described
themselves using positive self-statements, believed themselves to be competent providers
of psychological services, described situational variables that contributed to their
unethical behavior, and believed the sanctioning experience was humiliating and
devastating but ultimately positive. The nonsexual dual relationship was prone to blame
the client and to describe being a victim of a vengeful client or sanctioning board. The
sexual dual relationship group appeared to express more remorse in describing the
emotional damage that was done to all involved. Both groups felt strongly that they were
maltreated by the licensing board.
The control group (Group C) was given an optional question at the end of the
demographic questionnaire, Do you have any experience with the sanctioning process
you would like to share? Three male participants answered this question and 17
participants did not answer this question. The three participants that responded to the
question wrote, I have provided psychological evaluations of psychologists being
investigated by the licensing board. These evaluations were requested by the board. I
was a member of the state ethics committee for several years, and once I was asked by
an attorney to testify as an expert witness for his client before the licensing board that
was considering revoking his license. After hearing details of the case, I declined, telling
the attorney in my opinion his clients license should be revoked. Thus it appears with
the exception of these three participants, the control group participants have not been
involved in any meaningful way with the sanctioning process.

137
Summary of Results
The purpose of this study was to examine and understand potential differences
between psychologists who have engaged in a nonsexual and sexual dual relationship and
psychologists who have not. Volunteer psychologists from across the United States
(N = 59) completed questionnaires concerning object relations, parentification,
narcissistic injury, self-esteem, and ethical judgment. Measures included a demographic
questionnaire, the Bell Object Relations Inventory (BORI) with four subscales of
alienation, insecure attachment, egocentricity, and social incompetence), the
Parentification Questionnaire (PQ), the Narcissistic Injury Scale (NIS), the Rosenberg
Self-Esteem Scale (RSE), the Ethical Judgment Scale (EJS), and four open-ended
questions regarding the experience of being sanctioned.
In regard to demographic characteristics, two significant differences were found
for the sanctioned groups. One, more males than females engaged in nonsexual and
sexual dual relationships and two, there were more female than male client victims.
These findings are consistent with the literature that has repeatedly established that more
males engage in dual relationships than females and, female clients are more likely to be
victims than male clients. Other notable demographic characteristics of the sanctioned
groups include a mean age range at the time of the ethical violation of 45.6 years, 77% of
the participants worked in private solo practice at the time of the ethical violation, and
25% of the nonsexual dual relationship group and 53% of the sexual dual relationship
group were experiencing the loss of a significant relationship at the time of the ethical
violation.
A multivariate analysis of variance revealed no significant differences between
group membership and the Bell Object Relations Inventory subscales. For these groups,

138
object relations did not appear to be impaired as their scores were not above the cutoff on
the Bell Object Relations Inventory. However, it is notable that the mean scores on each
subscale for the nonsexual and sexual dual relationship groups were higher than for the
control group, suggesting that participants in the dual relationship group reported more
problematic object relations than the control group, though not significantly different.
A multivariate analysis of variance revealed a significant main effect for group
membership and the remaining measures (PQ, NIS, RSE, EJS). Subsequent analyses of
variance revealed significant differences on the Narcissistic Injury Scale and Rosenberg
Self Esteem Scale. Post hoc tests revealed the nonsexual and sexual dual relationship
groups had significantly higher scores on the Narcissistic Injury Scale and significantly
lower scores on the Rosenberg Self Esteem Scale than the control group. Thus, the dual
relationship groups reported more narcissistic injury in childhood and lower self-esteem
than the control group.
Emotional, physical, and/or sexual abuse emerged as important predictors in the
multiple regression analyses for the dual relationship groups. For the nonsexual group,
the variables, emotional abuse and physical abuse were most potent. That is, emotional
abuse emerged as a predictor of parentification and narcissistic injury. The demographic
variables emotional abuse and physical abuse together predicted a significant amount of
variance on the Parentification Questionnaire. Analyses for the sexual dual relationship
group revealed that a history of emotional abuse is the most powerful predictor.
Emotional abuse predicted insecure attachment, social incompetence, and narcissistic
injury. Not surprisingly, the demographic variable sexual abuse emerged as a predictor
of alienation (as sexual abuse increased, alienation decreased) and the demographic
physical abuse predicted a significant amount of variance on the Parentification

139
Questionnaire. Finally, the demographic age at the time of violation emerged as a
predictor of the Ethical Judgment Scale (as age at the time of violation increased, scores
on the Ethical Judgment Scale decreased).
Multiple regression analyses for the control resulted in two significant findings.
Emotional abuse accounted for a significant amount of variance on the Parentification
Questionnaire, which was similar to the nonsexual dual relationship group, and physical
abuse predicted a significant amount of variance on the Ethical Judgment Scale.
Pearson product moment correlations were computed for each group to assess the
relationship between the measures. For the nonsexual dual relationship group, increases
in alienation and insecure attachment were related to increases in social incompetence
and narcissistic injury. Conversely, as insecure attachment, egocentricity, social
incompetence, and parentification, and narcissistic injury increased, self-esteem
decreased. For the sexual dual relationship group, insecure attachment correlated
significantly with egocentricity, social incompetence, parentification, and narcissistic
injury. Additionally, higher egocentricity was related to higher parentification. Higher
social incompetence and parentification were related to higher indices of narcissistic
injury. Finally, a higher score on the Narcissistic Injury Scale correlated with a lower
score on the Rosenberg Self Esteem Scale.
Correlational analyses for the control group revealed that an increase in alienation
was related to a decrease in egocentricity and narcissistic injury. While for the nonsexual
group, an increase in alienation was related to an increase in narcissistic injury. For both
the control group and the nonsexual dual relationship group, an increase in insecure
attachment was related to an increase in social incompetence. Additionally, for the

140
control group, an increase in parentification was related to an increase in narcissistic
injury.
Responses to the open-ended questions for the sanctioned groups were analyzed
for themes. The nonsexual dual relationship group used positive terms to describe
themselves and their competency as psychologists. In response to what was happening in
their lives at the time of the ethical violation, statements were elicited regarding stressful
situational variables, stable life variables, and the feeling of being overworked. In regard
to the sanctioning process, some participants described feelings of humiliation, others felt
the sanctioning process was difficult but positive, and some perceived maltreatment from
the sanctioning Board of Psychology. Finally, some participants wrote responses
indicating personal and professional growth, blame of the client who filed the complaint,
and blame of the Board of Psychology who sanctioned them.
The sexual dual relationship group described themselves with positive selfstatements and statements regarding competency as a psychologist. In regard to what
was happening in their life at the time of the ethical violation, statements describing
stressful situational variables, stable life variables, and personal problems emerged. The
sanctioning process for this group was similar to the nonsexual group in that many
participants described devastation and shame, the sanctioning process was difficult but
positive, and maltreatment from the Board of Psychology who sanctioned them. Finally,
some participants in this group provided descriptions of the events that led to the
violation, the emotional cost of being sanctioned, and detailed descriptions of perceived
maltreatment by the Board who sanctioned them.

141
CHAPTER 5
Discussion
The purpose of this study was to examine and to understand potential differences
between psychologists who engage in nonsexual and sexual dual relationships with those
psychologists who do not. Specifically, this study posed research questions related to the
impact of object relations, evidence of narcissistic injury, the incidence and prevalence of
parentification, level of therapist self-esteem, and ethical judgment. Importantly, this
research was undertaken to add to the empirical literature on dual relationships, to
enhance training and preventive efforts in this area during graduate training, and to
inform state ethical boards of the nature of this problem so proper remedial action can be
taken when dealing with a psychologist who has committed an unethical violation.
Instruments for this study were selected with the intent to gather information
about a variety of experiences that may pose as risk factors for psychologists who engage
in a dual relationship with a client. These instruments targeted (a) demographics, (b)
object relations, including four subscales, (c) parentification, (d) narcissistic injury, (d)
self esteem, (e) ethical judgment and, (f) the experience of being sanctioned. The
demographic questionnaire for the sanctioned groups was used to gather basic
demographic information, childhood experiences of abuse, information relating to the
ethical violation for which the participant was sanctioned, and information regarding the
client-victim. The sanctioned groups received four open-ended questions to record
participants experience of being sanctioned by their respective state board of

142
psychology. The demographic questionnaire for the control group gathered demographic
information, childhood experiences of abuse, and an optional question regarding whether
the participants had any experience with the sanctioning process.
What follows is a discussion and exploration of the findings of this
research. Interpretations and explanations of the results will be offered as well as
implications of the findings. Future directions for research will then be presented. In
addition, throughout the text, anecdotal reports will be offered. These written words are
the responses from the four open-ended questions included at the end of the packet for
the two sanctioned groups (the questions read, How would you describe yourself as a
psychologist? Briefly describe what was happening in your life at the time of the
ethical violation. What has the experience of being sanctioned been like for you? and
What would best help this researcher understand your situation?). These more personal
reactions added to the richness of the discussion section, and in the spirit of investigation,
help to understand better those psychologists who have been sanctioned for engaging in
boundary violations with clients.
Research Question 1
The first research question sought to determine if there were differences in
demographic variables between the three groups. Results are presented according to the
demographic variable listed.
Gender. Consistent with prior literature, two significant gender differences were
found for the sanctioned groups (Butler & Zelen, 1977; Gabbard, 1994a; Jackson &
Nuttall, 2001; Pope, 1993; Somer & Saadon, 1999). One, more males than females

143
engaged in nonsexual and sexual dual relationships and two, there were more female than
male client victims. These findings are consistent with the literature that has repeatedly
established that more males engage in dual relationships than females and, female clients
are more likely to be victims than male clients. A caveat is offered that the gender
distribution of the American Psychological Association membership is 51% male and
49% female, which reinforces the issue of dual relationships as a gender issue.
One reason why some male psychologists perpetrate nonsexual and sexual
boundary violations on female clients may be explained by the need of some men for
power and status (Walker, 1989). The therapy relationship has been established as one
where the power lies with the therapist and the therapist has an ethical responsibility to
use that power in a beneficent manner (APA, 1992). A male psychologist who does not
inherently feel powerful enough, may oppress his female clients by engaging in some
form of dual relationship in order to enhance his own status.
The use of power appears to be an important variable in most, if not all, forms of
dual relationships with clients. Schoener (2000) explained how a therapeutic relationship
may become exploitive as a result of the misuse of power by the professional. For
example, the client may not know what to expect from the relationship, therefore, the
rules are set by the professional. As the client shares personal secrets, the therapists
power is enhanced. The fiduciary relationship places the therapist in a position of trust,
and as a result, power. Therapists have the power to classify clients and determine the
course of treatment. In psychotherapy, transference often develops thus giving the
therapist power and influence. In other words, the patient can be as vulnerable as a
child (p. 4). Finally, Schoener (2000) reported as the client improves and feels gratitude

144
toward the therapist, a dependency may also develop thus enhancing the therapists
power over the client.
Pope (1990a) framed the sexual dual relationship with a client in terms of an
incestual relationship. In other words, Pope (1990a) compared the power dynamics, lack
of genuine consent, and consequences for the victims of a sexual dual relationship with
their therapist as similar to that of an incestual relationship. While the data in this study
did not assess this dynamic, conjecture would address the possibility that the secrecy
created by male therapists around the sexual dual relationship may be similar to that of an
incestual relationship.
A second explanation for the propensity for offending psychologists to be male
may be found in the societal gender socialization process. Some males have a tendency
to sexualize relationships with women, and in fact, a male therapists sexualization of a
therapeutic relationship with a woman has been shown in research done by Stake and
Oliver (1991). Stake and Oliver (1991) state, Men are traditionally expected to have a
role of entitlement and dominance as they interact with women, especially in sexual and
romantic encounters, and some men may strive to validate their masculinity through
sexual or sexualized relations with women (p. 305). Perhaps some of the male offenders
in the present study allowed a sense of entitlement, dominance, and power to influence
the therapeutic relationship thus reenacting a larger societal expectation.
A related gender issue may be some mens propensity for restriction of affect as a
result of the societal gender socialization process. Restriction of affect may limit some
mens feeling of emotional connection, intimacy, and vitality that healthy relationships
can provide. As a result, the male psychologist may seek to meet these relational needs
in therapy with a client. Whereas outside the therapy office, the male psychologist may

145
feel restricted by his gender role in terms of emotional expression, inside the therapy
office he may feel more at ease to discuss his own emotional struggles.
In the present study, six (30%) of the female psychologists engaged in nonsexual
boundary violations. This finding corresponds with previous literature that reported a
prevalence rate for female offenders of nonsexual boundary violations of 38% (Lamb et
al., 1994).
Client victim characteristics. It has already been established that female clients
are more likely to be victims than male clients (Butler & Zelen, 1977; Gabbard, 1994a;
Kluft, 1990; Pope & Bouhoutsos, 1986; Pope & Tabachnick, 1993; Somer & Saadon,
1999). While no typical profile of a client victim has been established, Pope &
Tabachnick (1993) suggested that victims of therapist-client sexual misconduct
frequently entered into therapy following a relationship trauma, which may have placed
them in a vulnerable position within the therapeutic relationship.
A second explanation for the propensity for client victims to be female is that
females are more likely to be victims of incest (Herman, 1989; Somer & Saadon, 1999;
Walker, 1989). Somer and Saadon (1999) reported that their sample of client victims of
sexual misconduct were often victims of childhood sexual abuse. Kluft (1990) reported
that victims of incest who developed dissociative disorders were incapable of accurate
assessment and appropriate reactions in high-risk situations. Thus, some incest victims
have increased vulnerability to revictimization by offending psychologists. In the present
study, data in regard to a history of sexual abuse were not collected, however it appears
clear that some female clients are especially vulnerable to nonsexual and sexual boundary
violations. Additionally, the most common diagnostic impression given the client
victims by the offending psychologists was Borderline Personality Disorder, a diagnostic

146
category which has been established in related literature for victims (Gutheil, 1989; 1991;
Herman et al., 1989; Simon, 1989; 1995). Some females with Borderline Personality
Disorder have experienced childhood sexual abuse (Herman et al., 1989) and, as stated
earlier, are at an increased risk for being retraumatized by the offending psychologist.
In the nonsexual dual relationship group, four of the client victims were male and
two were female. All six participants described the client with whom they violated
boundaries as character disordered (e.g., narcissistic, paranoid, and borderline). To date,
there is no empirical literature that describes male client victims and their experience of
nonsexual boundary violations by a psychologist.
Age. Sanctioned participants mean age range at the time of the ethical violation
was 45.6 years. This supports prior literature that has shown the average age of offenders
to be in the mid-forties (Bouhoutsos et al., 1983). Two recent studies, Somer and Saadon
(1999) and Jackson and Nuttall (2001) reported the mean age of their samples to be 47.5
years and 48.8 years respectively. In the present study, females in both offending groups
had a mean age slightly lower than the males. Males were slightly younger in the
nonsexual dual relationship group.
Previous research on age and ethical judgment has noted that ethical judgment
appears to change as the therapist ages and gains more experience in practice (Borys &
Pope, 1989; Epstein, Simon, & Kay, 1992; Lamb, Woodburn, Lewis, Strand, Buchko, &
Kang, 1994; Rodolfa, Hall, Holms, Davena, Komatz, Antunez, & Hall, 1994; Stake &
Oliver, 1991). Recall that Borys and Pope (1989) found that participants with 30 or more
years of practice rated dual relationships as significantly more ethical than psychologists
with less than 10 years of experience. Similarly, Rodolfa et al. (1994) reported that older

147
psychologists (age 44 years or more) were significantly more inclined to consider sexual
involvement with a client than were younger psychologists (under age 44 years).
One explanation for why middle age seems to be a risk factor for engaging in
boundary violations is that narcissistic problems often become painful around the age of
48 years (Kernberg, 1975). With a history of personal boundary violations (e.g.,
emotional, physical, and/or sexual abuse) that may lead to unresolved narcissistic
injuries, some therapists may be at risk for re-enacting their history with a client,
especially during times of personal crisis. Additionally, Jung wrote that mid-life is a time
in which individuals often shift their values and act in opposition to their earlier life in
order to achieve balance (Stein, 1983). Perhaps some of these participants were engaged
in a major life change or shift in attitudes at the time of their ethical violation.
A second explanation may be that some of these psychologists may have been
close to retirement and may not have been concerned about jeopardizing their jobs or
reputation by entering into a dual relationship with a client. Nearing the end of their
careers, upholding strict ethical standards may not have been as important as it may have
been at the beginning of their careers.
Academic training. All respondents possessed a doctoral degree and there were
no differences found between psychologists trained in clinical and counseling psychology
programs. This may be due to the American Psychological Association accreditation
resulting in more similarities than differences in clinical and counseling psychology
training programs. Of note, the ratio of Counseling Psychologists to Clinical
Psychologists within the American Psychological Association membership is 32% to
68% respectively. In the present study, the ratio of Clinical Psychologists to Counseling

148
Psychologists is nearly the same, therefore this sample appears to be representative of the
American Psychological Association membership.
Theoretical orientation. The most common theoretical orientation noted in the
nonsexual dual relationship group was psychodynamic. This finding is divergent from
previous research that has reported therapists who endorse a psychodynamic orientation
were less likely to commit nonsexual and sexual boundary violations (Baer & Murdock,
1995; Borys & Pope, 1989; Pope et al., 1987). This discrepant finding provides new
information regarding theoretical orientation and nonsexual boundary violations. Perhaps
most importantly, this finding illustrates the point that theoretical orientation doesnt
necessarily preclude the occurrence of a boundary violation.
The sexual dual relationship group endorsed eclecticism as their most common
theoretical orientation. This finding is contrary to previous research that found therapists
endorsing a psychodynamic orientation were less likely to engage in sexual dual
relationships with clients (Baer & Murdock, 1995; Borys & Pope, 1989; Pope et al.,
1987). Eclecticism has been described by Celenza (2001) as "the therapist's own brand of
therapy that cannot be categorized or a way of characterizing the desire to have 'unlimited
flexibility in technique', i.e. a euphemism for omnipotent control" (A. Celenza, personal
communication, November 20, 2001). Therefore, one explanation of this finding may be
that endorsing eclecticism reflected the psychologists "unresolved narcissistic (grandiose)
stances toward the profession that may serve to place the psychologist above the ethical
code" (A. Celenza, personal communication, November 20, 2001).
In considering theoretical orientation, these two findings illustrate training alone
does not prevent boundary violations. In the nonsexual dual relationship group most
participants endorsed a psychodynamic orientation, an orientation that places special

149
emphasis on the maintenance of boundaries (i.e., transference/countertransference issues)
within the therapeutic frame. In the sexual dual relationship group, eclecticism was the
most common theoretical orientation.
Interestingly, participants who reported seeking therapy, analysis, or supervision
(voluntarily or as part of their sanction) sought out such services from a
psychodynamically oriented provider. It appears that participants who sought
psychodynamic services intuitively recognized there were factors outside their conscious
awareness that motivated them to engage in a dual relationship. A 50-59 year old male
wrote, I think that I used the experience productivelyI sought treatment and I enrolled
in a psychoanalytic training program to enhance my skills. Both the treatment and the
training were enormously helpful to me.
Work setting. Working in solo private practice has been repeatedly established as
a major risk factor for engaging in a dual relationship (Bouhoutsos et al., 1983; Epstein et
al., 1992; Somer & Saadon, 1999). Therefore, not surprisingly, 77% or three fourths of
the sanctioned psychologists in this study worked exclusively in private practice at the
time of the ethical violation. This finding adds more empirical support that for some
individuals, working in private practice can be a very serious risk factor for engaging in a
dual relationship. One reason for this finding could be that the isolation of private
practice enhances the power dynamic and as a result, the potential for exploitation,
between therapist and client. Additionally, the isolation of private practice allows for
greater freedom (and secrecy) for the development of a dual relationship because the
therapist is not closely scrutinized or held accountable to other professionals.
Partner status. At the time of the ethical violation, the demographic
characteristics of the sanctioned groups revealed that the most common scenario was a

150
married, middle-aged male in solo private practice who was experiencing the loss of a
significant other and who crossed boundaries with a much younger female client. Again,
these demographic characteristics mirror the literature almost perfectly (Butler & Zelen,
1977; Gabbard, 1994a; Pope, 1993; Somer & Saadon, 1999).
What is noteworthy about this demographic is that while 75% of the nonsexual
group and 68% of the sexual dual relationship group were married, 25% and 53%
respectively, were experiencing the loss of a significant relationship at the time of the
ethical violation. For some psychologists, this situational variable appears to be a potent
risk factor for engaging in boundary violations. The literature may explain why partner
status is such an important variable in the evolution of boundary violations. Butler and
Zelen (1977) interviewed 20 sexually offending psychologists and found 90% felt
vulnerable, needy, and lonely due to recent marital dissatisfaction, separation, or divorce.
Similarly, Celenza and Hilsenroth (1997) reported 50% of their sample was experiencing
the loss of a significant other at the time of the ethical violation. Moreover, it is likely
that most psychologists at some point in their career will experience the loss of a
significant other, such is the nature of life. What then, is different for these offending
psychologists?
One explanation for why this variable is so potent may be found in the childhood
histories of these offending psychologists. In the present study, the offending
psychologists experienced more narcissistic injury and parentification than the
nonoffending psychologists. The experience of narcissistic injury and parentification
reflects damage to the sense of self and caretaking behaviors. That is, when the childparent relationship becomes reversed as it does in parentification, a childs sense of self
suffers. In the therapy relationship, a therapists damaged sense of self and disordered

151
caretaking behaviors could potentially set the stage for boundary violations especially
during a separation, divorce, or loss of a loved one. In other words, the therapist may
look to the client to fill ones own self-esteem needs and may potentially become overinvolved in the clients life.
A second explanation is that based on the open-ended questions, many
participants in the sexual dual relationship group appeared to fit into the lovesick
category proposed by Gabbard (1994b). Gabbard (1994b) described narcissistic and
borderline tendencies in offending psychologists that may lead to boundary violations.
He also noted some lovesick therapists are essentially normal from a diagnostic
standpoint but are in the middle of a life crisis. Participants in the present study did not
have clinically significant scores on the Bell Object Relations Inventory, which would
indicate characterological problems. Instead, this group of offending psychologists was
more neurotic and more likely to be in the midst of a life crisis. Clearly, the combination
of being lovesick and losing a significant other is an important risk factor for engaging
in a dual relationship.
Childhood history of abuse. One finding that appears to support prior research is
the experience of childhood abuse. All three groups reported a childhood history of
emotional, physical, and sexual abuse, with emotional abuse perpetrated most often by
the mother or mother-figure. Literature on childhood experiences of therapists reveals
frequent histories of abuse (Elliot & Guy, 1993; Pope, 1992; Racusin et al., 1981) and
such was the case with these participants. Recall that Pope (1992) found 70% of the
women and 33% of the men in a national survey of psychologists reported physical or
sexual abuse histories. What demands attention, however, is the fact that all three groups
in the present study endorsed about the same rate of childhood abuse. The implication

152
here is that merely having a history of childhood abuse does not adequately explain why
one psychologist may violate boundaries with a client and another psychologist will not.
Additionally, what appears to be important for this group of participants is not necessarily
that they were abused, but rather how their abuse history affected them. How a history of
abuse affected the three groups differentially will be addressed later in this discussion.
Separating the types of childhood abuse, the sexual dual relationship group
endorsed a higher rate of physical and sexual abuse than the other two groups. This
finding adds to recent research about childhood abuse and subsequent boundary
violations. Recently, a history of sexual abuse has been identified as a risk factor for
therapists engaging in sexual dual relationships (Jackson & Nuttall, 2001). Specifically,
Jackson and Nuttall (2001) found that those who reported a childhood history of severe
sexual abuse were more than four times as likely as those without such a history to have
engaged in sexual activity with a client. Some of the offending therapists in their study
may have been vulnerable to acting out countertransference with clients who themselves
were severely abused as children and who may have developed erotic transferences and
projected expectations of being exploited on to their therapists (Jackson & Nuttall, 2001).
Jackson and Nuttall (2001) state that male therapists who experienced same-gender
sexual abuse may have engaged in a sexual dual relationship with a female client to
reassure themselves of their masculinity. Finally, therapists who have not resolved their
own victimization may seek repetitive, inappropriate sexual behavior as a reenactment of
their own trauma (Jackson & Nuttall, 2001).
Same sex exploitation. Six of the participants in the nonsexual dual relationship
group were female. Two of the six participants crossed boundaries with same-sex clients.
In both cases, the ethical violation was engaging in a social dual relationship with a

153
client. Inexperience and lack of good education in managing boundaries with difficult
clients (both of the client victims were assessed by the offending psychologists to have
Borderline Personality Disorder) may explain partially why these two women crossed
boundaries. A 60+ year old female who engaged in a social dual relationship with a
female client wrote, I was brand new to the field of therapy. I had no training in
diagnosis and did not recognize borderline behavior. I was fresh in the field and felt I
could help everyone.
In the sexual dual relationship group, two women offenders were sanctioned for
engaging in a sexual dual relationship with a female client. Several factors may help
explain why these two participants crossed boundaries with a client. Both participants
reported a history of emotional, physical, and sexual abuse; experiencing the loss of a
significant other at the time of the ethical violation, and inadequate training and
supervision contributed to their inability to recognize and set limits with difficult clients.
One 30-39 year old female participant wrote:
I was in a relationship for seven yearsthe relationship ended. I felt
undesirable, unable to take care of myself when others needs were great,
and unable to reject others who made unreasonable demands. I believe a
combination of childhood abuse issues and current depression combined
to make me vulnerable to a masterful borderline client who was able to
perceive my vulnerability and re-enact both our histories of abuse. Previous
supervision with this client was inadequate.
To assess other unconscious motivators for these two female participants was outside the
scope of the present study. However, Dr. Celenza (A Celenza; personal communication
December 6, 2001) believes a different set of unconscious motivating factors based

154
more on identification and merger rather than sadomasochistic control issues exist.
More research needs to be done to explore this issue.
In summary, the demographic characteristics of the offending psychologists
support previous research in the area of gender. That is, there were more male than
female offenders, and more female than male client victims. With the exception of these
two significant differences, there were no other significant differences in demographic
characteristics between groups. This lack of differences on demographic characteristics
between groups speaks to the possibility that, nonoffending and offending psychologists
are more alike than different, at least in terms of demographics. Hence, as stated earlier
in this text, there is a need for empirical research to go beyond designs that simply
measure demographics and prevalence rates. This study looked beyond visible,
demographic characteristics and as this discussion continues, more underlying
characteristics of offending psychologists will be discussed with possible explanations
given.
Research Question 2
The second research question sought to determine if a relationship exists between
measures of object relations (Bell Object Relations Inventory, four subscales) and being
sanctioned for an ethical violation (group membership). When measures of object
relations were examined in relation to group membership, there were nonsignificant
results. This finding appears somewhat surprising and unexpected given that prior
research has shown that psychologists who engage in a sexual dual relationship with a
client seem to have impaired object relations (Celenza & Hilsenroth, 1997; Celenza,
1998). Before looking to the literature for assistance in understanding this finding, it
warrants mentioning that the scores on the object relations subscales of alienation,

155
egocentricity, insecure attachment, social incompetence were below the threshold of
psychopathology as defined by Bell (1995) for the entire group of respondents.
Collectively, the scores did not indicate impaired object relations for this group of mental
health professionals regardless of group membership. However, it is notable that while
the scores on object relations subscales did not significantly differ, the overall means on
these object relations subscales were higher for both of the sanctioned groups than for the
control group.
One reason for this nonsignificant result could be differences in the
instrumentation used by this study and by previous studies. Celenza and Hilsenroth
(1997) and Celenza (1998) relied on extensive clinical interviews and on the Rorschach
for measurement of object relations. The authors of these two previously mentioned
studies were able to gather extensive evidence to assess the object relations of their
subjects. While the previous authors may have gathered extensive data in regard to
object relations, the data was subjective and vulnerable to reporting and interpretation
bias. The present study relied solely on the Bell Object Relations Inventory, a self-report
instrument that may be vulnerable to presentation bias (Bell, 1995). Looking at the Bell
Object Relations Inventory more closely, Bell (1995) reported that although it has been
shown that this inventory does not correlate with favorable self-presentation response
biases (Bell, et al. 1985), the instrument is vulnerable to purposeful negative or positive
self-report. He added that the Bell Object Relations Inventory is no more or less
vulnerable to deliberate deception than other self-report instruments.
Given that the participants in this study were psychologists, the Bell Object
Relations Inventory may not have been sophisticated enough to provide a truly objective
measure of object relations. Additionally, the literature suggests some sexually offending

156
psychologists are motivated to present themselves in a favorable light, and some
psychologists struggle with negative transference, preferring always to been seen in a
positive manner by clients (Celenza, 1998). In the present study, consideration should be
given to the possibility that the sanctioned psychologists were motivated to present
themselves in a positive manner. For example, the sanctioned psychologists used words
and phrases such as, caring, skilled, sensitive, insightful, effective, ethical, competent,
mature, bright, educated, knowledgeable, well trained, and among the brightest and best,
to describe themselves. On the other hand, this nonsignificant result did show a trend in
the direction of impaired object relations. The BORI may not be as sophisticated as the
Rorshach or extensive clinical interviews in gathering psychopathology data, as in
previous studies (Celenza & Hilsenroth, 1997; Celenza, 1998) therefore,
psychopathology may have been underrepresented in this group of participants.
A second explanation for the nonsignificant results related to the BORI is that the
subscales tap into current rather than past interpersonal relationships. The average age at
the time of the ethical sanction was 45.6 years. The current age range with the greatest
number of participants was 50-59 years old (51.3%) and 60+ years old (30.8%).
Potentially, some subjects may have engaged in sanctioned behavior over 15 years ago.
With such a time lag between the ethical violation and assessment of object relations, it is
nearly impossible to assess the quality of object relations during the time of the ethical
violation. Additionally, a lack of longitudinal research on the development of object
relations across the lifespan limits this part of the discussion to theoretical explanations.
Consensually, object relations theorists purport that early object relations
influence personality through the development of an internal self-other representation
(Glickhauf-Hughes & Wells, 1997; Horner, 1984; Kohut & Wolf, 1978; Mahler, M.,

157
Pine, F., & Anni, B., 1975; Miller, 1981). Object relations are formed through a lifetime
of interacting with others, but the early interactions with significant figures forms
patterns of expectations for how others are related to in the future (Gabbard, 1990).
Although the template for self-other object relations may be set early on in life, good
psychological treatment (or analysis) and maturity with significant life events may
positively influence an individuals intra and interpersonal world (A. Celenza, personal
communication, June 5, 2001). With this in mind, 49% of the sanctioned psychologists
were given a supervision requirement and 15% were given a psychological treatment
requirement as part of their discipline. Supervision and psychological treatment, together
or separately, may have contributed to the improvement of some participants object
relations, which in turn may have been reflected in the Bell Object Relations Inventory
scores.
An instrument that provided an unexpected glimpse into participants object
relations during the ethical sanction was the demographic questionnaire. Specifically,
both partner status at the time of the ethical violation and the open-ended questions were
designed to provide additional data. The literature suggests that one of the most common
demographic variables in psychologists who engage in a dual relationship with a client is
the loss of a partner due to separation, death, or divorce (Butler & Zelen, 1977; Gabbard,
1994a; Pope, 1993). In Celenza and Hilsenroths (1997) study, 50% of their subjects
reported experiencing the loss of a significant other at the time of the ethical
transgression. Recall that in the present study, 75% of the nonsexual dual relationship
group were married, and 68% of the sexual dual relationship group were married.
However, in the open-ended question number two (Briefly describe what was happening
in your life at the time of the ethical violation.), 25% of the nonsexual dual relationship

158
group and 53% of the sexual dual relationship group reported experiencing the loss of a
significant relationship (e.g., spouse or family member) at the time of the ethical
violation.
Thus, while impairment in object relations as measured by the Bell Object
Relations Inventory was not present currently in these two groups of sanctioned
psychologists, the situational variable of suffering the loss of a loved one due to
separation, divorce, death, or serious illness appears to be an important variable in how
the psychologist navigated his or her interpersonal relationship with a client at the time of
the ethical violation. This situational variable appears to support Gabbards (1994b)
contention that lovesick therapists may present themselves in therapy as needy and
vulnerable. This can lead to the role reversal that eventuates in a sexual dual relationship.
Research Question 3
The third research question sought to determine if significant differences exist
between measures of parentification, narcissistic injury, self-esteem, and ethical judgment
for psychologists who engaged in nonsexual dual relationships, psychologists who
engaged in sexual dual relationships and nonsanctioned psychologists. On measures of
parentification and ethical judgment, differences between groups were nonsignificant.
The analyses revealed significant differences among the three groups on indices
of narcissistic injury and self-esteem. In regard to narcissistic injury, the nonsexual and
sexual dual relationship groups reported more narcissistic injury than the control group.
This finding is congruent with recent research on sexually offending mental health
professionals. Celenza and Hilsenroth (1997) found that their subjects did not meet the
criteria for narcissistic personality disorder per se, but they presented as narcissistically
needy as a result of disturbances of the development of the self (p. 102).

159
In the present study, the higher scores of the two sanctioned groups on the
Narcissistic Injury Scale indicate that they have experienced more narcissistic injury than
the control group. Previous research has identified a cluster of vulnerabilities described
as narcissistically needy (Celenza & Hilsenroth, 1997). The present study adds new
information to previous research in this area. In other words, the sanctioned groups had a
greater disturbance in their sense of self, compared to the control group as measured by
the Narcissistic Injury Scale. The implication is that a disturbance in the sense of self
such as, restriction of affect, grandiosity, depression, and low self-esteem, is a risk factor
for entering into a dual relationship with a client. As boundaries are crossed, the therapist
with a damaged sense of self may use a client to feel a sense of vitality, splendor,
happiness, and positive self-esteem. This finding advances knowledge in the area of dual
relationships because both a control group of nonsanctioned psychologists and a
standardized instrument (the Narcissistic Injury Scale) were utilized to gather these data.
In regard to self-esteem, for participants in the sanctioned groups, self-esteem
scores were lower than the control group, and the sexual and nonsexual dual relationship
groups did not differ from one another. This finding advances knowledge in this area
because the present study utilized a control group. Recent literature without a control
group has indicated that mental health professionals who engage in a sexual dual
relationship with a client have struggled with long standing low self-esteem (Celenza and
Hilsenroth, 1997; Celenza, 1998).
These significant findings, (the sanctioned groups had higher narcissistic injury
and lower self-esteem than the control group), have important implications when
considering dual relationship risk factors. When normal childhood narcissistic needs for
respect, understanding, and mirroring go unmet, self-esteem may suffer. In the present

160
study, the participants in the sanctioned groups may have tried to gratify narcissistic and
self-esteem needs by engaging in dual relationship with a client.
The lack of significant difference between groups on the parentification scale is
divergent from previous research which has shown that as a result of parentification,
therapists are prone to adopt an over-functioning, care-taking interpersonal style that
often results in boundary crossings and difficulty in setting limits with clients (GlickhaufHughes & Mehlman, 1995; Mika et al., 1987; Valleau et al., 1995; Wells & Jones, 2000;
West & Keller, 1991). One reason for this finding in the current study could be the low
number of participants compared to previously mentioned studies, all of which had over
100 participants per study.
Finally, the lack of significant difference between groups on the ethical judgment
scale (EJS) warrants attention. The almost perfect scores from every group confirm
previous literature that psychologists who behave unethically are aware of the American
Psychological Association Ethical Code of Behavior (1992) (Celenza, 1991; Hamilton &
Spruill, 1999; Tabachnick et al., 1991; Pope & Vetter, 1992; Vasquez, 1988). In other
words, according to the EJS scores, the sanctioned psychologists were able to recognize
unethical dual relationships. One explanation could be that the ethical judgment scale
was too simplistic and not sophisticated enough to generate differences in ethical
judgment.
A second explanation could be that given the context that these sanctioned
psychologists were middle-aged with years of work experience provides further support
for the notion that psychologists who engage in a dual relationship with a client are more
likely to disregard ethical knowledge as they age and gain experience (Borys & Pope,
1989; Epstein et al., 1992; Lamb et al., 1994; Rodolfa et al., 1994). Thus, this finding

161
supports the contention that these two groups of offending psychologists in this study
engaged in the dual relationship for reasons other than lack of ethical judgment. It
appears more likely that the sanctioned psychologists were situationally vulnerable and
possibly lovesick due to a life crisis. The implication is that ongoing training and
psychotherapy is needed 10 to fifteen years after graduate school to recognize and deal
with potentially troublesome transference/ countertransference reactions that arise during
treatment. Specifically, training and psychotherapy is needed that addresses the
identification of unmet narcissistic needs and related self-esteem issues and midlife issues
that may lead to a dual relationship (Celenza, 1998; A. Celenza, personal communication,
November 20, 2001).
Research Question 4
The fourth research question sought to determine to what extent demographic
characteristics predicted scores on measures of object relations, narcissistic injury, selfesteem, and ethical judgment. Analyses reveals that for the sanctioned groups, a history
of abuse was a common predictor for the Bell Object Relations Inventory subscale of
Social Incompetence, and for the Parentification Questionnaire, and the Narcissistic
Injury Scale. Specifically, abuse (emotional abuse for the sexual dual relationship group
and physical abuse for the nonsexual dual relationship group) predicted social
incompetence. What this indicates is that the sanctioned groups experienced more
shyness, nervousness, uncertainty about how to act with the opposite sex, social isolation,
and unsatisfactory sexual adjustment as a result of abuse than the nonsanctioned control
group.
In addition, an inverse relationship occurred between sexual abuse and alienation.
That is, as sexual abuse increased, the sexual dual relationship group experienced less

162
alienation than the nonsexual dual relationship and control groups. In this study,
psychologists who entered into a sexual dual relationship experienced a greater sense of
belonging than other psychologists. Perhaps psychologists in the sexual dual relationship
group were able to establish intimacy in their own lives, but had difficulty maintaining
this connection as is evidenced by the next finding, that these psychologists had difficulty
in the area of insecure attachment.
As a result of emotional abuse, the sexual dual relationship group experienced
more disturbed object relations in the area of insecure attachment than the nonsexual dual
relationship and control groups. Psychologists who entered into a sexual dual
relationship felt more isolated and uncomfortable with social interactions than the other
psychologists. In other words, abuse caused more difficulties in regard to object relations
for psychologists in the sexual dual relationship group compared to psychologists in the
nonsexual dual relationship and control groups. This finding adds to previous research
which indicated that impairment in sexually offending mental health professionals
included chronic distress associated with interpersonal longing and neediness, and object
hunger (Celenza and Hilsenroth, 1997; Celenza, 1998). Additionally, in conjunction with
the demographic of work setting at the time of ethical violation (almost 80% of the
participants in the sexual dual relationship group reported working in private practice at
the time of the violation), childhood emotional and sexual abuse appears to be important
risk factors for psychologists in private practice for engaging in a sexual dual relationship
with a client. This finding replicates the most recently empirical study by Jackson and
Nuttall (2001) that identified a history of sexual abuse as a risk factor for therapists
engaging in sexual dual relationships.
In the present study, abuse predicted parentification in all three groups.

163
Specifically, for the nonsexual dual relationship group, emotional and physical abuse
predicted parentification; physical abuse predicted parentification in the sexual dual
relationship group; and, emotional abuse predicted parentification for the control group.
Of note, for the control group, emotional abuse accounted for less than half the variance
in parentification than was accounted for in the sanctioned groups. Thus, it seems abuse
is an especially important factor for the development of parentification in the sanctioned
groups.
For both of the sanctioned groups, emotional abuse predicted narcissistic injury.
Narcissistic injury infers that there is damage to an individuals basic sense of self. In
other words, emotional abuse for the sanctioned psychologists led to a restriction of
affect, feelings of grandiosity and depression, impaired parent-child relations, and
negative feelings about the self, as measured by the Narcissistic Injury Scale. The
presence of narcissistic injury in offending psychologists is a unique finding given
previous research and provides new information about psychologists who engage in
boundary violations with a client. Watson et al. (1995) found that greater parental
nurturance and self-esteem correlated with lower incidence of narcissism. Prior research
by Celenza and Hilsenroth (1997) and Celenza (1998) has suggested that sexually
offending therapists have vulnerabilities that are described as narcissistically needy.
Importantly, the present finding shows that emotional abuse is linked to narcissistic
injury in psychologists sanctioned for engaging in a dual relationship with a client.
Finally, an inverse relationship existed between age at the time of ethical violation
and ethical judgment. That is, as age at the time of ethical violation increased, scores on
the Ethical Judgment Scale decreased. In other words, the older the offending
psychologist was at the time of the ethical violation, the lower his or her ethical judgment

164
was in the clinical vignettes. For the offending psychologists in this study, what
constituted ethical or unethical behavior appeared to become more blurred with age. This
finding replicates prior research which has found a relationship between age, years of
practice, and ethical judgment (Borys & Pope, 1989; Epstein, Simon, & Kay, 1992; Lamb
et al., 1994; Rodolfa, et al., 1994; Stake & Oliver, 1991). The implications of this finding
suggest that continuing education about managing therapeutic boundaries is needed at all
stages of therapist development, not just graduate school and may be especially important
after 10 years of practice. This finding appears to support the recent trend of many state
licensing boards to require some ethics training in every renewal cycle.
In sum, for these sanctioned participants, abuse led to difficulty with object
relations, parentification, and narcissistic injury. However, parentification alone (as
found with the control group) did not seem to lead to a dual relationship with a client. In
other words, for this group of sanctioned participants, a mix of issues including
difficulty with object relations, narcissistic injury, and parentification appeared to be the
mediating factors that influenced the slippery slope of boundary violations. What seems
clear from these findings is that abuse plays a significant role in self and relational
difficulties, which in turn, may impact other key variables that influence whether a
psychologist engages in a dual relationship.
Research Question 5
This question sought to determine the relationship between measures of object
relations, parentification, narcissistic injury, self-esteem, and ethical judgment for each
group.
Nonsexual dual relationship group. For this group of participants, the Bell Object
Relations Inventory Subscales of Insecure Attachment, Egocentricity, Social

165
Incompetence, and the Parentification Questionnaire and the Narcissistic Injury Scale
were all negatively correlated to the Rosenberg Self-Esteem Scale. This seems to
indicate that this group struggled in the object relations realm, especially reporting
feelings of alienation and insecure attachment. This group appeared to struggle more
with alienation and insecure attachment, which is related to social incompetence, and
narcissistic injury. In other words, underneath this groups feeling of social
incompetence may be a sense of narcissistic injury.
Notably, the for the nonsexual dual relationship group, as egocentricity increased,
self esteem decreased. Egocentricity can be described as an exaggerated sense of selfimportance or self-interest. Thus, what this finding seemed to capture is, as a false selfinterest or regard increased, an authentic sense of self worth or regard decreased. This
group may overtly display feelings of high self-regard when, in fact, the reality may be
the inverse.
The Narcissistic Injury Scale and the Parentification Scale were negatively
correlated with self-esteem. The nonsexual dual relationship group appeared to be
struggling with alienation and insecure attachment, which are related to narcissistic injury
and low self-esteem. Additionally, for this group, parentification was negatively
correlated with self-esteem. Thus, this group appeared more prone to use their role as
psychologist in psychotherapy to gratify or master attachment needs because of a history
of parentification which may have led to lower self-esteem.
Sexual dual relationship group. One subscale of the Bell Object Relations
Inventory, in particular, stood out in the correlation analysis for this group. The Insecure
attachment subscale was positively related to four other measures, the Bell Object
Relations Inventory Subscales Egocentricity and Social Incompetence, the Parentification

166
Questionnaire, and the Narcissistic Injury Scale. Insecure attachment for this group
appears to have led to a sense of egocentricity and social incompetence. In other words,
how these psychologists attach (Insecure Attachment) was related to an inflated sense of
self (Egocentricity), how they relate to others (Social Incompetence), caretaking
behaviors (Parentification), and an underlying sense of damage (Narcissistic Injury).
Additionally, the Parentification Questionnaire was positively correlated with the
Narcissistic Injury Scale and the Narcissisitic Injury Scale was negatively related to selfesteem.
For the sexual dual relationship group, parentification was related to
egocentricity, insecure attachment, and narcissistic injury. This seems to highlight that
for this group, parentification in childhood may have led to an inflated sense of self and
attachment difficulties. Additionally, parentification was related to narcissistic injury,
whereas for the nonsexual dual relationship group, parentification was related negatively
to self-esteem. It appears for the sexual dual relationship group that the dynamic of
parentification led to an exalted position in the family, which was positively related to
insecure attachment, egocentricity, and narcissistic injury (and negatively related to selfesteem). Was this group engaging in a sexual dual relationship because they were in a
parent-like position (i.e., parentification)? A possible explanation for this is provided by
previous research by Butler and Zelen (1977) showing that 60% of their male sexual
offenders perceived themselves in the relationship with the client as a father-figure, and
reported their countertransference to be paternal in nature.
In summary, the sexual dual relationship group appeared not to feel alienated like
the nonsexual dual relationship group. Rather, they appeared to feel entitled (i.e.,
egocentric) and to use the therapy relationship improperly. When the parent-child

167
relationship has been violated via parentification, the individual appears to be vulnerable
to violate other relationships as well (Celenza, 1998; Glickhauf-Hughes & Mehlman,
1995; Jones & Wells, 1996). Because healthy boundaries may not have been modeled for
participants in this group, they may have been more prone to act out with new clients.
Perhaps this group unconsciously used the therapy to re-enact that earlier care-taking
role.
Control group. What is noticeable about the correlations for this group is that
there were so few significant relationships compared to the sanctioned groups. Of the
correlations that were significant, four relations were highlighted. The most interesting
correlation occurred between the Bell Object Relations Inventory Subscales of Alienation
and Egocentricity and the Narcissistic Injury Scale. Specifically, for the control group, as
alienation increased, egocentricity and narcissistic injury decreased. This correlation was
opposite to the nonsexual dual relationship group whereby an increase in alienation was
related to an increase in narcissistic injury. Similarly, for the sexual dual relationship
group an increase in alienation was correlated with an increase in both egocentricity and
narcissistic injury. The control group may have felt alienated and insecurely attached,
but this was not related to a sense of egocentricity (as was the case with the sexual dual
relationship group) and narcissistic injury (as was the case with both sanctioned groups).
Additionally, this group reported parentification was correlated with narcissistic injury,
which was similar to the sexual dual relationship group. However, noticeably missing
were negative correlations with self-esteem.
While all three groups reported a positive correlation between the Bell Object
Relations Inventory Subscales Insecure Attachment and Social Incompetence, the control
group had noticeably fewer correlations. That is, in the sanctioned groups where

168
attachment difficulties were related to myriad of other relational and self problems, the
control appeared to be relatively free of these relations. This group may have reported
feeling alienated, insecurely attached, and parentified, but they didnt appear to have the
same relationship with self-esteem as the sanctioned groups. Perhaps, this groups sense
of self was not as damaged as the sanctioned groups. Therefore, when psychologists in
the control group entered into a therapeutic relationship with a client, they were less
likely to use the client to meet their unmet needs and bolster their self-esteem. Instead,
they appeared to be able to maintain professional, ethical boundaries with the client.
Implications of the Study
Perhaps the most important ethical role of a psychologist is to protect the public
from harm (APA, 1992). Psychologists are granted much power in the therapeutic
relationship and it rests upon the individual to use that power responsibly. Simon (1992)
states that the therapists main source of personal gratification arises from the
professional gratification derived from the therapeutic process. His guideline seems
simple, but for some psychologists the slippery slope leading to a dual relationship seems
largely unforeseen. Lessons from Pope et al. (1986) and Gabbard (1996) warn that no
therapist is immune to erotic countertransference or the temptation for exploitation of
clients. This study brings forth new data in the quest to understand why some
psychologists risk everything to engage in a dual relationship with a client. Implications
for practice, training, and state licensing boards, have arisen from data derived from this
study and are provided below.
Practice. Sanctioned participants in this study were remarkably similar in regard
to demographic characteristics to participants in prior research. In this study as in
previous research, more middle-aged males in private practice engaged in dual

169
relationships than females and, at the time of the ethical violation, it was common for the
offending psychologist to be experiencing the loss of a significant other (Butler & Zelen,
1977; Celenza & Hilsenroth, 1997; Celenza, 1998; Gabbard, 1994a; Pope, 1993; Somer
& Saadon, 1999). Additionally, female clients were more likely to be victims than male
clients and the most common diagnostic impression given client victims was Borderline
Personality Disorder, which has been established in the anecdotal literature as a common
client diagnosis (Gutheil, 1989; 1991; Simon, 1989; 1995).
For some psychologists, the isolation of private practice is a high-risk work
environment. Perhaps the isolation of private practice exacerbates social incompetence
and narcissistic injury, and makes monitoring of errant psychologists nearly impossible.
Additionally, psychologists in private practice who experience a loss of a significant
other are at a high risk for crossing boundaries with a client. Finally, as some
psychologists age and gain more years of clinical experience, their standards about what
constitutes ethical behavior appears to lower. Presently, supervision or consultation is
seen as the most important preventive measure of sexual dual relationships (Gabbard,
1996; Hamilton & Spruill, 1999; Pope et al., 1986, Simon, 1999).
Thus, given the above information, it seems reasonable to recommend that
psychologists do the following: (a) obtain advanced training, supervision, consultation,
and/or psychotherapy to identify the risk factors associated with the slippery slope of
boundary violations; (b) obtain advanced training, supervision, consultation, and/or
psychotherapy to recognize and deal with erotic transference and countertransference; (c)
obtain advanced training, supervision, and/or consultation in dealing with difficult
clients, such as those diagnosed with Borderline Personality Disorder and Narcissistic
Personality Disorder; (d) seek professional psychotherapy when dealing with the loss of a

170
significant other, illness, midlife issues, or other emotionally stressful situations; (e) seek
psychotherapy to resolve any emotional issues attached to childhood abuse that may
interfere with the practice of therapy; (f) obtain advanced training, supervision,
consultation, and/or psychotherapy to discuss personal attitudes and risk factors in regard
to boundary behaviors because with age and years of practice, previously held beliefs
regarding ethical behavior may have changed to become more lenient.
Training. The results of this study lead to several implications for training and
education of psychologists. Since graduate training institutions are the gatekeepers into
the profession, it seems reasonable to expect that they be given the extraordinary
responsibility for protecting the public by selecting mentally and emotionally healthy
students and providing adequate training in issues related to nonsexual and sexual dual
relationships. Training issues related to nonsexual and sexual dual relationships include
how ones childhood history impacts current functioning as a psychologist and an indepth understanding of transference and countertransference. Training on how ones
childhood impacts current functioning may be one of the most effective preventive
measures. Additionally, graduate programs should move toward normalizing and even
expecting that their students receive psychotherapy as part of the education process.
Graduate training on transference and countertransference with regard to
nonsexual and sexual dual relationships is an important preventive measure for unethical
behavior. Recall that Hamilton and Spruill (1999) explain that the problem of sexual
misconduct with graduate trainees is not a matter of lack of exposure to the ethical
standards, but a failure on the part of the trainee to identify and deal effectively with
ethical conflicts when they arise in real-life situations. Specifically, Hamilton and Spruill
(1999) call for graduate training programs to explicitly and forcefully address this issue

171
through class discussion, role-plays, and skills training. Additionally, Pope and
Tabachnick (1993) state that graduate psychology students may lack the support to
develop knowledge, resources, confidence, and skills to acknowledge, accept, and
understand such [sexual] feelings when they occur in the therapists work. (p. 147).
Therefore, training must include didactic lectures on the topic as well as active role-plays
that help students develop the skills to deal directly with potentially troublesome
interactions with clients.
Regardless of the theoretical orientation of the graduate or training program, basic
training on the psychodynamic constructs of transference and countertransference is
essential as a preventive measure. One female who was sanctioned for engaging in a
sexual dual relationship wrote, My training had focused entirely on social behavioral
techniques and I did not realize the psychodynamics I was involved in until it was too
late.
Therefore, the following recommendations in regard to training are offered; (a)
psychotherapy during graduate school should be expected and normalized as part of the
process of becoming a psychologist, (b) supervisors and educators need to be trained to
look for risk factors, especially situational variables that make otherwise ethical students
and colleagues vulnerable to crossing treatment boundaries with clients; (c) training
programs must go beyond simply teaching the ethics code but must provide practice via
role plays in recognizing and dealing with erotic transference and countertransference;
(d) students need to be trained to recognize the slippery slope of boundary violations;
(e) students need to receive advanced training in dealing with clients diagnosed with
Borderline and Narcissistic Personality Disorders; (f) training programs need to provide
training in confronting unethical colleagues, dealing with complaints from clients

172
regarding the alleged unethical behavior of a colleague, and in providing supervision to
an impaired student or colleague, (g) psychologists need to receive advanced training 10
to fifteen years after graduate school to recognize and deal with potentially troublesome
midlife issues and transference/countertransference reactions that may arise during
treatment.
State Licensing Boards. Several implications for state licensing boards can be
gleaned from the direct experience of being sanctioned. There appears to be a
comparable lack of coherence in the due process of an alleged ethical violation against a
psychologist. Gonsiorek (1989) has noted, the same act committed by the same
therapist upon the same client may well result in widely differing outcomes by different
licensing bodies in the same state. This inconsistency makes all licensing bodies lose
credibility (p. 569).
Another issue is how to treat offending psychologists who self-report unethical
behavior. Should the psychologist who admits guilt and accepts responsibility be treated
similarly to other offending psychologists? One male therapist wrote, I admitted my
wrongdoing and cooperated with the licensing board investigation. They turned around
and used information I freely gave against me. Another male therapist called his state
licensing board anonymously to inquire about reporting himself. He wrote, The
secretary blatantly told me the Board did not give any consideration to source. She
actually stated I should wait and see if the client complained. Finally, a female therapist
wrote, I recognized I was in trouble and self-reported. The board didnt have any
process for self-report and seemed more bent on punishment than requested
rehabilitationit was a very stressful and degrading experience...self reporting helped
me to regain my self-respect, but professionally it was ruinous and humiliating.

173
Based on the qualitative information provided by sanctioned participants, the
following recommendations are made; (a) psychotherapy during graduate school should
be expected and normalized as part of the process of becoming a psychologist, (b)
psychotherapy throughout a psychologist's career should be expected and normalized as
part of the process of introspection in regard to risk factors for engaging in a dual
relationship.
Suggestions for Future Research
Over the last thirty years studies have been conducted that have advanced
knowledge in regard to prevalence and demographic characteristics of offending
psychologists. Much of the prior literature is anecdotal or case-related, not empirical.
The empirical studies that have been done have lacked a control group. While data have
been gleaned expost facto in comparison to characteristics of nonoffending psychologists,
the present study is the first to be specifically designed a priori to utilize a control group
of non-sanctioned psychologists. Use of a control group improves research in this area
by providing comparison data of psychologists who have not been sanctioned for a dual
relationship. Additionally, the present study utilized measures that attempted to quantify
qualitative results from other studies. For example, offending psychologists have been
described by Celenza and Hilsenroth (1997) as narcissistically needy. The present
study quantified this summation of offending psychologists characteristics by measuring
narcissistic injury with a standardized instrument. Similarly, Celenza and Hilsenroth
(1997) discussed their subjects object relations as a result of a comprehensive
psychological evaluation which included projective assessments and an extensive clinical
interview. The present research attempted to quantify object relations by utilizing a well-

174
known, reliable and valid measure. Finally, the Parentification Questionnaire was used to
capture the early parent-child interactions in a quantified way.
Recently, the field has turned its attention to complex research that attempts to
identify variables differentiating offending and nonoffending psychologists. The facts
are compelling: a majority of psychologists will at some time in their career experience
erotic transference and/or countertransference, common risk factors include being a
middle-aged male, working in private practice who recently experienced the loss of a
significant other, and a history of childhood emotional and/or sexual abuse.
As the American Psychological Association prepares to release an updated Code
of Ethical Conduct for Psychologists, it is imperative to continue research in the area of
dual relationships. The following research recommendations are offered; (a) devise
better instruments to assess psychodynamic constructs so understanding can be increased
about whether therapists characteristics or behavior should be more important in
classifying, treating, and assessing them, (b) devise better instruments to gather childhood
abuse information, (c) construct better instruments that measure the effects of the
sanctioning process, (d) conduct outcome studies on the effectiveness of ethics-related
training programs, (e) explore the role of object relations, parentification, and narcissistic
injury in childhood and the relation to boundary violations, (f) analyze characteristics of
female nonsexual and sexual dual relationship offenders, (g) conduct research on same
gender sexual exploitation, (h) assess the point at which the sexual boundary violations
occurred, (i) analyze characteristics of male client victims, (j) conduct qualitative studies
to clarify if longstanding personality vulnerabilities or the effects of the adjudication
process are being measured when studying sanctioned psychologists, (k) perform
outcome studies on therapists who have the capacity for rehabilitation.

175
Summary and Conclusion.
For this group of offenders, a life crisis may have contributed to the psychologist
committing boundary violations, however, it is noteworthy that a history of childhood
abuse (particularly emotional abuse) was related to troubled object relations,
parentification, and narcissistic injury. Thus, a history of abuse and maltreatment appears
to be an important risk factor for future boundary violations. This is not to say that every
psychologist with a history of abuse is a potential offender. Instead, psychologists with a
history of abuse and resulting damage in narcissistic injury and self-esteem should
examine carefully how such a history impacts them personally and professionally.
This is a preliminary study that attempted to find differences between
psychologists who were sanctioned for engaging in nonsexual or sexual dual relationship
with a client(s) and psychologists who were not. While this study revealed the
differences were fewer than the similarities between these three groups, these results
should be interpreted cautiously. There is much to be learned and this is the beginning of
empirical research that addresses psychodynamic characteristics of offending and
nonoffending psychologists. Also, there are several potential limitations of the study that
may have impacted the results.
Limitations
Volunteer participants may have differed from those who chose not to respond
and this limits the generalizability of these results. Groups A and B represented a
nonrandom population of psychologists. Individuals in the population of sanctioned
psychologists did not have an equal chance of being surveyed in this study. Names and
addresses were requested from the National Register of Health Service Providers and all
fifty state psychology boards that complied with the publics right to know when

176
professionals have been sanctioned for ethical violations. To further clarify, it is not
known where the sanctioned psychologists came from in regard to resident state or
professional organization.
In a similar vein, the breakdown of gender in the control group did not exactly
match the ratio of members of the American Psychological Association. This slight
overrepresentation of females in the present study, may have contributed differentially to
the results.
That the participants were psychologists was also a limitation. Psychologists are
trained in assessment. The Ethical Judgment Scale was designed to measure the
motivation to present oneself in a favorable light. Given the high scores on this scale,
interpretation of the motivation to present oneself in a favorable light was limited. In the
future, this scale should be expanded to include other scenarios with more complex
ethical dilemmas. Additionally, because psychologists are trained in assessment and may
have seen through the instruments, the accuracy of their scores may be questionable.
Participants in the present study may have deciphered the instruments and thus
manipulated the responses, which could have influenced the validity of the results.
Finally, for the sanctioned groups, it is unknown the extent to which the measures were
influenced by the psychological trauma of being sanctioned versus longstanding
personality variables. Additionally, this study did not address American Psychological
Association loss of membership or other American Psychological Association sanctions
that may have been received by sanctioned participants.
Another limitation of concern is the difficulty in assessing if these sanctioned
subjects committed multiple ethical violations. Although the demographic questionnaire

177
listed virtually all ethical violations, it was impossible to assess for repeated offenses.
Personality characteristics of multiple offenders versus one-time offenders may vary
considerably, thus present a very different profile ultimately affecting the results of the
study. A related issue involves the difficulty in assessing if any psychologists in the
control group ever engaged in a nonsexual or sexual dual relationship with a client. The
only assumption that can be made about the control group is that those participants had
never been sanctioned for such an ethical violation, which is supported by the optional
question on the demographic questionnaire.
In the present study, the issue of who initiated the dual relationship was not
addressed. This limitation speaks to the different profiles of offenders that may emerge if
the offender is the initiator vs. responder of the invitation to engage in a dual relationship.
The time between being sanctioned and participating in the study produced a
considerable time gap resulting in retrospective data collection. Celenza and Hilsenroth
(1997) and Celenza (1998) both collected data at the precise time when the therapist was
being sanctioned. For the present study a possible gap of 15 years or more between being
sanctioned and completing the questionnaire packet was another limitation. The ethical
climate for practicing psychotherapy has changed in the last fifteen years. For example,
due to media coverage and increased litigation, therapist-client dual relationship issues
have received more research, education, and preventative attention in the last ten years.
The most recent ethical code addresses the issue of dual relationships in a more
comprehensive manner than previous ethical codes. As a result, graduate programs have
taken steps to directly address the issue of dual relationships. A psychologists who
receives training in the year 2002 will probably have a much different educational
experience than a psychologist who completed graduate work just 15 years ago.

178
References
American Psychiatric Association (1994). Diagnostic and statistical manual of mental
disorders (4th ed.). Washington, D.C.: Author.
American Psychological Association (1953). Ethical standards of psychologists.
Washington, DC: Author.
American Psychological Association (1990). Ethical principles of psychologists
(amended June 2, 1989). American Psychologist, 45, 390-395.
American Psychological Association (1992). Ethical principles of psychologists and
code of conduct. American Psychologist, 47, 1597-1611.
American Psychological Association (1998). Report of the ethics committee. American
Psychologist, 54 (8) 701-710.
Anderson, S.K., and Kitchener, K.S. (1996). Non-romantic, nonsexual post-therapy
relationships between psychologists and former clients: An exploratory study
of critical incidents. Professional Psychology: Research and Practice, 27(1), 5966.
Baer, B.E., & Murdock, N.L. (1995). Nonerotic dual relationships between
therapists and clients: The effects of sex, theoretical orientation, and interpersonal
boundaries. Ethics and Behavior, 5(2), 131-145.
Bell, M. (1995). Bell Object Relations Inventory Manual. Western Psychological
Services: CA.
Bell, M., Billington, R., & Becker, B. (1986). A scale for the assessment of object
relations: Reliability, validity, and factorial invariance. Journal of Clinical
Psychology, 42(5), 733-741.

179
Borys, D.S., & Pope, K.S. (1989). Dual relationships between therapist and client: A
national study of psychologists, psychiatrists, and social workers. Professional
Psychology: Research and Practice, 20, 283-293.
Bouhoutsos, J., Holroyd, J., Lerman, H., Forer, B.R., & Greenberg, M. (1983). Sexual
intimacy between psychotherapists and clients. Professional Psychology:
Research and Practice, 14(2), 185-196.
Bridges, N.A. (1994). Meaning and management of attraction: Neglected areas of
psychotherapy training and practice. Psychotherapy, 31(3), 424-433.
Brightman, B.K. (1989). Narcissistic issues in the training experience of the
psychotherapist. Psychoanalytic Psychotherapy, 10, 293-317.
Brownlee, K. (1996). The ethics of nonsexual dual relationships: A dilemma for the rural
mental health practitioner. Community Mental Health Journal, 32(5),
497-503.
Burt, A. (1986). Generational boundaries in children of alcoholics. Unpublished
masters thesis, Georgia State University, Atlanta, GA.
Butler, S., & Zelen, S.L. (1977). Sexual intimacies between therapists and clients.
Psychotherapy: Theory, Research, and Practice, 14(2), 139-145.
Cass, V.C. (1979). Homosexual identity formation: A theoretical model. Journal of
Homosexuality, 4(3), 219-235.
Celenza, A. (1991). The misuse of countertransference love in sexual intimacies between
therapists and clients. Psychoanalytic Psychology, 8(4), 501-509.
Celenza, A. (1998). Precursors to therapist sexual misconduct: Preliminary findings.
Psychoanalytic psychology, 15(3), 378-395.

180
Celenza, A., & Hilsenroth, M. (1997). Personality characteristics of mental health
professionals who have engaged in sexualized dual relationships: A Rorschach
investigation. Bulletin of the Menninger Clinic, 61(3), 90-107.
Chase, N.D., Deming, M.P., & Wells, M.C. (1998). Parentification, parental
alcoholism, and academic status among young adults. The American Journal
of Family Therapy, 26, 105-114.
Coen, S.J. (1996). Love between therapist and client: A review. American Journal of
Psychotherapy, 50(1), 14-27.
Crowne, D.P., & Marlowe, D. (1960). A new scale of social desirability independent of
psychopathology. Journal of Counseling Psychology, 24, 349-359.
Elliott, D.M. & Guy, J.D. (1993). Mental health professionals versus non-mental-health
professionals: Childhood trauma and adult functioning. Professional Psychology:
Research & Practice, 24(1), 83-90.
Epstein, R.S., Simon, R.I., & Kay, G.G. (1992). Assessing boundary violations in
psychotherapy: Survey results with the exploitation index. Bulletin of the
Menninger Clinic, 56, 150-166.
Feldman-Summers, S., & Jones, G. (1984). Psychological impacts of sexual contact
between therapists or other health care practitioners and their clients. Journal
of Consulting and Clinical Psychology, 52(6), 1054-1061.
Finell, J. (1985). Narcissistic problems in analysts. International Journal of PsychoAnalysis, 66, 433-445.
Freud, S. (1958). Observations on transference-love. In J. Strachey (Ed. and
Trans.), The Standard Edition of the Complete Psychological Works of Sigmund
Freud (Vol.12, pp.157-173). London: Hogarth Press.

181
Gabbard, G. (1990). Psychodynamic Psychiatry in Clinical Practice. Washington, DC:
American Psychiatric Press.
Gabbard, G.O. (1991). Psychodynamics of sexual boundary violations. Psychiatric
Annals, 21(11), 651-655.
Gabbard, G.O. (1994a). Psychotherapists who transgress sexual boundaries with clients.
Bulletin of the Menninger Clinic, 58(1), 124-135.
Gabbard, G.O. (1994b). Sexual excitement and countertransference love in the analyst.
Journal of the American Psychoanalytic Association, 42(4), 1083-1107.
Gabbard, G.O. (1995). Transference and countertransference in the psychotherapy of
therapists charged with sexual misconduct. Psychiatric Annals, 25(2), 100-105.
Gabbard, G.O. (1996). Lessons to be learned from a study of sexual boundary
violations. American Journal of Psychotherapy, 50(3), 311-323.
Gartell, N., Herman, J., Olarte, S., Feldstein, M., & Localio, R. (1986).
Psychiatrist-client sexual contact: Results of a national study. American Journal
of Psychiatry, 143, 1126-1131.
Gelso, C.J., & Carter, J.A. (1994). Components of the psychotherapy relationship their
interaction and unfolding during treatment. Journal of Counseling
Psychology, 41(3), 296-306.
Glickauf-Hughes, C., & Mehlman, E. (1995). Narcissistic issues in therapists: Diagnostic
and treatment considerations. Psychotherapy, 32 (2), 213-221.
Goglia, L.R. (1982). An exploration of the long-term effects of parentification.
Unpublished masters thesis, Georgia State University, Atlanta, GA.
Goglia, L.R., Jurkovic, G.J., Burt, A.M., & Burge-Callaway, K.G. (1992).
Generational boundary distortions by adult children of alcoholics: Child as parent

182
and child as mate. The American Journal of Family Therapy, 20(4), 291-299.
Gonsiorek (1989). Sexual exploitation by psychotherapists: Some observations on male
victims and sexual orientation issues. In Schoener, G.R., Milgrom, J.H.,
Gonsiorek, J.C., Luepker, E.T., & Conrob, R. M. (Eds.), Psychotherapists sexual
involvement with clients: Intervention and prevention. (p. 113-119).
Minneapolis, MN: Author.
Gottlieb, M.C. (1990). Accusation of sexual misconduct: Assisting in the complaint
process. Professional Psychology, 21(6), 455-461.
Gottlieb, M.C. (1993). Avoiding exploitative dual relationships: A decision-making
model. Psychotherapy, 30, 41-48.
Gutheil, T.G. (1989). Borderline personality disorder, boundary violations and patienttherapist sex: Medico-legal pitfalls. American Journal of Psychiatry, 146, 597602.
Gutheil, T.G. (1991). Clients involved in sexual misconduct with therapists: Is a victim
profile possible? Psychiatric Annals, 21(11), 661-667.
Gutheil, T.G., & Gabbard, G.O. (1992). Obstacles to the dynamic understanding of
therapist-client sexual relations. American Journal of Psychotherapy, 44(4), 515525.
Gutheil, T.G., & Gabbard, G.O. (1993). The concept of boundaries in clinical practice:
Theoretical and risk-management dimensions. American Journal of
Psychiatry, 150, 188-196.
Gutheil, T.G., & Simon, R.I (1995). Between the chair and the door: Boundary issues in
the therapeutic transition zone. Harvard Review of Psychiatry, 2(6), 336-340.

183
Hamilton, J.C., & Spruill, J. (1999). Identifying and reducing risk factors related to
trainee-client sexual misconduct. Professional Psychology: Research and
Practice, 30(3), 318-327.
Haspel, K.C., Jorgenson, L.M., Wincze, J.P., & Parsons, J.P. (1997). Legislative
intervention regarding therapist sexual misconduct. Professional Psychology:
Research and Practice, 28(1), 63-72.
Herman, J.L., Perry, J.C., & van der Kolk, B.A. (1989). Childhood trauma in borderline
personality disorder. American Journal of Psychiatry, 146(4), 490-495.
Holroyd, J., & Bouhoutsos, J. (1985). Biased reporting of therapist-client sexual
intimacy. Professional Psychology: Research and Practice, 16(5), 701-709.
Holroyd, J., & Brodsky, A.M. (1977). Psychologists attitudes and practices
regarding erotic and nonerotic physical contact with clients. American
Psychologist, 32, 843-849.
Holroyd, J., & Brodsky, A.M. (1980). Does touching clients lead to sexual
intercourse? Professional Psychology: Research and Practice, 11, 807-811.
Horner, A.J. (1984). Object relations and the developing ego in therapy. New York:
Jason Aronson.
Howell, D. C. (1992). Statistical methods for psychology (3rd ed.). Belmont, CA:
Duxbury.
Jackson, H., and Nuttall, R.L. (2001). A relationship between childhood sexual abuse
and professional sexual misconduct. Professional Psychology: Research and
Practice, 32(2), 200-204.
Jones, R.A., & Wells, M. (1996). An empirical study of parentification and
personality. The American Journal of Family Therapy, 24(2), 145-152.

184
Kernberg, O.F. (1975). Borderline conditions and pathological narcissism. New York:
Aronson.
Kluft, R.P. (1990). Dissociation and subsequent vulnerability. Dissociation, 3, 167-173.
Kohut, H., & Wolf, E.S. (1978). The disorders of the self and their treatment.
International Journal of Psychoanalysis, 59, 413-425.
Ladany, N., Hill, C.E., Corbett, M.M, & Nutt, E.A. (1996). Nature, extent, and
importance of what psychotherapy trainees do not disclose to their supervisors.
Journal of Counseling Psychology, 43(1), 10-24.
Ladany, N., OBrian, K.M., Hill, C.E., Melincoff, D.S., Knox, S., & Petersen, D.A.
(1997). Sexual attraction toward clients, use of supervision, and prior
training: A qualitative study of pre-doctoral psychology interns. Journal of
Counseling Psychology, 44(4), 413-424.
Lamb, D.H., & Catanzaro, S.J. (1998). Sexual and nonsexual boundary violations
involving psychologists, clients, supervisees, and students. Professional
Psychology: Research and Practice, 29(5), 498-503.
Lamb, D.H., Woodburn, J.R., Lewis, J.T., Strand, K.K., Buchko, K.J., & Kang, J.R.
(1994). Sexual and business relationships between therapists and former clients.
Psychotherapy, 31(2).
Licht, M.H. (1995). Multiple regression and correlation. In Grimm, L.G. and Yarnold,
P.R. (Eds.), Reading and Understanding Multivariate Statistics (pp.19-64).
Washington D.C.: American Psychological Association.
Lothane, Z. (1999). Tender love and transference: Unpublished letters of C.G. Jung and
Sabina Spielrein. The International Journal of PsychoAnalysis, 80(6), 145-156.

185
Mahler, M., Pine, F., & Anni, B. (1975). The psychological birth of the human infant:
Symbiosis and individuation. New York: Basic Books.
Mika, P., Bergner, R.M., & Baum, M.C. (1987). The development of a scale for the
assessment of parentification. Family Therapy, 14 (3), 229-235.
Miller, A. (1981). The drama of the gifted child. New York: Basic.
Olarte, S.W. (1991). Characteristics of therapists who become involved in sexual
boundary violations. Psychiatric Annals, 21(11), 657-660.
Pope, K.S. (1986). Research and laws regarding therapist-client sexual
involvement: Implications for therapists. American Journal of Psychotherapy,
40, 564-571.
Pope, K.S. (1987). Preventing therapist-client sexual intimacy: Therapy for a
therapist at risk. Professional Psychology: Research and Practice, 18(6), 624628.
Pope, K.S. (1989). Sexual intimacies between psychologists and their students and
supervisees: Research, standards and professional liability. The Independent
Practitioner, 9, 33-41.
Pope, K.S. (1990a). Therapist-client sex as sex abuse: six scientific, professional, and
practical dilemmas in addressing victimization and rehabilitation.
Professional Psychology: Research and Practice, 21, 227-239.
Pope, K.S. (1990b). Therapist-client sexual involvement: A review of the research.
Clinical Psychology Review, 10, 477-490.
Pope, K.S. (1991). Dual relationships in psychotherapy. Ethics and Behavior, 1, 22-34.
Pope, K.S. (1993). Licensing disciplinary actions for psychologists who have been
sexually involved with a client: Some information about offenders. Professional

186
Psychology: Research and Practice, 24(3), 374-377.
Pope, K.S., & Bouhoutsos, J.C. (1986). Sexual intimacy between therapists and patients.
New York: Praeger.
Pope, K.S., & Feldman-Summers, S. (1992). National survey of psychologists sexual
and physical abuse history and their evaluation of training and competence in
these areas. Professional Psychology: Research and Practice, 23(5), 353-361.
Pope, K.S., Keith-Spiegel, P., & Tabachnick, B.G. (1986). Sexual attraction to clients:
The human therapist and the (sometimes) inhuman training system. American
Psychologist, 41(2), 147-158.
Pope, K.S., Levenson, H., & Schover, L.R. (1979). Sexual intimacy in
psychology training: Results and implications of a national survey. American
Psychologist, 34, 682-689.
Pope, K.S., & Tabachnick, B.G. (1993). Therapists anger, hate, fear, and sexual
feelings: A national survey of therapist responses, client characteristics, critical
events, formal complaints, and training. Professional Psychology: Research and
Practice, 24(2), 142-152.
Pope, K.S., Tabachnick, B.G., & Keith-Spiegel, P. (1987). Ethics of practice: The beliefs
and behaviors of psychologists as therapists. American Psychologist, 42, 9931006.
Pope, K.S., & Vetter, V.A. (1991). Prior therapist-client sexual involvement
among clients seen by psychologists. Psychotherapy, 28, 429-438.
Pope, K.S., & Vetter, V.A. (1992). Ethical dilemmas encountered by members of the
American Psychological Association. American Psychologist, 47(3), 397-411.

187
Racusin, G. A., Abramowitz, S.I., & Winter, W.D. (1981). Becoming a therapist: Family
dynamics and career choice. Professional Psychology, 12(2), 271-279.
Rios, P., & Hill, C.E. (1993). The correlates of narcissistic injury: Parental
bonding, self esteem, impact of events, depression, and grandiosity. Manuscript
in preparation.
Rodolfa, E., Hall, T., Holms, V., Davena, A., Komatz, D., Antunez, M., & Hall, A.
(1994). The management of sexual feelings in therapy. Professional Psychology:
Research and Practice, 25(2), 168-172.
Rosenberg, M. (1965). Society and the Adolescent Self-Image. Princeton, New Jersey:
Princeton University Press.
Schank, J.A., & Skovholt, T.M. (1997). Dual-relationship dilemmas of rural and smallcommunity psychologists. Professional Psychology: Research and
Practice, 28(1), 44-49.
Schoener, G.R. (2000). Exploitation of professional relationships. Paper presented at the
meeting of the Swiss Congress Against Violence and Abuse of Power, Germany.
Schoener, G.R. & Gonsiorek, J.C. (1990). Assessment and development of rehabilitation
plans for the therapist. In Schoener, G.R., Milgrom, J.H., Gonsiorek, J.C.,
Luepker, E.T., & Conrob, R.M. (Eds.), Psychotherapists sexual involvement with
clients: Intervention and prevention. (pp. 401-420). Minneapolis, MN: Author.
Sessions, M.W., & Jurkovic, G.J. (1986). The Parentification Questionnaire.
Available from Gregory J. Jurkovic, Dept. of Psychology, Georgia State
University, I University Plaza, Atlanta, GA 30303.
Silber, E., & Tippett, J. (1965). Self-esteem: Clinical assessment and measurement
validation. Psychological Reports, 16, 1017-1071.

188
Simon, R.I. (1989). Sexual exploitation of clients: How it happens before it
happens. Psychiatric Annals, 19, 104-112.
Simon, R.I. (1991). Psychological injury caused by boundary violation precursors to
therapist-client sex. Psychiatric Annals, 21(10), 614-619.
Simon, R.I. (1992). Treatment boundary violations: Clinical, ethical, and legal
considerations. Bulletin of the American Academy of Psychiatry Law, 20(3),
1992.
Simon, R.I. (1994). Transference in therapist-client sex: The illusion of client
improvement and consent, part one. Psychiatric Annals, 24(10), 506-512.
Simon, R.I. (1999). Therapist-client sex. The Psychiatric Clinics of North America,
22(1), 31-47.
Slyter, S.L. (1989). Kohuts psychology of the self: Measures of healthy and
defensive narcissism. Dissertation Abstracts International, 51, 467B.
(University Microfilms No. DA9012518).
Smith, D., & Fitzpatrick, M. (1995). Client-therapist boundary issues: An
integrative review of theory and research. Professional Psychology: Research
and Practice, 26(5), 499-506.
Somer, E., & Saadon, M. (1999). Therapist-client sex: Clients retrospective reports.
Professional Psychology: Research and Practice, 30(5), 504-509.
Sonne, J.L. (1994). Multiple relationships: Does the new ethics code answer the right
questions? Professional Psychology: Research and Practice, 25(4), 336-343.
Stake, J.E., & Oliver, J. (1991). Sexual contact and touching between therapist and
client: A survey of psychologists attitudes and behavior. Professional
Psychology: Research and Practice, 22(4), 297-307.

189
Stein, M. (1983). In Mid-life. Dallas, Tx: Spring Publications.
Stone, E.M. (1994). American Psychiatric Glossary, ed 7. Washington: American
Psychiatric Press, 1994, p.135.
Strasburger, L.H., Jorgenson, L., & Sutherland, P. (1992). The prevention of
psychotherapist sexual misconduct: Avoiding the slippery slope. American
Journal of Psychotherapy, 46(4), 544-555.
Tabachnick, B. G., & Fidell, L. S. (1996). Using multivariate statistics (3rd ed.).
New York, NY: HarperCollins College.
Tallman, G. (1981). Therapist-client social relationships, Unpublished manuscript,
California State University, Northridge.
Twemlow, S.W. (1997). Exploitation of clients: Themes in the psychopathology of their
therapists. American Journal of Psychotherapy, 51(3), 357-375.
Twemlow, S.W., & Gabbard, G.O. (1989). Sexual exploitation in professional
relationships. Washington, DC: American Psychiatric Press.
Valleau, M.P., Bergner, R.M., & Horton, C.B. (1995). Parentification and caretaker
syndrome: An empirical investigation. Family Therapy, 22(3), 158-164.
Walker, L.E.A. (1989). Psychology and violence against women. American
Psychologist, 44(4), 695-702.
Watson, P.J., Hickman, S.E., Morris, R.J., Milliron, J.T., & Whiting, L. (1995).
Narcissism, self-esteem, and parental nurturance. The Journal of Psychology,
129(1), 61-73.
Wells, M.C., & Jones, R. (2000). Childhood parentification and shame proneness. The
American Journal of Family Therapy, 28, 19-27.

190
West, M. L., & Keller, A. (1991). Parentification of the child: A case study of Bowlbys
compulsive care-giving attachment pattern. American Journal of
Psychotherapy, 11(3), 425-431.
Winnicott, D.W. (1949). Hate in the countertransference. International Journal of
Psychoanalysis, 30, 69-74.
Wolkin, J.R. (1984). Childhood parentification: An exploration of long-term
effects. Dissertation Abstracts International, 45, 2707 (University Microfilms No.
84-24601).
Zamostny, K.P., Slyter, S.L., & Rios, P. (1993). Narcissistic injury and its
relationship to early trauma, early resources, and adjustment to college. Journal
of Counseling Psychology, 40(4), 501-510.

191

Appendices

192

Appendix A
Letter of Introduction
(Groups A and B)

193

Dear Respondent,
In the Fall of 1998 I began to investigate and study the plight of psychologists who have
been sanctioned by their state licensing boards for various ethical violations. Since that
time, it has come to my attention that there is a dearth of research and a general lack of
understanding of this complex topic. I received your name from your state licensing board
and hope that you will consider participating in this study.
Unfortunately, to date the media and research communities focus mainly on the clients
experience, while neglecting another important side of the story, that is, the experience of
the psychologist who has been sanctioned for an ethical violation. I believe it is time to
address this issue and seek individuals, such as yourself, to aid in understanding the too
often neglected other party.
I am planning on conducting a confidential survey study in the Fall, 2000 to answer the
question of what variables are unique to psychologists who have been sanctioned by their
respective state psychology boards. This study will fulfill the requirements for a doctoral
dissertation. Completion of the slated questionnaire study will not only help to advance
knowledge, but will be an opportunity for you shed light on the side of the issue that is
often ignored or misunderstood. My plan is to use the results of this upcoming study to
inform the field of psychology and the scientific community of the complex issues faced by
sanctioned psychologists. Moreover, at this time, I am asking if you would be interested in
participating in this research.
Enclosed is a postcard for you to complete indicating your willingness to participate in this
confidential study. If you agree to participate, you will be sent a questionnaire next Fall
(participants will be assigned a code number) that will ask demographic information,
questions regarding childhood experiences, and questions regarding personal and
professional boundaries. Importantly, responses and data will be kept confidential and
anonymity will be maintained by the use of code numbers, not names.
Sincerely,

Debra K. Ehlert, M.A.

West Virginia University

Sherilyn Cormier, Ph.D.

West Virginia University

194

Appendix B
Postcard for Groups A and B

195

Returning this postcard signifies that I am willing to participate in the upcoming mail survey
study this fall. I understand that my participation is confidential and upon receiving this postcard
the principal investigator will assign a number to me to be used in lieu of my name from now
until the completion of the study. Additionally, if you are willing to participate in a brief
confidential phone interview, please check the box and provide your phone number.

Yes, I am willing to be interviewed via phone.

My phone number is:____________________________.

196

Appendix C
Cover Letter (Groups A and B)

197
Debra K. Ehlert
476 Winsley St.
Morgantown, WV 26501
Re: Psychosocial Characteristics of Psychologists
Dear Respondent #________,

January 15, 2001

Last year, you received a letter and postcard requesting your participation in an
upcoming study on psychologists who have been sanctioned by their respective state
psychology boards. Well, the time has come and I am asking for your help to complete a
study examining psychosocial characteristics of psychologists and the experience of
being sanctioned.
This study is comprised of a series of questionnaires designed to elicit information
about personality, family background, and your experience of being sanctioned by a
licensing board. The measures are interesting and I believe they will be meaningful to
you. The entire packet should take about thirty to forty minutes to complete.
The information you give will be entirely private and confidential. Names of
participants are not recorded on the raw data. All questionnaires are designed to be
answered anonymously. You have been given a subject number.
My hope is that you will enjoy participating and may even learn some new
insights about yourself. You will also be contributing to our knowledge of therapist
characteristics and the sanctioning process, which may benefit trainers, educators, and
members of ethics committees. If you would like a summary of the results of this study
please contact me with your request. Finally, this project will partially fulfill my
academic requirements for the WVU Counseling Psychology doctoral program.
Please read the enclosed information letter, complete the questionnaire packet, and
return the packet in the enclosed stamped envelope no later than March 1, 2001.
Remember, confidentiality and anonymity will be maintained by the use of code numbers,
not names. If you have any questions please feel free to contact me or Dr. Cormier.
Sincerely,

Debra K. Ehlert, M.A.

West Virginia University

Sherilyn Cormier, Ph.D.

West Virginia University

198

Appendix D
Information Form (Groups A and B)

199

INFORMATION FORM
Project Title: Psychosocial Characteristics of Psychologists
Introduction: You have been invited to participate in a study examining psychosocial
characteristics of psychologists. This research is being conducted by Debra K. Ehlert to
fulfill the requirements for a doctoral dissertation in Counseling Psychology in the
Department of Counseling Psychology at West Virginia University.
Purpose of Study: The purpose of this study is to elicit information about personality,
family background, and the experience of being sanctioned by a licensing board. This
study is comprised of a series of questionnaires that should take about thirty minutes to
complete. Approximately 100 subjects are expected to participate in this study. You do
not have to answer all the questions if you decide to participate.
Risks and Discomforts: There are no known or expected risks from participating in this
study, however, some questions may elicit some discomfort. All questionnaires are
designed to be answered anonymously. The information given will be entirely private
and confidential. Names of participants are not recorded on the raw data. The
dissertation of this study will describe the group as a whole, the details of what individual
participants say will remain confidential.
Alternative: You are free to withdraw and to discontinue participation in this study at
any time without prejudice. While responses to all of the items are desired, you are free
to omit answers to specific questions if you wish.
Benefits: This study is not expected to be of direct benefits to participants, but the
knowledge gained may contribute to the knowledge of therapist characteristics and the
sanctioning process, which may benefit trainers, educators, and members of ethics
committees.
Contact Persons: For more information about this research, contact Debra K. Ehlert at
304-293-3807 or her dissertation chair, Dr. Sherilyn Cormier at 304-293-3807. For
information regarding your rights as a research subject, contact the Executive Secretary
of the Institutional Review Board at 304-293-7073.

200

Appendix E
Demographic Questionnaire (Groups A and B)

201
Participant:

S#______

Please complete the following demographic questions and all the completed questionnaires
in the self-addressed stamped envelope and mail. Thank you for participating in this research.
1.

Age:_____20-29 yrs. _____30-39 yrs. _____40-49 yrs. _____50-59 yrs. _____60+ yrs.

2.

Gender: _______Female

3.

Academic Training: _____Counseling Psychology _____Clinical Psychology

Male________

_____Psy.D.

_____Other degree (please indicate)

4.

Theoretical Orientation:

_____Humanistic (e.g., Rogerian, Existential, Gestalt)

_____Behavioral
_____Cognitive
_____Psychoanalytic/Psychodynamic
_____Family Systems
_____Other (please specify)_____________________

5.

Your childhood experiences (age 0-18 years): (please check all that apply)
Emotional abuse perpetrated by:

_____father (or primary paternal figure)

_____mother (or primary maternal figure)
_____other relative
_____other non-relative

Nonsexual physical abuse perpetrated by:

_____father (or primary paternal figure)

_____mother (or primary maternal figure)
_____other relative
_____other non-relative

Sexual abuse perpetrated by:

_____father (or primary paternal figure)

_____mother (or primary maternal figure)
_____other relative
_____other non-relative

_____Not applicable (please skip to question 6)

202

6.

Type of ethical violation(s) for which you were sanctioned: (check all that apply)
______ abandoning a client
______ committed a felony offense
______ engaging in a business dual relationship with a client
______ engaging in a social dual relationship with a client
______ engaging in a sexual dual relationship with a client
______ failing to complete continuing education credits
______ failing to maintain adequate business records
______ failing to maintain confidentiality of a client
______ impairment due to mental illness
______ illegal billing practices
______ inappropriate self-disclosure
______ non-erotic physical contact
______ practicing while license was suspended
______ providing services that were unnecessary or unsafe
______ other (please specify in the following space): ___________________
______________________________________________________________
______________________________________________________________
______________________________________________________________

7. Type of sanction(s) you received: (check all that apply)

_____reprimand _____censure _____loss of licensure _____stipulated resignation
_____cease / desist order _____supervision requirement _____education / training requirement
_____evaluation

_____treatment requirement _____probation _____monetary fine

_____other (please specify)__________________________________________________

8. Work setting at the time of the ethical violation:
_____College or University counseling center _____Community mental health center
_____College or Univeristy faculty member _____Group practice
_____Independent private practice
_____State or Federal Prison
_____Veterans Hospital
_____Other (please specify) ___________________
9. Your partner status at the time of the ethical violation (circle):
Single

Married

Separated

Divorced

Living with partner

10. Your age at the time of the ethical violation: _______

11. Gender of the client(s) with whom the ethical violation occurred: _______
12. Age of the client(s) with whom the ethical violation occurred: _______
13. DSM-IV diagnostic impression of the client(s) with whom the ethical violation
occurred: ______________________________________________________________

203

Appendix F
Follow-up Postcard

204

Approximately two to three weeks ago you received a questionnaire

concerning a research project regarding psychosocial characteristics of psychologists. As
stated in the cover letter, this is an important area of research and your participation is
vital to the project. Please complete the questionnaire as soon as possible and return it to
the investigator. If you have already done so, please disregard this notice. Once again,
thank you for your participation.
Debra K. Ehlert, M.A.
West Virginia University

205

Appendix G
The Parentification Questionnaire (PQ)

206
(PQ-A)
Subject #_______
The following statements are possible descriptions of experiences you may have had while
growing up. If a statement accurately describes some portion of your childhood experience,
that is, the time during which you lived at home with your family (including your teenage
years), mark the statement true on your answer sheet. If the statement does not accurately
describe your experience, mark it false.
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
28.
29.
30.
31.
32.
33.
34.
35.

I rarely found it necessary for me to do other family members chores.

T
At times I felt I was the only one my mother/father could turn to.
T
My family members hardly ever looked to me for advice.
T
In my family I often felt called upon to do more than my share.
T
I often felt like an outsider in my family.
T
I felt most valuable in my family when someone confided in me.
T
It seemed like there were enough problems at home without my causing more.
T
In my family I thought it best to let people work out their problems on their own.
T
I often resented being asked to do certain kinds of jobs.
T
In my family it seemed that I was usually the one who ended up being responsible
for most of what happened.
T
In my mind, the welfare of my family was my first priority.
T
If someone in my family had a problem, I was rarely the one they could turn to for help. T
I was frequently responsible for the physical care of some member of my family,
i.e., washing, feeding, dressing, etc.
T
My family was not the kind in which people took sides.
T
It often seemed that my feelings weren't taken into account in my family.
T
I often found myself feeling down for no particular reason that I could think of.
T
In my family there were certain family members I could handle better than anyone else. T
I often preferred the company of people older than me.
T
I hardly ever felt let down by members of my family.
T
I hardly ever got involved in conflicts between my parents.
T
I usually felt comfortable telling family members how I felt.
T
I rarely worried about people in my family.
T
As a child I was often described as mature for my age.
T
In my family I often felt like a referee.
T
In my family I initiated most recreational activities.
T
It seemed like family members were always bringing me their problems.
T
My parents had enough to do without worrying about housework as well.
T
In my family I often made sacrifices that went unnoticed by other family members.
T
My parents were very helpful when I had a problem.
T
If a member of my family were upset, I would almost always become involved in some way.
T
I could usually manage to avoid doing housework.
T
I believe that most people understood me pretty well, particularly members of my family. T
As a child, I wanted to make everyone in my family happy.
T
My parents rarely disagreed on anything important.
T
I often felt more like an adult than a child in my family.
T

F
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F

207
36.
37.
38.
39.
40.
41.
42.

I was more likely to spend time with friends than with family members.
Other members of my family rarely needed me to take care of them.
I was very uncomfortable when things weren't going well at home.
All things considered, responsibilities were shared equally in my family.
In my house I hardly ever did the cooking.
I was very active in the management of my family's financial affairs.
I was at my best in times of crisis.

T
T
T
T
T
T
T

F
F
F
F
F
F
F

208

Appendix H
The Narcissistic Injury Scale (NIS)

209
NIS
Subject #______
On the following pages you will find a number of statements that may be used by many
persons to describe themselves. You will be asked to respond to the statements with a number,
ranging from six to one, according to the following scale:
6 = definitely most characteristic of you
5 = very characteristic of you
4 = somewhat characteristic of you

3 = somewhat uncharacteristic of you

2 = very uncharacteristic of you
1 = definitely most uncharacteristic of you

Please rate the extent to which EACH statement is characteristic of you and place the number
that best applies to the item in the space provided.
_____1. I have an amazing ability to perceive the needs of others who are important to me.
_____2. I am constantly asking myself what impression I am making, how I ought to be
reacting, or what feelings I ought to have.
_____3. I have a sense of really being alive.
_____4. I experience a wish to control others or events around me.
_____5. I must excel in everything I undertake, or I just wont attempt it.
_____6. I long for understanding from others.
_____7. I am special.
_____8. I always had to be strong for my parents.
_____9. I tend to make excessive demands upon myself.
____10. I must not show any dissatisfaction or disappointment with my parents, since this
would lead to their withdrawal and loss of affection.
____11. My parents were critical whenever anyone displayed weakness.
____12. I feel constricted.
____13. I have failed to live up to the ideal image I have of myself.
____14. I feel a sense of inner emptiness.
____15. I have a need to demonstrate my own superiority to others.
____16. I have a feeling of being abandoned.
____17. I have had grandiose (pie in the sky) fantasies.
____18. I find it difficult to tolerate loss.
____19. I feel humiliated.
____20. I have sympathy for the child I once was.
____21. I lack confidence in my own feelings and wishes.
____22. Because others need me constantly, I feel I am breaking down under the responsibility.

210
6 = definitely most characteristic of you
5 = very characteristic of you
4 = somewhat characteristic of you

3 = somewhat uncharacteristic of you

2 = very uncharacteristic of you
1 = definitely most uncharacteristic of you

____23. I must always be good and measure up to what everyone else expects or is doing.
____24. I may experience feelings of agonizing shame and painful nakedness when I feel that I
am on display.
____25. I treat feelings with ridicule and irony.
____26. My parents reacted negatively to any expression of anger on my part.
____27. I suffer from the feeling of guilt, in the sense of not having lived up to what my parents
expected of me.
____28. I long for attention.
____29. I have feelings of helplessness.
____30. I become aware of feelings only after several days when feelings have already passed.
____31. I know not only what I do not want but also what I want, and I am able to express this,
whether or not I will be accepted or rejected for it.
____32. I long for echoing from others.
____33. I usually feel that the demands are too great, but that I cannot change that.
____34. I complain of self-alienation and emptiness at times.
____35. As a child, I had been good, suffering quietly and without crying.
____36. I see myself as a failure.
____37. I tend to deny my own emotional reactions and feelings.
____38. My parents saw me as the person I really was.
____39. I have had the feeling of being in an inner prison.
____40. My parents understood me.
____41. I fear a loss of love.
____42. I feel alienated from myself.
____43. I have a sense of futility.
____44. I am aware of my needs and feelings, and the possibility of expressing them.
____45. I suffer from depression at times.
____46. I can love myself as I really am.
____47. My parents respected my feelings.
____48. I lack real emotional understanding.
____49. I have the sense that my life has no meaning.
____50. I have the sense of what my needs are.

211

Appendix I
The Rosenberg Self-Esteem Scale (RSE)

212

S#_____
RSE
Please circle the number which best describes your agreement or disagreement with the
statements below.
Strongly Agree
1

Agree

Disagree

Strongly Disagree

1. I feel that I am a person of worth, at least on an

equal basis with others.

2. I feel that I have a number of good qualities.

3. All in all, I am inclined to feel that I am a failure.

4. I am able to do things as well as most people.

5. I feel I do not have much to be proud of.

6. I take a positive attitude toward myself.

7. On the whole, I am satisfied with myself.

8. I wish I could have more respect for myself.

9. I certainly feel useless at times.

10. At times I think I am no good at all.

213

Appendix J
Ethical Judgment Scale (EJS)

214
Directions: Read the following vignettes and rate the psychologist on a scale of 1 to 5 in regard
to the ethical nature of his or her behavior.
1 = completely ethical behavior
2 = somewhat ethical behavior
3 = neither ethical nor unethical behavior
4 = somewhat unethical behavior
5 = completely unethical behavior
1. Soon after Grace began psychotherapy with Dr. Smith, she obtained four tickets to a local
play. Grace asked Dr. Smith if he and his wife would like to join her and her husband to the play
and for dinner afterwards. The evening was enjoyable for all parties. Other social interactions
among the foursome continued to occur. Dr. Smith finally confronted Grace during therapy with
his impression that nothing was moving. At that point Grace admitted that she was
experiencing numerous pressures and problems. But she felt that if she were honest about them
in therapy, Dr. Smith might choose not to socialize with her and her husband.
(circle only one number)

Completely
Ethical

5
Completely
Unethical

2. A 36-year-old single male with symptoms of depression entered therapy with a 37-year-old
female therapist. One night, after a few months of starting once-weekly supportive
psychotherapy, the therapist asked the client to return a book to the library for her as a favor.
Gradually, the therapist had the client perform other menial duties. The client began to have
trouble paying for his bill, so he agreed, at the therapists suggestion, to do yard work for her
office once a week in partial payment.
(circle only one number)

1
Completely
Ethical

5
Completely
Unethical

3. Dr. B. is in his late 40s. He is intelligent, attractive, carefully groomed, and has an
emotionally responsive nature and quick humor. He is divorced and living with his girlfriend of
several years. This relationship has been deteriorating, they are emotionally estranged, and he
has little hope for regaining a more satisfying relationship. Dr. B. has a client, Jane, who he
experiences as hard-to-reach and withholding. She is depressed, married to an alcoholic man, and
has great difficulty trusting men. She is quite resistant to talking about herself, and has spent
many sessions in silence, vigilantly watching Dr. B. Dr. B. offered to turn away or sit on the
other side of the room, thinking this might help her feel less threatened. When this seemed only
to exacerbate her anxiety, he offered to hold her hand in the hope that doing so would help her
feel safe. Dr. B. became increasingly affectionate toward his client, which he believed helped her
feel safe and encouraged her to open up. The hand holding, and after a while hugging at the end
of sessions, seemed to help in the sense that the client began to feel better. Jane began to open up
and felt she was falling in love with Dr. B. Dr. B. also felt as if he were falling in love and he
believed that Jane would be cured if she were loved in a constructive and caring way. Soon after

215
realizing he was in love with Jane, Dr. B. terminated their therapy relationship and they began
sexual relations.
(circle only one number)

Completely
Ethical

5
Completely
Unethical

4. Ms. Grant, a 32 year old, attractive, divorced woman is evaluated for mood swings and
chronic recurrent depression. She has a history of suicidal ideation and gestures; prior psychiatric
hospitalizations; chaotic interpersonal relationships; and long-standing, pervasive feelings of
emptiness. Although Ms. Grant graduated from law school, she does not practice law. Instead,
she has worked part-time as a real estate agent without much success. The psychologist, Dr.
Yates, is 52 years old and a widower. His wife died 5 years ago following a long bout with
cancer. Following her death, Dr. Yates slipped into a prolonged depression and experienced
profound feelings of loneliness and isolation, though he continued to practice. Seeing clients was
a welcome distraction from his own emotional pain. Dr. Yates feels an immediate attraction to
Ms. Grant during the first evaluation session. The description of her personal difficulties,
symptoms, and psychiatric history produce strong feelings of sorrow and sympathy for Ms. Grant.
The therapy proceeds unremarkably for the first 2 months; however, Dr. Yates realizes he is
almost brought to tears when Ms. Grant talks about the loss of her biological father and the years
of abuse by her stepfather. At these times, Dr. Yates attempts to console her by sitting next to her
and holding her hand.
Gradually, Dr. Yates departs from a position of neutrality by advising her about various problems
in her life. For example, he recommends his own accountant to Ms. Grant to assist her with some
income tax difficulties. At the end of each session, an easy familiarity develops in the interval
between the chair and the door. Before long, Dr. Yates and Ms. Grant begin to address each other
by first names. Ms. Grant is gradually treated as a special client. She is allowed to call Dr.
Yates at any time, day or night. During therapy sessions, Dr. Yates begins to self-disclose about
his depression and his personal devastation following the death of his wife. He openly confesses
that he finds Ms. Grant both physically and intellectually attractive. Therapy sessions are
terminated by a prolonged hug. When Ms. Grant tearfully recounts traumatic events from her
childhood, Dr. Yates embraces and holds her. Therapy sessions begin to extend beyond 50
minutes. He stops billing her and recognizes that he is committing serious boundary violations
but feels that the relationship with Ms. Grant is the exceptional circumstance because of their
growing love for each other. Gradually, Ms. Grants demands for Dr. Yates time and attention
escalate. She calls him 5 to 10 times a day. Hardly a night passes when Ms. Grant does not call.
Dating begins after the client promises she will call only once a day. Ms. Grant presses for a
sexual relationship because I cannot live without you. Dr. Yates finds himself unable to
refuse her request for sex, even though he is fully aware that sex with his client is
unprofessional, unethical, and legally actionable.
(circle only one number)

1
Completely
Ethical

5
Completely
Unethical

216

Appendix K
Open-ended Questions (Groups A and B)

217
Open Ended Questions

1. How would you describe yourself as a psychologist?

2. Briefly describe what was happening in your life at the time of the ethical violation.
3. What has the experience of being sanctioned been like for you?
4. What would best help this researcher understand your situation?

218

Appendix L
Cover Letter (Group C)

219
Debra K. Ehlert, M.A.
476 Winsley St.
Morgantown, WV 26501
re: Control Group
Dear _______________________,

January 15, 2001

In the Fall of 1998 I began to investigate and study the status of psychologists who have
been sanctioned by their state licensing boards for various ethical violations. Since that
time, it has come to my attention that there is a need for more research on this topic.
To advance scientific knowledge in this area, I am conducting a confidential survey study
to answer the question of what variables are unique to psychologists who have been
sanctioned by their respective state psychology boards. You have been randomly selected
to participate because you have not been sanctioned for an ethical violation. Your data will
serve as a comparison group to those psychologists who have been sanctioned. The
information you provide will significantly advance our knowledge of the psychosocial
characteristics of psychologists who engage in unethical behavior.
This study is comprised of multiple self-report questionnaires. The questionnaires are
designed to elicit information about family history, psychosocial characteristics, and for
those who have been disciplined, their experience of being sanctioned. This study will
fulfill the requirements for my doctoral dissertation. My plan is to use the results of this
study to inform the field of psychology and the scientific community of the complex issues
faced by sanctioned psychologists.
Most importantly, your participation will at all times be completely anonymous, there
wont even be a list matching subject number to name. In fact, your identity will never be
relevant. The packet you received is identifiable by subject number.
Please consider participating in this research, complete the questionnaire packet, and return
it in the enclosed stamped envelope no later than March 1, 2001.
Thank you for taking the time to participate in this important study. If you have any
questions please feel free to contact me or Dr. Cormier at dehlert@worldshare.net.
Sincerely,

Debra K. Ehlert, M.A.

West Virginia University

Sherilyn Cormier, Ph.D.

West Virginia University

220

Appendix M
Information Form (Group C)

221

INFORMATION FORM
Project Title: Psychosocial Characteristics of Psychologists
Introduction: You have been invited to participate in a study examining psychosocial
characteristics of psychologists. The information you provide will be used as control to
compare with those psychologists who have been sanctioned. This research is being
conducted by Debra K. Ehlert to fulfill the requirements for a doctoral dissertation in
Counseling Psychology in the Department of Counseling Psychology at West Virginia
University.
Purpose of Study: The purpose of this study is to elicit information about personality,
family background, and the experience of being sanctioned by a licensing board. This
study is comprised of a series of questionnaires that should take about thirty minutes to
complete. Approximately 100 subjects are expected to participate in this study. You do
not have to answer all the questions if you decide to participate.
Risks and Discomforts: There are no known or expected risks from participating in this
study, however, some questions may elicit some discomfort. All questionnaires are
designed to be answered anonymously. The information given will be entirely private
and confidential. Names of participants are not recorded on the raw data. The
dissertation of this study will describe the group as a whole; the details of what individual
participants say will remain confidential.
Alternative: You are free to withdraw and to discontinue participation in this study at
any time without prejudice. While responses to all of the items are desired, you are free
to omit answers to specific questions if you wish.
Benefits: This study is not expected to be of direct benefits to participants, but the
knowledge gained may contribute to the knowledge of therapist characteristics and the
sanctioning process, which may benefit trainers, educators, and members of ethics
committees.
Contact Persons: For more information about this research, contact Debra K. Ehlert at
304-293-3807 or her dissertation chair, Dr. Sherilyn Cormier at 304-293-3807. For
information regarding your rights as a research subject, contact the Executive Secretary
of the Institutional Review Board at 304-293-7073.

222

Appendix N
Demographic Questionnaire (Group C)

223
Participant (control group):
Please complete the following demographic questions and place all the completed
questionnaires in the self-addressed stamp envelope and mail. Thank you for participating in
this research.
1.

Age:_____20-29yrs. _____30-39 yrs. _____40-49 yrs. _____50-59 yrs. _____60+ yrs.

2. Gender: ________Female ________Male

3.

Academic Training: _____Counseling Psychology _____Clinical Psychology

_____Psy.D.
_____Other degree (please specify)

4.

Theoretical Orientation:

_____Humanistic (e.g., Rogerian, Existential, Gestalt)

_____Behavioral
_____Cognitive
_____Psychoanalytic/Psychodynamic
_____Family Systems
_____Other (please specify)_____________________

5. Your childhood experiences (ages 0-18 years): (please check all that apply)
Emotional abuse perpetrated by:

_____father (or primary paternal figure)

_____mother (or primary maternal figure)
_____other relative
_____other non-relative

Nonsexual physical abuse perpetrated by:

_____father (or primary paternal figure)

_____mother (or primary maternal figure)
_____other relative
_____other non-relative

Sexual abuse perpetrated by:

_____father (or primary paternal figure)

_____mother (or primary maternal figure)
_____other relative
_____other non-relative

_____Not applicable (skip to question 6)

6. (Optional) Have you ever had any experience with the sanctioning process for
psychologists youd like to share?____________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________

224

Curriculum Vitae

Name: Debra K. Ehlert

Date of Birth: May 2, 1968
Place of Birth: LaPorte, Indiana

Education
West Virginia University, Morgantown, West Virginia
Degree: Ph.D. in Counseling Psychology (APA approved) - 2002
West Virginia University, Morgantown, West Virginia
Degree: M.A. in Community Agency Counseling - 1997
University of Michigan, Ann Arbor, Michigan
Degree: B.A. in Education - 1991

Internship (APA approved)

Appalachian State University
University Counseling Center
August 2001 to August 2002