Client or former client? Implications of ex-client definition on social work practice.
The study discussed in this article investigated the effect of the variation in individual worker definition of "former client" in relationship to workers' perceptions of appropriate professional behaviors during the provision of social work services. A random sample of 654 social workers who possessed MSW degrees, provided direct services to clients, and were members of NASW were surveyed regarding their perceptions of appropriate behavior in seven practice domains: peripheral professional advice, concrete assistance, multiple or dual relationships, sexual and intimate relations, confidentiality and privacy, social relationships, and religion and prayer in practice. Variations in practice behavior perceptions were analyzed in relationship to the worker's definition of an "ex-client." The overall findings suggest that there is a definite lack of consensus regarding the definition of a former client, and that this may affect practice standards and variations in views of appropriate professional behavior.
Key words: client definition; ethics; practice standards; professional behaviors
The social work profession is rooted in a set of core values and ethical principles that have much to say about obligations and responsibilities to clients (Gambrill & Pruger, 1997; Levy, 1993; Lowenberg & Dolgoff, 1988; Reamer, 1995, 1998). The NASW Code of Ethics (2000) states that "'clients' is used inclusively to refer to individuals, families, groups, organizations, and communities" (p. 1). Social workers tend to apply this term broadly to refer to those who are receiving some type of service from the worker. However, the clarity of this definition becomes more ambiguous when considering the complexities of a seemingly simple question: When, if ever, does an individual cease to be a client? The answer to this question has important and broad implications affecting practice standards and variations in views of appropriate professional behavior.
The NASW Code of Ethics (2000) advances no definition of "former client" or "ex-client," although the terms are used implicitly or explicitly in several places (Sec. 1.07 (c), (n), and (o)). At times the terms client and former client appear to refer to the same individual and are used somewhat interchangeably, as in the statement, "Social workers should not engage in sexual activities or sexual contact with former clients because of potential for harm to the client" (p. 13).
The literature suggests three possible positions regarding the definition of former client, with many of these references found largely in the context of sexual behavior. The three positions are as follows: (1) There is no such entity as ex-client in that once a person is a client, he or she always remains a client in the context of professional relationships and responsibilities; (2) a specified time period after termination of services defines a transition from client to ex-client; and (3) a client ceases to be a client at the point of termination of services. Each perspective is based on assumptions and values that may affect interactions with clients.
Perspectives on Ex-Client Definition
Once a Client, Always a Client
Many of the arguments in support of the principle of once a client, always a client are grounded in concepts of power and the principle of "do no harm." Some authors argued that the very nature of the relationship between clients and social workers provides a context for ongoing professional responsibility (Epstein, 1994; Gabbard, 1994). Others asserted that there are posttermination ethical responsibilities, such as privacy and confidentiality, that should continue in perpetuity (NASW, 2000, Sec 1.07 (r); Reamer, 1998; Silbertrust, 1993). The concept of transference also is used to support this view. For example, Epstein (1994) noted that "it should be remembered that in the unconscious mind, time has no relevance" (p. 133). Therefore, the nature of the professional relationship continues even after services have terminated and time has passed. Herman, Gartell, Olarte, Feldstein, and Localio (1987) concluded after a nationwide survey of psychiatrists that "neither transference nor the real inequality in the power relationship ends with the termination of therapy" (p. 168). Others have also documented the persistence of the effect of transference (Buckley, Karasu, & Charles, 1981; Gabbard, 1994; Luborsky, Diguer, & Barber, 1994).
Perhaps the most compelling argument in favor of the once a client, always a client definition is the fact that clients often return for social work services when new or recurring problems arise. In this context clients are viewed as being "active" or "nonactive" rather than taking on the status of ex-client. In a survey of former clients, Silbertrust (1993) found that 69 percent of the respondents had some posttermination contact with their therapists, with only 14 percent indicating that under no circumstances would they contact their therapists in the future. Similarly, Hartlaub, Martin, and Rhine (1986) found that two-thirds of successfully analyzed patients had contact with their analysts within three years of termination. These data suggest that posttermination contact may be the rule rather than the exception. Implicit in these studies is the notion that the perception of the client is that he or she can return for services when the need and desire are present.
Trends in managed care are also important determinants in services delivery to clients (Reamer, 1997; Strom-Gottfried & Corcoran, 1998). Managed care firms often promote episodic versus long-term treatment with a primary provider to encourage continuity and reduce costs. It may then be perceived that a social worker who has once provided a client with services is also a potential provider of future services over time and on an ongoing basis. Therefore, those with this perspective believe that the nature of the social worker-client relationship continues indefinitely.
After Specified Time Limit
Some professional organizations take a somewhat less absolutist position regarding the definition of an ex-client and define the category as one based on some time period defining a transition from client to ex-client (American Association for Marriage and Family Therapy, 1991; American Counseling Association, 1995; British Association for Counseling, 1996). Time frames ranging from immediately on termination of services to several years beyond are used to define former client and what is acceptable contact after the conclusion of services. Regretfully, most of the literature addressing posttermination relationships does so in the context of sexual behavior (Bernsen, Tabachnick, & Keith-Spiegel, 1994; Sloan, Edmond, Rubin, & Doughty, 1998). For example, the Ethical Principles of Psychologists and Code of Conduct of the American Psychological Association (1995) require that a two-year period elapse before psychologists may have sexual contact with former clients. Implications for professional behaviors can be suggested that, if one can at some point in time be allowed to have sexual contact with a former client, other types of interactions and relationships may also be appropriate (dual relationships, business associations, and so forth).
The NASW Code of Ethics (2000) uses prohibitory language regarding sexual activity with clients and former clients, but states in the same section that social workers who do engage in sexual behavior with former clients as a result of extraordinary circumstances bear the full burden of "demonstrating that the former client has not been exploited, coerced, or manipulated intentionally or unintentionally" (Sec. 107 (c)). However, little guidance is given to social workers regarding any other posttermination contact with former clients. Although there is variation in the time frames and characteristics used to define a former client, the concept that a client can become a former client and, thus, different parameters of interaction and behavior apply, is supported by this position.
At Termination of Services
This position is based on the concept of mutually agreed on contracts that end after an agreed upon time period. Clients enter into service contracts with a variety of professionals (for example, lawyers and real estate agents) and are permitted to revoke the agreement at any time. In most agreements, once the contractual obligations are fulfilled, there are no ongoing responsibilities. This position argues that considerable attention is given in social work training regarding termination with clients. The Social Work Dictionary (Barker, 1999) defines termination as:
The conclusion of the social worker-client intervention process; a systematic procedure for disengaging the working relationship. It occurs when goals are reached, when the specified time for working has ended, or when the client is no longer interested in continuing. (p. 483)
The NASW Code of Ethics (2000) encourages adequate preparation for termination with clients (Sec.1.16). There is a clear implication that an ending of some sort is occurring.
Another argument for this position focuses on the differences in client definitions that can emerge when there is consideration of such issues as the differing nature and context of the services provided; the size and definition of the client system; and the length, frequency, and time limitations of the contact (Herlihy & Corey, 1992). For example, professionals in the role of consultants providing one-time evaluations may not view themselves as entering a contractual obligation that involves ongoing professional responsibilities.
Client Definition Implications
What is apparent in the literature is the missing voice of the social work profession. The definition of ex-client has been addressed in passing in psychology and psychiatry, but no research exists, to the best of our knowledge, on the relationship between such definitions by the worker and the professional behavior of social workers with clients. Because perceptions often guide our behavior and definitional vacuums are typically filled by selfpronouncements, this research attempts to bridge a critical gap in the social work practice literature.
The research reported here identifies the current lack of consensus in the social work profession regarding the definition of ex-client and hypothesizes that the absence of a consistent definition has a significant effect on what social workers perceive as appropriate professional behavior during the provision of services to clients. Suggestions regarding possible strategies to further explore this important issue also are provided.
Sample and Design
The study population consisted of 58,056 NASW members listed in the Membership Directory who possessed an MSW degree and identified themselves as being in direct practice. A random sample of 1,200 members meeting these criteria were mailed a 10-page questionnaire with a cover letter, commitment postcard, and return envelope. If the commitment postcard was not returned within three weeks, a second questionnaire, cover letter, and return envelope were mailed to the respondents. This procedure resulted in the return of 654 usable questionnaires (57.2 percent).
The mean age of respondents was 45.8 years, and 79.5 percent of the sample was female. Close to one-third (28.9 percent) earned an annual income between $35,000 and $45,000, whereas almost another third (29.9 percent) earned between $25,000 and $35,000. More than two-thirds of the respondents (67.7 percent) were married. The sample was predominantly white (90.6 percent). The majority of the respondents worked in either the public (28.3 percent) or the private nonprofit (33.3 percent) sector, and 27.4 percent were in private practice. The study sample compared well with the NASW membership as described by Gibelman and Schervich (1993). These authors noted that the median age of NASW members was between 41 and 45 years, including the younger BSW members. Women composed 75.7 percent of the membership and 88.5 percent were white. However, the study sample had a somewhat lower representation of workers in the public sector (28.3 percent) and the private nonprofits (33.3 percent) compared with 38.7 percent and 39. 1 percent, respectively, in NASW. These differences may at least in part be attributed to the fact that the NASW statistics include BSW practitioners, whereas this study sample deals only with MSW workers.
The critical predictor variable in this analysis references the definition of former client or ex-client. In this study we did not provide a definition of client or ex-client. Rather, we simply asked the following question:
Practitioners have different views on the definition of an ex-client or former client. When would you consider someone to whom you have provided services to be an ex-client?
(1) at the time services are terminated
(2) once a client, always a client
(3) other (specify)
We used this technique in the questionnaire because, as noted before, the NASW Code of Ethics (2000) does not define client or ex-client. This strategy not only presented the respondent with the extreme positions with regard to the definition of ex-client but also offered the option of a middle-ground response that they could specify individually.
Jayaratne, Croxton, and Mattison (1997) reported on a national study of practice behaviors and beliefs of direct practice social workers. Using information from this survey tool, which identified various categories of behavior related to ethics and standards of practice, information from a literature review of other professions regarding ethical practice issues (Borys & Pope, 1989; Pope, Tabachnick, & Keith-Spiegel, 1987), and feedback from both the state chapter and the national office of the NASW Committee on Inquiry cases, seven practice domains were identified for consideration in this study. A questionnaire was developed that contained a series of items referencing behaviors between workers and their clients. The questions asked the respondents to state the degree to which they considered the stated behaviors to be appropriate or inappropriate professional conduct, but did not ask if they actually performed the behaviors. The response patterns revealed the degree of acceptance or rejection of the identi fied behaviors as appropriate conduct for social workers.
Thus, the dependent variables in this study constitute seven different constructed scales of these practice standard domains (Jayaratne et al., 1997). A principal components factor analysis with varimax rotation was used for this purpose. Only items uniquely loading with a factor coefficient of .40 or better were included in a scale. The emerging scales were peripheral professional advice; concrete assistance; multiple or dual relationships; sexual and intimate relations; confidentiality and privacy; social relationships; and religion and prayer in practice. Responses were based on a five-point scale, with 1 = "very appropriate" and 5 = "not at all appropriate." Thus, in all instances the higher the score, the more inappropriate the behaviors represented in the scale.
Four demographic characteristics were examined in relation to the respondents' definition of a former or ex-client, given that prior research had indicated that these particular domains may have an effect on practice behaviors: gender, income, auspices, and age (see Table 1). Age was grouped above and below the mean age of 45.8 years for this analysis. Although race or ethnicity may be an important and significant explanatory variable, we did not conduct any race and ethnicity contrasts given the small number of ethnic minority respondents (61 across all ethnic minority groups in the study sample).
Only auspices emerged as significant between the two groups. Respondents in the private practice arena were far more likely to believe in the principle of once a client, always a client, whereas those in the public sector were more likely to report that clients become former clients at the point of termination of services. This finding could be explained by both the nature and character of services generally provided by the workers in these two contexts of practice. Public sector social workers compared with private practitioners are far more likely to engage in legally defined time-limited services and to provide concrete services, to see clients who by definition are transitory and temporary in character, and to have clients who are more likely to be involuntary.
The majority of respondents chose one of the two discrete definitions of ex-client that were provided rather than opting to write an individual definition. The respondents were almost equally split in their definition of former or ex-client, with 46.8 percent indicating once a client, always a client, and 40.9 percent indicating one becomes an ex-client at the time of termination. The remaining 12.1 percent, a little over 80 respondents, indicated various time periods ranging from six months to 10 years. The small numbers in these distinct categories precluded analyses related to these subsets of time periods.
Table 2 presents the different scales, constituent items, and alpha coefficients for internal reliability. Although the vast majority of respondents considered most of the questionable practice behaviors inappropriate professional conduct, a significant number of respondents were uncertain. For example, although 70.0 percent of the respondents considered it inappropriate to have as a client someone with whom you have another relationship, 20.1 percent were uncertain, and nearly 10 percent thought it was appropriate. Similarly, whereas nearly 49 percent of the respondents considered it inappropriate for social workers to pray with their clients, nearly a one-third were uncertain, and 21.4 percent considered this appropriate conduct. Thus, these illustrative response patterns clearly demonstrate considerable disagreement and uncertainty within the profession about many aspects of professional conduct.
Table 3 presents t tests comparing the mean scores of the two termination groups on the practice standards measures. It is clear that the definition of former client had a significant and consistent relationship to the judgment of whether specific sets of behaviors are considered appropriate professional conduct. In all instances, the practitioners who believed in the definition of once a client, always a client were significantly more conservative in judging the appropriateness of the measured behaviors.
Table 4 presents a regression analysis, where the demographic characteristics were entered first into the equation as control variables. The termination criterion emerged as a significant predictor in all instances but social relationships. Furthermore, with the exception of the social relationships scale, the definition of ex-client was the strongest predictor across all of the practice behavior dimensions. On the other hand, the small amount of variance explained suggests that the model used in this analysis is incomplete, and some important factors have been left out of the study.
When the data are examined more closely, subtle yet potentially important patterns emerge. Practice setting, or auspices, provides a clue to the acceptance of certain behaviors. We found that workers in the public sector (who were more likely to define someone as an ex-client at the point of service termination compared with their colleagues in other settings) were significantly more likely to consider appropriate the provision of concrete assistance and a breach of confidentiality. One could perhaps explain the issue of concrete assistance by virtue of the fact that much of public sector work consists of providing discrete services and support. The public sector provider is less likely to engage in long-term treatment. Rather, these workers are more likely to provide clients with specific resources (money and goods, for example) and are also more likely to refer clients to other service providers. On the other hand, explaining why these workers would condone the breaching of confidentiality is less evident. A somewhat negative and unlikely perspective would suggest that these workers show little professional consideration or regard for their public sector clients. A more positive view would be that these workers are attempting to build a supportive client environment, one that would enhance the well-being of the client, even at the risk of violating client confidentiality. This perspective is based on the fact that the scale items were constructed within the context of the client's best interest (see Table 2). Yet another explanation may be that these workers are forced to engage in these behaviors by virtue of existing rules and regulations. However, this does not answer the question of why such behavior would be condoned by the worker, given professional guidelines about confidentiality.
We also found that the public sector workers differed significantly from private practitioners in approving multiple or dual relationships with clients. We can only speculate, but this may truly be a function of the context of practice. Private practitioners (who were far more likely to define clients as once a client, always a client) are more likely to work with their clients for longer periods of time and are more likely to deal with problems of a more psychological or intimate nature compared with public sector workers. The very nature of the connection that typifies a private practitioner as "therapist" conjures an image of an intense and highly personal client--worker relationship. Any behavior that would impair or damage this relationship may be viewed as taboo, something that not only would harm the therapeutic alliance but also could result in the loss of a client. The fact that the nonprofit sector workers did not differ significantly from either the private or the public sector workers further rein forces this argument. Practitioners in these settings are more likely to see a far more diverse array of clients and hence engage in a broader spectrum of interventions.
The findings on age differences indicated that younger workers were less likely to condone behaviors related to dual relationships, intimacy, and social relationships with clients than their older counterparts. This could be viewed as "wisdom of youth," where the younger workers are not only sensitive to their own vulnerabilities but perhaps more attuned to the potential dangers associated with such behaviors. They may simply be afraid of engaging in behaviors that appear to have potential impropriety. It is also possible that the younger workers have had greater exposure to content on professional ethics by virtue of the relatively recent Council on Social Work Education (1994) standard on the infusion of content on values and ethics in the curriculum. The more experienced older workers may perceive such situations as less pertinent to them, and therefore view themselves as unlikely to engage in these behaviors. But their positive responses in this regard may be guided by experience and the belief that such relationships are inevitable. It is not uncommon, for example, to note that rural practitioners find themselves in unenviable and unavoidable dual relationship situations purely as a function of the context of practice. However, whether this justifies dual relationships remains a question in need of an answer.
Overall, the data suggest that certain behaviors may be questionable in the larger scheme of professional conduct and ethical behavior and are influenced both by the auspices of practice and the age of the practitioner. Although it could be argued that age is correlated with auspices to some extent, with older workers more likely to be found in private practice, the results point to independent effects. Both younger workers and private practitioners were more likely to disapprove of dual relationships compared with public sector workers and older practitioners. Thus, it would appear that something other than auspices and age played a critical role with regard to the approval of engaging in these boundary behaviors.
Our findings underscore the importance of defining when a client is no longer a client. The profession trains social workers in the process of termination but fails to clarify the nature or the client-worker relationship after termination. The result is a confused practitioner. We contend that defining when a client is no longer a client is of paramount importance in professional conduct and workers' judgment about a variety of behaviors that are arguably on the boundaries of appropriateness. This lack of agreement on the definition of an ex-client is found across all demographic contexts. Neither age, experience, practice setting, nor gender explained the variation. The lack of a universally accepted definition may place the client, the practitioner, and the profession at risk. Many of the concepts, guidelines, and prohibitions explicated in the NASW Code of Ethics (2000) rely on an understanding of the meaning of client. The absence of an agreed on definition results in practitioners operating under varyin g assumptions, that is, their own constructed definitions. Thus, both practice behaviors and judgments about ethical conduct may be compromised. The process of adjudication of cases by state and national committees on inquiry, licensing boards, and courts of law may be clouded and confused.
This study raises several issues for further research and exploration. The applicability of definitions and standards of practice must be examined in the context of practice and the scope of services delivery. Consideration should be given to whether all or some of the standards are universally applicable across all settings and client systems. Also, we know very little about what clients themselves think about their own relationship with a worker. When do they consider a "worker no longer their worker"? Furthermore, the advent of managed care and time-limited services within prescribed parameters may further muddy the situation and increase the need for more specific contracting with clients to clarify the nature and duration of the relationship. Finally, whereas our study focused only on direct services providers, interesting and parallel questions emerge if the practice of community organizers and administrators were to be examined.
The complex question of "Who is an ex-client?" needs to be addressed by the social work profession. Rather than leave decisions to others outside the profession, we need to take the initiative to engage in a substantive dialog to clarify and reach consensus regarding an ex-client definition. We do no service by operating out of our own individual assumptions about definitions that profoundly affect practice behaviors. We suggest that we owe a duty to our clients, our profession, and ourselves to address this lingering question and improve consistency in implementing our professional ethical standards.
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Table 1 Comparison of Termination Criterion, by Demographic Characteristics At Service Always a Termination Client Criterion N % N % Gender Male 52 48.1 56 51.9 Female 208 45.9 245 54.1 Income ($) 25,000 or less 42 51.2 40 48.8 25,001-35,000 82 50.0 82 50.0 35,001-45,000 69 42.3 94 57.7 45,001 or more 70 45.2 85 54.8 Auspices Public 88 55.4 70 44.3 Private practice 51 33.1 103 66.9 Nonprofit 86 45.5 103 54.5 Age Less than or equal to 45.8 years 128 46.9 145 53.1 More than 45.8 years 135 46.4 156 53.6 Criterion [chi square] Gender 0.175 Male Female Income ($) 2.787 25,000 or less 25,001-35,000 35,001-45,000 45,001 or more Auspices 16.114 (*) Public Private practice Nonprofit Age 0.014 Less than or equal to 45.8 years More than 45.8 years (*)p< .0005. Table 2 Distribution of Respondents (and %) across Scale Items Scale Scores 1-2 3 Criterion N % N % Peripheral professional advice ([alpha] = .75) Give medical advice to clients other than referring to a physician 44 6.9 79 12.4 Give legal advice to a client other than referring to a lawyer 41 6.4 69 10.7 Give financial investment advice to your clients 13 2.0 32 5.0 Concrete assistance ([alpha] = .79) Loan your car to a client 11 1.7 7 1.1 Give a ride to a client 153 24.0 172 26.3 Help a client with a move or other big chore 59 9.3 66 10.4 Loan tools or equipment to a client 47 7.4 108 17.1 Pay for a client's lunch with your own money 87 13.6 144 22.5 Multiple or dual relationships ([alpha] = .75) Accept business associates or coworkers as clients 55 8.5 81 12.6 Have clients with whom you have another relationship 63 9.9 128 20.1 Accept relatives or friends as clients 27 4.2 34 5.3 Sexual and intimate relations ([alpha] = .86) Go out on a date with an ex-client 11 1.7 20 3.1 Have sex with a client's relative or other individual with whom the client has a close personal relationship 8 1.3 7 1.1 End a professional relationship with a client in order to have a personal relationship 24 3.7 35 5.4 Kiss a client on the lips 10 1.6 2 0.3 Kiss a client on the cheek 47 7.4 76 11.9 Have sex with an ex-client 14 2.2 13 2.0 Confidentiality and privacy ([alpha] = .60) Share confidential information about client with relatives without client's consent when you thought it was in the client's best interest? 75 11.8 71 11.2 Share confidential information about client with others (not family relatives) without client's consent when you thought it was in the client's best interest? 81 12.7 88 13.8 Social relationships ([alpha] = .70) Accept a client's invitation to a party or special event (e.g., wedding?) 113 17.5 242 37.5 Participate in recreational or social activities with your clients? 107 16.8 86 13.5 Look after a client's belongings (house, pets, etc.) for a while? 12 1.9 25 3.9 Ask favors from a client (e.g., a ride home)? 12 1.9 33 5.1 Invite a client to your home for a social event? 19 3.0 29 4.5 Religion and prayer in practice ([alpha] = .80) Discuss your religious beliefs with your clients? 105 16.5 163 25.5 Pray with clients during sessions at their request? 138 21.4 191 29.8 Use the "serenity prayer" as part of your treatment program? 243 38.2 195 30.7 Recommend a religious form of healing? 57 8.9 106 16.6 Initiate or recommend the "laying on hands" as a healing technique? 32 5.1 74 11.7 Request a client to pray with you during a treatment session? 20 3.2 41 6.4 Scale Scores 4-5 Criterion N % Peripheral professional advice ([alpha] = .75) Give medical advice to clients other than referring to a physician 517 80.7 Give legal advice to a client other than referring to a lawyer 535 82.9 Give financial investment advice to your clients 596 93.0 Concrete assistance ([alpha] = .79) Loan your car to a client 624 97.2 Give a ride to a client 312 49.7 Help a client with a move or other big chore 509 80.3 Loan tools or equipment to a client 478 75.5 Pay for a client's lunch with your own money 410 63.9 Multiple or dual relationships ([alpha] = .75) Accept business associates or coworkers as clients 508 78.9 Have clients with whom you have another relationship 447 70.0 Accept relatives or friends as clients 576 90.5 Sexual and intimate relations ([alpha] = .86) Go out on a date with an ex-client 611 95.2 Have sex with a client's relative or other individual with whom the client has a close personal relationship 623 97.6 End a professional relationship with a client in order to have a personal relationship 584 90.9 Kiss a client on the lips 630 98.1 Kiss a client on the cheek 514 80.7 Have sex with an ex-client 611 95.8 Confidentiality and privacy ([alpha] = .60) Share confidential information about client with relatives without client's consent when you thought it was in the client's best interest? 489 77.0 Share confidential information about client with others (not family relatives) without client's consent when you thought it was in the client's best interest? 469 73.5 Social relationships ([alpha] = .70) Accept a client's invitation to a party or special event (e.g., wedding?) 291 45.0 Participate in recreational or social activities with your clients? 445 69.7 Look after a client's belongings (house, pets, etc.) for a while? 603 94.2 Ask favors from a client (e.g., a ride home)? 596 93.0 Invite a client to your home for a social event? 593 92.5 Religion and prayer in practice ([alpha] = .80) Discuss your religious beliefs with your clients? 371 58.0 Pray with clients during sessions at their request? 312 48.8 Use the "serenity prayer" as part of your treatment program? 198 31.1 Recommend a religious form of healing? 475 74.5 Initiate or recommend the "laying on hands" as a healing technique? 528 83.2 Request a client to pray with you during a treatment session? 577 90.4 Table 3 Comparison of Mean Scores on the Standards Measures, by Service Termination Criterion n M SD t value p Peripheral professional advice At service termination 259 4.413 0.82 -2.36 .05 Always a client 297 4.562 0.68 Concrete assistance At service termination 253 3.823 0.89 -5.81 .0001 Always a client 293 4.221 0.70 Multiple or dual relationships At service termination 257 4.107 0.92 -7.33 .0001 Always a client 295 4.580 0.59 Sexual and intimate relations At service termination 255 4.503 0.63 -3.46 .001 Always a client 295 4.661 0.43 Confidentiality and privacy At service termination 261 4.052 1.09 -2.77 .01 Always a client 299 4.289 0.94 Social relationships At service termination 263 4.123 0.83 -5.44 .0001 Always a client 300 4.451 0.60 Religion and prayer in practice At service termination 255 3.823 0.89 -3.55 .0001 Always a client 295 4.071 0.71 Table 4 Regression Analyses on Standards Measures, by Demographics and Termination Point Criterion [beta] f value p [R.sup.2] Peripheral professional advice Age .06 1.443 NS .01 Gender .01 (5,483) Income .04 Auspices -.03 Termination point .09 (*) Concrete assistance Age .03 8.346 .0001 .07 Gender .03 (5,475) Income .07 Auspices .12 (*) Termination point .24 (*) Multiple or dual relationships Age -.10 (*) 12.943 .0001 .11 Gender .05 (5,480) Income .07 Auspices .11 (*) Termination point .29 (*) Sexual or intimate relations Age -.15 (*) 4.371 .001 .03 Gender .04 (5,480) Income .04 Auspices -.01 Termination point .14 (*) Confidentiality and privacy Age -.01 3.852 .005 .03 Gender .12 (5,487) Income .05 Auspices .11 (*) Termination point .13 (*) Social relationships Age .19 (*) 4.999 .0005 .04 Gender .13 (*) (5,481) Income -.01 Auspices .02 Termination point -.04 Religion and prayer in practice Age .01 3.861 .005 .03 Gender .09 (5,480) Income .08 Auspices -.02 Termination point .14 (*) NOTE: NS = nonsignificant. (*)[beta]values are significant at < .05 or higher.