The stalking of psychotherapists by current or former clients: Beware of the insecurely attached!

Abstract

A survey of psychological therapists who worked in primary care showed that the incidence of psychotherapists being harassed or stalked by their current or former clients was more than twice the national average at 24%. The stalkers fell into three broad categories: those clients who were needy and made early attachments to their therapists; those experiencing erotic transference; and those with personality disorders, especially those with a narcissistic style. All of these are disorders of attachment. This paper discusses the neurobiological development of an insecure attachment and how that manifests during therapy in stalking behaviour. Psychotherapists who are aware of the dynamics within the therapeutic relationship can take preventative steps to inhibit the automatic fear response of a client who is insecurely attached and which may lead to stalking behaviour.

A survey of psychological therapists who worked in primary care showed that the incidence of psychotherapists being harassed or stalked by their current or former clients was more than twice the national average at 24%. The stalkers fell into three broad categories: those clients who were needy and made early attachments to their therapists; those experiencing erotic transference; and those with personality disorders, especially those with a narcissistic style. All of these are disorders of attachment. This paper discusses the neurobiological development of an insecure attachment and how that manifests during therapy in stalking behaviour. Psychotherapists who are aware of the dynamics within the therapeutic relationship can take preventative steps to inhibit the automatic fear response of a client who is insecurely attached and which may lead to stalking behaviour.     

Therapeutic Relationships Re-Defined

Abstract

The therapeutic relationship has traditionally been central to occupational therapy. This study surveyed 129 practicing occupational therapists in Connecticut, concerning how they define and use the therapeutic relationship with clients in today's cost-conscious health care environment. The following four hypotheses: (1) Therapeutic relationships are related to functional outcome, (2) Definitions of therapeutic relationships include words and phrases expressed in the literature and by experts, (3) There are differences in perceptions of therapeutic relationships among pediatric, adult, and geriatric specialty subgroups, (4) Most occupational therapists learned skills in developing therapeutic relationships “on the job,” rather than during professional education, were all supported. This study reaffirms the importance of the therapeutic relationship in occupational therapy practice and provides an updated definition: A trusting connection and rapport established between therapist and client through collaboration, communication, therapist empathy and mutual understanding and respect.     

Building and Handling Therapeutic Closeness in the Therapist-Client Relationship in Behavioral and Cognitive Psychotherapy

The present study unpacks an important dimension of clinical practice from the therapists’ vantage point. We interviewed 26 therapists in private practice about how the personal relationship with the client works from their perspective and conducted a grounded theory analysis. Three categories emerged. One refers to scope, aims and corollaries of the connection with the client; a second to preventing harm and managing drawbacks; and a third to taking therapeutic advantage of challenges related to closeness. Together, these categories form a model that describes how the close connection modifies therapeutic effects and generates challenges the therapist needs to deal with. The closer the dyad, the easier therapists will affect and be affected by the client. Therapists try to direct closeness to where it can nourish client process without harming the relationship, the client or themselves, and when closeness backfires, they may still try to harness uninvited effects for the benefit of therapy. This model concerning therapists’ lived experience is offered to inform research on the therapist-client relationship and as a contribution to clinical competency models.     

Legal and Ethical Issues in the Court-Mandated Treatment of Batterers

Summary

In the following article, we will explore the nature of the therapeutic relationship as it relates to batterers' treatment programs. We will consider the impact of obligations created by forces outside the relationship, such as those imposed by legal proceedings. We will discuss the concepts of confidentiality, privilege, and agency and their impact on the therapeutic relationship and the extent to which the therapists' understanding of the role these concepts play may be altered by court orders that impose treatment on a client/patient. Finally, we examine the issues and choices a therapist must make when engaging in court-ordered treatment of batterers, and the implications of those choices for both therapist and client; we will also suggest guidelines to help therapists sort through the often conflicting goals of therapy and the legal process.     

Therapeutic Relationship

This article addresses the important role of the therapeutic relationship in cognitive-behavioral therapy (CBT). As has been noted from the inception of CBT, there are critical features of both the therapist and the relationship that optimize the likelihood of therapeutic success, and this article briefly describes these features. It is further argued that a successful therapeutic relationship in CBT is not static but is flexible and adaptive both across and within clients, as their needs and concerns vary. A positive therapeutic relationship is viewed within CBT as a necessary but insufficient condition for change, as the relationship serves as a foundation upon which interventions are scaffolded, but that the client’s response to various interventions itself shapes the interactions between therapist and client. Finally, it is argued that the key therapeutic ingredients of CBT are largely teachable, and the article provides several suggestions to promote an effective therapeutic relationship in CBT.     

Creating Space for Therapeutic Change: Boundary Expansions with Autism Spectrum Clients

ABSTRACT

Boundaries provide safety for both clinicians and clients. Specifically chosen boundary crossings can serve therapeutic progress when proper ethical safeguards are used. Clients with High Functioning Autism Spectrum Disorder (HFASD) have neurodevelopmental challenges and delays linked to the activation of the autonomic nervous system (ANS), and often experience problems socially, emotionally, and adjusting to change. Creating space for therapeutic change by expanding boundaries can help the client with HFASD overcome neurodevelopmental challenges through an expanded relationship with the clinician, who plays many different roles in the helping relationship. Creating this space assists the client with HFASD in overcoming neurodevelopmental challenges, in addition to providing a model of relationship that expands to other people and situations in the client’s life.     

具身心理治疗:原理与技术

具身心理治疗是以身体心理治疗、舞动治疗为代表的,理论上契合具身认知观点、实践中注重身体作用的一种当代心理治疗取向。它将“身体”与“躯体”区分开来,赋予身体解剖学的、感觉运动的、认知的与嵌入环境等不同层面的意义。当前,已有不少研究证实身体有助于改善治疗关系,促进来访者认知、情绪的改变,并发展出一系列注重身体内外感知、姿势或运动的非言语治疗技术。具身心理治疗重构了身体在治疗过程中的概念与角色,发展了新的技术,是传统心理治疗的有益补充; 但也存在实证证据不足、理论框架尚未完全整合、容易过分强调身体作用等问题。今后需自觉整合其他治疗流派、开发独特的核心技术,推进循证的具身心理治疗的发展。     

Empathy as dialectic imagination

Abstract

The importance of relationship processes for humanistic and psychodynamic therapists makes empathy a critical concept in psychotherapy. Experimental work suggests that learning occurs only when the subject is actively and cooperatively engaged in the learning process. Similarly, psychotherapy is only effective when the client is willingly active in the therapeutic process. A crucial aspect of the therapist's activity is empathic imagination, defined here as the use of “dialectic” thinking capacities‐the recognition of conceptual alternatives in a given situation. These processes are at the heart of a humanistic view of agency. The therapist's use of this capacity allows imaginative projection into aspects of the client's experience, helping the client to feel understood in the relationship and emboldened to consider new possibilities in life.     

Is touch a valid therapeutic intervention? Early returns from a qualitative study of therapists' views

Findings are reported from six semi‐structured interviews with experienced psychotherapists, focusing on the reasons for using touch and the sort of touch used. They suggest that there is a distinction being made by therapists between ‘social space’ and ‘therapeutic space’, and a different view of touch taken if it is judged by the therapist to be ‘out of the therapeutic environment’. Whether or not touch was initiated by the therapist or the client would also appear to influence its further discussion by the therapist, either in processing it with the client or in supervision. What also emerged from the interviews was the finding that an exploration of touch in supervision was unusual. The implications for practice, supervision and training are discussed as areas for further exploration in the main survey, which will be conducted in the second year of the research.     

Transformational education for psychotherapy and counselling: a relational dynamic approach

ABSTRACT

An evolving relational dynamic approach to psychotherapy and counselling education is described. Key themes integrated within the approach are the learning community and transformational relationships. Learning is a reciprocal change process involving students, teachers, supervisors and therapists in overlapping learning communities. Drawing on evidence that effective outcomes in therapy correlate with effective aspects of the therapeutic relationship, the relational dynamic approach emphasises the findings of attachment and intersubjectivity theorists. The intersubjective matrix of infant/caregiver and client/therapist is mirrored and embodied in the relational ethos of training and actively engaged in group supervision. An emphasis on embodied relating is discussed, drawing on infancy studies and recent neuroscientific findings     

A meditation on the nature of self‐healing and personality change in psychotherapy based on Gendlin's theory of experiencing

Abstract

From a humanistic point of view psychotherapy is a creative transformational process in which therapists assist clients’ intrinsic self‐healing tendencies. However the nature of the self‐healing process is poorly understood. I briefly consider two theories of self‐healing, Rogers’ self‐actualization theory and dialectical theory, but focus on Gendlin's theory of experiencing as providing a more complete explanation. I consider the fundamentally implicational nature of change and portray personal change as “paradigm evolution” rather than paradigm revolution. I conclude with an examination of the self‐healing process in therapies that provide minimal prosthetic assistance to the client: client‐centered therapy, eye movement desensitization and reprocessing, and focusing‐oriented therapy. I conclude that the self‐healing/self‐change process occurs when intellectual, “top‐down” cognitive and self‐critical activity is interrupted, and when clients adopt a receptive, listening attitude towards inner experience.     

Therapist Self-as-Context and the Curative Relationship

This article discusses how the way the therapist relates to his or her personal responses to client material during the session contributes to making the relationship with the client an effective tool for treatment. Ideas from third wave behavior therapy are used to describe aspects of therapist involvement in the relationship and modes of therapist awareness of inner responses. In two vignettes, negative client reactions to an intervention bring problematic therapist material to the fore. Both cases highlight how the stories the therapists spun about themselves as professionals and persons could easily have limited their effectiveness in responding to the material. The vignettes also illustrate how clinicians can overcome personal meanings and judgments to access a more productive mode of interacting with the feelings a critical incident in the relationship evokes in them. It is argued that observing their own content from a psychological distance makes it possible for clinicians to use their feelings without getting caught up in them. These same feelings may then help the therapist perceive how the incident relates to the client’s daily life problems. The therapist’s engagement in a sense of self-as-context is described as a therapeutic stance that provides the psychological distance needed to help overcome alliance ruptures and other potential gridlocks and which may transform the therapist’s inner response to client content into a tool for addressing important client issues.     

A Both-And Approach: An Application of Narrative Interventions from a Modern Perspective

A contentious debate between the modern and postmodern epistemologies continue to wage on since the rise of constructivism and social constructionism in the 1990s. This debate has led to both modern and postmodernists falling into an either/or mindset. Others have proposed a solution, the both-and approach, that emphasizes integration of different therapeutic camps. Intentionality is a core component of this approach, as therapists must understand how employed interventions flow from the epistemology and theoretical orientation under which they operate. Another core component of this approach is tailoring the integration to the specific context of the client case. With this understanding and tailoring, therapists can utilize methods across the modern/postmodern divide, as they will coherently flow from their original epistemology and theoretical orientation. Applying methods from both modernism and postmodernism, then, enhances therapists’ therapeutic repertoire, allowing for more opportunities to adapt treatment to each client case. Altogether, the quality of services improve and the amount of clients therapists can help increases as well. This paper will provide an application of the both-and approach to a case study to provide an example of how the said method can be employed in therapy.

     

Writing and Praying Collects as an Intervention in Narrative Therapy

The integration of spiritual practices in therapy is a valuable tool for supporting and reinforcing change. This paper explores the use of a written form of prayer called a collect as an intervention in narrative therapy. A collect is a form of prayer with a structure that can be easily co-constructed by clients and therapists. This spiritual intervention serves as a therapeutic document to help reinforce the externalization of a client’s problem or help thicken alternative narratives. Relevant aspects of narrative therapy and written prayer are summarized. A guide for implementation, examples of collects, and a worksheet for helping clients write collects is provided.

     

Utilizing artistry in a therapeutic relationship

Abstract

In many humanistic approaches, therapeutic change involves utilizing the relationship between the client and therapist as a tool for personal growth. Like any relationship, the therapeutic relationship is one that is co‐created between those engaged in it, namely, the client and the therapist. Utilizing this co‐created relationship requires a sense of artistry on the part of the therapist. A therapist must be willing to engage in this meaningful relationship with the client. A therapist must also be aware of the personal values that he or she brings into therapy, and how they influence the therapeutic relationship. Finally, a therapist must acknowledge the power that the therapist and the client possess in the relationship, and understand how that power can be used to validate and invalidate the therapist's and the client's personal meanings. These aspects of therapeutic artistry are discussed and the use of therapeutic artistry in Eron and Lund's (1996) narrative solutions approach is presented.     

Resiliency: A shift in our perception?

Abstract

As our clients often underestimate their own resources and potential, do helpers fall victim to the same phenomena? This article contends that helpers are often overly attentive to client deficits and pathology to the detriment of acknowledging family and other client strengths and resources brought into the therapeutic arena. Much of our professional training results in an overreliance upon pathological lenses which is to the disadvantage of both client and helper. Family therapists must remain vigilant to not becoming seduced into the attractive web of “pathologizing.” Experiences that heightened this awareness for the author are described, followed by illustration of the importance and benefit of therapists becoming more sensitive to the study of human resiliency.     

The presence of the third party: systemic therapy and transference analysis

While today many therapists try to integrate different therapeutic models, it does not seem easy to define the specific clinical features of each model. In this article, the practice of systemic individual therapy is compared to the psychoanalytic practice of transference analysis. The relevant distinction is found in the different use of third parties within the therapeutic frame. In systemic therapy, the third party is 'presentified' within the therapeutic dialogue, which becomes centred on external relationships, while in transference analysis the third party is subsumed to the therapeutic (transferential) relationship, which is considered the core of therapy. The practical consequences of those two different 'technologies of the self' are discussed.     

Brief dynamic counselling: Making the right choice

Abstract

Brief dynamic counselling has become a frequently practised method of treatment. This paper examines the usefulness of short-term therapy for certain clients and describes the relevant selection criteria. However, it is argued that there exists a real danger to the client should they be inappropriately referred for this work. Demands upon therapy services often mean that therapists are under pressure to have a rapid ‘through-put’ of clients. This may lead to some clients being treated in a way that is unsuitable and inadequate for their needs. It is suggested that, more than being inadequate, such a situation could cause additional harm to the client. Professional assessment is considered to be of vital importance. Case material is included in order to illustrate the difference between clients who are likely to benefit from short-term counselling work and those for whom the longer time duration is an essential part of the therapeutic relationship and process. In terms of therapy service provision, the need for flexibility and the need for availability of a variety of treatments are discussed.     

Intimate boundaries: Therapists’ perception and experience of erotic transference within the therapeutic relationship

Aim: This study explored therapists’ understanding and experiences of erotic transference within therapeutic relationships. Method: A small‐scale qualitative research project was undertaken with six therapists working within different counselling contexts. Data was collected through semi‐structured face‐to‐face interviews, and an Interpretative Phenomenological Analysis used for analysis of individual perception and experience. Findings: All participants had experienced what they understood to be erotic transference and/or sexual and loving feelings within therapy. There was little differentiation between the two phenomena, and both were often referred to interchangeably. There were contradictory views as to whether using the phenomena would be beneficial to client work, but there was a strong motivation to learn more about it. Therapists who encountered sexual attraction within therapy experienced feelings including shame and embarrassment. Supervisory support was seen to be beneficial. Implications/conclusion: The importance for therapists to acknowledge a lack of clarity that exists around the understanding of erotic transference and its relationship to sexual attraction within therapy is noted. Also, a recognition that better access to training regarding erotic transference and sexual responsibility within client relationships might be helpful to therapists in their work.     

The Soul of Therapy: The Therapist’s Use of Self in the Therapeutic Relationship

This paper is based on the premises that the conscious, active and purposeful use of self by the therapist in the therapeutic process is an essential aptitude in establishing an effective therapeutic relationship, and that this therapeutically purposeful use of self can and should be incorporated in the training of all therapists in a explicitly systematic manner. The paper will attempt to identify the contributions of the “what and how” the use of self by therapists contributes to the therapeutic process. First of all, therapists’ use of self is meant to be viewed as a Common Factor as defined by Sprenkle, Davis & Lebow (2009), which is a perspective about the effectiveness of therapy that “asserts that the qualities and capabilities of the person offering the treatment are more important than the treatment itself” (p. 4). Secondly, the use of self by therapists emphasizes developing the skill set of the therapist in the conscious, active and purposeful use of self as is in the moment of the therapeutic engagement with clients, and does so without denying the importance of therapists working to resolve personal issues of theirs that may interfere with the therapist's professional effectiveness. Therapists’ use of self gives particular emphasis to the purposeful use of self as is in therapy’s relationship, assessment and interventions whatever the therapy model (Aponte & Kissil, 2016). Thirdly, the use of self represents an aptitude that can be developed and refined through well elaborated structures for schooling therapists in the therapeutic use of all they bring of their personal selves to the therapy relationship including through the use of their human vulnerabilities as they exist at the moment of empathic engagement with clients.