Boundaries and boundary management in counselling: The never-ending story

The concept of boundary has come into prominence in the field of counselling and psychotherapy in recent years. Its focus has been mainly problem-oriented because much of the thrust has come from concerns about boundary violations in the form of therapist sexual exploitation and abuse of clients. A consequence of this has been a growing caution and conservative stance to boundary management, running the risk of undermining aspects of therapeutic effectiveness. Attention is given to various non-sexual boundary dilemmas in recognition of the ubiquitousness of boundary matters in counselling. Essential therapeutic qualities are examined for their boundary-crossing expectations. Empathy, in particular, is seen as needing to involve boundary crossing, but with important qualifiers. Finally, in response to this process need, boundary management is considered, with the never-ending need for dynamic involvement and applying professional judgements, in contrast to operating rigid rules and adopting any fixed position. As well as arguing a theme, the paper provides an overview of boundary matters, serving as an introduction to the papers that follow in the symposium on boundaries.     

Chickens or eggs? A follow‐up case study exploring links between physical and psychological impact of Tourette's syndrome and sexual abuse

This follow‐up case study highlights the complex relationship when working at the interface between physical and psychological symptoms. The paper draws upon conversations between an ex‐client and myself, held seven years after the end of our six year therapeutic relationship. Conversational interviews, based upon social constructionist beliefs, led to an unexpected exploration of the client's subsequent diagnosis of Tourette's syndrome (given several years after the end of therapy) and evolved into a struggle to reach a shared understanding of how she now makes connection between her problem with eating in public, her neck and facial tics, and childhood sexual abuse. Our research relationship provided both of us with a rare opportunity to reflect upon how she had made meaning of her counselling and its outcomes. The paper draws attention to the impact of counselling and therapy discourses concerning sexual abuse on the work we did at the time and asks how that work might be different today. It also helps us understand the layers of complexity and ambiguity contained within the client's stories. This multi‐layered case study represents the overlap and ‘messiness’ that mirrors the ‘lived experience’ of the persons involved, and provides an example of how co‐constructed research conversations can evoke stories that create meaning as they are told.     

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.     

Counselling psychologists' perceptions of the impact of mandatory personal therapy on professional development--an exploratory study

A qualitative study was carried out with recently qualified and trainee counselling psychologists to investigate their opinions as to the impact of mandatory personal therapy on their professional development. The methodology employed was grounded theory using data obtained from indvidual and group interviews. The results indicate that mandatory personal therapy can lead to perceived positive outcomes in terms of professional development including: a sense of the self as a professional through developing reflexivity as a result of being in the role of client; socialization into a professional role through validational and normative experiences such as the therapist modelling good and poor practice; support during times of personal difficulty; and, personal development that leads to a perceived improved ability for the participant to distinguish between personal issues and those of the client. An important effect for participants who did not have a previous substantial experience of personal therapy appeared to be the validation of therapy as an effective psychological intervention.     

Psychological therapy in prisons: Professionals’ perceptions

This study explored professionals’ perceptions of providing psychological therapy in prisons. Eight professionals, affiliated with counselling as well as counselling, clinical and forensic psychology, were interviewed. A social constructionist paradigm was used to understand how social and discursive practices shaped professionals’ accounts, allowing for critical engagement with taken-for-granted practices. Participants’ accounts were analysed using a social constructionist informed thematic analysis. Four themes were constructed: (a) performing therapy, (b) humanising the client, (c) frames inside frames and (d) a challenging but rewarding experience. The findings of this investigation indicated that therapy provision was interwoven with the socio-political ideals governing prison, which created a conflict between therapeutic values and penal values. This conflict has important implications for establishing and maintaining ethical and deontological practices in prison, particularly surrounding the dynamics power. The study indicated it is important for professionals to monitor and manage potential stigma and discrimination within therapy or service delivery. The results also found that working in prisons is a complex experience, which requires careful consideration for enhancing professional development for the prison therapist.     

Therapist responses to requests for disclosure of therapeutic records: An introductory study

This paper describes a questionnaire survey of therapists in the UK who have been subject to requests for disclosure of client records as part of a legal process. Therapist responses are outlined in terms of the perceived effect of such disclosure on the client, therapist and the therapeutic relationship. Negative effects included the experience of exposure of sensitive client material in an adversarial legal system, of powerful emotional responses by therapists, and a sense of feeling professionally de‐skilled in an unfamiliar and often challenging legal environment. Positive effects for the client included the achievement of valued outcomes such as compensation, and, for the therapist, the facilitation of support for the client in this process. These findings are discussed in terms of a contrast between therapist perceptions of consensual and contested disclosure. In the former, therapist and client are in agreement about the restorative value and outcome of disclosure. In contested disclosure, the process is experienced as disrupting therapeutic privacy, undermining professional self‐confidence and introducing an unwelcome element of critical re‐evaluation of client motives for undertaking therapy.     

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.     

Experiential personal construct therapeutic artistry: The therapy relationship and the timing of interventions

Abstract

Experiential personal construct psychotherapy focuses on the intimate, interconnected, and evolving relationship between the therapist and the client as vital to therapeutic growth. Great creativity is demanded of the therapist who aspires to connect with clients in life‐changing psychotherapy. This article first describes the essential nature of the therapy relationship with its implicit and explicit demands for therapist creativity. These principles then are illustrated through a discussion of the critical issue of timing therapeutic interventions.     

The impact of the socio-economic crisis on intrapsychic and intersubjective processes within the therapeutic relationship: Implications for the ethical practice of counselling psychology and psychotherapy

Using attachment and mentalisation theories as a framework, the present paper aims to explore the impact of the current socio-economic crisis on the micro-processes and interpersonal dynamics that emerge between client and therapist as well as the ethical dilemmas that surface within the context of the therapeutic relationship. The first part of the paper focuses on the intrapsychic level and the subjective appraisal and experience of the crisis, as this may differ from individual to individual as well as the unique meaning-making processes that take place for clients and therapists alike. It is argued that the socio-economic crisis itself cannot be seen as an entity that is entirely independent and external to the individual but as a phenomenon that interacts in unique ways with the individual’s inner current and past experience. The second part focuses on the exploration of intersubjective processes that emerge between client and therapist, in particular the transference-countertransference dynamic, as this develops within conditions of increased arousal and anxiety. The role and responsibility of counselling psychologists in preserving reflexivity, empathy and a mentalising stance (through supervision and personal therapy) are highlighted in order to safeguard the ethical and competent practice of counselling psychology.     

Speaking Up:

This article challenges the lack of attention to issues of class in psychotherapy. It calls attention to the sociopolitical nature of therapy and defines some ways in which current therapeutic practices can become oppressive when class differences between client and therapist are ignored. I draw upon my own experience with clinical training and professional practice and invite other white, working class women, through narrative interviews, to share their experiences. Through this collaborative effort, I am able to suggest some ways in which therapy may better meet the needs of working class clients.     

The Right to be Desperate and Hurt and Anger in the presence of Carl Rogers: A racial/psychological identity approach

This paper attempts to establish the beginnings of a conceptual and theoretical framework for psychotherapists and counsellors to 'work with' racial identity psychologically and psychological identity racially in cross-cultural clients. Using the video presentation - of a black client in therapy with Carl Rogers (in the 1970s) - Right to be Desperate and Hurt and Anger as a case vignette, the paper argues that racial/psychological self understanding is possible in therapy. The therapy sessions are critiqued in terms of race and multi-cultural psychotherapy and counselling. Since the video was widely used in the 1990s and is currently used in counselling and multi-cultural therapy training, it was felt that an examination and analysis of some of its contents would offer clinical possibilities in terms of race, culture and ethnicity. Through the analysis of significant excerpts the paper attempts to show that the conflicts, confusions and tensions that arise between a white therapist and a black client can be used creatively to engender trust, openness and cross-racial therapeutic possibilities.     

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.     

How common is sexual attraction towards clients? The experiences of sexual attraction of counselling psychologists toward their clients and its impact on the therapeutic process

This study investigated counselling psychologists' experiences of sexual attraction to their clients. Self-reported incidence of this phenomenon, the reaction that it provokes in therapists, the way they manage their feelings, and the potential impact of their sexual attraction on the therapeutic process, were assessed. On the basis of previous studies of psychotherapists, it was hypothesized that sexual attraction toward clients is common, and that these perceived feelings are not necessarily negative to the therapeutic process or professional relationship; also, it was hypothesized that the disclosure of these feelings to the client could nevertheless lead to a positive therapeutic outcome. Questionnaires were sent to the 286 chartered counselling psychologists included in the British Psychological Society Register. The results showed that significantly more therapists were attracted to at least one client than not. Furthermore, half of the respondents who reported attraction to clients believed that their feelings had a positive impact on the therapeutic process. Therapists who had disclosed their feelings to their clients found significantly more frequently that the impact of their sexual attraction had been positive to the therapeutic process (87.5%), than therapists who did not disclose their sexual attraction (47.1%). The implications of these results for training, supervision and professional issues are discussed.     

Tainted therapy and mistaken memory: Avoiding malpractice and preserving evidence with possible adult victims of childhood sexual abuse

Recent malpractice cases reflect increased liability for psychotherapists working with possible adult victims of childhood sexual abuse. These cases have related to recovery of past memory of abuse and the fashion in which the therapist managed the recovery and treatment. Ways in which therapists may harm clients by omission and commission are explored. The emerging lack of clarity between investigative and therapeutic interviews is discussed. False memory is considered in relationship to malpractice liability, standards of care, and attempts to preserve potential evidence. The author proposes written informed consent and investigative interviewing procedures for working with potential memory recovery cases. Formats for general informed consent to psychotherapy for patient record keeping of newly emergent material are appended.     

The therapeutic alliance in adolescent substance abuse treatment: a one-with-many analysis

Studies of the therapeutic alliance typically use a one-with-many (OWM) design in which each therapist (the one) treats multiple clients (the many). This study used Kenny, Kashy, and Cook's (2006) OWM method to examine the composition of the therapeutic alliance and to analyze the association between alliance and outcome in a sample of 398 adolescents treated for substance abuse by 14 therapists. Both the client and therapist alliance ratings yielded large relationship variances, with limited consensus among clients treated by the same therapist about the quality of the alliance. If a client reported an especially strong alliance with his or her therapist, the therapist was likely to also report an especially strong alliance with that client (dyadic reciprocity). The association between the components of the alliance and treatment outcome was complicated, with different levels of measurement and different components of the alliance (perceiver, partner, or relationship) derived from different informants (therapist or client) relating to different outcomes.     

Play Therapy – respecting the spirit of the child

Play Therapy is an appropriate form of counselling for children; it is based in a therapeutic relationship where communication is developmentally appropriate and easily expressed. Using a variety of methods from non-directional to co-operative play, the therapist acts to affirm, articulate and co-regulate emotional expressions and joins the child in finding meaning, and understanding of the environment. Play Therapy is presented in this paper as an expression of spiritual connection. The relationship of mutual respect and positive expectation between therapist and child allows new understanding to emerge. The interaction between these two areas of knowledge, Play Therapy and children’s spirituality is examined through case study notes and experience of Play Therapy as an early intervention response to children at a time of community disaster. The author is a Clinical Play Therapist as well as a lecturer in children’s spirituality, so this work emphasises the importance of the spiritual nature of the child and the use of a spiritual connection with the therapist for children recovering from psychological distress.     

The impact of child sexual abuse on adult interpersonal functioning: A review and synthesis of the empirical literature

The many studies that have examined the long-term impact of child sexual abuse (CSA) on adult functioning have primarily focused on the personal distress of survivors, largely ignoring the impact of CSA on interpersonal relationships. This article reviews empirical findings concerning the interpersonal distress of survivors as expressed in their intimate and sexual relationships. First, current conceptualizations of the relationship between CSA and interpersonal relationships are reviewed, with a focus on the theoretical models that appear to have implications for the long-term interpersonal sequelae associated with CSA. This is followed by a review of the research conducted on intimacy within the area of social psychology and a summary of the empirical findings related to intimacy functioning in CSA survivors. A hypothesized typology of intimacy functioning for survivors is suggested. The effects of CSA on three components of sexuality—sexual dysfunctions, underlying psychological components of sexuality, and sexual orientation—are discussed. Finally, the interpersonal issues believed to be most salient for CSA survivors in the therapeutic setting are discussed, along with implications for the client–therapist relationship. Methodological, assessment, and conceptual issues are discussed throughout. Recommendations for future research and clinical endeavors are suggested.     

The impact of Christian counselling on survivors of sexual abuse

The absence of research and growing involvement of Christians in all areas of counselling gave rise to this study which explores the impact of Christian counselling on adult survivors of sexual abuse. The sample of 44 women and 5 men from an inter-denominational, self-help network, completed a self-report questionnaire of perceived Christian and professional counselling experiences involving issues of trust, power, directive approach, use of prayer and Scripture, responsibility and outcome. Results show that Christian counselling is experienced as qualitatively different from professional counselling: Christian counsellors are perceived as significantly more directive and more powerful than professional counsellors and the overall outcome was perceived more negatively. A number of key factors were identified which influenced the negative experience of some Christian counselling. These included having experience of professional counselling, an emphasis on the use of prayer and Scripture, perceiving the counsellor to have different goals from the client, feeling blamed for continued distress and having prior experience of prayer ministry. Implications for counselling practice and training are discussed.     

Sexual Abuse Litigation

Summary

Practicing psychologist Janet Sonne and attorney Julian Hubbard illuminate how the different aims and languages of psychotherapy and law can be either an asset or a liability in the emotionally-charged environment of sexual abuse litigation. Properly understood, these differences can optimize the ability of each professional to assist their common client, the sexual abuse survivor, in the litigation process and beyond. Dr. Sonne reviews the psychological and behavioral sequelae of childhood sexual abuse and identifies six elements of the client's psychological functioning key to the litigation process, as well as posing questions for the attorney's self-evaluation for the unique demands of sexual abuse litigation. Mr. Hubbard then addresses what survivors and therapists need to know about the litigation process, exploring dynamics of legal strategy that can exacerbate the client's psychological problems. In the final section, both offer tips to enhance professionals' focus on education and communication as a means to better serving the sexually abused client.     

Client perspectives: The therapeutic challenge of domestic violence counselling – a pilot study

Aims: This qualitative pilot study explored the perceptions of four female domestic violence clients regarding counselling they had concluded in order to identify a preliminary client‐preferred domestic violence counselling approach. Method: Semi‐structured interviews asking about significant events during counselling were held. An adapted grounded theory and narrative methodology was used. Results from the analysis were reviewed with two of the participants. Participants were offered additional counselling support if required after the research interview. Results/Findings: Domestic violence clients found starting counselling particularly difficult after years of keeping the abuse to themselves. Participants actively withheld and managed information for several sessions and needed to know they had time to explore their experiences. The counsellor being consistent and non‐judgemental, and understanding domestic violence and its effects was helpful. Having a clear ending was appreciated by the participants. Discussion: The initial development of the therapeutic relationship benefited from active discussion of how domestic violence could affect behaviour and emotions. Good early therapeutic relationships showed elements of the three main psychological schools. Participants benefited from a pro‐active discussion of endings. A key limitation of this research is the small sample size. Implications for practice: The research suggests that counsellors would benefit from knowledge and skills from different psychological schools and specific training in domestic violence. Allowing flexibility on the number of sessions available to clients may be helpful. Conclusions: Further work is required to explore these preliminary findings. However, early indications suggest that domestic abuse clients may benefit from non‐time‐limited specialist counselling services.