Exploitation in therapy and counselling: a breach of professional standards

Exploitation in therapy and counselling may occur in only a minority of cases, but when it does, its effects are potentially damaging to both the client and the profession. Exploitation in therapy may take the form of psychological, covert and overt abuse. The most reported form of abuse of the therapeutic relationship is of a sexual nature. However, psychological abuse usually forms the backdrop to sexual exploitation, preceding and perpetuating the sexual involvement. Sexual exploitation in therapy is an abuse of the power imbued in the therapist by nature of his professional role. It allows the therapist a sexual gratification which he would not have been likely to achieve outside the therapeutic relationship. The prevention of sexual exploitation in therapy is an issue of concern to training, employing and professional organisations who seek to maintain high standards of counselling delivery. Determining the variables which may contribute to exploitation is fundamental to avoiding its incidence. This paper discusses the factors underlying the use of therapy and counselling as a medium for therapist abuse. It examines (i) the prevailing conditions for abuse to occur, (ii) how the therapist overcomes client resistance, and (iii) the implications for the maintenance of professional standards.     

Couple-responsible therapy process: positive proximal outcomes

Therapist-couple struggle vs. cooperation is linked to clinical outcome. This research conceptualizes and investigates treatment process as it relates to the occurrence of struggle versus cooperation. Models of couple-responsible and therapist-responsible process in couple therapy were developed. Couple-responsible process consists of enactments, accommodation, and inductive process. Therapist-responsible process consists of primary therapist-couple interaction, therapist interpretation, and direct instruction. In counterbalanced order, 25 couples were exposed to couple-responsible and therapist-responsible episodes during one therapy session. Couples reviewed videotapes of the episodes and completed measures of responsibility, struggle, and cooperation. Perceived responsibility was higher and struggle was lower during couple-responsible episodes. No difference in cooperation was found. Presence or absence of a contrast condition, where couples reported on one therapist process after already experiencing its opposite, led to main effects for responsibility and struggle, and mediated effects of struggle and cooperation. Generally speaking, responsibility was even higher during couple-responsible episodes and even lower during therapist-responsible episodes when contrast was present. Similarly, struggle was even lower during couple-responsible episodes and even higher during therapist-responsible episodes when contrast was present. For both couple-responsible and therapist-responsible episodes, cooperation was negatively affected by a shift from the prior, opposite therapist process. Significant proportions of the variance in responsibility, struggle, and cooperation, however, were not accounted for by therapist process alone.     

Investigation of the effect of group counselling based on schema therapy on academic expectation stress in high school students

This research is a preliminary evaluation study to determine whether group counselling based on schema therapy has an effect on academic expectation stress in high school students. In this study, a 2 × 3 split-plot design was used. The Academic Expectation Stress Inventory was applied for data collection purposes. The effect of group counselling based on schema therapy on academic expectation stress was tested using a two-factor ANOVA for mixed measurements. As a result of the analysis, the intervention*time effect was found to be significant with regard to academic expectation stress. The findings obtained in the study reveal that group counselling based on schema therapy creates a significant decrease in adolescents' academic expectation stress level, and this decline continues, as shown in the follow-up test. As a result, it can be said that the group counselling programme based on schema therapy, which was developed as a preliminary evaluation study, has the potential to reduce the academic expectation stress level of high school students.     

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.     

The pregnant therapist and the psychotic client: A phenomenological understanding of the impact of the therapist’s pregnancy on the therapeutic process

This original paper examines the underresearched area of therapist pregnancy. It explores the impact of psychosis as an additional complicating factor to the therapeutic process and the experience of one British counselling psychologist working in the National Health Service whilst pregnant. Five brief client summaries/clinical examples are presented to explore the common themes of anger, rejection, abandonment and envy that often emerge following the disclosure of a therapist’s pregnancy or the opposite reactions of over-protectiveness and an unwillingness to engage in therapy for fear of harming the therapist. Recommendations are made for further research within this neglected area and the need to incorporate the themes within training for therapists and training for supervisors.     

Brief psychodynamic counselling with young adults

Short-term counselling is frequently employed within university counselling services in which there can often be an inherent institutional objective of returning students to the academic treadmill as soon as possible (Coren, 1996). On the other hand, this is perhaps tempered by the availability of counselling throughout the student's academic career, affording them the opportunity to return for further intensive short-term work (or longer-term if indicated or required). However, research into the effectiveness of short-term counselling suggests that interventions of less than eight sessions are as effective as those lasting significantly longer (Barkham, 1989). This may be particularly true in the case of students experiencing transitory problems relating to their life at university. This paper uses a case illustration to examine the value of short-term psychodynamic counselling in a university situation.     

The Greek Chorus and Other Techniques of Paradoxical Therapy

This paper has described some of the interventions developed at the Ackerman Brief Therapy Project in treating the families of symptomatic children. The interventions are based upon a differential diagnosis of the family system and upon an evaluation of that system's resistance to change. They are classified as compliance-based or defiance-based, depending upon the family's degree of anxiety, motivation, and resistance. Paradoxical interventions, which are defiance-based, are used as a clinical tool in dealing with resistance and circumventing the power struggle between therapist and family. A consultation group acting as a Greek chorus underlines the therapist's interventions and comments on the consequences of systemic change. This group is also sometimes used to form a therapeutic triangle among the family, therapist and group, with the therapist and group debating over the family's ability to change.     

The behavioural treatment of sexual inadequacy: A comparative study

Thirty-six couples complaining of sexual difficulties were treated with one of three methods: (1) systematic desensitisation plus counselling. (2) directed practice—based on that of Masters and Johnson—plus counselling. (3) directed practice with minimal contact. Both members of each couple were seen together, but half in each treatment group were treated by a single therapist and half by a therapist pair. Differences in outcome among the groups were not highly significant, but consistent trends were found which suggested that the combination of directed practice and counselling was associated with most change, particularly when two therapists were involved.     

The impact of psychological distress and university counselling on academic outcomes: Analysis of a routine practice-based dataset

Whole university approaches to student mental health and well-being increasingly involve university counselling and mental health services (UCMHSs) as key stakeholders in higher education and the fulfilment of good academic outcomes. However, previous research using routine outcome measures has focussed on psychological distress only. Research is needed to demonstrate the value of university counselling on academic outcomes. This study aimed at profiling the psychological distress of a student sample according to the Clinical Outcomes in Routine Evaluation—Outcome Measure (CORE-OM); measuring the change in perceived impact of problems on academic outcomes, and measuring the perceived impact of counselling on academic outcomes. Students from two UK university counselling services completed the CORE-OM and the Counselling Impact on Academic Outcomes (CIAO) questionnaire as part of routine practice. After counselling, 67.4% (n = 323) of students with planned endings to counselling showed at least reliable improvement on the CORE-OM. Significant reductions in the perceived impact of problems on all academic outcomes were also found. On average, 83% (n = 398) of students found counselling helpful for academic outcomes to at least a limited extent. University counselling was found to reduce psychological distress and the impact of problems on academic outcomes. Psychometric examination of the CIAO tool is warranted to strengthen its use. The need for robust data across UCMHSs is demonstrated by both the strengths and limitations of this study.     

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.     

Therapist response modes in the exploration stage: timing and effectiveness

In an investigation of the exploration stage of single counselling sessions with 26 anxious female volunteer clients and 13 female doctoral student therapists, no overall association was found between client narrative processing modes and subsequent therapist verbal response modes. There was evidence in a third of the sample for an association between therapist response modes and subsequent client narrative modes, such that clients used more internal than external or reflexive narrative processing modes when therapists used open questions about feelings and reflections of feelings. Client and therapist helpfulness ratings did not differ for different therapist response modes or client narrative process modes. Hence, overall results suggested that all four therapist response modes (open questions about thoughts, open questions about feelings, restatements, reflections of feelings) are effective during the exploration stage.     

Group psychodynamic counselling with final-year undergraduates in clinical psychology: A clinical methodology to reinforce academic identity and psychological well-being

Educational institutions should ensure that students develop a professional identity, as well as safeguarding their well-being and activating awareness and change processes. The aim of this study was to assess the efficacy of group psychodynamic counselling as a means of reinforcing academic identity – considered the forerunner of professional identity – and psychological well-being in a group of final-year undergraduates studying clinical psychology. Thirty-three final-year-students of clinical psychology who participated in six group psychodynamic counselling sessions were compared with sixteen final-year students of clinical psychology who had never participated in an intervention of this kind. The results suggested that group psychodynamic counselling made students feel more capable of managing their lives and more open to new experiences as well as encouraging them to perceive their relationships as more positive and satisfying, to believe that their life is meaningful, and to achieve greater self-acceptance. The in-depth exploration also prompted students to consider their commitment to their choice of career. Group psychodynamic counselling also reinforced students’ educational choice, as the likelihood of students becoming less committed to this choice was reduced after the intervention. Thus, the study confirmed the efficacy of group psychodynamic counselling as a means of reinforcing both academic identity and promoting well-being and demonstrated that it is a tool clinical psychologists and university teachers could use to activate self-reflection and change within educational settings.     

The experiences of therapy from the perspectives of carers of people with dementia: An exploratory study

Design: Interviews were conducted with six carers of people with dementia about their experience of receiving counselling/psychotherapy. Interviews were conducted in the carer's own home, and data were analysed thematically using a narrative approach. Findings: Three themes were identified from the data: ‘Still doing the best I can’ (identified as losses and processes of personal growth); ‘Feeling connected and being understood’ (identified as attributes believed to be important within the therapeutic relationship); and ‘Wanting to share information’ (identified as sharing information with someone ‘neutral’). Carers placed emphasis on the age of the therapist and the amount of therapist self‐disclosure. Attending counselling and/or psychotherapy also helped the carer to find a ‘safe space’ to disclose and share concerns. Discussion: Carer loss and personal growth are explored, together with the importance of building therapeutic relationships and, for the therapist, seeking supervision when managing personal self‐disclosure. The theme of therapist self disclosure is explored together with the importance of therapists seeking supervision when managing personal self‐disclosure.     

A systematic review of the literature on counselling and psychotherapy for the prevention of suicide: 2. Qualitative studies

Scope of review: The paper reports a meta‐synthesis of 13 qualitative studies of counselling and psychotherapy with people at risk of suicide. Publication time span: The studies considered were reported between 1997 and 2006. Publication origin: Seven studies were conducted in the UK, four in the USA, one in Canada, and one in Sweden. Findings: Themes in clients' and therapists' accounts of the process of counselling or psychotherapy were therapist qualities; therapy components; theoretical framework; and therapy techniques. Themes in their accounts of the effectiveness of counselling and psychotherapy were decrease in self‐destructive behaviour, and quality of life. Themes in clients' views of barriers to effective counselling or psychotherapy were therapist characteristics; therapy components; secrecy; and transferring to the real‐life situation. Secrecy was also identified as a barrier by therapists, as were responsibilities of the profession; training; and the nature of suicide and self‐harm. Facilitators of successful counselling and psychotherapy as identified by clients were responsibility; support; and teaching therapy skills to family members, the latter also being identified by therapists.     

Clients’ perceptions of personal psychotherapy or counselling for therapists

The purpose of this study was to examine clients’ opinions of therapists’ personal use of psychotherapy or counselling. Participants in this study, a nationwide sample of clients recruited through Amazon’s MTurk system, were asked to complete an online survey assessing their attitudes towards treatment use by therapists as well as their general attitudes towards psychological help-seeking and perceptions of stigma (social and self) with psychological treatments. In this study, we found that clients generally had positive views about therapists’ personal use of psychotherapy or counselling. Although overall positive attitudes were found, the results from repeated measures ANOVAs indicated that attitudes depended somewhat on whether the therapist had sought out treatment as part of a training requirement for self-enrichment, or for the treatment of a psychological problem. In addition, participating clients were less supportive of therapists disclosing a treatment use history with their clients. Regression analyses also indicated that attitudes towards treatment use by therapists were significantly predicted by general help-seeking attitudes and perceptions of stigma (social and self), but attitudes towards disclosure were not. The findings from this study have important implications regarding therapist treatment use and disclosure in practice.     

Zum Matching bei ambulanter Psychotherapie mit Psychosepatienten

In an outpatient setting the matching of patient and psychotherapist is essential as there is – in most cases – no protecting institutional frame. Because of the disturbance in his symbolic function the psychotic patient tends to act out his basic conflict between self- and object-related tendencies. As the patient strives for differentiation and separation, naturally, struggle is involved on various levels. The therapist must feel up to all aspects of this struggle including the more concrete ones. Also psychotic patients always induce an intricate interplay of narcissistic transference and countertransference. The psychotherapist should have the capacity to gain distance from his narcissistic countertransference, which as a rule should find support through supervision. It is necessary that in the patient there exist remnants of relatedness to his fellow-men and also a minimum amount of ego-strength and structure that enables him to cope with a cycle of more or less periodical appointments.     

Compulsive "helpfulness": or, how I learned to stop working so hard and love the group

Compulsive helpfulness, an anxiety-laden need by the therapist to feel helpful, akin to the notion of rescuing others, is a potential pitfall in developing an effective psychotherapy group. It can be regarded variously: (1) as a reaction formation against feelings of boredom and frustration stimulated by such phenomena as group resistance or the enactment of inauthentic relationships in the group; (2) as a therapist style driven by a transferential reaction to be regarded as competent and worthy; (3) as an induced countertransference enactment tied to group members' frustration and passivity about their own interpersonal inadequacies; (4) and as a manic defense against despair over the feeling that one's loving has not done any good. In this essay, the author explores his struggle to identify and come to terms with compulsive helpfulness as a dominant theme in the early stages of his tenure as leader of a psychotherapy group.     

The experience of ‘healing stories’ in the life narrative: A grounded theory

‘healing stories' are part of an emergent narrative literature in psychology and counselling. This research explored the subjective experience of ‘healing stories’ within the context of individual's life narratives. A grounded theory (Strauss and Corbin, 1990) method of analysis was used to generate and analyse six participant's life narratives. Analysis of these accounts revealed three categories. The first is the context of struggle that preceded the healing process. participants told of struggle in their relationships with others as well as turmoil in their experience of themselves. The second category, the healing process reflected the participants' growing awareness of life's existential givens (Yalom, 1980). This represented a personal exploration that opened lparticipants to a ‘healing story’ that offered them an insight into choices and possibilities for liberation. The third category illustrated that in the ongoing struggle the ‘healing story’ has continued to provide inspiration in the participants' lived experience as an ‘evoked companion’ (Stern, 1985). This research posited a core dynamic whereby participants' experience of their ‘healing story’ provided not only an initial inspiration that was healing but also, in their ongoing struggle, the ‘healing story’ continued to inspire their lived experience.     

A peocess model of ethnocultural counselling for African survivors of organized violence

By analysing some 500 counselling and psychotherapy cases of survivors of organized violence as a therapist and supervisor over ten years the author developed a heuristic framework for a process model of ethnocultural counselling considering: (1) African counsellor's indigenous concepts, (2) a WHO-UNHCR approach, (3) a heuristic approach to psychotherapy, (4) a constructive narrative perspective, (5) an ethnopsychotherapeutic approach, and (6) a counselling approach for lay counsellors. The counselling process model comprises the following components: (1) Establishing a counselling relationship and motivation for change; (2) defining the problem, explanatory models, goals, and finding interventional means; (3) social comparison, cognitive undoing, metaphors, shared experiences and relaxation techniques; (4) working through the trauma, testimony approach; (5) ritualistic, cognitive and supportive approaches; (6) principle of education and advice; (7) evaluating and revizing treatment and stabilizing behaviour. These seven counselling components are described and counselling case examples are provided from Sudanese refugees in a large camp in Uganda and Malawian torture survivors in Malawi.