The application of civil commitment law and practices to a case of delusional disorder: a cross-national comparison of legal approaches in the United States and the United Kingdom

Legal approaches to civil commitment in the United States and the United Kingdom are compared. A concise overview of the historical evolution of civil commitment in both countries precedes a discussion of the present scheme of commitment standards in each system. These current standards in U.S. and U.K. jurisdictions are then applied to a hypothetical case of delusional disorder. A discussion of the constructive use of civil commitment in patients with delusional disorder who may be dangerous focuses on its value as a preventive measure against potential harm to self or others, as well as the pros and cons of coercive assessment and treatment. Despite the many differences in approach to commitment, the authors concur that in both countries the patient with delusional disorder was committable before the commission of a serious criminal offense.     

The use of self-disclosure among Swedish psychotherapists

Although self-disclosure, when handled with discretion, is often seen as an important intervention in many psychotherapy orientations, including psychodynamic as well as humanistic and cognitive-behavioral approaches, many psychotherapists seem reluctant to use it. The frequency and type of those interventions from psychotherapists of different orientations is less well known. In this study, a random sample of Swedish psychotherapists was asked about their use of different types of self-disclosing information. The results showed that therapists with CBT orientation told their clients more about their training and about their personal ways of handling affective-relational issues. It was apparent that the trend toward more use of self-disclosure in relational psychodynamic treatment has not been accepted among a large number of psychodynamic and psychoanalytic psychotherapists in Sweden. It is recommended that psychotherapists inform their clients more about their training and in appropriate ways share more with their clients about their own relational experiences. Doing so may help enhance clients’ hope and their ability to address their ongoing difficulties.     

Psychotherapy as a Process of Value Stabilization

The Rokeach Value Survey (RVS) and a confidence rating scale (CRS) were given to 13 experienced psychotherapists and 62 of their clients in field settings at the beginning and termination of therapy, or after 6 months. Results from the RVS demonstrate that therapists are more value stable than their clients and that clients shift their value systems toward their therapists' value configurations. Results from the CRS indicate that therapists are more confident than are clients and that clients' confidence increases across therapy.     

Competence to proceed in SVP commitment hearings: Irrelevant or fundamental due process right?

Sexually Violent Predator (SVP) civil commitment, intended to incapacitate offenders and protect the public, has been implemented in 21 jurisdictions. While respondents in traditional civil commitment proceedings need not be competent to proceed, SVP commitment may present a greater deprivation of liberty and therefore greater procedural protections may be merited. Statutes and case law regarding competence in this context address two issues: competence to challenge unproven sexual offense allegations and competence to participate in the SVP commitment process. Of the 14 states that have addressed the issue, one concluded that respondents must be competent to challenge unproven allegations and one concluded that all SVP respondents must be competent to participate in the commitment process. Differences between SVP and traditional civil commitment, the rationale underlying the competence requirement, and decisions regarding competence in SVP commitment are reviewed to inform debate regarding whether SVP respondents must be competent to proceed with the commitment process. Copyright © 2010 John Wiley & Sons, Ltd.     

Beliefs and practices of therapists who practice sexual reorientation psychotherapy

There is currently controversy regarding whether sexual reorientation or conversion therapies are ethical and effective forms of treatment for dissatisfied homosexually oriented people. We present the results of a survey of 206 psychotherapists who practice sexual conversion therapy. 187 therapists said they believed homosexuality is a developmental disorder and that the 1973 decision by the American Psychiatric Association to "depathologize" homosexuality was politically motivated and unscientific. The therapists believe that the majority of dissatisfied homosexually oriented clients who seek conversion therapy benefit from it, experiencing both changes in their sexual orientation and improved psychological functioning. We conclude that therapists who persist in providing reorientation therapy do so because they believe it is an effective and ethical treatment option for their clients.     

Tarasoff and the Duty to Protect

Summary

The Tarasoff I and Tarasoff II cases were decided by the California Supreme Court in 1974 and 1976, respectively. These cases involved the murder of a young woman by her ex-boyfriend, who had been a patient at a University counseling center. The parents of the young woman sued, alleging negligence. Tarasoff I set forth a “duty to warn” on the part of psychotherapists. Upon rehearing in Tarasoff II, the decision was upheld but modified. The court ruled that when a therapist determines, or should have determined, that a patient presents a serious danger of violence to another, the therapist has a “duty to protect” that other person. In this article, we address subsequent cases that have arisen under the “duty to protect” doctrine, and analyze some of the legal issues that these cases have raised.     

Law and the confinement of psychopaths

Civil commitment in the United States historically has followed a medical, targeting individuals with serious mental disorders and providing for their treatment in the least restrictive setting. In the last decade, however, commitment laws have appeared in some states permitting the hospitalization of personality-disordered criminal offenders at the end of a penal sentence. The American Psychiatric Association has fiercely opposed these laws. The U.S. Supreme Court has given its qualified approval, although legal challenges persist. These laws, together with British proposals to permit the civil commitment of dangerous personality-disordered individuals, should be resisted by all professional disciplines.     

The function of punishment in the "civil" commitment of sexually violent predators

Two experiments find that support for civil commitment procedures for sexually violent predators is based primarily upon the retributive rather than incapacitative goals of respondents. Two discrete samples composed of students (N = 175) and jury-eligible citizens (N = 200) completed experimental surveys assessing their support or opposition to scenarios in which a sexual predator was to be released after completing his criminal sentence. Respondents were sensitive to likelihood of recidivism only when the initial sentence was sufficiently punitive. When initial sentence was lenient, respondents strongly supported civil commitment without regard to future risk. Results are discussed in light of the U.S. Supreme Court's ruling in Kansas v. Hendricks (1997) on the constitutionality of civil commitment laws for sexually violent predators.     

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.     

Recording therapy sessions: What do clients and therapists really think?

Aims: Recording therapy sessions has become part of routine practice amongst trainee psychotherapists. To date most research has focused on the benefits of recording sessions to support clinical supervision. There are few data about the benefits or risks for clients. This study aimed to explore the views of clients who had had their therapy sessions recorded and therapists who had recorded sessions. Design: Five clients and 25 therapists completed a qualitative survey, the results of which were analysed using thematic analysis. Findings: All clients and several therapists reported that the recording devices are soon forgotten. Both therapists and clients reported the benefits of recording as being purely for the therapist with none identified for clients. Conclusions: It was observed that clients perhaps did not always understand how recordings were used, suggesting the need for clearer practice guidance.     

Conflict of interest between therapist-patient confidentiality and the duty to report sexual abuse of children

All 51 jurisdictions in the United States require physicians to report suspected child abuse. In most jurisdictions, reporting requirements override both confidentiality and privilege associated with the physician-patient relationship. The authors review the literature relevant to the conflict between privacy and reporting abuse and report the results of a national survey of therapists at sex offender treatment units. They discuss ethical problems experienced under these statutes by therapists who attempt to provide treatment for sex offenders, and by therapists who are required to report past instances of child abuse even when there is no evidence of ongoing abuse.     

A Minister's Information-Handling

ABSTRACT

One of the roles which ministers perform is that of “caregiver.” Caregiving functions include such activities as visiting parishioners, hearing confessions, and counselling people. These functions are carried out within a legal context. In this paper, two aspects of the parish minister's information handling in respect to his/her role as caregiver are examined. Specific attention is given to the pastor's vulnerability, while carrying out pastoral duties, to civil lawsuits for malpractice and to her/his expectation of privilege against testifying in criminal proceedings. It is observed that in North America, considerable confusion exists over who actually owns and who can control the information a minister acquires and disseminates.     

Moving beyond counselling and psychotherapy as it currently is – taking therapy outside

Research was undertaken by the author in order to describe, interpret and explain what happens when counsellors and psychotherapists who have been trained to work indoors with their therapy clients take their therapy practice into outdoor natural spaces. A central research question addressed ‘What happens when counsellors and psychotherapists, who have been trained to work indoors with their therapy clients, take their therapy practice in to outdoor natural spaces?’ Semi-structured interviews were undertaken with therapists who practised outdoors. Three dominant themes emerged critiquing aspects of current counselling and psychotherapy practice. These were related to the unfolding ecological crisis, the context of the work and moving beyond current conceptions of distress and the role of therapy in addressing this.     

Erotic Countertransference and Clinical Social Work Practice: A National Survey of Psychotherapists' Sexual Feelings,Attitudes, and Responses

Male and female social work psychotherapists were surveyed on sexual feelings toward clients, sexual behavior with clients, and utilization of erotic countertransference. Relationships between these variables and therapists' self-reports of training in erotic counter-transference, utilization of supervisory consultation, length of clinical experience, and theoretical orientation were also examined. Male therapists were significantly more likely than females to report sexual attraction toward clients, and to report using erotic countertransference to further treatment goals. The frequency of therapists' discussion of sexual feelings toward clients in supervision was related to the reported frequency of utilization of sexual feelings in treatment. The majority of therapists reported that their social work training did not prepare them adequately to work with erotic countertransference.     

The fee in psychotherapy: Practitioners' accounts

This paper addresses the real and symbolic significance of fee-paying in the psychotherapeutic relationship through the context of available (mostly American) literature in this area and the extent to which the concerns expressed in the literature are reflected in the attitudes of a small sample of psychotherapists in Britain. Therapists were interviewed to establish whether they saw fee-paying as an essential or important element in the therapeutic relationship, whether they saw its presence or absence as affecting process or outcome and whether any counter-transferential issues could be deduced from the way therapists explored their money-relationships with their clients. Analysis of the interviews reflected the debates in the literature and indicated that those who felt most strongly that fee-paying was essential for effective psychotherapy, and that the payment of a fee was symbolically important for their clients, were also those who were most heavily dependent upon fee-paying for their livelihood and who tended to be less likely to express ambivalence about receiving money. Speculations on the basis of this research centre around whether therapists may assert client need in order to defend themselves against or legitimate their own need.     

Sexual Contact Between Psychologists and Their Former Therapy Patients: Psychoanalytic Perspectives and Professional Implications

Data was analyzed from the semi-structured interviews of 6 heterosexual male psychoanalytic psychotherapists who by self-report had not engaged in a post-termination sexual involvement. The focus of each interview was to elicit the participants' views about sexual contact between psychotherapists and their former therapy patients, as well as their related attitudes towards Standard 4.07 of the APA Ethics Code (1992). The results suggested great disparity of opinion regarding what might constitute acceptable, ethical behavior in this domain. Nonetheless, all the clinicians agreed that the potential for harm resulting from post-termination sexual involvements was great, They all shared the beliefs that transference did not resolve with termination, that professional responsibilities continued after treatment ended, and that power differentials between therapist and patient lingered, perhaps in perpetuity. However, it was determined to be premature to replace the current Standard 4.07 with an absolute prohibition against sexual involvements between therapists and their former patients.     

Humanizing Psychotherapy

The essence of the humanistic and existential approaches to psychotherapy is a commitment to conceptualizing, and engaging with people in a deeply valuing and respectful way. Hence, within these approaches, there is an emphasis on viewing clients’ behaviors as meaningful and freely chosen; and there is also a belief that clients have the capacity to become aware of the reasons for their thoughts, feelings and behaviors. Phenomenological exploration is thus a central element of many existential and humanistic psychotherapies, and this requires psychotherapists to put to one side their therapeutic techniques and interpretative assumptions and to listen to clients in an in-depth, non-analytical way. From an existential and humanistic standpoint, however, this valuing of human beings also extends to the psychotherapist's own humanity. Hence, within these approaches, there is an emphasis on the psychotherapists themselves being genuine in the psychotherapeutic encounter, and being willing to meet their clients at a level of “relational depth.” Existential and humanistic practices may not be appropriate for all clients and all psychotherapists, but it is concluded that the principles underlying these approaches are of universal relevance to the practice of psychotherapy.

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Learning from experience: Examining the impact of client work upon two trainee therapists

This qualitative research study, focusing on the learning and change of two trainee therapists over a nine‐month period, was conducted by the trainees themselves. In collecting and analysing their data, the researchers made use of the heuristic methodology, to which some of the principles of the co‐operative inquiry methodology were added. The findings shed light on some of the ways in which trainee counsellors and psychotherapists might learn through their work with clients, the forms and contexts in which this learning may arise, and how the learning might affect the trainees. The findings additionally highlight some of the possible benefits of engaging in research for trainee counsellors and psychotherapists, in terms of their roles as practitioners. These include positive changes in the ways in which they work with clients, and changes in the ways they think about their practice.     

Negativity in psychotherapists' evaluations of clients and personal acquaintances

Forty-seven psychotherapists were studied to determine if they construed their clients more negatively than personal acquaintances. The sample included personal construct therapists, psychoanalytic candidates, and therapists from a community mental health center; they varied in terms of sex, age, years of experience, and clinical discipline. Subjects chose six personal acquaintances and six nonpsychotic individual-therapy clients who were then used as elements in a repertory grid. Constructs were elicited by comparing pairs of elements; all elements were rated on the constructs. Elements were also directly rated on several dimensions, including liking and similarity to self. Results indicated that therapists selectively focused on clients' negative characteristics and acquaintances' positive characteristics. Clients were liked less than acquaintances and were judged to be less like the self. The correlations between valuative variables tended to be higher in the construing of clients than in the construing of acquaintances, whereas expected improvement with therapy was not related to affective evaluation. There were no gender differences in these effects. Although there were no differences in degree of negative construal of clients among the therapist subgroups, the psychoanalytic candidates construed acquaintances less positively than did other therapists. The results suggest that deviancy may be a major dimension distinguishing therapists' construal of clients from their construal of acquaintances. This dimension may result from both therapeutic ideology and the fact that clients selectively present negative aspects of themselves in therapy, producing a bias in the information therapists receive. Possible negative implications for the therapeutic relationship are discussed.     

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.