Digests - December 2011
- Avoiding boundary violations but continuing to work therapeutically - a subtlety in the management of sexual attraction in therapy
- Less than two complaints for every 1000 members per year, but male members are over-represented
- Acknowledging the lack of clarity that exists around understanding erotic transference
- Clients' attachment system found to be deactivated after seven weeks of therapy
- Cognitive errors and coping action patterns are related to client engagement in therapy
- Theory, practice experience and integrating theoretical concepts from other orientations contribute to therapists' concepts of MUS
- Outcome data displays unique therapeutic stories each with different twists and turns
- An invitation to move from the therapist's chair, into the thick of it
- The human element within self-help is key to reducing distress
1. Avoiding boundary violations but continuing to work therapeutically - a subtlety in the management of sexual attraction in therapy
This study examines therapists' experiences of sexual attraction in therapy. Martin et al identified a core process through which therapists move as they recognise and successfully manage situations in which they feel sexually attracted to a client. The authors performed in-depth interviews with experienced counselling and psychotherapy practitioners and drew on a grounded theory approach informed by the principles of Free Association Narrative methodology.
One of the conclusions of this study is that, while some therapists manage to use their experience to better understand their client’s issues and integrate this into their formulations for therapeutic benefit, some strategies employed to avoid boundary breaches may be non-therapeutic and even harmful to clients. The study identifies four problematic ways of reacting to this boundary pressure of potential harm to clients. The authors suggest that therapists and supervisors have a responsibility for managing these situations in the clients’ best interest, employing support and developing skills to use them therapeutically. Exploration of these events through reflective, open scrutiny is suggested as more useful to inform practitioners, trainers and supervisors than the more commonly examined behaviour of those whose practice has come under the scrutiny of complaints panels.
Managing boundaries under pressure: A qualitative study of therapists' experiences of sexual attraction in therapy
Carol Martin, Mary Godfrey, Bonnie Meekums & Anna Madill
2. Less than two complaints for every 1000 members per year, but male members are over-represented
Male members of the British Association of Counselling and Psychotherapy (BACP) are overrepresented in allegations of serious misconduct and the majority of complaints are brought by people who are themselves involved in counselling. These are some of the conclusions of this paper looking at the second stage of a three-stage audit of complaints made to the BACP.
Focusing on the Article 4.6 process which deals with serious allegations of misconduct, the aim of this study was to identify who complains, who is complained against, and the outcomes of such complaints.
The authors suggest that this audit project provides a starting point for a more informed discussion of complaints policy that can contribute to the development of policy and influence professional practice. However, further research into complaints made to other UK counselling and psychotherapy organisations and research examining what prevents members of the public from making complaints is called for.
Allegations of serious professional misconduct: An analysis of the British Association for Counselling and Psychotherapy's Article 4.6 cases, 1998–2007
Clare Symons, Suky Khele, Jack Rogers, Judith Turner & Sue Wheeler
3. Acknowledging the lack of clarity that exists around understanding erotic transference
Common concerns of curiosity, fear, lack of adequate preparation through training and areas of support for the therapist emerged in this small-scale, qualitative research project. Therapists who encountered sexual attraction within therapy experienced feelings that included shame and embarrassment and supervisory support was seen to be beneficial.
Aiming to explore therapists’ understanding and experience of erotic transference within therapeutic relationships Rodgers conducted semi-structured interviews with six therapists and used Interpretative Phenomenological Analysis (IPA) to analyse the data.
This study highlights a training gap around the exploration of erotic transference, and the conceptualisation and management of sexual attraction within therapeutic relationships. Rodgers also acknowledges that the subject is challenging due to its intensely personal nature and the complexities of understanding that are required by therapists and recognises the difficulties of developing appropriate education and the essential role of high-quality supervision.
4. Clients' attachment system found to be deactivated after seven weeks of therapy
Using an attachment interview and questionnaires to determine therapy outcome at the beginning and after seven weeks of therapy, Strauss and colleagues investigated the changes in attachment after therapy in forty women with either borderline or avoidant personality disorders. The results show that therapy in general was effective but that, in contrast with other studies, not many women were classified as secure at the end of their therapy.
This study adds further evidence to the existing literature that changes of attachment status might be induced by therapy, although the results primarily indicate a deactivation of the attachment system within a sample of clients that was predominantly classified as ambivalent/preoccupied before treatment.
The study also finds a positive correlation between changes in attachment status and therapy outcome indicating that it is worthwhile for counsellors and therapists to focus on attachment when planning their interventions.
Changes of attachment status among women with personality disorders undergoing inpatient treatment
Bernhard M. Strauss, Robert Mestel & Helmut A. Kirchmann
5. Cognitive errors and coping action patterns are related to client engagement in therapy
This study provides preliminary supporting evidence that cognitive errors and coping action patterns are linked to client engagement with therapy. The authors suggest that clients' cognitive appraisal tendencies may not only have relevance in identifying factors that maintain the problems clients bring to therapy, but are also important within the therapeutic process itself.
Aiming to explore the relationship between client’s involvement in therapy and their cognitive errors and coping action patterns, the Lewandowski et al examined client involvement using two measures.
The authors suggest that their work has particular implications for the practice of cognitive therapies. They suggest that an improved grasp of potential indicators can help practitioners understand how cognitive appraisal processes influence therapeutic involvement. This could encourage the development of different approaches to engaging different types of clients in therapy, ultimately facilitating positive therapy outcomes.
The relationship between therapeutic engagement, cognitive errors, and coping action patterns: An exploratory study
M. Lewandowski, D. D'Iuso, E. Blake, M. Fitzpatrick & M. Drapeau
6. Theory, practice experience and integrating theoretical concepts from other orientations contribute to therapists' concepts of MUS
Experienced therapists conceptualise from experience as well as from existing theory and some conceptualisations are common to both psychodynamic and CBT practitioners whilst others are modality specific. These are the main findings from this study examining therapists' conceptualisations of their psychodynamic and cognitive behavioural therapies with clients with medically unexplained symptoms (MUS).
Luca interviewed 12 therapists in NHS settings and, analysing her data using grounded theory, developed a conceptual model with the categories: informal bottom up experience-driven conceptualisations and formal top-down theory-driven conceptualisations.
Despite starting with the assumption that therapists from the two modalities would have distinct theoretical understandings from their professional training to conceptualise MUS, Luca found a more complex picture. She concludes that the participants’ understandings are characterised by experiencing clients as concrete, complaining and difficult, which she suggests, presents a potential difficulty in forming working alliances with MUS clients.
7. Outcome data displays unique therapeutic stories each with different twists and turns
The findings of this practice-based evaluation of school-based counselling provide an insight into the lifespan of the therapeutic relationship as reported using outcome measures. They indicate that the clients involved in this project showed improvements in their well-being, both while waiting for therapy and during therapy.
Hanley et al collected data from nine 13 – 15 year-olds at four intervals, using the YP-CORE self-report questionnaire. Outcome data is often presented as a simple two-stage process illustrating clients moving neatly from point A at the beginning of therapy to point B at the end of therapy. But by examining session-by-session data further, the authors of this study uncover the non-linear characteristics of the individual therapies, showing them to be unique and complex.
Qualitative data also collected during this study sheds further light on the complexity of interpreting outcome measure results and the results of this study go some way to highlighting the complexity inherent in conducting quantitative outcome studies.
Practice-based evidence in school-based counselling
Terry Hanley, Aaron Sefi & Clare Lennie
8. An invitation to move from the therapist's chair, into the thick of it
Presenting examples from a study of therapeutic process in a mental health setting using both ethnography and auto-ethnography, Siddique uncovers a sense of the researcher being caught in-between the two approaches. She presents this as uncomfortable but also as an opportunity to transform the experience of research for all participants and to enhance its quality.
In contrast with what she calls the arm’s length position of the interviewer in other qualitative research methodologies, Siddique presents ethnography as an opportunity to get closer to the action, and auto-ethnography as an opportunity for more creative exploration of phenomena. However it is when auto-ethnography is used as an approach within an ethnographic methodology that Siddique suggests the experience of feeling in-between can be used constructively by encouraging the observed and observer to share their narratives alongside the researcher’s observations. This is seen as an opportunity for psychotherapy research.
9. The human element within self-help is key to reducing distress
People do what they instinctively know will make them feel better, although getting to the point of action can be hampered by delays and confusion. People have a variety of self-help options available to them, the most important of which is having quality relationships with others. These are the conclusions of this qualitative study which drew on semi-structured interviews with 11 participants.
Aiming to identify what self-help approaches may be employed to reduce the effects of emotional distress and why these choices were made, Marley used a grounded theory analysis to identify a complex and multi-dimensional process of self help that was unique to each individual.
By recognising that each distressed individual has different needs and potential ways of coping, Marley suggests that, in addition to providing a quality therapeutic relationship, counselling should explore these unique and individual preferences to best support each client.