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A practical approach to boundaries

Posted on June 17, 2013 at 8:27 AM Comments comments (97)
A Practical Approach to Boundaries in Psychotherapy:Making Decisions, Bypassing Blunders, and Mending Fences

Kenneth S. Pope, Ph.D., ABPP
and Patricia Keith-Spiegel, Ph.D.

Abstract: Nonsexual boundary crossings can enrich psychotherapy, serve the treatment plan, and strengthen the therapist-client working relationship.  They can also undermine the therapy, disrupt the therapist-patient alliance, and cause harm to clients.  Building on Gutheil and Gabbard's (1993) conceptualization of boundary crossings and boundary violations, this article discusses and illustrates grounding boundary decisions in a sound approach to ethics. We provide 9 useful steps in deciding whether to cross a boundary, describe common cognitive errors in boundary decision-making, and offer 9 helpful steps to take when a boundary crossing  has negative effects. 

Read the article here.

The Concept of Boundaries in Clinical Practice:
Theoretical and Risk-Management Dimensions

Abstract: The authors systematically examine the concept of boundaries and boundary violations in clinical practice, particularly as they relate to recent sexual misconduct litigation. They selectively review the literature on the subject and identify critical areas that require explication in terms of harmful versus nonharmful boundary issues short of sexual misconduct. These areas include role; time; place and space; money; gifts, services, and related matters; clothing; language; self-disclosure and related matters; and physical contact. While broad guidelines are helpful, the specific impact of a particular boundary crossing can only be assessed by careful attention to the clinical context. Heightened awareness of the concepts of boundariesboundary crossings, and boundary violations will both improve patient care and contribute to effective risk management.

Read the article here.

My reading: This article, originally published in 1993 represented a landmark in the field of professional ethics. The authors place the context of boundaries in its historical context, making reference to the clinical work of Freud, Winnicott, Ferenczi and Melanie Klein. The confusion around boundaries stemms partly from the inconsistency between Freud's theoretical prescriptions on analytic technique and his practice. 

Therapists as patients

Posted on June 17, 2013 at 8:16 AM Comments comments (0)
Therapists as Patients:A National Survey of Psychologists' Experiences, Problems, and Beliefs
Kenneth S. Pope
Barbara G. Tabachnick

Abstract: A survey of 800 psychologists (return rate = 59.5%) found that of 84% who had been in therapy, only 2 described therapy as unhelpful, 22% found it harmful, 61% reported clinical depression, 29% reported suicidal feelings, 4% reported attempting suicide, 26% reported being cradled by a therapist, 20% reported withholding important (mostly sexual) information, and 10% reported violations of confidentiality. Women were more likely than men to report sexual material in therapy; psychodynamically oriented respondents were more likely to report sexual material. Of those who had terminated, 63% reported recent consideration of resuming therapy. Most believed that therapy should be a requirement of graduate programs and licensure, but only about a third believed therapy mandated by licensing boards for resuming practice after violations of professional standards to be clearly or even likely effective.

Read the article here.

Sexual feelings in psychotherapy

Posted on June 17, 2013 at 7:48 AM Comments comments (93)
Sexual Attraction to Clients: The Human Therapist and the (Sometimes) Inhuman Training System
Kenneth S. Pope
Barbara G. Tabachnick
Patricia Keith-Spiege

ABSTRACT: Although we currently possess considerable information about the incidence and consequences of sexually intimate relationships between psychotherapists and clients, there is virtually no documentation of the extent to which psychotherapists are sexually attracted to clients, how they react to and handle such feelings, and the degree to which their training is adequate in this regard. Feelings toward clients are generally relegated to vague and conflicting discussions of countertransference, without benefit of systematic research. Survey data from 575 psychotherapists reveal that 87% (95% of men, 76% of women) have been sexually attracted to their clients, at least on occasion, and that, although only a minority (9.4% of men and 2.5% of women) have acted out such feelings, many (63%) feel guilty, anxious, or confused about the attraction. About half of the respondents did not receive any guidance or training concerning this issue, and only 9% reported that their training or supervision was adequate. Implications for the development of educational resources to address this subject are discussed.

Full article available here.

Stanford prison experiment

Posted on December 12, 2012 at 6:30 AM Comments comments (98)
"The Stanford prison experiment was a study of the psychological effects of becoming a prisoner or prison guard. The experiment was conducted from August 14 to 20, 1971 by a team of researchers led by Psychology professor Philip Zimbardo (Also the host of the documentary series Discovering Psychology) at Stanford University. It was funded by a grant from the U.S. Office of Naval Research and was of interest to both the US Navy and Marine Corps in order to determine the causes of conflict between military guards and prisoners.

Twenty-four students were selected out of 75 to play the prisoners and live in a mock prison in the basement of the Stanford psychology building. Roles were assigned randomly. The participants adapted to their roles well beyond what even Zimbardo himself expected, leading the "Officers" to display authoritarian measures and ultimately to subject some of the prisoners to torture. In turn, many of the prisoners developed passive attitudes and accepted physical abuse, and, at the request of the guards, readily inflicted punishment on other prisoners who attempted to stop it. The experiment even affected Zimbardo himself, who, in his capacity as "Prison Superintendent," lost sight of his role as psychologist and permitted the abuse to continue as though it were a real prison. Five of the prisoners were upset enough by the process to quit the experiment early, and the entire experiment was abruptly stopped after only six days. The experimental process and the results remain controversial.

The results of the experiment are said to support situational attribution of behavior rather than dispositional attribution. In other words, it seemed the situation caused the participants' behavior, rather than anything inherent in their individual personalities. In this way, it is compatible with the results of the also-famous Milgram experiment, in which ordinary people fulfilled orders to administer what appeared to be agonizing and dangerous electric shocks to a confederate of the experimenter."

Hero factory

Posted on December 11, 2012 at 6:45 PM Comments comments (95)
Phil Zimbardo from Stanford University encourages us to be heroes. 

Client suicide. Online resources for therapists in training

Posted on November 30, 2012 at 4:57 PM Comments comments (99)
The impact of client suicide on therapists in training



Treatment of high-risk clients
An Overview of Dialectical Behaviour Therapy in the Treatment of Borderline Personality Disorder by Barry Kiehn and Michaela Swales(

How psychiatry became a damage limitation exercise Darian Leader

The Myth of Confidentiality Judy C. Roberts, M.A.  

Suicide and the law

Posted on November 20, 2012 at 8:02 AM Comments comments (149)
To follow through with the topic of suicide, here is a summary of the chapter titled "Suicide and refusal to accept life-saving treatment" from the book "Standards and Ethics for Counselling in Action" by prof. Tim Bond.

Tim Bond is an expert in professional ethics applied to counselling. He is the architect of the BACP Ethical Framework for good practice in Counselling and Psychotherapy

In the chapter on suicide, the author considers the dilemmas concerning working with a suicidal client, when the client refuses additional help or treatment, and discusses the law's in relation to autonomy, consent, mental capacity and confidentiality. 

Life is sacred
Therapists generally find themselves in two different camps. Some take the stance that life is sacred and has intrinsic value and the therapist's duty is to preserve it. Questioning the value of one's life is symptomatic of mental illness. The individual should be protected against suicidal feelings, which are often transient. This stance is embraced by many mental health professionals who work within the remit of preventing suicide. 

The alternative view is that every person has a right to choose, and suicide is an expression of choice. There are occasions when death may be preferable to life. The therapists that embrace this view tend to disagree with the medicalisation of mental illness.  

Tim Bond suggests that becoming entrenched in one position or other may be more for the benefit of the therapist, who is attempting to control their own anxiety about dealing with a client's death. In fact, the appropriate response is to weigh each individual case and be sensitive to each client's individual circumstances, thus allowing for a degree of flexibility and adaptability which is more facilitative than taking a rigid position. 

The English law
The held assumption that the therapist's duty of care is to protect the client from suicidal intent, may be based on misapplications of US law, says Tim Bond. In the states counsellors are required to breach confidentiality to report suicidal intent, but "there is no equivalent in Britain". "There is no general or automatic legal obligation to intervene on behalf of an adult who is suicidal or refusing medical treatment" (p.119)

Individual autonomy
In fact the English law is strongly favours the individual's autonomy unless there is evidence that the person is of unsound mind, that is suffering a diagnosable mental illness or is being coerced. 

Counsellors may suggest that the client access their GP, psychiatrist or community mental health team, but should be extremely cautious in breaching confidentiality against the clients' wishes. Clients frequently refuse to be treated by their GP because of a fear that their medical reports will be disclosed to their employers. 

If the counsellor insists on breaching confidentiality against the client's wishes they "could be liable for substantial damages for loss of earnings if the client's career were to be adversely affected by an inappropriate disclosure" (p. 107)

Therapists working independently of the NHS mental health services have no general duty to intervene. However therapists working with patients receiving compulsory mental health treatment under the Mental Health Act 2007 may have to follow the protocols agreed as part of the terms of their employment. 

For breaching of confidentiality against the client's wishes to be defensible, the therapist hast o believe that the client is seriously at risk of committing suicide and is suffering from a mental disorder (depression, schizophrenia, bipolar affective disorder). 

My note on this: although some psychotherapists are familiar with the DSM and have embraced the use dual diagnosis, we do not have the same remit as a trained psychiatrist to ascribe diagnostic labels. So arguing that a client has a mental disorder when in fact they have not been so diagnosed by their GP or an assessing psychiatrist may be problematic as far as I can see. We could easily be contradicted by a psychiatry expert. 

Crucially, the Mental Health Act excludes promiscuity, alcohol and drug abuse from compulsory treatment. 

Adult clients have the right to refuse life saving treatment. Therapists may challenge and explore the client's views but have to respect the client's right to make a decision for themselves, if they have the capacity to do so (evidence of capacity depends on whether the someone can retain information long enough to make a decision and whether they are able to weigh different options). Tim Bond stresses that the Mental Health Act cannot be used to achieve "the detention of an individual against her will merely because her thinking process is unusual, even apparently bizzarre and irrational, and contrary to the views of the overwhelming majority in the community at large".

Uncomfortable tension
What Tim Bond's exposition highlights for me is what I see as an uncomfortable tension between the law's respect for personal autonomy going all the way back to the Magna Carta and the current medicalisation of psychotherapy. The Department of Health policy to prevent and reduce suicide seems to create a culture in which NHS staff are pressured into standards of care and management of risk that may be at odds with the principles of confidentiality and autonomy. The latest report I have read on Schizophrenia suggests that the use of coercive treatment is on the rise. My own experience working for IAPT has informed me that even for clients without a formal psychiatric diagnosis, prevention is placed above the principle of confidentiality. 

It is understandable that clients seek treatment in an alternative, non-medical culture, but the independent provision of psychotherapy and counselling services is increasingly under the influence of a medical-model. Perhaps independent therapists begin to subscribe to this because the standards of care set by the medical model are part of a government-backed policy and thus appear to have legitimacy. There is also a fear of being accused of malpractice, and yet considerable confusion about what constitutes good practice, as different therapists have different views on this. Furthermore, therapists may want to do everything they can to avoid for themselves the pain and extreme anxiety caused by a client's suicide, which would throw into question of their competence by peers and supervisors and make them vulnerable to criticism and maybe even prosecution. 

Bereaved relatives of clients who have completed suicide may project their anger and grief onto the therapist, making accusations of incompetence or not caring. The therapists may feel torn between ethical, moral and legal principles that may at times feel at odds with each-other and make ethical dilemmas around suicide extremely difficult to navigate. 

Suicide prevention: realistically possible and and always desirable?

Posted on November 16, 2012 at 6:08 PM Comments comments (177)
One in five counsellors, psychologists and psychotherapists and one in two psychiatrist will experience a client's suicide in their career. (Clinicians and suicide loss by Nina Gutin, on

Prediction-prevention culture

How we experience a client's suicide is influenced not only by our own values but also the wider cultural context in which we work. Andrew Reeves (Counselling Suicidal Clients) refers to this as the "prediction-prevention culture" (p.44) 

In the UK several policy documents issued by the Department of Health (Saving our lives: our healthier nation and the National Suicide Prevention Strategy) make reduction and prevention of suicide key principles at the heart of health provision. 

The National Suicide Prevention document states that: "Each suicide represents both an individual tragedy and a loss to society. Suicide can be devastating forfamilies and other ‘survivors’ – economically, psychologically and spiritually. For these reasons the Government has made suicide prevention a health priority." 

As Andrew Reeves points out the policy takes a singular view on suicide and ignores the many shades of grey that become apparent when considering the circumstances around suicide and individual free choice. Some clients are not mentally ill - they have full mental capacity when taking a decision to end their life. They may suffer from a condition that will lead to a progressive loss of function or mental capacity that is incompatible with their sense of self and dignity. 

I think this "allways" approach may constrict and inhibit individual counsellor's willingness to explore alternative statements such as: "suicide should not always be prevented" or "suicide can only be understood ethically by looking at the particular circumstances of a particular individual". 

Counsellors and psychotherapists that work within the National Health System have no choice but to adopt suicide prevention, as it is their contractual duty to follow the protocols of the organisation for which they work. These protocols outline how suicide risk should be assessed, what constitutes suicide risk and what steps neet to be taken with a client who is at risk.

As a consequence of the tenets of the prevention-reduction culture, a counsellor who loses a client through suicide is strongly invited to consider that this reflects a professional failure. 

Is suicide preventable?

It is perhaps understandable that policy makers think in such optimist positivist terms but is this wishful thinking or reality? Can we really predict and prevent suicide? On what basis do policy makers assume that we can? Is this assumption setting counsellors, psychologists, psychotherapists, psychiatrists and social workers up to feel a deep sense of professional failure? 

It is highly unlikely that this question can ever be investigated in a scientific manner simply because one cannot envisage a research in which a control group of suicidal clients is subjected to prediction-prevention. Although we do have statistics to alert us to factors that suggest that a client is at higher risk (male, living alone, unemployment, alcohol or drug misuse, mental illness, access to means), this doesn't mean that we can automatically predict who will carry out a suicide act and when. Reeves suggests that trying to predict suicide is like trying to predict the winner in a horse race. Even with detailed information, it is difficult. 

Suicide statistics are about averages, whereas people processes are highly idiosyncratic and may not neatly fit with the average data. Reeves suggests that even allowing for this, we do have to weigh the facts and ultimately make a decision and, crucially, be prepared to back that decision up and show exactly how we went about considering a course of action. This is because when dealing with suicide there may be no clear right or wrong way. The ethical values we hold sometimes contradict each other. Sometimes we have to prioritise one over another. How we decide in an individual case cannot be dictates solely by statistics - it involves a careful consideration of each individual case in its own right. 

A radical thinker on the subject of suicide prevention, Thomas Szatz goes as far as to suggest that suicide prevention is doomed to fail because: "No one can prevent a person who wants to kill himself from doing so." (Suicide Prohibition p.7) He has a point. Patients who are in high security units manage to take their lives in spite of draconic measures to remove every harmful object or means. It is also known that a high suicide risk period is right after the patient is discharged from the hospital. So sectioning is not necessarily a fool-proof way of stopping someone from committing suicide. If used simply as a means to cover the counsellor's back and avoid the pain and anxiety of holding a suicidal client, it  is a way of handing over the problem to someone else. 

However an aspect not mentioned by Szatz is that some clients are grateful for the containment offered by a psychiatric ward and are willing to temporarily hand over responsibility for their wellbeing to someone else. These are the clients who give consent to be admitted temporarily in a psychiatric hospital. Again a sound decision can only be made by considering the client, their wishes and how they might respond to this type of care. 

Zero degrees of empathy

Posted on November 7, 2012 at 8:03 AM Comments comments (99)
Empathy. It is considered an essential skill and a core condition (Rogers) in psychotherapy and counselling. It is the ability to put oneself in another person's shoes, to experience the world as they are experiencing it. In essence when we are being empathic we are recreating in our own mind and body a map of another person's mind, we are resonating with their pain and experiencing it as our own. 

A while ago I read a book by Simon Baron-Cohen "Zero degrees of empathy". Baron-Cohen asked the question "why does evil exist?" and wanted to find a scientific answer rather than a religious one. Baron-Cohen is an expert in autism, a condition which is characterised by a person's reduced ability to pick up and interpret another person's facial and bodily expressions in order to understand what they are feeling. This causes a considerable amount of strain socially. People are unable to gauge whether what they are doing is appropriate to the situation at hand. For instance, they might tell you a story about a subject that they are passionate about and fail to notice that you are drifting off, getting bored and would like them to stop. People with autism feel lost in social situation. They find it difficult and confusing - a minefield. They notice that people frequently get irritated and fed-up and this is scary because they don't understand what they've done wrong. 

People with high-functioning autism (Asperger's) can be helped to manage social situations by being taught about non-verbal communication and the significance of social cues. It's a little bit like learning to colour by numbers. 

There is another category of individuals tthat display zero-empathy. Baron-Cohen suggests that in this category are people on the high-end of spectrum of personality disorders such as borderline personality disorder (BDP), narcissistic personality disorder and antisocial personality disorder. 

Amongst other traits, patients diagnosed with BDP show an inability to connect with the pain caused to others through their self-harming acts and suicidal threats. They do not understand or experience the turmoil and the extreme fear that the other person is overwhelmed with. 

Clients with narcissistic structures are unaware of the other having any needs. They fill up the space with their discourse and tend to put others down. 

Antisocial personality disorder (psychopathy) is a condition rarely encountered in the therapy room. Psychopaths who are also violent and break the law tend to end up in prison. Those who don't break the law may be highly successful professionals. Cambridge trained psychology researcher dr. Kevin Dutton is fascinated by psychopaths. He has interviewed many of these individuals. 

Dutton has a certain admiration for psychopaths. He has found that some psychopathic traits (charm, ruthlessness, low empathy, focus, low stress response under pressure), if  coupled in an individual with high intelligence and low predisposition to violence may be highly useful in certain professions such as surgery, law and the arm and facilitate a high degree of achievement in these areas. (Psychopath in your family is a short film uploaded on his website I also found this documentary: I am fishead that proposes the thesis that corporate leaders are psychopaths)

The psychopath can accurately create a map of another's mind. He (because it tends to be a man) is extremely good at gauging what the other may be experiencing or thinking. However, the psychopath fails to experience another person's pain and are themselves emotionally under-aroused. Functioning MRI brain scans show that in psychopaths the amygdala (the structure of the brain that gets activated when we experience negative emotion and fear) is under-activated. 

In other words psychopaths cannot display the kind of "hot" empathy that translates into compassion and moral restrain. They are very good at thinking on their feet, focused, driven and because they brain/body rarely triggers the stress response, their verbal and manual performance remains highly accurate even in the most daunting situations. 

Why is that? Stress response translates partly into the release of a steroid hormone - cortisol. This hormone triggers bodily reactions that are biased towards facilitating a motor reaction such as running really fast. Prolonged exposure to glucocorticoids however has negative effects on the hippocampus (the part of the brain involved in the retrieval of autobiographical memory). We have all experienced stressful situations in which we feel tongue tied and cannot remember facts that we do know. Cortisol is to blame. In fact, cortisol not only interferes with the functioning of the hippocampus but can also contribute to premature cell death at this site. Prof. Dr. Robert Sapolsky from Stanford University has proved that stress has a negative effect on memory and the hippocampus. (The audio of his talk Stress and memory Forget it! is uploaded on youtube. Ignore the picture of the cat.)

Psychopaths have no such concerns. They are able to withstand extremely stressful situations without their nervous system being overwhelmed and without their body swimming with adrenaline or cortisol. 

Unsurprisingly, it turns out that what all people with zero-degree of empathy have in common is that they are not so good at relationships. The inability to hold someone else's mind in your mind, to respond with compassion is not conducive to being able to form a strong bond with another human being. 

The good news is that we are getting better and better at identifying low-empathy in children and that there are ways to train people in empathy. 

And to end, I found this brilliant short animated history of empathy by Jeremy Rifkin. It is called "The empathic civilisation". Rifkin argues traces the evolution of the empathic brain and argues that our ability to extend empathy to others with whom we don't share the same culture and religion, as well as to other species is essential to our survival on this planet. 

Provocative questions about relational ethics

Posted on October 11, 2012 at 6:57 PM Comments comments (0)
I read an exciting article on Relational Ethics by Nic Neath, included in "Relational ethics in practice" (Lynne Gabriel and Roger Casemore ed.) Nic manages to ask about a hundred really provocative questions about our capacity as trainees, counsellors, trainers to live up to the ethical principles we profess to believe in. 

When are you making a relational ethical choice? 
When does your personal choice clash with the ethics of where you study/practice? 
How do we walk through the minefield of difference with consistency when all the time we are changing, evolving learning, bending against or towards an ever-changing world of phenomenological encounter?
Where does the client's informed consent begin to get informed? 
Isn't "informed consent" a dubious notion? Informed consent by what experience, by what perceptual beliefs, by trust in whose understanding of the world?
Who defines what "fair" and "impartial" treatment is? 
How do we know what is best for us?
Where does the power to set ethics come from?
How can we practice in a client-centred way when the engagement paradigm has already been predetermined?
What do we do when general consensus about "best" practice overrides the uniqueness of each client? 
Should we try to keep everyone safe? Doesn't learning and evolution actually come through risk taking, making mistakes, being out of comfort zones?
Who knows the rules? Who holds the power? Who leads the way? 
How long should therapy take?