Sexuality,Boundaries, Professional Ethics,and Clinical Practice

Abstract

Gay male therapists often practice in milieus where it is virtually impossible not to have contacts with clients outside of the therapy room. The necessity of maintaining appropriate boundaries can be strained when client-therapist contacts occur in situations that are overtly or even potentially sexual. This Practice Note addresses professional challenges and various approaches to these situations while maintaining necessary therapeutic appropriateness.     

Clients as Teachers: Reciprocal Influences in Therapy Relationships

The value of the continuing education industry for therapists is questioned, as is the usefulness of therapy books and journal articles, as a means of engaging therapists in life‐long learning. Instead, it is argued that our clients are our best teachers and that therapists learn most effectively from their clients. Drawing on research studies with prominent theoreticians and therapists, and on case studies from clinical work, a number of important themes are identified as ways in which therapists are influenced by their therapeutic encounters with their clients. The themes explored in this article include: (1) intimacy and high emotional arousal with clients as we witness profound change; (2) being challenged by clients; and (3) allowing for boundary ‘crossings’ in order to develop more flexible ways of working with clients. The implications for professional development are discussed.     

Clients’ perceptions of marriage and family therapists’ way‐of‐being: a phenomenological analysis

Previous research highlights the influence of therapist factors on treatment outcomes. One therapist factor proposed as fundamental to the process of therapy is the therapist's way‐of‐being, a relational concept that refers to how the therapist regards a client—either as a person or object (Fife et al., [2014] Journal of Marital and Family Therapy, 40, 20–33). Although this case has been made conceptually, there is little empirical research on therapists’ way‐of‐being with clients. The primary purpose of this research is to investigate clients’ perceptions of their therapists’ way‐of‐being. Utilizing a common factors perspective, the study seeks to explore: (a) how clients experience their therapists’ way‐of‐being and (b) the influence therapists’ way‐of‐being has on clients’ engagement. Phenomenological methods were used to gain a nuanced understanding of the phenomenon. Qualitative data were collected through semi‐structured face‐to‐face interviews with clients (N = 10) who received individual therapy from a marriage and family therapist. Results were organized into two main themes: core tenets (attunement, congruency, and aligning with clients) and operational tenets (providing affirmation and validation, balancing flexibility and structure, and accomplishing goals). Findings are used to make a case for adding the concept of way‐of‐being as an overarching construct for several well‐established therapist factors. Clinical and training implications are discussed.     

Creative Solutions and Development for Social Workers Treating People with Serious Mental Illness - Contributions from Supervision

Social workers who are engaged in a therapeutic work with clients who have serious mental illness often face specific challenges and find themselves in crisis states in therapy, which stem from the return of the clients’ symptoms and their cognitive impairments as well as social stigma. These crisis states cause dramatic changes in the way social workers mentalize their clients and they are propelled to draw from covert, unformulated, and dissociated knowledge that they have about the client’s experience, which contributes to achieving new, surprising, and creative ways to mentalize the client. Such crisis resolutions enhance therapists’ personal and professional development and serve as an identification model for their clients.     

User Involvement in Therapy: Couples' and Family Therapists’ Lived Experiences with the Inclusion of a Feedback Procedure in Clinical Practice

User involvement in therapy includes some form of feedback from the clients. The feedback guides the therapist and the clients toward a best possible result through a best possible therapy process. In recent years many different procedures for collecting feedback have been developed. In a previous study presented in this journal we explored the expectations therapists had before including the comprehensive clinical feedback procedure, Systemic Therapy Inventory of Change (STIC), in their clinical practices. Our aim with this present study is to explore couples' and family therapists’ experiences with STIC from the perspective of user involvement. We found that the term ‘using STIC’ represented many different variations both between therapists and between the families each therapist worked with. Likewise user involvement, combined with a feedback procedure like STIC, was also a many faceted area. We discuss how therapists’ experiences may relate to the different aspects of user involvement in therapy.     

Adolescents Seeking Mental Health Services

Summary

Inner-city adolescents receiving mental health services often get inadequate medical care. However, when those who seek counseling are asked about their health concerns, they say they want to discuss them with their therapists. Based on responses to a clinical self-assessment questionnaire (Adquest), adolescent mental health clients reported sleep difficulties, weight and eating concerns, and frequent headaches and stomachaches. Age and gender differences in patterns of vulnerability and willingness to talk were explored.     

Hidden Eating Disorders: Attachment and Affect Regulation in the Therapeutic Relationship

From the time I began working at a clinic that specialized in therapy with individuals with eating disorders, I have repeatedly encountered cases of clients hiding these symptoms from their therapists. When they finally do reveal the disorder, their therapists often worry that their clients are more disturbed than they thought and that, they, the therapists, did something wrong in the therapy. Although some therapeutic rupture can be part of the picture, I have found that these disclosures often reflect a client’s growing trust in the therapist’s presence and ability to help with feelings that have been, until now, dealt with through the eating behaviors themselves. In my attempts to understand what happens before and after an individual shares a hidden eating disorder with a therapist, I have found ideas from attachment theory, in particular those that explore links between attachment, affect regulation, and self-reflection, to be very helpful. Many authors have noted that eating disorders are related to problems with attachment, loss and separation, and affect regulation. Difficulties in these areas make it hard for clients to be self-reflective or use insight productively. In this article, I discuss my experience with the integration of these dynamics, which I have found to be key to successful psychotherapy with clients who hide their eating disorders.

Boundary Issues in Gay and Lesbian Psychotherapy Relationships

Abstract

Gay and lesbian psychotherapists face unique challenges when working with clients who also identify as gay or lesbian. Of particular importance are the roles professional boundaries play in working with sexual minorities. For example, clinicians must decide whether it is in the client's best interests to know the therapist is gay. Issues of contact outside of the therapy hour also become important, particularly when the therapist lives in a small community, or otherwise risks the possibility of seeing the client in the community. This chapter addresses some of these issues, and poses options for therapists on how to minimize professional boundary or ethical violations.     

You’re Deaf? Breaking through Myths for Effective Therapeutic Practice

ABSTRACT

Most mental health practitioners provide services to hearing clients and might be unprepared when a deaf individual requests services. The purpose of this article is to explore commonly held stereotypes and myths about deaf people and to provide guidance to clinicians who encounter deaf clients in their practices. Myths and stereotypes can affect the way clinicians perceive their clients’ needs. This can lead to miscommunication, misunderstanding, and misinformation, which can harm the therapeutic relationship, thus making effective therapy unattainable. Clinicians should reframe these beliefs and overcome barriers to make way for the therapeutic process to begin.     

Adoptees' and Birth Parents' Therapeutic Experiences Related to Adoption

ABSTRACT

This study examined adoptees' and birth parents' experiences in therapy, including the perceived level of helpfulness and preparation by therapists relating to adoption issues as a function of the year these experiences occurred. Participants consisted of 152 adoptees and 66 birth parents, with the majority (78%) of the respondents being female. Overall, adoption inquiry, addressing adoption issues, helpfulness, and preparedness by therapists increased from 1965 though the 1990s. Therapists who inquired about adoption (54%) or addressed adoption (72%) were perceived as being significantly more prepared and helpful compared to those therapists who did not inquire about or address adoption issues.     

Lesbian Therapists and Lesbian Clients

Abstract

The authors, on the basis of their own experience, explore issues specific to therapists working openly as lesbians with lesbian clients. Their discussion covers the structure of a private practice, the therapeutic relationship between lesbian therapist and lesbian client, and personal challenges for the lesbian therapist. Questions are raised and direction given with the aim of facilitating congruence among the therapist's personal capacities, the therapeutic setting, and the psychological intention of the therapeutic work. The authors note the therapist's need to tolerate the exposure of her personal life and the pressure toward fusion that are both entailed in work with lesbian clients, and they suggest that these special challenges, when the lesbian therapist's engagement with them is conscious, offer rich material that can deepen the therapeutic relationship and the therapeutic work.     

Action-oriented evaluation of an in-home family therapy program for families at risk for foster care placement

The purpose of this study was to conduct an action-oriented evaluation of an in-home family therapy program serving families deemed at risk for the placement of children in foster care. In this study, feedback was solicited from both clients and therapists. Results indicate "duality" associated with several aspects of in-home family therapy, including the opportunity to observe families in their own homes versus the vulnerability some families feel when therapy is conducted in-home; therapists suggesting that sufficient training is required for in-home family therapy to be effective versus clients' opinions that therapists' lived experiences are more relevant; and the importance of the therapeutic alliance versus feelings of abandonment upon termination. Implications for researchers and practitioners are discussed.     

Immigrant Therapists’ Unresolved Identity Problems and Countertransference

The difficult task of identify formation is greatly complicated by immigration in childhood or adolescence. This paper shows how the unresolved identity problems stemming from their immigration to Israel in childhood or early adolescence of three young therapists, two from Ethiopia and one from Russia, affected their countertransference in their treatment of their adolescent clients from their own countries of origin. The three examples are based on art works produced by the therapists and their clients in the framework of workshops on the integration of art therapy techniques into verbally based diagnosis and treatment. The paper highlights the need to help immigrant therapists recognize their own identity conflicts and resulting countertransference, as well as the identity issues of their immigrant clients.     

Systemic Practice in the Time of COVID: Conversations Among Culturally Diverse Therapists

The COVID‐19 pandemic has changed the delivery of clinical services and education of health professionals, including family therapists. This paper distils two separate Zoom conversations between myself (as the lead author) and two eminent family therapists, Professors Maurizio Andolfi and Harry Aponte, where challenges and opportunities for the profession during and after the pandemic are discussed. Creativity and resourcefulness are two important elements therapists and educators have needed to access during the pandemic to find alternative ways to continue to provide clinical services and teaching. Most therapists have transitioned using online technology and various platforms such as Zoom and Skype; for some this has been a somewhat familiar experience, for most it has been a novel one. Key themes emerged from the conversations including the personal and professional ‘lived experiences’ of the pandemic; the financial impact on clients and students; the importance of touch for human social connection; the use of ‘self’ as an instrument of change and alternative platforms of service delivery and teaching. We reflected on what has been lost, such as the nuances inherent in face‐to‐face human interactions, and what has been gained, such as observing families in situ in their own environments.     

How Do the Professional Lives of Family Therapists Affect their Private Relationships: A Qualitative Study

This article is based on a qualitative research project about how the professional lives of family therapists affect their private relationships. The overarching research question was: How does your professional work as a family therapist affect your private relationships? To answer this question, semi‐structured qualitative interviews were conducted with four therapists from two different Family Counseling Services. Through the use of interpretative phenomenological analysis, three main findings were identified: (1) family therapists’ knowledge and values are a basis for interpersonal encounters; (2) participants describe resonance in relation to clients’ stories; and (3) therapists can be challenged in managing confidential knowledge particularly where they belong to the same communities as clients. The study also explores societal expectations and discourses that accompany the role of therapist, which can affect therapists’ freedom of movement in their private lives. These issues are discussed in relation to family therapy theory and relevant research.     

A perfect fit: connecting family therapy skills to family business needs

The purpose of this article is to encourage family therapists to become more interested in family business practice. It does so in three ways: (a) highlighting the number of therapists already involved in family business issues; (b) showing the parallels between family business and family therapy by applying family business research findings to couples therapy; (c) discussing how family therapists already have the practice wisdom to be effective in working with family business clients. Limitations of this practice are also discussed along with suggestions for overcoming them.     

Collaborative Influence

Collaborative therapists acknowledge their role in influencing clients and the outcomes of therapy. But the word ‘influence’, for many new to the collaborative therapies, can be mistakenly connoted as an undue exercise of therapist power. From a dialogic and social constructionist perspective, this article reflects on how therapists can be influential in collaborative ways. Negotiating ‘shared intentionalities’ with clients, while privileging their preferences in meaning‐making and change—as part of respecting their primary authorship over their lives—assists therapists to employ their influence in ways that stay collaborative. Furthermore, by regarding client ‘resistance’ and misunderstanding as instructive, therapists can enhance their efforts to stay collaborative.     

Mental Health Professionals' Exposure to Clients with Problematic Internet Experiences

ABSTRACT

This paper examines clients' exposure to problematic Internet experiences among a national sample of 2,098 social workers, psychologists, marriage and family therapists, and other mental health professionals. This analysis finds that mental health professionals are working with clients experiencing a range of problems related to Internet use. However, these professionals have generally not been exposed to training or information in the professional literature on the topic of working with clients with problematic Internet experiences. We identify several areas in which additional training is needed and review practical implications for mental health professionals.     

A Thematic Guide To Bulimia Nervosa

This article offers a thematic guide to bulimia nervosa for both therapists and clients. It explores the relationship of common themes — developmental, interactional, sociocultural and behavioural — to the central issue of control. It uses examples from therapy sessions to highlight the themes as they emerge in therapy and to illustrate the ways in which the problem may be addressed.