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Issue Two 2013

Journal of the Counsellors and Psychotherapists Association of NSW, Inc.


The Australasian Constellation Intensive Sydney, 25 November - 1 December, 2013

Francesca Mason Boring

Marianne Franke-Gricksch

Judith Hemming

Ed Lynch

Bill Mannle

Gordon & Nancy Wheeler

Join this exceptional international faculty for the 2013 Australasian Constellation Intensive, an opportunity for professional and personal development and connection with community in a Retreat like environment. The Intensive offers a wide range of learning opportunities including special topic workshops such as Organizational, Educational, Professional Supervision, Indigenous constellations and more. Three different streams of learning will ensure professional development suited to different career stages. The venue at Collaroy Beach is only 30 km north of Sydney with stunning views of the ocean and Long Reef. Be nurtured and enriched; personally and professionally. 2013 Australasian Constellation Intensive 25 November - 1 December 2013 www.constellationintensive.com Venue & accommodation: residential program The Collaroy Centre Homestead Ave, Collaroy Beach Sydney NSW 2097 www.collaroycentre.org.au Early Bird: $1760 (incl. GST) $500 deposit due by 20 March, 2013. Final payment by 31 July 2013 Full fee: $1980 (incl. GST) Organisers: Maria Dolenc, Jonine Lee Gabay, Frank Breuer, Chris Walsh and Dean Mason Email: info@constellationintensive.com


Welcome

Editorial

Ethics is the activity of man directed to secure the inner perfection of his own personality ~Albert Schweitzer

Ethical practice is critical in all the helping professions but especially so in psychotherapy where clients are deeply vulnerable—often presenting in an already traumatised state— and asking for help while sharing their most intimate, even hidden, thoughts and feelings. Ethical practice, some might say, is the bedrock of therapeutic work, the foundation of the therapeutic alliance and arguably one of the most important aspects of clinical work. It is certainly a vital ingredient in ensuring that one helps without hurting, and in real life— outside the theoretical framework of a code of ethics—it is complex. Ethical dilemmas come dressed in unexpected colours, shapes and sizes and challenge one to build an ethical backbone. This issue of CQ aims to facilitate discussion on the critical thinking behind creating strategies to more successfully guide the practitioner along the path of ethical practice. It explores the areas of fallibility that can exist even for the most experienced, competent and conscientious of therapists and addresses the practice of ethics amongst the various cohorts of clients— individuals, couples, families, and children—dual and or multiple relationships, and within a multi-cultural context. I hope this issue stimulates the further illumination of answers to questions such as: Am I ethically awake, and how do I know? Do I question and challenge as an active process my own ethical awareness? How do I take personal responsibility on a daily basis for my ethical practice? Do I know my ethical weaknesses and blind spots? What are the ‘ethical certainties’ I take for granted or that I allow to go unchallenged? A very special thanks to Elisabeth Shaw and Elizabeth Riley for their much appreciated guidance and expertise in identifying appropriate contributors and for suggesting topics for as broad a coverage of the subject of Ethics as is possible within the limited space available for this issue. I would also like to thank all our contributors who have given so generously of their time and knowledge for which I am very grateful. We begin with an historical examination of the philosophical underpinnings of modern psychotherapy and the ways in which philosophical thought has informed and shaped modern psychotherapy. Elizabeth Riley and Elizabeth Day bring a wealth of experience and expertise in the areas of gender and sexual identity, post modern theories and ethics. Together, they examine the ethics of change, using reparative therapy to discuss the meaning of ethical fitness. In our second article, Elisabeth Shaw and Michael Carroll address the subject of ethical maturity head-on with clinical examples that illustrate the nuanced difficulties encountered in situations of ethical dilemma. As they so aptly state: “Ethical maturity is not a static state one achieves, nor is it marked by particular study or defined effort”, making it a complex subject that receives little attention that is often overlooked. Michael Carroll is a chartered counselling psychologist involved extensively in training. Individual, couple and family therapist Elisabeth Shaw specialises in professional ethics and explains that “[c]ouple and May 2013

family therapists arguably face more ethical challenges…”. She identifies these inherent challenges and why “codes of conduct and ethics have not always been of direct assistance” in her discussion of ethical competence. Children are amongst the most vulnerable in our society and often come to counselling under unique circumstances in that, as clients, they are not often there of their own desire and, depending on their age, vary in their ability to comprehend the therapeutic process. Mary Jo Mc Veigh, a trauma therapist who works with children, takes us through the multiple ethical challenges faced when working with children, the factors to consider and some of the inherent dangers of inadvertently causing harm to children. Robin Bowles, a psychotherapist with an extensive background working cross-culturally and with refugees, greatly enhances our understanding of the complexities in cross-cultural counselling and challenges us to question the inherent biases in our codes of ethics. Her vivid case examples take us into the therapy room helping us to better comprehend the dynamics at play and what it means to be a culturally competent counsellor. Ione Lewis the President of PACFA homes in on the ethics of dual roles and multiple relationships and takes a sharp look at CAPA’s Code of Ethics, finding room for improvement. Our columnist, Jewel Jones, ponders the advantages and disadvantages of working in private practice compared to working in agencies. Finally, I am informed that as you read this the CAPA website will have gone live. CQ contributor guidelines and advertising rates and specs can be found there or obtained from office@capa.asn.au, editor@capa.asn.au or advertising@capa.asn.au, depending on the nature of your enquiry. As always, this journal is for you, our valued members, and I enthusiastically encourage your active participation in the professional dialogue and sharing that this journal provides. Please have a look at the upcoming themes announced on page 36 of this issue and have your say on the topics that interest you. Journal articles are, by the nature of page space, limited, and early contact with me improves the chances of your contribution being included. Dialogue is welcome and encouraged. If you’d like to contribute to future issues, please contact me at editor@capa.asn.au

Roberta Parrott Editor Roberta Parrott, BA, Dip. is a freelance editor based in Sydney. She is a keen student of art history and languages, particularly French and Spanish and travels every chance she gets. Trained also as a Cordon Bleu chef, she balances her passion for cooking with an active lifestyle. 1


CAPA NSW Executive and Staff President Gina O’Neill president@capa.asn.au Vice-President Ebinepre Cocodia vicepresident@capa.asn.au Secretary Sharon Ellam secretary@capa.asn.au Treasurer Juliana Triml treasurer@capa.asn.au Ethics Chair Tara Gulliver ethics@capa.asn.au Membership Chair Linda MacKay membership@capa.asn.au Regional and Rural Liaison Chair Sharon Ellam regional@capa.asn.au Professional Recognition Chair Ebinepre Cocodia recognition@capa.asn.au Liaison Chair Alison Hood liaison@capa.asn.au Executive Member Tim Harvey webdev@capa.asn.au Executive Member Linda Newcomb strategy@capa.asn.au PD Coordinator Juliana Triml pde@capa.asn.au Consultant Operations Manager Jane Ewins com@capa.asn.au Membership Coordinator Melissa Neve membershipcoordinator@capa.asn.au Administrative Assistant Freddy Ortega office@capa.asn.au CQ: The CAPA Quarterly Editor Roberta Parrott editor@capa.asn.au Advertising Coordinator Roberta Parrott advertising@capa.asn.au

Contents Welcome

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Editorial ~ Roberta Parrott

CAPA News 3

From the President’s Desk ~ Gina O’Neill

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Regional and Rural Report ~ Sharon Ellam

Modality Profile 5 Clinical Hypnotherapy ~ Leon Cowen Features 6 8 10 12 14 16

Ethics: A Phenomenological Enquiry ~ Elizabeth Day and Elizabeth Riley Evolving Thoughts on Ethical Maturity ~ Elisabeth Shaw and Michael Carroll Ethical Competence in Couple and Family Therapy ~ Elisabeth Shaw To See or Not To See: Ethical Considerations in the Therapeutic Service of Children ~ Mary Jo Mc Veigh Ethical Issues in Cross-Cultural Psychotherapy ~ Robin Bowles Working in a Matrix of Human Relationships: Dual and Multiple Roles in Counselling and Psychotherapy ~ Ione Lewis

In the Therapy Room 18 Choices, Context and Clinical Conundrums ~ Jewel Jones Professional Development 20 Patterns From Our Past: The Self of the Therapist ~ Review by Juliana Triml 21 Professional Development Events Noticeboard 36 Calls for Contributions & Ad Rates Inside Back Cover Classifieds Back Cover Conference Calendar

CQ: The CAPA Quarterly respectfully acknowledges the Cadigal people of the Eora Nation, the traditional owners and custodians of the land on which the CAPA NSW office is located; and the traditional owners of all the lands through which this journal may pass.

Cover art by Jim Frazier Design by Cheryl Ward Printed by Unik Printing

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© CAPA NSW 2011. Copyright is held with CAPA NSW and individual authors. Please direct permission requests to the editor. Opinions expressed in CQ: The CAPA Quarterly do not necessarily represent those of the Editor or of CAPA NSW. While all reasonable care has been taken in the preparation of this publication, no liability is assumed for any errors or omissions. Liability howsoever as a result of use or reliance upon advice, representation, statement or opinion expressed in The CAPA Quarterly is expressly disclaimed by CAPA NSW and all persons involved in the preparation of this publication. The appearance of an advertisement in CQ: The CAPA Quarterly does not imply endorsement of the service or approval of professional development hours from the service. Advertisers are advised that all advertising is their responsibility under the Trade Practices Act.

CQ: The CAPA Quarterly


CAPA News

From the President’s Desk

Welcome to the second issue of CQ for 2013. The year is now well under way, and I hope that all of your calendars are full with clients and clinical work. CAPA members continue to support the Executive as we work our way through the implementation of the 2012 Future Strategic Plan to ensure CAPA stays relevant and represents our values in an ever changing and growing industry. By the time this issue goes to print, we expect the new CAPA website to be live, and we will be in the midst of ‘membership season’. Since Barry Borham began his campaign to build a new CAPA website late last year Tim Harvey, Alison Hood, and Paul Graham have also helped make Barry’s goal a reality. One of the Executive’s goals this year was to make our membership renewal procedure as supportive and simple as possible. In order to achieve this, Melissa Neve, a membership specialist, was contracted during the season to establish an integrated system to support members with answers to questions about their applications. This goal has also been inextricably linked to all parts of the operation at CAPA, including the office which has undergone a major restructuring to meet our goals. Jane Ewins—a consultant in organisational management, communications and marketing—resigned from her role as Vice-President to undertake this complex and overdue task. The CAPA Executive Committee co-opted her to consult as Operations Manager, reporting regularly to the Executive Committee. CAPA’s 2012 Future Strategic Plan has made the role of Office Co-ordinator redundant. Paul Dudley has been a friendly voice for our members phoning in with questions, especially during times of great change in late 2012. Thank you, Paul, for all of your hard work over the months, and the Executive Committee wishes you well in the future. Another goal for CAPA membership this year is to see our numbers grow. Members of the Executive have been speaking with training institutions to encourage both fledgling counsellors and graduate students to join CAPA. Our Membership Chair, Dr Linda Mackay, and Professional Recognition Chair, Ebi Cocodia, have been liaising with Melissa Neve on how best to restructure our student membership offers. I will be promoting this year’s PD events, which you will read about in the upcoming issues of the journal. A big thank you, again, to Juliana Triml for organising CAPA’s PD events, and we welcome your contacts or suggestions for future PD events. This issue of CQ addresses Ethics, which continues to be a current, hot topic within our industry. As we become more regulated and recognised by the government, so too does CAPA’s

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commitment continue to focus on maintaining a high standard of ethics. I recently attended an ethics training course and was surprised to find that my ‘take home’ message was: Most ethical issues are almost always resolved in the beginning with a simple meeting and an apology from the professional involved. When this does not occur, issues are most likely to escalate into complaints. Another tip I picked-up was that the St James Ethics Centre is a valuable tool that we can use to discuss any ethical issues or related questions. They have a free one-hour telephone session for the caller to talk through ethical problems. I was recently away in Milford Sound, New Zealand where, for five whole days, I did not have coverage for my iPhone. During this time, I was in complete contact with nature, my thoughts and feelings, and my body. I discovered how tired I had become, how I experienced tiredness in my life, and I made some decisions about how I will do ‘tiredness’ differently going forward. On reflection, I was able to do this only because I had time. A lot of my time is spent using technology, at work and with family and friends. A good reminder to ourselves, especially in our area of work, is to take time to restore ourselves. This is also an ethical topic. How do we maintain ourselves so that we are as effective as we can be in therapy sessions with our clients? We will all do this differently, and do it we must. What happens to a well intentioned, ethical therapist who does not take time to reflect, restore and review both herself and her practice? Ethical issues arise. At the PACFA AGM last year, the topic of supervision was discussed. A vote was made and, as of 1 July 2013, all practitioners with a case load of more than four hundred hours are required to have a minimum of fifteen hours of supervision per year. This ruling is an attempt to address some of the common themes relating to both the ethical complaints PACFA receives each year and the ethical issues that can arise for therapists or counsellors who do not take the time to reflect enough on themselves and their practices. My hope for all CAPA members is that you will reflect on yourselves and your practices in a way that benefits you, your practice and your clients with the best possible outcome for all. I hope you enjoy this edition of CQ. Warm wishes,

Gina O’Neill President president@capa.asn.au

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Regional and Rural Report

New Faces Answer the Regional Call The Regional and Rural Committee held a landline teleconference meeting in January to re-group and bring together new members who had volunteered to assist in response to our calls for help at the end of last year. I was humbled and relieved to find that we have a full and active group of people who are motivated to contribute. I would like to introduce these very special individuals to you. Claudia Pit-Mairbock is an ongoing Committee member. Claudia lives and works on the Central Coast and is the longest-serving member of our Committee. Having worked with Claudia for a couple of years now, I value her strengths— her organisational and communicative skills. Understanding what it’s like to be a regional member (even though she is still so close to Sydney compared to others), Claudia is working to find solutions to how we can better reach our regional members. She is also a great systems thinker. Shawn Stevenson has been a member of the Committee for one year. Situated in Leura, in the Blue Mountains, Shawn is motivated to develop strategies to help reduce the barrier of distance and to provide tangible support for regional members. Shawn says that he was drawn to this Committee by a desire to learn more about CAPA and to develop connections with other practitioners. Marie Novella-Mcmahon is a new member in the Southern Highlands. Also highly skilled and with a rich background working and volunteering, Marie says her motivation to volunteer comes from a desire to promote and strengthen the regional voice of representation within CAPA, and she believes it is not good enough to just be a member of an organisation, leaving the workload to a few. Her aim is to bring regional and rural members together to feel supported, encouraged and to experience professional development events at a reasonable cost. Hopefully through this forum, members will feel less isolated and will embrace and be part of a professional, caring organisation. Helen Larkey hails from the Byron shire. With a background as a counsellor and educator, Helen set up in 2006 a free counselling service for Coffs Harbour. Along with psychologist, Chris Boris, she was Senior Supervising Counsellor, running group supervision and trainings whilst also seeing clients. Helen believes that as a volunteer you get much more than you give. She wants to work with the Committee to bring conferences and trainings to regional areas as well as provide a network for counsellors working in private practice to gain support and to share. Jo Fleet lives just south of Sydney and is involved in more than one capacity within CAPA . At our recent meeting, Jo suggested that support, training, and supervision could be made more accessible for CAPA members outside the metropolitan area. She was actively involved in our brainstorming session on how to engage members for regional trainings and where to hold trainings so that the maximum number of members can benefit. Sheree James is a rural landowner and counsellor in the Mudgee area. She sees and experiences first-hand how regional 4

communities and the counsellors who serve them are negatively affected by distance. Sheree’s particular perspective further enriches the value of this Committee in meeting all members’ needs. I live and work on the western shores of Lake Macquarie. I work in private practice, volunteer as a Lifeline face-to-face counsellor and teach piano from home. Travelling to Sydney on a weekday night for a PDE is impossible with my schedule, as is the case for many CAPA members who live close to Sydney. My motivation has always been to improve the services for regional members so that there is greater equity. Improved communication, connections and access to training and support have always been my greatest wishes. I am currently working on the CAPA Executive Committee as Secretary as well as serving as the Regional and Rural Chair. Please contact us on regional@capa.asn.au if you can assist with supervision (group and/or individually), be a trainer at a regional PDE or have access to a venue and a local network for regional events. We encourage and appreciate your participation.

Take care,

Sharon

Sharon Ellam, Chair Regional and Rural Committee

Membership Total as at 1 April 2013 Clinical Member 410 Intern Member 124 Provisional Member 71 Student Member 70 Affiliate Member 28 Special Leave

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Life Honorary Member

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Total Financial Members 713 May 2013


Modality Profile

Clinical Hypnotherapy What is clinical hypnotherapy? This is a great question and one which is not easy to answer as the ‘experts’ can’t agree. The Greek word hypnos means ‘sleep’ (Janke & Hood 2010), but hypnosis is anything but sleep. Although definitions have been proposed (Araoz 2005, Elias 2009, Green et al. 2005, Heap 2005, Spiegel & Greenleaf 2005), a universally accepted definition of hypnotherapy is yet to be determined (Parliament of South Australia 2009b). Despite this, hypnotherapy is used as an adjunct by various health professionals (Elkins & Hammond 1998) to enhance their existing skills. It is acknowledged that clinical hypnotherapy has a distinct set of clinical skills (Parliament of South Australia 2009a), which may incorporate counselling and psychotherapy. Skills used in clinical hypnotherapy often mirror those used in counselling and psychotherapy. As the modality of clinical hypnotherapy develops, there is much debate about the required skills and even the professional title: is it hypnosis or hypnotherapy? For the purpose of this article, I will use the term ‘hypnotherapy’. The overlap between hypnotherapy and counselling and psychotherapy can be extensive. Progressive relaxation, as used in counselling and psychotherapy, has been identified as comparable to hypnosis (Hammond 2010, Jensen & Patterson 2006, Liossi et al. 2009, Stoelb et al. 2009), yet it is deemed to be non-hypnotic. Hypnotherapy has the ability to mobilise the subconscious mind in a way that other therapies do not. Using the client’s innate abilities, hypnotherapy can assist in the healing of physical and mental health issues. Client’s with physical conditions such as Irritable Bowel Syndrome (Gonsalkorale 2006, Whorwell 2008) and pain (Jensen 2009, Patterson & Jensen 2003) have reported relief and a better quality of life after using hypnotherapy. Mental health issues such as depression (Alladin 2010) and anxiety (Evans & Coman 2003, Hammond 2010) have also shown good results with hypnotic treatment. All this is brought about in a hypnotherapy consultation similar to a model already used by counsellors and psychotherapists. The structure of the consultation incorporates four phases: the greeting phase, counselling phase, hypnotherapy phase, and the wrap-up. The hypnotist or clinical hypnotherapist facilitates by assisting clients to achieve their goals using the hypnotic state. Areas of difference between hypnotherapy and counselling and psychotherapy occur in the counselling and hypnotherapy phases of hypnotherapy. Whilst the techniques used in the counselling phase overlap significantly with standard counselling techniques, the intended outcomes are appreciably different. The counselling phase outcomes provide the information that forms the basis for the techniques, which will later be used in the hypnotherapy phase. This latter phase is radically different and uses non-standard counselling and psychotherapeutic techniques. Susceptibility techniques can be used to determine the responsiveness of the client prior to the commencement of the hypnotherapy phase, which is then initiated using the induction technique, enabling the client to enter the hypnotic state, followed by the use of deepening techniques to enhance the hypnotic state. Various techniques such as progression,

Leon Cowen

regression, automatic writing, ideomotor questioning, dream therapy, hypnotic empty chair and other appropriate techniques can be employed, all of which are followed by suggestion. Suggestions are crucial to the outcome of the consultation and are invitations to the hypnotised client’s subconscious mind to make or reinforce the required changes. The manner in which the suggestions are given to the client depends on the style of hypnotherapy used. The variety of styles includes: ClientCentred (Cowen 2008), Ericksonian (Holdevici & Crăciun 2012), Permissive (Tomic 2011), and Authoritarian (Heap et al. 2002). If, for example, you chose Client-Centred, the suggestions would be constructed from the client’s own words gleaned from the counselling phase prior to the commencement of hypnosis. Once the suggestions are given, the client is awakened and the wrap-up then concludes the consultation. The concept that hypnotherapy provides the same outcomes as other mental health interventions is only part of the scenario; hypnotherapy’s capacity to affect physiology is the other (Landolt & Milling 2011, Patterson & Jensen 2003). The concept of psychosomatic illness is well researched and documented. Psychoneuroimmunology also postulates that the central nervous system communicates with the immune system (Torem 2007). Research has shown that hypnotherapy could have clinical efficacy in the treatment of anticipatory and chemotherapyinduced nausea and vomiting (Richardson et al. 2007). The understanding that the mind influences the body is growing, and this is the second realm of hypnotherapy. Could it be that the mechanisms causing psychosomatic illnesses are the very same mechanisms hypnotherapy uses to rectify physiological conditions (Flammer & Alladin 2007)? As yet, there is no concrete understanding of these mechanisms, but hypnotherapy research is continuing and may soon provide some answers. The potency hypnotherapy adds to the existing skills of health practitioners, even at a basic level, is being understood and embraced. Clinical hypnotherapy has been shown to be effective in a variety of clinical cases (Coelho et al. 2007, Dale et al. 2009, Farrell-Carnahan et al. 2010, Kraft & Kraft 2007, 2009, Landolt & Milling 2011, Lindfors et al. 2012, Pfitzer 2008, Sapp et al. 2007, Shih et al. 2009) ranging from mental health issues to physiological conditions. With growing support for hypnotherapy—evidenced by the public increasingly seeking hypnotherapy and by health practitioners expanding their practices and skill sets to incorporate hypnotherapy—more research will be undertaken, providing the empirical evidence supporting the psychological and physiological outcomes our clients are receiving. References Alladin, A 2010, ‘Evidence-Based Hypnotherapy for Depression’, International Journal of Clinical & Experimental Hypnosis, 58(2): 165-185 Araoz, D 2005, ‘Defining Hypnosis’, American Society of Clinical Hypnosis, 48(2/3):1-6 Coelho, HF, Canter, PH and Ernst, E 2007, ‘The Effectiveness of Hypnosis for the Treatment of Anxiety: A Systematic Review’, Primary Care & Community Psychiatry, 12(2):49-63 Cowen, LW 2008, ‘Client-Centred Hypnotherapy - Old Concept - New Application’, Australian Journal of Clinical Hypnotherapy and Hypnosis, 29(2): 27-34 Dale, HL, Adair, PM and Humphris, GM 2009, ‘Systematic Review of Post-Treatment Psychosocial and Behaviour Change Interventions for Men with Cancer’, Psycho-Oncology, 19 (3): 227-237

(continued on Page 34) May 2013

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Features

Ethics: A Phenomenological [E]thics is entirely my affair, not the affair of some hypothetical, impersonal or universal I running through a sequence of possible imperatives. Ethics is not a spectator sport; rather it is my experience of a claim or demand that I both cannot fully meet and cannot avoid ~Critchley on Levinas 2002:22

Therapeutic practice is more indebted to philosophical thought than may be evident at a cursory glance. Socrates, the originary thinker of Western philosophy, famously asserted at his trial that an unexamined life is not worth living. His Socratic method informs some elements of clinical practice in the form of dialogue and enquiry, and he and his followers, including Plato, professed human wellbeing as the highest goal of ethical thought and practice. If the idea is simple, the practice is challenging. It landed Socrates into trouble with the Athenian authorities, who sentenced him to death by hemlock. In a therapeutic context, ethical practice is more of a requirement than a threat to the state; however, in a context that now prefers its facts ‘hard’, the ‘soft’ and uncertain realm of ethical dilemma can pose genuine challenges to clinicians. Sound, ethical decision making demands attention to the many complexities inherent in the therapeutic relationship. While we have recourse to professional codes of practice, these are guides at best. The development of knowledge, critical self discovery, and the awareness of the multiple influences and biases that guide decision making are the aspirations of ethical intelligence. This paper invites an exploration into the philosophical supports for ethical practice, and it uses as its example some phenomenological methods to explore the role of shame in the controversial practice of reparative therapy. Ethics for Clinicians The majority of therapeutic contexts comprise a dyad or triad consisting of only the counsellor and the client, with no witnesses to the work and no external agent to affirm or critique the counsellor’s approach or processes. That is necessarily the case, and the confidential nature of the work requires this privacy. It means, though, that in addition to the application of our professed skills, the fiduciary relationship calls for standards of behaviour informed by ethics. Much of the grey area within the interpersonal relationships of therapy has to be navigated, therefore, by our principles, and systems of value and meaning. Ethical practice takes into account meta-ethics (the objective existence of moral/ethical properties as ‘right/wrong’, ‘good/ bad’), descriptive ethics (how ethical decisions are made, including influences such as moral principles and processes), and prescriptive ethics (codes and guidelines) (Miner & Petocz 2003:12). Ethics in the therapeutic context assigns clinicians the responsibility to exercise phronesis, the practical wisdom of acting “at the right time, toward the right people, in the right way and for the right reasons” (Audi 2001:51). This responsibility involves recognising the complexity involved in decision making in order to facilitate outcomes in the client’s best interest. Ethical practice requires of us a commitment to ‘ethical fitness’, to recognise ethical challenges, and to have the ability 6

to decide and live the right action (Kidder 2009). This idea is captured in the phrase “obedience to the unenforceable” (Moulton 1924), the execution of what is right when there is no one to judge or observe our actions. What is ‘right’ is of course a provisional, context-based and highly contested notion. This is why resorting to professional codes alone is inadequate for resolving ethical dilemmas. Moreover, reliance on codes alone can be said to reduce the ‘moral autonomy’ of the individual practitioner instead of appealing to a level of ethical intent; and it may constrain the practitioner to conform to a static notion of ‘good’—according to the code—diverting the process away from critical ethical thinking and responsibility (Coady 1996:49). A significant aspect of ethical fitness, for therapists, is to engage with a commitment to the field and to our congruence as practitioners. This necessitates a capacity for critical thinking and for processing input from others. We engage this through professional development, consultation with senior practitioners and supervisors, other forms of reflective practice, and through accessing quality research literature. Developing congruence also includes increasing self awareness by noticing and acknowledging assumptions that we make within the therapeutic encounter. Supervision is one avenue for this exploration. In supervision, however, we can present only our view of the situation, unless therapy sessions are recorded. This raises the questions: Do I remember the session accurately? Do I really know how I have affected this client? Am I being honest? Arguably, then, the practice of ethics can be held to sit somewhere in the middle of a spectrum between science and metaphysics, to the extent that ethical practice is neither empirically determinable nor based on bestowed wisdom. Its disciplinary origins are philosophy, and so the practice of ethics in therapy can reasonably be guided by philosophical enquiry. Philosophy and Phenomenology In Thinking for Clinicians, Orange (2010) makes a strong case for the return of the therapeutic endeavour to its philosophical roots. The philosophical frames of our practice support therapists to live the ‘examined life’ in order to inform, sharpen, and invigorate daily practice. Orange discerns the ethical commitment implicit within philosophical discourses that inform—in particular—the humanistic and relational psychotherapies. Her main motivation for a return to philosophical roots is this: Thoughtful psychoanalysts and other humanistic clinicians are practicing philosophers. Doing philosophy every day, we always need to think more about what we are unconsciously doing. Engaging in dialogue with great philosophers can help us to keep thinking and questioning. If we clinicians do not CQ: The CAPA Quarterly


Enquiry engage, we remain captives in an unexamined life, in the grip of philosophical assumptions we notice neither in our theory nor in our practice (2010:2). The most significant philosophical influence on relational and humanistic therapy of the twentieth and twenty-first centuries is Husserlian phenomenology. Phenomenological reduction was Husserl’s method for direct apprehension of the essence of a thing (Husserl 1931). While phenomenology developed over the twentieth century, and complete bracketing and reduction to essences are not considered achievable, its chief contribution is arguably its orientation as a philosophical method of enquiry into the reality of the here and now. Heidegger, a student of Husserl’s, adopted the term ‘being-in-the-world’ to combine and capture our intersubjective relationship to the world, with the sense of Husserl’s ‘intentionality’—that consciousness is always directed toward an object of thought; that things and the perception of things are entwined (Heidegger 1962). The intersubjective orientation of Husserlian phenomenology included the subjective experience of ‘being’ into the context of ‘knowing’. This provided a way to explore knowledge processes that based them in a community of understanding. This hermeneutic approach sees the organisation of knowledge as the effect of dialogue and understanding among enquirers, rather than as a series of neutral, observable facts found to stand distinct from the subject who knows them. The phenomenological method brought the living, breathing human subject back into the field of knowing and rendered uncertain the absoluteness of empirically derived knowledge, its status inevitably subject to debate and dialogue (Orange 2001, Parlett 2005). Importantly, when adapted into the emergent modes of psychotherapy, this orientation shifted the dynamics of the therapeutic encounter, allowing clients to be the knowing subjects of their own supported enquiry. Ethical fitness can, therefore, be supported by a phenomenological perspective—in its inherent inclusion of the agency of the client in the enquiry and in its method of enquiry that includes the therapist as a factor in the outcome. Field Theory A clinically and ethically useful extension of phenomenology is field theory. Earliest expressions of field theory can be attributed to Lewin (1943); however, it has evolved through dialogue and practice in psychotherapy to mean something approximating a “totality of mutually influencing forces that together form a unified interactive whole” (Yontef 1993:297). A field theory orientation is one in which the self is understood to be formed in and through relationships to others and the environment. In a clinical context, field theory acknowledges that clients and therapists bring various worlds with them into

Elizabeth Day and Elizabeth Riley

the therapeutic relationship. These include identities defined by gender, sexuality, ethnicity, family of origin, level of affluence, environmental stress, belief systems, and various experiences of the power differentials in the social, political and economic sphere. Significantly from a field theory orientation, events in the field are co-created. Individuals are intersubjectively influencing and influenced, from moment to moment through interaction with each other and with their environments. Relational Gestalt psychotherapists work with five principles for discerning and engaging a field orientation: Organisation: Our needs (therapist’s and client’s) are organising the dynamics of the field, and therapy involves mutual investigation of this. The constellation of a field, as a whole, conditions given types of behaviour. Contemporaneity: Both past and present are experienced in (and inform) present moment experience, and we construct meaning according to the present and past contexts in which our ‘selfing’ emerges. Singularity: Each situation and perspective is unique; the ‘same story’ is never the same, as each iteration affords the possibility for fresh insight. To respect this uniqueness, we need the ability to tolerate or cultivate uncertainty. Unique occurrences require unique perspectives rather than generalised assumptions. This makes change possible. Changing process: There is no static, absolute place to get to in therapy. Experience is provisional and context bound, and the field undergoes continual change. The emphasis is on the moment-to-moment process. What will unfold cannot be wholly predicted. Diagnoses are to be held lightly. Possible relevance: Nothing of the field can be excluded in advance as irrelevant to the current unfolding process, as attention to what is momentarily or persistently relevant or interesting will show how the field is organised (Parlett 2005). Engaging with field concepts of self and identity, therefore, contributes to ethical fitness. It supports a dialogic approach that informs and is informed by the client, and a relationship to change that is neither directive (by the therapist) nor coercive. In consideration of the client’s presentation, the therapist monitors and readjusts, creating a continual feedback loop that is responsive to the client’s needs as well as providing a reflection to the client. Through attention to the present-moment exchange, field-sensitive practitioners are implicated in the work and do not see themselves as set apart or unaffected. The ethical imperative in such momentto-moment work is for the therapists to manage intimacy and to develop the capacity to tolerate uncertainty (Staemmler 2009). Change and Ethical Practice A principle for change in therapy that matches this orientation is Beisser’s (1970) paradoxical theory of change. Beisser explains (continued on Page 22)

May 2013

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Evolving Thoughts on Ethical Every day we make a number of ethical decisions. Mostly we make them automatically without thinking about them. We hand back the extra change given by the till attendant. We stay within the speed limit, even when there are no speed cameras or speed cops around to catch us. We are faithful to our partners. We go to the assistance of an elderly person who falls in the street or needs help crossing the road. We don’t keep our clients in therapy longer than needed, because we need the money to pay the mortgage. Unthinkingly, we just do these things. Most of the actions above, along with the multiple other ethical ones that feature in your day and mine, come from within us and pop out without much deliberation. What we do speaks to who we are, and ethics and ethical actions are about who we are. Automatic ethical actions occur when we are in familiar territory. Our memories store what we have done, who we are, and we access them to help us decide what to do. Faced with new situations, where memory is not a good guide, we have to be more considered, thoughtful and deliberate (Kahneman 2011). Now we have to think about what we do. It would be wonderful if the same process came into being, and we just knew what to do and an answer came from within. Novel situations have a way of alerting us to possible dangers, and with those dangers, we often move from an inner guide to reliance on outer support. Ethical maturity quickly dissolves when fear enters the practice room. We have been asking people about the processes they go through when faced with an ethical dilemma or need to make an ethical decision. Many describe the first process above— the normal, fast and intuitive way of making that kind of decision—the one that pops out from who we are. When asked about new situations, individuals pause, then an interesting process emerges. Take the following example: You have really needed to boost your caseload and are relieved when you receive a new referral. The man you see is very anxious and finds it difficult to describe what is happening for him. He says that if you hold his hand, like his mother used to do, he can settle himself down and talk more easily. He says his last, very successful therapy involved hand holding, and he had been very grateful for this assistance. Over time, he said, he had been able to manage without it, but it helped him get started. It is not your usual practice. How might you respond? Neither of us, like many of you reading this example, has encountered this situation before, so no automatic response emerges from our past experiences. Had the client burst into tears, then we would have been ready and handed him some tissue. If he had taken out a knife and held it to his chest, we would know what to do, even if feeling somewhat panicky as we did so. In the immediacy of the situation of being asked to hold someone’s hand (because there is no time to take this to supervision or consult the ethical codes or frameworks) 8

what happens? Most individuals respond that their fast flowing minds think immediately of safety. What is the safe thing to do in this instance? In the nanoseconds in which this vignette occurs, practitioners are already considering possible scenarios: I hold his hand, then he wants to be hugged. He reports me to an ethical committee. I am found negligent, publicly shamed, and will forever carry the stigma of the professional who was incompetent around boundaries. Fear grips us, and we go for the safe option: Why don’t you tell me about how holding your hand helps you, you hear yourself say, and then we can decide whether that is appropriate to this relationship. The client starts talking and tells you how anxious he gets when beginning new relationships and that the soothing touch of another person makes him feel less alone. Crisis averted, the shame scenario has gone. The decision was made from fear. What would it be like if fear had been banished and, instead of being anxious about what might happen to me, I was to put the welfare of my client at the centre of my decision? I could instead have asked: What is the best thing for me to do just now that would help this client connect to me and be able to use his time most effectively in our sessions? As a result of that decision, I may choose not to hold his hand, or I may choose to do it; I don’t know in abstraction, outside the relationship and the room, what is best. In the moment of decision with ‘what is best for this client’ as the core question, I allow myself to feel what is happening to me, between us, and in the client. I hold all these considerations together and make a decision. A safe decision: never touch a client. An ethically mature decision: I am open to a number of possible options here, depending on what I decide is the best action for this man at this time. The latter is a lot more risky and involves my making a personal decision I have to stand by. Of course, it is also important to hold in mind that we are not slaves to our client’s requests. We have to be aware of our own best practice, and that may involve particular decisions (e.g., not hand holding) as that maintains us at our ethical best. I (Elisabeth) recall once changing sessions times at a client’s request to times that reduced the client’s stress but increased mine. Through that experience, I realised that being client-centred is not the same as meeting all the client’s requests. It is about both people coming from a position of integrity and exploring what is professionally reasonable and therapeutically useful to do. Care and Ethics Heidegger (1962:156) sees ‘care’ as our most fundamental stance in the world. Care has two eyes, he suggests: one is concern, which focuses on our relationship to objects; the other is solicitude, which focuses on our relationships with other people. Like care, solicitude also has two eyes or stances: ‘leaping-in solicitude’ where we take responsibility CQ: The CAPA Quarterly


Maturity for the other person and his/her actions, and ‘leaping-ahead solicitude’, which facilitates the responsibility of the others to make their own choices. Ethical maturity is about accepting responsibility for who we are, the choices we make, and how to engender a ‘leaping-ahead solicitude’ for ourselves and our clients (Mitchell 2009:160). How do we do that? When asked how they deal with ethical issues in their work, many practitioners respond that their first port of call will be to consult their supervisor. They see supervision as the arena where they can begin to discuss, dissect and decide. These are critical moments where difficult decisions have to be made. The instinct to consult the supervisor can be motivated by either: 1. shifting responsibility from making a decision from self to another by out sourcing ethical decision making to one who has more knowledge, experience and who will provide some answers. 2. setting up a reflective dialogue with someone who facilitates that decision-making process. Tim Bond (2012) gives an example of the first: A well-respected and internationally renowned researcher in the psychology of young people came to see me two years ago to discuss the ethics of a major project for which he had just received a large grant. “Just tell me what I need to do ethically and let me concentrate on the research,” was his request… It was clear that he was disconcerted by the dismay on my face at his plea.…I was taken off guard by his request to be told what to do to satisfy ethical requirements. He seemed to communicate a view of ethics as merely a set of rules to be satisfied before the real work could begin. Another dimension to this brief exchange that struck me with even greater force was the contrast between his confidence and eminence as a scientist, and his willingness to become like a child dependent on parental guidance in matters of ethics. He was putting himself in a position of ethical immaturity (335–6). Bond’s experience is not unusual. Many well qualified and well experienced practitioners move into ethically juvenile positions when faced with moral decisions. They look outwards to gurus, experts, or external authorities to make the decision for them. Looking outwards is not bad—it is always useful to consult the wisdom of others—but it is not the best place to start learning how to be ethically mature. All too often ethics is seen as a set of rules that will guide us rather than as an attitude based on values that provide anchor points for ethical decision making. The first suggestion in working towards an ethically mature decision is to go ‘inwards’ to your own wisdom. This will never result in the final decision but will be the starting place for ethical excellence. An example of the second motivation to use supervision to reflect on and make an ethically mature decision occurred in my (Michael’s) own work several years ago. I was asked by a

Elisabeth Shaw and Michael Carroll human resources (HR) director to give a psychological opinion on the resilience of a manager I was coaching. I had been supporting the manager on his journey back to work after several months off with severe depression. The HR director told me that the manager was about to be made redundant, but because of his recent fragility, he did not want to plunge the manager back into a depressive state. Hence the request to me: Did I consider this manager to be strong, robust and resilient enough to hear this news? I was caught in an ethical dilemma. I was certainly the best person to give that information, having worked with the manager for about three months, yet I had no agreement from him permitting me to pass on that kind of information. Nor was it my job to tell him he was going to become redundant. I brought this issue to my own supervision group, pretty certain that I couldn’t give the information asked for. However, in dialogue with them, holding in mind the contextual and organisational issues and what was best for my manager-client, I reached a different conclusion. Despite the risk involved, I decided I would give the HR director the information he wanted so that he could then decide whether or not to proceed at this stage with the redundancy conversation. I never felt I was giving away to my peer group my responsibility to make this ethical decision, as it was a very helpful forum in which were raised issues I had overlooked. It was also a lesson for me about putting my client and his welfare at the centre of the ethical conversation and moving my own safety and ‘playing by the book’ farther down the list of important factors to consider in making an ethically mature decision. The Centrality of Ethical Practice Ethical practice is a core requirement of every professional in the helping professions. We assume that we have ethics covered, simply by being the people that we are—altruistic, available, responsive, focussed on positive gains and personal growth. People who are so focussed on being and doing good are surely ethical as well. We can feel so clear that ethics is hard-wired into us that we do the least formal study of it. With the plethora of clinical techniques to be learned, it is always tempting, and seemingly legitimate, to focus on what we don’t believe we know (for example, the new technique) than what we think we already know (such as ethical practice) (Pope & Vasquez 2007). It is also easier to see the shortcomings in others than those in ourselves (Kahneman 2011). Over the course of our professional lives, we are going to encounter many ethical issues, from establishing and maintaining a measure of our own competence through to negotiating challenging clinical moments, providing the best possible treatment, and meeting the obligations of our profession, association and the community in ever-changing (continued on Page 25)

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Ethical Competence in Couple Ethics is more about the skills exercised in grappling responsibly and thoughtfully with complex questions than it is about measuring behaviour against rules alone. A core ethical responsibility to clients is the promotion of beneficence: doing good on the client’s behalf. This is reflected in a number of professional requirements, but starts with the therapist’s competence to practice. Couple and family therapists arguably face more ethical challenges than individually oriented therapists, yet codes of conduct and ethics have not always been of direct assistance. Often it seems that the principles, largely developed for individual approaches, lack the specificity to really attend to the relational context. Interestingly, couple and family therapy is commonly practiced by therapists with little or no specific training. It seems to be thought that if one is individually trained, then it is not a great stretch to see other family members (Shaw 2001). Nothing could be farther from the truth. Issues surrounding relationships (violence and abuse, family law matters, sexual concerns, infidelity and other betrayals, severe attachment disruptions) all render this work highly complex and specialised. Without an awareness of the potential ethical challenges in the work, therapists can be insufficiently prepared to face them. Clinical Competence A therapist has to be able to demonstrate competence in relationship practice, and without core training, duty of care is potentially breached. How do you measure whether your training is sufficient to practice in this area?1 One useful point of reference may be as follows: If you were seeking assistance for your relationship or family, what qualifications would you seek in your therapist? We shouldn’t provide less for our clients than we would require for ourselves. A significant values difference between couple and family therapy and other mental health services is an appreciation of context; this is grounded in the foundational premise of the family as a system. This means that it is the relationship that is the focus of the work, and all relationships exist within multiple other systems, including the therapeutic system (Wilcoxon et al. 2007). Relationship issues and the values we hold about relationships are completely entwined with their social and historical contexts. We are constantly exposed to theories about effective relationships and relationship pathology, whether they be evidence-based or common folklore. We cannot help but be influenced by these ideas nor by our own experience of relationships. New and emerging issues such as internet pornography, surrogacy, same-sex parenting, working 10

with perpetrators of abuse, and so forth offer ground breaking moments in the therapy room. The Individual versus the Collective Working with systems means being able to hold the relationship in mind over and above individual contributions: the notion that the sum is more than its parts. However, one still has to attend to: 1. individual pain and suffering, for example managing the effects of addiction, mental health issues, or family of origin trauma for example. How to address this in a relational context without pathologising one member and getting them off-side requires considerable skill. 2. perceived inequities in the tasks for therapy. For example, perpetrators of hurt have different tasks and responsibilities to those who have been hurt. 3. different ages and life stages. 4. ensuring that safety is attended to, and knowing how to take a position when necessary as with mandatory reporting. Further important issues in the field which involve specialised ethical and practice considerations include: 5. the perennial question of working with whoever can come to sessions or insisting that all must attend sessions. 6. being trained to work safely and responsibly with domestic violence, which includes being informed about the potential imperative to refuse therapeutic service until the relationships are safe, referring instead to specialized domestic violence services. 7. working effectively and respectfully with culturally diverse clients and communities. 8. working effectively and respectfully with the gay and lesbian communities and same-sex parents (Negash and Hecker 2010, Brown 2007). Couple and family therapists have a unique view into the complexities such circumstances bring and need to be able to respond effectively—or to know when and to whom to report things when it all goes belly up. Ethical and legal issues are often merged together; they may be linked, and they may be quite distinct issues. Ethical standards cover a wider range of behaviour than do laws, and also seek to define good and desirable (aspirational) behaviour. Laws and regulations deal only with the ‘do’s and don’ts’ of practice and tend to limit their attention to the threshold of minimal acceptable behaviour. Each issue confronting the practitioner will generally require professional judgment—for example determining risk of CQ: The CAPA Quarterly


and Family Therapy suicide as well as progressing to issues of ethics and the law (Reynolds-Welfel 2013). Informed Consent Couples will often ask for assistance when, on a covert level, they want a referee or a judgment about each other’s behaviour. Individual sessions and phone calls can be invitations to take sides, and neutrality can quickly be called into question. One person rings to make a couple/family appointment and remains the point of contact with you. You explain everything to the caller and email information to him/her as well. The very act of asking the initial caller to gather other family members for an appointment raises questions about the forms of “social coercion” that this might involve (Wilcoxon et al. 2007, Ramisch 2010). Having interviewed many an unwilling adolescent or reluctant partner, I recognize this as an important question for practice! There are different levels of power and opportunity in families. One member can decide for the group; others can be unfairly excluded from key decision making. How the therapist is positioned within this is crucial to consider. Further, there are complexities around informed consent with people across ages and circumstances, and we often give insufficient thought to follow-up communications such as therapeutic letters. Are the adults always the best gatekeepers for other family members? Do you assume that they have told others about the session? Not uncommonly, I have had children say to me that they have “no idea” about why they are in my room, despite my parental preparation. It is the duty of the therapist to be seen to have made all reasonable attempts to elicit age-appropriate informed consent from all family members (Reynolds-Welfel 2013). Even in couple work, it shouldn’t be assumed one is passing information to the other! Neutrality and Dual Relationships Working with relationships involves managing multiple alliances. It is not always possible to have everyone on side at the one time. Members of the couple or family may have conflicting or competing needs which they want equally acknowledged. Even trying to develop a focus for the work is fraught with challenges, as you question: Whose voice will prevail? Whose interests will be served? Improvement for one member mustn’t occur at the expense of another (Wilcoxon et al. 2011). Commonly, relationship therapists will think it might be a good idea to offer individual therapy to one family member, and may well be pursued to do so by the client. This is not considered good practice. Really good relational work can be brought asunder by selecting/engaging in work with one

Elisabeth Shaw

member, even after the relational work has concluded. Families can seem to manage the fluid move between seeing different members, including the parent subsystem, as if the therapist is engaged as a family resource much in the same way as the family doctor. This benevolent frame only lasts for as long as the family all moves in the desired direction. If the children think you are helping the marriage and the parents divorce, or the adolescent does work with the therapist to manage behaviour (sex, drugs) the parents don’t know about, then this can turn out very differently. In the case of couples, even if all parties agree that individual work is permissible, there are obviously times you will discuss the absent person, and this can be reported back. What if the relationship turns sour and you suddenly appear to be the one implicated in facilitating that? With one couple, in a private session with one party, an affair was disclosed. You ended up having a few sessions with this person to try and see if the primary relationship could be salvaged. The other party found out about the affair and the couple separated. A complaint was lodged that you hadn’t worked in both their interests and that duty of care had not been met. It is important to define the role at the outset (couple/ family therapist, individual therapist) and remain true to that contract. Other therapists can be included as appropriate to provide adjunct work. Confidentiality Having contact with individuals via phone calls or individual consultations within relational work raises a myriad of difficulties. While it can be useful in fleshing out particular themes and crucial in assessing for abuse, it also provides opportunities for disclosures that will significantly shape the work ahead. Parents might value separate time to be able to express in a less damaging way the issues they have with their children, but in such cases the parties not at the sessions are always conscious of a session without them that might have focussed on them. A family came to see you. The parents were very worried about the behaviour of their fifteen-year-old daughter. In a separate session, the daughter told you she has tried cannabis but only intends to use it socially, and her boyfriend “treats me a lot better than my dad treats my mum”. What do you do with this information? Moving between individual and couple work requires very careful case planning and is, in fact, often contra-indicated. In my experience, it is often the therapist who has become stuck and who suggests separate sessions to get a new foothold on the work! It is not uncommon for well intentioned therapists to find themselves in breach of confidentiality by juggling too many agendas. Therapists need to state limited (continued on Page 28)

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To See or Not to See:

Ethical Considerations in

When we are in service of others may we: bring hope where despair burdens, bring light where darkness creeps in, bring beauty where ugliness festers, bring joy where heaviness lies, bring love where pain sears. Only once in my thirty years of practice have I had a young person, a 16-year-old, refer herself for therapy. She presented herself at a child protection department and demanded to see me: “I know my rights as a state ward, and I want to see Mary Jo Mc Veigh”. This request came after a two-year break in therapy. Back then, she was brought kicking and screaming to the first session of the initial phase of therapy. A more usual presentation is that of Mary, a six-year-old, who hid behind her mother, burying herself so deeply in the fabric of her mother’s skirt that all that could be seen of her were tiny white knuckles curling around the patterned fold. Children come to the attention of therapists through adult referral, not their own volition; therefore, the concept of a voluntary client does not initially exist when it comes to providing therapeutic services to children. This being so, the first ethical judgement to emerge for the therapist is: If children do not self refer, should they be seen? Jones and Ramchandani (1999) remind us that not all children benefit from or need therapy. At the same time, trauma studies highlight the potentially harmful impact of abuse on children’s progress and development. Grief literature shows the benefits of bereavement work, and resilience research promotes the importance of adult mentors or supports for children and young people who face adversity. Margaret Somerville (2000:177–8), in her discussion on imposing medical treatment on seriously ill children, wrote about weighing up the “suffering/benefits ratio of treatment”. This ratio can be used when considering therapeutic treatment, but consideration is still required before decisions are made. Therapists must look at all the ways they can perceive suffering. Do we have a measurement for determining when suffering becomes chronic and requires intervention? Who decides when suffering needs intervention? The child, who is feeling the effects? The parents, because they love and care for their child? The therapist because of her/his wealth of clinical knowledge? Is it possible to validate all three? A child’s age and ability to understand fully what therapy involves are the two main considerations for determining a child’s suitability for therapeutic treatment. Beliefs in the most favourable age at which a child can engage in therapy vary. Those trained in the non-verbal techniques of engagement see the benefit in seeing children before they can fully engage in spoken conversation. Those trained in narrative or cognitive techniques see the advantage of the child being able to engage in spoken conversation. The issue of age needs to be looked at in terms of ‘processing age’, not chronological age. Therapists are aware that therapy requires a measure of emotional-, reflective- and thinking-based intelligences to look at issues affecting the self and to harness the 12

assistance afforded by another. Childhood status, per se, does not exclude children from the ability to reflect; as adults have differing abilities to do this, so does a child. Chronological age is, then, just one criterion of the decision to see or not to see the child. A more important consideration is the child’s capacity for therapeutic work. This should not be done solely by applying standard cognitive-based tests, because they do not capture the whole of the child. It would be more beneficial to talk with the referring adult about the child’s problem-solving abilities, emotional literacy, and reflective wisdom. This conversation will best guide the therapist’s judgement about whether the child is at the optimal ‘processing age’ for the work. When therapists consider seeing a child, they need to determine how much autonomy needs to be afforded to children in terms of familial participation. Research shows, for example, that when families are involved in children’s trauma work it improves their recovery rate (Jones & Ramchandani 1999, Greenwald 2000, Berg & Steiner 2003). Yet it is the custom in our current societal patterns of child rearing that the younger the child, the more parental input in the child’s daily life; the older the child, the more she or he is moving towards full independence. When considering whether to see a child, this continuum fits with the developmental and attachment reality of a child’s life. Within this societal pattern, though, there are familial differences in the level of independence or dependence. It is, therefore, important for the therapist to assess this and adapt the sessions accordingly. Within the sovereignty of children’s participation, there also lies the dilemma of how much, if any, information should be gathered from adults before seeing a child. If a therapist sees the parents or carers before seeing the child, there is the concern that it will align the therapist with the parent or colour her view of the child. Yet childhood should be as free as possible from professional intervention, despite the honourable intentions behind therapeutic actions. Highly trained professionals are able to hold a range of sources of information in a neutral stance and be guided by the work as it unfolds. To minimise unnecessary intrusion into children’s lives it is, therefore, preferable that any information required to guide intervention is gathered before seeing the child. Child Protection When it comes to the issue of child protection, this is even more vital. Safety issues for children must be identified and resolved before attempting to address the effects of trauma. Therapists’ role is not to perform the investigative function in child protection work, although they are a very important source of advocacy and support for the subject children and assist the protective agencies with their job. Statutory child protection agencies cannot fulfil their protective role unless they have the information upon which to proceed. CQ: The CAPA Quarterly


the Therapeutic Service of Children Mary Jo Mc Veigh The ethical issue of adherence to confidentiality for clients is one of the core principles taught in therapeutic training. When seeing children, the confidentiality principle is not absolute. When a therapist becomes aware of child protection concerns, it is no longer a matter of therapeutic ethics, but becomes a human rights issue and legal requirements pertain. Abuse breeds in the silence that perpetrators manufacture; it engulfs children and separates them from adult protection. Therapists can be guided in their practice by the governmental and professional child protection reporting requirements; however, far beyond the clinical intervention fence line lie the inalienable right of children to be protected. An adult speaking up on a child’s behalf creates that safety. Speaking up on behalf of children, especially when there can be an adult community of professionals or family who are disbelieving, can be daunting and takes a considerable amount of courage. Does an ethical framework exist from which a therapist can draw this courage? Scott Peck tells us it exists in the ethic of love. When we extend ourselves, when we take an extra step or walk an extra mile, we do so in opposition to the inertia of laziness or resistance of fear. Extension of ourselves or moving out against the inertia of laziness we call work. Moving out of the face of fear we call courage. Love then is a form of work or a form of courage. Specifically, it is work or courage directed toward the nurture of our own or another’s spiritual growth (Peck 1978:120). If confidentiality for children is limited, then therapists need to work openly with them and explain this to them. This requires more than the delivery of a statement; it requires an open and honest conversation. Inherent within this, then, is the child’s right to limit what he says. If a reporting of abuse is warranted, it is important that the child concerned is actively involved in the process, commensurate with his or her age and development. Of great importance at this stage is the continuation of the therapeutic relationship and constant liaison with the protective services to encourage an expedient discharge of the investigative process. Therapists can be left with the concern that they will contaminate evidence or hinder the investigative process, and investigative officers in their desire to protect evidence can inadvertently undermine the therapeutic relationship by insisting that it cease. The cessation of therapy does not guarantee the protection of evidence and can, in fact, hamper the disclosure process; the more a child is supported, the more that child will maintain an ability to disclose, feel safe, and heal more deeply. To stop therapy may cause the child to conclude that talking about such matters leads to important support people being withdrawn from him or her.

The role of the therapist in this post-disclosure phase is not to process the contents of the disclosure but to support the child while the investigative process takes its course. When therapy is under way, the issue for the therapist changes from considering whether to see a child to how to conduct sessions in a way that does not colonise the child’s identity with professional subjectivity. Johnella Bird (1994:44), writing about the professional talk in which we engage about our clients, felt that it objectifies our clients and puts us in danger of becoming abusive. “It is abusive,” she writes, “in that it creates a class of professionals who maintain and validate a regime of truth that is inflicted on others.” Language that is highly pathological reveals thinking that is highly pathological and amidst the creation of this “inflicted realm of truth is the risk of over-medicating children” (Bird 1994). Children who are referred to therapy under this ‘realm of truth’ principle and are described in a language that can be highly pathological in content. I have, in the bottom drawer of a filing cabinet, closed files amongst which is one containing a report that assessed a child of four years of age as being ‘beyond hope’ and ‘unfosterable’, not to mention the report that described a child of ten as evil. In that same bottom drawer, there are records of children from as young as three years of age being prescribed anti-psychotic medication, multi-combinations of mood medications and recipes of pills to counteract the effects of some of the prescribed drugs. The ‘suffering/benefits ratio of treatment’ must be applied here before we, as an adult population, support children’s ingestion of chemical stimulants or sedatives. If language, as Hugh Brody (2001) reminds us, is a relationship activity, then children are shaped by how they are spoken to—and, as John O’ Donohue (1999) cautioned us when stealing a people’s language, the soul is left bewildered. In working with children, our language must show that we work from an ethical standpoint that honours and truly sees children for who they are. We need to step aside from the magisterium of clinical certainty to work in the ethic of service to others. In doing so, we allow tender curiosity to be the guide that will not leave the soul of the work bewildered. Conclusion CS Lewis wrote in 1940: “[E]very time you make a choice you are turning the central part of you, the part that chooses, into something a little different from what it was before.” Let us end this exploration of the ethical considerations in forming therapeutic relationships with children with Lewis’ words in our hearts: “to wonder when we make ethical decisions in the (continued on Page 29)

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Ethical Issues in Cross-Cultural Ethical cross-cultural psychotherapy practice requires the therapist to be open in every aspect of the psychotherapeutic relationship to all the dimensions of culture, both in the client and in oneself. Ideas about culture, ‘ethical toleration’, ‘culture-centred counselling’ and ‘cultural safety’ are examined here as a backdrop to a discussion of ethical issues, psychotherapy and culture. This discussion is drawn from twenty-four years of experience working with refugees at the Service for the Treatment and Rehabilitation of Torture and Trauma Survivors (STARTTS). Themes include the diversity and fluidity of cultural identity, boundary and role issues, and the possibility of cultural issues acting as a smokescreen for minor enactments. Also addressed is the need in cross-cultural therapy for development of a capacity to tolerate difference and psychological separateness as part of the work, for both the therapist and the client. Drozdek (2007) writes that there are hundreds of definitions of culture. As a psychotherapist, the dimension of culture in psychotherapy work is a complex, fluid notion that changes over time and intersects every layer of our identity, feelings, thoughts, language, and relationships. Tension infuses how we think about culture in psychotherapeutic practice. One theme in the multicultural counselling literature acknowledges the complexity and fluidity of cultural identity in Western society, and urges us to avoid stereotyping, and to recognise the uniqueness of each individual. Many people are either bicultural or multicultural and cultural identity is not fixed. Other dimensions such as gender, sexual identity and disability can intersect with racial or ethnic identity (Pack-Brown & Williams 2003). Even though it is hard to define distinct ‘cultures’, it is still possible to experience different ‘cultural realities’, and it is useful to talk about a particular culture in relation to psychotherapy with refugees from a particular group (Nguyen & Bowles 1998). A political perspective recognises issues affecting people from minority groups who may be ‘falling through the net’, because so-called Western interventions may not be suitable for them. Rowson (2001) uses the words ‘ethical’ and ‘moral’ interchangeably, to refer to general ideas of right and wrong behaviour. Bowles W et al. (2006) define ethical practice as being “concerned with making decisions or judgements about how to act or what to do, and being able to justify those actions and behaviours within some kind of philosophical framework”. They distinguish between ‘values’—which are general, personal and professional ideals—and ‘principles’, which are like guides for how to operationalise the more general values. “Values do not tell us what to do, they tell us what is good. A number of principles may come out of one value” (2006:55). Holmes (2001) points out that while codes of ethics for psychotherapists appear straightforward, in fact, the actual work 14

of psychotherapy is full of uncertainties and challenges. We try to have clear goals for therapy work, yet we should not be controlling or imposing these on our clients. We try to be accepting and open, yet we constantly reveal our own values, for example, in our speech patterns, dress and facial responses. We may consciously believe that we are acting in a certain way, yet we may be re-enacting other dynamics of which we are not aware. Barnes and Murdin (2001) point out that every theory about psychosocial development implies a particular view about human nature and values certain kinds of behaviours, states of mind, and personality development as being desirable or better than others. The issue is who decides which are better? We respect the value of autonomy and believe that clients should be developing their own ideas of what is better or good, but the reality is that clients are vulnerable and everything that we do or say as therapists is influential. Our own value system is constantly being communicated to our clients. Barnes and Murdin (also Pack-Brown & Williams 2003, Pedersen 2007, Sue et al. 2009) point out how critical it is for psychotherapists to become aware of their own values. Much of the time, we are not aware of the values by which either we or our clients live. When we are working with clients from other cultures, these issues become heightened. The first fundamental principle in the CAPA Code of Ethics, for example, is Autonomy and Self Determination, which is defined as “respect[ing] the dignity and worth of each person, their culture and context” (CAPA:7). How can we ensure that we are respecting culture in our work? Do our codes of ethics themselves contain cultural biases? Relativism, Absolutism and Ethical Toleration Central questions underlying the subject of cross-cultural psychotherapy and ethics include whether there are any universal ethical standards or values which exist across cultures. How do we understand the relationship between culture and ethics? Are ethics objective moral truths or personal opinions and social/cultural attitudes (Rowson 2001)? The historical debate surrounding ‘relativism’ or ‘absolutism’ has probably been considered by scholars from many cultures, but we do know for certain that versions of it were outlined by Aristotle in Ancient Greece (Bowles W et al. 2006). ‘Cultural relativism’ posits the existence of neither fixed personality characteristics of a universal human nature nor universal ethical standards. This position holds that all cultures—along with the ethical standards within different cultures—are equally valuable. Spiro (1978), for example, pointed out that relativism undermines racist notions and the idea of a ‘primitive mentality’. Related to cultural relativism is the post-modern lens that views the existence of no single ‘truth’ but, instead, multiple realities and discourses and ways of understanding the world. This idea calls into question the authority and absolute CQ: The CAPA Quarterly


Psychotherapy standards of codes of ethics. For example, what kinds of dominant discourses have influenced their making and do they ignore the views of cultural minorities (Bowles W et al. 2006, Pedersen 2007, Pack-Brown and Williams 2003)? It could be argued that because no culture agrees universally about its own values, relativism is not a coherent position (Bowles W et al. 2006). A response to this argument holds that while people may be part of many cultures, that doesn’t mean morality is not relative to culture (Rowson 2001). Understanding something about relativism, including its complexities and limitations, can be useful for grappling with ethical situations that arise in everyday cross-cultural psychotherapeutic situations. This includes developing a capacity for tolerating different ethical and cultural viewpoints simultaneously. However, intellectual reasoning, as will be discussed later, is only one aspect of this process, which involves the ability to balance alternative values and cultural perspectives and to cope with difference. Bowles W et al. (2006) describe the three possible responses of a social worker to a client advocating female genital mutilation (FGM). A ‘relativistic response’ accepts FGM without judgement, because it is from another culture. The ‘absolutist response’, immediately rejects the notion of FGM in accordance with the social worker’s cultural/moral principles. The third response embodies both simultaneously. It is best, however, to avoid either extreme and instead opt for an ethical position between the two (Bowles W et al. 2006). This middle ground involves respectfully trying to understand the client’s cultural and ethical perspectives while working through the issue with the client to reach some point of mutual agreement where neither the client’s nor the therapist’s values are sacrificed. The sophisticated discussion by Bowles W et al. includes detailed philosophical arguments, which promote a style of working together that the authors term ‘ethical toleration’. While there are core elements in the authors’ approach that are relevant for psychotherapists, the ethical dilemma described is based in a welfare counselling context and includes community levels of intervention, rather than focussing on more internal, subjective psychotherapeutic processes. Codes of Ethics and Culture, Culture-Centred Counselling and Cultural Safety Authors (Pack-Brown & Williams 2003, Pedersen 2007, Barnett & Bivings) from the literature on multicultural counselling and ethics point out that ethical guidelines inevitably contain the cultural values of the group who wrote them. They further claim that sometimes multicultural counsellors can either follow culture-bound ethical guidelines, which will lead them to act towards their clients in inappropriate ways, or act appropriately but end up transgressing or bending the guidelines. Pack-Brown & Williams (2003) describe cultural issues in existing codes of ethics for counsellors and advocate culturally

Robin Bowles

appropriate ways of interpreting existing codes. They also describe working through different ethical dilemmas in multicultural counselling situations. A central issue is the individualistic bias in ethical codes and practices, compared with the values and behaviours derived from a more collective culture. Their general goal is to encourage ethical thinking and behaviour in accordance with primary values, rather than ‘rule-following’. Pack-Williams & Brown (2003), Pedersen (2007), Sue et al. (2009) describe how to develop ‘cultural competency’ or to become a ‘culture-centred counsellor’ or ‘multicultural counsellor’. Their different training programs broadly include three categories: becoming aware of one’s own cultural values, developing knowledge, and practising skills. This framework of ‘cultural competency’ has become widely recognised and includes the kind of person the professional is, the interventions and skills used, and the processes followed (Sue et al. 2009). The related notion of ‘cultural safety’ was originally developed in New Zealand by Maori nurses and was first adopted by indigenous people in Australia in the 1980s, as a way forward for their empowerment. Williams (1999) defines cultural safety as: [A]n environment that is spiritually, socially and emotionally safe, as well as physically safe for people; where there is no assault, challenge or denial of their identity, of who they are and what they need. It is about shared respect, shared meaning, shared knowledge and experience of learning together (Bin-Sallik 2003). Williams points out that cultural safety does not connote special treatment for indigenous people but, rather, all cultural groups can relate to it. She describes two processes to develop cultural safety amongst health professionals: the development of ‘cultural awareness’ of cultural differences and histories, and the development of ‘cultural sensitivity’ about oneself and others. Clinical Observations from a Cross-Cultural Psychotherapy Practice A good proportion of the staff at STARTTS come from refugee or refugee-like backgrounds, and this has been an important factor in our attempts to develop culturally sensitive interventions. The service operates on a ‘bio psycho social’ model, which integrates community development and clinical approaches. Since 1988, we have worked with refugees from over 150 countries. The different cross-cultural counselling models with which we have worked have included the bicultural counsellor model (working in co-therapy with bicultural colleagues), psychotherapy with interpreters, and working in English with clients who are from diverse cultures. The opinions expressed in this article are my own, and are not made on behalf of STARTTS. Any references to ‘my clients’ are not based on particular people but are general descriptions of commonly occurring situations. (continued on Page 30)

May 2013

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Features

Working the Matrix of

Dual and Multiple Roles

Human beings live in communities, where overlapping relationships commonly occur. Counselling and psychotherapeutic relationships, however, require some degree of separation from everyday life to create the conditions of safety and trust necessary for effective therapy. Boundaries maintain the effectiveness of counsellors and psychotherapists by limiting their personal involvement and identification with clients. Boundaries also establish clarity concerning therapist and client responsibilities and expectations, and allow clients to develop trust and to feel contained. When therapists enter into dual and multiple roles with clients, future outcomes are unknowable and difficult to predict. They involve grey areas of ethical decision making in which risks of adverse outcomes, and sometimes benefits, are greater for both practitioners and clients. Definitions of Dual and Multiples Roles Dual and multiple roles are situations in which practitioners take on two or more roles simultaneously or sequentially. An example is a practitioner who performs simultaneously the roles of therapist, supervisor and trainer for a client (Herlihy & Corey 2006). Dual roles also refer to the addition of the practitioner role within non-therapeutic relationships such as with an employer, business partner, friend, relative, or lover. The overlapping relationships and responsibilities inherent in dual and multiple roles increase the power differential between practitioners and their clients (Kitchener & Harding 1990). Practitioners working in rural and remote areas, in the same area as their clients, or in small communities such as gays and lesbians, the defense force, and churches all face a greater likelihood of dual and multiple relationships occurring in their practice (Kitson & Sperlinger 2007, Lamb et al. 2004). Risks of Dual and Multiple Roles Dual and multiple relationships increase the risk of harm to clients and to practitioners’ professional standing. If there is a disruption in one of the arenas in which the dual or multiple role occurs, this is likely to flow on to other areas. Such relationships may impair practitioners’ professional judgment through loss of objectivity about their client. Clients may develop incompatible expectations. For example, they may expect their therapist to respond with empathy and acceptance in other, non-therapy situations. The more incompatible the client’s expectations are across the two roles (for example, therapist and sexual partner), the more likely it is that harm will occur (Kitchener & Harding 1990).

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While overlaps between personal and professional roles are inevitable at times, particularly in small communities, they create additional risks for both clients and therapists. Where the power imbalance is small, and the boundaries between therapy and everyday life are maintained, the risks may never develop into adverse consequences and complaints; however, when the power imbalance is greater and boundaries are not held, poor client outcomes that develop into complaints are more likely. Where social, class or cultural differences also exist between therapists and clients, there is greater potential for harm. The occurrence of transference in therapeutic relationships further complicates dual relationships. Transference can be understood as the experiencing of affects, wishes, fantasies, attitudes and defenses in therapy that repeat patterns from past relationships (Day 2004). Confusion arises for clients when the therapeutic relationship, or a particular interaction in a session, provokes past experience that then flows over into non-therapeutic settings and complicates other, overlapping relationships and roles. Transference reactions may include feelings of attachment construed as love, having high expectations, wanting to annihilate the therapist, a desire for social contact, referring friends to the therapist’s practice, and so on. By its very nature, transference involves misperceptions and overreactions. When the relationship extends across a number of arenas, the development of insight and the resolution of transference are much more complex. Practitioners may put clients at risk by being unable to set appropriate boundaries and by not admitting the possibility that boundary problems could arise. Even where therapists are very experienced, serious harm may still arise in dual and multiple relationships. It is not new or poorly trained counsellors and psychotherapists who pose the greatest risk to the public. Rather, senior practitioners, usually male, commit the most serious boundary violations with the highest level of risk to clients (Borys & Pope 1989, Procci 2007). Clients are more vulnerable to harm in dual relationships when they are overly dependent on their therapist or have been previously traumatised. Trauma disrupts the formation and maintenance of self, the setting of boundaries and the capacity for self regulation, which leaves survivors more vulnerable to exploitation. Child-abuse survivors may find it more difficult to differentiate between acceptable and abusive therapeutic practices (Galletly 2004, Norris et al. 2003, Procci 2007). Research shows that risks arising from dual and multiple therapeutic relationships are considerable and are influenced by both therapist and client characteristics.

CQ: The CAPA Quarterly


Human Relationships:

in Counselling and Psychotherapy Benefits of Dual and Multiple Roles Are the consequences of dual and multiple relationships always negative? Therapeutic outcomes depend on the extent of the power differentials existing between therapist and client, the nature of the client’s presenting issues (for example, previous experiences of boundary violations), the trustworthiness of the therapist, and the capacity of both counsellor and client to process ethical issues within the counselling relationship. Gabriel (2005) refers to this capacity as ethical literacy. Many writers expound the benefits of some forms of dual relationship, in terms of increased trust, and the deepening of the therapeutic relationship. Some forms of social contact outside of therapy, such as attending a client’s wedding, contribute positively to therapeutic outcomes when they are carefully considered and are in the best interests of the client (Gabriel 2005, Pope & Keith-Speigel 2008). Ethical Principles The ethical principles involved in dual and multiple relationships are complex, subtle and difficult to fully articulate. Professional codes of ethics articulate the consensus of professional communities on what is acceptable and unacceptable practice and are effective in deterring unethical behaviour. Lamb et al. (2004) found that one of the four most common rationales for not pursuing sexual relationships with clients, when sexual attraction was present, was that such behaviour is unethical. The PACFA Code of Ethics states in Section 4.1.2 Dual relationships arise when the practitioner has two or more kinds of relationship concurrently with a client, for example client and trainee, acquaintance and client, colleague and supervisee. The existence of a dual relationship with a client is seldom neutral and can have a powerful beneficial or detrimental impact that may not always be easily foreseeable. For these reasons, practitioners are required to consider the implications of entering into dual relationships with clients, to avoid entering into relationships that are likely to be detrimental to clients. Where such a situation cannot be avoided, it is advisable that therapists discuss the implications of this with their clients, and be readily accountable to clients and colleagues for any dual relationships that occur (2012:13). The CAPA NSW Code of Ethics states in Section B4.5: A dual or multiple relationship exists for a counsellor/ psychotherapist ... with a client when there exists an additional relationship ... apart from the therapeutic relationship.

Ione Lewis

a) CAPA strongly recommends that supervision be sought in relation to any actual or impending dual relationship. b) CAPA strongly recommends that a counsellor considering a dual relationship reflect upon: • Obligations and responsibilities of the counsellor • Rights of the client • Motivation of the counsellor for the dual relationship • Implications of current and future dependency • Potential for “ doing harm” to the client • Potential damaging impact of the dual relationship on the professional standing of the counselling and psychotherapy profession c) CAPA strongly recommends that counsellors psychotherapists avoid a dual relationship wherever possible (2002: 12-13). CAPA’s Code more strongly proscribes dual relationships than does the PACFA Code, which relies on collegial consultation and transparency to reduce the harmful impact of dual roles. Neither code, however, differentiates between sexual and nonsexual dual roles. The former is arguably much more harmful and should be specifically proscribed in codes of ethics to provide greater protection for clients. Ethical breaches represent to some extent, areas of counselling and psychotherapy that are still coming to terms with regulation and accountability. For example, from 2007 to 2009, PACFA received a number of complaints involving ethical breaches in the area of counselling and psychotherapy training. These breaches resulted from the trainers’ dual and multiple roles with students who were also clients and/or supervisees. As a result of the complaints, PACFA established a working party on dual roles in counsellor and psychotherapy education. The working party developed a discussion paper on dual and multiple roles, with a recommendation to use the Society of Counselling and Psychotherapy Educators’ (SCAPE) Code of Ethics to address complaints against trainers, as many member associations’ codes of ethics did not address ethical principles for training programs. Once the PACFA Code of Ethics was developed to replace the PACFA Ethical Guidelines, it covered the ethical practice of educational programs and trainers. The number of ethical complaints received by PACFA about trainers decreased. This example demonstrates that ethical complaints may (continued on Page 32

May 2013

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In The Therapy Room

Choices, Context and Clinical My Context I work in private practice and have done so on and off for twelve or so years in Sydney’s outer west. Having also worked as a counsellor and group worker for many agencies in Sydney’s west, I have a fairly good sense of the differences between working for yourself and working for an agency. Perhaps some of you are thinking the grass is greener... If you are working in an agency, you may be ‘over’ the administrative requirements, poor pay, or management whose focus is on the bottom line. Those of you in private practice may be longing for holiday pay, regular income, or the cocoon of colleagues who share their experiences and help you debrief yours. I have been in private practice—my, almost, sole source of income as a single person—for more than four years now. In Penrith, this is quite a feat of both courage and determination. Out here in the sticks, we rarely have the luxury of clients calling to make an appointment without haggling or shopping around for the best price before deciding to book in. Ensuring people make an appointment, even once they get a sense of the cost, is an art. Most people cannot afford long-term work on their issues, and their world view is often quite different from those of the clients you may see in, for instance, Glebe or Newtown. Many locals travel long distances to work and cannot arrive at an appointment until after 7.30 pm. Some local counsellors travel to work in the inner west for a day or two a week just to get the income they need then valiantly persist in private practice out here as well. We usually have to travel for two hours or more to get to Sydney training events, so we are not so different from some of our country colleagues in this way. Having been raised on the mid-north coast, however, I concur that those distances are much greater! That said, I am well connected with one local agency and am often invited to do contract work for groups, management-type stints to fill in for a sick co-ordinator, or writing projects. At the moment, I am counselling part-time, for three months, whilst a colleague takes long-service leave. These opportunities keep me in relationships with colleagues there, give me a chance to explore my inner extravert and clown, and ensure me the occasional invitations to social events. Sometimes, this connection serves to update me on the current political landscape as it pertains to counsellors. It also boosts my income from time to time and adds variety, which is essential for my sanity. I’m easily bored! Contexts and Choices: Greener Pastures or Not? Each time I re-engage with a local agency (I also provide supervision and/or training to a number of organisations out here), I compare the grass quality and ask myself: “Is my grass greener and more lush than that provided by this agency? What works for me in private practice and what doesn’t? Are the perks of agency work the real-deal-Sir-Walter-Buffalo grass, or is it Kikuyu grass infested with bindies and other weeds? Do I need to fertilise my patch a bit or just remember to water it?” I have three days to go in my current part-time casual stint as a stand-in counsellor. It seems a good time to reflect on what I have learned from this recent experience and perhaps give you 18

the opportunity to explore your own options. Not everyone’s experience will be quite the same as mine, but it still seems valid to share my experience. (I hold strongly to the validity of autobiographical studies in any case.) I will also refer to incidents or themes that emerged from working in other agencies to broaden the landscape beyond this present experience. Money The buck stops here! I don’t know any rich counsellors, but I do have the sense that some savvy individuals, particularly in inner city areas, make reasonable money. I’m not one of them. I make choices based on my needs and context; I make enough to get by. When I work in an agency, I do not make good money. It seems our industry is not one that rewards our work. The main difference in the money is offset by the reliability, the sick pay and the superannuation. There are also hidden financial benefits in working for an agency: Free or subsidised training and supervision are provided. Stationery, computer technology (such as it is in agencies), electricity, phone use, library access and professional journals are often also provided. Client Load Most agencies, in my experience, demand that counsellors see five clients per day, or even more. This is a heavy workload, given the nature of the work. If it wasn’t for frequent no-shows and cancellations, I would see this as unsustainable in the long-term. The risk is that counsellors begin to cut corners clinically, choosing to provide psycho-education rather than therapy. In private practice, if I choose to see five clients in a day, I can pace myself by working a longer day if needed. I can have rest time the next morning or go for a swim between clients to refresh and refocus myself. If I am tired, I can book in fewer clients; when I am feeling energised, I can increase my workload. Paperwork Administration In private practice, my phone needs to be available at odd hours to take enquiries, change bookings, chase referrals or attend to other administrative matters.This includes IT assistance and repairs, booking training venues, purchasing stationery, and attending to book orders. The line between work and home life is blurred, although I do set boundaries around them. It takes commitment and determination to maintain those boundaries. At the beginning, it was easy to feel I always needed to be available so I could build the business. That was exhausting! I need to keep my own statistics, create systems for making sense of patterns in those numbers, and keep good records—both financial and clinical. Private practice demands management; I hire someone occasionally to help minimise my stress and to help me learn the processes needed. Administration is not one of my strengths. Invoicing and financial records take time. I have also needed to set up systems for communicating information to new clients, for changes to fees or policies, and for making referrals. It takes space and time to store records and to do administration. CQ: The CAPA Quarterly


Conundrums Work-Life Balance In agency work, the boundary between work and home is much clearer than in private practice. Work finishes at five or six or whenever the contract says I stop. For some, this may be the only way not to ‘take work home’. I work from home, so the risks of work leaking into my personal mind-space are greater, though over the years, this has become much easier to manage. Boundaries become easier when you want to get a life. I can decide when I want a holiday; I make the booking, clear the diary, and hit the road. A break needs to be negotiated in an agency. The downside is that there are no back-ups for clients in crisis when I do take leave; they are dependent on LifeLine and other such emergency services. When I am on a break, I choose to be available to take calls for appointments and enquiries. That is a cost I am prepared to bear. For personal reasons, I choose to take more leave than most agencies would give, and I can manipulate the diary to reduce the impact on clients. I can work Monday through Wednesday one week, and Wednesday through Friday of the last week of my leave so I actually have longer than one week away, because I only work part-time. That kind of flexibility would be a nightmare for a large organisation. Daytime breaks are easier too. I can do shopping, cleaning, cooking, or gardening during a working day, especially if there are cancellations. I can even lie down and take a nap if I am a bit offcolour. This is not so easy when you use hired rooms for private practice, although it is amazing how comfortable a couch can be. Isolation vs Teams I am blessed to have connections with local agencies. Even so, I can go for months with no agency connection. In private practice, I am lucky to have a friend and colleague to debrief with frequently or to just whinge that it was a long day. Many in private practice work in professional rooms, and this context may provide the same outlet and support. PACFA newsletters, CQ and other publications keep me connected to the broader social and political landscape of counselling. Safety I don’t think it is a good idea to be in private practice too early in your counselling career. Agencies teach good skills, and the accountability of stats and clinical processes can be a good way to get immediate feedback. The best features are the safety and anonymity agency work gives. Some clinicians are lucky enough to start in private practice in a group setting where there is greater safety. Agencies often require duress alarms, protocols about leaving the building, working alone, and Occupational Health and Safety policies regarding fire and physical safety. In private practice, especially working from home, you need to have really good radar at the intake phase. I depend on this. I have strategies for referring on clients who get through the intake, but who I later deem unsuitable or unwise to work with. I am pretty skilled at making sure clients see referrals as being the best thing for them. My years of experience running groups for men who use violence also helps me keep myself safe. May 2013

Jewel Jones

Having said all that, I acknowledge that there are real risks to working alone. I have good neighbours and some protections in place, which I will not divulge, but whatever the safety measures, it is not as safe as agency work unless, of course, you experience driving home from a men’s domestic violence group, and you think someone is following you. Differences in Clinical Work When you work for an agency, clients are provided. As I mentioned before, I have to work hard to get clients. A web page is essential, as are cold-calling and networking. I have been involved in the local Chamber of Commerce and a local business network. I freely give information to clients about cheaper alternatives if they can’t afford me, and I liaise with these cheaper alternatives regularly. I attend community days, events and meetings. I have been involved in a few charity events, promotional days and so forth. It costs money and time to promote your work, especially in areas that are disadvantaged. One of the best parts of private practice is the choice I have about which clients I take on. Unspeakable luxury! Over time, I have shaped my business so that I play to my strengths. I love supervising, for example. I’m effective with adolescent girls, but not so much with boys. Agency work often involves a lot of work with the Department of Community Services, mandated clients, legal issues and greater numbers of higher-needs clients. This can be exhausting and demoralising over a period of time and can lead to burnout. I choose my own supervisor. Such bliss! Opportunities Agencies offer opportunities for promotion sometimes. I have been given the opportunity to teach at three different agencies. Some agencies will have people in power who actively block any attempts you make to spread your wings. I moved on very quickly once I recognised the limitations imposed on me, holding me back from where I had hoped to fly! Now I create my own flight paths. Speaking of flight, I’m off to Port Macquarie for a teaching opportunity that has arisen in my private practice. How is that for a tough gig? I can say no if I am asked to facilitate, train, supervise, run a group, or step into a role I choose not to undertake. I prize that control. Call me a control freak if you like, but I have decided I love creating my own reputation, future, and opportunities. I feel I am being creative, as if I am creating an artwork. I could be out of work tomorrow, but then couldn’t we all?

Jewel Jones is a counsellor with over 14 years’ counselling experience in agencies and in private practice. She has a Masters in Adult Education and her private practice is increasingly concerned with having influence through training and supervision. www.jewel-jones. com.au, jeweljones@iprimus.com.au

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Professional Development

Patterns from Our Past: The Self of the Therapist

Review by Juliana Triml

Linda Mackay has a well established reputation in the counselling and family therapy fields in Australia, particularly in the field of trauma. She is a faculty member of The Family Systems Institute (FSI) in Sydney and passionate about teaching health professionals about working with clients from a Bowen family systems theory perspective. As part of her role at the FSI, Linda supervises a number of child and adolescent mental health and other NGO teams across NSW, including one in Tasmania. She also works part-time as a lecturer in the Counselling and Behavioural Sciences program at Notre Dame University and is an accredited Neurofeedback trainer. Linda serves as CAPA’s Membership Chair. After the EGM on 1 December 2012 and following the mariachi band during lunch, our Dr Linda Mackay gave a passionate presentation on the importance of our understanding, as therapists, of the behavioural patterns within our families of origin. What made this presentation so heartfelt and poignant was that Linda spoke as an observer of her own family dynamics. The rationale for therapists to continue to focus on their own personal work is based on the premise that they can take their clients only as far as they themselves have been able to go. As many therapists and their clients will attest, the commitment to continued work on oneself can take energy away from other important aspects of one’s life and relationships. So how do therapists continue to work on themselves? During the workshop, Linda identified several relational patterns within her own family, and it was her awareness of these patterns, she said, that enables her to identify specific patterns for clients and to assist them in getting “unstuck”. I remember in my early years of counselling, several trainers advised: “Clean out your own backyard first”; identify, acknowledge and deal with your issues as necessary.

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Linda suggested that by reflecting on our own behaviours— identifying the actions and triggers that precipitate them— we can be more empathic towards our clients and more understanding of the processing of issues. A good start would be for a therapist to ask of herself: “Who in my life brings out the best in me?” and “How do they do it?” This helps to identify the skills and attitudes one needs to trigger the best in others. At the same time, it is important to understand the opposite: “What are the triggers that elicit the worst in me?” Triggers from the past inherently influence our current behaviours and, therefore, have a personal meaning and variable intensity for each of us. Linda asked the audience to name several behaviours or situations that trigger the best in a person (e.g., safety, forgiveness, acknowledgement, love of self and others) and those that trigger the worst in a person (e.g., projection, dismissiveness and arrogance). Obviously, the ideal would be the ability to self-manage and maintain our ‘best’ in the presence of and despite someone’s ‘worst’. When presented with divergent opinions, we may have problems self-soothing and occupying a space of harmony that requires us to maintain feelings of both willingness and congruence. For example, when we are accommodating another’s needs, do we always feel balanced and, if not, why do we do that ‘something’ when, in fact, we do not feel like doing it? Linda’s presentation invited us to indulge in our own selfreflection and to follow her self-disclosing demonstration of self-reflection. In the end, it became clear that families of origin and relationships do follow reciprocal patterns that, although constructed a long time ago, still have the power to influence our behaviour in the present.

Juliana Triml is the CAPA NSW PD Coordinator. If you have any suggestions regarding future professional development events, please contact her at: pd@capa.asn.au

CQ: The CAPA Quarterly


CAPA NSW Professional Development Events CAPA NSW members must complete twenty hours of approved professional development each year. To help members meet this requirement, CAPA is hosting PDEs on the following dates:

Wednesday 29 May 2013 7.00–9.00 pm PD hours: 2 Kevin Keith

How Can Attachment Theory ‘Inform’ My Practice?

Attachment Theory has in recent years begun to importantly inform counselling and psychotherapy. These enhancements do not represent another modality but rather provide a framework for understanding emotional development and change with our clients. This workshop combines current theory and research with practical exercises to enhance our capacities for effective assessment, goal setting and work with our clients. Kevin Keith is a counsellor, psychotherapist and supervisor. He is a clinical member CAPA NSW/PACFA and a lecturer in JNI’s Masters Program. He is also a PhD candidate, University of Sydney, Faculty of Science (History and Philosophy of Science Unit) with research interests in Attachment Theory.

Tuesday 20 August 2013 7.00–9.00 pm PD hours: 2 Jackie Burke

Identifying Vicarious Trauma and Managing the Inevitable

Triggered by analysis of attrition rates throughout the industry, the NSW Rape Crisis Centre identified psychological injury stemming from vicarious trauma as the primary health and safety hazard for its counselling staff. A comprehensive package of management strategies was developed to effectively monitor and respond to this risk. As a result of implementing this package, no psychological injury claims have been made in the past eight years, and the Centre received the 2007 Safe Work Award for the best solution to an identified workplace issue from Workcover NSW. Jackie Burke, Clinical Director of the NSW Rape Crisis Centre, will discuss the key factors in this success and examine the implications of these results for other workplaces and industry sectors. The training is suitable for frontline and managerial staff. (A maximum of twenty-five participants is recommended.) Learning outcomes: Understand the vicarious trauma construct. Differentiate between vicarious trauma and burnout. Identify predictors of vicarious trauma. Recognise symptoms of vicarious trauma. Understand effective strategies to manage vicarious trauma. Jackie Burke has a background in both psychology and counselling disciplines and is a pioneer in the field of Vicarious Trauma Management. She is the co-author of A Best Practice Manual for Specialised Sexual Assault Crisis Telephone and Online Counselling.

Further 2013 Professional Development Events Saturday 26 October 2013 CAPA AGM: PD topic to be assigned Tuesday or Wednesday early in December 2013 CAPA Christmas party: PD topic to be assigned Suggestions from members for future PDE s are welcome. We are selective with the choice of presenters and invite only those who have qualifications adequate to garner PD credit for attendees. Topics are under negotiation as most presenters do not like to commit too far in advance, and there is always a risk that they may cancel, sometimes at short notice. Bookings: (02) 9235 1500 or office@capa.asn.au Please book as soon as possible. Spaces are limited due to Occupational Health and Safety requirements. Cost: Free for CAPA members. $30 for non-members Venue: Crows Nest Centre, 2 Ernest Place, Crows Nest, Sydney (unless otherwise stated)

If you have any suggestions for future PDEs, contact PD Coordinator, Juliana Triml, on pd@capa.asn.au. CAPA is also exploring more options for members in rural and regional areas. Please email the Regional and Rural Committee with your suggestions regional@capa.asn.au.

Journal ads and PD hours Please note that advertisements in the journal do not necessarily comply with CAPA’s professional development (PD) requirements. As with all workshops/courses/conferences, please check their eligibility using CAPA’s ‘Professional Development Policy 2009/2010’ in the members area of the website www.capa.asn.au If you have any queries, please contact CAPA’s Membership Chair on membership@capa.asn.au

May 2013

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how we come to the next step in our process—the change we want —by taking steps from where we actually are now. The apparent paradox is that change more likely occurs when it is neither aimed at nor compelled. Rather, when we cease resisting what is, the next step emerges. In other words, to move to the new we have to embrace what is actual in our experience. This requires a commitment to enquire into immediate experience—the phenomenological method. Though it may not be sufficient for lasting change and is more a principle than a model for change, it is arguably a necessary component. “It is this grounding in things-as-they-truly-are that permits deep and lasting change to begin” (Siegel 2010:xxi). The question of change in therapy has long engaged theorists and practitioners, as the regular enquiries into what works in therapy attest. We know from common factors research (Hubble et al. 1999, Lambert 1992, Lambert & Barley 2002, Rozensweig 1936, Sparks et al. 2008) that effective change in therapy has more to do with the intersubjective field—the therapeutic alliance—than with the action of specific techniques. Based in a relational context, the process of change in therapy too, then, is a matter for ethical enquiry. In the current social and political field—a context in which marriage equality and the rights of religious groups to discriminate against people on the basis of, inter alia, their sexuality are currently being challenged—a relevant example for enquiry into the ethics of change is the contested territory of reparative or conversion therapies. This history, apart from foregrounding the fallibility of diagnostic categories in the DSM and elsewhere—not objectively determined free of values and cultural influence— suggests that therapies whose aim is to convert homosexuals to heterosexuality has lost any scientific base from which to assert their credibility. Moreover, reparative therapy has been shown not only to be ineffective but to be damaging to clients. In the USA, a recent bill in California has banned reparative therapy for individuals under the age of eighteen due to the evidence of harm (Senate Bill 2012). The American Psychiatric Association has consequently posted a position statement on its website reminding professionals of the potential harm of these therapies and of professionals’ responsibilities. Nevertheless, reparative therapy continues to be practised and there are, as yet, no sanctions against its practice in Australia. In the absence of a position statement, we turn to this example to explore how philosophical enquiry might inform an ethics of therapy. If client concerns about their same-sexuality are inherently about their sense of self and their relationship orientation, then a mode of therapy that works explicitly with senses of self through a relational medium is arguably a good fit for this client cohort. Taking together elements of phenomenology, field theory and the paradoxical theory of change, discussed earlier, we explore how the reparative task—reversal of same-sexual orientation— is inimical to a phenomenological orientation and that phenomenological practice may render the conversion impossible. In Gestalt psychotherapy, the therapeutic process aims to support the linkage of the client’s presentation to the ground from which it emerges. This is inherently a field-theory orientation. It sets up enquiry into the contextual history of the client’s issue and draws on the relationship between therapist and client as part of the enquiry. If, in the case of reparative therapy, the client’s expressed desire is to somehow change sexual orientation from same-sexual to heterosexual (notably, never the 22

reverse), the therapist’s task from a field-sensitive perspective is to initiate enquiry into the ground of that desire. What generates some clients’ resistance to their sexuality? What is present in the relationship between therapist and client as the enquiry unfolds? Such a framework would oblige reparative therapists to resist immediate compliance with a client’s expressed wish to ‘reverse’ same-sexual orientation and instead notice their own investment in the client’s desired change, and their own subjective phenomenological response to the client’s disowned same-sexuality. For field-sensitive practice, the phenomenology of the therapist is data for inclusion. Rather than take the apparently ‘indifferent’ stance of complying with the client’s expressed wish, this perspective challenges the therapists to know their own role in the desire for the change of sexuality. Here, reparative therapists would be called upon to consider their own resistance to same-sexuality, rather than to mobilise it without reflection. This is a participatory, intersubjective, social and relational model of therapy, as distinct from an observational, diagnostic, subject-object model that sits more within the model of transforming pathology into health. For reasons that are no doubt obvious, the issue of changing same-sexual orientation to heterosexual is neither symmetric with, nor reversible to, the issue of changing from heterosexual to same-sexual. The latter is rarely expressed as a desire to become same-sexual and is more frequently expressed as the emergence— ‘coming out’—of a deeper truth. Moreover, the broader sociopolitical field still creates pressure to conform to heterosexual orientation, and the reverse cannot plausibly be said to be the case. Ground Shame The key to this irreversibility is the persistence of shaming as a tool for regulating sexuality. Shame has a positive function when it is our own subjective corrective to our own actions that conflict with our sense of integrity and relationship to the field, but shame has a negative and often destructive quality when it is imposed as a rejection of who we are in our inherent sense of self. The shaming of same-sexuality is a field phenomenon: a social and historical process of exclusion, disavowal, and punishment. It is this latter sense of shame that we consider in discussion about reparative therapy. Shame from a relational psychotherapeutic approach is understood to be the effect of a break in the field—a separation from support and contact. For Jacobs (2003:93), shame is “a signifier that an aspect of one’s self-experience has not found a welcome reception, perhaps not even recognition, in one’s experiential world”. Shame can arise when we reach out for contact and that motion is rebuffed. At key developmental stages, repetitions of such contact failure can lead to internalisation of shame. Lee (2007:39) points to the irony that we can experience this form of shame “as information about ourself (as being inadequate, worthless, unlovable, inappropriate, too much, too little, and so on), when in reality it is information about the field around us (others being preoccupied, disapproving, disinterested, uninformed, not knowing how to respond, absent, or the like)”. If the lack of reception is severe enough or persists, ‘ground’ shame forms. In relational gestalt therapy the ‘ground’—our sense of being-in-the-world—is the locus of our relational being. This means that with ground shame, the very place from which we relate with our world becomes inflected with shame. CQ: The CAPA Quarterly


The development of ground shame takes a person out of a relational sense of the world and deposits them in an individualistic paradigm in which they are disconnected, alone, and the subject of blame and disregard. Instead of the excitement and mobilising possibilities coincident with yearning the person is left with a sense of hopelessness and deflation (Lee 2007:39). With ground shame, the mere emergence of longing in any context can be a trigger for shame (Lee 2007). Clients motivated to seek to reverse their same-sexuality are likely to bring with them ground shame—a no-longer-visible-because-internalised sense of being co-created by the fields within which it has developed. From a field perspective, shame is a co-created event; clients who have been shamed by expressions or even intimations of their same-sexuality will, therefore, be best supported through inclusivity and re-connection with the field. The therapeutic alliance forms a current field in which rupture can be repaired. Here therapists’ inclusion of clients as they are, supports them to work gradually through the shame complex and find their own ground. This can resource clients to sustain enquiry into their subjective experience sufficiently to understand where the motivation for change, or self-acceptance, arises. Buber’s notions of ‘confirmation’ and ‘inclusion’ describe this aptly (1999). Confirmation is the support therapists provide for others to ‘show up’ as they are in a given moment. Inclusion here means that the whole of the therapist shows up to meet as much of the client as the latter can tolerate. This is not approval or validation at the personality level, rather it is participatory support for the potential whole of that person. In other modalities, this is approximated by terms such as ‘selfconsolidation’, also ‘mirroring’, or ‘recognition’. In confirmation, the other is not an object for diagnosis, analysis, treatment but, rather, a partner in the enquiry. It is core in relational therapy to support clients

May 2013

through the intersubjective relationship to locate the ground of their being-in-the-world. To reach the step over there, I first have to take the step here. To ‘become’ heterosexual, I first need to explore how it is for me to be same-sexual. How does it sit within me, how does it manifest? Therapeutic change, in this approach, is effected through supporting clients to come fully into their present being and potentiality (Israel & Selvidge 2003). It is not imposed externally from a set of ideas. It emerges from the reality of the present-moment intersubjective (verbal and nonverbal) dialogue and is thus more likely to be relevant, achievable and sustainable and, very often, unpredictable. The implicit acceptance of clients as they are in the present moment might, if done well, renderss the reparative task impossible. Conclusion A return to the philosophical roots of therapy for a sustained enquiry into the ethics of practice, challenges us, as therapists, to examine and define the basis of our decision-making practices, with all the complexities that are inherent in the therapeutic relationship, for purposes of cultivating both our own emotional intelligence and to better serve our clients’ needs. Furthermore, the historical development of intersubjectivity as the core of relational therapy, and its implication of the therapist in the process of change in therapy, not as a coercive agent but as a field-sensitive participant is pivotal to an understanding of the therapist’s role and the importance of ethical decision making. A phenomenological approach to the example of reparative therapy combined with the application of field principles is a powerful example of the impossibility of shame-driven change. In the current absence of regulatory codes to prevent the interpsychic harm that reparative therapy can cause, a rigorous reflective practice involving the whole of the therapist meeting the whole of the client is a powerful support for ethical practice.

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Features (continued) References

Audi, R 2001, The Cambridge Dictionary of Philosophy, Cambridge: Cambridge University Press Buber, M 1999, in J Buber Agassi (Ed.) Martin Buber on Psychology and Psychotherapy: Essays, Letters, and Dialogue, NY: Syracuse University Press Beisser, A 1970, ‘The Paradoxical Theory of Change’, in J Fagan and I Shepherd (Eds) Gestalt Therapy Now, NY: Harper (77-80) Coady, M 1996, ‘The Moral Domain of Professionals’, in M Coady and S Bloch (Eds), Codes of Ethics and the Professions, Melbourne: Melbourne University Press (28-51) Critchley, S 2002, ‘Introduction’ in S Critchley and R Bernasconi (Eds) The Cambridge Companion to Levinas, Cambridge: Cambridge University Press Heidegger, M 1962, Being and Time (trans.) J Macquarrie and E Robinson, New York: Harper & Row Hubble, M, Duncan, B and Miller, S (Eds) 1999, The Heart and Soul of Change: What Works in Therapy, Washington, DC: American Psychological Association Husserl, E 1931, Ideas: General Introduction to Pure Phenomenology (trans.) W Gibson, Oxford: Macmillan Israel, T and Selvidge, MM 2003, ‘Contributions of Multicultural Counseling to Counselor Competence with Lesbian, Gay and Bisexual Clients,’ Journal of Multicultural Counseling and Development, 31(2): 84-98 Jacobs, L 2003, ‘Ethics of Context and Field: The Practice of Care, Inclusion and Openness to Dialogue’, British Gestalt Journal, 12(2): 88-96 Kidder, RM 2009, How Good People Make Tough Choices: Resolving the Dilemmas of Ethical Living, NY: Harper Lambert, M 1992, ‘Implications of Outcome Research for Psychotherapy Integration’, in J Norcross and J Goldfried (Eds) Handbook of Psychotherapy Integration, NY: Basic (94-129) Lambert, M and Barley, D 2002, ‘Research Summary on the Therapeutic Relationship and Psychotherapy Outcome’, in J Norcross (Ed.) Psychotherapy Relationships That Work: Therapist Contributions and Responsiveness to Patients, Oxford: Oxford University Press Lee, R 2007, ‘Shame and Belonging in Childhood: The Interaction Between Relationship and Neurological Development in the Early Years of Life’, British Gestalt Journal, 16(2): 38-45 Lewin, K 1943, ‘Defining the “Field at a Given Time”’, Psychological Review, 50: 292-310 Miner, M and Petocz, A 2003, ‘Moral Theory in Ethical Decision Making: Problems, Clarifications and Recommendations’, Journal of Business Ethics, 42(1): 1-25 Moulton, J 1924, ‘Law and Manners’, The Atlantic Monthly, July, viewed at http://www2.econ.iastate.edu/classes/econ362/hallam/NewspaperArticles/ LawAndManners.pdf on 22 February 2013

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Orange, D 2001, ‘From Cartesian Minds to Experiential Worlds in Psychoanalysis’, Psychoanalytic Psychology 18: 287-302 Orange, D 2010, Thinking for Clinicians: Philosophical Resources for Contemporary Psychoanalysis and the Humanistic Psychotherapies, New York: Routledge Parlett, M 2005, ‘Contemporary Gestalt Therapy: Field Theory’ in AL Woldt and SM Toman (Eds) Gestalt Therapy: History, Theory and Practice, London: Sage Rozensweig, S 1936, ‘Some Implicit Common Factors in Diverse Methods of Psychotherapy’, American Journal of Orthopsychiatry 6(3): 412-415 State of California, USA, 2012, SB 1172 ‘Sexual Orientation Change Efforts’, Chapter 835: An act to add Article 15 (commencing with Section 865) to Chapter 1 of Division 2 of the Business and Professions Code, relating to healing arts, Legislative Counsel’s Digest viewed at http://leginfo.legislature.ca.gov/faces/billNavClient. xhtml?bill_id=201120120SB1172 on 22 February 2013 Siegel, D 2010, The Mindful Therapist. A Clinician’s Guide to Mindsight and Neural Integration, New York: W.W. Norton & Co Sparks, J, Duncan, B and Miller, S 2008, Common Factors in Psychotherapy, New York: Wiley Staemmler, F 2009, ‘Cultivated Uncertainty: An Attitude for Gestalt Therapists’, in Aggression, Time, and Understanding: Contributions to the Evolution of Gestalt Therapy, New York: Routledge, Taylor & Francis (335-357) Stewart, C 2005, ‘A Rhetorical Approach to News Discourse: Media Representations of a Controversial Study on ‘Reparative Therapy’, Western Journal of Communication 69(2): 147-166 Yontef, G 1993, Awareness, Dialogue & Process: Essays on Gestalt Therapy, New York: The Gestalt Journal Press Elizabeth Day, PhD BA (Hons) Grad. Dip. Relational Gestalt Psychotherapy, is a Senior Lecturer in Counselling at the Australian College of Applied Psychology based in Melbourne. Her research and practice interests are in postmodern theories of the subject, phenomenology, field theory, and intersubjectivity. Elizabeth practises relational psychotherapy, including work with gender and sexual identity, loss, intimacy, and existential anxiety. She is a member of the PACFA Research Committee and an executive member of SCAPE. Elizabeth Riley, PhD MA (Couns) Dip Hom BSc, is a counsellor, supervisor, and educator specialising in sexuality, gender, ethics and supervision. Elizabeth is the Counselling and Placement Lecturer at The Australian College of Applied Psychology and has spent many years as a counsellor, consultant and trainer for the St James Ethics Centre. Elizabeth is a trustee of Carmen Rupe Memorial Trust and has presented papers and workshops, both locally and internationally, in the areas of sexuality, gender identity, and ethics.

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circumstances. As mentioned, most of us will rely on training, experience and a good supervisor to get us through the unchartered territory. We may at times need to look up ethical guidelines and research literature. Ethical issues can, however, seem to be so context and situation specific that we can wonder whether, in these particular circumstances, something different is required. For example, in the scenario above involving touch in therapy, you might look up the literature on touch, on anxiety, on the therapeutic alliance. You might talk to colleagues. You may not, though, find an example that seems quite the same and, given that you want this to work, you might wonder whether this is a situation where you change your practice in the face of a unique client’s need. Would it make a difference if the person was blind? Was of the same or opposite gender? Was the same or different age? How does one evaluate these differences, and when is it best to stay within the working parameters established as a best fit with our approach? Ethical maturity is not a static state one achieves, nor is it marked by particular study or defined effort. It is important to acknowledge growth and wisdom, but also to accept the state of not-knowing and coming to know that not knowing is required for good ethical decision making. We learnt this from Socrates, who saw as his greatest knowledge the knowledge that he didn’t know. In his view, belief in one’s own assured knowledge immediately limits ideas and options (Grayling 2003). Components of Ethical Maturity Carroll and Shaw (2012) present six components of ethical maturity to guide us not only in making ethical decisions but in becoming ethically sensitive to the complexity of ethical decision making and the many factors involved. These components are not sequential stages in a process but are, rather, conditions that make for good ethical decision-making. The six are: 1. Fostering ethical sensitivity and watchfulness by creating ethical antennae that keep us alert to instances when ethical issues/dilemmas arise. This results in finding one’s moral compass/moral character. Ethical sensitivity provides the first alert that an ethical issue is at stake. To be ethically insensitive is to miss the signs of ethical presences and abort any further stages in the ethical decision-making process. Helping practitioners develop an ethical compass is one of the first tasks of supervision and will emerge primarily from supervisors who are themselves ethically aware and notice emerging ethical dilemmas and problems. Empathy enters the field at this stage as the primary virtue of ethical sensitivity. Fostering empathy and compassion as the twin anchors of ethical sensitivity is a key supervisory role. 2. Discerning ethical decisions and being able to make an ethical decision aligned to our ethical principles and our values. Awareness of ethical issues is only the beginning of the ethical procedure. Next comes the ability to make an ethical decision, and this is based on the ability to pause, reflect, consider, and decide on a mature course of action. Training programs and supervisors help budding practitioners at this stage of ethical development by enabling them to reflect on increasing the ways in which they consider what values are at the heart of their decision-making processes. Ethical maturity makes the values of relational care and fidelity central to ethical decision making. (See BACP Ethical Framework for other values that will inform mature ethical decision making such as integrity, respect for the person, awareness of culture, etc.) May 2013

3. Implementing ethical decision(s) made. Making a decision is again only part of the path towards ethical maturity. Decisions need to be implemented, and not all ethical decisions are. There is evidence that knowing what to do ethically does not always end in enacting that decision. Implementation may demand courage and perseverance or resilience to see a difficult task completed. 4. Being able to articulate and justify to stakeholders why the ethical decisions were made and implemented. Honesty and transparency become part of ethical justification. Reason, logic and the ability to speak clearly are all skills needed at this stage. Knowing oneself also helps us to articulate why actions were decided upon. 5. Ethical peace and sustainability—achieving closure on an event, even when there were other possible decisions or ‘better’ decisions that could have been made. Living peacefully with the consequences of ethical decision making is crucial to ongoing wellbeing. Letting go of what has been done is important in ethical closure. Practitioners learn to accept who they are, be compassionate towards themselves, be honest, and make restitution when needed. 6. Learning from what has happened and ‘testing’ the decision through reflection. Integrating what we have learned into our lives, develops our moral character and extends our ethical wisdom and capacity. Part of the process of developing ethical maturity is learning from experience. This again takes some time to develop the ability to be both honest with oneself and able to trust one’s experience even when others disagree. Emotional and social intelligence will play a large part in this. Ultimately, these six components result in ethical maturity. The six components come together in this definition or description of ethical maturity: Having the reflective, rational, emotional and intuitive capacity to decide whether actions are right and wrong or good and better, having the resilience and courage to implement those decisions, being accountable for ethical decisions made (publicly or privately), and being able to learn from and live with the experience. Codes and frameworks are starting points for ethical decisions, not end points. They rarely tell us what to do but do provide overarching principles to help us make decisions. Sticking only to codes results in an ethics of duty but not always an ethics of fidelity; it is this relational ethics of trust that is our aim. Bond (2007:436) defines this type of ethical stance: “Trust is a relationship of sufficient quality and resilience to withstand the challenges arising from difference, inequality, risk and uncertainty.” This kind of relationship in therapy supervision helps to create ethically mature practice. Ethical Stumbling Blocks and Blind Spots Some research is available to guide us on which ethical skills and capacities can be most challenging to achieve and perhaps most susceptible to ethical fading. This centres on two ‘bookends’ in ethical reflection and decision making. Firstly, there is the issue of moral sensitivity and awareness and how we can continue to hone our skills in that regard. I (Elisabeth) recall a colleague who was determined to report another professional for a serious boundary violation even though she would have 25


Features (continued) been forgiven for not taking the lead in the matter given that others were more central to the facts of the case. She was so clear about the violation and so committed to her obligation within her profession that she refused to take any of the ‘outs’ available to her. I thought then that if others had come across the information in the way that she had, they may not have perceived an obligation at all. These moments are useful to us all in raising ethical awareness about moral duty. As Kahneman (2011:24) notes, “We can be blind to the obvious and we are also blind to our blindness.” This means that we need to have as back-up practices, systems and colleagues that support ethical work. Had Lance Armstrong or Jimmy Saville been surrounded by such people could they have continued with the choices they made over so many years? This brings us to some interesting studies on moral courage and the implementation of ethical decisions—the other ‘bookend’ of ethical awareness. In a study by Smith et al. (1991), it was noted that professionals do, in most cases, know what is the ‘right’ decision—the decision they should make in given professional circumstances. It is not that they are ignorant of their codes and requirements. They may baulk at implementation if various factors are present. For instance, when it involves a close colleague and the relationship makes the practitioner feel inclined to want to ‘cut the colleague more slack’, or when one worries that reporting a colleague will make a working relationship impossible, especially when the ethical breach may not be a clear violation of a rule or a law. Where there is a clear breach of specific rules, or where the professional was a stranger, then one’s ability to act was easier. In another study, Betan and Stanton (1999:296) noted that the role of emotion in decision making is also significant. When the unethical

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conduct relates to someone in a relationship with us, our emotional response is higher. When a client is very affronted by certain behaviour, such emotions can guide a therapist to identify ethical issues and implications. Emotions can equally overwhelm us and result in paralysis, for example, in instances when they lead you to wonder whether you are being too subjective or should be ‘kinder’ to the colleague in question. Betan and Stanton conclude that inadequate ethical decisions can be made, in part, because professionals are not well-attuned to the influential role of emotions, values and contexts in their processing and procedures. This sort of research indicates that we need more exposure to matters of ethics in order to open our imaginations to the challenging possibilities we might face, and to be able to reflect and develop our knowledge and skill in reading situations well, honing our ethical radar and decision-making capacity. This will necessarily involve training in the areas of emotional competence (self regulation, self awareness), moral and professional judgment, and moral courage. Further, fostering empathy and imaginative self involvement in ethical situations—asking: Could that happen to me? What would I do? How might that have happened?—inhibits moral disengagement (Detert et al. 2008). In this context, self care in itself can be seen to be a moral imperative in relation to maintaining both emotional and skill-based competence, as we know that the gift of helping others is not enough to sustain us or to support rigorous thinking over time (Baruch 2004). Tiredness, lack of life balance, isolation, overwork and under development will all lead to impairment, and our ethical capacity is in such circumstances compromised (Tamura 2012).

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Conclusion Ethics are not problems to be solved. They are relational issues to be lived. That means the final answers to the questions asked by practitioners about making ethical decisions is: it depends. Sometimes we just know what to do. Sometimes we wait for an answer. Sometimes we use reason, sometimes emotion, often intuition. Sometimes we discern alone; often we consult others. At times, codes and ethical frameworks help us; at other times, they are of no use. Occasionally, we rely on past experience to guide present decisions; at other times, past experience leads us astray and we have to look for new pathways. Sometimes we don’t know what to do and we stay with unknowing; at other times, we take a risk and hope for the best. Claxton and Lucas (2007:80) provided a wonderful image when they imagined ethical problems as “more like tangled fishing nets than… mathematical equations”. References Baruch, V 2004, ‘Self Care for Therapists: Prevention of Compassion Fatigue and Burnout’, Psychotherapy in Australia, 10(4): 64-68 Betan, EJ and Stanton, AL 1999,‘Fostering Ethical Willingness: Integrating Emotional and Contextual Awareness with Rational Analysis’, Professional Psychology: Research and Practice, 30(3): 295-301 Bond, T 2007, ‘Ethics and Psychotherapy: An Issue of Trust’, in RE Ashcroft, A Dawson, H Draper and JR McMillan (Eds) Principles of Health Care Ethics (2nd edn), Chichester: Wiley and Sons (435-442) Bond, T 2012, Foreword in M Carroll and E Shaw, Ethical Maturity in the Helping Professions, Making Difficult Life and Work Choices, Melbourne: Psychoz Carroll, M and Shaw, E 2012 Ethical Maturity in the Helping Professions, Making Difficult Life and Work Choices, Melbourne: Psychoz (2013) Claxton, G and Lucas, B 2007, The Creative Thinking Plan, London: BBC Books Detert, JR, Trevino, LK and Sweitzer, VL 2008, ‘Moral Disengagement in Ethical Decision Making: A Study of Antecedents and Outcomes’, Journal of Applied Psychology, 93(2): 374-391 Grayling, AC 2003, What is Good? The Search for the Best Way to Live, London: Orion Books

Heidegger, M 1962, Being and Time (trans.) J Macquarie and ES Robinson, Oxford: Blackwell Kahneman, D 2011, Thinking, Fast and Slow, London: Penguin Mitchell, D 2009, ‘Responsibility in Existential Supervision’, in E Van Deurzen and S Young (Eds) Existential Perspectives on Supervision, Basingstoke, Hampshire: Palgrave Macmillan Pope and Vasquez 2007, Ethics in Counselling and Psychotherapy (3rd edn), USE: Jossey Bass Smith, TS, McGuire, JM, Abbott, DW and Blau, BI 1991, ‘Clinical Ethical Decision Making: An Investigation of the Rationales Used to Justify Doing Less Than One Believes One Should’, Professional Psychology, Research and Practice, 22(3): 235-239 Tamura, L 2012, ‘Emotional Competence & Well Being’, in S Knapp (Ed.) APA Handbook of Ethics in Psychology Vol 1, Washington DC: APA Elisabeth Shaw is an individual, couple and family therapist, supervisor and trainer in private practice in Drummoyne, NSW. She was previously a manager and director of Relationships Australia NSW. In recent years, she has specialised in working with professional ethics. She is a member of the PACFA and APS Ethics Committees and writes a column for Psychotherapy in Australia on ethical issues in practice entitled, ‘Sacred Cows and Sleeping Dogs’. Elisabeth is co-author with Michael Carroll of Ethical Maturity in the Helping Professions, Making Difficult Life and Work Decisions. Michael Carroll, PhD, is a Chartered Counselling Psychologist, accredited Executive Coach and Supervisor of Executive Coaches with Association for Professional Executive Coaches and Supervisors (APECS). He is visiting Industrial Professor in the Graduate School of Education, University of Bristol, and the winner of the 2001 British Psychological Society Award for ‘Distinguished Contributions to Professional Psychology’. Michael works with individuals, teams and organisations, specialising in the theme of learning. He supervises, coaches and trains both nationally and internationally within the private and public spheres and runs the Centre for Supervision Training, UK. He is the author/ co-author of many books, including: Training Counselling Supervisors: Strategies, Methods, Techniques; Counselling Supervision in Context; The Handbook of Counselling in Organisations; Counselling Supervision: Theory, Skills and Practice; Workplace Counselling; Integrative Approaches to Supervision; On Being a Supervisee: Creating Learning Partnerships; and Becoming an Executive Coachee.

Creating cultures of CArInG: Achieving diversity and inclusiveness in the practice of group work 2013 InstItute of Group Leaders ConferenCe The Institute of Group Leaders consists of an expert working group of specialists in the field of group leadership. IGL is recognized as the membership accrediting body for group leaders. It provides training courses in group leadership and on-going education workshops. Speakers include: Dr Ed Jacobs Making the most impact with your group work programs Mohamed Dukuly Responding to trauma experienced by refugees using group work Pam Cohen Charles Darwin’s lesson: Why groups help us cope with challenges Call for abstracts closes at the end of March 2013. To register or for more information visit: www.igl.org.au Conference date: Friday, Saturday 13th & 14th September 2013 InstItute of Group LeAders one dAy Wo rksho p Impact Therapy in group work: Working with vulnerable communities, offenders and their families’ workshop with Dr Ed Jacobs. This one-day workshop will introduce participants to Impact Therapy, which is an active, multisensory, creative, theory driven approach to counseling and group work. The emphasis is on making counseling, group work and the learning/change process clear, concrete and thought-provoking, rather than vague, abstract, and emotional. Monday, 16 september 2013 at sydney • Wednesday, 18 September 2013 at Canberra To register, locations or for more information visit www.igl.org.au

May 2013

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confidentiality in separate sessions and discourage between session communication; in couple work, in particular, sessions should occur with the transparent agreement that all information will make its way back to the joint sessions, as it is the relationship that is the focus of the work. This may be managed more judiciously with family work, as boundaries between parental and child subsystems may require limits of disclosure. You also need to bear in mind that couple/family notes are vulnerable to being used in Family Law action, and ensuring they meet professional requirements is crucial. Interventions and Case Management Couple and family therapy, like all therapies, has advanced different models of practice, all with varying emphases on the role of the therapist. The choice one makes (authoritative/ educational, interventionist, influential, facilitative) is influenced by personality and training and has a significant impact on how clients experience the work. Over time, techniques around change (for example, use of paradox, strategic manoeuvers, prescriptions, triangulation) have led to critical debate about how much stress is acceptable in achieving change (Wilcoxon et al. 2007). Although we may have preferences for therapeutic intervention, with relational work there are more requirements to be other things as well: advocates, educators, positional advisers (on abuse and violence, for example) and strategists in our case management. Considering these different demands as also part of effective therapy requires thought in advance of the requests that bring them into play (Shaw 2012). Relational work is particularly vulnerable to social bias, and it is crucial that we look at our own experience and social/cultural training and ensure we are not simply operating from our own personal opinions and preferences. Evidence-based practice plays an important role in balancing the common social stereotypes about how relationships should function (Corey et al. 2011). Ethical Practice Any ethical decision needs to be defended with reason, but intuition and experience also play a role in developing effective and justifiable responses (Carroll & Shaw 2012). Ensuring you can be judged as sufficiently trained and competent to do relational work is crucial (and different from your own desire

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to do it and your own assessment of your skill). Then, finding opportunities for professional development and rigorous debate about ethical issues in practice is crucial. Are you in supervision with others with specialised relationship training? How often do you reflect on ethical challenges in supervision? Finally, our best work will occur when we are also in the best possible shape. This may involve insight into our own familyof-origin issues and relationship experiences (Corey et al. 2011) but in practical terms also involves attention to self care, which is something we may tend to under emphasise. References Brown, J 2007, ‘Therapy with Same Sex Couples: Guidelines for Embracing the Subjugated Discourse’, in E Shaw and J Crawley (Eds), Couple Therapy in Australia, Issues Emerging from Practice, Melbourne: Psychoz Corey, G, Schneider-Corey, M and Callanan, P 2010, Issues and Ethics in the Helping Professions (8th edn), CA: Belmont, CA: Cengage Learning, Inc. Carroll, M and Shaw, E 2012, Ethical Maturity in the Helping Professions: Making Difficult Life and Work Decisions, Melbourne: Psychoz Hecker, L (Ed.) 2010, Ethics and Professional Issues in Couple and Family Therapy, New York: Routledge Kitchener, KS 1984, ‘Intuition, Critical Evaluation and Ethical Principles: The Foundation for Ethical Decisions in Counselling Psychology’, Counselling Psychologist, 12(3) 43-55 Negash, SM and Hecker, LL 2010, ‘Ethical Issues Endemic to Couple and Family Therapy’, in Newfield, SA, Newfield, NA, Sperry, JA and Smith, TE 2000, ‘Ethical Decision Making Among Family Therapists and Individual Therapists’, Family Process, Summer, 39(2): 177-188 Ramisch, J 2010, ‘Ethical Issues in Clinical Practice’, in L Hecker (Ed.) Ethics and Professional Issues in Couple and Family Therapy, New York: Routledge Reynolds-Welfel, E 2013, Ethics in Counselling and Psychotherapy; Standards, Research and Emerging Issues (5th edn), Belmont, CA: Brooks/Cole Shaw, E 2001, ‘The Anxiety in Maintaining the Couple Relationship’, Psychotherapy in Australia, May Shaw, E 2012, ‘The Place for Judgment in Post Modern Clinical Practice’, Psychotherapy in Australia (in press) Wilcoxon, AA, Remley, TP, Gladding, ST and Huber, CH 2007, Ethical, Legal & Professional Issues in the Practice of Marriage & Family Therapy (4th edn), New Jersey: Pearson

Elisabeth Shaw is an individual, couple and family therapist, supervisor and trainer in private practice in Drummoyne, NSW. She was previously a Manager and Director of Relationships Australia NSW. In recent years, she has specialised in working with professional ethics. She is a member of the PACFA and APS Ethics Committees and writes a column for Psychotherapy in Australia on ethical issues in practice entitled, ‘Sacred Cows and Sleeping Dogs’. Elisabeth is co-author with Michael Carroll of Ethical Maturity in the Helping Professions, Making Difficult Life and Work Decisions.

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therapeutic service of children what central part of us are we choosing from and what is it that will be different from before” (1996). References Berg, IS and Steiner, T 2003, Children’s Solution Work, London: W.W. Norton & Company Bird, J 1994, The Heart’s Narrative: Therapy and Navigating Life’s Contradictions, Auckland, NZ: Edge Press Brody, H 2001, The Other Side of Eden: Hunter-Gatherers, Farmers and the Shaping of the World, London: Faber and Faber Greenwald, R 2000, in KN Dwivedi (Ed.) In Post-Traumatic Stress Disorder in Children and Adolescents, London: Whurr Publishers Jones, DPH and Ramchandani P 1999, Child Sexual Abuse: Informing Practice from Research, Oxon: Radcliffe Medical Press Lewis, CS 1996, The Problem of Pain, New York: Simon & Schuster O’Donohue, J 1999, Anam Cara: Spiritual Wisdom from the Celtic World, London: Bantam Books Peck, MS 1978, The Road Less Travelled: A New Psychology of Love, Traditions and Spiritual Growth, London: Rider Press Somerville, M 2000, The Ethical Canary: Science, Society and the Human Spirit, Hawthorn, AU: Viking

Mary Jo Mc Veigh, BSSC (Hons) MSW, is the founder and Director of Cara House, Centre for Resilience and Recovery, in Sydney. She is a trained trauma therapist and an accredited mental health social worker. Mary Jo has written numerous training programs and practitioners’ manuals for social services and charitable organisations. In 2010, she was a nominee for the NSW Women of the Year Award for her work with children and adults traumatised by abuse.

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Features (continued) (continued from Page 15)

When I first started working at STARTTS in 1988, I was unsure about whether Western models of psychotherapy and counselling would be helpful to our refugee clients. Would we be ‘imposing’ a ‘Western’ model of working and did Western forms of psychotherapy have any relevance? Our way of working in psychotherapy at STARTTS has evolved organically over the years, from the grass roots upwards, in close collaboration with colleagues who were themselves from refugee backgrounds. We have tried to create what Pedersen (2007) describes as ‘culture-centred’ approaches to counselling where culture takes a central place in our interventions. We have tried to establish what Williams describes as ‘cultural safety’, providing structures for counsellors to have a safe place for working through and adapting various approaches for working with traumatised clients from their own countries. These structures include working in co-therapy with a cross-cultural colleague and receiving regular supervision and training. (For related publications please view our STARTTS website.) Many therapists may have clients from the same broad cultural background as their own, yet still experience ethical conflicts with their clients regarding cultural values and practices. The same beliefs are not shared by everyone from the same ethnic background. The social worker and the client in the example about FGM could have been from the same broad culture but from different groups within it. A point relevant to subjective experiences in psychotherapy is that many people have a multicultural identity. Therapists and clients may have a mixture of values, identities and relationship styles, all of which may not be integrated in a consistent, conscious framework. For example, people may belong to a family or a group that has a collective orientation, in which they place the values of the group as primary, and yet also have more separate, autonomous ways of functioning elsewhere. It is possible to have a fluid kind of cultural identity that changes over time, and both therapist and client may alternate between different cultural value-positions in their minds during a single psychotherapy session. Subjective phenomena can be experienced to some degree by both therapist and client in the ‘play area’ (using Winnicott’s concept) of a psychotherapeutic relationship. While some major ethical dilemmas can arise (for example, the situation involving FGM) many everyday ethical issues in crosscultural psychotherapy work are related to subtle and multi-faceted ways of respecting and being open to a different culture. It could be argued that these issues could occur with any client; whenever two people are in a therapy relationship, they are in a sense opening themselves up to the internal world of the other, including the cultures which helped form the other person. When the cultural differences are marked, the issues of ‘the other’ are heightened, with an awareness that a different world view, history, language, and cultural milieu has formed this person. Ethical practice includes developing an awareness of how culture can influence the dimensions of identity, relationships, feelings and expressions—the entire reality. The challenge is to open oneself as deeply as possible to the other, while also maintaining a sense of self. There are interesting ethical issues relating to the subtle aspects of relationships formed between people who share aspects of a ‘collective’ sense of self. What are the ethical professional boundaries, appropriate roles and behaviour for a therapist in this situation? Consider this example. An elderly grandmother from a traditional Asian family, newly arrived in Australia, having lost her daughter in a civil war, starts to 30

feel as though her younger therapist is, or is becoming, a replacement daughter. (This is in addition to the myriad unconscious projections, which occur all the time between client, therapist, and interpreter.) The interpreter is respectful to the grandmother in both verbal and nonverbal ways, always deferring politely to her. The interpreter does not know what words to use in their language to frame their relationships properly, particularly when the elderly grandmother starts to feel affectionately towards them, using words that suggest she feels the therapist is ‘ her daughter’. (For a discussion regarding ethics and psychotherapy with interpreters, please see Becker & Bowles 1991.) The therapist experiences a subtle shift in the boundaries of their relationship, or in the feeling in the room, as if she, the interpreter, and the client are all closer emotionally, having somehow ‘let each other in’. A kind of merging with the client at times occurs or a kind of valency towards the group forms comprising the interpreter, client, and therapist as if they were a family. The therapist is aware, to some degree, of how to behave respectfully with elderly people in this culture. She tries not to ‘put the client off’ for example, by speaking quietly and respectfully. Eye contact is a confusing issue for the therapist, because neither the interpreter nor the grandmother may wish to look at the therapist when speaking, feeling more comfortable to look away. The grandmother expresses deep feelings of grief but in understated, restrained ways. The therapist, at times, finds her client’s pain unbearable and allows herself to escape momentarily, removing herself in her mind from her position as therapist. For a few seconds she instead feels sort of ‘merged’ with her client in a kind of motherdaughter feeling, which has interesting cultural nuances that are difficult to pinpoint. A few moments later, the therapist struggles to return to the reality of the situation, to regain her mental position as the therapist. To do this, she must allow the pain that she and the client have been working through back into her mind while trying to also think about the confusing cultural dimensions of the situation. How do we understand what is happening here? Is the psychotherapy a ‘culture-centred’ style of working that fits the collective style of relationship and unconscious internal object relations inside the three women? Or is the therapist not maintaining enough professional distance and not setting appropriate emotional boundaries? Do the ‘cultural’ aspects of this relationship interfere with the psychotherapy work momentarily, acting as a defensive manoeuvre to avoid the pain of losing the real daughter? Or is the therapist allowing herself to experience the countertransference as fully as she can, in all the cultural and emotional aspects? In trying to be open to the client’s culture, does the therapist lose her own sometimes? All these ideas are useful to think about. The critical point is to try not to avoid the complexity and fluidity of the situation. Pedersen suggests thinking of complexity as ‘your friend’, rather your enemy, when coping with a complex multicultural world (Pack-Brown & Williams 2003). It is important to have a reflective space in supervision to think through what could be happening. Many ethical issues in cross-cultural psychotherapy work (as in all psychotherapy work) can relate to avoiding the pain of the work, for both the therapist and the client. Sometimes we can use culture as a kind of smokescreen for enactments, although this may only be one dimension of what is occurring. This is discussed in the following example. CQ: The CAPA Quarterly


Colleagues from STARTTS are often invited by colleagues to attend family events. I remember attending a funeral ceremony. Unexpectedly (I did not consider this beforehand, although it should have occurred to me), I realised that some of my clients were there as well. I worried that my clients might feel embarrassed, seeing me there in a public gathering of their community, and I suddenly realised that I might inadvertently be socialising with my clients and transgressing an ethical guideline. Another secret dimension was that the experience enacted briefly some kind of fantasy—and perhaps for the clients as well—that I could actually be in their community as a kind of relative, rather than being separate as their therapist. I experienced an emotional ‘collective pull’. I felt confused and guilty, and I worried that I was suddenly escaping into a fantasy to avoid the pain and boundaries of the work. In reality, we were actually joining together in experiencing real grief in a communal, religious setting, which had its own boundaries. The experience gave me a better understanding of their community and culture and probably further developed the attachment between us. Several processes were occurring at once, and it can take time to work through what is happening. The toleration of difference and pain requires a level of separation, healthy boundaries and balanced, emotional maturity. Melanie Klein described this developmental movement as progressing from the paranoid-schizoid position to the depressive position in our minds, and this movement is, to some degree, occurring every day in our thinking. Many of my clients, at times, cannot cope with any separation or difference between themselves and myself. In parts of our sessions I have received political or religious lectures from my clients asserting their views as ‘right’ and all others as ‘wrong’, enlisting me to somehow merge with them. Another version of this kind of black and white thinking or ‘split’ mental organisation typical of the paranoid-schizoid position is a situation where clients feel that they are worthless and their culture ‘second rate’. Clients may try to take on my culture instead, as if I have all the good aspects and the client all the bad. These feelings of inadequacy are reinforced by parts of their environment which validate the dominant culture. In both of these seemingly opposite situations, the work in psychotherapy attempts to assist the client (and myself) to move to a more balanced position where we can tolerate differences in each other, diversity in different cultures, and sit with each other as separate people. This is not only an intellectual exercise but also an emotional one. The therapist must tolerate intrusive projections and contain the client’s intense emotional experiences in order to help the client develop a more separate and balanced way of operating. The work involves constant backwards and forwards movement towards a more balanced view. Developing an ability to tolerate difference and ‘other’ cultures is more than a philosophical discussion— although this is one aspect of it. Tolerance depends much on the therapist’s ability to contain clients’ intense projections and—using Bion’s notion of ‘containment’—which assists them to attain a more integrated state of mind and to cope with ambiguity and different realities (1984). (A discussion of the application of psychodynamic concepts across cultures is beyond the scope of this paper.) Conclusion In summary, while the possibility of a universal code of ethics or morality remains unresolved, we can still follow general professional values and guidelines, but with awareness of the cultural biases in our codes and in ourselves. Ideas about ethical May 2013

tolerance, cultural safety and culture-centred counselling are useful for developing ethical thinking and practice which respect culture. Ethical cross-cultural psychotherapy is about respect and understanding. It requires the therapist to be as open as possible to clients’ internal worlds, including the cultural worlds that have shaped and continue to shape them. The challenge is to balance this openness with an awareness of our own developing values and sense of self. It is important to open oneself to the subtle, fluid presence of culture in all the dimensions of a psychotherapeutic relationship, including thoughts, feelings, behaviour, identity, and unconscious processes. It is also necessary to ensure reliable supervision in which we, as therapists, can sort through complex questions about culture and ethical practice as they arise. Being able to tolerate difference and ‘otherness’ is a developmental, psychological process with which we all struggle. Thank you to Wendy Bowles, Risé Becker, John Boots, Jorge Aroche, and Samira Hassan for their assistance. References Barnes, F and Murdin, L (Eds) 2001, Values and Ethics in the Practice of Psychotherapy and Counselling, Buckingham: Open University Press Barnett, J and Bivings, N ‘Culturally Sensitive Treatment and Ethical Practice’, viewed at www. apadivisions.org/divisions-31/publications/.../barnett-ethical.pdf on 20 December 2012 Becker, R and Bowles, R 2001, ‘When Three’s A Crowd: Ethical Considerations in the Practice of Psychotherapy with Traumatised Refugees When Working with an Interpreter’, paper presented at the International Mental Health Conference ‘Diversity in Health: Sharing Global Perspectives’, Sydney: Australian Transcultural Mental Health Network Bin-Sallik, M 2003, ‘Cultural Safety: Let’s Name it!’, The Australian Journal of Indigenous Education, 32: 21-28 Bion, W 1962, Learning from Experience, London: Karnac Books Bowles, W, Collingridge, M, Curry, S and Valentine, B 2006, Ethical Practice in Social Work: An Applied Approach, Crows Nest, NSW: Allen & Unwin Bowles, R 1993, ‘Culture, Self and the Analytic Relationship: The Relevance of some Kleinian Ideas for Working with Survivors of Torture and Trauma’, unpublished thesis: UNSW Counsellors and Psychotherapists Association of New South Wales Inc. 2002, Code of Ethics and Good Practice, Sydney: CAPA Drozdek, B and Wilson, J (Eds) 2007, Voices of Trauma: Treating Survivors Across Cultures, New York: Springer Klein, M 1997, ‘Some Theoretical Conclusions Regarding the Emotional Life of the Infant’, in Envy, Gratitude and Other Works 1946 – 1963, London: Vintage (61-93) Nguyen, T and Bowles, R 1998, ‘Counselling Vietnamese Refugee Survivors of Trauma: Points of Entry,’ Australian Social Work, 15(2): 41-47 Pack-Brown, S and Williams, C 2003, Ethics in a Multicultural Context, California: Sage Pedersen, P 2007, ‘Ethics, Competence, and Professional Issues in Cross-Cultural Counseling’, Counselling Across Cultures, California: Sage (5-20) Rowson, R 2001, ‘Ethical Principles’ in F Barnes and L Murdin (Eds) Values and Ethics in the Practice of Psychotherapy and Counselling, Buckingham: Open University Press (6-22) Spiro, M 1978, ‘Culture and Human Nature’ in G Spindler (Ed.) The Making of Psychological Anthropology, Berkeley, California: University of California Press (330-359) Sue, S, Zane, N, Gordon, C, Hall, N and Berger, L 2009, ‘The Case for Cultural Competency in Psychotherapeutic Interventions’, The Annual Review of Psychology, 60: 525-548 Williams, R 1999, ‘Cultural Safety – What Does it Mean for our Work Practice?’, Australian and New Zealand Journal of Public Health, 23(2): 213-214 Winnicott, DW 1951, ‘Transitional Objects and Transitional Phenomena’, in Winnicott, D W 1971, Playing and Reality, New York: Basic Books (1-25) Robin Bowles is a psychotherapist and clinical social worker who has been working at the Service for the Treatment and Rehabilitation of Torture and Trauma Survivors (STARTTS) for over twenty-four years. She currently works part-time as a psychotherapist and clinical consultant and has a part-time, private psychotherapy practice in Lindfield. A profound experience for Robin was undertaking the Post Graduate Training Program in Psychoanalytic Psychotherapy with the NSW Institute of Psychoanalytic Psychotherapy (NSWIPP). Robin believes it is important to stay open to different perspectives; she has trained in a number of modalities, particularly various trauma interventions and has a list of papers and publications to her name. Robin is particularly interested in learning more about the relationships between culture, trauma, psychoanalysis and politics in psychotherapy and about working with interpreters and bicultural colleagues at STARTTS.

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Features (continued) (continued from Page 16)

Table One: Ethical breaches involving dual and multiple roles reported to PACFA and member associations (MAs)

Issue Category

No. of Complaints to PACFA

No. of Complaints to MAs

Total

Breach of confidentiality

1 1.6%

6 9.8%

7 11.4%

Sexual misconduct

0 0%

5 8.2%

5 8.2%

Dual and multiple roles

4 6.6%

7 11.4%

11 18%

Discrimination

1 1.6%

2 3.3%

3 4.9%

Practising under the influence of drugs and/or alcohol

0 0%

0 0%

0 0%

Other misconduct

5 8.2%

19 31.1%

24 39.3%

Unsatisfactory service

1 1.6%

2 3.3%

3 4.9%

Complaint processes

1 1.6%

0 0%

1 1.6%

Fees/costs

0 0%

2 3.3%

2 3.3%

MA functions/activities

3 4.9%

2 3.3%

5 8.2%

Total

16

45

61

reveal areas of counselling and psychotherapy that have not developed ethical literacy at the same pace as other areas of practice and that codes of ethics do have an effect in reducing unethical practice. Complaints About Dual and Multiple Roles The above table demonstrates the number of complaints made to PACFA and member associations by issue category between 2006 and 2011. This table (PACFA 2011) demonstrates that dual and multiple roles comprise 18% (n = 11) of all ethical complaints made to PACFA and its member associations— nearly one fifth of total complaints—which is cause for concern. Counselling and psychotherapy are self-regulating professions, which include practitioners who have never formally been trained in ethics and who are not required to participate in professional development on ethics. Many practitioners work in very autonomous conditions, and their clients are, therefore, more vulnerable to exploitation and ethical breaches. At times, tension exists between the need to be human with clients and the need to maintain good boundaries that protect clients from exploitation. Counsellors and psychotherapists have a duty to manage the complexity of human relationships in a responsible way. It is important that practitioners abide by their professional codes of ethics to uphold the good standing 32

of the profession, protect vulnerable clients, and maintain their own integrity. Conclusion Risk of harm to clients from dual and multiple relationships can be reduced by ensuring practitioners undergo adequate training in ethical practice, maintain membership of a professional association, participate in regular supervision and professional development that explores ethical practice, and negotiate transparently with clients about dual and multiple relationships (Lewis 2001). Professional bodies such as CAPA NSW and PACFA are effective in ameliorating risks to the public through professional socialisation in ethical behaviour and the provision of continuing professional development. Their codes of ethics, however, should more specifically address differences between sexual and nonsexual forms of dual and multiple roles. Examples of ethical decision-making models that can be used to assess the risks and benefits of entering into non-sexual dual and multiple roles, such as Anderson and Kitchener’s (1998) model for post-therapy relationships, should be provided as resources for practitioners. References Anderson, SK and Kitchener, KS 1998, ‘Non Sexual Post Therapy Relationships: A Conceptual Model to Assess Ethical Risks’, Professional Psychology: Research and Practice, 29(1): 91-99 Borys, DS and Pope, KS 1989, ‘Dual Relationships Between Therapist and Client:

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A National Study of Psychologists, Psychiatrists, and Social Workers’, Professional Psychology: Research and Practice, 20(5): 283-293 Counsellors and Psychotherapists Association of New South Wales, Inc. 2002, Code of Ethics and Good Practice, Sydney: CAPA NSW viewed at http://www.capa.asn. au/files/CAPAGoodPractice.pdf on 23 January 2013 Day, SX 2004, Theory and Design in Counseling and Psychotherapy, Boston, MA: Lahaska Press Gabriel, L 2005, Speaking the Unspeakable: The Ethics of Dual Relationships in Counselling and Psychotherapy, Hove, UK: Routledge Galletly, CA 2004, ‘Crossing Professional Boundaries in Medicine: The Slippery Slope to Patient Sexual Exploitation’, Medical Journal of Australia, 181(7): 380-383

Psychotherapy and Counselling Federation of Australia 2012, Code of Ethics: The Ethical Framework for Best Practice in Counselling and Psychotherapy, Fitzroy North, Victoria: PACFA, viewed at http://www.pacfa.org.au/sitebuilder/aboutus/ knowledge/asset/files/4/2012pacfacodeofethics.pdf on 21 January 2013 Psychotherapy and Counselling Federation of Australia 2011, Submission to the Australian Options for the Regulation of Unregistered Health Practitioners to the Health Ministers Advisory Council, Fitzroy North, Victoria: PACFA, viewed at http://www.pacfa.org.au/sb/modules/news/attachments/251/PACFA_Response_ Options_for_Regulation_of_Unregistered_Health_Practitioners.pdf on 2 February 2013

Herlihy, B and Corey, G 2006, Boundary Issues in Counselling: Multiple Roles and Responsibilities (2nd edn), Alexandria, VA: American Counseling Association Kitchener, KS and Harding, SS 1990, ‘Dual Role Relationships’, in B Herlihy and L Golden (Eds.) Ethical Standards Casebook (4th edn), (145-148) Kitson, C and Sperlinger, D 2007, ‘Dual Relationships Between Clinical Psychologists and their Clients: A Survey of UK Clinical Psychologists’ Attitudes’, Psychology and Psychotherapy: Theory, Research and Practice, 80: 279-295 Lamb, DH, Catanzaro, SJ and Annorah, SM 2004, ‘A Preliminary Look at How Psychologists Identify, Evaluate, and Proceed When Faced with Possible Multiple Relationship Dilemmas’, Professional Psychology: Research and Practice, 35(3): 248-254 Lewis, I 2001, ‘Social Workers’ Strategies for Living and Working in Small Communities’, Rural Social Workers Action Group Conference Proceedings, Beechworth, VIC: RSWAG Norris, DMH, Gutheil, TG and H Strasburger, LH 2003, ‘This Couldn’t Happen to Me: Boundary Problems and Sexual Misconduct in the Psychotherapy Relationship’, Psychiatric Services, 54(4): 517‐522 Pope, KS and Keith-Speigel, P 2008, ‘A Practical Approach to Boundaries in Psychotherapy: Making Decisions, Bypassing Blunders and Mending Fences’, Journal of Clinical Psychology: In Session, 64(5): 638-652 Procci, WR 2007 ‘Patient-Therapist Boundary Issues: An Integrative Review of Theory and Research’, Focus, 5: 407-411

May 2013

Ione Lewis is the Head of the School of Counselling at the Australian College of Applied Psychology and the President of the Psychotherapy and Counselling Federation of Australia (PACFA). As an academic, Ione has been involved in undergraduate and postgraduate counselling and psychotherapy education and training, and supervision of higher degree research students for eighteen years. An active researcher in quality in higher education, violence against women and links to HIV transmission, gender, evaluation of women’s health services, supervision, and consumer participation in research, she has conducted and published research on violence against women and HIV in Papua New Guinea, and on men’s experience and use of violence. Ione contributed to counselling training for HIV counsellors and trainers from 2004 to 2010 in PNG, facilitated the development of the HIV Counsellors’ Code of Ethics and developed the Gender Relations Training Manual in partnership with the National HIV and AIDS Training Unit (NHATU) in 2010. She completed research for the United Nations Development Project in Papua New Guinea on organizational readiness to implement gender-based violence and HIV programs in January 2013. As President of PACFA she has made numerous submissions on mental health to the Australian Government and the Mental Health Recovery Framework. In 2010, she appeared as an expert witness before the Senate Inquiry into Suicide in Australia.

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Modality Profile (continued) (continued from Page 5) Elias, J 2009, ‘What Is Hypnosis?’, Journal of Experiential Trance, 1(1): 66-73 Elkins, GR and Hammond, DC 1998, ‘Standards of Training in Clinical Hypnosis: Preparing Professionals for the 21st Century’, American Journal of Clinical Hypnosis, 41(1): 55-64 Evans, B and Coman, G 2003, ‘Hypnosis with Treatment for the Anxiety Disorders’, Australian Journal of Clinical and Experimental Hypnosis, 31(1): 1-31 Farrell-Carnahan, L, Ritterband, LM, Bailey, ET, Thorndike, FP, Lord, HR and Baum, LD 2010, ‘Feasibility and Preliminary Efficacy of a Self-Hypnosis Intervention Available on the Web for Cancer Survivors with Insomnia’, E-Journal of Applied Psychology, 6(2): 10-23 Flammer, E and Alladin, A 2007, ‘The Efficacy of Hypnotherapy in the Treatment of Psychosomatic Disorders: Meta-analytical Evidence’, International Journal of Clinical and Experimental Hypnosis, 55(3): 251-274 Gonsalkorale, WM 2006, ‘Gut-Directed Hypnotherapy: The Manchester Approach for Treatment of Irritable Bowel Syndrome’, International Journal of Clinical and Experimental Hypnosis, 54(1): 27-50 Green, JP, Barabasz, AF, Barrett, D and Montgomery, GH 2005, ‘Forging Ahead: The 2003 APA Division 30 Definition of Hypnosis’, International Journal of Clinical and Experimental Hypnosis, 53(3): 259-264 Hammond, DC 2010, ‘Hypnosis in the Treatment of Anxiety- and Stress-Related Disorders’, Expert Review of Neurotherapeutics, 10(2): 263-273 Heap, M 2005, ‘Defining Hypnosis: The UK Experience’, American Society of Clinical Hypnosis, 48(2/3): 1-7 Heap, M, Aravind, KK and Hartland, J 2002, Hartland’s Medical and Dental Hypnosis (4th edn), London: Elsevier Health Sciences Holdevici, I and Crăciun, B 2012, ‘The Use of Ericksonian Hypnosis in Somatic Disorders’, Procedia - Social and Behavioral Sciences, 33(0): 75-79 Janke, FH and Hood, SM 2010 ‘Hypnotherapy: An Effective Tool for the Modern Medicine Cabinet’, Family Health, 26(3): 4 Jensen, M and Patterson, DR 2006, ‘Hypnotic Treatment of Chronic Pain’, Journal of Behavioral Medicine, 29(1) Jensen, MP 2009, ‘Hypnosis for Chronic Pain Management: A New Hope’, Pain, 146(3): 235-237 Kraft, T and Kraft, D 2007, ‘The Place of Hypnosis in Psychiatry, Part 2: Its Application to the Treatment of Sexual Disorders’, Australian Journal of Clinical and Experimental Hypnosis, 35(1): 1-18

Liossi, C, Santarcangelo, ELand Jensen, MP 2009, ‘Bursting the Hypnotic Bubble: Does Hypnotic Analgesia Work and If Yes How?’, Contemporary Hypnosis, 26(1): 1-3 Parliament of South Australia 2009a, A Review of the Department of Health’s Report into Hypnosis, viewed at http://www.parliament.sa.gov.au/NR/rdonlyres/77C502EC-F1C3-40CA-9CE7-E3466A0 91ABA/13770/29thReportReviewofDeptofHealthReportintoHypnsosi.pdf on 27 January 2013 Parliament of South Australia 2009b, A Review of the Department of Health’s Report into Hypnosis: Definition of Hypnosis, viewed at http://www.parliament.sa.gov.au/NR/ rdonlyres/77C502EC-F1C3-40CA-9CE7-E3466A091ABA/13770/29thReportRevie wofDeptofHealthReportintoHypnsosi.pdf on 27 January 2013 Patterson, DR and Jensen, MP 2003, ‘Hypnosis and Clinical Pain’, Psychological Bulletin, 129(4): 495-521 Pfitzer, BE 2008, A Step Towards a Broader Understanding of Complex Traumatization in Victims of Crime: Psychological and Physical Health Impacts and Implications for Psychological Interventions and Treatment Evaluation, PhD, Adelaide: University of Adelaide. Richardson, J, Smith, JE, McCall, G, Richardson, A, Pilkington, K and Kirsch, I 2007, ‘Hypnosis for Nausea and Vomiting in Cancer Chemotherapy: A Systematic Review of the Research Evidence’, [Meta-Analysis Review], European Journal of Cancer Care, 16(5): 402-412 Sapp, M, Obiakor, FE, Scholze, S and Gregas, AJ 2007, ‘Confidence Intervals and Hypnosis in the Treatment of Obesity’, Australian Journal of Clinical Hypnotherapy and Hypnosis, 28(2): 25-33 Shih, M, Yang, YH and Koo, M 2009, ‘A Meta-Analysis of Hypnosis in The Treatment of Depressive Symptoms: A Brief Communication’, International Journal of Clinical and Experimental Hypnosis, 57(4): 431-442 Spiegel, H and Greenleaf, M 2005, ‘Commentary: Defining Hypnosis’, American Society of Clinical Hypnosis, 48(2/3): 1-8 Stoelb, BL, Molton, IR, Jensen, MP and Patterson, DR 2009, ‘The eEfficacy of Hypnotic Analgesia in Adults: A Review of the Literature, Contemporary Hypnosis, 26(1): 24-39 Tomic, N 2011, ‘Treating Nocturnal Enuresis with Direct and Indirect Suggestions By Using Hypnosis’, Australian Journal of Clinical Hypnotherapy and Hypnosis, 32(1): 26-39 Torem, MS 2007, ‘Mind-Body Hypnotic Imagery in The Treatment of Auto-Immune Disorders’, American Journal of Clinical Hypnosis, 50(2): 157-170 Whorwell, P 2008, ‘Hypnosis for IBS’, Video MD for Peter Whorwell, MD viewed at http://www.videomd.com/Hypnosis-for-IBS-fv-2430.aspx on 29 December 2012

Kraft, T and Kraft, D 2009, ‘The Place of Hypnosis in Psychiatry, Part 3: The Application to The Treatment of Eating Disorders’, Australian Journal of Clinical and Experimental Hypnosis, 37(1): 1-20 Landolt, AS and Milling, LS 2011, ‘The Efficacy of Hypnosis As an Intervention for Labor and Delivery Pain: A Comprehensive Methodological Review’, Clinical Psychology Review, 31(6): 1022-1031 Lindfors, P, Unge, P, Nyhlin, H, Ljótsson, B, Björnsson, ES, Abrahamsson, H and Simrén, M 2012, ‘Long-Term Effects of Hypnotherapy in Patients with Refractory Irritable Bowel Syndrome’, Scandinavian Journal of Gastroenterology, 47(4): 414-421

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Leon Cowen Clinical Hypnotherapist Executive Director, Academy of Applied Hypnosis

CQ: The CAPA Quarterly


Introduction to Sandplay Therapy & Symbol Work with Children, Adolescents & Adults 3 days - May 9 - 11 in SYDNEY Trainer: Lynette Fox

Training in creative arts therapies around Australia and S.E. Asia since 1987

Practical experience, history and theory, Overview of the Sandplay literature, Role-play techniques to support integration, Input on Sandplay equipment, Contraindications for use, Illustrated case studies

Certiicate in Expressive Therapies with Children & Adolescents Starts August 2013 in Northern NSW Trainer: Monique Rutherford

Somatic Focussed, Creative Counselling for Emotional Integration

For details please visit:

www.expressivetherapies.com.au

Contact the director Mark Pearson at: 0419 492 713 or info@expressivetherapies.com.au

Code of Conduct for Unregistered Health Practitioners As counsellors and psychotherapists, we are legally required to display two documents in our practice(s): • t he NSW Code of Conduct for Unregistered Health Practitioners • information on how clients can make formal complaints to the Health Care Complaints Commission. Both are available online in the members area of the CAPA NSW website: www.capa.asn.au The Code of Conduct is also available in several community languages on the Health Care Complaints Commission website: www.hccc.nsw.gov.au These legal requirements are set out in ‘Public Health (General) Amendment Regulation 2008’ under the NSW Public Health Act (1991), and came into effect on 01/08/2008.

Ethics Checkout the CAPA NSW website for information on: 1. Ethics and Counselling 2. Problem Solving Steps 3. Client Confidentiality and Privacy and Relevant NSW and Commonwealth Legislation 4. Duty of Care 5. Workplace Bullying and Violence 6. Mandatory Reporting 7. Keeping Track of Paperwork 8. Information for Counsellors who have been served with Subpoenas 9. Complaints Form for Submission of Complaints and Grievances by a CAPA Member

Just login to the members area of www.capa.asn.au and click on the “Ethics” button on the left. May 2013

35


Noticeboard

Calls for Contributions November 2013 – The Profession

Every therapist and counsellor faces common challenges and issues in their practice that are specific to the profession. In this issue we invite you to discuss the needs, challenges and issues therapists and counsellors face as normal hazards of the profession. How do we prevent burnout, find the time and discipline to ensure adequate supervision, maintain a steady client base while achieving a worklife balance, stay current and ensure that you are ‘good enough’? The November issue of CQ: The CAPA Quarterly offers a forum for exploration of these and other questions about the personal side of being a therapist or counsellor. Step forward and have your say. Peer-reviewed papers due by: 1 May

Non-peer-reviewed due by: 1 August

February 2014 – Open Forum Do you have an insight to share about the practice of therapy, but haven’t been able to align it with any of the announced themes for CQ: The CAPA Quarterly? Now we have an Open Forum each February so that articles on any aspect of therapeutic practice can be welcomed. Share your knowledge with your peers and open up discussion on topics of importance to you. Peer-reviewed papers due by: 1 August

Non-peer-reviewed due by: 1 November

May 2014 – Mindfulness and Spirituality Mindfulness is often thought of in relation to spirituality, given its roots in esoteric traditions; however, therapeutic models are increasingly incorporating a range of approaches focussing on mindfulness and acceptance due to a growing body of research suggesting that mindfulness-based therapies may be effective in treating a variety of disorders including stress, chronic pain, depression and anxiety. In this issue, we will explore the historical and philosophical roots of mindfulness therapies, theoretical underpinnings, specific applications, and mindfulness treatment strategies—and how they might also relate to spirituality. We invite you to share in this exciting discussion by contributing to the May issue of CQ. Peer reviewed papers due by: 1 November

Non-peer-reviewed due by: 1 February

August 2014 – Cross-Cultural Issues in Counselling In this issue of CQ, we critically reflect upon the major concerns and sensitivities underlying issues of race and culture, and the impact they can have on relationships in counselling and psychotherapy. How can the cultural backgrounds of both the counsellor and client affect the therapeutic process? How do we become more culturally aware? What are the issues and what steps should we be taking to better prepare ourselves to meet the culturally diverse challenges faced in today’s therapy rooms? Share your professional insights and experiences surrounding the development of culturally sensitive counselling and cross-cultural awareness in the August 2014 issue of CQ. Peer reviewed papers due by: 1 April

Non-peer-reviewed due by: 1 May

Deadlines are for articles that have been accepted, not for new ideas. Please send expressions of interest as soon as possible, to maximise your chance of inclusion. For Contributor Guidelines contact editor@capa.asn.au

Advertising rates for 2013 Ad size Four Colour (available only full page) Inside front or inside back cover

Rate

Dimensions (height x width)

$550

250–280mm x 180 mm

Black and White Full page Half-page horizontal Quarter-page horizontal Column-wide vertical (per column centimetre) Spot colour additional A4 inserts – supplied by advertiser different event on reverse side

$400 $300 $155 $10 $50 $320 $220

250–280mm x 180 mm 110mm x 170mm 60mm x 170mm up to 250mm x 85mm CAPA blue (PMS 315) only A4 or smaller/flat or folded

Book your ad for a year (4 issues) and receive a 12% discount Booking deadlines February issue 1 December May issue 1 March August issue 1 June November issue 1 September Artwork/copy deadlines February issue 1 January May issue 1 April August issue 1 July November issue 1 October

For advertising specifications and bookings, contact our Advertising Coordinator at: advertising@capa.asn.au or 02 9235 1500

36

CQ: The CAPA Quarterly


Classifieds

A free service for CAPA NSW members, contact advertising@capa.asn.au

Rooms for R ent

Supervision

Woollahra

Supervision – Phone or Skype

Looking for like-minded therapists to share consulting rooms in Queen Street, Woollahra. Either half or full days available $60 and $110 respectively GST inclusive with nil other costs. The room is sun filled, furnished in earth tones with beautiful furniture and paintings with a warm inviting feel. The room is large and expansive easily big enough to do family or group work. The kitchen and bathroom are white, clean and tasteful, and the premises are serviced every two weeks. For further information call Slade Hugall on 0413 773 939 or email sladehugall@gmail.com.

CBD

Fully furnished and appointed quiet counselling room in Sydney CBD, heritage building, near MLC Building. Whole or half days available. Call or SMS 0425 281 251.

Crows Nest

Well presented consulting room in brand new clinic located in the heart of Crows Nest. Excellent parking and public transport. Sessional and permanent rates. Also available: group space for up to 14 people. Fair rates. Please contact Sabina on 0419 980 923 or sabina@wellforlife.net.au

Double Bay

Warm, bright, air-conditioned (if you are so inclined), spacious Counselling room available. Excellent Parking. Public transport to the door. Available Thursday, Friday, Saturday. Room is furnished. Contact Leone Ziade on 0418482494 or at ziade@ozemail.com.au

Edgecliff

Delightfully appointed room, Edgecliff. On station. Free Parking. Available 2 days per week, $160. Days negotiable. Susan Hamilton 0424 426 110

Glebe

Warm and inviting, well presented consulting rooms available for reasonable rates on a permanent, weekly or part-time basis. Large, pleasant waiting room, good facilities and great location on Glebe Point Road in the midst of Glebe village. Public transport at the door and ample off-street parking. Contact Lee on 0407 063 300

Lane Cove

Room available to rent on a daily basis in a well established mutli-modality Health Care Clinic. Ideal for a Professional Health Care Provider. Great working environment with unrestricted and ample parking. Flexible lease agreement. Please contact Catherine on 0416 178 517 or email to catherine@lrcc.com.au.

Counsellor, supervisor, group facilitator, with 16 years’ experience. CMCAPA, RMPACFA, ARCAP Registered (Clinical), PACFA Accredited Supervisor, Cancer Counselling Professional. Speciality areas include anxiety, depression, grief/loss, death/dying, samesex, carers, young carers, pain management, adults surviving child abuse, relationships, spirituality, group facilitation. Contact Erica Pitman, Bathurst, NSW. 6332 9498 or email ericap@ix.net.au

Supervision – Burwood & Dulwich Hill

Individual and group supervision for counsellors, group leaders and those supporting people with a disability or Asperger’s syndrome. Twenty years’ experience working in disability field; seven years in relationships and sexuality counselling and education including working with victims and perpetrators of sexual harassment and assault. CMCAPA . Burwood and Newtown. Contact Liz Dore on 0416 122 634 or lizdore@bigpond.com, www.relationshipsandprivatestuff.com

Supervision – Caringbah

Experienced supervisor. Registered member PACFA . Accredited supervisor with Australian Association of Relationship Counsellors (AARC). Available for psychotherapists, counsellors and group leaders. Caringbah. Contact Jan Wernej on 0411 083 694 or email janwernej@optusnet.com.au

Supervision for Working with Adolescents and Parents – Coogee and telephone

Individual and group supervision for counsellors, educators, allied health workers, group leaders and parents. Fifteen years in private practice as psychotherapist/counsellor; eighteen years working with pre-teen/teen girls and their parents, addressing developmental issues and popular culture/media’s impact on girls’ body image. Registered clinical member PACFA. Contact ShushannMovsessian on (02) 96654606. Web: www.shushann.com and www.soulfulwoman.com.au

Supervision – Edgecliff

Warm, rigorous supervision by experienced therapist. PACFA Reg Member. In private practice for 16 years. Former President, CAPA , committee member PACFA , trainer ACAP (6 yrs). At station. Free parking. Susan Hamilton 0424 426 110

Supervision – Faulconbridge & Newtown Available for those doing individual, couples and group work. Over twenty years of clinical experience. Accredited in Professional Supervision (CanberraUni), Registered member PACFA. Contact Vivian Baruch on (02) 9516 4399 or email via www.vivianbaruch.com

Supervision – Glebe

Experienced supervisor for counsellors and group leaders. Qualified trainer and supervisor, CMCAPA , Registered member PACFA . Call Jan Grant on (02) 99385860 or email jangrant@optusnet.com.au

Supervision – Glebe

20 yrs Clinical Experience. Supervisor of Individuals/Groups.Registered Clinical Member PACFA . Contact Armande van Stom BA, MASocPh 9660 2027 or 0430092027 www.armandevanstom.com

Supervision – Lilyfield

Supervision for individual, couple and group work, including counselling, psychotherapy and coaching approaches. Flexibly designed to suit your needs. Over twenty years of clinical experience. Clinical Member CAPA/Reg. PACFA. Contact Gemma Summers on 0417 298 370 or email gemma@goodmind.com.au. Web: www.goodmind.com.au

Supervision, Counsellors/ Hypnotherapists – Northern Beaches

Just graduated and looking to go into private practice? Supervision and business coaching available to help you on your way. Also rooms for rent on sessional/permanent basis. Contact Lidy@northernbeachescounselling.com.au or phone (02) 9997 8518 or 0414 971 871.

Counselling, Psychotherapy and Supervision – Mosman

For personal and professional development, self-care and mentoring. Thirteen years’ experience in private practice. PACFA Reg.20566. Location: Mosman. Contact Christine Bennett on 0418 226 961 or email christine@caring4couples.com.au Web: www.cb-counselling.com.au and www.caring4couples.com.au

Supervision – North Sydney

NSW Government accredited clinical supervisor. CMCAPA . PhD. Specialist

in trauma counselling and addictions. Experienced supervisor of most modalities. Centrally located near North Sydney Station. Also servicing Katoomba. Flexible rates. Concessions for students. Contact Dr Malcolm on (02) 9929 8643 or email mykarunamail@gmail.com

Supervision – Penrith & All Areas Skype

Experienced supervisor for counsellors, group workers, managers. PACFA Reg. Skype supervision is a great way for country counsellors to get high quality supervision. Contact Jewel Jones on 0432 275 468 or email jeweljones@iprimus.com.au Web: www.jewel-jones.com.au


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POSTAGE PAID AUSTRALIA

Journal of the Counsellors and Psychotherapists Association of NSW Inc ABN 50 035 123 804 If undeliverable, please return to: CAPA NSW Suite 134 / Level 13 183 Macquarie Street Sydney NSW 2000 Phone: +61 2 9235 1500 Email: office@capa.asn.au Web: www.capa.asn.au Changed your address? Please notify CAPA NSW

Looking for a Conference? To include your free conference listing here, contact editor@capa.asn.au

Looking for a conference? Some prominent psychology conferences in Australia and elsewhere this year are listed below. For a more comprehensive list of psychology conferences worldwide, visit http://www.conferencealerts.com/psychology.htm

11 May 2013 Hindmarsh

Counselling Association of South Australia Annual Conference

www.casa.asn.au/calendar.asp

14–17 May 2013 Hobart

Alzheimer’s Australia Fifteenth National Conference

http://www.alzheimers2013.com/

15–16 May Shenzhen, China

2013 International Conference on Art Therapy

http://www.anzata.org/conferences/

18 May 2013 Melbourne

2013 Freud Congress

http://www.freudconference.com

26–30 May Sydney

RANZCP 2013 Conference

www.ranzcp2013.com/

1–2 June 2013 Sydney

Australian Yoga Therapy Conference (AYTC) 2013

http://www.enlightenedevents.com.au/events/ australianyogatherapyconference2013

4–6 June 2013 Sydney

Advances in Clinical Supervision: Innovation & Practice International Conference

http://www.nswiop.nsw.edu.au/conference/

7–9 June 2013 Barcelona, Spain

Society for the Exploration of Pschotherapy Intergration (SEPI) XXIXth Annual Meeting

http://www.sepiweb.com/displaycommon.cfm?an=3

5–7 July 2013 Moscow

The First United Eurasian Congress for Psychotherapy

http://www.eurasian-psychotherapy.com/main-en.html

8–12 July 2013 Sydney

ACBS World Conference XI

http://anzact.com/

10–13 July 2013 Brisbane

Society for Psychotherapy Research (SPR) 44th International Annual Meeting

http://www.psychotherapyresearch.org/calendar.cfm

14 July 2013 Brisbane

4th Annual Conference for the Australian Clinical Psychology Association

http://www.acpa.org.au/news/

22–25 July 2013 Lima, Peru

7th World Congress of Behavioural and Cognitive Therapies

http://www.aacbt.org/viewStory/ INTERNATIONAL+EVENTS

5–6 August 2013 Gold Coast

14th International Mental Health Conference

http://anzmh.asn.au/conference/

15–18 August 2013 Sarawak, Malaysia

3rd Asia Pacific Rim International Counselling & Psychotherapy Conference

http://www.counselingmalaysia.com/

22–25 August 2013 Warsaw, Poland

ISPS Warsaw 2013: 18th International Conference

http://www.isps2013warsaw.pl

23–24 August 2013 Melbourne

11th Annual Conference of the Australia & New Zealand Academy for Eating Disorders

http://conference.anzaed.org.au/

24–25 August 2013 Brisbane

2013 AABCAP Annual Conference

http://www.buddhismandpsychotherapy.org/ events/annual-conference

24–27 October 2013 Adelaide

Australian Association for Cognitive and Behaviour Therapy 36th National Conference

http://www.aacbt.org/viewstory/NATIONCONFERENCE

CQ 2013-2 Ethics  
CQ 2013-2 Ethics  

Clinical Hypnotherapy ~ Leon Cowen Ethics: A Phenomenological Enquiry ~ Elizabeth Riley and Elizabeth Day Evolving Thoughts on Ethical Matur...

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