INTRODUCTION

Chapter 1

Individual TherapySSIT3112015

WHAT IS PSYCHOTHERAPY?

Two perspectives:

Profession-centred vs. user-centred.

Profession-centred definition:

Professional relationship between trained therapist and client.

Person-to-person – may involve more people.

Application of one or more psychological theories and a recognised set of communication skills, modified by experience, intuition and other interpersonal factors, to a client’s personal concerns, problems or aspirations.

Not advice giving – facilitation.

Brief or long duration.

More principled and confidential than friendship.

Always at the request of the client – no one can be ‘sent’ for psychotherapy.

Help client see difficulty from a different perspective.

Way of enabling choice / change / reducing confusion.

Non-judgemental.

No exploitation.

Client can talk openly and freely.

Therapist offers opportunity for client to express bottled up / difficult feelings without being burdened by them.

Acceptance and respect of client leads to feelings of trust developing.

Client-centred definition:

“Counselling is a purposeful, private conversation

arising from the intention of one person to reflect on

and resolve a problem in living, and the willingness

of another person to assist in that endeavour”

(McCleod, 2009, p. 5 – 6).

Basic assumptions of client-centred definition:

Client must want the psychotherapy – must invite the therapist to enter into a particular kind of relationship – client is active participant and not a passive recipient.

Client seeks therapy because of a “problem in living” –

something they have not been able to resolve through everyday resources. Client cannot get on with his/her everyday life.

Based on conversation – the “talking cure” – things need to be “talked through” – can generate new possibilities through dialogue.

Therapeutic space is characterised by:

Encouragement and permission to speak: in their own way and time. Express thoughts, feelings and experiences that were previously silenced.

Respect for difference: therapist does not judge based on own beliefs/prejudices. Assists client to solve difficulties within their personal values and beliefs.

Confidentiality: therapist refrains from passing on information they have gathered from the client to people in the client’s world.

Set of core values: honesty, care, integrity, belief in value of individual, commitment to dialogue, reflexivity, interdependence of persons.

Establishment of a particular relationship – secure in order to be able to express issues that are troubling and painful.

Seeking psychotherapy is not an indicator of personal weakness or pathology – the strengths and resources of the client are channelled in order to resolve the difficulties presented by the client.

Relies on ordinary human qualities: capacity to listen; sensitivity to experience of others; personal integrity; resourcefulness in solving difficulties of everyday life.

Potential outcomes of psychotherapy:

Resolution of problem in living – achieving understanding / perspective on problem; acceptance of personal problem / dilemma and taking action to change situation in which problem arose.

Learning – client may acquire new understandings, skills and strategies that make them better able to handle similar problems in future.

Social inclusion: client can be stimulated to contribute to the well-being of others and society.

Psychotherapy is always embedded in a social and cultural context:

“Client” and “therapist” are socially defined roles.

The practice of psychotherapy needs to take into account the social, cultural, historical and economical context of the client.

COUNSELLING VERSUS PSYCHOTHERAPY?

Considerable debate - two contrasting positions:

1. Clear distinction / fundamental difference:

Although some overlap between theories and methods employed by counsellors versus psychotherapists, there are fundamental differences.

Psychotherapy represents a deeper level of work, over a longer period of time, with more disturbed clients.

2. Essentially the same thing:

Required to use different titles due to the environment in which the service is offered

Title “psychotherapy” is used in traditional medical settings, such as a medical practice or hospital.

Title “counselling” is used in other settings, such as an educational institution (student counselling services).

Quite distinct vs. along a continuum?

Crisis intervention

Brief-term Psychotherapy

Cognitive Behavioural Therapy

Psychodynamic Therapy

Psychoanalysis 

Problem Solving Cognitive Insight

Similarities: Counselling and Psychotherapy

Provides the person with a confidential space in which to explore personal difficulties.

Effectiveness of the intervention relies to a great extent on the quality of the client-therapist relationship.

Self-awareness and personal therapy are considered important elements of training and ongoing development.

PSYCHOTHERAPY COUNSELLING

Professional – psychologists, psychiatrists, social workers.

Specialist professional workers (social worker) and paraprofessionals (bereavement counsellor, psychiatric nurse), volunteers, other occupational roles with counselling embedded, e.g. Priest, Teacher, HR Practitioner.

Public: inaccessible, expensive, middle class

Public: accessible, free, working class

Government: prominent role in mental health services

Government: invisible

Client: individual with problems in psychological functioning

Client: person in a social context

Training and practice focuses on delivering interventions

Not only delivering interventions, but also working with embedded colleagues and promoting self-help

PSYCHOTHERAPY COUNSELLING

Agencies/clinics separate from community

Agencies/clinics part of community – student counselling service

Treatment: application of specific protocol or therapy model

Treatment: client and counsellor work collaboratively, using methods that may stretch beyond traditional models

Treatment has theory derived brand name: Cognitive Behavioural Therapy, Psychoanalytic Psychotherapy

Treatment has context derived name: workplace counselling, student counselling, HIV counselling, etc.

Degree in Psychology is key entrance qualification

Counsellors come from wide variety of backgrounds. Entrance qualifications: maturity, life experience, age.

Focus is on pathology of client Focus is on strengths and resources of client

ETHICS IN PSYCHOTHERAPY

One of the fundamental principles of most approaches to psychotherapy is that the therapist needs to adopt an accepting or non-judgemental stance in relation to the client.

Most therapists would say that they are attempting to help the client arrive at solutions which are right for them. However, therapy is also a process of influence.

The dilemma for therapists is to allow themselves to be powerful and influential without imposing their own moral values and choices.

Therefore, a good therapist needs to have an informed awareness of the different ways in which moral and ethical issues may arise in their work.

Professional Ethical Codes / Guidelines

Psychotherapy and counselling are generally well regulated in most countries.

In South Africa, psychologists need to be registered with the Health Professions Council of South Africa (HPCSA).

Part of the work of these statutory bodies is to ensure ethical standards of practice.

They partly undertake this through the publishing of ethical guidelines for practice, together with procedures for dealing with complaints about unethical behaviour.

Clients / patients are also protected by the Mental Health Care Act and the Consumer Protection Act.

Clients need to be informed what ethical guidelines you are adhering to and how they can go about laying a complaint against you as a practitioner.

One of the other ways in which the HPCSA ensures ethical practice is by expecting therapists to gather CPD points every year. Some of these points have to specifically be gathered in the area of ethics.

General Ethical Principles:

Sometimes therapists need to refer to general philosophical or ethical principles in assisting them to make moral decisions.

Five moral principles that run through most theories regarding ethics:

Autonomy Non-maleficence Beneficence Justice Fidelity

Autonomy:

People have the right to freedom of action and choice, provided the pursuit of these freedoms does not interfere with the freedom of others.

Therefore a client needs to make the choice to undergo a therapeutic process (informed consent).

What about children?

Non-maleficence:

Refers to the instruction to all healers / helpers that they must “above all do no harm”.

One way of ensuring this moral principle is upheld is through the thorough training of competent therapists and the ongoing development of therapists through further education and supervision.

Also they must only work with their scope of practice.

Need to weigh up the risk versus the possible therapeutic gain in deciding whether to implement a particular therapeutic technique or behaviour.

Beneficence:

Based on the utilitarian notion of “the greatest good for the greatest number”.

The promotion of human welfare is what is at stake in this principle.

“How will this technique benefit my client?”.

“Will it interfere in the life of others in my client’s life?”.

Justice:

Has to do with the fair distribution of resources and services based on the assumption that people are equal, unless there is some acceptable rationale for treating them differently.

Is it ethical to offer some client’s long-term psychotherapy in a government clinic when there is a long waiting list?”.

Fidelity:

Refers to the existence of loyalty, reliability, dependability and action in good faith.

Lying, deception and exploitation are all examples of primary breaches of fidelity.

The rule of confidentiality in psychotherapy forms part of and reflects the importance of fidelity.

ETHICAL ISSUES IN CLINICAL PRACTICE

Negotiating informed consent.

Dual relationships.

Sex with patients.

Touch.

Example: Touch

Some approaches strictly oppose any form of touch in therapy.

Underlying fear that touch will lead to sexual

gratification on the behalf of either or both parties.

Client may feel violated but accept touch against wishes (e.g. abused persons).

Some cultures have rules about being touched by stranger or opposite sex.

HOW EACH THEORY WILL BE PRESENTED

Background

Historical aspects

Life story of the person who developed theory

Basic philosophy

View of human nature

Human motivation

Primary motives of human behaviour

Central constructs

Building blocks of the theory

Inform the theory’s ideas about development, health and dysfunction.

Theory of the person and development of the individual

Developmental sequence

Health and dysfunction

How healthly functioning is conceptualised and what constitutes dysfunction

Nature of therapy

Includes: atmosphere of therapy, length, role of the therapist, etc.

Process of therapy

Any critical events, processes or stages

Therapeutic techniques

Specific techniques used in that approach

Evaluation of the theory

Qualitites of the theory: empirical support and testability

Research: outcome and explanatory power