Article by Anna Keyter
BY: Online Therapy
Anxiety / Depression / Post Traumatic Stress Disorder / PTSD / Trauma
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Article by Marvis Bih,
What is PTSD?
Post-Traumatic Stress Disorder refers to a severe anxiety disorder that a person develops after being exposed to one or more serious life situations that result in deep psychological trauma (Nicholls, et al., 2006). Persons suffering from PTSD may have difficulty engaging in interpersonal relationships, have flashbacks and experience paranoia. Anyone can develop PTSD and it can happen at any age.
What causes PTSD?
Some causes of PTSD include witnessing serious physical, sexual and emotional abuse or assault (Spitzer, 2009), major man-made or natural disasters, war, genocides, major accidents, sicknesses or pandemics such as COVID-19 (Frans 2005). Many studies have linked PTSD with other comorbid psychiatric disorders (Gershuny, 2002; NIMH, 2020). In addition, some biological factors such as genes may make some people more likely to develop PTSD (NIMH, 2020).
Age and the effects of PTSD
Children and teenagers are more vulnerable to trauma and have extreme reactions. Symptoms in children may include but not limited to; unusually clingy with a parent, unable to talk and wetting the bed. However, older children often display symptoms like those seen in adults such as destructive behaviour, being disrespectful and disruptive (National Institute of Mental Health, 2020).
When to seek help
When a child or an adult’s symptoms last for a few weeks and not getting better, it is advisable to seek for help. A mental health counsellor or a trained therapist can recognise and treat trauma in children and adults, by addressing the root cause of the child’s behaviour and promote healing (Child Welfare Information Gateway, 2014).
The traumatic effect of COVID-19
The COVID-19 pandemic has affected the world, leading to nations shutting down their economy and services and people were encouraged to work from home. This situation created anxiety and mental stress for many people. Therefore, in these emotionally draining times, mental health practitioners need to be flexible in their approach to therapy.
Benefits of Online Therapy
The flexibility of Online Therapy means that practitioner can change the way they deliver therapy. With the age of technological advancement, we can now offer and receive therapy from the comfort of our homes through online therapy. Online therapy is different from face to face therapy, but certainly no less effective. Online therapy takes place online by connecting through technology such as smartphone, iPad, laptop or a desktop.
Online therapy platforms
There are different types of interventions used to deliver online trauma therapy. Methods include virtual technology such as Skype counselling or Zoom, telephone counselling, chats or a combination of any of these. More on online therapy and finding a good online therapist coming up next week. Join us next week as we explore online therapy, a good online therapist and how to find an online therapist.
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Gershuny B S, Baer L, Jenike M A, Minichiello W E, Wilhelm S. (2002). Comorbid posttraumatic stress disorder: impact on treatment outcome for obsessive-compulsive disorder. Am J Psychiatry, 159(5): 852-854.
Spitzer C, Barnow S, Volzke H, John U, Freyberger H J, Grabe H J. (2009). Trauma, posttraumatic stress disorder, and physical illness: findings from the general population. Psychosom Med, 71(9): 1012-1017.
BY: Online Therapy
Anxiety / Decisional Fatigue / Depression / Fatigue counselling
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By Sara Taveira
The anxiety of making choices
Today I decided to talk about the paradox of choices. I went to lunch at a restaurant with so many options on the menu; it made me anxious. I share my experience with you, dissected it from a Clinical and Health Psychology perspective to help get to an understanding of how the thought of “the more options we have the better”, is a great fallacy!
The menu offered more than 20 options for main courses and I felt the anxiety running through my body. The sweet anxiety of choice! The first consequence of this was mind-boggling, being confused without being able to read the name of all the dishes. I don’t need to explain how this increased my indecision, right? The truth is that it was really difficult to make a choice, without even realizing it. In fact, when I reflect on what happened, I now realize that my choice, like all of our choices, adds to anxiety on an unconscious level. In particular, here I was thinking about what others would think of my choices and even more, I ended up basing my choice on what I saw others selected.
Finally, I became aware of my anxiety about making choices and wondered if I had chosen the best meal. With so many options, my expectations naturally increased. When the meal finally arrived it was good, but I was disappointed because “I expected more”. Ultimately, I started to think that I made a mistake and felt guilty for not enjoying the meal as much as I could. That, of course, made me even more anxious and frustrated with myself. Do you notice the endless loop? Now let’s translate my experience of eager gastronomic choice to Psychology.
How many choices do we make a day?
We make an average of 35000 choices per day, from deciding whether to take a step left or right, to the more complex professional decisions. The simpler choices come from a fast, automatic, and intuitive system in the brain instead of the complex choices, which arise from a slower, analytical and rational system that therefore expends a lot of brain energy.
The more choices we make in our day-to-day lives, the more tired our brain gets, especially if they are complex. And it is at this point that we feel daily wear and tear and may wonder if we are depressed or just fatigued. Don’t get confused. This lack of mental energy for making too many choices is called “decisional fatigue” which has the consequences of reducing our capacity for self-control, leads to inertia and automatic decisions accepted by the status quo. This explains why I froze and ended up ordering what others ordered.
This phenomenon also explains why we sometimes make so many “mistakes” later in the day. We may decide not to go to the gym because we are tired, we get home, lie on the couch, order fast food and we binge-watch our favourite series. Sound familiar? That is, the more decisions you make during the day, the more difficult it is to make good decisions at night, as your self-control diminishes, your brain becomes tired, just like our muscles after an hour of physical exercise.
How to prevent this decisional fatigue?
Basically, we have to work with these two systems that I explained and automate as many daily decisions as possible to save the most rational system for when it is necessary to avoid impulsive decisions and mistakes.
What do I want you to retain today? Choices imply risks, losses, and changes, and for that reason are unpredictable which undoubtedly goes hand in hand with anxiety. Leaving things to chance is intolerable and that is why we try our best to prevent the risk of this happening. But by stopping chance, we decrease our happiness because we do not allow ourselves the possibility of pleasant surprises. Even more serious, we are stuck with regret and dissatisfaction because it is impossible to arrive at the ideal choice which leads to feelings of guilt, inadequacy, and high self-criticism. Another way to increase anxiety. The choice is, then, the hesitation before the decision, which, when increased and diversified, can lead us to mental confusion, to feelings of constant doubt, which diminishes our self-confidence.
A Solution strategy
Why not try to understand your choices as clouds? For example, have you ever heard someone say that cloud format was good or bad? Never, right? So why don’t we also think that choices are just that, choices, possibilities and that they can’t be good or bad? If we take this stance, we cannot make catastrophic mistakes even when it seems that we did it when we chose A or B. The truth is that everything ends up being resolved in one way or another. Think back to a problem that seemed huge and impossible to solve at the time. The likelihood is that now you even smile when remembering how you exaggerated your fears and anxieties. Trust yourself, as there are many roads to the right path.
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BY: Online Therapy
Clinical Psychology / Depression / Online Depression Counselling / Online therapist / Online Therapy / Seasonal Depression
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Article by Sara Taveira
WINTER IS COMING
Experiencing the Winter Blues (Seasonal Depression)?
What is seasonal depression? We are all familiar with this heading tagline from a famous TV Series. However, the expression is also highly used these days because of the difficulties of “surviving” through the winter, the so-called, winter blues. On a daily basis, we can already notice the slight changes in mood in everyone’s faces, the sense that people are already building up their emotions around the fact that the cold, dark and rainy days are ahead of us.
Why do we feel seasonal depression?
Well, although science has not come up with a specific answer yet, it mentions several contributing factors contributing.
- Vitamin D: “you are my sunshine, my only sunshine”, indeed! This vitamin is very important to our energy levels and mood as it helps with cell growth, our immune system and many other things in our body. During the winter period, most of us wake up when there is no daylight, go to work, spend all day in the office and then, when it’s time to return home, the daylight is already gone. As a result, we do not have much of this vitamin in the winter when comparing to spring and summer time.
- Hibernation: this may sound strange but some research talks about a physical slow down process that all mammals go through, during winter. Humans are no exception, although in a lighter way. The problem with this is that we actually cannot hibernate and have to keep going with our busy lives.
- The relation between body hormones, light, and circadian rhythm: these three dances harmoniously. In detail, daylight differences regulate our internal biological clock through the release of hormones, such as melatonin. Therefore, at night, because daylight ends, our body starts producing this hormone which makes us feel sleepy, decreases our body temperature, and many other modifications to tell us “it is bedtime”. The opposite process occurs every morning. So, if you consider all this, you will find the answer to the common question “why am I still so sleepy and tired every morning?”. That is right, in winter when you wake up, there is no daylight, so melatonin is still running happily through your veins, so you feel very sleepy. The lack of light also decreases another hormone, which is extremely important for mood, appetite, sleep, social behaviour and even sexual appetite regulation – serotonin. So, it makes sense that you feel less happy during dark, cold and rainy days, as our natural mood stabilizer is much less produced by our brain.
What can we do beat Seasonal Depression?
Well, I guess just like olive oil, garlic and onions are the basis of any good recipe, so exercise, diet, and sleep are the basis not only for avoiding the winter blues but for good mental health. For this reason, eat smart by avoiding sugar, alcohol, and caffeine, which can deteriorate your mood, and nourish yourself with chocolate once in a while as it helps to boost your mood. Aim for 8 hours of sleep, and get moving by simply going outside and doing a 30 minutes’ walk. You will kill two birds with one stone: you will exercise and get some natural daylight. Other ideas that may help are expressing your emotions and being near your social support for those harder moments, turning on the radio or other music you like at home to glow the dark rainy days or learn a new skill/new project. If your wallet is “booming”, plan a trip to a sunny place.
What if the above ideas are not enough?
It might come as a surprise to you, but there is in fact a mental health disorder caused by the above alterations in our body, a seasonal depression. Some examples of symptoms are sadness and loneliness, social withdrawn, excessive tiredness, irritability, etc. These symptoms have to cause clinically significant distress and/or impairment in important areas of your overall functioning.
So please talk to us if you are worried you might be experiencing seasonal depression. We can assess if you are, and if so, help you to overcome them.
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BY: Online Therapy
Anxiety / Assessment / Counselling / Depression / Depression Anxiety Stress Scale (DASS) / Screening Tool / Skype Counsellor / Stress
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Skype counsellor discussing Depression Anxiety Stress Scale (DASS):
In this article, the Skype counsellor discussing Depression Anxiety Stress Scale (DASS) developed by Lovibond S.H. and Lovibond P.F. The Depression Anxiety Stress Scale (DASS) was developed to report on negative emotional states employing a bipolar scaling measure (four-point rating scale, 0-3). Previously referred to as the Self-Analysis Questionnaire (SAQ), DASS has two additions, DASS-21 and DASS-42. The DASS-42 (42 items) is recommended for clinical use and the shortened version DASS-21 (21 items) for research.
The DASS is a screening tool, not meant for diagnosis of mental disorders. In this essay, the DASS-21 will be discussed in terms of how it relates to Depression, Anxiety and Acute Stress Disorder. DASS-21 will also be considered in terms of its relevance in the New Zealand context, psychometric properties, functions and limitations and ethical concerns.
Summarised from Lovibond & Lovibond, (1995a), DASS highlights three different negative states; the scales are not independent of the other. The authors used 30 samples that revealed three distinct scales which were labelled as Depression, Anxiety and Stress. They found that the internal consistency of the anxiety scale was consistently lower than stress and depression. However, it was an acceptable result to make inferences about individuals and groups.
The DASS-21 scales scored lower for internal consistency than DASS-42 due to the fact that it contained fewer items. However, it was within an acceptable range creating a balance between adequate consistency and adequate breadth of the measurement. The DASS-42 has a score range of 0-42 for each subscale which was upheld in a variety of populations, so does the DASS-21 since the scores are multiplied by two.
The initial development of the DASS was to differentiate between depression and anxiety. Utilising a factor analysis (the way observed correlated variables relate to unobserved variables), the DASS was administered to psychology students to identify items for the scales, depression and anxiety. A factor analysis arranges, in order of importance, values of observed data expressed as functions of possible causes.
Skype counsellor discussing Depression Anxiety Stress Scale (DASS) Relevance to New Zealand
A vast number of studies have been conducted in New Zealand (broader population) using the DASS to identify associations with depression, anxiety and stress (Robinson, Brocklesby, Garisch, et al., 2017; Kaplan, et al., 2015; Lovell, Huntsman & Hedley-Ward, 2014; Carter et al., 2014; King, 2014; Hunt, 2012; Samaranayake & Fernando, 2011; Rucklidge & Blampied, 2011).
According to the 2011/2012 New Zealand Health Survey, 14.3% of New Zealanders were diagnosed with depression at some point in their lives. Anxiety disorders also scored high, over 6.1% had disorders which include post-traumatic stress disorder (PTSD), generalised anxiety disorder (GAD), phobia and obsessive-compulsive disorder (OCD). Women scored higher than men. The diagnosis for women was 7.9% depression and 7.7% anxiety disorder v.s. 10.4% and 4.4% for men respectively. The 2012/13 Health Survey further indicates that 17.1% of deprived New Zealand adults have been diagnosed with a mental disorder, including bipolar/depression and/or anxiety disorder at some stage in their lives. This is 1.6 times higher than adults in less deprived areas. The Ministry of Health (2013) recorded for the period 2009-2013 that 1.7% (508) deaths in 2013 were suicides, with rates highest amongst Māori males,15-24. The Māori male youth suicide rate was almost twice that of Māori female, Pacific Islanders and other Asian ethnic groups as a due to stress that comes with stressors of economic and other deprivation.
Mental Health Issues
New to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) is the integration of a dimensional assessment (quantifying emotional states with scores) to the categorical approach (previously strictly categorical) (American Psychiatric Association [APA], 2013). DASS is not categorical, but a dimensional assessment based on a self-report of experiences within the past week (Lovibond & Lovibond, 1995a).
To derive a DSM-5 diagnosis during a clinical assessment, ensure that symptoms of each disorder are not attributable to a medical condition or better defined by another disorder. For a DSM-5 diagnosis, the episode should cause significant distress or impairment in social, occupational or essential areas of functioning (APA, 2013). The DASS timeframe for diagnosis falls outside of the DSM-5 Depression and Anxiety specification.
Major Depressive Mood Disorder must include at least five symptoms associated with criteria A in the DSM-5 presenting in a 2-week period and a change from previous functioning including one of the symptoms (1) depressed mood or (2) loss of interest/pleasure (APA, 2013). When considering the DASS-21 questions, depression is covered by items 3 (no positive feelings), 5 (difficulty doing things), 10 (nothing to look forward to), 13 (down-hearted), 16 (no enthusiasm), 17 (worthlessness), and 21 (meaninglessness), (Appendix A). These questions relate to negative effect.
Generalised Anxiety Disorder (GAD) includes excessive anxiety and worry occurring more often than not for at least six months and affects activities such as work or school performance and is associated with three or more of category C in the DSM-5 diagnostic manual (APA, 2013). The DASS-21 questions that relate to anxiety include question 2 (mouth dryness), 4 (breathing difficulty), 7 (trembling), 9 (worry), 15 (panic), 19 (heart rate) and 20 (scared for no good reason) (Appendix A). These questions cover physiological arousal.
Acute Stress Disorder (ACD) lasts at least three days to one month after trauma exposure, and the timeframe corresponds to the DASS-21 (identify items within the past week). To diagnose ACD the client should present with at least 9 symptoms from the 5 categories found in the DSM5 (APA, 2013). Questionnaire items on the DASS that cover stress include cognitive, subjective symptoms of anxiety including scale items 1 (difficulty winding down), 6 (over-react to situations), 8 (using nervous energy), 11 (agitation), 12 (difficult to relax), 14 (intolerant), and 18 (touchy).
Functions and Limitations of the Measure
Functions of the DASS-21
In clinical settings, the DASS-21 incorporates the clients’ self-reported emotional disturbance as part of the broader assessment. In this way, the clinician can assess the severity of symptoms of depression, anxiety and stress (Shea, Tennant & Pallant, 2009). Lovibond and Lovibond (1995a) stressed that the DASS-21 should not replace a clinical interview and that other disturbances not addressed by the scales should be identified through a clinical discussion. Furthermore, the scale has no direct implications for allocating diagnostic categories according to classification systems such as the DSM (Diagnostic and Statistical Manual of Mental Disorders) and ICD (International Classification of Disorders).
Reliability and Validity.
The DASS-21 normative data were based on one sample comprising 717 people between the ages of 17-69 years and found to be reliable. Alpha values (significant levels) for the 7-item normative sample scales were Depression 0.81, Anxiety 0.73, Stress 0.81. The factor structure (correlation between variables that measure a particular construct) and relative performance of individual items were found virtually the same in clinical and non-clinical samples and correlated highly to that reported by Beck (1988) on a clinical sample (Lovibond & Lovibond,1995b). Depression, anxiety and stress manifested by clinical outpatients and normal non-clinical groups differed primarily in severity. The results add to evidence suggesting that emotional disorders fall on a continuum with less extreme emotional disturbance where clinical disorders may represent the severe, inappropriate or chronic manifestation of syndromes (Lovibond & Lovibond,1995a). The scales are moderately inter-correlated at approximately rs= .5 – .7 which is in line with the BDI (Beck Depression Inventory) and BAI (Beck Anxiety Inventory).
Lovibond and Lovibond(1995b) made a comparison between the DASS, Beck Depression Inventory (BDI) and Beck Anxiety Inventory. They found that the anxiety scales were highly correlated (66% common variance r=0.81) and depression scales somewhat less correlated (55% r=.74). The lower cross-construct correlations between DASS and BDI scales (r=0.58 and r=0.54) indicate that there is a greater degree of convergent validity than in typically observed self-report scales.
The factor analysis was indicated as the primary reason for the lower correlation between DASS Depression and BDI, due to BDI’s inclusion of somatic symptoms, i.e. loss of libido, appetite, weight loss etc. and anxiety loss of sexual interest, loss of appetite, weight gain, increased sleep. The DASS correlates well with the Personal disturbance scale, Positive & Negative Affect Schedule, Hospital Anxiety and Depression Scale (Osman, Wong, Bagge, et al., 2012).
Researchers found the DASS-21 to be valid, reliable and easy to administer for both clinical and research purposes (Osman, Wong, Bagge, et al., 2012; Norton, 2007; Henry, Crawford, 2005; Crawford & Henry, 2003). Additional studies replicated the psychometric properties (Da Silva et al. 2016; Tran et al. 2013; Nieuwenhuijsen et al., 2003; and more).
Administration and Scoring.
Both DASS questionnaires (21 and 42) are public domain, and no special skills are required to administer the self-report instruments. However, interpretation should be carried out by professionals. The DASS-21 can be conducted manually, online or via computer. Note that professionals do not have permission to administer the DASS on a website or app open to the public. The scale’s administration is restricted to defined groups, clients or participants in research. Electronic administration for research purposes can be automated for scoring (Lovibond & Lovibond, 1995a).
It is recommended to administer the DASS-21 during the first interview and again after treatment to measure the significance of outcomes (Ronk, Korman, Hooke, & Page, 2013). Through the DASS-21 tool, depression, anxiety and stress are measured dimensionally varying on a continuum of severity ranging between 0-3 as follows (Appendix A):
0 Did not apply to me at all
1 Applied to me to some degree, or some of the time
2 Applied to me to a considerable degree, or a good part of the time
3 Applied to me very much, or most of the time
Included in the DASS Manual, clinicians receive a plastic scoring template to place over the completed response form. Scale information, i.e. D (Depression), A (Anxiety) and S (Stress) are listed alongside the rating scales, sum scores for each scale and multiply DASS-21 scores by two (Appendix B). DASS scores can be interpreted using the DASS-21 profile sheet to enable comparisons between the scales (Appendix C) (Lovibond & Lovibond, 1995a). Table 1 is a breakdown of the severity rating from normal to extremely severe.
Even though DASS scores should not be used exclusively to assess depression, anxiety or stress, high scores would alert clinicians of high levels of distress that could be explored further during an interview. During additional DASS administrations, changes in one scale (i.e. depression) and consistently high scores in another (i.e. anxiety) could inform a clinician to pay attention to co-existing anxiety, other problems or life-events that could be directly addressed in therapy (Lovibond & Lovibond, 1995a).
The DASS had over 25 translations available (Parkitny & McAuley, 2010) and was validated in numerous contexts including generational and racial groups (Norton, 2007). The measure is also widely used internationally (Oei, Sawang, Yong, & Mukhtar, 2013). Furthermore, the DASS was applied to older persons (Gloster, et al., 2008), children and adolescents (Szabó & Lovibond, 2006; Szabó, 2010; da Silva et al., 2016), from military veterans (MacDonell, Bhullar & Thorsteinsson, 2016) to validating the DASS-21 as screening tool in rural northern Vietnamese women (Tran, Tran & Fisher, 2013).
Limitations of the DASS-21
When using self-report questionnaires, psychologists rely on the honesty of participants. The DASS is unable to identify malingering (Lovibond & Lovibond, 1995a). Furthermore, people have different ways of completing forms; some prefer extreme points while others use midpoints, hence, completing questions may be unintentionally biased (Austin, Gibson, Deary, et al., 1998).
The DASS-21 is a screening tool for professionals to assess low or disturbed mood in clients. Caution is advised when using the scales since severity ratings were obtained from large, mostly heterogeneous samples of individual ratings. “The further away the score from a population mean the more severe the symptoms” (Parkitny & McAuley, 2010 p.204).
When considering risk, the DASS-21 does not assess suicidality. Risk assessment should be carried out during the clinical interview. According to Lovibond and Lovibond (1995a) items for suicidal tendencies were not found on any scale and an experienced clinician will recognise the need for a comprehensive risk assessment.
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BY: Online Therapy
Anxiety / Assessment / Counselling / Depression / Online Counselling / Online Counsellor / Online therapist / Online Therapy
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Article by Anna Keyter
Online Therapist Analysing InTreatment Week 4 | Sophie & Paul:
This article is a critical analysis of a therapy session based on an assessment of the HBO episode: In Treatment. (Disc Four) with Sophie and Paul. The purpose of the session was for Paul to write a report on Sophie’s suicidality. However, the assessment turned into therapy. Sophie presents self-harming behaviour, risky sexual activity and substance use.
Sophie was raped and exhibits the typical acting out behaviour of teenage rape victims. Signs of adolescent rape include conduct such as extreme agitation, anger outbursts, depression, sleep and school problems (NSOPW, n.d.). She also engages in alcohol misuse, promiscuity, eating disorder and running away from home and possibly comorbid depression (DSM5, 2013). Contextual variables, including transference-countertransference, will be discussed first, followed by the strategies Paul used to develop the therapeutic relationship. Ruptures will be addressed firstly by looking at ethical challenges that arose followed by ruptures due to cues Paul missed during the session. Each section describes behaviours/events and recommendations on the ruptures that occurred during the session.
The contextual variables will be discussed in terms of countertransference and transference experienced by Paul (therapist) and Sophie (client). From a psychodynamic perspective, countertransference can be defined as the therapist’s subconscious emotional reaction to the experiences of the client. Transference is when the client subconsciously redirects feelings for one person to the therapist. Gelso (2014) refers to a tripartite model of psychodynamic intervention, “asserting that all therapeutic relationships, to varying degrees, consist of a real relationship, a working alliance, and a transference-countertransference configuration”.
Paul | Countertransference
Paul, a middle-aged man with children, is providing therapy to Sophie, a teenage girl who was raped. Sophie’s experiences affect Paul. Countertransference is not necessarily bad and could serve as an internal barometer to assess personal reactions to social interaction when the psychologist is aware of it (Gelso, 2014). During my observation of the session, Paul seemed to assume an almost fatherly role in his interaction with Sophie which could be due to a subconscious need to act as a parent to her. Schaeffer (2007) expresses the importance for therapists to identify transference and countertransference as soon as possible for the therapist to be in control of it and not be controlled by it.
Hence, countertransference could be useful if Paul examines his reasons for the way he behaves. Even though Paul is a psychodynamic therapist, I am uncertain if he is aware of his emotions of countertransference. Paul should pursue personal therapy to distinguish reasons for the countertransference that was evoked by Sophie throughout the session. In particular, Paul reacted strongly when Sophie’s commented on the gymnast that told her sex with her was like having sex with someone who had been sexually abused. Paul responded by saying “Prick”. At one stage Paul also tried to comfort Sophie by putting his arm around her and stroking her shoulder and hugging her (which could have ethical implications).
Sophie | Transference
Sophie is a teenage girl who was referred to Paul after a bicycle accident that was possibly a suicide attempt. She has a strained relationship with her mother and only mentioned her father once. She is a hopeful Olympic level gymnast. However, she had been sexually abused by her coach Sy. Initially, the relationship with Sy’s family seemed close; she spent time at their house, babysitting their daughter Dena.
Sophie was on Sy’s bicycle the night of the accident, and it should have been Paul’s intention to assess possible suicidal behaviour. The helping relationship should be the interaction between the therapist’s intentions and the client’s reactions (Hill, 2014). According to Gelso (2014), the therapeutic relationship is the core of successful psychotherapy, and the two critical elements of the therapeutic relationship are transference and the real relationship. As a psychodynamic therapist, Paul should encourage this transference intentionally to assist Sophie to get insight into her distress through the therapeutic relationship. Transference is the way the client experiences and perceives the therapist. However, the client is shaped by her psychological structures, including past experiences and involves the displacement and carrying the feelings, attitudes, and behaviours to the therapist deriving from earlier significant relationships (Gelso, 2014).
Sophie displayed sexualised behaviour when she entered the therapy room. Paul did not successfully use transference to develop the conversation around transference behaviour. Instead, he played into it by taking her hand and bowing. During the session, Sophie seemed to “transfer” feelings from people in her life to her therapist Paul by the way she interacted with him. It is interesting to note that Sophie tried to commit suicide using Sy’s bike and taking an overdose of Paul’s medication in his office. Is Sophie trying to say something by using something belonging to Sy and Paul to commit suicide?
Therapeutic Strategies and Skills
Paul is a Psychodynamic therapist however, his methods seem more in line with the Rogerian model. Paul’s strategies include empathic reflections, probing for insights and listening. A positive of the session was that Sophie could speak openly and freely about her problems. Paul was listening to Sophie and displayed nonverbal cues such as nodding and using gestures. He prompted for more information by asking open-ended questions and restated comments. Paul also used alternatives, commenting that Sophie tried to get her mother’s attention by running away from her.
Therapeutic Alliance Ruptures
Safran and Muran (2000) define therapeutic alliance ruptures as impasses or ruptures in the therapeutic alliance. Three roads can lead to an impasse – therapist and client developing a hopeless narrative about presenting difficulties; therapeutic strategy halts; leaving the interaction trapped in a negative pattern. To overcome the impasse, the therapist should become solution-focused and get help during the consultation on developing a new strategy (Safran & Muran, 2000).
Many ruptures occurred during the session as indicated below:
Safran (1993) views ruptures in the therapeutic relationship as the breakdown of the collaboration between therapist and client as indicated below.
Contracting | Privacy and Confidentiality
Problem. Psychologists should be respectful to clients by including them in the decision-making process. Paul called Sophie’s mother behind her back. He did not obtain full and active participation from Sophie on decisions that affected her. Sophie mentioned her mother took her shopping on the weekend because Paul told the mother she was going to “off” herself. Sophie asked Paul why he called her mother. Later on, Sophie expressed anger in an outburst again, telling him how upset she was that he called her mother and told her she was going to kill herself. Paul brushed it off.
Recommendation. During the initial assessment, Paul should have discussed informed consent and the implications thereof. Before involving Sophie’s mother on her suicidal thoughts, Paul should have explained to Sophie that psychologists promote their client’s right to privacy, however, when there is a threat of harm to self and others they are compelled by law to report it. The relationship could repair if the client actively participates in the change process (Horvath, 2009).
Challenges in future sessions. Sophie may become reluctant to share critical information, and risk assessment could become difficult.
Issue. Paul seemed oblivious to the harm caused to Sophie as a result of the ruptures in their relationship. He did not clarify what Sophie could expect from the therapeutic encounter. On a number of occasions, Paul pushed Sophie to go on with her story, even when she was not ready to continue. Paul did not handle the situation competently; he was more interested in what happened next than how the event affected Sophie emotionally.
Recommendation. The therapist’s ideas should not be imposed on the client in therapy (Safran & Muran, 2000). Problems should be addressed within the therapeutic alliance so that the client can reflect on problems. Paul needs to discuss this case in supervision to get guidance on how to deal with the situation.
Issue. When Sophie showed Paul a backflip, she started to walk on the back of the couch; Paul did not know how to deal with the situation. He asked her to stop, but instead of addressing his concerns about her safety, after a perfect landing he said, “That was incredible.”
Recommendation. Paul should discuss potentially harmful behaviours honestly and openly with Sophie and establish boundaries within their relationship. In this way, Sophie could model boundary behaviours from Paul.
Issue. During the session, Sophie also disclosed that Sy had a sexual relationship with her, which Paul seemed to miss.
Recommendation. Paul should have addressed the seriousness of the situation with Sophie and worked towards a plan on how to report the case to the police.
Challenges in future sessions. Paul seems to have difficulty understanding serious issues and how to address it in a lawful way as well as safety practices in his office.
Integrity in Relationships
Issue. Paul was not honest with Sophie. When Sophie confronted Paul about his phone call to her mother, he said: “That’s not what I said.” Later on, Paul admitted to Sophie that he told her mother saying “because I was worried about you.”
Recommendation. A therapist with integrity would have an honest approach. Not dealing with Sophie’s question could hamper trust going forward. Sophie could also view this as an empathic failure and end the relationship. However, the relationship could still repair if they work through the trust issues.
Issue. Sophie does not have clear boundaries; she mentioned: “screwing half the Olympic gymnastics team.” She stayed up all night after a party and then walked to her session for her appointment with Paul. He does not seem to pick up on her cues about her excessive drinking and a boy that she felt was ‘eye candy’. Her lack of boundaries are further apparent when she lies on his couch, and it seemed like she was falling asleep.
Paul’s behaviour did not help. A boundary infringement from Paul was when he sat in front of Sophie, his face only inches away from hers and encouraged her to talk. He then got up and sat very close to Sophie. As a therapist, he should be aware of the boundary breakdown experienced by raped teenagers. He moved next to her and stroked her shoulder, which is highly inappropriate behaviour for a therapist.
Recommendation. Paul should understand the underlying issues of boundaries, perhaps attend a course on how to work with teenage survivors of rape. Paul could have used cognitive processing therapy. CPT treatment includes education, exposure and cognitive techniques. Survivors identify sections of the trauma that they battle to process and then work through stuck points (Galovski, Schuster Wachen, Chard, Manson & Resick, 2015).
Challenges in future sessions. Paul did not address the issue of personal boundaries with Sophie. If Paul does not address or respect boundaries, Sophie could remain vulnerable and victimised.
Responsibility to Society
Paul needs to engage in regular supervision to monitor, assess, and report on his ethical practices to safeguard his clients. An honest exploration of his countertransference would resolve the generational issues he possibly experienced. Furthermore, if Paul does not report Sy to the police, Paul would be doing a disservice to society as a whole, especially vulnerable groups.
Feelings of Dissociation.
Sophie tells Paul about a risky sexual encounter; a gymnast took her to his room, as usual, she felt nothing. On another occasion she said, “everything around me was falling apart, disintegrating, turning to ash right in front of me, … But as soon as I started to fall asleep the pasture would turn to rot, it’s terrible.” Sophie further commented on her eating disorder and how she experienced floating on clouds disassociating from her body when she would not eat when she was younger. She felt that same feeling of when she was on the beam, and enjoyed the sense of disassociation; she pushed until it felt like she didn’t have a body at all.
Effect on Relationship. Paul missed the consistent theme of disassociation.
Recommendation. From a behavioural perspective, survivors of rape can be assisted using CBT (Jaycox, Zoellner & Fao, 2002). Paul can help Sophie to get a new understanding of her thinking patterns that can lead to behavioural change and an understanding of underlying assumptions by directly addressing disassociation. According to the DSM5, disassociation is common in people who experienced PTSD.
Feelings of being objectified
Sophie felt that her mother hated that she was a gymnast. Her mother said:“Your boobs won’t grow, you will hate your body, be deformed”. Her mother also decided on the shoes. “She picked out those Barbie doll shoes” | “Sophie wore those Barbie doll shoes that you bought her…”
Effect on Relationship. Sophie felt objectified by her mother. Paul did not recognise Sophie’s feelings, and he did not explore the Barbie doll comments.
Recommendation. Paul should explore Sophie’s feelings on the shoes and her position as a gymnast. He did not ask her what Barbie doll meant to her. Paul is aware of Sophie’s eating disorder and body image issues. I would recommend DBT strategies which include mindfulness, emotion regulation, distress tolerance, and interpersonal effectiveness to help Sophie deal with these issues (Cooper & Parsons, 2010).
The desire to run away
Sophie expressed a desire to run away from her mother to the gymnasium. However, she is unable to get away from her mother.
Effects on Relationship. It is clear that Sophie is not happy at home. Instead of addressing her feelings to run away, Paul tells her the Wizard of Oz story. “…They remind me of, of Dorothy’s shoes. Dorothy discovered that she could go home anytime she wants with or without her shoes.” This was upsetting for Sophie, and she asked him “Why are you infantasizing me?”
Recommendation. Paul did not explore the reasons Sophie wanted to run to the gymnasium. He also did not ask her what she would find there. Exploration (Rogerian approach) could have worked in this instance.
Suicidal thoughts and attempts
Sophie came to therapy to get assessed for suicidal behaviour. The situation that brought her to therapy was when she was on Sy’s bike, and she admitted to Paul that she tried to kill herself. At the end of the session, Sophie went to Paul’s bathroom to vomit, reflected in the mirror, opened the medicine cabinet and removed a bottle of pills and consumed them. Once out of the bathroom, she said she’s going home. Paul told Sophie that they had more time, but she started slurring and fell to the ground.
Effects on the relationship. Sophie attempted suicide using Paul’s medication. This could be due to the culmination of therapeutic ruptures.
Recommendation. Paul did not do a proper risk assessment knowing that Sophie was suicidal. He did not ask her about suicidal plans or how often she had thoughts of killing herself. He should have worked with her on a safety plan. Knowing that he had a suicidal client, he should have removed the medication from his public bathroom.
Therapeutic collaboration stopped when Sophie attempted suicide. Paul did not explore the ruptures that happened during therapy. He did not seem to notice that the therapeutic interaction was blocked. Sophie was unable to cope, and Paul seemed distracted. Behaviours associated with the rupture include Paul’s inability to pick up on Sophie’s cues and the distress she expressed as a result of him speaking to her mother behind her back. When Paul did not know how to respond to issues, he brushed it off or changed the topic. Cozolino (2004) highlights the importance of the psychologist’s intentions to explore the client’s experiences in the moment, which Paul seemed unable to do.
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Galovski, T.E., Wachen J.S., Chard K.M., Monson C.M., Resick P.A. (2015). Cognitive Processing Therapy. In: Schnyder U., Cloitre M. (eds) Evidence Based Treatments for Trauma-Related Psychological Disorders. Springer, Cham
Jaycox, L.H., Zoellner. L., Foa, E.B. (2002). Cognitive-behavior therapy for PTSD in rape survivors. J Clin Psychol, 58 (8), 891-906.
Schaeffer, J. A. (2007). Transference and countertransference in non-analytic therapy: Double-edged swords. New York: UniversityPress of America.
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Article by Anna Keyter
The Process Model of Helping (PMH) as introduced by Clara Hill (2014), can be defined as three stages of intervention: Exploration, Insight, and Action. It incorporates client-centred, psychoanalytic, and cognitive–behavioral approaches. The PMH foundation (exploration stage) is based on the client-centred model due to its facilitative aspects of helping (Hill, 2014). People seek help for various reasons, whether it is problems with peers or living with parents. The goal to find therapy is based on difficult situations (Carkhuff, 1987), by addressing sensitive issues clients can understand themselves in new ways.
When the self-concept and ideal-self are similar (congruent) self-actualisation (optimal-self) can be achieved (Chodorkoff, 1954). Through a supportive relationship, the congruent and incongruent perception of the self that stems from interactions with others (previous experiences) can be addressed. People have an innate need for self-actualisation which refers to the need to reach their full potential (Rogers, 1959). Hill (2014) highlights the facilitative and healing aspects of helping in terms of using skills (natural ability and learning), creating facilitative conditions (empathy, warmth and congruence) and self-awareness (knowledge and insight).
Stage 1 | The Exploration Stage
Maslow (1968) was the first to use the term ‘self-actualisation’ when it came to a person’s ability to become what he or she is capable of becoming. According to Hill (2014), the exploration phase is based on the client-centred model, hence the focus is on attending, observing, listening and exploring thoughts and feelings. Rogers (1961) suggested that it was important to focus on building nonjudgmental therapeutic relationships, listening to the clients’ narratives and assisting them to experience feelings. The helper would display skills by observing non-verbal and minimal verbal behaviours, exploring by using restatements, asking open questions and considering feelings through reflections, disclosures and open-ended questions (Hill, 2014).
Stage 2 | Insight Stage
Summarising from Hill (2014), in some instances, stage one may be all a helpee needs to make important changes. However, in other situations, the exploration stage is the foundation on which to build the insight stage. Insights draw on the psychodynamic and attachment models. Psychodynamic theories do not focus on behavioural change, but look deeply into troubling issues such as early relationships, the importance of early childhood experiences and place emphasis on defence mechanisms. During the insights stage, the goals are to foster awareness (challenge), facilitate insights (probe, interpret, disclose insights), and working on the therapeutic relationship (immediacy). This stage set the foundation for the action stage where Hill departs from psychodynamic models and applies behavioural theories.
Stage 3 | Action Stage
According to Hill (2014), the action stage is the practical section of the PMH. There are two reasons action is needed, firstly people seek assistance to feel better or change behaviours. The second, to consolidate new thinking patterns into existing schemas and to ensure old habits do not resurface. This part of the intervention still has a client-centered underpinning, and the helper remains a supporter and coach and does not give advice. Hill (2014) draws on Behavioural and Cognitive theories including learning and treatment strategies. The Goals of the Action stage is to explore new behaviours, deciding on and developing new skills, assisting clients to evaluate and modify action plans and processing feelings about change. Types of action include relaxation for behaviour change, rehearsal, and decision making. Helper skills are displayed through open action questions, providing information and feedback to clients, advising on the process, directing guidance and disclosing strategies.
Hill’s (2014) aim was to provide a helping model, integrating affect cognition and behaviour as a framework for exploring helpee concerns, gaining insight into their issues and enabling them to make desired changes. The Three-Stage Model is based on an eclectic perspective (integrating diverse philosophies), that is grounding practice and theory on the philosophies of Rogers, Erikson, Maheler, Skinner and Ellis & Beck.
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Rogers, C.R. (1959). A theory of therapy, personality and interpersonal relationships, as developed in the client-centered framework. In S. Koch (ed.). Psychology: A study of science. (pp. 84-256). N.Y.: McGraw Hill.