Massage Therapy Proven Beneficial Health And Social Care Essay

Massage can be used in various forms to stimulate and relax. Physical and psychological benefits have been used throughout history and are used to treat conditions. The therapeutic touch has led to its use as a holistic treatment.
Massage is the manipulation of superficial layers of muscle and connective tissue to promote relaxation and well-being. Massage involves acting on and manipulating the body with pressure. The target tissues include muscles, tendons, ligaments, skin, joints and any other connective tissue as well as lymphatic vessels or any organs of the gastrointestinal system. There are over eighty different recognised massage modalities and the most cited reasons for introducing massage as therapy have been client demand and perceived clinical effectiveness. Rubbing parts of the body is a natural and instinctive way to relieve pain and discomfort. This instinct was probably led to most forms of massage. The first to be developed was the sense of touch and it is essential to our growth as human beings. Massage can be used to stimulate or relax.

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McDonald and Goldberg (1996:72-89) insist that throughout its history it has been used for both its physical and physiological benefits and is used to treat a range of conditions from both stress and posture related to headaches, abdominal, pelvic, muscle and back pain either a result from specific injuries like falls, sports and car accidents or just general pain. The therapeutic touch has led to its use as a holistic treatment, one that treats the body and mind as a whole. The word ‘massage’ is thought to be deprived either from the Arabic for ‘press softly’ or from the Greek for ‘knead’, massage treatments has been passed down through centuries for thousands of years. In ancient china over five thousand years ago there was a system of massage and exercise in use, it is almost certain that most races used massage and exercise in one form or another dating as far back as the prehistoric ages of man. People of ancient civilisations in Persia, Japan and Egypt practised the art of massage for cosmetic purposes and also found out that they all gained therapeutic effects when they rubbed oils and perfumes into their body to beautify their skin.
Around 500BC the Greek historian Herodotus applied exercises and massage on the treatment of disease principles about the technique of rubbing that began to be formulated. Massage was directed away from the heart and the pressure was varied during the treatment. It would begin with being gentle and then it becomes deeper and quicker and ends slowly. In the large cities of Greece, gymnastic centres were set up where students and philosophers could meet to discuss philosophy and attend lectures while bathing and exercising at the same time. Hippocrates, the father of medicine about 380BC really only used massage for the treatment of injuries and diseases, he found that it was more beneficial if rubbing was done towards the heart during the treatment although the circulatory system was not understood then. From his emphasis on pressure application he discovered the physiological effects of massage that are accepted today. During 130-200AD a famous doctor during the Roman era called Galen experimented in physiology and discovered that arteries were filled with blood, not air as previously believed. He varied the direction of massage and also greatly believed in treating injuries and diseases with it.
During the fifteenth, sixteenth and seventeenth centuries, Switzerland, France, Italy, Prussia and England produced several famous surgeons and physicians who began once again to use massage treatment for injuries and diseases. The old terminology of massage remained but new words were introduced such as pressure, kneading and manipulations. From the end of the eighteenth century a great revival in massage began. Many authorities wrote and expounded their theories on the subject, one extremist advocated that massage should be performed with great violence and they all had different ideas about the terminology, pressure, rate, rhythm and any medium such as oil or powder that can be used, the position of the patient and the duration of the treatment.
In the early nineteenth century Peter Henry Ling of Sweden made the most dramatic contribution to massage at this time. His influence spread throughout Europe and America, he realised that it was important to acquire certain knowledge of anatomy and physiology before applying massage treatments. He created a style of treatment to promote health by increasing blood circulation and stimulating the body’s healing abilities. It is known that Ling’s greatest influence came from a Chinese friend who was a master of martial arts and Chinese Tui Na massage.
A Dutch practitioner names Johan Georg Mezgar later developed a reduced set of Ling’s techniques to form our modern style of Swedish massage; it is Mezgar who adapted the French names commonly used to indicate the basic strokes.
Doctor Mezgar helped to establish massage as a reputable means of treatment by prescribing it widely and practising it himself. In 1894 a group of women joined together to form a society of trained masseuses in order to try to raise the reputation and standard of massage in this country. Although massage in physiotherapy had reached a high standard it seemed as though there was an urgent need to raise the standard in the beauty industry.
According to Jenkins, Massage of essence (2006), the term holistic comes from the Greek word ‘Holos’ which means whole. The holistic approach takes the persons whole body into account. The treatment takes an effect on the body arising from environment, psychology and nutrition. Holistic massage treats each person individually in context of their own life, it enables the person to improve and control their health, and it always keeps the principle of treating the body, mind and soul as one.
Holistic massage is about looking at the causes of tension and working with the whole body to help restore the whole body’s natural inner balance. The approach with holistic massage is based around oil-based Swedish massage (effleurage, petrissage and percussion)
Massage as a holistic treatment takes into consideration the physical, mental, spiritual and environmental circumstances of a person receiving a massage treatment, this means that the treatment should be different for each person.
Massage benefits the body because of the specific techniques it involves. The movements and firm pressure affect all systems in the body, including soft tissues such as muscles and ligaments and also nerves and glands. When the pressure is applied in movements to your muscles it is in tune with the natural flow of blood back to your heat. Massage is one of the best known antidotes for stress; reducing stress gives you more energy. It improves your outlook on life and reduces your likelihood of illness and injury. It can also relieve symptoms of conditions that are aggravated by anxiety.
There are psychological and physiological effects of massage, which some of them are:
Psychological
Encourages the mind and body
Concentration and alertness is often improved due to relaxation
Emotional outbursts
Energy levels are increased
Increase in confidence and positive outlook
Promotes a feeling of increased health and wellbeing
Reduces stress levels
Increases the clients feeling of being cared for, supported and nurtured
Physiological
Aids general relaxation
Stimulates blood circulation
Helps improve lymphatic flow
Reduces muscular tension
Layers of the skin are stimulated which increases cellular function and regeneration of cells
Relieves stiffness in the neck and shoulder resulting in pain relief
Loosens scar tissue
Warms the muscles
Nerve endings are soothed and stimulated
Aids in desquamation improving the texture of the skin
Softens fatty deposits
Helps reduce non medical swelling
Encourages deeper breathing to a more relaxed breathing
Effects on the skeletal system
Improves muscle tone and balance
Reduces the physical stress placed on joints and bones
It helps to free adhesions
Increases joint mobility, reducing any thickening of the connective tissue
Effects on the Muscular system
Relieves muscular tightness, stiffness , restrictions and spasms in the muscle tissue
Increases flexibility in the muscles
Increases blood circulation
Reduces muscle fatigue and soreness
Promotes rapid removal of waste and toxins from the muscle
Effects on the lymphatic system
Reduces oedema
Increases lymph drainage
Strengthens the immune system
Effects on the Nervous system
Stimulates sensory receptors
Reduces pain by the release of endorphins
Stimulates the parasympathetic nervous system
Promotes relaxation
Reduces stress
Effects on the cardiovascular system
Improves circulation
Dilates blood vessels
Produces an enhanced blood flow
Helps temporarily decrease blood flow
Decreases heart rate due to relaxation
Reduces ischemia
Effects on the skin
Improves circulation
Increased nutrition to the cells and encourages cell regeneration
Increases production of sweat from the sweat glands
Improves elasticity on the skin
Increases sebum production
Helps improve the skins colour
Helps to improve the skins suppleness and resistance to infection
Effects on the digestive system
Increases peristalsis in the large intestine
Helps to relieve constipation
Promotes the activity of parasympathetic nervous system. Which stimulates digestion
Effects on the urinary system
Increases circulation and lymph drainage from the tissues
Effects on the respiratory system
Slows down the rate of respiration
Improves lung capacity by relaxing tightness in the respiratory muscles
Massage uses specific techniques such as effleurage, petrissage, kneading and tapotement; these treat the soft tissues of the body. Movements are primarily towards the heart so it can improve blood and lymph circulation, as well as to reduce muscle tension and to encourage flexibility. The massage techniques have certain effects to the body which are:
Effleurage
Soothing effect on the nerves including relaxation
Increases both blood and lymph circulation
Tension relief, relaxing tense muscles
Aiding desquamation
Petrissage
Increases blood and lymph circulation
Increases venous return
Breaks down tension nodules
Aids relaxation
Speeds up the removal of waste products
Tapotement
Aids sluggish frictions
Tones and strengthens muscles
Helps loosen mucus in chest conditions
Produces erethyma
Stimulates nerve endings
Frictions
Helps to break down tight nodules
Aids in relaxation
Increases lymph and blood flow
Vibrations
Clears and stimulates the nerves pathways
Relieves tension in the neck and back
Can help increase the action of lungs
Helps to increase peristalsis in the colon
India
In India massage therapy was licensed in March 1955 by the department of Ayurveda, yoga and naturopathy, Unani, Siddha and homoeopathy under the ministry of health and family welfare.
China
In china many of the smaller massage parlours are fronts for prostitution. These are called falangmei. Most types of massage are not regulated in china without the exception of some traditional Chinese medicine.
Japan
In Japan oil and Thai massage are not regulated but shiatsu massage is prostitutes posing as massage therapists are fairly common in the larger cities; they pose in fashion health shops and pink salons.
France
In order to get a license it requires three years of study and two exams.
South Korea
In South Korea, only visually- impaired and blind people can become licensed massage therapists.
New Zealand
In New Zealand, massage is unregulated. The professional body for massage therapists and the registration at the remedial massage therapist denotes competency in the practice of remedial or orthopaedic massage; these are two levels of registration of massage in New Zealand. Both levels are defined by agreed minimum hours and competencies.
Mexico
Massage therapists in Mexico combine massage using oils or lotions, the therapists are called ”sob adores” and they are used to relieve digestive problems as well as back and knee pain. Many of these therapists work from the back of a truck and in many parts of Mexico prostitutes are allowed to sell sexual massage. This business is often confined to a specific area of Mexico such as zonte norte.
Client Care
When you give a massage treatment to a client appropriate care for that client involves considering all their needs relating to the massage. Client care involves practical steps you take to care for the client’s well- being before, during and after the treatment. A clean and calm atmosphere will help the client to feel more comfortable and relaxed, and to also focus on the person getting a massage throughout the whole treatment.
Client Modesty
A client’s privacy and modesty must be respected at all times during and after the treatment. You need to only expose the body part that gets treated one by one. Clients need privacy in which to undress, also any notes made during and after the treatment must be locked up securely afterwards. A consultation must be done where no body else can hear it.
Client Confidentiality
During a treatment anything the client says must be regarded and should not be discussed outside the treatment room or to any other therapist. If advice is needed from another therapist to progress clients needs then it should be understood from the other therapist that it maintains the confidentiality other than that the clients permission is needed to do so.
Health and safety
The health and safety laws are designed to protect the therapist and their clients and penalties for contravening these laws can be severe, therefore it is highly important that the therapist highlights their responsibilities and their rights.
The health and safety at work act 1974 covers all aspects of health, safety and welfare at work. It indentifies the responsibilities of the employers and employees. Employers are responsible for the health and safety to anyone who comes into their premises. They must provide a safe environment and personal protection. They must take reasonable precautions to protect the health and safety of themselves, colleagues and clients.
Cite study; Massage eases Anxiety
Karen J.Sherman, a senior investigator at the group health research institute (2010) states that on average three months after receiving ten massage treatments, patients had half the symptoms for anxiety. Massage therapy is among the most popular complimentary and alternative medical treatment for anxiety.
A trial began to asses how effective massage is for patients with an anxiety disorder. The trial was assigned 68 group health patients with a disorder to sessions in a pleasant and relaxing environment. Massage therapist’s delivered their treatments of massage or one of two control treatments. The massage treatments were designed to enhance the function of the nervous system and to relieve symptoms of anxiety including muscle tension. The control groups were relaxation and thermotherapy. Anxiety disorder can be treated also through medicine therapy which is medical and cost effective.
The benefits of massage may be due to a general relaxation response. The massage therapy reduces stress hormones and adrenaline and increases the relaxation of alpha brain waves and also reduces anxiety levels where as the negative effect is that massage is to be no more effective than simple relaxation with soothing music.
The outcomes of this study is that Massage easing anxiety is trying to prove that it isn’t just a massage that can help with anxiety; there are other ways of helping such as sitting in a calm environment listening to soothing music. It shows that massages decreases the symptoms of anxiety and can also be less expensive.
 

An Exploration of Narrative Therapy

Narrative theory posits that the human experience is contained within the stories that we tell (Phipps & Vorster, 2015). We tell these stories to others and ourselves so often that they become reality, whether they are accurate or inaccurate. We often emphasize certain dominant details and forget other details when we tell our experience stories. Incongruence occurs when we tell “problem-saturated” stories that do not match our lived experiences (p. 257). Narrative therapists help their clients create new stories using a process called reauthoring. Reauthoring involves working with clients to change the contexts of problem-saturated stories and ultimately create new, positive stories that no longer focus on problems. Narrative therapists use a variety of techniques to aid their clients. Externalization is used to separate perceived problems from clients’ stories. Narrative therapists also look for positive exceptions in their clients’ experiences and use those exceptions to help clients change how they view their stories and problems.

Narrative Therapy History

 Narrative therapy has its roots in postmodernism and the social constructionism and interpsychic movements that both flourished during postmodernism. Starting as a philosophical movement, postmodernism features a rejection of reason and objective knowing that permeated the arts and eventually spilled over into religion and science (Phipps & Vorster, 2015). Because knowing is no longer objective, knowledge cannot be acquired through external means; instead, postmodern knowing is a subjective experience both created and interpreted by the knower. Social constructionism builds on postmodern thought by adding that the knower not only creates his or her own reality but that the knower’s reality cannot be disputed without another person attempting to create an objective reality (Corey, 2017). Social constructionists believe that the knower’s language is the subjective tool used to create his or her indisputable reality.

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Even though the knower’s subjective reality is understood to be indisputable, the intrapsychic perspective holds that the knower’s thought and reasoning processes can be studied (Phipps & Vorster, 2015). The emphasis moved from psychologists and psychiatrists studying affect, behavior, and cognition between the minds of two or more people; with the intrapsychic perspective, the focus is wholly on the knower’s subjective experience and what can be learned from investigating the knower’s subjective experiences during psychotherapy.

Modern narrative therapy is a combination of social constructionism and the interpsychic perspective and can be traced to the publication of Narrative Means to Therapeutic Ends by Michael White and David Epston in 1990 (Phipps & Vorster, 2015). Providers used narratives in family therapy before White and Epston wrote about narrative therapy. However, it is their focus on how stories create experience, how telling those stories sometimes causes pain, and how creating new stories can ease pain that defines modern narrative therapy (White & Epston, 1990).

Narrative Therapy Process

 The narrative therapy process has four distinct phases: joining, examining patterns, reauthoring, and moving on (Neukrug, 2016). According to White and Epston (1990), clients experience incongruence when the stories they tell about their own lives, or the stories others tell about clients’ lives do not match all the clients’ lived experiences. The gaps between clients’ narratives and their reality create the pathologies that often bring clients to therapy. During the joining phase, narrative therapists establish therapeutic relationships with their clients, as clients tell their “problem-saturated” stories (Neukrug, 2016, p. 131). Narrative therapists pay close attention clients’ use of language and how clients have constructed their stories over time.  

 During the second phase of narrative therapy, examining patterns, clients are invited to examine their problem-saturated stories with the goals of finding contradictions and inaccuracies (Neukrug, 2016). Narrative therapists primarily use questions, externalization, and unique outcomes during this phase to help clients realize, often for the first time, that their narratives may not be accurate (White & Epston, 1990). Narrative therapists question problems to separate, or externalize, those problems from client narratives. When problems are externalized, clients generally find it easier to discuss details of their narratives that were previously missing. Adding those missing details to the narrative, or finding unique outcomes, marks the end of this phase. 

 During the third phase of narrative therapy, called reauthoring, therapists work with clients to incorporate unique outcomes identified during the examining patterns phase into the construction of new, positive narratives (White & Epston, 1990; Neukrug, 2016). After creating their new narratives, clients practice telling their new stories first to themselves and then to others (White & Epston, 1990). By telling their new stories to themselves, clients learn to ascribe new meaning to earlier life experiences. In addition, clients tell their new stories to audiences. When clients tell their reauthored stories to other people, they use audience verbal and non-verbal feedback to enhance and extend their stories in ways that emphasize unique outcomes.  

 The final phase of narrative therapy is called moving on and features clients using new narratives to make differences in other areas (Neukrug, 2016). During this phase, clients believe their new stories so much, they begin to see positive changes in affect, behavior, and cognition. Clients in this phase successfully use language to create new experiences. After therapy concludes, some narrative therapists use written language to strengthen clients’ new narratives. Narrative therapists may use certificates and written declarations to certify or declare that clients are free from the problems present in their earlier stories (White & Epston, 1990). Narrative therapists may also write letters of prediction to their clients, stating what they believe will happen in their clients’ futures; these letters often serve as self-fulfilling prophecies for clients.

Narrative Therapy Suitability

Clients Likely to Benefit

 The socially oppressed. Many counseling theories and approaches assume that client pathology is of the client’s making. While that may often be the case, those approaches do not consider the sometimes-harmful impacts that society, politics, and culture can have on client pathology. Narrative therapy works well for socially oppressed clients because the approach does account for society’s effects on clients (Neukrug, 2016). As previously addressed, narrative therapy recognizes that we create our experiences with the language we use to tell our stories, and the language we use may be tainted by social, political, or cultural expectations and negative feedback from social institutions. Narrative therapists work with clients to separate external problems from clients so they recognize that in some cases, the problems they have internalized were not of their own creation. Narrative therapists address social factors during treatment, making this treatment a good fit for those who are oppressed.

Clients with formal diagnoses. Narrative therapists use an anti-objectivist approach that places little value in models that claim to objectively understand and explain reality (Neukrug, 2016). As a result, narrative therapists are not overly concerned with formal diagnoses; instead, they focus on the psychological damage caused by formal diagnoses. Clients with diagnoses often respond well to narrative therapy because techniques like externalization and reauthoring can help clients separate themselves from their diagnoses. Clients may overidentify with their diagnoses, and as they tell their stories, it may become difficult for the client to see himself or herself as anything but a mental disorder. Narrative therapy helps clients with formal diagnoses see that there is more to their stories and experiences than a diagnosis; the diagnosis can be externalized; and the client can create new stories and experiences independent of diagnosis.

Clients Not Likely to Benefit

 Clients seeking expert solutions. Narrative therapy is a postmodern approach to both therapy and living. As such, it represents a shift from the premodern concepts of knowing and accepting knowledge based on faith and absolutes, to rejecting objective knowledge in favor of subjective creation and experience (Corey, 2017). For these reasons, clients who view the narrative therapist as an expert with the answers are not likely to benefit from narrative therapy unless they are able to accept a different worldview. Research shows that members of minority groups are more likely than their non-minority counterparts to view the narrative therapist as an expert (Corey, 2017). Those clients may respect and revere the narrative therapist and expect the therapist to fix their lives based on expertise; those clients are less likely to understand and accept that they own their own solutions. Narrative therapists can counter this by explaining that while they may be process experts, only clients can truly know what will work in their own lives.

 Christian Theists. A Christian theistic worldview is based on the beliefs that God is “infinite, personal, triune, transcendent, immanent, omniscient, sovereign, good,” and that His will is revealed in revelation (Sire, 2009, p. 28). A strict narrative approach will likely not work for Christian theists because client will likely see utility in creating subjective experiences when God’s very being shapes human life and experience. For Christian theists, truth and knowledge are found in God’s revelation, a concept counter to postmodern beliefs that objective knowledge and truth do not exist (Phipps & Vorster, 2015). The narrative therapy concept reauthoring may be used to counsel Christian theists if narratives are strengthened by using spiritually-sound unique outcomes. The concept externalization may hurt Christian theists if narrative therapists view sin as pathology and attempt to separate sin from clients’ narratives. Christian theists may benefit from its techniques, but a strict narrative approach to therapy may cause harm.

Narrative Therapy Efficacy

Narrative Therapy Successes

Use in family therapy. Narrative therapy appears to work well countering conflict in family therapy. Besa (as cited in Etchison & Kleist, 2000) used a case study research design and showed narrative therapy to be successful in reducing parent-child conflicts, defined as “defiant behavior, keeping bad company, abuse of drugs, school problems, and other conduct problems” (p. 62). St. James-O’Connor, Meakes, Pickering, and Schuman (as cited in Etchison & Kleist, 2000) used an ethnographic research design and found that narrative therapy helped families experiencing parent-child conflict by reducing negative symptoms associated with conflict and empowering individual family members. Finally, Weston, Boxer, and Heatherington (as cited in

Etchison & Kleist, 2000) used an exploratory study and found that when families undergo narrative therapy, children are more forgiving of their parents following parent-parent conflict.

People living with depression. Vromans and Schweitzer (2011) found narrative therapy to be moderately successful in relieving depressive symptoms in adults with major depressive disorder (MDD). The researchers noted significantly lower measured depression using the Beck Depression Inventory-II (BDI-II) and Outcome Questionnaire-45.2 for participants after eight narrative therapy sessions. Significant differences were present at completion but not between completion and a three-month follow-up. In a study comparing narrative therapy to cognitive-behavioral therapy (CBT), Lopes, Gonçalves, Machado, Sinai, Bento and Salgado (2014) found both forms of therapy benefitted adults with MDD. However, researchers noted a significant difference between the groups after completion when using the BDI-II to measure depressive symptoms; those in the CBT group improved more than those in the narrative therapy group. Narrative therapy is an effective treatment for adults with MDD but is not as effective as CBT.

Narrative Therapy Failures

 Transforming construction of problems. Narrative therapy is a postmodern approach that relies on clients’ abilities to construct subjective experiences and realities by manipulating language (Etchison & Kleist, 2000). However, Coulehan, Friedlander, and Heatherington (as cited in Etchison & Kleist, 2000) found that narrative therapy is not always successful when therapists try to help clients with problem construction. Specifically, they found that when family therapy sessions are not successful, the culprit is often an inability for family members to move from viewing problems intrapersonally to viewing them systematically. The difficulty in helping families to construct problems may be due to the therapist attempting to objectify subjective problems. The process of agreeing on what constitutes a major issue for the family requires objectivity, as members are asked to change the context in which they view their own problems. The issue is that narrative therapy is based on the belief that reality is known only to the knower.

 Lack of qualitative research. A lack of qualitative research continues to plague narrative therapy today. Postmodernists do not believe in objective knowing which is at the heart of qualitative research (Etchison & Kleist, 2000). Narrative therapists are generally opposed to qualitative research on their findings because qualitative research is a contradiction to the theories upon which narrative therapy was founded. This phenomenon causes two major issues for those attempting to complete qualitative research. First, narrative therapists attempting to complete qualitative research may lack proper training, which may result in research errors. Second, non-narrative therapists may attempt to complete qualitative research on narrative therapy, its techniques, and outcomes, and research may contain errors because the researchers may lack information about how narrative therapy works. Regardless of the sources of errors, it is recognized that there is a lack of qualitative narrative therapy research and more is needed.

Addition Training for the Narrative Therapist

There are currently no gatekeeping organizations or associations for narrative therapy, meaning any therapist can call himself or herself a narrative therapist. Additional training beyond the requirements to become a therapist is available but is not a requirement. For example, the Dulwich Centre in Australia, which was co-founded and directed by Michael White until his death, offers intensive training and a Master of Narrative Therapy and Community Work degree (Dulwich Centre, n.d.). That degree is accredited by the Australian Counseling Association. 

Ethical Considerations

Narrative therapists are generally anti-objectivists who challenge theoretical models used to define, objectify, or classify people (Neukrug, 2016). As a result, they tend oppose diagnoses found in the Diagnostic and Statistical Manual of Mental Disorders. Narrative therapists could do harm to clients and potentially be held liable if they miss or refuse to acknowledge when clients have diagnosable mental disorders that remain unaddressed. Every issue cannot be corrected with talk therapy; thus, narrative therapists must remain vigilant and address disorders or refer clients to other specialists when they encounter issues beyond their scopes of practice.

 Conclusion

Narrative therapy is relatively new, yet it offers promise for clients reporting with issues that have social, cultural, and political contexts; clients who over-identify with formal diagnoses; clients living with depression; and for families resolving parent-child conflicts. However, narrative therapy may be problematic when counseling theists or clients seeking expert solutions.  

Narrative therapy is also plagued by a lack of qualitative research and standardized specialty training. Despite these limitations, narrative therapy is used extensively to counsel families and individuals, and its techniques are used by therapists with varied theoretical backgrounds.

References

Corey, G. (2017). Theory and practice of counseling and psychotherapy (10th ed.). Boston, MA: Cengage Learning.

Dulwich Centre. (n.d.). Masters program in narrative therapy and community work. Retrieved from https://dulwichcentre.com.au/training-in-narrative-therapy/masters-program-in-narrative-therapy-and-community-work/

Etchison, M., & Kleist, D. M. (2000). Review of narrative therapy: Research and utility. The Family Journal: Counseling and Therapy for Couples and Families, 8(1), 61-66. doi: 10.1177/1066480700081009

Lopes, R. T., Gonçalves, M. M., Machado, P. P. P., Sinai, D., Bento, T., & Salgado, J. (2014). Narrative therapy vs. cognitive-behavioral therapy for moderate depression: Empirical evidence from a controlled clinical trial, Psychotherapy Research, 24(6), 662-674. doi: 10.1080/10503307.2013.874052

Neukrug, E. (2016). The world of the counselor: An introduction to the counseling profession (5th ed.). Boston, MA: Cengage Learning.

Phipps, W. D., & Vorster, C. (2015). Refiguring family therapy: Narrative therapy and beyond. The Family Journal: Counseling and Therapy for Couples and Families, 23(3), 254-261. doi: 10.1177/1066480715572978

Vromans, L. P., & Schweitzer, R. D. (2011). Narrative therapy for adults with major depressive disorder: Improved symptom and interpersonal outcomes, Psychotherapy Research, 21(1), 4-15. doi: 10.1080/10503301003591792

White, M., & Epston, D. (1990). Narrative means to therapeutic ends. New York, NY: W. W. Norton and Company.

 

Occupational Therapy After A Stroke Health And Social Care Essay

This meta analysis of the referenced studies aim to evaluate efficacy of occupational therapy: whether it focused specifically on personal activities of daily living improves recovery for patients following stroke and to know does .Occupational therapy aims to help people reach their maximum level of function and independence in all aspects of daily living.
Reviewing 07 studies with 1178 participants, people who had a stroke were more independent in personal activities of daily living like feeding, dressing, bathing, toileting and moving about and more likely to maintain these abilities if they received treatment from an occupational therapist after stroke.
Abstract (around 200-250 words)
Aims A systematic review of studies testing the effectiveness of occupational therapy in post stroke patient, focused specifically on personal activities of daily living improves recovery for patients following stroke.
Data sources We searched EBSCOMEDLINE, EMBASE, CINAHL and the Cochrane Library (2000- 2010). AMED:
Selection criteria Selection criteria included studies that used randomized controlled trials of an occupational therapy intervention compared to usual care or no care, where stroke patients practiced personal activities of daily living, or performance in activities of daily living was the focus of the occupational therapy intervention.
Review methods A meta-analysis, using a random effects model, of 24 programmes identified in 19 trials. Effect sizes were adjusted by inverse variance weights to control for studies’ sample sizes.
Findings.Main Result
We identified 64 potentially eligible trials and included nine studies (1258 participants). Occupational therapy interventions reduced the odds of a poor outcome (Peto odds ratio 0.67 (95% confidence interval (CI) 0.51 to 0.87; P = 0.003). and increased personal activity of daily living scores (standardised mean difference 0.18 (95% CI 0.04 to 0.32; P = 0.01). For every 11 (95% CI 7 to 30) patients receiving an occupational therapy intervention to facilitate personal activities of daily living, one patient was spared a poor outcome.
Conclusions
Patients who receive occupational therapy interventions are less likely to deteriorate and are more likely to be independent in their ability to perform personal activities of daily living. However, the exact nature of the occupational therapy intervention to achieve maximum benefit needs to be defined.
.
Chapter 1: Introduction:
The overall aim of this meta analysis was to evaluate the effectiveness of OT in post stroke patient. Extensive literature search was done by locating published stroke rehabilitation management intervention studies that measured personal activities of daily living outcomes among stroke patient. Data were extracted from study reports which included interventions designed to improve post stroke activities of patient.

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From WHO’s report of global burden of stroke it was found that Worldwide 15 millions people suffer a stroke annually. 5milloin of these die and another 5 million are left permanently disabled, causing burden on family and community. High blood pressure and tobacco use are considered as a major risk factor for stroke (WHO, 2010). The World Health Organisation (WHO) defines Stroke as “a clinical syndrome of resumed vascular origin, typified by rapidly developing signs of focal or global disturbance of cerebral function lasting more then 24 hours or leading to death” (WHO, 1978).
The causes of stroke can be classified as:
Ischaemic cause: blood supply to brain stopped due to formation of blood clot. It causes 70% of all cases.
Haemorrhagic: brain damage caused due to bursting of blood vessel which supply blood to brain
There is also a related condition known as a transient ischaemic attack (TIA), which affect 35 people per 100,000 of population each year and is associated with a very high risk of stroke in the first month of event upto one year (Coull, et al., 2004 ). In transient ischemic attack the blood supply to the brain is temporarily interrupted due to inadequate cerebral or ocular blood supply which is due to low blood flow, thrombosis or embolism. Symptoms last for less than 24hours causing a sort of ‘mini-stroke’ (Hankey and Warlow, 1994).
The risk of death due to stroke depends on its type like TIA has the best outcome whereas blockage of an artery is more dangerous, with rupture of blood vessels. It has found that even if country is having advance technology and facilities 60% people die or become dependent causing high cost of treatment (WHO, 2010).
Those of Afro-Caribbean origin are at increased risk of having a stroke, and the number of people affected by the condition is higher among this ethnic group than any other. This is because people of Afro-Caribbean origin have a genetic predisposition (a natural tendency) to developing diabetes and heart disease, which are two conditions that can cause strokes.
Ischaemic strokes occur when blood clots block the flow of blood to the brain. Blood clots typically form in areas where the arteries have been narrowed or blocked by fatty cholesterol-containing deposits known as plaques. This narrowing of the arteries is known as atherosclerosis.
As the age advances, our arteries become narrower, but certain risk factors can dangerously accelerate the process. Risk factors include:
smoking,
high blood pressure (hypertension),
obesity,
high cholesterol levels (often caused by a high-fat diet), and
a family history of heart disease or diabetes.
Diabetes is also a risk factor, particularly if it is poorly controlled, because the excess glucose in the blood can damage the arteries.
Haemorrhagic strokes occur when a blood vessel in the brain bursts. The main cause of this is high blood pressure (hypertension), which can weaken the arteries in the brain and make them prone to split or rupture.
The risk factors for high blood pressure include:
being overweight,
drinking excessive amounts of alcohol,
smoking,
a lack of exercise, and
stress, which may cause a temporary rise in blood pressure.
A person’s ethnic group can also be a risk factor for high blood pressure. Half of all people of black-African or Caribbean origin who are over 40 years of age are likely to have high blood pressure. Research has suggested this is because people of African origin have an increased sensitivity to the effects of salt, which can cause their blood pressure to rise. A haemorrhagic stroke can also sometimes occur as a result of a traumatic head injury (NHS Choices, 2008).
Every year, an estimated 150,000 people in the UK have a stroke. That is one person every five minutes (Office of National Statistics, 2001).The brain damage caused by strokes means that they are the largest cause of adult disability in the UK.
People who are over 65 years of age are most at risk from having strokes, although 25% of strokes occur in people who are under 65 years of age. It is also possible for children to have strokes (NHS Choices, 2008).
Around 1000 people under 30 have a stroke each year. Stroke can result in many different disabilities ranging from motor control and urinary incontinence to depression and memory loss. Disablement has been conceptualized by the world health organization in terms organ dysfunction (impairments), disability (difficulty with task), and handicap (social disadvantage) (Post stroke rehabilitation, 1995).
The analysis of cost of illness of stroke by Saka et al (2009) has found that stroke has greater impact on economy of UK, as treatment of and productivity loss arising due to stroke cost £8.9 billion a year. In which treatment cost is nearly 5% of total UK NHS costs. Direct care including diagnosis, inpatient care and outpatient care accounts for approximately 50% of the total, informal care costs 27% and the indirect costs that is cost resulting from premature death due to stroke is 24%. This study concluded that chronic phase of stroke is most costly and therefore suggested better understanding of long-term care in terms of its effectiveness and cost-effectiveness is necessary.
Due to stroke one side of the body may be paralyzed or the muscles on the affected side may weaken. After stroke treatment is comprise of care and rehabilitation (Post stroke rehabilitation, 1995). During the period of acute inpatient care, patient will receive rehabilitation and care input from a variety of qualified and unqualified nursing and allied health staff. It is therefore important that all staff should be familiar with the consequences of stroke, and able to effectively manage problems relating to stroke appropriately within their roles. The consequences of stroke are manifold; as well as the more visible physical problems; stroke survivors will likely have a number of emotional, cognitive, and communication problems (Ross et al, 2009) Research shows that patients benefit from treatment in stroke units in the acute and rehabilitation phases (Indredavik, 2008).
Rehabilitation is the process of overcoming or learning to cope with the damage the stroke has caused. It is about getting back to normal life and achieving the best level of independence by: relearning skills and abilities; learning new skills; adapting to some of the limitations caused by a stroke; and finding social, emotional and practical support at home and in the community. The benefits of stroke rehabilitation packages are well documented (SUTC, 2000) but little is known about the efficacy of the various components of such interventions.
Rehabilitation requires multidisciplinary approach involving therapist (physical therapist, speech therapist, and occupational therapist), doctors, psychologist and social workers. Occupational therapist teaches the patient daily living skills and how to use living aids such as walkers or bathroom grab bars (stroke rehabilitation, 2010).
After stroke life become difficult due to disability caused by it. stroke have high morbidity rates which means that patient with stroke suffer from both mental and physical disability following stroke. It is the leading cause of lower quality of life in adults. Rehabilitation offers a chance to restore quality of life after stroke. Brain damaged caused due to stroke cannot be healed but rehabilitation helps a patient in maintaining existing abilities and provide strategy for handling disabilities cause by stroke. Stroke treatment depends on time duration after stroke, risk factor that may affect treatment. Depending on these factors stroke treatment include blood thinner medication which can dissolve a blood clot, or brain surgery for rupture blood vessel. Rehabilitation after stroke begins after acute treatment. It helps in relearning the skills lost due to stroke and compensating for disability caused by stroke. It stroke includes memory rehabilitation, language rehabilitation and emotional rehabilitation, motor and sensory control rehabilitation (Healthtree, 2010).
Functional impairment following acute illnesses -such as stroke – frequently have severe physical consequences for adult and older patients (Desrosiers, 2003). Occupational therapy is an essential component for the rehabilitation of disabled patients, having a wide range of interventions available to assist persons towards independence (cup, 2003).
The goal of occupational therapy is to restore functional independence when possible and to facilitate psychosocial adjustment to residual disability (Landi, 2006).
The philosophy of occupational therapy is founded on the concept of occupation as a key element of health and well-being. Practice in social care services embraces the social model of disability and is based on holistic and person-centered care, emphasizing the promotion of self-reliance and resourcefulness (College of Occupational Therapists, 2008).
The Occupational therapy is commonly used in the post stroke patients by an occupational therapist with the specific aim of facilitating personal activities of daily living to improve the outcomes for patients following stroke. Different trials have been conducted in different countries to prove the effectiveness of occupational therapy but there is lack of evidence suggesting that occupational therapy interventions can reduce the likelihood of such deterioration and improve patients’ ability to perform personal activities of daily living. Therefore the aim of this Meta analysis is to evaluate the efficacy of occupational therapy on stroke rehabilitation.
The main aim of occupational therapy (OT) is to maintain, restore or create a match beneficial to the individual between the abilities of the person, the demands of his or her occupations and the demands of the environment (Creek, 2003) Activity and participation limitations in stroke typically diminish health and wellbeing As a result, improvement of functional abilities, improvement of participation in society and an increased quality of life are important outcomes of OT treatment (Steultjens, 2005).
Historically, several treatment approaches have been introduced and adopted by physical and occupational therapists. The stroke rehabilitation methods adopted by therapists vary widely depending on their background knowledge, clinical experience, clinical skills, and personal preferences [6-9]. The availability of a plethora of treatment methods shows that stroke rehabilitation practices are continually evolving. Previous studies conducted
in the United Kingdom used surveys to determine common treatment practices in stroke rehabilitation among physical therapists [10-11].
The result of the study by Landi et al. (2006) shows that patients with stroke who received the combined program of physical and occupational therapy had a greater level of independence in activities of daily living over a period of 8 weeks than patients who did not.
It has been found from the Cochrane review of benefits of stroke rehabilitation that it reduces approximately 22% in death or dependency and these benefits are more prominent under and over 75 years of age, in both sexes. Length of hospital stay is also reduced due to early rehabilitation (Scottish intercollegiate guidelines network, 2002). Stroke is a complex condition where knowledge base is continuously increasing. There is constant advance in understanding of the condition, assessment and intervention techniques. Occupational therapists are a vital component in the rehabilitation of patient with this condition (Edmans, 2000).
Occupational therapist work with individuals who have conditions that are physically, mentally, developmentally, or emotionally disabling. They help them develop, recover, maintain daily living and work skills. The goal of occupational therapist is to help their client have independent, satisfying and productive lives (Weeks and Zona, 2000).
Chapter 2: The Literature Search
Selection criteria – brief description of the main elements of the question under consideration. This is subdivided into:
Types of studies – eg: RCT’s
Types of participants – the population of interest. This section may include details of diagnostic criteria, if desired or appropriate.
Types of interventions – the main intervention under consideration and any comparison treatments.
Types of outcome measures – any outcome measures/endpoints (for example, reduction in symptoms) that are considered important by the reviewer, defined in advance; not only outcome measures actually used in trials.
Definition of Occupational therapy
World federation of occupational therapist (2004) define Occupational therapy as a profession concerned with promoting health and well being through occupation. The primary goal of occupational therapy is to enable people to participate in the activities of everyday life. Occupational therapists achieve this outcome by enabling people to do things that will enhance their ability to participate or by modifying the environment to better support participation.
The search strategy for systematic reviews of the efficacy of OT has identifies randomised trial comparing occupational therapy with other intervention or no intervention. It has been done by searching EBSCO host research database from 2000-2010. The other sources are Google Scholar and The Occupational Therapy Research Index and Dissertation Abstracts register, scanned reference lists of relevant articles, relevant journals. (1999-2010).
Fifty-three studies were identified and abstracted. Four studies reported total
hemorrhagic stroke as the outcome, which includes intracerebral and subarachnoid hemorrhage.4,7,10,11 None of the studies reported information on subdural hemorrhagic strokes. We have used the term hemorrhagic stroke throughout the article. Two reports consisted of the same case patients but different controls and were treated as 2 separate studies. 23,24 From the 53 studies, 18 were further excluded for various reasons. Two studies were excluded because combined risk estimates were reported for men and women but levels of alcohol consumption were not the same for men as for women.49,50 We excluded 5 studies that examined only the effect of binge drinking or acute alcohol consumption (within 24 hours before stroke)51-55 because our study assessed habitual alcohol consumption and relative risk of stroke. Five studies that lacked sufficient data for calculation of relative risk estimates were excluded.56-60 The remaining 6 excluded reports did not use abstainers as the reference group.61-66 We included 19 cohort studies and 16 case control studies in our final analysis
Types of studies
This study included randomized controlled trials of stroke patients receiving an occupational therapy intervention provided by an occupational therapist. All of the selected studies intend to improve personal activities of daily living compared to usual care or no care in post stroke patient.
If large randomized trials are impractical, we have to draw the most reliable conclusions from smaller trials. Unfortunately, the conventional approach, the narrative review is unreliable. Conventional review usually fails to define the review question, to ensure that all relevant trials are explicitly based on the evidence. Systematic reviews set out to improve upon narrative reviews by applying scientific methods to the review of the research evidence (Langhorne, et al., 2008).
Types of participants:
This study included the trial if the participant of the study met the clinical definition of stroke as defined by WHO “a clinical syndrome of resumed vascular origin, typified by rapidly developing signs of focal or global disturbance of cerebral function lasting more then 24 hours or leading to death” . All of the included studies have given clear inclusion criteria. They include participant on the basis of clinical diagnosis, except Sackley et al (2006) included residents with moderate to severe stroke-related disability by using Barthel Activity of Daily Living Index score (BI score 4 to 15 inclusive). Participants with other acute illness are excluded from the studies.
Types of intervention:
In this study trials are include if they have following features:
• Occupational therapy intervention which specially focused on activities of daily living and tried to improve their personal activities of daily living.
• The trials are included in which control group receives normal care or no intervention.
• Interventions are provided under the supervision of qualified occupational therapist.
The study by Sackley et al (2006) has developed an intervention by using existing evidence with the help of a group of expert occupational therapists delivered on individual level. The period of intervention was three month which include occupational therapy and carer education, wheras
INCLUSION CRITEIA:
Researcher included studies that used randomized or controlled clinical designs, of an occupational therapy intervention, compared to usual care or no care. In which stroke patient’s performance in terms of activities of daily living was the focus of the occupational therapy intervention
Data sources
Selected database is EBSCO host web research database this collection of databases provide access to key journals, many having links to full text journal articles.
It contains various databases as follow:
AMED
British Nursing Index
CINHAL plus with full text
MEDLINE with full text
SocINDEX with full text
The other sources are Google Scholar and The Occupational Therapy Research Index and Dissertation Abstracts register, scanned reference lists of relevant articles, relevant journals. (1999-2010) (See Appendix 1).
Key words or term used in literature search
KW: Stroke in Title
Rehabilitation in Abstract
Randomised controlled trail in Abstract
Selection criteria
Time frame: 2000-2010
Randomized controlled trial
Language or national context: English language only
Main focus of paper: Stroke rehabilitation
Peer reviewed journal only
National and international studies.
Types of outcome measure
The out come measure are that reflected the change in personal activities of daily living in stroke patient after receiving occupational therapy
Primary outcome
(1) Performance in personal activities of daily living (pADL including:
feeding, dressing, bathing, toileting, simple mobility and
transfers) at the end of scheduled follow up.
(2) Death or a poor outcome. Death or a poor outcome is defined
as the combined outcome of being dead or:
• having deteriorated, characterised by experiencing a
deterioration in ability to perform personal activities of daily
living (that is, experiencing a drop in pADL score); or
• being dependent, characterised by lying above or below a
pre-defined cut-off point on a given pADL scale; or
• requiring institutional care at the end of scheduled follow
up.
Secondary outcomes of interest
(1) Death at the end of scheduled follow up
(2) Number of patients dead or physically dependent at the end
of scheduled follow up
(3) Number of patients dead or requiring institutional care at the
end of scheduled follow up
(4) Performance in extended activities of daily living (community
and domestic activities) at the end of scheduled follow up
(5) Patient mood at the end of scheduled follow up
(6) Patient subjective health status or quality of life at the end of
scheduled follow up
(7) Carer mood at the end of scheduled follow up
(8) Carer subjective health status or quality of life at the end of
scheduled follow up
(9) Patient and carer satisfaction with services
We aimed to record outcomes that reflected resource use (that is the
number of admissions to hospital, number of days in hospital, aids
and appliances provided, number of staff required per caseload).
Search methods for identification of studies
See: ‘Specialized register’ section in Cochrane Stroke Group
Occupational therapy
Secondary outcome
EXCLUSION CRITERIA:
Papers excluded from the review were works that focused predominantly upon:
Stroke rehabilitation studies before 2000.
Which are not published studies
Which are other than English language
Research Design
A meta-analysis, by using quantitative methods such as a random effects model, of 7 randomized controlled trial identified literature search.
Analysis of Data
Researcher will analyse binary outcomes with a fixed-effect model, as odds ratios (OR) with 95% confidence intervals (CI). For continuous outcomes, a random-effects model will be used to take account of statistical heterogeneity. As there is some heterogeneity between the trials in terms of their design, duration of follow up and selection criteria for patients.
Researcher will performed an intention to treat analysis to reduce potential biases in terms of follow-up, publication, and reporting bias associated with extracting data from published reports. Publication bias will be assessed with a rank correlation test and a funnel plot.
Systematic reviews show that occupational therapy increases functional ability and/or social participation in elderly people and in patients with stroke or rheumatoid arthritis. For patients with progressive neurological diseases, cerebral palsy or mental illnesses the efficacy of occupational therapy is still unclear because high-quality studies are lacking.
Chapter 3 – Methodology
Justification of methodological approach – qualitative or quantitative
Methods of the review – description of how studies eligible for inclusion in the review were selected, how their quality was assessed, how data were extracted from the studies (evaluated), how data were analysed, whether any subgroups were studied or whether any sensitivity analyses were carried out,
A major challenge with stroke rehabilitation is that the intervention itself is likely to be very complex and non uniform. Any intervention developed by therapist or multidisciplinary team will involve many components which may interact in different ways. It is likely that these interventions may a mixture of both effective and ineffective elements so it is important that we are aware of variability between the different trials and we explore this variability when analyzing the result (Langhorne, et al., 2008).
Chapter 4 – The Studies
Description of studies – how many studies were found, what were their inclusion criteria, how big were they, etc.?
Methodological quality of included studies – were there any reasons to doubt the conclusions of any studies because of concerns about the study quality?
4.1 Characteristics of included studies:
Characteristics of included studies
STUDY
METHODS
PARTICIPANTS
INTERVENTION
OUTCOME
Cindy 2004
HongKong
Pretest and posttest randomized control trial
design
-53 participants
-Age: 55 years or older.
-Mean age: 72.1
-With primary diagnosis of stroke
-Living at home
Intervention group received additional home-based intervention in the use of devices
immediately after discharge, but the control group did not.
Subjects were assessed by
1.Functional Independence Measure and
2. The Quebec User Evaluation of Satisfaction with Assistive Technology.
Gilbertson,
2000.
Glassgow
Single blind randomised controlled trial.
-138 participants
-Mean age: 71
-with clinical diagnosis of stroke
-were admitted to
Glasgow royal infirmary NHS trust were
Intervention group received 6wk domiciliary programme and control group received included inpatient multidisciplinary
Rehabilitation.
Subjects were assessed by
1.Nottingham extended activities of daily living scale
2. Barthel activities of daily living index.
Landi, 2004
USA
-50 Participants
-Mean age: 78.3
– With primary diagnosis of ischemic stroke
Intervention group received received 8 weeks of a combined rehabilitation program based on occupational therapy and physiotherapy
received no input from the occupational therapists
Subjects were assessed by
-MDS-PAC
– ADL scale
Logan,2004
UK
Randomised controlled trial.
-168 participants
-Mean age: 74
– clinical
diagnosis of stroke in previous 36 months
Intervention group received leaflets with assessment
and up to seven intervention sessions by an occupational
therapist. Control group received leaflets describing local transport services for
disabled people
-Postal questionnaires
– Nottingham extended
activities of daily living scale, Nottingham leisure questionnaire,
and general health questionnaire.
Parker,2000
UK
Multicentre randomized controlled trial.
-466 Participants
-Mean age: 72
.Randomization was done in three groups.
two treatment
groups received occupational therapy interventions at home for up to six months after recruitment.
The General Health Questionnaire (12 item), the
Nottingham Extended ADL Scale and the Nottingham Leisure Questionnaire
Logan,2004
UK
Randomised controlled trial with concealed
allocation and blinded assessment.
-168 Participants
-Mean age:74
-patients with a clinical diagnosis of stroke in the
previous 36 months
Control group received one session consisting of advice, encouragement, and the provision of leaflets describing local mobility services. intervention group received
the leaflets plus occupational therapy assessment and
up to seven intervention sessions for up to 3 months.
Primary outcome was self-report, Secondary outcomes were 1-self-report of the number of journeys outdoors in the past month, 2-Nottingham extended activities of daily living scale, 3-Nottingham leisure questionnaire. 4-general health questionnaire.
Sackley,2006
UK
cluster randomized controlled trial
-118 Participant
-Residents with moderate to severe
stroke-related disability
– Residents with acute illness and those admitted for end-of-life care.
Occupational therapy was provided to intervention group but included carer education.
control group received usual care
1-Barthel Activity of Daily Living Index (BI) scores
2-Rivermead Mobility Index.
Characteristics of intervention included in study
Author
Sample size
interventin
control
consent
Randomization detail
Setting
Cindy 2004
HongKong
M
F
Gilbertson,
2000.
Glassgow
M
F
Landi, 2004
USA
M
F
Logan,2004
UK
M
F
Parker,2000
UK
M
F
Logan,2004
UK
M
F
Logan,2004
UK
M
F
Chapter 5 Findings / Results
What do the data show? The synthesis of results – thematic analysis or statistical analysis. Accompanied by a graph to show a meta-analysis, if this was carried out.
Chapter 6 – Discussion
Interpretation and assessment of results.
Chapter 7 – Conclusion
Subdivided into Implications for practice and Im
 

Role of the Therapeutic Relationship in Cognitive Behavioural Therapy

The therapeutic relationship is seen as one of the main therapeutic tools for achieving client change (Luborsky, 1994).

Critically evaluate the above comment, describing the role of the therapeutic relationship and of theory and technique in CBT.

The importance of the relationship between practitioner and client has long been documented in psychodynamic therapy to be a fundamental tool in achieving client change (Rosenzweig 1936; Rogers, Laurance, & Shaffer, 1957; Orlinsky, Grawe & Parks, 1994). Conflictingly, CBT has been historically criticised for its textbook, structured approach and ignoring the importance of the practitioner-client interaction with a focus instead on theory and technique (Easterbrook & Meehan, 2017). In 2001, Wampold in his controversial article, “The Great Psychotherapy Debate”, criticised the use of empirically supported treatment for specific psychological presentations and explored the concept of common factors across all therapies with an emphasis on the therapeutic relationship when considering change outcomes (Wampold, 2001; Wampold, 2015). This therefore suggests that the therapeutic relationship is as important in CBT as other therapies. In agreement with this, there are some researchers which even suggest a stronger association between therapeutic relationship and outcome in CBT more than any other therapy (Bohart et al., 2002; Stiles et al., 1998). Conversely, researchers such as Raykos et al., (2014) concluded that in their study on the use of the therapeutic relationship in CBT with clients living with bulimia, there showed no evidence that the relationship can predict treatment retention or outcome. In my previous work as a Psychological Wellbeing Practitioner (PWP) and in my current role as a Trainee Counselling Psychologist, I find the therapeutic relationship of crucial importance particularly when working with clients from a range of backgrounds in a short term therapeutic setting. Thus, due to the conflicting evidence on this topic; this essay will aim to critically explore and evaluate the scope of the therapeutic relationship within CBT and of theory and technique, focusing also on the role of the practitioner versus the client in this relationship and the consequences, if any, in achieving client change when the therapeutic relationship is challenged or ruptured.

 

How important is the therapeutic relationship in CBT?

 

Throughout research the therapeutic relationship within CBT has been defined in many ways. Leahy & Gilbert, (2017, p.10) offer the most updated definition stating that the therapeutic relationship is, “the affective bond and partnership; the cognitive consensus on goals and tasks and relationship history of the participants”. Today the majority of CBT research acknowledges some form of therapeutic relationship and the impact of this on change outcomes (Wampold, 2015; Easterbrook & Meehan, 2017; Leahy & Gilbert, 2017, p.10). Moreover, at present, the British Association for Behavioural & Cognitive Psychotherapies (BABCP) as one of its accreditation criteria, stipulate that practitioners should be reflecting a genuine, warm, concerned interest in the client’s perspective and presentation (BABCP, 2017). In psychodynamic theory, the therapeutic relationship is often considered to be in three parts; the working alliance, transference/countertransference and the real relationship (Bordin & Kovacs, 1979). Critically, Kazantzsis (2018) also state within CBT there are also 3 specific elements present within therapeutic relationship; collaboration, empiricism and Socratic questioning. Despite this, both practice based research and technique in CBT are also seen to have key influence and there is ongoing debate about which of these factors has the most significance in achieving lasting client change.

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To work collaboratively with their clients; CBT textbooks suggest practitioners should operate as the guide rather than the instructor and acknowledge the client as the expert in their experience (Bennett-Levy, 2010 p90). Arguably, this is similar to the working alliance of psychodynamic theory which suggests, “A therapeutic alliance based on the patient experiencing the therapist as supportive and helpful” and “a sense of working together in a joint struggle against what is impeding the patient” (Horvath, 1993). Despite this similarity in this first key aspect of the therapeutic relationship, Kennerley, Kirk & Westbrook (2017 p. 44) suggest it is instead the nature of the client’s participation that is the strongest predictor of client change and outcome and not the relationship when it comes to CBT. An idea mirrored by Kazantzsis, Whittington & Dattilio, (2010) who suggest that a CBT client who engages in tasks, offers suggestions about treatment and consistently completes homework will have better outcomes than a client who does not regardless of therapeutic relationship.

Yet, when considering the importance of the relationship versus theory and technique in CBT, it is also important to account for the many varieties in which CBT can be offered. For example, Turner, Carpenter & Brown (2018) explored the effects on the therapeutic relationship when looking at CBT completed over the phone. They found that telephone work can accommodate collaboration but not other aspects of the therapeutic relationship which often practitioners and service users hope for. Furthermore, with online therapy there can often be a complete absence of a relationship particularly when clients use guided self-help computer programmes but dropout rates for these programmes are high and improved when a practitioner is assigned to interact with the client (Papworth & Marrinan, 2013). This would therefore suggest that clients require more than just evidenced based practice and technique from sessions. Moreover, Chaddock (2013) has proposed that attending to interpersonal factors is even more important in short term therapies where a relationship must be built quickly to increase client participation and facilitate change. In my own experience as a PWP in primary care, the therapeutic relationship is one of the biggest factors for change and in increasing homework adherence and client attendance. Often clients whom I struggled to build this relationship as quickly would complete less homework and often not attend sessions as regularly. It could then be argued that the relationship allows the client to engage with theories and technique more easily; an idea echoed by Teyber (2011) who states that the therapeutic relationship is the foundation of trust a key factor in leading to change for the client.

The second criteria for the therapeutic relationship within CBT according to Kazantzsis (2018) explores empiricism. As part of applying theory to practice and in successfully using CBT techniques, the CBT practitioner has the responsibility for individualising each intervention to the client’s experience (e.g. mood ratings, thought diaries) and using these as a gauge for evaluating client’s hypothesis about what will happen in treatment and the changes they would like to make going forward in their lives (Glenn et al., 2013). It can therefore be argued that in addition to the skilful use of common factors and counselling skills, CBT has specific structured components which require the practitioner to be even more flexible with the relationship (Glenn et al, 2013). This then suggests some support for studies which show that the therapeutic relationship is even more important in CBT than in other forms of therapy (Bohart et al., 2002; Stiles et al., 1998). Additionally, the second aspect of the therapeutic relationship in psychodynamic theory highlights the importance of countertransference and transference. These two are also closely monitored in CBT and not absent. Practitioners are required to be self-reflecting and research highlights the importance of the CBT therapist becoming aware of their own dysfunctional thoughts, behaviours and emotions as to not negatively impact their relationships with their clients. As a result, much of these concepts are built into reflective and supervision processes within CBT (Leahy & Gilbert, 2017). In my personal experience, using empiricism and careful application of technique individualised to clients, can create substantial motivation for change particularly with clients who may have tried to apply CBT approaches in the past and found them unsuccessful. For example, I have experience of using mindful chocolate eating or mindful tea making in sessions to allow creativity for clients who feel they have been unsuccessful with learning more traditional mindfulness approaches in the past and found by individualising the technique this increased mindfulness uptake. Additionally, supervision and reflection in my opinion, allows me to further explore the relationship and aids positive outcomes.

The third criteria by Kazantzsis (2018) for the effective therapeutic relationship in CBT is the use of Socratic questioning (Padesky, 1995). Used in CBT to aid guided discovery, Socratic questioning it is a key part of CBT’s value that clients should become their own therapists at the end of their treatment (Kennerley, Kirk & Westbrook, 2017). In my work, I feel this is the ultimate goal for client change and for preventing relapse. Teaching clients to become their own practitioners has also been shown to be effective in preventing relapse by Degnan et al., (2016). Unfortunately, limited research exists on the third aspect of the psychodynamic therapeutic relationship the ‘real relationship’ and the meaning of this within psychodynamic therapy.

Thus, within CBT it seems difficult if not impossible to separate theory and technique from the therapeutic relationship. For example, Persons, Davidson & Thompkins, (2001), suggest between session interventions or ‘home practice’ work as the main vehicle for change, more so than any other element in CBT. Yet CBT therapists take a collaborative, empirical and Socratic approach to reviewing home practice. For this reason, further research is needed to explore the breakdown of specific aspects of the therapeutic relationship and the application of these to each evidence-based technique used in CBT. Some research has already begun in this area with Kazantzis et al. (2018) suggesting a, “Russian doll”, process which concludes that techniques (including homework, agenda adherence and other key factors) are inseparable from the therapeutic relationship but also highlights that some aspects of the therapeutic relationship are more significant than others but this paper also acknowledges the need for further research. Moreover, it would be helpful for future research to compare further the therapeutic relationship in CBT and the similarities and differences to the therapeutic relationship in psychodynamic and other therapies.

Roles within the relationship: Client versus Practitioner

Like all relationships roles are adopted in CBT and as a result both therapist and client have roles to play when it comes to the therapeutic relationship. Recent research has highlighted the importance of thinking outside of the immediate dynamic between client and practitioner and beyond collaboration, empiricism and Socratic questioning to look at within characteristics of both client and practitioner and the impact this may have on outcomes. For example, research by Zuroff et al., (2016) states that the within characteristics of the therapist are one of the biggest factors in determining client outcomes when it comes to depression. Further, more recent research by Kazantzsis (2018) also suggests that the amount of flexibility the therapist has with a client and the more open minded the therapist can be, the better implications client change. Moreover, Bennett-Levy (2010) suggest the therapist’s level of training is also a key factor and that insecure therapists are often over involved in their client’s goals and have poorer client outcomes. Research by Fonagy, Allison & Hilsenroth, (2014) has also highlighted the therapist characteristics which are associated with negative aspects of the therapeutic relationship including being ridged, uncertain, distant, and tense or distracted as a therapist. This research would therefore suggest the therapist has a great deal of power in the therapeutic relationship to produce change perhaps sometimes even more so than the client.

However, some researchers argue there are several within characteristics influencing the client in the relationship which have the biggest impact on outcomes. For example, Degnan et al., (2016) suggest that service users with more preoccupied attachment styles may find it difficult to form positive attachments. In my personal experience in assessing clients with attachment disorders as an assistant psychologist the therapeutic relationship is more difficult to establish and maintain but is helped with appropriate supervision from more experienced colleagues. However, in a study conducted by Hollon, Stewart & Strunk et al., (2006), clients show no increased vulnerability following the end of therapy suggesting perhaps the have the role of the therapist becomes less important over time. Moreover, an alternative hypothesis is also suggested by Derubis, Brotman & Gibbons, (2005), who state that in depressed client’s cognitive symptom reduction causes improvements in the therapeutic relationship and not vice versa.

In my own experience, it is a combination of both the client and the therapist unique characteristics which can create the biggest change in the client. As described by Leahy & Gilbert (2017) both client and therapist bring their own experiences of past relationships to the therapeutic setting. Therefore, it is a dysfunctional belief that all therapists have the flexibility, interpersonal and technical skills to work with all clients and this is an important factor to consider. For both parties the therapeutic relationship will be a process of an ongoing negotiation between the needs of self versus the needs of other (Leahy & Gilbert, 2017). In this way the therapeutic relationship is an important tool for change within CBT, but the role of the therapist and client can vary drastically from one therapist-client relationship to the next. Although further research is needed in this area, the potential uniqueness of each client-practitioner relationship could have important ramifications particularly in terms of the reproducibility and external validity of studies.

Moreover, there are a number of factors outside the role of the client and the therapist which affect the therapeutic relationship. For example, Leahy & Gilbert (2017) suggest for clients to benefit from therapy the treatment often needs to be of more than six months in length in order for there to be enough time for a sufficient therapeutic relationship to form. Additionally, culture, social status and other demographic variables also have a role to play (Hays, 2013). For example, Chu et al., (2016) also found that in a number of studies matching therapist and client in terms of cultural background can improve outcomes, enhance the therapeutic relationship and decrease premature termination of therapy. Therefore, as well as the therapeutic relationship itself and the within characteristics of both client and therapist external factors are an important consideration.

 

Factors affecting change: Ruptures and Boundaries

 

Finally, when considering the therapeutic relationship as one of the main therapeutic tools for achieving client change in CBT it is important to consider what happens when the relationship goes wrong. Notably, within therapy a positive therapeutic relationship is seen as necessary but not sufficient for change to occur (Leahy & Gilbert, 2017). Heins, Knoop & Bleijenberg (2013) suggest that when using CBT for chronic fatigue syndrome a large part of treatment variance (25%) relies on a positive working relationship developed early on in therapy and being developed and maintained throughout treatment. In contrast, Kennerley, Kirk & Westbrook (2017, p 49) encourage practitioners to not be afraid of ruptures in the relationship. They advise practitioners to, “not be surprised that ruptures in the working alliance occur’ stating that ‘your client’s problems have often become so entrenched that he is unable to deal with them independently”. They suggest emotional distress, not carrying out homework and various other client signals as signs that there is a rupture in the relationship. Similarly, Watson, Thomas & Daffern (2017) suggest using ruptures as a chance to provide the client with a corrective emotional experience; however they emphasise doing this carefully as clients in their study who end therapy with poorer therapeutic alliance and major ruptures were associated with poorer outcomes.

Furthermore, when using ruptures in the relationship to create change, it is also imperative to consider the power within the relationship and the client’s view of this. In my experience, the nature of the therapeutic relationship means the practitioner often knows the client’s deepest feelings and the client knowing only superficial facts about the therapist. This can easily lead to a power imbalances throughout therapy (Bhui, 2018). Within CBT power is typically balanced using collaboration and other aspects of the relationship (Bhui, 2018), but the idea of using ruptures may force a client to engage in material (s)he is not ready for causing a significant power imbalance. Muran et al., (2009) suggest power can be rebalanced if the therapist develops self-awareness to their own subjective feelings and understands the rupture as an ongoing negotiation process constantly in flux and uses the rupture as a window into the patient’s interpersonal belief system. However, therapists can easily underestimate the seriousness of a client’s problem (Snow et al., 1990). It then seems plausible that they could easily led a client to address something for which they are not yet ready which could have an impact on client outcomes. Moreover, clients are often likely to feel inferior to their therapist and made hide this for fear of losing the therapeutic relationship (Leahy & Gilbert, 2017).

With this in mind, there is also conflicting research on the best ways to use ruptures in CBT. Aspland et al., (2008) suggest a rupture repair model for CBT therapists which does not involve discussing the rupture with the client. Conversely, Muran et al., (2009) recommend a five stage approach to ruptures including exploring the rupture with the client in sessions. Upon reflection on my own practice, I find ruptures in relationships with clients a difficult process. As a trainee, keen to please the client and improve service outcomes, I struggle to use ruptures as a way of emphasising the change process. Research in this area is limited and I would therefore welcome further research into more specific methods of using ruptures with clients in CBT and would be keen to learn more about the impact of the concept of wanting to please in practitioners, particularly trainees who may be keen to prove themselves.

In conclusion, the myth that the therapeutic relationship is not important in CBT is in more recent times largely unsupported. At the most fundamental level, if a client is willing to reveal personally significant material, carry out behavioural experiments and trust the therapist, a positive relationship must be formed for effective therapy to occur (Kennerley, Kirk & Westbrook 2017, p35). As highlighted by Kazantzis et al., (2018) when CBT was designed by Beck the need for the therapeutic relationship or ‘collective empiricism’ seems to have been not clearly understood. The therapeutic relationship in CBT is embedded within its evidence base and techniques and shares common factors with other therapeutic relationships in other forms of therapy. As described by Leahy & Gilbert (2017), there is much to suggest the therapeutic relationship and technical aspects of skill building in CBT are likely to act in reinforcing ways. In this respect the therapeutic relationship can be seen as one of the main therapeutic tools for achieving client change. However, more research is needed to explore the exact definition of the therapeutic relationship in CBT, the links between each aspect of the relationship and the evidence based techniques used and careful consideration is needed for other factors of the relationship including the within characteristics of the practitioner and of the client, external factors including session length, social and cultural factors and the impact of client-therapist matching. Careful consideration must also be given to the best use of ruptures in the relationship. In my experience, only in this way can the therapeutic relationship within CBT be fully utilised as a tool to achieving lasting client change.

References

 

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Watson, R., Thomas, S. & Daffern, M. (2017). The Impact of Interpersonal Style on Ruptures and Repairs in the Therapeutic Alliance between Offenders and Therapists in Sex Offender Treatment. Sexual Abuse: A Journal of Research and Treatment, 29(7), pp.709–728.

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Existensial Approach to Individual Therapy

 

To begin, there have been many approaches to group therapy. Some recently discussed approaches include the Psychoanalytic approach founded by Sigmund Freud (1856-1939), the Adlerian approach founded by Alfred Adler (1870-1937), and the psychodrama approach to group therapy founded by Moreno, Moreno, & Blatner (1930) as stated by Corey (2016). The Existential approach was founded by Irvin Yalom (1931). According to Corey (2016), Yalom was born in the poor inner city of Washington, D.C. where he preferred to read fictional novels instead of playing outside. Corey (2016) states that Yalom enjoyed reading the fictional novels so much that he decided that it would be very accomplishing if he wrote his own novel. From that moment, Yalom has produced many novels including Momma and the Meaning of Life (2000) and The Theory and Practice of Group Psychotherapy (1970/2005). Furthermore, Corey (2016) states that Yalom advocates using the here and now and bases his belief of existential therapy on the meaning of life, the role of death, and self-awareness in therapeutic work.

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 Although Irvin Yalom has previously discussed existential therapy as a therapeutic approach to individual therapy, Corey (2016) brings forth Yalom’s therapeutic approach to existential therapy for group settings as well. What is existential therapy? In defining existential therapy, one must first understand the meaning of the word existential. Gerald Corey (2016) best states that the existential approach influences a counselor’s therapeutic practice that focuses on key concepts such as meaning of life, freedom, self-awareness, self-determination, personal responsibility, anxiety, aloneness, authenticity, and death while assisting clients in exploring the existential “givens of life” or existence. It further states that this approach helps individuals regain control over his/her life by acknowledging those existing concerns that are affecting his/her ability to live an effective and productive lifestyle.

  The existential approach is especially useful when in a group setting that yields existential concerns from different group members (Corey, 2016). As a counselor or group leader, you may have a counseling group consisting of individuals who are struggling with handling different existential concerns or issues in their life at the time. One group member may be struggling with overcoming the death of a close family member or companion. One member of the group may be trying to search for meaning in his/her own life. Another member may be suffering from loneliness or isolation. However, the existential approach will be able to assist each group member’s individual concerns by acknowledging the key concepts of the existential approach as mentioned earlier. Corey (2016) states that the existential approach is based on the belief that we as individuals are free and responsible for our own actions, behaviors, and choices in life. In counseling individuals in group therapy using the existential therapeutic approach, the goal is to assist each individual as they try to develop a sense of understanding to their existential givens of life or concerns as a human. As the counselor, we are here to help the clients realize that no one has control over their lives except themselves. The counselor helps the clients understand that he or she has control and is able to guide themselves in the direction that he or she wants to go. According to Schneider and Krug (2010), as stated by Corey (2016), the existentialist is present to help guide the client in the direction of the path the client chooses to pursue by helping the client reclaim and regain control of their own life. In assisting the client in reclaiming their control, Schneider and Krug identified four essential aims of existential therapy, which are: (1) help clients become present to self and others; (2) help clients realize when they are no reaching their full potential of their own presence; (3) help clients assume responsibility for their own life; and (4) encourage clients to choose more expanded ways of being in their current life. Bohart &Wade (2013), as mentioned in Corey, states that clients in group therapy are co-authors of therapy, meaning the group members have say so in the direction they want therapy to go. The beliefs, expectations, and group members’ motivations are influential in the outcome of therapy. 

 In addition to Yalom (1931), Corey (2016) states that there were other cofounders who contributed to the existential theory. Those individuals are Soren Kierkegaard (1813-1855) who is considered the founder of existential philosophy, Martin Heidegger (1889-1976), Jean-Paul Sartre (1905-1980), Rollo May (1981), and James Bugental (1987). Kierkegaard (1813-1855) was a Danish Philosopher who believed that anxiety is how we as human learn to be ourselves. Kierkegaard also believed that human should be encourages to take risks and have faith in making sound choices for ourselves. Heidegger (1889-1976) states that we as human need to remember that we exist in the world and are not just a part of the world. We as human need to live in the real world and acknowledge our authentic selves, in other words, be real with ourselves. Sartre (1905-1980) believed that we as human are free to choose what we are and how we want to live. We choose our own values. We as human tend to not be able to express our freedom so we make excuses and blame our imperfection and inability to express and control ourselves on our condition, illness, or past experiences. Sartre states that no matter what we have been through or the experiences that we have overcome or attempted to move past, whether good or bad, we are able to make choices and become something different. As addressed by Corey, James Bugental (1987) and Emmy van Deurzen (2012) were significant contributors to the development of existential therapy. Corey states that Bugental introduced life changing psychotherapy which helped clients recognize ways in which they have addressed life’s existential questions and analyze how they addressed their issues so that they can live a more authentic life. Bugental analyzed clients’ authenticity during therapy and in real life settings. The British contributor, Deurzen (2012), recognized through client-therapist interactions that clients are resilient and intelligent in the sense of being able to overcome problems and obstacles in their life. Deurzen recognized that her clients did not allow their past issues or hardships define them as a person but found meaning behind their issues and concerns. Clients acknowledge what is most important to them in life.

 Now with giving a little insight on the thoughts and perceptions of the founders and co-contributors of existentialism, Corey explains the purpose of an existential group. When in group therapy, the counselor or group leader wants the clients or participants to view the group setting as the world in which they operate and function by discovering who they are and the purpose they serve while sharing existential concerns whether personal or impersonal. Participants interacting with one another in group therapy will eventually focus on the here and now (Yalom & Josselson, 2014). Through participants’ self-exploration in group therapy, Deurzen (2012) defined these goals as follows: (1) members become authentic with themselves, (2) members’ perspective of themselves and the world is broadened, (3) clarification of members’ meaning to present and future life, (4) come to terms with past, present, and future crises, and (5) understand themselves and others better through effective communication. According to Sharp & Bugental (2001), as stated in Corey, the therapeutic process in existential group therapy focuses attention towards clients finding meaning and purpose within themselves. Members are encouraged to listen to themselves and become more aware of their experiences in life by acknowledging a more openness to life and themselves. Individuals in group therapy start to feel belonged and as a part of individuals who are promoting togetherness amongst one another, providing comfort, sharing existential concerns and a sense that the individual is not alone.

 The current focus of existential approach to group therapy is to direct attention to the individuals’ experiences of overcoming anxiety related to being alone in the world, regaining control over one’s life, and searching for meaning (Corey, 2016). Through exploration of this focus, Corey mentions key concepts of the approach which include self-awareness, self-determination, freedom, and personal responsibility, existential anxiety, death and nonbeing, the search for meaning, the search for authenticity, and aloneness and relatedness. When discussing the human expansion of self-awareness, we think about freedom, choice, and responsibility for self. As an individual’s awareness increases, authenticity increases. Individuals realize that they are able to make new decisions regardless of past experiences and/ or decisions. By learning from the past, everyone is capable of changing and developing their own future (Corey, 2016). Also, Corey mentions that existential group therapy allows individuals to discover their uniqueness in the world by helping them define who they are and become aware of their existence. Increasing awareness in individuals help them to openly express their own unique feelings and views in their world. When expressing feelings and concerns, individuals may be confronted by other group members, which may cause great deals of anxiety especially if an individual is just beginning to open up and acknowledge existence for themselves. However, Corey (2016) believes that anxiety helps individualize an individual by making them aware of the inauthentic self that others may want the individual to be. Bringing self-awareness to individuals allows them recognize that they can make choices for themselves (Corey, 2016). As practicing counselors, we tend to become involved with different clients and families where we may be live that the individual is in counseling involuntarily. We may have children who are seeking counseling because someone such as a parent or guardian told them to. These individuals have not become aware of self because if they were, then they would know that they have a choice whether to be in therapy or not. Some may ask if an individual who has been court ordered to attend 12 group therapy sessions has the choice to attend therapy. The answer is yes. Even though the individual is court ordered to attend sessions, that individual still has a choice. Now the choice may be to attend therapy and have an incident expunged from his record or not attend the sessions and be in contempt of court. However, the individual still has a choice.

 The next key concept that Corey (2016) mentions is self-determination, freedom, and personal responsibility. Individuals are able to assume responsibility for their actions in order to live an authentic lifestyle. Schneider & Krug (2010), as explained in Corey (2016), stated three values that existential therapy embraces: freedom to become, capacity to reflect, and the capacity to act. Viktor Frankl (1963) suggests that there is a connection between freedom and responsibility. Freedom implies that we are responsible for our lives, for our actions, and for our failures to take action. Once we realize and understand that our lives are freely controlled by ourselves, we begin to increase authenticity, meaning we begin to become true to ourselves and begin to live under our own control. We have the capability to be who we are despite existential factors that may try to hinder our being (Frankl, 1963). Corey (2016) described Frankl’s upbringing in which he stated that Frankl where he was part of a German concentration camp where he was a prisoner with no outside freedom. Frankl believed that even then, he made the choice to take control of his own life vowing that he would not choose to suffer. Frankl believed that freedom is not related to the freedom of the conditions or circumstances that present itself but how an individual stand against those conditions or circumstances. We are the change that is waiting to happen. If we wait until others tell us what to do or until the environment or society tells us which way to go, then we would only be bringing more misery and hopelessness to ourselves (Frankl, 1963). Individuals are to become aware of the roles that they have in their own life and once they come to the realization that they can make their own choices and decisions, they will resume control of their life and being. Yalom &Josselson (2014) state it best that once an individual in group therapy begin to openly express themselves to other group members, that individual will begin to see themselves through the eyes of others by learning how their behaviors affect themselves and others.

 Another key concept that Corey (2016) mentions pertains to the clients accepting anxiety as a condition of life. Many of the existentialist mentioned early on state that anxiety is an aspect of human life and is unavoidable. Anxiety arises existentially as a result of being confronted by the givens of life. Vontress (2013) and Yalom (1980) present givens of life to be death, freedom, choice, isolation, and meaninglessness. Deurzen (2012), as stated in Corey (2016) explains existential anxiety to be the basic unease that we experience when we become aware of our vulnerability and our inevitable death. Thinking about the givens of life causes many individuals to have a great amount of anxiety, however, individuals still have the ability to overcome this anxiety through therapy and being able to recognize and acknowledge what he/she can do in order to overcome this anxiety and determine what may be causing this anxiety. Therapist distinguish between normal anxiety and neurotic anxiety. Corey describes normal anxiety as an appropriate response to an event being faced in which freedom is accepted and responsibility is accepted for actions made. Individuals are faced with choices without clear guidelines or knowing the outcome. Neurotic anxiety is said to result when a client fails to move through anxiety related to concrete things that are out of proportion to the situation immobilizing the person (Deurzen, 2012).

 The next concept Corey describes is death and nonbeing. Corey (2016) states that in order for an individual to discover meaning and purpose in life, that individual must acknowledge that death is essential to life and acknowledgment of death will allow the individual to live. It is said that death should not be viewed as a bad thing but if it is acknowledged and individuals realize that death is a part of life then human will start to appreciate life more. Recognizing that everyone is going to die one day will teach the person to live fully. Think about death as you would about life. Clients can use their awareness and acceptance of death as a way to view whether or not he or she is living life fully. Frankl (1963) believes that the length of our time on earth is not as important as how we live our life which will determine the meaning and quality of the life we live. Many are afraid and get great anxiety when thinking about death or dying. Individuals forget to continue living life when thinking about death, but until an individual realizes and comes to the actualization and awareness of self that one day he or she is going to die, life will never be lived fully. That individual will spend the rest of life worrying, searching for meaning and isolating themselves from reality or their authentic self. Corey mentions asking the group to ask themselves how they feel about the quality of their life. Then to question the group with the same question only to answer that question as if they knew that they were about to die. By asking these questions, the client will be able to reflect upon their life to see if they have really been living their life to the fullest. Some individuals may state that they wish they could have done this or that now that they know that they are dying which signifies that they have not been living life to the fullest and being their authentic self.  

 What is meant by the search for meaning? Another concept of existential approach is helping clients discover their meaning in life. Existential therapy helps clients challenge the meaning in their life. The counselor aides in assisting clients to find meaning to their life by asking questions such as “Do you like the direction of your life?” “Are you leased with what you now are and what you are becoming?” “If you are confused about who you are and what you want for yourself, what are you doing to get some clarity?” “What gives your life purpose and meaning?” (Corey, 2016). Viktor Frankl (1963) mentioned that a main reason for stress and anxiety in human nature is due to lack of meaning, viewing existential neurosis as the experience of meaningless leading to emptiness and hollowness known as the existential vacuum. Frankl (1963) also invented logotherapy to help clients find meaning to their life. Frankl explains that even through suffering a pain, an individual is capable of finding meaning in life. It is not the responsibility of the counselor or therapist to tell the client what they should do or what their life should be. The therapist or counselor is there to support and encourage the client to develop his or her own meaning of life for themselves. With the support of the group, participants are able to develop a value system that is consistent with their meaning of life and not conformed to the being of others (Corey, 2016).

 When speaking about authenticity and becoming one’s own self, Corey explains that existential group therapy is beneficial in helping individuals view oneself and believe in their own belief without reflecting what others think. There may be many suggestions and conversation about what direction a person should take or how an individual may handle a particular problem, however, it is up to the individual to decide what they would want to do or how they would like to handle a particular situation. Group counseling helps individuals sort out who they are and allows individuals to come to a full appreciation of themselves in relation to others in the group setting (Corey, 2016).

 Corey (2016) describes existential isolation as being our aloneness in the universe. Each individual would like to create his or her own identity, however, in doing so, we as human tend to connect with others as well. Aloneness and isolation are pertinent factors that can hinder an individual from being able to connect with others while trying to identify with themselves. What individuals fail to realize is that when they are trying to connect with others while searching for answers for themselves, the individual tends to inherit the beliefs and values of others causing the individual to fall into the stigma of society and how the society perceives human to be. This causes the individual to not be true to themselves or authentic but subjective to what others expect or suppose is expected (Corey, 2016). In the text, Corey explained the courage to be, the experience of aloneness, experience of relatedness, and struggles with our identity in unmasking who we are as human beings. As counselors, we are expected to assist our clients with building courage to acknowledge their existence and being in the world no matter how difficult or scary it may be. Corey states that aloneness is part of human experience and in order to overcome this sense of aloneness, the individual has to come to realization that he or she cannot depend on anyone else other than themselves to find meaning to their life and acknowledge how he or she will live. The client must be able to stand alone before he or she can team up with another individual(s). It is the client’s challenge to learn to build that rapport with themselves before building relationships with someone else. Find out and get to know yourself before entering into someone else’s world or allowing someone else to control your world. We as human feel that we need to be a part of a relationship other than with ourselves. We feel that we need to help others before helping ourselves. We become trapped in a doing mode rather than being mode (Farha, 1994). As the counselor, we are there to help clients realize that they have lost their identity through allowing others to control and have the say so of what is and what should be of their life. Counselors allow clients the opportunity to now find their own answers and solutions to their problems.

 In addressing the roles and functions of the group leader, we focus on the main role of the group leader, according to Bugental (1997), is to increase awareness to group members individually. Corey (2016) states that the primary role of the group leader, when relating to encouraging cohesion in the group, is to foster meaningful relationships amongst members of the group by having each member openly discuss existential concerns while other members interact and give feedback so that concerns can be fully explored. Existential therapists value authenticity and use of self disclosure to help build therapeutic relationships with group members. Group leaders encourage members to assess restrictions on their own freedom, reflect on increasing choices, and take responsibility for their choices. Existential therapists help clients reflect on situations in their present life, face what happens, and think for themselves without depending on the thoughts and expectations of others.

    According to Corey (2016), the existential approach does not focus on techniques to incorporate with clients as does other approaches that have been mentioned before. Emphasis is on understanding the client in the present moment. May (1983) states that in order to be able to incorporate techniques with clients in therapy, you must show understanding of the client in his or her subjective world. Encounter and dialogue between client and therapist are what heals the client, not theories and techniques (Elkins, 2007). Clients are encouraged to face their concerns and difficulties rather avoid and go around them. Although there is no specific technique(s) for existential therapy, existentialist use a variety of techniques and interventions from various therapeutic approaches (Deurzen & Adams, 2011). In addition to Deurzen (2011) stating that the existential approach does not have a specific technique to incorporate in therapy, she mentions, as stated by Corey (2016), that silence, questions, and making interpretations are some interventions suggested. Corey also mentions three phases of existential therapy: initial phase, middle phase, and final phase. During the initial phase, clients identify and clarify beliefs, values, and assumptions. Middle phase is when clients are involved in self-exploration causing them to restructure attitudes and values of self. The final phase is where clients are instructed to now use all they have learned and put skills and learned information into action.

 Strengths to existential therapy in group is its focus on spirituality and meaning of life (Corey,2016). The greatest peace of mind comes from individuals listening to themselves and finding authenticity of their lives (Vontress, 2013). Limitations to this approach to group therapy include it being useless for individuals who do not want to find meaning and existence to their life; those who are seeking problem-solving methods; and those who looking for someone to direct them in the direction to go in life. 

Recent studies of a therapeutic group of white British elderly individuals was conducted to examine how existential therapy helps elderly in their transition to retirement. It was concluded that majority of the elderly found comfort in the group therapy as well as began to find meaning to oneself and enjoyed and appreciated the help and insight they received from interactions within the group from members. One member, however, discontinued sessions with the therapy because she was unable to find a connection or build rapport with the therapist. Another study described the togetherness that arrived between a group of Latinas who had been diagnosed with breast cancer. The study indicated that the women were feeling as if they were alone and had no since of self before therapy.

To conclude, Corey (2016) states that existential group therapy focuses on individuals finding meaning and authenticity of their own life. It focuses on four given of human life which are death, freedom, isolation, and meaninglessness (Yalom & Josselson, 2014). As the counselor, we are her to encourage and help the client regain control over his or her own life. Counselor helps the client realize that he or she has the freedom, ability, and control to take over their life while being given insight and support from those individuals in the group setting (Corey, 2016).

Works Cited

Corey, G. (2017). Theory and practice of group counseling (9th Ed.). Boston, MA: Cengage      Learning.

Edwards, W., & Milton, M. (2014). Retirement Therapy? Older people’s experiences of existential therapy relating to their transition to retirement. Counseling Psychology                         Review, 29(2), 43-53.

Gonzalez, J., & Barden, S. M. (2014). Existential Counseling as a Vehicle to Support Latina     Breast Cancer Survivors. Counseling & Values, 59(1), 49-64.

 

Ethical Dilemma Encountered in Group Therapy

Psychiatric Mental Health Ethical Scenario: The Case of Paula

Group Therapy has multiple ethical issues, and one of the most frequent and usually seen in the involuntary group members are, informed consent and confidentiality. Ethically a counselor must instruct patients about theirs rights and responsibilities and advise them of any possible concern they could experience, if they choose to follow treatment. So, informed consent is very important when participation is mandatory, and all psychologist, counselor, and therapist must obtain from patients, and it is important because the counselor must follow guidelines during their sessions. A counselor becomes complicated when a patient becomes an involuntarily member in a group therapy, because the incorporation of the patient places limitations on the trail of the sessions in the group. Members should join to a group therapy of their own will, and with adequate information on the goals, rules, fees, confidentiality, rights and responsibilities of group members (Tuckman & Jensen, 1977). It is a must that new members know the consequences of breaching rules of the group, and the importance of treating other group members with respect and avoiding arguments. It is also vital for the group counselor to instruct the need for confidentiality by group members. A counselor may face several ethical issues in counseling, from bias or double relationship, involuntary patient, breach of confidentiality, moral dilemmas and other significant factors. In this case study we will find some ethical dilemmas that usually are encountered by counselors and supervisors (Sederer L, 2013). This ethical issue happened at LF Mental Wellness Center during my clinical hours of psychotherapy rotation. I’m an FNP, currently pursuing my PMHNP and performing my clinical rotation at LS clinic Center. Asuncion is the psychiatrist PMHNP, and Paula the LMHC, which is my clinical supervisor and preceptor.

Ethical Problems 

Basically, the ethical problem started when Paula was requested to violate confidentiality by giving personal information about her patients during a periodical report. One more ethical issue I experienced, was when a patient refused medical care. It seems to happen due to an inappropriate informed consent, because an involuntary group therapy admission of a patient, and a breach of confidentiality, that occurred during treatment. The administrator requested to Paula a list of patients that were treated on monthly basis, and a list of community providers with whom she refers and consults. This data was demanded to complete a periodical report. Paula was concerned about disclosing this information, as it is her ethical responsibility to protect her client’s confidentiality. Her unwillingness to provide the names is due to her prior experience, when the administrator revealed confidential information to others, particularly to her secretary. Moreover, Paula witnessed this secretary sharing confidential information with other employees not involved in the case. Paula seeks guidance to her boss on how to proceed to maintain her ethical, moral, and legal responsibilities without risking her job.

Ethical Principles Involved

From the perspective of Paula and mine, justice includes taking steps to guarantee the protection of the clients and to implement the appropriate ethical code. Non-maleficence and beneficence comprise upholding privacy. Throughout the process the administrator, should respect Paula’s autonomy and knowledge about the situation and the clinic environment. Regarding fidelity, Paula is likely to work against disclosing confidential client’s information, including their participation in counseling (Glosoff & Pate, 2002). From the position of the patients and guardians, justice would include Paula and the clinic system respecting their privacy. Glosoff, Herlihey and Spence (2000) said that most individuals seeking counseling assume their information will be kept in confidence. Regarding non-maleficence, to avoid harm, personal information shouldn’t be disclosed unless the patient/guardian gives consent. Under the category of beneficence, some patients/guardians may be comfortable providing information to contribute to a report to improve services in the future. Autonomy would allow for the patients/guardians to make their own choices about whether to be included in this report without Paula passing judgment or imposing their own goals (Herlihy & Corey, 1996). To support fidelity, the patients/guardians may see Paula’s responsibility to keep the promise of confidentiality.

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First, Paula was asked to violate confidentiality by providing identifying information about the clients for a report. Second, the clinical setting included inappropriate practices, as both the administrator and the secretary had shared confidential information with others. Third, by not providing an appropriate informed consent to the patient and guardians had provoked a rejection to treatment. Therefore, increasing patient’s stress and fear to be treated (Sederer L, 2013). As a PMHNP student I must follow institution’s policies, but these policies required from me to violate my ethical obligations. However, since I’m a student of the clinic, it is implied I agrees with the general policies and principals of the institution (ACA, 2005). Since these policies require me to violate ethical obligations, I should inform clinic’s administration to change the standard, so I not required to breach confidentiality (ACA, 2005). Managing confidentiality is an extensive and stimulating issue (Isaacs, 1999). The ACA Code of Ethics establishes trust and confidentiality as “two cornerstones of any counseling relationship, and counselors are expected to discuss with clients how, when and with whom client’s information is to be shared” (ACA, 2005).

All Possible Courses of Action

Several choices can be made in this case, fluctuating from completely ignoring the situation, to giving data without asking for it, with countless choices in between. The purpose of it, is to inspire flexibly all the options, regardless of penalties, and to guarantee all available options considered. Consequently, possible paths of action, may include: to ignore the situation; to get more info about the situation, with prior events, local policies, to consult with the ACA Ethics and Professional Standards Department, other professionals within the district, other supervisors with counseling experience; to comply with the request and make the requested list in a appropriate manner; refuse to follow the request based on ethical responsibility; to contact every patient for permission to reveal information; educate the director/administrator about ethical requirements and negotiate to present the information in such a way to meet theirs’s goals without compromising confidentiality; and present the information in a coded format to protect the patient’s privacy (Phillips, E., 2007).

Also, she may ignore the situation, but the request may finally result in the information no longer being needed, or to cause Paula to appear resistant or disobedient to her boss. This could become the motivation for a huge fight for power between the two, and the purpose of protecting patient privacy may be lost. If she gathers more information and understands more about everyone’s priorities in the situation with a clear review of precedents and policies, this may disclose a solution that could satisfy everyone. Paula and the administrator could engage in a open dialogue to assess if the number of patients seen and the general list of providers offering services would serve for his report. The administrator could still require Paula to submit all the names of agencies and patients she counsels, or he might allow Paula to report this data without any identifying information. Paula could submit coded data without breaking ethical violations.

Actual Course of Action with the Rationale

The clinical supervisor has responsibility in the resolution of ethical dilemmas, when a counselor is under supervision. The ACA Code of Ethics states “supervisors should educate supervisees about client rights including privacy and confidentiality” (ACA, 2005). Counselors must guarantee that aids will follow confidentiality. The ACA Code specifies supervisors will “ensure that supervisees inform clients of their right to confidentiality and privileged communication” (ACA Code, 2008).

Whereas I understand her responsibility as a counselor and supervisor to follow the ACA Code of Ethics (ACA, 2005), Paula is also required to remind others of such responsibilities and discourage from disclosing confidential client information to the administrator without signed consent forms. As the supervisor, Paula is responsible to guide my critical thinking process about many ethical issues that arise in my clinical work, to instruct how to apply appropriate ethical codes, to be knowledgeable of prevalent ethical violations and how to minimize them (ACES, 2009). If she revealed information about the patients to the administrator this would be a clear violation of the ACA (2005) and ASCA (2004) codes. It will be important for Paula to work with team involved together to ensure the confidentiality of the patients is maintained and no ethical violation occurs. Paula’s first step is to gather information from the principal about specific requirements of his periodical report. She would meet ethical guidelines by opening communication with her director and administrator about this issue. If they continue to insist upon knowing the names of patients seen, the next step would be to consult. Paula might consult with any other mental health providers who would likely be bound by similar ethical guidelines. Paula could talk with them about how they plan to proceed with the request to provide the confidential information and consult with other clinical counselor supervisors to determine how they have guided supervisees to act when faced with similar ethical dilemmas. She can discuss their joint responsibility to uphold confidentiality so that he does not view her failure to submit client names and associated agencies as blocking progress (Kaplan, 1995). The relationship between Paula and the patients could suffer irreparable harm from the disclosure, resulting in patients withholding information from her, and to could prevent them from seeking counseling in the future and undermine treatment goals and progress (Phillips, 2007). The final step is to implement the course of action. It is reasonable to expect that Paula and the administrator will find an acceptable and ethically sound solution to this dilemma.

Influences Shaping Decisions

Obtaining permissions from the affected parties would protect Paula from violating confidentiality. Doing so, may also raise questions from patients concerning who will have access to the information and how it will be used. This may cause students to remove from counseling due to fear of others knowing about their personal challenges. Paula could educate the administrator about applicable ethical codes. She could approach this discussion with him in a professional and tactful manner, mentioning detailed segments of ethical codes that stress the importance of privacy and confidentiality. Therefore, the supervisor may collaborate to find the best solution. The applicable ethical codes in this case encourage counselors to consult when met with ethical dilemmas, as consultation increases the probability of seeing the situation from multiple perspectives to identify an appropriate solution (ACA, 2005; ASCA, 2005; ASCA, 2004). Again, the consultation process may take some time, causing Paula to appear defiant. It is also possible that even with consultation, no concrete solution can be found to satisfy all parties. Generating the lists as requested and submitting them promptly would certainly pacify the administrator. But, this would evidently be a violation of the ethical code to protect confidentiality (Kaplan, 1995) and might lead to reasonable complaints from patients. A flat refusal, even in the name of compliance with ethical standards of protecting privacy, will be unprofessional and defiant on Paula’s part. It is possible the administrator would understand her objection, but this is not likely based on the power differential between them.

In summary, in this case, Paula confronted several ethical dilemmas.  I outlined the ethical dilemmas and considered multiple professional ethical standards to guide my recommendations, attempting to support professional ethics by maintaining the best interests of Paula’s patients and justifying potential actions based upon best practices. As trusted savers in the counseling profession, it is our desire that consistent and disciplined analysis of ethical dilemmas continue to guide our practice.

 References

American Counseling Association. (2005). ACA code of Ethics. Alexandria. VA: Author.

American School Counselor Association. (2005). The ASCA National Model: A Framework for School Counseling Programs. Second Edition. Alexandria, VA: Author.

Association for Counselor Educators and Supervisors. (2009). Best practices in clinical supervision. ACES Task Force Report at the 2009 Annual ACES Conference in San Diego, CA.

Corey, G., Williams, G., & Moline, M. (1995). Ethical and legal issues in group counseling. Ethics & Behavior, 5(2), 161-183. Retrieved from: http://dx.doi.org/10.1207/s15327019eb05

Glosoff, H. & Pate, R. (2002). Privacy and confidentiality in school counseling. Professional School Counseling, 6(1), 20-27.

Glosoff, H., Herlihy, B., & Spence, B. (2000). Privileged communication in the counselor client relationship: An analysis of state laws and implications for practice. Journal of Counseling.

Herlihy, B., & Corey, G. (1996). ACA ethical standards casebook. (5th ed.). Alexandria, VA.                              American Counseling Association.

Isaacs, M. L. (1999). School counselors and confidentiality: Factors affecting professional choices. Professional School Counseling, 2 (4), 258-267.

Kaplan, L. S., (1995). Principals versus counselors: Resolving tensions between different practice models. School Counselor, 42 (4), 261-268.

Phillips, E. (2007). The dilemma of practicing and teaching confidentiality within the clinic.

Sederer L. (2013). The Right to Treatment and the Right to Refuse Treatment. Retrieved from: http://careforyourmind.org/the-right-to-treatment-and-the-right-to-refuse-treatment/

Tuckman, B. and Jensen, M. (1977). Stages of Small-Group Development Revisited. Group & Organization Management, 2(4), pp.419-427.

 

EMDR Therapy for Anxiety & Depression

Therapy can help a person overcome whatever life is throwing at them. It helps them process their feelings, their pains, and can be guided through life with goals to work towards. Anxiety and depression go hand in hand. It’s common for one that struggles with anxiety to also suffer from depression. Not everyone likes to go the medication route. There are different ways to help, such as complementary and alternative treatments. EMDR, also known as Eye Movement Desensitization and Reprocessing, is one of many of them.

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 “Eye Movement Desensitization and Reprocessing is a type of psychotherapy treatment that was originally designed to alleviate the distress associated with traumatic memories”. (EMDR Institute, Inc., 2018, para 1). EMDR therapy helps alleviate bad memories from traumatic events or life experiences that leave a person struggling with any form of emotional distress such as Post-traumatic stress disorder (PTSD), anxiety, or depression. EMDR therapy can prove that your mind can and will heal from emotional trauma just as it can heal from physical trauma such as a broken bone or a laceration. EMDR therapy makes the client revisit the stressful event that happened.

 EMDR therapy has eight different phases that last 90 minutes. During phase one, the therapist collects history and data from the patient. “The therapist will assess the client and identify possible targets that will be used in the treatment, which will include any stressful memories from the past or current situations that are causing any form of emotional distress. The length of treatment depends on the number of traumas and the age of which the emotional distress started”. (EMDR Institute, Inc., 2018, para 7).

 In the second phase of EMDR, the therapist goes over different ways that he/she can handle emotional distress. The client can use different stress reduction techniques between sessions and in the 90-minute session.

 Phases three through six run together. During these phases, “a target is identified and processed using EMDR therapy procedures.” (EMDR Institute, Inc., 2018, para 8). The procedures involve three different things: a vivid visual, sound, or person related to the memory, a negative belief about them self, and any related emotions and body sensations the client may have experienced or are experiencing. The client will also be asked to express a positive attribute they believe they have and will need to rate the positive and the intensity of the negative belief. (EMDR Institute, Inc., 2018, para 8). The client is then told to focus on all three things while the therapist engages the EMDR processing through rapid eye movements, taps, or tones. “After each set of stimulation, the clinician instructs the client to let his/her mind go blank and to notice whatever thought, feeling, image, memory, or sensation comes to mind” (EMDR Institute, Inc., 2018, para 9). Once the client vocalizes that they aren’t experiencing any more stress to the memory that was once causing them to experience stress, they are asked to think about the positive belief that they said during the start of the session. Once they start to think about the positives, they use that during the next distressing memories that they might have during the rest of the session.

 Phase seven is to achieve closure that the client needs. The client will be asked to keep a weekly journal for a week that includes anything that may happen that week that relates to the material to help the client remember any self-calming events that were used.

 Phase 8 is the last phase of EMDR therapy where the therapist examines how much progress has been made and helps the client understand the memories that caused distress, any current distressing situations and future events that will need to be prepared for.

 EMDR therapy is a newer type of psychotherapy that is exceptionally helpful with PTSD. EMDR therapy works in a complex way that may make someone wonder how it actually works. “The different pattern of movements from your left brain and the right brain stimulates your brain helping the memories that are trapped to be released. This can be done by tapping on the client’s knees by alternating the taps between each left and right knee at different paces. There are also vibrating devices the client can hold in both of their hands that buzz between each hand simultaneously”. (Kirchner, 2015) Stress causes our bodies to go into a fight or flight mode and sometimes feelings that arise become trapped in our minds and we never properly cope with what has happened or allow ourselves to process the trauma that we go through. Unprocessed feelings later come back and causes the stress that is experienced is what causes the stress. That stressor that is triggered can even come back so vivid it’s like the person experiencing the trauma is back in that moment experiencing it again. “The trapped feeling is what causes the stress part of the disorder. The actual trapping makes it recur because the body has never gotten rid of the fear or anxious response”. (Kirchner, 2015, para 1). EMDR therapy puts the client through the eight different phases mentioned above which stimulates both sides of the brain. When the brain is being stimulated, the central nervous system turns the stressful memories that are trapped in the brain and makes the memories more bearable or take them away. The client will still be able to remember and recall the stressful events, but they won’t correlate them with bad feelings of anxiety or depression.

 You can receive EMDR treatment in a clinical setting from a licensed mental health practitioner. “This interactional, standardized approach has been empirically tested in over 20 randomized controlled studies with trauma patients, and hundreds of published case reports evaluating a considerable range of presenting complaints, including depression, anxiety, phobias, excessive grief, somatic conditions and addiction.” (EMDR Institute, Inc., 2018, US Basic Training Overview, para 1). The training for a mental health practitioner has to go through a training class that consists of a lecture, demonstrations and supervised practice in a clinical setting to gain a full therapeutic technique and learn patient safety. The goal of basic training for EMDR therapy is to learn how to be sufficient with a wide range of situations that a client may need help overcoming. You can get Training through EMDR institute and it is a two weekend course that has 10 hours of didactic and 10 hours of supervised practice each weekend.”(EMDR Institute, Inc., 2018, US Basic Training Overview). To receive a certificate of completion, the requirements are to complete the weekend one and weekend two training sessions, reading a textbook, “EMDR: Basic Principles, protocols and procedures (Shapiro 2001)” (EMDR Institute, Inc., 2018, US Basis Training Overview, para 5).

 There are some pros and cons to EMDR therapy; more pro’s than cons though. A client can have re-live a certain past event that can cause intense emotions during the session that can cause more stress or memories. It isn’t completely understood as to how EMDR treatment actually works, which can cause some clients to question if the therapy is right for them. (12 keys rehab, 2016, para 10). EMDR therapy is more likely to take the memories and feelings caused from trauma away than to cause more pain. It can stop the client from reacting to the stressors, the sessions may bring up the trauma but true healing can only happen if you are aware of the trauma and can process it in a healthy way, it offers quick relief and it “can treat a wide range of symptoms, many of which are experienced by those battling addiction, including panic attacks, relationship issues, low self-esteem, anxiety, phobia, insomnia, excessive worrying and anger issues.” (12 keys rehab, 2016, para 9).

 Long term care residents and even dementia patients would benefit from EMDR treatment as well. I, personally, have taken care of residents who re live traumatic events that have happened in their lives. One specifically was re-living the war he was in. He was very agitated, yelling out, combative and all around inconsolable. As stated by (Amano and Toichi, 2014), a “few studies support it’s use in the older adult (Hyer, 1995;Thomas & Gafner, 1993). Hyer (1995) reported a case of treatment in treating PTSD in older adults with dementia in whom significant improvement was seen after three sessions of EMDR.” (pg. 51) You would think using EMDR therapy in older adults wouldn’t work well considering their cognitive state and other illnesses that may affect the ability of the resident to fully focus on the EMDR treatment, but there are many studies that have been done to show that it helps decrease anxiety and calms the person down when in a stressful situation. Just by the tapping on the knee technique and reminding the resident that it’s going to be okay, the situation is over, or that person is gone will help relax the patient quicker and easier. Without the use of medication to mask the stressful feelings.

References

Audrey Kirchner, CMT, (2015) Article: Effective Treatment for PTSD: EMDR Therapy What is EMDR? Ahdi-west, Retrieved from http://www.ahdi-west.org/effective-treatment-for-ptsd-emdr-therapy-what-is-emdr/

Francine Shapiro, PhD(2018) US Basic Training Overview. EMDR institute, Inc. Retrieved from http://www.emdr.com/us-basic-training-overview/

Francine Shapiro, PhD (2018). What Is EMDR? EMDR institute, Inc. Retrieved from http://www.emdr.com/what-is-emdr/

Tamaki Amano, Motomi Toichi, (2014, November 2). Effectiveness of the On-the-Spot-EMDR Method for the Treatment of Behavioral Symptoms in Patients With Severe Dementia. Ingentaconnect. Retrieved from http://www.ingentaconnect.com/content/springer/emdr/2014/00000008/00000002/art00001?crawler=true

12 Keys Rehab, (2016, May 4) EMDR Therapy: The Pros and Cons. 12 Keys Rehab, Retrieved from https://www.12keysrehab.com/emdr-therapy-pros-and-cons/

 

Advantages and Disadvantages of Personal Therapy for Counsellors

“All these personal counselling / therapy requirements for counsellors in training encourage selfish introspection. Counsellors are there to help others, and if they need counselling themselves, they should not be in the job.” Discuss with reference to your own experience and beliefs and to counselling literature.

In this essay, I will be exploring if the requirement for trainees to be in personal therapy encourages selfish introspection, the requirements of local courses and theories, requirements of registering organisations and will also include my own experiences, beliefs and understanding of the requirement.

Personally I feel indignant at this statement as it questions the suitability of counsellors and shows a lack of knowledge, understanding and awareness of the positive impact of trainee’s personal therapy on the therapeutic process.

To the best of my knowledge personal therapy benefits not just the trainee but the client as it contributes in the formation of the therapeutic relationship. However, I also believe that personal therapy may have some adverse effects on the trainee dependent on the individual’s personality, culture and life experience and I wish to explore this further.

Many opinions exist within differing theories/courses. Many theories of counselling psychology stress the importance of self-awareness to be fundamental. In particular, humanistic approaches – person centred and existential therapies. Carl Rogers the founder of humanistic psychology emphasizes the personal worth & uniqueness of the individual, that each individual has the capacity to distinguish their own external locus of evaluation to strengthen their internal locus of evaluation to establish their organismic self; reaching their full potential to self-actualize – becoming a fully functioning person. Mearns, D. and Thorne, B. (2007, pp.19-25)

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In order to facilitate this personality change, the counsellor must provide six necessary conditions for effective therapy which include three core conditions. These conditions cannot be established without the counsellor having achieved to a degree their organismic self in their own personal therapy. Rogers, C. (1967, pp.132-155) In order to change, one needs to fully accept themselves, by accepting ourselves, we are then truly in a position to accept and help others.

The BACP is the largest professional body in the UK. 2018, Ethical guidelines section 18:  We will maintain our own physical and psychological health at a level that enables us to work effectively with our clients

BACP therefore, suggests self awareness is critical to avoid doing harm. In 2005 BACP changed their requirement from 40 hours’ personal therapy for accreditation so that all theoretical approaches, including those not required to have personal therapy were included, instead making self awareness a criterion. The BACP did not remove the criteria for personal therapy for accreditation if it is a requirement of the courses for trainees. Hewes, B. (2010)

The Human Givens institute, claim that the BACPs decision no longer require counsellors to undergo personal therapy proves that personal therapy is not necessary to produce an effective counsellor. They claim that too many protected egos and financial investment are at risk to completely eliminate personal therapy. Human Givens believe that trainee counsellors do not need to have personal therapy in order for them to be more effective practitioners. Human Givens claim therapy is only needed when in distress and the main qualities needed to become a good counsellor is intelligence and life experience. Although, I could not find any evidence to support this claim. Scott, C. (2006)

Crysalis courses do not require personal therapy not stating why yet, their website lists the advantages, this seems contradicting. ()

Inter-Psyche require trainees to undertake 60 hours of personal therapy, emphasizing the importance of self-awareness, becoming aware of areas that require further exploration in order to work effectively.  ()

Existential approaches require personal therapy one hour weekly throughout the training process – () WPF guidelines require trainees to be in individual therapy at least once a week and the Foundation for Psychotherapy and Counselling require trainees to have been in therapy for 6 months prior to contact with clients. ()

Little research has been undertaken to determine the outcome of trainee personal therapy comparably, as research is generally narrative. However, a meta-synthesis of qualitative research combined findings on mandatory therapy and discovered there are many benefits to personal and professional development but that it also had negative effects such as stress/anguish and a negative impact on personal relationships. Bennett-Levy, J (2018) However, I have found no clear result for either argument.

Freud, S (1964, pp.216-253) the founder of personal therapy cited “personal therapy is the deepest and most non-negotiable part of clinical education” recognising the importance of the awareness of self in order to work effectively with a client.

Initially, I was unsure if personal therapy was necessary. However, I soon understood that I could not be a professional me and a personal me. I opted to enter therapy during the certificate course. I had acknowledged from triads that my childhood had had a profound effect upon me and I wanted to begin to lessen the possible negative effects on the diploma as I feared distraction from learning. I slowly began to address the past and negative patterns. One pattern was that I would submerge myself in others to focus all of my energy outwards. A defence mechanism to prevent myself acknowledging painful memories. I have now confronted this pain and I am comfortable with it. If I was uncomfortable with my pain, I could have transferred this discomfort and not dealt with the client’s issues. Crouch, A. (2007, pp.93-94)

The benefits of personal counselling for a trainee are plentiful, the experience of active listening and UPR first-hand allow us a greater understanding in offering the conditions fully and allows us to experience being the client. The higher internal awareness establishes who we can and cannot work with, by highlighting prejudices and minimising cultural assumptions, it discerns projective identification, over identification & organised attachment so that I can accurately recognise if its mine or the clients. Crouch, A. (2007, p.170)

Self awareness also prevents unconsciously deluding with clients and not challenging them. To avoid parallel processes and recognise potential transference & counter transference but also to learn about my own transference difficulties. By acknowledging my vulnerabilities, it will promote self empathy and increase emphatic responses therefore, helping personal and professional development. The relationship with the self will positively impact all of my work with a client. Mearns, D. and Thorne, B (2007, pp. 45-62)

There are many different opportunities to work on self-awareness other than personal therapy, Johari Window, EQ, reflective Journal and PD groups all help obtain self awareness allowing us to live outside of our façade and prevent over identification. Rowan, J (1998, pp. 1-12)

On a negative side, by exploring my inner world, I then doubted my own version of events. I sought corroboration from my siblings, which, for them, arose painful buried memories. As the eldest of four children, I felt responsible for their emotions, I believed I should make them feel better. This highlighted a core belief of mine that, could potentially hinder future therapeutic relationships of being a helper rather than a supporter. However, now that I am aware, I can now explore and understand it further.

I can also understand the essay statement, some may believe that by being in therapy it makes you defective and shows incompetence. It may also, be a transferential need for the counsellor to be seen as a perfect person and therefore themselves too. The avoidance of self introspection can sometimes be viewed as unselfish due to Christian tradition where its considered unhealthy to reflect overly on one’s self which could prevent active participation. Mearns, D. and Thorne, B (2007, pp. 45-47)

The negatives for personal therapy are also plentiful. Mandatory therapy does force students into therapy regardless of their position to address the self in order to qualify. A student may not actively participate in its purpose due to fear of the unknown or the stress that may arise. If one is in a nearly constant state of incongruence, an individual may hide their true feelings by distorting reality instead believing that they are their persona. Due to this they will not benefit from its purpose and it will also be financially demanding which, in itself is a large dedication for those economically disadvantaged. Trainees may not have the time to meet the requirement or feel pressured into continuing with an unsuitable counsellor. Self reflection may impact negatively on relationships and it can also be emotionally draining which may effect training. Overall, it can have a negative impact on training due to personal therapy becoming a painful experience. Macaskills, N.D (1998, pp. 199-226)

I do believe it selfish to be working with clients without self awareness, if for example a counsellor has an external locus of evaluation they wont be able to work effectively with a client possibly, due to fear of causing upset.

In conclusion, I believe personal therapy is of benefit to all trainees. Trainees need to have had personal therapy to gain self awareness and be fully functioning practitioners. Although, personal therapy does not guarantee self awareness; if the trainee is not in the correct psychological capacity to address the self. One needs to be aware of their own inner world in order to congruently sit with others in theirs, as stated by Mearns, D and Thorne, B. Without self awareness, our own experiencing may hinder the process.

By recognising who we can and cannot work with due to prejudices it allows us to work ethically, otherwise we compromise empathy. It is essential for counsellors to understand their cultures and worldviews before helping others. Effective counsellors need to be able to recognise diversity and cultural differences, in order to offer the core conditions fully to the client. Aldridge, S. and Rigby, S. (2001, pp. 65-83)

I believe if your aim for personal therapy is self awareness and growth, it is with the intention to ensure you are in the best position to work effectively. I have no doubt that it is essential to have personal counselling to self develop and to continue to do so as the process of self actualisation is never ending. Rowan, J. (1998, pp. 1-12) Therefore, I conclude that trainees requiring personal therapy does not encourage selfish introspection, it encourages self awareness in order to effectively work as a good counsellor.

References:

 

 

Aldridge, S. and Rigby, S. (2001) Counselling Skills in Context. London: Hodder & Stoughton in association with the British Association for Counselling and Psychotherapy.

BACP. (2018) Ethical Guidelines, Section 18 [Internet] www.bacp.co.uk> [Accessed 10/10/18].

Bennett-Levy, J. (2018) Meta synthesis. [Internet] Why therapists should walk the talk: The theoretical and empirical case for personal practice in therapist training and professional development, Journal of Behavior Therapy and Experimental Psychiatry

https://doi.org/10.1002/capr.12162> [Accessed 17/10/18].

Chrysalis Courses: Why Does Personal Therapy Benefit Trainee Counsellors? [Internet] https://www.chrysaliscourses.ac.uk/news/why-does-personal-therapy-benefit-trainee-counsellors> [Accessed 18/10/18].

Crouch, A. (2007) Inside Counselling: Becoming and Being a Professional Counsellor. London: Sage Publications.

Freud, S. (1964) Analysis Terminable and Interminable. In P. Reiff (ed) New York: Collier (original work published 1937).

Hewes, B. (2010) Therapy Today [Internet]  http://www.therapytoday.net/article/show/1713/> [Accessed 10/10/18].

Inter-Psyche [Internet] www.interpsyche.co.uk> [Accessed 10/10/18].

Macaskills, N. D (1998) Personal Therapy in the Training of Psychotherapists: Is it effective? British Journal of Psychotherapy: [Internet] https://www.researchgate.net/publication/227758628_Personal_Therapy_in_the_Training_of_the_Psychotherapist_Is_it_Effective> [Accessed 10/10/18].

Mearns, D & Thorne, B. (2007) Person Centred Counselling in Action, third edition. London: Sage Publications.

Rogers, C. R (1967) On Becoming a Person: A Therapists View of Psychotherapy. London: Constable.

Rowan, J. (1998) The Reality Game, second edition: A Guide to Humanistic Counselling and Psychotherapy. London, Routledge.

Scott, C. (2006) Human Givens Website: [Internet] Self and Society – A forum for contemporary psychology, Volume 33 – No.5: www.hgi.org.uk/resources/delve-our-extensive-library/mental-health-services-nhs-cbt-psychotherapy/doctrines> [Accessed 10/10/18].

 

Occupational Therapy Communication

Abstract
Occupational Therapy is a new and developing profession in the medical felid. Along with all other professions Occupational Therapy is unique to itself. It includes a specific way it is conducted and how the professionals act within the profession. Occupational Therapists need to have an understanding of the discourse, communication, resources and the style manual within the profession. Occupational Therapists also need to know and understand the history that pertains to the Occupational Therapy profession. Communication skills within the field are important for communication between others within the medical field and patients to the Occupational Therapist.
Research Project
DISCOURSE
Academic discourse for every professional field is different. All professional fields use the same way of finding information for there discourse. This information is used towards new ideas and new research. The use of communication is an important part of discourse. Through the use of informal and formal communication professions find new ideas for research. Informal communication is done through emails, phone conversations and letters. Many professionals will use email as a way to communicate their writings that need editing or other ideas. Formal communication is done through academic journals and books. Professionals use formal communication for the use of discovering new ideas and new information for research.
Professionals in the same field use the same discourse. Use of the same discourse consists of using the same communication language. Professionals also have the same understanding of there writings. Professionals with in the same field of work are considered professional communities. These communities count on each other for new information. 1
The profession of Occupational Therapy assists people in every day activities. Occupational Therapists help out the disabled and chronic ill patients. As an Occupational Therapist the core focus on helping someone is on their everyday activities that may be performed. As stated by Gelya Frank in the article Occupational Therapy & Occupational Science Interdisciplinary Interest Group: A Proposal to the National Association for Practice of Anthropology, “Occupational therapy, therefore, is a profession whose focus is on enabling a person (i.e. individual client) or group of persons (i.e. group, community or an organization client) to access and participate in activities that are meaningful, purposeful and relevant to their lives, roles and sense of well being.”. (p 2) Occupational therapists are there for people who need assistance in being taught a task that might be difficult for them to do because of a disability.

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Writing documented records in Occupational Therapy follows the demands of ethics and laws in formal writing. The documentation of a treatment or consultation of the patient needs to be professional and well organized. Patient’s records are a private matter between the therapist and the patient. Records should be easily read. (p 3) There should be no use of negative words against the patient or the patient’s disability.
Documentation in Occupational Therapy is thought to be one of the most difficult aspects of the profession. Documentation occurs after visiting with a patient, it must be clear and precise. Patients have the right to read their records from the Occupational Therapist. These records should be easily understood by patients. 3 (p 6) These documentations use keywords to point out important information from the Occupational Therapist.
Included with the documentation of the visits with the patient should include a written painted picture of the patient that is easily understood by others. Professional Occupational Therapist and the patient should be able to understand the visit through the painted picture. Also included in documentation of patients are goals set by the patient and Occupational Therapist, and the plan for treatment decided by the Occupational Therapist. After every treatment there should be an evaluation of how the Occupational Therapist feels the patient is doing in the treatment plan.3 (p 5)
Not only should the documentation include the painted picture, but the documentation needs to have meaning. In Pierre’s article, “Occupational Therapy as Documented in Patient’s Records,” one occupational therapist stated “There must be descriptions in running text in order to maintain a unique picture of a patient. Documentation must not be just a lot of words, but have content.” 3 (p 5) The information included in documentations should be considered extremely important and an Occupational Therapist needs to spend time considering the information needed for the documentation and the context of the writing.
HISTORY
Moral treatment was used as a treatment for the mentally ill. Moral treatment started in the 18th and 19th century in Europe and North America. Treatment of mentally ill patients in the early 1990’s included doing everyday tasks that included house work and other activities that were thought to help someone return to normal health. These everyday tasks were called occupations. An occupation is where occupational therapy received its name. Occupational Therapy is a therapy where patients do occupations to recover. These tasks included cleaning house, different craft projects and physical activities. (p31-31)
William Tuke named and founded the ideas of Moral treatment. His ideas include treating mentally ill patients as if the patient is really mentally well. Through Williams’s ideas of moral treatment he started the making of asylums for the mentally ill. These asylums were used for housing and caring of the mentally ill. (p427)
Figure one is a table of the principles of moral treatment. These moral treatment principles are the ideas from the article “The relevance of moral treatment to contemporary mental health care” according to Annie Borthwick et. Al. William was the founder of these principles for moral treatment.5 (p431) 5(p431)
Through the ideas of moral treatment began the formation of Occupational Therapy. Many doctors had helped contribute to the creating and establishing of Occupational Therapy schools, hospitals, books and the fundamental ideas.4(p.30)
In the early 20th century young doctors and nurses generated the idea of Occupational Therapy through using moral treatment as the foundation. There principal ideas included doing everyday tasks to help with the recovery of the mentally ill. This principal was similar to the principals of moral treatment. 4(p27)
In 1917 a group of young doctors come together to plan a therapy process for people with metal illness. These young doctors formed the National Association for Occupational Therapy. 4(p27)
William Rush Dunton, Jr. graduated from the University of Pennsylvania with a degree in medicine. He began his work with Occupational Therapy through the principles of moral treatment for the mentally ill. Dunton worked at the Sheppard Asylum. He used William Tukes ideas for moral treatment at the Sheppard Asylum. The Sheppard Asylum promoted William Dunton to be the director of Occupational Therapy for the mentally ill. Through his experiences William Dunton was a founder and leader of the National Association of Occupational Therapy. 4(p34)
Adolf Meyer received his Masters in the area of neurology from a school in Switzerland where he was a native. He immigrated to Chicago after receiving his masters. Meyer believed in the connections someone’s mind and body had. He also believed that it required thinking to do actions. He did not agree with Freud’s ideas of the mind and body. He also believed everyone’s life story affected and contributed to the person’s attitudes and behavior. He believed that a mental illness was developed from flawed habits that were learned by the person. His care included changing the flawed habit that a mentally ill patient had. Through his treatments to his patients he made the work meaningful to them. His care included making sure the patient had good care, received enough rest, and socializing among others. 4(p33)
Eleanor Clark Slagle attended Hull House which was part of the Chicago School of Civics and Philanthropy. She was enrolled in a course of amusements and occupations. This course work was founded by Meyer Meyer. Clark started programs like Meyers in Michigan and New York through out different mental health hospitals. During World War One Clark was asked by the Chicago Red Cross to help with the training of other Red Cross nurses on Occupational Therapy. The training included therapy for soldiers who would return from war from battle fatigue and injury. She developed programs for mentally ill people through Meyer ideas. These programs included walks, activates, exercise and small group meals. 4(p36)
Clark and Meyer both provide their services on Occupational Therapy training. There services were provided at the John Hopkins University in the Henry Phipps Psychiatric Clinic. 4(p36)
Herbert James Hall graduated in 1895 from Harvard Medical School as a general practitioner. Hall thought that working with crafts would help mental ill patients. He believed that through crafts patients could not fail. This gave patients the feeling of becoming successful and not failing. Crafts also diverted the minds of patients from their mental illness. Hall was also the founding father of The Boston School of Occupational Therapy in 1918. Herbert also was an author of some of the first books in Occupational Therapy. 4(p28)
Susan Elizabeth Tracy was a nursing student who attending and graduated from Massachusetts Horneopathic Hospital. While working at a hospital Tracy found that patients who participated in hospital activities improved faster than those who did not participate in hospital activities. Tracy used occupational treatment when she began practicing her own private nursing. Tracy started her own experimental study of occupations in a Jamaica Plain Hospital. Her courses are considered the first organized classes in Occupational Therapy education. Tracy believed that therapy needed to engage the patients in activities that captured there attention. These therapy activities also needed to hold some kind of meaning to the patients. 4(p38)
In early Occupational Therapy it was believed the patients needed to have the motivation to recover. Early Occupational Therapy was based on therapy through occupations. Occupations included crafts, activities, games, and any physical activities. Early occupational therapy found it important that the occupation would pertain to the patient’s life. Occupational Therapy in the beginning also included the focus of how the occupation pertained to the patient’s life and health. Also the focus was on how the occupation could be used as a therapy. Motivation had a strong importance on emphasizing the occupations. Many doctors felt encouragement through therapy was also needed by the doctor and family members. 4(p43)
During the 1940’s through the 1950’s there was a strong urge that Occupational Therapy take medicine in to consideration. During this time many Occupational Therapists were forced to go in coalition with medicine. Occupational Therapy field moved to the use of medical terms when caring for a patient. Occupational Therapist had to use concepts that were taken from the practice of medicine.4(p55)
Starting in the early 1960’s Occupational Therapy changed because of new technology and more information of the human body. Occupational Therapists were able to detect psychological problems of patients because of the new theories of the human body. During this time body functions and impairments were clarified. In the 1960’s scientific terms were used in the occupational therapy work place. There was also a better understand the emotional issues with patients who were mentally ill. 4(p54-55)
After the 1960’s Occupational Therapist realized that through the medical intervention many of the original ideas of Occupational Therapy were lost. Many doctors of Occupational Therapy found that there was no connection between the activities used in therapy compared to the names given to them from the medical terminology. Occupational Therapy almost lost its identity by trying to identity if self with medicine. Because of misidentification Occupational Therapists have gone back to the use of occupations as treatments as it was at the development of Occupational Therapy.4(p54-55)
RESOURCES
There are many resources offered to Occupational Therapist. Resources include websites, academic journals, videos, newsletters, and memberships to many Occupational Therapy organizations. Websites include the Minnesota Occupational Therapy Association, the American Occupational Therapy Foundation, and National Board for Certification in Occupational Therapy. Academic journals include American Journal of Occupational Therapy, Journal of American Medical Association and other medical journals.
The Minnesota Occupational Therapy Association website gives members many opportunities and special options. A member of the Minnesota Occupational Therapy Association grants any Minnesotan Occupational Therapist access to many databases, libraries, videos, newsletters, and publications.
These other databases include American Medical Association, National Association of Home Care, Sensory Integration International, National Rehabilitation Information Center, and American Academy of Pediatrics. Government Agencies are also offered through being a member of the Minnesota Occupational Therapy Association Website. 6
These government agencies include Medicare, Medline, and Occupational Outlook Handbook. Publications are another Resource that Occupational Therapist can use for new information. 6
Minnesota Occupational Therapy Association website offers three publication links. These links include ADVANCE for Occupational Therapy Practitioners, Merck Manual of DX and The Neuroscience Center. Other Occupational Therapy sites provided by the Minnesota Occupational Therapy Association include Occupational Therapy Internet World, Skills for the Job Living, and Occupational Therapist.com. 6
Becoming a member of the Minnesota Occupational Therapy Association includes other advantages. Members receive the Minnesota Occupational Therapy Association newsletter quarterly. Students who are part of Minnesota Occupational Therapy Association attending to school to become an Occupational Therapist have the option of becoming a member. Student members have the opportunity to apply for scholarships. Members receive discounted prices in any conferences that are held for Occupational Therapist in Minnesota. Through the use of the membership members have the opportunity to communicate with each other for new information and new research options. Members of the association have voting rights to decide how the association will be organized and operated. A member also includes being recognized for contributions for Occupational Therapy within Minnesota. These are the main benefits for joining the Minnesota Occupational Therapy Association. 6
Another option on the Minnesota Occupational Therapy Association web site includes employment opportunities. The site offers many job listings for the use of Occupational Therapist who are members of the Minnesota Occupational Therapy Association. Other Occupational Therapists and businesses have the option to post job listings on the web site. 6
The American Occupational Therapy Foundation is another resource for Occupational Therapist. This resource supplies Occupational Therapist with opportunities for research funding. Through the use of this web site it was hoped to build a better understanding of Occupational Therapy science. There is also a scholarship provided for any Occupational Therapy student.
The American Occupational Therapy Foundation provides awards for research in Occupational Therapy. The site provides recognition to Occupational Therapists that have shown renowned contributions for Occupational Therapy science. American Occupational Therapy Association helped to build the foundation needed to build the American Occupational Therapy Foundation. 7
National Board for Certification in Occupational Therapy, Inc. is a resource for graduated Occupational Therapist. Occupational Therapist must complete all required Field work along with the educational program to join the National Board for Certification in Occupational Therapy. The National Board for Certification in Occupational Therapy requires that Occupational Therapist pass there examination to be certified. This exam tests the skills, understanding and abilities of all Occupational Therapist. National Board for Certification in Occupational Therapy is a non-profit organization that administers the certifying of Occupational Therapist. Along with the Minnesota Occupational Therapy Association the American Occupational Therapy Foundation is a not-profit organization.
The American Journal of Occupational Therapy is one of the many academic journals that Occupational Therapist can use. Included in this journal are researched peer-read articles from professional Occupational Therapist. These articles include information that is theory-based and theoretical research. Occupational Therapist can use this information towards new ideas; other research projects and there own patients.
The American Medical Association Journal offers information on general medical reviewed articles. There main objective is to promote the art of medicine and to help make public health better for all. These journals provide Occupational Therapist with the newest research available to them in medicine.
Other journals Occupational Therapists may refer to are journals based on pediatrics, autism, ADHD, learning disorders, psychology, and neurology. Depending on where an Occupational Therapist may work will determine which journals will be read. An Occupational Therapist working with children will read journals on pediatrics along with other medical and Occupational Therapy Journals.
These are the many resources offered to Occupational Therapists. These recourses include academic journals, web sites, and organizations. Occupational Therapists have the option to join many organizations to better the understanding of Occupational Therapy science to others and to gain benefits for themselves. Through the use of these recourses Occupational Therapists communicate there new ideas and the new research information.
COMMUNICATION
To become a well developed and successful Occupational Therapist many qualities are needed. These qualities include great interpersonal, writing, grammar, public speaking, and computer skills. Some of these skills can be learned from other experienced Occupational Therapist and others are learned with work experience. During an email interview with Nancy Klassen, member of Canadian Association of Occupational Therapists and an Occupational Therapist Registered(OTR) (written communication, March 2008), gave me a handful of information pertaining to the communication skills of Occupational Therapist. Through her experiences as an Occupational Therapist she has found that as an Occupational Therapist many qualities are needed. Through this paper many of her ideas will be shared with the readers.
Interpersonal skills are required for Occupational Therapist to communicate with others who are involved with the patients care and treatment plans. Communicating with others includes children’s parents, specialists, educators, and childcare providers. An Occupational Therapist may need to have an informational meeting with parents and others involved in the client’s life to educate and instruct on the best treatment plan care for the client. An Occupational Therapist must be able to communicate in a tactful, clear way to make others understand the information given to them on the treatment of the patient (Klassen, written communication).
Occupational Therapist will have opportunities to share research information with other co-workers. Communicating with other Occupational Therapist includes sharing new research information, medical information on clients, and discussions on client progression. As an Occupational Therapists who work in a team might have to give presentation on clients at team meetings (Klassen, written communication).
Occupational Therapist may need to prepare and give seminars or presentations. During these seminars Occupational Therapist may have the option of presenting new research information, new program ideas and other ideas that may pertain to assisting other Occupational Therapist (Klassen, written communication).
As an Occupational Therapist writing is a skill that will be used to write reports. Reports will be presented to other Occupational Therapist, social workers, schools, children’s hospitals, physicians, and the client’s parents. Other written material includes progress notes, and letter writing. During a clients treatment time with an Occupational Therapist progress notes or progress charts need to be taken. These reports are taken right after the treatment session with the Occupational Therapist. These reports are put in to the personal file of the patients. Evaluations may also be done on a patient. Evaluations are used for placement of a patient in school or other education programs that best fit the ability of the patient (Klassen, written communication).
Proposals, handouts, and request are another type of documentation Occupational Therapist may have to write. An Occupational Therapist may have new ideas for research or treatment plans, which would require a proposal. Handouts are given to teachers, social workers, parent’s of the client, and others who may want to be educated on the treatment plan and the disability of the client. Handouts can include pamphlets, brochures, and medical research papers. Through the knowledge of an Occupational Therapist there maybe the need to request funding for a research program from the government and other non-profit companies that may support new research in Occupational Therapy (Klassen, written communication).
Along with the requirement of writing proposals, progress reports, and handouts Occupational Therapist are required to have great grammar skills and spelling skills. Occupational Therapist Nancy Klassen thought it was important to have a vast vocabulary. Through the writings Occupational Therapist need to use vocabulary as an essential factor towards the credibility an Occupational Therapist may have. Grammar and a vast vocabulary are important to help with the explanation on treatment plans and other medical terminology that maybe used for the patients disability (Klassen, written communication).
Presentations may need to be presented from Occupational Therapist requires public speaking skills. An Occupational Therapist needs to be able to give information to a group of other Occupational Therapist, parents, physicians, social workers, and educators. The wide rage of knowledge from the listens’ can not limit an Occupational Therapist on the information that is given to the group during the presentation. Presentations include presenting new ideas and new research to other Occupational Therapist. Another form of presentations includes delivering information on a treatment plan to the family and educators who interact with a patient (Klassen, written communication).
Many Occupational Therapists communicate using telephone or email. Through the use of a computer email is an easy way to communicate with people within the same office or on a patient’s treatment. Occupational Therapist may need to get a hold of educators for a patient. The World Wide Web seems to be an easy and speedy way for interactions between different people (Klassen, written communication).
Klassen, ORT, believes that social skills are the most important part of an Occupational Therapist. She felt that social skills can lead an Occupational Therapist to successfulness. Another aspect Klassen, OTR, felt Occupational Therapist must have the ability to teach the information in a meaningful and clear manner to others (Klassen, written communication).
Through emailing Klassen, OTR, these are the ideas that she felt Occupational Therapist must posses to become successful in the medical field as an Occupational Therapist (Klassen, written communication).
STYLE
Each profession provides a style manual for that occupation. This means there are many different style manuals. Occupational Therapists use the American Medical Association Manual of Style (AMA). AMA is on its 10th edition which was newly updated in 2007. American Psychological Association (APA) is a commonly used manual within colleges and high schools. APA is on its 5th edition which was updated as of 2003. Looking through these two different style manuals I found many differences.
Some of the major differences included the use of terms, numbers, and the reference list. AMA is a medical manual which serves for a person who is in the medical field where as APA is used for psychologist and literature workers along with a few other professions. AMA seemed to focus more of the manuals attention on using measurements, numbers, statistic, typography, medical indexes, and manuscript preparation. APA focused more on the design, grammar, and gender12.
AMA references are important within a research paper. Reference list provides readers with acknowledgements, where additional information on the topic can be found, and providing more support for a researcher’s paper. A reference list needs to be complete and in the correct format so all medical profession can understand the meaning of the reference page. Thoroughness of the reference page can aid another researcher to farther there knowledge on the topic read in the research paper. Within in the reference list misspelling of last names, Journal names, internet sites, along with incorrect page numbers. AMA style manual also suggest reading the primary source when writing a research paper where a writer may take a secondary source from another paper11.
The reference list within an AMA style manual research paper should be number. Arabic number system should be used when doing the reference list. The reference list goes in order of from when the reference is used. This means that the first reference used would the first reference on the resource page. This does not involve using last name as an alphabetical order reference list. It is strictly by when it is used11.
APA’s style manual is used to identify reference used within the paper. The reference list is only used to cite any sources used within the paper. As an author, of an APA format paper, there is a need to check over the reference list and cited sources to make sure both appear with in the paper. The citations with in a paper along with the reference list needs to be correct and the same for each reference. If there is a misspelled word or an incorrect writing within a manuscript the author of the paper is at cost for the mistake.
The reference list needs to be in alphabetical order. Alphabetical order starts with the first author’s last name in a reference. If there are multiple authors with the same last name the next letter to use is the first initial of the first name of the author’s12. Abbreviations maybe used within an AMA style manual paper. If many abbreviations are being used within one paper it may become confusing for people reading the paper. Abbreviations are acceptable if one word will be used multiple times within the same paper. This will save space within the paper as well. Some instructors may put a limit on how many abbreviations may be used within one paper11.
Ideal use of abbreviations includes numerous terms. Academic degrees along with certificates and some kind of honor can be abbreviated within a paper. Within the United States military titles are another form that can be abbreviated with in an AMA style manual paper. A few other potential words that can be abbreviated include days of the week, addresses, states, countries, and titles of people11.
Within an APA paper many instructors prefer that abbreviations are used sparingly. APA instructors feel abbreviations affect the flow of a paper if to many are used. Abbreviations in a paper include measurements, time, and, chemical compounds. APA does accept abbreviations that are offend used. An example from the Publication Manual of the American Psychological Association included “IQ, REM, ESP, AIDS…”12(105).
APA style allows the use of numbers to be kept as numerals and not written out in certain situations. APA style believes it is easier to follow numerals than written out numbers. A few instances where numbers can be kept as numerals include a mixed fraction, measure of time, temperature measurements, and a measurement of a currency12.
Numbers that should be written out according to the APA style include the beginning of a sentence. This also includes if it is a title, or a heading. Other written out numbers include one when it is used as a pronoun within a sentence, and when a number is being used to rank items or people11.
APA style’s rule towards the use of number includes written and numerals. If a number is below 10 it should be written out. If a number is above 10 it can be written out as a number. Within a paper numerals and written numbers can be combined. An example of this would be 6 million. The six is in a form of a numeral, but the million is written out11.
AMA and APA style manuals have identical formats. Both of these styles include a title page for the article, an abstract, the paper, and than a resource page. Within the paper it is where the differences of these two different style manuals com into play. A paper written in the style manual AMA includes subheadings that are in all capitalized letters where as an APA style manual does not. In APA the first letter of the subheading is the only letter capitalized. The resource page for the style manuals is also very different. Each style manual has there own way to cite and reference articles11, 12.
CONCLUSION
Occupational Therapy is a great medical field that is used to help patients improve skills that maybe hard for them. It is also a challenging profession that requires the knowledge of many skills that will be used when working. Occupational Therapists discourse is important towards the building and developing of new research within the profession. Discourse is done through the use of different communication with other Occupational Therapist and other medical doctors. Occupational Therapy is a newer field that started in the early 1900’s. During the beginning Occupational Therapy was used for solders and mentally the ill. Through history Occupational Therapy has changed its way of caring and understand the use of occupations for patients. Now Occupational Therapy is used to assistant many other people who have disabilities. Many resources can be used by Occupational Therapist to gain more knowledge for the profession. There are many resources Occupational Therapist can use. Resources include websites, academic journals, and Occupational Therapy associations. Occupational Therapists need to have a vast understanding and use of communication skills. A
 

Comparison Betweeen Emotion-focused Family Therapy and Solution-focused Family Therapy

A. Emotion-focused family therapy

The experiential models of family therapy developed from the phenomenological theories, highlighting the immediacy of the therapeutic encounter, “in the present” emotional processing, addressing emotional suppression, getting in touch with one’s inner world, and increasing awareness of vulnerabilities. The experiential models are less systemic in nature, don’t reflect a strict theoretical standpoint, and emphasize different aspects than the other family therapies based on cognitive and behavioral approaches or social constructivist theory. In their humanistic aspect, the experiential models propose a customized approach to the needs and specific goals of the client, auto-determination and self-fulfillment. In the mid-1980s, Susan Johnson and Leslie Greenberg developed a new experiential approach, the emotionally focused couple therapy (EFCT), having roots in the attachment theory and combining affective expression and relational availability with the attachment responses. These two authors are notable for their efforts to research the principles of the emotionally focused couple therapy and demonstrate its effectiveness (Goldberg & Goldberg, 2012).

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To date, research has established that EFCT has one of the strongest empirical support of all family therapies, which fulfills and sometimes exceeds the guidelines for an evidence-based couple therapy (Wiebe & Johnson, 2016). Founders of the EFCT advance the idea that EFCT offers an original perspective to the family and couple therapy, based on new scientific findings (Johnson & Wittenborg, 2012). Basically, the emotionally focused couple therapy (EFCT) is a process integrating humanistic and existential principles (client-centered, free will, eliciting empathic responses), Gestalt therapy (increasing awareness through present emotional experience), Satir’s congruent communication, and Bowlby’s attachment theory with application to adult couples. Therapist’s role in the EFCT is to facilitate emotional communication and processing between the clients who learn how to recognize dysfunctional patterns and what triggers in them emotional reactivity. Clients are guided and encouraged to explore their emotional responses in the moment, which leads them to become comfortable in understanding and accepting vulnerabilities, respond compassionately to each other, and change inflexible behaviors (Goldberg & Goldberg, 2012). Process of change in EFCT takes place in three stages which include de-escalating negative cycles, changing relational attitudes, by getting involved the withdrawn partners and softening those who criticize, and consolidation and integration of positive outcomes (Johnson & Boisvert, 2002).

 John Bowlby’s attachment theory had an important contribution to the development of EFCT. Bowlby described how early interactions with caregivers shape the quality of future relationships (Holmes, 2014). The emotionally focused couples therapy applies these concepts to distressed adult couple relationships, in the context of attachment anxiety and attachment avoidance (Johnson, 2004). People experiencing attachment anxiety or attachment anxiety are more likely to express emotional hyperactivation, be involved in troubled or distrustful relationships and affairs, blaming the partners for relationship difficulties, avoiding intimacy or have unfulfilling sexual relations, and withdraw emotionally from the relationship contract. Emotionally focused couples therapy works on the premise that changing these anxious and avoidant attachments into secure attachments will lead couples to more satisfying relationships. In the course of emotionally focused couple therapy, clients identify negative emotional patterns blocking their relationship and then reprocess these barriers to create more secure attachments. In doing this, clients redefine those emotional experiences from a new perspective, getting a new understanding of their own emotional needs and their partners. Thus, new patterns of interaction are formed, based on stronger and more genuine emotional bonds. 

Proponents of the EFCT boast compelling evidence in support of the effectiveness of their model, beyond outcomes of any other therapeutic approach, with 86-90% of couples experiencing significant improvements and 70-73% of the couples reporting recovery from distress. Research shows that a general good predictor of successful therapy is a variable called “softening”, which describes the empathic response of partners reaching out one to another as a result of expressions of emotional vulnerability. This is particularly important in resolving relationship conflicts (Meneses & Greenberg, 2011). It is believed that the positive lasting and reliable outcomes are due to EFCT effectively helping couples to form a secure emotional attachment (Johnson & Wittenborg, 2012). It appears that studies show stable relationship improvement and decreases in attachment anxiety. A two-year follow-up of a study of parents with chronically ill children evidenced 38.5% of couples continued to improve on their relationship (Cloutier et al., 2002). Another long-term follow-up study showed that after taking EFCT, couples which experienced “attachment injuries” (infidelity or abandonment at a difficult time) regained trust, reached relationship satisfaction, and forgiveness (Halchuk, Makinen, & Johnson, 2010). Research performed on the EFCT client change process revealed how couples experience forgiveness and reconciliation in therapy. In cases of attachment injuries (hurtful betrayal of relationship), it was found that clients who are deeply engaged with their intrapsychic experience are more likely to reconnect with their partners (Zuccarini, Johnson, Dalgleish, & Makinen, 2013).

Burgess Moser et al. (2016) conducted research to verify changes in relation-specific attachment in the process of EFCT and the results showed decrease in attachment anxiety and avoidance, with a move toward a more secure bond. Another study measuring relationship functioning and relation-specific attachment levels pre- and post-therapy found that attachment anxiety decreased because of EFCT, with further improvements throughout follow-up, although it was not the same with the attachment avoidance. The relation-specific attachment avoidance was found to be lower throughout follow-up compared to pre-therapy (Wiebe et al., 2017). However, a new study is challenging empirical evidence supporting the assertion that EFCT facilitates changes in attachment for clients involved in EFCT. Researchers examined 461 couples in an eight-session EFCT and found relative constant attachment anxiety and avoidance scores throughout therapy. These seem to be in line with previous studies showing that we cannot be definitive and conclude that therapy can change attachment (Benson et al., 2013; Seedall & Wampler, 2013; Johnson et al., 2016).

 Emotionally focused therapy with couples (EFCT) was found effective in treatment of various couple populations from different cultures, sexual orientations, or spiritual beliefs (Johnson, Bradley, & Furrow, 2011; Furrow, Johnson, Bradley, & Amodeo, 2011). Effectiveness of EFCT was demonstrated in practice with couples facing relationship distress because of partners struggling with depression, both men and women (Dessaulles, Johnson, & Denton, 2003; Wittenborg, Culpepper, & Liu, 2012), military relationships of those affected by PTSD (Blow, Curtis, Wittenborg, & Gurman, 2015), survivors of childhood abuse (Dalton, Greenman, Classe, & Johnson, 2013), couples with family members diagnosed with chronic illness, terminal illness, neurodegenerative, or other medical conditions (Walker, Johnson, Manion, & Cloutier, 1996; Tie & Poulsen, 2013; Ghedin et al., 2017; Fitzgerald & Thomas, 2012). EFCT was applied successfully in cases of couples having one partner struggling with sexual addiction (Love, Moore, & Stanish, 2016), improving sexual relationships of couples during and after cancer (Grayer, 2016), or increasing sexual satisfaction of infertile couples with marital conflicts (Soleimani et al., 2015). “Hold Me Tight” is a relationship enhancement psychoeducational program for couples based on the principles of EFCT. Program’s effectiveness was demonstrated by improving intimate relationship, relationship satisfaction, emotional bond, forgiveness, and behavioral functioning (Khan, 2018; Conradi, Dingemanse, Noordhof, Finkenauer, & Kamphuis, 2018). Emotion-focused family therapy (EFFT) has wide applications. For example, when used in a children’s mental health center, EFFT did augment the effects of solution-focused therapy (Efron, 2004), enhanced best practices in treatment of eating disorders in case of children and adolescents (Robinson, Dolhanty, & Greenberg, 2013), and provided a successful two-day intervention strategy in helping families with members experiencing eating disorders (Robinson et al., 2016).

 B. Solution-focused family therapy

Solution-focused therapy (SFT) was developed in the 1980’s by researchers at the Brief Family Therapy Center in Milwaukee, Wisconsin, influenced by the activity of the Mental Research Institute in Palo Alto, California and the work of Milton Erickson who stressed the importance of utilizing client’s resourcefulness (Gurman, 2008). Solution-focused brief therapy (SFBT) is a postmodern model based on a social constructivist approach and the power of language to create solutions and effect change by helping the client to describe life in new perspectives (Miller, 1997). SFBT is a strength-based approach highlighting client’s goals, creativity, hope, and gradual improvement, with the therapist acting as a skilled facilitator engaging the client with interactive solution-focused questions: the miracle question, exception question, pretreatment question, scaling question, or coping questions. De Jong and Berg (2008) outlined five stages of therapy: defining the issue, identifying clear goals, exploring exceptions, end-of-session feedback, and scaling progress. SFBT is also hope-focused. Clients are responsible to develop well defined goals and encouraged to have hopeful expectations that they hold the solution to their problem (de Shazer, 1985).

Language utilized in formulation of questions is such paramount that can lead to effective therapeutic change. A cross-cultural study showed significant increase in self-efficacy, goal orientation, and action steps, with significant decrease of negative affect when clients were asked solution-focused as opposed to problem-focused questions (Neipp, Beyebach, Nuñez, & Martínez-González, 2016). Utilizing solution-focused questions and avoiding problem-focused questions during the intake procedures can influence the information that the clients present at the interview and even produce pre-treatment change (Richmond, Jordan, Bischof, & Sauer, 2014). In a qualitative study, it was observed that after clients report no improvement in previous therapy sessions, focusing on the positive as opposed to negative topics in the follow-up conversations can be helpful (Sanchez-Prada & Meyebach, 2014). SFBT’s therapeutic techniques have been the subject of many studies. McKeel (2012) did a review on the process change research and found that solution-focused conversation, presuppositional questions, and instillation of hope and positive expectations are precursors of change. Another systematic review published in 2016 examined the process research of SFBT and found strong scientific support for SFBT practice, especially for SFBT techniques combined: strength and resources, future-oriented, and multiple techniques. The review supports previous studies showing the uniqueness of language-oriented techniques of SFBT, which are distinct from other strategies, like MI or CBT (Franklin, Zhang, Froerer, & Johnson 2017).

A review of the literature between 1990 and 2010 revealed that SFBT was tentatively effective as an early intervention in families with children having internalizing and externalizing behavior issues. Most of the well-evidenced studies came from USA, UK, Australia, Canada, Cyprus, Lithuania, Norway, Romania, Sweden, Hong Kong, and Korea. SFBT was often used in combination with other approaches. Only five high-quality studies were identified, which does not represent an enough strong evidence base. Some of the studies dealt with the therapeutic process rather than the results. It was suggested that more controlled studies are needed (Bond, Woods, Humphrey, Symes, & Green, 2013).  

Since both SFBT and experiential family therapy are strength-based approaches, they can be integrated successfully, or at least some of the techniques. For example, solution-based family sculpting can facilitate the client to move from words to images, thus expanding the repertoire of possible solutions (Reiter, 2016). SFBT and Motivational Interviewing (MI) are utilized extensively in medical therapy. Because of the similarities of these approaches, evidence was established for effective integration of SFBT and MI in helping patients deal with ambivalence in a solution-oriented medical treatment setting (Stermensky & Brown, 2014).

C. Compare EFCT and SFBT

Emotions are not neglected in SFBT. Although SFBT does not appear to deal with emotions, attachment, or self-concept, de Shazer, founder of SFT, asserts that helping clients to create new emotion rules to follow can enhance the solution-building process (Miller & de Shazer, 2000). One way of doing this is by utilizing enactments, which can lead clients to construct new emotions and access more exceptions (Seedall, 2009). From a contextual and social constructivist perspective, positive emotions like hope, happiness, joy, gratitude, faith, courage, trust, pride, and interest can play an important role in the SFBT process of change by making clients to remember and keep those feelings connected to the context of the conversation (Kim & Franklin, 2015).

 There are some commonalities between EFCT and SFBT. Both models are relatively short-term, strength-based, and looking for the reduction of presenting problem behavior, they are client-centered, less directive, and respectful. EFCT and SFBT increase couple resourcefulness by improving communication style, problem-solving skills, and coping skills. Clients experience improvement in fulfillment of psychological needs, intimacy, trust, and ability to interact successfully with social systems. EFCT and SFBT have strong support for their efficacy and even inexperienced therapists can manage to apply their principles and obtain positive results. Although SFBT is not interested in increasing awareness and insight into presenting problem or weaknesses, both therapies lead to new perceptions and new meanings that can facilitate change. EFCT and SFBT are theory-based models, relatively structured, using specific techniques which are applied systematically, as a series of therapeutic tasks.

 There are also notable differences between EFCT and SFBT. EFCT is based in the humanistic-existential tradition, insight-, in-the-moment-, vulnerabilities-, and problem-oriented. SFBT is a postmodern, social constructivist approach, future-, solution-, hope-, and strength-oriented. In EFCT, clients discover meaning or co-create meaning mostly in session; through various tasks and homework, SFBT is looking to disrupt the patterns outside of the therapy. EFCT is paying attention to the emotional process, whereas SFBT is paying attention to the linguistic discourse to resolve the presenting problem and not working through the underlying emotional issues. In EFCT, clients pursue mediating, process goals, as opposed to SFBT, where clients set clearly defined goals aimed at solving the presenting problem. SFBT relies minimally on theory, is not interested in conceptualizing the abnormal, and has no theory to describe difficulties in a relation, while EFCT is strongly founded in the attachment theory. EFCT helps by increasing emotional awareness, meaning and attribution, SFBT focuses on behavioral change. EFCT elicits an empathetic response leading to an increased sense of safety, SFBT seeks exceptions to change stuck interactions.

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