How to Build a Trusting Counselor Patient Relationship
“Emotional bonding between counselor and client is different for every “Yet without the foundation of a constructive relationship, anything else that we explains Guterman, a licensed mental health counselor (LMHC) in Fort. The Therapeutic Relationship in E-Therapy for Mental Health: A . c Synchronous communication between therapist and patient takes places. A trustworthy counselor patient relationship is the foundation for successful counseling and is possible when these 12 factors exist.
The widespread use of the Internet has affected mental health care delivery, with a rapid expansion of e-therapy [ 2 ]. Although there is growing evidence that e-therapy is effective for a variety of conditions [ 24 - 6 ], researchers have expressed concerns about e-therapy use [ 78 ]. One of the primary concerns about e-therapy is related to the perceived difficulty of developing an effective therapeutic relationship in the absence of nonverbal cues [ 6 ].
Extensive literature on face-to-face psychotherapy indicates that the therapeutic relationship accounts for more variability in psychotherapy outcomes than do specific therapy ingredients [ 9 - 11 ]. Given the crucial role of the therapeutic relationship in face-to-face interventions, it is important to assess the role of therapeutic relationship in e-therapy as well.
Although e-therapy research began over 15 years ago, there has been no attempt to review the findings pertaining to the status of the therapeutic relationship in online interventions. This paper represents the first attempt to summarize and review the existing findings. The search was limited by language the paper had to be in Englishby methodology the study had to be a clinical trial; randomized controlled trial; clinical trial, phase 1; clinical trial, phase 2; clinical trial, phase 3; clinical trial, phase 4; comparative study; controlled clinical trial; or a technical reportand by sample human subjects.
This search, with these limits, and taking only the items with an abstract, yielded a total of abstracts. The search was limited by language the paper had to be in English and by publication type the study had to be a peer-reviewed research article.
Selection Strategy We carefully screened the abstracts of all articles identified by the electronic searches in total to determine whether the abstracts met the following inclusion criteria: Specifically, abstract text had to use the word relationship or alliance to be included in the review.
Interventions had to be consistent with the above definition of e-therapy. This excluded interventions that were described as self-help, peer-led groups, online communities, or volunteer-led online support.
If a given study had multiple intervention groups, at least one intervention group had to meet the e-therapy definition.
There were no inclusion or exclusion criteria regarding the focus of the treatment. They may wish to break the taboo of silence that the therapist has imposed, to speak out truthfully about what has happened to them.
They may seek justice and restitution in the courts. They may try to prevent the therapist from abusing other patients by filing formal complaints with professional ethics committees, the hospital or clinic if any employing the therapist, and licensing agencies, in part to see if to what degree these organizations are serious about protecting patients from abuse.
They may try to make sense of and work through their experience of abuse so that they can move on with their lives. But on the other hand, they may believe that they need to protect the abusive therapist at all costs.
The Therapeutic Relationship in E-Therapy for Mental Health: A Systematic Review
Abusive therapists are often exceptionally adept at creating and nurturing these dynamics. Exploited patients may learn from the therapist that the most important thing is to keep the sexual relationship secret so as not to harm the therapist's career. They may have been led to believe that the sexual relationship was an act of great self-sacrifice on the part of the therapist, a moral and ethical act that was the only way that the therapist could "cure" whatever was wrong with the patient.
Ambivalence of this kind is often found among those who have experienced other forms of abuse. Incest survivors, for example, may experience contradictory impulses to flee the abusive parent, and yet also to cling to and protect that same parent. Similarly, some battered women will desperately want to escape to safety but also feel an overwhelming impulse to submit to the batterer, to take all blame upon themselves, and to keep the battering secret from all others.
Cognitive Dysfunction Many people who have been sexually involved with a therapist, whether the sex started before or after termination, will experience intense forms of cognitive dysfunction.
Sex Between Therapists and Clients
There may be interference with attention, memory, and concentration. The flow of experience will often been interrupted by unbidden thoughts, intrusive images, flashbacks, memory fragments, or nightmares. These cognitive impairments may interfere significantly with the person's ability to work, to participate in social activities, and sometimes even to carry out the most routine aspects of self-care.
Sometimes the pattern of consequences may fit the model of post-traumatic stress disorder. Emotional Lability Emotional lability reflects the severe disruption of the person's characteristic ways of feeling in a way that is similar to cognitive dysfunction reflecting the severe disruption of the person's characteristic ways of thinking. Intense emotions may erupt suddenly and without seeming cause, as if they were completely unrelated to the current situation.
The emotional disconnect can be profound: Emotions begin to feel alien and threatening, as if they were unwanted intruders into the inner life. Cognitive dysfunction can involve interrupting the flow of experience with unbidden thoughts, intrusive images, etc. The person begins to feel helpless, as if the emotions were completely out of control, as if he or she were at the mercy of a powerful, intrusive enemy, an occupying force.
Emptiness and Isolation People who have been sexually involved with a therapist may experience a subsequent sense of emptiness, as if their sense of self had been hollowed out, permanently taken away from them. The sense of emptiness is often accompanied by a sense of isolation, as if they were no longer members of society, cut off forever from feeling a social bond with other people. She wrote in If I am alone, I will cease to exist. Guilt People who become sexually involved with a therapist may become flooded with persistent, irrational guilt.
The guilt is irrational because it is in all instances the therapist's responsibility to avoid sexually abusing a patient.
It is the therapist who has been taught, from the earliest days of training, that engaging in sex with patients is prohibited, no matter what the rationale. It is the therapist whose ethics code clearly classifies sexual involvement with patients as a violation of ethical behavior.
It is the therapist who is licensed by the state in recognition of the need to protect patients from unethical, unscrupulous, and harmful practices, and it is the licensing boards and regulations that clearly charge therapists with refraining from this form of behavior that can place patients at risk for pervasive harm. As the research summarized in subsequent sections will show, gender effects in this area are significant.
It is possible that gender may be associated with the ways in which this irrational guilt develops and is sustained. Psychiatrists Melanie Carr and Gail Robinson wrote: The almost universal expression of guilt and shame expressed by women who have been sexually involved with their therapists is a testament to the power of this conditioning" p. Psychiatrist Virginia Davidson, analyzing the similarities between therapist-patient sex and rape, wrote: Women victims in both instances experience considerable guilt, risk loss of love and self-esteem, and often feel that they may have done something to "cause" the seduction.
As with rape victims, women patients can expect to be blamed for the event and will have difficulty finding a sympathetic audience for their complaint.
Added to these difficulties is the reality that each woman has consulted a therapist, thereby giving some evidence of psychological disequilibrium prior to the seduction.
How the therapist may use this information after the woman decides to discuss the situation with someone else can surely dissuade many women from revealing these experiences. Impaired Ability to Trust When therapists intentionally and knowingly violate their patients' trust, as they do when they decide to become sexually involved with them, the effects on the patients' ability to trust can be profound and lasting. Therapy may rest on a foundation of exceptional trust.
People may walk into the offices of complete strangers and, if the stranger is a therapist, begin talking about thoughts, feelings, and impulses that they would reveal literally to no one else. Every state, appreciating the exceptionally sensitive nature of the "secrets" that patients may entrust to their therapists, have established in their laws a formal therapist-patient privilege. The ethics codes of all major mental health professions recognize the therapist's responsibility to maintain confidentiality when patients trust the therapist to the extent that they disclose personal information in therapy.
Beyond investing therapists with trust regarding their own privacy, confidentiality, and "secrets," patients trust therapists to act in a way consistent with patient well-fare and to avoid intentionally engaging in any behavior that not only is unethical and prohibited by law but also places the patient at so needless a risk for harm.
In some ways, therapy is similar to surgery. Patients agreeing to surgery allow themselves to be opened up physically because they have been led to believe that the process has some reasonable prospects of leading to improvement.
They allow a professional to do to them--i. They trust that the professional will not take advantage of them or abuse them, sexually or otherwise, during this process. Therapy patients submit themselves to a process in which they open up psychologically because they also have been led to believe that this process is likely to yield improvement. They trust therapists to avoid any exploitation or abuse during the process.
It was Freud who first noted this similarity. He wrote that "talking therapy" was "comparable to a surgical operation. Increased Suicidal Risk As a group, patients who have been sexually involved with a therapist have significantly increased risk of both suicide attempts and completed suicides when compared with the general population and other groups of patients.
Role Reversal and Boundary Confusion Therapists who sexually exploit their patients tend to violate both roles and boundaries in therapy. The focus of sessions shifts from the clinical needs of the patient to the personal desires of the therapist. The therapist brings about a reversal of roles: The fundamental clinical, ethical, and legal boundary that would prevent a therapist from turning patients into sources for the therapist of sexual pleasure, experimentation, relief, variety, or control is violated.
In a legitimate therapy, the therapeutic process, effectiveness, and improvements that therapist and patient work on during each sessions is expected to continue between sessions and, ultimately, after termination.
Entering psychotherapy to become less depressed, to overcome stage fright, or to resolve conflicts with a partner would make little long-term sense if the depression stage fright, and conflict resumed immediately after termination. Unfortunately, the harm as well as the benefits that therapy brings about can be long-term. The negative effects of the therapist's violation of boundaries and reversal of roles can generalize beyond the therapy and persist long after the termination of the therapy and the sexual relationship.
The roles and boundaries that people use to define, mediate, and protect the self may become not only useless for the patient but also self-defeating and self-destructive. Sexual Confusion It is perhaps not surprising that many patients who have been sexually exploited by a therapist wind up deeply confused about their own sexuality.
Psychologist Janet Sonne served as one of the group therapists in and for some of the patients who participated in the UCLA Post Therapy Support Program, the first university-based program offering services to patients who had been sexually involved with their therapists, conducting research in this area, and providing training to graduate students.
She wrote that female patients who had been sexually involved with a prior therapist "expressed a cautiousness or even disgust with their sexual impulses and behavior as a result of sexual involvement with their previous therapists.