Grief and Loss

Solution-Focused Brief Therapy and Worden's Grief Tasks

Research paper:
Solution-Focused Brief Therapy and Worden’s Grief Tasks

Much has been written on Worden’s four-task approach to grief; much less has been written about how a strengths-based approach, such as Solution-Focused Brief Therapy (SFBT), might be useful to counsellors working within Worden’s formulation.

The average number of client sessions entered into for grief and loss counselling at AnglicareSA’s Loss & Grief centre in Hindmarsh, Adelaide is five; Simon (2010), citing Simon & Nelson (2005), reports that the average number of sessions run when using SFBT is 4.5, although Simon does not state the average number of sessions required for Loss and Grief counselling. He does, however, go on to present three case studies in the area that are between one and two sessions in length, with the suggestion being that two to three sessions are his typical duration.

However, it should be noted that Simon limits his loss and grief scope of practice to those who have had some time lapse (a minimum of one month in his case studies) from the death event – he does not suggest SFBT interventions for events nearer in time. Generally, one would expect some resilience and coping strategies would have been utilised by the client after one month: “This has been a difficult time for you. What is it that keeps you going day after day? How did you just get up out of bed and come here to see me?” (Simon, 2010, p. 91)

A solution-focused approach, argues Simon, allows the client and counsellor, in partnership, to co-create possibilities rather than limitations. But what effect does the type of partnership between counsellor and client have on the therapeutic outcome?

Recognising the well-cited What works in therapy (Duncan, Miller, Wampold, & Hubble, 2014) claim that 70-75% of the success of therapy can be put down to the strength of the therapeutic relationship, Miller, Duncan and Hubble (1997) claim that the clinical bond and therapy duration are not connected. So it seems that the strength of the relationship is key, but the relationship need not be a long one. But it is not just the counsellor and client that can be agents of change; solution-focused practitioners view the individual as part of diverse social systems, where social systems are both the context and agent for positive change (de Shazer, 1991; cited in Simon, 2010). But there is an ‘either/or’ dichotomy at work in much of the general population’s knowledge of grief—one is either grieving or one is healing. In reality the two co-exist: healing is taking place at the same time as grieving is being undertaken (Simon, 2010).

Worden (2008) proposes four tasks that the bereaved and grieving need to attend to in order to healthily process their grief and move forward with their life. These can best be remembered by the acronym ‘tear’:

· To accept the reality of the loss;

· Experience the pain of the loss;

· Adjust to the new environment without the lost person; and

· Reinvest in the new reality whilst staying connected to the lost person (Psychology Tools, 2008-2016).

Worden quotes Shucter and Zisook who write:

A survivor’s readiness to enter new relationships depends not on “giving up” the dead spouse but on finding a suitable place for the spouse in the psychological life of the bereaved—a place that is important but that leaves room for others. (Worden, 2008, p. 51)

Worden argues that these four tasks must be accomplished for the process of mourning to be completed and equilibrium to be re-established. He acknowledges that people may need to revisit certain tasks over time, that grief is not linear, and that it is difficult to determine a timeline for completing the grief tasks.

It is in regard to the first and third tasks, accepting the reality of the loss and adjusting to the new environment, that SFBT and other strength-based approaches may have something to say. The author’s wife lost her first husband to cancer and she strongly believes that a strengths perspective is invaluable in meeting the requirements of tasks one and three.

She suggests that, in order to help the bereaved accept the death of a loved one, they be encouraged to write down all the things that they can no longer do—for example, go dancing, go walking together, visit the cinema together, and so on. But, and here is where a strength approach is helpful, the bereaved is also encouraged to write down all of the things that they can now do—perhaps finish a project that required lots of time, take a holiday to a place the other person didn’t want to visit, and so on. Alongside this, the bereaved is asked to ask of themselves, “What routine can I no longer do, what can I replace it with?”

Traditional counselling often stays clear of solution-talk, but to ask the client about their various resources is not a counselling crime. Traditional counselling’s approach is a neglectful and disrespectful one; as if asking a client about their strengths and resources would make the counsellor blind to their problems. This would be like an accountant not noting a company’s assets in case it caused blindness to its debts (Ratner, George, & Iveson, 2012).

Additionally, problem-focused counselling (traditional counselling) assumes that the grieving process is long and troubled. However, in some cases, that may not be so. I am reminded of a client of mine who has been grieving the sudden death of his wife of 48 years. Because their marriage had been ‘difficult’ for the last two decades he is both sad at his loss and relieved at the same time. In a sense he had already grieved for the loss of his marriage and is now looking at moving on to a new relationship. Indeed, during his first session with me he asked me how long he should grieve for before he could see someone new. SFBT is a strengths-based therapeutic model that rests on the belief that all individuals have strengths and resources, even when the situation is the bleakest (De Jong & Berg, 2013). SFBT does not pathologise clients. Instead, it perceives clients as only being “stuck” in dealing with their problems (Ng, Parikh, & Guo, 2012).

Because of its focus on cognitions and behaviour and its time-limited orientation, SFBT often does not allow therapists time to explore the affective experience of clients. Also, discussing emotions during counselling is not encouraged in purist-led SFBT because it is perceived as ‘problem talk’ (Ng et al., 2012). However, there is an example of the counsellor displaying client-centred approach, which Ng et al. (2012) showed with clarity in the second session of their case study. And it should be remembered that attending to emotions is a requisite to developing a therapeutic working alliance – without which counselling cannot progress. “It is unclear if SFBT is best suited to individuals who are more resilient; but it is the job of counselors to help clients locate and use their resources to build solutions to their problems” (Ng et al., 2012, p. 229). As Sharry and colleagues point out, a good therapist should be flexible enough to adapt to the client’s wishes, “even if it means abandoning the solution-focused model if required” (Sharry, Madden, & Darmody, 2003, p. 90).

Conclusion

With every therapeutic approach that works, it works, in the end, because the client has been helped to draw in some different way on their resources: therapy doesn’t change people, it enables them to discover their own resources so they can make the changes themselves (G. Miller, 2014). A strengths-based approach, such as SFBT, enables the counsellor to assist the grieving client find the resources they need to get through the difficult days, weeks and months ahead after a loss.

References

De Jong, P., & Berg, I. K. (2013). Interviewing for solutions (2nd ed.). Pacific Grove, Calif: Brooks/Cole.

Duncan, B. L., Miller, S. D., Wampold, B. E., & Hubble, M. A. (Eds.). (2014). The heart & soul of change: Delivering what works in therapy (Second ed.). Washington, DC: American Psychological Association.

Miller, G. (2014). Burkean Dialectics and Solution-Focused Consultation*. InterAction, 6(1), 8-22.

Miller, S., Duncan, B., & Hubble, M. A. (1997). Escape from Babel: Toward a unifying language for psychotherapy practice. New York: Norton.

Ng, K.-M., Parikh, S., & Guo, L. (2012). Integrative solution-focused brief therapy with a Chinese female college student dealing with relationship loss. International Journal for the Advancement of Counselling, 34(3), 211-230. doi:10.1007/s10447-012-9152-x

Psychology Tools. (2008-2016). TEAR model of grief. Retrieved from http://psychology.tools/tear-model-of-grief.html

Ratner, H., George, E., & Iveson, C. (2012). Solution-focused brief therapy: 100 key points & techniques. Hove, UK: Routledge.

Sharry, J., Madden, B., & Darmody, M. (2003). Becoming a solution detective: Identifying your clients’ strengths in practical brief therapy. Binghampton, NY: The Haworth Press.

Simon, J. K. (2010). Solution focused practice in end-of-life and grief counseling. New York: Springer.

 

If you want to discuss this further, please contact me.

The difference between a psychiatrist, a psychologist and a counsellor

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A client asked me the other day what the difference was between a psychiatrist, psychologist and me, a counsellor.

I answered that a psychiatrist is interested in the medical model and is the only one, apart from a GP, who can prescribe drugs. A psychologist works by seeing if you fit into a diagnostic ‘box’ and a counsellor works in a holistic manner with the person who walks into the room. Both psychiatrists and psychologists are only likely to see you once a month, whereas a counsellor will probably be able to see you more often than that.

Also, you don’t get a Medicare rebate with counsellors whereas you do with psychiatrists and psychologists. But with psychologists that you might be seeing on a Mental Health plan, you have a limited number of sessions with them that Medicare will pay for. After that you are up for the $200+ fee per session yourself.

As a rough guide, you would probably see a counsellor for a few sessions, and a psychologist or psychiatrist for personal challenges that appear to be taking longer to fix. But having said that, I have clients that have been seeing me weekly for over a year.

Sharry, Madden and Darmody (2012, p. 10) drew up the following table to reflect the differences between a solution-focused therapist (of which I am one) and problem-focused therapists (irrespective of whether they are psychiatrists, psychologists or counsellors):

‘Problem detective’ ‘Solution detective’
Looks for ‘clues’ that will reveal deeper problems and diagnoses Looks for ‘clues’ that reveal hidden strengths and positive possibilities
Tries to understand fixed problem patterns in the client’s life Tried to understand how positive change occurs in the client’s life
Elicits detailed descriptions of problems and unwanted pasts Elicits detailed descriptions of goals and preferred futures
Interested in categorising problems and applying diagnoses Interested in the person ‘beyond the problem’ and in the unique story he or she has to tell
Focuses on identifying ‘what’s wrong’, ‘what’s not working’ and on deficits in individuals, families and communities Focuses on ‘what’s right and what’s working’ and on strengths, skills and resources in individuals, families and communities
Interprets and highlights the times the client ‘resists’ or is inconsistent in his or her responses Highlights and appreciates any time the client co-operates or goes along with the therapist’s questions
Explores how trauma has affected or damaged the client Explores how the client has coped with trauma and how he or she has survived its damaging effects

Source: Sharry, Madden and Darmody (2012). Becoming a solution detective (2nd Ed.). New York: Routledge.

Acceptance and Commitment Therapy (ACT)–A review

Acceptance and Commitment Therapy (ACT) - a review

Acceptance and Commitment Therapy: the foundations

This post will look at Acceptance and Commitment Therapy (ACT) and its foundations of Functional Contextualism (FC), Applied Behavioural Analysis (ABA) and Relational Frame Theory (RFT). It will consider the latest research and meta-analyses of the efficacy of ACT and will conclude that whilst ACT shows promise as a therapeutic tool for many psychological conditions, it shows no greater promise than traditional Cognitive Behavioural therapies (CBT).

Background

ACT as we currently understand it has been a long time coming (Harris, 2009). Seeing that as far back as 1986 randomised controlled trials (RCT) were showing its efficacy in treating depression, the journey from a ‘possibly useful’ new therapeutic option to a now widely-recognised and talked-about therapy has been a long, slow but behind-the-scenes busy one.

Steven Hayes, the originator and champion of ACT, explains (Harris, 2008; cited in Harris, 2009) that the time between initial development and its current popularity has been time well spent on establishing sound theoretical, measurement and philosophical bases. Without such underpinnings, explains Hayes, ACT could have withered under intense scrutiny and died.

Functional Contextualism (FC)

Functional Contextualism is the underlying philosophy of the ‘third wave’ of behavioural therapies, of which ACT is one (Benson, Sevier, & Christensen, 2014). From the perspective of FC, no thought we might have is considered problematic, dysfunctional or pathological (Harris, 2009); it is only the context within which the thought operates that determines its meaning, and that meaning is experiential (Jonassen, 2006). Thoughts can be toxic and harmful, but depending on whether we are cognitively fused with them or in a state of mindful diffusion those same thoughts can either hold us back or not from valued living. FC seeks to understand people within their environments, and that whilst behaviour can look very similar in different circumstances, the function of that behaviour can be very different (Boone, Mundy, Morrissey Stahl, & Genrich, 2015).

FC views ‘truth’ as contextual and pragmatic (Hayes, Luoma, Bond, Masuda, & Lillis, 2006). Given a set of circumstances and thoughts to work with, FC chooses to work with ‘what works for a given goal’ (Boone et al., 2015). Therefore, a FC therapist would not ask a client to examine the veracity of their thought, as a CBT practitioner would, but instead ask whether it is useful in the pursuit of a particular client-held value or goal. As Boone and his colleagues note, a pragmatic-focused criterion keeps therapists from getting bogged down in ‘what is reality’ questions and instead sharpens their focus onto what effectively helps people.

It should be noted that FC is not a widely-published academic theory; four authors (Steven Hayes, Jennifer Gregg, Elizabeth Gifford and Anthony Biglan) account for the majority of the literature on FC. As Jonassen (2006, p. 45) points out, “It is an interesting theory worthy of consideration, but it is not a major neo-behaviorist movement.”

Relational Frame Theory (RFT)

FC starts with basic principles of learning theory such as operant conditioning (e.g. positive and negative reinforcement) and classical conditioning; Relational Frame Theory takes FC further by seeking to account for the complexity of human behaviour through taking into account the role of language in learning. A substantial literature demonstrates the potential for RFT to contribute to the understanding of language and cognitive development (Cullinan & Vitale, 2009). RFT is a behaviour analytic approach to the study of human language and cognition.

RFT describes a process whereby humans learn to relate to stimuli in their social environment based on assumptions and conventions that are social and cultural. ACT is an intervention, grounded in RFT, that addresses problem behaviours that arise from human relations derived from language and cognition (McKeel & Dixon, 2014). ACT notes that individuals engage in experiential avoidance which leads them to undesirable behaviours. What is noted in RFT is that humans don’t take into account just the physical characteristics of given stimuli, but that they attach all manner of interpretations to it, ‘framing’ the stimuli. Relational framing is thought to be an unconscious process, but one that is capable of being consciously considered (McLaren, Dillard, Tusing, & Solomon, 2014). RFT states that people interpret or ‘frame’ messages and thoughts as relevant to either of two domains: dominance-submissiveness (reflecting the power, influence or status between communicators) or affiliation-disaffiliation, which encompasses the degree of solidarity, liking or esteem that a communication receiver has for another communicator (Dillard et al., 1996; cited in McLaren et al., 2014). Framing is an unconscious process precisely because it needs to be fast-moving; people must quickly figure out how to appropriately respond to a message during an interaction. According to RFT, the various relational frames that people construct are said to possess three properties: mutual entailment, combinatorial entailment and transformation of function. It is beyond the scope and length of this essay to do more than note the existence of these three properties. Each is complex in design and description.

To many the theory remains controversial and complex (Dymond, May, Munnelly, & Hoon, 2010). To others the fact that the vast majority of academic publications about RFT occur in low-impact or no-impact journals suggests low levels of academic support except amongst a small group of practitioners—somewhat akin to the existence of journals that take into account religious perspectives (e.g. Journal of Psychology & Christianity, Journal of Psychology & Theology), it is possibly a case of the converted speaking only to the converted. There doesn’t appear to have been a concerted wider effort at evangelism. Also of note is that the studies, whilst numerous, have most often times been conducted in an experimental setting and with very small numbers of subjects. It would be nice to see RFT studies conducted in broader settings.

Applied Behavioural Analysis (ABA)

Applied behaviour analysts have been helping people to enhance the quality of their lives for decades (see, for example, Zifferblatt & Hendricks, 1974). ABA is a scientific approach to the study of behaviour, paying close attention to the social validity of concerns and outcomes. As Gambrill (2013) notes, thousands of studies can attest that people’s lives can be improved by drawing on basic behavioural principles. It is in the applicability of theory that ABA shines, particularly in educational settings, where it has been shown to be extremely helpful with autism (Lovitt, 2012; see also www.lovass.com).

ABA allows for the prediction and influence of behaviour. Whilst a multi-faceted tool (see Lovitt, 2012 for a breakdown of the seven components: direct measurement, contingency management, precise behavioural language, behavioural processes, self-management, pinpointing behaviours, and charting), of particular interest to ACT is functional behavioural analysis, which asks the question, “What purpose does this behaviour serve?” ABA has a simple A-B-C formula to help with answering that question; Antecedent-Behaviour-Consequence. ‘Antecedent’ asks what happens before a behaviour that plays a major role in influencing it. ‘Behaviour’ is the behaviour we have under consideration, the focus of our investigation (perhaps because the client feels that it is ‘wrong’ behaviour). ‘Consequence’ is a look at the effects the behaviour has on the self, others or the environment. By analysing the ‘ABC’ of a problem behaviour we free up the client to be able to explore and clarify their values. From this value awareness, the client is able to make different choices about what to do when troubling thoughts occur, behaviour that has more life-enhancing outcomes.

Acceptance and Commitment Therapy (ACT)

There is not the space here to show in any great depth what ACT is, other than to note that more than 60 books on ACT have been written, so further elucidation is not far from hand (Hayes, Strosahl, & Wilson, 2012). In addition, hundreds of academic papers have been written about the therapy, suggesting that ACT can be efficacious—either on its own or when used in conjunction with other therapies—when treating depression, OCD, workplace stress, chronic pain, the stress of terminal cancer, anxiety, PTSD, anorexia, heroin abuse, marijuana abuse, and even schizophrenia (Harris, 2006). It has also shown promise as an internet-based tool (Lappalainen et al., 2014).

ACT is a ‘third wave’ therapy; it is characterised by an openness to older clinical traditions, it has a focus on contextual change, an emphasis on function over form, and an interest in the construction of flexible and effective repertoires (Hayes, 2004).

ACT relies on the philosophy of FC to provide its pragmatic base. FC, it should be remembered, considers what is ‘true’ to be what is ‘working’. In ACT, holds Hayes (2004), there is a conscious posture of acceptance and openness to all psychological events, even if they are seen as ‘negative’, ‘irrational’, or even ‘psychotic’.

RFT in ACT points directly to the likelihood of cognitive fusion and experiential avoidance. In ACT it is the tendency to take experiences literally and to fight against them that is viewed as harmful. With ABA, ACT therapists are able to measure what the antecedents and consequences of behaviour are.

The principle aim of ACT is to dismantle inflexible repertoires, favouring the acceptance of a feared private event when that private event generates counterproductive attempts to avoid or control (Ruiz, 2010). In order to meet its objectives, ACT makes use of paradoxes, metaphors and experiential exercises, training the client to be present with their feared private event and to choose to behave in a way that aligns with their stated values.

ACT assumes that within language and learning processes lie the origins of despair and pain (Jones & Butman, 2011). In this regard Hayes has himself drawn a line to both biblical (Hayes, Strosahl, & Wilson, 1999) and to Buddhist (Hayes, 2002) views of suffering and its amelioration.

Meta-analyses

Several meta-analyses have been conducted on ACT. Öst (2008, 2014) found little evidence for the alleged greater efficacy of ACT compared to traditional treatments. Ruiz (2012) conducted a comparison review of ACT and CBT and found a positive result for ACT, whilst acknowledging the small sample sizes of most of the studies. Powers et al. (2009) found “there is no evidence yet that ACT is more effective than established treatments.” But Levin and Hayes (2009) re-analysed Powers et al.’s database and found that ACT was better than established treatments. Powers and Emmelkamp respectfully disagreed and stuck by their original finding (Powers & Emmelkamp, 2009).

Hayes and his colleagues noted with dismay that ACT was continually being compared with CBT and wrote a plea to colleagues to stop that and instead measure ACT on its own terms (Hayes, Levin, Plumb-Vilardaga, Villatte, & Pistorello, 2013), perhaps feeling that ACT had been around long enough to warrant a more serious level of attention and acknowledgement.

It should be noted that not all meta-analysts agree with each other. Morina, A-Tjak and Emmelkamp (2015) took issue with a peer who commented that their meta-analysis (A-Tjak et al., 2015) and that of Öst (2014) reached “strikingly contrasting conclusions” (A-Tjak et al. found that ACT can provide similar outcomes as established psychological interventions; Öst found no such finding for any disorder). Morina and his colleagues argued that issues of trial relevancy and inclusion, the statistical procedures used to analyse the data, and the criteria applied to interpret the results all play a part in the different findings of the two meta-analyses. What is clear is that small sample sizes can hinder interpretations. As Morina et al. point out, there needs to be a standardised procedure for meta-analyses so that apples can be compared with apples (and also so that potential bias can be reduced or eliminated).

Conclusion

ACT is a relatively new weapon in the counsellor’s armoury. It works by helping the client psychologically ‘unhook’ from problematic thoughts and instead help the client consider and decide whether the thoughts work in the client’s best interests and towards the client’s values. By basing itself on proven theories and philosophies it sits within the ‘third wave’ of behavioural therapies—therapies that build on solid empirical foundations of ‘first’ and ‘second wave’ behaviourism and use mindfulness to facilitate cognitive defusion. Several meta-analyses of ACT have been conducted, most often comparing ACT to traditional, ‘first wave’, CBT, and the results have been mixed and controversial.

References

A-Tjak, J. G. L., Davis, M. L., Morina, N., Powers, M. B., Smits, J. A. J., & Emmelkamp, P. M. G. (2015). A meta-analysis of the efficacy of Acceptance and Commitment Therapy for clinically relevant mental and physical health problems. Psychotherapy and Psychosomatics, 84(1), 30-36.

Benson, L. A., Sevier, M., & Christensen, A. (2014). Reply to the commentaries: Of course, we do not yet know what it is all about, but Functional Contextualism is a good place to start. Journal of Marital and Family Therapy, 40(1), 1-4. doi: 10.1111/jmft.12036

Boone, M. S., Mundy, B., Morrissey Stahl, K., & Genrich, B. E. (2015). Acceptance and Commitment Therapy, Functional Contextualism, and Clinical Social Work. Journal of Human Behavior in the Social Environment, 25(6), 643-656. doi: 10.1080/10911359.2015.1011255

Cullinan, V., & Vitale, A. (2009). The contribution of Relational Frame Theory to the development of interventions for impairments of language and cognition. The Journal of Speech and Language Pathology – Applied Behavior Analysis, 4(1), 132-145.

Dymond, S., May, R. J., Munnelly, A., & Hoon, A. E. (2010). Evaluating the evidence base for Relational Frame Theory: A citation analysis. The Behavior Analyst, 33(1), 97-117.

Gambrill, E. (2013). Birds of a Feather: Applied Behavior Analysis and Quality of Life. Research on Social Work Practice, 23(2), 121-140. doi: 10.1177/1049731512465775

Harris, R. (2006). Embracing your demons: An overview of Acceptance and Commitment Therapy. Retrieved 12th August, 2015, from http://nph.net.au/project/embracing-your-demons-an-overview-of-acceptance-and-commitment-therapy/

Harris, R. (2008). An interview with Steven Hayes. The Happiness Trap Newsletter, (November).

Harris, R. (2009). ACT made simple: An easy-to-read primer on Acceptance and Commitment Therapy. Oakland, CA, USA: New Harbinger.

Hayes, S. C. (2002). Buddhism and acceptance and commitment therapy. Cognitive and Behavioral Practice, 9(1), 58-66. doi: http://dx.doi.org/10.1016/S1077-7229(02)80041-4

Hayes, S. C. (2004). Acceptance and commitment therapy, relational frame theory, and the third wave of behavioral and cognitive therapies. Behavior Therapy, 35(4), 639-665. doi: http://dx.doi.org/10.1016/S0005-7894(04)80013-3

Hayes, S. C., Levin, M. E., Plumb-Vilardaga, J., Villatte, J. L., & Pistorello, J. (2013). Acceptance and Commitment Therapy and Contextual Behavioral Science: Examining the progress of a distinctive model of behavioral and cognitive therapy. Behavior Therapy, 44(2), 180-198. doi: http://dx.doi.org/10.1016/j.beth.2009.08.002

Hayes, S. C., Luoma, J. B., Bond, F. W., Masuda, A., & Lillis, J. (2006). Acceptance and Commitment Therapy: Model, processes and outcomes. Behaviour Research and Therapy, 44(1), 1-25. doi: http://dx.doi.org/10.1016/j.brat.2005.06.006

Hayes, S. C., Strosahl, K. D., & Wilson, K. G. (1999). Acceptance and Commitment Therapy: An experiential approach to behavior change. New York: Springer.

Hayes, S. C., Strosahl, K. D., & Wilson, K. G. (2012). Acceptance and Commitment Therapy: The process and practice of mindful change (2nd ed.). New York: Guilford.

Jonassen, D. H. (2006). A Constructivist’s perspective on Functional Contextualism. Educational Technology Research and Development, 54(1), 43-47. doi: 10.1007/s11423-006-6493-3

Jones, S. L., & Butman, R. E. (2011). Modern psychotherapies: A comprehensive Christian appraisal (2nd Edition). Westmont, IL, USA: InterVarsity Press.

Lappalainen, P., Granlund, A., Siltanen, S., Ahonen, S., Vitikainen, M., Tolvanen, A., & Lappalainen, R. (2014). ACT Internet-based vs face-to-face? A randomized controlled trial of two ways to deliver Acceptance and Commitment Therapy for depressive symptoms: An 18-month follow-up. Behaviour Research and Therapy, 61, 43-54. doi: http://dx.doi.org/10.1016/j.brat.2014.07.006

Levin, M. E., & Hayes, S. C. (2009). Is Acceptance and Commitment Therapy superior to established treatment comparisons? Psychotherapy and Psychosomatics, 78(6), 380.

Lovitt, T. C. (2012). Applied Behavior Analysis: A Method That Languished but Should Be Restored. Intervention in School and Clinic, 47(4), 252-256. doi: 10.1177/1053451211424598

McKeel, A., & Dixon, M. (2014). Furthering a behavior analytic account of self-control using relational frame theory. Behavioral Development Bulletin, 19(2), 111-118.

McLaren, R. M., Dillard, J. P., Tusing, K. J., & Solomon, D. H. (2014). Relational Framing Theory: Utterance form and relational context as antecedents of frame salience. Communication Quarterly, 62(5), 518-535.

Morina, N., A-Tjak, J. G. L., & Emmelkamp, P. M. G. (2015). Reducing biases in meta-analyses: Reply to Hertenstein and Nissen. Psychotherapy and Psychosomatics, 84(4), 252.

Öst, L.-G. (2008). Efficacy of the third wave of behavioral therapies: A systematic review and meta-analysis. Behaviour Research and Therapy, 46(3), 296-321.

Öst, L.-G. (2014). The efficacy of Acceptance and Commitment Therapy: An updated systematic review and meta-analysis. Behaviour Research and Therapy(61), 105.

Powers, M. B., & Emmelkamp, P. M. G. (2009). Response to ‘Is Acceptance and Commitment Therapy Superior to Established Treatment Comparisons?’. Psychotherapy and Psychosomatics, 78(6), 380a-381.

Powers, M. B., Zum Voerde Sive Voerding, M. B., & Emmelkamp, P. M. G. (2009). Acceptance and Commitment Therapy: A Meta-Analytic Review. Psychotherapy and Psychosomatics, 78(2), 73-80. doi: http://dx.doi.org/10.1159/000190790

Ruiz, F. J. (2010). A Review of Acceptance and Commitment Therapy (ACT) Empirical Evidence: Correlational, Experimental Psychopathology, Component and Outcome Studies. International Journal of Psychology and Psychological Therapy, 10(1), 125-162.

Ruiz, F. J. (2012). Acceptance and Commitment Therapy versus Traditional Cognitive Behavioral Therapy: A Systematic Review and Meta-analysis of Current Empirical Evidence. International Journal of Psychology and Psychological Therapy, 12(3), 333-357.

Zifferblatt, S. M., & Hendricks, C. G. (1974). Applied behavioral analysis of societal problems: Population change, a case in point. American Psychologist, 29(10), 750-761.

Ethics conundrum #2

This is taken from my Ethics formal assignment, Semester 1, 2015.

Context

A client has reached a point where they no longer wish to continue cancer treatments and instead wish to die.

Ethical dilemma

Do I take steps to notify relevant bodies of my client’s intentions to die, or do respect their wishes and assist them to live what remains of their life in as fulfilling a manner as possible?

Deontological perspective

The CCAA (2012) is clear on this:

3.5 The exception to maintaining confidentiality is a client threatening to harm self or another through suicide, homicide, or serious and imminent abuse. It is the duty of counsellors to disclose such information to their supervisors and to the authorities including, where relevant, the Police and the relevant Child Protection Authority in their jurisdiction.

PACFA (2014) is less clear on the topic and more open-ended and flexible. It refers to the need to keep the trust of the client:

3.1.3 Keeping trust

D. Situations in which clients pose a risk of causing serious harm to themselves or others are particularly challenging for the practitioner. These are situations in which the practitioner should be alert to the possibility of conflicting responsibilities between those concerning their client, other people who may be significantly affected, and society generally. Resolving conflicting responsibilities may require due consideration of the context in which the service is being provided. Consultation with a supervisor or experienced practitioner is strongly recommended, whenever this would not cause undue delay. In all cases, the aim should be to ensure for the client a good quality of care that is as respectful of the client’s capacity for self-determination and their trust as circumstances permit.

As can be seen, the PACFA-ethical practitioner could arguably leave the door open for the client to self-determine and respectfully be allowed to self-euthanise.

The Criminal Law Consolidation Act 1935 (1935) speaks to us of suicide. Section 13A(1) of the Act states that “It is not an offence to commit or attempt to commit suicide.” But it is, however, an offence under section 13A(5) to aid, abet or counsel someone else to commit suicide or attempt to commit suicide.

As Dale (2010, p. 31) puts it, “As counsellors our practices are governed firstly by the laws of the land, secondly through our adherence to ethical guidelines and codes of practice set out by the professional bodies to which we belong and thirdly to our own personal views of ethics and morality.” In this instance my membership of CCAA would mean that I would have to notify my supervisor as well as the police and any other relevant bodies.

Having been at the point that forces one to attempt suicide in order to alleviate one’s psychic pain, I have some personal sympathy and empathy with my client. I know that to consider taking one’s own life is not a selfish act, as some have suggested, but is instead an act of great courage. Every fibre of one’s being screams for life; to act upon oneself to draw a veil over one’s life takes immense fortitude and strength. Suicide, especially in a country like Australia where firearms are not easily obtainable, is a courageous and not easy act.

The law holds that I cannot physically do anything to help my client end their life, lest I be charged with manslaughter and being an accessory to manslaughter. But equally I know the pain of depression; also having been a first-hand witness to my wife’s and my mother’s painful, debilitating cancer treatments, I know the suffering that is inflicted upon the cancer victim. From their experiences I know too the feelings they had of being unwell and unable to do anything about it. It is a complete lack of quality of life (QOL) that my client is experiencing.

So do I, the counsellor, take ‘seeking to protect life’ as a supreme ethical cornerstone for my work, or, as Dale (2010) suggests, do I respect client autonomy, even if this means that the client may choose to die? “Do we empathise, explore the suicidal thoughts with our clients and take no action, or do we need (or want) to alert others, most usually the client’s GP, or other medical practitioner, of the perceived danger?” (Dale, p.32).

My own reading of the SA Mental Health Act 2009 (2009) seems to indicate, but I am not a lawyer, that notification is only required if the client has a mental illness; if my client does not, in my eyes, have a mental illness but is instead tired of the pain and lack of QOL and wishes to prolong it no longer, then there are two avenues open to me as I see it. One would be to work with their medical practitioner to increase the dosages and timings of painkiller medications for my client so that pain and discomfort no longer plague him. The other is to allow him autonomy, agency and confidentiality and keep his intentions to myself.

Virtue

Virtue ethics is not a stance I would have entertained before this course, principally because I had not heard of them. I would have classed myself as a Consequentialist before this course. But Virtue ethics are instructive in this instance of trying to decide what the ‘right’ thing to do is.

Virtue ethics are normative ethical philosophies that place their emphasis on ‘being’ rather than ‘doing’. Through ‘right being’ I am more likely to be ‘right doing’. As Aristotle said in the Nicomachean Ethics (2002), the chief human good is happiness, achieved through the development and display of wisdom and reason, and balancing the components of courage, moderation, open-handedness, munificence (i.e. spending in proportion to the occasion), greatness of soul, honour, mildness of temper, conversational excellence and technical skill-based excellences (Stewart, 2010). Progression towards these goals leads to general human excellence. For me as a counsellor to display the Aristotelian virtues would require of me the following:

  • Courage to possibly disagree with my supervisor and ignore the CCAA code of ethics 3.5 and not notify the police or other relevant bodies;
  • Moderation in balancing my responsibilities under CCAA’s code of conduct versus the needs of my client;
  • Open-handedness in my dealings with my client, my supervisor and me;
  • Somehow to display ‘megalopsychia’ (Aristotle, 2002) or greatness of soul which, according to Curzer (1990), is ‘greatness and self-knowledge’;
  • The display of Honour in my dealings with all of my clients, colleagues and others;
  • Mildness of temper;
  • Conversational excellence; and
  • Excellence in my tradecraft.

These are virtues worth striving for, in my humble opinion. They call on me to do my best in all circumstances, and to apply phronēsis, or ‘practical wisdom’ (Hinman, 2013).

What I would do

I would attempt to exercise and display the Aristotelian virtues by letting my client exercise autonomy. I would not encourage them to suicide, but would instead encourage them to seek out palliative care; such providers are better skilled than I in meeting the needs of the soon-to-be-deceased. I would of course discuss the case with my supervisor but I would not be swayed from allowing my client the respect due to them, which comes attached with notions such as autonomy and self-agency.

And as in the first case study, I would document everything.

 

Bibliography for both Ethics Conundrum #1 and #2

Aristotle. (2002). Nicomachean ethics: Translation, introduction, and commentary. Oxford: Oxford University Press.

CCAA. (2014). Code of ethics. Retrieved from: http://ccaa.net.au/images/documents/CODE_OF_ETHICS_Sept_2014.pdf

Curzer, H. J. (1990). A great philosopher’s not so great account of great virtue: Aristotle’s treatment of ‘Greatness of Soul’. Canadian Journal of Philosophy, 20(4), 517-537. doi: 10.1080/00455091.1990.10716503

Dale, S. (2010). Where angels fear to tread : An exploration of having conversations about suicide in a counselling context. Newcastle upon Tyne: Cambridge Scholars Publishing.

Government of South Australia. (1935). Criminal Law Consolidation Act 1935. Adelaide: Government of South Australia Retrieved from http://www.legislation.sa.gov.au/LZ/C/A/CRIMINAL%20LAW%20CONSOLIDATION%20ACT%201935.aspx.

Government of South Australia. (2009). Mental Health Act 2009. Adelaide: S.A. Government Retrieved from http://www.legislation.sa.gov.au/LZ/C/A/MENTAL%20HEALTH%20ACT%202009.aspx.

Hinman, L. M. (2013). Ethics: A pluralist approach to moral theory (Fifth ed.). Boston, USA: Wadsworth.

King, I. (2008). How to make good decisions and be right all the time: Solving the riddle of right and wrong (Kindle ed.). London: Bloomsbury Academic.

Miner, M. H. (2006). A proposed comprehensive model for ethical decision-making (EDM). In S. Morrissey & P. Reddy (Eds.), Ethics and professional practice for psychologists (pp. 25-37). South Melbourne: Thomson.

PACFA. (2014). Code of Ethics: The ethical framework for best practice in counselling and psychotherapy. Retrieved from: http://www.pacfa.org.au/wp-content/uploads/2014/10/PACFA-Code-of-Ethics.pdf

Stewart, A. E. (2010). Explorations in the Meanings of Excellence and Its Importance for Counselors: The Culture of Excellence in the United States. Journal of Counseling & Development, 88(2), 189-195.

Wikipedia. (n.d.). Ethical non-naturalism. Retrieved 28th May, 2015, from http://en.wikipedia.org/wiki/Ethical_non-naturalism

Ethics condundrum #1

This is taken from my Ethics formal assignment, Semester 1, 2015.

Context

I believe my client has reached the end of fruitful counselling and has been using me as a crutch rather than take responsibility for their own life. I believe I should terminate the relationship but my supervisor believes we should keep the relationship going as the client pays the full fee and on time.

Meta-ethical perspective

The author’s meta-ethical perspective is one of ethical non-naturalism (Wikipedia, n.d.). That is to say, ‘right’ and ‘wrong’ are self-evident and reached by either ‘common sense’ or rational, non-empirical, non-sensory processes, or by special revelation by a deity (Miner, 2006).

Ethical dilemma

Do I continue seeing a client just because they pay the full fee and on time? What of their needs?

Consequentialism

Drawing on a long heritage that goes back to ancient Greece and Aristotle, early Enlightenment philosophers John Locke and David Hume[1] laid the foundation for writer Jeremy Bentham in 1789 to propose a ‘calculus’ for determining right from wrong. The system was simple: do whatever is best.

This is simple—all one needs to do is to determine which action will bring about the best consequences and do it (King, 2008). There is a beguiling logic to this; after all, as John Stuart Mill asked in the Greatest Happiness Principle, how could anybody want anything but the best consequences?

There are, of course, some minor problems with such a system. For example, comparing what people want is fraught with difficulty: who is to say that one of my needs—to keep a full-fee paying client for the practice or agency—outweighs one of the client’s needs to move forward with their life?

Doing whatever brings about ‘the best consequence’ doesn’t offer any clear rules for behaviour. If I look for moral certainty with this calculus, I cannot find it. So at times, ‘seek the best consequence’ seems like a very empty sort of advice (King, 2008).

In addition, my intentions—as distinct from the outcomes from my act—may be deleterious to my client. I may intend to keep my client coming to see me for as long as I can in order to pay my rent, irrespective of the benefit to them of continuing therapy.

Deontological

Deontology places its emphasis on doing one’s duty, which is obedience to some predetermined higher moral absolute. It is in the following of predetermined ethical duties that the deontological decision can be reached.

To bring deontological principles to bear on the case study, I would only be acting ethically if I were following the prescribed rules for handling such situations, rules embedded either in workplace codes of conduct or the codes of any relevant professional bodies—in this instance, Christian Counsellors Association of Australia (CCAA) and Psychotherapy and Counselling Federation of Australia (PACFA).

The PACFA Code of Ethics (PACFA, 2014) doesn’t have any specific rules that dictate what to do in our current situation; but the CCAA Code of Ethics (CCAA, 2014) does. Code 2.6.3 states:

2.6 Counsellors shall not:-

2.6.3 Unnecessarily prolong therapy or continue counselling with high fee clients.

However, PACFA do have in their code some general principles that should guide ethical behaviour:

2.2.4 Non-maleficence: a commitment to avoiding harm to the client

Non-maleficence involves: avoiding sexual, financial, emotional or any other form of client exploitation;

Clearly here there is an imperative to not exploit the client financially by insisting on them continuing with their therapy. But there is a big gulf between ‘insisting’ and agreeing to see the client when they renew their appointment at the end of each session. One is coercive; the other is allowing the client freedom and agency. In considering the CCAA directives, the client may be still deriving benefit from the sessions (have we asked them?). The therapy room may be the only place they have where they can ‘vent’, or talk through decisions they need to make.

The CCAA have something further to say:

3.8 Counsellors should not abruptly cut off or end services without giving notice and adequately preparing the client for termination or referral. Termination or referral is indicated when:-

· 3.8.1 objectives have largely been achieved;

· 3.8.2 the client declines further counselling; and/or

· 3.8.3 the client no longer benefits from counselling.

Clearly, deontological principles can impact on our end decision about what to do in this instance, but a strictly rule-based approach doesn’t take into account the client’s views—we may think we have reached the end of the road with them, but the client may not agree. So a purely deontological approach to our case study is not sufficient in this instance.

What I would do

Both consequentialism and deontology have been examined and individually found wanting. So, bearing in mind Miner’s (2006) reminder that the goal of ethical decision-making is a fully-informed decision, I would take both approaches into account. I would firstly ask the client what they wanted to do, pointing out why I thought they had gone as far as they could with me as their counsellor. Armed with the knowledge of what the client felt was best for them, I would do my best to meet their needs. If they requested further counselling sessions, I would acquiesce.

And document everything.


[1] I can’t think of David Hume without thinking of Monty Python’s ‘The Philosophers Song’ [https://www.youtube.com/watch?v=xQycQ8DABvc]

Bipolar Disorder II: A review

Lithium is the current gold standard for the pharmacological treatment of bipolar disorder
Lithium is the current gold standard for the pharmacological treatment of bipolar disorder. Flickr: www.flickr.com/photos/home_of_chaos/4928878371

This post will look at Bipolar Disorder (BD) and where possible focus on the variant Bipolar Disorder II. It will examine its genetic and psychosocial aetiologies, and consider its diagnosis and treatment. A brief visit will be paid to online spaces for treatment. The post will conclude that Bipolar Disorder is a pernicious illness but that hope remains for the sufferer that with good management and strong support they can lead a productive life.

Continue reading Bipolar Disorder II: A review

The sacred and the profane

Can you reprogram her?
Can psychology reprogram people? Or just help them adapt better to their environment? Flickr: www.flickr.com/photos/hikingartist/6996819236

 

How Christianity and psycho-therapy can work together to bring about healing and change

 

I’m a sceptic.

I came into this degree with the jaundiced eye of one who believes that spirituality has no place in the modern psychotherapist’s armoury. But my eyes have been partly cleared to see that there is a place for the Spirit-filled counsellor in today’s world. This post will consider the various factors that brought me to this new place of integration and understanding.

Continue reading The sacred and the profane

Cognitive Behavioural Therapy (CBT) and me

CBT (although I'm not talking about a bank)
CBT (although I’m not talking about a bank)

This post will look at Cognitive Behavioural Therapy (CBT), its background, its theoretical standpoints and its cohesion or otherwise with Christianity. To end, this post will consider how it can be applied to my own psychological challenge/disability—bipolar disorder.

Continue reading Cognitive Behavioural Therapy (CBT) and me

Case study: A power dilemma

The Church is having a hard time with homosexuality
Diablo. Flickr: flickr.com/photos/notunlike/728065107

Case study:

A client is referred to you by a senior leader/pastor within your national church organisation.

Context: The church leader has been working with 23-year-old Michael for six months striving to help him overcome his same-sex attraction. Michael is desperate to be straight and thinks he should find a loving, female partner. The church leader and Michael’s local church community have been very supportive of him in his quest.

Continue reading Case study: A power dilemma

The Reality Slap and my gap

The Reality Slap by Dr Russ Harris
The Reality Slap by Dr Russ Harris

I’ve been reading Russ Harris’ The Reality Slap and have just finished it (in two days).

I’m reading it because it was pointed out to me that it may help with my literature review and looking at grief and Acceptance and Commitment Therapy (ACT).

I have to say I’m not convinced that ACT has something to add when it comes to grief. Yes, Harris makes a compelling case, but I would have liked to have seen more exercises, more ‘things to do’.

The academic literature jury* is out on the efficaciousness of ACT, despite the compelling writings of Harris.

* Öst, L.-G. (2014). The efficacy of Acceptance and Commitment Therapy: An updated systematic review and meta-analysis. Behaviour Research and Therapy, 61(2014), 105-121.