VIRTUES AND VICES OF A TEAM APPROACH: researching the management of boundaries in therapy

1. VIRTUES AND VICES OF A TEAM APPROACH: researching the management of boundaries in therapy Martin et al.SPR UK 2010 Carol Martin, Bonnie Meekums, Mary Godfrey and Anna Madill, University of Leeds Research funded by the BACP

2. Martin et al.SPR UK 2010 Outline • Introduction to the problem • Outline of the research • Summary of the findings • The methodological issues • Our response to the challenges • Strengths and limitations • Future developments Martin et al.SPR UK 2010 22

3. Martin et al.SPR UK 2010 Introduction to the problem • Sexual boundary violations occur and bring the profession into disrepute (Halter et al., 2007) • BACP already audited the complaints received within the organisation (Khele et al., 2008) • Aware that there are mixed views even about appropriate boundaries, and that information provision is insufficient to ensure ethical conduct • BACP supporting research as a stakeholder in promoting and protecting ethical conduct • Concerned to assist practitioner development and promote good practice in relation to clients Martin et al.SPR UK 2010 33

4. Martin et al.SPR UK 2010 The research evidence • Well summarised by Halter et al. (2007) but with some caveats • The literature is not limited to psychological therapists • Some of the findings on prevalence leave us unclear • There is useful material in the reflective literature Martin et al.SPR UK 2010 44

5. Martin et al.SPR UK 2010 The current study • Aims • To identify the indicators that lead to SBVs by practitioners of psychological therapies • To make recommendations to minimise risk of SBVs by these practitioners • Reframed for the study as • How therapists manage threats to boundaries successfully Martin et al.SPR UK 2010 55

6. Martin et al.SPR UK 2010 CURRENT STUDY: SAMPLE • 13 interviews • Mixed professional backgrounds • All registered with UKCP, BACP or BCC • Even balance of sex • Difference and diversity issues considered in the sampling • Mixed ages but in general older rather than younger • None fulltime-NHS- either part-time or independent • All could give accounts of experiences of attraction and of boundary strain; none admitted a reported SBV Martin et al.SPR UK 2010 66

7. Martin et al.SPR UK 2010 Method • Recruitment of a sample of experienced practitioners through several routes- advertisements, e-mailings and purposive sampling • Semi-structured interviews by one of the team • Debriefing and initial reflections with a member of the team • Transcription and manual coding for themes by the interviewer and another team member • Discussion and consensus on themes and additional use of the experience of the interview • Initial draft constructed by one team member Martin et al.SPR UK 2010 77

8. Martin et al.SPR UK 2010 METHODOLOGICAL ISSUES • The need for the clinicians to report gross misconduct • Outlining a strategy to require a participant to actively choose to continue if the interviewer was concerned about the direction of the interview • A sensitive topic- accounts shaped by anxiety • Adopting principles from Free Association Narrative Interviewing (the concept of the defended subject: Hollway and Jefferson, 2000) • Using four interviewers, two of whom were clinicians • Debriefing interviews • Joint analysis sessions Martin et al.SPR UK 2010 88

9. Martin et al.SPR UK 2010 THE DEBRIEFING • Each interviewer met and discussed the interview with another team member as soon as possible after each interview • Each time the pairing was a clinician and a no-clinician • The discussion was recorded and was available to other team members and for team discussions • Aims were to round out meaning of the data, to consider gaps and contradictions, to consider moments of anxiety and of collusion Martin et al.SPR UK 2010 99

10. Martin et al.SPR UK 2010 EXAMPLE: DEBRIEFING • Discussion about participant’s capacity to distinguish feeling and action; ‘it’s OK to have fantasies’ • Felt credible to her at the time, explored in an open way- not naïve, but wondering about the sense of positivity. What does it mean? • Discussion about what the role of the therapist is with these feelings- keeping the boundaries or using to client benefit? • Recognising the blind spot and potential personal contribution to this- not questioning or challenging, idealising? Martin et al.SPR UK 2010 1010

11. Martin et al.SPR UK 2010 EXAMPLE: ADDED MEANING • Discussion of insight- can participants identify their own limitations and spell out the subtext or describe what they have learned? • Importance of a flawed personal account rather than a smooth and seamless account • Resolutions- • Check this transcript for experiences rather than opinion • The variability of approaches to the experience of attraction, and their implications for clients • Seduction in the interview- what we can’t then know Martin et al.SPR UK 2010 1111

12. Martin et al.SPR UK 2010 PROS AND CONS • Pro • Added consistency to analysis across the sample though the use of multiple analysts • Increased shared meaning and depth of discussion • Reduction in the risk of speculation or idiosyncratic accounts • Cost effective- strategic focus on data • Increased use of the interviewer’s experience as a tool for understanding the data; and an external researcher to challenge for collusion and enactments • Con • Extra time and meetings • Extra costs in transcribing • Potential conflicts that require time and diplomacy to resolve Martin et al.SPR UK 2010 1212

13. Martin et al.SPR UK 2010 FINDINGS (1): PRACTITIONER VIEWS • Consensus on feelings of attraction being ubiquitous, even universal • While there is variability in where the decision about unacceptable conduct starts- flirting and fantasising being limits for some, touching acceptable for others • Supervision was cited as the first resource to turn to • Uncertainty over third party reporting Martin et al.SPR UK 2010 1313

14. Martin et al.SPR UK 2010 FINDINGS (2): PROCESS OF SUCCESSFUL MANAGEMENT UNDER PRESSURE • Managing intimacy and distance: engagement in the work • Noting anxiety, disquiet • Facing up to it personally • Reflecting (symbolic thinking, acceptance) • Processing (developing an understanding, working through personal implications) • Owning a formulation • Working with the issue; doing differently for therapeutic benefit Martin et al.SPR UK 2010 1414

15. Martin et al.SPR UK 2010 FINDINGS (3): PROBLEMATIC RESPONSES UNDER PRESSURE • Self-protective/ defensive • Reminding of the boundaries; discharge • Moralising/ omnipotent • Acting as though the client is over-demanding or selfish; relying on expert status • Neediness/ over-identification • Becoming overly affected by emotions; wanting a special emotional relationship • Over-protective anxiety • Giving extra support or information; touch Martin et al.SPR UK 2010 1515

16. Martin et al.SPR UK 2010 Findings (4): the stance • The concept of the participant-observer- a balance between becoming involved with the immediate experience of the relationship and maintaining a capacity for reflection rather than acting Martin et al.SPR UK 2010 1616

17. Martin et al.SPR UK 2010 CLINICAL LITERATURE • The findings of the study support conclusions from the clinical and professional literature • The participant-observer stance is close to the definition of empathy offered by Celenza (1995: 305) • “Empathy is a skill… a simultaneous process of feeling resonant with the patient while remaining apart and observing one’s own reactions.” Martin et al.SPR UK 2010 1717

18. Martin et al.SPR UK 2010 Conclusions • Team working, while it adds extra sources of variability, has benefits that may outweigh the apparent consistency of a lone researcher approach (which is the conventional method for in depth interviewing) • By working as dyads and then through team discussions, the interviewer’s understanding of the dynamics of the interviews in which they participated can be extended • Furthermore, the team approach can add to the rigour of the analysis, allowing identification of and potentially reducing unexamined bias and speculation • The focus on the experience of the interviewer facilitated reflection on the experience of the participant Martin et al.SPR UK 2010 1818

19. Martin et al.SPR UK 2010 References • Halter, M., Brown, H. & Stone, J. (2007) Sexual Boundary Violations by Health Professionals- an overview of the published empirical literature. London: CHRE. • Khele, S., Symons, C. & Wheeler, S. (2008) An analysis of complaints to the British Association of Counselling and Psychotherapy, 1996-2006. Counselling and Psychotherapy Research, 8 (2): 124-132. Martin et al.SPR UK 2010 1919