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The Experiences of mental health nurses whose clients disclose sexual contact with a former physician… Rae, Margaret I. 1995

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THE EXPERIENCES OF MENTAL HEALTH NURSES WHOSE CLIENTS DISCLOSE SEXUAL CONTACT WITH A FORMER PHYSICIAN: THREE COMPARATIVE CASE STUDIES  By  MARGARET I . RAE B.S.N., The U n i v e r s i t y of B r i t i s h Columbia, 1992 The U n i v e r s i t y o f B r i t i s h C o l u m b i a , THESIS SUBMITTED  1995  I N PARTIAL FULFILLMENT OF THE REQUIREMENTS  FOR THE DEGREE OF MASTERS OF SCIENCE I N NURSING THE FACULTY OF GRADUATE STUDIES The S c h o o l o f N u r s i n g  We a c c e p t t h i s  t h e s i s as c o n f o r m i n g t o  the r e q u i r e d  standard  THE UNIVERSITY OF BRITISH COLUMBIA A p r i l 1995 © M a r g a r e t I . Rae, A p r i l , . 1995  In  presenting this  degree at the  thesis  in  University of  partial  fulfilment  of  this thesis for  department  or  by  his  or  scholarly purposes may be her  representatives.  permission.  of  The University of British Columbia Vancouver, Canada  DE-6 (2/88)  for  an advanced  Library shall make  it  agree that permission for extensive  It  publication of this thesis for financial gain shall not  Department  requirements  British Columbia, I agree that the  freely available for reference and study. I further copying of  the  is  granted  by the  understood  that  head of copying  my or  be allowed without my written  11  ABSTRACT This study e x p l o r e d the s u b j e c t i v e experiences community mental  h e a l t h n u r s e s whose c l i e n t s  of  disclosed  s e x u a l c o n t a c t w i t h a former p h y s i c i a n . Theory, o p i n i o n literature, belief  a n d my  own  clinical  experience support  t h a t d i s c l o s u r e s such as t h e s e c h a l l e n g e n u r s e s  t h e i r c o m p l e x i t y and their clients' and g e n e r a t e d  intensity.  Three nurses'  accounts  d i s c l o s u r e s c o n s t i t u t e d cases a beginning theoretical  c o l l e c t e d by m u l t i p l e ,  for  with of  comparison  framework. Data were  indepth, unstructured,  i n t e r v i e w s . Open c o d i n g a n d  audiotaped  a x i a l coding techniques  c o n t e n t a n a l y s i s were u s e d t o a n a l y z e the d a t a and  the  of  collected,  e a c h s e t o f d a t a was .then c o m p a r e d a n d c o n t r a s t e d . The  C y c l e o f F o c u s i n g A t t e n t i o n was  i n t e g r a t i n g concept how  nurses  and  on t h e m s e l v e s ,  suffering.  i d e n t i f i e d as  i n a c o n c e p t u a l framework t h a t d e s c r i b e s  a l t e r n a t e l y f o c u s t h e i r a t t e n t i o n on t h e w i t h the goal of a l l e v i a t i n g  Contained  i n t h i s c y c l e w e r e : two  F o c u s i n g on t h e C l i e n t and F o c u s i n g on S e l f ; concepts,  the  client  client  concepts, four  sub-  C o l l e c t i n g Information, Using Interventions,  E x p e r i e n c i n g F e e l i n g s , and A n a l y z i n g T h o u g h t s ; a n d modifying-concepts,  A n a l y z i n g Boundaries  two  and A n a l y z i n g  Power. Data a n a l y s i s r e v e a l e d that d e s p i t e the passage of t h e d e t a i l s and c i r c u m s t a n c e s remained v i v i d moral  outrage  of the d i s c l o s u r e  i n the nurses' minds. Nurses and p o w e r l e s s n e s s  time  experience  experienced  a t the p h y s i c i a n s ' misuse  of  Ill  professional  power, and t h e s e f e e l i n g s d i d n o t l e s s e n  time. Despite t h e i r personal f e e l i n g s a professional clients  demeanor a n d c o n s i s t e n t l y  i n caring  clients  treated  maintained their  a n d r e s p e c t f u l ways. The n u r s e s w e r e  immediately c e r t a i n that unethical.  the. n u r s e s  with  the physician's  sexual behavior  They u n d e r s t o o d t h e t h e r a p e u t i c  was  needs o f t h e i r  r e l a t e d t o c l i e n t - t h e r a p i s t s e x u a l c o n t a c t , and t h e  s o c i a l a n d e t h i c a l demands o f  reporting.  Implementation of the study's findings more e f f e c t i v e c l i n i c a l p r a c t i c e ,  could  lead to  thereby lessening  s u f f e r i n g o f b o t h c l i e n t and nurse.  the  iv  TABLE Of CONTENTS Page ABSTRACT  •.  i  TABLE OF CONTENTS L I S T OF FIGURES  i  ... i v ..  v i  ACKNOWLEDGEMENTS  v i i  CHAPTER ONE: INTRODUCTION Background  and s i g n i f i c a n c e o f t h e Problem  1  Research Question  . 15  Conceptual D e f i n i t i o n s .  15  I n t r o d u c t i o n t o t h e Method  15  Limitations  17  Summary  ..18  CHAPTER TWO: METHOD Introduction  •  Selection of Participants  19 20  Selection Criteria  20  Recruitment Procedures  21  Data C o l l e c t i o n  ,  21  Data A n a l y s i s  25  Ethical Considerations  27  Criteria  28  f o rRigor  Summary  30  CHAPTER THREE: FINDINGS a n d DISCUSSION Introduction. .  32  Case  Studies Cathy.  32  Lynne  34  Alice. .  36  Conceptual Explication  Framework: O v e r v i e w of the Cycle of Focusing  Focusing  on t h e C l i e n t  Focusing  on S e l f  Discussion of Focusing  38 Attention..41 42 . ...... .46  on t h e C l i e n t  50  Discussion of Analyzing Boundaries  65  D i s c u s s i o n o f A n a l y z i n g Power  75  CHAPTER FOUR: SUMMARY, CONCLUSIONS, IMPLICATIONS, a n d RECOMMENDATIONS Summary a n d C o n c l u s i o n s  85  I m p l i c a t i o n s and Recommendations..  90  Practice  91  Research  '  92  Education.  93  Administration'  94  REFERENCES. '.  -. .'  96  APPENDIX A: Sample o f ' T r i g g e r S t a t e m e n t  101  APPENDIX B: P a r t i c i p a n t  102  C o n s e n t Form  LIST OF  FIGURES  F i g u r e 1. C o n c e p t u a l Framework: The  C y c l e of Focusing A t t e n t i o n  vii  ACKNOWLEDGEMENTS  T h i s t h e s i s came a b o u t t h r o u g h t h e c o m b i n e d e f f o r t s o f many p e o p l e . My i d e a f o r t h i s t h e s i s o r i g i n a t e d f r o m o b s e r v i n g my c o l l e a g u e a n d f e l l o w t r a v e l l e r , D a v i d C o n l i n , s t r u g g l e t o make m e a n i n g o f h i s c l i e n t ' s d i s c l o s u r e o f s e x u a l c o n t a c t w i t h a p h y s i c i a n . " A l i c e " , . "Cathy", and "Lynne" answered q u e s t i o n s about t h e i r d i s c l o s u r e experiences, and i n so doing, r e - e x p e r i e n c e d t h e i r s t r u g g l e s . I am g r a t e f u l t o them f o r t h a t . C l a r i s s a G r e e n and J i n n y Hayes, w i t h t h e i r l a r g e r v i s i o n , e n c o u r a g e d , d i r e c t e d , and supported both the process o f research and o f a c a d e m i c w r i t i n g . More i m p o r t a n t l y , C l a r i s s a , J i n n y , a n d J a n e t E r i c k s e n o f f e r e d me e m p a t h y a n d r e a s s u r a n c e t h u s p r o v i d i n g me w i t h c o m f o r t t h r o u g h o u t t h i s d i f f i c u l t c h a l l e n g e . L i n d a D a v i d s o n l e a r n e d how t o do o p e n c o d i n g , a n d t h e n s p e n t many h o u r s c o - a n a l y z i n g my d a t a . A l i s o n Beaumont c r i t i c a l l y read innumerable d r a f t s , and g e n t l y and humorously o f f e r e d i n v a l u a b l e l i t e r a r y suggestions. I n the e a r l y morning Joan Ferguson read c o u n t l e s s d r a f t s before yoga. I want' t o a c k n o w l e d g e S h e r r e F r i b e r g , ' who f o r h e a l t h r e a s o n s , was u n a b l e t o accompany me o n my l a s t a c a d e m i c w r i t i n g j o u r n e y . I ' t h a n k a n d a c k n o w l e d g e my t r e a s u r e d f r i e n d s who, w i t h u n d e r s t a n d i n g a n d g r a c i o u s n e s s , a l l o w e d me to disappear from our r e l a t i o n s h i p s and w r i t e t h i s t h e s i s . F i n a l l y , I am d e e p l y t o u c h e d b y my d a d , Tom Mimee, who l i s t e n e d , a n d g a v e me h i s t o t a l , l o v i n g s u p p o r t . Thank-you, a l l .  1  CHAPTER ONE:  Making the D i s c l o s u r e o f  C l i e n t - T h e r a p i s t Sex  Visible  Background and S i g n i f i c a n c e o f the Problem The contact  very  serious problem of c l i e n t - t h e r a p i s t sexual  i s d e m a n d i n g o u r a t t e n t i o n more a n d more  frequently,  e i t h e r b e c a u s e i t i s o c c u r r i n g more o f t e n o r b e c a u s e i t i s being  reported  01 a r t e , involves  more c o n s c i e n t i o u s l y  the abused person  that a previous  ( u s u a l l y a woman) d i s c u s s i n g t h e  current health professional.  t h e r a p i s t has had s e x u a l  c l i e n t presents  professional 1987;  Herman,  F e l d s t e i n , & L o c a l i o , 1986). T y p i c a l l y , d i s c l o s u r e  problem with her/his  her/his  (Gartrell,  a number o f i s s u e s  (Brown, 1990; G a l l e t l y ,  Strasburger,  contact  Learning with  f o r the second  1993; K i e l y and K i e l y ,  J o r g e n s o n , a n d R a n d i e s , 1 9 9 0 ) . Many  p r o f e s s i o n a l s h a v e f o u n d t h a t t h e y t h e m s e l v e s a r e made t o a p p e a r u n e t h i c a l when t h e y r e p o r t p r o f e s s i o n a l bodies Similarly, reported  ( S t o n e , 1984; c i t e d i n P e n f o l d ,  1992).  a s i g n i f i c a n t number o f a b u s e d c l i e n t s a r e  t o have e x p e r i e n c e d harassment, r e p e a t e d  to t h e i r c r e d i b i l i t y , t h e i r past sexual  (Penfold,  r e l a t i o n s h i p s , , when t h e y h a v e  c o n s t i t u t e s f u r t h e r abuse  second c r i s i s  notified  o r e t h i c s committees of t h e i r  1992). F o r t h e abused c l i e n t  1992), and t h e c u r r e n t  challenges  and h u m i l i a t i n g i n t e r r o g a t i o n s about  professional organizations abuse  t h e abuse t o t h e s u i t a b l e  this  response  ( S t o n e , 1984; c i t e d i n P e n f o l d ,  h e a l t h p r o f e s s i o n a l must r e s p o n d t o a  (Galletly,  1993).It  i s known t h a t many o f  t h e s e h e a l t h p r o f e s s i o n a l s do n o t r e p o r t c l i e n t - t h e r a p i s t  2  sexual are  abuse  ( G a r t r e l l e t a l . , 1987). While reasons f o r t h i s  suggested i n the l i t e r a t u r e  Galletly,  1993; P e n f o l d ,  ( G a r t r e l l e t a l . , 1987;  1992), t h e c o g n i t i v e p r o c e s s e s  leading to the current  health professionals' decisions  not  research  been s t u d i e d . This  analyzes'the  report describes  experiences of three  and  female community m e n t a l  h e a l t h n u r s e s whose c l i e n t s d i s c l o s e d s e x u a l previous  have  contact  with  a  physician.  Sexual contact  o f any k i n d between a h e a l t h  p r o f e s s i o n a l and a c l i e n t  care  i s unethical. According  to  Black's  Law D i c t i o n a r y , m e d i c a l a n d m e n t a l h e a l t h p r o f e s s i o n a l s a r e i n a " f i d u c i a r y r e l a t i o n s h i p where t h e r e confidence  r e p o s e d i n t h e one who  i s special  i n e q u i t y and good  c o n s c i e n c e i s b o u n d t o a c t i n g o o d f a i t h a n d w i t h due t o t h e i n t e r e s t s o f one r e p o s i n g  the confidence"  1979, p. 7 5 3 ) . The C o m m i t t e e on P h y s i c i a n S e x u a l [CPSM] and  (1992) s t a t e s t h a t s e x u a l  contact  regard  (Black, Misconduct  between a  physician  a p a t i e n t i s always u n e t h i c a l . E x p l o i t a t i o n ' , the use of v  someone f o r o n e ' s own s e l f i s h p u r p o s e s , i s t h e e s s e n c e o f p a t i e n t - p h y s i c i a n sexual Medical  Association  Psychiatrists  contact  (CPSM,  1 9 9 2 ) . The  Canadian  (CMA) Code o f E t h i c s A n n o t a t e d f o r  (1980) a d d r e s s e s t h e n a t u r e o f t h e p a t i e n t -  p s y c h i a t r i s t r e l a t i o n s h i p , s t a t i n g that the e t h i c a l psychiatrist will  scrupulously  avoid using  t o g r a t i f y h i s o r h e r own e m o t i o n a l , needs.  this relationship  financial,  and  sexual  3  A physician o f f e r i n g medical is  or mental h e a l t h  i n a f i d u c i a r y r e l a t i o n s h i p . This  i s a special  r e l a t i o n s h i p i n which the p h y s i c i a n accepts confidence interest  services  the t r u s t and  of the patient to act i n the l a t t e r ' s (Feldman-Summers, 1 9 8 9 ) . P h y s i c i a n s  p o s i t i o n o f power and t r u s t and t h e y b e t r a y  best  occupy a t h a t t r u s t when  t h e y s e x u a l i z e t h e r e l a t i o n s h i p (CMA, 1980; CPSM, 1 9 9 2 ; Penfold,  1992; R u t t e r ,  psychotherapeutic  1991). T h i s  i s especially true of  r e l a t i o n s h i p s where c l i e n t s a r e e n c o u r a g e d  to suspend t h e i r u s u a l defences and r e v e a l p r i v a t e thoughts and  f e e l i n g s (Canadian P s y c h i a t r i c A s s o c i a t i o n  As w e l l ,  [CPA],  c l i e n t s a r e a c t i v e l y encouraged t o develop  strong  f e e l i n g s toward the t h e r a p i s t which a r e m a n i f e s t a t i o n s transference,  of  that i s , a r e p e t i t i o n of a t t i t u d e s and •  f e e l i n g s experienced  i n earlier  (Blackshaw & Patterson,  important  1992; R u t t e r ,  relationships  1991).  C l i e n t s a r e h a r m e d when t h e y h a v e s e x u a l their physicians 1990;  1989).  Williams,  contact  o r mental h e a l t h p r o f e s s i o n a l s 1992). I n a survey s e e k i n g  with  (Brown,  information  from  p s y c h o l o g i s t s a b o u t t h e i r p a t i e n t s who h a d b e e n s e x u a l l y involved with a previous reported effects impaired and  therapist, the psychologists  t h a t 90% o f t h e s e p a t i e n t s h a d s u f f e r e d s e v e r e including depression,  emotional  s o c i a l adjustment, s u i c i d a l  disturbance,  feelings- and behavior,  i n c r e a s e d use o f drugs and a l c o h o l . E l e v e n  hospitalized, Holroyd,  ill  a n d 1% h a d c o m m i t t e d s u i c i d e  & Lerman, 1983; c i t e d i n G a l l e t l y ,  percent  were  (Bouhoutsps, 1 9 9 3 ) . Pope a n d  4  Bouhoutsos  (1986) d e s c r i b e  a Therapist-Patient  Syndrome c l o s e l y r e s e m b l i n g  a Post  Syndrome, w h i c h i n c l u d e s t h e ambivalence, g u i l t ,  f e e l i n g s of i s o l a t i o n ,  inability  to t r u s t ,  o f mood, s u p p r e s s e d r a g e , and  Stress  f o l l o w i n g symptoms:  emptiness, c o g n i t i v e dysfunction, disturbance,  Traumatic  Abuse  f e e l i n g s of  i d e n t i t y and sexual  increased  boundary  confusion, suicidal  risk.  symptoms h a v e b e e n w e l l d o c u m e n t e d b y  other mental  professionals  1992;  CPSM, 1992;  (Blackshaw & P a t t e r s o n ,  Rutter,  1991;  Abused c l i e n t s r e p o r t abandonment, f e a r , and  Searight  lability These  health  Penfold,  1992;  & C a m p b e l l , 1993) .  f e e l i n g s of h u r t , l o n e l i n e s s ,  guilt  (CPSM, 1 9 9 2 ) . As w e l l ,  research  i n d i c a t e s t h a t a s i g n i f i c a n t number o f t h e s e a b u s e d  clients  h a v e b e e n s e x u a l l y a b u s e d as c h i l d r e n o r a d u l t s , a n d  are'  t h e r e f o r e not  therapy  (Rutter,  o n l y r e v i c t i m i z e d by  1991), but  a l s o f e e l ashamed and  a t t e m p t t o p r o t e c t t h e a b u s e r by (Galletly,  sexual  contact  in  self-blaming,  concealing  the r e l a t i o n s h i p  1993).  Despite  c o d e s o f e t h i c s and  literature alerting  h e a l t h p r o f e s s i o n a l s to i t s destructiveness, e x p l o i t a t i o n of c l i e n t s c o n t i n u e s  to occur.  3.1%  A 1986  national  of female p s y c h i a t r i s t s acknowledged sexual  with their clients  mental  sexual  s u r v e y o f A m e r i c a n p s y c h i a t r i s t s • r e v e a l e d t h a t 7.1% and  and  of  male  contact  ( G a r t r e l l et a l . ) . Another n a t i o n a l  A m e r i c a n s u r v e y b y G a r t r e l l e t a l . (1987) f o u n d t h a t 65% 143 2 r e s p o n d e n t s r e p o r t e d sexual  contact  t r e a t i n g p a t i e n t s who  with previous  t h e r a p i s t s . A 1986  had  had  survey  of  of  5  American psychologists  i n p r i v a t e p r a c t i c e i n d i c a t e d 9.4% o f  m a l e s a n d 2.5% o f f e m a l e s a c k n o w l e d g e d s e x u a l their  clients  Gartrell,  (Pope, K e i t h - S p e i g e l ,  Milliken,  contact  & Tabachnick).  I n 1992,  Goodson, Thiemann, and Lo s u r v e y e d  10,000 A m e r i c a n f a m i l y p r a c t i t i o n e r s , obstetrician-gynecologists,  internists,  and surgeons t o d e t e r m i n e t h e  current prevalence of physician-patient  sexual  contact.  p e r c e n t o f 1,891 r e s p o n d e n t s a c k n o w l e d g e d s e x u a l  survey,  3.8% o f m a l e s a n d 2.3% o f f e m a l e s r e p o r t e d  contact  with  their clients  s e x u a l i z e d by t h e i r  physician sexual  (CPSM, 1 9 9 2 ) . C l e a r l y , therapists i s a  Nine  contact  w i t h one o r more p a t i e n t s . I n a B r i t i s h C o l u m b i a n  being  with  clients  significant  problem. I n c r e a s i n g p u b l i c and p r o f e s s i o n a l o u t c r y , w r i t t e n by v i c t i m s of p h y s i c i a n sexual  contact,  from consumer groups have a l e r t e d c l i e n t s destructiveness contact.  and i m m o r a l i t y  As c l i e n t s  feel  and  to the  pressure  prevalence,  of c l i e n t - t h e r a p i s t  sexual  a r e informed of the i s s u e s and t h e  source of the problem i s c l e a r l y physician,  books  i d e n t i f i e d as t h e  i t i s p o s s i b l e t h a t more a n d more c l i e n t s  s u f f i c i e n t l y encouraged and supported, t o r e v e a l  sexual  contact  informed by a c l i e n t of sexual  previous  physician or psychiatrist,  (Galletly, presents  past  to their present therapist.  A mental h e a l t h p r o f e s s i o n a l , such as a mental nurse,  may  1993). A c c o r d i n g  contact  faces  to Galletly  as a c o n f l i c t of r i g h t s  with  health a  a complex problem  (1993), t h e problem  which include:  (a) t h e  6  p a t i e n t has  the r i g h t not  do n o t h i n g may  s e x u a l l y , e x p l o i t e d , and  c o n f i r m a p e r c e p t i o n of themselves  powerless  victim;  treatment  and  ongoing  t o be  (b) t h e p a t i e n t h a s  the r i g h t  as  to  (c) t h e p a t i e n t h a s  as a f u r t h e r d i s r e g a r d f o r h i s o r h e r needs  p s y c h i a t r i s t have the r i g h t not (e) t h e a c c u s e d  expect  to  be  t h e p s y c h i a t r i c p r o f e s s i o n ; (d) o t h e r p a t i e n t s o f  ethical  effective  the r i g h t  c o n f i d e n t i a l i t y and b r e a k i n g c o n f i d e n t i a l i t y may  allegations;  a  the sexual c o n t a c t s e v e r e l y j e o p a r d i z e s  psychotherapy;  experienced  to  t o be  p s y c h i a t r i s t has  standards;  and  this  sexually exploited;  the r i g h t  ( f ) t h e p r o f e s s i o n has  by  t o answer,  the duty  (g) t h e c o m m u n i t y h a s  to  maintain  the r i g h t  to  e t h i c a l conduct from those e n t r u s t e d w i t h the c a r e  the m e n t a l l y  of  ill.  Health p r o f e s s i o n a l s , i n c l u d i n g mental h e a l t h nurses, when l e a r n i n g a b o u t c l i e n t - t h e r a p i s t s e x u a l c o n t a c t , p r e s e n t e d w i t h t h i s complex and nurses  are  d i f f i c u l t p r o b l e m . How  r e s o l v e d t h i s d i f f i c u l t y was  the focus of  three  my  research. I n d u c t i v e a n a l y s i s r e q u i r e s t h a t the a s s u m p t i o n s a b o u t t h e phenomenon be suspended  (Oiler,  f u l l y understand  1 9 8 6 ) . The  1986). Heidegger  s t a t e d and  r e s e a r c h e r may  the experience  i m p o s e an a p r i o r i  researcher's then  t h e n be  able  o f t h e i n d i v i d u a l and  h y p o t h e s i s on t h e e x p e r i e n c e ( c i t e d i n Packer  & Addison,  to  not  (Oiler,  1989)  argues:  T h a t i n o r d e r t o know a n y t h i n g a t a l l , we m u s t h a v e some p r e - u n d e r s t a n d i n g o f w h a t i s k n o w a b l e . T h i s p r e understanding, or fore-structure,, remains l a r g e l y i n  7 t h e b a c k g r o u n d as t a k e n - f o r - g r a n t e d . However, when o b j e c t o f i n v e s t i g a t i o n - i s human a c t i v i t y , i t i s i m p o r t a n t to r e c o g n i z e the i n f l u e n c e of our f o r e s t r u c t u r e i n o r d e r t o a r r i v e a t a more e x p l i c i t i n t e r p r e t a t i o n o r a c c o u n t , (p. 52) My  clinical  mental h e a l t h p r a c t i c e shapes  my  p r e u n d e r s t a n d i n g of the nurses' d i s c l o s u r e e x p e r i e n c e . p r i m a r y f o c u s o f my c l i e n t s who therapist,  clinical  I am  aware not  c h i l d r e n . As  o n l y of the  immense  damage t h a t i s done t o t h e s e p e o p l e a t t h e the  long  l a s t i n g and  Hearing a d i s c l o s u r e i s always d i f f i c u l t ,  How  c l i e n t s and  psychological  e m o t i o n a l and  i s a passionate  struggle  c l i e n t - t h e r a p i s t sexual i n t r i g u e d . The if  nurse-  but  also abuse.  cognitive  reactions.  difficult  described  mine. his  following a client's disclosure contact,  I found myself  i n c i d e n t s p a r k e d my  of  I must a l w a y s  i n t e r e s t of  H e n c e , when a s o c i a l w o r k e r c o l l e a g u e psychological  and  adult  psychological  time,  therapists i n fact resolve  issues  a  d e b i l i t a t i n g e f f e c t s of sexual  s e e k ways o f r e s o l v i n g my  The  p r a c t i c e i s working with  w e r e s e x u a l l y a b u s e d as  the  curiosity,  of  exceedingly  and  I wondered  female mental h e a l t h nurses would have s i m i l a r s t r u g g l e s  when t h e i r c l i e n t s d i s c l o s e d s e x u a l  contact  with  their  physician.' •I have worked i n mental h e a l t h and  I understand the  struggles  b e l i e v e t h a t most n u r s e s not but  years,  of mental h e a l t h n u r s e s .  only care  a l s o a r e d e e p l y t r o u b l e d by The  for twenty-nine  about t h e i r  clients'  I  clients,  abuse d i s c l o s u r e s .  c u l t u r e o f t h e m e n t a l h e a l t h teams a f f e c t e d  p r e u n d e r s t a n d i n g of the n u r s e s ' d i s c l o s u r e  my  experience.  8  C l i e n t s are Registered  cared Nurse  f o r by p r i m a r y w o r k e r s who (RN),  Registered  S o c i a l Worker, P s y c h o l o g i s t , Occasionally  other  or Occupational  backgrounds are represented  d e s c r i p t i o n and  does the  n u r s e s can  injectable medications).  identical  job  l i c e n s i n g d i f f e r e n c e s b e t w e e n t h e RNs operational  on  mental h e a l t h  the  j o b , and  a (RPN),  Therapist. on  these  the d i f f e r e n c e s  b a c k g r o u n d o r t r a i n i n g e v e r y o n e has  give  be  P s y c h i a t r i c Nurse  m u l t i - d i s c i p l i n a r y teams as w e l l . D e s p i t e educational  can  the  same  (however, o n l y The  and  not  they are both r e f e r r e d to  as  literature  influenced  my  p r e u n d e r s t a n d i n g of the nurses' d i s c l o s u r e e x p e r i e n c e s t h e phenomenon o f c l i e n t - t h e r a p i s t s e x u a l  contact;  r e v i e w e d some o f t h e  incidence  l i t e r a t u r e about the  p r e v a l e n c e o f t h i s phenomenon and an  learned  i n d i c a t i o n of other  imbedded i n  significant issues  phenomenon o f c l i e n t - t h e r a p i s t ,  client  T h e r e i s no  sexual  contact  the  mental  some this  sex.  most i m p o r t a n t p r e u n d e r s t a n d i n g i s t h a t I  t h a t c l i e n t - t h e r a p i s t sex  had and  i s s u e . As w e l l , I r e v i e w e d s p e c i f i c a l l y seeking  unethical.  I  of  that reporting  h e a l t h nurses' d i s c l o s u r e experiences,  My  and  nurses.  In addition,- the  a b u s e was  job  the  educational  RPNs a r e  in  believe  i s always wrong; i t i s a b s o l u t e l y  e t h i c a l dilemma about t h e r a p i s t among n u r s e s who  have a good  u n d e r s t a n d i n g o f what an e t h i c a l d i l e m m a i s ( D a v i s , Davis used questionnaires  t o d e t e r m i n e how  2 05  s e l e c t e d n u r s e s u n d e r s t o o d t h e c o n c e p t o f an  1981).  randomly  ethical  dilemma  9  a n d how  t h e y d e f i n e d an e t h i c a l  dilemma i n t h e i r  F i f t y - t w o p e r c e n t of respondents concept.  Diploma  practice.  had a good g r a s p of  nurses d e s c r i b e d the c l i n i c a l  this  issues  i n v o l v e d i n t h e i r d i l e m m a more o f t e n t h a n d e g r e e n u r s e s . Diploma  n u r s e s d i s a g r e e d more o f t e n w i t h p h y s i c i a n s on  ethical  i s s u e s than d i d degree n u r s e s . Younger nurses had  more e t h i c a l and  dilemmas w i t h p a t i e n t s ,  institutions Determining  specific  ethical  i s s u e s was Berger,  families,  physicians  than o l d e r nurses. the frequency w i t h which nurses i s s u e s a n d how  these  t h e f o c u s o f an e x p l o r a t o r y s t u d y d e s i g n e d  Seversen,  and C h v a t a l  (1991), and p a r t o f  sample drawn from f o u r s u r g i c a l three intensive care units, 250-bed h o s p i t a l .  encountered  units,  by  my  proportional  three medical  units,  and n u r s i n g a d m i n i s t r a t i o n i n a  Q u e s t i o n n a i r e s w e r e s e n t t o 104  w i t h a 5 0% r e t u r n r a t e . The  of  encountered  d i s t u r b e d t h e y were by  p r e u n d e r s t a n d i n g . They u s e d a random s t r a t i f i e d  nurses  -  nurses,  f i n d i n g s showed t h a t ,  few e t h i c a l  i s s u e s and  overall,  that their  d i s t u r b a n c e i n c r e a s e d a s t h e number o f e t h i c a l  level  issues  i n c r e a s e d . This study d i d not support the f i n d i n g s r e p o r t e d in  other l i t e r a t u r e which  ethical  dilemmas. Nurses  encountered  suggested  reported that they  professional ethical  abuse, i l l e g a l  activity,  a recent increase i n rarely  i s s u e s s u c h as  o r p a t i e n t a b u s e . The  substance researchers  c l a i m e d t h a t the i s s u e of u n d e r r e p o r t i n g or f a i l u r e r e c o g n i z e an e t h i c a l  i s s u e c a n n o t be o v e r l o o k e d , a n d  recommended more s t u d y i n t h i s  area.  to have  10  Major mental h e a l t h p r o f e s s i o n a l i n c l u d i n g those of n u r s i n g ,  have codes of e t h i c s d i r e c t i n g  them t o r e p o r t u n e t h i c a l b e h a v i o r . reported,  and  t h i s was  However, i t i s n o t  a n o t h e r o f my  C h i l d abuse, l i k e c l i e n t - t h e r a p i s t behavior, by  law  but  u n l i k e the  report  sex/  p r o f e s s i o n a l s are  subjects'  Registered  (39%), Master's l e v e l (10%),  Ph.D.  Clinical  experimentally  t y p e o f a b u s e , and  i n t e r v i e w . The situation. report  subjects  Results  in Florida.  therapists  subject  factors  were randomly a s s i g n e d  t e n d e n c y t o r e p o r t d e p e n d e d on The  (7%),  three  included  v i c t i m reactions during  i n d i c a t e d 81%  occurring.  (41%),  Psychologists  to a  of the c l i n i c i a n s  t h e p r e s e n t e d c a s e o f c h i l d a b u s e . The  a b u s e was  mental  controlled vignette with  s y s t e m a t i c a l l y m a n i p u l a t e d f a c t o r s . The  the  to  clinicians  included Bachelor's l e v e l  Doctor P s y c h i a t r i s t s (3%). Each  c o m p l e t e d an  v i c t i m age,  101  community h e a l t h c e n t e r s  professions  Nurses  Medical  required  F o l l i n g s t a d (1988)  c h i l d abuse. A sample c o n s i s t e d of  health technicians  the  i s unethical  tendency of mental h e a l t h p r o f e s s i o n a l s  working w i t h i n three  and  latter,  always  preunderstandings.  t o r e p o r t . K a l i c h m a n , C r a i g , and  i n v e s t i g a t e d the  The  organizations,  an  vignette tended  clinician's  c e r t a i n t y t h e y had  victim's behavior during  that the  i n t e r v i e w seemed t o a f f e c t r e p o r t i n g t h r o u g h i t s i m p a c t the  c l i n i c i a n ' s c o n v i c t i o n t h a t t h e a b u s e was  more e d u c a t e d p r o f e s s i o n a l s r e p o r t e d A n o t h e r o f my  more  happening.  on The  frequently.  p r e u n d e r s t a n d i n g s about the  reporting unethical behavior includes  to  frequency  a s t u d y by  of  Gartrell,  11  et  a l . (1987). These r e s e a r c h e r s i n v e s t i g a t e d t h e  p r a c t i c e s o f p s y c h i a t r i s t s who colleagues. American  reporting  knew o f s e x u a l m i s c o n d u c t  S u r v e y s w e r e s e n t t o 5574 r a n d o m l y - s e l e c t e d  psychiatrists.  four percent  (n = 84)  The  response  '= 92 0) o f r e s p o n d e n t s  r a t e was  of the respondents  c o n t a c t s w i t h a t o t a l o f 144  patients.  26%.  Six point  acknowledged s e x u a l  S i x t y - f i v e percent  r e p o r t e d t r e a t i n g p a t i e n t s who  been s e x u a l l y i n v o l v e d w i t h a p r e v i o u s t h e r a p i s t . o f f e n d e r s were t h e l e a s t l i k e l y , likely, of  the respondents  who  had  0.8%  t r e a t e d these p a t i e n t s  who  a s s e s s e d t h e c o n t a c t as sometimes  (n = 53 6) o f t h e r e s p o n d e n t s  their helpful;  had  filed  (56%)  o f t h e s e 53 6  complaints. E i g h t percent of  t r e a t e d p r e v i o u s l y abused p a t i e n t s  w i t h a p r o f e s s i o n a l a s s o c i a t i o n . The f a v o r e d mandatory r e p o r t i n g of  respondents  filed  m a j o r i t y of  a report respondents  therapist-patient  s e x u a l c o n t a c t . Although the response and r a i s e s c o n c e r n s  Thirty-  knew p s y c h i a t r i s t s  h a d b e e n s e x u a l l y i n v o l v e d , a n d o n l y 6%  respondents who  harmful to  percent  assessed  a s s e s s e d the c o n t a c t as h e l p f u l i n a l l c a s e s .  nine percent  had  Non-  Eighty-seven  t h e p r e v i o u s s e x u a l c o n t a c t as a l w a y s 6.4%  (n  and r e p e a t o f f e n d e r s m o s t  t o have t r e a t e d such p a t i e n t s .  patients;  by  r a t e of the survey  moderate  (26%)  about  t h e 6.4%  o v e r a l l prevalence of t h e r a p i s t p a t i e n t  was  generalizability, sexual  c o n t a c t found i n t h i s survey i s c o n s i s t e n t w i t h the prevalence rate i n other surveys. A factor that affects therapists' is  t h e s t r e s s t h a t r e p o r t i n g may  cause  decisions to report the c l i e n t .  My  12  c o n c e r n a b o u t t h a t s t r e s s was p a r t well.  In the opinion  o f my p r e u n d e r s t a n d i n g a s  of Strasburger,  Jorgenson, and Randies  ( 1 9 9 0 ) , t h e t h e r a p i s t ' s d i l e m m a when t h e r e p o r t i n g o f sexually e x p l o i t a t i v e psychotherapists Mental health professionals t h e r a p i s t - p a t i e n t sexual  unanimously agree  contact  therapists decide to report,  i s made m a n d a t o r y .  i sunethical.  t h e y must c o n s i d e r  that When the negative  e f f e c t s o f t h e r e p o r t i n g , n o t o n l y upon t h e p a t i e n t ( p o s s i b l e r e v i c t i m i z a t i o n ) , b u t a l s o upon t h e p a t i e n t ' s relationship with due  the treating therapist  to a loss of confidentiality).  Reporting i s a c r u c i a l  i s s u e because a s u b s t a n t i a l p r o p o r t i o n t h e r a p i s t s abuse m u l t i p l e v i c t i m s unreported,  these perpetrators  (possible d i s t r u s t  of e x p l o i t i v e  ( G a r t r e l e t a l . , 1987). I f  c a n be e x p e c t e d t o v i c t i m i z e  u n s u s p e c t i n g f u t u r e p a t i e n t s . G a r t r e l and h i s claim  that  reporting  three  colleagues  American s t a t e s have adopted mandatory  s t a t u t e s ; t h e i r approaches v a r y from  survivors' of sexual  educating  exploitation to requiring the patient's  consent t o report. A n o t h e r o f my p r e u n d e r s t a n d i n g s was t h a t o f t e n are  n e g a t i v e c o n s e q u e n c e s f o r n u r s e s who r e p o r t  behavior.  In t h e i r a r t i c l e of opinion,  (1987) d e s c r i b e who f e l t patient  there  unethical  K i e l y and K i e l y  t h e consequences o f d i s c l o s i n g f o r nurses  e t h i c a l l y bound t o a c t i n t h e i n t e r e s t o f t h e rather  than of t h e i r employer. Nurses found  t h e y h a d no l e g a l r e c o u r s e i f t h e y w e r e dismissed.  that  subsequently  A l t h o u g h , o n t h e one h a n d , m o s t  professional  13  a s s o c i a t i o n s now r e q u i r e n u r s e s t o r e p o r t b e h a v i o r endangers c l i e n t w e l f a r e ,  on t h e o t h e r  that  hand, t h e y have n o t  always supported d i s c l o s i n g the incompetent p r a c t i c e of a fellow health Kiely,  team member (CNA, 1984; c i t e d i n K i e l y a n d  1987) . I n a d d i t i o n , h o s p i t a l management may u s e  suppressive  t e c h n i q u e s such as d i s m i s s a l , b l a c k - l i s t i n g , o r  t h r e a t s o f p h y s i c a l v i o l e n c e as a response t o "whistleblowing"  (Westin,  1981; c i t e d i n K i e l y and K i e l y ,  1987). Peers and c o l l e a g u e s  may i s o l a t e a n d s h u n t h e n u r s e  who d i s c l o s e s . The d e c i s i o n t o d i s c l o s e h a s s e r i o u s ramifications  f o r both t h e i n d i v i d u a l making t h e d e c i s i o n  and  involved parties.  the other  Everyone has a p s y c h o l o g i c a l i s s u e and t h i s ,  t o o , was p a r t o f my p r e u n d e r s t a n d i n g . I  u s u a l l y respond with about h e l p i n g article  response t o an e t h i c a l  f e e l i n g s of i n d i g n a t i o n , and I t h i n k  t h e v i c t i m and punishing  of opinion,  Brown  (1990) d e s c r i b e s  behavior a f f e c t s the offender's professionally,  the offender.  and s o c i a l l y .  colleagues  I n an  how u n e t h i c a l personally,  She c o n t e n d s t h a t  f e m i n i s t t h e r a p i s t s have championed c o n f r o n t i n g  although unethical,  a b u s i v e and s e x u a l l y e x p l o i t i v e p r a c t i c e s by male therapists,  f e m i n i s t t h e r a p i s t s have c o l l e c t i v e l y d e n i e d and  reframed the existence  of sexual  e x p l o i t a t i o n o f women b y  women. C o l l e a g u e s o f t h e o f f e n d i n g and  betrayed,  confrontation  t h e r a p i s t f e e l wounded  and s u f f e r a l o s s o f t r u s t .  Brown  describes  s t r a t e g i e s , and suggests a process o f  14  mediation for the problematic the  f e m i n i s t therapy colleague and  client. To  s u m m a r i z e my p r e u n d e r s t a n d i n g s , t h e l i t e r a t u r e  indicates that c l i e n t - t h e r a p i s t sexual growing problem o r i t i s being Disclosure  contact  reported  i s f r e q u e n t l y made t o o t h e r  i seither a  more o f t e n . health  professionals,  i n c l u d i n g mental h e a l t h nurses. I t i s apparent d i s c l o s u r e presents and able  t h e second p r o f e s s i o n a l w i t h a d i f f i c u l t  c o m p l e x p r o b l e m t h a t must b e r e s o l v e d . to resolve  that  P r i o r t o being  t h i s p r o b l e m , t h e phenomenon m u s t b e b e t t e r  u n d e r s t o o d . R e s e a r c h l i t e r a t u r e shows t h a t p r o f e s s i o n a l s c a n i d e n t i f y e t h i c a l d i l e m m a s . When t h e r a p i s t s b e l i e v e a c l i e n t ' s d i s c l o s u r e , they tend t o report  the offending  t h e r a p i s t . However, t h e p o s s i b i l i t y o f r e p o r t i n g confronts  therapists with  the necessity of weighing the  consequences of p r o t e c t i n g f u t u r e c l i e n t s threatening with  the therapeutic  from abuse  against  r e l a t i o n s h i p they c u r r e n t l y have  t h e i r c l i e n t . When n u r s e s e x p o s e u n e t h i c a l  management may d i s m i s s ,  often  black  list  behavior,  or physically assault  them. A s w e l l , t h e y may b e s h u n n e d b y t h e i r  colleagues.  Hence, I t h o u g h t a s t u d y w h i c h compares a n d c o n t r a s t s mental h e a l t h nurses' experiences would provide though p r e l i m i n a r y , experience. the  a detailed,  description of the disclosure  Once t h i s phenomenon i s c l e a r l y d e s c r i b e d , a n d  i s s u e s and c o n f l i c t s a r e i d e n t i f i e d ,  other  nurses i n  t h i s s i t u a t i o n may b e e n c o u r a g e d t o b e r e f l e c t i v e a n d  15  analytical. mental  The  p u r p o s e o f t h i s , s t u d y was  t o show how  three  h e a l t h n u r s e s made m e a n i n g o f . t h i s phenomenon. Research Q u e s t i o n  The  research question for this  s t u d y was:  nature of the experience of a mental  What i s t h e .  h e a l t h n u r s e when a  c l i e n t d i s c l o s e s sexual c o n t a c t w i t h a former p h y s i c i a n ? Conceptual The  Definitions  following conceptual d e f i n i t i o n s  informed  the  research:. 1. S e x u a l c o n t a c t : any  overt or covert sexual  between a male p h y s i c i a n and h i s female 2. M e n t a l h e a l t h n u r s e : c l i e n t s w i t h mental not  a female  behaviors  or male p a t i e n t .  RN  o r RPN  h e a l t h c o n c e r n s . M a l e RNs  who  counsels  o r RPNs w e r e  i n c l u d e d i n o r d e r t o make t h e s t u d y as homogeneous as"...  possible. 3. F o r m e r p h y s i c i a n : a m a l e m e d i c a l d o c t o r who a treatment  r e l a t i o n s h i p w i t h a female  p s y c h i a t r i c reasons. Again i n an a t t e m p t  to l i m i t  female  the case  excluded  t h e v a r i a t i o n i n t h e phenomenon. Method  s t u d y m e t h o d and c o n t e n t a n a l y s i s  were  c h o s e n as m e t h o d o l o g i c a l a p p r o a c h e s f o r t h i s r e s e a r c h . case  s t u d y method has p r o v i d e d t h e b a s i s from w h i c h  social  s c i e n c e knowledge has been d e v e l o p e d  1982;. R u n y a n , 1982; 1985).  A case  had  or male p a t i e n t f o r  d o c t o r s have been  I n t r o d u c t i o n t o the Both  has  S t e r l i n g & McNalley,  The  most  ( K a z d i n & Tuma,  1992;  Younger,  s t u d y i s an i n t e n s i v e i n v e s t i g a t i o n i n t o  and  s y s t e m a t i c p r e s e n t a t i o n of i n f o r m a t i o n about the background,  16  current status,  and e n v i r o n m e n t a l i n t e r a c t i o n s o f a s i n g l e  unit:  an i n d i v i d u a l ,  (Yin,  1 9 8 4 ; K a z d i n & Tuma, 1 9 8 2 ; R u n y a n , 1 9 8 2 ; P o l i t  Hungler,  a group,  an o r g a n i z a t i o n ,  or a society &  1991).  The  c a s e s t u d y m e t h o d may b e u s e d t o g e n e r a t e  hypotheses  w h i c h may b e t e s t e d b y o t h e r r e s e a r c h , t o a d d r e s s  research questions i n which  t h e v a r i a b l e s and  i n t e r c o n n e c t i o n s have n o t been i d e n t i f i e d ,  and t o understand  the s u b j e c t i v e e x p e r i e n c e o f an i n d i v i d u a l .  The c a s e  m e t h o d may a l s o b e u s e d when t h e r e i s l i t t l e e v e n t s , when t h e t i m e f r a m e i s r e s t r i c t e d , sample i s n o t a v a i l a b l e  study  control  over  o r when a l a r g e  ( K a z d i n & Tuma, 1 9 8 2 ; Holm, 1 9 8 3 ;  M e i e r & Pugh, 1986; S t e r l i n g & M c N a l l e y ,  1992). N u r s i n g has  n o t s y s t e m a t i c a l l y used t h e case s t u d y method t o g e n e r a t e knowledge  (Holm, 1 9 8 3 ; M e i e r & Pugh, 1 9 8 6 ; S t e r l i n g  McNalley,  1992; Younger, 1985); however, t h e s t r a t e g y i s  recommended f o r i m p r o v i n g c l i e n t c a r e  &  ( K a z d i n & Tuma, 1 9 8 2 ;  M e i e r & Pugh, 1986; S t e r l i n g & M c N a l l e y ,  1992).  Cases a r e f l e x i b l e and s y s t e m a t i c enough t o be open t o any methods a p p r o p r i a t e f o r c o l l e c t i n g and a n a l y z i n g d a t a ( K a z d i n & Tuma, 1 9 8 2 ; Runyan, 1 9 8 0 ; Y i n , 1 9 8 9 ) . When a q u e s t i o n i s d i s c o v e r e d d u r i n g t h e course o f c o l l e c t i n g and a n a l y z i n g data, a q u a l i t a t i v e methodology i s a p p r o p r i a t e l y used t o s y s t e m a t i c a l l y guide f u r t h e r  inquiry.  Q u a l i t a t i v e methods a r e u s e d t o u n c o v e r ,  d e s c r i b e , and  u n d e r s t a n d w h a t l i e s w i t h i n a n y phenomenon a b o u t little  which  i s known ( M i l e s & Huberman, 1 9 9 4 ; S t r a u s s & C o r b i n ,  17  1990).  Since l i t t l e  i s known a b o u t t h e n u r s e s '  experiences  when a c l i e n t d i s c l o s e s s e x u a l c o n t a c t w i t h a p h y s i c i a n , comparing case  studies, using a qualitative  an a p p r o p r i a t e a p p r o a c h  m e t h o d , seemed  to beginning understanding  of the  phenomenon; In q u a l i t a t i v e words  r e s e a r c h , t h e data a r e i n t h e form o f  ( M i l e s & Huberman, 1 9 9 4 ) ,  and i n t e r v i e w s and  o b s e r v a t i o n a r e t h e most common m e t h o d s o f d a t a ( S t r a u s s & C o r b i n , 1990).  In t h i s study,  collection  indepth,  u n s t r u c t u r e d i n t e r v i e w s were used t o c o l l e c t d a t a . collection  takes place c o n c u r r e n t l y w i t h data  analysis  ( M i l e s & Huberman, 1994; S t r a u s s & C o r b i n , 1 9 9 0 ) . analysis directs  the focus f o r f u r t h e r data  ( M i l e s & Huberman, 1 9 9 4 ) . d i r e c t e d data c o l l e c t i o n  Comparative and a n a l y s i s  Data  Data  collection  content for this  analysis study  (Glaser  & S t r a u s s , 1967; S t r a u s s & C o r b i n , 1990) . Limitations The f i n d i n g s o f c o m p a r a t i v e  case s t u d i e s a r e not  g e n e r a l i z a b l e t o a p o p u l a t i o n ; t h e y a r e g e n e r a l i z a b l e t o an existing  o r new t h e o r y  ( M i l e s & Huberman, 1 9 9 4 ) .  This  e x p l o r e d o n l y the experiences of t h r e e female mental n u r s e s who w o r k i n a c o m m u n i t y m e n t a l not address settings, have t h e i r  e x p e r i e n c e s . As w e l l ,  nor  the former  therapists'  It did  i n other  nor those w i t h other p r o f e s s i o n a l bases,  o f m a l e n u r s e s was n o t a d d r e s s e d ,  health  health setting.  the experiences of other nurses  own u n i q u e  study  who  would  the experiences  and n e i t h e r t h e c l i e n t s '  r e a c t i o n s were  investigated.  18  F i n a l l y , .both t h e w i d e v a r i a t i o n o f t i m e b e t w e e n d i s c l o s u r e s and  t h e . i n t e r v i e w s , and t h e d i f f e r e n t c o n t e x t s  d i s c l o s u r e s took place, preclude understanding provide  an optimum  of d i s c l o s u r e experience,  i n which the  indepth  t h o u g h t h e y do  breadth.  I n summary, t h i s  study has been d e s i g n e d  three mental h e a l t h nurses'  to explore  d i s c l o s u r e experiences.  Little  i s known o f how m e n t a l h e a l t h n u r s e s make m e a n i n g o f t h i s difficult  and complex e x p e r i e n c e .  I n C h a p t e r One I h a v e  described  t h e background and t h e s i g n i f i c a n c e o f t h e  r e s e a r c h p r o b l e m , r e v e a l e d my p r e u n d e r s t a n d i n g s ,  introduced  the methodology, and i d e n t i f i e d t h e l i m i t a t i o n s o f t h i s research.  I n C h a p t e r Two I w i l l  describe the research  method  i n more d e p t h . F o l l o w i n g t h a t , i n C h a p t e r T h r e e I w i l l • present will the  and d i s c u s s t h e f i n d i n g s , and, i n Chapter Four, I  s u m m a r i z e my f i n d i n g s , s t a t e my c o n c l u s i o n s , study's  suggest  i m p l i c a t i o n s , a n d make r e c o m m e n d a t i o n s f o r  nursing p r a c t i c e , research,  education,  and a d m i n i s t r a t i o n .  19  CHAPTER  TWO  METHOD A q u a l i t a t i v e case three mental  study approach  h e a l t h nurses'  was c h o s e n t o s t u d y  experience of c l i e n t s '  disclosure of c l i e n t - t h e r a p i s t sexual contact. In this chapter,  I describe the procedures  participants,  c o l l e c t d a t a , p r o t e c t human r i g h t s , a n d  e s t a b l i s h methodological A case  I used t o s e l e c t  rigor.  study i s an i n t e n s i v e i n v e s t i g a t i o n and  s y s t e m a t i c p r e s e n t a t i o n o f i n f o r m a t i o n about t h e background, current status,  and environmental  interactions of a single  unit:  an i n d i v i d u a l ,  (Yin,  1 9 8 9 ; K a z d i n & Tuma, 1 9 8 2 ; R u n y a n , 1 9 8 2 ; P o l i t  Hungler,  1991).  understand to  A c a s e s t u d y m e t h o d may b e u s e d :  &  (a) t o  t h e s u b j e c t i v e e x p e r i e n c e o f an i n d i v i d u a l ,  generate  research,  a group,, an o r g a n i z a t i o n , o r a s o c i e t y  hypotheses  (b)  w h i c h may b e t e s t e d b y o t h e r  (c) t o a d d r e s s  research questions i n which the  v a r i a b l e s and i n t e r c o n n e c t i o n s have n o t been i d e n t i f i e d , when t h e r e i s l i t t l e  c o n t r o l over events,  frame i s r e s t r i c t e d ,  ( f ) when a l a r g e s a m p l e i s n o t  available,  and/or  (d)  (e) when t h e t i m e  (g) t o i m p r o v e c l i e n t c a r e  (Holm, 1 9 8 3 ;  K a z d i n & Tuma, 1 9 8 2 ; M e i e r & Pugh, 1 9 8 6 ; S t e r l i n g & McNalley,  1992; Younger,  Given case  1985).  the circumstances  a s s o c i a t e d w i t h my s t u d y , t h e  s t u d y m e t h o d was s u i t a b l e b e c a u s e : t h e r e s e a r c h  question addressed individual,  t h e s u b j e c t i v e e x p e r i e n c e o f an  t h e r e was l i t t l e  c o n t r o l oyer d i s c l o s u r e  events,  20  t h e r e was  a r e s t r i c t e d t i m e frame, and a l a r g e sample  not a v a i l a b l e .  was  Case s t u d i e s a r e f l e x i b l e and s y s t e m a t i c  e n o u g h t o accommodate any a p p r o p r i a t e means o f and a n a l y z i n g d a t a  ( K a z d i n & Tuma, 1982;  collecting  R u n y a n , 1982; Y i n ,  1989). Q u a l i t a t i v e methods were i n d i c a t e d s i n c e t h e y a r e used to uncover, d e s c r i b e , which l i t t l e  a n d u n d e r s t a n d phenomena  about  i s known ( M i l e s & Huberman, 1 9 9 4 ) , a n d f o r t h i s  s t u d y , c o n t e n t a n a l y s i s was using multiple,  s e l e c t e d . Data were  collected  indepth, unstructured interviews,  and  a n a l y z e d u s i n g open c o d i n g and a x i a l c o d i n g t e c h n i q u e s (Strauss & Corbin, 1989)  1 9 9 0 ) . The  e n t i t i e s as whole  units (Yin,  were t h e n compared and c o n t r a s t e d w i t h e a c h . o t h e r . S e l e c t i o n of  Participants  The p u r p o s e o f a q u a l i t a t i v e c a s e s t u d y a p p r o a c h i s t o u n d e r s t a n d t h e s u b j e c t i v e e x p e r i e n c e o f an  individual  ( K a z d i n & Tuma, 1 9 8 2 ) . I n c a s e s t u d y m e t h o d e a c h is considered a unit, P a r t i c i p a n t s who  a whole  entity  individual  ( Y i n , 1989) .  h a v e a c t u a l l y .had t h e e x p e r i e n c e u n d e r  study are s e l e c t e d . For t h i s study, I s e l e c t e d t h r e e female m e n t a l h e a l t h n u r s e s who  had e x p e r i e n c e d a c l i e n t  sexual c o n t a c t w i t h a former t h e r a p i s t .  disclose  Characteristics  t h e t h r e e n u r s e s a r e d e s c r i b e d more f u l l y  of  i n the next  chapter. Selection  Criteria  S e l e c t i o n c r i t e r i a w e r e e s t a b l i s h e d t o e n s u r e a s much homogeneity  a s p o s s i b l e . The  sampling c r i t e r i a f o r  p a r t i c i p a n t s w e r e : a f e m a l e n u r s e who  had m e n t a l  health  21  experience,  who w o r k e d o n a m e n t a l h e a l t h team, who h a d  experienced  the d i s c l o s u r e experience,  to p a r t i c i p a t e study,  i n one o r two h o u r - l o n g  a n d who was w i l l i n g i n t e r v i e w s . For  this  t h e o f f e n d i n g t h e r a p i s t was r e q u i r e d t o b e a m a l e  p h y s i c i a n who h a d h a d a c o u n s e l l i n g r e l a t i o n s h i p a n d h a d abused the c l i e n t .  T h e r e w e r e no r e s t r i c t i o n s a b o u t t h e  client. Recruitment  Procedures  I p o l l e d colleagues and acquaintances disclosure experiences, t o them, a n d i n v i t i n g  about p o s s i b l e  e x p l a i n i n g t h e p u r p o s e o f my s t u d y  them t o p a r t i c i p a t e .  I a l s o asked  m e n t a l h e a l t h team d i r e c t o r s t o r e a d a memo t o t h e i r r e q u e s t i n g v o l u n t e e r s f o r my s t u d y .  v o l u n t e e r s . To a n y o n e t e l e p h o n i n g • a n d  how  I would p r o t e c t both  confidentiality. participated,  for  making an i n q u i r y , I  time e x p e c t a t i o n s , and  t h e i r and the o f f e n d e r s '  Of t h e s i x n u r s e s  who v o l u n t e e r e d ,  one d r o p p e d out b e c a u s e she t h o u g h t  another  nurse  b e c a u s e she moved f r o m t h e c i t y .  three  that  r e c o u n t i n g her d i s c l o s u r e experiences would be too and  teams  I n t h i s memo I b o t h  e x p l a i n e d t h e p u r p o s e o f my r e s e a r c h a n d a s k e d  d e s c r i b e d the i n t e r v i e w procedures,  four  painful,  The r e m a i n i n g  was n o t c h o s e n b e c a u s e t h e o f f e n d i n g t h e r a p i s t was a  priest,  r a t h e r than a medical Data  doctor.  Collection  In q u a l i t a t i v e research, i n t e r v i e w s and observations a r e t h e m o s t common m e t h o d s o f d a t a c o l l e c t i o n Corbin,  1990). I n t h i s  study,  (Strauss &  the r e s e a r c h q u e s t i o n  provided  22  the i n i t i a l by  focus f o r data c o l l e c t i o n .  Data were  indepth, u n s t r u c t u r e d i n t e r v i e w s , which  collected  are typically  u s e d when t h e r e i s no p r e c o n c e i v e d i d e a o f t h e c o n t e n t . The aim o f t h e r e s e a r c h e r u s i n g u n s t r u c t u r e d i n t e r v i e w s i s t o wholly understand refrain  from  t h e p a r t i c i p a n t ' s e x p e r i e n c e and t o  influencing the p a r t i c i p a n t  (Polit &  Hungler,  1991) . During the i n i t i a l  interview, I reviewed  the purpose of  the study and reminded each p a r t i c i p a n t t h a t she c o u l d w i t h d r a w from t h e s t u d y a t any time. Each p a r t i c i p a n t and  s i g n e d the consent  asked  foradditional  read  ( s e e A p p e n d i x B, p. 1 0 2 ) , a n d none  i n f o r m a t i o n a l t h o u g h q u e s t i o n s were  e n c o u r a g e d . S i n c e q u a l i t a t i v e r e s e a r c h i s "an o n g o i n g , dynamic, changing p r o c e s s , and  consequences  [arise],  [wherein]  unforeseeable  events  r e s e a r c h e r s need t o f a c i l i t a t e  n e g o t i a t i o n and r e n e g o t i a t i o n t o p r o t e c t our c o l l a b o r a t o r s ' human r i g h t s "  ( M u n h a l l , 1988, p. 1 5 1 ) . A t t h e s e c o n d  interview,  I not only reviewed  a l s o asked  a g a i n f o r and r e c e i v e d p e r m i s s i o n t o i n t e r v i e w .  In  the purpose o f the study, b u t  a d d i t i o n , because p a r t i c i p a n t s a r e a t r i s k  p s y c h o l o g i c a l d i s c o m f o r t as they t a l k about experiences  (Ramos, 1 9 8 9 ) ,  I asked  f o r some  their  the study nurses  about  t h e i r r e a c t i o n s t o t h e p r e v i o u s i n t e r v i e w . The s t u d y w e r e a w a r e t h a t I w o u l d , w i t h t h e i r p e r m i s s i o n , make a r r a n g e m e n t s f o r them t o r e c e i v e p r o m p t t h e r a p e u t i c i n t e r v e n t i o n i fnecessary,  and i f m u t u a l l y agreed on.  nurses  23  N e i t h e r t h e p a r t i c i p a n t s n o r I found  i t necessary t o  implement t h i s p l a n . B e f o r e b e g i n n i n g t h e i n t e r v i e w , I engaged t h e participant  i n small "talk"  a n d u s e d humor t o c r e a t e a  r e l a x e d a t m o s p h e r e f o r b o t h o f u s . E a c h i n t e r v i e w was a p p r o x i m a t e l y one h o u r l o n g a n d t o o k p l a c e a t e i t h e r t h e p a r t i c i p a n t ' s o r my o f f i c e .  E a c h o f t h e s e o f f i c e s was  p r i v a t e and q u i e t , and had comfortable c h a i r s arranged a t r i g h t angles,  facilitating  feelings. Although I found  t h e s h a r i n g o f thoughts and  I made a t t e m p t s  t o increase our comfort,  the research s t y l e of interviewing (asking questions  f o r the researcher's b e n e f i t ) uncomfortable  and d i f f i c u l t ,  s i n c e i t i s c o n t r a r y t o my t h e r a p e u t i c s t y l e o f i n t e r v i e w i n g (asking questions f o r the c l i e n t ' s Initially, nurses' 101),  a broad  statement  benefit). relating  d i s c l o s u r e e x p e r i e n c e was u s e d  then subsequently  only prompting  to the study  ( s e e A p p e n d i x A, p . comments w e r e u s e d t o  c l a r i f y and expand t h e i r e x p l a n a t i o n s . I f o l l o w e d t h i s process u n t i l  the participants  i n d i c a t e d t h a t t h e y h a d no  more t o s a y a b o u t t h e i r d i s c l o s u r e e x p e r i e n c e , a n d I f e l t satisfied  that I r e a l l y understood  audiotaped  t h e i r e x p e r i e n c e . The  i n t e r v i e w s were s u b s e q u e n t l y  transcribed  verbatim  by a p r o f e s s i o n a l t y p i s t .  T r a n s c r i p t s w e r e r e t u r n e d t o me  w i t h i n two o r t h r e e d a y s .  I made c o p i e s o f t h e s e  transcriptions,  a n d d e l i v e r e d them t o my r e v i e w e r who h a d  been s e l e c t e d f o r h e r t h e o r e t i c a l s e n s i t i v i t y phenomenon.  to the studied  The r e v i e w e r ' s t a s k was t o p r o v i d e a n  24  independent coding of the i n t e r v i e w n a r r a t i v e s (Hinds, Scandrett-Hibden,  & McAulay,  Data a n a l y s i s , collection,  f o c u s i n g the d i r e c t i o n  a n a l y z i n g the i n i t i a l transcripts,  I had  a p r e l i m i n a r y understanding  of the  study  e x p e r i e n c e s . However, I r e c o g n i z e d t h a t I d i d about s p e c i f i c  r e l e v a n t . ' So and  I arranged e x p a n d my  not  understanding  understandings.  of t h e i r e x p e r i e n c e s .  The  Again,  validate, I asked  open  Second i n t e r v i e w s f o r two  t h i r d p a r t i c i p a n t c o u l d not  r e i n t e r v i e w e d b e c a u s e she was  issues I  comments t h a t w o u l d d e e p e n  o c c u r r e d w i t h i n s i x weeks o f t h e f i r s t participants.  As  forgotten anything  a second i n t e r v i e w to  e n d e d q u e s t i o n s o r made p r o m p t i n g  not  elements.  t a l k e d about d i f f e r e n t  wanted t o c o n f i r m t h a t t h e y had  my  After  data from each of the t h r e e i n t e r v i e w  s i n c e the study nurses  refute,  collection  Strauss & Corbin, 1990).  have a complete u n d e r s t a n d i n g well,  f o r data  takes place c o n c u r r e n t l y w i t h data  ( M i l e s & Huberman, 1994;  nurses'  1990).  of  the  be  out of town f o r a  prolonged  period. F i e l d notes w r o t e down my  a d d e d more d a t a . A f t e r e a c h i n t e r v i e w I  r e a c t i o n s . t o the content  t h e i n t e r v i e w , my the p a r t i c i p a n t , language, thoughts  thoughts and my  posture, and  and  and  o r h u n c h e s I may  the process have had  o b s e r v a t i o n s about t h e i r  a n a l y s i s and u s e  my  I j o t t e d down  p a r t s o f d i s c u s s i o n s t h a t I h a d w i t h t h e r e v i e w e r who v a l i d a t i n g my  about  body  speech p a t t e r n s . I also, noted  f e e l i n g s as I a n a l y z e d d a t a , a n d  of  was  of c o d i n g d e s c r i p t o r s . These  25  notes were s c r i b b l e d down on 3 X 4 p i e c e s of paper, to  a paper,  and kept i n a f i l e  one i d e a  f o l d e r marked "notes t o me".  These notes h e l p e d me focus so that I c o u l d s y n t h e s i z e and understand the data, as w e l l as keep a check on my v a l u e s and assumptions.  A f t e r a n a l y z i n g the f i r s t  s e t o f data, I  made notes which I took i n t o a l l subsequent i n t e r v i e w s , reminding me to ask those q u e s t i o n s t y p i c a l of a r e s e a r c h e r r a t h e r than those of a t h e r a p i s t  ( P o l i t & Hungler,  1991).  Data A n a l y s i s The p r o c e s s of a n a l y z i n g the data took p l a c e c o n c u r r e n t l y w i t h data c o l l e c t i o n . To i l l u s t r a t e the t e c h n i c a l approaches,  the f o l l o w i n g b r i e f l y d e s c r i b e s my  p r o c e s s w i t h one nurse's data s e t : F o l l o w i n g t r a n s c r i p t i o n , comparative  content a n a l y s i s  was used to analyze the data. Content a n a l y s i s i s a procedure f o r a n a l y z i n g v e r b a l communications i n a s y s t e m a t i c and o b j e c t i v e f a s h i o n began by r e a d i n g the complete  (Miles & Huberman, 1994). I.  t r a n s c r i p t t o r e f r e s h my  memory of the i n t e r v i e w . Then I c a r e f u l l y read each and/or  phrase  sentence, and searched f o r a concept word t h a t would  capture i t s meaning. I n i t i a l l y I had g r e a t d i f f i c u l t y a r r i v i n g a t concept words which would a c c u r a t e l y d e s c r i b e the i d e a embedded i n the phrases, c l a u s e s , sentences, and s e c t i o n s . Once s e l e c t e d I wrote the concept word b e s i d e the phrase on the t r a n s c r i p t , and on a s t i c k i e - n o t e I wrote the word, page, and p a r t i c i p a n t ' s number, and I a t t a c h e d i t to the c o r r e s p o n d i n g p l a c e i n the t r a n s c r i p t . M e t h o d i c a l l y , I  26  w o r k e d my  way  through  the t r a n s c r i p t .  I experienced  a  w e l c o m e f a m i l i a r i t y when I r e c o g n i z e d a p r e v i o u s l y d i s c u s s e d phenomenon o r i d e a . A p r e v i o u s l y c h o s e n c o n c e p t d e s c r i p t o r was  then noted.  Strauss & Corbin  word  (1990) c a l l  e x p l o s i o n of the d a t a i n t o c o n c e p t u a l p a r t s open A f t e r I h a d w r i t t e n numerous c o n c e p t t r a n s c r i p t and a s s e s s my  stickie-notes,  I c o n s u l t e d my  through notes  the t r a n s c r i p t ,  and  the concepts  facts."  i s c a l l e d c a t e g o r i z i n g , and  " a s k i n g d i r e c t q u e s t i o n s " , and  categories, revealing,  named " i n t e r v e n t i o n s " . As I t r i e d to understand  "asking f o r  t o g e t h e r and  " q u e s t i o n i n g . " T h i s c a t e g o r y was  o t h e r s and  i s more a b s t r a c t  story", "exploring client's  I grouped these concepts  category  called  the  grouped w i t h  I examined  the  t h e theme t h e y w e r e  o r were p a r t o f .  Each of the study nurse's  i n t e r v i e w s was  analyzed  t h e same m e t h o d . E v e n t u a l l y I r e a l i z e d t h e d a t a r e v e a l i n g a s t o r y about the study nurse's paying  meaning  o p e n c o d i n g I c o n c e p t u a l i z e d some  "expanding c l i e n t ' s  experience,"  stickie-  g r o u p e d u n d e r i t ( S t r a u s s & C o r b i n , 1990) .  For example, employing d a t a as  read  simultaneously removing the  t h e phenomenon r e p r e s e n t e d b y a c a t e g o r y than  observations  & McAulay, 1990). Then I  This grouping process  to  consistency  c r e a t i n g groups which c o n t a i n e d s i m i l a r  concepts.  the  reviewer  p r o v i d e s i n f o r m a t i o n on t h e r e p e a t a b i l i t y o f my  this  coding.  w o r d s on  c o n s i s t e n c y i n s o r t i n g . This check of  (Hinds, Scandrett-Hibden,  or  using  were  experience  a t t e n t i o n . t o e i t h e r h e r s e l f or the c l i e n t .  of  Subsequent  27  to  this,  I r e i n t e r v i e w e d two o f t h e s t u d y n u r s e s  to clarify  data and broaden the d e s c r i p t i o n of the concepts and c a t e g o r i e s , a n d a f f i r m e d o r r e f u t e d my I  c o n t i n u e d t o examine t h e d a t a  configurations, case--and  associations,  o n l y then  a n d e f f e c t s within  t o comparative  ( u s u a l l y l i m i t e d ) number o f c a s e s " M i l e s & Huberman, 1 9 9 4 ) .  "looking at  causes,  [I turned]  interpretations.  the  analysis of a  ( R a g i n , 1978; c i t e d i n  I looked f o r s i m i l a r i t i e s and  d i f f e r e n c e s among t h e s t u d y n u r s e s ' e x p e r i e n c e s , a n d when a p p r o p r i a t e I u s e d t h e same c o n c e p t examining  a n d c a t e g o r y names. B y  and comparing t h e concepts  the three case  studies,  i n t e g r a t i n g concepts  and c a t e g o r i e s a c r o s s  I e s t a b l i s h e d more a b s t r a c t a n d  ( S t r a u s s & C o r b i n , 1990).  F o r example,  t h e c a t e g o r y o f " i n t e r v e n t i o n s " was g r o u p e d u n d e r a p r i m a r y concept  which  I e v e n t u a l l y c a l l e d F o c u s i n g on t h e C l i e n t . Ethical  Considerations  P r i o r t o beginning the study,  I obtained approval  from  the U n i v e r s i t y of B r i t i s h Columbia B e h a v i o r a l Sciences S c r e e n i n g Committee f o r Research  and Other  Human S u b j e c t s . Then I p o l l e d t h e m e n t a l searching f o r nurses w i l l i n g I  ensured  Studies Involving  h e a l t h teams  to p a r t i c i p a t e i n the study.  c o n f i d e n t i a l l y b y t h e f o l l o w i n g m e a s u r e s : (a)  I u s e d a n i d e n t i f i c a t i o n number, r a t h e r t h a n a name, o n t h e t r a n s c r i p t a n d on t h e t a p e ; w e r e l o c k e d i n my f i l i n g audiotapes  (b) a u d i o t a p e s  and t r a n s c r i p t s  c a b i n e t when n o t b e i n g u s e d ;  and t r a n s c r i p t s w i l l  the study is- completed;•(d)  be d e s t r o y e d a y e a r  o n l y two members o f my  (c) after  thesis  28  committee, t h e reviewer, and myself had access i n f o r m a t i o n ; a n d , (e) b y p r e a r r a n g e d  t o t h e coded  a g r e e m e n t , t h e name o f  the o f f e n d e r and t h e agency were n o t mentioned b y t h e participants.  T h i s l a s t p r e c a u t i o n was v e r b a l l y n o t e d a t t h e  beginning of every i n t e r v i e w . L a s t l y , d i s g u i s e d t o ensure  their  t h e n u r s e s ' names w e r e  confidentiality.  C r i t e r i a f o r Rigor Case s t u d i e s have t r a d i t i o n a l l y been c r i t i c i z e d f o r l a c k o f r i g o r and poor g e n e r a l i z a b i l i t y R u n y a n , 1982; Y i n , 1989; Y o u n g e r , 1 9 8 5 ) . several tactics  t h a t can ensure  ( M e i e r & Pugh, 1 9 8 6 ; Y i n (1989)  suggests  r i g o r once t h e d a t a a r e  c o l l e c t e d and analyzed. Since these t a c t i c s a r e n o t a p p r o p r i a t e f o r q u a l i t a t i v e r e s e a r c h where d a t a and  collection  a n a l y s i s a r e done s i m u l t a n e o u s l y , t h e c r i t e r i a f o r  e s t a b l i s h i n g r i g o r i n i n t e r p r e t i v e s t u d i e s were u s e d instead. Q u a l i t a t i v e s t u d i e s i n c l u d e f o u r methods f o r establishing rigor: and  confirmability  Sandelowski  1986).  r e p r e s e n t s such  credibility,  fittingness,  (Guba & L i n c o l n ,  1981; c i t e d i n  "A q u a l i t a t i v e s t u d y i s c r e d i b l e when i t  f a i t h f u l descriptions' or interpretations of  a human e x p e r i e n c e t h a t t h e p e o p l e h a v i n g t h a t would immediately  experience  r e c o g n i z e i t from those d e s c r i p t i o n s o r  i n t e r p r e t a t i o n s a s t h e i r own" this  auditability  (Sandelowski,  1986, p. 3 0 ) . I n  s t u d y , c r e d i b i l i t y was a c h i e v e d b y t h o r o u g h l y  the data gathered  t o determine  checking  i f i t made s e n s e when i t was  c o m p a r e d w i t h o t h e r d a t a c o l l e c t e d . An u n i n v o l v e d  mental  29  h e a l t h t h e r a p i s t - c o l l e a g u e i n d e p e n d e n t l y coded t h e d a t a . As well,  i n t e r p r e t a t i o n s o f t h e d a t a w e r e t a k e n b a c k t o two o f  the p a r t i c i p a n t s  f o rv e r i f i c a t i o n of intent. F i n a l l y ,  a  r e p r e s e n t a t i v e s e l e c t i o n o f t y p i c a l d a t a were i n c l u d e d i n the r e p o r t of t h e f i n d i n g s . "When t h e f i n d i n g s o f t h e s t u d y  " f i t ' into the contexts  o u t s i d e t h e s t u d y s i t u a t i o n a n d when i t s a u d i e n c e f i n d i n g s as meaningful experience" 1986,  views i t s  and a p p l i c a b l e i n terms o f t h e i r  (Guba & L i n c o l n ,  own  1981; c i t e d i n S a n d e l o w s k i ,  p. 3 2 ) , t h e n f i t t i n g n e s s ,  t h e second  criterion, i s  achieved. Fittingness i s the truth value of the data. In this  s t u d y f i t t i n g n e s s was a c h i e v e d b y my g i v i n g a t r u e  r e p r e s e n t a t i o n o f t h e d a t a p r e s e n t e d , by an  independent  c o d i n g o f t h e d a t a , and by r e c e i v i n g a v a l i d a t i n g f r o m a n o t h e r n u r s e when I t e l l A u d i t a b i l i t y i s another reliability,  h e r a b o u t my  a n d i s a c h i e v e d when a l l d e c i s i o n s i n v o l v e d i n  1989).  can c l e a r l y  findings.  c r i t e r i o n f o r measuring  transforming data i n t o t h e o r e t i c a l statements (Burns,  "a-ha"  are reported  A s t u d y i s a u d i t a b l e when a n o t h e r  follow the decision-making  trail  researcher  of the  r e s e a r c h e r i n t h e s t u d y , a n d come t o c o m p a r a b l e c o n c l u s i o n s (Sandelowski,  1986).  To a c h i e v e t h i s  i n this  study,  I  c l e a r l y d e s c r i b e d t h e data c o l l e c t i o n process and c o m p l e t e l y r e c o r d e d a l l d a t a . I gave s u f f i c i e n t raw d a t a t o i l l u s t r a t e my c o n c e p t u a l d e c i s i o n s , a n d p r o v i d e d d e f i n i t i o n s e x p l a i n i n g my r a t i o n a l e f o r t h e d e v e l o p m e n t o f c o n c e p t s concepts.  and sub-  N o t e s d e s c r i b i n g my c o n t i n u a l l y e v o l v i n g  30  theoretical decisions  have been k e p t . F i n a l l y , c o n c e p t s ,  sub-concepts, and c a t e g o r i e s  were c o n t i n u a l l y  compared  with  raw d a t a t o e n s u r e t h e l i n k between t h e t h e o r e t i c a l s t a t e m e n t s a n d d a t a was c l e a r Confirmability rigor  (Burns,  i s the f i n a l  1989).  criterion for establishing  i n q u a l i t a t i v e r e s e a r c h , and r e f e r s  or unbiasedness o f the data criterion  to the n e u t r a l i t y  (Sandelowski, 1986).  This  i s met when a u d i t a b i l i t y , f i t t i n g n e s s , a n d  c r e d i b i l i t y have been s u i t a b l y  established.  Also of concern i s the r e c i p r o c a l e f f e c t that the investigator Huttlinger,  and t h e p a r t i c i p a n t have on e a c h o t h e r  (Lamb &  1989). I n q u a l i t a t i v e r e s e a r c h t h e i n v e s t i g a t o r  makes e x p l i c i t p e r s o n a l a s s u m p t i o n s a n d p r e c o n c e p t i o n s a t the  o n s e t o f t h e r e s e a r c h , a n d t h e n s u s p e n d s , them d u r i n g t h e  inquiry process the  inquiry,  (Lamb & H u t t l i n g e r ,  the investigator's  1 9 8 9 ) . However;  during  personal views a r e a f f e c t e d  by. t h e p a r t i c i p a n t ' s u n d e r s t a n d i n g o f t h e i r  experience  (Anderson, 1991). These r e c i p r o c a l i n f l u e n c e s a r e continuous; therefore, beliefs'and their  I constantly  m o n i t o r e d my  values,  i n t e r e s t s . Not o n l y d i d I t r y t o u n d e r s t a n d  influence  on t h e s t u d y , b u t I a l s o  understanding i n t o the study's findings 1989; c i t e d i n Lamb & H u t t l i n g e r ,  integrated (Marcus &  this Fischer,  1989).  Summary The c a s e s t u d y method,  i n t h i s instance  three in-depth cases of nurses' d i s c l o s u r e produces a promising i n i t i a l  analysis  a comparison of experiences,  of the nurses'  31  process. selected,  In this  study,  three mental  h e a l t h nurses  and then p a r t i c i p a t e d i n m u l t i p l e ,  in-depth,  u n s t r u c t u r e d i n t e r v i e w s . Open c o d i n g a n d a x i a l  coding  t e c h n i q u e s were used t o a n a l y z e t h e d a t a c o l l e c t e d , case  were  and each  s t u d y ' s d a t a were then compared and c o n t r a s t e d w i t h  e a c h o t h e r . The r e s u l t was a n i n f o r m a t i v e a n d r i c h of these nurses' d i f f i c u l t problem  picture  s t r u g g l e t o make m e a n i n g o f t h e c o m p l e x a n d of c l i e n t disclosure. This s t r u g g l e i s  d e s c r i b e d and d i s c u s s e d i n t h e next  chapter.  32  CHAPTER THREE FINDINGS AND DISCUSSION T h i s r e s e a r c h was composed o f t h r e e c a s e t h i s chapter,  a synopsis o f each d i s c l o s u r e case  context f o r t h e concepts study  and s k i l l s ,  t h e context and s e t t i n g o f t h e  and the nurse's  experience.  Concepts emerging from t h e study  specific  single disclosure  descriptions areorganized into a conceptual  to  and  the findings. Relevant  e l a b o r a t e and d i s c u s s s p e c i f i c The  case  case  a d e s c r i p t i o n of the nurse's  disclosure,  I use t o present  provides  t h a t t h e three c o n t a i n . Each  i s introduced through  experience  studies. In  nurses' framework w h i c h  literature  i s used  findings.  studies are presented using f i c t i t i o u s  names  i n thechronological order of thec l i e n t s ' d i s c l o s u r e s  of t h e i r abuse e x p e r i e n c e s :  thed i s c l o s u r e t o Cathy  15 y e a r s b e f o r e I i n t e r v i e w e d h e r , occurred f i v e years p r i o r ,  occurred  t h e d i s c l o s u r e t o Lynne  and t h e d i s c l o s u r e t o A l i c e  o c c u r r e d o n e a n d a h a l f y e a r s b e f o r e . The p a r t i c i p a n t s initially  were  i n t e r v i e w e d w i t h i n one m o n t h o f e a c h o t h e r . The  terms c l i e n t and p a t i e n t a r e used i n t e r c h a n g e a b l y as a r e t h e terms p a r t i c i p a n t ,  nurse  therapist,  and study  nurse.  Case S t u d i e s Cathy's D i s c l o s u r e Account Cathy i s a r e g i s t e r e d nurse, years  experience  with approximately  i n p s y c h i a t r i c acute  nine  care n u r s i n g and  p s y c h i a t r i c o u t p a t i e n t c a r e . When t h e d i s c l o s u r e e x p e r i e n c e h a p p e n e d , 15 y e a r s a g o , C a t h y was i n h e r f i r s t y e a r o f  33  community m e n t a l h e a l t h n u r s i n g . contact  Her  client disclosed  w i t h a former p s y c h i a t r i s t .  The  m e n t a l h e a l t h team w h e r e C a t h y w o r k e d i s m a n d a t e d  to provide  p s y c h i a t r i c care  illnesses,  and  i t s goal  for patients with  serious  i s to prevent the need f o r  p s y c h i a t r i c h o s p i t a l i z a t i o n s . At  the  study took place.  w o r k e r s who  c o u l d be  p s y c h i a t r i c nurses, or p s y c h o l o g i s t s . responsible  E a c h team was  patients,  E a c h h e a l t h c a r e w o r k e r was  and  f o r p r o v i d i n g c o n s u l t a t i o n f o r the  she  would choose a w i t h e a c h one.  d e p e n d i n g on  for the primary  would determine the c l i e n t who  the  I n t h e r a p y , C a t h y was a c t i n g out b e h a v i o r  and  i l l n e s s and constantly  As  she  see  well,  interviews.  abuse e x p e r i e n c e t o  a y o u n g d i v o r c e d woman. C a t h y h a d  both a psychotic  Cathy would  consulting  frequency of the  d i s c l o s e d her  with  consulting  the needs of the c l i e n t .  a psychiatric hospitalization, had  the  a p r i m a r y worker, Cathy would o f f e r t o work  psychiatrist,  was  directly  were r e s p o n s i b l e  c l i e n t a l o n e o r accompanied by  The  care  therapists,  prescribing medication for  p s y c h i a t r i s t to a s s i s t her  she  where  f o r h e r / h i s p a t i e n t ' s care.. I n a d d i t i o n ,  s p e c i f i c p a t i e n t s and  the  city  registered  s o c i a l workers, occupational  diagnosing,  w o r k e r s . As  future  composed o f h e a l t h  r e g i s t e r e d nurses,  teams e n g a g e d p s y c h i a t r i s t s who assessing,  mental  time of d i s c l o s u r e ,  t h e r e w e r e s e v e n s u c h m e n t a l h e a l t h teams i n t h e the  sexual  worked w i t h her knew t h a t t h e  Cathy during client  a substance abuse problem. i n t e r v e n i n g i n the  (taking minor drug overdoses,  client's attempting  34  suicide,  demanding e x t r a appointments, b e i n g  abusive,  and r e f u s i n g t o comply w i t h  a n d / o r i n .the c l i e n t ' s p s y c h o t i c  verbally '  treatment  requests)  and d e l u s i o n a l t h i n k i n g .  C a t h y saw t h i s c l i e n t e i t h e r w e e k l y f o r s u p p o r t i v e counselling,  o r s e v e r a l t i m e s a week f o r c r i s i s management.  In counselling sessions, months, t h e c l i e n t  over a period of several  t a l k e d t o Cathy about h e r a s s o c i a t i o n  w i t h a f o r m e r p s y c h i a t r i s t . She t o l d C a t h y t h a t s h e was " i n love", had, the  that  " t h i s was t h e b e s t r e l a t i o n s h i p " s h e h a d e v e r  a n d t h a t i t was a s e x u a l c l i e n t had psychotic  r e l a t i o n s h i p . Since  episodes,  C a t h y knew  she thought she had t o  make s u r e t h a t t h i s was. n o t a n a s s o c i a t i o n c o n n e c t e d the  client's  fantasy  life.  with  After exploring the s i t u a t i o n ,  carefully,  C a t h y d e t e r m i n e d t h a t t h e c l i e n t h a d a n d was  continuing  t o have a sexual, l i a i s o n w i t h h e r former  psychiatrist. Cathy f e l t  " c o n c e r n e d " a n d " f r u s t r a t e d i n a n a n g r y way"  when s h e r e a l i z e d t h a t t h e r e was a s e x u a l immediately discussed psychiatrist. client,  liaison,  this s i t u a t i o n with the consulting  She b e l i e v e d  t h e l i a i s o n was h a r m f u l t o t h e  a n d a l t h o u g h s h e d i d n o t know s p e c i f i c a l l y  a c t i o n t o take,  and she  what  s h e knew t h a t s h e w a n t e d t h e l i a i s o n  Lynne's D i s c l o s u r e  t o end.  Account  Lynne i s a h e x p e r i e n c e d r e g i s t e r e d p s y c h i a t r i c n u r s e . She  has worked i n p s y c h i a t r i c acute care h o s p i t a l s e t t i n g s ,  . a n d i n b o t h e m e r g e n c y a n d m e n t a l h e a l t h team c o m m u n i t y s e t t i n g s . A t t h e time o f t h e d i s c l o s u r e Lynne had been  35  w o r k i n g i n t h e c o m m u n i t y f o r 13 y e a r s , a t a m e n t a l team d i f f e r e n t f r o m C a t h y ' s b u t p a r t service,  and t h e r e f o r e  organization, Further,  clients,  e x h i b i t i n g t h e same s t r u c t u r e , and method o f d e l i v e r i n g  t r a i n i n g i n working with  abuse, and she had u n d e r t a k e n i n t e n s i v e  t r a i n i n g . A l t h o u g h Lynne had t h e e x p e r i e n c e o f while  health  service.  Lynne had a p r i v a t e p s y c h o t h e r a p y p r a c t i c e .  She h a d h a d e x t e n s i v e sexual  o f t h e same  health  working with  a private practice client,  survivors  of  psychotherapy disclosure s h e was  s i m u l t a n e o u s l y w o r k i n g on a c o m m u n i t y m e n t a l h e a l t h  team, a  f a c t o r common t o a l l t h r e e n u r s e s i n t h i s s t u d y . The d i s c l o s u r e h a p p e n e d f i v e y e a r s b e f o r e , t h i s d a t a c o l l e c t i o n . Lynne had been s e e i n g t h i s c l i e n t  study's for a  month, f o r one h o u r a week. A t t h e t i m e , t h e c l i e n t was i n crisis;  s h e was  t a l k i n g about r i t u a l  sexual  abuse,  sexual  a b u s e , s u i c i d e , a n d shame. She t o l d L y n n e o f t h e many therapists described  t o whom s h e h a d d i s c l o s e d h e r a b u s e h i s t o r y , how  and  f e a r f u l s h e h a d f e l t when none o f t h e s e  therapists believed  her. In t r y i n g to understand her  c l i e n t ' s e x p e r i e n c e more f u l l y , been abused by a t h e r a p i s t " ?  L y n n e a s k e d "have y o u e v e r  The c l i e n t d i s c l o s e d  that  two  y e a r s b e f o r e , h e r p s y c h i a t r i s t a t the time had t h r e a t e n e d t o commit h e r t o a l o c a l p s y c h i a t r i c h o s p i t a l i f s h e d i d n o t h a v e s e x -with h i m on a w e e k l y b a s i s . no c h o i c e ,  Believing that  she had  the c l i e n t had acquiesced.  Lynne i m m e d i a t e l y f e l t  "furious"'. At the time,  n o t e d t h e f e e l i n g and t e m p o r a r i l y  p u t i t away, w i t h  she the  36  resolve later.  t h a t she Also,  she  would t a l k to a t h e r a p i s t f r i e n d about i t had  the  thought " t h i s  b e c a u s e I've  h e a r d a b o u t t h i s guy  that  still  "he  was  doing  her  exploration provided  situation. not  OK;  t o do  She  i t was anything  informed her very  understood her  h a p p e n e d two  years before,  c l i e n t was client's  client,  asked her  i f she  the c l i e n t r e f u s e d . r e f u s a l . Since  n e i t h e r she  nor  take p r i o r i t y over the  s a f e t y and  other  therapy  one  and  a p p r o x i m a t e l y two  the  "what t h a t p e r s o n d i d  wanted  Lynne  this the  was  incident  had  client  fact that  the to  her  issues.  Account  A l i c e ' s d i s c l o s u r e e x p e r i e n c e was a h a l f years before y e a r s a f t e r she  c o m m u n i t y m e n t a l h e a l t h team. A t A l i c e had  appalled  a c t i v e l y s u i c i d a l . . Lynne p r o c e e d t o a t t e n d  Alice's Disclosure  occurred  felt  me,  h e r w i t h more d e t a i l s a b o u t client  a b o u t i t , and  i t should  and  a t t e n t i o n toward her  u n e t h i c a l " . She  a c c e p t e d and  believed  before",  s u r p r i s e to  it."  Lynne then d i r e c t e d her and  i s no  considerable  had the  t h e most r e c e n t .  our  interview,  s t a r t e d work time of  It  and • at'a  disclosure  e x p e r i e n c e as a r e g i s t e r e d  p s y c h i a t r i c nurse. P r i o r to j o i n i n g the  team, she  had  worked  i n a p s y c h i a t r i c a c u t e c a r e h o s p i t a l u n i t and- a p s y c h i a t r i c day  p r o g r a m ; as w e l l she  a Registered  had  taught mental h e a l t h nursing  P s y c h i a t r i c Nurses' Program, a t a  community  college. Her  d i s c l o s u r e experience took place  h e a l t h team s e t t i n g . S i n c e  i t was  the  i n the  same m e n t a l  mental health  in  37  team a s L y n n e ' s , a n d s i m i l a r t o C a t h y ' s , t h e s e t t i n g similar characteristics of  d e s c r i b e d above. An e s s e n t i a l  care that a c l i e n t receives a t a l l the mental  teams i s a n i n i t i a l  a comprehensive.psychiatric interview.  latter,  health  (intake  Both the  d a t a ) , and consulting  and t h e p r i m a r y worker a r e i n v o l v e d i n t h e  a n d i t i s n o r m a l l y done when t h e y i n t e r v i e w  for the f i r s t  a client  time.  A l i c e and t h e c o n s u l t i n g of  part  assessment. This assessment i s comprised  of d a t a s u b m i t t e d by t h e r e f e r r i n g p e r s o n  psychiatrist  bore  the c l i e n t ' s i n i t i a l  psychiatrist  were i n t h e m i d s t  a s s e s s m e n t when t h e  disclosure  e x p e r i e n c e o c c u r r e d . A l i c e h a d r e a d on t h e i n t a k e d a t a the  male c l i e n t had a long p s y c h i a t r i c  following  diagnoses: borderline  sociopathic relationship  traits,  that  history with the  personality  disorder,  and s u b s t a n c e abuse. As w e l l ,  a sexual  w i t h a f o r m e r p s y c h i a t r i s t was r e p o r t e d . A s  part of their i n i t i a l  assessment, the  consulting  p s y c h i a t r i s t .and A l i c e a s k e d t h e c l i e n t many q u e s t i o n s . Suddenly, , A l i c e r e p o r t e d  "the c l i e n t insinuated  was a c u r r e n t s e x u a l r e l a t i o n s h i p general practitioner."  that  between him and h i s  He made t h i s d i s c l o s u r e  "voluntarily,  spontaneously, and i n t h e middle of t a l k i n g about topic." the  Without a l l u d i n g  to the alleged  another  relationship  previous p s y c h i a t r i s t mentioned i n the i n t a k e  Alice  there  with  data,  c o n f i r m e d w i t h t h e c l i e n t t h a t he was t a l k i n g a b o u t a  relationship  with h i s current general  practitioner.  38  Alice  immediately  f e l t appalled that this  c o u l d h a p p e n . " She  recalls  thinking  f e e l i n g an u r g e n c y  t o do s o m e t h i n g  "situation  "this i s serious" about i t ,  though  and  she  c h o s e n o t t o show h e r f e e l i n g s o r t o make a n y comment. A l i c e and  the c o n s u l t i n g p s y c h i a t r i s t m e n t a l l y noted  disclosure, arranged  and  f i n i s h e d the i n i t i a l  f o r a subsequent  appointment  assessment. w i t h the  Both  the  They client.  These t h r e e d i s c l o s u r e cases, though t h e y o c c u r r e d  over  a w i d e s p a n o f t i m e , o f f e r e d an o p p o r t u n i t y t o e x p l o r e t h e n a t u r e of the d i s c l o s u r e experience f o r nurse The  accounts  o f t h e t h r e e e v e n t s and  of t h e i r responses  therapists.  the nurses'  t o them r e v e a l a s i n g l e ,  description  cyclical  process  t h a t c a n be e x p l a i n e d i n t e r m s o f s e v e r a l • c o n c e p t s . Conceptual Framework: Overview This s e c t i o n presents the f i n d i n g s of the study d i s c l o s u r e e x p e r i e n c e s . The concurrently to minimize d e s c r i b e my and  findings are  repetition.  nurses'  presented  Initially,  I  shall  g e n e r a l c o n c e p t u a l i z a t i o n o f t h i s phenomenon,  s u b s e q u e n t l y d i s c u s s and e l a b o r a t e t h r e e c o n c e p t s  detail, concepts  illustrating  in  them w i t h q u o t a t i o n s f r o m t h e d a t a .  of t h i s c o n s t r u c t i o n are c a p i t a l i z e d ;  The  concepts  s e l e c t e d f o r d i s c u s s i o n are underlined. The  nurses' d i s c l o s u r e experiences are conceptualized  as' a p r o c e s s c a l l e d The primary concept,  C y c l e of Focusing A t t e n t i o n .  Focusing Attention,  i n t e g r a t e s two  This main  c o n c e p t s w h i c h emerged f r o m t h e d a t a : F o c u s i n g on t h e a n d F o c u s i n g on S e l f . B o t h o f t h e s e f u r t h e r s e p a r a t e  Client into  39  sub-concepts 1, p.  40)  and m o d i f y i n g - c o n c e p t s . The  illustrates  sub-concepts,  diagram  the i n t e g r a t i n g concept,  and m o d i f y i n g - c o n c e p t s ,  (see F i g u r e  the  concepts,  the c o g n i t i v e  and  b e h a v i o r a l process of a nurse c o n c e n t r a t i n g her a t t e n t i o n e i t h e r her c l i e n t or h e r s e l f . mental  cyclical  and b e h a v i o r a l p r o c e s s w i t h p a r t s t h a t a r e  mutually exclusive; and  I t i s a complex,  i n fact,  not  I s e e them a s h i g h l y  interdependent. For the purposes  of t h i s  integrated  discussion,  h o w e v e r , t h e y a r e d e s c r i b e d as s e p a r a t e a n d d i s c r e t e F o c u s i n g A t t e n t i o n emerged a s t h e e s s e n t i a l i n t e g r a t i n g concept  of a l l t h r e e nurses'  on  parts.  and  disclosure  experiences. Focusing A t t e n t i o n i n v o l v e s the  nurse's  c o g n i t i v e and b e h a v i o r a l p r o c e s s of c o n c e n t r a t i n g h e r a t t e n t i o n on e i t h e r h e r c l i e n t o r h e r s e l f . c y c l i c a l mental  I t i s a complex,  and b e h a v i o r a l p r o c e s s w i t h t h e g o a l , o f  alleviating client  suffering.  In t h i s process, the  a l t e r n a t e l y F o c u s e s A t t e n t i o n on h e r c l i e n t a n d on When t h e n u r s e and  f o c u s e s on t h e c l i e n t ,  t h e n r e f o c u s e s on t h e c l i e n t ,  C y c l e of F o c u s i n g The  f o c u s e s on  t h i s may  herself.'  herself,  be c a l l e d  the  Attention.  e s s e n t i a l aspect of the nurse's  experience,  nurse  disclosure  the Cycle of Focusing A t t e n t i o n ,  r e l a t i o n to her c l i e n t .  i s the nurse i n  This r e l a t i o n s h i p i s comprised  of  two m a i n c o n c e p t s : F o c u s i n g on t h e C l i e n t a n d F o c u s i n g  on  Self.  (  40  F i g u r e 1. Cycle of Focusing  A t t e n t i o n (Primary  Concept]  Focusing  F o c u s i n g on t h e C l i e n t (Concept)  on S e l f (Concept]  * A n a l y z i n g Thoughts (Sub-concept)  'Collecting Information (Sub-concept)  *Analyzing Boundaries * A n a l y z i n g Power (Modifying-concepts) *Experiencing Feelings (Sub-concept)  *Using I n t e r v e n t i o n s (Sub-concept)  When t h e n u r s e i s F o c u s i n g  on t h e C l i e n t ,  observes her c l i e n t ' s behavior. Self,  she turns inward  received while behavior,  When s h e i s F o c u s i n g  and processes  and she n o t i c e s h e r p e r s o n a l  processing,  on  the c l i e n t ' s  reactions  (feelings  Then, b a s e d o n t h e r e s u l t s o f h e r m e n t a l  the nurse returns t o Focusing  makes a v e r b a l o r b e h a v i o r a l i n t e r v e n t i o n . another  t o and  t h e i n f o r m a t i o n she has  l i s t e n i n g t o and observing  or thoughts) t o i t .  she l i s t e n s  on t h e C l i e n t and This  begins  cycle.  Focusing concepts,  o n t h e C l i e n t i s c o m p r i s e d o f two s u b - -  C o l l e c t i n g Information  and Using  Interventions.  When t h e n u r s e i s C o l l e c t i n g I n f o r m a t i o n ,  she l i s t e n s  client  Using  and she observes h e r / h i s behavior.  to the  41  I n t e r v e n t i o n s i n v o l v e s what t h e n u r s e s a i d a n d how s h e a c t e d towards h e r c l i e n t . Focusing Attention,  on S e l f ,  the other.concept  of Focusing  i s c o m p r i s e d o f two s u b - c o n c e p t s :  Experiencing  F e e l i n g s a n d A n a l y z i n g T h o u g h t s . When t h e n u r s e i s A n a l y z i n g Thoughts she i s c o n s i d e r i n g c o n c e p t u a l l y t h e i s s u e s t h a t h e r c l i e n t may b e e x p e r i e n c i n g . Two m o d i f y i n g - c o n c e p t s  that  f u r t h e r d e s c r i b e A n a l y z i n g Thoughts i n c l u d e A n a l y z i n g B o u n d a r i e s a n d A n a l y z i n g Power. When t h e n u r s e i s A n a l y z i n g Boundaries,  she t h i n k s about c r o s s e d therapy  boundaries  w h i c h a l l o w e d c l i e n t - t h e r a p i s t s e x t o o c c u r ; when A n a l y z i n g Power, s h e t h i n k s a b o u t t h e p o w e r d i f f e r e n t i a l  that  allowed  t h e c l i e n t a b u s e . When t h e n u r s e i s E x p e r i e n c i n g F e e l i n g s , she  r e c a l l s her emotional  and/or  responses t o h e r c l i e n t ' s  words  behaviors.  I conceptualize the study nurses' d i s c l o s u r e experiences  as t h e C y c l e o f F o c u s i n g  c o n s i s t s o f : two c o n c e p t s , Focusing Using  on S e l f ;  Focusing  four, sub-concepts,  A t t e n t i o n . The C y c l e on t h e C l i e n t a n d Collecting  Information,  I n t e r v e n t i o n s , E x p e r i e n c i n g F e e l i n g s , and A n a l y z i n g  T h o u g h t s ; a n d two m o d i f y i n g - c o n c e p t s ,  Analyzing  a n d A n a l y z i n g Power. I n t h i s C y c l e , t h e n u r s e ' s a l t e r n a t e s between F o c u s i n g  Boundaries attention  on t h e C l i e n t a n d F o c u s i n g  Self. E x p l i c a t i o n of the C y c l e of F o c u s i n g A t t e n t i o n This sub s e c t i o n takes o u t l i n e d and e x p a n d s . i t .  the conceptualization just  on  42  Focusing  on t h e C l i e n t  Focusing  on t h e C l i e n t  Focusing Attention. nurses'  cognitive  attention  i s a concept  i n the Cycle of  F o c u s i n g on t h e C l i e n t and b e h a v i o r a l p r o c e s s e s  on t h e i r c l i e n t s ' t h o u g h t s ,  refers  of concentrating  feelings,  and  b e h a v i o r s . As c l i e n t s d e s c r i b e d t h e i r t h o u g h t s , and b e h a v i o r s ,  the nurses  focused  Collecting  feelings,  their attention  c l i e n t s a n d became i n v o l v e d i n C o l l e c t i n g Information i s the cognitive  to the  on t h e i r  Information.  process  of compiling  data about t h e i r c l i e n t by l i s t e n i n g t o the c l i e n t , and o b s e r v i n g t h e c l i e n t ' s b e h a v i o r . Through t h i s process,  the nurses  attempted  problems and t o f a c i l i t a t e verbal,  non-verbal,  to understand  ongoing  their  clients'  t h e i r c l i e n t s ' recovery by a  o r b e h a v i o r a l response.  F o r example,  Lynne r e p o r t e d l i s t e n i n g s e n s i t i v e l y and r e s p e c t f u l l y , she  recalled  distress.  watching  She a c t i v e l y  experience.  She t a l k e d  f o r signs of  t r i e d to understand  Lynne r e c a l l e d  s i m i l a r understandings goal.  her c l i e n t closely  and  her c l i e n t ' s  t h a t b o t h she and h e r c l i e n t had  about t h e problem and t h e therapy  about t h i s mutual u n d e r s t a n d i n g  like  this:  We w e r e w o r k i n g on i s s u e s r e l a t e d t o h e r s e x u a l a n d r i t u a l a b u s e . . . . When I a s k e d h e r i f s h e w a n t e d t o r e p o r t h i m [ t h e p s y c h i a t r i s t ] s h e . s a i d "no", a n d I t o t a l l y u n d e r s t o o d . We c a r r i e d on d e a l i n g w i t h o t h e r i s s u e s t h a t w e r e more p r e s s i n g a t t h e t i m e . . . . She was s u i c i d a l a t the time. L i k e L y n n e , when C a t h y was C o l l e c t i n g r e p o r t e d t h a t h e r g o a l was t o u n d e r s t a n d experience.  I n f o r m a t i o n she  her c l i e n t ' s  U n l i k e L y n n e , who h a d t h e same u n d e r s t a n d i n g  of  43  the  p r o b l e m as h e r c l i e n t , Cathy and h e r c l i e n t  different thinking  understandings of the problem. h e r c l i e n t ' s p r o b l e m was  Cathy  recalled  t h a t s h e was  having a  sexual l i a i s o n w i t h a former p s y c h i a t r i s t , client  had  t h o u g h t t h a t h e r p r o b l e m was  whereas  t h a t s h e was  the  not having  e n o u g h s e x u a l m e e t i n g s w i t h h i m . As p a r t o f t h e p r o c e s s o f Collecting  I n f o r m a t i o n , C a t h y remembered l i s t e n i n g t o  o b s e r v i n g b e h a v i o r d e s i g n e d t o maneuver h e r facilitating  (Cathy)  and  into  the sexual l i a i s o n s .  We s p e n t s e s s i o n a f t e r s e s s i o n w i t h h e r w a n t i n g me t o h e l p make p h o n e c a l l s o r f i g u r e o u t how s h e c o u l d meet h i m a t h i s a p a r t m e n t o r o f f i c e . He was l i k e a magnet f o r h e r . . . . I c o u l d n ' t c h a n g e h e r m i n d o r g e t -\ h e r t o w o r k on a n y t h i n g e l s e . Cathy a l s o r e c a l l e d verbally  l i s t e n i n g to her c l i e n t not o n l y  a b u s i n g and t h r e a t e n i n g h e r , b u t  unrealistically praising  h e r and a s k i n g h e r  When t h e o f f e n d i n g p s y c h i a t r i s t meetings,  also forgiveness.  restricted their sexual  Cathy r e c a l l e d o b s e r v i n g her c l i e n t ' s a c t i n g  behavior which included p r e s c r i p t i o n  and  non-prescription  drug o v e r d o s e s , i n c r e a s e d f a m i l y c o n f l i c t , and t h r e a t s suicide  and  Alice's  of  homicide. experience of C o l l e c t i n g  s p e c i f i c d i s c l o s u r e a c c o u n t , was a n d C a t h y ' s . U n l i k e L y n n e who  Information, i n her  different  from b o t h Lynne's  r e p o r t e d t h a t she and  c l i e n t had a s i m i l a r u n d e r s t a n d i n g of the problem t h e r a p y g o a l , a n d u n l i k e C a t h y who the  out  her  and  recalled understanding  problem d i f f e r e n t l y than her c l i e n t , A l i c e r e p o r t e d that  she f e l t  she n e v e r u n d e r s t o o d what h e r c l i e n t t h o u g h t h i s  44  p r o b l e m was. " I j u s t d i d n ' t know what he w a n t e d  ... h i s  a g e n d a k e p t c h a n g i n g . . . . I j u s t n e v e r knew ... h i s f a c t s k e p t c h a n g i n g . " She r e p o r t e d  listening  to her c l i e n t ' s  i n s i n u a t i o n s t h a t he was c u r r e n t l y h a v i n g a relationship with h i s physician. various  t i m e s he w o u l d t h r e a t e n  She r e c a l l e d t h a t a t to set himself  f r o n t o f h e r ; on s e v e r a l o c c a s i o n s her  office  sexual  on f i r e i n  he d r a g g e d h i m s e l f  into  i n a s e m i - c o m a t o s e s t a t e due t o l i t h i u m o v e r d o s e s  and/or a l c o h o l i n t o x i c a t i o n . A f t e r C o l l e c t i n g Information it,  and m e n t a l l y  processing  the study nurses then used the data t o guide  interventions. Using Interventions,  their  a sub-concept of  F o c u s i n g on t h e C l i e n t , i s a p r o c e s s t h a t a l l t h r e e r e c a l l using.  This  or b e h a v i o r a l  responses of the nurse, d i r e c t e d towards the  client,  with  recovery. verbal  concept captures the v e r b a l ,  nurses  the i n t e n t i o n of .fostering the c l i e n t ' s  A l i c e remembered t h a t h e r i n t e r v e n t i o n s w e r e  and b e h a v i o r a l .  She r e c a l l e d e x p l o r i n g h e r c l i e n t ' s  i m p l i c a t i o n t h a t he a n d h i s g e n e r a l a sexual  non-verbal,  relationship. After using  p r a c t i t i o n e r were h a v i n g interventions to  u n d e r s t a n d h i s m e a n i n g , s h e remembered e x p l a i n i n g t o h i m that t h i s sexual  r e l a t i o n s h i p was a b u s i v e ,  r e c a l l e d was n o t h i s p e r c e p t i o n . supportive,  w h i c h she  A l i c e saw h e r s e l f a s  understanding, consistent,  c l e a r , and  e m p o w e r i n g , a n d when t h e c l i e n t became a t r i s k himself,  f o r harming  she r e c a l l e d i m m e d i a t e l y i n t e r v e n i n g and  preparing  45  f o r h o s p i t a l i z a t i o n on e i t h e r a v o l u n t a r y o r i n v o l u n t a r y basis. Like Alice,  when C a t h y s p o k e a b o u t U s i n g  Interventions  she  r e m e m b e r e d u s i n g b o t h v e r b a l a n d non. v e r b a l  She  remembered a s k i n g q u e s t i o n s  reality.  to determine her c l i e n t ' s  " I w a n t e d t o know i f t h i s s e x u a l r e l a t i o n s h i p was  r e a l or part of her psychosis.... having  behaviors.  a sexual r e l a t i o n s h i p . "  I t was r e a l ;  they  were  She r e c a l l e d how s h e  u n s u c c e s s f u l l y attempted t o s e t l i m i t s w i t h h e r c l i e n t , and t o show t h e c l i e n t behavior  the connection  (threats of committing  between h e r a c t i n g o u t  suicide, taking  medication  overdoses, and abusing  a l c o h o l ) , and h e r s e x u a l  with the psychiatrist.  Cathy r e p o r t e d a c t i n g q u i c k l y t o have  her  c l i e n t assessed  f o r medications,  c r i s i s h o s t e l o r a h o s p i t a l . At times,  involvement  and admitted  to a  when n e c e s s a r y ,  she  would have h e r committed t o h o s p i t a l . D i f f e r e n t from b o t h A l i c e ' s and Cathy's experiences Using  I n t e r v e n t i o n s , Lynne r e p o r t e d u s i n g o n l y v e r b a l  interventions.  She remembered i n t e r v e n i n g w i t h  w h i c h expanded h e r c l i e n t ' s b e l i e f s and f e e l i n g s . not  i n t e r v e n t i o n s which  only defined the p s y c h i a t r i s t ' s behavior  experience  as a b u s i v e .  questions  s t o r y and/or e x p l o r e d h e r  She r e p o r t e d u s i n g  wrong, b u t a l s o s u p p o r t e d  by  of  as abusive  and v a l i d a t e d h e r c l i e n t ' s  She a t t e m p t e d t o empower h e r c l i e n t  asking  f o r d i r e c t i o n on w h e t h e r o r n o t t o r e p o r t t h e  offender,  a n d b y a c c e p t i n g and. s u p p o r t i n g h e r c l i e n t ' s  negative  decision.  and  46  F o c u s i n g on t h e C l i e n t of F o c u s i n g A t t e n t i o n , respond  i s the f i r s t  aspect of the C y c l e  the p r o c e s s used by the nurses  t o abuse d i s c l o s u r e s ,  p a r t o f t h e f i n d i n g s . The  and h a s b e e n u s e d  to  to present  second p a r t of the C y c l e , F o c u s i n g  on S e l f , w i t h i t s s u b - c o n c e p t s  E x p e r i e n c i n g F e e l i n g s and  A n a l y z i n g T h o u g h t s , and m o d i f y i n g - c o n c e p t s A n a l y z i n g Boundaries  and A n a l y z i n g Power, i s a p a r a l l e l p a r t o f  p r o c e s s o f F o c u s i n g on t h e C l i e n t . s e l e c t e d concepts  In the f o l l o w i n g  from t h i s aspect of the C y c l e of  the  section Focusing  A t t e n t i o n a r e e l a b o r a t e d and d i s c u s s e d i n t h e c o n t e x t o f relevant literature. to f a c i l i t a t e F o c u s i n g on The  their  These s e l e c t e d c o n c e p t s  are underlined  identification.  Self  major concept,  F o c u s i n g on S e l f ,  i s an  integral  p a r t o f t h e n u r s e s ' d i s c l o s u r e e x p e r i e n c e . As w e l l F o c u s i n g on t h e i r C l i e n t s , I n t e r v e n t i o n s the nurses Self,  the  searched  as  C o l l e c t i n g I n f o r m a t i o n , and  l o o k e d i n w a r d , and,  f o r t h e i r own  Using  i n Focusing  on  r e a c t i o n s to the i n f o r m a t i o n .  These i n c l u d e d b o t h c o g n i t i v e p r o c e s s i n g and  identifying  feelings. A n a l y z i n g T h o u g h t s was d i s c l o s u r e e x p e r i e n c e , and  p a r t of each n u r s e - t h e r a p i s t ' s o c c u r r e d when t h e  r e f l e c t e d upon t h e i r a n a l y t i c a l is  the mental  nurses  thoughts. A n a l y z i n g Thoughts  p r o c e s s o f t h i n k i n g a b o u t t h e i s s u e s embedded  i n t h e r a p y . T h i s p r o c e s s a l l o w e d them a c c e s s t o a theoretical the problem,  framework which  enhanced t h e i r u n d e r s t a n d i n g  and a l e r t e d them t o t h e t h e r a p y i s s u e s t h a t  of  47  t h e i r c l i e n t s w o u l d most l i k e l y e x p e r i e n c e . T h i s  knowledge  g u i d e d t h e i r i n t e r v e n t i o n s and f o c u s e d t h e i r t h i n k i n g .  For  e x a m p l e , L y n n e remembered t h i n k i n g a b o u t t h e n o t i o n s o f b o u n d a r i e s , power, aware  and b r e a k i n g t r u s t ,  being  t h a t s h e w o u l d n e e d t o be c o g n i z a n t o f t h e s e  (The u n d e r l i n e d c o n c e p t s in  and r e c a l l s  issues.  a r e e l a b o r a t e d upon and d i s c u s s e d  detail). A l i c e remembered t h i n k i n g a b o u t t h e n o t i o n s o f  boundaries,  and because t h e y were b l u r r e d , h e r c l i e n t  was  a b l e t o m i s i n t e r p r e t h i s p h y s i c i a n ' s b e h a v i o r s and words. Taking time to t r y to determine c l i e n t ' s d i s c l o s u r e was  the t r u t h f u l n e s s of her  a s i g n i f i c a n t p a r t of her  e x p e r i e n c e . She remembered t h i n k i n g a b o u t t h e i s s u e s o f b r e a k i n g t r u s t and  power.  Cathy had d i f f i c u l t y remembering h e r t h o u g h t s d i s c l o s u r e e x p e r i e n c e happened t h a t s i n c e then,- h e r t h o u g h t s considerably.  15 y e a r s b e f o r e . She r e p o r t e d about s e x u a l abuse had  and she wondered i f  e v e r an a c c e p t a b l e t i m e f o r c l i e n t s and  to get i n v o l v e d sexually.  therapists  She remembered t h i n k i n g a b o u t  p s y c h i a t r i s t s had t h e power t o m a n i p u l a t e relationship,  changed  She remembered t h i n k i n g t h a t t h e o f f e n d i n g  p s y c h i a t r i s t was w i t h o u t b o u n d a r i e s t h e r e was  since her  how  the therapy  and t o c o e r c e o t h e r s i n t o n o t r e p o r t i n g  them.  A n o t h e r p a r t of t h e d i s c l o s u r e e x p e r i e n c e and o f F o c u s i n g on S e l f o c c u r r e d a s t h e n u r s e s clients'  abuse s t o r i e s .  listened to  their  Each of these nurses r e p o r t e d  experiencing intense feelings.  Experiencing Feelings i s  48  n o t i c i n g and naming an i n t e r n a l p h y s i c a l s e n s a t i o n . Lynne r e c a l l e d Experiencing F e e l i n g s of being "ho r r i f i e d " ,  " a p p a l l e d " , and " f u r i o u s . "  feeling  "powerless"  system.  When w o r k i n g w i t h h e r c l i e n t ,  "caring"  and "outraged"  and f e e l i n g  "Powerless",  "concerned"  "impotent",  "outraged", She remembered  about the r e p o r t i n g she r e c a l l e d  feeling  about h e r .  "helpless",  and "angry"  were  t h e f e e l i n g w o r d s C a t h y used-when s h e remembered b o t h t h e d i s c l o s u r e e x p e r i e n c e and h e r attempts  to stop the sexual  e n c o u n t e r s . A t times she s a i d t h a t she would d r e a d  seeing  her c l i e n t because the c l i e n t would "take e v e r y t h i n g out of me."  She remembered f e e l i n g  "concern"  f o r her since her  c l i e n t was f r e q u e n t l y e i t h e r t h r e a t e n i n g s u i c i d e o r a c t i v e l y suicidal.  She r e p o r t e d f e e l i n g  o f f e n d i n g p s y c h i a t r i s t who client. way:  "frustrated" with the  s h e b e l i e v e d was m a n i p u l a t i n g h e r  Fifteen- years l a t e r ,  Cathy  expressed her caring  " A t t i m e s I t h i n k a b o u t h e r a n d w o n d e r how  this  she's  doing." Alice,  also,  t a l k e d about t h e f e e l i n g s she e x p e r i e n c e d .  S h e . r e m e m b e r e d s h e was  " a p p a l l e d " and " s u r p r i s e d " a t t h e  p o s s i b i l i t y of a sexual r e l a t i o n s h i p , she  felt  an "urgency"  t o i n t e r v e n e . She remembered  "powerless" and " r e a l l y f r u s t r a t e d " changing  and she r e c a l l s  feeling  that the c l i e n t  kept  h i s treatment g o a l s and h i s d i s c l o s u r e s t o r y .  was f r e q u e n t l y i n c r i s i s "concern",  and a t those times she  " s t r e s s e d " , and  "harried".,  that  felt  He  49  I n summary, as I d e s c r i b e d a n d nurses'  accounts  compared the  of t h e i r responses t o t h e i r  d i s c l o s u r e of s e x u a l c o n t a c t by a p r e v i o u s e l e m e n t s e m e r g e d f o r me. p a g e 40)  clients'  t h e r a p i s t , nine  These n i n e elements  I c o n c e p t u a l i z e d as f o l l o w s : the  (see F i g u r e  working  of S e l f ;  concepts  are Focusing  subsumed u n d e r , F o c u s i n g  concepts,  A t t e n t i o n ; the  on t h e C l i e n t a n d  on S e l f a r e two  sub-concepts,  and  Power. l i t e r a t u r e s t r o n g l y supports  boundaries  the n o t i o n  that  and p o w e r a r e c r u c i a l d y n a m i c s i n s i t u a t i o n s  client-therapist 1992;  modifying-  of A n a l y z i n g Thoughts are A n a l y z i n g B o u n d a r i e s  Analyzing The  sub-  Interventions;  E x p e r i e n c i n g F e e l i n g s and A n a l y z i n g T h o u g h t s ; two concepts  Focusing  on t h e C l i e n t a r e two  C o l l e c t i n g I n f o r m a t i o n and U s i n g  subsumed u n d e r F o c u s i n g  1.  primary  i n t e g r a t i n g concept i s the Cycle of Focusing two  study  G u t h e i l and  sexual contact  (Gutheil,  Gabbard, 1993). F u r t h e r ,  1989;  Herman,  although  t h e r a p i s t s debate the r e l a t i v e importance of r e l a t i o n s h i p between c l i e n t and  the  therapist, this  report  a s s e r t s t h a t the r e l a t i o n s h i p between the study nurses t h e i r c l i e n t s was experience  of  a fundamental f a c t o r i n the  and  nurses'  of c l i e n t d i s c l o s u r e .  These t h r e e concepts  (boundaries,  power, and  the  c l i e n t - t h e r a p i s t r e l a t i o n s h i p ) a r e c o n s i d e r e d germane t o phenomenon u n d e r s t u d y , c o n t a c t and  t h a t of c l i e n t - t h e r a p i s t  the  sexual  i t s d i s c l o s u r e to a subsequent mental h e a l t h  p r o f e s s i o n a l . These•concepts are t h e r e f o r e s i n g l e d out  for  50  s p e c i a l a t t e n t i o n i n t h i s s t u d y . The r e l a t i o n s h i p i s s t u d i e d by  t a k i n g a c l o s e l o o k a t F o c u s i n g on t h e C l i e n t i n t h e  c o n t e x t o f t r a d i t i o n a l w r i t i n g s on t h e t h e r a p e u t i c relationship.  Later, A n a l y z i n g Boundaries  and A n a l y z i n g  Power a r e a l s o d i s c u s s e d w i t h r e f e r e n c e t o t h e r e l e v a n t literature. D i s c u s s i o n of F o c u s i n g on the F o c u s i n g on t h e C l i e n t was p i v o t a l disclosure experience.  Client  t o each  I t r e f e r s to the nurse's  nurse's cognitive  and b e h a v i o r a l p r o c e s s o f c o n c e n t r a t i n g a t t e n t i o n on h e r client's  thoughts,  feelings,  and b e h a v i o r s . I t i s an  e s s e n t i a l element of the t h e r a p e u t i c r e l a t i o n s h i p ;  without  F o c u s i n g on t h e C l i e n t t h e r e c a n b e no t h e r a p y . As a therapist, which  the nurse  she a c c e p t s  enters into a special r e l a t i o n s h i p i n  t h e t r u s t and c o n f i d e n c e o f h e r c l i e n t t o  act i n the l a t t e r ' s best i n t e r e s t Although  (Feldman-Summers,  1989).  t h e s t u d y nurses d i d n o t use t h i s e x a c t term,  literature  typically calls  the  this a therapeutic relationship.  Hence, I t u r n b r i e f l y t o t h e t h e r a p e u t i c r e l a t i o n s h i p l i t e r a t u r e to b e t t e r understand e x p e r i e n c e and t h e concept  the p a r t i c i p a n t s '  disclosure  o f F o c u s i n g on t h e C l i e n t .  The t h e r a p e u t i c r e l a t i o n s h i p h a s l o n g b e e n c o n s i d e r e d an e s s e n t i a l p a r t o f t h e p s y c h o l o g i c a l t h e r a p y  process.  Although p s y c h o t h e r a p i s t s b e l i e v e t h a t therapy cannot done w i t h o u t s u c h a r e l a t i o n s h i p , each o t h e r about i t s importance.  be  t h e y do n o t a g r e e , w i t h S i n c e i t was  first  51  a r t i c u l a t e d by Freud has An  (Kahn, 1 9 9 1 ) , i n t h e l a t e 1 8 9 0 s ,  b e e n much c o n t r o v e r s y  about i t s importance and dynamics.  h i s t o r i c a l perspective  controversial  there  i s h e l p f u l i n understanding the  i s s u e s , a n d i n e x p l a i n i n g what t h e n u r s e s  reported. The  n o t i o n was c o i n e d  b y F r e u d who was t r a i n e d t o  b e l i e v e t h a t w h a t m a t t e r e d most was w h a t t h e p h y s i c i a n d i d . to, and f o r , the p a t i e n t ' s c o n d i t i o n ; the r e l a t i o n s h i p b e t w e e n t h e p a t i e n t a n d p h y s i c i a n was i r r e l e v a n t . I n t h e l a t e 189 0s,  h o w e v e r , a s he o b s e r v e d a c o l l e a g u e  woman w i t h h y s t e r i a , he b e g a n o b s e r v i n g  treat a  w h a t was h a p p e n i n g  b e t w e e n t h e two. F r e u d d e t e r m i n e d t h a t t h i s r e l a t i o n s h i p , w h i c h he c a l l e d t h e t h e r a p e u t i c  r e l a t i o n s h i p , was much  d e e p e r a n d more c o m p l e x t h a n t h e c o n v e n t i o n a l  patient  physician relationship. F r e u d became c o n v i n c e d t h a t i n p s y c h o a n a l y s i s r e l a t i o n s h i p between p a t i e n t and p h y s i c i a n crucial, very  the  (analyst)  t h a t i t was i n v a r i a b l y i n t e n s e , m y s t e r i o u s ,  complex r e g a r d l e s s  was and  o f how i t may a p p e a r o n t h e s u r f a c e  (Kahn, 1 9 9 1 ; P a r l o f f , 1 9 8 6 ) . H i s way o f b e i n g  with  patients  was a c t i v e a n d e n g a g i n g . He c a r r i e d o n a r e a l d i a l o g u e p a t i e n t s and tended t o t h e i r c u r r e n t  n e e d s . He  intuitively  knew when t o e n g a g e a n d when t o b e d i s t a n t . H o w e v e r , of a d v o c a t i n g  that other  analysts  e n c o u r a g e d them t o b e d i s t a n t  with  instead  follow.his behavior,  (Kahn,  What t h e s t u d y n u r s e s d e s c r i b e d  he  1991). as F o c u s i n g on t h e  C l i e n t resembles Freud's s t y l e of being  with h i s clients.  A  52  10 0 y e a r s a f t e r F r e u d , t h e s e n u r s e s d e s c r i b e d experiences observing,  as b e i n g  their  actively involved i n listening,  and i n t e r v e n i n g . They behaved d i f f e r e n t l y  from  F r e u d ' s f e l l o w a n a l y s t s who w e r e d i s t a n t , r e m o t e , a n d silent.  These a n a l y s t s w a i t e d  f o r the transference to  " a p p e a r " a n d s p o k e o n l y when o f f e r i n g a n i n t e r p r e t a t i o n about t h e p a t i e n t ' s t r a n s f e r e n c e .  Transference,  Freud  b e l i e v e d , was t h e m a i n p o i n t o f p s y c h o t h e r a p y , a n d i t r e f e r s to the p a t i e n t s t r a n s f e r r i n g t h e i r a t t i t u d e s , f e e l i n g s , fears, 1991;  a n d w i s h e s f r o m l o n g ago o n t o t h e i r a n a l y s t s  (Kahn,  Jacobson, 1993). I t i s beyond t h e scope o f t h i s  to describe  thesis  t h e dynamics o f t h i s complex p r o c e s s o f  transference;  simply put,  the analysts' therapy  goals  were  t o p r o v i d e maximum i l l u m i n a t i o n o f t r a n s f e r e n c e manifestations,  t o p r o t e c t c l i e n t autonomy, a n d t o p r o t e c t  c l i e n t ' s v u l n e r a b i l i t y t o e x p l o i t a t i o n (Jacobson, Freud's f o l l o w e r s had goals nurses reported  g o a l s when F o c u s i n g  encouraging the transference Focusing  f o r therapy,  on t h e C l i e n t ,  1993).  and t h e study  on t h e C l i e n t .  However,  was n o t one o f them; when  t h e i r g o a l s were t o h e l p  their  c l i e n t s a n d t o p r o t e c t them f r o m harm. I n t h e 1 9 4 0 s , a n A m e r i c a n a n a l y s t , C a r l R o g e r s , was a major force i n i n i t i a t i n g perceptions  a change w h i c h humanized t h e  about psycho.therapy  (Kahn, 1991) . He b e l i e v e d  t h a t t h e t h e r a p e u t i c a t t i t u d e r e q u i r e d empathy a n d unconditional regard  f o rclients,  p a r t o f t h e t h e r a p i s t . Rogers  and g e n u i n e n e s s on t h e  (1961) d i r e c t e d t h e r a p i s t s t o  53  d e m o n s t r a t e an a t t i t u d e o f uncompromising r e s p e c t f o r t h e c l i e n t and t o r e f r a i n from imposing t h e i r onto t h e i r c l i e n t s . D i f f e r e n t therapeutic  interpretations  from a n a l y s t s ,  whose  a t t i t u d e was d i s t a n t a n d s i l e n t ,  n u r s e s ' a t t i t u d e s were r e s p e c t f u l  the study  and c a r i n g ,  closer  to the  Rogerian view. ,The r a d i c a l p o l i t i c a l democratic therapeutic  climate  o f t h e 1 9 6 0 s demanded  a  r e l a t i o n s h i p . Therapists searched f o r  ways t o make t h e c l i n i c a l  r e l a t i o n s h i p more e g a l i t a r i a n .  T h i s g r o u n d s w e l l l e d t o t h e e n c o u n t e r movement w h i c h • e m p h a s i z e d a u t h e n t i c i t y a n d symmetry Authenticity and  the therapist  that  the therapist  be w i l l i n g  c l i e n t was asked- t o do. E n c o u n t e r  1991).  s h o u l d be as h o n e s t  as e m o t i o n a l l y exposed as t h e c l i e n t ,  demanded the  meant t h a t  (Kahn,  and symmetry  t o do a n y t h i n g  that  therapists  s p o n t a n e o u s l y and openly r e v e a l e d whatever f e e l i n g s o r t h o u g h t s were evoked, and o f t e n confrontation. hostility,  used  unrestrained  They i n t e n t i o n a l l y s h a r e d t h e i r f e e l i n g s o f  boredom, e x c i t e m e n t , o r s e x u a l a t t r a c t i o n  t h e i r c l i e n t s (Kahn,  with  1991).  The s t u d y n u r s e s w e r e d i f f e r e n t f r o m t h e r a d i c a l therapists  described previously.  Not o n l y d i d t h e y  t h e i r own f e e l i n g s , b u t t h e y a d a m a n t l y a s s e r t e d wrong f o r t h e r a p i s t s i n sex with that  i t was  t o a c t out t h e i r f e e l i n g s by engaging  their c l i e n t s . A l i c e stated:  " I was  i t m i g h t e v e n be a s e x u a l r e l a t i o n s h i p . "  declared:  that  contain  appalled  Cathy  " I t was s o w r o n g , he r e a l l y t o o k a d v a n t a g e o f h e r .  54  She  was s o v u l n e r a b l e .  He was w r o n g t o h a v e a  r e l a t i o n s h i p w i t h her." strongly: and  sexual  Lynne e x p r e s s e d h e r b e l i e f s  "Sex b e t w e e n a t h e r a p i s t a n d a c l i e n t ,  a client,  a physician  i s t o t a l l y taboo, i t ' s t o t a l l y wrong, i t ' s a  m a s s i v e abuse o f power.... I t ' s a v i o l a t i o n o f t r u s t ! " A l t h o u g h Rogers  (1961) was a c t i v e l y i n v o l v e d  i n , and  i n f l u e n c e d b y , t h e e n c o u n t e r movement, h i s n o t i o n s o f a u t h e n t i c i t y and o f p o s i t i v e regard by  were t a k e n t o extremes  some members o f t h i s movement. Some o f t h e s e  practiced i n a harshly  c o n f r o n t a t i o n a l manner, a n d b e l i e v e d  they had permission t o give sexual  support  c l i e n t s p h y s i c a l , l o v i n g , and  (Kahn, 1 9 9 1 ) . R o g e r s , h o w e v e r , p r a c t i s i n g i n '  a less aggressive emotional  therapists  manner, b e l i e v e d he s h o u l d p r o v i d e  only  support.  When t h e s t u d y n u r s e s w e r e F o c u s i n g o n t h e C l i e n t  they  o f f e r e d e m o t i o n a l support, as Rogers' would have w i t h i n t h e context of the therapeutic  r e l a t i o n s h i p . But, u n l i k e him,  t h e y g a v e more. When t h e i r c l i e n t s w e r e b e h a v i n g i n h a r m f u l and  d e s t r u c t i v e ways  (such as t h r e a t e n i n g  drug overdoses) the nurses r e c a l l e d that voluntary  suicide or taking they had arranged  and i n v o l u n t a r y h o s p i t a l a d m i s s i o n s o r emergency  d o c t o r a p p o i n t m e n t s . They were w o r k i n g w i t h severe p e r s o n a l i t y disorders unlike the high-functioning  a n d who w e r e patients  c l i e n t s who h a d low-functioning,  t y p i c a l l y seen by  a n a l y s t s . A n d u n l i k e t h e e n c o u n t e r movement t h e r a p i s t s , who in t h e i r therapeutic  r e l a t i o n s h i p s sometimes e x p l o i t e d and  (harmed t h e i r c l i e n t s  (Kahn, 1 9 9 1 ) , t h e t r a n s c r i p t s r e v e a l  55  these nurses  a s h a v i n g b e e n warm, e m p a t h i c ,  caring.  h e l p f u l , and • '  The  d e b a t e c o n t i n u e s t o d a y among t h e r a p i s t s  importance  of the therapeutic relationship.  therapeutic relationship  the following:  object relations  therapy, p s y c h o s o c i a l therapy,  therapy, G e s t a l t  and v a r i o u s b o d y - o r i e n t e d  therapies  (Kahn, 1 9 9 1 ) .  cognitive  therapy, behavior therapy,  Although  therapists  c h a n g e s , t h e y do a g r e e  participants  to facilitate  that a positive  r e l a t i o n s h i p p r o m o t e s a p o s i t i v e outcome Similar  employing  and a d v i c e - g i v i n g  t h e r a p y do n o t a c t i v e l y u s e t h e r e l a t i o n s h i p patients'  F o r example, t h e  i s deemed i n d i s p e n s a b l e i n  psychodynamic t h e r a p i e s i n c l u d i n g psychoanalytic therapy,  about the  t o psychodynamic t h e r a p i s t s ,  (Lambert,  1982).  the study  b e l i e v e d t h a t F o c u s i n g o n t h e C l i e n t was a n  e s s e n t i a l p a r t o f t h e i r t h e r a p y work. They u s e d t h e relationship  as a s e t t i n g where t h e i r c l i e n t s c o u l d  t a l k about and r e c o v e r from p a s t and p r e s e n t difficulties. client  both  emotional  I n F o c u s i n g on t h e C l i e n t Lynne e n c o u r a g e d h e r  t o t a l k a b o u t some t e r r i f y i n g s i t u a t i o n s  from h e r  p a s t . L y n n e r e p o r t e d : " I was l i s t e n i n g t o h e r t a l k a b o u t h e r p a s t s e x u a l abuse and I n o t i c e d t h a t she l o o k e d s c a r e d . I j u s t k e p t a s k i n g h e r more q u e s t i o n s , a n d s h e t o l d me some h o r r i b l e a b u s e s . " on t h e C l i e n t ,  Cathy p r o v i d e d t h i s data: by F o c u s i n g  she c r e a t e d an e m o t i o n a l e n v i r o n m e n t where  her c l i e n t r e v e a l e d s u i c i d a l and h o m i c i d a l thoughts, subsequently  about  accepted Cathy's  and she  h e l p . Lynne's and Cathy's  56  interactions  and i n t e r v e n t i o n s  c o u l d n o t have t a k e n  place  w i t h o u t t h e p r o c e s s o f F o c u s i n g , on t h e C l i e n t . C a r l Rogers as the  "a h e l p i n g intent  (1961) d e f i n e d a t h e r a p e u t i c  relationship  i n w h i c h one o f t h e p a r t i e s h a s  o f promoting the growth, development,  improved f u n c t i o n i n g , other"  relationship  improved coping w i t h l i f e  maturity, of the  (p. 3 9 ) . I m p l i c i t i n t h i s d e f i n i t i o n i s t h a t  t h e r a p e u t i c r e l a t i o n s h i p has a s p e c i f i c i n t e n t  a  and t h e  h e l p e r h a s a u n i q u e r o l e . The e s t a b l i s h m e n t o f a t h e r a p e u t i c relationship  d e p e n d s on c e r t a i n b e h a v i o r s o f t h e h e l p e r a n d  c l i e n t which can e i t h e r relationship. essential  foster or hinder a therapeutic  H e l p e r and c l i e n t ' s mutual c o o p e r a t i o n i s  f o r a therapeutic  relationship.  A t h e r a p e u t i c r e l a t i o n s h i p has a s p e c i a l F o c u s i n g on t h e C l i e n t , goal.  To me, s p e c i a l  specific  intent  and i n  study nurses suggested they had a  intent  E v a l u a t i n g and t r e a t i n g  intent,  i s t h e same a s a  initial  forestablishing  goal.  c l i e n t p r o b l e m s was t h e a therapeutic  relationship  and  was t h e g o a l o f t h e s e n u r s e s when t h e y w e r e F o c u s i n g on  the  C l i e n t . Each nurse p r o v i d e d data about t h e purpose o f  her  therapeutic relationship.  client  control  C a t h y ' s g o a l was t o h e l p h e r  t h e "symptoms o f h e r p s y c h o t i c i l l n e s s a n d  s u b s t a n c e abuse problems," and t o p r o v i d e s u p p o r t d u r i n g a crisis  state  i n w h i c h s h e was h a v i n g  "terrible  arguments  w i t h h e r m o t h e r a n d b r o t h e r . " A l i c e ' s g o a l was t o p r o v i d e safety  f o r h e r c l i e n t who was t h r e a t e n i n g s u i c i d e ,  provide support f o r d i f f i c u l t i e s  and " t o  a r i s i n g from h i s substance  57  a b u s e and Client,  personality disorder."  her  g o a l was  to childhood The  and  work t h r o u g h i s s u e s  l i t e r a t u r e supports the  B a r c i a and  Ruiz  interpersonal  o r hope i s the  (1990) b e l i e v e  ritual  notion  that  the  attain health.  therapeutic  Raising  an  clients  meet  the p a t i e n t ' s  morale  i n t e n t o f most p s y c h o t h e r a p i e s a c c o r d i n g  (1982) and  P a r l o f f (1986). Promoting p a t i e n t  development, improved f u n c t i o n i n g ,  i n t e n t i o n of reducing  and  and  to  growth  coping are  (1961). F i n a l l y ,  (1991) c o n t e n d s t h a t t h e p a t i e n t the  related  abuse.  relationship is  bond i n t e n d e d t o h e l p  i n t e n t i o n s p u r p o r t e d by R o g e r s  with  and  the  i n i t i a t e d by h a v i n g s p e c i f i c i n t e n t .  helping  t h e i r n e e d s and  and  her  adolescent sexual  r e l a t i o n s h i p s are  Lambert  to help  When L y n n e F o c u s e d on  the  Meisler  t h e r a p i s t come t o g e t h e r  or r e s o l v i n g the  patient's  problems. In a therapeutic specific  r o l e , and  r e l a t i o n s h i p , the  i n F o c u s i n g on  n u r s e s s u g g e s t e d t h e y had believed  t h e y s h o u l d be  clients,  t o c o n c e n t r a t e on  a mission  the  By  study  needs and  concealing  of put  their feelings  abuse, t h e s e s t u d y n u r s e s  n e e d s a h e a d o f t h e i r own,  clients.  a  or a s p e c i f i c r o l e . They  their clients'  when c l i e n t s d i s c l o s e d s e x u a l  benefit  C l i e n t the  a v a i l a b l e f o r the b e n e f i t  t h e s e n e e d s a h e a d o f t h e i r own.  their clients'  the  t h e r a p i s t has  Lynne gave t h e s e  and  put  were p r e s e n t  to  data:  W e l l , I d o n ' t l e t my f u r y show, b e c a u s e t h a t ' s w r o n g , mean i t ' s n o t O.K. T h e s e a r e my f e e l i n g s . S h e ' s n o t h e r e t o l i s t e n t o my f e e l i n g s , so ... I ' l l d e a l w i t h them e l s e w h e r e . So I a s k h e r q u e s t i o n s a b o u t w h a t i t was l i k e f o r h e r ... I s i t on my f e e l i n g s . W e l l , I  I  58 d o n ' t s i t o n them. I while.... But I take w h o l e l o t more- a b o u t t o do ... a n d I t o l d person did.  s o r t o f p u t them away f o r a some o f my a n g e r a n d I t h i n k a h e r e x p e r i e n c e a n d what s h e wants h e r t h a t i t ' s wrong what t h a t  N o t e how L y n n e v o i c e d h e r own f e e l i n g s . A l i c e described her  how s h e p u t h e r c l i e n t ' s n e e d s a h e a d o f  own i n t h i s way. When h e r c l i e n t i n s i n u a t e d t h a t h e was  c u r r e n t l y having sexual practitioner, appalled, time....  a c t i v i t y with his  Alice said,  "I felt  surprised,  b u t d i d not share that w i t h We f i n i s h e d t h e a s s e s s m e n t  terminated."  She r e p o r t e d  general somewhat  the c l i e n t a tthe  ... t h e n t h e s e s s i o n was  t h a t s h e c h o s e n o t t o show h e r  f e e l i n g s b e l i e v i n g t h i s r e v e l a t i o n would have a  negative  e f f e c t on h i m . L i t e r a t u r e supports Lynne s and A l i c e ' s d e c i s i o n s t o 1  conceal  their  needs f i r s t  f e e l i n g s a s a way o f p u t t i n g t h e i r  a n d o f F o c u s i n g o n t h e i r C l i e n t s . When  t h e r a p i s t s show t h e i r  f e e l i n g s , p a t i e n t s o f t e n behave i n  ways t h a t r e s p o n d .to t h e t h e r a p i s t s ' p e r c e i v e d Lambert  clients'  needs.  (1982), i n h i s r e v i e w o f t h e r a p i s t b e h a v i o r s  contribute  to a p o s i t i v e or negative  relationship,  reports  Vanderbos  therapeutic  that therapist expressiveness  e f f e c t on p a t i e n t s ' p e r c e p t i o n s  consciously  that  "pathogenic"  or unconsciously,  has an  and t r u s t . Karon and  (1972; c i t e d i n L a m b e r t , 1 9 8 2 ) , t e s t e d  hypothesis  that  their  ( t h e i r quotes) t h e r a p i s t s , . use t h e i r p a t i e n t s t o s a t i s f y  t h e i r own n e e d s . , T h e s e t h e r a p i s t s w e r e f o u n d t o b e more noxious and l e s s c l i n i c a l l y  e f f e c t i v e t h a n t h e r a p i s t s who  59  put  t h e p a t i e n t s ' needs b e f o r e  t h e i r own. P a t i e n t s o f t h e  more b e n i g n t h e r a p i s t s w e r e f o u n d t o f u n c t i o n a t h i g h e r levels  than those of the "pathogenic" t h e r a p i s t s .  A l i c e ' s disclosure experience i l l u s t r a t e s  a n o t h e r way  o f p u t t i n g t h e c l i e n t ' s n e e d s a h e a d o f h e r own, t h a t i s t o say,  o f F o c u s i n g on t h e C l i e n t . I n o r d e r  to put her c l i e n t ' s  n e e d s f i r s t A l i c e s u s p e n d e d h e r own r e a l i t y a n d b e l i e v e d h e r c l i e n t ' s disclosure, supporting report  the alleged offending  suspending her r e a l i t y  him w i t h encouragement t o  physician. Alice  t h i s way:  [Although]  described  "the c l i e n t  i n s i n u a t e d t h a t he was c u r r e n t l y h a v i n g a s e x u a l with h i s general  liaison  p r a c t i t i o n e r , " A l i c e had worked w i t h  this  p h y s i c i a n and had a f a v o r a b l e p r o f e s s i o n a l r e l a t i o n s h i p w i t h him.  As w e l l , she  reported:  T h i s d o c t o r h a d a v e r y g o o d c l i n i c a l r e p u t a t i o n a n d was h i g h l y r e s p e c t e d w i t h i n t h e m e n t a l h e a l t h community. W h e r e a s [my] c l i e n t h a d l i e d a b o u t a l o t o f t h i n g s ... he s a i d t h a t he was H I V p o s i t i v e ... a n d a b l o o d t e s t r e s u l t we g o t showed he w a s n ' t . . . . To me t h e d i l e m m a i s [ i n b e l i e v i n g ] someone w i t h a d i a g n o s i s o f s o c i o p a t h i c t r a i t s , b o r d e r l i n e p e r s o n a l i t y d i s o r d e r , and substance a b u s e r . So t h e r e i s a l o t o f n e g a t i v e c o n n o t a t i o n s t o t h o s e d i a g n o s e s ... v e r s u s someone who h a s a g o o d r e p u t a t i o n . . . . B u t no m a t t e r how " f l a k y ' a c l i e n t i s , y o u n e e d t o b e l i e v e them. The c o n t e x t  o f t h i s s t a t e m e n t makes A l i c e ' s d i l e m m a c l e a r ,  and b e l i e v i n g h e r c l i e n t ' s to her personal  r e p o r t s w h i c h were  contradictory  e x p e r i e n c e , was a d i l e m m a f o r h e r .  Like a l l therapists i n therapeutic  r e l a t i o n s h i p s , these  n u r s e s u s e d i n t e r v e n t i o n s when F o c u s i n g on t h e C l i e n t . Interventions  are behaviors that study nurses used t o help  t h e i r c l i e n t s r e g a i n o r improve t h e i r coping  a b i l i t i e s and  60  prevent  further d i s a b i l i t y  ( S t u a r t & Sundeen, 1991).  are f o r the b e n e f i t of the c l i e n t . passive,  s u c h as l i s t e n i n g ,  The  T h e s e b e h a v i o r s may  or a c t i v e ,  the s i g n i n g of committal papers  f o r an  l i s t e n i n g was  ambulance.  p a r t of  L y n n e ' s d i s c l o s u r e e x p e r i e n c e a n d o f F o c u s i n g on t h e She  reported her experience t h i s  be  s u c h as o r g a n i z i n g  or phoning  i n t e r v e n t i o n of c a r e f u l  They  Client.  way:  [The c l i e n t ] was t a l k i n g a b o u t t h e number o f p e o p l e , d i f f e r e n t t h e r a p i s t s t h a t she had seen o v e r t h e y e a r s ... a b o u t what a f r i g h t e n i n g e x p e r i e n c e i t h a d b e e n f o r h e r t o s e e so many d i f f e r e n t p e o p l e , a n d n o b o d y r e a l l y b e l i e v e d h e r s t o r y , w h i c h was s e v e r e s e x u a l a b u s e . As w e l l ,  Lynne r e c a l l e d t h a t she l i s t e n e d f o r what  c l i e n t had not s a i d .  She went on:  the  " I a s k e d a b o u t who  had  a b u s e d h e r o r i f she had e v e r been a b u s e d by a  professional  ...  she had  and  she s a i d ,  'Yes'....  s e e i n g some y e a r s ago." she c o u l d u n d e r s t a n d  A p s y c h i a t r i s t who  Lynne l i s t e n e d t o h e r c l i e n t  and e m p a t h i z e  so t h a t  w i t h h e r . As w e l l ,  r e p o r t e d t h a t she v a l i d a t e d h e r c l i e n t ' s e x p e r i e n c e  been  she  by  saying: What t h a t p e r s o n d i d w a s n ' t O.K.; i t was v e r y u n e t h i c a l . . . . I a s k e d h e r i f s h e w a n t e d t o do a n y t h i n g a b o u t i t . . . . She d i d n ' t want t o do a n y t h i n g a b o u t i t ... I t o t a l l y s u p p o r t e d t h a t . . . . She d i d n ' t h a v e e n o u g h ego s t r e n g t h t o go t o t h e C o l l e g e , o r go t o t h e p o l i c e ... I r e s p e c t e d h e r c h o i c e . . L i t e r a t u r e s u p p o r t s Lynne's i n t e r v e n t i o n of listening. Frank, 1982)  The  r e s u l t s of a c l a s s i c  Imber, B a t t l e , N a s h , & S t o n e ,  study 1966,  careful  ( T r u a x , Wargo, c i t e d by  Lambert,  showed t h a t p a t i e n t s whose t h e r a p i s t s w e r e j u d g e d  i n l e v e l s o f a c c u r a t e empathy, n o n - p o s s e s s i v e w a r m t h o r  high  61  r e s p e c t , and genuineness, improvement on o v e r a l l  showed s i g n i f i c a n t l y more  i n d i c e s o f change t h a n  those  t h e r a p i s t s who w e r e j u d g e d l o w . A c t i v e i n t e r v e n t i o n s , w e r e p a r t o f both Cathy's and Alice's practice with their disclosing clients, F o c u s i n g on t h e C l i e n t .  They r e p o r t e d i n t e r v e n i n g q u i c k l y  a n d d e c i s i v e l y when t h e y d e t e r m i n e d was  and of  their clients'  safety  t h r e a t e n e d . T h e y t a l k e d a b o u t i t t h i s way: t h e i r  were angry,  anxious, and prone t o b e i n g i n c r i s i s ;  frequently threatened suicide, over-the-counter,  took overdoses  and r e c r e a t i o n a l drugs,  arranged then,"  immediately  f o r a h o s p i t a l bed,"  of prescribed,  Cathy and  and c o n c r e t e l y . " I  " I booked an appointment  " I t o o k h e r t o [a c r i s i s  detox,"  they  a n d demanded  immediate h e l p f o r p e r s o n a l and s o c i a l chaos. A l i c e remembered r e s p o n d i n g  clients  facility]",  " I made e m e r g e n c y a p p o i n t m e n t s  right  " I took him t o  t o t a l k o r t o have  h e r meds a d j u s t e d " . The and  l i t e r a t u r e r e v e a l s , t h a t t h e s e a c t i o n s a r e common  important  i n psychosocial therapy  p r o v i d e t h e p a t i e n t w i t h o r encourage understanding  1982).  They  intellectual  o f t h e r e l a t i o n s h i p between f e e l i n g s and  b e h a v i o r , h e l p reduce  anxiety, provide support,  a c t i n g o u t b e h a v i o r . Bandura, J e f f e r y , cited  (Lambert,  i n L a m b e r t , 19 82)  and l i m i t  and Wright  (1974;  found i n t h e i r study t h a t t h e  h i g h e s t d e g r e e o f b e h a v i o r a n d a t t i t u d e c h a n g e was e f f e c t e d i n c l i e n t s who r e c e i v e d t h e most s t r u c t u r e d i n t e r v e n t i o n s .  62  Therapists exhibit therapeutic qualities relationships,  and i n F o c u s i n g on t h e C l i e n t ,  i n therapeutic study nurses  p r a c t i c e d an a t t i t u d e c o n t a i n i n g such q u a l i t i e s .  Their  a t t i t u d e i s a c o n c e r n e d way o f b e i n g w i t h a c l i e n t p r e s e r v e s human d i g n i t y ,  r e s t o r e s humanity,  and a v o i d s  reducing persons t o the moral status of object 1988).  that  (Watson,  Each o f t h e study nurses r e c a l l e d h e r c o n c e r n f o r h e r  client.  F o r example,  C a t h y was w o r k i n g i n a new  environment:  I was new a n d I f e l t i n o v e r my h e a d [ r e f e r r i n g t o h e r c l i e n t ' s s u i c i d a l a n d d e m a n d i n g b e h a v i o r ] ... b u t I r e a l l y wanted t o h e l p h e r and I c o u l d n ' t . . . . I t r i e d e v e r y t h i n g I c o u l d t h i n k o f s h o r t o f l o c k i n g h e r up ... to s t o p h e r from s e e i n g him. Cathy  felt  abilities: the  f r u s t r a t e d w i t h b o t h t h e c l i e n t a n d h e r own " I was new a t t h e team a n d n o t a t a l l h e l p f u l t o  client."  Summarizing,  she d e s c r i b e d t h e s i t u a t i o n as  " i m p o s s i b l e " , b u t Cathy kept working w i t h h e r c l i e n t and k e p t w a n t i n g t o make a d i f f e r e n c e .  Even a f t e r t h e c l i e n t ' s  d i s c h a r g e , Cathy c o n t i n u e d t o t h i n k about h e r :  " I would  w o n d e r how s h e i s d o i n g - - O . K . I h o p e . " L y n n e r e p o r t e d h e r c o n c e r n when s h e t a l k e d a b o u t h e r client  refusing to take action against the offending  psychiatrist.  She s a i d :  I t h i n k i t t a k e s a l o t o f c o u r a g e t o t a k e on t h e a l l p o w e r f u l m e d i c a l system. I t o t a l l y u n d e r s t a n d h e r s a y i n g n o . . . . She c o u l d b a r e l y make i t t h r o u g h t h e d a y ... u n a b l e t o w o r k ... b a r e l y a b l e t o c a r e f o r h e r k i d s . . . . I w o u l d n e v e r e n c o u r a g e somebody t o go a n d do s o m e t h i n g i f t h e y w e r e n ' t f e e l i n g O.K. a b o u t i t . The  t h e r a p i s t ' s q u a l i t i e s h a v e b e e n much s t u d i e d a n d  reported. Lazarus  (1971; c i t e d i n L a m b e r t ,  1982) i n a n  63  u n c o n t r o l l e d study of h i s p a t i e n t s , found t h a t the most f r e q u e n t l y mentioned t h e r a p i s t q u a l i t i e s were s e n s i t i v i t y , g e n t l e n e s s , and honesty.  Other q u a l i t i e s i n c l u d e d l i k i n g  p a t i e n t , a c t i v e involvement, (Frank,. 1974; love  i n s p i r i n g hope and  cited in Parloff,  the  confidence  1986); t h e r a p e u t i c warmth or  ( B a r c i a and Ruiz, 1990); c a r i n g , empathic,  understanding,  and i n t e r e s t  (Lambert, 1982). Indeed, Rogers  (1961) claimed t h a t the q u a l i t i e s of the t h e r a p i s t are more important  than therapy  techniques.  E s s e n t i a l to e s t a b l i s h i n g a t h e r a p e u t i c r e l a t i o n s h i p i s mutual c o o p e r a t i o n between the t h e r a p i s t and the  client.  E i t h e r the t h e r a p i s t and/or the c l i e n t can a c t i n ways which p r e c l u d e the formation of a t h e r a p e u t i c r e l a t i o n s h i p . F o c u s i n g on the C l i e n t , together with  these nurses  their clients,  In  t a l k e d about working  t h a t i s , mutual c o o p e r a t i o n .  Working together means behaving  i n ways congruent  with  the  agreed upon t h e r a p e u t i c g o a l s . A l i c e r e p o r t e d t h a t when she was  Focusing on the C l i e n t ,  she f a i l e d to c r e a t e a  t h e r a p e u t i c r e l a t i o n s h i p . She because there was  found i t " r e a l l y  frustrating  no r e l a t i o n s h i p . " Her c l i e n t came to the  c l i n i c a s k i n g f o r h e l p which she was  w i l l i n g to g i v e . A l i c e  remembered wanting to p r o t e c t her c l i e n t from harm due c l i e n t t h e r a p i s t sex and she became immediately  involved  w i t h p l a n s to c o n f r o n t and r e p o r t the a l l e g e d o f f e n d e r . client  to  Her  i n i t i a l l y agreed. As w e l l , A l i c e r e p o r t e d :  The c l i e n t s a i d t h a t he wanted to work on h i s i s s u e s a r i s i n g from c h i l d h o o d sexual abuse, and g r i e f r e l a t e d to h i s p a r t n e r d y i n g . . . . I agreed to work on these  64 therapy i s s u e s w i t h him. But i n s t e a d o f working w i t h me, he k e p t c h a n g i n g h i s a g e n d a . . . . H i s b e h a v i o r became more a n d more d i f f i c u l t . . . . He was u s i n g a l o t o f d r u g s and a l c o h o l ... he t h r e a t e n e d u s w i t h v i o l e n c e . . . . He even t h r e a t e n e d t o douse h i m s e l f w i t h g a s o l i n e and s e t h i m s e l f on f i r e i n f r o n t o f u s - - i n t h e c l i n i c . . . He w o u l d d r a g h i m s e l f i n on a l l f o u r s , i n a n a l m o s t c o m a t o s e s t a t e , a n d w i t h a L i t h i u m l e v e l o f 2.1 ... t o x i c l e v e l . . . . L i k e he w a n t e d e v e r y b o d y t o s e e h i m . . . . I j u s t c o u l d n ' t h e l p him. I've wondered i f c o n f r o n t a t i o n s o e a r l y i n t r e a t m e n t p r e v e n t e d me f r o m forming a therapeutic r e l a t i o n s h i p . Research supports A l i c e ' s claim that a  therapeutic  r e l a t i o n s h i p had n o t been e s t a b l i s h e d . T h e r a p i s t that prevent the formation much r e s e a r c h  P r o c h a s k a and N o r c r o s s that  includes  patient  a therapeutic relationship. ( 1 9 8 1 ; c i t e d i n L a m b e r t , 1982) f o u n d  that c l i e n t q u a l i t i e s or c h a r a c t e r i s t i c s account  a greater proportion  o f t h e outcome v a r i a n c e  therapist characteristics. Specific qualities poor i n t e r p e r s o n a l s k i l l s  t h a n do  they c i t e are  and a h i s t o r y o f p o o r  interpersonal relationships. A l i c e reported had  received  t h e r e was a n i n c r e a s i n g c o n s e n s u s among t h e r a p y  researchers for  o f a r e l a t i o n s h i p have  attention. Current research  q u a l i t i e s which preclude  qualities  that her c l i e n t  b o t h poor i n t e r p e r s o n a l s k i l l s and a h i s t o r y o f poor  interpersonal relationships. Locating  t h e s t u d y n u r s e s ' r e f l e c t i o n s on F o c u s i n g on  t h e C l i e n t w i t h i n t h e more t r a d i t i o n a l v i e w o f  therapeutic  r e l a t i o n s h i p s d e m o n s t r a t e s how t h e y b o t h f i t a n d do n o t f i t with h i s t o r i c a l Collecting  and p r e s e n t e v o l u t i o n o f b e l i e f s .  Information  nurses turned  and U s i n g I n t e r v e n t i o n s ,  these  i n w a r d , F o c u s i n g on S e l f , t h e o t h e r  concept i n the Cycle  After three  primary  o f F o c u s i n g A t t e n t i o n . F o c u s i n g on S e l f  65  is  t h e process t h a t they used  t o search f o r t h e i r mental and  e m o t i o n a l r e a c t i o n s t o t h e i r c l i e n t s ' words o r b e h a v i o r s . N o t i c i n g r e a c t i o n s i s important f o r therapy, s i n c e study nurses used  them t o i n f o r m t h e i r i n t e r v e n t i o n s .  attended t o e i t h e r t h e i r thoughts attending t o t h e i r thoughts,  They  o r t h e i r emotions.  the study nurses  When  thought  about  t h e phenomenon o f c l i e n t - t h e r a p i s t s e x c o n c e p t u a l l y ; I h a v e c a l l e d t h i s process A n a l y z i n g Thoughts. T h i s  important  p r o c e s s enhanced study nurses' u n d e r s t a n d i n g o f t h e i r clients'  potential  i s s u e s , m a k i n g i t p o s s i b l e f o r them t o  i n t e r v e n e more p o t e n t l y . When t h e s e n u r s e s their clients'  thought  about  d i s c l o s u r e s c o n c e p t u a l l y , t h e y remembered  t h i n k i n g about i s s u e s o f boundary and t r u s t v i o l a t i o n s , and o f t h e abuse o f power. I n t h e C y c l e o f F o c u s i n g A t t e n t i o n , have c a l l e d t h e s e i s s u e s m o d i f y i n g - c o n c e p t s them A n a l y z i n g B o u n d a r i e s  and have  labeled  a n d A n a l y z i n g Power. To e n r i c h t h e  understanding of the study nurses' d i s c l o s u r e and  I  these modifying-concepts,  I turn f i r s t  experiences  to the l i t e r a t u r e  about t h e r a p e u t i c boundary. D i s c u s s i o n of A n a l y z i n g Boundaries J u s t as t h e l i t e r a t u r e about t h e t h e r a p e u t i c r e l a t i o n s h i p r e v e a l s t h a t t h e r a p i s t s d i s a g r e e about t h e importance  of the relationship,  demonstrates  so t o o t h e l i t e r a t u r e  t h a t t h e r a p i s t s do n o t a g r e e  on a s i n g l e  d e f i n i t i o n f o r a t h e r a p e u t i c boundary. I n f a c t ,  t h e term  t h e r a p e u t i c boundary r e f e r s t o t h r e e n o t i o n s , namely: t h e d i v i s i o n between t h e p r o f e s s i o n a l and p e r s o n a l b e h a v i o r s o f  66  the  therapist, the a c c e p t a b i l i t y of therapeutic  interventions,  and the s t r u c t u r a l elements o f t h e  t h e r a p e u t i c r e l a t i o n s h i p . How d i d t h i s c o n f u s i o n S i m i l a r t o the term t h e r a p e u t i c  happen?  r e l a t i o n s h i p , t h e term  b o u n d a r y was c o n f u s e d f r o m t h e t i m e o f i t s f i r s t a r t i c u l a t i o n by Freud  ( L i p t o n , 1977; c i t e d i n G u t h e i l a n d  G a b b a r d , 1993).' I n t h e 1 9 0 0 s , F r e u d was d e v e l o p i n g teaching be  psychoanalytic  theory.  He s t a t e d t h a t a n a l y s t s m u s t  c l e a r about t h e t h e r a p i s t ' s r o l e ,  p r o f e s s i o n a l and p e r s o n a l This  and  keeping  their  relationships absolutely  separate.  s e p a r a t i o n was t h e t h e r a p e u t i c b o u n d a r y . B u t t h e s e  i n s t r u c t i o n s c o n t r a d i c t e d h i s own b e h a v i o r .  F o r example,  when w r i t i n g , F r e u d u s e d m e t a p h o r s i n v o l v i n g t h e o p a q u e n e s s of a m i r r o r and t h e d i s p a s s i o n a t e to describe reflect  the analyst's role.  the abstinence  a n d on one r e p o r t e d  (Lipton,  d i d not He  l e n t them b o o k s , g a v e them  occasion  gave a p a t i e n t a meal  1977; c i t e d i n G u t h e i l a n d G a b b a r d , 1993) . P e r h a p s  the most s t r i k i n g personal  However h i s b e h a v i o r  a n d a n o n y m i t y t h a t he a d v o c a t e d .  sent h i s p a t i e n t s post cards, gifts,  o b j e c t i v i t y of the surgeon  i l l u s t r a t i o n of boundary c o n f u s i o n  between  a n d p r o f e s s i o n a l r e l a t i o n s h i p s was F r e u d ' s  a n a l y z i n g h i s d a u g h t e r Anna'. This discrepancy  between t h e o r y  a n d p r a c t i c e was  g e n e r a l l y v i s i b l e among p r o m i n e n t p s y c h o a n a l y s t s time.  of that  M e l a n i e K l e i n e n c o u r a g e d a p a t i e n t t o go o n h o l i d a y s  w i t h h e r and c o n t i n u e  w i t h h i s a n a l y s i s ; and W i n n i c o t t  hands w i t h a f r i g h t e n e d p a t i e n t , and ended h i s s e s s i o n s  held with  67  coffee their  and  b i s c u i t s ( G u t h i e l and  f o l l o w e r s had  therapeutic  an u n c l e a r  similar  still  among most a n a l y s t s ,  the  the  not  few  considered  literature reveals  many  examples.  Unlike  these analysts,  about the d i v i s i o n , and  understanding of  boundary. A l t h o u g h I have used o n l y a  examples of b e h a v i o r s t h a t are acceptable  G a b b a r d , 1993) . H e n c e ,  personal  the  s t u d y n u r s e s were c l e a r  the boundary, between t h e i r  professional  r e l a t i o n s h i p s . Lynne e x p r e s s e d i t t h i s  way:  I f s h e ' s g o n n a come and s e e me, I d o n ' t w a n t h e r t o even t h i n k t h a t I w o u l d c r o s s t h a t b o u n d a r y l i n e . . . . I w a n t t o be r e a l l y c l e a r and I s a y t h i s i s who I am; t h i s i s what I do; t h i s i s w h a t I do n o t d o . . . . I d e f i n e m y s e l f r e a l l y c l e a r l y ... I p u t up my own b o u n d a r i e s and I l e t h e r know who I am ... and my h o p e i s t h a t t h e r e ' s a sense, o f s a f e t y b u i l t i n . A l i c e and  C a t h y b o t h r e c a l l e d t h a t t h e y had  their clients'  i n v i t a t i o n s t o go  out  behavior they kept t h e i r personal  always  for coffee,  and  declined  and  professional  by  this  roles  separated. The  t e r m b o u n d a r y . c a n a l s o be  therapeutic  i n t e r v e n t i o n s . Orthodox a n a l y s t s  only acceptable that a l l other (Eissler,  u s e d when r e f e r r i n g t o  1953;  i n t e r v e n t i o n i s an  claim that  i n t e r p r e t a t i o n , arguing  comments o r a c t i o n s a r e  unacceptable  c i t e d i n G u t h e i l & Gabbard, 1993).  claim that a l l other  the  interventions cross  the boundary  of  acceptable  a n a l y t i c technique.  acceptable  i n t e r v e n t i o n s cause problems f o r l e s s orthodox  p s y c h o a n a l y s t s and e f f e c t i v e l y use  This very  They  l i m i t e d range  f o r t h e r a p i s t s from other m o d a l i t i e s  i n t e r v e n t i o n s s u c h as  clarification,  of  who  68  confrontation,  a d v i c e and p r a i s e ,  ( G u t h e i l and Gabbard, Like  s u g g e s t i o n and a f f i r m a t i o n  1993).  other psychotherapists,  the study nurses used a  v a r i e t y of interventions  with  not  these nurses d i d not view  t r a i n e d as a n a l y s t s ,  i n t e r p r e t a t i o n as t h e o n l y they consider  their clients.  S i n c e t h e y were  acceptable intervention,  their active interventions  nord i d  unacceptable or  v i o l a t i o n of boundary. Finally, or  boundary i s used i n r e l a t i o n t o the s t r u c t u r e ,  the r u l e s , of the therapeutic  r e l a t i o n s h i p . I t can r e f e r  t o a f i g u r a t i v e membrane, o r f r a m e , w h i c h s u r r o u n d s t h e therapeutic  r e l a t i o n s h i p . In that  sense boundary r e f e r s t o  all  t h e s t r u c t u r a l elements of t h e r e l a t i o n s h i p and  the  following:  therapists' r o l e , the scheduling  appointments, length office  of sessions,  appointments  of  arrangements f o r fees,  s e t t i n g , g i f t s and s e r v i c e s ,  disclosure, physical contact,  includes  language,  and r u l e s  self-  f o r emergency  ( G u t h e i l a n d G a b b a r d , 1 9 9 3 ; Herman, 1 9 9 2 ;  Simon, 1989). A l i c e p r o v i d e d an e x c e l l e n t  example o f  " s e t t i n g t h e frame" w h i c h I p r e s e n t l a t e r i n t h e d i s c u s s i o n . Herman  (1992) r e f e r s t o t h i s f r a m e a s a t h e r a p y  contract.  I n summary, t h e r e i s no s i n g l e d e f i n i t i o n f o r a t h e r a p y b o u n d a r y . A b o u n d a r y may r e f e r t o a n y o f t h e f o l l o w i n g : t h e boundary and  ( d i v i s i o n ) between t h e b e h a v i o r s o f p r o f e s s i o n a l  p e r s o n a l r e l a t i o n s h i p s , the boundary  structure  or the rules of the therapeutic  (frame) a r o u n d t h e r e l a t i o n s h i p , and  the boundary between a c c e p t a b l e and u n a c c e p t a b l e  69  interventions.  I do n o t i n c l u d e t h i s  l a t t e r way o f d e f i n i n g  b o u n d a r y i n my d i s c u s s i o n s i n c e i t a p p l i e s t o a n a l y s t s a n d the study nurses are not t r a i n e d a n a l y s t s . r o l e boundaries  S t r u c t u r a l and  of the therapeutic r e l a t i o n s h i p ,  however,  are r e l e v a n t to the study nurses' d i s c l o s u r e experiences, and  I now e x p l o r e t h e s e more Boundaries  exist  fully.  f o r the p r o t e c t i o n of both the  t h e r a p i s t and t h e c l i e n t . W i t h i n t h e t h e r a p e u t i c r e l a t i o n s h i p , boundaries unacceptable relationship. and  d e l i n e a t e what i s a c c e p t a b l e and  f o r therapist,  client,  and t h e t h e r a p e u t i c  Clear boundaries provide safety f o r the c l i e n t  t h e t h e r a p i s t . The t h e r a p i s t i s r e s p o n s i b l e f o r m a k i n g  these boundaries  c l e a r and e x p l i c i t .  When F o c u s i n g o n S e l f  and A n a l y z i n g Thoughts, s t u d y n u r s e s c o n s i d e r e d t h e p r i n c i p l e s of psychotherapy,  and t h e n o t i o n o f t h e r a p e u t i c  boundaries. Analyzing.Boundaries i s the process of knowing and d e m o n s t r a t i n g  acceptable therapist behavior.  A n a l y z i n g B o u n d a r i e s was p a r t o f A l i c e ' s e x p e r i e n c e , when s h e was F o c u s i n g o n S e l f . ensuring her c l i e n t ' s  disclosure  She t h o u g h t  s a f e t y , and she s t a r t e d by  about  setting  c l e a r s t r u c t u r a l boundaries. Noting that the intake data r e v e a l e d t h a t h e r c l i e n t had had d i f f i c u l t i e s  with  boundaries w i t h previous professionals, A l i c e  talked  e s t a b l i s h i n g therapeutic boundaries  this  about  way:  I h a d t o s e t r e a l l y , r e a l l y c l e a r l i m i t s . ... I h a d t o s e t a r e a l l y c l e a r t r e a t m e n t f r a m e [ b o u n d a r y ] . On t h e f i r s t i n t e r v i e w f o l l o w i n g t h e i n i t i a l a s s e s s m e n t , he was g i v e n b a s i c a l l y a f r a m e f o r how we w e r e g o i n g t o d e a l w i t h h i s t r e a t m e n t . . . . I am a n u r s e , a n d I am h e r e  70 t o p r o v i d e s u p p o r t and I w o u l d be v e r y s p e c i f i c i n what ways I w o u l d do t h a t . . . . I g i v e a v e r y c o n c r e t e p r e s e n t a t i o n . . . . I would say t h a t I w i l l see you f o r s u p p o r t i v e s e s s i o n s i n t h e o f f i c e f o r s p e c i f i c amounts o f t i m e , o n s p e c i f i c d a t e s , o n c e a week, f o r h a l f a n h o u r . . . . The o t h e r p e r s o n i n v o l v e d i n y o u r c a r e i s t h e p s y c h i a t r i s t who i s h e r e o n a c o n s u l t i n g b a s i s f o r s u c h c o n c e r n s a s m e d i c a t i o n . . . . I made i t r e a l l y c l e a r how t h e two p e o p l e w o r k t o g e t h e r . . . . A n d t h e c l i e n t h a s t o agree t o t h a t p l a n . The  l i t e r a t u r e supports A l i c e ' s understanding  about  boundaries. Careful a t t e n t i o n t o boundaries provides protection  (Herman, 1 9 9 2 ) .  w i t h i n these boundaries,  When b o t h p a r t i e s a g r e e  a safe arena  client  t o work  f o r t h e work o f  t h e r a p y i s c o n s t r u c t e d ( G u t h e i l a n d G a b b a r d , 1 9 9 3 ; Herman, 1992;  Simon,  1991).  A n a l y z i n g Boundaries  was a l s o p a r t o f L y n n e ' s  d i s c l o s u r e e x p e r i e n c e and t h e process o f A n a l y z i n g Thoughts. When r o l e b o u n d a r i e s  are clear,  t a l k e d a b o u t how s h e s o u g h t  c l i e n t s a r e p r o t e c t e d . Lynne  to protect her c l i e n t by  c r e a t i n g a c l e a r r o l e b o u n d a r y t h i s way: " I d e f i n e m y s e l f really clearly....  I p u t u p my own b o u n d a r i e s  and I l e t h e r  know who I am ... a n d my hope i s t h a t t h e r e ' s a s e n s e o f safety built  i n . " Herman (1992) s u p p o r t s L y n n e ' s  actions;  c l e a r r o l e b o u n d a r i e s p r o v i d e a s a f e arena f o r t h e work o f therapy. Role boundaries the t h r e e uses  a r e perhaps  of boundaries  cited  t h e most i m p o r t a n t o f ( G u t h e i l and Gabbard,  1993). Boundaries  exist  to protect clients  from  therapists'  e x p l o i t i n g them f o r t h e i r own b e n e f i t . A n a l y z i n g was  Boundaries  p a r t o f L y n n e ' s d i s c l o s u r e e x p e r i e n c e when F o c u s i n g o n  Self.  She was v e r y c l e a r t h a t s h e was i n t h e s e s s i o n o n l y  71  f o r h e r c l i e n t ' s b e n e f i t . When h e r c l i e n t d i s c l o s e d and  sexual  and  f e e l i n g s t o h e r s e l f . She r e v e a l e d  threats  abuse by a p s y c h i a t r i s t , Lynne k e p t h e r t h o u g h t s the following:  I t h o u g h t t h a t f u c k i n g b a s t a r d , I hope h e g e t s i t someday! ... b u t I d o n ' t l e t my f u r y show. I t h i n k I'm s u p p o r t i v e t o h e r a n d I s a y y o u know w h a t h e d i d w a s n ' t O.K. ... I d o n ' t t h i n k i t ' s my p l a c e t o l e t my f e e l i n g s r e a l l y be a l l o v e r t h e p l a c e , as sometimes t h e y ' r e f e e l i n g i n s i d e . I don't t h i n k t h a t ' s a p p r o p r i a t e . She's n o t c o m i n g t o t h e s e s s i o n t o w a t c h me do my w o r k , s o I do i t away f r o m h e r t i m e . I t h i n k my c l i e n t s g e t a v e r y , v e r y c l e a r message a b o u t b o u n d a r i e s f r o m me. The' l i t e r a t u r e boundaries. Freud abstinence, clients  s u p p o r t s Lynne's i n t e r p r e t a t i o n o f  ( c i t e d Simon, 1 9 9 1 ) , i n h i s p r i n c i p l e o f  s t a t e d t h a t t h e r a p i s t s must a b s t a i n  f o r t h e i r own p e r s o n a l  therapeutic  interventions  a r e made f o r t h e b e n e f i t o f derive  gratification  from p a r t i c i p a t i n g i n the p s y c h o t h e r a p e u t i c process and  the p s y c h o l o g i c a l  growth o f t h e i r c l i e n t s  S i m o n , 1 9 9 1 ) . Good t h e r a p e u t i c boundaries help  client.  influence  (Herman, 1 9 9 2 ;  interventions  and c l e a r  preserve therapist n e u t r a l i t y , which  ensures that treatment i n t e r v e n t i o n s the  using  gratification. A l l  c l i e n t s and t h e i r treatment. T h e r a p i s t s only  from  The p e r s o n a l  then  a r e made o n b e h a l f o f  needs o f t h e t h e r a p i s t s h o u l d n o t  t h e t r e a t m e n t s i t u a t i o n . The t h e r a p i s t ' s  only  material  r e w a r d o r s a t i s f a c t i o n i s payment f o r t h e r a p e u t i c  services  (Simon,  1991).  A l l boundaries w i t h i n the therapeutic be  crossed  or v i o l a t e d but a l l crossings  If  the intervention benefits  boundary c r o s s i n g ;  the c l i e n t  r e l a t i o n s h i p can  are notv i o l a t i o n s . i t i s deemed a  i f i t harms t h e c l i e n t  i t i s deemed a  72  boundary v i o l a t i o n However, B r o w n important  ( G u t h e i l a n d G a b b a r d , 1 9 9 3 ; S i m o n , 1991) .  (1994) c l a i m s t h a t a l t h o u g h t h e c l i e n t i s a n  s o u r c e o f a u t h o r i t y on w h e t h e r i t i s a b o u n d a r y  crossing or violation,  many c l i e n t s h a v e  repeated boundary v i o l a t i o n s  i n the context o f therapy and  as a consequence have d i f f i c u l t y boundaries. final  Brown  identifying  their  own  (1994) b e l i e v e s t h a t t h e r a p i s t s c a r r y t h e  responsibility  i n identifying  When A n a l y z i n g B o u n d a r i e s clear  experienced  understanding  boundary  violations.  the study nurses  of boundaries,  showed a  and they used  this  u n d e r s t a n d i n g when e v a l u a t i n g b o u n d a r y v i o l a t i o n s . very clear  Cathy  was  about t h e boundary between p e r s o n a l and  p r o f e s s i o n a l b e h a v i o r , and A n a l y z i n g Boundaries p a r t o f h e r d i s c l o s u r e e x p e r i e n c e . She e x p r e s s e d  was a m a j o r i t this  way: My c l i e n t was i n l o v e w i t h h i m ( h e r f o r m e r p s y c h i a t r i s t ) . . . . She was d r a w n t o h i m l i k e a m a g n e t . . . and she w o u l d s e e t h i s p e r s o n and d e s c r i b e i t as t h e b e s t t i m e s h e ' d e v e r h a d i n h e r l i f e , a n d i t was w o n d e r f u l ... t h e h o u r s t h e y s p e n t t o g e t h e r was t h e m o s t r e w a r d i n g t i m e s h e h a d e v e r e x p e r i e n c e d . . . . He made h e r f e e l w o n d e r f u l ... s h e was t o t a l l y f o c u s e d o n h i m . . . . She w o u l d phone h i m a t h i s o f f i c e o r home, a n d she w o u l d go down t o h i s o f f i c e ... d r o p p i n g i n t o h i s a p a r t m e n t ... I d i d n ' t g e t t h e i m p r e s s i o n t h a t h e was p h o n i n g h e r o r a s k i n g h e r o u t ... he j u s t seemed t o go a l o n g w i t h i t . . . . T h i s went o n f o r s o l o n g a n d I c o u l d n ' t s t o p i t ... I f e l t f r u s t r a t e d ... t o t a l l y impotent. The  l i t e r a t u r e ascribes the role  of boundary keeping t o  the t h e r a p i s t and i n s t r u c t s  t h e r a p i s t s t o manage  countertransference issues.  Indulging i n sexual  their behavior  w i t h a c l i e n t i s a c o u n t e r t r a n s f e r e n c e i s s u e (Simon,  1991).  73  Countertransference is  f o r the  client.  i s f o r the  I t r e f e r s to a l l the  a t t i t u d e s about the c l i e n t (Kahn, 1 9 9 1 ) . F r e u d  t h a t occur i n the  therapist  warned t h a t  therapist's personal  not  offending  in  a love  because  of  charm.  Cathy t a l k e d about the dangers to b o t h her the  and  t h a t when a p a t i e n t f a l l s  i s b e c a u s e o f t h e a n a l y t i c s i t u a t i o n and  the  transference  feelings  ( c i t e d i n S i m o n , 1991)  t h e r a p i s t must r e c o g n i z e it  t h e r a p i s t what  client  and  p s y c h i a t r i s t when r o l e b o u n d a r i e s w e r e  violated: He s e t no l i m i t s . . . . T h e r e was a t o t a l l a c k o f l i m i t s e t t i n g . . . . Then when he t r i e d t o s e t some l i m i t s a n d t r i e d t o s t o p t h e phone c a l l s and v i s i t s she became d e s p o n d e n t and t h o u g h t h e r l i f e w a s n ' t w o r t h l i v i n g . . . . She t o o k o v e r d o s e s and she e v e n t h r e a t e n e d t o k i l l h i m a t one p o i n t . This  e x p e r i e n c e h a p p e n e d 15 y e a r s ago  experience,  the d i a g n o s i s  but  not  been a s s i g n e d  h e r b e h a v i o r s s u g g e s t i t now.  states that therapists experience great setting  l i m i t s and  holding  my  of b o r d e r l i n e p e r s o n a l i t y  r a r e l y u s e d . C a t h y ' s c l i e n t had diagnosis  when, i n  The  was  that literature  difficulty  in  firm, boundaries f o r f e a r of  p a t i e n t ' s v o l c a n i c response to being  thwarted or  A patient with a borderline disorder  is particularly  to vengeful  expressions  1 9 9 2 ) . Simon disorders, and  of rage  (1991) c l a i m s  ( G u t h e i l , 1989;  that patients with  t h e r a p i s t out  of the  confronted. prone  Herman, borderline  i n p a r t i c u l a r , ' f r e q u e n t l y attempt to  draw the  the  manipulate  treatment r o l e .  They  attempt to evoke boundary v i o l a t i o n s i n c l u d i n g s e x u a l  may acting  74  out  by the t h e r a p i s t  therapists are s t i l l not  ( G u t h e i l , 1989). responsible  Nonetheless,  f o r t h e i r b e h a v i o r a n d must  a c t o u t ( G u t h e i l , 1 9 8 9 ; Herman, 1 9 9 2 ) . ' Boundaries e x i s t f o r t h e b e n e f i t and p r o t e c t i o n o f  t h e r a p i s t s as w e l l and A l i c e t a l k e d about t h e p r o t e c t i o n o f the  t h e r a p i s t i n t h i s way: This c l i e n t had a b l u r r e d n o t i o n about a p p r o p r i a t e r o l e b e h a v i o r . . . . He h a d d i f f i c u l t i e s w i t h w o r k i n g w i t h p e o p l e who w e r e h i s c a r e g i v e r s a s j u s t c a r e g i v e r s . . . . He w o u l d g e t i n v o l v e d i n f r i e n d s h i p s , o u t o f o f f i c e k i n d s o f r e l a t i o n s h i p s a n d s o f o r t h . . . . He h a s a h i s t o r y of b o r d e r l i n e p e r s o n a l i t y d i s o r d e r and o f m i s i n t e r p r e t i n g b e h a v i o r s o f c a r e g i v e r s . . . . He s a i d t h a t h i s GP v i s i t e d a t home a n d a t a r e s t a u r a n t ... w h i c h when y o u l o o k a t i t i n c o n t e x t may n o t b e u n u s u a l , b e c a u s e t h e GP was t r e a t i n g h i s p a r t n e r who was d y i n g a t home f r o m A I D S . ... . When h i s p a r t n e r d i e d t h e GP g a v e h i m a h u g . . . . B u t I t h i n k t h e GP was n o t r e a l l y , r e a l l y c l e a r about h i s p r o f e s s i o n a l b o u n d a r i e s . . . . Anyway t h e c l i e n t s a i d h e was h a v i n g a s e x u a l r e l a t i o n s h i p w i t h h i s GP.... L a t e r when we c o n f r o n t e d h i m h e s a i d t h a t h e h a d l i e d ... t h a t t h e GP h a d o n l y h u g g e d h i m . . . . The c l i e n t may h a v e m i s i n t e r p r e t e d w h a t was h a p p e n i n g o r h e may n o t h a v e . Lack o f absolute  false accusations, disorders  c l a r i t y about boundaries c a n . l e a d  and persons w i t h b o r d e r l i n e  personality  c o n s t i t u t e t h e m a j o r i t y o f t h o s e p a t i e n t s who  f a l s e l y accuse t h e r a p i s t s o f sexual  involvement  (Gutheil,  1989). Persons w i t h a b o r d e r l i n e p e r s o n a l i t y d i s o r d e r to l o s e t h e boundary between s e l f and o t h e r under s t r e s s Gutheil  to  ( G u t h e i l , 1989). T h i s boundary  (1989) c l a i m s ,  i s a feature of this  tend  when t h e y a r e confusion, disorder.  A l t h o u g h i t i s beyond t h e scope o f t h i s paper t o d e s c r i b e the psychodynamics o f b o r d e r l i n e p e r s o n a l i t y , g i v e n t h e s u s c e p t i b i l i t y o f these p a t i e n t s t o boundary  confusion,  75  t h e r a p i s t s must be scrupulous, even o v e r s c r u p u l o u s , a t t e n t i o n t o c l e a r boundaries  i n their  and t o the p r e s e r v a t i o n of the  p r o f e s s i o n a l nature of the r e l a t i o n s h i p  ( G u t h e i l , 1989;  Simon, 1991). Boundaries  a r e an important  feature of therapeutic  r e l a t i o n s h i p s and these nurses' d i s c l o s u r e e x p e r i e n c e s . When they a r e c l e a r l y and e x p l i c i t l y d e f i n e d , they c r e a t e s a f e t y f o r both t h e r a p i s t s and c l i e n t s . C l i e n t s w i t h diagnoses o f b o r d e r l i n e p e r s o n a l i t y d i s o r d e r , due t o the nature of. the dynamics of t h i s d i s o r d e r , experience the most t r o u b l e s t a y i n g w i t h i n boundaries.  T h e r a p i s t s must take boundary  d e l i n e a t i o n s v e r y s e r i o u s l y . When the study nurses were A n a l y z i n g Boundaries, boundaries  they demonstrated an understanding of  which was c l e a r not o n l y t o them, but i s  supported by l i t e r a t u r e . As they c o n t i n u e d F o c u s i n g on S e l f , they were a l s o A n a l y z i n g Power, the second  modifying-concept  of the C y c l e of Focusing. D i s c u s s i o n o f A n a l y z i n g Power Another means the p a r t i c i p a n t s used when F o c u s i n g on S e l f and A n a l y z i n g Thoughts i n the C y c l e of F o c u s i n g A t t e n t i o n was A n a l y z i n g Power. Power i s a l s o an aspect of the t h e r a p e u t i c r e l a t i o n s h i p and F o c u s i n g on the C l i e n t . A n a l y z i n g Power r e f e r s t o the study nurse t h i n k i n g about the n o t i o n of power.in the t h e r a p e u t i c r e l a t i o n s h i p s between h e r s e l f and c l i e n t and the o f f e n d i n g p h y s i c i a n and c l i e n t . H a r d i n e t a l . (1985) b e l i e v e :  76 Power i s a d y n a m i c , p o t e n t i a l a n d a c t u a l f o r c e t o i n f l u e n c e another to a c t , think, or f e e l i n a c e r t a i n way. I t o p e r a t e s w i t h i n t h e c o n f i n e s o f d e p e n d e n c e a n d r e l a t i o n s h i p s and i s a c t u a l i z e d t h r o u g h use o f s a n c t i o n s ( r e w a r d s a n d p u n i s h m e n t s ) , ( p . 92) B a c h a r a c h and L a w l e r  (1980) c l a i m t h a t p o w e r i s a n  i n t e r a c t i o n phenomenon; w h e r e t h e r e  i s no r e l a t i o n s h i p t h e r e  i s no p o w e r . T h e y a l s o b e l i e v e t h a t d e p e n d e n c y a n d  sanctions  a r e power's e s s e n t i a l f e a t u r e s . Dependency c a u s e s t h e need f o r exchange, and s a n c t i o n s actual manipulation  (rewards o r punishments) a r e t h e  o f what h a p p e n s t o a n o t h e r .  F r e n c h and Raven  (1960) d e f i n e p o w e r a s i n f l u e n c e a n d  i n f l u e n c e as p s y c h o l o g i c a l change. They c l a s s i f y  power  according  power,  expert  to i t s sources:  r e w a r d power, c o e r c i v e  power, l e g i t i m a t e power, r e f e r e n t power, and  i n f o r m a t i o n a l power. L e g i t i m a t e  power i s t h e r i g h t t o  i n f l u e n c e a n o t h e r b a s e d on t h e p e r c e p t i o n b y b o t h p a r t i e s t h a t t h e i n f l u e n c e e has an o b l i g a t i o n t o a c c e p t influence. and  Expert  p o w e r i s b a s e d on h a v i n g  superior  k n o w l e d g e . Reward power i s t h e a b i l i t y t o  positive sanctions. negative  sanctions  Coercive  skills  provide  power i s t h e a b i l i t y  to  apply  to another.•  The t h e r a p e u t i c  r e l a t i o n s h i p has a l l these e s s e n t i a l  e l e m e n t s o f power. I t i s a p p r o p r i a t e therapeutic  that  to turn again  to the  r e l a t i o n s h i p l i t e r a t u r e to b e t t e r understand the  n o t i o n o f power i n t h e r e l a t i o n s h i p , t h e p a r t i c i p a n t s ' d i s c l o s u r e experiences, Analyzing  and t h e m o d i f y i n g - c o n c e p t o f  Power. An h i s t o r i c a l  review  of the balance of  power i n t h e t h e r a p e u t i c r e l a t i o n s h i p i s h e l p f u l i n  77  understanding the s i g n i f i c a n t the  study nurses The n o t i o n  by  Freud,  reported. of the therapeutic  from the t r a d i t i o n a l  relationship and  i s s u e s and i n e x p l a i n i n g what  (Kahn, 1 9 9 1 ) . I n m a t t e r s o f m e d i c a l  (Nelson,  an  illness  structure  N e l s o n , Sherman, & S t r e a n ,  cure.  (physician/analyst  interpretation)  therapeutic  From t h e b e g i n n i n g ,  was  the  task  created  in•the r o l e of a u t h o r i t y ) ,  ( f r e e a s s o c i a t i o n and a power i m b a l a n c e i n f a v o r o f t h e  (Kahn, 1 9 9 1 ; N e l s o n e t al-.',  Rogers  (19 61)  relationship. illness  1968) . F r e u d  (the p a t i e n t paying f o r s e r v i c e ) , the r o l e  the therapeutic  analyst  taken  the view that the p a t i e n t ' s neurosis  t h a t he s h o u l d  definitions and  diagnosis  r o l e o f a u t h o r i t y was  c a r r i e d t h i s medical a t t i t u d e i n t o the relationship with  derived,  physician-patient  treatment, the physician's  for granted  r e l a t i o n s h i p was  envisioned  1968).  a more e q u a l b a l a n c e i n t h e  He d i d n o t r e g a r d  emotional d i f f i c u l t i e s  as an  t h a t n e e d e d t o be c u r e d , a n d he saw a d a n g e r i n  c o m p a r i n g m e d i c i n e a n d p s y c h o l o g y . He r e f u t e d  Freud's  a n a l o g y t h a t t h e r a p i s t s do t h e r a p y i n t h e same way s u r g e o n s do s u r g e r y . with t h e i r c l i e n t s  that  He b e l i e v e d t h a t t h e r a p i s t s s h o u l d (Kahn, 1 9 9 1 ) . H i s manner c r e a t e d  work  more  e q u a l i t y ; he n o t o n l y c o n v e y e d t h e m e s s a g e t h a t he was the c l i e n t ,  b u t a l s o t h a t he u n d e r s t o o d t h e c l i e n t ' s  experience.  He r e f e r r e d t o t h e p e r s o n a s a c l i e n t  with  rather  t h a n a p a t i e n t , a s w e l l he v i e w e d t h e ' c l i e n t a s a w o r t h w h i l e human b e i n g  who was s t r u g g l i n g f o r g r o w t h a n d d e v e l o p m e n t .  78  However, the e q u a l i t y that Rogers advocated  was  not  enough f o r the r a d i c a l t h e r a p i s t s of the encounter  movement  or the humanistic  these  and  f e m i n i s t t h e r a p i s t s . In f a c t  t h e r a p i s t s o b j e c t e d so s t r o n g l y to the power imbalance i n the t r a d i t i o n a l r e l a t i o n s h i p that Freud's t h e o r i e s were taught o n l y i n p s y c h o a n a l y t i c i n s t i t u t e s . In the 197 0s, p s y c h o a n a l y s i s r e t u r n e d to favor when the a n a l y s t s , G i l l  and  Kohut, c a l l e d f o r more power e q u a l i t y and urged a n a l y s t s to work w i t h the p a t i e n t (Kahn, 1991). In a d d i t i o n , o t h e r t h e r a p i s t s decided to take what was  u s e f u l i n the t h e o r i e s ,  and l e a v e behind what they determined  as s e x i s t  (Brown,  1987) . L i k e the t h e r a p i s t s i n the mid-1970s, Cathy and  Alice  attempted to work w i t h t h e i r c l i e n t s . Cathy r e p o r t e d : "I wanted to h e l p her; I l i s t e n e d and I understood emotional p a i n  her  ... but she kept on and on wanting to see  more of him.... I c o u l d do nothing." A l i c e r e c a l l e d : wanted to h e l p  ... I never r e a l l y understood  "I  what he  wanted." F e m i n i s t t h e o r i s t s and t h e r a p i s t s examined the of power i n t h e r a p e u t i c r e l a t i o n s h i p s , evidence  balance  and searched f o r  of sexism and misogyny. They claimed t h a t  t h e r a p i s t s were o p p r e s s i v e and abused t h e i r power by l a b e l i n g , diagnosing, and p s y c h o p a t h o l o g i z i n g normative feminine g e n d e r - r o l e b e h a v i o r s . They c r i t i c i z e d t r a d i t i o n a l male-model v i s i o n s of human behavior 1987,  1990,  the (Brown,  1994), and worked towards the g o a l of an '.  79  e g a l i t a r i a n r e l a t i o n s h i p . Nonetheless,  f e m i n i s t s , who  s t e r e o t y p i c a l l y v i e w e d men a s t h e a b u s e r s o f p o w e r a n d women as  t h e i r v i c t i m s , were h o r r i f i e d t o l e a r n t h a t  some  feminist  t h e r a p i s t s w e r e s e x u a l l y e x p l o i t i n g b o t h women a n d men. B y d e f i n i t i o n f e m i n i s t t h e r a p i s t s s h a r e d power w i t h  their  c l i e n t s a n d d i d n o t abuse power e i t h e r s e x u a l l y o r a n y otherway  (Brown,  1990).  L i k e f e m i n i s t t h e r a p i s t s , Lynne Analyzing  too.considered  Power t o b e v e r y i m p o r t a n t . She s a i d i t t h i s way:  F e m i n i s m i s my u n d e r p i n n i n g s ... my t h e r a p y i s i n f o r m e d b y f e m i n i s t t h e o r y . . . . One o f t h e m a j o r t h i n g s I l o o k a t i n a t h e r a p y s e s s i o n i s power, a n d t h e u s e a n d abuse o f p o w e r , a n d how t h e s y s t e m h a s t r e a t e d women.... I u s e p o w e r w i s e l y ... I'm r e a l l y c o n s c i o u s o f t r y i n g n o t t o do a p o w e r t r i p o n them. I n summary, t h e r e relationship. someone w i t h  i s u n e q u a l power i n t h e t h e r a p e u t i c  The t h e r a p i s t i s t y p i c a l l y u n d e r s t o o d a s special expertise,  dependent, and r e l i a n t feminist all  equal.  (Gabor, 1 9 8 9 ) . H u m a n i s t i c a n d  theorists aspire  a s p e c t s o f power  and t h e c l i e n t as t r u s t i n g ,  to therapeutic  r e l a t i o n s h i p s where  (status, a u t h o r i t y , and r o l e s ) a r e  However, F r e n c h a n d R a v e n  (1960) h a v e i d e n t i f i e d  five  s o u r c e s o f p o w e r : c l i e n t s p o t e n t i a l l y h a v e two s o u r c e s (reward and c o e r c i v e sources  power), and t h e r a p i s t s have  (legitimate, expert,  five  reward, c o e r c i v e , and  informational). H a v i n g r e v i e w e d t h e h i s t o r i c a l h i g h l i g h t s o f power i n the  therapeutic  nurses reported  r e l a t i o n s h i p , I t u r n now t o w h a t t h e s t u d y when t h e y w e r e A n a l y z i n g  Power i n t h e C y c l e  80  of Focusing.  As my  previous  t h e r a p i s t s agree t h a t the  d i s c u s s i o n has  therapeutic  shown, m o s t  relationship is  p r i m a r y f a c t o r i n i n f l u e n c i n g c l i e n t h e a l i n g and Therapists  are  s e e n as h a v i n g  and  the  the  l e g i t i m a t e r o l e of h e a l e r .  as  literature  supports  the  behavior.  more p o w e r t h a n t h e  client,  the view t h a t t h e r a p i s t s have The  c l i e n t ' s p o s i t i o n i s seen  powerless. When s t u d y  n u r s e s were A n a l y z i n g  a b o u t t h e n o t i o n of power i n the b e t w e e n t h e m s e l v e s and physicians  and  emphatically  clients.  Power t h e y  thought  therapeutic relationship  their clients,  and  the  offending  Lynne spoke most c l e a r l y  about h e r use  of power t h i s  and  way:  I t ' s n o t my j o b t o make p e o p l e do t h i n g s . My j o b i s t o be t h e r e s o r t o f as a g u i d e , as a l i s t e n e r , as a s u p p o r t p e r s o n as t h i s p e r s o n i s on t h e i r journey.... So i t ' s n o t f o r me t o , t o t a k e t h e b a s t a r d t o c o u r t , y o u know, c a l l t h e C o l l e g e , i t ' s n o t w h a t I d o . . . . I c e r t a i n l y i n f o r m p e o p l e what t h e i r r i g h t s a r e . . . . . As a t h e r a p i s t i n t h i s s o c i e t y , I h a v e a l o t o f p o w e r ... c l i e n t s a r e v u l n e r a b l e . . . . I use i t w i s e l y . . . . I t r y t o do s t u f f t h a t ' s e m p o w e r i n g , o r t r y t o g e t them t o do s o m e t h i n g t h a t w i l l empower t h e m s e l v e s . Lynne's views are  s i m i l a r to the  e t h i c s w h i c h "acknowledges the ...  [and  i n h e r e n t power  instructs] therapists i n using  b e n e f i t of the c l i e n t ,  not  to take  r i g h t f u l l y belongs to the c l i e n t " Lynne u s e d h e r power t o g i v e h e r reported  f e m i n i s t code  i t this  of  differentials  i t [power] f o r  the  c o n t r o l of power w h i c h (Brown, 1987,  p.  c l i e n t p o w e r , and  39). she  way:  I a s k a w h o l e l o t o f q u e s t i o n s , and t h e n a s k i n g h e r w h e t h e r she w a n t e d t o do ... a n y t h i n g a b o u t i t [ r e p o r t t h e o f f e n d e r ] , I t h i n k I was e m p o w e r i n g , r a t h e r t h a n me s a y i n g , "I'm g o i n g t o do s o m e t h i n g a b o u t i t . " She s a i d  81  t h a t s h e d i d n ' t w a n t t o do a n y t h i n g [and] I t o t a l l y r e s p e c t h e r . . . . We s t a r t e d t a l k i n g a b o u t o t h e r t h i n g s ; she was q u i t e s u i c i d a l a t t h a t p o i n t . By  informing  h e r c l i e n t of h e r r i g h t t o r e p o r t and by  r e s p e c t i n g h e r answer, Lynne e q u a l i z e d t h e power between h e r s e l f and h e r c l i e n t . A l i c e and Cathy had v e r y d i f f e r e n t e x p e r i e n c e s Analyzing experience  of  Power, f r o m L y n n e . C a t h y t a l k e d a b o u t h e r t h i s way:  I was c l e a r i n my m i n d t h a t s e x w i t h a p s y c h i a t r i s t i s n e v e r OK.... I was f r u s t r a t e d i n t r y i n g t o w o r k w i t h t h i s p e r s o n . . . . She was d e t e r m i n e d t o s e e h i m . . . . B u t t h i n k i n g b a c k , I f e l t k i n d o f u s e d a t t i m e s a s I was a route f o r h e r t o get t o see t h i s other doctor [ c o n s u l t i n g p s y c h i a t r i s t ] a t o u r o f f i c e . She w o u l d p h o n e a n d s h e ' d o n l y want t o s p e a k t o h i m , s h e w o u l d n ' t s p e a k t o me l o t s o f t i m e s . . . . S h e ' d f i r e me ... i f s h e c o u l d n ' t speak w i t h D o c t o r So-and-so, she'd g e t so a n g r y a n d h a n g up ... a n d s h e ' d j u s t a p p e a r i n t h e o f f i c e d e m a n d i n g t o s e e h i m . . . . I t r i e d t o s e t some l i m i t s w i t h h e r . . . . [Then] I t h o u g h t t h a t i f t h a t ' s w h a t s h e w a n t s t o do t h e r e ' s n o t much I c a n do t o p r e v e n t i t . But u s u a l l y t h e s e o u t b u r s t s were s o r t o f f o l l o w e d by a l o t o f remorse on h e r p a r t and she w o u l d p h o n e a n d t e l l me how much I h a d h e l p e d . Manipulation, I think i t ' s called. Clearly, being  C a t h y was e x p r e s s i n g  f e e l i n g s of f r u s t r a t i o n a t  manipulated by her c l i e n t ,  exploiting her patient  who i n C a t h y ' s o p i n i o n ,  was  role.  A l i c e r e c a l l e d Analyzing  Power t h i s way:  The c l i e n t was i n f o r m e d [ a b o u t ] how we w o u l d d e a l w i t h t h i s i s s u e [ a l l e g e d s e x u a l . a b u s e ] . . . . We t o l d h i m we h a d t o a c t o n h i s i n f o r m a t i o n . . . . He a g r e e d t o c h a n g e p h y s i c i a n s . . . . The c o n s u l t i n g p s y c h i a t r i s t was g o i n g t o c o n t a c t h i s [ t h e c l i e n t ' s ] d o c t o r . . . . A t t h a t p o i n t he f o u n d a new d o c t o r ; he became v i s i b l y u p s e t b y t h i s . . . . I n a n o t h e r s e s s i o n he came i n a n d s a i d t h a t h e was a c t u a l l y e m b e l l i s h i n g , he was l y i n g , a n d t h a t t h e r e was no s e x u a l r e l a t i o n s h i p ; . . . t h e r e w e r e l u n c h e s , a n d t h e r e was h u g g i n g . He d i d n ' t s e e t h i s a s a d i f f i c u l t y . . . . We s t i l l d i d . . . . He d i d n ' t w a n t u s t o make a n i s s u e o f i t , he s a i d he was s o r r y he h a d s a i d  82  a n y t h i n g . And t h e n t h e r e was a n o t h e r c r i s i s ; . . . he d r o p p e d o u t o f t r e a t m e n t . . . . I t seems so u n f i n i s h e d . . . . I f e l t an u r g e n c y t o do s o m e t h i n g . . . . We p u t i t i n t h e c l i e n t ' s l a p , g a v e him t h e r e s p o n s i b i l i t y ... [and] he declined.... It's unfinished. B o t h C a t h y and and  their  Alice  c l i e n t s , by  w e r e d e p e n d e n t and effect  virtue  change. K i p n i s '  power of  the  l e g i t i m a t e and of  (1974) m o d e l o f  seven s t e p s of  understand t h i s s i t u a t i o n .  s t e p s i n c l u d e the  therapists,  t h e i r n e e d t o be  a p p r o p r i a t e b e h a v i o r by (b)  clients  legitimate role sanctions;  (d)  consumers, the  to  therapists' law,  In  the  (g)  t h i s model, the  behaviors are  t h e i r peers;  resisting  and  support;  therapists'  (Kipnis,  l e g i t i m a t e power of  by  (c)  therapists'  rewards and/or by  therapists  as  persuasion,  (f) c l i e n t s  respond by  rejection.  o n l y s o u r c e of power i s 1 9 7 4 ) . When C a t h y ' s  and  nullified  t h e i r n u r s e s . These c l i e n t s not  a l o n g w i t h C a t h y ' s and  p r o m o t i n g s u g g e s t i o n s , but t h r e a t s of p h y s i c a l  (a)  esteem i s enhanced  l e s s e n e d by client's  the  inhibited  (e)  model  influence  c l i e n t s u s e d t h e i r c o e r c i v e power, t h e y  r e f u s e d t o go  and  resist;  through such e f f o r t s  c o m p l i a n c e , and  complying or Alice's  and  reward, c o e r c i o n ,  i n f l u e n c e ; and,  client  comply or  power  following:  c l i e n t s , s t r i v e to  can  could  this  satisfied  e n a b l e s them t o d i s t r i b u t e  influence clients threat,  In  t h e r a p i s t i s traced throughout  m o t i v a t e d by  position,  neither study nurse  t h e r a p e u t i c p r o c e s s . The  clients;  e x p e r t power,  their help-seeking  v u l n e r a b l e . But  i n t h e r a p y h e l p s us the  had  Alice's  health  they responded w i t h v e r b a l  violence.  only  abuse  83  Finally,  the study nurses  r e p o r t e d A n a l y z i n g Power i n  the o f f e n d i n g p h y s i c i a n - c l i e n t r e l a t i o n s h i p .  They a l l t a l k e d  a b o u t t h e o f f e n d e r a b u s i n g p o w e r i n t h e phenomenon o f client-therapist a position, fragile,  sex. Cathy s a i d :  "He  [ t h e o f f e n d e r ] was  a p o s i t i o n o f p o w e r , t h a t she was  d e p e n d e n t and,  uh,  a  in  very  d i s t r a u g h t y o u n g woman, t h a t  r e a l l y d i d take advantage of the s i t u a t i o n . " t o b e i n g v e r y a n g r y when she r e c a l l e d h e r  Lynne  he  admitted  client's  situation: He t h r e a t e n e d h e r .... t o h a v e s e x w i t h h i m ... w e e k l y . . . . She was t e r r i f i e d t h a t i f she d i d n ' t go a l o n g w i t h him, he w o u l d l o c k h e r away i n [a p s y c h i a t r i c h o s p i t a l ] , w h i c h i s w h a t he t h r e a t e n e d t o do. So s l e a z y . I t ' s j u s t e x p l o . i t a t i v e . I t ' s t o t a l e x p l o i t a t i o n . Sexual e x p l o i t a t i o n of a v u l n e r a b l e p e r s o n . E v e r y o n e who comes f o r t h e r a p y i s v u l n e r a b l e . . . . He knew who t o c h o o s e ; t h e y a l l do, t h e y know w h a t t h e y ' r e d o i n g , t h e y know how t o g e t them t o do w h a t t h e y w a n t them t o do. T h e y ' r e v e r y p o w e r f u l . . . . They d o n ' t p i c k p o w e r f u l p e o p l e t h e y p i c k v e r y v u l n e r a b l e p e o p l e ... i n s e c u r e p e o p l e . . . who d o n ' t t r u s t t h e i r own e x p e r i e n c e . . . . And t h e p s y c h i a t r i s t s , w i t h a l l t h e power t h e y have i n our s o c i e t y , j u s t . r e a l l y abuse i t . Summary Lynne's 'statement experience:  her outrage  t h e r a p i s t sex p r e s e n t s  says and  so much a b o u t t h e d i s c l o s u r e anger, the d i f f i c u l t i e s  t o t h e subsequent c o u n s e l l o r , and i t  h i n t s a t t h e dilemma- i n t o w h i c h ' she the best  client-  i s thrust, wanting  f o r h e r c l i e n t as w e l l as t o r i g h t p a s t  but  t h i s .study o f t h e n u r s e s '  do  and  p o s s i b l e f u t u r e wrongs. Such i s s u e s n o t o n l y p r o v o k e d beginning  to  my  d i s c l o s u r e experiences,  a l s o arose d i r e c t l y from t h e • t e x t u a l d a t a p r o v i d e d  t h e t h r e e n u r s e s . A p a r a d i g m d e s c r i b i n g how  they handled  by the  84  d i s c l o s u r e e m e r g e d f o r me. F o c u s i n g A t t e n t i o n . The  This paradigm I c a l l  nine elements of t h i s C y c l e  been d i s c u s s e d i n d e t a i l . particular  i n t e r e s t and  experience. was  Boundaries  importance were found  t o be  elements i s supported  t o be  found  i n these  of  c r u c i a l because i t  a power  Power  was  differential  s i g n i f i c a n c e of  i n the l i t e r a t u r e about  therapist sexual contact. F i n a l l y ,  t o be  i n the d i s c l o s u r e  i m p o r t a n t b e c a u s e i t was  t h a t a l l o w e d t h e c l i e n t a b u s e . The  of  have  Three elements were found  a boundary v i o l a t i o n the c l i e n t experienced;  found  was  the C y c l e  F o c u s i n g on  these  clientthe  i n s t a n c e s to c o n s t i t u t e p a r t of  Client the  t h e r a p e u t i c r e l a t i o n s h i p - ( F o c u s i n g on S e l f c o n s t i t u t e s t h e o t h e r p a r t ) and essential  as s u c h ,  i n my  f o r these c l i e n t  view,  c r e a t e d the  disclosures.  environment  85  CHAPTER FOUR SUMMARY, CONCLUSIONS, IMPLICATIONS, and RECOMMENDATIONS FOR NURSING Summary and C o n c l u s i o n s The  v e r y s e r i o u s problem  of client-therapist  sexual  c o n t a c t i s d e m a n d i n g o u r a t t e n t i o n more a n d more f r e q u e n t l y , e i t h e r b e c a u s e i t i s o c c u r r i n g more o f t e n o r b e c a u s e i t i s being reported more :  client-therapist disparity  conscientiously.  I t i s known t h a t  s e x u a l abuse i s u n d e r r e p o r t e d ,  between occurrence  and t h i s  andreportage suggests  c l i e n t ' s d i s c l o s u r e presents a problem  thatthe  f o r t h e second  p r o f e s s i o n a l . A review of thel i t e r a t u r e concerning the problems experienced by nurses of and  as they r e s o l v e other  d i s c l o s u r e i n d i c a t e s that nurses  struggle with  types  ethical  r e p o r t i n g dilemmas. Y e t t h e l i t e r a t u r e does n o t a d d r e s s  the s u b j e c t i v e experience o f h e a l t h p r o f e s s i o n a l s as they are faced w i t h the d i s c l o s u r e o f c l i e n t - t h e r a p i s t c o n t a c t . T h i s s t u d y was u n d e r t a k e n  t o understand the  d i s c l o s u r e experiences o f t h r e e female h e a l t h n u r s e s whose c l i e n t s  sexual  community  mental  revealed sexual contact with a .  previous physician. In  this  study, a q u a l i t a t i v e  to understand  c a s e s t u d y m e t h o d was u s e d  t h e nurses' d i s c l o s u r e e x p e r i e n c e s . Case  study  m e t h o d i s f l e x i b l e a n d s y s t e m a t i c a n d c a n accommodate a n y methods a p p r o p r i a t e f o r c o l l e c t i n g qualitative describe,  anda n a l y z i n g data, and  methodology i s g e n e r a l l y used t o uncover,  andunderstand  a phenomenon a b o u t w h i c h  little i s  86  known. The p r i n c i p l e s o f c o n t e n t a n a l y s i s d i r e c t e d c o l l e c t i o n and i t s a n a l y s i s .  The w h o l e e n t i t i e s  data  (case  s t u d i e s ) were then compared and c o n t r a s t e d . Three female mental  h e a l t h n u r s e s , who h a d t h e  experience of c l i e n t s d i s c l o s i n g sexual contact w i t h a former p h y s i c i a n , p a r t i c i p a t e d i n t h i s nurses'  study. These  study  e x p e r i e n c e s were i n t e n s i v e l y e x p l o r e d u s i n g  u n s t r u c t u r e d i n t e r v i e w s . The a u d i o t a p e d  i n t e r v i e w s were  t r a n s c r i b e d v e r b a t i m . U s i n g c o n t e n t a n a l y s i s and  working  i n d e p e n d e n t l y of each o t h e r , a r e v i e w e r and I a n a l y z e d t h e transcriptions.  Once c o n c e p t s  were i d e n t i f i e d ,  two  p a r t i c i p a n t s were r e - i n t e r v i e w e d i n o r d e r t o c l a r i f y  and  d e e p e n my u n d e r s t a n d i n g  extended  (one p a r t i c i p a n t w e n t o n a n  h o l i d a y a n d c o u l d n o t be r e - i n t e r v i e w e d ) . The c o m p a r a t i v e ,  q u a l i t a t i v e case  study approach  proved  t o be t h e a p p r o p r i a t e c h o i c e o f method f o r e x p l o r i n g t h i s important but under-documented area of c l i n i c a l T h i s method p r o v i d e d a c c e s s t h e f o l l o w i n g means: understanding (b) i t was  t o t h e phenomenon  practice.  under study by  (a) i t f a c i l i t a t e d a n i n d e p t h  of three i n d i v i d u a l d i s c l o s u r e  experiences,  f l e x i b l e a n d s y s t e m a t i c e n o u g h t o accommodate  methods a p p r o p r i a t e f o r c o l l e c t i n g and a n a l y z i n g d a t a , it  c o u l d be u s e d i n a r e s t r i c t e d t i m e frame,  any  (c)  (d) i t u s e d t h e  r e s t r i c t e d number o f i n f o r m a n t s who w e r e a v a i l a b l e , : a n d (e) i t maximized t h e use of t h e i r s e p a r a t e and d i f f e r e n t disclosure  stories.  87  The  f i n d i n g s emerging from these  that the three nurses  case s t u d i e s i n d i c a t e d  were i n v o l v e d i n a complex, of focusing  cyclical,  cognitive,  and b e h a v i o r a l process  their  attention.  I n t h i s process,  Attention,  t h e nurse a l t e r n a t e l y f o c u s e d h e r a t t e n t i o n on  c a l l e d The C y c l e o f F o c u s i n g  the c l i e n t and on h e r s e l f , w i t h t h e g o a l o f a l l e v i a t i n g client  s u f f e r i n g . Contained  i n the Cycle of Focusing  A t t e n t i o n w e r e : two c o n c e p t s , Focusing Using  on S e l f ;  Focusing  four sub-concepts,  Collecting  Information,  I n t e r v e n t i o n s , E x p e r i e n c i n g F e e l i n g s , and A n a l y z i n g  T h o u g h t s ; a n d two m o d i f y i n g - c o n c e p t s , and  on t h e C l i e n t and  Analyzing  Analyzing  Boundaries  Power.  When t h e n u r s e was i n v o l v e d i n t h i s C y c l e , h e r a t t e n t i o n c o n t i n u a l l y a l t e r n a t e d between F o c u s i n g C l i e n t and Focusing  o n S e l f . When F o c u s i n g  on t h e C l i e n t ,  t h e n u r s e l i s t e n e d t o .her c l i e n t a n d o b s e r v e d behavior.  When s h e was F o c u s i n g  and p r o c e s s e d  on S e l f ,  on t h e  her/his  she t u r n e d  t h e i n f o r m a t i o n she r e c e i v e d w h i l e  to the c l i e n t and observing h e r / h i s behavior,  inward  listening  and she  n o t i c e d h e r personal r e a c t i o n s ( f e e l i n g s o r thoughts)  to i t .  Then, b a s e d o n t h e r e s u l t s o f h e r m e n t a l p r o c e s s i n g , t h e nurse returned t o Focusing non-verbal,  o r b e h a v i o r a l i n t e r v e n t i o n . T h i s r e f o c u s i n g on  the c l i e n t began another and  o n t h e C l i e n t a n d made a v e r b a l ,  continuous,  c y c l e . This process  was o v e r l a p p i n g  and n o t d i s c r e t e and l i n e a r as t h e  l i m i t a t i o n s o f l a n g u a g e w o u l d make i t s o u n d .  88  Focusing concepts,  o n t h e C l i e n t was c o m p r i s e d o f two s u b -  C o l l e c t i n g Information and Using I n t e r v e n t i o n s .  When F o c u s i n g  o n t h e C l i e n t t h e n u r s e was i n v o l v e d i n t h e  c o g n i t i v e process client,  of compiling data by l i s t e n i n g t o h e r  and o b s e r v i n g h e r o r h i s b e h a v i o r s  (Collecting  I n f o r m a t i o n ) , o r she used t h i s data t o i n f o r m h e r v e r b a l , non-verbal,  and/or b e h a v i o r a l response  (Using  Interventions). A f t e r Focusing t u r n i n g inward  on t h e C l i e n t ,  t o search  the nurse  reported  f o r h e r mental and emotional  r e a c t i o n s t o t h e c l i e n t ' s words o r b e h a v i o r s . Focusing  on S e l f ,  concepts,  Termed  t h i s c o n c e p t was c o m p r i s e d o f two s u b -  E x p e r i e n c i n g F e e l i n g s and A n a l y z i n g  A n a l y z i n g T h o u g h t s was t h e m e n t a l p r o c e s s t h i n k c o n c e p t u a l l y about t h e therapy  Thoughts.  the nurse used t o  i s s u e s embedded i n t h e  c l i e n t ' s d i s c l o s u r e . A n a l y z i n g Boundaries and A n a l y z i n g Power w e r e two m o d i f y i n g - c o n c e p t s they  served  of Analyzing  Thoughts;  t o i l l u m i n a t e t h e d y n a m i c s embedded i n t h e  phenomenon o f c l i e n t - t h e r a p i s t s e x u a l c o n t a c t . When A n a l y z i n g Boundaries, therapy boundaries occur;  t h e nurse thought about  crossed  which allowed c l i e n t - t h e r a p i s t sext o  when A n a l y z i n g Power, s h e t h o u g h t a b o u t t h e p o w e r  differential  t h a t a l l o w e d t h e c l i e n t a b u s e . The f i n a l s u b -  concept r e f e r s t o the nurse's responses:  a t t e n d i n g t o h e r own  Experiencing Feelings represented  emotional  the nurse's  n o t i c i n g and naming h e r i n t e r n a l p h y s i c a l s e n s a t i o n s i n response t o the c l i e n t ' s r e v e a l i n g sexual  contact.  89  The a n a l y s i s was e n h a n c e d b y t h e u s e o f b o t h i n t h e form of knowledge t h a t I brought as p a r t o f i t s f o r e - s t r u c t u r e ,  out  concepts d u r i n g  a n a l y s i s . R e l e v a n t l i t e r a t u r e was u s e d elements  to the research  and t h a t w h i c h I sought  i n o r d e r t o i l l u m i n a t e the emerging  major  literature,  to develop  three  from t h e C y c l e : F o c u s i n g on t h e C l i e n t ,  A n a l y z i n g B o u n d a r i e s , a n d A n a l y z i n g Power. The d i s c l o s u r e e x p e r i e n c e was more f u l l y e l u c i d a t e d through t h i s  nurse's  e x p l a i n e d and  discussion.  A number o f c o n c l u s i o n s e m e r g e d f r o m t h e C y c l e o f Focusing. Study nurses experienced v e r y s t r o n g f e e l i n g s of moral outrage and powerlessness a t the p h y s i c i a n s ' misuse  of  p e r s o n a l and p r o f e s s i o n a l power. F u r t h e r , t h e s e f e e l i n g s d i d not l e s s e n w i t h the passage  of time.  Despite their personal feelings,  the nurses maintained  t h e i r p r o f e s s i o n a l demeanor a n d c o n s i s t e n t l y t r e a t e d clients  their  i n v e r y c a r i n g and r e s p e c t f u l ways. They f o c u s e d  t h e i r a t t e n t i o n on t h e i r c l i e n t s a n d o n t h e i r i m p l i c i t of  alleviating client  suffering;  were d i s p l a y i n g d i f f i c u l t c o n t i n u e d t o c a r e about  E v e n when t h e i r  behaviors, the study  goal  clients  nurses  them a n d t o i n t e r v e n e i n p o t e n t i a l l y  h e l p f u l ways. C l i e n t p h y s i c a l s a f e t y ,  a s w e l l , was a p r i m a r y  concern. Study n u r s e s were i m m e d i a t e l y c e r t a i n t h a t t h e physicians'  s e x u a l b e h a v i o r was u n e t h i c a l . T h e y l a b e l l e d i t  u n e t h i c a l and/or  wrong and v o i c e d t h i s  to their  clients.  90  Study nurses revealed two  levels.  clients  t h a t t h e y were k n o w l e d g e a b l e on  They u n d e r s t o o d t h e t h e r a p e u t i c  r e l a t e d to c l i e n t - t h e r a p i s t sexual  needs o f t h e i r contact.  They  a l s o u n d e r s t o o d t h e s o c i a l a n d e t h i c a l demands o f r e p o r t i n g . Finally,  t h e d i s c l o s u r e e x p e r i e n c e was v i v i d  i n the  n u r s e s ' m i n d s , a l t h o u g h two t o f i f t e e n y e a r s h a d Study nurses had l i t t l e  intervened.  t r o u b l e c l e a r l y remembering t h e  d e t a i l s and c i r c u m s t a n c e s o f t h e a c t u a l d i s c l o s u r e , t h e b e h a v i o r s and concerns of t h e i r c l i e n t s , emotional and i n t e l l e c t u a l  o r t h e i r own  responses.  I m p l i c a t i o n s and Recommendations The  f i n d i n g s from t h i s study o f mental h e a l t h  d i s c l o s u r e e x p e r i e n c e s have i m p l i c a t i o n s f o r practice,  research,  education,  nurses'  nursing  a n d a d m i n i s t r a t i o n . The c a s e  s t u d y method e s t a b l i s h e d t h e e x i s t e n c e  o f a phenomenon, a n d  the  c o m p a r i s o n o f m u l t i p l e c a s e s showed t h a t t h e phenomenon  was  e x p e r i e n c e d b y more t h a n one n u r s e a n d was n o t ,  therefore, wholly Inductive  i d i o s y n c r a t i c ( M i l e s & Huberman,  findings illuminated i n detail  t h e dynamics o f  each p a r t i c u l a r case, b u t were n o t g e n e r a l i z a b l e population beginning  to a  ( M i l e s & Huberman, 1994) a n d c o n s t i t u t e o n l y t h e o f a d e t a i l e d d e s c r i p t i o n o f t h e phenomenon. The  d e s c r i p t i o n generated modestly contributes o f k n o w l e d g e a n d may e n h a n c e n u r s i n g education,  1994).  to nursing's  practice,  research,  and a d m i n i s t r a t i o n i n t h e f o l l o w i n g ways:  (  body  91  Practice The  f i n d i n g o f t h e c o n c e p t u a l framework which  from t h e e x a m i n a t i o n o f these d i s c l o s u r e contains the potential  emerged  experiences  f o rparticular usefulness i n  situations of c l i e n t disclosures.  I f this  conceptual  f r a m e w o r k w e r e a v a i l a b l e t o them, n u r s e s c o u l d t h e n b e a w a r e of  t h e movement a n d r h y t h m o f t h e p r o c e s s w h i c h  lies  of  them i n d e a l i n g w i t h d i s c l o s u r e . The n u r s e s '  confidence  and e f f e c t i v e n e s s w o u l d be enhanced b y t h i s  ahead  f o u n d a t i o n . The  f r a m e w o r k c o u l d b e u s e d a s a map, g u i d i n g them i n c h o o s i n g i n t e r v e n t i o n s and t h i n k i n g c o n c e p t u a l l y . I t c o u l d p o i n t t h e way t h r o u g h a n i m p o r t a n t i s s u e s o t h a t n u r s e s w o u l d n o t g e t lost  i n s u b j e c t i v i t y and outrage. I n a d d i t i o n ,  this  would  p r o v i d e r e a s s u r a n c e when t h e y a r e b e i n g i n t r o s p e c t i v e  about  their experience(s). The  f i n d i n g s t h a t d e s p i t e t h e passage o f time,  nurses had l i t t l e  study  t r o u b l e remembering t h e d e t a i l s o f t h e  disclosure experience, that the i n t e n s i t y of t h e i r  feelings  a l s o d i d n o t d i m i n i s h w i t h time, and t h a t t h e i r p e r s o n a l f e e l i n g s i n c l u d e d moral  outrage, suggest  that the nurses  found t h e d i s c l o s u r e e x p e r i e n c e complex and c h a l l e n g i n g . Therefore,  i t i s important f o r nurses  t h e i r own m e n t a l  t o take the s t a t u s of  h e a l t h v e r y s e r i o u s l y and a c t i v e l y care f o r  themselves'. Recommendation: C r i t i c a l  i n c i d e n t d e b r i e f i n g and/or  s u p e r v i s i o n w o u l d be a p p r o p r i a t e a c t i o n s .  clinical  92  Given  t h e f i n d i n g about t h e d i f f i c u l t y  practice situation, experiences  nurses  inherent i n this  involved i nd i s c l o s u r e  s h o u l d be acknowledged a n d p r a i s e d f o r  exemplary n u r s i n g  their  care.  Recommendation: I n f o r m a t i o n a b o u t t h e i r e x e m p l a r y c a r e be  disseminated  literature,  o r a l l y from person t o person,  could  i n published  and a t p r o f e s s i o n a l meetings i n c l u d i n g b r i e f i n g s  i n t h e work p l a c e . Recommendation: Q u a l i t a t i v e r e s e a r c h c o u l d b e c o n d u c t e d t o e x p l o r e how e x p e r t n u r s e s  i n t e r v e n e s u c c e s s f u l l y and  e f f e c t i v e l y w i t h c l i e n t s who d i s c l o s e s e x u a l Research The  • findings of this  study have m e a n i n g f u l  f o r n u r s i n g r e s e a r c h . The d e v e l o p m e n t o f a f r a m e w o r k , The C y c l e o f F o c u s i n g r e s e a r c h which would support, Recommendation: T h i s a d d i t i o n of data be  implications  conceptual  A t t e n t i o n , suggests  extend,  further  or refutei t .  framework c o u l d be e x t e n d e d b y t h e  from o t h e r  "cases",  o r t h e phenomenon c o u l d  e x t e n d e d u s i n g o t h e r q u a l i t a t i v e methods, s u c h as  phenomenology, Grounded Theory, o r n a t u r a l i s t Obtaining a sufficient  identify The  inquiry.  sample remains a concern,  e x p o s u r e i n t h e l i t e r a t u r e may h e l p n u r s e s and  contact.  although  t o come  forward  themselves.  f i n d i n g s t h a t time does n o t l e s s e n t h e i n t e n s i t y o f  f e e l i n g s about t h e d i s c l o s u r e and t h a t study nurses had little  t r o u b l e c l e a r l y remembering t h e d e t a i l s and  circumstances  of the d i s c l o s u r e suggest the d i s c l o s u r e had a  93  s t r o n g impact  on these n u r s e s . T h i s i n d i c a t e s t h e need f o r  further inquiry.into the aftermath of disclosure f o r the second  t h e r a p i s t . T h i s knowledge would i n c r e a s e t h e n u r s e -  t h e r a p i s t ' s s e l f - a w a r e n e s s as she works w i t h disclosure  client  situations.  Recommendation: A n e x p l o r a t o r y s t u d y d e t e r m i n i n g t h e n a t u r e of t h i s  impact  on t h e second  therapist.  I t was f o u n d t h a t t h e c a s e s t u d y was a u s e f u l m e t h o d t o s o l v e the r e s e a r c h problem sampling  concerns.  As w e l l ,  a n d t o accommodate t h e t i m e a n d i t p r o v i d e d a manageable b u t  comprehensive experience w i t h data c o l l e c t i o n , analysis,  and r e p o r t i n g t h e f i n d i n g s .  This  data  positive  e x p e r i e n c e may e n c o u r a g e s t u d e n t r e s e a r c h e r s t o p u b l i s h their  f i n d i n g s a n d do more r e s e a r c h .  Recommendation: E n c o u r a g e t h e u s e o f c a s e n u r s i n g f o r master's  s t u d y method i n  t h e s e s . Case s t u d y i s s u i t a b l e f o r t h e  b e g i n n i n g s t u d y o f r e l a t e d phenomena a n d when s a m p l e s a r e s m a l l because of e t h i c a l concerns.  T h i s method p r o v i d e s  n u r s e s w i t h a n e x c e l l e n t way o f r e f l e c t i n g o n a n d e v a l u a t i n g nurses'  practice.  Recommendation: E n c o u r a g e s t u d e n t s t o p u b l i s h f i n d i n g s o f t h e i r r e s e a r c h , a n d e s t a b l i s h means support)  to assist  (infra  structure  them i n d o i n g s o .  Education The  findings of this  implications  s t u d y have o n l y  indirect  f o r n u r s i n g e d u c a t i o n . These f i n d i n g s  apply  e q u a l l y t o t h e t r a i n i n g p r o g r a m s o f RNs a n d RPNs. A l t h o u g h  a  94  theoretical curricula it.  f r a m e w o r k was d i s c o v e r e d  until  As w e l l ,  other  i t cannot be used i n  studies replicate,  although  and support  the m a j o r i t y of the f i n d i n g s suggest  that the d i s c l o s u r e of c l i e n t - t h e r a p i s t significant  extend,  i s s u e f o r these  nurses,  v a l i d a t e d t h r o u g h more r e s e a r c h . c o u l d be i n f o r m a l l y shared  sexual contact  these  i sa  f i n d i n g s must be  However, p a r t s o f t h e d a t a  with students  i n their  clinical  groups, and w i t h others a t p r o f e s s i o n a l i n s e r v i c e s . Recommendation: S t u d e n t s c o u l d b e t a u g h t  that sexual  between p r o f e s s i o n a l s and c l i e n t s does o c c u r  abuse  and t h a t  they  may h e a r a b o u t i t a t some p o i n t i n t h e i r p r a c t i c e . Recommendation: I n c l i n i c a l encouraged t o explore,  groups, students  s h o u l d be  and t a l k w i t h each o t h e r about  thoughts and f e e l i n g s concerning  client-therapist  their  sexual  abuse. Administration The  f i n d i n g s o f t h i s study have i m p l i c a t i o n s f o r  n u r s i n g a d m i n i s t r a t i o n . The f i n d i n g s t h a t s t u d y  nurses  r e v e a l e d knowledge about t h e t h e r a p e u t i c needs o f t h e i r clients  and s o c i a l and e t h i c a l  procedures), their  requirements  c o n s i s t e n t l y maintained  t h e i r c o n c e n t r a t i o n on  i m p l i c i t goal of a l l e v i a t i n g c l i e n t suffering,  i d e n t i f i e d the physician's sexual behavior immediately  addressed t h i s  demonstrated expert situation openly  (reporting  issue with their  nursing care  clearly  as immoral and c l i e n t s , and  ina difficult  practice  suggest that nursing a d m i n i s t r a t o r s should  more  acknowledge such exemplary n u r s i n g p r a c t i c e . T h i s  95  acknowledgement would p r o v i d e  these nurses w i t h  r e c o g n i t i o n and g r a t i f i c a t i o n , job  some  w h i c h i n t u r n would enhance  s a t i s f a c t i o n and perhaps performance.  Recommendation: A d m i n i s t r a t o r s  should suggest and  facilitate  n u r s e s ' needs f o r r e c o g n i t i o n and d e b r i e f i n g . F o r example, they could  sanction  and i n i t i a t e  the c r e a t i o n of c r i t i c a l  i n c i d e n t d e b r i e f i n g groups, f a c i l i t a t e opportunities, counselling  and s a n c t i o n  f o r the nursing  and support  inservice professional  staff. Summary  This  research  is'important  s i g n i f i c a n t aspect of the sexual  because i t has i l l u m i n a t e d a a b u s e phenomenon.  nurses' experience of c l i e n t d i s c l o s u r e of sexual with  a f o r m e r t h e r a p i s t was shown t o be a d i f f i c u l t  s t r e s s f u l nursing for  nursing  e x p e r i e n c e . 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Newbury Park, CA: Sage P u b l i c a t i o n s .  101  Appendix A Initial P l e a s e t e l l me  a little  Trigger  Statement  a b o u t what i s was  like  have y o u r c l i e n t d i s c l o s e s e x u a l c o n t a c t w i t h a  f o r you t o therapist  102  Appendix B R e s p o n d e n t C o n s e n t Form A M e n t a l H e a l t h N u r s e ' s E x p e r i e n c e when a C l i e n t D i s c l o s e s Sexual C o n t a c t w i t h a Former T h e r a p i s t : A Case Study I n s i g n i n g t h i s document, I am g i v i n g c o n s e n t t o b e i n t e r v i e w e d b y M a r g Rae, a g r a d u a t e s t u d e n t a t UBC. I u n d e r s t a n d t h a t s h e i s i n t e r e s t e d i n s t u d y i n g my e x p e r i e n c e when a c l i e n t d i s c l o s e d t o me t h a t s h e h a d h a d s e x u a l contact w i t h a former t h e r a p i s t . This study w i l l p r o v i d e i n depth i n f o r m a t i o n t o nurses and o t h e r p r o f e s s i o n a l s about one p e r s o n ' s e x p e r i e n c e w i t h t h i s s i t u a t i o n . The r e s u l t s o f t h i s s t u d y may s u p p o r t a n d g u i d e o t h e r p r o f e s s i o n a l s i n understanding the issues r e l a t e d to r e p o r t i n g c l i e n t t h e r a p i s t s e x u a l c o n t a c t , and s t a r t g e n e r a t i n g knowledge a b o u t t h i s phenomenon. I understand that being a respondent i n t h i s study w i l l i n v o l v e b e i n g i n t e r v i e w e d and audiotaped i n a s e t t i n g which i s c o n v e n i e n t t o me a n d t h a t my i n v o l v e m e n t may r e q u i r e two t o f o u r s e p a r a t e i n t e r v i e w s o f one h o u r d u r a t i o n . I n t e r v i e w s w i l l be t r a n s c r i b e d i n t o w r i t t e n form. . I u n d e r s t a n d my name a n d a n y o t h e r i d e n t i f y i n g i n f o r m a t i o n w i l l n o t b e r e v e a l e d when r e p o r t i n g t h e r e s u l t s o f t h e s t u d y . My i d e n t i t y w i l l be known o n l y t o M a r g Rae s i n c e s h e w i l l u s e a s p e c i a l c o d e t o i d e n t i f y my i n t e r v i e w s when s h e t r a n s c r i b e s t h e a u d i o t a p e s . I understand that the anonymity of the offender and the a g e n c y w i l l be e n s u r e d , a n d t h a t a n y m e n t i o n t h a t I may make t o them when I am i n t e r v i e w e d w i l l n o t a p p e a r i n t h e transcripts. I h a v e b e e n i n f o r m e d t h a t I am u n d e r no o b l i g a t i o n t o p a r t i c i p a t e i n t h i s s t u d y , a n d t h a t I am f r e e t o t e r m i n a t e my i n v o l v e m e n t a t a n y t i m e w i t h o u t j e o p a r d y . S i m i l a r l y , I h a v e b e e n i n f o r m e d t h a t I may r e f u s e t o a n s w e r a n y q u e s t i o n s d u r i n g t h e • i n t e r v i e w ( s ) . I am a w a r e t h a t I may e x p e r i e n c e some p s y c h o l o g i c a l d i s c o m f o r t a s I t a l k a b o u t my e x p e r i e n c e . I u n d e r s t a n d t h a t i f t h i s happens, and I r e q u e s t i t , Marg Rae w i l l , p r o m p t l y a r r a n g e f o r a p p r o p r i a t e a n d m u t u a l l y a g r e e a b l e t h e r a p e u t i c i n t e r v e n t i o n s . As w e l l , I have b e e n i n f o r m e d t h a t I w i l l n o t r e c e i v e any f i n a n c i a l b e n e f i t from my p a r t i c i p a t i o n i n t h i s s t u d y . I u n d e r s t a n d t h a t t h e r e s u l t s o f t h i s s t u d y w i l l be made a v a i l a b l e t o me i f I r e q u e s t them, a n d t h a t M a r g Rae i s t h e p e r s o n to, c o n t a c t i f I h a v e a n y q u e s t i o n s o r c o n c e r n s r e g a r d i n g my p a r t i c i p a t i o n i n t h i s s t u d y . I c a n c o n t a c t M a r g Rae a t 682-1994. I n a d d i t i o n , I may c o n t a c t h e r c o m m i t t e e  103 members C l a r i s s a G r e e n ( 8 2 2 - 7 5 0 7 ) , V i r g i n i a H a y e s ( 8 2 2 7 4 7 7 ) , a n d J a n e t E r i c k s e n ( 8 2 2 - 7 5 0 5 ) ; o r members o f t h e E t h i c s Committee (822-8584). I , t h e u n d e r s i g n e d , u n d e r s t a n d t h e n a t u r e o f Marg Rae's s t u d y , a n d I g i v e my c o n s e n t t o p a r t i c i p a t e a s a r e s p o n d e n t i n h e r s t u d y . I acknowledge r e c e i v i n g a copy o f t h i s c o n s e n t form Date:  Respondent's Respondent' Respondent's  name: p h o n e number: signature:,  

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