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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 University of B r i t i s h Columbia, 1992 The U n i v e r s i t y of B r i t i s h Columbia, 1995 THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTERS OF SCIENCE IN NURSING THE FACULTY OF GRADUATE STUDIES The School of N u r s i n g We accept t h i s t h e s i s as conforming to the r e q u i r e d s t a n d a r d THE UNIVERSITY OF BRITISH COLUMBIA A p r i l 1995 © Margaret I . Rae, A p r i l , . 1995 In presenting this thesis in partial fulfilment of the requirements for an advanced degree at the University of British Columbia, I agree that the Library shall make it freely available for reference and study. I further agree that permission for extensive copying of this thesis for scholarly purposes may be granted by the head of my department or by his or her representatives. It is understood that copying or publication of this thesis for financial gain shall not be allowed without my written permission. Department of The University of British Columbia Vancouver, Canada DE-6 (2/88) 11 ABSTRACT T h i s s t u d y e x p l o r e d the s u b j e c t i v e e x p e r i e n c e s o f community mental 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 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 l i t e r a t u r e , and my own c l i n i c a l e x p e r i e n c e s u p p o r t t h e b e l i e f 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 w i t h t h e i r c o m p l e x i t y and i n t e n s i t y . Three n u r s e s ' a c c o u n t s o f t h e i r c l i e n t s ' d i s c l o s u r e s c o n s t i t u t e d c ases f o r c o m p a r i s o n and g e n e r a t e d a b e g i n n i n g t h e o r e t i c a l framework. Data were c o l l e c t e d by m u l t i p l e , i n d e p t h , u n s t r u c t u r e d , a u d i o t a p e d i n t e r v i e w s . 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 o f c o n t e n t a n a l y s i s were used t o a n a l y z e the d a t a c o l l e c t e d , and each s e t of d a t a was .then compared and 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 d e n t i f i e d as t h e i n t e g r a t i n g c oncept 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 how n u r s 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 c l i e n t and on t h e m s e l v e s , w i t h t h e g o a l o f a l l e v i a t i n g c l i e n t s u f f e r i n g . C o n t a i n e d i n t h i s c y c l e were: two 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 and F o c u s i n g on S e l f ; f o u r sub-c o n c e p t s , C o l l e c t i n g I n f o r m a t i o n , U s i n g 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 Thoughts; and two 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 B o u n d a r i e s 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 t h a t d e s p i t e t h e passage of time 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 d i s c l o s u r e e x p e r i e n c e remained v i v i d i n t h e n u r s e s ' minds. Nurses e x p e r i e n c e d m o r a l o u t r a g e and p o w e r l e s s n e s s a t the p h y s i c i a n s ' misuse of Ill p r o f e s s i o n a l power, and 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 t i m e . D e s p i t e t h e i r p e r s o n a l f e e l i n g s the. n u r s e s m a i n t a i n e d a p r o f e s s i o n a l demeanor and c o n s i s t e n t l y t r e a t e d t h e i r c l i e n t s i n c a r i n g and r e s p e c t f u l ways. The 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 p h y s i c i a n ' s s e x u a l b e h a v i o r was u n e t h i c a l . They u n d e r s t o o d the t h e r a p e u t i c needs o f t h e i r c l i e n t s 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 and e t h i c a l demands of r e p o r t i n g . I m p l e m e n t a t i o n o f the s t u d y ' s f i n d i n g s c o u l d l e a d t o 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 , t h e r e b y l e s s e n i n g t h e s u f f e r i n g o f b o t h c l i e n t and n u r s e . iv TABLE Of CONTENTS Page ABSTRACT •. i i TABLE OF CONTENTS . . . i v LIST OF FIGURES . . 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 Re s e a r c h Q u e s t i o n . 15 C o n c e p t u a l 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 the Method 15 L i m i t a t i o n s 17 Summary ..18 CHAPTER TWO: METHOD I n t r o d u c t i o n • 19 S e l e c t i o n of P a r t i c i p a n t s 20 S e l e c t i o n C r i t e r i a 20 R e c r u i t m e n t P r o c e d u r e s 21 Data C o l l e c t i o n , 21 Data A n a l y s i s 25 E t h i c a l C o n s i d e r a t i o n s 27 C r i t e r i a f o r R i g o r 28 Summary 3 0 CHAPTER THREE: FINDINGS and DISCUSSION I n t r o d u c t i o n . . 32 Case S t u d i e s Cathy. 32 Lynne 3 4 A l i c e . . 36 C o n c e p t u a l Framework: Overview 3 8 E x p l i c a t i o n of t h e C y c l e of F o c u s i n g A t t e n t i o n . . 4 1 F o c u s i n g on t h e C l i e n t 42 F o c u s i n g on S e l f . ...... .46 D i s c u s s i o n of F o c u s i n g on t h e C l i e n t 50 D i s c u s s i o n of A n a l y z i n g B o u n d a r i e s 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, and RECOMMENDATIONS Summary and 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 P r a c t i c e 91 Res e a r c h ' 92 E d u c a t i o n . 93 A d m i n i s t r a t i o n ' 94 REFERENCES. '. -. .' 96 APPENDIX A: Sample of' T r i g g e r Statement 101 APPENDIX B: P a r t i c i p a n t Consent Form 102 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 o f F o c u s i n g A t t e n t i o n vii ACKNOWLEDGEMENTS T h i s t h e s i s came about t h r o u g h the combined 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 from o b s e r v i n g my c o l l e a g u e and 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 meaning 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 e x p e r i e n c e s , and i n so d o i n g , 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 Green 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 , encouraged, d i r e c t e d , and s u p p o r t e d b o t h the p r o c e s s o f r e s e a r c h and o f academic 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 , and J a n e t E r i c k s e n o f f e r e d me empathy and 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 comfort 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 son l e a r n e d how t o do open c o d i n g , and the n spent many hours 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 r e a d 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 s u g g e s t i o n s . I n th e e a r l y morning Joan Ferguson r e a d c o u n t l e s s d r a f t s b e f o r e yoga. I want' t o acknowledge 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 un a b l e t o accompany me on my l a s t academic w r i t i n g j o u r n e y . I'thank and acknowledge 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 and g r a c i o u s n e s s , a l l o w e d me to d i s a p p e a r 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 touched by my dad, Tom Mimee, who l i s t e n e d , and gave 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 Disclosure of Client-Therapist Sex V i s i b l e Background and Significance of the Problem The v e r y s e r i o u s problem 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 i s demanding our a t t e n t i o n more and more f r e q u e n t l y , e i t h e r because i t i s o c c u r r i n g more o f t e n o r because i t i s b e i n g r e p o r t e d more c o n s c i e n t i o u s l y ( G a r t r e l l , Herman, 01 a r t e , 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 i n v o l v e s the abused p e r s o n ( u s u a l l y a woman) d i s c u s s i n g t h e p r o b l e m w i t h h e r / h i s c u r r e n t h e a l t h p r o f e s s i o n a l . L e a r n i n g t h a t a p r e v i o u s t h e r a p i s t has had s e x u a l c o n t a c t w i t h h e r / h i s c l i e n t p r e s e n t s a number o f i s s u e s f o r t h e second p r o f e s s i o n a l (Brown, 1990; G a l l e t l y , 1993; K i e l y and K i e l y , 1987; S t r a s b u r g e r , J o r g e n s o n , and R a n d i e s , 1990). Many p r o f e s s i o n a l s have found t h a t t h e y themselves a r e made t o appear u n e t h i c a l when t h e y r e p o r t the abuse t o t h e s u i t a b l e p r o f e s s i o n a l b o d i e s (Stone, 1984; c i t e d i n P e n f o l d , 1992). S i m i l a r l y , a s i g n i f i c a n t number o f abused c l i e n t s a r e r e p o r t e d t o have e x p e r i e n c e d harassment, r e p e a t e d c h a l l e n g e s t o t h e i r c r e d i b i l i t y , 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 t h e i r p a s t s e x u a l r e l a t i o n s h i p s , , when t h e y have n o t i f i e d p r o f e s s i o n a l o r g a n i z a t i o n s o r e t h i c s committees o f t h e i r abuse ( P e n f o l d , 1992). F o r the abused c l i e n t t h i s r e s p o n s e c o n s t i t u t e s f u r t h e r abuse (Stone, 1984; c i t e d i n P e n f o l d , 1992), and the c u r r e n t 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 second c r i s i s ( G a l l e t l y , 1 9 9 3 ) . I t i s known t h a t many of 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 not r e p o r t c l i e n t - t h e r a p i s t 2 s e x u a l abuse ( G a r t r e l l e t a l . , 1987). W h i l e r e a s o n s f o r t h i s a r e s u g g e s t e d i n the l i t e r a t u r e ( G a r t r e l l e t a l . , 1987; G a l l e t l y , 1993; P e n f o l d , 1992), t h e c o g n i t i v e p r o c e s s e s l e a d i n g t o the c u r r e n t h e a l t h p r o f e s s i o n a l s ' d e c i s i o n s have not been s t u d i e d . T h i s r e s e a r c h r e p o r t d e s c r i b e s and a n a l y z e s ' t h e e x p e r i e n c e s of t h r e e 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 c o n t a c t w i t h a p r e v i o u s p h y s i c i a n . S e x u a l c o n t a c t o f any k i n d between a h e a l t h c a r e p r o f e s s i o n a l and a c l i e n t i s u n e t h i c a l . A c c o r d i n g t o B l a c k ' s Law D i c t i o n a r y , m e d i c a l and mental 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 i s s p e c i a l c o n f i d e n c e r e p o s e d i n the one who i n e q u i t y and good c o n s c i e n c e i s bound t o a c t i n good f a i t h and w i t h due r e g a r d 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 t h e c o n f i d e n c e " ( B l a c k , 1979, p. 753). The Committee on P h y s i c i a n S e x u a l M i s c o n d u c t [CPSM] (1992) s t a t e s t h a t s e x u a l c o n t a c t between a p h y s i c i a n and a p a t i e n t i s always u n e t h i c a l . v E x p l o i t a t i o n ' , t h e use o f someone f o r one's own s e l f i s h p u r p o s e s , i s t h e essence o f p a t i e n t - p h y s i c i a n s e x u a l c o n t a c t (CPSM, 1992). The C a n a d i a n M e d i c a l A s s o c i a t i o n (CMA) Code of E t h i c s A n n o t a t e d f o r P s y c h i a t r i s t s (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 t h a t the e t h i c a l p s y c h i a t r i s t w i l l s c r u p u l o u s l y a v o i d u s i n g t h i s r e l a t i o n s h i p 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 , f i n a n c i a l , and s e x u a l needs. 3 A p h y s i c i a n o f f e r i n g m e d i c a l o r m e n t a l h e a l t h s e r v i c e s i s i n a f i d u c i a r y r e l a t i o n s h i p . T h i s i s a s p e c i a l r e l a t i o n s h i p i n w h i c h the p h y s i c i a n a c c e p t s t h e t r u s t and c o n f i d e n c e o f t h e p a t i e n t t o a c t i n the l a t t e r ' s b e s t i n t e r e s t (Feldman-Summers, 1989). P h y s i c i a n s occupy a 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 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, 1992; P e n f o l d , 1992; R u t t e r , 1991). T h i s i s e s p e c i a l l y t r u e o f p s y c h o t h e r a p e u t i c r e l a t i o n s h i p s where c l i e n t s a r e encouraged t o suspend t h e i r u s u a l d e f e n c e s and r e v e a l p r i v a t e t h o u g h t s 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 [CPA], 1989). As w e l l , c l i e n t s a r e a c t i v e l y encouraged t o d e v e l o p s t r o n g f e e l i n g s toward the t h e r a p i s t w h i c h a r e m a n i f e s t a t i o n s o f t r a n s f e r e n c e , t h a t i s , a r e p e t i t i o n o f a t t i t u d e s and • f e e l i n g s e x p e r i e n c e d i n e a r l i e r i m p o r t a n t r e l a t i o n s h i p s (Blackshaw & P a t t e r s o n , 1992; R u t t e r , 1991). C l i e n t s a r e harmed when t h e y have s e x u a l c o n t a c t w i t h t h e i r p h y s i c i a n s o r mental h e a l t h p r o f e s s i o n a l s (Brown, 1990; W i l l i a m s , 1992). I n a s u r v e y s e e k i n g i n f o r m a t i o n from p s y c h o l o g i s t s about t h e i r p a t i e n t s who had 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 , t h e p s y c h o l o g i s t s r e p o r t e d t h a t 90% o f t h e s e p a t i e n t s had s u f f e r e d s e v e r e i l l e f f e c t s i n c l u d i n g d e p r e s s i o n , e m o t i o n a l d i s t u r b a n c e , i m p a i r e d s o c i a l a djustment, s u i c i d a l f e e l i n g s - and b e h a v i o r , and i n c r e a s e d use of drugs and a l c o h o l . E l e v e n p e r c e n t were h o s p i t a l i z e d , and 1% had committed s u i c i d e (Bouhoutsps, H o l r o y d , & Lerman, 1983; c i t e d i n G a l l e t l y , 1993). Pope and 4 Bouhoutsos (1986) d e s c r i b e a T h e r a p i s t - P a t i e n t Abuse Syndrome c l o s e l y r e s e m b l i n g a P o s t T r a u m a t i c S t r e s s Syndrome, w h i c h i n c l u d e s the f o l l o w i n g symptoms: am b i v a l e n c e , g u i l t , f e e l i n g s o f i s o l a t i o n , f e e l i n g s o f e m p t i n e s s , c o g n i t i v e d y s f u n c t i o n , i d e n t i t y and boundary d i s t u r b a n c e , i n a b i l i t y t o t r u s t , s e x u a l c o n f u s i o n , l a b i l i t y o f mood, s u p p r e s s e d rage, and i n c r e a s e d s u i c i d a l r i s k . These symptoms have been w e l l documented by o t h e r 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 (Blackshaw & P a t t e r s o n , 1992; P e n f o l d , 1992; CPSM, 1992; R u t t e r , 1991; S e a r i g h t & Campbell, 1993) . Abused c l i e n t s r e p o r t f e e l i n g s o f h u r t , l o n e l i n e s s , abandonment, f e a r , and g u i l t (CPSM, 1992). As w e l l , r e s e a r c h 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 of t h e s e abused c l i e n t s have been s e x u a l l y abused as c h i l d r e n o r a d u l t s , and a r e ' t h e r e f o r e not o n l y r e v i c t i m i z e d by s e x u a l c o n t a c t i n t h e r a p y ( R u t t e r , 1991), but a l s o f e e l ashamed and s e l f - b l a m i n g , and a t t e m p t t o p r o t e c t t h e abuser by c o n c e a l i n g t h e r e l a t i o n s h i p ( G a l l e t l y , 1993). D e s p i t e codes of e t h i c s and l i t e r a t u r e a l e r t i n g 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 t o i t s d e s t r u c t i v e n e s s , s e x u a l 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 t o o c c u r . A 1986 n a t i o n a l s u r v e y of American 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% o f male and 3.1% o f female p s y c h i a t r i s t s acknowledged s e x u a l c o n t a c t w i t h t h e i r c l i e n t s ( G a r t r e l l e t a l . ) . A n o t h e r n a t i o n a l A m e r i c a n s u r v e y by G a r t r e l l e t a l . (1987) found t h a t 65% o f 143 2 r e s p o n d e n t s 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 had had s e x u a l c o n t a c t w i t h p r e v i o u s t h e r a p i s t s . A 1986 s u r v e y of 5 Ame r i c a n p s y c h o l o g i s t s 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 males and 2.5% o f females acknowledged s e x u a l c o n t a c t w i t h t h e i r c l i e n t s (Pope, K e i t h - S p e i g e l , & T a b a c h n i c k ) . I n 1992, G a r t r e l l , M i l l i k e n , Goodson, Thiemann, and Lo s u r v e y e d 10,000 American f a m i l y p r a c t i t i o n e r s , i n t e r n i s t s , o b s t e t r i c i a n - g y n e c o l o g i s t s , and surgeons t o d e t e r m i n e t h e c u r r e n t p r e v a l e n c e o f p h y s i c i a n - p a t i e n t s e x u a l c o n t a c t . N i n e p e r c e n t o f 1,891 re s p o n d e n t s acknowledged s e x u a l c o n t a c t 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 Columbian p h y s i c i a n s u r v e y , 3.8% of males and 2.3% o f females r e p o r t e d s e x u a l c o n t a c t w i t h t h e i r c l i e n t s (CPSM, 1992). C l e a r l y , c l i e n t s b e i n g s e x u a l i z e d by t h e i r t h e r a p i s t s i s a s i g n i f i c a n t p roblem. 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 , books w r i t t e n by v i c t i m s o f p h y s i c i a n s e x u a l c o n t a c t , and p r e s s u r e from consumer groups have a l e r t e d c l i e n t s t o t h e p r e v a l e n c e , d e s t r u c t i v e n e s s and i m m o r a l i t y of 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 . As c l i e n t s a r e i n f o r m e d of t h e i s s u e s and t h e s o u r c e o f the problem i s c l e a r l y i d e n t i f i e d as t h e p h y s i c i a n , i t i s p o s s i b l e t h a t more and more c l i e n t s may f e e l s u f f i c i e n t l y encouraged and supported, t o r e v e a l p a s t s e x u a l c o n t a c t t o t h e i r p r e s e n t t h e r a p i s t . A m e n t a l h e a l t h p r o f e s s i o n a l , such as a m e n t a l h e a l t h n u r s e , i n f o r m e d by a c l i e n t of s e x u a l c o n t a c t w i t h a p r e v i o u s p h y s i c i a n o r p s y c h i a t r i s t , f a c e s a complex p r o b l e m ( G a l l e t l y , 1993). A c c o r d i n g t o G a l l e t l y (1993), t h e p r o b l e m p r e s e n t s as a c o n f l i c t of r i g h t s w h i c h i n c l u d e : (a) t h e 6 p a t i e n t has the r i g h t n ot t o be s e x u a l l y , e x p l o i t e d , and t o do n o t h i n g may c o n f i r m a p e r c e p t i o n o f t h e m s e l v e s as a p o w e r l e s s v i c t i m ; (b) the p a t i e n t has t h e r i g h t t o e f f e c t i v e t r e a t m e n t and the s e x u a l 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 ongoing p s y c h o t h e r a p y ; (c) the p a t i e n t has t h e r i g h t t o 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 be e x p e r i e n c e d 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 by 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 t h i s p s y c h i a t r i s t have the r i g h t not t o be s e x u a l l y e x p l o i t e d ; (e) t h e a c c u s e d p s y c h i a t r i s t has the r i g h t t o answer, a l l e g a t i o n s ; ( f) the p r o f e s s i o n has t h e d u t y t o m a i n t a i n e t h i c a l s t a n d a r d s ; and (g) the community has t h e r i g h t t o e x p e c t e t h i c a l conduct from th o s e e n t r u s t e d w i t h t h e c a r e o f t h e m e n t a l l y i l l . H e a l t h p r o f e s s i o n a l s , i n c l u d i n g m e n t a l h e a l t h n u r s e s , when l e a r n i n g about 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 , a r e p r e s e n t e d w i t h t h i s complex and d i f f i c u l t problem. How t h r e e n u r s e s r e s o l v e d t h i s d i f f i c u l t y was t h e f o c u s o f my r e s e a r c h . 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 r e s e a r c h e r ' s a s sumptions about the phenomenon be s t a t e d and t h e n suspended ( O i l e r , 1986). The r e s e a r c h e r may t h e n be a b l e t o f u l l y u n d e r s t a n d the e x p e r i e n c e o f the i n d i v i d u a l and n o t impose an a p r i o r i h y p o t h e s i s on the e x p e r i e n c e ( O i l e r , 1986). Heidegger ( c i t e d i n P a c k e r & A d d i s o n , 1989) a r g u e s : That i n o r d e r t o know a n y t h i n g a t a l l , we must have some p r e - u n d e r s t a n d i n g o f what i s knowable. T h i s p r e -u n d e r s t a n d i n g , o r f o r e - s t r u c t u r e , , remains l a r g e l y i n 7 t h e background as t a k e n - f o r - g r a n t e d . However, when the 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 t o r e c o g n i z e the i n f l u e n c e o f 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 c l i n i c a l m e ntal 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 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 . The p r i m a r y f o c u s of my c l i n i c a l p r a c t i c e i s w o r k i n g w i t h a d u l t c l i e n t s who were s e x u a l l y abused as c h i l d r e n . As a n u r s e -t h e r a p i s t , I am aware not o n l y of the immense p s y c h o l o g i c a l damage t h a t i s done t o t h e s e p e o p l e a t the t i m e , b u t a l s o o f t h e l o n g l a s t i n g and d e b i l i t a t i n g e f f e c t s o f s e x u a l abuse. H e a r i n g a d i s c l o s u r e i s always d i f f i c u l t , and I must always seek ways of r e s o l v i n g my e m o t i o n a l and c o g n i t i v e r e a c t i o n s . How c l i e n t s and t h e r a p i s t s i n f a c t r e s o l v e d i f f i c u l t p s y c h o l o g i c a l i s s u e s i s a p a s s i o n a t e i n t e r e s t o f mine. Hence, when a s o c i a l worker c o l l e a g u e d e s c r i b e d h i s p s y c h o l o g i c a l s t r u g g l e f o l l o w i n g a c l i e n t ' s 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 s e x u a l c o n t a c t , I found m y s e l f e x c e e d i n g l y i n t r i g u e d . The i n c i d e n t s p a r k e d my c u r i o s i t y , and I wondered i f female m e n t a l h e a l t h n u r s e s 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 c o n t a c t w i t h t h e i r p h y s i c i a n . ' • I have worked i n m ental h e a l t h f o r t w e n t y - n i n e y e a r s , and I u n d e r s t a n d the s t r u g g l e s of m e n t a l h e a l t h n u r s e s . I b e l i e v e t h a t most n u r s e s not o n l y c a r e about t h e i r c l i e n t s , b u t a l s o a r e d e e p l y t r o u b l e d by c l i e n t s ' abuse d i s c l o s u r e s . The c u l t u r e o f the m ental h e a l t h teams a f f e c t e d my 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 e x p e r i e n c e . 8 C l i e n t s a r e c a r e d f o r by p r i m a r y w o rkers who can be a R e g i s t e r e d Nurse (RN), R e g i s t e r e d P s y c h i a t r i c Nurse (RPN), S o c i a l Worker, P s y c h o l o g i s t , o r O c c u p a t i o n a l T h e r a p i s t . O c c a s i o n a l l y o t h e r backgrounds a r e r e p r e s e n t e d on t h e s e 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 t h e d i f f e r e n c e s i n e d u c a t i o n a l background o r t r a i n i n g everyone has t h e same j o b d e s c r i p t i o n and does the i d e n t i c a l j o b (however, o n l y t h e n u r s e s can g i v e i n j e c t a b l e m e d i c a t i o n s ) . The e d u c a t i o n a l and l i c e n s i n g d i f f e r e n c e s between the RNs and RPNs a r e n o t o p e r a t i o n a l on the j o b , and t h e y a r e b o t h r e f e r r e d t o as m e n t a l h e a l t h n u r s e s . I n a d d i t i o n , - the l i t e r a t u r e i n f l u e n c e d my 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 e x p e r i e n c e s o f 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 ; I had r e v i e w e d some of the l i t e r a t u r e about the i n c i d e n c e and p r e v a l e n c e of t h i s phenomenon and l e a r n e d t h a t r e p o r t i n g t h e abuse was an 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 m e n t a l h e a l t h 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 s , s e e k i n g some i n d i c a t i o n o f o t h e r s i g n i f i c a n t i s s u e s imbedded i n t h i s phenomenon of c l i e n t - t h e r a p i s t , sex. My 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 b e l i e v e t h a t c l i e n t - t h e r a p i s t sex i s always wrong; i t i s a b s o l u t e l y u n e t h i c a l . There i s no e t h i c a l dilemma about t h e r a p i s t -c l i e n t s e x u a l c o n t a c 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 of what an e t h i c a l dilemma i s ( D a v i s , 1981). D a v i s used q u e s t i o n n a i r e s t o d e t e r m i n e how 2 05 randomly s e l e c t e d n u r s e s u n d e r s t o o d the c oncept of an e t h i c a l dilemma 9 and 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 p r a c t i c e . F i f t y - t w o p e r c e n t of r e s p o n d e n t s had a good g r a s p o f t h i s c o n c e p t . Diploma n u r s e s d e s c r i b e d t h e c l i n i c a l i s s u e s i n v o l v e d i n t h e i r dilemma more o f t e n t h a n degree 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 e t h i c a l i s s u e s t h a n d i d degree n u r s e s . Younger n u r s e s had -more e t h i c a l dilemmas w i t h p a t i e n t s , f a m i l i e s , p h y s i c i a n s and i n s t i t u t i o n s than o l d e r n u r s e s . D e t e r m i n i n g the f r e q u e n c y w i t h w h i c h n u r s e s e n c o u n t e r e d s p e c i f i c e t h i c a l i s s u e s and how d i s t u r b e d t h e y were by t h e s e i s s u e s was the 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 by B e r g e r , Seversen, and C h v a t a l (1991), and p a r t o f my p r e u n d e r s t a n d i n g . They used a random s t r a t i f i e d p r o p o r t i o n a l sample drawn from f o u r s u r g i c a l u n i t s , t h r e e m e d i c a l u n i t s , t h r e e i n t e n s i v e c a r e u n i t s , 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 250-bed h o s p i t a l . Q u e s t i o n n a i r e s were s e n t t o 104 n u r s e s , w i t h a 5 0% r e t u r n r a t e . The f i n d i n g s showed t h a t , o v e r a l l , n u r s e s e n c o u n t e r e d few e t h i c a l i s s u e s and t h a t t h e i r l e v e l o f d i s t u r b a n c e i n c r e a s e d as the number of e t h i c a l i s s u e s i n c r e a s e d . T h i s s t u d y d i d not s u p p o r t the f i n d i n g s r e p o r t e d i n o t h e r l i t e r a t u r e w h i c h s u g g e s t e d a r e c e n t i n c r e a s e i n e t h i c a l dilemmas. Nurses r e p o r t e d t h a t t h e y r a r e l y e n c o u n t e r e d p r o f e s s i o n a l e t h i c a l i s s u e s such as s u b s t a n c e abuse, i l l e g a l a c t i v i t y , o r p a t i e n t abuse. The r e s e a r c h e r s 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 o r f a i l u r e t o r e c o g n i z e an e t h i c a l i s s u e cannot be o v e r l o o k e d , and have recommended more s t u d y i n t h i s a r e a . 10 M a j o r mental h e a l t h p r o f e s s i o n a l o r g a n i z a t i o n s , i n c l u d i n g t h o s e 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 . However, i t i s n o t always r e p o r t e d , and t h i s was 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 . 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 s e x / i s u n e t h i c a l b e h a v i o r , b u t u n l i k e the l a t t e r , p r o f e s s i o n a l s a r e r e q u i r e d by law t o r e p o r t . K a l i c h m a n , C r a i g , and F o l l i n g s t a d (1988) i n v e s t i g a t e d t h e tendency o f 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 t o r e p o r t c h i l d abuse. A sample c o n s i s t e d o f 101 c l i n i c i a n s w o r k i n g w i t h i n t h r e e community h e a l t h c e n t e r s i n F l o r i d a . The s u b j e c t s ' p r o f e s s i o n s i n c l u d e d B a c h e l o r ' s l e v e l m e n t a l h e a l t h t e c h n i c i a n s ( 3 9 % ) , M a s t e r ' s l e v e l t h e r a p i s t s ( 4 1 % ) , R e g i s t e r e d Nurses ( 1 0 % ) , Ph.D. C l i n i c a l P s y c h o l o g i s t s ( 7 % ) , and M e d i c a l D o c t o r P s y c h i a t r i s t s ( 3 % ) . Each s u b j e c t c o m p l e t e d an e x p e r i m e n t a l l y c o n t r o l l e d v i g n e t t e w i t h t h r e e 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 f a c t o r s i n c l u d e d v i c t i m age, t y p e of abuse, and v i c t i m r e a c t i o n s d u r i n g an i n t e r v i e w . The s u b j e c t s were randomly a s s i g n e d t o a v i g n e t t e s i t u a t i o n . R e s u l t s i n d i c a t e d 81% o f t h e c l i n i c i a n s t e n d e d t o r e p o r t the p r e s e n t e d case o f c h i l d abuse. The c l i n i c i a n ' s t e ndency t o r e p o r t depended on the c e r t a i n t y t h e y had t h a t t h e abuse was o c c u r r i n g . The v i c t i m ' s b e h a v i o r d u r i n g t h e 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 impact on t h e 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 abuse was happening. The 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 more f r e q u e n t l y . A n o t h e r of my p r e u n d e r s t a n d i n g s about t h e f r e q u e n c y of r e p o r t i n g u n e t h i c a l b e h a v i o r i n c l u d e s a s t u d y by G a r t r e l l , 11 e t 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 r e p o r t i n g p r a c t i c e s of p s y c h i a t r i s t s who knew of s e x u a l m i s c o n d u c t by c o l l e a g u e s . Surveys were s e n t t o 5574 r a n d o m l y - s e l e c t e d A m e r i c a n p s y c h i a t r i s t s . The response r a t e was 26%. S i x p o i n t f o u r p e r c e n t (n = 84) o f t h e r e s p o n d e n t s acknowledged s e x u a l c o n t a c t s w i t h a t o t a l of 144 p a t i e n t s . S i x t y - f i v e p e r c e n t (n '= 92 0) of r e s p o n d e n t s 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 had 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 . Non-o f f e n d e r s were the l e a s t l i k e l y , and r e p e a t o f f e n d e r s most l i k e l y , t o have t r e a t e d such p a t i e n t s . E i g h t y - s e v e n p e r c e n t of t h e r e s p o n d e n t s who had t r e a t e d t h e s e p a t i e n t s a s s e s s e d the p r e v i o u s s e x u a l c o n t a c t as always h a r m f u l t o t h e i r p a t i e n t s ; 6.4% a s s e s s e d the c o n t a c t as sometimes h e l p f u l ; 0.8% a s s e s s e d t h e 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 . T h i r t y -n i n e p e r c e n t (n = 53 6) of the r e s p o n d e n t s knew p s y c h i a t r i s t s who had been s e x u a l l y i n v o l v e d , and o n l y 6% o f t h e s e 53 6 r e s p o n d e n t s f i l e d c o m p l a i n t s . E i g h t p e r c e n t o f r e s p o n d e n t s who had 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 f i l e d a r e p o r t 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 m a j o r i t y o f r e s p o n d e n t s (56%) f a v o r e d mandatory r e p o r t i n g of t h e r a p i s t - p a t i e n t s e x u a l c o n t a c t . A l t h o u g h the response r a t e of t h e s u r v e y was moderate (26%) and r a i s e s c o n c e r n s about g e n e r a l i z a b i l i t y , t h e 6.4% o v e r a l l p r e v a l e n c e o f t h e r a p i s t p a t i e n t s e x u a l c o n t a c t found i n t h i s s u r v e y i s c o n s i s t e n t w i t h t h e p r e v a l e n c e r a t e i n o t h e r s u r v e y s . A f a c t o r t h a t a f f e c t s t h e r a p i s t s ' d e c i s i o n s t o r e p o r t i s t h e s t r e s s t h a t r e p o r t i n g may cause the c l i e n t . My 12 c o n c e r n about t h a t s t r e s s was p a r t of my p r e u n d e r s t a n d i n g as w e l l . I n the o p i n i o n of S t r a s b u r g e r , J o r g e n s o n , and Randies (1990), the t h e r a p i s t ' s dilemma when t h e r e p o r t i n g o f s e x u a l l y e x p l o i t a t i v e p s y c h o t h e r a p i s t s i s made mandatory. 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 unanimously agree t h a t t h e r a p i s t - p a t i e n t s e x u a l c o n t a c t i s u n e t h i c a l . When t h e r a p i s t s d e c i d e t o r e p o r t , t h e y must c o n s i d e r the n e g a t i v e e f f e c t s of the r e p o r t i n g , n o t o n l y upon the 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 r e l a t i o n s h i p w i t h the t r e a t i n g t h e r a p i s t ( p o s s i b l e d i s t r u s t due t o a l o s s o f c o n f i d e n t i a l i t y ) . R e p o r t i n g 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 o f e x p l o i t i v e 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 ( G a r t r e l e t a l . , 1987). I f u n r e p o r t e d , t h e s e p e r p e t r a t o r s can 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 c o l l e a g u e s c l a i m t h a t t h r e e American s t a t e s have adopted mandatory r e p o r t i n g s t a t u t e s ; t h e i r approaches v a r y from e d u c a t i n g s u r v i v o r s ' of s e x u a l e x p l o i t a t i o n t o r e q u i r i n g t h e p a t i e n t ' s c o n s e n t t o r e p o r t . 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 t h e r e a r e n e g a t i v e consequences f o r n u r s e s who r e p o r t u n e t h i c a l b e h a v i o r . I n t h e i r a r t i c l e of o p i n i o n , K i e l y and K i e l y (1987) d e s c r i b e the consequences o f d i s c l o s i n g f o r n u r s e s who f e l t e t h i c a l l y bound t o a c t i n the i n t e r e s t o f t h e p a t i e n t r a t h e r t h a n of t h e i r employer. Nurses found t h a t t h e y had no l e g a l r e c o u r s e i f th e y were s u b s e q u e n t l y d i s m i s s e d . A l t h o u g h , on the one hand, most p r o f e s s i o n a l 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 t h a t endangers c l i e n t w e l f a r e , on the o t h e r hand, t h e y have n o t always s u p p o r t e d d i s c l o s i n g the incompetent p r a c t i c e o f a f e l l o w h e a l t h team member (CNA, 1984; c i t e d i n K i e l y and K i e l y , 1987) . I n a d d i t i o n , h o s p i t a l management may use s u p p r e s s i v e 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 re s p o n s e t o " w h i s t l e b l o w i n g " (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 and shun 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 has s e r i o u s r a m i f i c a t i o n s f o r b o t h the i n d i v i d u a l making t h e d e c i s i o n and t h e o t h e r i n v o l v e d p a r t i e s . Everyone has a p s y c h o l o g i c a l r e s ponse t o an e t h 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 r e s p o n d w i t h 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 about h e l p i n g the v i c t i m and p u n i s h i n g the o f f e n d e r . I n an a r t i c l e of o p i n i o n , Brown (1990) d e s c r i b e s how u n e t h i c a l b e h a v i o r a f f e c t s the o f f e n d e r ' s c o l l e a g u e s p e r s o n a l l y , p r o f e s s i o n a l l y , and s o c i a l l y . She contends t h a t a l t h o u g h 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 u n e t h i c a l , 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 t h e r a p i s t s , 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 r e f r a m e d the e x i s t e n c e of s e x u a l e x p l o i t a t i o n o f women by women. C o l l e a g u e s of the o f f e n d i n g t h e r a p i s t f e e l wounded and b e t r a y e d , and s u f f e r a l o s s o f t r u s t . Brown d e s c r i b e s c o n f r o n t a t i o n s t r a t e g i e s , and s u g g e s t s a p r o c e s s o f 14 m e d i a t i o n f o r t h e p r o b l e m a t i c f e m i n i s t t h e r a p y c o l l e a g u e and the c l i e n t . To summarize 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 i n d i c a t e s t h a 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 i s e i t h e r a gr o w i n g problem o r i t i s b e i n g r e p o r t e d more o f t e n . D i s c l o s u r e i s f r e q u e n t l y made t o o t h e r h e a l t h p r o f e s s i o n a l s , i n c l u d i n g m ental h e a l t h n u r s e s . I t i s app a r e n t t h a t d i s c l o s u r e p r e s e n t s the 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 and complex problem t h a t must be r e s o l v e d . P r i o r t o b e i n g a b l e t o r e s o l v e t h i s problem, the phenomenon must be 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 can i d e n t i f y e t h i c a l dilemmas. 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 , t h e y t e n d t o r e p o r t the o f f e n d i n g t h e r a p i s t . However, the p o s s i b i l i t y o f r e p o r t i n g o f t e n c o n f r o n t s t h e r a p i s t s w i t h the n e c e s s i t y o f w e i g h i n g t h e 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 from abuse a g a i n s t t h r e a t e n i n g the t h e r a p e u t i c r e l a t i o n s h i p t h e y c u r r e n t l y have w i t h t h e i r c l i e n t . When n u r s e s expose u n e t h i c a l b e h a v i o r , management may d i s m i s s , b l a c k l i s t o r p h y s i c a l l y a s s a u l t them. As w e l l , t h e y may be shunned by t h e i r c o l l e a g u e s . Hence, I thought a s t u d y w h i c h compares and c o n t r a s t s 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 s would p r o v i d e a d e t a i l e d , though p r e l i m i n a r y , d e s c r i p t i o n o f the d i s c l o s u r e e x p e r i e n c e . Once t h i s phenomenon i s c l e a r l y d e s c r i b e d , and the 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 , o t h e r n u r s e s i n t h i s s i t u a t i o n may be encouraged t o be r e f l e c t i v e and 15 a n a l y t i c a l . The purpose of t h i s , s t u d y was t o show how t h r e e m e n t a l h e a l t h n u r s e s made meaning o f . t h i s phenomenon. Research Question The r e s e a r c h q u e s t i o n f o r t h i s s t u d y was: What i s t h e . n a t u r e o f t h e e x p e r i e n c e o f a m e n t a l 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 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 ? Conceptual Defi n i t i o n s The f o l l o w i n g c o n c e p t u a l d e f i n i t i o n s i n f o r m e d t h e r e s e a r c h : . 1. S e x u a l c o n t a c t : any o v e r t o r c o v e r t s e x u a l b e h a v i o r s between a male p h y s i c i a n and h i s female o r male p a t i e n t . 2. M e n t a l h e a l t h n u r s e : a female RN o r RPN who c o u n s e l s c l i e n t s w i t h m e n t a l h e a l t h c o n c e r n s . Male RNs o r RPNs were not i n c l u d e d i n o r d e r t o make the s t u d y as homogeneous as"... p o s s i b l e . 3. Former p h y s i c i a n : a male m e d i c a l d o c t o r who has had a t r e a t m e n t r e l a t i o n s h i p w i t h a female o r male p a t i e n t f o r p s y c h i a t r i c r e a s o n s . A g a i n female d o c t o r s have been e x c l u d e d i n an attempt t o l i m i t the v a r i a t i o n i n t h e phenomenon. Introduction to the Method B o t h t h e case s t u d y method and c o n t e n t a n a l y s i s were chosen as m e t h o d o l o g i c a l approaches f o r t h i s r e s e a r c h . The c a s e 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 most s o c i a l s c i e n c e knowledge has been d e v e l o p e d ( K a z d i n & Tuma, 1982;. Runyan, 1982; S t e r l i n g & M c N a l l e y , 1992; Younger, 1985). A case 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 th e background, 16 c u r r e n t s t a t u s , 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 u n i t : an i n d i v i d u a l , 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 ( Y i n , 1984; K a z d i n & Tuma, 1982; Runyan, 1982; P o l i t & Hu n g l e r , 1991). The case s t u d y method may be used t o g e n e r a t e hypotheses w h i c h may be t e s t e d by o t h e r r e s e a r c h , t o a d d r e s s r e s e a r c h q u e s t i o n s i n whi c h 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 ot been i d e n t i f i e d , and 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 i n d i v i d u a l . The case s t u d y method may a l s o be used when t h e r e i s l i t t l e c o n t r o l o v e r e v e n t s , when the time frame i s r e s t r i c t e d , o r when a l a r g e sample i s not a v a i l a b l e ( K a z d i n & Tuma, 1982; Holm, 1983; 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, 1983; M e i e r & Pugh, 1986; S t e r l i n g & M c N a l l e y , 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, 1982; 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, 1982; Runyan, 1980; Y i n , 1989). 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 the c o u r s e o f c o l l e c t i n g and a n a l y z i n g d a t a , 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 u sed t o s y s t e m a t i c a l l y g u i d e f u r t h e r i n q u i r y . Q u a l i t a t i v e methods a r e us e d t o uncover, d e s c r i b e , and u n d e r s t a n d what l i e s w i t h i n any phenomenon about w h i c h l i t t l e i s known ( M i l e s & Huberman, 1994; S t r a u s s & C o r b i n , 17 1990). S i n c e l i t t l e i s known about the n u r s e s ' e x p e r i e n c e s 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 s t u d i e s , u s i n g a q u a l i t a t i v e method, seemed an a p p r o p r i a t e approach t o b e g i n n i n g u n d e r s t a n d i n g o f t h e phenomenon; I n q u a l i t a t i v e r e s e a r c h , t h e d a t a a r e i n t h e form o f words ( M i l e s & Huberman, 1994), 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 the most common methods o f d a t a c o l l e c t i o n ( S t r a u s s & C o r b i n , 1990). I n t h i s s t u d y , i n d e p t h , 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 . Data c o l l e c t i o n t a k e s p l a c e c o n c u r r e n t l y w i t h d a t a a n a l y s i s ( M i l e s & Huberman, 1994; S t r a u s s & C o r b i n , 1990). Data a n a l y s i s d i r e c t s the f o c u s f o r f u r t h e r d a t a c o l l e c t i o n ( M i l e s & Huberman, 1994). Comparative c o n t e n t a n a l y s i s d i r e c t e d d a t a c o l l e c t i o n and a n a l y s i s f o r t h i s s t u d y ( G l a s e r & 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 of c o m p a r a t i v e case s t u d i e s a r e n o t 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 e x i s t i n g o r new t h e o r y ( M i l e s & Huberman, 1994). T h i s s t u d y e x p l o r e d o n l y t h e e x p e r i e n c e s of 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 work i n a community mental h e a l t h s e t t i n g . I t d i d not a d d r e s s t h e e x p e r i e n c e s of o t h e r n u r s e s i n o t h e r s e t t i n g s , n or t h o s e w i t h o t h e r p r o f e s s i o n a l b a s e s , who w o u l d have t h e i r own unique e x p e r i e n c e s . As w e l l , t h e e x p e r i e n c e s of male n u r s e s was not add r e s s e d , and n e i t h e r t h e c l i e n t s ' n or t h e former t h e r a p i s t s ' r e a c t i o n s were i n v e s t i g a t e d . 18 F i n a l l y , .both t h e wide v a r i a t i o n o f time between 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 the d i f f e r e n t c o n t e x t s i n w h i c h t h e d i s c l o s u r e s took p l a c e , p r e c l u d e an optimum i n d e p t h u n d e r s t a n d i n g of d i s c l o s u r e e x p e r i e n c e , though t h e y do p r o v i d e b r e a d t h . I n summary, t h i s s t u d y has been d e s i g n e d t o e x p l o r e t h r e e m e n t a l h e a l t h 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 s . L i t t l e i s known o f how mental h e a l t h n u r s e s make meaning o f t h i s d i f f i c u l t and complex e x p e r i e n c e . I n C h a p t e r One I have d e s c r i b e d the background and t h e s i g n i f i c a n c e of t h e r e s e a r c h problem, 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 , i n t r o d u c e d t h e methodology, and i d e n t i f i e d t he l i m i t a t i o n s o f t h i s r e s e a r c h . I n Ch a p t e r Two I w i l l d e s c r i b e t h e r e s e a r c h method i n more de p t h . F o l l o w i n g t h a t , i n Ch a p t e r Three I w i l l • p r e s e n t and d i s c u s s the f i n d i n g s , and, i n C h a p t e r Four, I w i l l summarize 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 , s u g g e s t the s t u d y ' s i m p l i c a t i o n s , and make recommendations f o r n u r s i n g p r a c t i c e , r e s e a r c h , e d u c a t i o n , 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 s t u d y approach was chosen t o s t u d y t h r e e 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 o f c l i e n t s ' 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 s e x u a l c o n t a c t . I n t h i s c h a p t e r , I d e s c r i b e the p r o c e d u r e s I used t o s e l e c t p a r t i c i p a n t s , 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 , and e s t a b l i s h m e t h o d o l o g i c a l r i g o r . A case 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 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, c u r r e n t s t a t u s , 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 u n i t : an i n d i v i d u a l , 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 ( Y i n , 1989; K a z d i n & Tuma, 1982; Runyan, 1982; P o l i t & Hu n g l e r , 1991). A case s t u d y method may be used: (a) t o u n d e r s t a n d 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 , (b) to g e n e r a t e hypotheses w h i c h may be t e s t e d by o t h e r r e s e a r c h , (c) t o address r e s e a r c h q u e s t i o n s i n w h i c h 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 ot been i d e n t i f i e d , (d) when t h e r e i s l i t t l e c o n t r o l o ver e v e n t s , (e) when t h e time frame i s r e s t r i c t e d , ( f ) when a l a r g e sample i s not a v a i l a b l e , and/or (g) t o improve c l i e n t c a r e (Holm, 1983; K a z d i n & Tuma, 1982; M e i e r & Pugh, 1986; S t e r l i n g & M c N a l l e y , 1992; Younger, 1985). G i v e n t h e c i r c u m s t a n c e s a s s o c i a t e d w i t h my s t u d y , t h e case s t u d y method was s u i t a b l e because: t h e r e s e a r c h q u e s t i o n a d d r e s s e d 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 , t h e r e was l i t t l e c o n t r o l o y e r d i s c l o s u r e e v e n t s , 20 t h e r e was a r e s t r i c t e d time frame, and a l a r g e sample was not a v a i l a b l e . 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 enough t o accommodate any a p p r o p r i a t e means of 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, 1982; Runyan, 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 t o uncover, d e s c r i b e , and u n d e r s t a n d phenomena about w h i c h l i t t l e i s known ( M i l e s & Huberman, 1994), and 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 s e l e c t e d . Data were c o l l e c t e d u s i n g m u l t i p l e , i n d e p t h , u n s t r u c t u r e d i n t e r v i e w s , 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 ( S t r a u s s & C o r b i n , 1990). The e n t i t i e s as whole u n i t s ( Y i n , 1989) 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 . Selection of Participants The purpose of a q u a l i t a t i v e case s t u d y approach i s t o u n d e r s t a n d 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 ( K a z d i n & Tuma, 1982). I n case s t u d y method each i n d i v i d u a l i s c o n s i d e r e d a u n i t , a whole e n t i t y ( Y i n , 1989) . P a r t i c i p a n t s who have a c t u a l l y .had the e x p e r i e n c e under s t u d y a r e s e l e c t e d . F o r t h i s s t u d y , 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 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 former t h e r a p i s t . C h a r a c t e r i s t i c s o f 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 i n t h e n e x t c h a p t e r . S e l e c t i o n C r i t e r i a S e l e c t i o n c r i t e r i a were e s t a b l i s h e d t o ensure as much homogeneity as p o s s i b l e . The s a m p l i n g c r i t e r i a f o r p a r t i c i p a n t s were: a female n u r s e who had m e n t a l h e a l t h 21 e x p e r i e n c e , who worked on a mental h e a l t h team, who had e x p e r i e n c e d the d i s c l o s u r e e x p e r i e n c e , and who was w i l l i n g t o p a r t i c i p a t e i n one o r two h o u r - l o n g i n t e r v i e w s . F o r t h i s s t u d y , 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 be a male p h y s i c i a n who had had a c o u n s e l l i n g r e l a t i o n s h i p and had abused the c l i e n t . There were no r e s t r i c t i o n s about t h e c l i e n t . R e c r u i t m e n t P r o c e d u r e s I p o l l e d c o l l e a g u e s and a c q u a i n t a n c e s about p o s s i b l e d i s c l o s u r e e x p e r i e n c e s , e x p l a i n i n g the purpose o f my s t u d y t o them, and i n v i t i n g them t o p a r t i c i p a t e . I a l s o a s k e d f o u r 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 teams 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 . I n t h i s memo I b o t h e x p l a i n e d t h e purpose o f my r e s e a r c h and ask e d f o r v o l u n t e e r s . To anyone t e l e p h o n i n g • a n d making an i n q u i r y , I d e s c r i b e d t h e i n t e r v i e w p r o c e d u r e s , time e x p e c t a t i o n s , and how I would p r o t e c t b o t h t h e i r and the o f f e n d e r s ' c o n f i d e n t i a l i t y . Of the s i x n u r s e s who v o l u n t e e r e d , t h r e e p a r t i c i p a t e d , one dropped out because she thou g h t t h a t r e c o u n t i n g h e r d i s c l o s u r e e x p e r i e n c e s would be too p a i n f u l , and a n o t h e r because she moved from t h e c i t y . The r e m a i n i n g n u r s e was not chosen because th e o f f e n d i n g t h e r a p i s t was a p r i e s t , r a t h e r t h a n a m e d i c a l d o c t o r . Data C o l l e c t i o n I n q u a l i t a t i v e r e s e a r c h , i n t e r v i e w s and o b s e r v a t i o n s a r e t h e most common methods of d a t a c o l l e c t i o n ( S t r a u s s & C o r b i n , 1990). I n t h i s s t u d y , the r e s e a r c h q u e s t i o n p r o v i d e d 22 the i n i t i a l f o c u s f o r d a t a c o l l e c t i o n . Data were c o l l e c t e d by i n d e p t h , u n s t r u c t u r e d i n t e r v i e w s , w h i c h a r e t y p i c a l l y u sed 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 of 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 w h o l l y u n d e r s t a n d the 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 r e f r a i n from i n f l u e n c i n g the p a r t i c i p a n t ( P o l i t & H u n g l e r , 1991) . D u r i n g t h e i n i t i a l i n t e r v i e w , I r e v i e w e d t h e purpose o f th e s t u d y 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 t i m e . Each p a r t i c i p a n t r e a d and s i g n e d t h e consent (see Appendix B, p. 102), and none as k e d f o r a d d i t i o n a l 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 encouraged. 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 ongoin g , dynamic, c h a n g i n g p r o c e s s , [wherein] u n f o r e s e e a b l e e v e n t s and consequences [ a r i s e ] , 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. 151). A t t h e second i n t e r v i e w , I n o t o n l y r e v i e w e d t h e purpose o f t h e s t u d y , b u t a l s o a s ked 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 . I n 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 f o r some p s y c h o l o g i c a l d i s c o m f o r t as th e y t a l k about t h e i r e x p e r i e n c e s (Ramos, 1989), I asked t h e s t u d y n u r s e s about t h e i r r e a c t i o n s t o the p r e v i o u s i n t e r v i e w . The s t u d y n u r s e s were aware t h a t I would, w i t h t h e i r p e r m i s s i o n , make arrangements f o r them t o r e c e i v e prompt t h e r a p e u t i c i n t e r v e n t i o n i f n e c e s s a r y , and i f m u t u a l l y a g r e e d on. 23 N e i t h e r the p a r t i c i p a n t s n o r I found i t n e c e s s a r y 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 the i n t e r v i e w , I engaged t h e p a r t i c i p a n t i n s m a l l " t a l k " and used humor t o c r e a t e a r e l a x e d atmosphere f o r b o t h o f us. Each i n t e r v i e w was a p p r o x i m a t e l y one hour l o n g and took 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 . Each 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 c o m f o r t a b l e c h a i r s a r r a n g e d a t r i g h t a n g l e s , f a c i l i t a t i n g t he s h a r i n g o f t h o u g h t s and f e e l i n g s . A l t h o u g h I made at t e m p t s t o i n c r e a s e our c o m f o r t , I found the r e s e a r c h s t y l e of i n t e r v i e w i n g ( a s k i n g q u e s t i o n s f o r t h e r e s e a r c h e r ' s b e n e f i t ) u n c o m f o r t a b l e 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 ( a s k i n g q u e s t i o n s f o r t h e c l i e n t ' s b e n e f i t ) . I n i t i a l l y , a b r o a d statement r e l a t i n g t o t h e s t u d y 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 was used (see Appendix A, p. 101), t h e n s u b s e q u e n t l y o n l y p r o m p t i n g comments were 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 p r o c e s s u n t i l t h e p a r t i c i p a n t s i n d i c a t e d t h a t t h e y had no more t o say about 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 , and I f e l t s a t i s f i e d t h a t I r e a l l y u n d e r s t o o d t h e i r e x p e r i e n c e . The a u d i o t a p e d i n t e r v i e w s were s u b s e q u e n t l y t r a n s c r i b e d v e r b a t i m 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 were 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 days. I made c o p i e s o f t h e s e t r a n s c r i p t i o n s , and d e l i v e r e d them t o my r e v i e w e r who had 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 t o t h e s t u d i e d phenomenon. The r e v i e w e r ' s t a s k was t o p r o v i d e an 24 i ndependent c o d i n g of the i n t e r v i e w n a r r a t i v e s (Hinds, S c a n d r e t t - H i b d e n , & McAulay, 1990). Data a n a l y s i s , f o c u s i n g t h e d i r e c t i o n f o r d a t a c o l l e c t i o n , t a k e s p l a c e c o n c u r r e n t l y w i t h d a t a c o l l e c t i o n ( M i l e s & Huberman, 1994; S t r a u s s & C o r b i n , 1990). A f t e r a n a l y z i n g the i n i t i a l d a t a from each o f t h e t h r e e i n t e r v i e w t r a n s c r i p t s , I had a p r e l i m i n a r y u n d e r s t a n d i n g o f 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 . However, I r e c o g n i z e d t h a t I d i d n o t have a complete u n d e r s t a n d i n g about s p e c i f i c e l e m e n t s . As w e l l , s i n c e the s t u d y n u r s e s t a l k e d about d i f f e r e n t i s s u e s I wanted t o c o n f i r m t h a t t h e y had not f o r g o t t e n a n y t h i n g r e l e v a n t . ' So I a r r a n g e d a second i n t e r v i e w t o v a l i d a t e , r e f u t e , and expand my u n d e r s t a n d i n g s . A g a i n , I a s k e d open ended q u e s t i o n s o r made p r o m p t i n g comments t h a t would deepen my u n d e r s t a n d i n g of t h e i r e x p e r i e n c e s . Second i n t e r v i e w s o c c u r r e d w i t h i n s i x weeks of the f i r s t f o r two o f t h e p a r t i c i p a n t s . The t h i r d p a r t i c i p a n t c o u l d not be r e i n t e r v i e w e d because she was out of town f o r a p r o l o n g e d p e r i o d . F i e l d n o t e s added more d a t a . A f t e r each i n t e r v i e w I w r o t e down my r e a c t i o n s . t o the c o n t e n t and t h e p r o c e s s o f t h e i n t e r v i e w , my thoughts o r hunches I may have had about the p a r t i c i p a n t , and my o b s e r v a t i o n s about t h e i r body language, p o s t u r e , and speech p a t t e r n s . I a l s o , n o t e d my t h o u g h t s and f e e l i n g s as I a n a l y z e d d a t a , and 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 had w i t h t h e r e v i e w e r who was v a l i d a t i n g my a n a l y s i s and use o f c o d i n g d e s c r i p t o r s . These 25 notes were scribbled down on 3 X 4 pieces of paper, one idea to a paper, and kept i n a f i l e folder marked "notes to me". These notes helped me focus so that I could synthesize and understand the data, as well as keep a check on my values and assumptions. After analyzing the f i r s t set of data, I made notes which I took into a l l subsequent interviews, reminding me to ask those questions t y p i c a l of a researcher rather than those of a therapist (P o l i t & Hungler, 1991). Data Analysis The process of analyzing the data took place concurrently with data c o l l e c t i o n . To i l l u s t r a t e the technical approaches, the following b r i e f l y describes my process with one nurse's data set: Following transcription, comparative content analysis was used to analyze the data. Content analysis i s a procedure for analyzing verbal communications i n a systematic and objective fashion (Miles & Huberman, 1994). I. began by reading the complete tra n s c r i p t to refresh my memory of the interview. Then I c a r e f u l l y read each phrase and/or sentence, and searched for a concept word that would capture i t s meaning. I n i t i a l l y I had great d i f f i c u l t y a r r i v i n g at concept words which would accurately describe the idea embedded i n the phrases, clauses, sentences, and sections. Once selected I wrote the concept word beside the phrase on the transcript, and on a stickie-note I wrote the word, page, and participant's number, and I attached i t to the corresponding place i n the tra n s c r i p t . Methodically, I 26 worked my way t h r o u g h the t r a n s c r i p t . I e x p e r i e n c e d a welcome 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 chosen co n c e p t word o r d e s c r i p t o r was t h e n n o t e d . S t r a u s s & C o r b i n (1990) c a l l t h i s e x p l o s i o n o f 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 c o d i n g . A f t e r I had w r i t t e n numerous concept words on t h e t r a n s c r i p t and s t i c k i e - n o t e s , I c o n s u l t e d my r e v i e w e r t o a s s e s s my c o n s i s t e n c y i n s o r t i n g . T h i s check of c o n s i s t e n c y 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 o b s e r v a t i o n s (Hinds, S c a n d r e t t - H i b d e n , & McAulay, 1990). Then I r e a d t h r o u g h the t r a n s c r i p t , s i m u l t a n e o u s l y removing th e s t i c k i e -n o t e s and c r e a t i n g groups w h i c h c o n t a i n e d s i m i l a r meaning c o n c e p t s . T h i s g r o u p i n g p r o c e s s i s c a l l e d c a t e g o r i z i n g , and t h e phenomenon r e p r e s e n t e d by a c a t e g o r y i s more a b s t r a c t t h a n t h e c o n c e p t s grouped under i t ( S t r a u s s & C o r b i n , 1990) . F o r example, employing open c o d i n g I c o n c e p t u a l i z e d some d a t a as "expanding c l i e n t ' s s t o r y " , " e x p l o r i n g c l i e n t ' s e x p e r i e n c e , " " a s k i n g d i r e c t q u e s t i o n s " , and " a s k i n g f o r f a c t s . " I grouped t h e s e c o n c e p t s t o g e t h e r and c a l l e d t h e c a t e g o r y " q u e s t i o n i n g . " T h i s c a t e g o r y was grouped w i t h o t h e r s and named " i n t e r v e n t i o n s " . As I examined th e c a t e g o r i e s , I t r i e d t o u n d e r s t a n d the theme t h e y were r e v e a l i n g , o r were p a r t o f . Each of the s t u d y n u r s e ' s i n t e r v i e w s was a n a l y z e d u s i n g t h e same method. 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 were r e v e a l i n g a s t o r y about the s t u d y n u r s e ' s e x p e r i e n c e o f p a y i n g a t t e n t i o n . t o e i t h e r h e r s e l f o r t h e c l i e n t . Subsequent 27 to t h i s , I r e i n t e r v i e w e d two of the s t u d y n u r s e s t o c l a r i f y d a t a and broaden the d e s c r i p t i o n o f t h e c o n c e p t s and c a t e g o r i e s , and a f f i r m e d o r r e f u t e d my i n t e r p r e t a t i o n s . I c o n t i n u e d t o examine the d a t a " l o o k i n g a t c o n f i g u r a t i o n s , a s s o c i a t i o n s , causes, and e f f e c t s within t h e case--and o n l y t h e n [I turned] t o c o m p a r a t i v e a n a l y s i s o f a ( u s u a l l y l i m i t e d ) number o f c a s e s " (Ragin, 1978; c i t e d i n M i l e s & Huberman, 1994). I l o o k e d 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 the s t u d y n u r s e s ' e x p e r i e n c e s , and when a p p r o p r i a t e I used the same concept and c a t e g o r y names. By ex a m i n i n g and comparing the c o n c e p t s and c a t e g o r i e s a c r o s s the t h r e e case s t u d i e s , I e s t a b l i s h e d more a b s t r a c t and i n t e g r a t i n g c o n c e p t s ( S t r a u s s & C o r b i n , 1990). F o r example, the c a t e g o r y o f " i n t e r v e n t i o n s " was grouped under a p r i m a r y c o n c e p t w h i c h 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 . E t h i c a l Considerations P r i o r t o b e g i n n i n g the s t u d y , I o b t a i n e d a p p r o v a l from t h e U n i v e r s i t y o f B r i t i s h Columbia B e h a v i o r a l S c i e n c e s S c r e e n i n g Committee f o r Re s e a r c h and Other S t u d i e s I n v o l v i n g Human S u b j e c t s . Then I p o l l e d t h e men t a l h e a l t h teams s e a r c h i n g f o r n u r s e s w i l l i n g t o p a r t i c i p a t e i n t h e s t u d y . I e n s u r e d c o n f i d e n t i a l l y by the f o l l o w i n g measures: (a) I used an 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, on t h e t r a n s c r i p t and on the tape; (b) a u d i o t a p e s and t r a n s c r i p t s were l o c k e d i n my f i l i n g c a b i n e t when n o t b e i n g used; (c) a u d i o t a p e s and t r a n s c r i p t s w i l l be d e s t r o y e d a y e a r a f t e r t h e s t u d y i s - completed;•(d) o n l y two members o f my t h e s i s 28 committee, the r e v i e w e r , and m y s e l f had a c c e s s t o t h e coded i n f o r m a t i o n ; and, (e) by p r e a r r a n g e d agreement, t h e name of th e o f f e n d e r and t h e agency were n o t mentioned by t h e p a r t i c i p a n t s . 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 b e g i n n i n g o f e v e r y i n t e r v i e w . L a s t l y , t h e n u r s e s ' names were d i s g u i s e d t o ensure t h e i r c o n f i d e n t i a l i t y . C r i t e r i a for 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 ( M e i e r & Pugh, 1986; Runyan, 1982; Y i n , 1989; Younger, 1985). Y i n (1989) s u g g e s t s s e v e r a l t a c t i c s t h a t can ensure 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 a n a l y z e d . S i n c e t h e s e t a c t i c s a r e not 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 c o l l e c t i o n and 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 , the 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 used i n s t e a d . 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 e s t a b l i s h i n g r i g o r : c r e d i b i l i t y , f i t t i n g n e s s , a u d i t a b i l i t y and c o n f i r m a b i l i t y (Guba & L i n c o l n , 1981; c i t e d i n S a n d e l o w s k i 1986). "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 r e p r e s e n t s such f a i t h f u l 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 o f 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 e x p e r i e n c e w ould i m m e d i a t e l y r e c o g n i z e i t from t h o s e 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 as t h e i r own" ( S a n d e l o w s k i , 1986, p. 3 0 ) . I n t h i s 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 by t h o r o u g h l y c h e c k i n g t h e d a t a g a t h e r e d t o dete r m i n e i f i t made sense when i t was compared 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 m e n t a l 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 w e l l , i n t e r p r e t a t i o n s of t h e d a t a were t a k e n back t o two o f the p a r t i c i p a n t s f o r v e r i f i c a t i o n o f i n t e n t . 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 of 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 o f 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 the s t u d y " f i t ' i n t o t h e c o n t e x t s o u t s i d e t h e s t u d y s i t u a t i o n and when i t s a u d i e n c e v i e w s i t s f i n d i n g s as m e a n i n g f u l and a p p l i c a b l e i n terms o f t h e i r own e x p e r i e n c e " (Guba & L i n c o l n , 1981; c i t e d i n S a n d e l o w s k i , 1986, p. 3 2 ) , t h e n f i t t i n g n e s s , t h e second c r i t e r i o n , i s a c h i e v e d . F i t t i n g n e s s i s t h e t r u t h v a l u e o f t h e d a t a . I n t h i s 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 by 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 the d a t a p r e s e n t e d , by an independent c o d i n g of the 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 "a-ha" from a n o t h e r n u r s e when I t e l l h e r about my f i n d i n g s . A u d i t a b i l i t y i s a n o t h e r c r i t e r i o n f o r m e a s u r i n g r e l i a b i l i t y , and 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 t r a n s f o r m i n g d a t a i n t o t h e o r e t i c a l s t a t e m e n t s a r e r e p o r t e d (Burns, 1989). 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 r e s e a r c h e r can c l e a r l y f o l l o w the d e c i s i o n - m a k i n g t r a i l o f t h e r e s e a r c h e r i n t h e stu d y , and come t o comparable c o n c l u s i o n s ( S a n d e l o w s k i , 1986). To a c h i e v e t h i s i n t h i s s t u d y , I c l e a r l y d e s c r i b e d the d a t a c o l l e c t i o n p r o c e s s 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 , and 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 the development o f c o n c e p t s and sub-c o n c e p t s . Notes 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 t h e o r e t i c a l d e c i s i o n s have been k e p t . F i n a l l y , c o n c e p t s , s u b - c o n c e p t s , and c a t e g o r i e s were c o n t i n u a l l y compared w i t h raw d a t a t o ensure the 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 and d a t a was c l e a r (Burns, 1989). C o n f i r m a b i l i t y i s the f i n a l c r i t e r i o n f o r e s t a b l i s h i n g r i g o r 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 t o t h e n e u t r a l i t y o r u n b i a s e d n e s s o f the d a t a ( S a n d e l o w s k i , 1986). T h i s c r i t e r i o n 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 , and c r e d i b i l i t y have been s u i t a b l y e s t a b l i s h e d . A l s o o f c o n c e r n i s the r e c i p r o c a l e f f e c t t h a t t h e i n v e s t i g a t o r and the p a r t i c i p a n t have on each o t h e r (Lamb & H u t t l i n g e r , 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 assumptions and p r e c o n c e p t i o n s a t the o n s e t of t h e r e s e a r c h , and th e n suspends, them d u r i n g t h e i n q u i r y p r o c e s s (Lamb & H u t t l i n g e r , 1989). However; d u r i n g the i n q u i r y , the i n v e s t i g a t o r ' s p e r s o n a l v i e w s 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 of t h e i r e x p e r i e n c e (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 c o n t i n u o u s ; t h e r e f o r e , I c o n s t a n t l y m o n i t o r e d my v a l u e s , b e l i e f s ' a n d 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 t h e i r i n f l u e n c e on the s t u d y , b u t I a l s o i n t e g r a t e d t h i s u n d e r s t a n d i n g i n t o the s t u d y ' s f i n d i n g s (Marcus & F i s c h e r , 1989; c i t e d i n Lamb & H u t t l i n g e r , 1989). Summary The case s t u d y method, i n t h i s i n s t a n c e a c o m p a r i s o n o f t h r e e i n - d e p t h c a s e s of 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 s , p r oduces a p r o m i s i n g i n i t i a l a n a l y s i s o f t h e n u r s e s ' 31 p r o c e s s . I n t h i s s t u d y , t h r e e m e n t a l h e a l t h n u r s e s were s e l e c t e d , and th e n p a r t i c i p a t e d i n m u l t i p l e , i n - d e p t h , 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 and a x i a l c o d i n g t e c h n i q u e s were used t o a n a l y z e the d a t a c o l l e c t e d , and each case 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 each o t h e r . The r e s u l t was an i n f o r m a t i v e and r i c h p i c t u r e o f t h e s e n u r s e s ' s t r u g g l e t o make meaning o f t h e complex and d i f f i c u l t p r o b lem o f c l i e n t d i s c l o s u r e . T h i s 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 the n e x t c h a p t e r . 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 case s t u d i e s . I n t h i s c h a p t e r , a s y n o p s i s of each d i s c l o s u r e case p r o v i d e s c o n t e x t f o r the co n c e p t s t h a t t h e t h r e e c o n t a i n . Each case s t u d y i s i n t r o d u c e d t h r o u g h a d e s c r i p t i o n o f t h e n u r s e ' s e x p e r i e n c e and s k i l l s , t he c o n t e x t and s e t t i n g o f t h e d i s c l o s u r e , and the n u r s e ' s s p e c i f i c s i n g l e d i s c l o s u r e e x p e r i e n c e . Concepts emerging from the s t u d y n u r s e s ' d e s c r i p t i o n s a r e o r g a n i z e d i n t o a c o n c e p t u a l framework w h i c h I use t o p r e s e n t the f i n d i n g s . R e l e v a n t l i t e r a t u r e i s used t o 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 f i n d i n g s . The c a s e s t u d i e s a r e p r e s e n t e d u s i n g f i c t i t i o u s names and i n t h e c h r o n o l o g i c a l o r d e r of the c l i e n t s ' d i s c l o s u r e s o f t h e i r abuse e x p e r i e n c e s : the d i s c l o s u r e t o Cathy o c c u r r e d 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 , the d i s c l o s u r e t o Lynne o c c u r r e d f i v e y e a r s p r i o r , and the 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 one and 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 were i n i t i a l l y i n t e r v i e w e d w i t h i n one month o f each 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 , n u r s e t h e r a p i s t , and s t u d y n u r s e . Case Studies 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 n u r s e , w i t h a p p r o x i m a t e l y n i n e y e a r s e x p e r i e n c e i n p s y c h i a t r i c a c u t e c a r e 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 happened, 15 y e a r s ago, Cathy 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 . Her c l i e n t d i s c l o s e d s e x u a l c o n t a c t 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 where Cathy worked i s mandated t o p r o v i d e p s y c h i a t r i c c a r e f o r p a t i e n t s w i t h s e r i o u s m e n t a l i l l n e s s e s , and i t s g o a l i s t o p r e v e n t t h e need f o r f u t u r e 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 . A t the t i m e of d i s c l o s u r e , t h e r e were seven such m e n t a l h e a l t h teams i n t h e c i t y where the s t u d y t o o k p l a c e . Each team was composed of h e a l t h c a r e w o r k e r s who c o u l d be r e g i s t e r e d n u r s e s , 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 s , s o c i a l w o r k e r s , o c c u p a t i o n a l t h e r a p i s t s , o r p s y c h o l o g i s t s . Each h e a l t h c a r e worker was d i r e c t l y r e s p o n s i b l e 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 , t h e teams engaged p s y c h i a t r i s t s who were r e s p o n s i b l e f o r a s s e s s i n g , d i a g n o s i n g , p r e s c r i b i n g m e d i c a t i o n f o r t h e p a t i e n t s , 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 p r i m a r y w o r k e r s . As a p r i m a r y worker, Cathy would o f f e r t o work w i t h s p e c i f i c p a t i e n t s and she would choose a c o n s u l t i n g p s y c h i a t r i s t t o a s s i s t h e r w i t h each one. C a t h y would see t h e c l i e n t a l o n e o r accompanied by t h e c o n s u l t i n g p s y c h i a t r i s t , depending on t h e needs of t h e c l i e n t . As w e l l , she would d e t e r m i n e the f r e q u e n c y of t h e i n t e r v i e w s . The c l i e n t who d i s c l o s e d h e r abuse e x p e r i e n c e t o C a t h y was a young d i v o r c e d woman. Cathy had worked w i t h h e r d u r i n g a 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 , and she knew t h a t t h e c l i e n t had b o t h a p s y c h o t i c i l l n e s s and a s u b s t a n c e abuse problem. I n t h e r a p y , Cathy was c o n s t a n t l y i n t e r v e n i n g i n t h e c l i e n t ' s a c t i n g out b e h a v i o r ( t a k i n g minor drug o v e r d o s e s , a t t e m p t i n g 34 s u i c i d e , demanding e x t r a appointments, b e i n g v e r b a l l y ' a b u s i v e , and r e f u s i n g t o comply w i t h t r e a t m e n t r e q u e s t s ) and/or i n .the c l i e n t ' s p s y c h o t i c and d e l u s i o n a l t h i n k i n g . C athy 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 c o u n s e l l i n g , 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. I n c o u n s e l l i n g s e s s i o n s , o v e r a p e r i o d o f s e v e r a l months, t h e c l i e n t 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 former p s y c h i a t r i s t . She t o l d Cathy t h a t she was " i n l o v e " , t h a t " t h i s was t h e b e s t r e l a t i o n s h i p " she had e v e r had, and t h a t i t was a s e x u a l r e l a t i o n s h i p . S i n c e C a t h y knew the c l i e n t had p s y c h o t i c e p i s o d e s , she thought she had t o make s u r e t h a t t h i s was. not an a s s o c i a t i o n c o n n e c t e d w i t h t h e c l i e n t ' s f a n t a s y l i f e . A f t e r e x p l o r i n g t h e s i t u a t i o n , c a r e f u l l y , Cathy d e t e r m i n e d t h a t t h e c l i e n t had and was c o n t i n u i n g t o have a sexual, l i a i s o n w i t h h e r former p s y c h i a t r i s t . C athy f e l t "concerned" and " f r u s t r a t e d i n an ang r y way" when she 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 l i a i s o n , and she i m m e d i a t e l y d i s c u s s e d t h i s s i t u a t i o n w i t h t h e c o n s u l t i n g p s y c h i a t r i s t . She b e l i e v e d the l i a i s o n was h a r m f u l t o t h e c l i e n t , and a l t h o u g h she d i d not know s p e c i f i c a l l y what a c t i o n t o t a k e , she knew t h a t she wanted t h e l i a i s o n t o end. Lynne's D i s c l o s u r e Account Lynne i s ah 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 a c u t e c a r e h o s p i t a l s e t t i n g s , . and i n b o t h emergency and me n t a l h e a l t h team community s e t t i n g s . A t the 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 community f o r 13 y e a r s , a t a m e n t a l h e a l t h team d i f f e r e n t from Cathy's b u t p a r t o f t h e same h e a l t h s e r v i c e , and t h e r e f o r e e x h i b i t i n g t h e same s t r u c t u r e , o r g a n i z a t i o n , c l i e n t s , and method of d e l i v e r i n g s e r v i c e . F u r t h e r , 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 had had e x t e n s i v e t r a i n i n g i n w o r k i n g w i t h s u r v i v o r s o f s e x u a l abuse, and she had u n d e r t a k e n i n t e n s i v e p s y c h o t h e r a p y t r a i n i n g . A l t h o u g h Lynne had the e x p e r i e n c e o f d i s c l o s u r e w h i l e w o r k i n g w i t h a p r i v a t e p r a c t i c e c l i e n t , she was s i m u l t a n e o u s l y w o r k i n g on a community 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 happened f i v e y e a r s b e f o r e , t h i s s t u d y ' 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 f o r a month, f o r one hour a week. A t the t i m e , t h e c l i e n t was i n c r i s i s ; she was t a l k i n g about r i t u a l s e x u a l abuse, s e x u a l abuse, s u i c i d e , and shame. She t o l d Lynne o f t h e many t h e r a p i s t s t o whom she had d i s c l o s e d h e r abuse h i s t o r y , and d e s c r i b e d how f e a r f u l she had f e l t when none of t h e s e t h e r a p i s t s b e l i e v e d h e r . I n t r y i n g t o u n d e r s t a n d h e r c l i e n t ' s e x p e r i e n c e more f u l l y , Lynne asked "have you e v e r been abused by a t h e r a p i s t " ? The c l i e n t d i s c l o s e d t h a t 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 t h e 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 she d i d n o t have sex -with him on a weekly b a s i s . B e l i e v i n g t h a t she had no c h o i c e , t h e c l i e n t had a c q u i e s c e d . Lynne i m m e d i a t e l y f e l t " f u r i o u s " ' . A t t h e ti m e , she 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 t h e 36 r e s o l v e t h a t she would t a l k t o a t h e r a p i s t f r i e n d about i t l a t e r . A l s o , she had the thought " t h i s i s no s u r p r i s e t o me, because I've h e a r d about t h i s guy b e f o r e " , and f e l t a p p a l l e d t h a t "he was s t i l l d o i n g i t . " Lynne t h e n d i r e c t e d h e r a t t e n t i o n toward h e r c l i e n t , and h e r e x p l o r a t i o n p r o v i d e d h e r w i t h more d e t a i l s about t h e s i t u a t i o n . She i n f o r m e d h e r c l i e n t "what t h a t p e r s o n d i d was not OK; i t was v e r y u n e t h i c a l " . She a s k ed h e r i f she wanted t o do a n y t h i n g about i t , and the c l i e n t r e f u s e d . Lynne a c c e p t e d and u n d e r s t o o d h e r r e f u s a l . S i n c e t h i s i n c i d e n t had happened two y e a r s b e f o r e , n e i t h e r she nor t h e c l i e n t b e l i e v e d i t s h o u l d t a k e p r i o r i t y o v e r the f a c t t h a t t h e c l i e n t was 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 t o h e r c l i e n t ' s s a f e t y and o t h e r t h e r a p y i s s u e s . A l i c e ' s D i s c l o s u r e 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 t h e most r e c e n t . I t o c c u r r e d one and a h a l f y e a r s b e f o r e our i n t e r v i e w , and • a p p r o x i m a t e l y two y e a r s a f t e r she had s t a r t e d work a t ' a community mental h e a l t h team. A t the t ime of d i s c l o s u r e A l i c e had c o n s i d e r a b l e 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 n u r s e . P r i o r t o j o i n i n g t h e 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 program; as w e l l she had t a u g h t m e n t a l h e a l t h n u r s i n g i n a R e g i s t e r e d P s y c h i a t r i c N urses' Program, a t a community c o l l e g e . Her d i s c l o s u r e e x p e r i e n c e took p l a c e i n t h e m e n t a l h e a l t h team s e t t i n g . S i n c e i t was t h e same m e n t a l h e a l t h 37 team as Lynne's, and s i m i l a r t o C a t h y ' s , the s e t t i n g b o r e s i m i l a r c h a r a c t e r i s t i c s d e s c r i b e d above. An e s s e n t i a l p a r t of c a r e t h a t a c l i e n t r e c e i v e s a t a l l t h e me n t a l h e a l t h teams i s an i n i t i a l assessment. T h i s assessment i s c o m p r i s e d of d a t a s u b m i t t e d by the r e f e r r i n g p e r s o n ( i n t a k e d a t a ) , and a c o m p r e h e n s i v e . p s y c h i a t r i c i n t e r v i e w . B o t h the c o n s u l t i n g p s y c h i a t r i s t and the p r i m a r y worker a r e i n v o l v e d i n t h e l a t t e r , and 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 a c l i e n t f o r t h e f i r s t t i m e . 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 were i n t h e m i d s t o f t h e c l i e n t ' s i n i t i a l assessment when the d i s c l o s u r e e x p e r i e n c e o c c u r r e d . A l i c e had r e a d on the i n t a k e d a t a t h a t the male c l i e n t had a l o n g p s y c h i a t r i c h i s t o r y w i t h t h e f o l l o w i n g d i a g n o s e 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 , s o c i o p a t h i c t r a i t s , and su b s t a n c e abuse. As w e l l , a s e x u a l r e l a t i o n s h i p w i t h a former p s y c h i a t r i s t was r e p o r t e d . As p a r t o f t h e i r i n i t i a l assessment, the c o n s u l t i n g 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 i n s i n u a t e d t h a t t h e r e 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 between him and h i s g e n e r a l p r a c t i t i o n e r . " He made t h i s d i s c l o s u r e " v o l u n t a r i l y , s p o n t a n e o u s l y , and i n the m i d d l e of t a l k i n g about a n o t h e r t o p i c . " W i t h o u t a l l u d i n g t o the a l l e g e d r e l a t i o n s h i p w i t h the p r e v i o u s p s y c h i a t r i s t mentioned i n t h e i n t a k e d a t a , A l i c e c o n f i r m e d w i t h the c l i e n t t h a t he was t a l k i n g about a r e l a t i o n s h i p w i t h h i s c u r r e n t g e n e r a l p r a c t i t i o n e r . 38 A l i c e i m m e d i a t e l y f e l t a p p a l l e d t h a t t h i s " s i t u a t i o n c o u l d happen." She r e c a l l s t h i n k i n g " t h i s i s s e r i o u s " and f e e l i n g an urgency t o do something about i t , though she chose not t o show h e r f e e l i n g s o r t o make any comment. B o t h 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 n o t e d t h e d i s c l o s u r e , and f i n i s h e d t h e i n i t i a l assessment. They a r r a n g e d f o r a subsequent appointment w i t h t h e c l i e n t . These t h r e e d i s c l o s u r e c a s e s , though t h e y o c c u r r e d o v e r a wide span of 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 e x p e r i e n c e f o r n u r s e t h e r a p i s t s . The a c c o u n t s of t h e t h r e e e v e n t s and t h e n u r s e s ' d e s c r i p t i o n o f t h e i r r e s p o n s e s t o them r e v e a l a s i n g l e , c y c l i c a l p r o c e s s t h a t can be e x p l a i n e d i n terms of s e v e r a l • c o n c e p t s . Conceptual Framework: Overview T h i s s e c t i o n p r e s e n t s the f i n d i n g s o f t h e s t u d y 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 s . The f i n d i n g s a r e p r e s e n t e d c o n c u r r e n t l y t o m i n i m i z e r e p e t i t i o n . I n i t i a l l y , I s h a l l d e s c r i b e my 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, and 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 i n d e t a i l , i l l u s t r a t i n g them w i t h q u o t a t i o n s from t h e d a t a . The c o n c e p t s o f t h i s c o n s t r u c t i o n a r e c a p i t a l i z e d ; c o n c e p t s s e l e c t e d f o r d i s c u s s i o n a r e u n d e r l i n e d . The 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 s a r e c o n c e p t u a l i z e d as' a p r o c e s s c a l l e d The C y c l e of F o c u s i n g A t t e n t i o n . T h i s p r i m a r y c o n c e p t , F o c u s i n g A t t e n t i o n , i n t e g r a t e s two main c o n c e p t s w h i c h emerged from the d a t a : 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 . B oth o f t h e s e f u r t h e r s e p a r a t e i n t o 39 s u b - c o n c e p t s and m o d i f y i n g - c o n c e p t s . The diagram (see F i g u r e 1, p. 40) i l l u s t r a t e s the i n t e g r a t i n g c o n c e p t , t h e c o n c e p t s , s u b - c o n c e p t s , and m o d i f y i n g - c o n c e p t s , t h e 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 a n u r s e 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 . I t i s a complex, c y c l i c a l m e n t a l 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 n o t m u t u a l l y e x c l u s i v e ; i n f a c t , I see them as h i g h l y i n t e g r a t e d and i n t e r d e p e n d e n t . F o r the purposes o f t h i s d i s c u s s i o n , however, 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 and d i s c r e t e p a r t s . F o c u s i n g A t t e n t i o n emerged as t h e e s s e n t i a l and i n t e g r a t i n g c oncept of a l l t h r e 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 s . F o c u s i n g A t t e n t i o n i n v o l v e s t h e n u r s e ' 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 . I t i s a complex, c y c l i c a l m e n t a l 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 goal, o f a l l e v i a t i n g c l i e n t s u f f e r i n g . I n t h i s p r o c e s s , t h e n u r s e a l t e r n a t e l y Focuses A t t e n t i o n on h e r c l i e n t and on h e r s e l f . ' When the n u r s e f o c u s e s on t h e c l i e n t , f o c u s e s on h e r s e l f , and t h e n r e f o c u s e s on the c l i e n t , t h i s may be c a l l e d t h e C y c l e of F o c u s i n g A t t e n t i o n . The e s s e n t i a l a s p e c t of the 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 , 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 , i s t h e n u r s e i n r e l a t i o n t o h e r c l i e n t . T h i s r e l a t i o n s h i p i s c o m p r i s e d o f two main 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 and F o c u s i n g on S e l f . ( 40 F i g u r e 1. C y c l e o f F o c u s i n g A t t e n t i o n ( P r i m a r y Concept] F o c u s i n g on t h e C l i e n t (Concept) F o c u s i n g on S e l f (Concept] ' C o l l e c t i n g I n f o r m a t i o n (Sub-concept) * U s i n g I n t e r v e n t i o n s (Sub-concept) * A n a l y z i n g Thoughts (Sub-concept) * A n a l y z i n g B o u n d a r i e s * A n a l y z i n g Power ( M o d i f y i n g - 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 (Sub-concept) When t h e nu r s e i s F o c u s i n g on the C l i e n t , she l i s t e n s t o and ob s e r v e s h e r c l i e n t ' s b e h a v i o r . When she i s F o c u s i n g on S e l f , she t u r n s i n w a r d and p r o c e s s e s t h e i n f o r m a t i o n she has r e c e i v e d w h i l e l i s t e n i n g t o and o b s e r v i n g the c l i e n t ' s b e h a v i o r , and she n o t i c e s h e r p e r s o n a l r e a c t i o n s ( f e e l i n g s o r t h o u g h t s ) t o i t . Then, based on the 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 n u r s e r e t u r n s t o F o c u s i n g on t h e C l i e n t and 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 . T h i s b e g i n s a n o t h e r c y c l e . F o c u s i n g on t h e C l i e n t i s c o m p r i s e d of two sub--c o n c e p t s , 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 I n t e r v e n t i o n s . 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 t o t h e c l i e n t and she obs e r v e s h e r / h i s b e h a v i o r . U s i n g 41 I n t e r v e n t i o n s i n v o l v e s what the nu r s e s a i d and how she a c t e d towards h e r c l i e n t . F o c u s i n g on S e l f , t he o t h e r . c o n c e p t o f F o c u s i n g A t t e n t i o n , i s c o m p r i s e d o f two su 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 Thoughts. When the 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 be 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 t h a t 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 and A n a l y z i n g Power. When the n u r s e i s A n a l y z i n g B o u n d a r i e s , she t h i n k s about c r o s s e d t h e r a p y b o u n d a r i e s 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 sex t o o c c u r ; when A n a l y z i n g Power, she t h i n k s about t h e power d i f f e r e n t i a l t h a t a l l o w e d t h e c l i e n t abuse. When the nu 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 h e r e m o t i o n a l r e s p o n s e s t o h e r c l i e n t ' s words and/or b e h a v i o r s . I c o n c e p t u a l i z e the s t u d y 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 s as the C y c l e of F o c u s i n g A t t e n t i o n . The C y c l e c o n s i s t s o f : two 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 and F o c u s i n g on S e l f ; four, s u b - c o n c e p t s , C o l l e c t i n g I n f o r m a t i o n , U s i n g 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 Thoughts; and two 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 B o u n d a r i e s and 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 t t e n t i o n a l t e r n a t e s between F o c u s i n g on the C l i e n t and F o c u s i n g on S e l f . E x p l i c a t i o n of the Cycle of Focusing Attention T h i s sub s e c t i o n t a k e s the c o n c e p t u a l i z a t i o n j u s t o u t l i n e d and e x p a n d s . i t . 42 F o c u s i n g on the C l i e n t F o c u s i n g on the C l i e n t i s a concept 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 . F o c u s i n g on the C l i e n t r e f e r s t o t h e n u r s e 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 e 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 t h e i r c l i e n t s ' t h o u g h t s , f e e l i n g s , 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 , f e e l i n g s , and b e h a v i o r s , t h e n u r s e s 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 and became i n v o l v e d i n C o l l e c t i n g I n f o r m a t i o n . C o l l e c t i n g I n f o r m a t i o n i s the c o g n i t i v e p r o c e s s o f c o m p i l i n g d a t a about t h e i r c l i e n t by l i s t e n i n g t o t h e c l i e n t , and o b s e r v i n g the c l i e n t ' s b e h a v i o r . Through t h i s o n g o i n g p r o c e s s , the n u r s e s a t t e m p t e d t o u n d e r s t a n d t h e i r c l i e n t s ' problems and t o f a c i l i t a t e t h e i r c l i e n t s ' r e c o v e r y by a v e r b a l , n o n - v e r b a l , o r b e h a v i o r a l r e s p o n s e . 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 , and she r e c a l l e d w a t c h i n g h e r c l i e n t c l o s e l y f o r s i g n s o f d i s t r e s s . She a c t i v e l y t r i e d t o u n d e r s t a n d h e r c l i e n t ' s e x p e r i e n c e . Lynne r e c a l l e d t h a t b o t h she and h e r c l i e n t had s i m i l a r u n d e r s t a n d i n g s about the p r o b l e m and t h e t h e r a p y g o a l . She t a l k e d about t h i s mutual u n d e r s t a n d i n g l i k e t h i s : We were 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 and r i t u a l abuse.... When I asked h e r i f she wanted t o r e p o r t him [the p s y c h i a t r i s t ] s h e . s a i d "no", and 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 were 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 t i m e . L i k e Lynne, when Cathy was C o l l e c t i n g I n f o r m a t i o n she 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 h e r c l i e n t ' s e x p e r i e n c e . U n l i k e Lynne, who had t h e same u n d e r s t a n d i n g o f 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 had d i f f e r e n t u n d e r s t a n d i n g s o f the problem. Cathy r e c a l l e d t h i n k i n g h e r c l i e n t ' s p r o blem was t h a t she was h a v i n g a s e x u a l 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 , whereas t h e c l i e n t thought t h a t h e r problem was t h a t she was n o t h a v i n g enough s e x u a l meetings w i t h him. As p a r t o f t h e p r o c e s s o f C o l l e c t i n g I n f o r m a t i o n , Cathy remembered l i s t e n i n g t o and 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 (Cathy) i n t o f a c i l i t a t i n g the s e x u a l l i a i s o n s . We spent 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 phone c a l l s o r f i g u r e out how she c o u l d meet him a t h i s apartment 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 change h e r mind o r g e t -\ h e r t o work on a n y t h i n g e l s e . C a t h y a l s o r e c a l l e d l i s t e n i n g t o h e r c l i e n t n o t o n l y v e r b a l 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 a l s o u n r e a l i s t i c a l l y p r a i s i n g h e r and a s k i n g h e r f o r g i v e n e s s . 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 r e s t r i c t e d t h e i r s e x u a l m e e t i n g s , Cathy r e c a l l e d o b s e r v i n g h e r c l i e n t ' s a c t i n g out b e h a v i o r w h i c h i n c l u d e d p r e s c r i p t i o n and n o n - p r e s c r i p t i o n d r u g 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 o f s u i c i d e and h o m i c i d e . A l i c e ' s e x p e r i e n c e of C o l l e c t i n g I n f o r m a t i o n , i n h e r 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 d i f f e r e n t from b o t h Lynne's and C a t h y ' s . U n l i k e Lynne who r e p o r t e d t h a t she and h e r 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 p r o b l e m and t h e r a p y g o a l , and u n l i k e Cathy who r e c a l l e d u n d e r s t a n d i n g the p r o b l e m d i f f e r e n t l y t h a n h e r c l i e n t , A l i c e r e p o r t e d t h a t 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 hought h i s 44 pro b l e m was. " I j u s t d i d n ' t know what he wanted ... h i s agenda k e p t c h a n g i n g . . . . I j u s t n ever 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 l i s t e n i n g t o h e r 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 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 p h y s i c i a n . She r e c a l l e d t h a t a t v a r i o u s t i m e s he would t h r e a t e n t o s e t h i m s e l f on f i r e i n 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 he dragged h i m s e l f i n t o h e r o f f i c e i n a semi-comatose 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 I n f o r m a t i o n and m e n t a l l y p r o c e s s i n g i t , t h e s t u d y n u r s e s t h e n used the d a t a t o g u i d e t h e i r i n t e r v e n t i o n s . U s i n g I n t e r v e n t i o n s , a sub-concept o f F o c u s i n g on the 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 n u r s e s r e c a l l u s i n g . T h i s concept c a p t u r e s t h e v e r b a l , n o n - v e r b a l , o r b e h a v i o r a l r e s p o n s e s o f the n u r s e , d i r e c t e d towards t h e c l i e n t , w i t h the i n t e n t i o n o f . f o s t e r i n g t h e c l i e n t ' s r e c o v e r y . 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 were v e r b a l 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 and h i s g e n e r a l p r a c t i t i o n e r were 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 . A f t e r u s i n g i n t e r v e n t i o n s t o u n d e r s t a n d h i s meaning, she remembered e x p l a i n i n g t o him t h a t t h i s s e x u a l r e l a t i o n s h i p was a b u s i v e , w h i c h she r e c a l l e d was not h i s p e r c e p t i o n . A l i c e saw h e r s e l f as s u p p o r t i v e , u n d e r s t a n d i n g , c o n s i s t e n t , c l e a r , and empowering, and when the c l i e n t became a t r i s k f o r harming h i m s e l f , 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 p r e p a r i n g 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 b a s i s . L i k e A l i c e , when Cathy spoke about U s i n g I n t e r v e n t i o n s she remembered u s i n g b o t h v e r b a l and non. v e r b a l b e h a v i o r s . She remembered a s k i n g q u e s t i o n s t o d e t e r m i n e h e r c l i e n t ' s r e a l i t y . " I wanted 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 o r p a r t of h e r p s y c h o s i s . . . . I t was r e a l ; t h e y were 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 . " She r e c a l l e d how she u n s u c c e s s f u l l y a t t e m p t e d 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 the c l i e n t t he c o n n e c t i o n between h e r a c t i n g out b e h a v i o r ( t h r e a t s of c o m m i t t i n g s u i c i d e , t a k i n g m e d i c a t i o n o v e r d o s e s , and a b u s i n g a l c o h o l ) , and h e r s e x u a l i n v o l v e m e n t w i t h t h e p s y c h i a t r i s t . 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 h e r c l i e n t a s s e s s e d f o r m e d i c a t i o n s , and a d m i t t e d t o a c r i s i s h o s t e l o r a h o s p i t a l . A t t i m e s , 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 e x p e r i e n c e s o f U s i n g 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 i n t e r v e n t i o n s . She remembered i n t e r v e n i n g w i t h q u e s t i o n s w h i c h expanded h e r c l i e n t ' s s t o r y and/or e x p l o r e d h e r b e l i e f s and f e e l i n g s . She r e p o r t e d u s i n g i n t e r v e n t i o n s w h i c h not o n l y d e f i n e d the p s y c h i a t r i s t ' s b e h a v i o r as a b u s i v e and wrong, b u t a l s o s u p p o r t e d and 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 as a b u s i v e . She at t e m p t e d t o empower h e r c l i e n t by a s k i n g f o r d i r e c t i o n on whether o r not t o r e p o r t t h e o f f e n d e r , and by 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 n e g a t i v e d e c i s i o n . 46 F o c u s i n g on the C l i e n t i s t h e f i r s t a s p e c t o f t h e C y c l e of F o c u s i n g A t t e n t i o n , the p r o c e s s used by t h e n u r s e s t o r e s p o n d t o abuse d i s c l o s u r e s , and has been used t o p r e s e n t p a r t o f t h e f i n d i n g s . The second p a r t o f t h e 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 sub-concepts 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 Thoughts, 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 B o u n d a r i e s 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 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 . I n t h e f o l l o w i n g s e c t i o n s e l e c t e d c o n c e p t s from t h i s a s p e c t of 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 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 t h e r e l e v a n t l i t e r a t u r e . These s e l e c t e d c o n c e p t s a r e u n d e r l i n e d t o f a c i l i t a t e t h e i r i d e n t i f i c a t i o n . F o c u s i n g on S e l f The major co n c e p t , F o c u s i n g on S e l f , i s an i n t e g r a l 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 as F o c u s i n g on t h e i r C l i e n t s , 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 I n t e r v e n t i o n s the n u r s e s l o o k e d i n w a r d , and, i n F o c u s i n g on S e l f , s e a r c h e d f o r t h e i r own r e a c t i o n s t o t h e 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 i d e n t i f y i n g f e e l i n g s . A n a l y z i n g Thoughts was p a r t o f each n u r s e - t h e r a p i s t ' s d i s c l o s u r e e x p e r i e n c e , and o c c u r r e d when the n u r s e s 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 t h o u g h t s . A n a l y z i n g Thoughts i s t h e m e n t a l p r o c e s s of t h i n k i n g about the 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 t h e o r e t i c a l framework wh i c h enhanced t h e i r u n d e r s t a n d i n g o f t h e problem, and a l e r t e d them t o the t h e r a p y i s s u e s t h a t 47 t h e i r c l i e n t s would 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 . F o r example, Lynne remembered t h i n k i n g about t h e n o t i o n s o f b o u n d a r i e s , power, and b r e a k i n g t r u s t , and r e c a l l s b e i n g aware t h a t she would need t o be c o g n i z a n t o f t h e s e i s s u e s . (The u n d e r l i n e d c o n c e p t s a r e e l a b o r a t e d upon and d i s c u s s e d i n d e t a i l ) . A l i c e remembered t h i n k i n g about t h e n o t i o n s o f b o u n d a r i e s , 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. T a k i n g time t o t r y t o d e t e r m i n e t h e t r u t h f u l n e s s o f h e r c l i e n t ' s d i s c l o s u r e was a s i g n i f i c a n t p a r t o f h e r e x p e r i e n c e . She remembered t h i n k i n g about the 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 s i n c e h e r d i s c l o s u r e e x p e r i e n c e happened 15 y e a r s b e f o r e . She r e p o r t e d t h a t s i n c e then,- h e r t h o u g h t s about s e x u a l abuse had changed c o n s i d e r a b l y . 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 and she wondered i f t h e r e was e v e r an a c c e p t a b l e time f o r c l i e n t s and t h e r a p i s t s t o g e t i n v o l v e d s e x u a l l y . She remembered t h i n k i n g about how p s y c h i a t r i s t s had the power t o m a n i p u l a t e t h e t h e r a p y r e l a t i o n s h i p , and t o c o e r c e o t h e r s i n t o n ot r e p o r t i n g them. A n o t h e r p a r t of the 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 as the n u r s e s l i s t e n e d t o t h e i r c l i e n t s ' abuse s t o r i e s . Each of t h e s e n u r s e s r e p o r t e d e x p e r i e n c i n g i n t e n s e f e e l i n g s . E x p e r i e n c i n g F e e l i n g s 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 E x p e r i e n c i n g F e e l i n g s of b e i n g " o u t r a g e d " , "ho r r i f i e d " , " a p p a l l e d " , and " f u r i o u s . " She remembered f e e l i n g " p o w e r l e s s " and "outraged" about t h e r e p o r t i n g system. When w o r k i n g w i t h h e r c l i e n t , she r e c a l l e d f e e l i n g " c a r i n g " and f e e l i n g "concerned" about h e r . " P o w e r l e s s " , "impotent", " h e l p l e s s " , and "angry" were the f e e l i n g words Cathy used-when she 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 a t t e m p t s t o s t o p t h e s e x u a l e n c o u n t e r s . A t ti m e s she s a i d t h a t she would d r e a d s e e i n g h e r 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 o f me." She remembered f e e l i n g "concern" f o r h e r s i n c e h e r 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 s u i c i d a l . She r e p o r t e d f e e l i n g " f r u s t r a t e d " w i t h t h e o f f e n d i n g p s y c h i a t r i s t who she b e l i e v e d was m a n i p u l a t i n g h e r c l i e n t . F i f t e e n - y e a r s l a t e r , Cathy e x p r e s s e d h e r c a r i n g t h i s way: "At ti m e s I t h i n k about h e r and wonder how she's d o i n g . " A l i c e , a l s o , t a l k e d about the f e e l i n g s she e x p e r i e n c e d . She.remembered she 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 s e x u a l r e l a t i o n s h i p , and she r e c a l l s t h a t she f e l t an "urgency" t o i n t e r v e n e . She remembered f e e l i n g " p o w e r l e s s " and " r e a l l y f r u s t r a t e d " t h a t t h e c l i e n t k e p t c h a n g i n g h i s t r e a t m e n t g o a l s and h i s d i s c l o s u r e s t o r y . He was f r e q u e n t l y i n c r i s i s and a t t h o s e t i m e s she f e l t " c o n c e r n " , " s t r e s s e d " , and " h a r r i e d " . , 49 I n summary, as I d e s c r i b e d and compared the s t u d y n u r s e s ' a c c o u n t s of t h e i r r e s p o n s e s t o t h e i r 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 by a p r e v i o u s t h e r a p i s t , n i n e elements emerged f o r me. These n i n e elements (see F i g u r e 1. page 40) I c o n c e p t u a l i z e d as f o l l o w s : the p r i m a r y i n t e g r a t i n g concept i s 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 ; t h e two w o r k i n g c o n c e p t s a r e 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 o f S e l f ; subsumed under, F o c u s i n g on t h e C l i e n t a r e two sub-c o n c e p t s , 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 I n t e r v e n t i o n s ; subsumed under F o c u s i n g on S e l f a r e two 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 Thoughts; two m o d i f y i n g -c o n c e p t s of A n a l y z i n g Thoughts a r e A n a l y z i n g B o u n d a r i e s and A n a l y z i n g Power. The l i t e r a t u r e s t r o n g l y s u p p o r t s t h e n o t i o n t h a t b o u n d a r i e s and power a r e c r u c i a l dynamics i n s i t u a t i o n s 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 ( G u t h e i l , 1989; Herman, 1992; G u t h e i l and Gabbard, 1993). F u r t h e r , a l t h o u g h t h e r a p i s t s debate th e r e l a t i v e i m p o r t a n c e o f t h e r e l a t i o n s h i p between c l i e n t and t h e r a p i s t , t h i s r e p o r t 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 th e s t u d y n u r s e s and t h e i r c l i e n t s was a fundamental f a c t o r i n t h e n u r s e s ' e x p e r i e n c e o f c l i e n t d i s c l o s u r e . These t h r e e c o n c e p t s ( b o u n d a r i e s , power, and t h e 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 t h e phenomenon under st u d y , t h a t 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 and i t s d i s c l o s u r e t o a subsequent m e n t a l h e a l t h p r o f e s s i o n a l . These•concepts a r e t h e r e f o r e s i n g l e d out f o r 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 the t h e r a p e u t i c r e l a t i o n s h i p . L a t e r , A n a l y z i n g B o u n d a r i e s 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 l i t e r a t u r e . Discussion of Focusing on the C l i e n t 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 t o each 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 . I t r e f e r s t o t h e n u r s e ' 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 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 c l i e n t ' s t h o u g h t s , f e e l i n g s , 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 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 ; w i t h o u t F o c u s i n g on the C l i e n t t h e r e can be no t h e r a p y . As a t h e r a p i s t , the n u r s e e n t e r s i n t o a s p e c i a l r e l a t i o n s h i p i n w h i c h she a c c e p t s the 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 a c t i n t h e l a t t e r ' s b e s t i n t e r e s t (Feldman-Summers, 1989). A l t h o u g h t h e s t u d y n u r s e s d i d n o t use t h i s e x a c t term, t h e l i t e r a t u r e t y p i c a l l y c a l l s t h i s a t h e r a p e u t i c r e l a t i o n s h i p . 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 t o b e t t e r u n d e r s t a n d 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 e x p e r i e n c e and the concept of 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 has l o n g been 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 the p s y c h o l o g i c a l t h e r a p y p r o c e s s . A l t h o u g h 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 t h e r a p y cannot be done w i t h o u t such a r e l a t i o n s h i p , t h e y do n o t agree, w i t h each o t h e r about i t s i m p o r t a n c e . S i n c e i t was f i r s t 51 a r t i c u l a t e d by F r e u d (Kahn, 1991), i n t h e l a t e 1890s, t h e r e has been much c o n t r o v e r s y about i t s i m p o r t a n c e and dynamics. An h i s t o r i c a l p e r s p e c t i v e i s h e l p f u l i n u n d e r s t a n d i n g t h e c o n t r o v e r s i a l i s s u e s , and i n e x p l a i n i n g what t h e n u r s e s r e p o r t e d . The n o t i o n was c o i n e d by 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 what m a t t e r e d most was what t h e p h y s i c i a n d i d . t o , and f o r , the p a t i e n t ' s c o n d i t i o n ; t h e r e l a t i o n s h i p between the p a t i e n t and 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, however, as he o b s e r v e d a c o l l e a g u e t r e a t a woman w i t h h y s t e r i a , he began o b s e r v i n g what was happening between the two. Fr 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 the 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 deeper and more complex t h a n t h e c o n v e n t i o n a l p a t i e n t p h y s i c i a n r e l a t i o n s h i p . 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 t h e 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 ( a n a l y s t ) was c r u c i a l , 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 , and v e r y complex r e g a r d l e s s of how i t may appear on t h e s u r f a c e (Kahn, 1991; P a r l o f f , 1986). H i s way o f b e i n g w i t h p a t i e n t s was a c t i v e and engaging. He c a r r i e d on a r e a l d i a l o g u e w i t h p a t i e n t s and tended t o t h e i r c u r r e n t needs. He i n t u i t i v e l y knew when t o engage and when t o be d i s t a n t . However, i n s t e a d of a d v o c a t i n g t h a t o t h e r a n a l y s t s f o l l o w . h i s b e h a v i o r , he encouraged them t o be d i s t a n t (Kahn, 1991). What t h e s t u d y n u r s e s d e s c r i b e d 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 o f b e i n g w i t h h i s c l i e n t s . A 52 10 0 y e a r s a f t e r Freud, t h e s e n u r s e s d e s c r i b e d t h e i r e x p e r i e n c e s as b e i n g a c t i v e l y i n v o l v e d i n l i s t e n i n g , o b s e r v i n g , 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 Freud's f e l l o w a n a l y s t s who were d i s t a n t , remote, and s i l e n t . These a n a l y s t s w a i t e d f o r t h e t r a n s f e r e n c e t o "appear" and spoke o n l y when o f f e r i n g an 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 . T r a n s f e r e n c e , F r e u d b e l i e v e d , was t h e main p o i n t o f p s y c h o t h e r a p y , and i t r e f e r s t o t h e 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 , f e a r s , and wis h e s from l o n g ago onto t h e i r a n a l y s t s (Kahn, 1991; J a c o b s o n , 1993). I t i s beyond t h e scope o f t h i s t h e s i s t o d e s c r i b e the dynamics of t h i s complex p r o c e s s o f t r a n s f e r e n c e ; s i m p l y p u t , the a n a l y s t s ' t h e r a p y g o a l s 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 m a n i f e s t a t i o n s , t o p r o t e c t c l i e n t autonomy, and 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, 1993). Freud's f o l l o w e r s had g o a l s f o r t h e r a p y , and t h e s t u d y n u r s e s r e p o r t e d g o a l s when F o c u s i n g on t h e C l i e n t . However, e n c o u r a g i n g the t r a n s f e r e n c e was not one o f them; when F o c u s i n g on the C l i e n t , t h e i r g o a l s were t o h e l p t h e i r c l i e n t s and t o p r o t e c t them from harm. I n the 1940s, an American a n a l y s t , C a r l Rogers, was a major f o r c e i n i n i t i a t i n g a change w h i c h humanized t h e p e r c e p t i o n s 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 and u n c o n d i t i o n a l r e g a r d f o r c l i e n t s , and genuineness on t h e p a r t o f the t h e r a p i s t . Rogers (1961) d i r e c t e d t h e r a p i s t s t o 53 demonstrate an a t t i t u d e of 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 i m p o s i n g t h e i r i n t e r p r e t a t i o n s onto t h e i r c l i e n t s . D i f f e r e n t from a n a l y s t s , whose t h e r a p e u t i c a t t i t u d e was d i s t a n t and s i l e n t , t h e s t u d y 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 and c a r i n g , c l o s e r t o t h e R o g e r i a n v i e w . ,The r a d i c a l p o l i t i c a l c l i m a t e o f t h e 1960s demanded a d e m o c r a t i c t h e r a p e u t i c r e l a t i o n s h i p . T h e r a p i s t s s e a r c h e d f o r ways t o make th 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 the e n c o u n t e r movement w h i c h • emphasized a u t h e n t i c i t y and symmetry (Kahn, 1991). A u t h e n t i c i t y meant t h a t the t h e r a p i s t s h o u l d be as h o n e s t and as e m o t i o n a l l y exposed as t h e c l i e n t , and symmetry demanded t h a t t h e t h e r a p i s t be w i l l i n g t o do a n y t h i n g t h a t t h e c l i e n t was asked- t o do. Encounter t h e r a p i s t s s p o n t a n e o u s l y and o p e n l y 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 used u n r e s t r a i n e d c o n f r o n t a t i o n . 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 h o s t i l i t y , 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 w i t h t h e i r c l i e n t s (Kahn, 1991). The s t u d y n u r s e s were d i f f e r e n t from t h e r a d i c a l t h e r a p i s t s d e s c r i b e d p r e v i o u s l y . Not o n l y d i d t h e y c o n t a i n t h e i r own f e e l i n g s , b u t t h e y adamantly a s s e r t e d t h a t i t was wrong f o r t h e r a p i s t s t o a c t out t h e i r f e e l i n g s by e n g a g i n g i n sex w i t h t h e i r c l i e n t s . A l i c e s t a t e d : " I was a p p a l l e d t h a t i t might even be a s e x u a l r e l a t i o n s h i p . " C a t h y d e c l a r e d : " I t was so wrong, he r e a l l y t o o k advantage o f h e r . 54 She was so v u l n e r a b l e . He was wrong t o have a s e x u a l r e l a t i o n s h i p w i t h h e r . " Lynne e x p r e s s e d h e r b e l i e f s s t r o n g l y : "Sex between a t h e r a p i s t and a c l i e n t , a p h y s i c i a n and a c l i e n t , 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 ma 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 by, the en 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 of p o s i t i v e r e g a r d were t a k e n t o extremes by some members o f t h i s movement. Some o f t h e s e t h e r a p i s t s p r a c t i c e d i n a h a r s h l y c o n f r o n t a t i o n a l manner, and b e l i e v e d t h e y had p e r m i s s i o n t o g i v e c l i e n t s p h y s i c a l , l o v i n g , and s e x u a l s u p p o r t (Kahn, 1991). Rogers, however, p r a c t i s i n g i n ' a l e s s a g g r e s s i v e manner, b e l i e v e d he s h o u l d p r o v i d e o n l y e m o t i o n a l s u p p o r t . When t h e s t u d y n u r s e s were F o c u s i n g on the C l i e n t t h e y o f f e r e d e m o t i o n a l s u p p o r t , as Rogers' would have w i t h i n t h e c o n t e x t o f the t h e r a p e u t i c r e l a t i o n s h i p . But, u n l i k e him, t h e y gave more. When t h e i r c l i e n t s were 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 s u i c i d e o r t a k i n g d r u g overdoses) the n u r s e s r e c a l l e d t h a t t h e y had a r r a n g e d v o l u n t a r y 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 c l i e n t s who had s e v e r e p e r s o n a l i t y d i s o r d e r s and who were l o w - f u n c t i o n i n g , u n l i k e the h i g h - f u n c t i o n i n g p a t i e n t s t y p i c a l l y seen by a n a l y s t s . And u n l i k e the en c o u n t e r movement t h e r a p i s t s , who i n t h e i r t h e r a p e u t i c 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, 1991), t h e t r a n s c r i p t s r e v e a l 55 t h e s e n u r s e s as h a v i n g been warm, empathic, h e l p f u l , and c a r i n g . • ' The debate c o n t i n u e s today among t h e r a p i s t s about t h e im p o r t a n c e 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 . F o r example, 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 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 t h e f o l l o w i n g : p s y c h o a n a l y t i c t h e r a p y , o b j e c t r e l a t i o n s t h e r a p y , G e s t a l t t h e r a p y , p s y c h o s o c i a l t h e r a p y , and v a r i o u s b o d y - o r i e n t e d t h e r a p i e s (Kahn, 1991). A l t h o u g h t h e r a p i s t s e m p l o y i n g c o g n i t i v e t h e r a p y , b e h a v i o r t h e r a p y , and a d v i c e - g i v i n g t h e r a p y do not a c t i v e l y use the r e l a t i o n s h i p t o f a c i l i t a t e p a t i e n t s ' changes, t h e y do agree t h a t a p o s i t i v e r e l a t i o n s h i p promotes a p o s i t i v e outcome (Lambert, 1982). S i m i l a r t o psychodynamic t h e r a p i s t s , t h e s t u d y p a r t i c i p a n t s b e l i e v e d t h a t F o c u s i n g on t h e C l i e n t was an 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 used t h e r e l a t i o n s h i p 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 b o t h 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 e m o t i o n a l d i f f i c u l t i e s . I n F o c u s i n g on t h e C l i e n t Lynne encouraged h e r c l i e n t t o t a l k about 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 . Lynne 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 about 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 , and she t o l d me about some h o r r i b l e abuses." Cathy p r o v i d e d t h i s d a t a : by F o c u s i n g on t h e C l i e n t , she c r e a t e d an e m o t i o n a l environment where h e r 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 t h o u g h t s , and she s u b s e q u e n t l y a c c e p t e d Cathy's h e l p . Lynne's and Cat h y ' s 56 i n t e r a c t i o n s 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 p l a c e w i t h o u t t h e p r o c e s s of Focusing, on t h e C l i e n t . C a r l Rogers (1961) d e f i n e d a t h e r a p e u t i c r e l a t i o n s h i p as "a h e l p i n g r e l a t i o n s h i p i n w h i c h one o f t h e p a r t i e s has the i n t e n t o f p r o m o t i n g the growth, development, m a t u r i t y , improved f u n c t i o n i n g , improved c o p i n g w i t h l i f e o f t h e o t h e r " (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 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 f i c i n t e n t and t h e h e l p e r has a unique 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 r e l a t i o n s h i p depends 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 and c l i e n t w h i c h can e i t h e r f o s t e r o r h i n d e r a t h e r a p e u t i c r e l a t i o n s h i p . 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 e s s e n t i a l f o r a t h e r a p e u t i c r e l a t i o n s h i p . 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 i n t e n t , and i n F o c u s i n g on the C l i e n t , s t u d y n u r s e s s u g g e s t e d t h e y had a g o a l . To me, s p e c i a l i n t e n t i s the same as a g o a l . E v a l u a t i n g and t r e a t i n g i n i t i a l c l i e n t problems was t h e s p e c i f i c i n t e n t f o r 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 and was the g o a l of t h e s e n u r s e s when t h e y were F o c u s i n g on the C l i e n t . Each n u r s e p r o v i d e d d a t a about t h e purpose o f he r t h e r a p e u t i c r e l a t i o n s h i p . Cathy's g o a l was t o h e l p h e r c l i e n t c o n t r o l the "symptoms of h e r p s y c h o t i c i l l n e s s and 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 c r i s i s s t a t e i n w h i c h she was h a v i n g " t e r r i b l e arguments w i t h h e r mother and 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 s a f e t y 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 , and " t o p r o v i d e s u p p o r t f o r d i f f i c u l t i e s a r i s i n g from h i s s u b s t a n c e 57 abuse and p e r s o n a l i t y d i s o r d e r . " When Lynne Focused on t h e C l i e n t , h e r g o a l was t o h e l p h e r work t h r o u g h i s s u e s r e l a t e d t o c h i l d h o o d and a d o l e s c e n t s e x u a l and r i t u a l abuse. The l i t e r a t u r e s u p p o r t s the n o t i o n 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 s a r e 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 . B a r c i a and R u i z (1990) b e l i e v e t h e r e l a t i o n s h i p i s an i n t e r p e r s o n a l h e l p i n g bond i n t e n d e d t o h e l p c l i e n t s meet t h e i r needs and a t t a i n h e a l t h . R a i s i n g the p a t i e n t ' s m orale o r hope i s t h e i n t e n t of 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 t o Lambert (1982) and P a r l o f f (1986). P r o m o t i n g p a t i e n t growth and development, improved f u n c t i o n i n g , and c o p i n g a r e t h e i n t e n t i o n s p u r p o r t e d by Rogers (1961). F i n a l l y , M e i s l e r (1991) contends t h a t the p a t i e n t and t h e r a p i s t come t o g e t h e r w i t h t h e i n t e n t i o n o f r e d u c i n g o r r e s o l v i n g t h e p a t i e n t ' s p r oblems. I n a t h e r a p e u t i c r e l a t i o n s h i p , t h e t h e r a p i s t has a s p e c i f i c r o l e , and i n F o c u s i n g on the C l i e n t t h e s t u d y n u r s e s s u g g e s t e d t h e y had a m i s s i o n o r a s p e c i f i c r o l e . They b e l i e v e d t h e y s h o u l d be a v a i l a b l e f o r t h e b e n e f i t o f c l i e n t s , t o c o n c e n t r a t e on t h e i r c l i e n t s ' needs and p u t t h e s e needs ahead of t h e i r own. By c o n c e a l i n g t h e i r f e e l i n g s when c l i e n t s d i s c l o s e d s e x u a l abuse, t h e s e s t u d y n u r s e s p u t t h e i r c l i e n t s ' needs ahead of t h e i r own, and were p r e s e n t t o b e n e f i t the c l i e n t s . Lynne gave t h e s e d a t a : W e l l , I don't l e t my f u r y show, because t h a t ' s wrong, I mean i t ' s not O.K. These a r e my f e e l i n g s . She'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 ask h e r q u e s t i o n s about what 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 58 don't s i t on them. I s o r t o f p u t them away f o r a w h i l e . . . . But I t a k e some o f my anger and I t h i n k a whole l o t more- about h e r e x p e r i e n c e and what she wants t o do ... and I t o l d h e r t h a t i t ' s wrong what t h a t p e r s o n d i d . Note how Lynne v o i c e d h e r own f e e l i n g s . A l i c e d e s c r i b e d how she p u t h e r c l i e n t ' s needs ahead o f h e r 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 he was c u r r e n t l y h a v i n g s e x u a l a c t i v i t y w i t h h i s g e n e r a l p r a c t i t i o n e r , A l i c e s a i d , " I f e l t s u r p r i s e d , somewhat a p p a l l e d , b u t d i d n o t share t h a t w i t h the c l i e n t a t t h e t i m e . . . . We f i n i s h e d the assessment ... the n t h e s e s s i o n was t e r m i n a t e d . " She r e p o r t e d t h a t she chose 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 n e g a t i v e e f f e c t on him. L i t e r a t u r e s u p p o r t s L y n n e 1 s and A l i c e ' s d e c i s i o n s t o c o n c e a l t h e i r f e e l i n g s as a way o f p u t t i n g t h e i r c l i e n t s ' needs f i r s t and of F o c u s i n g on 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 the t h e r a p i s t s ' p e r c e i v e d needs. Lambert (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 t h a t c o n t r i b u t e t o a p o s i t i v e o r n e g a t i v 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 p o r t s t h a t t h e r a p i s t e x p r e s s i v e n e s s has an 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 and t r u s t . K a ron and Vanderbos (1972; c i t e d i n Lambert, 1982), t e s t e d t h e i r h y p o t h e s i s t h a t " p a t h o g e n i c " ( t h e i r quotes) t h e r a p i s t s , . c o n s c i o u s l y o r u n c o n s c i o u s l y , 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 needs.,These t h e r a p i s t s were found t o be more n o x i o u s 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 p u t 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 were found t o f u n c t i o n a t h i g h e r l e v e l s t h a n t h o s e o f the " p a t h o g e n i c " t h e r a p i s t s . 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 i l l u s t r a t e s a n o t h e r way of p u t t i n g t h e c l i e n t ' s needs ahead 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 the C l i e n t . I n o r d e r t o p u t h e r c l i e n t ' s needs f i r s t A l i c e suspended h e r own r e a l i t y and b e l i e v e d h e r c l i e n t ' s d i s c l o s u r e , s u p p o r t i n g him w i t h encouragement t o r e p o r t t h e a l l e g e d o f f e n d i n g p h y s i c i a n . A l i c e d e s c r i b e d s u s p e n d i n g h e r r e a l i t y t h i s way: [Although] "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 l i a i s o n w i t h h i s g e n e r a l p r a c t i t i o n e r , " A l i c e had worked w i t h t h i s 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 r e p o r t e d : T h i s d o c t o r had a v e r y good c l i n i c a l r e p u t a t i o n and 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 me n t a l h e a l t h community. Whereas [my] c l i e n t had l i e d about a l o t o f t h i n g s ... he s a i d t h a t he was HIV p o s i t i v e ... and a b l o o d t e s t r e s u l t we got showed he wasn't.... To me t h e dilemma 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 s u b s t a n c e 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 th o s e d i a g n o s e s ... v e r s u s someone who has a good r e p u t a t i o n . . . . But no m a t t e r how " f l a k y ' a c l i e n t i s , you need 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 tatement makes A l i c e ' s dilemma 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 r e p o r t s w h i c h were c o n t r a d i c t o r y t o h e r p e r s o n a l e x p e r i e n c e , was a dilemma f o r h e r . L i k e a l l t h e r a p i s t s 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 , t h e s e n u r s e s used 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 . I n t e r v e n t i o n s a r e b e h a v i o r s t h a t s t u d y n u r s e s used t o h e l p 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 c o p i n g a b i l i t i e s and 60 p r e v e n t f u r t h e r d i s a b i l i t y ( S t u a r t & Sundeen, 1991). They a r e f o r the b e n e f i t o f t h e c l i e n t . These b e h a v i o r s may be p a s s i v e , such as l i s t e n i n g , o r a c t i v e , such as o r g a n i z i n g the s i g n i n g o f c o m m i t t a l papers o r p h o n i n g f o r an ambulance. The i n t e r v e n t i o n of c a r e f u l l i s t e n i n g was p a r t o f Lynne's 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 t h e C l i e n t . She r e p o r t e d h e r e x p e r i e n c e t h i s way: [The c l i e n t ] was t a l k i n g about t h e number of 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 ... about 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 had been f o r h e r t o see so many d i f f e r e n t p e o p l e , and nobody 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 abuse. 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 t h e c l i e n t had not s a i d . She went on: " I asked about who had abused h e r o r i f she had e v e r been abused by a p r o f e s s i o n a l ... and she s a i d , 'Yes'.... A p s y c h i a t r i s t who she had been s e e i n g some y e a r s ago." Lynne l i s t e n e d t o h e r c l i e n t so t h a t she c o u l d u n d e r s t a n d and empathize w i t h h e r . As w e l l , she 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 by s a y i n g : What t h a t p e r s o n d i d wasn't O.K.; i t was v e r y u n e t h i c a l . . . . I asked h e r i f she wanted t o do a n y t h i n g about i t . . . . She d i d n ' t want t o do any t h i n g about 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 have enough ego s t r e n g t h t o go t o the 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 o f c a r e f u l l i s t e n i n g . The r e s u l t s of a c l a s s i c s t u d y (Truax, Wargo, Frank, Imber, B a t t l e , Nash, & Stone, 1966, c i t e d by Lambert, 1982) showed t h a t p a t i e n t s whose t h e r a p i s t s were j u d g e d h i g h 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 warmth o r 61 r e s p e c t , and genuineness, showed s i g n i f i c a n t l y more improvement on o v e r a l l i n d i c e s o f change t h a n t h o s e t h e r a p i s t s who were judged low. 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 b o t h Cathy's and A l i c e ' s p r a c t i c e w i t h t h e i r d i s c l o s i n g c l i e n t s , and o f F o c u s i n g on the 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 and d e c i s i v e l y when th e y d e t e r m i n e d t h e i r c l i e n t s ' s a f e t y was t h r e a t e n e d . They t a l k e d about i t t h i s way: t h e i r c l i e n t s were angry, a n x i o u s , and prone t o b e i n g i n c r i s i s ; t h e y f r e q u e n t l y t h r e a t e n e d s u i c i d e , took o v e r d o s e s o f p r e s c r i b e d , o v e r - t h e - c o u n t e r , and r e c r e a t i o n a l d r u g s , and 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. Cathy and A l i c e remembered r e s p o n d i n g i m m e d i a t e l y and c o n c r e t e l y . " I a r r a n g e d f o r a h o s p i t a l bed," " I booked an appointment r i g h t t h e n , " " I took h e r t o [a c r i s i s f a c i l i t y ] " , " I t o o k him t o de t o x , " " I made emergency appointments t o t a l k o r t o have h e r meds a d j u s t e d " . The 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 and i m p o r t a n t i n p s y c h o s o c i a l t h e r a p y (Lambert, 1982). They p r o v i d e t h e p a t i e n t w i t h o r encourage i n t e l l e c t u a l u n d e r s t a n d i n g of the 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 a n x i e t y , p r o v i d e s u p p o r t , and l i m i t a c t i n g out b e h a v i o r . Bandura, J e f f e r y , and W r i g h t (1974; c i t e d i n Lambert, 19 82) found i n t h e i r s t u d y t h a t t h e h i g h e s t degree o f b e h a v i o r and a t t i t u d e change 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 the 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 T h e r a p i s t s e x h i b i t t h e r a p e u t i c q u a l i t i e s 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 , and i n F o c u s i n g on the C l i e n t , s t u d y n u r s e s 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 . T h e i r a t t i t u d e i s a concerned way o f b e i n g w i t h a c l i e n t t h a 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 r e d u c i n g p e r s o n s t o the mora l s t a t u s o f o b j e c t (Watson, 1988). Each o f t h e s t u d y n u r s e s r e c a l l e d h e r c o n c e r n f o r h e r c l i e n t . F o r example, Cathy was w o r k i n g i n a new environment: I was new and I f e l t i n over my head [ 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 and demanding 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 of 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 f e l t f r u s t r a t e d w i t h b o t h the c l i e n t and h e r own a b i l i t i e s : " I was new a t t h e team and not a t a l l h e l p f u l t o the c l i e n t . " 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 k e p t w o r k i n g w i t h h e r c l i e n t and ke 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 wonder how she i s doing--O.K. I hope." Lynne r e p o r t e d h e r c o n c e r n when she t a l k e d about h e r c l i e n t r e f u s i n g t o t a k e a c t i o n a g a i n s 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 . She s a i d : I t h i n k i t t a k e s a l o t o f courage 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 no.... 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 day ... u n a b l e t o work ... 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 would never encourage somebody t o go and do something i f t h e y weren't f e e l i n g O.K. about i t . The t h e r a p i s t ' s q u a l i t i e s have been much s t u d i e d and r e p o r t e d . L a z a r u s (1971; c i t e d i n Lambert, 1982) i n an 63 uncontrolled study of his patients, found that the most frequently mentioned therapist q u a l i t i e s were s e n s i t i v i t y , gentleness, and honesty. Other q u a l i t i e s included l i k i n g the patient, active involvement, i n s p i r i n g hope and confidence (Frank,. 1974; c i t e d i n Parloff, 1986); therapeutic warmth or love (Barcia and Ruiz, 1990); caring, empathic, understanding, and interest (Lambert, 1982). Indeed, Rogers (1961) claimed that the q u a l i t i e s of the therapist are more important than therapy techniques. Es s e n t i a l to establishing a therapeutic r e l a t i o n s h i p i s mutual cooperation between the therapist and the c l i e n t . Either the therapist and/or the c l i e n t can act i n ways which preclude the formation of a therapeutic r e l a t i o n s h i p . In Focusing on the Client, these nurses talked about working together with t h e i r c l i e n t s , that i s , mutual cooperation. Working together means behaving i n ways congruent with the agreed upon therapeutic goals. A l i c e reported that when she was Focusing on the Client, she f a i l e d to create a therapeutic re l a t i o n s h i p . She found i t " r e a l l y f r u s t r a t i n g because there was no relationship." Her c l i e n t came to the c l i n i c asking for help which she was w i l l i n g to give. A l i c e remembered wanting to protect her c l i e n t from harm due to c l i e n t therapist sex and she became immediately involved with plans to confront and report the alleged offender. Her c l i e n t i n i t i a l l y agreed. As well, A l i c e reported: The c l i e n t said that he wanted to work on his issues a r i s i n g from childhood sexual abuse, and g r i e f r e l a t e d to his partner dying.... I agreed to work on these 64 t h e r a p y i s s u e s w i t h him. But i n s t e a d o f w o r k i n g w i t h me, he ke p t c h a n g i n g h i s agenda.... H i s b e h a v i o r became more and more d i f f i c u l t . . . . He was u s i n g a l o t o f drugs and a l c o h o l ... he t h r e a t e n e d us 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 would d r a g h i m s e l f i n on a l l f o u r s , i n an a l m o s t comatose s t a t e , and 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 wanted everybody t o see him.... 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 so 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 from f o r m 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 . R e s e a r c h s u p p o r t s A l i c e ' s c l a i m t h a t a t h e r a p e u t i c r e l a t i o n s h i p had not been e s t a b l i s h e d . T h e r a p i s t q u a l i t i e s t h a t p r e v e n t the f o r m a t i o n o f a r e l a t i o n s h i p have r e c e i v e d much r e s e a r c h a t t e n t i o n . C u r r e n t r e s e a r c h i n c l u d e s p a t i e n t q u a l i t i e s w h i c h p r e c l u d 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 . P r o c h a s k a and N o r c r o s s (1981; c i t e d i n Lambert, 1982) found t h a t t h e r e was an i n c r e a s i n g consensus among t h e r a p y r e s e a r c h e r s t h a t c l i e n t q u a l i t i e s o r c h a r a c t e r i s t i c s a c c o u n t f o r a g r e a t e r p r o p o r t i o n o f the outcome v a r i a n c e t h a n do t h e r a p i s t c h a r a c t e r i s t i c s . S p e c i f i c q u a l i t i e s t h e y c i t e a r e po o r 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 p o o r i n t e r p e r s o n a l r e l a t i o n s h i p s . A l i c e r e p o r t e d t h a t h e r c l i e n t had 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 i n t e r p e r s o n a l r e l a t i o n s h i p s . L o c a t i n g the 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 the C l i e n t w i t h i n the more t r a d i t i o n a l v i e w o f t h e r a p e u t i c r e l a t i o n s h i p s demonstrates how t h e y b o t h f i t and do n o t f i t w i t h h i s t o r i c a l and p r e s e n t e v o l u t i o n of b e l i e f s . A f t e r 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 I n t e r v e n t i o n s , t h e s e t h r e e n u r s e s t u r n e d 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 p r i m a r y c o n c e p t i n t h e C y c l e of 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 i s t h e p r o c e s s t h a t t h e y used t o s e a r c h f o r t h e i r m e n t a l 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 i m p o r t a n t f o r t h e r a p y , s i n c e s t u d y n u r s e s 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 . They a t t e n d e d t o e i t h e r t h e i r t h o u g h t s o r t h e i r emotions. When a t t e n d i n g t o t h e i r t h o u g h t s , the s t u d y n u r s e s thought about th e phenomenon o f c l i e n t - t h e r a p i s t sex c o n c e p t u a l l y ; I have c a l l e d t h i s p r o c e s s A n a l y z i n g Thoughts. T h i s i m p o r t a n t p r o c e s s enhanced s t u d y n u r s e s ' u n d e r s t a n d i n g o f t h e i r c l i e n t s ' p o t e n t i a l i s s u e s , making 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 thought about t h e i r c l i e n t s ' 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 of boundary and t r u s t v i o l a t i o n s , and of t h e abuse o f power. I n 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 , I 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 and have l a b e l e d them A n a l y z i n g B o u n d a r i e s and A n a l y z i n g Power. To e n r i c h t h e u n d e r s t a n d i n g of the s t u d y 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 s and t h e s e m o d i f y i n g - c o n c e p t s , I t u r n f i r s t t o t h e l i t e r a t u r e about t h e r a p e u t i c boundary. Discussion of Analyzing Boundaries J u s t as t h e l i t e r a t u r e about the 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 im p o r t a n c e o f t h e r e l a t i o n s h i p , so too t h e l i t e r a t u r e d e m o n s t r a t e s t h a t t h e r a p i s t s do not agree 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 the 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 t h e r a p i s t , t h e a c c e p t a b i l i t y o f t h e r a p e u t i c i n t e r v e n t i o n s , 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 happen? S i m i l a r t o the term t h e r a p e u t i c r e l a t i o n s h i p , t h e term boundary was c o n f u s e d from the time o f i t s f i r s t a r t i c u l a t i o n by F r e u d ( L i p t o n , 1977; c i t e d i n G u t h e i l and Gabbard, 1993).' I n the 1900s, F r e u d was d e v e l o p i n g and t e a c h i n g p s y c h o a n a l y t i c t h e o r y . He s t a t e d t h a t a n a l y s t s must be c l e a r about t h e t h e r a p i s t ' s r o l e , k e e p i n g t h e i r p r o f e s s i o n a l and p e r s o n a l r e l a t i o n s h i p s a b s o l u t e l y s e p a r a t e . T h i s s e p a r a t i o n was the t h e r a p e u t i c boundary. But 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 used metaphors i n v o l v i n g t h e opaqueness o f a m i r r o r and the d i s p a s s i o n a t e o b j e c t i v i t y o f t h e surgeon t o d e s c r i b e t h e a n a l y s t ' s r o l e . However h i s b e h a v i o r d i d n o t r e f l e c t the a b s t i n e n c e and anonymity t h a t he a d v o c a t e d . He s e n t h i s p a t i e n t s p o s t c a r d s , l e n t them books, gave them g i f t s , and on one r e p o r t e d o c c a s i o n gave a p a t i e n t a meal ( L i p t o n , 1977; c i t e d i n G u t h e i l and Gabbard, 1993) . Perhaps the most s t r i k i n g i l l u s t r a t i o n o f boundary c o n f u s i o n between p e r s o n a l and 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 Freud's a n a l y z i n g h i s daughter Anna'. T h i s d i s c r e p a n c y between t h e o r y and 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 prominent p s y c h o a n a l y s t s o f t h a t t i m e . M e l a n i e K l e i n encouraged a p a t i e n t t o go on 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 h e l d 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 w i t h 67 c o f f e e and b i s c u i t s ( G u t h i e l and Gabbard, 1993) . Hence, t h e i r f o l l o w e r s had an u n c l e a r u n d e r s t a n d i n g of t h e t h e r a p e u t i c boundary. A l t h o u g h I have used o n l y a few examples of b e h a v i o r s t h a t a r e s t i l l n o t c o n s i d e r e d a c c e p t a b l e among most a n a l y s t s , the l i t e r a t u r e r e v e a l s many s i m i l a r examples. U n l i k e t h e s e a n a l y s t s , the s t u d y n u r s e s were c l e a r about th e d i v i s i o n , the boundary, between t h e i r p r o f e s s i o n a l and p e r s o n a l 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 she's gonna come and see me, I don't want h e r t o even think t h a t I would c r o s s t h a t boundary l i n e . . . . I want t o be r e a l l y c l e a r and I say t h i s i s who I am; t h i s i s what I do; t h i s i s what I do n o t do.... 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 hope i s t h a t t h e r e ' s a sense, of s a f e t y b u i l t i n . A l i c e and Cathy b o t h r e c a l l e d t h a t t h e y had always d e c l i n e d t h e i r c l i e n t s ' i n v i t a t i o n s t o go out f o r c o f f e e , and by t h i s b e h a v i o r t h e y k e p t t h e i r p e r s o n a l and p r o f e s s i o n a l r o l e s s e p a r a t e d . The term boundary.can a l s o be used when r e f e r r i n g t o t h e r a p e u t i c i n t e r v e n t i o n s . Orthodox a n a l y s t s c l a i m t h a t t h e o n l y a c c e p t a b l e i n t e r v e n t i o n i s an i n t e r p r e t a t i o n , a r g u i n g t h a t a l l o t h e r comments o r a c t i o n s a r e u n a c c e p t a b l e ( E i s s l e r , 1953; c i t e d i n G u t h e i l & Gabbard, 1993). They c l a i m t h a t a l l o t h e r i n t e r v e n t i o n s c r o s s t h e boundary o f a c c e p t a b l e a n a l y t i c t e c h n i q u e . T h i s v e r y l i m i t e d range of a c c e p t a b l e i n t e r v e n t i o n s cause problems f o r l e s s o r t h o d o x p s y c h o a n a l y s t s and f o r t h e r a p i s t s from o t h e r m o d a l i t i e s who e f f e c t i v e l y use i n t e r v e n t i o n s such as c l a r i f i c a t i o n , 68 c o n f r o n t a t i o n , a d v i c e and p r a i s e , s u g g e s t i o n and a f f i r m a t i o n ( G u t h e i l and Gabbard, 1993). L i k e o t h e r p s y c h o t h e r a p i s t s , the s t u d y n u r s e s used a v a r i e t y of i n t e r v e n t i o n s w i t h t h e i r c l i e n t s . S i n c e t h e y were not t r a i n e d as a n a l y s t s , t h e s e n u r s e s d i d n o t v i e w i n t e r p r e t a t i o n as the o n l y a c c e p t a b l e i n t e r v e n t i o n , n o r d i d t h e y c o n s i d e r t h e i r a c t i v e i n t e r v e n t i o n s u n a c c e p t a b l e o r v i o l a t i o n of boundary. F i n a l l y , boundary i s used i n r e l a t i o n t o t h e s t r u c t u r e , o r the r u l e s , 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 . I t can r e f e r t o a f i g u r a t i v e membrane, o r frame, w h i c h s u r r o u n d s 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 n t h a t sense boundary r e f e r s t o a l l t h e s t r u c t u r a l elements of the r e l a t i o n s h i p and i n c l u d e s t h e f o l l o w i n g : t h e r a p i s t s ' r o l e , the s c h e d u l i n g o f app o i n t m e n t s , l e n g t h of s e s s i o n s , arrangements f o r f e e s , o f f i c e s e t t i n g , g i f t s and s e r v i c e s , language, s e l f -d i s c l o s u r e , p h y s i c a l c o n t a c t , and r u l e s f o r emergency appointments ( G u t h e i l and Gabbard, 1993; Herman, 1992; 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 the frame" w h i c h I p r e s e n t l a t e r i n the d i s c u s s i o n . Herman (1992) r e f e r s t o t h i s frame as a t h e r a p y c o n t r a c t . 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 boundary. A boundary may r e f e r t o any o f t h e f o l l o w i n g : t h e boundary ( 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 and p e r s o n a l r e l a t i o n s h i p s , the boundary (frame) around t h e s t r u c t u r e o r the r u l e s of 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 , 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 i n t e r v e n t i o n s . I do not 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 boundary 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 and the s t u d y n u r s e s a r e not t r a i n e d a n a l y s t s . S t r u c t u r a l and r o l e b o u n d a r i e s o f the t h e r a p e u t i c r e l a t i o n s h i p , however, a r e r e l e v a n t t o t h e s t u d y 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 s , and I now e x p l o r e t h e s e more f u l l y . B o u n d a r i e s e x i s t f o r the p r o t e c t i o n o f b o t h t h e t h e r a p i s t and the 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 , b o u n d a r i e s d e l i n e a t e what i s a c c e p t a b l e and u n a c c e p t a b l e f o r t h e r a p i s t , c l i e n t , and 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 . C l e a r b o u n d a r i e s p r o v i d e s a f e t y f o r t h e c l i e n t and 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 making t h e s e b o u n d a r i e s c l e a r and e x p l i c i t . 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, 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 o f p s y c h o t h e r a p y , and t h e n o t i o n o f t h e r a p e u t i c b o u n d a r i e s . A n a l y z i n g . B o u n d a r i e s i s t h e p r o c e s s o f knowing and d e m o n s t r a t i n g a c c e p t a b l e t h e r a p i s t b e h a v i o r . 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 d i s c l o s u r e e x p e r i e n c e , when she was F o c u s i n g on S e l f . She thought about e n s u r i n g h e r c l i e n t ' s s a f e t y , and she s t a r t e d by s e t t i n g c l e a r s t r u c t u r a l b o u n d a r i e s . N o t i n g t h a t t h e i n t a k e d a t a 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 w i t h b o u n d a r i e s w i t h p r e v i o u s p r o f e s s i o n a l s , A l i c e t a l k e d about e s t a b l i s h i n g t h e r a p e u t i c b o u n d a r i e s t h i s way: I had 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 had 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 frame [boundary]. 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 assessment, he was g i v e n b a s i c a l l y a frame f o r how we were 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 , and 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 would be v e r y s p e c i f i c i n what ways I would 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 of t i m e , on s p e c i f i c d a t e s , once a week, f o r h a l f an hour.... 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 her e on a c o n s u l t i n g b a s i s f o r such c o n c e r n s as 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 the two p e o p l e work t o g e t h e r . . . . And t h e c l i e n t has t o agree t o t h a t p l a n . The l i t e r a t u r e s u p p o r t s A l i c e ' s u n d e r s t a n d i n g about b o u n d a r i e s . C a r e f u l a t t e n t i o n t o b o u n d a r i e s p r o v i d e s c l i e n t p r o t e c t i o n (Herman, 1992). When b o t h p a r t i e s agree t o work w i t h i n t h e s e b o u n d a r i e s , a s a f e a r e n a f o r the 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 and Gabbard, 1993; Herman, 1992; Simon, 1991). A n a l y z i n g B o u n d a r i e s was a l s o p a r t of Lynne's d i s c l o s u r e e x p e r i e n c e and the p r o c e s s 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 a r e c l e a r , c l i e n t s a r e p r o t e c t e d . Lynne t a l k e d about how she sought t o p r o t e c t h e r 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 boundary t h i s way: " 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 put 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 hope 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 . " Herman (1992) s u p p o r t s Lynne's a c t i o n s ; 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 a r e n a f o r t h e work o f t h e r a p y . R o l e b o u n d a r i e s a r e perhaps t h e most i m p o r t a n t o f the t h r e e uses o f b o u n d a r i e s c i t e d ( G u t h e i l and Gabbard, 1993). B o u n d a r i e s e x i s t t o p r o t e c t c l i e n t s from t h e r a p i s t s ' 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 B o u n d a r i e s was p a r t of Lynne'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 on S e l f . She was v e r y c l e a r t h a t she 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 t h r e a t s and s e x u a l 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 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 the f o l l o w i n g : I thought t h a t f u c k i n g b a s t a r d , I hope he g e t s i t someday! ... but I don'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 and I say you know what he d i d wasn't O.K. ... I don'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 er the 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 not coming t o t h e s e s s i o n t o watch me do my work, so I do i t away from 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 about b o u n d a r i e s from me. The' 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 p r e t a t i o n o f b o u n d a r i e s . F r e u d ( c i t e d Simon, 1991), i n h i s p r i n c i p l e o f a b s t i n e n c e , 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 from u s i n g c l i e n t s f o r t h e i r own p e r s o n a l g r a t i f i c a t i o n . A l l t h e r a p e u t i c i n t e r v e n t i o n s a r e made f o r t h e b e n e f i t o f c l i e n t s and t h e i r t r e a t m e n t . T h e r a p i s t s d e r i v e g r a t i f i c a t i o n o n l y 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 p r o c e s s 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 (Herman, 1992; Simon, 1991). Good t h e r a p e u t i c i n t e r v e n t i o n s and c l e a r b o u n d a r i e s h e l p p r e s e r v e t h e r a p i s t n e u t r a l i t y , w h i c h t h e n e n s u r e s t h a t t r e a t m e n t i n t e r v e n t i o n s a r e made on b e h a l f o f the c l i e n t . The p e r s o n a l needs of the t h e r a p i s t s h o u l d n o t i n f l u e n c e 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 o n l y m a t e r i a l reward 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 s e r v i c e s (Simon, 1991). A l l b o u n d a r i e s w i t h i n the t h e r a p e u t i c r e l a t i o n s h i p can be c r o s s e d o r v i o l a t e d b u t a l l c r o s s i n g s a r e not v i o l a t i o n s . I f t h e i n t e r v e n t i o n b e n e f i t s the c l i e n t i t i s deemed a boundary c r o s s i n g ; i f i t harms the c l i e n t i t i s deemed a 72 boundary v i o l a t i o n ( G u t h e i l and Gabbard, 1993; Simon, 1991) . However, Brown (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 an i m p o r t a n t s o u r c e o f a u t h o r i t y on whether i t i s a boundary c r o s s i n g o r v i o l a t i o n , many c l i e n t s have e x p e r i e n c e d r e p e a t e d boundary v i o l a t i o n s i n the c o n t e x t o f t h e r a p y and as a consequence have d i f f i c u l t y i d e n t i f y i n g t h e i r own b o u n d a r i e s . Brown (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 f i n a l r e s p o n s i b i l i t y i n i d e n t i f y i n g boundary v i o l a t i o n s . When A n a l y z i n g B o u n d a r i e s the s t u d y n u r s e s showed a c l e a r u n d e r s t a n d i n g o f b o u n d a r i e s , and t h e y used t h i s u n d e r s t a n d i n g when e v a l u a t i n g boundary v i o l a t i o n s . C a t h y was v e r y c l e a r about the 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 B o u n d a r i e s was a major 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 i t t h i s way: My c l i e n t was i n l o v e w i t h him (her former p s y c h i a t r i s t ) . . . . She was drawn t o him l i k e a magnet... and she would see 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 time she'd e v e r had i n h e r l i f e , and i t was w o n d e r f u l ... t h e hours t h e y spent t o g e t h e r was t h e most r e w a r d i n g time she had 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 ... she was t o t a l l y f o c u s e d on him.... She would phone him a t h i s o f f i c e o r home, and she would 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 apartment ... 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 he was ph o n i n g h e r o r a s k i n g h e r out ... 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 on f o r so l o n g and 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 i m p o t e n t . The l i t e r a t u r e a s c r i b e s the r o l e o f boundary k e e p i n g 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 t h e i r c o u n t e r t r a n s f e r e n c e i s s u e s . I n d u l g i n g i n s e x u a l b e h a v i o r 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 C o u n t e r t r a n s f e r e n c e i s f o r t h e t h e r a p i s t what t r a n s f e r e n c e i s f o r the c l i e n t . I t r e f e r s t o a l l t h e f e e l i n g s and a t t i t u d e s about the c l i e n t t h a t o c c u r i n t h e t h e r a p i s t (Kahn, 1991). F r e u d ( c i t e d i n Simon, 1991) warned t h a t a t h e r a p i s t must r e c o g n i z e t h a t when a p a t i e n t f a l l s i n l o v e i t i s because of the a n a l y t i c s i t u a t i o n and not because o f the t h e r a p i s t ' s p e r s o n a l charm. Cathy t a l k e d about the dangers t o b o t h h e r c l i e n t and the o f f e n d i n g 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 were v i o l a t e d : He s e t no l i m i t s . . . . There 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 and t r i e d t o s t o p the phone c a l l s and v i s i t s she became despondent and thought h e r l i f e wasn't w o r t h l i v i n g . . . . She t o o k overdoses and she even t h r e a t e n e d t o k i l l him a t one p o i n t . T h i s e x p e r i e n c e happened 15 y e a r s ago when, i n my e x p e r i e n c e , the d i a g n o s i s o f b o r d e r l i n e p e r s o n a l i t y was r a r e l y used. Cathy's c l i e n t had not been a s s i g n e d t h a t d i a g n o s i s b u t h e r b e h a v i o r s suggest i t now. The l i t e r a t u r e s t a t e s t h a t t h e r a p i s t s e x p e r i e n c e g r e a t d i f f i c u l t y i n s e t t i n g l i m i t s and h o l d i n g f i r m , b o u n d a r i e s f o r f e a r o f t h e p a t i e n t ' s v o l c a n i c response t o b e i n g t h w a r t e d o r c o n f r o n t e d . A p a t i e n t w i t h a b o r d e r l i n e d i s o r d e r i s p a r t i c u l a r l y prone t o v e n g e f u l e x p r e s s i o n s of rage ( G u t h e i l , 1989; Herman, 1992). Simon (1991) c l a i m s t h a t p a t i e n t s w i t h b o r d e r l i n e d i s o r d e r s , i n p a r t i c u l a r , ' f r e q u e n t l y a t t empt t o m a n i p u l a t e and draw the t h e r a p i s t out o f the t r e a t m e n t r o l e . They may a t t e mpt t o 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 a c t i n g 74 out by the t h e r a p i s t ( G u t h e i l , 1989). N o n e t h e l e s s , t h e r a p i s t s a r e s t i l l r e s p o n s i b l e f o r t h e i r b e h a v i o r and must not a c t out ( G u t h e i l , 1989; Herman, 1992).' B o u n d a r i e s e x i s t f o r the 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: T h i s 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 had 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 were h i s c a r e g i v e r s as j u s t c a r e g i v e r s . . . . He would g e t i n v o l v e d i n f r i e n d s h i p s , out 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 and so f o r t h . . . . He has 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 and a t a r e s t a u r a n t ... wh i c h when you l o o k a t i t i n c o n t e x t may n o t be u n u s u a l , because the 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 from AIDS. ... . When h i s p a r t n e r d i e d t h e GP gave him a hug.... But 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 the c l i e n t s a i d he 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 him he s a i d t h a t he had l i e d ... t h a t t h e GP had o n l y hugged him.... The c l i e n t may have m i s i n t e r p r e t e d what was happening o r he may n o t have. Lack o f a b s o l u t e c l a r i t y about b o u n d a r i e s c a n . l e a d t o f a l s e a c c u s a t i o n s , and p e r s o n s w i t h 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 s c o n s t i t u t e the 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 a ccuse t h e r a p i s t s o f s e x u a l i n v o l v e m e n t ( G u t h e i l , 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 t e n d t o l o s e the boundary between s e l f and o t h e r when t h e y a r e under s t r e s s ( G u t h e i l , 1989). T h i s boundary c o n f u s i o n , G u t h e i l (1989) c l a i m s , i s a f e a t u r e o f t h i s d i s o r d e r . A l t h o u g h i t i s beyond the scope of t h i s paper t o d e s c r i b e t h e 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 t h e s e p a t i e n t s t o boundary c o n f u s i o n , 75 therapists must be scrupulous, even overscrupulous, i n t h e i r attention to clear boundaries and to the preservation of the professional nature of the relat i o n s h i p (Gutheil, 1989; Simon, 1991). Boundaries are an important feature of therapeutic relationships and these nurses' disclosure experiences. When they are c l e a r l y and e x p l i c i t l y defined, they create safety for both therapists and c l i e n t s . C l i e n t s with diagnoses of borderline personality disorder, due to the nature of. the dynamics of thi s disorder, experience the most trouble staying within boundaries. Therapists must take boundary delineations very seriously. When the study nurses were Analyzing Boundaries, they demonstrated an understanding of boundaries which was clear not only to them, but i s supported by l i t e r a t u r e . As they continued Focusing on Self, they were also Analyzing Power, the second modifying-concept of the Cycle of Focusing. Discussion of Analyzing Power Another means the participants used when Focusing on Self and Analyzing Thoughts i n the Cycle of Focusing Attention was Analyzing Power. Power i s also an aspect of the therapeutic r e l a t i o n s h i p and Focusing on the C l i e n t . Analyzing Power refers to the study nurse thinking about the notion of power.in the therapeutic relationships between herself and c l i e n t and the offending physician and c l i e n t . Hardin et a l . (1985) believe: 76 Power i s a dynamic, p o t e n t i a l and a c t u a l f o r c e t o i n f l u e n c e a n o t h e r t o a c t , t h i n k , o r 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 dependence and 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 (rewards and 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 power i s an i n t e r a c t i o n phenomenon; where 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 power. They a l s o b e l i e v e t h a t dependency and s a n c t i o n s a r e power's e s s e n t i a l f e a t u r e s . Dependency causes t h e need f o r exchange, and s a n c t i o n s (rewards o r punishments) a r e t h e a c t u a l m a n i p u l a t i o n o f what happens t o a n o t h e r . F r e n c h and Raven (1960) d e f i n e power as i n f l u e n c e and 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 a c c o r d i n g t o i t s s o u r c e s : reward power, c o e r c i v e power, e x p e r t 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 based on t h e p e r c e p t i o n by 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 t h a t i n f l u e n c e . E x p e r t power i s based on h a v i n g s u p e r i o r s k i l l s and knowledge. Reward power i s t h e a b i l i t y t o p r o v i d e p o s i t i v e s a n c t i o n s . C o e r c i v e power i s the a b i l i t y t o a p p l y n e g a t i v e s a n c t i o n s t o a n o t h e r . • 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 t h e s e e s s e n t i a l elements o f power. I t i s a p p r o p r i a t e t o t u r n a g a i n 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 t o b e t t e r u n d e r s t a n d t h e n o t i o n o f power i n the 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 e x p e r i e n c e s , and the m o d i f y i n g - c o n c e p t o f A n a l y z i n g Power. An h i s t o r i c a l r e v i e w o f t h e b a l a n c e o f 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 u n d e r s t a n d i n g t h e s i g n i f i c a n t i s s u e s and i n e x p l a i n i n g what the s t u d y n u r s e s r e p o r t e d . The n o t i o n of 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 d e r i v e d , by F r e u d , from t h e t r a d i t i o n a l p h y s i c i a n - p a t i e n t r e l a t i o n s h i p (Kahn, 1991). I n m a t t e r s o f m e d i c a l d i a g n o s i s and t r e a t m e n t , t h e p h y s i c i a n ' s r o l e o f a u t h o r i t y was t a k e n f o r g r a n t e d (Nelson, N e l s o n , Sherman, & S t r e a n , 1968) . F r e u d c a r r i e d t h i s m e d i c a l a t t i t u d e i n t o the t h e r a p e u t i c r e l a t i o n s h i p w i t h the v i e w t h a t t h e p a t i e n t ' s n e u r o s i s was an i l l n e s s t h a t he s h o u l d c u r e . From t h e b e g i n n i n g , t h e s t r u c t u r e (the p a t i e n t p a y i n g f o r s e r v i c e ) , t h e r o l e d e f i n i t i o n s ( p h y s i c i a n / a n a l y s t i n • t h e r o l e o f a u t h o r i t y ) , and t h e t h e r a p e u t i c t a s k ( f r e e a s s o c i a t i o n and i n t e r p r e t a t i o n ) c r e a t e d a power imbalance i n f a v o r o f t h e a n a l y s t (Kahn, 1991; N e l s o n e t al-.', 1968). Rogers (19 61) e n v i s i o n e d a more e q u a l b a l a n c e i n t h e r e l a t i o n s h i p . He d i d not r e g a r d e m o t i o n a l d i f f i c u l t i e s as an i l l n e s s t h a t needed t o be c u r e d , and he saw a danger i n comparing m e d i c i n e and 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 the same way t h a t surgeons do s u r g e r y . 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 work with t h e i r c l i e n t s (Kahn, 1991). H i s manner c r e a t e d more e q u a l i t y ; he not o n l y conveyed the message t h a t he was w i t h t h e 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 e x p e r i e n c e . He r e f e r r e d t o the p e r s o n as a c l i e n t r a t h e r t h a n a p a t i e n t , as w e l l he v i e w e d t h e ' c l i e n t as 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 growth and development. 78 However, the equality that Rogers advocated was not enough for the r a d i c a l therapists of the encounter movement or the humanistic and feminist therapists. In fact these therapists objected so strongly 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 theories were taught only i n psychoanalytic i n s t i t u t e s . In the 197 0s, psychoanalysis returned to favor when the analysts, G i l l and Kohut, c a l l e d for more power equality and urged analysts to work with the patient (Kahn, 1991). In addition, other therapists decided to take what was useful i n the theories, and leave behind what they determined as sexist (Brown, 1987) . Like the therapists i n the mid-1970s, Cathy and A l i c e attempted to work with t h e i r c l i e n t s . Cathy reported: "I wanted to help her; I l i s t e n e d and I understood her emotional pain ... but she kept on and on wanting to see more of him.... I could do nothing." A l i c e r e c a l l e d : "I wanted to help ... I never r e a l l y understood what he wanted." Feminist theorists and therapists examined the balance of power i n therapeutic relationships, and searched for evidence of sexism and misogyny. They claimed that therapists were oppressive and abused t h e i r power by labeling, diagnosing, and psychopathologizing normative feminine gender-role behaviors. They c r i t i c i z e d the t r a d i t i o n a l male-model visions of human behavior (Brown, 1987, 1990, 1994), and worked towards the goal 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 . N o n e t h e l e s s , 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 ewed men as the ab u s e r s o f power and 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 f e m i n i s t t h e r a p i s t s were s e x u a l l y e x p l o i t i n g b o t h women and men. By 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 t h e i r c l i e n t s and d i d n ot abuse power e i t h e r s e x u a l l y o r any other-way (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 t o o . c o n s i d e r e d A n a l y z i n g Power t o be 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: Feminism 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 by f e m i n i s t t h e o r y . . . . One o f t h e major 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, and t h e use and abuse of power, and how the system has t r e a t e d women.... I use power 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 power t r i p on them. I n summary, t h e r e i s unequal 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 . 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 as someone w i t h s p e c i a l e x p e r t i s e , and t h e c l i e n t as t r u s t i n g , dependent, and r e l i a n t (Gabor, 1989). H u m a n i s t i c and f e m i n i s t t h e o r i s t s a s p i r e t o t h e r a p e u t i c r e l a t i o n s h i p s where a l l a s p e c t s o f power ( s t a t u s , a u t h o r i t y , and r o l e s ) a r e e q u a l . However, F r e n c h and Raven (1960) have i d e n t i f i e d f i v e s o u r c e s o f power: c l i e n t s p o t e n t i a l l y have two s o u r c e s (reward and c o e r c i v e power), and t h e r a p i s t s have f i v e s o u r c e s ( l e g i t i m a t e , e x p e r t , reward, c o e r c i v e , and i n f o r m a t i o n a l ) . H a v i n g r e v i e w e d the 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 t h e r a p e u t i c r e l a t i o n s h i p , I t u r n now t o what t h e s t u d y n u r s e s r e p o r t e d when t h e y were A n a l y z i n g Power i n t h e C y c l e 80 o f F o c u s i n g . As my p r e v i o u s d i s c u s s i o n has shown, most t h e r a p i s t s agree t h a 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 i s t h e 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 b e h a v i o r . T h e r a p i s t s a r e seen as h a v i n g more power t h a n t h e c l i e n t , and t h e l i t e r a t u r e s u p p o r t s the v i e w t h a t t h e r a p i s t s have the l e g i t i m a t e r o l e o f h e a l e r . The c l i e n t ' s p o s i t i o n i s seen as p o w e r l e s s . When s t u d y n u r s e s were A n a l y z i n g Power t h e y thought about th e n o t i o n of power i n the t h e r a p e u t i c r e l a t i o n s h i p between themselves and t h e i r c l i e n t s , and t h e o f f e n d i n g p h y s i c i a n s and c l i e n t s . Lynne spoke most c l e a r l y and e m p h a t i c a l l y about h e r use of power t h i s way: I t ' s n ot 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 of 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 j o u r n e y . . . . So i t ' s not f o r me t o , t o t a k e the b a s t a r d t o c o u r t , you know, c a l l t h e C o l l e g e , i t ' s not what I do.... 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 have a l o t o f power ... 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 empowering, o r t r y t o g e t them t o do something t h a t w i l l empower t h e m s e l v e s . Lynne's views a r e s i m i l a r t o t h e f e m i n i s t code o f e t h i c s w h i c h "acknowledges the i n h e r e n t power d i f f e r e n t i a l s ... [and i n s t r u c t s ] t h e r a p i s t s i n u s i n g i t [power] f o r t h e b e n e f i t o f the c l i e n t , not t o t a k e c o n t r o l o f power w h i c h r i g h t f u l l y b e l o n g s t o the c l i e n t " (Brown, 1987, p. 3 9 ) . Lynne used h e r power t o g i v e h e r c l i e n t power, and she r e p o r t e d i t t h i s way: I ask a whole l o t of q u e s t i o n s , and t h e n a s k i n g h e r whether she wanted t o do ... a n y t h i n g about 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 empowering, 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 something about i t . " She s a i d 81 t h a t she d i d n ' t want 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 about 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 i n f o r m i n g 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 o f A n a l y z i n g Power, from Lynne. Cathy t a l k e d about h e r e x p e r i e n c e t h i s way: I was c l e a r i n my mind t h a t sex w i t h a p s y c h i a t r i s t i s nev 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 work 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 see him.... But t h i n k i n g back, I f e l t k i n d o f used a t ti m e s as I was a r o u t e f o r h e r t o g e t t o see t h i s o t h e r d o c t o r [ c o n s u l t i n g p s y c h i a t r i s t ] a t our o f f i c e . She wo u l d phone and she'd o n l y want t o speak t o him, she woul d n ' t speak t o me l o t s o f t i m e s . . . . She'd f i r e me ... i f she 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 angr y and hang up ... and she'd j u s t appear i n t h e o f f i c e demanding t o see him.... 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 thought t h a t i f t h a t ' s what she wants t o do t h e r e ' s n o t much I can 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 of remorse on h e r p a r t and she would phone and t e l l me how much I had h e l p e d . M a n i p u l a t i o n , I t h i n k i t ' s c a l l e d . C l e a r l y , Cathy 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 b e i n g m a n i p u l a t e d by h e r c l i e n t , who i n Cathy's o p i n i o n , was e x p l o i t i n g h e r p a t i e n t r o l e . A l i c e r e c a l l e d A n a l y z i n g Power t h i s way: The c l i e n t was i n f o r m e d [about] how we would 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 him we had t o a c t on h i s i n f o r m a t i o n . . . . He a g r e e d t o change 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 [the 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 found a new d o c t o r ; he became v i s i b l y u p s e t by t h i s . . . . I n a n o t h e r s e s s i o n he came i n and s a i d t h a t he 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 , and 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 were l u n c h e s , and t h e r e was hugging. He d i d n ' t see t h i s as 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 want us t o make an i s s u e o f i t , he s a i d he was s o r r y he had 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 ropped out 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 gency t o do something.... We p u t i t i n t h e c l i e n t ' s l a p , gave him the r e s p o n s i b i l i t y ... [and] he d e c l i n e d . . . . I t ' s u n f i n i s h e d . B o t h C a thy and A l i c e had l e g i t i m a t e and e x p e r t power, and t h e i r c l i e n t s , by v i r t u e of t h e i r h e l p - s e e k i n g p o s i t i o n , were dependent and v u l n e r a b l e . But n e i t h e r s t u d y n u r s e c o u l d e f f e c t change. K i p n i s ' (1974) model of seven s t e p s of power i n t h e r a p y h e l p s us u n d e r s t a n d t h i s s i t u a t i o n . I n t h i s model the power of t h e t h e r a p i s t i s t r a c e d t h r o u g h o u t the t h e r a p e u t i c p r o c e s s . The s t e p s i n c l u d e th e f o l l o w i n g : (a) t h e r a p i s t s , m o t i v a t e d by t h e i r need t o be s a t i s f i e d by a p p r o p r i a t e b e h a v i o r by c l i e n t s , s t r i v e t o i n f l u e n c e c l i e n t s ; (b) c l i e n t s can comply o r r e s i s t ; (c) t h e r a p i s t s ' l e g i t i m a t e r o l e e n a b l e s them t o d i s t r i b u t e rewards and/or s a n c t i o n s ; (d) t h e r a p i s t s ' b e h a v i o r s a r e i n h i b i t e d by consumers, the law, and t h e i r p e e r s ; (e) t h e r a p i s t s i n f l u e n c e c l i e n t s t h r o u g h such e f f o r t s as p e r s u a s i o n , t h r e a t , reward, c o e r c i o n , and s u p p o r t ; (f) c l i e n t s r e s p o n d t o i n f l u e n c e ; and, (g) t h e r a p i s t s ' esteem i s enhanced by c l i e n t c o m p l i a n c e , and l e s s e n e d by r e j e c t i o n . I n t h i s model, the c l i e n t ' s o n l y s o u r c e o f power i s c o m p l y i n g o r r e s i s t i n g ( K i p n i s , 1974). When Cathy's and A l i c e ' s c l i e n t s used t h e i r c o e r c i v e power, t h e y n u l l i f i e d t h e l e g i t i m a t e power of t h e i r n u r s e s . These c l i e n t s n o t o n l y r e f u s e d t o go a l o n g w i t h Cathy's and A l i c e ' s h e a l t h p r o m o t i n g s u g g e s t i o n s , but t h e y responded w i t h v e r b a l abuse and t h r e a t s of p h y s i c a l v i o l e n c e . 83 F i n a l l y , the s t u d y n u r s e s r e p o r t e d A n a l y z i n g Power i n t h e 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 about th e o f f e n d e r a b u s i n g power i n t h e phenomenon of c l i e n t - t h e r a p i s t sex. Cathy s a i d : "He [the o f f e n d e r ] was i n a p o s i t i o n , a p o s i t i o n of power, t h a t she was a v e r y f r a g i l e , dependent and, uh, d i s t r a u g h t young woman, t h a t he r e a l l y d i d t a k e advantage of the s i t u a t i o n . " Lynne a d m i t t e d t o b e i n g v e r y angry when she r e c a l l e d h e r c l i e n t ' s s i t u a t i o n : He t h r e a t e n e d h e r .... t o have sex w i t h him ... 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 would 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 what 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 . S e x u a l 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 . Everyone 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 choose; t h e y a l l do, t h e y know what 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 what t h e y want them t o do. They're v e r y p o w e r f u l . . . . They don'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 don't t r u s t t h e i r own e x p e r i e n c e . . . . And the p s y c h i a t r i s t s , w i t h a l l the 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 says so much about t h e d i s c l o s u r e e x p e r i e n c e : h e r o u t r a g e and anger, t h e d i f f i c u l t i e s c l i e n t -t h e r a p i s t sex p r e s e n t s t o the subsequent c o u n s e l l o r , and i t h i n t s a t the dilemma- i n t o which' she i s t h r u s t , w a n t i n g t o do t h e b e s t 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 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 my b e g i n n i n g t h i s .study o f the 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 s , b u t a l s o a r o s e 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 by the t h r e e n u r s e s . A paradigm d e s c r i b i n g how t h e y h a n d l e d t h e 84 d i s c l o s u r e emerged f o r me. T h i s paradigm I c a l l 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 . The n i n e elements of t h i s C y c l e have been d i s c u s s e d i n d e t a i l . Three elements were found t o be o f p a r t i c u l a r i n t e r e s t and i m p o r t a nce i n t h e d i s c l o s u r e e x p e r i e n c e . B o u n d a r i e s were found t o be c r u c i a l because i t was a boundary v i o l a t i o n the c l i e n t e x p e r i e n c e d ; Power was found t o be i m p o r t a n t because i t was a power d i f f e r e n t i a l t h a t a l l o w e d the c l i e n t abuse. The s i g n i f i c a n c e o f t h e s e elements i s s u p p o r t e d i n t h e l i t e r a t u r e about 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 . F i n a l l y , F o c u s i n g on the C l i e n t was f o u n d i n t h e s e i n s t a n c e s t o c o n s t i t u t e p a r t 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 - ( 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 as such, i n my view, c r e a t e d t h e environment e s s e n t i a l f o r t h e s e c l i e n t d i s c l o s u r e s . 85 CHAPTER FOUR SUMMARY, CONCLUSIONS, IMPLICATIONS, and RECOMMENDATIONS FOR NURSING Summary and Conclusions The v e r y s e r i o u s problem of 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 i s demanding our a t t e n t i o n more and more f r e q u e n t l y , e i t h e r because i t i s o c c u r r i n g more o f t e n o r because i t i s b e i n g r e p o r t e d : m o r e c o n s c i e n t i o u s l y . I t i s known t h a t c l i e n t - t h e r a p i s t s e x u a l abuse i s u n d e r r e p o r t e d , and t h i s d i s p a r i t y between o c c u r r e n c e and r e p o r t a g e s u g g e s t s t h a t t h e c l i e n t ' s d i s c l o s u r e p r e s e n t s a problem f o r t h e second p r o f e s s i o n a l . A r e v i e w of the l i t e r a t u r e c o n c e r n i n g t h e problems e x p e r i e n c e d by n u r s e s as t h e y r e s o l v e o t h e r t y p e s of d i s c l o s u r e i n d i c a t e s t h a t n u r s e s s t r u g g l e w i t h e t h i c a l and r e p o r t i n g dilemmas. Y et t h e l i t e r a t u r e does n o t a d d r e s s 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 h e a l t h p r o f e s s i o n a l s as t h e y a r e f a c e d w i t h t h e 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 s e x u a l c o n t a c t . T h i s s t u d y was un d e r t a k e n t o u n d e r s t a n d t h e d i s c l o s u r e e x p e r i e n c e s of t h r e e 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 r e v e a l e d s e x u a l c o n t a c t w i t h a . p r e v i o u s p h y s i c i a n . I n t h i s s t u d y , a q u a l i t a t i v e case s t u d y method was used t o u n d e r s t a n d 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 s . Case s t u d y method i s f l e x i b l e and s y s t e m a t i c and can accommodate 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 , and q u a l i t a t i v e methodology i s g e n e r a l l y used t o uncover, d e s c r i b e , and u n d e r s t a n d a phenomenon about w h i c h l i t t l e 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 d a t a c o l l e c t i o n and i t s a n a l y s i s . The whole e n t i t i e s (case s t u d i e s ) were th e n 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 had t h e e x p e r i e n c e o f c l i e n t s d i s c l o s i n g 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 , p a r t i c i p a t e d i n t h i s s t u d y . These s t u d y n u r s e s ' 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 w o r k i n g 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 t r a n s c r i p t i o n s . 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 deepen my u n d e r s t a n d i n g (one p a r t i c i p a n t went on an e x t e n d e d h o l i d a y and c o u l d not 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 s t u d y approach p r o v e d t o be t h e a p p r o p r i a t e c h o i c e of method f o r e x p l o r i n g t h i s i m p o r t a n t b u t under-documented a r e a o f c l i n i c a l p r a c t i c e . T h i s method p r o v i d e d a c c e s s t o the phenomenon under s t u d y by the f o l l o w i n g means: (a) i t f a c i l i t a t e d an i n d e p t h u n d e r s t a n d i n g o f t h r e e i n d i v i d u a l d i s c l o s u r e e x p e r i e n c e s , (b) i t was f l e x i b l e and s y s t e m a t i c enough t o accommodate 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 , (c) i t c o u l d be used i n a r e s t r i c t e d t ime frame, (d) i t used t h e r e s t r i c t e d number of i n f o r m a n t s who were a v a i l a b l e , : a n d (e) i t m aximized the 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 d i s c l o s u r e s t o r i e s . 87 The f i n d i n g s emerging from t h e s e c a s e s t u d i e s i n d i c a t e d t h a t t h e t h r e e n u r s e s were i n v o l v e d i n a complex, c y c l i c a l , 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 o f f o c u s i n g t h e i r a t t e n t i o n . I n t h i s p r o c e s s , c a l l 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 , the nu r s e 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 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 of a l l e v i a t i n g c l i e n t s u f f e r i n g . C o n t a i n e d i n 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 were: two 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 and F o c u s i n g on S e l f ; f o u r s u b - c o n c e p t s , C o l l e c t i n g I n f o r m a t i o n , U s i n g 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 Thoughts; and two 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 B o u n d a r i e s and A n a l y z i n g Power. When t h e nu 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 on t h e C l i e n t and F o c u s i n g on 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 and o b s e r v e d h e r / h i s b e h a v i o r . When she was F o c u s i n g on S e l f , she t u r n e d i n w a r d and p r o c e s s e d the 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 l i s t e n i n g t o t h e c l i e n t and o b s e r v i n g h e r / h i s b e h a v i o r , and she n o t i c e d h e r p e r s o n a l r e a c t i o n s ( f e e l i n g s o r th o u g h t s ) t o i t . Then, based on t h e r e s u l t s of h e r men t a l p r o c e s s i n g , t h e n u r s e r e t u r n e d t o F o c u s i n g on t h e C l i e n t and made a v e r b a l , n o n - 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 . T h i s r e f o c u s i n g on the c l i e n t began a n o t h e r c y c l e . T h i s p r o c e s s was o v e r l a p p i n g and c o n t i n u o u s , and not 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 of language would make i t sound. 88 F o c u s i n g on the C l i e n t was c o m p r i s e d o f two sub-c o n c e p t s , 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 I n t e r v e n t i o n s . When F o c u s i n g on the C l i e n t t he 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 p r o c e s s o f c o m p i l i n g d a t a by l i s t e n i n g t o h e r c l i e n t , 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 ( C o l l e c t i n g I n f o r m a t i o n ) , o r she used t h i s d a t a t o i n f o r m h e r v e r b a l , n o n - v e r b a l , and/or b e h a v i o r a l r e sponse ( U s i n g I n t e r v e n t i o n s ) . A f t e r 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 r e p o r t e d t u r n i n g i n w a r d t o s e a r c h f o r h e r men t a l and e m o t i o n a l r e a c t i o n s t o the c l i e n t ' s words o r b e h a v i o r s . Termed F o c u s i n g on S e l f , t h i s c o ncept was c o m p r i s e d o f two sub-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 Thoughts. A n a l y z i n g Thoughts was the men t a l p r o c e s s t h e n u r s e u s e d t o t h i n k c o n c e p t u a l l y about t h e t h e r a p y 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 B o u n d a r i e s and A n a l y z i n g Power were two m o d i f y i n g - c o n c e p t s o f A n a l y z i n g Thoughts; t h e y s e r v e d t o i l l u m i n a t e t h e dynamics 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 B o u n d a r i e s , the n u r s e thought about c r o s s e d t h e r a p y b o u n d a r i e s 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 ex t o o c c u r ; when A n a l y z i n g Power, she thought about t h e power d i f f e r e n t i a l t h a t a l l o w e d t h e c l i e n t abuse. The f i n a l sub-co n c e p t r e f e r s t o the n u r s e ' s a t t e n d i n g t o h e r own e m o t i o n a l r e s p o n s e s : E x p e r i e n c i n g F e e l i n g s r e p r e s e n t e d t h e n u r s e ' 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 re s p o n s e t o the c l i e n t ' s r e v e a l i n g s e x u a l c o n t a c t . 89 The a n a l y s i s was enhanced by the use o f l i t e r a t u r e , b o t h i n t h e form of knowledge t h a t I b r o u g h t t o t h e r e s e a r c h as p a r t o f i t s f o r e - s t r u c t u r e , and t h a t w h i c h I sought out i n o r d e r t o i l l u m i n a t e the emerging c o n c e p t s 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 used t o d e v e l o p t h r e e major elements from the 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 , and A n a l y z i n g Power. The 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 was more f u l l y e x p l a i n e d and e l u c i d a t e d t h r o u g h t h i s d i s c u s s i o n . A number of c o n c l u s i o n s emerged from t h e C y c l e o f F o c u s i n g . Study n u r s e s e x p e r i e n c e d v e r y s t r o n g f e e l i n g s o f m o r a l o u t r a g e and p o w e r l e s s n e s s a t t h e p h y s i c i a n s ' m i s u s e o f 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 o f t i m e . D e s p i t e t h e i r p e r s o n a l f e e l i n g s , t h e n u r s e s m a i n t a i n e d t h e i r p r o f e s s i o n a l demeanor and c o n s i s t e n t l y t r e a t e d t h e i r c l i e n t s 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 and on t h e i r i m p l i c i t g o a l of a l l e v i a t i n g c l i e n t s u f f e r i n g ; Even when t h e i r c l i e n t s were d i s p l a y i n g d i f f i c u l t b e h a v i o r s , t h e s t u d y n u r s e s c o n t i n u e d t o c a r e about them and 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 , as w e l l , was a p r i m a r y c o n c e r n . 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 p h y s i c i a n s ' s e x u a l b e h a v i o r was u n e t h i c a l . They 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 t o t h e i r c l i e n t s . 90 Study n u r s e s r e v e a l e d t h a t t h e y were knowledgeable on two l e v e l s . They u n d e r s t o o d the t h e r a p e u t i c needs o f t h e i r c l i e n t s 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 . They a l s o u n d e r s t o o d the s o c i a l and e t h i c a l demands o f r e p o r t i n g . F i n a l l y , t he 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 t h e n u r s e s ' minds, a l t h o u g h two t o f i f t e e n y e a r s had i n t e r v e n e d . Study n u r s e s had l i t t l e 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 the 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 , o r t h e i r own e m o t i o n a l and i n t e l l e c t u a l r e s p o n s e s . Implications and Recommendations The f i n d i n g s from t h i s s t u d y o f me n t a l h e a l t h 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 s have i m p l i c a t i o n s f o r n u r s i n g p r a c t i c e , r e s e a r c h , e d u c a t i o n , and a d m i n i s t r a t i o n . The case s t u d y method e s t a b l i s h e d the e x i s t e n c e o f a phenomenon, and the c o mparison o f m u l t i p l e c ases showed t h a t t h e phenomenon was e x p e r i e n c e d by more th a n one nu r s e and was n o t , t h e r e f o r e , w h o l l y i d i o s y n c r a t i c ( M i l e s & Huberman, 1994). I n d u c t i v e f i n d i n g s i l l u m i n a t e d i n d e t a i l t h e dynamics o f each p a r t i c u l a r case, but were n ot 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 ( M i l e s & Huberman, 1994) and c o n s t i t u t e o n l y t h e b e g i n n i n g of 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 g e n e r a t e d m o d e s t l y c o n t r i b u t e s t o n u r s i n g ' s body of knowledge and may enhance n u r s i n g p r a c t i c e , r e s e a r c h , e d u c a t i o n , and a d m i n i s t r a t i o n i n the f o l l o w i n g ways: ( 91 P r a c t i c e The f i n d i n g o f the c o n c e p t u a l framework w h i c h emerged from t h e e x a m i n a t i o n of t h e s e d i s c l o s u r e e x p e r i e n c e s c o n t a i n s the p o t e n t i a l f o r p a r t i c u l a r u s e f u l n e s s i n s i t u a t i o n s o f c l i e n t d i s c l o s u r e s . I f t h i s c o n c e p t u a l framework were 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 be aware of t h e movement and rhythm of t h e p r o c e s s w h i c h l i e s ahead 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 ' c o n f i d e n c e and e f f e c t i v e n e s s would be enhanced by t h i s f o u n d a t i o n . The framework c o u l d be used as 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 an i m p o r t a n t i s s u e so t h a t n u r s e s would n o t g e t l o s t i n s u b j e c t i v i t y and o u t r a g e . I n a d d i t i o n , t h i s w ould 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 t h e i r e x p e r i e n c e ( 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 t i m e , s t u d y n u r s e s had l i t t l e t r o u b l e remembering t h e d e t a i l s o f t h e d i s c l o s u r e e x p e r i e n c e , t h a t the i n t e n s i t y o f t h e i r f e e l i n g s a l s o d i d not d i m i n i s h w i t h t i m e , 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 m o r a l o u t r a g e , suggest t h a t t h e n u r s e s 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 . T h e r e f o r e , i t i s i m p o r t a n t f o r n u r s e s t o t a k e t h e s t a t u s o f t h e i r own men t a l 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 c a r e 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 c l i n i c a l s u p e r v i s i o n would be a p p r o p r i a t e a c t i o n s . 92 G i v e n t h e f i n d i n g about the d i f f i c u l t y i n h e r e n t i n t h i s p r a c t i c e s i t u a t i o n , n u r s e s i n v o l v e d i n d i s c l o s u r e e x p e r i e n c e s s h o u l d be acknowledged and p r a i s e d f o r t h e i r e xemplary n u r s i n g c a r e . Recommendation: I n f o r m a t i o n about t h e i r e xemplary c a r e c o u l d be d i s s e m i n a t e d o r a l l y from p e r s o n t o p e r s o n , i n p u b l i s h e d l i t e r a t u r e , 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 be 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 c o n t a c t . R e s e a r c h • The f i n d i n g s o f t h i s s t u d y have m e a n i n g f u l i m p l i c a t i o n s f o r n u r s i n g r e s e a r c h . The development o f a c o n c e p t u a l framework, The C y c l e of F o c u s i n g A t t e n t i o n , s u g g e s t s f u r t h e r r e s e a r c h w h i c h would s u p p o r t , extend, o r r e f u t e i t . Recommendation: T h i s framework c o u l d be exte n d e d by t h e a d d i t i o n of d a t a from o t h e r "cases", o r the phenomenon c o u l d be 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, such as phenomenology, Grounded Theory, o r n a t u r a l i s t i n q u i r y . O b t a i n i n g a s u f f i c i e n t sample remains a c o n c e r n , a l t h o u g h e xposure i n the l i t e r a t u r e may h e l p n u r s e s t o come f o r w a r d and i d e n t i f y t h e m s e l v e s . The f i n d i n g s t h a t time does n ot 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 s t u d y n u r s e s had l i t t l e 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 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 t h e s e 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 f u r t h e r i n q u i r y . i n t o t h e a f t e r m a t h o f d i s c l o s u r e f o r t h e 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 c l i e n t d i s c l o s u r e s i t u a t i o n s . Recommendation: An 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 the second t h e r a p i s t . I t was found t h a t the case s t u d y was a u s e f u l method t o s o l v e the r e s e a r c h problem and t o accommodate t h e time and s a m p l i n g c o n c e r n s . As w e l l , i t p r o v i d e d a manageable b u t comprehensive e x p e r i e n c e w i t h d a t a c o l l e c t i o n , d a t a a n a l y s i s , and r e p o r t i n g the f i n d i n g s . T h i s p o s i t i v e e x p e r i e n c e may encourage 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 t h e i r f i n d i n g s and do more r e s e a r c h . Recommendation: Encourage the use o f case s t u d y method i n n u r s i n g f o r master's 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 of r e l a t e d phenomena and when samples a r e s m a l l because of e t h i c a l c o n c e r n s . T h i s method p r o v i d e s n u r s e s w i t h an e x c e l l e n t way o f r e f l e c t i n g on and e v a l u a t i n g n u r s e s ' p r a c t i c e . Recommendation: Encourage 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 , and e s t a b l i s h means ( i n f r a s t r u c t u r e s u p p o r t ) t o a s s i s t them i n d o i n g so. E d u c a t i o n The f i n d i n g s o f t h i s s t u d y have o n l y i n d i r e c t i m p l i c a t i o n s 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 a p p l y e q u a l l y t o t h e t r a i n i n g programs of RNs and RPNs. A l t h o u g h a 94 t h e o r e t i c a l framework was d i s c o v e r e d i t cannot be us e d i n c u r r i c u l a u n t i l o t h e r s t u d i e s r e p l i c a t e , e x t e n d , and s u p p o r t i t . As w e l l , a l t h o u g h the m a j o r i t y of t h e f i n d i n g s s u g g e s t t h a t t h e 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 s e x u a l c o n t a c t i s a s i g n i f i c a n t i s s u e f o r t h e s e n u r s e s , t h e s e f i n d i n g s must be 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 . However, p a r t s o f t h e d a t a c o u l d be i n f o r m a l l y s h a r e d w i t h s t u d e n t s i n t h e i r c l i n i c a l g r o ups, and w i t h o t h e r s 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 be t a u g h t t h a t s e x u a l abuse 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 and t h a t t h e y may h e a r about 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 groups, s t u d e n t s s h o u l d be encouraged t o e x p l o r e , and t a l k w i t h each o t h e r about t h e i r t h o u g h t s and f e e l i n g s c o n c e r n i n g c l i e n t - t h e r a p i s t s e x u a l abuse. A d m i n i s t r a t i o n The f i n d i n g s of t h i s s t u d y 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 n u r s e s r e v e a l e d knowledge about the t h e r a p e u t i c needs o f t h e i r c l i e n t s and s o c i a l and e t h i c a l r e q u i r e m e n t s ( r e p o r t i n g p r o c e d u r e s ) , c o n s i s t e n t l y m a i n t a i n e d t h e i r c o n c e n t r a t i o n on t h e i r i m p l i c i t g o a l of a l l e v i a t i n g c l i e n t s u f f e r i n g , c l e a r l y i d e n t i f i e d t h e p h y s i c i a n ' s s e x u a l b e h a v i o r as immoral and i m m e d i a t e l y a d d r e s s e d t h i s i s s u e w i t h t h e i r c l i e n t s , and dem o n s t r a t e d e x p e r t n u r s i n g c a r e i n a d i f f i c u l t p r a c t i c e s i t u a t i o n s u ggest t h a t n u r s i n g a d m i n i s t r a t o r s s h o u l d more o p e n l y 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 t h e s e n u r s e s w i t h some 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 , w h i c h i n t u r n would enhance j o b 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 s h o u l d s u g g e s t and f a c i l i t a t e 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, t h e y c o u l d s a n c t i o n and i n i t i a t e t he c r e a t i o n o f 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 i n s e r v i c e o p p o r t u n i t i e s , and s a n c t i o n and s u p p o r t p r o f e s s i o n a l c o u n s e l l i n g f o r the n u r s i n g s t a f f . Summary T h i s r e s e a r c h i s ' i m p o r t a n t because i t has i l l u m i n a t e d a s i g n i f i c a n t a s p e c t of the s e x u a l abuse phenomenon. The n u r s e s ' e x p e r i e n c e of c l i e n t d i s c l o s u r e of s e x u a l c o n t a c t w i t h a former t h e r a p i s t was shown t o be a d i f f i c u l t and s t r e s s f u l n u r s i n g e x p e r i e n c e . The r e s e a r c h has i m p l i c a t i o n s f o r n u r s i n g p r a c t i c e , r e s e a r c h , e d u c a t i o n , and a d m i n i s t r a t i o n . I f a t t e n t i o n i s p a i d by t h e n u r s i n g system t o t h e s e i m p l i c a t i o n s , c l i n i c a l p r a c t i c e w i l l become even , more- e f f e c t i v e , and s u f f e r i n g o f b o t h c l i e n t and n u r s e w i l l be d e c r e a s e d . 96 REFERENCES Anderson, J . M. (1991). R e f l e x i v i t y i n f i e l d w o r k : Toward a f e m i n i s t e p i s t e m o l o g y . Image: J o u r n a l o f N u r s i n g S c h o l a r s h i p , 23, 115-118. Bacharach, S. B., & L a w l e r , E. J . (1980). Power and p o l i t i c s i n o r g a n i z a t i o n s . 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Newbury Park, CA: Sage Publications. 101 Appendix A I n i t i a l T r i g g e r Statement P l e a s e t e l l me a l i t t l e about what i s was l i k e f o r you t o 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 t h e r a p i s t 102 Appendix B Respondent Consent Form A M e n t a l H e a l t h Nurse'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 S e x u a l C o n t a c t w i t h a Former T h e r a p i s t : A Case S t u d y 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 be i n t e r v i e w e d by Marg 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 she 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 she had had s e x u a l c o n t a c t w i t h a former t h e r a p i s t . T h i s s t u d y w i l l p r o v i d e i n d e p t h i n f o r m a t i o n t o n u r s e s 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 and 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 u n d e r s t a n d i n g the i s s u e s r e l a t e d t o 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 about t h i s phenomenon. I u n d e r s t a n d t h a t b e i n g a respondent i n t h i s s t u d y 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 a u d i o t a p e d i n a s e t t i n g w h i c h i s c o n v e n i e n t t o me and 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 hour 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 and any 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 be 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 Marg Rae s i n c e she w i l l use a s p e c i a l code t o i d e n t i f y my i n t e r v i e w s when she t r a n s c r i b e s the a u d i o t a p e s . I u n d e r s t a n d t h a t the anonymity o f t h e o f f e n d e r and t h e agency w i l l be ensured, and t h a t any mention 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 not appear i n t h e t r a n s c r i p t s . I have been i n f o r m e d t h a t I am under 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 , and 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 any time 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 have been i n f o r m e d t h a t I may r e f u s e t o answer any 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 aware 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 as I t a l k about 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 and 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 been i n f o r m e d t h a t I w i l l not 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 the r e s u l t s of 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, and t h a t Marg Rae i s the p e r s o n to, c o n t a c t i f I have any 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 can c o n t a c t Marg 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 committee 103 members C l a r i s s a Green (822-7507), V i r g i n i a Hayes (822-7477), and J a n e t E r i c k s e n (822-7505); o r members o f t h e E t h i c s Committee (822-8584). I , the u n d e r s i g n e d , u n d e r s t a n d the n a t u r e o f Marg Rae's s t u d y , and I g i v e my consent t o p a r t i c i p a t e as 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 name: Respondent' phone number: Respondent's s i g n a t u r e : , 

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