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A dissertation submitted to the Faculty of Arts in partial fulfillment of the requirements for a Masters Degree in Clinical Psychology at the University of Zululand, 2008. / Confidentiality is an essential tool in a therapeutic relationship, thus, the focus of this study was based on the views and experiences of intern psychologists and registered psychologists on the concept of confidentiality in a therapeutic relationship. The researcher selected ten participants, of which four were intern psychologists and six were registered psychologists. A qualitative research method of collecting data was used in a form of an open-ended questionare. This questionare was consitituted of two quastions which formulated vignettes of participants. A phenomenomenological approach was adopted in this study to facilitate the understanding of the information gathered. The findings from the present study indicated that confidentiality in a therapeutic relationship is a confusing stance. There was a strong view that confidentiality leaves psychologists in a dilemma especially where there is conflict of interest. This was noted to be of significance that the participants believed that the clients they serve are their first priority. It was also found in this study that the lawyer-client relationship is protected as compared to a client-psychologist relationship. This study concluded with a brief discussion on the limitations of the study and recommendations of future research.

Background: A low adherence is one of the reasons for the development of drug resistant Tuberculosis. One of the identified factors connected to adherence is the relations between health care personal and patient. Nurses all over the world daily work close to the patient supporting them to achieve a high adherence to their treatment plan. Still there is an underrepresentation in a scientific view of exploring and evaluating this preformed work. Aim: The aim of this study wad to explore how the Namibian nurses experienced adherence to treatment in patients diagnosed with multidrug-resistant tuberculosis. Method: A qualitative research technic was used to collect data. The interview questions were constructed in a semi-structure with partly opened questions. The data was analysed with Graneheim and Lundman (2004) analysis model. Result: Strategies that was used by the nurses to enable a high adherence was providing information, counselling and education to the patient together with a practical support of delegating DOTS and providing the patient with medicine. There was a divided opinion on how to communicate with the patient depending on the nurse fundamental view of adherence. A doctor centred view resulted in a one way communication by informing the patient. A patient centred view of adherence resulted in a two way communication when the nurse aimed to learn about the patient own point of views. Conclusion: To enable a high adherence there has to be a two way communication which demands high communicational skills from the nurse.

Background: A history of complex trauma alters basic self-structure, attachment system and core areas of interpersonal functioning and relationships. There is increasing recognition of the high proportions of complex trauma histories within substance misusers and limited research into the sequelae of complex trauma, particularly in relation to comorbid complex trauma and substance misuse. There is a distinct lack of adequate theory and guidelines for treatment. Research Aim: to explore psychologist’s experiences of and perspectives about their work with substance misusers with a history of complex trauma. Complex trauma is a term used to describe experience’s which arise from severe, prolonged and repeated trauma which is often interpersonal in nature. Courtois & Ford (2009) have defined complex trauma as “involving stressors that: are repetitive or prolonged, involve direct harm and/or neglect and abandonment by ostensibly responsible adults, occur at developmentally vulnerable times in the victim’s life, such as early childhood, have great potential to compromise severely a child’s development.” (p1). The prototype trauma that was first described under the term complex trauma was child abuse and neglect. Method: Semi-structured interviews were conducted with eleven clinical and counselling substance misuse psychologists working across four health boards in Central Scotland. The data was analysed using Interpretative Phenomenological Analysis (IPA). Results: Six main superordinate themes emerged from the data: 1. Challenges in negotiating therapeutic relationship; 2. Balancing relational forces; 3. Walking the tightrope of comorbidity; 4. Conceptual dearth (surrounding complex trauma); 5. Emotional impact of Work, and, 6. Core role of therapeutic relationship (in treatment and recovery). Discussion: Participants accounts suggest there are many risks to balance as well as paradoxes inherent in this type of work. The nature of a history of complex trauma means that often clients have difficulties with attachment and relational aspects in their lives, which in turn affect their engagement in the therapeutic relationship. The findings of this study suggest that it is precisely because relationships seem so threatening and challenging for these clients, that the therapeutic relationship appears to form such a vital role in the therapeutic treatment and recovery process for these client.

This thesis examines an aspect of embodied relationship that is recognised in colloquial figures of speech but is not theorised, nor even much acknowledged in the psychotherapeutic literature. It argues that when we experience subtle sensations of extending towards another person, as we might when our "heart goes out" to them, and of pulling away, as we might when we "draw back", this seemingly internal experience is snesed by the other. Using a phenomenological-hermeneutic methodology underpinning by Merleau-Ponty, van Manen and Todres, exercised were used to bring such experiences to the awareness of several cohorts of experienced and inexperienced therapists attending a training course. Verbal and written accounts of what was felt during the exercised, and of similar experiences from more naturalistic settings, were collected along with the researchers' own accounts. These accounts are discussed within the framework of a Gadamerian Conversation with a view to making explicit the implication for Person-centred therapy with regard to practice, supervision and training. The conversation speaks of the the impact of these experiences upon whether or not clients perceive therapists as authentic, unconditionally accepting and empathic. Assumptions are uncovered and challenged and an alternative narrative emerges from a consideration of multiple contexts. The conversation also speaks of an unseen dance of closeness and distance that arises as each moves towards and away from the other. Conversation (and silence) is inevitably accompanied and impacted by this dance, which happens in the background of every interaction. The unseen dance impacts not only the relationship, but also each person's organismic state.

This is the first known occupational therapy (OT) study to examine the emergent patterns of the client-therapist working alliance during the course of a community-based OT intervention. The experiences of both the adult client and OT in each of four dyads are explored and described as they relate to the evolution of the alliance over time and the impacting contextual factors. These experiences were considered alongside the therapy outcomes. Mixed methods, including quantitative scales and interviews, were used in this multiple-case study situated within a pragmatism paradigm. Individual case and cross case analyses were conducted leading to the identification of eleven cross case themes. These findings suggest that the interpersonal relationship between a client and OT develops with the goal of becoming a safe harbour for the clients. The strengthening interpersonal bond appears to create an impetus within the client to engage in therapeutic activities. This enticed engagement results in the client’s performance of novel activity purposefully selected by the OT as bearing personal meaning for the client. The clients’ engagement often results in enhanced insight into their abilities and meaningful functional gains. This success appears to reinforce and energize both the momentum toward the collaboratively-established therapy goals, as well as provides a positive feedback mechanism into the working alliance. The OT’s training, philosophy and skill, client’s attributes, and environmental influences (both physical and social) all appear to have potential implications upon the working alliance’s development and/or the therapeutic achievements. Further research will be needed to confirm or disconfirm these findings and may include further study with variable client populations (e.g., different ages, different conditions), the role of humour in the therapeutic process, the impact of client’s degree of social isolation on the alliance, as well therapists’ disparate levels of use-of-self and the related impacts upon the alliance.

This is the first known occupational therapy (OT) study to examine the emergent patterns of the client-therapist working alliance during the course of a community-based OT intervention. The experiences of both the adult client and OT in each of four dyads are explored and described as they relate to the evolution of the alliance over time and the impacting contextual factors. These experiences were considered alongside the therapy outcomes. Mixed methods, including quantitative scales and interviews, were used in this multiple-case study situated within a pragmatism paradigm. Individual case and cross case analyses were conducted leading to the identification of eleven cross case themes. These findings suggest that the interpersonal relationship between a client and OT develops with the goal of becoming a safe harbour for the clients. The strengthening interpersonal bond appears to create an impetus within the client to engage in therapeutic activities. This enticed engagement results in the client’s performance of novel activity purposefully selected by the OT as bearing personal meaning for the client. The clients’ engagement often results in enhanced insight into their abilities and meaningful functional gains. This success appears to reinforce and energize both the momentum toward the collaboratively-established therapy goals, as well as provides a positive feedback mechanism into the working alliance. The OT’s training, philosophy and skill, client’s attributes, and environmental influences (both physical and social) all appear to have potential implications upon the working alliance’s development and/or the therapeutic achievements. Further research will be needed to confirm or disconfirm these findings and may include further study with variable client populations (e.g., different ages, different conditions), the role of humour in the therapeutic process, the impact of client’s degree of social isolation on the alliance, as well therapists’ disparate levels of use-of-self and the related impacts upon the alliance.

Regardless of therapeutic orientation, the therapeutic relationship has been consistently shown as central to the therapeutic process. However, research has also shown that this can be difficult to achieve when working with sex-offenders. Less is known about the experience of this relationship and little qualitative research has been conducted in this area. This current study therefore aimed to provide valuable insight into the first-hand accounts of therapists directly working with this client group through exploring their experience of the therapeutic relationship, using a qualitative approach. The study focused upon the experiences of eight Counselling Psychologists, in order to keep the sample homogenous, and explored the differences the therapists may have experienced compared to other client groups. Additionally, it aimed to highlight what difficulties, if any, have arisen in the therapeutic relationships and potentially how these have been experienced, managed, overcome and addressed. Semi-structured interviews were carried out with eight counselling psychologists who have worked therapeutically with sex-offenders. Verbatim transcripts of the interviews were then analysed using Interpretative Phenomenological Analysis (IPA). The analysis illustrated four master themes: i) Forming a relationship- negotiating the degree of intimacy; ii) overcoming barriers to the relationship- contending with the context; iii) establishing a relationship- feeling a reaction yet managing a response; iv) reaping the rewards of the relationship- out of the darkness and into the light. A description of these master themes and the related subordinate themes were presented. The results of the analysis were considered in light of existing theory and their clinical implications.

This is the first known occupational therapy (OT) study to examine the emergent patterns of the client-therapist working alliance during the course of a community-based OT intervention. The experiences of both the adult client and OT in each of four dyads are explored and described as they relate to the evolution of the alliance over time and the impacting contextual factors. These experiences were considered alongside the therapy outcomes. Mixed methods, including quantitative scales and interviews, were used in this multiple-case study situated within a pragmatism paradigm. Individual case and cross case analyses were conducted leading to the identification of eleven cross case themes. These findings suggest that the interpersonal relationship between a client and OT develops with the goal of becoming a safe harbour for the clients. The strengthening interpersonal bond appears to create an impetus within the client to engage in therapeutic activities. This enticed engagement results in the client’s performance of novel activity purposefully selected by the OT as bearing personal meaning for the client. The clients’ engagement often results in enhanced insight into their abilities and meaningful functional gains. This success appears to reinforce and energize both the momentum toward the collaboratively-established therapy goals, as well as provides a positive feedback mechanism into the working alliance. The OT’s training, philosophy and skill, client’s attributes, and environmental influences (both physical and social) all appear to have potential implications upon the working alliance’s development and/or the therapeutic achievements. Further research will be needed to confirm or disconfirm these findings and may include further study with variable client populations (e.g., different ages, different conditions), the role of humour in the therapeutic process, the impact of client’s degree of social isolation on the alliance, as well therapists’ disparate levels of use-of-self and the related impacts upon the alliance.

Encounters in which shared decision-making occur relies on patients and healthcare professionals establishing a partnership. Yet, little is known about the therapeutic relationship (TR) specifically for the implementation and use of patient decision aids (PDA) to facilitate shared decision-making. The aim of this thesis was to explore how the TR is considered when planning PDA implementation for patients eligible for or with an implantable cardioverter-defibrillator (ICD). Using Thorne's interpretive description approach, I conducted a secondary thematic analysis using transcripts with 17 healthcare professionals, ten patients and three family members. Findings were mapped to the TR elements. I identified three themes. First, Pieces of the puzzle: Elements of the TR revealed that while respect and therapeutic communication were identified as important for PDA implementation, other TR were either referred to implicitly or not at all. Second, Good intentions and challenges of establishing a TR revealed that healthcare professionals wanted to engage in TR but lacked time and felt discomfort navigating ICD decisions. Finally, in PDA as support for the TR, participants considered PDAs as being able to facilitate TR elements such as communication and respect, enhancing the consultation. In conclusion, there is a role for TR elements when planning PDA implementation. Further research is needed to explore the other therapeutic relationship elements of genuineness, manifesting a presence, active listening, and reciprocity.