ETHICAL ASPECTS OF PSYCHOTHERAPY

MONIKA ULRICHOVÁ

LUBLIN 2014

THE ETHICAL TRAINING A N D S E L F -T R A I N I N G

OF THE THERAPIST WITH A FOCUS

ON LOGOTHERAPY AND EXISTENTIAL

ANALYSIS

E T H I C A L A S P E C T S

O F PSYCHOTHERAPY

This book was produced with the support of the European Social Fund and State Budget of the CR as part of the project “Innovation of the Study Field of Transcultural Communication and Implementation of Teaching in the English Language“ (CZ.1.07/2.2.00/28.0131).

CATALOGUE ENTRY – NATIONAL LIBRARY CR Ethical Aspects of Psychotherapy. – 1st edn – Hradec Králové: Katedra kulturnícha náboženských studií PedF UHK, 2014. – 116 pp.Cultural and Social AnthropologyPhilosophical AnthropologyBiblical AnthropologyPersonalismNihilismTheory of Culture

Reviewed by doc. MUDr. Alena Vosečková, CSc.PhDr. Ivanka Binarová, Ph.D.

© Monika Ulrichová, 2014

Published by EL-PRESS: Lublin, 2014

ISBN 978-83-86869-41-1

Dedicated to Lucia Marušiaková,

my unique friend

CONTENTS

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111 The conditions of the psychotherapeutic situation . . . . . . . . . . . . . . . 15

1.1 The psychotherapeutic relationship . . . . . . . . . . . . . . . . . . . . . . . 151.2 The requirements placed on therapists – developing

their personhood and personality . . . . . . . . . . . . . . . . . . . . . . . . . 181.2.1 Neglecting oneself, burnout syndrome . . . . . . . . . . . . . . . . 251.2.2 Frankl’s conception of burnout syndrome . . . . . . . . . . . . . 301.2.3 The existential analytical view of the development

of exhaustion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 311.2.4 The theory of Alfried Längle . . . . . . . . . . . . . . . . . . . . . . . 311.2.5 Treatment of burnout syndrome . . . . . . . . . . . . . . . . . . . . . 34

1.3 The training of the psychotherapist . . . . . . . . . . . . . . . . . . . . . . . 351.3.1 Group training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 361.3.2 Supervision . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38

1.4 The setting of the therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 442 The definition of logotherapy and existential analysis as a field

of psychotherapy, the personality of Victor E. Frankl . . . . . . . . . . . . 472.1 The difference between existential analysis and logotherapy . . . 482.2 The concept of meaning and conscience . . . . . . . . . . . . . . . . . . . 492.3 Emptiness in life, failure to fulfil meaning . . . . . . . . . . . . . . . . . . 532.4 Values in existential analysis and logotherapy . . . . . . . . . . . . . . . 56

3 The principles of ethical action in psychotherapeutic practice . . . . . . 593.1 The issue of boundaries and their violation . . . . . . . . . . . . . . . . . 703.1.1 Sexual contact with a client as one of the most serious

violations of the boundaries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 713.2 The issue of the value of religion as an instrument

in therapeutic practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 753.2.1 The power of prayer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 793.2.2 Religion and ethics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81

3.3 The value of diversity and multiculturalism in logotherapy . . . . 833.3.1 The connection between transcultural communication

and logotherapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 873.3.2 The cultural contingency of logotherapy . . . . . . . . . . . . . . 90

3.4 Breach of confidentiality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 943.5 Jealousy and disloyalty between colleagues. . . . . . . . . . . . . . . . . 973.6 The issue of payment for therapy . . . . . . . . . . . . . . . . . . . . . . . . 1003.7 The problem client . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102

Final reflections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109

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This book is intended for anyone training or already working in a helping profession, and especially for those whose interests and energies are focused on psychotherapy or counselling. It may also, of course, be helpful to anybody undergoing therapy. The book outlines several situations in which both the helping professional and the client can find themselves. An official ethical code is a help for therapists in decision-making, but in life and in the client-therapist relationship situations arise in which the therapist has to take decisions, as it were, beyond the required framework of rules. This is why it is immensely important to take into account values, to cultivate conscience, and constantly work on the development of one’s own personality. Indeed, this is considered to be the most important dimension of all, because a professional, working in communication-based therapy, finds himself or herself in a field that poses one of the greatest challenges in life. This book has been written in hope that it will stimulate the reader’s thinking, emotions, beliefs and values relating to morality and ethics.

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INTRODUCTION

Therapy can solve problems but at the same time it generates many problematic situations and dilemmas. These can be dilemmas presented by the patient, but also problems that may be weighing on the therapist or counsellor personally, or some overall situation that is having an unfavourable effect on the therapeutic work. 1The fundamental promise of therapy lies in its capacity to help people who are wounded or in some way in need. This promise changes people’s lives, reducing emotional distress and improving overall satisfaction in life. The effectiveness of psychotherapy is a matter primarily of the relationship between the therapist and client, as well as variables on the side of the client, the techniques used and extra-therapeutic factors. Michael Lambert, a leading reasercher in psychotherapy, has addressed the question of whether psychotherapy works, and the following is a summary of his conclusions:

1. Psychotherapy is effective. Lambert has collated the results of studies and on this basis has reported that 75% of people who undergo therapy get at least partial benefit from it. This finding applies to the variety of problems for which therapy is indicated. Lambert stresses that for the majority of psychological problems, with the exception of serious disorders including those with a biological basis, psychotherapy rather than pharmacological treatment should be considered as the primary treatment.

2. The effect of psychotherapy is not a mere placebo effect or limited to that of informal encouragement of the patient. The effect of psychotherapy is on average twice as great as the effect of a placebo and as much as four times greater than when the patient receives no treatment of any kind.

3. The results of psychotherapy are symptom-relevant and lasting. The effect of psychotherapy has been measured not just by the method of self-assessment by patients, but also by independent observers. The range of problems that can be effectively addressed by psychotherapy has been identified: it includes

1 For more detail on the factors involved in therapy see WAMPOLD, B.: The Reasercher Evidence for the Common Factors Models: A historically situated perspective. In DUNCAN, B.; MILLER, S.; WAMPOLD, B.; HUBBLE, M.: The Heart, Soul of Change. American Psychological Association, 2010, pp. 47–82.

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psychopathological symptoms, interpersonal problems, difficulties in social role, and so forth. Overall the effects of psychotherapy can be said to be discernible with the passage of time, given a standard length of therapy of at least two years.

4. Psychotherapy can lead to improvement but also to deterioration; 5–10% of patients get worse during therapy and another 15–25% experience no improvement.2

Despite the overall significant success of therapy, at a certain stage professionals can encounter problems that may complicate and even vitiate the course of therapy. For example, initial feeling of relief by the effects of therapy may cause the client to think that he no longer needs to work on himself, or alternatively, in the case of transferences that are very hard to control to develop in the context of much longer-term contact between the therapist and the client. This book does not pretend to address all the ethical questions that can arise in some comprehensive way, but merely to highlight a number of moral and ethical dilemmas that even the experienced psychotherapist may encounter in his work. Just like anyone else, therapists can – and do – make mistakes in therapeutic work. What is necessary is to look at these wrongly handled situations with detachment, with appropriate self-searching, and as far as possible to learn from these “defeats”. Apart from the triumphs and disasters, however, there are situations in therapeutic practice that are not black-and-white – neither good nor bad but ambiguous and ethically debatable. In these ethically problematic situations the therapist may even weaken or damage the patient by sticking rigidly to the “correct” norm. According to surveys in psychotherapy, 57% of psychotherapists admit that they have deliberately breached an ethical principle in the interest of the client or higher values.3 How, for example, should a therapist react if a client tells him/her that she was abused in her childhood, or what action should a therapist take in the psychotherapy of a child who asks for help but whose parents do not agree with the treatment?

As Hana Jůnová states, in the Czech Republic it has really only been since 1989 that efforts have been made to build up the ethics of the psychological profession in a focused and conscious way, and unfortunately from scratch.4 By 1989 psychology in the West was already routinely working, for example, with the Universal Code of Ethical Principles for Psychologists and other ethical

2 See VYBÍRAL, Z.; ROUBAL, J. (eds.): Současná psychoterapie [Contemporary Psychotherapy]. Praha: Portál, 2010, p. 54.3 See SMITKOVÁ, H.: Etická dilemata v psychoterapii a psychologickém poradenství [Ethical Dilemmas in Psycho-

therapy and Psychological Counselling]. In WEISS, P. et al.: Etické otázky v psychologii [Ethical Questions in Psycholo-gy]. Praha: Portál, 2011, p. 226.

4 See.JUNOVÁ,H.:Kultivaceetikypsychologicképráce–úkolpromezinárodníspolupráciipročesképsychology[The Cutivation of the Ethics of Psychological Work – a Task for International Collaboration for Czech Psycholo-gists]. In WEISS, P. et al.: Etické otázky v psychologii. Praha: Portál, 2011, p. 315

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framework aids in therapeutic work.5 Elizabeth Reynolds has identified five dimensions of positive ethical ideals in the profession of psychotherapy. The first is the capacity for understanding of skill and judgment as to how best to make use of effective interactions with the client.6 The second is respect for the human dignity and freedom of the client. The therapist should know how to use his/her inner strength as a responsible professional. He/she should also use the kind of techniques that encourage the public to view the therapeutic profession with a positive attitude, and his/her highest priority should be the welfare of the client. The therapist does not do his/her work in a vacuum, but is affected by many factors and realities, hence before we consider specific unclear areas in psychotherapy, we shall first present outline situations in which optimal therapy takes place. We will then talk about the conditions of psychotherapeutic practice.

5 See BERRY, J. W.; POORTINGA, Y. H.: Cross-cultural Psychology. 3rd edn Cambridge: Cambridge University Press, 2011, pp. 444–445.

6 See WELFEL, REYNOLDS, E.: Ethics in Counseling & Psychotherapy. 5th edn Belmont: Brooks/Cole, 2010, 2013, p. 3.

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1 THE CONDITIONS OF THE

PSYCHOTHERAPEUTIC SITUATION

The whole therapeutic process unfolds in a certain context, or framework, which should meet a number of preconditions for correct therapeutic process. The content of this framework creates the conditions from which a successful, or less successful, therapeutic situation arises. If we go back to the first ethical dimension mentioned by Elizabeth Reynolds, i.e. the therapist’s capability for understanding and his/her skills, we find that these capabilities have a great deal to do with the therapist’s education/training, his/her supervision experience and activities, etc. We therefore need to devote appropriate attention to this topic.

1.1 The psychotherapeutic relationship

In counselling and psychotherapy the relationship between the client and the therapist is very important. Indeed, it is the ground from which the success or failure of the therapy develops. Many therapeutic schools concur that the therapeutic relationship is one of the most powerful tools of treatment, even more powerful than any other method employed.7 This relationship cannot be something that is artificially created – something that the therapist needs to “turn on” for interaction with the client just for the next 50 minutes. The psychotherapeutic relationship is the condition for the progress of the client and, at the same time, it is a tool of treatment. It is generated on both sides, the therapist’s and the client’s, and we can generally say that the healthier, better and more natural this relationship is, the better the progress of treatment of the client. The relationship changes and evolves in the course of therapy, and has its own regularities and dynamics. It is understandable that at the beginning there is a stage of mutual “sounding out” by client and therapist, that initially there is a certain distance and then gradually mutual trust can be established and grow. Some clients have a tendency to overstep the boundary in the direction of the therapists, which is

7 A more detailed examination of the psychotherapeutic relationship is to be found in the article by John C. Nor-cross, The Therapeutic Relationship, see DUNCAN, B.; MILLER, S.; WAMPOLD, B.; HUBBLE, M.: op. cit., pp. 113–133.

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clear in questions they ask him/her about where he/she lives, his/her marital status and matters of personal life. If the client shows increasing emotionality, the therapist needs to offer a more stable, but at the same time, warm relationship. The therapist must be aware of boundaries, but at the same time should not lack authenticity in the relationship or readiness to be a support for the client even in the context of unpleasant events/matters. His/her main working tool is therefore his/her personality, and the basic component of personality is moral. Moral obligation and the responsibility that arises from it is thus an essential part of the relationship. Trust is the key to the client-psychotherapist relationship and we can say that the basic pillar of this trust is an ethical approach to the client.8 While the main responsibility concerning the therapeutic process, the progress of treatment and the relationship falls on the shoulders of the therapist, these days we also talk about the client’s responsibility, which involves certain moral demands, and especially the ability to be authentic.9 In his book Petr Mikoška writes about what he calls meta-skills, which are connected to the personal traits of the therapist.10 He bases his approach on Freud’s conception of the therapeutic relationship and considers the crucial meta-skills to be fluidity – which is the capacity to perceive processes in one’s own self, one’s own lived experience of the situation, the courage to take risks, not to be afraid of entering into the lived experience of the other, and the ability to “recycle” i.e. not to write off the apparently unimportant, as well as empathy, “love for the universe” and so on.11

The presence of trust and hope is an essential condition for a good psychotherapeutic relationship. Hope here means fundamental responsibility, is part of life and an expression of positive forces.12 Irvin Yalom accentuates that a lasting and positive relationship between therapist and client is the inevitable ground for all considerations of technique. The basic relational attitude of the therapist to the client must be pure and empathic, filled with interest and acceptance. C. G. Rogers, who devoted a great deal of thought to the pure authenticity of the therapist-client relationship, characterised the key effective factors in psychotherapy as empathy, authenticity and acceptance. Rogers argued that the more a person is accepted, the more a relationship is created that can be positively exploited in therapy. By acceptance he meant a warm respect for the client as a human being who has unconditional value –regardless of his state of

8 See.HUBÁLEK,S.;KOŤOVÁ,M.:Etikavpsychoterapii[EthicsinPsychotherapy].InWEISS,P.etal.:op. cit., p. 233.9 See.HUBÁLEK,S.;KOŤOVÁ,M.:op. cit., p. 233.10 See. MIKOŠKA, P.: Metadovednosti a (ne)vědomí v psychoterapii: fenomenologická studie podmínek efektivního využívání

psychoterapeutických technik [Meta-Skills and (Un)Awareness in Psychotherapy: Phenomenological Studies of the Effective Use of Psychotherapeutic Techniques].ČervenýKostelec:PavelMervart,2013,p.62.

11 See MIKOŠKA, P.: op. cit., pp. 24–25.12 SeeVYMĚTAL,J.:Úvoddopsychoterapie [Introduction to Psychotherapy]. 2., updated edition. Praha: Grada, 2003,

p. 98.

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mind, his behaviour or his feelings.13 In this respect Rogers has a very optimistic view of core of the human being. Indeed, he has a highly optimistic expectations of the body/organism – the foundation of all human experience – and he considers it to be wiser than human consciousness.14 No technical strategies have higher priority over this approach. Of course, there are moments when the therapist and client go through a stage of confrontation for “therapeutic reasons”, but this is effective only when the basic preceding relationship has been grounded in acceptance and goodwill.15

Some authors put stress on trust, strength and care as the basic necessary prerequisites for a good therapeutic relationship. We may regard these three virtues as important challenges in psychotherapy. Society expects therapists to be trustworthy, to be unceasingly beneficent towards their clients, and to fulfil all the obligations that go with professionalism.

The concept of trust is fundamental because clients rightly expect their trust in the therapist to be well placed. Actually, many clients are afraid that their trust will be misused, and therapists are often repeatedly asked for assurances that they would not tell anyone some piece of confidential information. Some clients starting therapy are entirely unaware that their problem with trust is connected with their difficulties in personal life, or at work, or general problem with living their life well and to the fullest. Some therapists test out trust at the beginning of the therapy by an exercise in which they deliberately ask a client very personal and sensitive questions, and the clients tend to share information they would never communicate to anyone else.16 However, there are various different ways of conducting a therapeutic dialogue – and at the beginning most therapists prefer mainly to listen, because the client is taking the initiative by coming and above all they need to be accepted, to be heard out. He/she is coming because what he/she lacks is understanding and sympathy, and sometimes the therapist is really the only person ready to hear out a particular problem, albeit for a limited time, who is genuinely interested in the client and prepared to help. This is very crucial, particularly at the beginning of the therapy, because the initial sessions form the basis for the growth of trust between client and therapist and naturally lay the groundwork for the therapy, which is often demanding on the client. It is only through a good relationship that mutual reliability is created in the therapeutic setting. If a therapist betrays a client’s trust, this can cause a major deep hurt, often fatal to the relationship, because clients do not trust therapists out of faith in some abstract principle, but on a purely personal basis.

13 See ROGERS, C. R.: Ako byť sám sebou [How to Be Oneself]. Bratislava: Iris, 1995, p. 38.14 See DRAPELA, V. J.: Přehled teorií osobnosti [Overview of the Theory of the Personality]. Praha: Portál, 1997, p. 125.15 See YALOM, I. D.: Teorie a praxe skupinové psychoterapie [The Theory and Practice of Psychotherapy]. Praha: Portál,

2007, p. 125.16 See POPE, S. K.; VASQUEZ, J. T. M.: Ethics in Psychotherapy and Counseling. 4th edn New Jersey: Wiley, 2011, p. 34.

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The trust that society and the individual clients vest in the therapist is a great source of power. This logically brings us to the second of the virtues described by Reynolds and mentioned in the introduction: the strength to maintain respect for the client and not to betray him by abusing it. Another important attribute is a sustained care. A mature therapist is aware that the whole trust that he/she is earning from the client – the very trust that helps to create the therapist’s strength – must never be deliberately damaged. Trust must go hand-in-hand with care for the person that the therapist has before him/her, and must be complemented with concern for the client’s happiness and balance in life.17 Balance in life means in this context is precisely what the therapist is supposed to help the client to find, without passivity and pointless sentimentality. Care and interest mean providing an answer to the client’s legitimate needs, and thus this requires great personal responsibility on the part of the therapist. For a therapist, solicitude for the client is his fundamental personal responsibility.

A vast number of authors consider the psychotherapeutic relationship to be the most pivotal factor in therapy. When Michael Lambert speaks about the overall positive effectiveness of psychotherapy he notes that what clients rate most highly of all the factors in therapy is the personality of the therapist, their understanding of the client’s problems, their courage in opening up matters that are unpleasant for the client, their ability to communicate with understanding for the other person, and their capacity to help the client enlarge his self-awareness.18

The personality of the therapist, and overall setting of the therapy, is likewise immensely important in other conditions and aspects of the psychotherapeutic situation.

1.2 The requirements placed on therapists – developing their personhood and personality

The basic requirements placed on therapists are summed up in official professional ethical codes, for example the Ethical Code of the Czech Psychotherapeutic Association or the Ethical Code of the Czech-Moravian Psychological Society or the Ethical Code of the Association of Clinical Psychologists.19 Several such professional codes have been formulated and every counsellor and therapist ought, by definition, to uphold the principles contained in them. Yet this is not enough. There are other requirements on therapists, above all on their human maturity, which, of course, are implicit in the ethical codes even if unwritten. The main

17 See POPE, S. K.; VASQUEZ, J. T. M.: op. cit. , p. 39.18 See LAMBERT, M.; SHAPIRO, D.; BERGIN, A. E.: The Effectiveness of Psychotherapy. In BERGIN, A. E.; GARFIELD,

S. L.: Handbook of Psychotherapy and Behaviour Change.3rd edn. New York: Wiley, 1986, pp. 157–173.19 See WEISS, P.: Etické otázky v psychologii [Ethical Questions in Psychology]. In WEISS, P. et al.: op. cit., pp. 329–335.

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working instrument is the personality of the therapist and this is something that cannot be entirely taught. Slavomil Hubálek and Magdalena Koťová argue that one of the therapist’s most important characteristics is “wisdom”, but can this wisdom be transmitted just by precept? 20 How can a therapist learn to be good in such a way that this “goodness” is truly natural to him/her and a part of his/her personality even behind closed doors when he/she is alone with the client? How can anyone ensure that this “goodness” is not just a quality artificially imported into comments during supervisions so as to give a “good” impression while the therapist is inwardly on a different trajectory, following the track of “goodness” sometimes when pragmatically necessary, but in fact inwardly following on his/her own goal? It is certainly possible to teach a therapist the ethical code, knowledge of law, “decent” behaviour to the client, and even responsibility, discretion, etc.,but we believe that apart from all this knowledge and skills the therapist needs to have a certain kind of strength. This is the strength that is genuinely anchored in qualities like liking the person in front of him/her, being truly on his side, and the ability to get close to the boundary of the other without violating it (which frequently means real tact based on a sense of affinity with the core, and a sympathetic understanding of the person in front of the therapist). There are therapists, however, who are unable to get that far in imagination, let alone in reality, and do not know how to find the potential within themselves for a truly good relationship with their clients. This kind of therapist may perform his/her work in a way that is partially effective, but they still never really perceive the clients in their essence, core, and they will never be able to fully awaken the client’s own potential for betterment. This type of therapist is far too afraid about his/her boundary. Generally, the best preventive measure of all kinds of incongruities, dysfunctions and unethical exchanges in the psychotherapeutic process is the development of the therapist’s own emotional, social, intellectual and moral understanding.

There are great emotional demands on the therapist. It is no easy task to carry the burden of the task: to be stable, courageous and accepting, to cultivate and authentically experience interest in the client, and to develop sensitivity and perceptiveness. What is vital is that the therapist should treat himself/herself well, so that a certain balance should be evident both in an inner and outer direction. Seen in this way, the requirement placed on the therapist is for a certain level of human maturity.

Yes, the therapist needs to be mature. According to existential analysis (EA), a therapist is mature if he/she has what is known as an activated personhood.21 Personhood in EA is a certain strength in handling situations and our own selves.

20 SeeHUBÁLEK,S.;KOŤOVÁ,M.:op. cit., p. 230. 21 Taken from lectures on logotherapy and EA self-experience training in the years 2008–2011.

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It is the most interior power that we possess, because it is what gives us the power to make decisions. Viktor Frankl claimed that the person in us cannot get ill. We should stress that we are not talking here of some kind of mood or impulse, as the level concerned is deeper. It is thanks to personhood, which I, as an individual, can take a stance, and this capacity cannot be fettered. This is a power that can often be perceived among people imprisoned by totalitarian regimes (whether Communist or Nazi or elsewhere). Some continued to resist the huge pressure for a long time, and some never gave in. Frankl spoke vividly of his own experiences in a concentration camp, saying that what it took to resist the pressure to succumb to overall indifference and hopelessness was the constant activation of one’s own personhood and adoption of a stance in the face of “fatefulness”. Other characteristics of personhood include its mystery, in which can be found a strong spiritual element. Personhood is an element that is innate and honed in relationships. The individual’s personhood is not some abstract quantity but it is active and effectual; it has the power to oppose. Here is the core of what is known as the “resistant power of the spirit”. Personhood is the free component in man and it is the dynamic of how individual persons treat the world, how they define themselves in in contrast to the world, etc.

According to EA the abilities of personality include the power to accept the self, to take a distanced view of the self, and to transcend the self.22 Self-acceptance means that I accept myself: I “embrace myself”. I have a positive loving relation with myself. I take a stance with regard to myself. I know about my qualities, I understand my weaknesses, but despite knowing them I can still love myself. It might be argued that it is just this quality that enables the individual to be capable of relationships. Ability to have a relationship with other people is based on his relationship to his own personality, his knowing his own self. This involves not just the capacity to create a relationship, but the ability to maintain and cultivate it; the capacity to love oneself and love another person. The exact task of the therapist is to guide the client on the way to building the necessary relation with himself. People (clients) mistakenly think that there is something wrong about love for oneself. Just the other way round; nobody can love another person – no matter whether a similar one or entirely different one – unless they accept themselves, unless they stop fight themselves, unless they love themselves with all their flaws and shortcomings. The capacity to build a relationship is tested out in self-acceptance. If an individual is able to accept himself, love himself and forgive himself, he can accept, love and forgive others. Relationship to another person is born out of an experience of relationship to oneself. A person who is too impulsive and too critical, is in fact frightened; he is afraid that other people are better than him. The person who is constantly criticising is not free, 22 Taken from lectures in logotherapy and EA training exercises in the years 2008–2009.

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but is disguising his fears with his criticism. Fear often arises from weaknesses – from the inability to accept and bear failures and mistakes in life. Inability to accept self, in fact, means that a person rejects his own self. We can see this in those individuals who have an endless need to defend themselves and are unable to discuss various matters in a spontaneous open way. Aggression expresses the same kind of problem. An excessively authoritarian attitude shows that the individual is not free, but is afraid of not being able to defend their opinions in case of opposition. All these fears, signs of aggression, and excessive criticism to others have, then, a common denominator: the fear that springs from a lack of acceptance of the self, and failure to be at ease with oneself. Thus, it is very important a therapist to have a good, balanced attitude to himself/herself, which is expressed in acceptance of himself/herself and then acceptance of the diversity of clients.

The second important ability of the personality is the capacity to take a distanced view of the self. This involves the individual’s ability to accept that he/she may be over-loaded, or engulfed by various feelings and influences and his/her view may be distorted. Distance on the self means that I am able to step back from myself and look at myself with detachment: at my thoughts, their manifestations, the way I am living events, and my attitude to myself and to others. Taking a distance from the self is highly beneficial for the therapist and indeed for anyone, for it is the ground to enlarge the inner space of freedom. This freedom shows us that a therapist does not always have to be right, and even a well-intentioned approach may not fall on fertile ground in the case of a specific client. Distance from the self is crucial for successful critical reflection on self. Insufficient distance from the self may lead to a situation in which the therapist offers well-meant views on a concrete situation when the client is not yet ready for them, or when they may even be useless to the client. The lack of distance from the self can be the reason behind a therapist’s insistence on a method that is not necessarily beneficial to the client, and that may push him in an artificial and diversionary direction. Distance from the self is important for the successful course of therapy and a healthy relationship between client and therapist, particularly when, even with the best intent in mind and with the regard for the client’s welfare, the therapist is still bound by his/her own limits and boundaries. It is the capacity for detachment that enables him/her to stop, to reassess and reconstruct his/her view of the client as well as of the whole context.

The third important ability of the personality is self-transcendence. Self-transcendence is what enables the individual to commit himself to a task, a cause or a person. It means the ability to go out of one’s own self, to move beyond the circle of one’s own self, for the sake of something or someone. It is the power to relinquish oneself as the central point. We need to stress, however, that even

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when we are moving beyond ourselves towards something or someone else, it is crucial to retain the relationship with oneself, i.e. to keep returning from that world “outside” to one’s own world “inside” so that the motives that lead us to self-transcendence would remain alive and actual. It is self-transcendence from which the capacity for responsibility grows. Self-transcendence is, of course, very closely connected with distance from the self, which is implied when an individual gives himself up to something or someone else and comes out of himself. This movement out of the self and the ability to leave the self behind is important for a meaningful life. Yet, as we have just noted, returning to oneself is essential if a person’s reasons for self-transcendence are to remain living and authentic, and if he is not to merely “commit good” in an unreal way. If the return to oneself is missing, the individual who is constantly “doing or enacting good” may feel abused and paradoxically experience feelings of frustration, jealousy and hatred. Self-transcendence may be, but may not be, connected with the religious conception of transcendence. It is true that religious perception of self-transcendence may help therapists on condition they are believers themselves, to view the client as a unique being for whom they are here, with desires and goals that may differ from the desires and goals of the therapist’s. Yet religiosity assists in this respect only if the therapist draws on these transcendental sources in an open way and is saturated with “ordinary” good things, which are in balance and give rise to compassion, sympathy and the desire to help the other for no personal gain. If the religiosity of the therapist entails rigid views and beliefs on “how the world ought to work” and so leads him/her away from real transcendence; (which is actually nothing but pure love for the other and an acceptance of them with all that is entailed by this), the therapist needs to revise his/her attitudes in supervision or by some other form of reflection on self and self-critique, because this kind of religiosity may not help the client well.

These attributes of personality ultimately provide space enabling human beings to exercise their capacity to love, make decisions and shoulder responsibility. We could indeed say that these abilities constitute the framework and context of the ethical code for every counsellor or therapist.

We can now return to the maturity that is needed to be part of the therapist’s personality. We have said that great demands are made on the therapist; that he/she should be mature and have what is known as an activated personality. We can determine whether a therapist has an activated personality from his/her other capabilities, namely the ability to open up the self, to stay with the topic and to have a steady relationship. 23

The ability of the therapists to open themselves up corresponds strongly with a phenomenological approach, i.e. understanding the need to wait for what will 23 Taken from lectures and EA and logotherapy training exercises in the years 2008–2010.

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reveal itself, to let things take their course, and not to insist that a therapist must know everything immediately. What is essential is a constant focus on the client – the individual that the therapist has in front of him/her. Often nothing seems to be happening for long periods, but these times themselves are healing for the client – knowing that there is someone that accepts him and does not criticise him; in this stage of the therapy the work is often focused on the client’s sense of his own value, which may be hurt. It is a part of the process in which another demand is placed on the therapist – the demand for courage. The therapist reassures the client, supports him and waits. Sensing that the therapist can “carry” him, and is open to him, enables the client to talk. If the therapist is too pre-occupied with himself/herself, this capacity for self-opening may be absent.

Another capacity that the therapist should have is the capacity to stay with a topic. This is connected with emotional stability, and the need for the therapist to endure and cope with the unpleasant, which can sometimes last quite a long time. Frequently a client comes to a therapist in great pain and expects the therapist to endure the whole situation, stay with it and indeed keep coming back to the painful matter. The exploration of each painful topic involves the client ventilating his feelings, and in these moments the therapist is responsible for the course of the process, for staying with the unpleasant and maintaining the emotional movement. Knowing that the therapist is able to stay with the unpleasant, painful topic gives the client strength, and this is very fundamental. The client recognizes that there is someone here that can, as it were, “abide”, and does not evade or dodge issues. In this situation the client often experiences a normalisation of basic physiological needs – an easing of sleeping and eating disorders. Gradually the client may also be coming to terms with his problems and experiencing a satisfaction of other spiritual needs.

The capacity to be relational is definitely a key quality for the therapist and should inform his whole personality. The kind of relationship we have with ourselves, with others and with the life itself can be either inspiring or repulsive. The therapist achieves relationality – the capacity to form, sustain and cultivate relationships – through critical introspection and the above mentioned abilities. The therapist needs greater strength of resilience than the client and should be able to cope even with unpleasant blows from the client. He/she should be able to remain in relationship despite the unpleasantness.

Emotional competence for therapy also means that the therapist is aware of his/her own emotions as unique and at the same time subject to human error. This emotional side depends on the therapist’s self-knowledge, relationship to himself/herself and critical reflectivity. For good therapeutic practice any therapist must know his/her own limits, his/her needs and his/her sources, and not just those of the client. In therapy we encounter strong emotional reactions, both in the client

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and in the therapist, and especially in cases of clients who have been tortured or suffered other violence.24 If the therapist is inadequately prepared for the work with intense stress, his/her way of treating the client may be unproductive or even detrimental.

Each therapist has his/her own history. For example, if he/she experienced sexual violence in his/her family, at school, or in his/her wider network of relatives in childhood or youth, this may have a major effect on his/her emotional competence. While there is no point in over-generalising in these sensitive matters, the impact of these events on the personality of the therapist cannot be underestimated. A study conducted by the American therapist Kenneth Pope found that out of a thousand psychotherapists involved in the survey 56.5% had wept in front of their clients, 90% had told a client that they were angry with him about something, 52% had told a client they were disappointed with him, 72% had admitted that they had sexual fantasies about a client, and suchlike.25In another study concerned with therapists’ own experience of abuse, 21% of female therapists admitted that they had been sexually abused by someone in their family during adolescence, and as many as 40% of female therapists said they had been sexually abused at least once in the past. Among male therapists. 6% said they had experienced sexual violence in childhood and adolescence, and as many as 26% had experienced one incident of sexual violence in childhood and adolescence. As adults 40% of female therapists had experienced sexual harassment, and just under 2% of male therapists. 26

The fact that a therapist has experienced sexual abuse does not make him/her either more or less competent for the work of a therapist. No study has been conducted that shows this one way or the other. Similarly there is no evidence that people who have never experienced abuse are better or worse therapists. In this respect every person is an individual and should be judged without any stereotypes. What matters is simply that we should be aware that all these circumstances may have a conscious or unconscious effect on the therapist, i.e. an effect on his or her emotional competence. 27

Intellectual competences as well as emotional competences, are an important source of success in therapy. The therapist with sufficient intellectual competences has “know-how” in various areas – in training exercises, education, supervisions; such therapists understand research in psychotherapy, different theories, various interventions etc.. Intellectual competences also mean that the therapist is able to recognize his/her limits in knowledge or understanding28 Some therapists

24 See POPE, S. K.; VASQUEZ, J. T. M.: op. cit., p. 62.25 See POPE, S. K.; VASQUEZ, J. T. M.: op. cit., pp.62–64.26 See POPE, S. K.; VASQUEZ, J. T. M.: op. cit., p. 64.27 See POPE, S. K.; VASQUEZ, J. T. M.: op. cit., p. 64.28 See POPE, S. K.; VASQUEZ, J. T. M.: op. cit., p. 61.

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understand the problems of depression in adulthood but are not such experts when it comes to depression in childhood. Knowing how to recognize what he/she can do and what would be best if handed over to a colleague is one of the intellectual competences of any therapist.

Emotional competences in therapy are no less important than intellectual competences. Thus, talking about his/her feelings with others not only makes an addition to the therapist‘s own experience but it is also a way for the therapist to develop resources for sustaining the emotional vitality necessary for his/her work. This is why care for the self is of the highest importance in the profession of a psychotherapist. It is a priority that must be respected unless therapists are to encounter exhaustion, long-lasting tension, and even burn-out, which we therefore have to discuss it in more detail.

1.2.1 Neglecting oneself, burnout syndrome

Ethical decision-making is an active process, requiring the therapist to cultivate a heightened awareness and constant introspection. Simultaneously this process of self-awarness is affected by external events over which the therapist has no control. Once it might be the level of colleague’s responsibility, next time it might be a quality of co-operation with an insurance company, or a decisions of the relevant professional body such as the Psychotherapeutic Association. Naturally the combination of internal and external pressures make great demands on therapists, and can cause tension or even burnout if not adequately handled.

The work of the therapist is generally very challenging. If a therapist neglects his/her needs, it can mentally and physically exhaust him/her. It is crucial to cultivate attention to oneself alongside with all other activities. Kenneth Pope and Melba Vasquez mention several situations that arise from a psychotherapist’s neglecting himself/herself, for example when a therapist begins to treat his/her client disrespectfully.29 When a therapist is overloaded, he/she may come to think of patients simply as another source of pressure on him/her, and consequently he/she loses the basic respect. The clients may be tormented by blaming themselves of laziness, lack of motivation, selfishness, and worthlessness, and the therapist’s contempt for the client, caused by overload, exhaustion and loss of empathy, may worsen the client’s condition even more. In some cases the therapist may relieve his/her tension at a client’s expense, and even mock him/her, for example calling him a “psycho” in conversation with other colleagues. Yet, when a therapist ceases to respect the client, he/she is in fact ceasing to respect his/her own work. Therapists may start to trivialise or ridicule the work itself, and to see it ineffectual, 29 See POPE, S. K.; VASQUEZ, J. T. M.: op. cit., pp. 70–77.

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empty and pointless. This may be expressed in late arrivals for sessions or in failing to answer clients ‘calls.

Overworked therapists tend to make more mistakes in their work. Despite the best efforts and intentions, every therapist makes mistakes, but if a therapist fails to pay attention to his/her needs, then the mistakes multiply – for example accidental booking of two clients for the same appointment time, or telephone calls to the wrong client. As errors proliferate the therapist loses energy, because his/her source of energy is not inexhaustible. He/she gets up in the morning already tired; he/she needs stimulants to be able to function; his/her mind wanders during sessions, he/she wants to get them over with and he/she is glad when they are over at last!30 He/she then starts to feel anxious and even afraid, realizing that he/she cannot keep going like this for much longer. If he/she has put care for himself/herself on the backburner for too long, his/her work no longer feels meaningful to him/her, and he/she begins to lose all sense of pleasure, growth, purpose and interest in anything.31

Elizabeth Reynolds notes that studies of burnout syndrome have shown that it affects a specific group of therapists, school counsellors, family therapists and school psychologists.32 Another group that is vulnerable to exhaustion are psychotherapists working regularly with traumatised clients who have experienced war, violence and natural catastrophes.

Specialist studies dealing with exhaustion and excessive stress among therapists have found that 97% of therapists are very frightened that a client will commit suicide, 91% fear that the client will get worse, 88% of therapists report fear and exhaustion at the thought that they may be criticised by colleagues for the way they are working with a client, 86% admit they are afraid that a client will need help that they themselves are unable to provide, 83% are afraid that they may have a confrontation with a client, and 18% that a client may assault them. 12% stated that a client has made a formal complaint against them.33 The way of stress manifestation also depends, of course, on personal qualities such as vulnerability, reactivity and anxiety. These are personality features that determine whether an individual will succumb to stress or continue to withstand it.34

It is clear that if a therapist does not take proper care of himself/ herself in a profession as stressful as psychotherapy, tensions will mount up and they may result in “full-scale” burnout syndrome. Therapy is often stressful because it

30 See POPE, S. K.; VASQUEZ, J. T. M.: op. cit., p. 71.31 See POPE, S. K.; VASQUEZ, J. T. M.: op, cit., pp. 71–72.32 See WELFEL, REYNOLDS, E.: op. cit., p. 101.33 See POPE, S. K.; VASQUEZ, J. T. M.: op. cit., pps. 77–78.34 For more on this subject see ULRICHOVÁ, M.: Člověk, stres a osobnostní předpoklady: souvislost osobnostních rysů

a odolnosti vůči stresu [The Person, Stress and Personality Preconditions: The connection between features of personality and resistance to stress].ÚstínadOrlicí:OftisincollaborationwiththeEducationFacultyoftheUniversityofHra-dec Králové, 2012, pp. 38–43.

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involves a “conflict” between authenticity and empathy. It might seem at first sight that these two phenomena could never be at odds, but in practice it can easily happen. There may be situations in which the client can be telling a story and the therapist can be inwardly asking, “How on earth can the client have put up with this for so long?” This might happen for example in the case of a woman who has been subjected to long-term domestic violence by her husband but cannot leave the relationship despite its destructive effects. Also there are many other cases when the therapist finds himself/herself at the limits of authenticity of response yet still needs to show empathy. If it persists for too long, such a dilemma can exhaust the therapist. Not every client as it were “suits” every therapist, and there are cases when the therapist and client are “fighting”. There can be situations in which a therapist is internally shaken up: some facts from a client’s life may have a strong personal impact on him/her, and he/she experiences things he/she finds difficult to understand while still trying to work for the good of the client in line with proper ethics and his/her conscience. These are not easy situations and in long-term context the internal stress may lead to burnout syndrome.

Our approach in this book draws a great deal from logotherapy and existential analysis, and in our view these schools are particularly valuable in preventing burn-out syndrome and in cultivating the therapist’s capacity to treat himself/herself in the right ethical way. In the course of his/her work every therapist has found himself/herself on a “slippery slope” in the sense of struggling to combine authenticity with empathy for the client. In order to be able to make the right decisions in regard to the client and also to treat himself/herself well, therapists needs not only to have information on potential states of fatigue arising from exhaustion, but above all they need to know how to “embrace themselves”, as EA puts it. We shall now set out in detail the way in which existential analysis and logotherapy see burn-out syndrome.

According to Freudenberger the burn-out syndrome may be divided into 10 stages:35

1. Pressure to prove oneself, idealisationA person sets out to work with great commitment, and puts high demands on

himself.

2. Intensified commitment, what is known as the “workaholic” stageIn this stage the individual takes on extra new tasks, extra work, starts to

work overtime and takes on more responsibility. At this point it is the ideal,

35 See ZVÁNOVCOVÁ, I.: Musím a nemohu jinak [I Must and Cannot Do Otherwise]. Final dissertation in Logotherapy and Existential Analysis – psychotherapeutic training, p. 7. In: Psychoterapie-iz [online]. [cit. 2014-01-22] Accessi-ble at: http://www.psychoterapie-iz.cz/index.php/odborne-texty.

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the meaningfulness of the work that is the great driving force. Yet from the EA perspective this motivation may be generated by the absence of a sufficient lived sense of personal value – a lack of confidence in the answer to the question, “Am I entitled to be myself?” The individuals enthusiastically seek confirmation and praise through work, but they paradoxically doubt when it is received from the outside.

At this point we need to pause and look into the concept of the value as it is. In EA value is simply defined by virtue of its being. For example, I love being with you just for the sake of it, not just for the sake of some task or function that would be accomplished by being with you. It is the experience of “being” itself that fulfils the needs of a human being, In burnout syndrome experience of “having” prevails over the experience of “being”: “Being” is subordinated to an extrinsic intention, plan or function. If a person truly experiences the value in itself, and they are relation-oriented, this value shifts this person to the true living, but if the value is not properly felt, people tend to make instrumental claims on existence, they prefer function over existence, and the objects of their relations can easily become interchangeable. Of course, goal-orientation is a necessary aspect of living, but when the activities are aimed solely at an extrinsic goal, at a function, the individual ultimately feels frustration and emptiness. The experience that leads to burn-out syndrome is that the sufferer believes that in order to be worthwhile, they must constantly be “functioning”. They cannot fully enjoy repose and the consequences may be detrimental.

3. Neglecting of one’s own needsThe person has the feeling that he/she has no time, and loses contact with his/

her own needs. He/she may start consuming more coffee, food and nicotine. He/she may develop sleep disorders. He/she starts to be very sensitive to criticism from those around him/her about his/her way of life.

4. Suppression of conflicts and needsThe person starts to suppress his/her own mode of life. He/she neglects his/her

interests and needs, and lacks the energy for hobbies and entertainment. What is more serious – sleep disorders develop, as well as feelings of weakness. In this and the previous stages there are characteristic strenuous efforts to keep on functioning at the same tempo. Food serves as a tranquiliser, a way of switching off and escaping.

5. Transformation of valuesValues are “reinterpreted” and they acquire different meanings. Values unrelated

to work are experienced as a drag, and the person “lives to work”.

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6. Increasing denial of the problemsThe stressful situation gradually reflects in the personal and family relationships,

and in the case of people in the helping professions it affects not only the family but also the working environment with clients. The individual gets more and more irritable and quarrelsome, liable to explode and he/she tries to conceal his/her anxiety, fears, inner disturbance, tension, weariness and weaknesses. At this stage the person experiences what is known as an “internal resignation“. This is the stage when he/she already needs professional help. Some authors talk of the interaction (or inter-related nature) of various stressful situations and psychological disorders. Poor physical condition affects the individual’s immune system and increases his/her vulnerability and susceptibility to various diseases.36

7. Withdrawal from the world, and lifeThe individual loses his/her internal assent to the way he/she is living and what

he/she is doing; he/she is loses his/her connection with work, with himself/herself, and with what he/she wants. He/she makes an effort to perform achievements; he/she goes to work mechanically but procrastinates the work as no real interest is involved in it He/she experiences an inner emptiness, a lack of fulfilment, and he/she looks for something to fill up for the work and the associated excitement. At this stage he/she is no longer capable of making the change himself/herself due to the lack of power needed for taking up a stance The experience he/she lives out is dominated by the imperative “I must!”

8. Significant changes in behaviour, interactions, attitudes, dehumanisationAt this stage the individual’s social life becomes deflated and flat. He/she

avoids people and social contacts, and withdraws into isolation. If the person concerned is the one who works with clients, he/she is no longer able to see the client in his human needs, and cannot see beyond his/her own self-pity. He/she disrespects others, does not appreciates their value and is cynical towards them.

9. Depersonalisation (the loss of feeling for one’s own self), internal emptinessThe person gets estranged to himself/herself, his/her relationship to himself/

herself has been disrupted. His/her performance is just automatic and increasing psychosomatic difficulties are experienced. He/she lacks any anchorage anywhere, retreats into isolation, and feels disgust and repugnance for himself/herself and others.

36 See FRANK, J. D.; FRANK, J. B.: Persuasion and Healing. 3rd ed Baltimore: JHU Press, 1993, p. 121.

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10. Depression and exhaustion, complete burn-outWhen depression and deep physical exhaustion occur, the individual wants

to be left alone, to be able to sleep. He/she feels hopelessness and there is a high risk of suicide. He/she is in danger of a complete breakdown on all levels – physically and mentally.

1.2.2 Frankl’s conception of burnout syndrome

From the point of view of EA and logotherapy burnout syndrome is an illness caused by loss of meaning. The meaning of life is integrally connected to the values that we live, and for which we decide. The lives of many people show that we are not entirely exposed at the mercy of fate. However but we can become so if we cling tenaciously to a single desire, and unless it is granted, everything around us seems to be valueless

Jaro Křivohlavý argues that the opposite of loss of meaning is the search for wisdom. Wisdom means living in a certain spirit of hope. 37

Unless a human being lives out the values in which he/she believes in and which he/she fully experiences, he soon succumbs to a state of exhaustion. On the basis of his approach to anthropology Frankl defines this exhaustion in the following areas:

1. Physical dimension– physical weakness, susceptibility to illnesses, tension in the muscles and neck, lower immunity, sleep disorders, etc..

2. Psychological dimension – overall emotional exhaustion, sadness, loss of taste for life and creation, loss of joy and increased irritability.

3. Noetic dimension – a devaluing approach to the self and to the world. The individual doubts the value of life, experiences significant loss of spiritual orientation, and what Frankl described as an “existential vacuum”.

“Today there is an ever greater tendency for people to have a sense of emptiness, a feeling that their own existence is not meaningful”.38 Frankl quotes the words of a young client of his: “I am 22 years old, I am financially secure and have access to more sex and power than I can cope with. But I have to ask what the meaning of all this is.”39 An existential vacuum means that an individual has no meaning, and so experiences aimlessness and boredom.

37 See.KŘIVOHLAVÝ,J.: Psychologie moudrosti a dobrého života [The Psychology of Wisdom and the Good Life]. Praha: Grada, 2009, p. 11.

38 TAVEL, P.: Smysl života podle Viktora Frankla [The Meaning of Life according to Viktor Frankl]. Praha: Triton, 2007, p. 113.

39 TAVEL, P.: op. cit., p. 113.

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1.2.3 The existential analytical perspective on the development of exhaustion

According to EA, burnout syndrome means exhaustion. How does this exhaustion arise? There is no doubt that sufferers lack inner fulfilment, which, in terms of EA, can be defined as a state when the individual accomplishes the values he/she believes in, which he/she lives for, and which he considers “his” as opposed to universal values. Living a fulfilled and meaningful life means to bring the value we believe in into reality. In this context there is a huge difference between an individual living existential meaning and an individual living an illusory, unrealistic meaning. An illusory meaning, such as pursuing one’s career or social acceptance, leads to experiential emptiness. A life of this kind is stressful and draining away all joys of life. Instead of joy in creation the best it can offer is merely a sense of pride in achievements, and neither pride nor conceit provide warm emotions or sustain life.

If a person lives out internal fulfilment, it keeps him going on even if he/she is sometimes tired and exhausted, because the major factor here is the attitude to the self, and the feeling of the inner assent. According to EA inner fulfilment can be defined as a positive response to certain concrete situations by drawing something good from them. If someone responds to situations, relationships and life in this creative way, he fills his life with existential meaning.40

1.2.4 The theory of Alfried Längle

Alfried Längle was a pupil of the founder of logotherapy and EA, Viktor Frankl. In this part of the book we shall look at four theories that he has put forward to show how existential analysis conceives of the symptoms and etiology of burnout syndrome.41

Theory 1Burnout syndrome is a state of long-term creative activity that is not

actually lived out.It can be said that fulfilment in work is the best protection against burnout

syndrome. If we are doing our work with joy, with inner assent, we are most unlikely to slide into burnout syndrome. It is, however, necessary to make a distinction between this experience and mere feelings of enthusiasm for and idealisation of work.

40 See ZVÁNOVCOVÁ, I.: op. cit., p. 11.41 See ZVÁNOVCOVÁ, I.: op. cit., pp. 12–20.

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Another fundamental factor for the development of burnout syndrome is when work is the only thing that a person has, so that he is dependent on it and it is his sole source of meaning in life.

The vulnerable individual is motivated largely by illusory meaning, which is often to do with prestige and money, and he/she starts to feel as if he is in a cage. This is when the feeling “I must do this and have no alternative!” prevails. This experience is principal for the development of burnout syndrome. The person does not live in accordance with his inner self; he is ceasing to serve a particular purpose, a particular real task, but instead he/she is serving career, influence, income, recognition, praise, social acceptance, and the mere performance of duty. The people and tasks concerned have therefore become essentially interchangeable for him, because his focus is on the activity and not the value of the object.

Theory 2Burnout syndrome arises from formal motivation (motivation not directly

related to the task itself) and leads to merely formal interest in work, a thing, task, or person. The individual’s actions are primarily driven by subjective inner need and only secondarily by objective need.

For the syndrome to develop there has to be an initial need in which a life attitude causing psychological illness takes root. There are also people who have just adopted their life attitudes from others, or in some case derived them from attitudes to religion.

In EA we look for the specific attitude to life that has led a person to behaviour of this kind. This attitude may be either conscious or unconscious, but always reflects the subjective view of the person and his understanding of what he cares about in life. We can speak of a “non-existential attitude” where activity becomes a mere means to an end, and all this leads to is a deficit symptomology on the somatic, psychological and noetic level.

Work becomes just a utilitarian value, i.e. a means whereby the individual tries to fulfil a certain goal. This strong goal-orientation is the expression of a life attitude, i.e. what a person takes for essential in life to live to its fullest.

By goal-orientation, life itself loses its living value. Since the living values evoke emotionality in us, a person affected by burnout of emotionality becomes one-dimensional, thus warmth, vibrancy and colours in life fade out. By exploiting the tasks offered by life for his own extrinsic objectives, the individual “burns these objectives and his life turns cold in their ashes.”

Theory 3A goal-orientated attitude in life, with consequent loss of vital feelings is

a manifestion of burnout syndrome.

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A person stricken with burnout syndrome becomes blind to the existential reality, fails to respect his own value and the same value in other people, and all of this leads him to materialize relations (relational values). This pushes aside feelings, the body, human needs and thus a sense of “what is right” and consequently the individual loses his relationship to himself. The result is the emotional withdrawal from the self which is best expressed in the phrase, “my heart isn’t in it”. The whole situation causes stress. Life becomes discordant.

The inner emptiness, lack of fulfilment, frustration of psychological need and loss of life feelings gradually come to dominate the individual’s experience. “Emotional death” sets in, and work no longer provides joy and refreshment, but it becomes a substitute for the missing closeness and the never-arriving touch of being.

Theory 4Behind burnout syndrome there is a double impoverishment of relations:

on the one hand externally, in regard to other people, and on the other hand internally in regard to the self and one’s own emotions. From the EA perspective, a deficit in existential personal motivations is the deepest cause and source of burnout syndrome.

To get a better understanding of burnout syndrome from the EA point of view we need to highlight these motivating questions: 1. May I be?

Can I afford to be? Do I have enough basic space, am I threatened by danger? Without living out feelings of safety individuals may seek security in rigidly organized activity, so as to have everything secure, and to maintain a protected life space.2. Do I want to be?

The second fundamental personal motivation is concerned with the emotional quality of life and affection for one’s being as a value. Disorders on this level include blocked emotions, and fear of relationships that lead to the basic feelings of obligation, guilt and depression. People with such problems are likely to enter the helping professions and, bound by their feeling of indispensability, they get involved in helping others.3. Can I be what I am? Can I be myself?

The third fundamental motivation is concerned with how a person evaluates himself, whether he sees himself worthwhile, and whether he really lives the feeling of being allowed to be himself. Disorders in this context lead to concentration on item that are supposed to increase one’s own value – career success, prestige and money. The individual strives primarily to be recognized and respected by those around him.

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4. Do I want meaning?A fourth fundamental motivation concerns meaning, and gives direction in life.

If there is a deficit on this level, the individual is susceptible to illusory meaning.

1.2.5 Treatment of burnout syndrome

How can we actually deal with burnout syndrome and treat it? Treatment of burnout syndrome firstly consists in alleviation of the pressure. The focus of therapy is oriented on establishing the boundaries where a person’s responsibility begins and ends; the client in this situation is encouraged to take a realistic view of what he can accomplish, and to set for himself realistic goals. Alleviation of the pressure is also aided by analysis of dysfunctional elements, models of thinking and uncovering faulty strategies. It is very important to encourage self-awareness (see own value) realistically, and Schmidbauer warns that unrealistic helpers are chronic sources of disappointment and disillusionment because their exaggerated expectations can never be met.42

Apart from easing the pressure, it is important to enlarge the individual’s field of vision, and to work on deficits in basic personal motivations. This involves appeal to the values that the individual wishes to live but “is not able to” live. Paths forward are identified using questions such as “What do you most get out of work and or what does work provide for you as a replacement?” in the framework of basic personal motivations (BPM): security, safety, relationality, emotionality and the need for recognition.

A major part of prevention and treatment of burnout syndrome involves encouragement to live one’s own values – in relations, in the family and also in small things. People need to experience their lives in the field of motivation defined by the statement, “I want and am able to do things in a different way”. In this context logotherapy and EA are particularly helpful by teaching the individuals to examine their own values, plus what they really want and need for a good life, and by leading them to the genuine ability to decide in favour of those values. The individuals need to go through a process of self-reflection and ask themselves, “What will happen if I don’t do this?”, “What will happen next?”, “And do I really have to?”

Honest answers have a tendency to reveal that the concerned person does not really have to do whatever it is, and that the supposed imperative merely derives from the idea that the person has created about himself for the reasons already discussed. If an individual has too little for himself, he loses the specific form of his potentials, the space to be himself, and the ground for his existence as a person.

42 See SCHMIDBAUER, W.: Syndrom pomocníka [The Helper Syndrome]. Praha: Portál, 2008, p. 227.

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The prevention and treatment of burnout syndrome involves finding a path to a shift within. This shift is firstly inward-oriented – towards the self and then outward-oriented towards the world. Logotherapy and EA help people find the way to move on that path and above all they lead clients not only to a better understanding of a given situation, but also to actually TAKING the steps that will provide them with greater joy. EA guides them towards an emotionally volitive living experience, a responsible management of their individual lives, and a full existence as persons.

The therapist’s effective care for the self means being attentive to self, and recognizing when tiredness is starting to block a realistic perception of the client and situation. In this way the therapist is sensitive to warning signals that something is wrong, and thus it allows him/her to reassess what is good for himself/herself as well as for the clients, and to make changes where necessary.

If we have devoted a lot of space in this book to burnout syndrome it is because the burnt out and exhausted therapist is very prone to ethical failure. This makes the topic an immensely important one not only in psychotherapy but in all the helping professions. The therapist should observe himself and constantly monitor the way he is treating himself and his client. Prompt and correct self-reflective monitoring enables the therapist to avoid unprofessional and damaging treatment of himself and his client.

One pillar of care for the maturity of the therapist’s personality is the required training, in this case – psychotherapeutic training. Then there is, of course, continuous supervision and undergoing everything that is summed up by Erikson in his definition of his seventh stage of life as “generativity over stagnation”, by which he meant first and foremost the virtue of taking care and of a constructive creative approach to the self and society.43 In the next chapter we shall therefore address the education and training of the therapist.

1.3 The training of the psychotherapist

No account of ethics in psychotherapy can ignore the basis for the profession of psychotherapist, which is how the therapist is trained, his/her way of gaining knowledge and skills and everything else that is involved in his/her professional formation. The development of ethical norms is integrally connected with the overall cultivation of the discipline of psychotherapy and with the development of the therapist-client relationship as well. The better the therapist is equipped for his/her work professionally, and the more naturally sensitive he/she is, the more likely he/she is to intuitively recognize potentially dangerous or disputable 43 SeeHUBÁLEK,S.;KOŤOVÁ,M.:op. cit., p. 235.

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situations and react to them adequately. Of course, good supervision and the progressive cultivation of training exercises are further tools for improving the level of psychotherapeutic education.44

1.3.1 Group training

Participation in psychotherapeutic group training in order to gain experience of oneself is indispensable for the therapist. Some experts even claim that this kind of training is the most important element in the therapist’s education. In the Czech Republic today there are several psychotherapeutic schools that organize long-term group practice for their future therapists, (most of the courses 4-7 years long). The number of hours prescribed for training in introspection differs between these schools, as does the number of supervisions and other necessary training elements for qualification in psychotherapy, but the rationale for psychotherapeutic group training is very similar in all schools of thought: it is about acquiring certain personality competences that cannot be learned theoretically from books or lectures. The exploration of one’s own personality in a group serves as the best prevention of potential incongruences in future therapeutic work. Discovering blind and frequently suppressed or unconscious spots in one’s own personality is often an uncomfortable experience for the student, but it is certainly a useful and important aspect of education (as long as it is directed by a competent therapist leader) for the therapist’s future work. During practice some people even discover that psychotherapeutic work is not for them; they might potentially be good theorists but they are not able to venture into the deep corners of the soul because they do not feel competent to do so. If a person makes this discovery about himself for himself, the situation is more fortunate than if the judgment is made from outside as a “recommendation”, but the saddest situation (which one hopes is very rare), is when a student goes successfully through the practice training but he/she lacks the ability to establish a close relationship with another person in need of help.

Currently, training in EA and logotherapy involves both tutorial and supervision components necessary for completion of the course.

The tutorial part of training lasts four years, and takes the form of three-day blocs. It is divided into two parts:

1) Basic education – the core of basic education is mediation of the theories of EA and logotherapy on the basis of self-experience (individual and group), and takes roughly two and one-fourth years (i.e. 17 blocs).

44 See.MIOVSKÝ,M.;DANELOVÁ,E.:Etickéaspektypsychoterapeuticképráce[EthicalAspectsofPsychotherapeu-tic Practice]. In VYBÍRAL, Z.; ROUBAL, J. (eds.): op. cit., p. 56

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2) Clinical Part – in clinical training the student gets acquainted with the phenomenological pictures of various clinical disorders, their diagnosis and therapy. This part takes approximately one and three-fourths of a year (i.e. 11 blocs).

A student who successfully completes both parts gains the status of psychotherapist working under supervision.

The supervision part of the training involves 150 hours in total. The student must be able to submit a total of 600 hours of his/her own psychotherapeutic work with clients.

The training also involves attending expert lectures, practice, self-experience of at least 70 hours, written examinations at the end of the basic and clinical parts of the course and also submitting thesis on the application of EA and logotherapy.

Every country has a slightly different legislative framework as regards the regulations of the profession of psychotherapy. The American Psychological Association, whose ethical codes are binding for all psychotherapists working the American territory, stipulates conditions for education and training in its Standard 7. This lays down quite detailed requirements, for example, that the participant in training is not obliged to reveal personal information relating to sexual history, psychological treatment, abuse, relations with parents, classmates, siblings and others. It also strictly forbids any kind of sexual contact between students, supervisors and everyone involved in training.45

The European Association for Psychotherapy (EAP) has created an instrument for the standardised assessment of qualification criteria for psychotherapy.

The EAP code consists of a preamble and nine sections describing basic ethical principles: 1. Responsibility; 2. Competences; 3. Ethical and Legal Norms; 4. Confidentiality; 5. Benefit to the Client; 6. Professional Relations; 7. Public Declarations; 8. Diagnostic Techniques; 9. Research.46

The Czech Republic is among the countries that have not as yet developed a very effective legislative basis for psychotherapy. The most widespread model for becoming a psychotherapist in the CR is a combination of degree studies in psychology followed by psychology education in the form of specialisation in psychotherapy by training practice. 47 This qualification is intended to equip the psychotherapist for work in the healthcare system. After finishing a psychology degree students can take an exam qualifying the individual as a clinical psychologist 48 They may then embark on specialist training for psychotherapy and after meeting all the conditions they can become a certificated professional

45 See POPE, S. K.; VASQUEZ, J. T. M.: op. cit., pp. 346–347.46 See VYBÍRAL, Z.; ROUBAL, J. (eds.): op. cit., p. 60.47 SeeMIOVSKÝ,M.;DANELOVÁ,E.:op. cit. p. 57. 48 SeeMIOVSKÝ,M.;DANELOVÁ,E.:op. cit., p. 57

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to work in systematic psychotherapy in the healthcare system. The healthcare system in the CR does not recognize any other way of acquiring qualifications in psychotherapy, and this means that Czech healthcare legislation is essentially in breach of the Strasbourg Declaration for Psychotherapy in 1990, which prioritises psychotherapy as an independent discipline with different models of qualification studies. 49

Stanislav Kratochvíl argues that psychotherapy should be carried out by a qualified person and that nurses and social workers, for example, should be trained in the discipline for purposes of team work. In addition to therapeutic activity in the health service psychotherapy is applied in psychological counselling of clients who have not been diagnosed with a mental illness but who are in danger of mental illness as a result of their conflicts, traumas, frustration and stress.50Although there exists a whole range of different schools of psychotherapy in the CR, including depth, dynamic, Rogers, behavioural, cognitive and communicational psychotherapy, Gestalt therapy, existential and humanistic, eclectic and integrative psychotherapy and others,51 it remains unclear who may actually become a psychotherapist. Whether it can only be those who have a psychology degree, have met all the requirements including exams and gone through psychotherapeutic training, or even those who do not have a one-subject degree in psychology, and may, for example, have studied education, social work or special education and gone on to gain a qualification through a relevant course of training? Until the problem of psychotherapeutic qualifications has been solved, it will be impossible to ground ethical norms in legislation with more clarity.

Supervision is another form of continuous, long-term training. It is not only confined to psychotherapists at the beginning of their careers, but it is also crucial to those more experienced ones, because clients are inevitably so diverse that no single-oriented approach can fit them all, and a therapist always needs an opportunity and challenge to revise and evaluate his/her attitudes to clients.

1.3.2 Supervision

Supervision is a natural integral part of the training of the therapist, and makes a valuable and irreplaceable contribution to it. Today not even an experienced psychotherapist is allowed to practice without being regularly supervised. Supervision plays a very important role in therapeutic practice and not just in the course of initial training, as it makes a therapist to reflect on their treatment both of clients and of themselves.49 SeeMIOVSKÝ,M.;DANELOVÁ,E.:op. cit., pp. 57–58.50 See KRATOCHVÍL, S.: Základy psychoterapie [Principles of Psychotherapy].5th edn Praha: Portál, 2006, pp. 13–14.51 See KRATOCHVÍL, S.: op. cit., p. 19.

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Yalom argues that supervision requires above all the establishment of a supervision alliance, in which the purpose is to convey to the student an atmosphere of therapeutic collaboration. The supervisor not only transmits expertise and theoretical knowledge, but is also a model of professional values and ethics.52The supervisor should interact with the student or other supervisee in such a way that the latter feels a certain closeness, an alliance, which he/she can then convey to clients. Yalom even states that a too critical and even humiliating supervision not only fails to fulfil its purpose but puts the supervisee off. 53A conflict between supervisor and supervisee, even if never articulated, always upsets the process of supervision and may ultimately harm the client.

The distribution of roles in relationships during supervision is very important. Supervision involves at least three participants: the client, the supervisor and the supervisee. Sometimes these relationships may become confused. That is why it is crucial that everyone involved should be aware of his or her responsibility. Supervision has responsibility for the client in the sense that it is about ensuring that he or she gets the best care. While the rationale of supervision is the professional growth of the supervisee, the welfare of the client remains in first place in supervision.

Apart from the professional growth of the supervisee, another purpose of supervision is to protect the public from incompetent and clumsy therapists and make sure that clients gets adequate care suitable for their individual needs.54 Kitchener points out that the role of the supervisor is complex, including advisory, social, training and other aspects. 55It is just because of this complex role of the supervisor that the supervisee is more personally vulnerable than in the teacher – student relationship, since unlike working purely with the client, he or she is being judged by a larger number of team members.

If we want to reflect more deeply on the relations that evolve in supervision, we might first look into the relationship between the supervisor and the supervisee’s client. The welfare of the client is the first priority of the supervisor. Sometimes, for example, a client’s extraordinary requests may cause the supervisee therapist to feel exhausted and in need of rest. The supervisor then may exercise his/her influence on the supervisee/therapist in discussion of how likely this would be the right decision. Frankly, much depends on the kind of relationship between the supervisor and supervisee at that time.

52 See YALOM, D. I.: op. cit., pp. 536.53 See YALOM, D. I.: op. cit, p. 536.54 See POPE, S. K.; VASQUEZ, J. T. M.: op. cit., p. 316.55 See POPE, S. K.; VASQUEZ, J. T. M.: op, cit., p. 316.

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The next fundamental relationship is therefore the relationship between supervisor and supervisee. This relationship can be a conscious or unconscious source of ethical complications during supervision. What the supervisor thinks about the therapist undergoing supervision becomes apparent in the deductions that the supervisor makes from the behaviour of the therapist, for example, his or her answers and reactions. Various situations in the therapeutic process can reflect the supervisor’s relationship with the therapist-supervisee, for example, when the therapist embraces a client, or works with a client who is worried about being diagnosed of cancer and at the same time the therapist is going through the same problem.56 Too much strictness on supervisor’s side may cause the therapist to experience negative feelings and to doubt about the supervisor’s work, which may generate a certain tension between each other.

Tension may also be caused by differences in priorities on the supervisee’s and the supervisor’s sides which may be a source of conflict, because one of them believes that the values he or she avows will be brought up into the supervision and discussed about. Sometimes the supervisee does something that, for example, his own therapist would do (if he had a therapist of this kind) but what the supervisor does not approve.57 Values such as openness – the ability of the supervisee to reveal himself, may present an obstacle and ethical problem for a more reserved and rigid supervisor. Supervisees are most likely to treat their to clients in ways that they themselves have been treated during therapeutic training. This means that it is very important that every supervisor should also be under a certain supervision, so that the potential for open, constructive and yet realistic therapy would be constantly maintained.

What kinds of conflict can arise during supervision? It is important that the supervisor should not be too friendly like, therapist like or teacher like, because prevalence of one of his or her roles may spoil the supervision itself. Each of the roles that a therapist plays has its pitfalls. If the supervisee and supervisor are friends who have known each other for some time they need to work out whether they are sufficiently critical enough about each other and perceptive about each other’s weaknesses. In the same way, any kind of sexual relationship between the two is considered very unethical behaviour, which reduces the level and quality of the supervision. The supervisor ought to be erudite, able to teach, knowledgeable, able to “read between the lines” and keen to make the best of the supervision, but he or she should not try to be too much a teacher. That risks turning the supervision into a kind of seminar or intellectual discussion, which

56 See CLARKSON, P.: Ethics. New York: Wiley, 2000, pp. 156–157.57 See CLARKSON, P.: op. cit., p. 157

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is not the purpose, since if that being the case the client is likely to fade out of the whole process. 58

The questioned responsibility a supervisor ought to have and actually has constitutes a major theme. Petruska Clarkson sums up the supervisor’s responsibilities as a matter of guiding and evaluating the therapist’s work with the client and the ethical and professional behaviour of the therapist to the client as well. She also adds that the supervisor is fully responsible for professional work in relation to society, the public, and to anyone involved in the therapy. 59

The supervisor may, for example, have a supervisee who is grieving for the loss of someone close and unable to work to the usual extent or at all. This has an ethical dimension, because who is the one to determine when the therapist can return back to work with a client and provide the therapy in undiminished quality?

It is obvious from the above that all relations between all those participating in the supervision are important. In supervision, as always, the welfare of the client should be the utmost priority and all other relations should be subordinated to that requirement. It is also important that the supervisor should be fully prepared for the supervision, giving it adequate thought beforehand, and that the supervision session should be a micro-world that is running in accordance with ethical and humane norms.

Petruska Clarkson draws attention to a number of ethical dilemmas that may arise in the course of supervision. She divides them into two areas: the first is supervision and supervision of supervision, and the second concerns ethical issues of the training and organisation. The ethical and moral dimension of supervision is to a large extent a matter of professionalism, because it holds for the relationships of all who are involved in the training, no matter whether students and their relationship to the clients, to the public to the training organisation or to their professional peers.60

Clarkson is specific with examples of dilemmatic:61

It had something to do with a former trainee of mine who got in touch with his former female patient. This was shared with me by my present patient who was a friend of the concerned woman. I had to deal with several dilemmas.“Is it fact, fiction or mix of both?” “Can it be interpreted as transference? Am I to confront the former patient? Suppose the information turns out to be true, how am I to protect the patient who shared the information with me?How am I understand the information?”

A therapist under my supervision shared with me that her ex-partner had fallen in love with a young patient of his, and he was reluctant to quit. We agreed 58 See CLARKSON, P.: op. cit., p. 160.59 See CLARKSON, P.: op. cit., p. 162.60 See CLARKSON, P.: op. cit., p. 173.61 See CLARKSON, P.: op. cit., p. 179.

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that in the first phase she should remind him of ethical norms of his professional chamber, and warn him against grave consequences for his future career. It was a dilemma despite there was no risk of him having suicidal attempts or trying to get a revenge over his ex-wife. The dilemma was in the question how to deal with confidentiality and whether to report it and suggest investigation.

A colleague was confronted with a problem when her client shared with her his recollection of being abused in his childhood. The abuser was a member of the family who was currently employed in caring profession, working with children. The client was not willing to bring that to the public and confront the abuser. The colleague is now wrestling with the dilemma whether to breach the confidentiality or not to do anything and thus put other children in danger. Another aspect of the dilemma is an absence of any proof for client’s claim.

These examples show how professionals grapple with issues of therapists’ reputations, empathy with the client, loyalty to organisations and often the problem of confidentiality. Thus decisions that are professional, ethically and legally appropriate can eventually be reached. These are often very serious matters raising questions to which there are no clear or black-and-white answers.

The second category of ethical problems concerns the training and its organisation. Very little research has been carried out in this area, but although data on training and organisation are only starting to be collected in this context, there are indications of potentially serious problems. The first partial analysis is based on the work of Clarkson and Lindsay, whose data, categories and rating system are used by Pope and Vetter. The study showed therapists in training courses rating colleagues as inappropriate, dangerous and incompetent in relationship to patients. 62

The most serious and recurrent theme of doubt about the ethics and competence of colleagues in training is illustrated in the following examples. More than 50% of the dilemmas are concerned with younger therapists not considered ready for practice by their older colleagues.

I’m afraid she will be a disastrous counsellor, but I don’t feel that it’s within my competence to expose that, or even suggest it, because I have no contact with her supervisors. Am I right to say that I can’t do anything?

A therapist in training – at the beginning of the course – came to me for personal therapy. This therapist is intensely narcissistic, unwilling to work on generally serious problems in relation to herself and others, and she left after two sessions. It was very hard for me to decide how to inform the training organisation about my doubts about her therapeutic qualities and about the 62 See CLARKSON, P.: op. cit., pp.182–189.

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fact that she had not completed therapy. For reasons of confidentiality I didn’t contact them, relying on the hope that the problems would be addressed in her supervisions and training. All the same, I have doubts about the quality of the admissions procedures of the training organisation.

I have experienced a dilemma with a peer and colleague of mine in the context of psychotherapy and supervision. I wondered whether or not to report her inadequate supervision and a lack of experience in work with patients who dissimulate. She had a tendency to shift her problems onto the counsellors involved and also wanted to involve me in her problems. It was very difficult to take a stance and decide whether to report information about her.

My knowledge of applicants to be accepted to the course could influence whether or not they were accepted. One of the trainee therapists, with whom I had worked for 2 years as a therapist, wanted to get permission for starting to work with patients in practice. In view of her unresolved problems I didn’t think it was appropriate for her to start work in counselling. She stopped coming to me, found another advisor, and after two sessions she obtained the permission to start practising that she had wanted.

I was sure that a trainee therapist, whose main teacher I had been, had an incompetent therapist who evidently had no idea how to cope with her. In a case like this it is usually enough to mention this tactfully to the student. But in this particular case I knew the therapist concerned and the situation became really desperate. I recommended my student to stop seeing him; then I went along with her to explain the steps I had taken. Naturally he was angry about my interference, but he didn‘t ask me to explain what I thought he was doing badly. In the end it was beneficial for my student, who is stronger than he.

These are the kind of dilemmas that psychotherapists can encounter today, and we shall look into some of them in greater depth in the chapter Disloyalty and jealousy between professionals. If a therapist at the beginning of his or her career encounters an incompetent colleague in the period of his or her formation, this can be particularly difficult. An experienced therapist is more capable to defend himself/herself, but someone with no experience who is just starting out and feels that something is wrong is limited in means of self-defence. Many other dilemmas than those we have outlined can arise in practice, and in the case of more serious ethical dilemmas a student can turn with his questions to the ethics committee of the organisation administering his training.

We shall now move from the question of dilemmas to the more formal organisation of the therapy. For favourable outcome of the therapy it is inevitable to agree on certain rules with the client at the very outset of the therapy and

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abide by them during the therapy. Particularly important is what is known as the setting of the therapy.

1.4 The setting of the therapy

By setting clear boundaries for meetings, the therapist prevents various later disputes with the client. From the point of view of the organisation of therapy, the therapist and client should agree on the frequency of meetings, the way the therapy will be paid for (if the therapist has no contract with a health insurance company) and principles relating to the potential abandonment of the therapy. This provides, as it were, the formal framework for the therapy, which is a prerequisite of good work and a prevention of possible disagreements. The first meeting with the client is very important. Usually clients contact a therapist by telephone, either on the basis of information available on the Internet, or on the recommendation of a friend. Clients may also make initial contact with the therapist by email.

At the first meeting it is crucial that the therapist critically evaluates his own competence and potential regarding the help to the client with the problem he or she has outlined. It is no secret that although clients often come for a certain reason, during the therapy a completely different cause of the client’s problems emerges, but for the time being, right at the start the therapist should make a shrewd evaluation on whether he/she is likely to be of any help to the client with his/her problem. Sometimes a client requires a prescription of drugs. A therapist is to have contacts with psychiatrists and can provide the client with professional advice, but it is a good thing if the therapist shows interest in how the visit to the psychiatrist turned out.

For some therapists the question of billing is always sensitive. If he works on the basis of direct payment, the therapist and client should agree on the price at the first meeting. The therapist should also state the conditions under which a client may cancel a planned session without having to pay. If the therapist has a contract with an insurance company covering the client, he should still make it clear to the client that he is not providing his services free; he is providing a service to the client and should be remunerated for that, as in any other profession. As regards missed appointments, some therapists have a rule that the client must pay for the therapy session missed unless they apologize from the session at least 24 hours in advance. It must be stressed that there is a big difference between the client not arriving for the second meeting, and not turning up for the thirtieth. All these issues need to be addressed at the first meeting with the client.

A therapist should not accept a person with whom he/she is in personal contact in other contexts. The more a client knows the therapist in a private situation, the

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less he will benefit from the therapy. The whole therapeutic situation is founded on the therapist being neutral for the client, and if the client is acquainted with the therapist this requirement cannot be met. Another rule is that an existing client’s spouse should not be accepted as another client unless this is part of marital counselling or therapy.

The client should be made well aware than each session lasts 50 minutes. Since every minute is precious, proper time-keeping is a prerequisite for successful therapy. This is also the responsibility of the therapist. In some situations a therapist may continue for a few minutes beyond the allotted time, either because a serious topic has been uncovered, or when the client is not immediately capable of “finishing” what he is trying to say. This is why it is important to try to avoid a situation in which a serious topic emerges just before the end of a session. If the client is very agitated and upset at the end of a session, it is a good thing for the therapist to ask what the client has planned to do next – whether he is going straight home; sometimes it is best to wait and “attend to” the client for a little while longer, for the client should not leave in what is known as an “exposed” state (for example weeping). Another unwritten ethical rule is to observe time and not let an intensely emotional situation arise just before the end of the session.

On average clients come for a session once a week. Therapy is based on regular sessions so as to ensure ongoing inner movement, the process of change, and this is not possible unless the client undergoes therapy on a regular basis. Fortnightly arrangements are also common but it is important to keep an eye on the question of whether the existing frequency is beneficial for the client and whether it might not need to be intensified, or relaxed. Meetings once every three weeks are more a matter of counselling than psychotherapy. In any event it is the therapist who has the responsibility for setting the frequency of meetings.

The place where the therapy takes place is also important. It ought to be a relatively quiet room, not exposed to noise, or even the risk of a telephone ringing in the next room. The room should be safe, and so the therapist should put up a notice on his door saying “No interruption during therapy”. The therapist should on no account take telephone calls during the session. It is best if the therapy room is in a neutral location; if the therapist works at home, this can lead to overlap between work and personal life and this is not conducive to his/her psychological hygiene.

In most cases the therapist has three or more chairs in the room. When a new client arrives he usually chooses the place where he wants to sit and start therapy. It is a good idea for the therapist to have a small mirror in the room or somewhere close by, because some clients like to check their appearance before they leave the room. To maintain a certain intimacy it is best if the client leaves the room on time and so does not encounter the next client on his way into the room. This

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underlines the need to maintain time discipline during therapy. It is also a good idea to have a blanket in the room, because some depressed patients can feel cold and shivery.

In most cases the therapist has a few free minutes between clients to stretch his/her legs, change position, make himself/herself a cup of tea and so on. The client’s first session has specific features. It is important that the therapist introduces himself/herself using his/her whole name, should shake hands and show the client around – indicating the WC, coat-rack, wash basin etc. In the first hour the therapist gets a broad rather than deep view of the client’s problem. He/she takes notes and should manage to reassure the client that it’s a good thing that he has come. He/she should outline to the client how he/she sees their joint work in the future, what they will be working on and how often they would meet. The client should feel the therapist’s understanding and his/her ability to articulate some things that the client is unable to formulate for himself/herself. The client should leave with a sense that something has been agreed upon, that he understands what needs to be changed and what he would like to change.

The last therapy session is also usually important both for the client and the therapist. The ideal situation is when the last session flows from the whole process, and the client and therapist are in agreement on what has been achieved. The whole process is usually concluded by reflection on its course, even if on the client’s side this should be brief and condensed. It is good when the last hour constitutes a genuine ending in this way. In the last session recapitulation may for example run along three lines: defining what the movement in the client has been, what has been experienced, and the ways in which the client is now different. We also need to talk about the fact that although therapy is ending there may still be several unresolved matters that remain for the client to address through work on himself. We may say that this implies that the client is overall more competent than before. Last but not least, there is a need to reflect on the therapeutic relationship. Of course the therapist also expresses his/her views on all these issues; it is good when emotion comes to the surface, and so the leave-taking is warm.

In this publication we are considering questions in psychotherapy that arise in all schools of psychotherapy. Nonetheless, we have a particular approach – one that is grounded in the school of logotherapy and existential analysis. In order to be able to get to grips with certain realities in an effective way, it will be useful for us to offer a closer account of this school: logotherapy and existential analysis.

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2 THE DEFINITION OF LOGOTHERAPY

AND EXISTENTIAL ANALYSIS AS A FIELD OF PSYCHOTHERAPY,

THE PERSONALITY OF VIKTOR E. FRANKL

The question of ethics is universal and applies to all schools of psychotherapy, but to explore the ethical aspects of psychotherapy more deeply we shall first present one psychotherapeutic school, and that is logotherapy and existential analysis.

Logos is a Greek word denoting meaning/purpose. The concept of meaning has a well- defined place in existential analysis where it is related to such concepts as values, consciousness and reflection. Logotherapy focuses on the meaning of human existence and the human search for this meaning. According to logotherapy, the striving to find meaning in one’s own life is a primary driving force. For this reason we speak of the will to, meaning in contrast for example to the Freudian concept of the pleasure principle.63

For existential analysis and logotherapy the picture of the human being is made up of three dimensions: the physical, the psychological and the noetic. Logotherapy teaches that although the physical and psychological are strong dimensions, the spiritual is greater. The human being has always had the noetic dimension, but Frankl was the first to theorise the noetic component and to emphasise it. One recent work that has explored this question of spirituality in detail is Chris Cook’s Spirituality and psychiatry.64 The physical and psychological dimensions are closely bound up with each other; we all know from our own experience that physical illness has an impact on mental state. By contrast the noetic dimension works independently, enabling human beings to make a choice. This makes it different from the psychological element, where one object can easily be replaced by another and where the aim is often a relaxation of tension. The noetic dimension emerges strongly in therapy, but far from being exclusively in therapy. It is constantly involved in everyday life, where the individual has the power to choose and chooses a particular face, concerned that it should be good and not just that it should exist.

63 SeeFRANKL,V.E.:Člověkhledásmysl [Man in Search of Meaning. Praha: Psychoanalytické nakladatelství J. Kocou-rek, 1994, p. 65.

64 See COOK, CH.; POWELL, A.; SIMS, A.: Spirituality and Psychiatry. London: The Royal College of Psychiatrists, 2009, p. 4.

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In our socio-cultural conditions most people have no fundamental material problems, but many suffer from the lack of a sense of meaning in life. We all suspect and perhaps know that material superabundance often brings along spiritual emptiness, and today there is even talk of an epidemic of depression in economically advanced countries, with three million young Americans sometimes toying with the idea of suicide.65 How is it possible that these well-off young people, as well as the middle-aged and seniors, are so prone to the feeling of emptiness, despair and distaste for living?

Logotherapy provides answers to questions of self-transcendence without necessarily basing these in religious sentiment. In our Czech society, which suffered under the communist regime for 40 years, existential analysis together with logotherapy is a movement that offers individuals spiritual transcendence without religious content and is in fact the first psychotherapeutic school leading people to the realization of spiritual values with an emphasis on personal choice and responsibility.

We now need to consider the question of how EA sees the human being, its anthropology of the individual and how meaning is defined in EA, but first we shall explain the difference between existential analysis and logotherapy.

2.1 The difference between existential analysis and logotherapy.

Existential analysis is derived from the words ex-sisto, which means to come forth, emerge – a movement to the outside. To make something to happen we must move outwards – as if coming out onto the stage, from somewhere. It is in this sense that entering into life is to be understood; the individual comes out of his inner self. What is essential is that the human being should be in constant dialogue with both his inner and outer world. We can all imagine the consequences if an individual only exists closed up in himself or only “out in the world”. By contrast, if he lives in equilibrium between the inner and outer, he is in relationship and gives an answer to the world.

Analysis means dissolving blockages and identifying what is inhibiting us from a living a meaningful life. In concrete therapeutic practice with a client we investigate whether he has the necessary conditions to lead a good and meaningful life, and, speaking of conditions, we have in mind three questions to answer: 1. Can I be? 2. Do I want to be? 3. Am I allowed to I be myself, the kind of person that I am?

65 See TAVEL, P.: op. cit., p. 62.

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The central point of existential analysis is to embrace our lives, to be able to find inner consent with the experience: “I am happy in this world, I want to be in this particular life.” It should be pointed out here that this is not to be confused with an attitude of resignation. If we wanted to offer an academic definition of existential analysis, we might say that it is a phenomenological personal psychotherapeutic method that aims for spiritually and emotionally free experiences, authenticity of attitudes and activation of the human being’s capacity to deal with life in a way that is his own, unfalsified and responsible, with regard to himself and the world around him.66

By contrast, logotherapy is derived from the word logos– meaning, and directs the individual to his task of finding meaning. We can therefore define logotherapy as the final stage of existential analysis. Here the individual asks himself, “For what or for whom do I want to live? What is the meaning of all this?”

Viktor Frankl developed the idea of this “pure” logotherapy, but he himself did not have a chance to analyse his own inner self in detail. Alfried Längle later elaborated a theory stating that we all need to explore our inner self, and that understanding ourselves helps us to be able to go out into the world purified, realizing why we do certain things, not just with the mechanical imperative of “committing good”.

Knowledge of the anthropology of the human being helps us to understand human needs. The power of the spirit has been described by David Guttmann67 using a well-known example that can never become trite. This is the story of Viktor Frankl, who became aware of the power of the noetic dimension of his own being in relation to someone he loved and was physically separated from. He was in a concentration camp, but despite the terrible material and physical conditions, he clearly realized that his wife existed inside his soul. Even in these most dreadful straits people can feel the beloved person, despite everything. In existential analysis we call this noetic antagonism, the resistant independence of the spiritual power. It is important to stress out that this is a manifestation of a specific human feat.

Even in the worst possible circumstances a human being can find a reason for living. This reason is meaning.

2.2 The concept of meaning and conscience

Längle defines meaning as the human capacity to recognize what is the best possible for him.68 Both these words are immensely important, because the actual

66 Taken from lectures and training in EA and logotherapy in the years 2008–2010.67 David Guttmann is an emeritus professor in Israel. He has been involved in logotherapy for many years. See

GUTTMANN, D.: Finding Meaning in Life at Midlife and Beyond: Wisdom and Spirit from Logotherapy. Westport, Lon-don: Praeger, 2008, pp. 30–31.

68 See LÄNGLE, A.:Smysl uplně žít:aplikovanáexistenciálníanalýza [LivingMeaningfully: Applied Existential Analysis]. Brno: Cesta, 2002, pp. 39–52.

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conditions are important in the realization of meaning; a man must accept reality and choose the best out of it. Meaning is an entirely concrete path that matches the given circumstances. Logotherapy teaches that in all circumstances and until a man’s last breath, life has the capacity to be meaningful.

Let us explain in specific terms what means to “live meaningfully” (live a meaningful life).

1. Fulfiling the concrete task that we face.Meaning is defined as what should happen through us. It is a very personal matter, and essentially rests in the ability to recognize the highest possible value of a given situation and to make that value a reality. The meaning of the present moment is very well conveyed by David Guttmann using an example69 in which a Mr. Miller tells his therapist a story. A friend of his, with whom he had worked for many years in one company, was about to retire and came to him for advice about his pension and other benefits before he went to the personnel department. Mr. Miller was very busy and told his friend to come back the next day, but the next day his friend did not turn up. Mr. Miller forgot this episode right up to the moment many years later when he was standing in front of the personnel department wanting to discuss the level of his pension, and was in the same situation. He did not understand until then that life had given him an opportunity to help someone in need, but he had failed to grasp what was most significant in that moment, and that he had missed the boat…

Meaning is thus a very definite thing and recognizing it requires our engagement with all our intellectual and emotional capacities.

2. Meaning cannot be handed over by others.Parents cannot dictate to their children the meaning of their life, nor can a boss

prescribe it for his employee. Meaning cannot be given from outside or ordered, but must be recognized and discovered. Everything that happens has to squeeze through the “eye of the needle” of personal understanding. Of course, just by avowing a certain type of values themselves, parents have immense influence on the formation of their child‘s personality as the meaning is closely connected with values, i.e. with what we prioritize in life, and what we marginalise or try to suppress. One essential sign of meaning is that meaning does not compel, it does not involve “you must”, even though it is hard to ignore when discovered. Meaning is a child of freedom.

69 See GUTTMANN, D.: op. cit. , p.46.

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3. Challenges to find meaning are present in the world.The world passes challenges to our noetic potential, offering us the chance to

work on various tasks, values and so on. This may be a matter of creative values, when someone fulfils a task that is needed. The world “addresses”, “fascinates”, catches at our hearts, arouses wonder or amazement whenever we experience the lived out values . This challenge also applies for difficult times when the human being must come to grips with loss or pain. Such extreme situations are associated with suffering; meaning in such extreme situations has to “be wrest from them” and it lies in the way how we cope with them. The harder the circumstances in life, the more profound meaning is hidden in them.

4. Meaning means to accept the whole complex.To recognize meanings for ourselves, we have to see the realities that come

to us in terms of contexts, their relationship as a whole. We have to recognize links between these realities. One may anchor his/her meaning in God, or in fellowship with someone, or in an idea… The whole complex is encompassed with the question, “What for?”

5. A meaningful life does not lie in comfort, career or material prosperity. Meaning transcends all means that are not the ultimate goal in themselves.

Meaning tends to reveal as a challenge, involving many risks. A meaningful life does not guarantee everlasting pleasant experiences. What is good and right may often be unpleasant. We must, however, be alert to distinguish carefully, because in practice – especially in the caring professions – staying in a state of perpetual hurry, exhaustion and weariness may not be justifiable, and may be just an “alibi” for our cowardice, or for our inability to make a change that involves risk and stepping beyond conventional securities. Meaning very often requires courage, while clinging to something that ceased to provide meaning long ago externalises the insufficient living out our own values and the understanding of the challenges of life. Längle argues that there are two kinds of meaning: the specific ontic meaning and the ontological meaning. The first is the matter of meaning in the individual’s specific situation, while the other is more the matter of philosophy or credo of the individual.

6. Anyone can find meaning.Everyone can find meaning regardless of intellect or age, providing the person

is able to make a decision. In doing so he is aided less by his sensory organs than by what logotherapy conceives as the most fundamental “organ”. This is the conscience. Conscience is the “organ” that provides us with orientation what is right; it is the human being’s inner voice. Viktor Frankl writes that conscience is irrational. It is an emotion. An intuitive sense of the hierarchy of values that the

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specific person considers right, and consequently good for him/her. Conscience gives us no guarantees that something will turn out well, and sometimes conscience can be deformed, but ultimately it is the only instrument a man has, and that is why it plays such an important role in his life. In logotherapy, however, what is even more important than conscience is the PERSONALITY in a human being, the persona, and this has the very last word. The question of PERSONALITY is complex and would take us beyond the framework of this book. That is why we shall assume conscience to be an advisory organ. Conscience is a feeling that can be cultivated and developed. In logotherapy conscience is what supports us in difficult moments. We shall now set out several characteristics of conscience according to existential analysis and logotherapy.

Characteristics of conscience:1. Conscience is intimate – no-one other than the individual himself/herself

can better articulate what is right... Conscience is not transferable from one situation to another.

2. Conscience lets us keep freedom – it does not force anything on us, but offers options.

3. Conscience is bound to individual situations – it does not tell us in some objective universal way what should or should not be done. A year later my decision in the same situation may be different…

4. Conscience helps the individual to know and understand himself/herself – it develops us, it reveals our feelings…

5. Conscience needs time and space.

Conscience is a feeling different from emotion; many people tend to be flooded with their emotions, and that is precisely that reason why they reach their conscience. Conscience is not a controlling organ, but an advisory one, and is not to be confused with other experiences.

In order to prevent various pathological phenomena, first we need to know how we can actually cultivate our conscience. Frankl says that we need to learn to listen to our conscience, but above all to take and follow its advise. Conscience speaks through experience. That is why we must train the way we live out our experience.

How can conscience be trained?1. First we must create the conditions for fully experiencing ourselves – i.e. the

capacity to be still, concentrated and calm. In this sense the desire to listen to our heart is the active step.

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2. Cultivation of perception – the individual should learn how to cultivate perception, hone perception, so that his feelings and experience would be more observant. This gives the individual a tool to distinguish with high definition.

3. To hold a dialogue with oneself – this means asking oneself questions, reflecting oneself, knowing oneself. The individual should be well able to see what is good for him, to know how to enter into the dialogue and into the situation of the other, and ultimately to draw back to his inner voice.

Jan Payne describes conscience as something susceptible to getting ill which may mislead us at times. Despite its potential to bring unpleasant feelings, it is a great source of information and the main source of humane characteristics.70 In many cases conscience is healthy and parents have an enormous influence on its formation from an early age. Sometimes an individual may misunderstand the signals of his conscience and consequently feels frustration. In this context logotherapy uses the term of existential frustration.

2.3 Emptiness in life, failure to fulfil meaning

The question of conscience and the true nature of meaning is at the heart of situations in which an individual fails to integrate these two fundamental “quantities” in life and may escape into a world of illusions, deceptions and into the inability to live his existence in a real way. The consequence is feelings of disappointment, dissatisfaction and despair that may end in adopting what is known as “pseudo-meaning”. The absence of meaning pushes the individual to look for a substitute. Regardless of material security a man is created to pusrue something higher than just comfort and happiness. With this aspect in mind it is not very surprising that those who take happiness for their goal in life are precisely those who never achieve it. In fact, human beings need to have a reason for happiness.71 A healthy individual cannot feel genuine satisfaction through either power or pleasure; the only satisfaction can be experienced through living for a person or task. Those who work in caring professions experience this fact on a daily basis. They encounter people who have given up looking for meaning in life, who have exchanged the meaning of life for drugs, or those who sell their bodies, or people who have suffered a loss and do not know how to climb back up from the bottom. Or with people who just no longer want to live. There is

70 SeePAYNE,J.:Etikaapsychoterapie[EthicsandPsychotherapy].InVYMĚTAL,J.:Obecná psychoterapie [General Psy-chotehrapy]. 2nd enlarged and revised edn Praha: Grada, 2004, p. 172.

71 See TAVEL, P.: op. cit., p. 69.

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probably no need to stress out that taking one’s own life is no solution. Suicide conserves what has happened, and instead of removing the unfortunate situation that was the culprit of it, it just removes one’s own self.72 In some particularly difficult life situations thoughts of suicide are understandable, but still there are options that are not possible to be revealed by the individual. And they always exist indeed, for every such individual. Frankl compares life to a game of chess, and the suicide as someone who sweeps all the pieces away from the board instead of trying to keep on playing. The rules allow you to lose, but they never allow you to give up.73 Guttmann emphasises that suicide always causes suffering to others.74

What are the main reasons why people feel emptiness and despair? They may be unable to understand that the life of each and every person has, under all circumstances, a particular, unique meaning. In search for meaning the individual needs a considerable amount of patience and courage, because meaning lies in committing oneself to something, which is a value itself. Emptiness arises when someone aspires to something that is not to be a goal, for example success. This is very common nowadays. The individual does not ask a question, “What for?” but pursues success for its own sake. The consequent emptiness then forces the individual to pursue happiness through success even harder. Physical symptoms of stress, such as tension, headaches, and tiredness then begin to appear and take their toll. The obsessive “urge to success” can also lead to mental disorders, aggression, destructive behaviour to others often associated with substance addiction and so on.75

Disappointment and frustration are common in people who are consciously or unconsciously dependent on success. Frankl compares this obsession with the frenzy of compulsive gamblers. A success dependent individual is capable of working by day and night – everything that he does is driven by the only objective: success. Yet, this provides neither genuine pleasure nor warmth to the individual. Success, in the terms of power, prestige, money, luxury, and self-confirmation, becomes the entire measure of the value of his life. Despite working harder and harder, the individual remains empty inside and starts to become numb, often without realizing it. Alcohol can play a major role in this case.76 A success oriented person needs it repeatedly and experiences increasing anxiety about potential failure, mistakes and faults. This kind of neurosis is caused by unfulfiled need for joy, satisfaction or pleasure, which compels the individual to try even harder but the more obsessively and directly he tries to achieve the experience the emptier the outcome is. In this context Frankl often talks about

72 See TAVEL, P.: op. cit., p. 61.73 See TAVEL, P.: op. cit., p. 61.74 See GUTTMANN, D.: op. cit., p. 154.75 See LÄNGLE, A.: op. cit., pp. 59–60.76 See LÄNGLE, A.: op. cit., p. 60.

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the “model of sexual neurosis”, that arises out of the most common failure when a person is desperately oriented on satisfaction instead of on his/her loved one which should be at the centre of his attention.77

One of the mental states that block the realization of meaning is depression. Depression itself is accompanied by serious stress, a slowing down of psychological processes, self-accusation, somatic and ultimately even psychotic symptoms.78 Swinton speaks of depression as a deep spiritual experience: a profound existential, physical, psychological and relational crisis of the individual, which demands a full, literally holistic response from the individual. Everyone who has experienced depression knows that it includes a loss of meaning, a sense of isolation and feelings of abandonment.79

What can logotherapy actually offer in these cases? Meaning makes an individual to shift his/her priorities from success or goal to the appreciation of the value of a certain person or thing itself. Satisfaction will then follow as a “by-product” of the activities and attitudes that the individual is consciously devoting to a task or a particular person. According to logotherapy the essential thing in these circumstances is to lead a person who has lost a sense of meaning back to himself, to his attitudes, values and motives. We might say that we are leading the person to responsibility, but in this meaning responsibility has nothing to do with obligatory tasks and actions required by others. Responsibility is a matter of liberty. Responsibility is the expression of integral connection with a person or idea. Responsibility expresses relationship. To be responsible means to devote himself/herself. The highest goal of Frankl’s logotherapy is to guide a person to personal responsibility, for then life is truly lived out.80

A frequent reason why people lose the ground under their feet and experience emptiness is their inability to realize their own value. The term “one’s own value” has a very important place in existential analysis and logotherapy. “One’s own value” is a sense of being worthwhile, an appreciation of one‘s own self as a value and conscious attitude to oneself. If this sense of own value is healthily strengthened, people have no need to fill up an empty place and search feverishly for various substitutes. The problem is that this is not simply a matter of knowing the necessity of self-value; it is necessary to make it a lived out part of one’s experience. The picture that a person attains of himself comes both from inside and outside. We need to balance between the way others evaluate us and the way we relate to ourselves. A sense of one’s own value is difficult to find for those who obsessively constantly compete, comparing themselves with others. From

77 See LÄNGLE, A.: op. cit., p. 61.78 See SWINTON, J.: Spirituality and Mental Health: Rediscovering the Forgotten Dimension. London: Jessica Kingsley

Publishers, 2001, p. 95.79 See SWINTON, J.: op. cit., p. 131.80 See LÄNGLE, A.: op. cit., p.70.

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our earliest years we are bombarded with evaluations and comparisons, which makes discovering our own value extremely hard but crucially important, leading not to emptiness and sadness, but on the contrary to a meaningful life, because everyone is an original and originals cannot be ranked. Our own value is given by the essence of our being, and this is in contrast to the utilitarian value, which is always subordinated to an extrinsic aim, plan, or intention; which is oriented on need, which has something to do with functioning. One’s own value by contrast is born from the experience of BEING, when I affirm myself and want you to be part of it. This experience ultimately moves us to real living. One’s own value leads to relationality, to a full life.

2.4 Values in existential analysis and logotherapy

At the beginning of the book we spoke of how meaning is connected with values. But what is a value? What does it do with us? When we picture something valuable for us, we experience a generally agreeable feeling; it delights us, provides us with pleasure. The value shifts us, gives us a sense of its intrinsic rightness – in logotherapy the important feeling of meaningfulness. Logotherapy and EA present values as a challenge; they are given and the individual leans towards them and brings them to life. It is the human being that accentuates a particular value. This fact is crucial for counselling and therapeutic practice, because if, for example, a client never endorsed a certain value because his mother failed to support him and then suffers from this deficiency in adulthood, this does not necessarily mean that he cannot, as an adult, actively relate himself to this value by himself and experience a feeling of fulfilment. Frankl says that a value is something that challenges me to responsibility.

Logotherapy works mainly with three principal paths leading to the fulfilment of meaning:81

1. Creative values –A person creates or makes something meaningful. He is engaged in a meaningful activity, which may, of course, be represented by anything; from carrying out a successful neurosurgery to cooking a delicious meal. Creative values do not mean only doing something exceptional, but include all activities that fill the individual with a sense of meaning and good.

2. Experiential values– these include all that a human being experiences. They, as it were, encompass the individual, giving him strength. The utmost of these values is love – the fact that the individual is capable of loving, accepting and living out love.

3. Attitudinal values– these are a matter of how we cope with suffering and 81 See VYBÍRAL, Z.; ROUBAL, Z. (eds.): op. cit., p. 323.

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take up a stance in regard to our often difficult fate. We may speak in this context of a certain artery of life, a depth encountered by an individual within a specific suffering or difficulty. Frankl pointed out that this fact is precisely what makes people so different. He illustrates this point by talking about his experience in a concentration camp, where among his fellow prisoners, there were some who cooperated with the Gestapo, betraying their own folk, but others who would share their last crust of bread with you. This attitude to situations, to life, illustrates people’s capability to fulfil individual meaning even in the hardships of being.

Logotherapy further divides values into the individual, the general and the situational. We encounter general values in society. Our socio-cultural background determines which of these values are acceptable and which are not. We attain certain norms from our culture, for example a man’s courtesy to open the door to let the woman pass through first in the Western culture, while Islam does not emphasise this. On the contrary, in that world the emphasis is on values entirely different and even unacceptable from our own. General values are of the kind initially indoctrinated in the individual by parents and later by society.

Another category is that of individual, personal values. Despite general values every person within a particular group is unique. Personal values are those which the specific individual embraces, adopts and regards as intrinsically important. Not all general values need to be embraced as personal values – for example, one may disapprove of legal abortion even though it is generally accepted by his society. Or not every Muslim may necessarily agree with the stoning of adulterous women, which is actually still carried out in some Muslim countries. Individual values are purely personal and the individual comes to them through his own development and process of understanding.

The last category represents situational values. In the course of his life the individual is faced with various situations that force him to make a new decision. Situational values mean that in a particular situation I revise and evaluate both universal and personal values. In life, as in therapy, situations may arise that force me to renounce my existing values and adopt new ones with a different, more intuitive with respect to the current circumstances. Maturity of an individual is manifested in his/her ability to reflect critically on himself and his existing values.

The matter of values is the core issue for logotherapy and existential analysis. The values embraced and appreciated by the client provide the therapist with a lead for the therapy. The question of values is very much tied up with ethics. That is why the next chapter deals with ethical principles in psychotherapeutic practice.

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3 THE PRINCIPLES

OF ETHICAL ACTION IN PSYCHOTHERAPEUTIC

PRACTICE

One psychology dictionary defines the word ethics as the “science of the morality of the human being, the origin and development of his moral consciousness, conscience and action; according to the socio-biologists, human emotional reactions and the ethical principles founded on them have been programmed by natural selection over thousands of generations.”82 In short, we can see ethics as the science of morality. Morality may be generally defined as the “the system of regulatory principles of human behaviour based on the distinction between right and wrong and the ability to act practically on these criteria, including transformation in the field of norms, values, models and action.”83. Professional ethics is defined as “the rules of behaviour for members of a certain profession including their rights and duties; rules for relations with the client and his family and rules for relations with colleagues.”84.

One may wonder why the topic of professional ethics is so important. If we want to understand this topic, we might start with the fact that we all play various different roles in life, sometimes even at the same moment. You can be a student and also at the same time a friend, brother, flatmate, foreigner, etc. As a student the individual has a duty not to cheat, as a friend he has an obligation to help his friend, as a flatmate he has an obligation to keep his room clean, and as a foreigner he must respect the laws and duties established by the state or government. Some ethical rules, embodying the basic duty not to harm other people, probably spring from the fundamental role of the individual as member of a human community. There is, then a strong connection between the role that we play in society and the duties and obligations that flow from it. 85

In some roles there may arise an ethical conflict, for example a journalist exposing crucial information may, at the same time, harm someone’s privacy. An entirely honest lawyer may not be able to defend his client unless he gets

82 HARTL, P.; HARTLOVÁ, H.: Psychologický slovník [Psychological Dictionary]. 2nd ed Praha: Portál, 2009, p. 144.83 BAŠTECKÁ, B. (ed.): Psychologická encyklopedie: aplikovaná psychologie [Psychological Encylopaedia: Applied Psycholo-

gy]. Praha: Portál, 2009, p. 92.84 BAŠTECKÁ, B. (ed.): op. cit., p. 92.85 See ROWAN, J.; ZINAICH, S.: Ethics for the Professions. Wadsworth Publishing Company, 2002, p. 1.

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in conflict with his conscience. Many ethical dilemmas arise in the profession of a therapist or counsellor. For instance, if a therapist is providing therapy for a female client, he/she ought to avoid offering his/her service to her husband or wife, even if they were divorced long ago and the divorce was a smooth and friendly one. Especially at the beginning of his/her career, an inexperienced therapist may encounter a predicament for example if his/her client is a successful financial investor. Despite being aware of not being supposed to enter into any other relationship with his/her client but the purely therapeutic one, he/she may not be able to resist temptation and accept advice from the client on where to invest his/her private money, or he/she even entrusts the client with his/her funds. This, described by some authors as a “dual-purpose” relationship between the client and therapist, may lead to the loss of the original therapeutic relationship, due to the gradual disappearance of the vital boundary between the client and therapist. If the therapist is also a client’s lover, lawyer, best friend or financier, the fundamental meaning and goal of the therapeutic relationship is abandoned.86

The dual-purpose relationship also prevents the therapist from maintaining an objective view of the situation, which is inevitably detrimental. The utmost imperative for the therapist is the client’s welfare, i.e. the most beneficial course of action he/she can take for his/her client. Existence of a dual-purpose relationship, however manifests that the client’s interests are not the therapists top priority any more.

A therapist dealing with a client as the person who takes care of his/her finances, for example, will tend to feel a certain lack of freedom, and may develop the impression of being manipulated due to the suspicion that the client does not invest the money carefully enough. Then his/her behaviour to the patient may then become destructive. In a dual-purpose relationship a therapist is engaged in a way that makes his/her own needs primary – whether these are sexual, social, or pragmatic. Another pitfall of an unprofessional relationship with a client is when the latter evolves enjoyment in the pathological relationship and stays in the therapy even though it should have been ended long time ago.87Lonely therapists may seek out the company of the client after the end of the session. Clients, encouraging such relations, naturally change their behaviour even during the therapy and accept such behaviour from the therapist as well.

All in all we can conclude that there are a great many rational reasons to avoid such “dual purpose” relationships, even when not of sexual undertone. Examples of such relationships might be the client painting the therapist’s office or baby-sitting for his/her children. Such relationships block the therapist’s objective

86 See POPE, S. K.; VASQUEZ, J. T. M.: Nonsexual Multiple Relationships. In ROWAN, J.; ZINAICH, S. op. cit., pp. 323–324.

87 See POPE, S. K.; VASQUEZ, J. T. M.: op. cit., pp. 323–324.

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view of the client, interfere with healthy therapeutic techniques and consequently make the treatment impossible. Some therapists and clients claim that their relationship was not damaging. Yet, the argument is hardly consistent with the effort to ensure a safe and effective guidance on the way to the client’s good. Some therapists see no problem in such relations. Pope and Vasquez consider that these relations are cultivated especially by male therapists with female clients.88At all events, the creation of a dual purpose relationship is (and should be) entirely the therapist’s responsibility and the therapist must be wholly in control of the matter. In this context the person who comes to therapy seeking help is very vulnerable. Any damage to the client and unpredictable consequences arising from such a relationship outweighs any kind of short-term “gain”. At all times the therapist should remain alert, highly conscious and sensitive, keeping in mind that the client cannot achieve the changes to heal his personality unless the therapeutical relationship is transparent, unencumbered but warm.

There are a number of principles that have to be observed in psychotherapeutic practice. Some authors consider the following principles to be crucial: beneficence, non-maleficence, and respect for autonomy, justice, fidelity (loyalty), respect, sympathy, competence, reliability and courage.89 If we want to deal with breach of principles, we need to explain some of them in detail beforehand.

In psychotherapy the principle of beneficence is embodied in the therapist’s positive attitude to the patient. The therapist must create conditions that are conducive to the client’s benefit rather than serving his own purposes (e.g. a pathological desire to exercise power and have “the upper hand” over the client). Petr Weiss argues that acting in accordance with the principle of beneficence requires deep and systematic erudition in the field, providing the groundwork for maintaining professionalism of method, supervision and self-critical evaluation of therapist’s own potential to help, especially in periods when the therapist himself is experiencing his own crisis.90

Certainly therapists need a good education in order to guide clients in the best possible way. The basic component of the therapist’s education is psychotherapeutic training practice as we have noted above. The quality of psychotherapeutic practice is certified by accreditation, which guarantees that the training meets the specified standard. Such training can initiate the development of skills on the basis of which the therapist can build a productive relationship with the client. Moreover, it can deepen the empathy, abet the ability to communicate, and improve sensitivity without which a good therapy is impossible.

88 POPE, S. K.; VASQUEZ, J. T. M.: Nonsexual Multiple Relationships. In ROWAN, J.; ZINAICH, S. op. cit., 328–329.89 SeeHUBÁLEK,S.;KOŤOVÁ,M.:op. cit., p. 235. 90 SeeHUBÁLEK,S.;KOŤOVÁ,M.:op. cit., p. 236.

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Some authors point out that if therapists are overburdened with duties related to the operation of modern healthcare and therapeutic facilities, and overloaded with various commitments (e.g. teaching, to professional development, to publication activities etc.), they are not able to be fully engaged in the therapy and in the problems of the client.91 Such overwork and exhaustion can take their toll on therapeutic work. Despite wide differences between the personalities of therapists there are limits as to how many clients one therapist can see daily in fifty-minute sessions. To be sure of working well, effectively and sensitively, therapists should see no more than five or six clients each day. Even five clients are sometimes too many if a therapist has other commitments such as teaching. To concentrate on five different lives, and to stay effective and fully perceptive to the client is a major challenge. Therefore it is very important for therapists to get enough rest and recreation and combine their emotionally and psychologically demanding job with outside activities that bring joy and strength into their lives.

The principle of beneficence also makes it important for therapists to strictly respect the rules of confidentiality, and maintain the proper setting – i.e. breaks between clients, proper time-keeping in consultations. Therapists also need to be thorough in keeping files concerning their clients. When working with a minor, it is necessary for the therapist to get an agreement from a minor’s legal representative. When audio-visual recordings are made during the session, it is necessary to get the client’s consent. It is very important for a therapist to end therapy when he feels that the right moment has come. Ending therapy takes place by the mutual agreement of the client and therapist. A therapist should not continue therapy if the sessions do not bring any benefit to the client or if they make the client dependent on his therapist. The principle of benefit to the client is hard to pin down or measure by externals, for it is a matter of the mind and heart, which are invisible. It can only be evaluated much later – by satisfied clients, who are leading happier lives than they did before they sought out a therapist. It is a mark of the maturity of a therapist that he genuinely has no wish for the client to be dependent on him, and does not try to maintain the client‘s dependence artificially for any unhealthy reasons.

The principle of non-maleficence is the reverse side of the principle of beneficence. This means that the therapist ought to refrain from any action that could harm the client, which may happen unless the therapist closely reflects on the asymmetry of his relationship with the client, especially in the phase when the latter is dependent on him. The therapist may abuse his position by wanting to have “the upper hand” over a client, and trying at any cost to have an effect on the client in a way that relegates the client’s problem to the background. The therapist should also resist the temptation to accept gifts, services, money outside 91 See WEISS, P.: op. cit., p. 236.

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the agreed framework of payment, or sponsorship gifts in situations when a client has a tendency to “ingratiate” himself with the therapist92. The potential for abuse of the patient concerns not just material gifts and services, but also emotions – erotic relationships and sexuality. A therapist who is unable to control his own needs may produce a situation in which he, rather than the client, becomes the centre of interest. In the framework of ethical codes it is crucial that the therapist should constantly be aware of his boundaries and limits.93 For the therapist the best way to preclude harm to the client is to have a natural and cultivated respect for him. In the course of their work, therapists come into contact with many people: clients, their families, students, supervisors, colleagues, etc. These contacts must be governed by the fundamental principle of respect for every person. Thus an individual should never be regarded as some kind of “guinea-pig” but should be treated with respect regardless of gender, ethnic or religious identity, or sexual orientation, age or any other difference. Respect for personal freedom, privacy and the value of the individual as such creates and develops other benefits that are important for therapy. Respect is the wellspring of a sense of fairness and the trust that is crucial in the psychotherapeutic process.

In the therapeutic process confidentiality relates to the proper treatment of the sensitive information communicated by the client in consultations. Trust is at the centre of the client-therapist relationship and is the ground on which the therapeutic relationship emerges, grows and develops. Some authors argue that without trust between client and therapist no relationship leading to a fuller life for the client can emerge.94 Therapists and counsellors have an ethical as well as a legal obligation to talk about the nature and limits of confidentiality before starting therapy with a client. There are some situations in which confidentiality cannot be maintained, for example in the case of abuse of a child or dependent adult, or a danger to the therapist presented by the client. Every therapist with any significant experience behind him/her knows that confidentiality has its limits and that informing his/her client of the fact does not mean that therapy will be inhibited by this knowledge.

Trustworthiness in counselling and psychotherapy is the central pillar of the relationship because it allows clients to confide even the most intimate aspects of their lives freely and without fear. The therapist is bound to confidentiality and secrecy; this is taken for granted. Reynolds outlines exceptions when, for legal or other reasons, the information must be divulged.95 These include situations when either a client himself asks for the information to be released or on the basis of a court order. Another legitimate exception is when the therapist is endangered, or

92 SeeHUBÁLEK,S.;KOŤOVÁ,M.:op. cit., p. 237.93 SeeHUBÁLEK,S.;KOŤOVÁ,M.:op. cit., p. 238.94 See COREY, G.: Theory and Practice of Counseling and Psychotherapy. 9th edn Belmont: Brooks/Cole, 2013, p. 41.95 See WELFEL, REYNOLDS, E.: op. cit., p. 155.

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when an underage client has been abused or is at risk of abuse. Confidentiality is not binding if a therapist deals with a dangerous client, no matter in which way – whether he seriously threatens life of his or the others; is planning a crime, who has a serious or terminal communicable disease such as AIDS and thus could infect someone else. Another important exception is when a client has suicidal intents. We often encounter the issue of breach of confidentiality while working with with children, adolescents or other dependent groups (It is questionable whether a child-client is capable of keeping some facts from parents or guardian, for example.).96 There is a wide range of issues regarding trust and trustworthiness, and it is the therapist’s responsibility to consider all the involved factors. Respect for the client is also implied in the principle of autonomy and recognition of the client’s personhood: the therapist must regard the client as a unique human being. Infractions of the principle of autonomy may include a therapist’s tendency to try to change the client’s worldview, to force his own value system on the client, to argue aggressively with the client’s faith, etc.97 The therapist should be capable of recognising whether he is able to respect the client’s different opinions and values, and if not, he/she should pass the client on to another therapist. One example for clarity: a therapist is a very devout believer and is confronted with a client struggling with the question of his homosexuality. In such cases the therapist should be capable of making an honest decision on whether he can truly accept these diversities. Another dilemma might arise in the case of an infertile female therapist working with a female client considering abortion. To have respect and feel sympathy for a person means to recognise their right to their own feelings and the unique way in which they experience them. It means acceptance and respect for their attitudes of the moment regardless of how far these contradict the attitudes of the therapist. This acceptance of the other creates warmth, cordiality and safety in the relationship.

A feeling of being accepted and appreciated as a person is an immensely important element in the helping relationship.98 Rogers emphasises that acceptance should involve understanding the person, including his feelings and ideas even though they might seem to the therapist awful, weak, or sentimental. The client cannot feel fully free unless the therapist embraces the same view of these “strange” thoughts or feelings of the client. This freedom enables the individual to explore himself both at a conscious or unconscious level without moral and diagnostic judgment. Such acceptance leads to openness, which means that my feelings are visible, and that empathic understanding allows me to see the private

96 See WELFEL, REYNOLDS, E.: op. cit., p. 155.97 SeeHUBÁLEK,S.;KOŤOVÁ,M.:op. cit., p. 238.98 SeeHUBÁLEK,S.;KOŤOVÁ,M.:op. cit., p. 238.

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world of the client through his eyes.99 Trust and respect in the relationship with the client are crucial principles for development of a good therapeutic relationship.

Trust may be undermined or even destroyed if the therapist attempt to cheat or lie to the client. A lie here may be defined as any kind of deliberately deceitful communication to the client, whether written or spoken.100 Some authors also include the “lie by omission”, when the therapist deliberately allows his/her client to believe something that is positive to be false. Deceit is a wider concept than the straightforward lie, and so deceiving a client also means any tricks, dishonesty, traps or deliberate distortion of the truth.101 Why do people tell lies and employ dishonesty in therapy? Ronald Stein suggests that the most frequent motive is compassion and even kindness.102 He gives as example – a case involving a 9-month-old baby that has been examined for physical handicap and found to have not only physical handicap but also severe mental impairment. The parents of this only child struggle with each other and other members of the family. After internal and external struggles both parents finally accept that their child will be physically handicapped, but are clearly not ready to accept the mental handicap, as is evident from their words, “Thanks be to God we don’t have to cope with that [mental] handicap”. How can one respond to parents in this situation? Essentially there are two kinds of answer. One would be something like, “Yes, it’s great that your child isn’t mentally handicapped.” The other would involve saying, with the tact proper to a therapist, “We need to talk matters over, because observation and experience suggest that your son has symptoms of mental retardation as well, even though he is too small for us to be able to determine the extent of the damage with any certainty.” The lie in the first answer could be seen as a kindness and some professionals would regard it as putting the client first. The justification would be that there is very little the parents can do to change the state and prospects of their son, and the “myth” will allow them to live longer with the idea that their child is normal. Stein compares this with communicating information to a dying patient; the professional is neither able to change the patient’s situation nor is allowed to hurt him.

Another reason why people lie or do not speak the truth is to prevent injury or harm to the other. Ronald Stein compares this with lying to the enemy in wartime. He says that a lie that saves lives and the country from enemies is legitimate. The therapist may also sometimes lie to save a life, for example a counsellor working on a crisis line when talking to a client threatening to commit suicide. Another, less noble reason for lying is, of course, personal gain or costly consequences if telling the truth. Someone may lie in an attempt to escape punishment for

99 SeeHUBÁLEK,S.;KOŤOVÁ,M.:op. cit., p. 238.100 See STEIN, R. H.: Lying and Deception in Counseling. In ROWAN, J.; ZINAICH, S.: op. cit., p. 330.101 See STEIN, R. H.: op. cit., p. 330.102 See STEIN, R. H.: op.cit., p. 330.

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some wrong-doing, or simply to avoid an unpleasant situation. Some therapists believe that it is acceptable to lie in order to strengthen their relationship with the client. In a situation where a therapist decides to use a lie or otherwise deceive the client, however, one thing is particularly interesting: he then feels morally bound to justify his behaviour, either to himself or others. Truth rarely requires justification, a lie always does. Therapists often argue that by lying they have actually protected the client’s rights; for example mutual trust in the relationship. Indeed, the most frequent argument for justification of a lie is that the situation was one in which the lie protected the client, sometimes even his life. Yet, some authors describe situations in which a lie has led to damage to the client. This occurs when the lie fails to relieve a problem, just the other way round, it causes damage. Therapists or counsellors who lie may start to feel afraid of being trapped, of being exposed to extortion or even to an act of violence. A lie harms the liar, and isolates him, so eventually he loses his freedom and the lie prevents the others from making effective decisions. By lying the therapist may weaken or even destroy his relationship with the client. We do not claim that there are no situations in which a therapist might feel obliged to suppress facts or not to speak the full truth; such an absolute stance would be naive. All the same, a therapist in such a situation should ask himself two questions: 1. “Is there a reasonable and ethical alternative?” If so, he should tell the truth, for lying should only be a “last resort”; 2. “What are the moral arguments for and against a lie in the specific situation?” It is also important for the therapist to consider what might happen if the client and those around him find out that he has not been telling the truth.103 The question of whether or not to tell the whole truth is a major ethical issue and every therapist must decide with his best conscience in the specific situation whether telling the patient the truth may cause any harm or may bring a certain kind of hope.

The principle of justice concerns respecting social equality and avoiding “discrimination”. Clients should not be treated differently on the basis of sex, race, religion, age, etc. Some surveys show that therapists have a tendency to prefer young, attractive, intelligent clients to old, sick or less attractive ones. What is important is that the therapist should be aware of all his motives and know how to deal with them.104 Stanislav Hubálek and Magdalena Koťová offer examples of unethical behaviour on the part of professionals, seeing most such behaviour as characterised by at least one of the following failures:105

103 See STEIN, R. H.: Lying and Deception in Counseling. In ROWAN, J.; ZINAICH, S.: op. cit., p. 330.104 SeeHUBÁLEK,S.;KOŤOVÁ,M.:op. cit., p. 240.105 SeeHUBÁLEK,S.;KOŤOVÁ,M.:op. cit., pp. 240–241.

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• they ignore the ethical standards of the profession, either due to unacquaintance or ignoring them;

• they intentionally or unintentionally exceed their competence. This behaviour may spring from insufficient professional proficiency or from an inability to cope with the demands of the profession because of emotional reasons, illness, or even dependence;

• they are insensitive either to those with whom they work, or to the situational dynamics of the therapy. This category covers un-empathic professionals, people with an excessive urge to control others, and strongly prejudiced therapists;

• they exploit patients, prioritise their own needs over those ones’ they should be helping, they abuse trust, authority and professional knowledge;

• they behave irresponsibly for reasons of stress, laziness or inadequate acquaintance with the legis artis of the profession. Such irresponsible behaviour also includes covering up one’s own mistakes and blaming others;

• they behave vengefully to patients or colleagues;• they are struggling with burnout syndrome or emotional disturbances;

difficult life circumstances and the stress can also often lead to poor professional judgment and bad decisions;

• they have no sense or an impaired sense of boundaries in interpersonal relations;

• they have a tendency to justify their profitable behaviour;• there are also therapists who usually behave competently and ethnically,

but under the influence of situational variables do things that they would otherwise never consider doing.

Joan E. Sieber offers a conspectus of risk factors that can hinder decision-making even for a mature and experienced therapist. They include the following risks: an entirely unexpected dilemma, an unavoidable dilemma (i.e. the dilemma cannot be resolved without harm to one of the parties), an unclear dilemma or conflict of different ethical principles.106 In practice ethical impacts sometimes schematically correspond with the psychoanalytical model of the id, ego and superego. The therapist should win the battle with their passions, remain sufficiently perceptive and have respect for the client while keeping their feet firmly on the ground of the reality of life and the world.

As already suggested above, the basic principle of psychotherapy, preventing damage to the client, demands the application of the rule primum non nocere. It is unethical to offer a short course of counselling to a patient who is in need of long-term therapy for suffering from a serious personality disorder. Although 106 SeeHUBÁLEK,S.;KOŤOVÁ,M.:op. cit., p. 241.

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the therapist cannot predict how long therapy will take, it is important to make an agreement before the actual therapy commences, because the client has the right to know the therapist’s qualifications, what treatment may be employed and what alternative methods could be involved in the treatment. This is a process of mutual communication between the client and therapist, with the aim of making matters clear on both sides.

In practice what is central in this context is what is known as “informed consent”, which will be discussed later in this book. Informed consent respects the individual’s freedom, autonomy and dignity and involves certain decisions. It is very important that obtaining informed consent should be a useful process, not a static ritual. Gaining competent informed consent shows that the professional regards the client as a human being, and not simply as a diagnosis or a problem. At the centre are two people, The therapist and client, are in the centre of the treatment – they both want to invest energy and commitment in the process. Informed consent has two central aspects.- first is the provision of the relevant information that the client needs in order to decide whether therapy and all that it entails can commence, and the other that might be called “free-will consent” which means that the client’s decision is made without any input that might be interpreted as some degree of pressure. 107 Full and valid consent determines the client’s level of commitment to the treatment. By granting the informed consent the client becomes an autonomous being who is making a decision, shifting his life in a meaningful direction, co-operating with the professional, and capable of making the essential changes. The professional – the therapist, is helping the client to achieve his goal. Knapp and VandeCreek argue that the process of informed consent is the basis of the shared responsibility for the decisions that are implemented during the treatment of the client.108 Zuckerman presents five alternative ways how to reach informed consent. In Czech conditions all these methods are used, but it is still useful to set them out explicitly. The first option is to provide the client with an information brochure.. The brochure sums up detailed information on the benefits in psychotherapy, its risks, aims, methods, together with the cost of therapy, its length and organisation. It also sets out the standards of care that the client can expect.

The second format for informed consent is in the form of questions – a kind of questionnaire that enables the client to gain all required information about the therapy through a conversation with the therapist. This form maintains his or her active role and is an effective tool for building the therapeutic relationship. The questionnaire might for example contain these simple questions:

107 See WELFEL, REYNOLDS, E.: op. cit., pp. 162–163.108 See WELFEL, REYNOLDS, E.: op. cit., p. 163.

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• What is the name of the type of therapy offered? • How can I tell that I am getting better? • How can I get hold of the therapist in the event of a crisis?• If I do not pay the bill for my therapy, what will happen?

The third format outlines the client’s rights, offering a succinct and clear account of these rights. The fourth format for written informed consent is a contract for psychotherapy or counselling that outlines the rights and responsibilities of both sides. A document of this kind may be especially useful in the case of somewhat reluctant or hesitant clients, and usually is preceded by discussion and mutual assent on both sides. The fifth, final possibility is a brief statement of agreement on assent to treatment. This is mainly used when other agreements seem to be too detailed.109 In fact, the use of written agreements are rare in the Czech Republic but all the same at least a verbal “contract” between the client and therapist is essential for the therapy to begin. What is crucial is that the client should understand the counselling or therapeutic processes and agree to co-operate in this spirit, and also that the client’s autonomy should be respected. The client needs to be aware of the risks, benefits and options presented by various forms of alternative methods. All in all, this process symbolises the joint effort of the client and therapist in achieving the desired goal.

Jeremy Holmes argues that in some cases psychotherapy is similar to other helping professions, such as teaching, medicine, etc., but he goes on to point out certain differences in relation to professional ethics. Clients in psychotherapy are particularly vulnerable; clients are people who have come in search of help. Another difference is that clients, who are in some way hurt, may see some events in a more intensely emotional light than is usual, and this may complicate the position in the increasingly intimate therapeutic relationship. Unconscious mechanisms on the side of the client, but also of course on the side of the therapist, play a role here.110 It is indisputable that psychotherapy and ethics are inseparable. It is also very important to respect and keep up the mutual boundaries between the therapist and client; in this aspect the self-awareness is immensely necessary because good therapy cannot be provided without a neutral and undistorted stance. The issue of boundaries is fundamental, that is why we shall devote the next chapter to it.

109 See WELFEL, REYNOLDS, E.: op. cit., pp. 171–172.110 See HOLMES, J.: Ethical Aspects of the Psychotherapies. In BLOCH, S.; CHODOFF, P.; AGREEN, S.: Psychiatric Ethics.

Oxford: Oxford University Press, 1999, p. 231.

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3.1 The issue of boundaries and their violation

The issue of boundaries presents frequent dilemmas in counselling and psychotherapy. How close can the relationship with the client be? Is the therapist still keeping reasonable distance or has he already got into a situation that he finds unpleasant but is unable to withdraw from? Glen Gabbard defines the professional boundary as the limiting parameter of an intimate relationship in which one person (the patient) entrusts his welfare to another (the psychotherapist) and the latter is paid for the whole service. The boundary implies a professional distance and respect that is characterised by ethically professional behaviour, but at the same time it demands taking individual treatment into account.111

In logotherapy and EA we use the boundary as a tool to express our very selves. It is by means of the boundary that facilitates and underscores my “I” differentiation from other people. Boundaries as described in the 3rd BPM (Basic Personal Motivation) are a kind of tool, and one might also say a sense for what is one‘s own, and indeed if this sense for what is one’s own is absent, then the sense for the values of the others may also be missing. The individual is thus unable to sense and perceive either his own boundary or the boundary of the others. This is a frequent phenomenon in practice. People with missing sense of what is their own come to the therapy, and then in conversation the therapist reveals that their own boundaries have often been violated and consequently they have never been able to establish a relationship with themselves. They are therefore living an immensely distorted and burdened relationship both to themselves and others, and this situation is getting over them. Under such circumstances the therapist’s task is to lead the client to a basic recognition of what is his own, of what makes him happy (does him good), and in this way the client learns to “reach out” for these things without a sense of guilt or a sense that he is asking too much for himself. The boundary on one hand protects us, and, on the other hand, marks what is our own, what belongs to us, and what needs to be accentuated so that nobody would violate that line. Due to the boundary we are not only visible but also protected. In this way we protect our own value, as already discussed above. Our own value is expressed in the fact that we are able to take a stance. Taking a stance, however, should not mean the kind of defence mechanism by which people simply quickly and clearly react to a stimulus. We mean an attitude that a person adopts precisely through a kind of calming effect, involving his capacity for honest insight into his experience, and ability to identify

111 See GABBARD, G. O.: Professional Boundaries in Psychotherapy. In GABBARD, G. O. (ed.): Textbook of Psychothe-rapeutic Treatments. [Arlington]: American Psychiatric Publishing, 2009, p. 809.

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his innermost experience. This capacity is what facilitates taking a stance; it is a kind of anchoring, settling and calming down.

The boundary of a relationship is a term of fundamental importance. It includes the definition of roles, the conditions of meeting, sharing information about oneself, about one’s private life and other circumstances. It is useful to summarize all of this into a signed or verbal contract with the client before the beginning of regular sessions. The contract should also include agreement on the time, frequency of meetings, venue and payment for the sessions as well as the conditions concerning missed sessions or termination of therapy. 112 Boundaries can be violated in a very serious way – by sexual contact between the therapist and client, or by less serious non-sexual contact.

3.1.1 Sexual contact with the client as one of the most serious violations of the boundaries

Intimate relations between the therapist and client are among the most serious violations of the boundary, and in Czech conditions the problem is surprisingly frequent. Through regular meetings with a client who is emotionally unfulfilled (as is often the case), the therapist may be providing such fulfilment and as a result – wrongly – the physical boundaries between the client and therapist are breached. Not subject to professional ethics like the therapist, the client demands more and sometimes even believes that he or she has a right to “that” in the course of treatment. A therapist who may not necessarily be in a stable relationship and may be going through upheavals in personal life, may accept this “proposal” and a vicious circle starts, with dim prospects. This flagrant violation usually has grave consequences, which may even include re-traumatisation of the client, especially in the case of a female.

According to data collected by the American Psychiatric Association in 1991, as many as 65% of psychiatrists treated a patient who had earlier been abused by another doctor. Although the ethics code prohibits any sexual contact, even after the end of treatment, sexual contact with a professional appears not to be a marginal phenomenon.113 If it is generally applies for health care that the first medicine prescribed by a doctor is the doctor himself, in psychotherapy it is doubly true. Kertay and Reviere outline the conditions under which physical contact between the client and therapist is permissible, so long as this is a matter of a relationship in line with therapeutic goals:

112 See SMITKOVÁ, H. Etická dilemata v psychoterapii a psychologickém poradenství [Ethical Dilemmas in Psycho-therapy and Psychological Counselling]. In WEISS, P. et al.: op. cit., p. 226.

113 SeeWEISS,P.:Eticképroblémysexuálníchkontaktůvrámciterapie[EthicalProblemsofSexualContactswithinthe Therapy]. In WEISS, P. et al.:

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• there should be no physical contact in the initial stages of treatment;• before there is any physical contact, the therapist should discuss with the

patient the use of touch, the relationship boundary within the therapy and possible feelings associated with a touch;

• the therapist should first ask the client for consent or indicate to him/her that he/she is going to touch them;

• the therapist should make sure that the client feels in control of the situation and does not feel coerced into anything;

• the therapist must be clear about his own motivation and must take full responsibility for his and the client’s reactions, and the therapist should be under long-term supervision or have the possibility to consult with his colleagues.114

Weiss outlines situations that are no longer lege artis and where the therapist is transgressing the ethical boundary. Alertness is required if a therapist:

• starts to talk about his own personal problems or offers details of his own personal life including the sexual ones; all of this within therapy;

• is reluctant to accept payment for sessions or significantly reduces the fee for a patient in the course of paid services;

• suggests meetings beyond regular therapy sessions or in a venue different from the regular one;

• attempts to touch the client, even in apparently innocent ways such as putting an arm round a client’s shoulders during the therapy, holding his or her hand, hugging;

• regularly starts to extend the sessions by 10-15 minutes;• suggests contact beyond the boundaries of the therapeutic relationship –

e.g. advice on financial matters, etc.115

Warning signals of unethical approaches in the course of therapy also include telling of sexual jokes or stories, “making eyes” at a client, discussion of the therapist or counsellor’s own sexual life, and sitting too close to the client.116

Other warning signals are when a professional:• offers a “special” therapy;• invites a patient out to lunch, dinner or other social activities;• sets up a date with him/her;

114 See WEISS, P.: op. cit., pp. 246–247.115 See WEISS, P.: op. cit., pp. 246–247.116 See WEISS, P.: op. cit., p. 247.

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• changes his usual appointment times, meets the client outside his place of work;

• makes the client a confidante – shares with him or her personal and work problems;

• tells the client how much he likes him/her, that he/she is special;• relies on the client’s personal or emotional support;• gives or accepts significant or expensive presents;• offers alcohol during a therapy session.

According to experts, sexual contact does not only mean actual sexual intercourse, but includes behaviour intended to arouse sexual feelings, from suggestive verbal communications to embracing and kissing to genital contact.

Many experts have been dealing with reasoning why sexual contacts between the client and therapist are undesirable. Even though measures are taken to prevent such contacts, statistics and studies confirm that it is unfortunately not uncommon. Elisabeth Reynolds points out that clients who have decided to undergo therapy are often very emotionally stressed and live in relationships that are far from stable, and that they are often confused and lacking in self-confidence. In this condition people are far more vulnerable to exploitation by professionals than they would be otherwise.117 Clients who have been, or are experiencing trauma are even more vulnerable. Kluft, Somer and Saadon claim that most clients who have had a sexual relationship with their therapists had experienced sexual trauma or incest in childhood.118 If the clients themselves are weakened by stress, they find it very difficult to resist various advances from irresponsible professionals, especially if the therapist claims that this “method” is part of the treatment. Another factor that increases the vulnerability of clients is the fact that people seeking help are socially stigmatised. If this stereotype, combined with a temporarily very undermined self-confidence and sometimes a great deal of mental pain, the client can find himself/herself in a situation in which he/she ignores his/her own feelings or “instinct for self-preservation”, and responds positively to the unprofessional proposals of the therapist. Sexual contact not only brings the therapeutic process to a halt, but also causes damage to the client. The younger the client the more problematic the consequences, especially when sexually abused minors are concerned. Christine Adams, a specialist in treatment of sexually abused teenagers, describes this phenomenon in her paper.119

Pope and Vasquez outline ten consequences that can affect clients who have sexual contact with their therapist. They are:

117 See WELFEL, REYNOLDS, E.: op. cit., p. 191.118 See WELFEL, REYNOLDS, E.: op. cit., p. 191.119 See ADAMS, Ch. B. L.: Beyond Attachment: Psychotherapy with a Sexually Abused Teenager. American Journal of

Psychoterapy. Volume 66, number 4, 2012, pp. 313–330.

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• ambivalence;• feeling of guilt;• feeling of emptiness and isolation;• sexual insecurity;• damaged capacity to place trust;• role confusion and disorders in sensing the boundaries;• emotional instability; • suppression of anger;• liability to depression, higher risk of suicidal behaviour; • cognitive dysfunction manifested in the loss of concentration and memory,

with frequent flashbacks. 120

Depression, suicide and hospitalisation seem to be frequent consequences of sexual contact between the client and therapist.121 Pope and Vetter report that 11 % of the investigated sample needed psychiatric care and 14% of clients who had had sexual contact with their therapists claimed considering suicide. 122 Another very negative result of this improper contact is the fact that clients are very reluctant to return to the therapy. Professionals committing such sexual transgressions are also likely to be responsible even for other grave lapses; they often tend to break rules in other respects, e.g. by providing inadequate treatment involving elements of risky or unproductive interventions hindering the client’s problems.123 We can say that sexual contact with a client is unethical, just as is sexual contact with students and other employees who may be taken, to a certain extent, responsible. The American Psychotherapeutic Society bans in its code intimate relations between a client and a therapist for at least 2 years after the end of treatment, but this is another difficult question because some experts believe that even two years is not enough to guarantee that such a relationship can be ethical and may damage either of them .

Kenneth Pope has investigated the reasons why therapists and social workers consider intimate contact with a client to be wrong. They gave the following range of reasons: they find it unethical, unprofessional, and against therapeutic values; they are, in most cases in a relationship that is valuable for them; fear of rejection; loss of reputation; it is illegal.124 The issue of intimate relations between the therapist and client brings up the issue of ethics as more than just the observation of certain clearly defined rules or obligations – and as the constant active awareness of the self and the client. It requires the never ending awareness

120 See POPE, S. K.; VASQUEZ, J. T. M.: op. cit., p. 211.121 See WELFEL, REYNOLDS, E.: op. cit., p. 194122 WELFEL, REYNOLDS, E.: op. cit., p. 194.123 See WELFEL, REYNOLDS, E.: op. cit., p. 195.124 See POPE, S. K.; VASQUEZ, J. T. M.: op. cit., p. 216.

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and self-inspection as to whether my current activities and actions are right, and what the motivations are. Of course, this involves a clear imperative to keep in mind the ban on any kind of sexual contact with the client. We have already outlined the question of values, which is closely associated with the development of ethical approach and sensitivity in psychotherapy. The therapist’s values have a major bearing on the ethics of the work he or she does in particular cases;, that is why we shall now look in more detail into values that may be well-intended in therapeutic practice but may nonetheless generate ambivalences both in the therapist and the client.

3.2 The issue of the value of religion as an instrument in therapeutic practice

Autonomy and respect for the client play a core role in therapeutic practice. This principle may be violated in situations where, for example, the therapist wants to change the client’s worldview and impose his own views and perspective on the world. Love may turn into an unhealthy and damaging passion just as so many other values, which in themselves neutral, may slide in a counter-productive direction. Such values include attitude to money, e.g. therapists in unhealthy need may tend to amass it. Another example may be the attitude to faith, which may turn into a tool for manipulation with the client. This is one of the many reasons why it is very important for every counsellor or therapist to begin to examine and explore his own values as early as in the period of his training and professional formation. Values are ingrained in the centre of our self, both in our personal and professional life. The values that a therapist avows have a conscious and unconscious effect on work with the client, affecting his approach to the sessions with the client, his goal, and his/her evaluation of the result of therapy and of the client’s current life situation. The therapist should not only try to avoid using his influence, which may have a really great impact on the client in certain stages of the therapeutic process, but also not to instil his own hierarchy of values in his client. Even if a therapist does not agree with a client’s values, he needs to respect them in their whole breadth, especially if the client is from a different cultural background. Later we shall look more closely at the issue of clients from other cultures. Gerald Corey distinguishes between values that the therapist reveals to the client, and values that he imposes on the client, trying to persuade him that they are the only the right ones.125 Values that are not merely offered may coercively determine the client’s behaviour, attitudes and even faith.

125 See COREY, G.: op. cit., p. 23.

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Let us now look at certain specific dilemmas that may appear in practice and cause particular trouble. One example is a situation frequently encountered in practice by many therapists – believers: a relatively orthodox Roman Catholic therapist dealing with a client that is also a believer, struggling with a long-term dysfunctional marriage and considering a divorce. The consultant believes in inseparability of marriage, however, there is a client who is unable to keep the marriage, in fact, it is the other way around, keeping the marriage up would damage the development of children born in this wedlock. Unless the therapist can give up his perception of the world and the family, he may impose these values on the client regardless of the ethic of the therapist – client relationship. Despite the enormous effort of empathy, some principles of strongly religious people can simply be unbearable. It is inevitable to evaluate what options are realistic in each specific situation. In some situations faith is the last thing a client can lean on. What are the realistic options of how to solve this difficult situation for a person, who, on one hand, does not recognize a divorce due to his or her faith, on the other hand, the marriage in which he or she lives is, due to alcohol and domestic violence, highly destructive. No therapist can deprive a person of their faith, which would turn out to be non-ethical and unprofessional behavior. No therapist can judge the faith of the person despite viewing it restrictive and life-preventing. In fact, what can a therapist do in a situation like this? He has no other choice but to lead the person to his or her innermost core, to make the client examine their heart and mind so that they would be able to answer the uttermost question – what faith means for them in the day-to-day life, in what way it frees them, what it provides for them, and on the other hand in what way it binds them to the extent that it makes life impossible. In this sense, the therapist is to track the values independent on belief. The values that indicate whether they are assumed, and thus lived out. It is a tough task, requiring a lot of patience and wisdom.

In this context the therapist ought to remain free of his own ideas and be fully able to adopt the stance of the client in front of him/her. He is the one who is responsible for the client’s good by looking through his eyes, by helping the client to carry his burden in an ethical way that is not, at the same time, in conflict with therapist’s conscience. Nevertheless, we must admit that these are really difficult situations, when each correctly chosen word is worth gold, and when time and humility are, along with maturity and kindness, the best therapist‘s tools at most cases.

Similar examples are linked with the problems of pre-marital sexuality and of masturbation. Unless the therapist is mature, suppressing his prejudices and can appreciate the client‘s faith, he can cause the client more incongruences than the client was dealing with at the time he sought out the therapist. Even in these

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controversal questions the therapist is bound to keep in mind the client‘s good, with long-term effect if possible. This is a delicate matter in which the therapist is involved while trying to lead his client to a meaningful life, thus it is inevitable that the therapist himself follows the ethic principles, especially in connection with overloading, with being supervised by a mature and experienced colleague and with the cultivation of his/her own conscience.

The cultivation of conscience was dealt with in the previous chapter. We assume this is one of the pivotal tasks of the therapist, especially when faith is involved. Pursuing client‘s good and being kind, yet wise, places such high demands on the therapist that it is impossible to gain all the skills just by education or learning. Such skills must be sparked even before he started his formation as a therapist. However, personal cultivation is a never-ending process for a therapist.

As a matter of fact, how shall we define religion on the theoretical level, and what is the link between religion and psychotherapy? There are many features in common for both the important phenomena that can be found in various humanities and psychological disciplines, including logotherapy. Religion is perceived as “any system of thoughts and acts that is common to a group of people, which provides them with a framework for orientation and with an object for worshipping126. Religion facilitates the relationship with transcendence; it has a system of symbols, rituals. It is a diverse phenomenon.

The matter of religion is also described by religionistics, which is a science about religion. The name religion is derived from a Latin word religio, which describes the notion of religion in many languages. According to one explanation the word religio, is derived from ligare, which means “to twine”, thus re-ligare may mean “intertwine”. Re-ligio can thus be explained as a mutual tie between a man and a reality that reaches behind him.127

Psychotherapy, especially logotherapy, deals with spiritual issues, particularly the question of meaning and, ultimately, the question of God. Therefore it cannot avoid confrontation with theology. Unlike theology the aim of psychology is to become aware of things, reality, to heal, not to bring salvation. “The aim of psychology is mental healing where the aim of religion is the salvation of the soul” 128 In this concern the priorities differ substantially, as the priest struggles for the salvation of a believer regardless if the believer falls down into even deeper emotional tension, which he cannot be spared of, as a Jesuit priest from USA mockingly remarked: “Religion is more than a mere means of delivering people from psychosomatic stomach ulcers“. Religion can unintentionally but consequently, have psychohygienic and psychotherapeutic impacts. Religion

126 FROMM, E.: Psychoanalýza a náboženství [Psychoanalysis and Religion]. Praha: Aurora, 2003, p. 31.127 SeeŘÍČAN,P.:Psychologie náboženství a spirituality [The Psychology of Religion and Sprituality]. Praha: Portál, 2007,

pp. 33–34.128 FRANKL, E. V.: Psychoterapie a náboženství [Psychotherapy and Religion]. Brno: Cesta, 2006, p. 46.

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enables people to live out safety and grounding that they would not find anywhere else; safety and grounding in transcendence. Similarly, unintentional side effect can be observed in the field of psychotherapy, when the client re-discovers the long-lost original source of the primeval, unconscious, suppressed disposition to faith.129

Intensive co-operation of theologians, ministers, psychologists and psychiatrists is an ideal state. Patients often see a doctor with their struggle for meaning in life, often with a feeling of spiritual distress, which may manifest itself in pathological somatic symptoms such as high blood pressure, eczema or chronic fatigue.

Logotherapy falls into the psychiatry and medical category – thus it is entitled to deal not only with the will for meaning but also with the will for the upper meaning. Faith is a trust in upper meaning. Our perception of religion has just little in common with religious short-sightedness that represents a God as a being that serves the only purpose: to make as many believers as possible, believing in him just in the prescribed religious way. Each branch of psychology thus percieves faith as a belief in meaning. Paul Tillich offers this definition: “Being religious means to ask passionately questions about the meaning of our existence.”130

Research has shown a positive relationship between religion, spirituality and individual health. There are examples of spiritual and religious factors that positively affect mental health. Religion has positive impacts on health in these spheres:

a) Mobilization of internal sources of a personality – it increases self-esteem, contentment with life, happiness; improves sense of meaningfulness, motivation; increases hope;

b) Enhancement of social support to a person through external sources – both in practical and emotional levels;

c) Help in specific problems of an individual – e.g. higher adaptation to sorrow, increased effectiveness in treatment of addictions (alcoholism), reduces anxiety, loneliness, number of suicides131

Everything in life can be used for good or evil, and this truth holds for both religion and psychotherapy itself. We can all mean well, but with terrible consequences. Earlier in this book we looked critically at forms of badly applied, even though well intended approaches. Nevertheless, our aim is to search for the good linking points that serve individuals in all their dimensions – i.e. physical, mental, social and spiritual ones.

True religion can be found wherever there is a religion employed in the fields of mental health or social health with the function of:

129 See FRANKL, E. V.: Psychoterapie a náboženství. Brno: Cesta, 2006, p. 46.130 FRANKL, E. V.: op. cit., p. 52131 See COOK, CH.; POWELL, A.; SIMS, A.: op. cit., p. 19.

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1. liberation, not enslavement2. therapy, not devastation3. genuine stabilization, not destabilization4. a basis for real self-realization and purposeful mastering of challenges in

personal and social life. 132

3.2.1 The power of prayer

Some psychotherapeutic theories deal with the importance of prayer in the therapy. The relation between rituals, religion and psychotherapy is described in the works of Valerie Demarinis.133 A prayer covers processes of communication, participation, listening and transcendence. A prayer enables communication with the existence, helps to make a person become aware of his existence and of the personal meaning of life. It may contribute to rhythmic shifts between dependence and autonomy, it leads to mature dependence on trustworthy environment without losing the sense of the own autonomy. A prayer can support the hope of a fearful person and it can transform vision of a self-accusing person to the brighter one. J. P. Webster distinguishes between different kinds of prayer – concentrating, imaginative and verbal.134 Concentrating prayer is a prayer of an individual with accent on breathing rhythm, simply structured phrases or on combination of both. This kind of meditation mediates the awareness of the present transcendence, leads a person to concentration on his “false self” and to realize of his “spontaneous self”. It can help both the therapist and the client break through their defensive behavior and get to their true experience. Webster contends that therapists can use this concentrating prayer for themselves before the session with the client so that they would meet with the client without an agenda which can turn out to be an obstacle in understanding of what the client is currently experiencing. There can be profit from the concentrating prayer for the client as well. It is possible to utilize the prayer at the beginning or at the end of the session, depending on whether you want to deploy it either for concentration or integration of the therapy. Imaginative prayer is a method about how to create mental images in order to re-live and stay in the situations of the past, present and future. It is also a way to re-live a dream. All the prayer attitude enables the client to search within. Verbal prayer enables the client to articulate what he or she found within. An articulated prayer opens the mind and heart, thus clients can overreach the

132 See ROBINSON, S.: Spirituality, Ethics and Care. [London]: Jessica Kingsley Publishers, 2007, p. 15.133 See DEMARINIS, V. A.: Psychotherapeutic Exploration of Religious Ritual as Mediator of Memory and Meaning. In

AUNE, M. B.; DEMARINIS, V. (ed.): Religious and Social Ritual: Interdisciplinary Explorations. Albany, NY: State Univ. of New York Press, 1996, pp. 235–266.

134 See GUBI, P. M.: Prayer in Counselling and Psychotherapy. [London]: Jessica Kingsley Publishers, 2007, p. 64.

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existing limits of perspective and will. Webster sets an example of prayer at the beginning of the session:

“Lord, here I am standing here in my spirit still fluttering about.. I want to turn all my attention to you, turn all that ove to you I turn to you. I give you my heart, O, God, in this special time with my therapist. I ask for your touch and your kindness; I give thanks for thess times and for your presence in everything, always leading and nudging and encouraging and feeding and nurturing.. I look forward in anticipation to all you do in my life, in the lives of those that I love and those whose lives are connected to mine.”135

Verbal prayer reveals and discloses one‘s relationship with God, to oneself and to others. It leads on to the frantiers of human notions of God, that require growth and an enlargement of heart and mind. Words elicit and enable the therapist and the client to concentrate rather on experiences, they are instruments for expression of the client‘s true self; and link the client to the therapist, who can offer the acceptance and validation of the client‘s true self. Webster states that verbal prayer serves purposes that consistent with the purposes of psychotherapy. He suggests that a therapist may have an opportunity to pray when circumstances in the session result in five general scenarios:

• if the client expresses a desire to turn attention to God;• if the client wants to develop his autonomy;• if the client is ready to admit the need for help; • if the client accepts the challenge to cross his self-imposed limitations;• if the therapist is able to mirror the client’s relationship with God.136

When a client requests prayer, Webster discusses what the clint has in mind and what this means in the therapeutic relationship, e.g.

Client: Can we pray during the therapy?Therapist: If you would like to. But what prompts you to ask?…What have

you in mind in terms of pray in here?… When we enter into prayer, I want you to feel free to pray in words or be silent ,to do whatever is comfortable for you…How does that seem to you?… Do you have any idea of when you would like to pray in therapy?137

All this should be conveyed in a respectful way; the therapist should respectfully make the client‘s request clear, he/she should discuss with him the concept of

135 GUBI, P. M.: op. cit., p. 64.136 See GUBI, P. M.: op. cit., p. 65.137 See GUBI, P. M.: op. cit., pp. 65–66.

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freedom, the client’s control and autonomy, which are essential for authentic prayer. By no means should there be a dictate imposing the form and content of the prayer to the client. The therapist should not impose the prayer itself to the client, unless he asks for it. The therapist should respect the client‘s requests; there are times when clients just need to calm down. What is important is that the therapist and client would be authentic and would not do anything they consider wrong and thus could not live out. A real situation could arise when the client asks for a prayer, however, he does not want to pray himself. If it is clear what value the prayer represents for the client in the process, it can create the viable space for the client to feel psychologically accepted, which naturally facilitates the experience of oneself. Webster also recommends that the prayer should not exceed five minutes.138 A prayer is supposed to reveal the client‘s feelings and thoughts that he might deny otherwise.

As logotherapy and existential analysis are specializations largely concentrating on man‘s spirituality, an existential analyst is liable to come across quite a lot of clients who are believers. A prayer should be something natural, it should deepen the relationship with God, others and themselves, and it should discover options of the client‘s further orientation. In this regard a therapist should remain authentic and not force himself into situations where he does not feel comfortable. Suppose he feels not to be the right person for the client, he should handle the situation in a healthy and mature way. Prayer is just a means of how to deepen and improve the process of the entire therapy.

3.2.2 Religion and ethics

Religion and ethics have a number of common features. In healthy form both should enable the human being and at the same time mark out the boundaries that ultimately give freedom and fulfil meaning. Frankena identifies several paths on which religion and ethics may intersect.139 Religion offers a metaphysical foundation for ethics by mediating or even creating doctrines that, to a certain extent, define current and absolute reality. Present reality may furnish a perspective that offers insight into the workings of absolute reality. Within Christianity there have been created various schools of thought emphasising positive or negative views of humanity or the mutual dependence of humanity. All of this can ground and mould a set of human needs, which provide feedback for ethical practice. Absolute reality is in its essence what transcends this world and relates to the divine creation and divine presence, and what may come true at the end of times.

138 See GUBI, P. M.: op. cit., p. 66.139 See ROBINSON, S.: op. cit., p. 15.

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Another way in which ethics and religion are mutually connected is in terms of motivation. Religion motivates people. Motivation may be positive or negative. A religiously-oriented person may, for example, have a great desire to serve God, and this is a relationship reachable through prayer. His obligation to a higher being then serves as a constant reminder to him to abide by ethics. Another motivation is the desire to gain salvation, which requires doing good deeds. In a negative way, the attempt to gain salvation is an attempt to avoid damnation. Motivation can also be strengthened by rituals: habitual activities that remind believers of the basis, the core of their faith and its relationship to practice. Since ritual has a tendency to be expressed communally (for example attending mass is not matter of just individuals but of a community), this also consolidates motivation, because the presence of others strengthens the individual.

Another link between ethics and religion is in the way religion provides an unconditional and transcendent view of ethics by raising us above self-centredness. In other words, I would like to act in a self-centred way but religion commands me to take others into consideration. Behind this lies the acceptance of human limitations, both material and moral, that is expressed in the theology of sin. This means that as human beings we are sinful, and consequently unable to keep to the ethical code without God’s help.

Yet another connection between ethics and religion is that religion as manifestation of spiritual experience and rituals may facilitate a development of awareness that makes more moral behaviour possible. Typical religious experience i.e. experience with holiness, mystery gained, for example, in spiritual exercises) heightens awareness. This consciousness can regard the human being himself, others and society in general.

The religious community may also play an important role in the moral formation of the individual.140 This is partly a matter of the creation of model practice – the child watches a group of people in a certain community and imitates them. It is often associated with stories and texts (such as the parable of the Good Samaritan).

The connection is also reflected in the work of many authors including imaginative writers and in broader fields, e.g. education. It has been found, for example, that young believers respect authority more.

Spirituality is a concept transcending the religion. As a spiritual being, a person in interaction with the world, the human being cannot but depend on a spiritual understanding of the given in order to be able to cope well with it. His fundamental relationality, both with himself and others, can be considered as a “spiritual gift”. Prerequisite for it is a kind of “phenomenological openness” and willingness to “let himself being touched” so as to be able to fathom the meaning of the given. We understand spirituality as a lived spiritual openness towards the quantity that 140 See ROBINSON, S.: op. cit., p. 16.

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transcends the human being, and such a spirituality is the experiential basis for any religion. All religion is barren unless based on this. Care for the soul cannot be done in contradiction to spirituality or even without it. Indeed, we can only speak of care for the soul if it involves care for the expressing spiritual connections between living out and experience.141 The results of the decisions of the individual go across the framework of ethics, organised religion, individual’s beliefs and rejections, as well as the wider perspective of private spirituality.

3.3 The value of diversity and multiculturalism in logotherapy

Diversity is a burning issue today and the subject of transcultural communication has become very urgent. In the next section we shall consider what logotherapy and existential analysis have in common with transcultural communication, and where we may come across ethical problems when dealing with a culture entirely different from our own. What are the ways to seek and find meaning in another culture and another religion and what role can logotherapy play in meeting this pressing challenge of the present time. Martin Buber wrote that human life is a never-ending meeting. During meeting the relationship is formed. The person is always drawn into relationship both to his inner world and the world outside. This relationship is supposed to begin in the family, to continue towards our neighbour, to our colleague, to our country and to all who are from different cultures. This relationality cannot remain merely theoretical or merely intellectual, but is also emotional. Unless we are capable of this specific relationality, we will be deceiving ourselves regarding our ability to have a relationship with someone very different from us, and this person will remain merely “the other” for us, with whom we will “communicate” only on a theoretical, often scientific level. If we are capable of coming out of ourselves, then we will be able to establish dialogue with these “others”, and as a result, experience a linked mutual setting with them. Logotherapy and transcultural communication share common desires and ideals in the sense of the wish to meet with ourselves, with others, to be tuned to ourselves and others, to be related…

Transcultural communication does not have an ambition to create a universal culture. This is very fundamental: it does not aspire to combine all cultures together in one huge culture, but to facilitate the mutual dialogue of different cultures. The question that naturally arises is what logotherapy and existential analysis have in common with transcultural communication.

141 SeeLÄNGLE,S.;SULZ,M.(ed.):Žítsvůjvlastníživot [Living One’s Own Life]. Praha: Portál, 2007, pp. 47–48.

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The answer is just openness to life, respect for individuality, the unique, and at the same time the desire to be in relationship with others; the desire to create together while maintaining unique differences. The essential issue here is genuine existence, i.e. conscious answering of the questions posed by life. Conscious inner assent: YES, to every life. In terms of logotherapy to genuinely exist means to live meaningfully; to fulfil one’s existence. The existence that is the core focus of logotherapy means to live open-mindedly, to never cease to give answers, and to take a stance in regard to every new specific life situation. I have the final responsibility; I desire to devote myself to something; and above all I am relational. Relationality is the basic feature of both logotherapy and the core of dialogue between different cultures.

This account leads us to an important question of whether logotherapy itself is culturally conditioned. We live in a Judaeo-Christian culture and tradition, so to what extent is living the values linked with the school of logotherapy something universal? To what extent is the search for the meaning in life given by the religion of the Western tradition? Or is it anthropologically universal? In logotherapy the central concept of meaning as the specific potential of living, acting and taking a stance does not find its rationale in religion, nor does it seek to pose religious questions. The options for meaning are far wider and diverse, not just from a person to person but also from a situation to situation.142

Viktor Frankl claimed that the life of the human being has meaning at all circumstances and that the individual can find answers to the questions posed to him by life itself even in seemingly hopeless situations. This approach represents a strong connection with the issue of diversity of cultures, because any human being can find his own, individual meaning even despite the difference of cultures.. Frankl himself applied his theories while being imprisoned in concentration camps (he survived four), where his theoretical conclusions were tested and proved to be right in the hardest possible conditions of “practice”. In the concentration camps there were imprisoned Jews from all European countries, all social classes and all branches of Judaism – from the highly orthodox to the liberal ones. There, in the worst state of pain, deprivation and misery, in a place where man was deprived of his dignity and faith, Frankl applied his method of logotherapy. Through this method he managed to comfort the sick, frozen, huddling prisoners, claiming that every suffering, even this has meaning. He taught that meaning is fulfilled in the way the human being bears what fate has made “inevitable”, and that the meaning of their lives in that particular situation lay in the courage and bravery.143

142 See FRANKL, V. E.; LAPIDE, P.: Bůh a člověk hledající smysl [God and Man in Search of Meaning]. Brno: Cesta, 2011, p. 33.

143 See FRANKL, V. E.: Přesto říci životu ano [Yet Still to Say Yes to Life]. KostelníVydří:Karmelitánskénakladatelství,2006, p. 77.

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Even in a fateful situation like this, when a person cannot change a thing, and which blocks his ability to create or experience beauty, he or she still retains the freedom to take a meaningful stance in regard to the situation. In less historically dramatic, but everyday conditions, this includes situations in which the individual is forced to cope with the death of someone close, with terminal illness or painful treatment, and also in situations in which the individual protects his cultural values and heritage. Frankl emphasises that any specific meaning is bound to human responsibility. Comprehension of all the connections and contexts in life of should, in ideal case, reveal the meaning, but Frankl insists that meaning cannot be revealed without the recognition of the meaning in a specific situation, the understanding of the challenge it presents and the implementation. The answer to the question of the meaning of life is gained internally –through our self. Although generally the question of the meaning in life is metaphysical in nature, logotherapy has a very pragmatic conception of the way to answer it. The meaning in life is not determined by revelation and faith; it is the meaningful moulding of one’s own life that makes possible the development of meaning.144

Frankl first used the term logotherapy before the academic audience in 1926 while the term existential analysis which represents an anthropological-philosophical school providing a framework for logotherapy and deepening it through spiritual care, was introduced in a lecture seven years later.145

Viktor Frankl, the exponent of “pure” logotherapy, did not have the chance to analyse himself and his inner life. Alfried Längle developed the idea of self-experience for everyone. He stated that the human being should explore his/her heart in order to be able to set out into the world cleansed and to understand why to do certain things; in other words – not to “commit good”

“In his search for meaning the human being is guided by his conscience. Conscience is an organ of meaning and can be defined as the ability to reveal the unique and unrepeatable meaning hidden in every situation. Conscience urges the individual to face the fate at all circumstances and conditions, and requires him to create his fate, to act, to take fate into his own hands.”146

Logotherapy is called “the will to meaning” – i.e. it asserts that the search for meaning in human life is a primary force, and that this meaning is unique and special in the sense that every human being can and must fulfil it himself. According to Frankl we do not invent the meaning of our existence but reveal it. Frankl’s approach to values is particularly interesting who argues that values, unlike needs, neither drive nor push us forward but they tend to exert a pull on us

144 See FRANKL, V. E.; LAPIDE, P.: op. cit., p. 32.145 See FRANKL, V. E.; LAPIDE, P.: op. cit., p. 8.146 TAVEL, P.: op. cit., pp. 36–37.

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instead, and without bringing the values to life the individual experiences grief, emptiness and disappointment.

Of course, there can arise situations in which an individual frustrates or destroys his meaning. This may happen either when he is too focused on the performance and reluctant to listen to what his inner self says through his conscience, and using an excessively strong rationalisation (which may seem very “reasonable”), ultimately drowning out what the voice of his conscience is telling him subtly and often quietly and freely; or when he does not want to change his conditions or himself, or when he is just too lazy to pursue what is right though hard for him, and for these or other reasons misses his meaning. This waste is followed by what we call existential frustration. Existential frustration means that the individual is blocking his will to meaning, and this may eventually lead to existential neurosis, which is in logotherapy called “noogenic neurosis”. Noogenic neurosis does not origin in the psyche, which we approach psychologically, but in noos (spirit) as the deeper dimension of human existence. Logotherapy directs itself with this term to the “spiritual” core of human existence, but it is important that in logotherapy the word “spiritual” has a psychiatric rather than a primarily religious meaning.

Rolf von Eckartsberg of the Department of Social Relations at Harvard University conducted a longitudinal study that lasted more than 20 years and involved more than a hundred Harvard students. The study showed that 25% of former students at the prestigious university with equally prestigious current employment spontaneously reported a crisis in their lives relating to the question of the meaning of life. They were all earning very good salaries, but nonetheless felt the lack of a special task or activity in life in which they could provide a unique contribution.147

It is obvious that logotherapy ventures to touch the spiritual dimension of human existence and considers its task to be of help to the patient to find meaning in his life. This search for meaning and values can, of course, cause (temporarily) inner tension rather than inner balance, but such tension is a prerequisite for spiritual health. For as Nietzsche says, “He who has a why to live can bear almost any how.”

Frankl recalled that those who were capable of surviving in the Nazi camps were those who knew they had a task to fulfil (When sent to the concentration camp, Frankl had to hand over everything he had written but not yet published, and his desire to rewrite the texts helped him to survive the camp and all the horrors). Spiritual health is based on a certain degree of tension between what we have already achieved, what we have yet to fulfil, what is proper to the human being. and what is essential.

147 See FRANKL, V. E.: Lékařská péče o duši [Medical Care for the Soul]. Brno: Cesta, 2006, pp. 25–26.

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This is why it is not homeostasis what is essential, but what is known as “noodynamics”, i.e. a spiritual dynamics in the polar field of conflict caused on one hand with the meaning to be fulfilled, and with the person to fulfil the meaning on the other hand.

Thus the meaning of human existence does not lie in self-realisation but in self-transcendence; which means we need to step away from ourselves so that the centre of our life would lie outside ourselves. It should mentioned in this place that transcendence of meaning can be lived in an everyday manner, quietly, and is a matter of a sort of tuning of the individual. At the same time, however, our transcendence is tested by drastic life situations with which we are, to a certain extent, confronted.

3.3.1 The connection between transcultural communication and logotherapy

It is obvious from the above text that logotherapy involves and touches the values of the individual, which can be intimate and at the same time common for all people, regardless of culture, colour or ethnicity, throughout the world. We might argue that values essentially common to most people in the world include a desire to live together in peace and quiet, and what might be called a man’s universal desire for happiness. This desire is fulfilled with respect to oneself and at the same time with respect to others, their values, their cultural grounding and their spiritual level. In this context existential analysis leads the individual to introspection as to whether the offered values are really intrinsic for him/her, whether they represent something to strive for and whether he/she wants and is able to live these values genuinely in a different cultural setting.

An individual (expert) who is professionally dealing with the diversity of cultures not only at an academic level but also with the regards to conflicts arising from the diversity and difference of cultures, must be a mature personality or at least be striving for maturity. An individual, in this case literally a disseminator of peace, who has gone through a process of deep introspection, will accept and spread this approach and kind of personal tuning. Logotherapy and EA can be deployed into the process because they offer and encourage such introspection. Logotherapy and EA do not offer any recipes for a happy life as an end in itself, but lead to a search for meaningfulness in every life situation. To make good decisions in life we need to go through our own introspection of the life values – experiences, understanding of situations and phenomena – and mainly learning to create our own attitudes that we work out for ourselves and that are fully ours and authentic. Every life situation is unique. It cannot be substituted, repeated, or lived by anyone else. Life “pushes” us forward whether we like it or not. Anyone

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who has lived for any length of time in a foreign country knows the difficulties – different customs, different lifestyle, unfamiliar food, another language, different standards for assessment of work, a different time zone, and a great deal more. What is crucial is to keep in mind that the initial experience in a foreign country is not necessarily easy, and sometimes not even attractive. If a person has decided freely to move there, this decision of his can give him strength in tough situations. Acting meaningfully does not mean that the results will be nothing but pleasant. A meaningful, good life is not necessarily always a pleasant one. On the contrary, even when a person finds meaning in an apparently meaningless, but unique for him,, he has achieved full of meaning. Bohumil Hrabal describes this in his book Too Loud a Solitude. It is the story of a man who works alone in a dump in a badly lit basement. His work consists in making compressed bales out of various kinds of waste paper using a hydraulic press. The hero decides to decorate every bale with religious pictures that he finds among the waste brought to the dump with other pieces of scrap paper. He finds a special meaning in his work, transforming the apparently wretched, depressing conditions together with his loneliness and the noise of the machine into an extraordinary situation, and after work hurrying home to read all the books he has discovered. He creates a wonderful world full of meaning and beauty for himself. He is able to step away from himself and at the same time raise himself above all the conditions around him, and to find meaning and the riches concealed in the dumped trash paper.. He accepts his life with love, lives the life he wants and takes responsibility for his decision. This capacity to life, a life that delights us, this is what gives us back a value that is important and essential for our mental health.148

With this story we return to our starting point: that the search for meaning need not necessarily be conditioned by religion. Hrabal’s character is probably not a believer and may even be a materialist. Is the search for meaning thus integral to every person? In every culture? Is it shared by the man with a professorial chair in theology and the man who works on a production line sorting waste paper every day? Actually, the latter may be closer to fulfilling his personal existence than an educated man encompassed by something that, in fact, does not fulfil his existence.

The process of finding meaning in our situation – in the context of the topic we are discussing here – i.e. multiculturalism – may not be entirely easy and depends on many factors. If logotherapy and EA are accepted as the guides and if their findings are applied to this situation, then we need to ask what a person needs in order to be able to live his life well even in a different cultural environment. He will certainly need acceptance, solid ground under his feet. In order to be able to accept himself in his uniqueness, he will need to know how to accept himself 148 See GUTTMANN, D.: op. cit., pp. 71–72.

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with all his different characteristics. At the same time, at the very moment when leaving his culture behind and coming to a different country, he will need to have understanding for the values of the individual or country that is so different from his own. To live in a different culture he needs not only acceptance by the others but also trust – faith in his ability to cope in the new situation but also trust in the others. Apart from trust, an important role in the whole process of adaptation is played by others taking him seriously, by the solid grounding of his own value and by his ability not just to observe events, but to enter into them and change them. What is fundamental is that the person should see meaning in things. That is the factor that mobilises, shifts him forward and changes. Meaning is once-in-a-lifetime, it is unique and no one else can impose it or foist it onto another person.

In the context of meaning, which is the core of logotherapy and EA, we are naturally faced with the question of whether culturally conditioned values dominate over values that are universally given, and identical for all – such as the desire for happiness, peace, etc. To clarify this problem, let us consider a specific, even though a rough example. In the case of a sexually assaulted woman, the majority of Czechs see it as a matter to be subordinate to the Czech jurisdiction, whereas for the majority of Muslims it will be subordinate to sharia law. This has obvious consequences. In the case of a non-Muslim woman raped by a non-Muslim man, the culprit will go to prison, or if a deviant, will be subject to compulsory treatment. If a Muslim rapes a Muslim woman, the procedure will be entirely different – the woman will be sentenced to 100 slashes of flogging or even to stoning for adultery, because it is hard to find four men who will claim that they saw the man raping the woman.

Even though, the Muslim in this case is a human being, and no matter how different, we cannot ignore the fact. In this situation transcultural communication becomes relevant, as does logotherapy and EA, which teaches that the life of every person has meaning, and in every situation. If we are to say YES to every life, that must include even lives of a kind very different from our own.

What role can logotherapy play in these situations? What does the raped woman feel? Will the dehumanising feelings be the same for all women, regardless of difference of culture? Will a Czech woman experience the same feelings as an Egyptian woman? Is it ingrained to the human nature, is it basically the same for all, that every individual craves for acceptance, even if the forms of acceptance may be different? Frankl claims that apart from the conscience that the human being has and should cultivate there exists something even more important, and that is the PERSON. We have mentioned the person in preceding chapters. By self-acceptance, self-distance and self-transcendence, people can intensify freedom of

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spirit and love. Scott Peck talks about so-called “transcending one’s own culture” which is inseparable from spiritual growth and wisdom gained through life.149

3.3.2 The cultural contingency of logotherapy

What is the meaning of culture? Max Weber wrote that, “from the human point of view culture is a finite segment of the meaningless infinity of the world process, a segment on which human beings confer meaning and significance.”150. The question of meaning is also connected with the question of purpose. Do we live to work or work to live? The objective purpose of culture does not determine either its meaningfulness or meaninglessness.151 The fulfilment of life resonates with our personal, specific meaning. There is an example of young Afghans waiting on the Greek Island of Lesbos as long as two or three years just for the moment to get a chance to smuggle themselves onto a cargo vessel and get to Germany or Austria. For these young men, setting off for a better life is the specific meaning; they wait months or even years, for the moment that will change their undignified conditions of life.

Frankl even argues that the utmost fulfilment of meaning paradoxically lies in suffering, in its possibilities, i.e. not only despite suffering, but in suffering and through suffering. Judaism was born from the poverty of nomadic forefathers, who were deprived of the last piece of bread and who wandered in the desert as Bedouins, from famine to famine. They were migrants in this world, who believed in promises, and then they and their descendants toiled on the construction of pyramids as slaves and serfs for 400 years; on buildings that are today the main tourist attractions of Egypt. Then they left for the promised land, only to experience exile, expulsion and oppression. And just like Baron Prášil they had the strength to lift themselves from the swamps of defeat, in the firm conviction that the future is the greatest dimension of God.

What about Christianity? It came into the world through the ruin of the career of one wretched rabbi from Nazareth. People in Galilee gave him the nickname of glutton, drunkard and friend of whores. And he finally was crucified on a cross as the worst kind of criminal. Yet from the depth of this failure, that could hardly have been more abject, was born faith in the resurrection, in the kingdom of heaven, and faith in the healing of every human being.152

Are logotherapy and EA culturally conditioned? There is a strong affinity between the message of logotherapy in Judaism and Christianity. In Islamic

149 See PECK, S.: V jiném rytmu: vytváření společenství [The Different Drum: Community Making and Peace]. Praha: Portál, 2012, p. 209

150 RABAN, M.: Duchovní smysl člověka dnes [The Spiritual Meaning of Man Today]. Praha: Vyšehrad, 2008, p. 27.151 See RABAN, M.: op. cit., p. 27.152 See FRANKL, V. E.; LAPIDE, P.: op. cit., pp. 75–76.

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culture the predominant belief is that planning the future is beyond any kind of human competence. As a result insurance, for example, is not socially acceptable. Insurance is against a future misfortune sent by Allah, and therefore not permissible to believers.153

In his book The Spiritual Meaning of Man Today, Miloš Raban seeks to identify the common points of logotherapy and different religions. He notes that the well-known Jewish philosopher Leo Baeck actually called logotherapy Jewish psychotherapy, meaning that logotherapy is closest to Judaism, arguing that the common foundation of logotherapy and Judaism is in the field of meaning and values such as free will, self-transcendence, suffering, repentance, support for life, desire for search.154

The above mentioned affinity between logotherapy and Christianity can be illustrated using the example of the rich man who lives in an existential vacuum despite his social, economic and even moral self-realisation. He goes to Jesus to seek an answer to his emptiness but is unable to follow Him because he is afraid to make the choice. He is also terrified to abandon his self-realisation up to that point and to depend fully on God, who offers him the utmost personal meaning.

It requires a great courage to leave behind possessions and realities, no matter whether material things or not, one’s life up to this point, various perhaps very respected positions, but it means to pursue something truly meaningful and beneficial for the individual. Another example is Jesus’ conversation with the woman of Samaria which can be interpreted in terms of the woman’s step away from her existential frustration (even though she has led a full and uninhibited sexual life – “you have had five husbands…”) towards the desire for a fuller life, when she asks Christ: “Give me this living water, that I shall no longer thirst...”Another example might be Jesus’ visit to a Pharisee called Simon and praises the emotional existential relationship of a sinful woman, which quality is totally missing in the Pharisee: “Weeping she came to me from behind to my feet, and started to wet them with her tears and wipe them with her hair, kissing them and anointing them with precious oil.” Jesus shows that a lack of this existential faith is at the root of the lack of existential meaning in the Pharisee and his behaviour: “You gave me no water for my feet […], you gave me no kiss […], you did not anoint my head with oil”155 The form was correct, as is often the case today, but what was absent was content and fulfilment.

A certain connection can also be found between logotherapy and Oriental religions. The understanding of the transformation of the pleasure principle into the transcendent plays an important role both in Hinduism and in

153 See RABAN, M.: op. cit., p. 28.154 See RABAN, M.: op. cit., p. 142.155 See RABAN, M.: op. cit., p. 142.

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logotherapy. Three-dimensional existential analysis consisting of the physical, psychological and noetic spheres, corresponds to the body, conscious personality and unconsciousness in Hinduism. Atman is noetic and also has therapeutic potential because it emerges from the unconscious. The final meaning can be reached through personal reflection, which corresponds to the path through understanding. This understanding is originally emotional through love. According to Smith Buddhism contains seven characteristic aspects that can also be found in logotherapy: • empirical, based on personal experience;• scientific, grounded in the search for causality;• effective in relationship organising existence;• pragmatic, associated with the issue of human existence;• therapeutic, helping in suffering;• psychological, focused on problems of human nature and on the dynamics

of its evolution;• democratic, open to all, without prejudices against any social class, oriented

individually, encouraging every human being on their path.156

Frankl saw his psychotherapy – logotherapy – as a science, but a science that is spiritually oriented. This was why, with Albert Einstein, he rightly claimed that “science without religion is paralysed, religion without science is blind”157.

Our question – to what extent is the desire for meaning culturally universal, without a specific ideological or religious basis – invites further exploratory answers. For example migration is a typical example of the people in search for a better life willing to leave for somewhere unknown, accepting the prospect that the beginning may be marked by poverty. Courageous people like this endeavour it for their children. For example in the USA Mexicans work incredibly hard, in difficult conditions for as many as 16 hours a day for several years so that they, but above all their children, would have a better life. They are pursuing the hope that their children will have a better, fuller existence. This hope drives them, and it is for the sake of this hope that they are able to leave the country they love and to make this sacrifice. They leave everything behind for the sake of a better future for their children, even though they have no certainty that they will succeed.

Of course, there are often people who do not leave their country despite their difficult economic situation, but behind this we can see pursuing the meaning. The reason need not be just fear of the new and unknown – but also the ties – family, relationships, etc. In 1941 Viktor Frankl let his visa to America expire because he could not bear to leave his parents. A few months later, like hundreds

156 See RABAN, M.: op. cit.. p. 143.157 RABAN, M.: op. cit., pp. 143–144.

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of other Viennese Jews, he received a summons to a “gathering point”. For Frankl his relationship with his family was too important for him to leave the country without them, although he and his wife were in grave danger.

On the other hand we might think of situations that seem to disprove the universality of desire for meaning, e.g. the issue of the Palestinian-Israeli conflict. This conflict is dominated by immense hatred. Both sides know that it threatens the future of their children, who in the Palestinian case have lived for generations in refugee camps. How is it possible that this hatred overcomes the desire for happiness and a better future for the children (they could for example emigrate)? For the Palestinians, the idea of a meaningful future is the idea of the destruction of the state of Israel and conquest of these territories. This is not the only example of the pursuit of a “pseudo-meaning” according to our European conception; some Muslims see meaning in suicide murder of the enemy and the achievement of “divine justice”.

It would seem that not all cultures agree on the question of the search for meaning. The example of female circumcision also known as female genital mutilation (FGM) – its method, instruments, and its reasons, are hardly acceptable to us, Europeans. Nonetheless, its p ractitioners see in this act a meaning that is perhaps more culturally than religiously conditioned. We could mention many more such examples.

Nonetheless, based on the existential analysis that is backed by logotherapy and its premises that there is meaning in every life, we can say yes to this intrinsic truth.truth. However it is unacceptable to see meaning in a suicide murder or the stoning of women for adultery. All the same, despite these divergent values logotherapy and existential analysis are tools that can help the phenomenon of transcultural communication – via a reflective view of oneself, the exploration and comprehension of the views of the other, of diversity, and the art of transforming the conditions of life to the greater welfare of the individual.

What emerges from this account of the possibilities of the search for meaning for the existential analyst in practice? In his work the therapist may encounter a client who comes from diametrically different conditions, a different culture, whose some values or traditions of his will be incomprehensible. Some family members from a different culture may find it hard to understand why they are, as an immediate family, “cut off” from information relating to the client. Values such as freedom, autonomy and decision for one’s own good may be at odds with the traditions of the other culture. Autonomy has roots in Western philosophy and seems very alien to some cultures. Values relating to one’s own growth and to the strengthening of autonomy may be in conflict with other cultural roots.

The therapist ought to know how to recognise these differences, and to realise that the comprehension of meaning and values is strongly influenced by the

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environment from which the client comes. He should appreciate that there may arise situations in which a client’s values are at odds with professional ethical principles. The issue of culture, values and ethnocentrism is one that has been explored for example by Jefferson Fish.158 Understanding of a client’s native culture, behaviour and approaches must be balanced with an understanding of the culture, roots and knowledge of the country where the client is now living.

3.4 Breach of confidentiality

Another important ethical theme is breach of confidentiality over information confided in with the therapist by the client. The therapist’s work is not easy and speaking with others about clients over lunch, in a leisure moment or on some other occasion can seem like a relief for the therapist who may then feel better. A sort of “whisper system” may even develop among therapists, about who is treating whom and what information the client has offered and so on. Of course, this is a situation where ethical principles are being violated. It is crucial that a therapist should not disclose this intimate information to anyone other than those authorised. Earlier, in the chapter on trust, we set out examples of situations in which the therapist has a duty to disclose, i.e. where confidentiality has its limits. These are circumstances when there is a threat of violence, whether sexual or other towards a minor or person unable to defend themselves, when the client has committed a crime or there is a major risk that the client is planning to harm a certain person and tells the therapist about his “fantasies”. A therapist is also obliged to provide confidential information if this is required by law and the therapist is subject to subpoena as a witness. It is also legitimate to override confidentiality in the case of a client with suicidal tendencies, if an experienced therapist determines that the risk is very serious, and also in the case of clients with HIV.

In this chapter, however, when we speak of breach of confidentiality we mean situations in which none of these legitimising considerations apply – i.e. situations in which a therapist abuses confidentiality, passing on information that the client has confided in with him in good faith. This includes situations in which the therapist talks about his client in front of other therapists who are insufficiently aware of the importance of not betraying the information. Therapists also need to be very careful of mentioning the name of a client in public, for we live in a small world. A therapist should not talk about a client’s problems with friends in

158 See FISH, J. M.: Cross-cultural Commonalities in Therapy and Healing: Theoretical Issues and Psychological and Sociocultural Principles. In GIELEN, U. P.; FISH, J. M.; DRAGUNS, J. G. (eds.): Handbook of Culture, Therapy and Hea-ling. Mahwah, NJ: Lawrence Erlbaum Associates, 2004, pp. 67–79.

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a restaurant, or with students that he is teaching, or with his life partner. A therapist should take the principle of confidentiality extremely seriously and not violate it without a really good reason. It is very unprofessional for a therapist to talk to a colleague on a bus on the way to work about the problems of his clients, since fellow passengers might easily work out that the person in question is one of their acquaintances, neighbours or even friends. If a therapist is overworked and not taking care of his mental hygiene, he may even breach confidentiality and consult with a colleague about his “difficult” client without noticing that the client is nearby, within earshot.

Consultations should be purely private and should take place in a safe space. When at the therapist’s consulting room the client should never see files bearing the names of other clients. A therapist may, without knowing, treat two patients who know each other and finding out about the other would be very unpleasant. Most therapists take notes from their consultations with individual clients not only for themselves, but also for insurance companies that may require some information. Files of these notes should be kept in a place inaccessible to clients, even when the therapist has to leave the room for a short moment. The therapist should not answer telephone calls during a session. This is not just because the client has the right to the full attention of the therapist for the entire course of the session but also because of the risk of breach of confidentiality should the therapist by chance mention the slightest thing about another client during such a call. The therapist cannot be sure which of his clients know each other, and sometimes the most innocent remark may give the client a hint about whom the therapist is speaking. Such slips may violate the principles of respect and trust for the client and the reputation of the whole profession.

It is sometimes hard to find a consensus on precisely what information may be exempted from confidentiality and under what circumstances. Tim Bond has set out a number of principles that can be applied to a wide range of situations in the psychotherapeutic process and which are applicable to most ethical and legal requirements:159

1. Professionals in communication therapies are legally obliged to maintain a high degree of confidentiality regarding personal and intimate matters of the client, unless the clients themselves stipulated restrictions on this requirement..

2. There is no absolute right to privacy and confidentiality. Professionals may be considered legally responsible for situations in which they are too lax, but also for situations in which they are too rigid in upholding the

159 SeeBOND,T.:TheLawofConfidentiality–aSolutionorPartoftheProblem?InJENKINS,P.(ed.):Ethics in Practice Series: Legal Issues in Counselling & Psychotherapy. London: SAGE, 2002, p. 141.

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right to privacy. The legal framework relating to treatment of confidential importation has been created in such a way as to respect circumstances and the application of personal and professional judgment in the assessment of any kind of demand. In a contract with a client the issue can be addressed for example as follows:

A high degree of confidentiality will be maintained regarding information about the client. The information will only be provided with the client’s consent. In exceptional cases a professional may breach confidentiality without the consent of the client, to protect him, or protect other people from a threat, or if required to do so by law.

3. A decision relating to the maintenance or over-riding of confidentiality of intimate information requires careful consideration of all available information. The court does not expect that all professionals will make the same decision in similar situations. It appears that courts take into account the degree of care that a particular professional has devoted to his decision.

4. The client’s consent to the release of information is both ethically appropriate and the best legal protection for the professional. The best course of action is to gain the client’s signed consent.

5. Professionals should be cautious about any request for the communication of intimate information.

6. Ordinary practice relating to the giving of court testimony may present ethical difficulties for the therapist. The therapist should think very carefully about what he writes in records about a client, because any kind of record may be used in court proceedings.

A relatively frequent ethical problem is what a therapist should or should not write down in records about a client, in order to avoid a situation in which his good intentions are turned against him in a court of law.

Kenneth Pope notes that some therapists have to be content with verbal informed consent, even though gaining signed consent can prevent a misunderstanding between the client and therapist that in certain circumstances could lead to a catastrophe.160 Both of them need to know precisely what information the therapist intends to divulge. Keith-Spiegel and Koocher describe the following hypothetical example of how a therapist might respond to the request of a patient for his services to be covered by a health insurance company. “If you decide to use your health insurance company, I shall have to fill in a form in which I inform the insurance company when our consultations take place and what services 160 See POPE, S. K.; VASQUEZ, J. T. M.: op. cit., p. 282.

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I have provided (for example psychotherapy, counselling and so forth). I will also have to formulate a diagnosis and notify the insurance company. The insurance company claims that it keeps all information confidential, but I have no control over this as soon as the information leaves our office. If you have any doubts, you should contact the insurance company. Of course, another possibility is that you can pay me directly for my services and avoid the insurance company.”161

Naturally some clients who may suffer from anxiety disorders may be alarmed by such words, and the idea that the therapist is going to inform other people might put them off. This is why the way in which the therapist tells the client about the facts is very important.

3.5 Jealousy and disloyalty between colleagues

Another important ethical problem is rivalry between colleagues – therapists, psychologists and psychiatrists. This is not a topic that we read about much in books, but that does not mean that the problem does not exist. On the contrary, it is quite frequent, and rivalry appears in psychotherapy as it does in many other occupations. It is a problem more related to the personality of the individual than to ethics per se, but we will still look into it in this chapter

How may rivalry manifest itself? Often it appears right at the beginning of the future psychotherapist’s career in the training practice. It is unprofessional and damaging if training is led by an entirely unbalanced person who feels threatened, for example, by the growing qualities of one of the students. In the course of training, which takes several years, students are supposed to do well, work hard on their personalities, and develop both as human beings and professionals. This kind of progress is not evident in every case, and sometimes we find that the slower and more difficult a student’s progress is, the more he or she seems to gain the sympathy of the group leader. This may be an expression of insufficient maturity and competence on the leader’s part. We consider such responses ethically harmful, but they are also hard to prove. When a student is doing genuinely well, it is very important that the leaders of training should be mature people without tendencies to give way to jealousy or deep internal incongruences, who have reconciled with all their own weaknesses. If this is not the case, a very tragic scenario may develop, and needless to say that the inadequate leader’s behaviour is unethical. In situations in which the leader does not fully understand that he may not be popular with all the students and that not all students will see him or her as a role model, he may start to show conscious or

161 POPE, S. K.; VASQUEZ, J. T. M.: op. cit., p. 282.

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unconscious tendencies toward vengeful behaviour to the students. Unfortunately this is a real danger in training.

To protect himself, a therapist may create an atmosphere of fear during training, although this will ultimately not be the best kind of protection. We have said that not all students and training leaders will necessarily suit each other perfectly, and that this is a normal, healthy situation. The problem starts the moment that someone has a tendency to “punish” another for this otherness, in a way that can be both covert yet intense.

Let us offer another example of wrongful behaviour: a training leader who in his past abandoned theological seminary education and has had a rather thorny path in life and has not reconciled with this “loss” may make mocking comments about the lives of clergy. This is a comically sad situation, which cannot pass unnoticed by perceptive people.

The people involved in the professional formation of others are sinners as well and it is important to remember that every person has his limits and weaknesses. What is crucial, however, is that the individual should be aware of these facts and not turn them against others. It is very important that the training leader should constantly bear in mind the purpose of the whole exercise: it is not about getting students to like him or her, or about persecuting someone, but about helping the students with the growth of their personalities, their development, and their proper understanding of psychotherapeutic work. In this position the leader fulfils the function of a kind of tool to aid the maturation of the students. If a therapist and his/her future colleague meet and develop a relationship of mutual liking, acceptance and friendship, this is a good basis for quality work based on trust, which can offer much satisfaction. This is because the student is to a certain extent influenced by the treatment that he encounters in training sessions, and it is hard to imagine good future therapeutic work unless the student himself has sensed goodwill, acceptance and friendliness in their teacher. What is more, every group experience presents a significant therapeutic potential.

A therapist can encounter rivalry and jealousy in his later engagement on too. For example a colleague who, despite having insufficient time and capacity for some clients, never passes these clients on to him. Or psychiatrists who, for various reasons, refuse to send their clients to therapists for the therapy they need. Sometimes such difficulties arise because they have a poor opinion of a colleague, and some therapists even consider warning a client against a colleague. Certain therapists go so far as to slander colleagues in front of the others. In the chapter on the ethical dilemmas of supervision we have given some examples relevant to this problem.

The professional should consciously work on some manifestations of his/her negative emotions connected with blocks that he has not yet worked through,

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on issues such as loneliness, power, dying and death, and intimate relationships. Not that a therapist can be expected to get rid of all his own conflicts, for this is beyond human capabilities. The key is to be aware of his or her difficulties and to be able to assess what potential damage they may cause in his/ her personal and professional life. Therapists cannot lead clients further than they have come themselves. If a therapist is not able and willing to work on himself and uncover blind spots, how can he hope to inspire the client to discover the values that are important to himself? If a therapist, or a psychiatrist, is reluctant to work on his own anxieties and fears, how can he participate in the process of self-uncovering and recovery with his client? Neither the training group nor further education can provide a sufficient degree of self-knowledge, which is both the prevention and at the same time remedy for various incongruences in the individual. Many authors talk about the important of personal psychotherapy of the self.

Yalom points out that if a therapist lacks sufficient insight into his own personal motivations he may for example avoid conflict in the group, because he has a tendency to suppress his feelings; or he may by contrast encourage confrontation because he himself is looking for vivacity. He may make excessive efforts to excel in coming up with brilliant interpretations, and in that way deprive the group of their energy. He may be afraid of intimacy and consequently block the open expression of feelings by premature interpretations – or on the contrary, over-emphasizing feelings, insufficiently connecting things by explanation, and being excessively encouraging and reassuring to clients who may not actually find it pleasant.162 Yalom praises the advantages of the therapeutic group for psychotherapists, where, unlike in student groups, there is little problem with competition; members are strongly motivated and used to thinking psychologically.163 What is very important is that every therapist should acknowledge his fallibility and show a sufficient degree of humility, without which there can be no mutuality in the client-therapist relationship, let alone between two professionals.

Signs of a certain kind of jealousy and disloyalty towards the client may also show in the therapist’s attempt to tie up his/her client into a relationship of unhealthy dependence on him. We consider this a very dangerous ethical problem, although also hard to prove. Indeed, the question of the therapist’s use of his “power” to create dependence in the client is a major ethical problem for psychotherapy as such. It is the reason why some people actually challenge psychotherapy as a practice that encourages immature therapists to impose on people in the pursuit of the position of “guru”. Where this happens it is all associated with failures on the part of therapists to work through their issues, as considered above, and when a therapist is aware of these faulty motivations in

162 See YALOM I. D.: op. cit., p. 548.163 See YALOM I. D.: op. cit., p. 549.

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himself/herself but does not seek to correct them it may unfortunately be hard for others to recognise these faulty motivations even during his training. As we have already shown, rivalry is primarily an issue of the personality of the individual, and, on the other hand, there are therapists who have encountered it only rarely.

3.6 The issue of payment for therapy

As in every other employment, so in the helping professions including psychotherapeutic work, people are paid for their services. There is no doubt that before he becomes a “good specialist”, the therapist has to undergo a financially demanding process of education. Psychotherapy is an exacting profession in all respects. The therapist is in frequent interaction with human pain which he seeks to alleviate. He is confronted with the most intimate facts of human lives, and while he is trying to do his best for the good of a “stranger”, the therapist may struggle with events and problems in his own life. For hours he listens to accounts of events which may be unimaginable for some people and receives clients in an uninterrupted flow, sometimes at the expense of his personal time and his hobbies. In psychotherapeutic practice can turn up moments when the therapist and client reach the utmost limits of human possibilities, when they do their best for each other, whether in terms of information, understanding or emotions. Sometimes, each financial remuneration can seem to be inappropriate, but it is understandable and logical that the therapist is paid for such work.

Nonetheless, in this activity more than in any other we can get to a slippery slope in matters of remuneration. The work of the therapist is not like any other “work”: it is much more intimate and personal; it is not the usual kind of “classic” job. We cannot compare the therapist with a ‘nine-to-fiver’. If we admit that the work of the therapist is special, the question of financing and payment for therapy is also a little special. Some clients cannot afford to pay 400–700 CZK for a one-hour private psychotherapeutic session, but often the very same people are most needy for therapy. Of course, some therapists have a contract with a health insurance company, and the client does not pay the therapist directly. Unfortunately, there is often a long waiting-list for therapy covered by insurance. Moreover, these therapists usually do not work in the afternoons or evenings when the said clients can come. Furthermore, the therapist with the contract with a health insurance company may not be the right one for the client. At this moment it is as if the principle ideal of this profession faded away because those who cannot afford paying for the therapy are excluded. The aim of psychotherapy is to give help to those who really need it, who are in distress, and soul sick. Petr Weiss points out that the financial claims of some therapists are disproportionate,

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bordering on commercial exploitation. He adds that through this absurd and incomprehensible behaviour certain therapy centres become “the fashion facilities just for so called celebrities and rich snobs”. Unfortunately, this phenomenon is not rare and he points out that even life priorities of some very experienced therapists are deformed. They succumb to the consumer way of life and strive to protect themselves against uncertainty in life by hoarding property.164 The relationship between the therapist and his client can become impaired in case the therapist has an inner dilemma whether to earn plenty of money or to help to the client regardless the lower profit. This situation is mentioned by Sidney Bloch who warns that the “client to therapist” relationship may be seriously impaired not only by sexual or other unhealthy contact, but also by the temptations of Mammon.165 It is hard to establish the point in which the craving for financial security starts to prevail over the view of payment as a justifiable and defensible component of therapy. This issue has one’s turn whenever a psychiatrist specifies the type of medicaments therapy or a therapist suggests the number of paid sessions and so on. The option of treatment procedure is influenced not only by skills and interests of the therapist but also by his financial situation. Does this particular patient need further treatment, or does the therapist need the extra income? As soon as a therapist starts to lie to himself, the ethical risk arises. Here we can see a flustering contrast between the therapist as a healer and the therapist as a businessman, and this is the pitfall which Edmund Pellegrino pointed out when spoke about the medical profession in general: “Today our profession is facing an inevitable compromise between two contradictory moral imperatives; the first is based on ethical duty to the patient, and the second on the need of one’s own success in trade and securing a worthy livelihood. These two imperatives cannot essentially be reconciled. Whether you like it or not you have to choose between them.”166

One of the most important changes that has come about in psychotherapeutic work is the gradual replacement of the two-sided relationship by the three-sided relationship thanks to accession of the health insurance companies. The change from the model of Freud has been motivated by economic considerations (to reduce the excessive direct economic burden for the patient), but has ethically complicated the position and responsibility of the therapist. Nowhere is it more evident than in direct and indirect imperilment of confidentiality. Whenever a third party enters the relationship, neither a psychiatrist nor a therapist can promise a client absolute confidentiality. This is because when the therapist

164 SeeHUBÁLEK,S.;KOŤOVÁ,M.:op. cit., p. 230.165 See. CHODOFF, P.: Misuse and Abuse of Psychiatry: an overview. In BLOCH, S.; CHODOFF, P.; GREEN, S. A.: op.

cit., p. 53.166 CHODOFF, P.: Misuse and Abuse of Psychiatry: an overview. In BLOCH, S.; CHODOFF, P.; GREEN, S. A.: op. cit.,

p. 54.

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needs to charge the insurance company the costs of treatment, he has to give to them diagnostic and other information. The resulting ethical dilemma can cause unpleasant feelings of discomfort for doctors and therapists, and is one of reasons why many professionals have negative attitudes towards payment by a third party.167 A further ethical-economic problem is the pressure exerted by the third party on the therapist to reduce treatment costs even at the expense of the quality of treatment for the patient.

It is necessary to realize that treatment is the result of a compromise between the quality and treatment costs. How ethical is it to reduce rates and work for “social tariff”? Who makes decisions about that; the therapist alone? If a client cannot afford to pay 600 CZK per session, is it correct to provide him the therapy at half the price? How will the other clients react when they find out this fact? The question of payment for therapy is a highly sensitive one. Despite all the rules and proposals, this is an area which has to be left to the therapist and his conscience to find a solution. We can only hope that the therapist is guided by wisdom and by undistorted perception.

3.7 The problem client

In psychotherapy, a therapist works with various clients. It can happen that he likes sessions with some clients more than with some others. Each therapists has already experienced such a situation. That does not mean that the therapist wants to take the part with some clients and think of them as “better” ones, but it has to do with clients who, despite the fact that the therapist devotes to them as much energy and does his best, behave as if they were on strike, and they refuse the potentiality of the psychotherapeutic relationship; therefore all psychotherapeutic effort is wasted.

According to Yalom, the category of problematic clients includes the following types: the monopolist, the silent client, the boring client, the help-rejecting complainer, psychotic or bipolar client, the schizoid client, the borderline client, and the narcissistic client.168 In this text, we shall focus on the monopolist client and the silent client, because while the other defined clients are problematic, they have a specific diagnosis according to the International Classification of Diseases (ICD).

The monopolist is a person who feels an urge to talk endlessly. Surely, every therapist has had such a client. If such a client turns up in a group therapy, he

167 See CHODOFF, P.: Misuse and Abuse of Psychiatry: an overview. In BLOCH, S.; CHODOFF, P.; GREEN, S. A.: op. cit., p. 54.

168 See YALOM, I. D. op. cit., p. 381.

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hardly lets someone take the floor. He talks even in the briefest gaps of “silence”. If he is forced to be silent, he feels big anxiety. The monopolist persists in describing his conversations with other people up to the infinite details. Yalom notes how labile clients with liking for drama can monopolise the group using the method of crisis: in the group they regularly submit the reports of their important life crises, which seem to require urgent and long-time attention.169 Other clients keep silent, because their stories seem trivial in comparison to a drama of this kind. During such a course of therapy, both the clients and the therapist can feel frustration and anger, because the monopolist, in comparison with other clients, is consuming too much time for himself. The cause of urge talking of the monopolist is the pursuit of settlement with his anxiety. Nevertheless, this behaviour has to be curtailed either by the group or by the therapist, because the topics, about which the monopolist speaks, do not reflect deeply felt affairs but are chosen for a different reason: to entertain, to gain attention which the individual has never had, to justify his position, to submit complaints, etc.

In group therapy, the aim of the monopolist is to stand off and inhibit the other members from having meaningful relationships with each other. Just for that reason, the therapist must intervene. Some monopolists do not accept this; and they furiously leave the group therapy. Yalom says that although this is a troublesome event, the result of therapist’s inactivity would make the situation worse because, in spite of the fact that some clients express regret at the departure of a group member, they frequently admit that if that client had not left, they themselves would have.170 The basis of the therapist’s effort should be to lead the monopolist to live his own life, and not “outside” events.

The silent client could also be a problem. It happens that the therapist has a client that does not want to undergo the therapy, but is “compelled” by his partner to do so. Otherwise the partner threatens with divorce. Of course, many other reasons may exist. The silent client can be a less disturbing element than the monopolist, but also represents a difficult problem. Yalom illustrates this case with a story that used to circulate among therapists. It is about a man who attended group therapy without saying a word. At the end of the fiftieth session, he announced that he would not come any more. He said that his problems were solved and that he was getting married the next day. He thanked the group members for their help.171 Of course, this is an extreme example, and may not be truthful. However, rather than taking care of truthfulness of the story, we should concentrate on whether silence always represents a problem. Or better still, in which moment the silence becomes a problem. Yalom comes with evidence

169 See YALOM, I. D. op. cit., p. 382.170 See YALOM, I. D. op. cit., pp. 384–385.171 See YALOM, I. D. op. cit., p. 387.

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that the more active client has the greater chance to have benefit from the group therapy. It is known that the silent client does not have benefit from long-term group therapy. The self-disclosure is essential not only for group solidarity, but also for the positive result of the therapy and client’s work.

The greater is the client’s verbal participation, the greater fellowship feeling he experiences. Subsequently, the client is better rated by other members, and ultimately he thinks much of himself. Of course, it is important to understand why a client keeps silent. Some clients may be scared of self-disclosure; they are afraid that anything they say will be used against them later. Another reason may be an intimate feeling connected with aggression in case they cannot present themselves and speak. As if they fight against themselves and then are angry with themselves for speaking too much or, conversely, not speaking at all. Some people keep silent because they take themselves for inexperienced speakers. Others keep silent because they stand off from their fellow clients or from the therapist.172

There are many reasons why a client may keep quiet. The fundamental thing for a therapist is to understand the silence dynamics and appropriately support the client. An experienced therapist can do it in different ways. However, it is known by experience that if the client refuses to engage in conversation for more than three months, the prognosis is bad. In group therapy, the group can become weary of perpetual encouraging the silent, blocked client. At that point, the therapist must solve the important ethical question of how to cope with a situation like this, i.e. how to exclude the silent client without damaging those who wish well towards him. In individual therapy, where the therapist is spending time with just one client, the therapy can be terminated by mutual agreement. In group therapy, other members may contribute to exclusion of the silent client because they consider the situation to be disruptive and not conducive to the group dynamics and growth of the clients. Of course, the client may have “his own reasons” for silence, but at the same time his attitude is affecting the whole group. If he is not capable of self-disclosure and systematic work on his improvement, neither he nor the group advance. That is what should determine what to do with such a client.

It would certainly be possible to write about many other ethical issues, because this is a nearly inexhaustible well. Thanks to the great diversity of clients and their problems the therapist is always encountering new challenges. Here we have tried to outline some ethical issues that are particularly sensitive and the most frequent dilemmas in this profession.

172 See YALOM, I. D. op. cit., p. 388.

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A FINAL REFLECTION

We have talked about ethical aspects of psychotherapy, the dilemmas that the therapist meets on his path, the pitfalls that he encounters in his practice, the burnout syndrome as well as the demands imposed on the therapist. Our next topic is closely associated with the above discussed demands and requirements. There is no doubt that they are high, but the therapist is supposed to meet them. On 21 May 2006, the famous psychotherapist Petruska Clarkson, whom we have mentioned abundantly in this book, was found dead in a hotel room in Amsterdam, after committing suicide by a drug overdose. This shocking news affected many hundreds of psychotherapists, her colleagues, collaborators, publishers of her books, clients she worked with, and of course her family. In the hotel room, she left a hand-written farewell letter, in which she said that she was content with her life and had been reflecting upon suicide for some considerable time. Her suicide was not a momentary impulse. It was a thoughtful act. This is what she wrote in her farewell letter:

PLEASE DO NOT RESUSCITATE PLEASE

My will is in my wallet with my passport. I have no next of kin.I love being in this city of canals and liberal laws. It is raining and I am happy.

I believe that it is a basic human right to decide when you want to die – abortion after all is taking the life of another human being. But soon this will have to be considered as the elderly over-populate and over-burden the planet. In time perhaps people like me will be given incentives to do it. Or at least supported, even approved of, valued.

Freedom must include the right to choose whose slave you want to be or not. I have understood that my research of recent years retains its continuity

and integrity – from apartheid, women’s liberation, gay rights, & with Vincent, changing English Law to prevent more abuses of clients and students etc. etc. – generally the alleviation of human suffering and the development of human potential*.

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I could have done better, but I could certainly have done worse. *However, the clues are all there already. Hidden in my previous published

and unpublished writings. I am sorry that I did not have the time and protection to spell this out.

I am grateful and feel blessed by my life’s gifts. I have loved and been loved like few other women I have ever met. Several long times. Many short eternities too. I’ve always loved my womb.

Fortune – I have made some but not been interested enough not to just give it away (e.g. a million pound p.a. turnover company for 1 penny!). And that’s only 1 example of many more…

Fame – didn’t like it. Wasn’t suited to it. Researched it. Hurt me more than helped me. Even on such a minor scale. Read it.

I’ve been to wonder-full places, had amazing experiences and interacted with beauty. I have been happier than I ever imagined humans could be in these last years.

I’ve had a sufficiency. My tummy for life is full and pc wants to go home now.Yes, fear (of survival),

griefanger, but mostlypeace = full-ness,

mostly joy,gratitude and lovemostly.173

After reading this letter some people may feel grief, emptiness, frisson, but others may feel peace. The authoress herself says that she feels a fulfilled life. Some of her colleagues say that she had difficulties, which were the source of some anguish and sorrow. They describe her as a highly creative and sensitive person, and it was her sensitivity that set limits to her capacity to cope with the amount of turmoil in her life. Probably, there were many reasons why this celebrated psychotherapist took own life. However, they are mere speculations, and the whole truth remains obscure.

Petruska Clarkson insisted “that there be no funeral, cremation or memorial service of any kind held for me”. In accordance with her will, she was cremated without a public ceremony on 14th June 2006, i.e. about three weeks after her death. Her only wish was “that all those who have valued my work just continue to ‘help the people’… ”. For years, she was out of touch with her family.174

Petruska Clarkson’s suicide raises many questions. How could a therapist who had worked for many decades with clients and students, and had written quite

173 PETRUSKA CLARKSON [online]. [cit. 2014-02-04]. Accessible at: http://petruskaclarkson.blogspot.cz/.174 PETRUSKA CLARKSON [online]. [cit. 2014-02-04]. Accessible at: http://petruskaclarkson.blogspot.cz/.

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a number of books relating to the ethics of psychotherapy, take her own life? Why? What was behind her decision? Why, despite writing about a fulfilled life, did she voluntarily end her life prematurely? Why did a woman who had tried to bring greater happiness to dozens, even hundreds of confused, sad and depressed people, die by a deliberate overdose? Why did she do it when no one knew better than she that suicide makes many people sad and probably even more confused? Did she work in a way that went against her natural temperament just to make people like her? Was there anything missing in her life? What kind of profession is it that can drive a person to that point? Was it an escape from reality which was hard and impossible to cope with? Do people talk about happiness when they are actually experiencing it, or they refer to it at a moment when this is not the case? What does she actually leave as a legacy after ending her life in this way?

Her books meant a great deal to the whole professional world. She wrote in a readable, distinctive style, and was an outstanding professional. We can only speculate on what led Petruska Clarkson to such act. In any case, this vocation can lead a person to the very edge of their possibilities (resources). If in his desire to help and be useful a therapist knowingly neglects his boundaries, he may find himself beyond them. Petruska Clarkson must have had a deficit in replenishing her mental energy and enthusiasm. Probably, she invested too much energy in her work. So much so that it killed her at last. Or was it a lack of family support? She was out of touch with any member of her family for years. The work of therapists is emotionally demanding and they need to replenish their strength in emotionally warm and amicable relationships.

This story of a famous therapist raises many ethical questions concerning the psychotherapeutic profession as such. Of course, we cannot exclude the share of personality of the particular individual from the context of the whole situation. There is no doubt that psychotherapy is an exacting profession. In some situations, not even ethical rules are sufficient for us to judge the serious situations that may arise in practice. Despite the spirituality that permeates a particular personality, men and women are creatures of flesh and blood and, especially in psychotherapy, this should never be underestimated.

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REFERENCES

ADAMS, Ch. B. L.: Beyond Attachment: Psychotherapy with a Sexually Abused Teenager. American Journal of Psychoterapy. Volume 66, number 4, 2012

BAŠTECKÁ, B. (ed.): Psychologická encyklopedie: aplikovaná psychologie [Psychological Encylopaedia: Applied Psychology]. Praha: Portál, 2009

BERRY, J. W.; POORTINGA, Y. H.: Cross-cultural Psychology. 3rd edn Cam-bridge: Cambridge University Press, 2011

BOND, T.: The Law of Confidentiality – a Solution or Part of the Problem? In JENKINS, P. (ed.): Ethics in Practice Series: Legal Issues in Counselling & Psychotherapy. London: SAGE, 2002

CLARKSON, P.: Ethics. New York: Wiley, 2000COOK, CH.; POWELL, A.; SIMS, A.: Spirituality and Psychiatry. London:

The Royal College of Psychiatrists, 2009COREY, G.: Theory and Practice of Counseling and Psychotherapy. 9th edn

Belmont: Brooks/Cole, 2013DEMARINIS, V. A.: Psychotherapeutic Exploration of Religious Ritual as

Mediator of Memory and Meaning. In AUNE, M. B.; DEMARINIS, V. (ed.): Religious and Social Ritual: Interdisciplinary Explorations. Albany, NY: State Univ. of New York Press, 1996

DRAPELA, V. J.: Přehled teorií osobnosti [Overview of the Theory of the Per-sonality]. Praha: Portál, 1997

DUNCAN, B.; MILLER, S.; WAMPOLD, B.; HUBBLE, M.: The Heart, Soul of Change.American Psychological Association, 2010

FISH, J. M.: Cross-cultural Commonalities in Therapy and Healing: Theoreti-cal Issues and Psychological and Sociocultural Principles. In GIELEN, U. P.; FISH, J. M.; DRAGUNS, J. G. (eds.): Handbook of Culture, Therapy and Healing. Mahwah, NJ: Lawrence Erlbaum Associates, 2004

FRANK, J. D.; FRANK, J. B.: Persuasion and Healing. 3rd ed Baltimore: JHU Press, 1993

FRANKL, E. V.: Psychoterapie a náboženství [Psychotherapy and Religion]. Brno: Cesta, 2006

110

FRANKL, V. E.: Člověk hledá smysl [Man in Search of Meaning. Praha: Psy-choanalytické nakladatelství J. Kocourek, 1994

FRANKL, V. E.: Lékařská péče o duši [Medical Care for the Soul]. Brno: Cesta, 2006

FRANKL, V. E.: Přesto říci životu ano [Yet Still to Say Yes to Life]. Kostelní Vydří: Karmelitánské nakladatelství, 2006

FRANKL, V. E.; LAPIDE, P.: Bůh a člověk hledající smysl [God and Man in Search of Meaning]. Brno: Cesta, 2011

FROMM, E.: Psychoanalýza a náboženství [Psychoanalysis and Religion]. Praha: Aurora, 2003

GABBARD, G. O.: Professional Boundaries in Psychotherapy. In GA-BBARD, G. O. (ed.): Textbook of Psychotherapeutic Treatments. [Arling-ton]: American Psychiatric Publishing, 2009

GIELEN, U. P.; FISH, J. M.; DRAGUNS, J. G. (eds.): Handbook of Culture, Therapy and Healing. Mahwah, NJ: Lawrence Erlbaum Associates, 2004

GUBI, P. M.: Prayer in Counselling and Psychotherapy. [London]: Jessica Kingsley Publishers, 2007

GUTTMANN, D.: Finding Meaning in Life at Midlife and Beyond: Wisdom and Spirit from Logotherapy. Westport, London: Praeger, 2008

HARTL, P.; HARTLOVÁ, H.: Psychologický slovník [Psychological Dictio-nary]. 2nd ed Praha: Portál, 2009

HOLMES, J.: Ethical Aspects of the Psychotherapies. In BLOCH, S.; CHO-DOFF, P.; AGREEN, S. Psychiatric Ethics. Oxford: Oxford University Pre-ss, 1999

HUBÁLEK, S.; KOŤOVÁ, M.: Etika v psychoterapii [Ethics in Psychothera-py]. In WEISS, P. et al. [Ethical Issues in Psychology] Praha: Portál, 2011

CHODOFF, P.: Misuse and Abuse of Psychiatry: an overview. In BLOCH, S.; CHODOFF, P.; GREEN, S. A.: In BLOCH, S.; CHODOFF, P.; AGREEN, S. Psychiatric Ethics. Oxford: Oxford University Press, 1999

JUNOVÁ, H.: Kultivace etiky psychologické práce – úkol pro mezinárodní spolupráci i pro české psychology [The Cutivation of the Ethics of Psycho-logical Work – a Task both for International Collaboration and for Czech Psychologists]. In WEISS, P. etal.: Etické otázky v psychologii. Praha: Por-tál, 2011

KRATOCHVÍL, S.: Základy psychoterapie [Principles of Psychotherapy].5th edn Praha: Portál, 2006

KŘIVOHLAVÝ, J.:Psychologie moudrosti a dobrého života [The Psychology of Wisdom and the Good Life]. Praha: Grada,

LAMBERT, M. SHAPIRO, D. BERGIN, A. E.: The Effectiveness of Psycho-therapy. In BERGIN, A. E., GARFIELD, S.L.: Handbook of Psychotherapy and Behaviour Change. 3rd edn. New York. Wiley, 1986

111

LÄNGLE, A.:Smysl uplně žít: aplikovaná existenciální analýza [LivingMea-ningfully: Applied Existential Analysis]. Brno: Cesta, 2002

LÄNGLE, S.; SULZ, M. (ed.): Žít svůj vlastní život [Living One’s Own Life]. Praha: Portál, 2007

MIKOŠKA, P.: Metadovednosti a (ne)vědomí v psychoterapii: fenomenolo-gická studie podmínek efektivního využívání psychoterapeutických technik [Meta-Skills and (Un)Awareness in Psychotherapy: Phenomenological Stu-dies of the Effective Use of Psychotherapeutic Techniques]. Červený Koste-lec: Pavel Mervart, 2013

MIOVSKÝ, M.; DANELOVÁ, E.: Etické aspekty psychoterapeutické práce [Ethical Aspects of Psychotherapeutic Practice]. In VYBÍRAL, Z.; ROU-BAL, J. (eds.): Současná psychoterapie [Contemporary Psychotherapy]. Praha: Portál, 2010

PAYNE, J.: Etika a psychoterapie [Ethics and Psychotherapy]. In VYMĚTAL, J.: Obecná psychoterapie [General Psychotehrapy]. 2nd enlarged and revi-sed edn Praha: Grada, 2004

PECK, S. V jiném rytmu: vytváření společenství [The Different Drum: Com-munity Making and Peace]. Praha: Portál, 2012

PETRUSKA CLARKSON [online]. [cit. 2014-02-04]. Accessible at: http://pe-truskaclarkson.blogspot.cz/.

POPE, S. K.; VASQUEZ, J. T. M.: Ethics in Psychotherapy and Counseling. 4th edn New Jersey: Wiley, 2011

POPE, S. K.; VASQUEZ, J. T. M.: Nonsexual Multiple Relationships. In ROWAN, J.; ZINAICH, S.: Ethics for the Professions. Wadsworth Publish-ing Company, 2002

RABAN, M.: Duchovní smysl člověka dnes [The Spiritual Meaning of Man Today]. Praha: Vyšehrad, 2008

ROBINSON, S.: Spirituality, Ethics and Care. [London]: Jessica Kingsley Pu-blishers, 2007

ROWAN, J.; ZINAICH, S.: Ethics for the Professions. Wadsworth Publishing Company, 2002

ŘÍČAN, P.: Psychologie náboženství a spirituality [The Psychology of Religi-on and Sprituality]. Praha: Portál, 2007

SCHMIDBAUER, W.: Syndrom pomocníka [The Helper Syndrome]. Praha: Portál, 2008

SMITKOVÁ, H. Etická dilemata v psychoterapii a psychologickém poraden-ství [Ethical Dilemmas in Psychotherapy and Psychological Counselling]. In WEISS, P. et al.: Etické otázky v psychologii [Ethical Questions in Psy-chology] Praha: Portál, 2011

112

STEIN, R. H.: Lying and Deception in Counseling. In ROWAN, J.; ZINAICH, S.: Ethics for the Professions. Wadsworth Publishing Company, 2002

SWINTON, J.: Spirituality and Mental Health: Rediscovering the Forgotten Dimension. London: Jessica Kingsley Publishers, 2001

TAVEL, P.:Smysl života podle Viktora Frankla [The Meaning of Life accord-ing to Viktor Frankl]. Praha: Triton, 2007

ULRICHOVÁ, M.: Člověk, stres a osobnostní předpoklady: souvislost osobnostních rysů a odolnosti vůči stresu [The Person, Stress and Personality Preconditions: The connection between features of personality and resistance to stress]. Ústí nad Orlicí: Oftis in collaboration with the Ed-ucation Faculty of the University of Hradec Králové, 2012

VYBÍRAL, Z.; ROUBAL, J. (eds.): Současná psychoterapie [Contemporary Psychotherapy]. Praha: Portál, 2010

VYMĚTAL, J.: Úvod do psychoterapie [Introduction to Psychotherapy]. 2., updated edition. Praha: Grada, 2003

WAMPOLD, B.: The Researcher Evidence for the Common Factors Models: A historically situated perspective. In DUNCAN, B.; MILLER, S.; WAM-POLD, B.; HUBBLE, M.: The Heart, Soul of Change.American Psycholo-gical Association, 2010

WEISS, P.: Etické problémy sexuálních kontaktů v rámci terapie [Ethical Pro-blems of Sexual Contacts within the Therapy]. In WEISS, P. et al.: Etické otázky v psychologii [Ethical Questions in Psychology]. Praha: Portál, 2011

WEISS, P.: Etické otázky v psychologii [Ethical Questions in Psychology]. Praha: Portál, 2011

WELFEL, REYNOLDS, E.: Ethics in Counseling & Psychotherapy. 5th edn Belmont: Brooks/Cole, 2010, 2013

YALOM, I. D.: Teorie a praxe skupinové psychoterapie [The Theory and Practice of Psychotherapy]. Praha: Portál, 2007

ZVÁNOVCOVÁ, I.: Musím a nemohu jinak [I Must and Cannot Do Otherwi-se]. Final dissertation in Logotherapy and Existential Analysis – psychothe-rapeutic training, In: Psychoterapie-iz [online]. Accessible at: http://www.psychoterapie-iz.cz/index.php/odborne-texty.

Strana Problém Je Má být116 nejsou doplněná jména Translation ???, 2014

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- references

MONIKA ULRICHOVÁ

THE ETHICAL TRAINING A N D S E L F - T R A I N I N G

OF THE THERAPIST WITH A FOCUS

ON LOGOTHERAPY AND EXISTENTIAL

ANALYSIS

E T H I C A L A S P E C T S

O F PSYCHOTHER APY

Translation Anna Bryson, 2014

Peer-review MUDr. Alena Vosečková, CSc.,PhDr. Ivanka Binarová, PhDr.

Published by EL-PRESS, Lublin 2014 Oficyna Wydawnicza sj. 20-227, tel. +48 81 444 10 84

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