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Betrayals of Therapist Trust:Lessons from the FieldJill C. Thomas aa SUNY Upstate Medical University , Syracuse, NewYork, USAPublished online: 19 May 2011.

To cite this article: Jill C. Thomas (2011) Betrayals of Therapist Trust: Lessonsfrom the Field, Journal of Constructivist Psychology, 24:3, 208-233, DOI:10.1080/10720537.2011.571565

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Journal of Constructivist Psychology, 24: 208–233, 2011Copyright C© Taylor & Francis Group, LLCISSN: 1072-0537 print / 1521-0650 onlineDOI: 10.1080/10720537.2011.571565

BETRAYALS OF THERAPIST TRUST:LESSONS FROM THE FIELD

JILL C. THOMASSUNY Upstate Medical University, Syracuse, New York, USA

This article explores violations of therapist trust in the practice of psychother-apy and how they can be understood from an experiential personal constructpsychology (EPCP) perspective. Case examples are used to highlight the ways inwhich therapists, sometimes naı̈vely or unknowingly, place a great deal of trustin clients, and thus are vulnerable to injury. The examples also demonstrate howEPCP can be a powerful perspective from which to anticipate potential injuries,as well as to understand and heal from them. Based on the lessons learned fromthese examples, suggestions for clinical training are offered.

For humanistic and other therapies grounded in the beliefthat the therapy relationship is the vehicle for client change,rapport in the therapy relationship is of great importance (e.g.,Rogers, 1961). The primacy of the therapeutic relationship is fun-damental to these and other approaches (e.g., psychodynamic,object relations, and interpersonal) because of their basic theo-retical beliefs about the formative and transformative power ofrelationships. However, even for approaches in which relation-ships do not play such a central role (e.g., behaviorism and ratio-nal emotive behavior therapy), rapport remains important, giventhe research evidence suggesting that the quality of the therapyrelationship makes substantial contributions to therapy outcomeregardless of theoretical orientation (Norcross, 2002). As such,training in basic helping skills often starts with teaching clinicianshow to develop rapport (Hill & O’Brien, 1999). The assumption,

Received 27 July 2010; accepted 19 October 2010.This article is an elaboration of a paper presented at the 14th Biennial Conference

of the Constructivist Psychology Network, Niagara Falls, New York, July 2010. All clinicalmaterial has been distorted to protect client confidentiality. I would like to thank LarryLeitner for his comments on an earlier version of this article.

Address correspondence to Jill C. Thomas, PhD, Department of Psychiatry, SUNYUpstate Medical University, 750 E. Adams St., Syracuse, NY 13210. E-mail: thomasji@upstate.edu

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Betrayals of Therapist Trust 209

although often unarticulated, is that rapport is a reflection of thelevel of trust the client has for the therapist. A therapist who is ableto establish good rapport with a client is able to connect with theclient in such a way that the client feels heard, understood, andrespected enough to risk sharing personal and painful aspects ofhis or her experience. Effective therapy, then, seems to begin witha therapist’s ability to engender the client’s sense of trust towardthe therapist. But what about the reverse? Whereas much atten-tion is paid to developing a client’s trust, it seems that the trustrequired on the therapist’s side of the relationship is often takenfor granted.

At least two approaches make explicit some aspect of trust onthe therapist’s side of the relationship. Personal construct therapy(PCT; e.g., Epting, Gemignani, & Cross, 2003; Kelly, 1955, 1969;Neimeyer & Baldwin, 2003) and experiential personal constructpsychology (EPCP; e.g., Leitner, 2009; Leitner & Thomas, 2003), atherapeutic approach grounded in PCT and Kelly’s (1955) social-ity corollary, both assert that therapists should take a “credulousapproach” in the therapy relationship (Leitner, Dunnett, Ander-son, & Meshot, 1993). A credulous approach is one in which thetherapist takes everything a client says as true. This is not to sug-gest that therapists are naı̈ve or should be uncritical or unques-tioning in their approach, but rather that they should operate un-der the assumption that a client’s report is a valid reflection ofthe client’s personal truth, whether or not it aligns with the ex-periences of others. In essence, this is another way of saying thatthe therapist must be able to truly see things from the client’s per-spective and accept or trust the validity of that perspective beforetrying to help the client see the ways in which the client’s way ofbeing and experiencing the world may be limiting or damagingand in need of change.

Thus, the credulous approach does not imply that thera-pists should blindly believe everything their clients say. However,it seems that the credulous approach and other basic aspects ofgood therapy relationships, like openness and unconditional pos-itive regard (Rogers, 1961), can be a slippery slope leading to ther-apist gullibility. Therapists are often accused of being too “warmand fuzzy,” perhaps too trusting, so that they end up with a ratherdistorted view of the client and his or her circumstances and some-times find themselves advocating for a client based on limited

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210 J. C. Thomas

or inaccurate information. It is difficult to find the fine balancebetween accepting a client’s truth and leaving room for the pos-sibility that this truth may not be representative of what othersexperience.

Beyond the credulous approach, which makes issues of truston the therapist’s part somewhat more explicit, there are otherways in which the trust therapists invest in their clients is implicitin the nature and structure of the relationship but that are rarelydiscussed. It seems that issues of trust from the therapist’s perspec-tive are often only laid bare when trust is broken. In this article,I consider some of the ways in which therapists place a great dealof trust in clients on a daily basis, although they may often be un-aware of what or how they are investing in the relationship. Fur-ther, I discuss some lessons learned from these examples of trustbetrayed. The examples and discussion demonstrate that thera-pist trust is a pantheoretical issue in the sense that breeches oftrust can occur in any kind of therapy. At the same time, the ex-amples will illustrate how an EPCP perspective can be a usefullens through which to examine the experience of therapist in-jury when trust is broken, even when those injuries occur in otherkinds of therapies. While the focus of this article is on therapistinjury, there are certainly circumstances in which clients are in-jured by therapists, as well. A full discussion of how therapists maybreak clients’ trust is beyond the scope of this article, althoughEPCP may prove useful in understanding clients’ experiences ofthese injuries, as well.

The Therapy Relationship as a ROLE Relationship

A major focus of clinical training in a humanistic approach (ora humanistic constructivist approach like EPCP) entails startingfrom the assumption that, at the core, people are basically goodand well-intentioned. They may stray from this path at times andthings may go awry so that on the surface they do not look likeor act like “good” people, but in order to develop rapport and beeffective in helping people find their way, therapists are trainedto find the good. Although this may make us effective at what wedo, it also may create a blind spot that can lead to feeling sur-prised or hurt when our clients do not act in accordance with ourassumption that they are basically good and the assumption that

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Betrayals of Therapist Trust 211

we, because we have such a special relationship with them, are insome way immune to experiencing the ugliness and harm theymay show to others.

When surprised or injured in this way, one’s impulse might beto retreat from the relationship by terminating therapy or trans-ferring the client to another provider. Alternatively, one mightcontinue to work with the client but find various ways to retreatfrom the relationship in an attempt to protect oneself from fur-ther injury (Leitner, Faidley, & Celentana, 2000). Although thisstrategy may be useful, it also involves many potential costs, in-cluding but not limited to loss of connection with clients, loss ofpassion for helping others, job dissatisfaction, and burnout. Giventhe magnitude of these costs, it may be wise to consider an alter-native way of making sense of these experiences. EPCP offers aframework for understanding that may help therapists find waysto continue to engage, rather than retreat, and work through theinjury with a useful and meaningful way of viewing others stillintact.

In EPCP, the term ROLE relationship is used to describea quality of relationship that facilitates psychological health andleads to a meaningful existential experience. By definition, ROLErelationships are potentially awful and aweful (Leitner & Faidley,1995). They are vital, significant relationships based on a mutualdeep revealing of our very cores, in which we must risk terror toexperience richness and meaning in life. Without them we expe-rience safety yet numbness and emptiness. Because of the dualnature of this kind of relationship, we simultaneously experiencea pull to engage in the awefulness and a pull to retreat from theawfulness. According to EPCP, the degree to which one can suc-cessfully manage the balance between engaging in and retreatingfrom ROLE relationships determines one’s degree of psychologi-cal health (Leitner & Pfenninger, 1994).

Just as ROLE relationships are necessary and transformativein life, EPCP holds that it is this kind of relationship throughwhich one finds meaning and transformation in therapy. Thus,EPCP therapists strive to engender such a relationship with theirclients. A major difference between a ROLE relationship that oc-curs between two people in the outside world and the two (ormore) people inside the therapy room is that the sharing andrevealing is not necessarily mutual or equal. However, I would

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argue that therapists, although not disclosing details of their ownlives, may still be revealing their cores in other ways—by shar-ing their emotional responses to what is happening in the room,by communicating empathy, by being truly genuine and openin response to what is shared—in essence, by speaking from theheart and allowing themselves to be affected and changed by theirclients. In this way, although not self-disclosing in the traditionalsense of the word, therapists are genuinely laying themselves bare,and thus, like their clients, are also vulnerable to injury in the re-lationship. Just as our clients feel injured when we do not honorthe relationship and break their trust in some way, we are vulnera-ble to feeling injured, although likely to a lesser degree, when ourclients do the same.

By conceptualizing the therapy relationship as a ROLE rela-tionship, EPCP helps us understand, from the start, the emotionalrisk inherent in being a therapist. In this way, simply working fromthis frame is a way of combating a potential blind spot. Concep-tualizing the therapy relationship in this way also makes our mostcentral assumption explicit—that the therapy relationship is pow-erful and transformative, and thus we must honor and protect it.If we hold this assumption at a conscious level, we may then alsobe more conscious of another basic assumption that is often unar-ticulated or taken for granted—that our clients hold the therapyrelationship in the same regard, and thus will honor and protectit. In some cases, this may be true; in other cases, not.

Although viewing the therapy relationship as a ROLE rela-tionship is clearly a particular way of conceptualizing the therapyrelationship based on a specific theoretical orientation, I would ar-gue that the experience of feeling connected to one’s clients andsometimes feeling injured by one’s clients is not an experiencethat is distinct to EPCP or any other constructivist therapy. At thesame time, EPCP offers a unique framework and vocabulary forunderstanding the therapist’s (and client’s) experience within therelationship that may be relevant to practitioners from manytheoretical orientations, including other relational perspectives.The language and concepts exclusive to EPCP are centeredaround the costs and benefits of engaging in and retreating fromintimate relationships and the dilemma we all face when decidingwhether to engage in something that is potentially enrichingbut also potentially painful. EPCP also offers a vocabulary for

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describing specific ways in which problems with engaging andretreating manifest when trying to find the appropriate balance(e.g., Leitner et al., 2000).

EPCP shares similar foundations with other approaches, likepsychodynamic and psychoanalytic perspectives, but it suggestsa different (or supplementary) way of understanding some pro-cesses that occur in therapy, like the traditional psychoanalyticnotion of countertransference, for example. In contrast to ana-lytic or dynamic approaches, EPCP understands countertransfer-ence as one way a therapist can retreat in the therapy relationship(Leitner, 1997). Countertransference, defined as transferring ex-periences from other relationships onto the client, is necessarilya retreat because when one is engaged in a countertransferenceprocess one is by definition no longer engaging in the relation-ship with the core processes of the client but rather with one’sown issues. This different way of understanding countertransfer-ence, as a retreat from an intimate relationship rather than simplyas a reaction that might be indicative of the client’s or therapist’sparticular issues or style, can be a useful tool in that it returnsthe focus to the quality of the therapy relationship and signalsa need for attention to the relationship. In EPCP the therapistmust recognize and engage the countertransference in order tounderstand the nuances of the retreat from the relationship andaddress them so that the therapist can be more fully present. Fur-thermore, when the therapist has a better understanding of the re-treat, the therapist can (and should) use the countertransferenceto increase the depth of the ROLE relationship with the client.

The following examples illustrate cases in which a therapisttrusted a client to honor the therapy relationship and was injured,shocked, or dismayed when that trust was betrayed. These casesalso illustrate what the therapists learned from the experienceswhen viewing them from an EPCP perspective.

Trust in Clients to Keep Their Word

One of the most anxiety-provoking aspects of a therapist’s jobis the potential for a client suicide (Jobes & Maltsberger, 1995).Therapists have many ways of managing that anxiety (Thomas& Leitner, 2005), one of which is asking the client to sign a no-suicide contract. Unfortunately, research has shown these to be

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largely ineffective. For example, one study reported that 31% ofadmitted multiple attempters had previously signed no-suicidecontracts (Meichenbaum, 2009). Furthermore, the 2003 AmericanPsychiatric Association Practice Guidelines for Managing Suicidal Behav-ior suggested that “[t]he use of an oral or written ‘contract forsafety’ in the management of suicidality has been demonstratedto have serious limitations and to lack sufficient evidential basisfor having a protective impact on acts of deliberate self-harm”(Meichenbaum, 2009). Given this information, it seems that ask-ing a client to sign one of these may do more to meet the needsof the therapist than the needs of the client. Despite the evidenceagainst the effectiveness of asking clients for such an agreement,therapists continue to do so. Perhaps this is because, although notsupported by the research evidence, such an intervention is con-sistent with the basic beliefs and values of many therapists andtherapies about the power of the therapeutic relationship. We re-alize that we ultimately cannot control what our clients do, but wetrust that the therapy relationship means enough to our clients toassure that they will honor their promises.

Bonnie was a new therapist working in an outpatient psychi-atric clinic. Shortly after she began her new job, she met Bruce, anintelligent, talented, and creative young man struggling with basicexistential issues. He was searching for his purpose in life but, con-stantly confronted by the dysfunction, manipulation, and abuse inhis family of origin, he was having trouble believing that anythinghad meaning. Bruce was starving for connection with another whocould help him find, see, and experience the beauty and meaningof life even in the midst of destruction and pain—but this was abig task for a new therapist. Bruce decided early on to put somefaith in the therapy relationship and worked to build a connec-tion with Bonnie, despite his anxiety about getting close to others.Connecting with Bruce was a struggle, as he constantly challengedthe boundaries of the relationship and openly tested Bonnie’s car-ing for and commitment to him. However, over time, after shehad passed many tests, Bruce developed some trust in Bonnie,which was evident through the changes in what he shared andhow he expressed himself in therapy. At the same time, because ofsome unfortunate circumstances in his life, Bruce lost his housing,and, after exhausting all other options except for sleeping on thestreet, he had to return to live with his family. Once back in the

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Betrayals of Therapist Trust 215

family, Bruce became more enmeshed in their dysfunction andmore pained by the absence of love and caring among his familymembers. The more entrenched he became, the more depressedhe became, and Bruce began sharing thoughts about suicide ona regular basis. As Bruce was rather impulsive, Bonnie was con-cerned that the vague thoughts he was sharing in sessions couldquickly turn into action. Bonnie shared this concern with himalong with her feelings about what a loss his death would be forher. She expressed her wish that he think carefully before takingany action to harm himself, and she asked him to call her beforeacting on any such impulse he might have. Bruce agreed to do soand in fact did keep his promise for some time. However, after sev-eral months of promising and trying to make sense of his life andcreate something better for himself, Bruce broke his promise andended his life by drinking the antifreeze he found in his family’sgarage.

Bonnie was devastated by this loss. As often is the case fortherapists who lose a client to suicide, she had a mixture of com-plex emotions as she grieved the loss and reexamined what shemight have done differently (e.g., Fox & Cooper, 1998; Kolodny,Binder, Bronstein, & Friend, 1979; Valente, 1994). Bonnie was alsoheartbroken for Bruce’s family and friends. She was angry withBruce for making this choice. She could understand his wantingto hurt his family because of all the anguish they had caused, butwhy would he do this to her, especially when he gave his word thathe would not harm himself? Bonnie was also angry that Bruce haddenied her the opportunity to ever fully understand his decision.She would never know why he did what he did. Bonnie began toquestion whether she and Bruce had really had any connection atall. She thought the hope she had for him and his life was enoughto get him through for the time being. Just as Bonnie questionedBruce’s connection with her and his faith in the process—one shethought he valued enough to honor—she began to question herown faith in the therapy process.

Although her initial response was shock and anger, Bonniequickly noticed that she was also not really surprised by Bruce’ssuicide. Somewhere inside, she could see this coming. Bonnie wasclose enough to Bruce to sense his hopelessness and pain and toknow that he considered suicide a viable option. As she started tothink about her relationship with Bruce and the connection she

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felt to him, she also began to consider the ways in which she haddistanced herself or retreated from the relationship. Bonnie re-alized that although she knew Bruce’s experience on a cognitivelevel, she had not allowed herself to fully feel or grasp the im-pact of his pain and anger. These feelings were intense, ugly, andoverwhelming for Bonnie, so she did not allow herself to get tooclose to them. From an EPCP perspective, Bonnie was engagedin the relationship enough to understand Bruce’s experience onsome level, but in order to manage her anxiety about his feelings,she had distanced herself from him by emotionally minimizing,denying, or avoiding contact with his pain. Based on her knowl-edge of the risk factors for suicide, Bonnie knew that Bruce wasat risk. Bonnie truly cared about Bruce and did not want him totake his life. Although she was familiar with the research aboutno-suicide contracts, she had ignored the facts and relied on herrelationship with Bruce for some sense of security that he wouldnot harm himself. This choice was based both on her blind faithin the relationship and on her denial of the depth of his pain.

Examining the relationship through an EPCP lens helpedBonnie to work through her complicated emotions about Bruce’ssuicide, to move beyond her initial sadness and anger to under-stand her feelings of guilt and anxiety. This analysis also helpedher to move beyond blaming Bruce and to reconstrue her expe-rience such that she was more than just a “survivor” of his suicideor a “victim” of his choice. Bonnie remained connected to the in-jury she felt as a result of his choice to die as a reminder of theemotional risk of the work she chose to do. At the same time,Bonnie was also reminded of her responsibility as the therapist ina ROLE relationship to be conscious of what she, herself, bringsto the relationship—specifically, to the ways in which she engagesin or retreats from therapy relationships just as her clients do. Shelearned about some of the feelings that make her anxious and wasable to explore these more in her own therapy so that she couldbetter manage her anxiety and learn to sit with, rather than avoid,these feelings. This allowed her to be more present and open inher work with other clients. Ultimately, Bonnie did not concludethat Bruce’s suicide was due solely to a failure of empathy on herpart, nor did she conclude that his death was simply a failure onhis part to honor the therapy relationship. Instead, Bonnie wasable to understand the act as an expression of feelings he could

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Betrayals of Therapist Trust 217

not communicate in any other way. For Bonnie, the act signaleda breakdown in the relationship, and in looking at it through anEPCP lens, she was able to see what had contributed to the break-down on her part so that she could respond differently in thefuture.

Although Bonnie had learned about risks for suicide andeffective versus ineffective suicide interventions (e.g., no-suicidecontracts) in graduate school, she was not fully prepared to han-dle the intense emotions in this case. Perhaps the curriculum fortherapists-in-training cannot ever truly prepare one for somethinglike this, but the best preparation is likely to come from super-vised clinical experience. Intensive supervision is essential duringtraining, and this example suggests that supervision that teachesthe trainee how to be self-reflective and self-aware, how to recog-nize when one’s own issues are being triggered and affecting thetherapy relationship, is important in building the skills necessaryfor independent practice. Furthermore, this example suggests theimportance of ongoing peer supervision, case consultation, or in-dividual therapy after training. We all have our blind spots. Seek-ing support and consultation can be important for even the mostseasoned professionals and is especially crucial for the novice.

Trust in Clients Not to Cause Physical Harm

The “safety regulations” of the helping professions have less todo with the physical qualities of the work environment and moreto do with ethics. For example, the American Psychological Associa-tion’s Ethical Code (American Psychological Association, 2010) laidout the ways in which psychologists, teachers, and researchers areto practice so as to do no harm. In other words, this documentspelled out the ways in which the psychology profession promotesand creates an environment of physical and emotional safety forthose it serves. This document also provided some sense of safetyfor practitioners in that it outlines the expectations of ethical prac-tice and offers some assurance of protection from legal liabilityso long as one meets those expectations. On a more local level,individual therapists also work to create an emotionally safe envi-ronment for clients to make vulnerable some of the most painful

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parts of themselves. In graduate school trainees are taught aboutcreating this kind of emotional safety for clients through

• validation: empathic communication about the legitimacy of theclient’s personal experience;

• containment: making emotional experience and expression feelmore manageable both by keeping the work within the frame oftherapy—time, place, and so on—and by taking on some of theemotional burden so that clients do not have to hold and bearit all alone; and

• the invitational mode: explicit in EPCP (Leitner, 2009) but alsopresent in other approaches, this is a manner of openness onthe part of the therapist that invites clients to talk about any-thing they need to express but does not pressure them to do so,allowing clients to go at their own pace.

Therapists also may create a sense of safety by being consis-tent, reliable, and gentle in tone and manner. These are just afew examples of how therapists are taught to help clients to feelsafe in the therapy relationship, a major and fundamental focusof clinical training. But what about therapist safety?

Often safety discussions in graduate training go no furtherthan suggesting where in the room the therapist should sit whenworking with a client who may be dangerous or threatening (i.e.,closest to the door). However, Pope and Vasquez (2007) suggestedthat stalking, threatening behavior, and assault are occupationalrisks for all psychologists. Based on their recent review of the lit-erature (see http://kspope.com/stalking.php), they stated:

• Almost 20% of psychologists reported having been physically at-tacked by at least one client.

• More than 80% of psychologists reported fear of a client attack.• More than 50% reported fantasies about a client attack.• More than 25% had requested police or security personnel for

protection from a client.• About 3% reported obtaining a weapon to protect themselves

against a client.

Despite these statistics, most therapists likely go to work each daytaking for granted that they will not be threatened or attacked. We

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Betrayals of Therapist Trust 219

feel we know our clients, trust that they know we care about them,and believe they would never hurt us. In this way, we are putting alot of trust in our clients and the therapy relationship.

Julie was a young psychologist working as a home-based thera-pist for clients with disabling emotional issues. She had been work-ing for over a year with David, a young African American malewho lived in an apartment in the city with his father. David wasdiagnosed with epilepsy as well as bipolar disorder. Despite onlyirregularly taking medication for his epilepsy (which would alsopurportedly treated the mood disorder), David did not seem tohave any symptoms of mania or depression. Rather, David pre-sented as an immature 21-year-old who often postured in order tolook like a tough guy from the street. He was a bit impulsive inspeech and irritable at times, but despite talking big talk, he wasrather passive. Although he grew up in a rough neighborhood andwas tougher than other kids in that sense, David described him-self mostly as a “softie” and a “teddy bear.” He loved music and heloved to sing and perform. David could most often be found walk-ing the neighborhood listening to his walkman and singing outloud.

Julie had worked with David for many months, and she hadalso met David’s father on several occasions. When David was nothome at scheduled appointment times, David’s father talked withher about his concerns about David. Although his personality wasnot as endearing as David’s, he was generally pleasant and respect-ful. Although his father clearly did not have a lot of resources and,like David, seemed a bit immature, he appeared to care aboutDavid and to want the best for him.

In Julie’s experience with home-based work, safety seemed tobe a concern of the sponsoring agency—especially as there wereso many unknowns and so little control over the “work environ-ment.” She had attended the required safety orientation and hadparticipated in treatment team meetings at which safety issueswere discussed. She even took an optional self-defense trainingclass, but she never expected to have to use what she learned. De-spite the real potential for danger, Julie rarely experienced evenfleeting concern for her physical safety. If anything, Julie was moreworried about the risk she was taking by going into some of theneighborhoods in which her clients lived. Even so, she trusted, onsome level, that being associated with her clients or being known

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as someone helping those in the neighborhood would keep hersafe.

As was the case with her other clients, Julie had faith and trustin the therapeutic relationship she had developed with David. Assuch, she had no concern in her mind when she went to David’shome for her typical visit. When Julie arrived at the house, thereseemed to be some tension between David and his father, but thiswas not uncommon. As usual, David and Julie sat together in theliving room and began talking about some of the struggles Davidwas having. The conversation had just gotten started when some-thing shifted and the atmosphere in the home changed dramat-ically. David’s father stormed into the room and began yelling atDavid. Julie was stunned, realizing that she must have arrived inthe middle of an argument David’s father was determined to fin-ish. It was clear that David’s father was extremely angry, as his eyeswere filled with rage and he was screaming at the top of his lungs.Just as quickly as David’s father had escalated (or reescalated) thefight, David’s anger also ramped up. At this point, Julie felt un-comfortable and wanted to leave the situation. However, she hada difficult time figuring out how to do so—both in terms of get-ting to the door without coming in between them and in findingsome way to excuse herself.

Within a matter of minutes, it became clear that the anger ofboth her client (a rather large man) and his father was now some-how focused on her. This turn of events was confusing and almostinexplicable, as the argument they were having had nothing to dowith her, as far as Julie could tell. In fact, up to that point it wasas if they had forgotten she was in the room. David and his fa-ther frequently had conflicts with one another, but neither Davidnor his father had ever expressed any anger toward Julie. She hadsensed some tension with David’s father at times about the factthe she was supporting some changes David wanted to make inhis life that his father did not agree with, but this did not seemto be what they were fighting about presently—although she wastoo distracted by her fear and by thinking about how to escapeto really attend to the content of their argument. She heard thefight but had not really been listening. As Julie was feverishly try-ing to find a way out and to make some sense of the situation,things worsened. Before she knew what was happening, both werethreatening physical violence and using racial slurs like “honkey.”

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When David stopped pacing to go into the other room to get hisbaseball bat, threatening to use it on “the honkey,” Julie ran asquickly as she could out the door and got into her car, locking thecar door behind her. David appeared in the doorway with his batbut did not pursue her.

After that day, Julie was much less trusting (not of all of herclients, but of this one in particular). Sadly, the therapeutic re-lationship was never the same. Julie met with her client the fol-lowing week after consulting with her supervisor and speakingwith David on the phone to tell him that she would no longersee him at home but would be willing to meet him in a publicplace. All of their further contacts were carried out in a crowdedrestaurant. Because of this, little meaningful conversation couldbe conducted, and there was much more motivation for David toact out, using his tough guy or singing teddy bear routines to getattention from others. Julie no longer felt safe and, as such, couldnot fully engage with David. David seemed to feel regret for hisbehavior, but he was also upset that Julie could not seem to trustthat he would not do this again. With Julie’s apparent loss of faithin him, David seemed to lose some faith in himself. Julie was notharmed or threatened again, but David made no progress in therelationship from that point forward.

Julie’s fear and subsequent decision not to meet with thisclient in his home were certainly valid. What was unfortunateabout her response, however, was that it seemed to freeze on mis-trust toward David and retreat from the relationship. She wasnot able to move beyond her initial hurt and fear in order toreconstrue David in a more useful way and reengage with himmore fully. If Julie had conceptualized this experience from anEPCP standpoint, she might have seen that, in one way, David’saggression toward her was an important communication aboutthe therapy relationship as well as about David’s relationship withhis father. In this therapy, there was more than just the relation-ship between Julie and David. Because the therapy took place ina cramped apartment in which both David and his father lived,the therapy milieu was from the start populated with two otherrelationships—the relationship between Julie and David’s fatheras well as the relationship between David and his father.

When thinking about the course of events from a perspectiveempathic to David’s experience, Julie might have seen as well that

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David’s retreat from his relationship with her through the threatof violence was a way in which he may have been attempting to en-gage in the relationship with his father. Because Julie was a con-sistent, supportive, and caring presence in his life, it was muchsafer for David to align with his father and turn on Julie, some-one he knew he could count on, rather than risk damaging thealready shaky relationship with his father. To challenge his father,on whom he depended, by defending Julie would have openedup a good deal of anxiety for David. It is often the case in relation-ships that feelings about one person or situation are displacedonto another, safer person or easier situation. In this way, it mighthave been anyone that David turned on in that moment when hewas most concerned about preserving his connection with his fa-ther, as dysfunctional as it was, and wanting to avoid his anxietyabout dealing directly with their relational issues.

If Julie had been able to reengage in the therapy relationshipand consider the events from David’s perspective—to really stepinto his shoes and see from his perspective, which is the epitomeof a ROLE relationship—she might have been able to talk withhim about her experience of the events. She might have beenable to share her hypotheses about the lack of safety in his rela-tionship with his father, his fears about confronting these issues,and how these things might have played into the events of thatday. In this way, she might have worked through her relationalinjury and also helped David explore his feelings, how they wereexpressed, and alternatives for dealing with or expressing thosefeelings in the future. At the same time, Julie’s hypothesis mayhave missed the mark entirely. Maybe David’s anger was an expres-sion of some feelings he had toward her that he could not showher in some other way. In any case, by attempting to move beyondher personal experience to try to understand the experience inthe context of the relationship, Julie might have opened herselfto different ways of understanding the events and engaging herclient—ways that could facilitate discussion and healing as well asa deepening of the relationship.

At the same time as advocating for an empathic relationalapproach to these situations, I also want to make clear that thereis a line here. No one should tolerate abuse, violence, or threats ofviolence, no matter how empathic one is to the reasons for thoseactions. As can be seen in this example, there are ways to set this

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limit and communicate it to the client therapeutically and withrespect for the relationship, regardless of the actions the therapistdecides to take in order to stay safe.

Fortunately, in the situation with David, Julie had a caringand responsive supervisor who suggested a safer alternative fortheir meetings (i.e., in public) and attempted to reinforce the im-portance of Julie’s personal safety despite a culture that Julie even-tually realized ultimately prized performance expectations overpersonal safety. Because of the off-site nature of the work, therewas not much oversight of her daily activities. Thus, it was up toJulie to make judgments about risk and to set limits to help ensureher safety. Although she had some book knowledge and training,Julie did not have enough field experience to be a good assessor ofrisk or to feel empowered to set limits. She was concerned aboutdoing a good job and performing as her supervisors expected,and as such was more than hesitant to refuse any assignment.

When Julie began the job she had almost no professional ex-perience, but she immediately found herself in a position whereshe needed to work independently. As graduates with advanceddegrees, many new therapists, in fact, often start out in positionswith a great deal of responsibility or in leadership roles with-out ever having experienced a full-time job. Although they arequalified in many ways for these positions upon completion oftheir training, they still have much to learn, and the transitioncan be difficult. As such, workshops in professionalism, manage-ment, and leadership—beyond what is learned in courses on clin-ical supervision—could be of great benefit to students and newprofessionals.

Trust in Clients to Adhere to the Financial Contract

One of the basic aspects of a contract for therapy is that the ther-apist will provide a service for which the client pays. Most oftenclients make the effort to pay for the service rendered—evenif they have to do it over time with some special arrange-ments or accommodations. There are, of course, those fewwho end treatment with a balance owed and seem to vanishaltogether—avoiding whatever unfinished business they have withthe therapy, including the bill. Although these situations are frus-trating and often create much grief for therapists who wrestle with

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whether and how to pursue fair payment for their work (e.g.,through collection agencies), these therapists likely do not as-sume malice on the part of their clients. But what about the clientwho intentionally deceives the therapist about payment rather thansimply disappearing in order to avoid the charges?

Susan was a new psychologist in private practice in a largecity. She was just establishing herself and therefore relied on herclients to pay in full for her work until the time when she couldbegin accepting insurance payments. She told each of her clientsup-front that they would need to pay in full at the time of ser-vice and that she was unable to accept insurance reimbursement.Shortly after opening her practice, Susan met Chad, a young manwho came to therapy to find ways to stop lying to his girlfriendabout financial matters. Susan met with Chad twice. In both ses-sions Chad appeared to be invested in working through his issues,and although they were continuing to get to know one another,the connection between him and Susan seemed to be strong. Asagreed, Chad paid the full fee for both sessions with checks fromhis personal checking account. He then canceled the third sessionwith less than 24 hours’ notice, thus accruing a cancellation fee.He did not show for his fourth session, again accruing a cancella-tion fee.

When Chad did not respond to any of Susan’s attempts toreach him, she assumed he was no longer interested in workingwith her and planned to close his case. Susan then attempted todeposit his checks and learned that they were fraudulent, havingbeen written on a nonexistent account. When they began ther-apy, Chad had also given Susan his health insurance information.Chad planned to seek reimbursement from his insurance com-pany directly because Susan was not on the insurance panel. Su-san decided to contact the health insurance company to see ifthey might be able to reimburse her. She then learned that thehealth insurance information Chad had provided was incorrect;his insurance identification number was missing multiple digits.Furthermore, when they searched their database by name, theyfound no record of anyone with that name. Susan made multi-ple attempts after that to contact Chad to discuss the therapy andpayment but was never able to reach him.

At the moment she learned of his deception, Susan felt hurtand angry. Rather than helping Chad to overcome his problems,

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she felt she had become another of his victims. She felt blind-sided, and this event really challenged her basic constructions ofclients and their “goodness” as human beings. Although she triednot to let the incident color the way she viewed her other clientsat a fundamental level, thus leading her to retreat from those re-lationships in some way, she was aware that the experience wasaffecting the way she thought and practiced.

In hindsight, given Chad’s presenting problem, it made senseto Susan that there were problems with payment for services. HadChad continued in therapy with Susan after she discovered that hehad been deceptive with her about financial issues, it could havebeen useful for them to process this issue in their relationship as away to help him work through the same issue in his relationshipswith others.

Although Susan was able to better understand and heal herwounds by setting aside some of her personal reactions in orderto look more broadly at the case, she could experience similarinjuries in the future if she does not also make some changes toher business practices. Susan realized that had she attempted tocash the first check right away, she might have had the oppor-tunity to address the issue when Chad returned for his secondvisit. When Susan started in private practice, she had no experi-ence or training in basic business practices. This may be commonamong clinicians in training and may be a set of skills that do notcome naturally to many who enter the helping professions. Thus,a workshop in basic business practices (accounting, hiring, book-keeping, taxes, etc.) could be a useful part of advanced clinicaltraining, perhaps during the internship year or as a postgraduatecontinuing education course, when these issues are more timelyand relevant.

From an EPCP perspective, all of the “transactions” that takeplace as part of the therapy contract—not just the interpersonalones between the client and therapist—both contextualize andcontribute to the therapy relationship. Thinking about the ther-apy relationship as extending beyond the exchange that takesplace in the therapy room allows for a fuller understanding of theclient’s experience of the therapy relationship, which may includeanything from parking issues at the therapist’s office to the friend-liness of the front desk staff, from the chairs in the waiting roomto the way in which the therapist handles the fee. Furthermore,

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conceptualizing the therapy relationship in this way opens manyopportunities for exploration of relational issues (more grist forthe mill, so to speak) and communicates that no topic is off limits.

Many therapists, especially new therapists, are uncomfortablewith the financial aspects of the contract. They feel awkward aboutdiscussing money, as culturally we are often taught that financialmatters are private. They may also feel guilty for requiring a feefor their services, as if that taints the genuineness of their caringfor the client. Because of this, therapists may prefer to avoid theseconversations and leave issues of money to someone else (e.g., thebilling department). In doing so, they are missing an opportunityto work through their discomfort and are subtly communicatingthat this topic is off limits for exploration, and thus that thereare parts of the relationship that cannot be discussed. This kindof avoidance represents a retreat from the ROLE relationship. Inmy experience, especially in working with clients who struggle at afundamental level with trust and attachment, some good work canbe done through discussions of the fee for service and what thatmeans to the person about the therapist’s caring and the client’swillingness to truly engage in the therapy process—in short, whatit means about the relationship.

Trust in Clients Not to Use or Manipulate the TherapyRelationship for Personal Gain

The credulous approach, prescribed by PCT and EPCP, requirestherapists to assume that their clients are telling the truth—at leastin the way that clients see it and can express it. This caveat sug-gests that there is a bit of skepticism built into this approach inthe sense that these therapists are also mindful that what clientsshare represents one personal truth but not the only truth. Inpsychology more generally, trainees are sometimes taught to bequite skeptical, but typically this skepticism is reserved only forsituations in which there is an obvious potential for personalgain—cases involving disability claims or custody battles, for ex-ample. Intentional deception or manipulation may be a primaryconcern in some cases and settings and thus in the forefront ofthe minds of some clinicians, but for many therapists outside ofsuch settings and situations, this issue is not even on the radar.

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Again, this may be due to basic theoretical assumptions, madeexplicit in humanistic therapies, that people are fundamentallygood and ultimately striving to be the best they can be and thatgood rapport or a strong working alliance is an important or es-sential (depending on the orientation) part of the change pro-cess. These fundamental assumptions about human nature andwhat makes a good therapy relationship create a particular mind-set that is not consistent with an attitude of suspicion and mistrustof those seeking help. Just as it is difficult to hold any two incon-sistencies in experiential awareness simultaneously, it is difficult tobelieve in the goodness of people and feel compassion, empathy,and a desire to help our clients while at the same time suspectingthat they might be using and manipulating us. As such, it seemsthe default is to assume the best and ignore the possibility of theworst.

In cases of suspected malingering, it is often clear what theclient might gain from feigning or exaggerating symptoms. How-ever, malingering is only one kind of deception or manipulation.There are certainly situations in which clients stand to gain sec-ondary benefit from a therapy relationship in ways that therapistscannot anticipate. For example, clients sometimes present them-selves and aspects of their lives in such a way as to pull for a certainresponse from the therapist so that they can use that response inorder to tell others in their lives, “my therapist says . . .,” so thatthere is more “authority” behind what they want to do or believein the first place. This is a rather insignificant breach of trust,but there are more serious ways in which similar manipulationsoccur.

Steve was a first-year graduate student who was struggling withthe transition from undergraduate to graduate studies. He pre-sented for therapy after failing his first graduate class because heknew he needed some help if he was going to be successful inhis program. After months of struggling and finally realizing thathe would not be successful in school without some interventionbeyond his participation in psychotherapy, Steve decided to starttaking medication again, as this had been helpful to him in thepast. In the meantime, he continued to fail his courses. Havingbeen put on academic probation after his first semester, Stevewas at risk for dismissal due to his continued failures. A shorttime later, he was recommended for dismissal, and he decided to

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appeal this decision. The committee to which Steve presented hiscase rejected his plea, thus forcing him to try a second appeal tothe dean.

Throughout this process, Catherine, the therapist Steve ac-cessed through the university’s student counseling service, wasinvolved in emotionally supporting Steve, validating his feelings,and working with him on some concrete problem-solving, plan-ning, and coping skills. In addition, as was her role, Catherineadvocated for Steve, with his consent, with the faculty commit-tee and the dean. She wrote letters of support and ultimately hada conversation with the dean about Steve, his struggles, and hisability to succeed given the appropriate support. Catherine wasopen with Steve about the conversations she had with faculty andadministrators about him, because she wanted to preserve Steve’strust. When it came time for his final appeal to the dean, Steve wasvery anxious. He asked about their conversation multiple times,and Catherine reported to Steve what each party had shared inthat discussion. The dean ultimately decided to dismiss Steve, inresponse to which Steve was distraught and angry. He decided topursue legal action against the dean and the university. As Stevewas no longer a student at the university and had to leave the area,Catherine could not continue to see him in therapy.

Several months after they had stopped working together,Catherine received an email from Steve stating that he neededto “confess” because it was about to be revealed that he had se-cretly taped one of their therapy sessions—the one in which heasked Catherine to relay information about her conversation withthe dean. He was providing a transcript of the session as part ofhis lawsuit, because his attorney said it would help his case. Stevewrote that he knew taping a session without permission was a “be-trayal” of their relationship and that this could ultimately hurtCatherine, because the dean was her boss. However, he also saidthat he was so upset about what he thought were their lies thathe had to expose them, regardless of the cost to anyone else. Itseems that later Steve felt some guilt about this, given the wayhe expressed what he had done to Catherine, but it seemed toCatherine that the main reason for his “confession” was that hewas about to be caught.

Catherine felt devastated and betrayed by Steve’s actions.Although she was certain she had not done anything wrong in

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sharing the content of the conversation between her and the deanwith Steve, she worried about how this would be perceived by out-siders to the therapy process and was concerned that her employ-ment could be at risk. Believing that she and Steve had a strong re-lationship, she was blindsided by such a betrayal of trust. Althoughshe did not lose her job, Catherine did lose, at least temporarily,some of the trust she had previously had in the benevolence ofher clients and the power of the therapy relationship.

In an effort to heal and to reconstrue her experience in amore helpful way, Catherine looked back on the therapy andthe events that had occurred using an EPCP perspective. In do-ing so, she was able to make sense out of what happened, givenSteve’s personal struggles and given that his actions were consis-tent with his general way of being in relationships. In hindsight,Catherine realized that it might have been useful to conceptual-ize her relationship with Steve as being similar to his other in-timate relationships, rather than as an anomaly. Had she doneso, she might have been able to anticipate how some of Steve’scharacteristic ways of retreating from ROLE relationships mightmanifest in the therapy relationship. Furthermore, had Cather-ine been more in tune with the ways in which Steve felt injuredand reacted to injury in other aspects of his life, she might havebeen better able to anticipate the ways in which he experiencedand responded to this particular event. This kind of understand-ing of her client might have opened some lines of communi-cation between Catherine and Steve about his impulses, poten-tial actions and consequences, choices, and responsibility for hischoices.

As Catherine was dealing with this situation, she learned sev-eral things that might have been helpful for her to know in ad-vance. For example, she consulted with two local attorneys aboutthe legalities of taping someone without consent in order to bet-ter understand her rights to privacy in the therapy relationship.In addition, she learned something about educational law, the le-gal processes involved in educational suits, and the protections af-forded to her by her employer. Of course, the knowledge Cather-ine gained was limited to what was relevant in her particular case,but this example highlights the potential importance of therapistsunderstanding the broader context, including the legal context,in which they work.

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Conclusion

During training therapists learn explicitly that trust is essential forthe kind of therapy relationship that can ultimately be healingand transformative. Specifically, we learn about the importance ofengendering our clients’ trust in us and in the therapy processby creating a safe space and providing the kinds of conditionsunder which they can risk sharing painful and intimate parts ofthemselves. What is less often discussed in psychotherapy train-ing, however, is the degree of trust and emotional risk the ther-apist also has invested in the relationship—an investment that isalso facilitative of client growth.

The fact is, according to EPCP, given enough time relationalinjury of some sort is inevitable when two people truly and gen-uinely engage with one another in an intimate way. That is the riskof intimacy, and there is no way around that. EPCP refers to thiskind of intimate relationship (a ROLE relationship, as describedabove) as both aweful and awful for this very reason. I argue thatfrom an EPCP perspective, the therapy relationship is a ROLE re-lationship and that it should be a ROLE relationship, because it isonly through these kinds of deep interpersonal connections thatone can make sense and meaning in life (first in the therapy roomand then in connections outside the room).

If we begin with these assumptions, we know from the startthat we could feel hurt or injured. However, because this is a ther-apy relationship and in some ways unlike other ROLE relation-ships, we strive to maintain an appropriate professional perspec-tive (i.e., optimal therapeutic distance; Leitner & Thomas, 2003),through which we are able to experience and construe injuries ina way that allows for empathy and understanding. Furthermore,the beauty of the therapy ROLE relationship is that the inherentdistance and professional nature of the relationship—includingthe ability of the therapist to attend to relational issues—alongwith its safety features create an experiential space for more eas-ily recognizing relational retreats and working to risk furtherengaging when we and our clients might typically choose toretreat.

Even when not working from an EPCP perspective, this ap-proach may be a useful way of helping students and young pro-fessionals understand the experience of being injured by a client.

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For example, Bonnie learned that her countertransference expe-riences have a direct impact on the nature and quality of her ther-apy relationships, and that attending closely to the relational con-sequences of these issues is key for therapeutic change. Clinicalsupervision is already a part of clinical training, but not all super-vision explicitly teaches trainees these skills. Teaching clinicianshow to recognize and handle their countertransference responseswith a focus on the implications for the therapy relationship is animportant part of any kind of clinical supervision.

Beyond demonstrating how the EPCP approach can be use-ful, the stories in this article also suggest some potentially use-ful pantheoretical additions to graduate or postgraduate trainingfor clinicians. For example, for Julie and others like her, opportu-nities to both experience and discuss managerial or leadershiproles while in training would have been useful. At a more ba-sic level, discussion, exploration, and practice with issues relatedto professionalism could be invaluable for trainees. The lessonslearned by Susan and Catherine, in part, had to do with someof the more practical aspects of clinical practice, including day-to-day business practices and management, understanding the “busi-ness” of therapy as part of the therapy itself, and the legal con-texts and nuances that are part of clinical work, as well. Althoughcomprehensive training in business and law is certainly not thegoal, trainees and early career professionals would be well servedby exposure to these aspects of practice and training in how tohandle them, including who to call for help when these issuesarise.

These suggestions are offered as a starting point for furtherdiscussion about how educators can help trainees and early ca-reer professionals eliminate some of the pitfalls exemplified hereand better anticipate and understand their investment in theirtherapy relationships and the consequent potential for injury inthese clinical encounters. The hope is that, given the opportu-nity to learn more about these practical aspects of clinical workand to process some of the difficult emotional aspects of clinicalwork during training, therapists will be better prepared to preventand handle personal injuries in the therapy relationship in waysthat will maintain the integrity of their work and their therapyrelationships.

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References

American Psychological Association. (2010). American Psychological Association eth-ical principles of psychologists and code of conduct with the 2010 amendments. Re-trieved from http://www.apa.org.

Epting, F. R., Gemignani, M., & Cross, M. C. (2003). An audacious adventure:Personal construct counseling and psychotherapy. In F. Fransella (Ed.), Inter-national handbook of personal construct psychology (pp. 237–245). London, UK:Wiley.

Fox, R., & Cooper, M. (1998). The effects of suicide on the private practi-tioner: A professional and personal perspective. Clinical Social Work Journal,26, 143–157.

Hill, C. E., & O’Brien, K. M. (1999). Helping skills: Facilitating exploration, insight,and action. Washington, DC: American Psychological Association.

Jobes, D. A., & Maltsberger, J. T. (1995). The hazards of treating suicidal patients.In M. Sussman (Ed.), A perilous calling: The hazards of psychotherapy practice (pp.200–214). New York, NY: Wiley.

Kelly, G. A. (1955). The psychology of personal constructs (Vols. 1–2). New York, NY:Norton.

Kelly, G.A. (1969). The psychotherapeutic relationship. In B. Maher (Ed.), Clin-ical psychology and personality: The selected papers of George Kelly (pp. 216–223).New York, NY: Wiley.

Kolodny, S., Binder, R. L., Bronstein, A. A., & Friend, R. L. (1979). The workingthrough of patients’ suicides by four therapists. Suicide and Life-ThreateningBehavior, 9, 33–46.

Leitner, L. M. (1997, July). Transference and countertransference in experientialpersonal construct psychotherapy. Paper presented at the 12th InternationalCongress on Personal Construct Psychology, Seattle, WA.

Leitner, L.M. (2009). Doing(?) experiential personal construct psychotherapy.In L. M. Leitner & J. C. Thomas (Eds.), Personal constructivism: Theory andapplications (pp. 193–213). New York, NY: Pace University Press.

Leitner, L. M., Dunnett, N. G. M., Anderson, T. M., & Meshot, C. M. (1993).Unique aspects of personal construct therapy. In L.M. Leitner & N. G. M.Dunnett (Eds.), Critical issues in personal construct psychotherapy (pp. 3–17). Mel-bourne, FL: Krieger.

Leitner, L. M., & Faidley, A. J. (1995). The awful, aweful nature of ROLE rela-tionships. In G. Neimeyer & R. Neimeyer (Eds.), Advances in personal constructpsychology (Vol. 3, pp. 291–314). Greenwich, CT: JAI.

Leitner, L. M., Faidley, A. J., & Celentana, M. A. (2000). Diagnosing humanmeaning making: An experiential constructivist approach. In R. A. Neimeyer& J. D. Raskin (Eds.), Construction of disorder: Meaning-making frameworks forpsychotherapy (pp. 175–203). Washington, DC: American Psychological Associ-ation.

Leitner, L. M. & Pfenninger, D. T. (1994). Sociality and optimal functioning.Journal of Constructivist Psychology, 7, 119–135.

Dow

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ded

by [

Uni

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ry]

at 0

9:17

28

Sept

embe

r 20

14

Betrayals of Therapist Trust 233

Leitner, L. M., & Thomas, J. C. (2003). Experiential personal construct psy-chotherapy. In F. Fransella (Ed.), International handbook of personal constructpsychology (pp. 257–264). London, UK: Wiley.

Meichenbaum, D. (2009, March). Suicidal behavior and comorbid disorders: A life-span treatment perspective. Presented as the 6th Annual Seymour Fisher Memo-rial Workshop, Syracuse, NY.

Neimeyer, R. A., & Baldwin, S. A. (2003). Personal construct psychotherapy andthe constructivist horizon. In F. Fransella (Ed.), International handbook of per-sonal construct psychology (pp. 247–255). London, UK: Wiley.

Norcross, J. C. (2002). Psychotherapy relationships that work: Therapist contributionsand responsiveness to patients. New York, NY: Oxford University Press.

Pope, K. S., & Vasquez, M. J. T. (2007). Ethics in psychotherapy and counseling: Apractical guide (3rd ed.). San Francisco, CA: Jossey-Bass.

Rogers, C. R. (1961). On becoming a person. Boston, MA: Houghton Mifflin.Thomas, J. C., & Leitner, L. M. (2005). Styles of suicide intervention: Profes-

sionals’ responses and clients’ preferences. The Humanistic Psychologist, 33,145–165.

Valente, S. M. (1994). Psychotherapist reactions to the suicide of a patient. Amer-ican Journal of Orthopsychiatry, 64, 614–621.

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