Ethics in the Different Psychology Settings In the Classroom and Therapy

ETHICS IN THE DIFFERENT PSYCHOLOGY SETTINGS 1

Ethics in theDifferent Psychology Settings: In the Classroom and Therapy

Ethics is paramount in all professions dealing with human servicesand psychology is one of the fields that have a strong ethicalfoundation. For many years, the AmericanPsychological Association has been updating the ethicalcode for psychologists that touch on issues such as disclosures,consent, multiple relationships, and competence. These issues formthe foundation for the practice and prosperity of psychology as afield. Besides, they aim at ensuring the effectiveness of those whopractice within the field. Upon acquiring relevant certification, apsychology graduate can work in many settings such as schools andhospitals, among others. Many of the studies in the field ofpsychology have concentrated on the ethics for psychologists workingoutside the classroom settings. Consequently, many psychologyteachers have been lax when implementing the code of ethics forpsychologists. Unlike therapists, the line between personal andprofessional roles for teaching psychologists is very thin. Forexample, a psychology teacher may also serve as a student’s mentoror sport coach. Consequently, it is hard for teaching psychologiststo avoid entering into multiple relationships with their students. Onthe other hand, the majority of therapists tend to view certain levelof violation of the boundary between them and their client as crucialfor the effective delivery of therapeutic services. Such violation ofboundary includes hugging as well as visiting clients in theirresidences. However, almost every psychology practitioner has adifferent opinion on what constitutes unethical behavior on each ofthe core aspect contained in the American Psychological Association’sethical code for psychologists. Some of the areas where violations ofthe code have been rampant include the principle of confidentialityand the boundary between a student/client and the teachingpsychologist/therapist. This paper will concentrate on the publishedscholarly work on the ethical expectation for psychologists workingin the therapy and classroom settings.

Boundary violation for therapist and teaching psychologist

Clinical therapists are required to resist any opportunity ortemptation to engage in multiple relationships with their clients.According to Koocher &amp Keith-Spiegel (2013), while there are manyadvantages that come with offering professional services to friendsand family members, sustained therapy relationships should beavoided. There exists a huge difference between personal andprofessional relationships. For example, personal relationship costnothing, aims at the satisfaction of mutual needs, and is usually along-term venture. On the other hand, professional relationshipsinvolve the client making some form of payment to the therapist.Additionally, professional relationships have to be terminated uponthe satisfaction of the client’s needs. The American PsychologyAssociation (2010) forbids psychologists from engaging in multiplerelationships with their clients for several reasons. First, multiplerelationships are likely to hinder the psychologist’s objectivity.For example, it would be hard for a therapist to be objective whenhis/her client is his/her fiancé, girlfriend/boyfriend, child,friend, or any other individual close to him/her.

The lack of objectivity may be manifested by the practitionersignoring the established methods for diagnosing certain problems whenthey share a close relationship with their clients. Additionally, itis possible for multiple relationships to prevent a practicingpsychologist from adhering to the set standard for honesty whendealing with clients (Koocher &amp Keith-Spiegel (2013). The samemay happen with the client where he/she may choose not to disclosecertain information to his/her therapist for the fear of therepercussion that comes with the disclosure.

The other reason the American Psychological Association forbidsmultiple relationships is because of their ability to prevent apractitioner from performing his/her duty effectively. Respecting theprofessional boundary means that the interaction between a client andhis/her therapist should only take place in the therapy settings.Besides, it should only be centered on the therapist helping his/herclient to resolve any issues he/she may have. As such, in the therapysettings, both the client and the therapist are required to respectthe boundary between them. For example, it would be unethical for atherapist to accept an invitation to his/her client’s party. Koocher &amp Keith-Spiegel (2013) gives an example of a therapistwho was invited by his new client to visit her affluent beach home.However, the therapist noticed that after he and his wife acceptedthe invitation, the client become reluctant when disclosinginformation about her problems. When the counselor confronted her,she admitted that she was afraid that disclosing certain informationwould destroy the new found relationship her family and that of hertherapist shared. This scenario demonstrates the repercussion the actof therapists accepting their client’s invitations has on theeffectiveness of their services.

Sometimes a therapist may violate the boundary if doing so will helphim/her serve his client more efficiently. This mostly happens withfamily therapy where a therapist may deem it necessary for him/her toobserve his/her client in his/her home. Some therapists, particularlythose who have specialized in home-based counseling tend to visittheir clients’ homes more often (Friedman, 2012). Additionally,there are some clients who cannot access the therapist’s workplacemaking it mandatory for the counselor to visit them in theirresidence. Although this means violating the boundary between thetherapist and the client, the experience helps to build rapport morequickly. Additionally, the therapist is in a better position tomonitor the use of the environment by his/her client hence, theviolation serves to improve the delivery of services. In this case,such level of violation of the boundary is non-ethical as it does notaffect the therapists’ objectivity as well as the effectiveness ofthe services offered to the client.

Apart from the issue of some therapists visiting their client’sresidence, there are cases of a few of them developing sexualrelationships with persons whom they have evaluative authority over.According to the American Psychological Association (2010),psychologists should not engage in sexual intimacies with theircurrent therapy clients. This results in multiple relationships thataffects the objectivity and effectiveness of the practitioner.However, it is also possible for the sexual relationship to developupon the client successfully completing his/her therapeutic sessions.If this happens, the American Psychological Association advisestherapists to engage in sexual relationships with such clients onlyafter two years have passed since the termination of therapysessions. The American Psychological Association (2010) argues thatthe lack of respect for the boundary between a therapist and his/herclient tends to increase the likelihood of a violation andexploitation of trust. As such, even if a therapist develops a sexualrelationship with his/her clients after two years have elapsed sincethe therapy sessions ended, the counselor must demonstrate that therelationship was not as a result of him/her sexually exploitinghis/her patients in the course of the therapy. Some of the factorsthat may point to the possibility of sexual exploitation perpetratedby the therapists towards his/her include the two spending much timetogether during the period immediately following the end of thetherapy sessions. Healing is an ongoing process which means that evenafter successfully undergoing therapy, a former patient is usuallygullible and may easily fall for the tricks of his/her therapist.It is also possible that the client may feel indebted to his/hercounselor and falling in love may be his/her way of rewarding thetherapist. Additionally, if the termination of the professionalrelationship between a therapist and his/her client has anything todo with the former having or attempting to have sex with the latterduring the course of the therapy, any form of sexual relationshipbetween the two even if two years have passed is still unethical.Lastly, the therapist primary duty is to see that his/her clients’needs are met instead of trying to gratify his/her desires. As such,a therapist should only enter into sexual relationships with a formerclient only after he/she is confident that the person is mentallyprepared to handle the effects of dating.

On the other hand, boundary violation between a teacher and his/herstudents is not viewed by many as having the ability to jeopardizethe teaching psychologist`s delivery of therapeutic services. This isbecause it is usually hard for teaching psychologists to avoidmultiple relationships when compared to therapists. Teachers usuallyhave a profound impact on their student’s life. According toHarris &amp Dalton (2014), research shows thatpersonal growth and learning are facilitated to a large extent by apositive relationship between a student and his/her teachers.

Besides, previous studies have revealed that a positivestudent-teacher relationship can result in enhanced academic outcomesfor students and increased cooperation in the classroom context. Apart from teaching in the classroom, a psychology teacher may playthe role of a coach, a spiritual leader, and a mentor to his/herstudents. As such, students may end up spending a substantial amountof time with their teachers outside the classroom context.Consequently, the ethical principle for psychologists that requiresthat therapists avoid dual-role relationships that apply to clinicalpsychologists does not hold the same magnitude to teachingpsychologists. For example, a teaching psychologist may find it hadto decline an invitation to attend student’s parties taking partinside the school compound.

Tabachnick,et al., (2011) in their study of therapists’ perceptions of certainbehaviors that raise some ethical questions within the psychologyfield found that it was a common phenomenon forstudents to conduct business with their teachers. For example, someteaching therapists who were interviewed by Tabachnickand her colleagues reported loaning some money to theirstudents. In the study, 25% of the teaching psychologists reportedhaving sold goods such as cars or books to their students(Tabachnick, et al., 2011). While it is not unethicalfor teachers to play other roles apart from teaching to theirstudents, it is ethically wrong for them to engage in any form oftransaction. While the line between professional and personal rolefor teaching psychologists is often thin, careful consideration isparamount before softening the boundaries between a teachingpsychologist and his/her students (Koocher &amp Keith-Spiegel,2013). For example, business and sexual relationships pose inherentrisk regardless of who is involved.

Sexual relationships between students and individuals who aresupposed to serve as their teachers or therapists have been plaguingthe teaching psychology profession for years. The debate on whetherit is unethical for a teaching therapist to be sexually attracted tohis/her students, especially when the latter is 12 years and abovehas attracted mixed reactions among scholars in the field ofpsychology. In many jurisdictions, the legal age of consenting tosexual relationship is 12 years. The majority of the teachingpsychologists who were surveyed byTabachnick, et al., (2011) reported having experiencedsexual attraction towards their students. However, more malerespondents reported experiencing sexual fantasies towards theirstudents compared to the females. Despite a substantial proportion ofteaching psychologists confessing to harboring sexual desires towardtheir students, only a small percentage reported having revealedthese feelings to anyone within the school settings. According toTabachnick, et al., (2011) many of their respondentssaid that the expression of sexual feelings towards one’s currentor former student is unethical. The AmericanPsychological Association (2010) considers any form ofphysical advances toward a client, whether verbal or nonverbal to bea form of sexual harassment. Under section 7.07 of the psychologistscode of ethics, counseling practitioners should desist from engagingin any form of sexual relationship with students or any other personwhom they are likely or have evaluative authority over (The AmericanPsychological Association, 2010).

Confidentiality in the therapy and the classroom settings

Confidentiality is central to the practice of psychology.Psychologists have an obligation to protect any information regardingtheir clients which may be oral or stored in any medium. Immediatelya therapist enters into a professional relationship with his/herclients, the two should have a discussion on the circumstances underwhich the things that may arise in the course of the therapy may notbe revealed to a third party. TheAmerican Psychological Association (2010) is very explicit on theconditions under which a therapist may reveal information provided tothem by their clients in the course of the therapy to a third party.

First, aclient may authorize his/her therapist to reveal certain informationto particular individuals such as his/her parents or partner.Additionally, the law may force a therapist to violate theconfidentiality principle by sharing certain information provided bytheir clients with relevant authorities such as the police. Forexample, if a client reveals to his/her therapist his/her intentionto murder a certain individual, the counselor is mandated by the lawto do everything he/she can to save the persons` life. In this case,the therapist may have no other alternative but to violate theconfidentiality principle by informing the police of the client’splans to cause death. Besides, a therapist using his/her ownprofessional judgment may see it fit for him/her to reveal to a thirdparty information that may have been brought to his/her attention inthe course of the therapy session (Fuller, 2011).For example, a client may reveal to the therapist that he/she hasheld a certain person hostage for whatever reason. It would beunethical for the therapist to safeguard the client’s informationat the expense of the life of the person in the hands of his/herpatient.

Research shows that as opposed to therapists, teachings psychologistsare more likely to violate the high level of confidentiality expectedof those who practice within the psychology field. Gossip is the mostcommon form of betrayal of teacher- student confidentiality amongsome teaching psychologists. A large portion of psychologists workingin the classroom context reported having gossiped about theirstudents’ issues to other teachers(Tabachnick, et al., 2011).However, the vast majorityof those who reported having revealed their students’ problems toother teachers believed that is was unethical as it amounted to aviolation of the ethical code of conduct for psychologists(Tabachnick, et al., 2011).

Just likeclients in a therapy session, students expect their teachers touphold a high level of confidentiality, especially when the latterare trained psychologists. Confidentiality is crucial in acounseling setting because it creates a conducive environment forclients to disclose personal information with the hope that whateverthey say to their therapists will not be revealed to someone else.Secure relationships create a sense of psychological safety. As such,it would be impossible to establish a positive relationship between ateacher and his/her student without trust (Harris &amp Dalton,2014).

Previousstudies show that a large number of students view a shared positiverelationship with their teachers as of more importance compared toeven the instructor’s competency. Earlier published scholarly workshows that academic psychologists differ from their colleagues inother fields in several ways. For example, psychology professors tendto be more skilled when it comes to offering a helping hand to theirstudent compared to their colleagues who teach other disciplines(Harris &amp Dalton, 2014). The nature of the field of psychologyencourages disclosures not likely to be experienced in other courses.Consequently, students expect a high level of confidentiality whendisclosing to their psychology instructors compared to when dealingwith professors from other fields (Harris &amp Dalton, 2014).

Touching the client

Several psychotherapist studies have revealed that the majority oftherapists are involved in some form of physical contact with theirclient. According to Zur (2011), in one of the studies, 87% of therespondent confessed to making some form of physical contact withtheir clients. In the same study, 85% of those who were interviewedsaid that they usually hugged their clients. Since the inception ofcounseling as a profession, the question of touch in therapy has beensubjected to vigorous debates. There have been concerns that any formof physical contact from the therapist may be interpreted as havingsexual intent.

Since time immemorial, most Western cultures have encouraged the actof two or more individuals establishing physical contact. Bridgingthe space between two individuals and especially through touching isa way of expressing one’s concern over what the other person isgoing through. According to Zur &amp Nordmarken (2016), touch playsa pivotal role in human development. For example, it is an importantmethod of communication, a powerful healing force, in addition toplaying an important role in the growth and healthy development ofinfants. Zur &amp Nordmarken (2016) adds that touch is part of theancient healing process and has its roots in religious and shamanicpractices. Most Euro-American cultures contain several unspokentaboos regarding the issue of touch. Since time immemorial, touchingan opposite gender has been discouraged as the act may be interpretedas an expression of sexual feelings towards the person (Zur &ampNordmarken, 2016). Until recently, touching a person of one’sgender has been prohibited by most cultures as the act was seen as asign that a person is a homosexual. It was also morally wrong totouch the elderly, the dead, the sick as well as strangers. Thismeans that since time immemorial, the act of one person touching theother carries an explicit meaning.

In the counseling context, research shows that touch acts as atherapeutic tool. For instance, in therapy making physical contact islikely to enhance the client’s perception of being understood,acknowledged, and heard by his/her therapist. Besides, it plays ahuge role in invoking a sense of calm, safety, empathy and comfort ina therapeutic setting. According to a study conducted by the TouchResearch Institute, touch invokes a series of chemical responses suchas a decrease in urinary stress hormones and an increase in dopamineand serotonin levels (Zur &amp Nordmarken, 2016). The change inthese chemicals plays a major role in decreasing depression. Thismeans that even if touch may amount to a violation of the boundarybetween the client and the therapist, it plays a huge role in helpingpatients deal with the issues that are troubling them.

Even Freud initially advocated for the use of touch by therapistswhen he was developing his theory of psychotherapy, but changed hisposition when he realized that physical contact between a client anda therapist was capable of destroying the reputation of the newprofession. According to Zur (2011),Freud’s change of perception towards the use ofphysical contact in therapy was witnessed when he scolded one of hispromising male students for allowing a female client to kiss him.Freud was of the idea that physical contact has the potential ofculminating in sexual enactments (Zur, 2011).

For many years, different groups within psychology have helddiffering opinions regarding the use of physical contact duringtherapy. For example, one side of the discussion comprises of family,group, feminist, cognitive-behavioral therapists who have a positiveview of the use of touch in therapy. Besides, this group oftherapists also does not see anything wrong with otherboundary-crossing behaviors such as self-disclosure, dualrelationships, and gift exchange (Zur, 2011).

Despite the significant roles played by touch in counseling, theAmerican Psychological Association has not been explicit on when andhow it should be used. This is despite the majority of practicingtherapists saying that they usually make physical contact with theirclients at some point in the course of the therapy session. According to a study conducted by Holroyd and Brodsky, 48.9% of thetherapists who participated in the research reported having acceptedor offered a handshake to a client, although rarely, while 48.2% saidthat they did it frequently (Zur &amp Nordmarken, 2016).

The question of whether touch in therapy setting is unethical or notdoes not have a clear answer, and it depends on the therapists’attitudes toward it or their tendency to sexualize. While most of thetime touch is usually initiated by the therapist, some clients mayrequest it. If this happens, the therapist has to evaluate whethergiving or withholding touch is ethically and clinically beneficial tothe process of aiding the client to overcome their problems. Fuller(2011) argues that psychologists should always act within theprinciple of beneficence and nonmaleficence when deciding whether ornot to touch their client during therapy. The principle remindspsychologist not to do harm and always to choose the interventionthat best suit their clients. As revealed above, touch is deeplyemotional, and this means that it can elicit powerful positive ornegative feelings in both the client and the therapist. For example,Fuller (2011) asserts that clients who have been victims of abuse orviolence, as well as those who suffer from borderline and paranoidpersonality disorders, may view touch as threatening and intrusive.As such, therapists should only utilize touch in their therapy whenthey understand their client well such that they can predict theirreactions.

When the practitioner comes to a conclusion that he/she needs totouch the client in the course of the therapy sessions, consentshould be sought first. However, if a therapist seeks to utilizetouch as the primary therapeutic tool, it is advisable that he/sheensures that the client signs a consent document authorizing him/herto go ahead. According to Fuller (2011), while the use of touch,especially when the client has not consented to it is unethical,withholding it when needed undermines the principle of integrity andjustice in therapy. For fear of the repercussions of physicallytouching individuals whom they have evaluative authority, manytherapists have opted to exclude touch in their therapy sessions. Asretaliated by this paper, a counselor’s loyalty is to his/herclients and not him/herself. This means that a therapist does not getpaid to protect him/herself from the consequences of touching his/herclients. Instead, the payment he/she receives obligates him/her to doeverything he/she can to heal or help his/her client. For example,the failure by a therapist to hug his/her patients may not be takenlightly by an AIDs patient who is already suffering fromdiscrimination. As such, therapists should only make physical contactwith their clients if it is in the patient’s best interest.

Apart from receiving a verbal or written consent authorizing atherapist to touch his/her client, he or she should seek tounderstand how the client’s culture perceive touch. Additionally,the counselor should also assess his/her own cultural assumptionsregarding the issue of touch (Fuller, 2011). As such, it isunethical when a counselor involves touch in his/her therapeuticsessions for his/her own benefits. With the development in the fieldof counseling, fewer therapists are reporting either touching orhugging their clients. According to Zur (2011),hugging is less prevent among therapists compared toteaching psychologist. For examples, it is a common phenomenon to seea psychologist parting a student on the back as a way ofcongratulating him/her for a good performance. Besides, most teachingpsychologists, unlike therapists, hug their students in the openhence the act is unlikely to be interpreted as having bad intentions.This is one of the reasons hugging seems pervasive in classroomsettings compared to in therapy sessions. However, when it comes toassessing whether hugging or any other form of physical contact witha student is harmful or not, teaching psychologists should alsoadhere to the same rules as the therapists. For example, a teachershould assess whether or not a hug will be viewed by the students asoffensive and intrusive. This means that the teaching psychologistsshould be aware of how the student’s culture perceives the act ofaccepting or offering a hug to different groups of individuals.Besides, the teacher should only hug a student whom he is wellacquainted with.

Just like in all the other professions, everything that a therapistdoes should be aimed at helping the client. This makes certain formsof physical contact between a client and his/her therapist unethicalbecause they do not have the client`s interest at heart. While manyof the therapists have admitted to touching their clients, such asthrough handshaking or hugging, a substantial number of them admittedto kissing their patients. In the study conducted by Holroyd andBrodsky, 27% of the therapist said that they occasionally engaged inaffectionate touching or nonerotic hugging and kissing with theiropposite-sex patients (Zur &amp Nordmarken, 2016). Any form ofphysical contact between a therapist and a client is unethical whenit is not geared towards helping the patient to heal.

Barteringarrangements with clients

This mostly happens in the therapy setting where the client and thetherapist come to consensus on how the former with make payment forthe counseling services offered to him/her. The AmericanPsychological Association (2010) defines bartering as the acceptanceof goods, services, and other nonmonetary remuneration from patientsin return for psychological services. According toKoocher &amp Keith-Spiegel (2013), for many years theAPA ethical code of conduct for psychologists has discouragedexchanging anything of value other than money for therapeuticservices. However, the 1992 version of the APA code approved the actof therapists accepting anything of value from a client as paymentsfor therapeutic services offered. However, the version cautionedpractitioners against taking advantage of their client’s diresituation to exploit them either materially or in any other way.

Consequently, the American Counseling Association in 2005 advisedits members always to sign a contract with their clients regardinghow they will receive payments for services rendered(Koocher &amp Keith-Spiegel, 2013). Such a move wasaimed at cautioning therapists from any form of litigation that maybe filed by their clients regarding the method of payments fortherapeutic services. The most recent code of conduct forpsychologists as published by the American Psychological Associationencourages the exchange of goods and services for therapeuticservices. However, this publication is very explicit on theconditions under which the bartering should take place. For example,the code holds that a psychologist’s fee practice should beconsistent with the law. This means that a therapist cannot offertherapeutic services in exchange for illegal goods and services suchas marijuana. Besides, the psychologist is forbidden frommisrepresenting his/her fee when engaging in the barteringarrangements.

According to Koocher&amp Keith-Spiegel (2013), the reason behind the moveby therapists to accept products as payment for therapy has beenmotivated by the harsh economic situations that have affected almosteveryone in some way. Sometimes, some people have the desire toattend therapeutic sessions but may lack the financial ability to payfor these services, prompting them to offer their skills or items intheir possession as a form of payment. This makes the act ofbartering arrangements with clients on how the latter will pay forcounseling services offered ethical.

Psychology is a very sensitive field that is likely to be abused,particularly by the practitioners. Besides, the solid reputation ofthe profession is likely to be tarnished if the set ethical code ofconduct is not adhered to. The ethical code of conduct is regularlyupdated by the American Psychological Associations to meet thedynamics of the changing society. For example, initially, it wasunethical for practitioners to exchange goods and services fortherapeutic services. However, the code has changed to accommodatepotential clients who may lack money, but have valuable goods orskills which they can trade for therapeutic services. Apart from themeans of payment for therapeutic services, the ethical code forpsychologists touches on the issue of disclosures, the violation ofboundary, and multiple relationships. Due to the diverse nature ofthe situations that therapists find themselves in daily, the codeonly provides the general guidelines as to how a psychologist oughtto act when handling a patient. This means that it is the duty of apractitioner to assess each situation and make a professionaljudgment as to whether his/her action or inaction will serve theclient better. For example, while touching is essential in a therapysetting, a therapist needs to assess the chances that it would bewrongly interpreted by the client. Additionally, while therapistsare forbidden from entering into multiple relationships with theirclients, the nature of the teaching profession requires psychologistsworking in the school settings to have personal engagements withtheir students. For example, a psychologist in a school may alsodouble as a football coach or even a mentor to his/her students. Besides, it is through students sharing a positive relationship withtheir teachers that they can realize personal and academic growth.This means that psychologists may end up spending much time withtheir students, which is not likely to happen in a therapy setting.However, this should not be interpreted to mean that teachers canengage in sexual relationships with their students. Regardless of thesetting, a psychologist works in multiple relationships provide anavenue for the therapist to sexually exploit his/her client.Additionally, multiple relationships prevent psychologists fromoffering therapeutic services objectively. It is for this reasonthat all psychologists are advised to avoid engaging in sexualrelationships with their current and if possible, former clients.

References

AmericanPsychological Association. (2010). “Ethical Principles ofPsychologists and Code of Conduct.” Retrieved on September 2, 2016.From&nbsphttp://www.apa.org/ethics/code/index.aspx&nbsp

Friedman, D. (2012). “Home is where the client is.” Retrieved onSeptember 2, 2016. http://ct.counseling.org/2012/09/home-is-where-the-client-is/

Fuller, K. (2011). Training Students on the ethics of touch inpsychotherapy. Newsletter, 8(2

Harris, G.E., &amp Dalton, S. (2014). University Student Expectations ofConfidentiality when Disclosing Information to theirProfessors.&nbspHigherEducation Studies,&nbsp4(1),43.

Koocher, G.P, &amp Keith-Spiegel, P. (2013). Boundary Crossings and the Ethicsof Multiple Role Relationships. Courses for Mental HealthProfessionals. Retrieved on September 2, 2016. http://www.continuingedcourses.net/active/courses/course066.php

Tabachnick,B. G., Keith-Spiegel, P., &amp Pope, K. S. (2011). Ethics ofTeaching: Beliefs and behaviors of psychologists aseducators.&nbspAmericanPsychologist,&nbsp46(5),506.

Zur, O. &amp Nordmarken, N. (2016). To Touch or Not To Touch:Exploring the Myth of Prohibition on Touch in Psychotherapy andCounseling. Accessed September 2, 2016.http://www.zurinstitute.com/touchintherapy.html

Zur, O. (2011).Touch in therapy and the standard of care in psychotherapy andcounseling: Bringing clarity to elusive relationships.&nbspUSAssociation of Body Psychotherapy Journal 6, 61,&nbsp93.