Traditionally, the therapeutic space includes secluded space, sound proof, enough lighting, and other elements. In traditional African style, people sit around the fire and discuss their personal matters. P6 also reported:
… we realise that sitting in our offices, people are out there and they need our services, we are failing them … there is a lot that is happening outside there and it needs our intervention and for us to sit in our offices, I do not think we are helping…
In an uBuntu setting, a practitioner may consider taking the service to the people. For example, P4 also has taken the service to the people:
yes I have done that but not as often, as I say in 12 years those are the 3 consultations.
This indicates that it is still unusual and not always practical to take the service to the people or to see clients outside of the traditional therapy space. In this regard, P2 reflecting on her space for seeing clients said:
… mostly in my office, it’s not an issue for me as long as it’s a secluded area and my client feels safe, my client feels comfortable that they do not have to look around and be worried about who sees me …
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This emphasises safety and comfort, but also that there is possibly a stigma attached to people attending psychotherapy. The therapy room assures the privacy of the client and assists in keeping the material confidential.
P7 reported his experiences regarding spaces for psychotherapy and suggests that moving practice from the therapy room outwards may convey important messages to a client.
… in my practice life, psychotherapy is not there in the room…how does that child feel when a psychologist gets into her house? He/she feels valuable, worthy that the psychologist here at home it makes something to that client of mine being visited by this person and to me it forms part of psychotherapy that you know.
The above quote also indicates taking the service to the people. Since psychotherapy is about the healing, this can take place in a different space prompted by something else such as a child seeing a psychotherapist getting into his or home. In relation to hospital visits, P3 said:
It’s not different, what is important is that privacy, for example when I go there then I would draw/close the curtain and then keep the volume down and talk…
P3 and P8 view hospital rooms as possibilities for conducting psychotherapy. This therefore means that they also consider that clients can be seen out of the traditional therapy space. Participants do not necessarily worry about the issues of space sometimes as P4 reported:
…so they don’t feel they have to come to your office to talk about things they feel they can talk to you anywhere.
However, the use of a space for psychotherapy outside the traditional therapy rooms are not without flaws. P8 shared her lived experience:
The sort of challenge is people talking outside, you know they’ve drawn their curtains and eyes cannot see it but the ears, they will be going about their daily routines. Therefore in any case when people are laying in hospital, they are ill physically so there aren’t secrets deep that they want to talk about concerns illness and sometimes certain things about their families, you know, that worry them that they might like, those are the sorts of challenges that happen in my case …
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This means although psychotherapy in other spaces such as hospitals can take place, privacy and confidentiality may be compromised.
Another aspect of uBuntu activities is giving and receiving of gifts as well as exchanging goods for services.
5.4.2 Gifts and bartering
In our amaXhosa tradition when you visit a king (Inkosi) ‘uchamel’inkundla’ (you bring a gift). Moreover, if umXhosa gives you a gift and you do not accept it, it is interpreted as you rejecting the owner of the gift. Most psychotherapists are thus faced with a dilemma where we were trained not to accept gifts from clients. Moreover, the ethical code of psychology from HPCSA forbids practitioners to receive gifts from clients. P7 gave an example:
It was a cake from one of my clients when I was an intern, I ate it.
P4 reported:
… I once got a slab of chocolate and I took it, it was an oldish age mama of a child and I sort of had this feeling that I cannot take it but I took it, it stayed in my drawer for many years eventually I gave it away to the girls,
Participant 4 reflected on the gift that was in her disposal for many years that she could not use. Eventually due to discomfort, she gave it away. This means although the participant felt she could not refuse from the client for fear of causing offence, she could not consume it herself because she is aware of the ethics governing her practise, prohibiting practitioners from receiving gifts from clients.
It seems common to most participants have experiences of being offered gifts by clients. P5 also reported:
I did have someone who gave me a book but I never opened that book; it’s even more than 5 years now. I explained to him: you know we are not encouraged to take stuff from clients and he just insisted that I need to read that book.
It is interesting to find that although psychotherapists accepted gifts from clients, most of them could not consume those gifts. This means that due to the dilemmas participants are faced with about receiving gifts from clients, dissonance occurs. Psychotherapists feel the
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need to explain what they did with the gift they received. Receiving a gift from the client and using it seem to be two different processes for participants. P7 reported:
Yes it is there on … of all code of ethics, it is there. It talks about it in … but don’t you think it is going to create harm if I don’t accept it? If this person is the only thing she has to show appreciation to me and I say no, what is that going to do to my client if I don’t especially if the person was dealing with a rejection, I reject him now to me depends… but it is good to disclose it, it is good to disclose it that is why I disclosed it but I never said I am not going to take it I took it in fact in the whole department we ate that cake.
Using one’s discretion in dealing with some ethical issues is thus the way participants proceeded. Psychotherapists recommend that one way of managing such dilemmas was to disclose the gift to colleagues and even sharing it with them.
In order to justify clients’ giving, P7 indicated:
To pay for the session and during the internship times you don’t have to pay the full money just and that little bit is too much so for her to show appreciation and for me not to break that trust that we have developed for in many sessions knowingly … I would accept it of course they will not like it.
In South African institutions where psychologists are trained, psychological services are offered to the public by an intern-psychologist that works under supervision. In such cases the public pays minimum amounts for consultation. Regarding the quotation above, for someone not to afford that minimum amount is indicative of a gross financial constraint. In the above quote, again a practitioner is justifying his reasons for accepting the gift but also indicated that ‘they will not like it’. The ‘they’ referred to is the qualified psychologists who understand and enforce ethics because they are also in the business of training other
psychologists.
Another lived experience involved bartering with clients as an ethical dilemma. P7 indicated the following justifying reasons for bartering:
She didn’t have money to pay, she didn’t have money to pay and the only thing she could give it to me, the only thing that she had was cake. It depends on how to
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interpret that cake and my interpretation at that time was to say I don’t have money to give it to you. This is my appreciation. And bartering was good…
P7 indicated that although he was scolded by his peers for accepting a cake from a client and had disclosed the gift to the entire psychology department, almost everyone in the department ate/enjoyed the cake. Recommendations on how to deal with this gifts dilemma was made by some participants. P7 shared:
That can be helpful to a client but is not actually clearly in our ethics. Why we can’t have bartering if it is the only form of payment. If this person has a jersey beautiful jersey that the client has but doesn’t have money and this client says this is the only this thing that I have for you to show appreciation, would I say no? What do you want me to say do you want me to say no no no please, it depends to what was the presenting and I always like to use an example when I talk about this, of rejection will I be reinforcing rejection if I would say no?
This further illustrates the various considerations that a practitioner would grapple with. Participants are thus frustrated by the confusion felt when faced with receiving gifts and acting ‘professionally’. P3 reported, trying to justify her reasons for taking a gift from a client:
‘Kaloku mna’ I’m an African Lumka. And we were no longer now in therapy, we are no longer in that relationship, we have even finished our sessions, you know and now I stood there thinking, oh my God, do I take this fish or not take it. Oh I am going to hurt the feelings of that mom because she’s doing it with her heart you know. And I was in a dilemma but I took it, I thought the reason for taking it was this person is giving this with her heart and does not know anything about therapist whatever client relationship and we are not even having those sessions. And I last saw her on my last session. Here now I am saying, no I can’t take it. For me it did not feel right and I did not think it was right. So I took the fish, you see, I took the fish because. So now the Western rules would say nope. I mean the client-therapist relationship but as Africans how do you. You know some things as Africans how do you really, hayi maan they are… bayasisokolisa maan (they make things difficult for us).
The above quotation highlights frustration that is sometimes felt by practitioners when they refer to ethics and the practitioner’s traditional background and the confusion these cause.
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Authorities who see to the adherence of ethics are blamed for making things difficult for practitioners by not understanding their dilemma caused by such experiences.
The above quotes human-ness and empathy for the client. It seems as though participants recommend giving and receiving gifts to and from clients in a responsible manner that does not exploit any of the two parties.
5.4.3 Normalising
To normalise is to change something in order to fit the standard norm. For example the idiom ‘akuhlanga lungehlanga’ is translated as’ what has happened to you has happened before’. This is an amaXhosa way of normalising difficult experience that is painful to deal with. In this occurrence P5 normalises by externalising, she reports:
…especially with couples I like to externalise issues like you guys are fine but there’s a problem with the relationship, let’s look at the relationship, so that they can remain at least know that there are ok but the issue is with the relationship and see how the interactions in the relationship is affecting them . So I like to do that with couples…
Again, P5 expressed her way of normalising by reporting:
I normalise with people who are traumatised to say you know what you are going through it’s normal, it’s normal for a person who has been through trauma, for instance when the person is avoiding, to avoid going to that space or sometimes is avoiding even to think about it and even to talk about it.
In both quotations above, P5 seems to be normalising within the boundaries of acceptable practice in psychotherapy. On the other hand P6 reported:
I share my personal experiences to a limited extent… at the same time people come to me not to hear about me, they come to me for my professional services, so I do not want it to turn out to be about me as if I am anybody on the street, but if I feel that it is relevant, I will.
The above examples show that there is professional practice expected from psychotherapists but they may use examples to normalise. One of the golden rules of ethics is ‘do no harm’,
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which a therapist must be cognisant of every time therapy frames are at play. In other words it is recommended by participants that one must always be cognisant of beneficence.
5.5 Suggestions for psychotherapy expansions
Psychotherapy is a formally structured intervention. It is therefore apparent that it must have rules and guidelines. The diagram below illustrates some suggestions for expanding
psychotherapy.
Figure 5.3: Suggestions for psychotherapy expansions
A subtheme on suggestions of psychotherapy expansions was the split between the Eurocentric way of doing psychotherapy and the reality psychotherapists are faced when practising psychotherapy on amaXhosa clients.