Institute Inbrief - 28/07/2015
Welcome to Edition 229 of Institute Inbrief! In this edition’s featured article we explore ethical considerations for counsellors engaging into social media-based relationships with clients. More specifically, we look at boundaries, dual relationships, and questions to ask yourself (the therapist) before “friending” a client on Facebook.
Also in this edition:
- Latest news and updates
- Articles and CPD information
- Wellness tips
- Therapist Q&A
- Social media review
Enjoy your reading!
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Imagine Being Passionate About Your Work
And Assisting People Every Day Lead Better Lives
It’s rare these days to hear people talk about their work with true passion. You hear so many stories of people working to pay the bills; putting up with imperfect situations; and compromising on their true desires.
That’s why it’s always so refreshing to hear regular stories from graduates living their dream to be a Counsellor. They’re always so full of energy, enthusiasm and passion. There’s no doubt that counselling is one of the most personally rewarding and enriching professions.
Just imagine someone comes to you for assistance. They’re emotionally paralysed by events in their life. They can’t even see a future for themselves. They can only focus on their pain and grief. The despair is so acute it pervades their entire life. Their relationship is breaking down and heading towards a divorce. They can’t focus on work and are getting in trouble with their boss. They feel they should be able to handle their problems alone, but know they can’t. It makes them feel helpless, worthless. Their self-esteem has never been lower. They’re caught in a cycle of destruction and pain.
Now imagine you have the knowledge and skills to help this person overcome their challenges. You assist to relieve their intense emotional pain. You give them hope for the future. You assist to rebuild their self-esteem and lead a satisfying, empowered life.
As a Counsellor you can experience these personal victories every day. And it’s truly enriching. There is nothing more fulfilling than helping another person overcome seemingly impossible obstacles.
Social media: Breeding Ground for Multiple Relationships
It starts out innocently. You email the client a scanned copy of an article relevant to something that came up in session. She emails you back to say thank you, and then asks a question related to her therapy, which you feel duty-bound to answer, so you do; before you know it, there is regular email exchange taking place. A few weeks later, she rings on your cell phone to clarify something you said in session, so you take the time to explain and she hangs up happy – only to ring again a week later about something else. Then you find she has visited your professional Facebook page, “Liked” it, and left comments – nice, complimentary ones – but ones which could identify her as your client.
You are mortified, as you have been working so hard to keep her material confidential. You realise you must bring this all up in session, but when she comes face to face with you, she suddenly discloses that she is not coming to counselling anymore as she is relocating to another community. Relieved, you think that might solve the burgeoning issue of these technology-related boundary violations, but the worst is yet to come. A few days later you come home from work and log on only to find a “Friend” request from this now former client, whom you cannot call back to session to explain why “friending” is problematic. Truly, you think, you have entered the Digital Age of counselling; how can a practitioner navigate ethically through its alien landscape?
Boundaries and dual relationships
A major consequence when boundaries are crossed or violated is that it is possible that a dual relationship – with clients, employees, supervisees, students, research participants, or trainees – may develop. The concept of the dual relationship stems from conflict theory. It refers to the situation in which a person fills two or more roles whose responsibilities may differ in some respects. Each role has its set of social expectations and, when the person is required to fulfil more than one at a time, conflicts occur (Yonan, Bardick, & Willment, 2011).
When a person cannot reasonably fulfil the differing expectations, he or she can respond in one of three ways: by relinquishing one role and committing to the other, by attempting to make a compromise between the roles, or by abandoning both roles together. Ultimately, when the person doesn’t meet the expectations for the culture in which the role occurs, that society or cultural group deems the person ineffective at handling his or her responsibilities.
In counselling we can define multiple relationships as those in which a mental health professional is in a professional role with a person in addition to another role with that same individual, or with another person who is close to that individual (CCPA, 2008). We should state at this juncture that few, if any, codes of ethics state that (nonsexual) multiple relationships are inherently unethical (Corey, Corey, & Callanan, 2011).
Many note, further, that not all of them are harmful and in fact, there are situations in which avoiding multiple relationships may not be helpful: for instance, where counsellors are working with communally-based cultures, in which cultural events of the culture need to be attended by the counsellor so that the therapeutic alliance will not be jeopardised by clients’ perception that the counsellor seemed to believe they were “too good for the rest of the people” (Nigro, 2004). That said, dual and multiple relationships are strongly discouraged because of the potential for the impairment of counsellors’ judgment, their ability to render effective services, and the potential to cause harm or exploitation to clients (Corey et al, 2011).
The difference between benign and harmful multiple relationships is typically a matter of conflict and power. When a counsellor is involved in a single-role relationship with a client, it is (should be!) clear that the client’s best interests are the priority. When there is a dual relationship with a client, however, the client’s best interests can come second to whatever the therapist is attempting to do, especially with the other relationship. The shift in focus, accompanied by the inherent power asymmetry of the relationship, spawns an environment in which the potential for psychological or physical harm to the client accelerates dramatically (Yonan et al, 2011).
The intensity of the injunction to beware of multiple relationships goes up several notches when we look at the implications for mental health professionals having them in the cyber domain. To “get” the ethics of counselling in the context of online technologies, we must go into the rationale for this strong discouraging. Looking at the online world, we can see how subtly the dual relationship can start developing. Because of the disconnection between real-life interactions and the perceived anonymity of the online world, we can become “friends” with someone on a social networking site by merely clicking a mouse. Online relationships are, in fact, exceedingly easy to establish and maintain.
Clients have many reasons for desiring one with their mental health professional. Those who have good working relationships with their counsellor may wish to connect with them on a more personal level. Other clients may feel isolated in their private lives and desire an online “friendship” with their mental health helper to take that relationship to the next level. Or they may wish to feel “special” and define that as the counsellor being willing to connect with them on Facebook (Bratt, 2010). Some writers have pointed out that digital natives routinely send out “friend” requests to just about everyone, and doing so is not at all laden with deep psychological meaning about their relationship with the professional (Zur, 2014)!
Let’s follow a typical scenario leading down a path to a troublesome dual relationship. The client sends through a “friend” request. The counsellor may be quite busy at the moment the request comes through and perhaps makes a hasty decision, accepting the Friend request. The first thing we need to note is that there may be an assumption of consent for sharing of information. At first and on the surface, things may not seem problematic, but the difficulties can come when outcomes are not as expected or information becomes more public than originally intended. Second, there can be the danger of self-disclosure when professionals are “Friends” with clients on social networks.
Counsellors could easily end up sharing information about themselves that affects the trust of their clients and the clients’ families. Witt describes a situation that could arise in a nursing context. The nurse may post on Facebook how she is exhausted at work as she got very little sleep the night before. Let’s say she describes how that was because of the fabulous party she attended: not a winning post as far as her patients may be concerned, but great information – Witt points out with some asperity – for the patient’s lawyer if/when something goes wrong with the care and a complaint is made (Witt, 2009)!
Like nurses, mental health professionals are bound by ethical standards in their professional practice. Like nurses, they can stumble, making errors of judgment about what is appropriate conduct.
Consider this before “Friending” a client
The same questions counsellors use to make wise decisions about dual or multiple relationships in the real world may be employed when considering the ethical consequences of engaging in an online dual relationship with a client:
- Is entering into a relationship in addition to the professional one necessary, or should I avoid it?
- Can the dual relationship potentially cause harm to the client?
- If harm seems unlikely, would the additional relationship prove beneficial?
- Is there a risk that the dual relationship could disrupt the therapeutic relationship?
- Can I evaluate this matter objectively? (Corey et al, 2011, p 273).
Specific to the question of social media, Zur (2014) recommends a comprehensive review of the situation through a set of questions that many digital immigrants would need to get consultation in order to answer accurately. They involve examination of all factors, from the profile contents and set-up through who gets access in what therapeutic context to the meaning of the request for both client and counsellor.
What is on the Facebook profile?
A strictly professional profile should be considered in a different light than a personal one, which may include family photos, photos from a party, holiday video footage, and so on.
Does the therapist have a Facebook Page or only a Facebook Profile?
Having a Facebook Page can reduce many problems in regard to self-disclosure, confidentiality, privacy, and other areas, although as we noted it may not entirely eliminate the problems. In many cases, the mental health professional is not just a counsellor, but also an author, presenter, workshop facilitator, group leader, or centre manager. A Page can cover all those areas of professional activity and also note details about the clinical practice. Unlike a Profile, a Page is for professional interactions and generally respected as such. The American Counseling Association Code of Ethics (revised in 2014) requires that counsellors keep professional and personal Pages separate (American Counseling Association, 2014). The Facebook Page works quite well to meet this requirement.
Does the therapist use privacy controls to control access?
Many people may not realise it, but mental health professionals using social networking sites can segment the list of “friends” into different groups, such as Public, Friends, and Close Friends. Using the segments, professionals can post things that belong only to one group and control the postings that each group can view. Thus, when one adds a client to a list, accepting a friend request from that same client theoretically does not have to mean the client gets unfettered access to the clinician’s or clinic’s profile. As Kolmes (2010b) and Younggren (2010) have pointed out, however, privacy settings do not always provide the privacy they promise to protect.
What can a client view on the therapist’s profile?
Obviously it is imperative to understand what clients may be privy to on one’s social networking site. The prerequisite understanding, then, is how privacy controls work and how to add “friends” to lists such as, say, “Public” or “Friend” before one considers accepting a friend request from a client. Counsellors can decide what friends on various lists can see. It goes without saying that privacy controls are extremely important when therapists have sensitive information on their profile. The controls are also useful in helping professionals determine how clients and others can communicate with them on their site: can they write on the wall? Send a message? For digital immigrants and/or anyone unsure of what a client will be able to see once they are added to a particular list, the Zur Institute (2014) recommends using Facebook’s privacy test. One types in the name of the client and can then see what the profile looks like from that person’s point of view.
What is the context of therapy?
To adequately consider this question in the context of a “friend” request, we are in the business of acknowledging counselling and psychotherapy as art, not science. A full set of factors determines whether accepting a request is inappropriate or not, clinically beneficial or not, and ultimately, ethical or not. The context of therapy includes client factors, such as the person’s diagnosis, age, culture, and relationship to technology. It includes consideration of the setting of the therapy, such as whether it takes place in a private practice, a clinic, a hospital, or a prison, and what the therapeutic relationship has been like: one of trust? Distance? Warmth? Or is there a marked power differential?
Different modalities of therapy call for different approaches, and experienced therapists know that the therapy of a client being treated with Cognitive Behavioural Therapy is likely to be very different than that of an existential approach, both of which are different again from psychodynamic or transpersonal modalities. Finally, we cannot fairly exclude the therapist from examination here, and must ask: what are the counsellor factors that make a difference? These might include training, age, relationship to technology, and comfort with self-disclosure.
Who is the client?
If it is your high-functioning colleague or possibly a long-term client who belongs to the “worried well” category, the situation is clearly different than if the client is a very disturbed person with intense needs, who may need clear limits, whereas the former categories may benefit from a flexible approach.
Why did the client post the request?
This question may hit at the heart of the issue better than most others as we seek to understand harmful secondary relationships. The digital natives – all younger clients – have very different attitudes toward disclosure via social media than do some digital immigrants, especially the sub-group of the latter referred to as “reluctant adopters” (the category into which many older mental health professionals fall) (Zur & Zur, 2010). The natives share much with many and typically send out “Friend” requests to just about everyone they know – it’s a routine thing! – and often to people they don’t know personally. This question blends into the next one.
What is the meaning of the “Friend” request?
Was the request to become friends just a routine thing by your digital native client, as in the question above? Or alternatively, are you dealing with a client who habitually attempts to push boundaries and has little sense of how intrusive he or she is? By making your therapeutic relationship public, might the client be attempting to de-pathologise the therapeutic work? Is the client seeking a deeper relationship with you as therapist than what might be appropriate?
What is the nature of the therapeutic relationship?
Overlapping with previous questions, we must ask here how the relationship is constellated. Is it family or group therapy? Intensive, individual psychodynamic therapy? Or perhaps it is someone who comes only intermittently for follow up: say, once or twice a year over a long period of time? Clearly, different types of therapeutic relationships need different communication approaches.
Where is the therapy taking place?
As per the comments on the context of therapy, above, we must ask how the setting for the therapy – that is, private office, clinic, home office, community mental health centre, hospital, or prison, etc. – has a bearing on the request to “friend”. A request from a highly paranoid new client in an inpatient mental health setting needs to be seen differently than a colleague who comes for intermittent long-term therapy.
What is the community location of the therapy?
In a small or isolated rural community, everyone seems to know everyone else’s business anyway; possibly no privacy settings will suffice! A more anonymous, urban, metropolitan environment may be easier in this regard.
What does saying yes to the friend request mean for the mental health professional?
Let’s say you are the professional who receives the request. The client will undoubtedly have developed or be developing transference to you; what sort of transference is it when you decode it? And just as importantly, what is your countertransference to the client? Your feelings, desires, and aspirations must be explored, not only with respect to the client, but also with respect to the friend request and to technology.
What is the effect on other or potential clients?
Current, past, or potential clients may become your online “friends” – or your clients’ friends. People often make the acquaintance of others online, including through the profiles of other friends. The degree to which your clients are allowed to interact on your site will affect how likely they are to get to know your other friends. The default option on most sites is to make one’s friend list public; if you do that, you must consider the aggregate effect on your connections.
What are the ramifications of accepting a friend request from a client for confidentiality, privacy, HIPAA compliance (learn more), and record keeping?
This is one of the most important considerations in deciding to accept the request or not.
Does accepting a friend request automatically constitute a dual or multiple relationship?
It may or may not, as we explain above. If the friend acceptance is likely to create a dual relationship, you as the treating professional must assess whether the dual relationship is ethical or clinically advised.
How might the therapist’s response to a friend request affect treatment and the therapeutic relationship?
As with most types of boundary crossings and dual relationships, counsellors must do a risk/benefits analysis. If it is you faced with accepting the request or not, your task is to think through whether accepting is likely to cause harm, exploitation, loss of objectivity, or loss of therapeutic effectiveness.
The 2014 ACA code of ethics has added in a section stating a new requirement that counsellors avoid “personal virtual relationships” with clients. What does that mean? Zur (2014) contends that, while it is unclear, it would likely include creating friend relationships with clients on the therapist’s personal social media profiles (section adapted from Zur, 2014).
This article was adapted from the upcoming Mental Health Academy course Ethical Use of Social Media in Counselling. The purpose of this course will be to acquaint you, the mental health professional, with the main issues related to ethical use of social media in counselling.
This article was adapted from the upcoming Mental Health Academy course Ethical Use of Social Media in Counselling. The purpose of this course will be to acquaint you, the mental health professional, with the main issues related to ethical use of social media in counselling.
References:
American Counseling Association. (2014). 2014 ACA Code of Ethics, as approved by the ACA governing council. American Counseling Association. Retrieved from: hyperlink.
Bratt, W. (2010). Ethical considerations of social networking for counsellors. Canadian Journal of Counselling and Psychology, Vol 44, No 4, pp 335-345. ISSN 0826-3893.
CCPA (Canadian Counselling and Psychotherapy Association). (2008). Standards of practice for counsellors. Ottawa, Ontario. Canadian Counselling and Psychotherapy Association.
Corey, G., Corey, M.S., & Callanan, P. (2011). Issues and ethics in the helping professions (8th Ed.) Belmont, CA: Brooks & Cole.
Nigro, T. (2004). Counselors’ experiences with problematic dual relationships. Ethics & Behavior, Vol 14, No 1, pp 51-64. Doi: 10.1207/sl5327019ebl401_l
Yonan, J., Bardick, A.D., & Willment, J.H. (2011). Ethical decision making, therapeutic boundaries, and communicating using online technology and cellular phones. Canadian Journal of Counselling and Psychotherapy (Online), Vol 45, No 4, pp 307-326. Retrieved from hyperlink.
Witt, C.L. (2009). Social networking: Ethics and etiquette. Advances in neonatal care, Vol 9, No 6, pp 257-258. Retrieved from: hyperlink.
Zur Institute. (2014). To accept or not to accept? How to respond when clients send “Friend Request” to their psychotherapists or counselors on social networking sites. Retrieved from: hyperlink.
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How to close the chronic pain pathway
We would like to introduce you to two people; in fact, more than introduce you. For the next several minutes, we would like you to become these people. The first is a chronic pain patient, and the second is the family member caring for that patient.
The patient
We’ll call you Chris. You are of working age and are one out of the every three Australians who live with chronic pain. Yours started years ago at your job at the mail order delivery company. Rushing to get heavy merchandise indoors as a huge rainstorm approached, you lifted and twisted, herniating three discs in your spine. The next morning when you woke up, you couldn’t move. You went back to work, but the deepening pain eventually meant that you had to quit. You tried part-time work, but with the back pain you were somewhat uncoordinated and had several falls, injuring yourself further, you are now unemployed.
Pain, stigma, depression, and constraint
Your back causes you pain all day and keeps you from sleeping at night. It grinds you down relentlessly, so much so that you (like 20% of chronic pain patients) have considered suicide. Yet no medical professional seems to believe you are really in pain. You were not surprised to learn that four out of five people like yourself experience that most others doubt the reality of your pain. You can no longer commit to social events because you will be exhausted the next day. Your world has become narrow – and constrained, because the disability pension does not cover your living costs. Exhausted, depressed, stigmatised, cash-strapped, with eroded self-esteem, you are a shadow of your former active, upbeat self.
The caregiver
Now please de-role from being Chris. For the next few seconds, imagine that you are Pat, the only child of and caregiver for Chris. Chris was widowed a number of years before the accident, so when Chris could not work anymore, you offered to have your parent come and live with you; you work full time and give care to Chris the rest of the time. You are doing your duty, but at great cost to yourself. You are continually exhausted, on edge, approaching burnout, and aware that, as caregiver, you have a 58% higher premature mortality rate than non-caregivers. It is not just the stress of the caregiving that gets you; you also have lost both meaning and hope. You are depressed, with no end to your situation in sight.
Closing the pain pathways
OK, now consider this last bit as yourself. The sketches of Chris and Pat are depressing, but they are all too common. How can we help chronic pain patients or their caregivers? To reduce the $34.3 billion expenditure Australia makes per annum on chronic pain (about $11,000 for each person with chronic pain), we probably need to alter the way you think about it. Medication, physio, surgery, and some allied health modalities are well-known to fight chronic pain. Not everyone knows about retraining the mind and refocusing the attention through Cognitive Behaviour Therapy. Here are three crucial thoughts from CBT to consider if you are either in chronic pain or trying to help someone who is.
1. Focusing on pain means more pain. Every sensation of pain which registers on our consciousness sends a signal through our pain pathways. The more signals we send (that is, the more thoughts focusing on pain), the more pain receptors our nerves create to handle all the signals. The more receptors we have, the more sensitive our nerves become, leading to our spines becoming highly sensitised. The more sensitivity we have, the more pain we experience. The more pain we experience, the more pain thoughts we have, creating a vicious cycle.
2. Attention is finite. To interrupt the above cycle, people can be reminded that each of us has a finite amount of attention to give to life. Putting major amounts of attention onto one’s pain means much less attention for anything else. By inserting pleasurable experiences to life, we increase our production of the so-called “feel good” chemicals – the neurotransmitters – such as the endorphins. With a high percentage of attention on our enjoyable experiences, we emotionally and chemically reduce our pain.
3. Attention is like a muscle. It can be strengthened by using it, and it can be directed to do the “heavy lifting” in whatever direction we require. Therefore, in pain control the objective is “attention enhancement”: growing the capacity for attention and then directing that newly enhanced capacity to those experiences that generate “feel-good” (i.e. pain inhibiting) chemicals, thus limiting or closing the formerly active pain pathways.
All of this means that we help people control their pain by encouraging them to distract themselves from the pain, reducing pain signals, adding in enjoyable sensations and experiences, facilitating the production of pain-inhibiting endorphins. When we help people grow their capacity for paying attention, they are even more powerful at regulating these processes.
Mindfulness exercises and techniques can help people do this. We don’t have space to explain those in this post (watch this space for later posts), but an internet search on the subject yields many interesting mindfulness exercises. Mindfulness exercises are great for both Chris and Pat, and even for those of us blessed to live without chronic pain!
Written by Dr Meg Carbonatto B.S., M.A., and Ph.D.
This article was originally published in Asteron Life’s Balance Blog. AIPC regularly contributes to Balance’s wellbeing blog category.
Psychological Treatments for Chronic Pain
Pain can have a profound social and psychological impact on those who suffer from it, and also those who care for them. Some of the psychosocial consequences of living with chronic pain include the tendency for sufferers to become dependent on medication and over-reliant on their families and other caregivers. Those in search of a solution to long-term pain can be inappropriate in their repeated utilisation of health care services, and anxious and fearful even when tended to. Such angst lends itself to withdrawal from friends and family and poor job performance if, indeed, the person feels able to continue working at all.
Counselling Sexual and Gender Minorities: Three Key Issues
To come into relationship with the notion that one is – and probably has always been – different from the “norm” of heterosexuality is for many individuals a terrifying experience, bringing with it a plethora of social, interpersonal, intrapersonal, employment, and sometimes religious and legal issues. Once the dawning of awareness has happened, however, few feel like it is possible to go back to the pre-dawn consciousness of attempting to engage life as before. Most wish to continue the journey of authenticity, finding out how to be in life as their inner identities dictate. Many will desire assistance from counsellors, psychotherapists, and psychologists for this journey. Yet how many mental health helpers are prepared (as in: qualified, skilled, experienced, and willing) to work with this population?
to continue reading this article.
Q&A with Toula Gordillo (Clinical Psychologist)
Q. Bullying among young people is everywhere – in schools, at home, on the bus, in sport. It is a growing problem and I would like to help my young clients work out ways to prevent bullying, reduce it or to cope with it. What can I do to help them?
A. To help a young person to stop bullying others, or to cope with bullying if they are the victim, there are at least three strategies the young person needs to learn: 1. How to Build Inner Resources, 2. How to Develop Effective Ways of Coping, and 3. How To Prevent The Bullying Cycle. These strategies are interrelated and may be discussed simultaneously using stories and images.
Building a young person’s inner resources includes developing ways of coping. If a teen or preteen can develop effective ways of coping, they may be able to prevent the cycle. To help the young person cope with bullying, parents, teachers and counsellors can present oral, written and digital bullying stories with accompanying images. Digital online stories, called Story Image Tools (SIT-2), may be delivered in Story Image Therapy (SITT)™ or as part of an educational delivery method.
Online bullying stories can have a substantial impact in helping to create changes to bullying behaviour. In therapy, or as part of regular classroom use, show the young person bullying stories via YouTube and discuss. Pay particular attention to the actions of the bully, how the person being bullied would feel and reasons why bullying occurs. Show bully victims ways to cope via oral/written methods, as well as showing the bully how it can make their life better by refraining from bullying behaviour.
Specifically, parents/carers, teachers and/or counsellors can use stories and images to help the young person to:
Develop Effective Ways of Coping
- Recognise their present ways of coping i.e., using technology.
- Learn to feel their inner strength and tell themselves they can cope with the bullying.
- Work out ways of keeping themselves safe.
Build Inner Resources
- Take martial arts/self-defence lessons.
- Don’t be tempted to bully back.
- Learn ways to defeat the bully.
Prevent the Cycle
- Recognize the type of bully and bullying behaviour.
- Understand that cyberbullying is as real as face-to-face or real life bullying.
- Report all bullying to an authority figure and be proactive in helping to prevent bullying.
Some bullying YouTube clips (Story Image Tools – SIT-2) to generate discussion, include:
When Adults Don’t Act
“Harmless Horseplay”: Teacher who allows the bullying to continue, and allegedly joins in. Ask the students/client whether they think it is just harmless, or whether the boy was genuinely scared –
“Bus Bullying”: When the bus driver doesn’t act, the behaviour doesn’t stop. Discuss with the young person what they think of the bus driver’s actions, as well as the boys doing the bullying.
Raising Awareness
With Support
“A Sign of Unity”: Heart-warming story of Bullied Water boy of a first grader name Danny Keefe with friends’ support.
“Say No!” Bullying song-story to empower teens and pre-teens to ‘have the guts to say no’ to bullying.
Toula Gordillo is a Clinical Psychologist, AIPC private assessor/tutor and regular contributor for Institute Inbrief. Toula has an extensive work history as a Clinical Psychologist, Teacher, and Guidance Officer. For more information, visit www.talktoteens.com.au.
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Do you believe in psychic phenomena?
Belief in the weird and wonderful is a consistent and significant component of the human condition. The tendency to believe in psychic powers and related phenomena that contradict known scientific laws and principles is not only a common feature found in all cultures across the world, but has been a factor in human existence throughout history. There is evidence that widespread beliefs in psychic powers, crop circles, water diving and assorted paranormal beliefs are as popular as ever, indeed, recent opinion polls tend to suggest that belief in Astrology, psychic healing, and haunting by disembodied spirits are in fact on the increase (e.g., Hemelryk, 2006; Karr, 2001).
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