In this series we consider ethical dilemmas and concerns that come up in CBT and think about how we might respond to them. These articles are intended to stimulate reflection and discussion, without necessarily providing a definitive answer.
Thank you to members who have contacted us to ask questions and share dilemmas they face. We will include some of these as anonymised examples in future editions.
As CBT psychotherapists, wellbeing practitioners, researchers, teachers and supervisors and related practitioners, we are expected to hold ourselves to high standards of conduct. This means to protect the public, act in the best interests of our clients and uphold the reputation of the profession.
In many situations, it can be very clear how to act in accordance with ethical principles. In this column, we look at issues that have come up for our members – perhaps where it seems that ethical principles may conflict with each other, or where it may not be obvious how to apply them in the circumstances. We also consider themes from complaints that have been brought about members – or where decisions made by our members have been questioned on professional or ethical grounds. There are some questions to reflection at the end of the article.
The situation
A therapist in a primary care NHS psychological therapies service is seeing a client whose presenting difficulty has been identified as Social Anxiety Disorder. The client is responding well to treatment at session six, they are working collaboratively together with an agreed and recommended protocol, with regular clinical supervision. The therapist works in a service which aims to complete ‘high intensity’ CBT treatments in a maximum of 12 hours’ contact time, usually meaning a maximum of 12 one-hour sessions, or fewer if the session is 90 minutes long. The therapist and their colleagues are generally encouraged to avoid 90-minute sessions because it makes the appointments diary more complicated to manage.
Whilst some clients do well in the limited time frame, the therapist is aware of the NICE guidance recommending that treatment for Social Anxiety Disorder consists of 14 to 16 sessions of 60 to 90 minutes. The therapist anticipates that 16 hours of treatment should be sufficient to help the client achieve a good outcome.
They are worried that this will be frowned on, or even not approved by their line manager who has to approve all episodes of treatment which go above 12 sessions. In addition, they have heard colleagues say that it’s implied that the therapists ‘aren’t very good’ if they need more, and ‘most of our therapists can stick to the number of sessions we provide our clients’, calling it ‘extra’ sessions. There seems to be a strong message that they would be responsible and ‘someone else will be waiting longer because of them’, or ‘they are skewing our outcomes’. They feel they have a professional and ethical duty to provide the NICE-recommended dose of treatment, as well as a professional responsibility to comply with the service targets they are expected to meet.
The situation means that the therapist feels under pressure to provide therapy in fewer sessions than the recommended dose, being aware of the high demand for the service, with many people waiting for treatment. They feel that they may be in some way judged negatively or have other unwanted consequences if they take action to ensure that they are able to provide the full number of sessions they believe the client will benefit from.
Similar dilemmas can arise when therapists feel under pressure to make a treatment plan for fewer sessions, or feel it is difficult to argue for the number of sessions needed. This can happen when there are factors such as additional physical health needs, personal circumstances, protected characteristics or other needs, such working through an interpreter. It can be further complicated if the service requires one single presenting diagnosis to be recorded, even if an assessment suggests that there are other presenting problems which are not complex, risky or severe enough to be seen in a different service or pathway of treatment.
The situation can arise where therapists do provide the full NICE-recommended number and length of sessions, but only when they make a specific request and provide justification either in supervision or to a manager. Clinic diaries may be set up so that it is more difficult to arrange sessions which are 90 minutes long, which again may lead to pressure being experienced to make most or all sessions happen within 60 minutes, for example.
The situation could also be influenced by initial information provided to clients about the service, as well as the contract agreed with the individual client. The number of sessions needed will probably be estimated early in the episode of therapy – as part of the assessment and case conceptualisation process. This usually results in making a collaborative, evidence-based agreement to complete a certain number of sessions – with a more in-depth review of how it is going after a few sessions. The client themselves may or may not be familiar with NICE recommendations. It may not always be clear how many sessions overall will be needed at the start of therapy, although a reasonable estimate may be offered.
In this scenario, the therapist has completed six sessions with the client and has concluded that 16 hours’ time is appropriate at this stage. There may be different conversations at session 1 or 2 compared to discussing this at session 11, for example. It may also lead to a different approach and impact if the client is aware of service guidance and/or NICE recommendations and expects a certain number or length of sessions before starting.
The ethical principle of beneficence can be considered in this situation, doing good may appear to be insisting that the NICE-recommended dose of treatment be provided to everyone.
Utilitarianism is an ethical theory put forward initially by Jeremy Bentham in 1776 (Kingdon et al, 2017). This supports the idea of doing the greatest good for the greatest number. The dilemma here is that with many people waiting for therapy, would it be better to provide as much quality therapy as possible to a greater number of people when resources are limited? Kant’s ethical theory of deontology (Kingdon et al, 2017), is more based on the concept of duty and rules to guide behaviour, and using this approach to ethical theory might suggest that the most appropriate course of action is to follow the employer’s guidance. On the other hand, it could also be argued that the service has been set up to provide NICE-recommended type and dose of treatment, so once again using a different ethical theory to guide our approach may still lead to a dilemma.
In the same way we can consider non maleficence as an ethical principle focused on doing no harm. Again, this could be argued from both perspectives, in trying to decide which approach is most likely to avoid doing harm.
The principle of autonomy means that a person can make their own decisions and is based on the idea that a rational individual has capacity to make an informed decision without pressure from others. It involves seeing that the actions taken will result in the most positive outcome. Once again, from the perspective of the individual receiving treatment and from the point of view of the therapist, this would suggest that completing the expected dose of treatment would be the best course of action. However, a professional responsibility to respect people equally applies, meaning that the principle of autonomy and the most positive outcome must also be considered for people who are not currently receiving treatment.
We can further consider the ethical principle of justice, what would be most ‘fair’ in this situation, taking into account fairness for the client, people who are waiting for therapy, or society in general.
It may also impact on ‘fairness’ to deny the therapist the autonomy to decide what is most appropriate in the situation. The therapist could feel as if they are not able to provide the best possible care, potentially experiencing “moral injury”. That is, psychological distress resulting from witnessing suffering or feeling unable to provide adequate care (for example, due to resource constraints). They may feel that they themselves are somehow ‘failing’ because colleagues seem to mostly manage within the recommended number of sessions in the service. If the situation violates the person’s individual moral or ethical code, it can be experienced as unease, a betrayal or result in shame and guilt feelings, and overall increased stress.
For reflection
- What is your own response to the scenario?
- Have you experienced similar situations, or have you supervised someone who has?
- How have you approached managing potential ethical dilemmas involved?
- The therapist is feeling under pressure, and is worried that they will be judged negatively – if you were their supervisor, how would you approach the situation?
- What might you take to supervision, case management or your Clinical Lead if this was happening in your clinical practice?
- If you were the Commissioner of this service, managing a tight budget, how would you want the service to work?
- Would you consider ‘whistleblowing’, making a complaint, or leaving the service to work elsewhere? Would you receive support if you did so? How might this affect you and the people around you?
To share your thoughts and reflections about this, or to ask an ethical question for a future issue – contact communications@babcp.com with ‘CBT Today – Ethics’ in the subject line
Further reading and reference:
Kingdon D, Maguire N, Stalmeisters D, & Townend M (2017). CBT Values and Ethics. Sage Publishing
Ethical decision-making in practice (Kingdon et al 2015)
- When we are putting values and ethics into practice, there are some considerations that help with making an informed decision
- Identifying the issue, and reflecting on whose problem it is- considering who we owe an obligation or alliance to in the situation concerned
- Putting it into context-
- are there laws, organisational policies or ethical codes which apply in this situation?
- If this situation involves a client, what do I understand about their values?
- Reasoning – what ethical theories and principles can be used to help with this decision?
- Who can I consult with? – Clinical supervisor, or senior member of my team, my professional body- other?
- Processing and reflecting the information gathered so far – using discretion and judgement to consider the most appropriate options
- Deciding – making a decision which has a rationale, and is sensible and justifiable
- Evaluating – is there anything to learn from this situation? Can I or my colleagues do more to ensure that situations like this are resolved helpfully? Does anyone including me need more training or other professional development to help in the future?
