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 client has been seeing a therapist who is working in an NHS service. They have asked whether the therapist will see them privately. How could the therapist
decide what to do?
This particular situation could arise at any point, such as if the client asked at an initial screening – perhaps when discussing how long they will be waiting for active treatment. It could happen at the start of an episode of therapy, part way through, or towards the end. It could happen if the client wanted more sessions which the service does not provide. The therapist may have to give the client information because they are leaving the service and could be asked at that point. Being asked could also occur whether or not the outcome meets the expectations for the type of difficulty, whether or not there are outcome targets for the service, or if the client and/or the therapist had been expecting a specific outcome.
Whenever such a request happens, it can create ethical dilemmas in a number of ways. In addition to our Standards of Conduct, Performance and Ethics, deciding how to face these dilemmas will help the therapist respond to the client’s request.
The therapist may already have a policy or agreement in place which sets out whether or not such a transfer of care is permitted in this context. Some NHS Trusts or other employing organisations may have clear policies on transfers from their care to a private provider, and it can sometimes be written into a contract of employment as well. It may be clear from this whether or not – and in what circumstances- it is permitted to see a client privately when the therapist has already seen the client in a different role. There may be stipulations about how long after the end of therapy the client could then be seen in another context.
It would be highly unusual and likely to be unethical if the therapist is part way through an episode of care and transfers the person to their private practice, or sees the person in both contexts at the same time.
If it is possible in some circumstances to see a client in private practice after they have been seen by the same person in the NHS, the client’s individual needs would then contribute to the decision-making process. The therapist themselves may decide that they never want to do this, even if permitted. If they may take a referral this way, they may also have their own guidance or policies about a period of time between one context and another.
There is risk of conflict of interest. Questions could arise when a client is seen in the NHS (or another employing organisation) and is then seen on a private paying basis by the same therapist – about whether the therapist has been ‘marketing’ themselves, using their NHS role to generate private work – and as a result, they could be seen as profiting unfairly from their work.
What would the therapist need to consider with regard to what the client wants to work on? Services sometimes have strict limits on the number of sessions available to people accessing the service, or may not accept referrals for certain types of difficulty. There may be no local services which meet the client’s needs. In addition, the opportunity for a second ‘episode’ of treatment or an onward referral within the NHS could result in waiting time.
There may be an additional ethical concern if the therapist does not agree with the service limits on number of sessions, or are concerned that they don’t meet the evidence base for ‘dose’ of treatment.
In a situation where availability and access are a challenge, would the decision-making process be affected? For example, the therapist could be working providing a specialist service, or is trained and experienced in affirmative practice with people who have particular minoritised characteristics which the client may have. The geographical location and resources in the area might mean that there are limited alternative choices available to the person who has asked. This could make it more complicated to decide on the best course of action in terms of doing good and avoiding harm.
We aim to ensure that the therapy we provide and the way we provide it generally does good, but in this situation it is not straightforward to assume this will be the case. The change from working with someone in one context to another could result in potential for harm. For example, if there are expectations about the therapy itself which are not met. There may be financial consequences for the client if they decide to pay for a service which they previously accessed without a direct cost.
The impact will vary according to the client’s circumstances, and this in itself may make it difficult to treat each client equitably if they ask to be seen privately. The therapist should consider carefully whether work in private practice would be in the best interest of the client. It may be more tempting to agree to see a client that you like and enjoy working with, with the added benefit of being paid for it- but does the client really need this work and how do you ethically decide when it ends.
Some therapists working in independent practice choose to see people with different presentations, or people with less complex needs if they are lone workers.
In addition, a client may expect more sessions of therapy than the evidence base or their own progress through treatment would suggest for the presenting issues. Alternatively, they may assume they will have faster or better outcomes if they pay privately. The therapist and client should also be aware that the therapy might seem different if transferred to private practice. The setting will be different, there would be a change of when the sessions can take place. Some therapists see people in their own home, or in a more personal space at their independent practice. This can reveal more – or different things- about the therapist themselves, and needs consideration in terms of the effect on boundaries or potential impact on the therapeutic relationship.
The principle of autonomy and professional responsibility to respect people equally also applies. It could be seen as condescending to decide for a client whether or not they can choose the therapist they want to see – and in what setting.
The principle of justice also applies, considering whether it is ‘fair’ – to say no, or not for a specified amount of time or to say yes. We would need to consider fairness for the client, perhaps their significant others or society in general. It may also impact on ‘fairness’ to deny the therapist the opportunity to care for people, use their skills, carry out their business and earn income in their non-NHS time.
Where the therapist is not permitted to see someone privately having seen them in the NHS setting, they will need to reflect on how to have that conversation with the client, and may need to specify whether that means ‘never’, ‘not while I still work for the NHS’ or not for at least a specified minimum period of time- and if so, how long is that period of time.
Therapists would also need to reflect on the information that they know about the client, the data they have access to and what impact that would have on them being seen in a private setting later.
Actions to consider if this situation could arise in your clinical practice
- In advance, ensure you are familiar with any policies or clauses in your contract or agreement with the employer or agencies you work for which cover this situation.
- If you may, in some circumstances agree to see someone privately, and this is not covered by formal policies or your contract, it will be good practice to discuss this with your clinical supervisor and clinical lead or line manager if this does This is to ensure that there is an opportunity to consider unintended consequences, ensure transparency and to make a declaration of conflict of interest if needed.
- If there is a specified period of time between ending your work in the NHS, and considering seeing someone privately, consider how you would ensure you adhered to that, while also meeting data protection expectations.
- Consider the most appropriate approach to discussing this with the client, for example how they could find your details and contact you outside NHS working hours.
- You might decide that you will suggest that the client sees a different therapist if they want private In that case, would you recommend someone you know, or refer them to the CBT Register even if you have trusted colleagues in the area – and what would influence that decision?
For reflection
- What is your own response to the scenario?
- What might you take to supervision if this happened in your clinical practice?
- Have you experienced similar situations, or have you supervised someone who has?
- How have you approached managing potential ethical dilemmas involved?
- If the outcome is clear that a transfer of care to your private setting will not happen, what are your reflections on how to have this discussion with a client – particularly one who can be persuasive or who you believe could really benefit from it?
- If a transfer of care may be permitted – what would influence your decision and how would you approach it?
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?
