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 ‘sent’ for therapy.
This creates ethical dilemmas about ensuring informed consent, confidentiality, and boundaries – as well as managing potential therapeutic ruptures.
An example situation has been shared with us, where a client has been ‘sent’ for therapy by their employer.
The client had been having difficulty regulating their emotions, for example getting inappropriately angry with colleagues, becoming frustrated or being ‘in a bad mood’. The client was also ‘bursting into tears’ at work. The client was also leaving work early, or not coming in to work at all. Their functioning at work could be affected for several weeks at a time.
The client is generally well-liked at work, and usually performs well. However, this difficulty with regulating emotions means their colleagues are unsure what to do or how to help. They have had several HR meetings at work to try and resolve these issues. The employer has offered to pay for a number of therapy sessions to help them work out these issues. The message is that they want the client to be at work, at full capacity. However the implication is that if things don’t improve, then disciplinary action may be taken. The client has come for the sessions, but has shared that they would not have sought therapy if their employer had not asked him to come.
While it is not legal in the UK for an employer to ‘force’ someone to attend therapy, there is an implication that the client may lose their job or face other consequences if they do not attend.
There are several other examples where someone could be ‘sent’ for therapy. These include situations where ‘informal’ pressure may be applied to attend for therapy, or where there are unwanted consequences for refusing.
These could occur when a client’s partner has asked them to attend therapy, with an implied or overt consequence – such as separation or divorce – if they do not.
A parent may want their child to attend therapy, whether or not the child wishes to. Informed consent in this situation is more complex and partly depends on the age and development of the child or young person. Young people aged 16 or 17 are presumed in UK law, like adults, to have the capacity to consent to medical treatment. Unlike adults, though, a child refusing treatment can be overridden by their parent (or person with parental responsibility) in some circumstances – as well as by a court – even at age 16 or 17 (Note: In secondary schools, a young person may be able to access therapy without parental consent if they are considered Gillick Competent (see MDU, 2024)).
Sometimes pressure can be applied to access therapy in order to ‘change’ a person – perhaps because the person has minoritised characteristics, such as sexuality or gender which are not accepted by a particular family, faith or community’s norms. The implication here may be that there is something ‘wrong’ with the person, and pressure experienced that they may be excluded from their group if they do not have therapy and then conform to certain expectations.
When a person is pursuing a personal injury claim for compensation – for example, they were injured in an accident for which they are not to blame, they have a legal duty to ‘mitigate their financial losses’. In the case of ‘psychological injury’ such as PTSD, this may mean that they are expected to seek therapy, because the law requires claimants to ensure that they take sensitive steps, where possible, to keep their losses ‘down and reasonable’.
In many modalities of psychotherapy and counselling, personal therapy is required during training, and it is not possible to complete training without receiving therapy. While this does not formally apply in CBT and CBT-informed approaches, self-practice and self-reflection increasingly form part of CBT trainings and is expected as good practice. While this is usually welcomed and experienced as positive – and regarded as enhancing the therapist’s competence- it may not be optional if the person wishes to successfully complete their training.
Formal court-ordered therapy
A court may order therapy for one or both parents during a divorce or separation, especially if a judge is deciding on custody/residence for a child or children.
This can also apply to a parent who has lost custody of their child or children because of abuse, addiction, or having been convicted of a crime. They may be ordered to undergo therapy, before a court reconsiders custody/residence arrangements.
Mental health treatment orders can also require a person to undergo therapy – which can be a hospital or community-based order. A judge may also order therapy as an alternative to prison for relatively minor offences. This may be treatment for substance addiction, or anger management for example. The person would go to prison if they did not complete the mandated therapy.
In all of the court-ordered situations, and to a certain extent in the more ‘informal’ situations where the client is ‘sent’ for therapy, the therapist is being asked to treat someone, but the situation is likely to be different for a client who attends entirely voluntarily.
The requirement and the consequences for refusal are usually clear in the court-ordered situation. It also could affect usual confidentiality expectations if the therapist is obliged to report on progress to the court or someone else.
Considering ethical principles in this situation, there are a number of areas which are relevant. Doing good and avoiding harm may imply that we might not offer to provide therapy in situations where there is an element of pressure or coercion. The principle of respecting rights and dignity of all people could be violated in a situation where someone has not freely chosen to attend therapy.
On the other hand, we may also be doing more good by helping someone to increase their quality of life and functioning, as well as to avoid the consequences of not attending therapy. CBT and CBT-informed approaches have the best evidence for changing behaviour and improving functioning and quality of life in many conditions. Reducing the possible negative outcomes such as prison, loss of job, partner or contact with children could also be seen as doing good and avoiding harm.
The principle of autonomy means that therapists may have conflicting roles in this situation, because they are providing care but at the same time have control over the client. This can have an impact on how the client sees the situation and the therapist themselves, as well as having an impact on informed consent, and on the therapy relationship. The principle of justice also applies, considering whether it is ‘fair’ – both on the client, perhaps their significant others or society in general.
The therapist themselves may experience pressure as well. The client may be highly motivated to achieve a positive outcome, such as seeing their children again, or keeping their job – and the therapist may find it challenging to work with the client, or to report a negative outcome. For example, concerns that the client is not being open with them; or that their behaviour was unacceptable even if they are in a process of change. The therapist may also worry that the client or another party may make a complaint if the outcome isn’t what they wanted – and reporting may be challenging if there is uncertainty about whether long-term changes have been made.
There is evidence that involuntary treatment ordered by a court can lead to reduced criminal behaviour, improved social functioning and promote better quality of life. It is less clear for ‘informal’ pressure’ to attend therapy, but there is some evidence that people who felt pressured to attend may have poorer outcomes (O’Donohue et al., 2015).
Court-mandated treatments imply a dual role for a therapist. Evidence also suggests that whether or not a person chooses to attend therapy is not as much of a factor in their treatment’s effectiveness than whether their therapist has used the best approach for that person.
Motivation is also a key factor (Hatchel et al., 2019). A skilled therapist will be able to work with the client on whether achieving change is important to them. There are likely to be challenges in motivation where someone is made to attend, and resolving ambivalence about this can be a powerful motivator. Motivation is also enhanced if the client is able to express confidence in their ability to change, meaning it is important for the therapist to support self-efficacy.
If the therapist does accept a referral in a situation where there is a court order, overt coercion, or possibly a pressure to attend, what might the therapist do to manage this?
- Providing a safe space and agreeing a therapy contract will include clarity about confidentiality and its limits, record-keeping and sharing, safeguarding and supervision. These would apply to any therapy encounter, but there are specific variations here. If the therapist is transparent about the standards that they keep to; what information must be recorded or shared, and what actions they will take, this is likely to help to build trust.
- If the client does not agree to engage with the sessions, but must attend them, the therapist may still be required to provide a report for a court on the outcomes. This may offer an opportunity to look at advantages and disadvantages of engaging with possible change – that is – resolving The therapist can look with the client at how CBT approaches could make a difference, and whether this might be more helpful than ‘turning up because you have to’.
- Considering the person’s values – and how the person lives according to what is important to them (or not) may also lead to a genuinely collaborative approach to deciding what is done in therapy, and enhance motivation, even if the actual attendance was not freely chosen.
- Negotiating a collaborative working relationship is always part of therapy, but may present a particular challenge if a client is not attending freely. Open communication and acknowledgement that they have not chosen to attend voluntarily can make it more likely that the person will engage, and their response to the pressure or coercion can be included in the assessment and inform a collaborative formulation process to make a shared understanding of what the issues
- Agreeing goals may include a third party’s expectations for the outcome of therapy; and again, open discussion of the impact of that – and whether or not the person does want to make any changes – may help with developing the therapy relationship, and an agreement on what interventions may work.
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?
- Would you accept a referral from a court for ‘mandated’ therapy? What would you do if you started an assessment with someone, and realised that they were under pressure from someone to attend?
- Do we need a different approach from working someone who is coming to therapy voluntarily?
References
Becker JE, Cecil A, & Gottlieb MC (2021). Ethical considerations of court-ordered outpatient therapy. In M Trachsel, J Gaab, N Biller-Andorno (Eds.) & fi Tekin & JZ Sadler (Ed.), The Oxford handbook of psychotherapy ethics (pp.687–696). Oxford University Press.
Hachtel H, Vogel T, Huber CG (2019). Mandated Treatment and Its Impact on Therapeutic Process and Outcome Factors. Front Psychiatry. 2019 Apr 12;10:219. doi: 10.3389/fpsyt.2019.00219. PMID: 31031658; PMCID: PMC6474319.
Medical Defence Union (2024). What is Gillick competence? Here’s what you need to know about capacity and consent in young people. https://www.themdu.com/guidance-and-advice/guides/gillick-competence (retrieved 30-10-24)
Merkt H, Wangmo T, Pageau F, Liebrenz M, Devaud Cornaz C, Elger B (2021). Court-Mandated Patients’ Perspectives on the Psychotherapist’s Dual Loyalty Conflict – Between Ally and Enemy. Front Psychol. 2021 Jan 6;11:592638. doi: 10.3389/fpsyg.2020.592638. PMID: 33488459; PMCID: PMC7815763.
O’Donoghue B, Roche E, Shannon S, Creed L, Lyne J, Madigan K, et al (2015). Longer term outcomes of voluntarily admitted service users with high levels of perceived coercion. Psychiatry Res (2015) 229(1–2):602–5. 10.1016/j.psychres.2015.07.013 [DOI] [PubMed] [Google Scholar][Ref list]
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?
