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 question: Can I form a romantic relationship with a former client?
This question has come up when a CBT therapist encountered a former client in a social situation – a party held by someone who turned out to be a mutual friend – more than three years after the professional therapeutic relationship had ended.
The therapy had been successful, and while the therapist and client had a good relationship and worked well together, there had been no suggestion of a social relationship at the time.
At the party three years later, the former client and therapist had a conversation – which included acknowledging that it was a little awkward to realise they had friends in common, as well as enjoying the conversation and finding other interests and activities that both are involved in.
At the end of the conversation, the former client has asked the therapist to meet them for a coffee sometime, which the therapist would like to do. The therapist is concerned that this may breach professional boundaries, and at the same time, feels that they enjoy the company of their former client and does not think there would be a breach of standards such as a power imbalance if a friendship- or more- was to develop.
What should the therapist do? Perhaps take time to consider your own thoughts here, or reflect on your own situation.
What we would expect the therapist to do:
- Reflect for themselves on the therapy and the therapy relationship, and potential implications if the nature of the relationship were to change.
- Consider how would they ensure that they address potential conflict of interest and adhere to their professional obligations?
- Review the BABCP’s Standards of Conduct, Performance and Ethics, and the principles informing them
- Review any employer’s policies that are relevant to the situation
- Take the matter to clinical supervision and reflect on this with honesty and openness.
In considering ethical principles, how would the therapist do good and avoid harm if they were to meet the former client for a coffee?
Most, if not all the time, developing a different relationship with a former client would be seen as having potential to do harm, be a breach of professional boundaries, and therefore inappropriate.
There is a risk of exploitation and potential for power imbalance. It may not be clear that they are acting fairly and with justice, and avoiding bringing the profession into disrepute.
It can be helpful to think about what this might look like as a newspaper headline, or a complaint made to a professional body about conduct.
These considerations are likely to lead to a decision to refuse and carefully communicate to the former client that this is not something that they can agree to do, based on the nature of their previous relationship.
Is it truly possible for the circumstances of both therapist and former client to change enough for a different type of relationship to develop in a healthy way?
The former client (and therapist) may feel that they have the right to move on from the client having therapy in the past. Does it reduce their dignity or freedom to choose for themselves, or mean treating a person differently for the wrong reasons, if the therapist decides that a friendship is not possible? Could it be seen as patronising, or an assumption that the client will always be vulnerable, even permanently judged, on the grounds of having had that therapeutic relationship in the past.
CBT therapies often include relatively short-term episodes of therapy and is aimed at making helpful changes. Does that mean that someone could never become personally friendly with a former therapist?
We can also consider whether what the therapy was for would influence the decision. For example, would it make any difference if the person receiving therapy had been addressing a single traumatic accident that happened when they were an adult, a phobia about having injections, or severe and enduring depression which had been present since their early teens- and why would there be any difference? If there were cultural, ethnic or faith differences and similarities between the former client and therapist, and whether these would have an impact on the decision-making process, and why.
Would your approach be different if the scenario was that the former client was offering a potential business relationship rather than a personal friendship.
Would it make any difference if it had been twenty years since the episode of therapy? If the therapist was working in a different area or was no longer a therapist? If the client had now done extensive training and qualified in providing therapy themselves and was now currently working in a similar field?
Counselling and psychotherapy bodies generally advise against developing relationships with former clients. Our own Standards specify that we must act in the best interests of people who use our services, keep high standards of professional conduct, provide us with important information about conduct, and we must behave with honesty and integrity and make sure our behaviour does not damage public confidence in our practice. Kingdon et al (2017) state that CB therapists must be aware that their responsibilities extend beyond the therapy room and be able to justify and account for their decisions and actions when necessary. BACP refers to ‘exceptional’ situations where a relationship with a former client may be possible and provides advice on building appropriate relationships in their Ethical Code. HCPC’s Standards of conduct performance and ethics state that relationships with service users and carers must be professional, with no clear guidance on when or whether a relationship with a former client could be appropriate. They suggest that pursuing a personal relationship with a previous client is possible but that the therapist should be ‘cautious’ about doing so.
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?
