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
Should I breach my client’s confidentiality against their wishes when they have disclosed a single incident of historic abuse?
This question has come up for a CBT therapist in a primary care service working with adults who have anxiety and depression.
The therapist has so far had seven sessions with a client in her 40s to address symptoms of moderate depression which have recurred several times since she was about 15 years old. While exploring some beliefs and assumptions about other people, the client disclosed a situation which happened when she was about 11. Her older brother’s friend, aged about 13, had agreed to wait with her to keep her company at home while her parents took her brother for one of his activities for a couple of hours.
The client describes that he put on a film which she realised later was pornographic. He told her to watch while he touched his genitals. At the time, she remembers feeling curious and sort of excited, but also a bit disgusted by this. Afterwards, she remembers making sure she wasn’t alone in the house with him again, and somehow ‘knew’ that it was a secret.
She has never told anyone before, and on the one hand, says it was ‘just him experimenting’. At the same time, she also expresses feelings of shame, as well as some confusion. While describing the incident, the client uses the person’s full name. She tells the therapist that the incident isn’t relevant to her depression.
The therapist responds with empathy and compassion to this, and ensures that there is space in the session to understand the impact of speaking about this incident. The client’s formulation includes difficulties trusting others, and there have been occasions where the client has ended a romantic relationship when she has struggled with intimacy and trust.
The therapist believes that this incident has had a deeper effect on the client’s long-term wellbeing than she realises, while the client says that – although it did come to mind – she does not think it has had a big impact on her life.
The therapist has already screened for post-traumatic symptoms with the client, and carefully revisits possible symptoms of trauma – which are not present – and re-checks whether there were any other incidents that the client remembers. There are no other incidents that the client recalls. She knows that the person who did this is now a parent of two step-children, both girls aged 10 and 12, and is still friends with the client’s brother in the local area as their own children are similar ages, and they are both coaches for the under 13’s girls football team.
The therapist asks about consulting the NHS safeguarding team in the service, to ask for advice on whether any action would be appropriate, and to work together with the client on how to proceed. The therapist approaches this with the intention of collaborating, and is fairly sure that they should in some way report the incident.
Some questions to consider and reflect on
What would happen if the client is very sure that this would be harmful, and does not want this to go any further? For example, the client stating that it’s in the past and she would hate to bring it up, and says firmly that there’s no reason to believe that he would hurt anyone now.
Would it make any difference to the therapist’s next steps if the client also stated that this would be a breach of her confidentiality which is not justified from the conversation they had about limits and safety when they started therapy; or if the client also expresses feeling really anxious about the idea that she was learning to trust the therapist, and this would feel like a betrayal?
Or if the client says that she feels that if anyone was to find out, her ageing parents and her brother might know – and might react with concern and be supportive, but it would spoil her brother’s lifetime of friendship. It could be a problem between her and her brother, and it might damage someone’s reputation without good reason- and on the other hand would her family accuse her of making it up?
What we would expect the therapist to do:
- Collaborate as far as possible with the client, to repair potential ruptures in the therapeutic relationship and to reach shared decisions if this can be achieved.
- Take the matter to their clinical supervision and reflect on this with honesty and openness. This may include any personal connection with the issues raised that might have an impact on the therapist – which would allow for discussion of whether further support or input may be helpful.
- Review the standards of conduct performance and ethics, and the safeguarding guidance and the principles informing
- Reviewing any employer’s policies that are relevant to the situation.
In considering ethical principles, how would the therapist do good and avoid harm if they were to decide to ask the safeguarding team for advice against the client’s wishes – or if they decided not to?
Is there a risk that the therapist is mistakenly defining what happened as abuse when the client’s view is that it was ‘just experimenting’ and believes that what happened was within normal developmental behaviours? Would the therapist be taking control or using their power and influence in a way which is not justified?
How would the therapist work together with the client to decide what is fair and justified in the circumstances. In respecting the client’s dignity and freedom to choose for themselves, would the therapist then be led to re-defining what happened to the client as ‘not abuse’?
Our own Safeguarding guidance suggests that therapists do have a choice about reporting non-recent abuse. The therapist may be in a difficult position if they ask for advice anonymously, since they do know the name of the person concerned.
Our Standards of Conduct, Performance and Ethics specify that we must act in the best interests of people who use our services, keep high standards of professional conduct, act with honesty and integrity and make sure our behaviour does not damage public confidence in our practice. While it is unlikely that a report of this specific incident would result in a prosecution, for example, the therapist cannot know whether there have been other expressions of concern about this person. How could they use these ethical principles to decide which path to take?
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.
For reflection
- What is your own response to the scenario, and how does it relate to your understanding of safeguarding responsibilities?
- Are there any relevant personal experiences to reflect on?
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?
