This article was originally published in CBT Today magazine, May 2026 issue.
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.
Therapy rooms and clinical spaces
A number of members have shared concerns about the spaces they use to deliver therapy. Concerns include being expected to use spaces where they are overheard during telephone or other online sessions in the centre where they are based. There are situations where therapists are delivering sessions in buildings where there are loud noises or shared spaces with other services with different needs, or shared waiting areas, which is leading to difficulties for some clients and sessions. Changes to room layout, size, availability and accessibility have also led to ethical questions.
The principles of acting in the best interests of clients, doing good and avoiding harm, acting with justice (being fair), may be breached if there is a concern about confidentiality because conversations could be overheard. Telephone appointments in a call-centre style setting can increase access to therapeutic interventions, particularly in high-volume, low intensity services – which increases the ‘good’ that can be done for a larger number of people. However, the client is informed that confidentiality will be respected – hearing background noise during a call could be a challenge and undermine confidence in confidentiality. Even if a client is not aware of other people in the same space, the therapist is also committed to respecting confidentiality, which would not be the case if conversations could be overheard.
Overhearing confidential, sensitive or triggering information could also impact the person hearing it. In a clinic room in a face-to-face session, it may not be disruptive to therapy to hear people walk past for example, but loud noises, conversations outside the door or interruptions are likely to have an impact on both the therapist and client, process and progress in a session.
If a clinical room is an inappropriate size for the therapy to take place, this will also raise ethical concerns. A very small room may not be accessible to the client or therapist if they are a large physical size, need mobility aids or another person needs to be in the room. There could be an interpreter, significant other or advocate for the client, or the therapist’s clinical supervisor for example.
Individual characteristics or the nature of the presenting issues in therapy could affect how the therapist and client may feel if they must sit very close together in the room. Cultural expectations of keeping a respectful distance from each other could be compromised if the accommodation is not suitable to achieve this. Whether or not there are windows and ventilation or the room is a comfortable temperature could have an impact, for example if someone experiences high anxiety in an enclosed space. There could be an increased risk of transmitting infection.
A small room could have a disproportionate and potentially discriminatory effect on clients who are traumatised, have disabilities, neurodivergence or need support. It could also be discriminatory for therapists with protected characteristics.
In terms of therapeutic activities during sessions, we may need to move around the room, manoeuvre a wheelchair, take ‘pacing breaks’, carry out behavioural experiments, exposure, use equipment or an ‘empty chair’ for example. The space we are working in should accommodate the activities we need to do.
We may also need recording equipment, or access to online or written materials. The furniture available also matters, for example, being able to take notes, having a desk, different types of chair, access to online materials, a coffee table or whiteboard.
Although perhaps less likely, being expected to work in a very large space could also have an impact on creating a helpful ambience in a clinical session, unless this is specifically to do with the therapeutic work being carried out.
Availability of rooms at different times during working hours or even ‘competition’ to book clinical rooms can also have an impact on access for clients and effective time management or wellbeing for the practitioner.
In summary, the space in which therapy is delivered is important for quality and safety of care, equity, choice and access, staff wellbeing and efficient, effective delivery of services. In terms of keeping to our Standards of Conduct, Performance and Ethics, accommodation should include options that support safe, effective, equitable, and sustainable delivery of psychological therapies, alongside staff wellbeing, as well as meeting legal obligations.
Addressing concerns can be supported by reference to our Standards of Conduct, Performance and Ethics as well as our recently published guidance on best practice in services (see details below), and NHS guidance on suitable accommodation (details below). Ensuring that our workplaces have suitable spaces to deliver care and support practitioners doing their work can help to support wellbeing, and therefore fitness to practice, reduce burnout, and enhance the service we provide to our clients – ultimately leading to better outcomes.
- If you were experiencing these challenges, what steps would you take next?
- How can the ethical decision-making steps outlined help with deciding what to do?
- As a peer or trusted colleague, how would you respond if a concern about clinical spaces was brought to you for your advice?
- Is there a role for clinical supervision as a safe opportunity to reflect on actions we can take to ensure that the spaces we work in support good standards of care and our wellbeing?
- Evaluating – is there anything else to learn from this situation?
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?
