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.
How do I know if my own fitness to practice may be impaired – and what should I do? Part 1
The situation
A CBT therapist working for an agency on a temporary contract has recently had a severe viral infection, which has left them feeling tired, irritable and finding it difficult to concentrate. While they are feeling better than they were, they aren’t completely better. After being back at work for 10 days, they are feeling really tired at the end of the day, and ‘snappier’ at home than usual. They are not sure that they are managing their work as well as usual.
They are a lone parent. Recently, one of their two children has been repeatedly in trouble at school – the therapist worries that they are being labelled as ‘naughty’ by the school, and feels that they, as a parent are responsible for their child’s challenging behaviours. They have a very strained relationship with their ex-partner who is mostly absent from the children’s lives and they have little support from other family members. They are living on a tight budget and can’t afford to be off work any longer, needing to go back to work as soon as they were well enough.
They feel as if their clients at the end of the day do not receive quite the same high quality as those they see at the start of the day. They have started to worry about making a mistake at work, they are also aware of worry about ‘not being there’ for their children. At the same time, the therapist really believes that it is better to see the clients than make them wait longer for help. They are confident that their clients are not being harmed, even if they are potentially not receiving the very best from them, temporarily.
They are concerned about taking this overtly to clinical supervision. They feel that their supervisor is focused on technical excellence but is less ‘in tune’ with the emotional demands of the work, meaning that they worry their supervisor might not be supportive of their current struggles.
Considering this dilemma leads to a reflection about fitness to practice, and how to approach fitness to practice concerns. The issue identified means that the therapist should consider whether pausing, restricting or reporting their clinical practice may be needed because their fitness to practice could be impaired.
How can we know if our own fitness to practice is impaired and what actions should we take?
Our first responsibility is to do no harm, which protects the public from practice that falls below our standards. Referring to codes of practice, employer policies or similar guidance can help inform decisions about this. Our Standards of Conduct Performance and Ethics (currently under review) state:
‘When we say someone is ‘fit to practise’, we mean that they have the skills, knowledge, character and health to practise safely and effectively within your scope of practice.’
If the therapist’s ability to deliver patient care or make appropriate clinical judgements or other professional decisions falls below the BABCP standards, then their fitness to practice is impaired. Reflecting on what that means may help to resolve the therapist’s dilemma.
Before continuing with that reflection, there are other situations which may lead to our fitness to practice being compromised. Potential indicators that our own fitness to practice is adversely affected might be:
- Noticing signs of ‘burnout’ – being cynical, detached or emotionally drained, for example.
- More overt warning signs might be noticing that we over-use alcohol. Taking drugs or prescribed medication which impairs functioning and concentration would also be cause for concern.
- Realising that we are close to over-stepping appropriate professional boundaries is another indicator that fitness to practice should be reviewed and reflected on.
- Most therapists are very familiar with risks of infection, particularly since the COVID-19 pandemic, and their responsibilities to minimise risk – failing to meet those responsibilities also impairs fitness to practice.
- Colleagues raising concerns with us is another reason to consider our own fitness to practice.
- Noticing that we are making mistakes or forgetting to do important things -especially if that could harm a patient and put them at risk -would indicate a fitness to practice concern.
We can approach potential concerns we have about our own fitness to practice using reflection, or consultation on different perspectives, which could help to make appropriate decisions:
- Using BABCP’s Standards of Conduct, Performance and Ethics to put this into context and guide next steps, considering how to put those standards into practice in this situation. Seeking advice as soon as possible if unsure.
- Seeking supervision. In this particular scenario, the therapist is reluctant to be completely transparent and consult their supervisor openly. This may prompt the therapist to reflect more broadly about how they are using their clinical supervision, whether they are avoiding addressing an issue, if it has implications about their character or health, or whether the supervision is meeting their needs. Some practitioners have more than one supervisor, or have case management supervision as well as clinical supervision, which may provide options to explore this further.
- Using a self-practice, self-reflection (SP/SR) process allows us to be honest and open about whether there is a reason to be concerned. Asking the question – ‘would I like a loved one to be treated by someone who is in my current state?’ could be a useful part of that reflection, and use values about our practice to inform actions to be taken.
- Speaking to a trusted colleague as another person they might consult, may also help to find more clarity. This could include reflecting with them on what to take to supervision as well as how to address all their supervisory needs.
- Processing the information gathered so far may also mean deciding whether they do need to take more Leave or arrange a phased return. This would also lead to problem solving implications for increasing financial stress.
- Considering a referral for an Occupational Health assessment as another consultation.
- Reporting: If there has been a potential effect on patient safety, or other concern about meeting professional and care standards, a report should be made. This can be to the agency/employer and to BABCP (and other regulatory bodies if applicable).
BABCP has a responsibility to protect the public, and individual members have a responsibility to act in the best interests of patients. This is based on ethical principles of beneficence and non-maleficence. Addressing fitness to practice concerns is not intended to be about punishing people, but rather about making sure that we do meet standards well enough to practice safely. This means taking into account the therapist’s competence, knowledge, character and health.
- If you were in this situation, what steps would you take next?
- As a peer or trusted colleague, how would you respond if this was brought to you for your advice?
- Are there actions we can take as clinical supervisors to pay attention to areas where we tend to be less focussed, or to ensure that therapists feel safe to bring difficult concerns or dilemmas openly to supervision?
- Evaluating – is there anything else to learn from this situation?
- Does anyone in this scenario need more training or other professional development to help in the future?
In the next article, we will explore implications if we are concerned about a colleague or supervisee whose fitness to practice may be impaired.
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?
