This article was originally published in CBT Today magazine, September 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.
Time for preparation and note-keeping, communication, reflection between sessions
Some of our members have been in touch to let us know that they have been asked to work in patterns which don’t allow adequate time to prepare and plan their sessions, or that there is little time to reflect and manage the impact that therapy has on them. ‘Overbooking’ or back-to-back contacts with clients, having little influence on how the work diary is organised and being without adequate time between clinics or client sessions can lead to using break times, being behind on note-taking or other actions, and can lead to additional stress.
We would expect to have enough time to get ready for sessions, such as reviewing notes and having measures, equipment or handouts ready – or, for example, ensuring an interpreter is available and briefed, or that transport to an out of office session is arranged.
After sessions, there will need to be time to write up notes, communicate with others about risk or safeguarding concerns, for example, as well as having some ‘buffer’ time to reflect, and take care of physical needs and wellbeing. Even if some sessions are ‘back-to-back’ for positive reasons, there will still need to be time in the day to do these clinical-related activities.
This presents an ethical challenge if lack of time between clients leads to difficulties in recall when catching up on note-keeping later. It is likely to lead to additional fatigue or even compromise clinical judgement or boundaries. If that happens, it is not sufficient for best practice. There is a need to take the time to manage our own responses to traumatic content or other emotionally difficult material, otherwise this may affect our work with the next client and could compromise the therapist’s wellbeing too. Not having enough time can also mean we are more likely to make procedural errors.
In some settings, a specific amount of time for preparation and reflection is embedded in job planning, although this does not happen for everyone. People working independently or for organisations may also need to manage their day around room availability, moving between locations or when interpreters are available – as well as taking into account clients’ needs and availability.
The traditional ‘therapy hour’ of 50 minutes allowed for 10 minutes to write up notes and be ready for the next client, although that tradition did not include the potential for variation in the time needed.
In CBT and CBT-informed approaches, the amount of time spent directly with a patient or client may vary between brief assisted self-help sessions and much longer sessions, such as prolonged exposure or behavioural experiments out of the usual therapy space. Planning sessions may take little time in some cases, whereas others may take more time to prepare. The therapist may need to make arrangements such as contacting other people and ensuring equipment is both available and working.
Someone who is a student, newly-qualified or recently joined a team in a new role may need more time to prepare and navigate systems than someone who is very experienced at using them. Working patterns may need to be adapted and flexible to ensure that people with specific needs are appropriately included.
In some situations, we may be able to predict the approximate amount of time needed to achieve this, however there may also be times when an unexpected risk, safeguarding or other issue emerges, meaning that there is a need for some flexibility to be available as well.
Sessions themselves may sometimes be more demanding for a variety of reasons, whether it is presenting issues, the characteristics of the person, their context, the community or location that they are based in, or the interaction with the therapist’s own characteristics and circumstances. We need time to reflect, considering whether there are additional learning, supervision or other support needs, for example. We will need the opportunity to process the impact when there has been particularly difficult or unexpected content. Maintaining our fitness to practice includes taking care of our physical needs and wellbeing during a working day.
Many services and individual therapists are in demand to deliver as many therapy sessions as they can, in the interests of meeting as much need as possible, based on the principle of doing the greatest good for the greatest number of people. Expectations to manage time and be as efficient as possible are reasonable, however this can present a challenge if they are not realistic. Balancing this against having time to prepare, keep records and reflect is not always clear-cut.
There are some processes that can help to ensure that we do have enough time when we are not in direct contact with clients, while also working well and effectively to meet the needs of the people we see.
Job planning can help by identifying reasonable amounts of time for these activities, seeing them as essential to clinical effectiveness. Are there tips from administrators, leaders or other colleagues that would genuinely help us to be more efficient, so we are making best use of the time we have? In some settings, leaders in the service really understand how long it takes to do certain tasks. Time to reflect, take a moment and ‘re-set’ between clients is valued positively. However, if this is not the case, it is possible that there an opportunity for dialogue and demonstrating that this has a helpful impact for the work with clients. Would it be possible to complete an audit project to look at the value of between-client preparation, action and reflection times, by demonstrating what actually happens in the time, and how this contributes to better outcomes and safer practice. Clinical supervision sessions can provide a space to explore competing demands and reach a workable, ethical and sustainable working pattern.
For reflection
- How can the ethical decision-making steps outlined help with protecting enough time to carry out essential clinical-related activities when not in direct contact with clients?
- As a peer or trusted colleague, how would you respond if a concern about ‘taking too long to write up notes’ was brought to you for your advice?
- How would you respond if a service allowed a strict ten-minute space between clients in every case, and regarded supervision sessions as enough time to do any reflection needed?
- How can we use our clinical supervision as a safe opportunity to consider how we use the time between seeing clients or between clinics to ensure good standards of care, efficient use of time and our wellbeing?
- Evaluating – is there anything else to learn from this potential dilemma?
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?
