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 situation
A qualified CBT therapist working in an NHS setting has brought a situation to clinical supervision. They have seen a client on two occasions. The client was referred for therapy for PTSD following an assault several months ago. The client has a number of complex factors in their history, losing a parent when very young, growing up in an area with a ‘bad reputation’, high unemployment, poor housing and little social connection or opportunity. During the second session with this client, the therapist has realised that the assault took place during a march the client was taking part in. The client had been assaulted by protesters who were part of a counter-demonstration against the march. The client expresses views that are very opposed to therapist‘s own, making statements that are prejudiced and stereotyping about a faith group that several colleagues in the service belong to. The client has made some comments that appear to assume that the therapist would obviously agree with them – and is sure that they are ‘right’ about their views. The assault has confirmed the client’s position more strongly- it has even made them popular in one of the online groups that they belong to. The therapist is against any kind of violence, while at the same time strongly sympathetic to the counter-demonstrators’ views and their generally peaceful beliefs, despite the assault.
The therapist and their supervisor are working through this situation together. Initially, the therapist felt strongly that they cannot continue to work with the client, as they are concerned that they will be judgmental, or over-focussed on challenging the client’s beliefs.
The therapist is feeling a conflict between wanting to help their client, being non-judgmental in principle, while finding the client’s views somewhat extreme and offensive.
When sensitive issues come up in sessions, this therapist usually feels able to explore differences in background, culture, or religion, for example without finding it a challenge ethically. However, in this situation, because the client holds views that are hurtful about people with a different faith, it feels more difficult to navigate. The supervisor and therapist are both agreed that the therapist should not accept any direct abuse such as racism, for example, and would challenge this if it arose in the session. The supervisor has asked the therapist to reflect on whether the client’s views are simply very different from their own, whether it is extremist and must be challenged- and whether it could be a safety concern and potential risk. The group that the client belongs to does hold strong beliefs but the group is not banned. While there have been concerns expressed there is no direct evidence of hate crime for example. The client has not indicated that they intend to harm anyone.
The therapist is fully acknowledging their own emotional reaction and are concerned that they may inadvertently disclose how much they disagree. This in turn could harm the relationship with the client and get in the way of providing the therapy that they have come for. On the other hand, they feel as if they may be colluding with the client by not challenging them – or by allowing them to continue to assume that the therapist will share their views. The therapist is also concerned about how to respond if the client asks them a direct question or checks whether they do in fact agree with their views.
Many clinicians do not discuss their own political, religious or other beliefs with their clients – although sometimes people have visible characteristics such as the colour of their skin, how they dress or religious symbols which will provide some information, whether this is discussed overtly or not.
It can be tricky to decide how much to share, particularly if a client is asking for personal information. Generally, it is considered good practice to focus on whether (and how) this might benefit the client and their welfare and redirect the session if these kinds of questions arise. Depending on the situation, the therapist may choose to explore it further to understand why it was asked.
The therapist has reflected that their own emotional response is due to the conflict of values, making it partly a problem for them. It could be a problem in the service, for example if the client’s views affect their behaviour or willingness to engage with other colleagues in the team. The therapist feels they owe an obligation to the client and to try to do good for them- at the same time feeling that this situation puts them in conflict with their loyalty to colleagues and leads to difficulty in Identifying the ‘right’ thing to do.
The client does not appear to have broken laws and currently does not present as a risk to others (or to themselves). The therapist understands something of the client’s values and recognises that this in itself is leading to their dilemma. The ethical principle of beneficence and acting in the client’s best interests has led the therapist to consider referring them to a different clinician. They are unsure they can work to the same high standards that they expect of themselves and others in the profession. At the same time, referring the client on could be seen as rejection of them, and could call into question the therapist’s ability to be non-judgmental more generally. They also wonder whether it is ‘doing good’ to expect another colleague to see them instead.
The therapist has also considered whether this may be an opportunity for the client to evaluate or challenge their beliefs – and potentially reach a more balanced view. The supervisor has explored the therapist’s concerns that this means that they may have a ‘hidden agenda’ which is not completely aligned with the client’s goals in coming for help with PTSD symptoms. The therapist has also noticed their own thoughts that the client may be exaggerating their symptoms in order to demonstrate how badly the assault affected them, although all court proceedings in relation to the assault have been concluded.
The situation has activated the therapist’s own sense of justice, and they are trying to work out what would represent ‘fairness’ in relation to the client, since they seem to be the ‘unfair’ person in the circumstances.
For reflection
- If you were their supervisor, how would you approach the situation?
- What might you take to supervision or case management if something similar happened to you?
- What do you say to a client who endorses a racist or extreme view during a therapy session? Would you do anything differently if the client does not appear to know that it is racist? If they said it was a ‘joke’?
- How would you approach someone who is determined to learn your political or religious affiliations or someone who believes they know something about you (your sexuality, relationship status- or how you voted, for example)- and sees that as a problem?
- While reflecting on this situation, would it be different if the client was expressing offensive views that are directly related to the therapist’s own characteristics – whether visible or not, as opposed to views about someone else or a different group?
- Evaluating – is there anything else to learn from this situation? Can this therapist- or their colleagues do more to ensure that situations like this are resolved helpfully?
- Does anyone need more training or other professional development to help in the future?
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?
