Ethical agonising

Do no deliberate harm – neither should we fantasise therapeutic relationships as a problem-free zone. We should probably aim at the middle ground of humanness and wisdom
by Colin Feltham

Ethical agonising can be seen as both an inescapable and proper part of the profession of counselling and psychotherapy and also a symptom of a neurotic, punitive and inhuman trend likely to undermine the very core of therapeutic creativity. The necessary injunction to ‘do no harm’ might easily slide into a ‘take no risks’ and ‘play everything by the book’ approach. Views can get emotionally and theoretically polarised – from Brian Thorne’s historical case of the ‘naked embrace’¹ to Robert Langs’² rigid prescriptions for frames and Carter Heyward’s³ perception that she was abused by her too rigidly correct psychoanalytic psychotherapist. Many of these perspectives are summarised in Controversies in Psychotherapy and Counselling⁴. It may also be the case – very tricky for us to address honestly – that some of the most inventive of therapists, such as Fritz Perls and RD Laing, are known to have been high risk-takers who on occasion also had sex with some of their clients⁵. This isn’t the place to analyse the creative-but-predatory male therapist legend and its presumed corollary of safe-but-dull practitioner, but this may be one of the factors at play.

The range of violations
Consider some of the ways (in no particular order) in which boundaries are thought to be breached in therapy:

• Seeking and having sex with a client
• Succumbing to a client’s sexual seduction
• Making a cup of tea for your clients
• Allowing sessions to continue for 10 minutes or so after the agreed end time
• Visiting a client in hospital
• Accepting a lift from a client passing in rainy weather
• Accompanying a client on a therapeutic trip to a cemetery
• Becoming a client’s friend some time after therapy ends
• Telling a client that you find her/him attractive
• Attending a client’s wedding
• Telling a client details about your own relationships
• Writing about clients anonymously but without permission
• Seeing the client’s friend for therapy, giving therapy to a student, and other dual relationships.

I think it’s fairly clear that some of these are more serious and culpable than others but I don’t know if colleagues would agree with me. Talking a client into having sex with you would always be more damaging than innocently accepting a lift in the rain, I imagine, although one thing can lead to another. Is intent a necessary ingredient of worse forms of damage? Or is damage to be defined simply by principle and outcome? What if (unlikely but just possible) sex-within-therapy for one (shall we say, extremely inhibited) client fortuitously turned out to be very liberating and to have no real negative after-effects? Or, on the other hand, the client you compassionately visit in hospital, even though he had agreed – indeed, requested it – turns out to feel humiliated and distressed? Does the fact that individuals may react differently indicate that we should judge each case purely on its merits? And of course there is a vast difference between making unorthodox judgements and taking unethical actions that result in no complaint and those that do. We have no idea at all how many unreported boundary violations occur and I doubt that we will ever have any practical way of determining this.

The main fixation
Sex, for some reason, is usually our main fixation here. Yet there are surely differences between a client being raped (an extreme event I have never heard of but which is possible); consciously consensual sex between client and therapist during therapy or long after; the therapist being seduced and perhaps even blackmailed; and so on. The assumption is that the therapist should know better and is always the perpetrator or has had insufficient personal therapy or has been poorly supervised. But a proportion of clients may have a litigious personality disorder and/or be sexually predatory. Is a female therapist who is seduced by a predatory male client less culpable than the opposite and more expectable scenario of a predatory male therapist seducing a female client? What about the therapist who has no sex with his client but whose warm congruence (in his own eyes) conveys and half-conceals a borderline flirtatiousness that the client takes to be a romantic overture? Is such flirting necessarily less culpable and damaging than sexual intercourse? I suspect that sex has such a high profile due to our sexually repressed culture, and that, furthermore, at some unconscious level all parties (therapist, client, supervisor, adjudicator et al) are involved in a psychological orgy of guilt, reparation, punishment and voyeurism. The film Basic Instinct 2 portrays many such unconscious and narrative twists relating to therapy, sex and violation.

At one level, it’s all very clear – the client must never in any way be abused by boundary violations and the therapist is probably always in the wrong (the ‘no smoke without fire’ superstition); and the professional body will vigorously police practice, take complaints seriously and act to protect the victim and uphold the standing of the profession. Sometimes matters are this clear, explicit and linear and sometimes not. For public relations reasons it is important that an unambiguously clear message be sent out: we will never tolerate any professional abuse. But, again, it is the professional body that defines abuse and its scope.

Unsatisfactory therapy
Generally of far less publicised interest than sexual boundary violation, for example, is the case of the therapist not providing ultimately effective therapy, best intentions notwithstanding. It would be an easy matter for a therapist to answer a complaint of this kind by arguing that she clinically applied her theoretical model consistently, in good faith, and received good supervision, even though there may be little or no evidence-base for that theoretical approach and even though the client may have paid good money for something that did not match her expectations. I suspect the professional body is less interested in individual cases of unsatisfactory outcomes in therapy because it represents members who have allegiances to therapeutic approaches that are not invariably effective.

Such cases are not construed as outrages in the same way that sexual abuse gains the character of outrage. But it seems to me quite likely that some clients’ time and money is in fact wasted in this very way, not to mention that their suffering has continued and possibly worsened. The scenario of the client-to-be accessing a private practitioner via the Yellow Pages or other impersonal sources, and paying the high fees often demanded, is perhaps the one most likely to lead to this sort of abuse. Where ex-clients in the UK have written about unsatisfactory experiences, these often involve a depth of therapeutic relationship (often but not always psychoanalytic psychotherapy in private practice) that the client had never sought but the therapist had encouraged or insisted upon^6,7. Why do we not examine the ‘boundary’ between clients’ perceived needs (often, for so-called symptomatic relief in the shortest possible time) and some therapists’ theoretical and practice dogma that insists upon non-specific depth exploration and months and years of therapy?

The fear culture
Some have suggested that counselling itself is part of a fear-generating and risk-averse culture⁸. We have become anxious, perhaps overanxious, when we board aeroplanes or allow our children to go on school trips because bad things can happen and in a very small proportion of cases have happened. We are right to note very seriously the phenomena of increasing numbers of students complaining against academics, of some priests sexually abusing children and the ease with which Harold Shipman killed hundreds of his patients, and we are right to take whatever protective steps we can. But we should also note the effects of a litigious culture that thrives on fear, and we should pause to consider that the actual incidence of complaint and legal follow-up in our profession is very low indeed. In other words, although awful and hurtful things certainly happen, we can overestimate their prevalence and awfulness, and heighten our anxiety, making ourselves institutionally phobic and dysfunctional.

We are also susceptible to the fantasy that risk and negative outcomes can and should be altogether banished, but of course they cannot be. Every close relationship entails risk and a small but significant number turn to pain⁹. By writing in this polemical manner, I risk the possibility of being misunderstood as not giving sufficient weight to the protection of clients. This is not my intention or position but I know it is a possibility. Some eras, cultures and professions are more brutal or more litigious than others. Each of us has to assess our personal, professional and cultural risks; and professional bodies, like governments, must make policy decisions – on best current evidence – that may sometimes turn out not to be for the best.

For example, what degree of risk is involved in allowing the possibility of contemporary dual relationships and of intimate relationships between clients and practitioners after the end of therapy? I understand that some marriages have resulted from relationships started in therapy and I am sure human rights would be breached if anyone were to suggest annulment! Serious and sincere disagreements exist about all such matters: a certain fear of abuse is reasonable and a degree of risk is present. We might say that all therapy is potentially risky and of course much therapy explicitly encourages purposeful risk-taking. But I have supervised little if any of the dreaded ‘hyper-defensive practice’ said to be connected with this debate; nor, for that matter, have I known of much if any hyper-creative practice associated with too laissez-faire an attitude.

Improving matters
What practically can and should be done to improve matters? In the UK we pride ourselves on a tradition of built-in supervision, as if this ensures the reduction of misdemeanours and poor skills. In principle, it should mean that British practice is less susceptible to boundary violations than in countries where supervision is not mandatory. It might be possible to research whether this is the case, although I am doubtful it can be done¹⁰. It could easily be made mandatory for all practitioners to give all their clients a standard professional body advice sheet that outlines what should always happen and what should never happen in therapy and what to do when misgivings arise (although this standardisation is made difficult by the different stands taken by different theoretical approaches). This could provide statistics on the latest known incidence of professional abuse and misdemeanours, thus alerting consumers to the safety record of counselling and psychotherapy.

Changes in the training curriculum in preparation for statutory regulation might lead to clearer teaching and reinforcement of professional ethics. Examining the subtleties of transferential complications might be made compulsory on all courses.
All such changes are likely to add to the length of training and therefore increased fees, but I suspect that this is inevitable anyway. Better means of interviewing and recruitment might help deselect candidates with a propensity towards transgression. (Unfortunately – and so politically incorrect as to be unworkable – male candidates would probably require additional screening.) I suspect, however, that there are diminishing returns in ever-tighter monitoring procedures. Just as few if any societies can eliminate crime or accidents, so we must accept that we will never eliminate all exploitation and error from the professions. We can of course provide funding for consumer protection and debriefing such as those provided by Witness (www.popan.org.uk) and Therapy Breakdown (www.therapybreakdown.com).

Conclusion
In the few cases of serious boundary-breaking I happen
to have known about, there has often been some degree
of murkiness – not outright, unambiguous lies and abuse but some reciprocal attraction, mutual foolishness or impulsivity, revenge-seeking and so on. (We all have to pause to consider potential culpability as a bystander for sometimes knowing without acting!) Sometimes a situationally foolish but essentially moral and effective practitioner has made a mistake and perhaps desperately tries to cover it up, making herself or himself look worse. Sometimes both client and therapist work through boundary violation messes and come to accept what happened and leave it behind. A friend tells me that she suffered terribly in therapy from her therapist’s ambiguous relationship style, but she insists she nevertheless gained a great deal therapeutically from other aspects of this painful experience.

I hope I am not, however, conveying the impression that we should be at all cavalier about all this. Rather, I want to underline the frailty of human nature¹¹, the inevitability of human error and of the very high statistical probability that some small number of therapeutic relationships will go awry. Overreaction in the form of professional hysteria, harsh policing and punishment can end up in a dehumanising and scape-goating abuse of errant practitioners. Equally, too great a tolerance of laissez-faire approaches will presumably undermine the profession. As always, it is at the middle ground of humanness, of wisdom, that we should probably aim. Do no (deliberate) harm – of course; but remember that no therapeutic relationship can be guaranteed to be problem free.

Colin Feltham is Professor of Critical Counselling Studies at Sheffield Hallam University and the author of What’s Wrong With Us? The Anthropathology Thesis (Wiley, 2007). Email c.d.feltham@shu.ac.uk

References

1. Dryden W. (ed) Key cases in psychotherapy. London: Croom Helm; 1984
2. Langs R. A primer of psychotherapy. New York: Gardner Press; 1988
3. Heyward C. When boundaries betray us. San Francisco, CA: HarperCollins; 1994
4. Feltham C. (ed) Controversies in psychotherapy and counselling. London: Sage; 1999
5. Masson JM. The tyranny of psychotherapy. In: Dryden W, Feltham C. (eds) Psychotherapy and its discontents. Buckingham: Open University Press; 1992
6. Bates Y. Shouldn’t I be feeling better by now? London: Palgrave; 2005
7. Sands A. Falling for therapy. London: Palgrave; 2000
8. Furedi F. Culture of fear. London: Cassell; 2006
9. Wilmer HA. (ed) Closeness in personal and professional relationships. Boston, NA: Shamabala; 1991
10. Lawton B, Feltham C. Taking supervision forward. London: Sage; 2000
11. Feltham C. What’s wrong with us? The anthropathology thesis. Chichester: Wiley; 2007