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• This month’s dilemma
  Ahmed, a newly accredited counsellor, is in private practice. He routinely uses his mobile phone to allow clients to make initial contact or to leave brief messages. He has been working with Tess for several months now and they have developed a strong relationship. Her presenting problem was relationship difficulties which, when explored, led her to remember distressing childhood experiences, particularly with her father. The day before her appointment Tess rings Ahmed to say that she is feeling desperately unhappy and anxious that she might do ‘something silly’. She asks if he will come to her house, just this once. What should Ahmed do?
  
  Jo Couling (senior accredited counsellor and supervisor)
  It would clearly be inappropriate for Ahmed to go to the house of his client, but this call will leave him in an anxious and uncertain state, especially as he is newly accredited and in private practice. The way he manages this crisis will be informed by his knowledge of his client. The fact that he has been working with her for several months and has developed a strong relationship with her means that he should be able to have some sense of her stability and the seriousness of her threat. For example, has she ever previously expressed suicidal thoughts or indeed made an attempt?
  
  He also may need time to think through his options and one way of doing this would be to tell her that he would like to give it some further thought and will call her back to discuss it further. This would allow him time to consult with his supervisor, or failing that, an experienced and trusted colleague. This gives his client a safety net, as well as buying Ahmed time.
  
  Ahmed’s challenge is to help his client feel held and supported, at the same time as demonstrating clear and firm boundaries. This is particularly important in view of the probable lack of boundaries she has experienced with her father. Clearly, if his sense is that his client is seriously at risk, he will need to take necessary steps such as alerting her GP or a crisis team, ideally with her consent and co-operation. The fact that she has made this call suggests that this is more likely to be a cry for help. He could use his call to her to offer his support and give her the number of the Samaritans so that she has someone to talk to if she feels the need. He could also remind her that she has an appointment the next day and that this will be an opportunity to talk in depth about how she is feeling. This session should also include a review of the counselling relationship.
  
  Finally, it would be useful, in his next supervision session, to discuss how he uses his mobile phone. He may find it works better if he restricts contact to arrangements about appointments and makes this part of his initial counselling agreement with his clients.
  
  Jonathan Freilich (integrative practitioner in private practice, Hythe, Kent)
  There are two key issues to this dilemma. Firstly, the initial issue for Ahmed concerns his capacity to hold the clinical frame. He uses his mobile phone solely for the initial contact and brief messages. The client is now requesting that he consents to seeing her in her house and Ahmed’s first priority is to assess the seriousness of her anxiety that she may do ‘something silly’. So as to maintain clinical boundaries I suggest that he offers her a telephone session for around 30 minutes to help her regulate her feelings, and brings the next session forward to as early as possible. In this way he meets his duty of care and maintains his professional boundary.
  
  The second key issue springs from the client’s ‘distressing childhood experiences, particularly with her father’. If her cry for help is calling for the good father in Ahmed (that she did not have), then his efforts to meet her without losing the therapeutic frame may serve to facilitate the release of painful memories towards healing. Alongside that, Ahmed needs to be mindful of the source of his own feelings, such as the desire to rescue the client, and how his capacity to do what is clinically sound may be compromised by phantom images from his own family and around feeling adequately held.
  
  The client and he have a strong relationship so Ahmed can afford to be challenging, coupled to the core conditions. Yet, because of the strong relationship, Ahmed may not want to disappoint her. However, he may have to frustrate her in the interest of his client’s long-term welfare and manage the uncertainty of the relationship.
  
  Vernon Cutler (accredited counsellor and trainer in private practice)
  I sense a lot of fear in the question, ‘What should Ahmed do?’ We are told that Ahmed allows clients to contact him on his mobile phone. I question the apparent significance of this information, given that increasingly therapists in private practice use their mobiles as their dedicated professional phones. I also question the apparent intrinsic assumption that therapy may only take place in the consulting room.
  
  I believe that we are in danger of becoming so entrapped in fear that we completely lose sight of the main issue here; namely that a client’s life may be at stake. The BACP Ethical Framework for Good Practice in Counselling and Psychotherapy commits us to ‘Engaging with the challenge of striving to be ethical even when doing so involves making difficult decisions or acting courageously’ (p4). From a person-centred standpoint, I do not experience the same degree of difficulty that seems to be anticipated in this question. If we accept Brian Thorne’s assertion that the human organism is trustworthy,¹ bearing in mind too that acceptance of the veracity of what our clients tell us lies at the heart of the therapeutic relationship, then we have to consider that the client’s expressed concern that she may do ‘something silly’ is an honest expression of her felt sense. In which case, I do not see an ethical dilemma as such. If the client were indeed to carry out her threat, Ahmed arguably might again feel ethically challenged.
  
  Given that the client has had difficulty in the past developing relationships but has developed a strong relationship with her counsellor, my immediate sense is that the client could subconsciously be testing the relationship to answer her own fears: ‘Is my therapist trustworthy?’ ‘Will he be there for me?’ In that sense, is she not challenging Ahmed to be congruent? Perhaps, therefore, the important question in this situation is whether Ahmed trusts himself. As therapists, we have a duty to our clients to maintain an ongoing commitment to self-knowledge. Thus, perhaps only Ahmed can answer this question and ask it if it is a dilemma for him. Does he trust his own integrity? Can he maintain his own absolute congruence? We understand that he is accredited and therefore must trust that the answer to both these questions is in the affirmative.
  
  He will, of course, be alert to the possibility that the client is seeking to compromise her counsellor in some way, but that would immediately endanger the very relationship that the client is clearly so desperate to maintain and would be self-defeating. Equally, it is acknowledged that in a setting other than the consulting room, Ahmed cannot guarantee the safety of the therapeutic space, and Thorne himself immediately qualifies his statement about trustworthiness by saying that caution is also necessary. However, that does not absolve us from the necessity of self-knowledge, integrity and ultimately engaging with the therapeutic journey, wherever that may take us.
  
  Reference:
  1. Thorne B. Person-centred counselling: therapeutic and spiritual dimensions. London: Wiley-Blackwell; 1991.
  
  Sue Flint (counsellor in private practice and volunteer counsellor for Manna House Counselling Service, Tamworth, Staffs)
  I hope Ahmed has alarm bells ringing in his head. He needs to check out what doing ‘something silly’ means to Tess and remind her of their contract regarding harm to self or others and his ethical responsibility. If Tess is using this term as manipulation, Ahmed will surely sense this from her reply. However, if she is seriously considering suicide he needs to gain permission from Tess to contact her GP for crisis intervention/medical help, if she is not willing to do so herself. Hopefully Ahmed’s experience leading up to accreditation will have taught him good ethical boundaries and he will not visit Tess at home. He may need to reassure Tess that he is not rejecting her and affirm that he is looking forward to her next appointment the following day.
  
  Ahmed should record as much of the conversation as he can remember following the telephone call in case of eventualities or a complaint being filed. He would do well to contact his supervisor for reassurance of his actions and exploration of his own feelings in coping with this dilemma.
  
  Karen Rogers (counsellor in private practice)
  I question the rationale of contact with clients outside the counselling room other than to rearrange appointments. Everything about this situation feels wrong to me. Ahmed may be newly accredited, but this means he is an experienced counsellor, and should know better than to place himself in the position of potential ‘rescuer’ to his clients. His actions encourage client dependency, not client autonomy. He needs to be aware of boundaries and self-care in order to sustain his effectiveness as a counsellor.
  
  I recommend he re-read the Ethical Framework, revisit the client contract, and build in a clause to state that the client can only contact him outside their allotted time to rearrange or cancel appointments. Or, if he offers telephone counselling, build this into the contract, but stating clearly what it is he is offering, in order to manage the expectation of his clients.
  
  If Ahmed worked for an agency, clients would not expect to see him at any time, nor would communication be accepted or encouraged outside the counselling room, unless it was for a pre-agreed specific issue such as End of Life care. His private practice should follow the same suit. He is described as having a strong relationship with this client, but this needs to be boundaried, and these boundaries need to be outlined clearly, both for the wellbeing of his client and himself. This means not going to the client’s house, but instead exploring what happened during their next session, including exploration of the client’s support network outside the counselling relationship. I would hope he has a responsible supervisor with whom he could discuss this openly, as he needs to make changes to avoid situations like this happening again.
  
  Rachel Taylor (trainee psychodynamic counsellor)
  This scenario highlights the importance of the therapist having their own personal boundaries in place, when the client may not. As a trainee therapist, it also highlights for me the potential difficulties in private practice, the importance of assessment and risk assessment, as well as good supervision. From the outset Ahmed’s boundaries have perhaps not been as clear as they could be. Encouraging a client to leave a message initially may be useful, but using a personal mobile number might make future maintenance of boundaries difficult, and a dedicated number may be more appropriate.
  
  The client is described as experiencing ‘relationship difficulties’ whose origins perhaps lie in her ‘distressing childhood experiences’ in relation to her father. Whatever these difficulties, Tess may be experiencing feelings towards Ahmed in the transference, which reflect the ‘intensity’ of the developing relationship for her, and may represent her earliest unboundaried experiences coming through in the therapeutic relationship. Ethically, Ahmed would be wrong to visit Tess at home, since a visit would not be in her best interest; potentially acting into a transference mirroring her earliest paternal experience. A visit to her may in fact be harmful, reinforcing a feeling that all boundaries are cloudy and that she is uncontainable.
  
  Tess’s anxiety that she may do ‘something silly’ needs clarifying. As an ongoing part of the therapy Ahmed will have assessed risk, and so will have some idea of this client’s past history, suicidal ideation and also an idea of her support networks. Ahmed will need to reassess this risk. If relationships have been difficult in the past, and unboundaried, then containment in this situation is the best outcome for Tess. Hopefully, Ahmed will have contracted robustly early on in the therapy regarding meeting times and setting, and he can use this agreed contract between him and Tess as evidence that he is there for her – indeed will be there the next day – but that meetings outside of those times are not possible. The issue of contact between sessions and use of the mobile phone number will also be future considerations for Ahmed.
  
  Ahmed is in need of supervision regarding this client. It may be that the intensity of relationship which is developing from the client’s, and possibly from Ahmed’s, perspective feels uncontained. There may be an erotic element to it, for one or both. Ahmed’s refusal to see the client at her home might in itself produce difficult feelings for her. She may be extremely angry; she may not attend the next session for any number of reasons, not least anger or shame. Ahmed will need his supervisor’s help in clarifying these issues, and help in repairing the rupture which is likely to occur as a result of this episode.
  
  Sara Faulkner (trainee counsellor)
  My first reaction to Ahmed visiting Tess at her home was a massive no way. Boundaries would be broken and the therapeutic frame weakened, especially at such an early stage of the work. Ahmed’s method of using his mobile phone for communicating with his clients feels overly familiar. I realise that, in today’s techno climate, texting is one of the fastest ways of contacting each other but again so soon into the relationship, familiarity could lead to disrespect (contempt).
  
  Ahmed and Tess have established a very strong relationship after only a few months and already the erotic transference is evident. The secure and trusting relationship Tess would have desired with her father, could be unconsciously played out with Ahmed, hence her wishes for him to visit her at home, where it is safe and secure for them to be alone. The threat of her doing ‘something silly’ if he doesn’t help her with these unhappy and anxious feelings should urge Ahmed to look at feelings of guilt and shame that Tess may be experiencing due to her early childhood distresses. Therefore after talking to Tess on the phone to assess her safety (if Ahmed felt concerned he could contact her GP), he should be encouraging her to use her next session to continue the work and look at how she felt when Ahmed did not visit her at home.
  
  Dennis Wilkes (person-centred trainee counsellor)
  The importance of ethics, boundaries and confidentiality comes to mind with Ahmed’s dilemma. Ahmed should have a separate phone for clients and established office hours for them to make contact with him. Giving his mobile number to clients, some of whom will be vulnerable, could result in Ahmed being bombarded with calls at all hours, day or night. This could become unethical; a client could call at a time when Ahmed is distracted with shopping or out with friends.
  
  Hopefully Ahmed and Tess will have agreed a way of working together using a contract that he can refer her back to and in that contract there should be a section on time boundaries and procedures that are in place in the event of an emergency.
  
  Given that Tess has presented with relationship difficulties, Ahmed should be mindful of this when explaining that he cannot see clients outside office hours, and that he has to apply the same rules for every client. It is important to make sure that Tess doesn’t feel rejected and that she fully understands Ahmed’s reasons for this. Because he has put himself in this position, Ahmed has a duty of care towards his client and should therefore explore some options with Tess, for example, try to help her with the problem over the phone, and find out if she can contact her GP or family and friends for support. There are 24-hour helplines whose numbers Ahmed could give to Tess.
  
  Another section of the contract should be about confidentiality and the exceptions to it; such as a client posing a danger to themselves or others. First I would recommend that Ahmed carry out a suicide assessment on Tess (over the phone) and then decide on the best way forward. Is she trying to manipulate him into coming round by saying she ‘might do something silly’? Does Tess pose a serious risk to herself? Does she have enough support in place until her appointment the next day? Should she go to hospital voluntarily or involuntarily? Regardless of the answer to these questions, Ahmed should speak to his supervisor as soon as possible and have a rethink on his client contact procedures.
  
  October’s dilemma
  Bethany works as a counsellor for a voluntary organisation, working with very fragile clients. Due to cuts, the service is likely to have to close in four weeks. However, because there is a chance that alternative funding will be found at the last minute, management have directed counsellors not to tell their clients. Bethany has argued that long-term clients need time to make as good an ending as possible, and is worried that if more money is not found, the centre will close and clients be given little or no notice, causing unnecessary distress. What should Bethany do?

• Please keep your responses to 500 words or less. Outline your responses to the dilemma and make your thinking as transparent as possible. A small selection of answers will be published in Therapy Today, with others appearing on this website. Please email your responses before 26 September to Heather Dale at hjdale@gmail.com.
  
  The views expressed above are those of the contributors and not necessarily Heather Dale’s or BACP’s.