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• This month’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?

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  John Daniel (psychosynthesis counsellor in private practice)
  What makes this dilemma particularly tricky for Bethany is the uncertainty encapsulated within it. We do not know for certain that the service will close in four weeks’ time and yet we are told that this scenario looks ‘likely’. Bethany is faced with the challenge of having to balance a directive from her employer with the needs of her clients, who we learn are ‘very fragile’. Were she to respect the directive, and should the organisation succeed in finding alternative last-minute funds, it could be argued that, by saying nothing to her clients about the uncertainty of the situation, she will save them unnecessary distress. However, should the organisation fail to find funds, Bethany will be faced with having to terminate abruptly with her clients, which I would argue could be a cause of greater distress.
  
  I would be interested to learn how Bethany initially contracted with her clients around endings, and the desirable notice period agreed for a ‘good enough’ ending. Should the initial contract have specified a notice period (which, for long-term clients would seem to me to be appropriately set at four weeks), Bethany would risk breaching her clients’ trust should she honour the demands of her employer above the terms of her contract with her clients. In so doing, her employer is placing her in the untenable position of failing to act in accordance with the trust placed in her by her clients.
  Clearly this is an issue for Bethany to take to supervision. For her sake, I would hope that her supervision is independent from her line management, so that she can have an opportunity to explore her thoughts and feelings around what, I would argue, could be seen as unethical practice on the part of her employer.  I suggest that by directing Bethany to withhold knowledge of the ‘likely’ closure of the service from her clients, the organisation is forcing her to breach her clients’ right to autonomy by denying them the opportunity to make their own decision about how to proceed. A four-week notice period would provide adequate time for Bethany to contain and work with her clients’ feelings about the likely possibility of an ending, and an opportunity for her to explore with them potential sources for onward referral. This is especially important given that she is working with ‘very fragile’ clients.
  
  By not giving them notice, I would argue that Bethany would be failing her clients on three crucial fronts: by not acting in their best interests, by not promoting their wellbeing, and by not respecting their right to be self governing. By risking abandoning her clients without a sufficient notice period, Bethany would also fail in her commitment to avoid harm to her clients.
  
  On balance I would argue that Bethany’s duty of care is first and foremost to her clients and that she must work with what she knows at present, which is that closure is ‘likely’, and act accordingly. Whilst saying this, however, I realise that should she not succeed in persuading her employer that their thinking is unethical, she will be placed in the unenviable position of deciding whether or not to act unilaterally, without their sanction. Should she have colleagues within the service who intend to honour the directive and say nothing to their clients, a very ‘messy’ situation could result if she were to tell her clients and face the not unlikely possibility of her clients then spreading the word about the possible closure to other clients within the same service.

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  Richard Bryant-Jefferies (author, workshop facilitator and former counsellor and supervisor in NHS and private practice)
  Having worked in an agency and seen funding cuts impact on the provision of continued counselling, I can appreciate this dilemma. I am not sure though that I agree with the management stance, which seems to be against the interests of the clients. They are being deceived and whilst it may be that funding is found, there is a chance that it may not be, and then what? Therapists can find themselves effectively emotionally blackmailed into providing unpaid ending sessions because the funding has not been found.
  
  I wonder whether the agency might be using the continuing work with clients as a lever to get more funding, arguing that they need more, to at least provide appropriate endings, and buy themselves a little more time.
  
  I appreciate the fragile factor, but what about trusting the client’s own strengths and capacities? How do we know that being open with them will not help them find inner strength to cope with the change that may happen? At least they are then in a process of preparedness. I can recall a situation in which clients in fragile process were told of an ending that was due to happen (albeit with many months’ notice) and they moved on constructively within themselves during that period of ending in unexpected and deeply encouraging ways.
  
  So, back to basics. Trust the clients. Give them time to talk it through. Explore options in case the agency has to close (hopefully the agency would be fostering those links to seek ongoing therapy and support where required). Be attentive to their concerns. Be aware of your own anxieties and process them and if you share them with the clients, do so in a way that conveys your warmth and concern for them, rather than pile your anxiety on to theirs.
  
  Please, for anyone reading this who funds services, make your funding around decisions at least six months in advance, and where possible fund for a minimum of three years, not annually.

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  Sarah Freeman (person-centred counsellor in private practice, school and voluntary work)
  I can empathise with Bethany’s dilemma. I feel my first reaction would be to consider my clients on an individual basis. Seeing as Bethany has a few long-term clients, I would imagine some kind of trusting relationship has developed. So I’m sure Bethany would understand and appreciate each one’s personal circumstances.
  
  I personally feel I would need to be as honest as possible with my clients, possibly taking time after a session with them (so as not to deprive them of ‘their space’) and explain the predicament the agency is in. Most people at the moment seem aware of the current economic climate in this country, so I can’t imagine it would come as a great surprise. I’d explain that there is a possibility of alternative funding but that in the meantime nothing is confirmed, so the future of the agency is in question. There is also the possibility that these clients may well feel they could do something to assist an agency that has helped and supported them through a difficult time. It might not be with funding, but I’m sure if more people contacted their local MPs, they might listen to how the funding cuts are affecting people who need and appreciate counselling.

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  Duncan Whittington (mental health practitioner, social worker and director, Passport2parenting)
  Bethany’s central dilemma is whether or not to bite the hand that feeds (pays) her.
  
  One might argue that there is no sense telling people that the centre may close as it will only upset people. However if Bethany is being congruent, transparent and trustworthy she may decide that she does not have the power to decide just how her clients might take the bad news, and therefore she should follow her instincts and tell her clients.
  
  It seems to me that the management of the organisation need to look to how they might feel if news was kept from them and allow the patients to learn alongside the staff (whilst they can access the centre’s support).

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  Reg O’Brien (voluntary counsellor)
  Management have made a blanket decision not to speak to clients just yet but if our counselling practice is based on beliefs such as fidelity, beneficence, non-maleficence and justice, at what point should the dilemma be introduced into the client counselling experience?
  
  As a way of organising a response to the dilemma it is useful to have a plan of action. Gabriel and Casemore (2008),¹ in the BACP publication Talking therapies: an essential anthology, state: ‘It is important to resist reactive responses or attempts to avoid thinking about situations – responses should be both considered and managed.’ To aid this process they propose the use of a 10-point plan for ethical decision making. This offers a multi-dimensional approach to making decisions when responding to ‘complex, diverse and conflicting aspects of human experience that are encountered in therapeutic work’. The plan also provides a process which can be explained to everybody, to show a procedure is being followed, legal requirements are being considered and decisions taken which conform with guidance as laid out in the BACP Ethical Framework.
  
  Whilst management focuses on the financial issues and trying to sustain provision, Bethany, as a counsellor, is rightly endeavouring to ensure that the client perspective remains a significant part of management considerations. Nobody wants to see the voluntary organisation close, with the loss of the counselling service to the local community. It may well be that everybody involved is more than aware of the external distal forces (Smail, 1999)² that have brought the organisation to this unhappy point, particularly in these austere times. Meetings have to be arranged to keep employees and volunteers informed. This process, as Gabriel and Casemore point out, needs considered management. However, at some point clients will also need to be informed. As Bethany has argued, a plan of action is required that maintains the organisation’s caring principles, that acknowledges the diversity of clients and allows counsellors and clients to build towards an agreed ending. For counsellors, the ethical questions raised by this experience may well need addressing within supervision.
  
  Deciding on the best course of action is fraught with difficulties, and some disappointmens are inevitable. The possible alternative funding, if it materialises, may be insufficient to maintain the previous level of service, or it may arrive after the rest of the funding has been spent. Delaying the decision about when to inform clients because of these unknowns may well bring other issues. For example, if the funding was insufficient and some staff had to be laid off, who is to go and who to be retained? What criteria are to be used in making this decision? This has a knock-on effect for certain clients. What are the short, medium and long- term consequences of the decision? It is impossible to say but the management and individuals involved will have to grapple with the question of accountability.
  
  References:
  
  1. Gabriel L, Casemore R. Guidance for ethical decision making: a suggested model for practitioners. In: Talking therapies: an essential anthology (2nd ed). Lutterworth: BACP; 2008: 143-150.
  2. Smail D. The origins of unhappiness. London: Harper Collins Publishers; 1999: 74.

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  November’s dilemma
  Aimee is a young counsellor. She is keenly aware of fashion and it is important to her to dress in a fashionable and attractive way. She likes to wear low-cut tops and short skirts, or low-cut dresses in summer, and either peep-toe sandals or high heels. She wears full makeup and perfume as a matter of course.
  
  Aimee has a strong religious faith and wears a symbol of this outside her clothing. This too is important to her. However, a colleague has recently mentioned that this might be off-putting to some of her clients. Aimee took this to her supervisor, who responded by saying that, in fact, her whole style of dress may be inappropriate as it may give the wrong signals. However, Aimee believes that if she changed her style of dress she would be uncomfortable and not congruent. Inevitably, she believes, this would spill over into her client work. What are the issues that Aimee should consider?
  
  Please keep your responses to 500 words or less. Outline your responses to the dilemma and make your thinking as transparent as possible. A selection of answers will be published in Therapy Today, with others appearing on TherapyToday.net. Email your responses before 28 October to Heather Dale at hjdale@gmail.com.