This month’s dilemma
Isla has been seeing Benjamin, a young man in his 20s, for a couple of months. He has come into therapy to please his parents who are worried about his eating. As Benjamin has little money, they are paying for his therapy.

Benjamin is ambivalent about therapy, although accepting that he has a problem, and saying his eating is out of control.

At his last session three weeks ago Benjamin did not pay, saying that he would bring the money next time. However, he did not attend the next booked session and has not responded to letters.

Should Isla inform his parents, asking them to pay for the missed sessions?

Joanna Green (integrative counsellor/psychotherapist)
When I read this dilemma my instinctive feeling was that it would be inappropriate for Isla to contact Benjamin’s parents about his non-payment and subsequent no-shows. Firstly, on the grounds of confidentiality, I think it is unethical to discuss with a third party (other than a supervisor) what goes on between patient and therapist and this includes any issues which are raised over payment of fees.

Secondly, contacting Benjamin’s parents feels to me like an undermining of his autonomy and I would even go so far as to suggest that it reinforces a feeling of collusion between Isla and his parents which may have been unconsciously set up by her accepting their money. By contacting his parents I think that Isla would be giving out a message that Benjamin is not responsible for his own actions which could further devalue somebody who I suspect has very little sense of his own worth.

There seem to be a number of issues around control and power contained within this dilemma. Despite not being physically present, Benjamin’s parents are nonetheless exerting a controlling influence in that he is trying to please them by coming to therapy and they are paying for it. I wonder what his underlying, perhaps unacknowledged, feelings are about this.

Benjamin’s relationship with food is also described by him as ‘out of control’ which may be a reflection on other aspects of his life, things which are too difficult to own. If we think about Benjamin’s behaviour, he is sending out a strong message to Isla; by not paying what is owed and then not coming for his therapy, I suspect that he is angry about ‘being sent’ to therapy and is behaving in a way which is both defensive and aggressive. If he is ambivalent about the therapy and is there as an act of submission to his parents, this could be seen as a way of retaliating in a subversive and non-confrontational way. So despite his apparent subservience, he is fighting back.

Payment is a significant part of the therapeutic relationship and is often a contentious issue. In Benjamin’s particular case I think the fact that his parents were paying could be subject to closer examination and I would hope it was given some breathing space to be explored in the therapy sessions. I wonder if this situation would have arisen if Benjamin had contributed something towards his own therapy. Perhaps this could have given him a sense of value not only for the therapy and therapist but also for himself. I think this dilemma opens up the wider question about whether or not it is ever appropriate for someone you know personally to pay your therapy fees. In this particular case, my feeling is that Isla unfortunately needs to take the financial hit and hope that by giving Benjamin the freedom to make his own decisions, he will be able to act appropriately.

Jean Dyerson (integrative counsellor working in two agencies, one generic and the other drug and alcohol)
My first uncensored thought was that Benjamin is keeping the money that his parents are giving him for counselling, as some extra cash for himself, as he does not really want counselling. This is my judgment and as this is not really my place, I would take my thoughts to supervision.

My intuition tells me that Benjamin is not ready for counselling. However, now he knows it is available to him. Hopefully, one day he will return to address the underlying issues around his eating problem. If he self-refers and funds his own counselling he may well receive the support he needs and learn to work on himself and gain self-awareness and self-worth.

I do not believe that Isla should contact Benjamin’s parents as Isla’s counselling contract is between her and Benjamin and not her and Benjamin’s parents. If Isla decides to contact his parents, she will be breaking confidentiality.

During the session when Benjamin did not bring the money, Isla could have stuck to professional boundaries and stopped the session to make it clear that sessions need to be paid for in order to continue counselling. As it was, Isla trusted Benjamin to return the following session with the money for two sessions and this trust was broken.

What Isla could do now is to send Benjamin another letter in the post stating the amount of money that is owed and offering him another appointment. She might also ask him to confirm he will be attending the next session, explaining that if he does not confirm, no further counselling sessions will be offered to him. If he does not return, Isla will have a loss of only two session payments and will have had some learning on how to do things differently in the future.

Turiya Martyn Gough (BACP accredited member in private practice and a GP surgery)
Isla’s dilemma highlights the drawbacks associated with seeing a client who is not necessarily in therapy voluntarily but perhaps has been persuaded by others to attend. In this instance it appears that Benjamin’s parents have pressured him to attend counselling and have offered to pay the fees on his behalf. I doubt that anyone reading this article will not intuitively suspect that the nature of Benjamin’s presenting issue could well be around the very people funding his counselling – 
his parents – which is always a difficult issue. Indeed one could even be suspicious that perhaps their choice to ‘pay for his therapy’ may reflect a parenting style of hiring professionals to raise their son and abdicating their own role? Benjamin’s ambivalence around therapy may indeed reflect his discomfort in his relationship with his parents as well as uncertainty about confidentiality between the therapist and his parents. Any breach of confidentiality could deter Benjamin from ever returning to counselling.

With regard to payment of fees, Benjamin is an adult and Isla’s contract is with him. I sincerely hope that she would not entertain any notion of breaching her client’s confidentiality by discussing outstanding fees with any third party, especially his parents. She has written to Benjamin and must now decide whether to write off the fees or instigate recovery action, the latter being a course of action that I would hope very few, if any, therapists would ever consider.

Helen Lill (BACP senior accredited counsellor in private practice; manager of an NHS workplace service)
My first thoughts went to the initial contracting between Isla and Benjamin. If Benjamin is an ambivalent client there are important aspects to consider, such as his commitment to attendance, cancellation terms and conditions, responsibility for payment and the overall conditions within which Isla provides counselling.

How much does Benjamin accept that he has an issue/problem and wants therapy? I think contracting is all-important, along with anticipating the context for counselling before these dilemmas are reached. My own work is grounded in time-limited therapy but as a principle I believe in reaching out for the adult in clients to ensure that they value their therapy and make the decision to engage from the first session.

Colin Feltham¹ introduces a note of caution in relation to certain types of people who may not benefit from this form of counselling. He says, for example, people (who he states, are often men) may deny their dependency needs and be unwilling to collaborate or to accept responsibility for their own lives. Also Culley and Wright² suggest that client histories are not irrelevant and it depends how feasible connections are between a client’s past and present to discover how changes can be facilitated or symptoms relieved.

Contracting could assist Isla to sort out some of these parameters at the beginning of counselling rather than after session three where Benjamin did not attend for a fourth session or pay for his third session. The dilemma of breaching confidentiality/ responsibility by informing his parents or asking them to pay for the missed sessions would not arise if the psychological contract was clearer at the outset.

Alternatively I can see that some clients are accepted for what one may call pre-therapy to experience empathy/core conditions/relational depth or agree with the modality that is offered, before they decide to commit to the therapy. If Isla is working in a longer-term context where this is normal, I think the wider surround to the counselling context still needs to be illuminated and the conditions for such absences or payment still need to be clear to Isla. This is within a longer-term service or privately. It is still about the context within which the counselling is offered and not about the individual client per se; as therapists we may anticipate these issues arising.

The Ethical Framework charges us to appreciate how we provide our services equitably, fairly and respectfully and with sound judgment for our clients.

References:

1. Feltham C. Time limited counselling. Sage; 1996.
2. Culley S, Wright J. In McMahon G, Palmer S (eds). Handbook of counselling. Sage; 1997.

Michelle Mennitto (counsellor-in-training)
It is clear that Benjamin is all too aware of his problem. However it is also clear that his ambivalence about therapy is the same ambivalence in the relationship with his parents. As Benjamin is in his mid-20s I would say that informing his parents of his missed sessions would be an unethical breach of confidentiality.

Ending the counselling without notice might have also been Benjamin’s only way to deal with the pressure from his parents and I wonder to what extent his lack of assertive skills is contributing to the maintaining of his avoidant behaviour; hence disclosing such information to his parents and the confrontation that might follow could escalate into a violent outburst, as Benjamin is clearly struggling to find an adaptive behaviour within his interpersonal relationships.

It is unclear if Isla has, during the two months of contact, helped Benjamin to identify a clear goal. This is something that could have been worked on at the outset of therapy, taking into consideration the pressure from his parents, followed by the financial help for Benjamin to attend counselling for his eating disorder.

I would have been keen to find out if counselling was what Benjamin really wanted, and I suspect that with the right level of consideration for the client, the answer might have been no, or, on the other hand, the direction of therapy could have taken a totally different route from that of the presenting problem.

In addition, as a trainee counsellor, I feel uncomfortable at the thought that in my future practice clients might end the relationship as abruptly as Benjamin did. If I was in Isla’s position, I would be wondering if accepting him as a client might have exacerbated his lack of assertiveness, thereby further damaging his decision-making skills and perhaps helping him maintain his eating disorder.

Financial gain is something that I would have taken to supervision, as it might be the reason why Isla accepted work with this client in the first place. I would personally not have worked with this client, and perhaps, as a consequence, the client might have had the chance to get in touch, however briefly, with his feelings about his current situation and might seek counselling as a choice not as a condition.

February’s dilemma
Betty and Tanya are second year students on a diploma course. Both see the same supervisor, although at different times. Betty has found supervision very difficult and challenging at times, whilst Tanya is much more enthusiastic. However, the course demands that students maintain the same supervisor for at least a year and there are penalties for students who change supervisors mid-year.

Tanya recently asked Betty if she could tell her something in absolute confidence. As they are friends, not professional colleagues, Betty agreed. Tanya confided that her supervision sessions have become more personal and she has started to meet with her supervisor outside of supervision times. As Tanya is so near the end of her course, they have agreed that they will continue with their supervision contract until the end of the academic year, when Tanya will find a new supervisor.

Betty is very unsure about this and would like to talk it over with someone more experienced. However, she feels bound by her agreement with Tanya to keep her confidence. She is also aware that, in order to finish the course, she needs to maintain her own contact with the supervisor. What should Betty do?

Please keep your responses to 500 words or less, making your thinking as transparent as possible. A small selection of answers will be published in Therapy Today, with others appearing on TherapyToday.net.

Please email your responses, as well as suggestions of (suitably disguised) dilemmas, to Heather Dale at hjdale@gmail.com.