|"Ben wants to work as a counsellor in the agency where he is already employed as the receptionist. His manager feels under pressure to support his career development, but would this dual role be ethical?" |
|"Satya feels she has really benefited from therapy. Now she wants her partner to come to a therapy session. But perhaps the key question for her therapist is not whether but why?" |
|"Cameron gets on well with his therapist. They have developed a quasi-supervisory relationship during his counselling training. Now he needs to find a supervisor, and thinks she might be ideal"|
Janet recommends her own supervisor to a friend looking for a therapist. Then they fall out. And suddenly Janet’s relationship with her supervisor becomes a potentially unsafe space
Dilemmas: A friend in need
This month’s dilemma
Janet, a psychotherapist in private practice, has become friendly with Alma, whom she met through a social club. Alma has been in and out of therapy over the years and is currently looking for a new counsellor.
She asks Janet if she could suggest someone, explaining that she needs a counsellor with skills and knowledge in a particular area. As it happens, these are exactly the areas in which Janet’s supervisor specialises, and so she suggests her.
However, Janet and Alma have a falling out and their friendship ends. Janet is left feeling very uncomfortable about the situation. She believes that her former friend will be discussing her in therapy and she is anxious that this might have an impact on her own work in supervision. She knows that, for reasons of confidentiality, her supervisor could not tell her anything Alma has said and wonders what she should do.
Matthew Henson (existential psychotherapist in private practice)
I sympathise with Janet. It is natural to want to recommend the best support to friends and what better recommendation than someone she has personal experience of working with? However, while this particular situation could not have been predicted, therapists do need to be aware that these kinds of problems can arise.
The main concern here has to be that, for whatever reason, Janet feels that the situation with Alma might have an impact on her work in supervision. One of the vital roles of supervision is that it protects both the therapist and her clients. In any client–therapist, therapist–supervisor relationship there are potentially all manner of internal inhibitions that need to be negotiated and this is an integral part of the process. However, when the therapy/supervision is limited by external factors, this is much more problematic. If, as it seems, Janet feels inhibited by her fantasies about what Alma might be saying in therapy, then her working relationship with her supervisor is compromised. This makes the supervision less safe and could have negative consequences both for Janet and her clients.
Janet and her supervisor both have an ethical duty to address this issue. We cannot assume that Janet’s supervisor is aware of the situation, so Janet has a responsibility to raise it with her. While it is correct that the supervisor should not disclose anything Alma might have said, there is no reason why she cannot discuss the situation in general with Janet. Janet is entitled, and I would say she is morally obliged, to talk about her concerns, both for her own protection and that of her clients. Janet could, for example, ask her supervisor directly for her views on whether their relationship has been compromised and how this might be managed. After all, supervisors are there to help.
The situation is not necessarily irreparable. Therapists and supervisors can hold difficult boundaries while working separately with two or more people who know one another. This is often the case, for example, when therapy is provided within small organisations supporting a specific client group. The key to success is that all parties trust the therapist/supervisor’s ability to maintain appropriate boundaries.
It might be that Janet’s discussions with her supervisor result in her feeling reassured and that they are able to maintain an appropriate and supportive working relationship. Alternatively, Janet and/or her supervisor might conclude that the situation with Alma means that an effective supervisory relationship is no longer tenable. Regrettably, in those circumstances Janet would need to find a new supervisor, having learned a difficult lesson the hard way.
Jonathan Rosen (therapist and supervisor in private practice)
With all the pitfalls of dual relationships and unforeseen connections, this is one scenario that might have been anticipated. As professionals we have a duty to take care of all aspects of our work, including making referrals. Did Janet talk this through with her supervisor before making the suggestion? I suspect not, as any supervisor worth their salt would have wanted to discuss how appropriate this referral was.
However even if Janet hadn’t alerted her supervisor to this possible referral, one might have thought this would emerge during the assessment process with Alma. Had this happened, at this point the supervisor could have considered whether this might impact on the supervisory relationship with Janet.
I wonder also what has happened between Janet and Alma. There appears to have been some blurring of boundaries and also a disruption of their relationship. Does this feel familiar to Janet? Is this a pattern of which she is aware, or becoming aware? And how might that awareness be used in her work with her clients, both in her ability to empathise and in her ability to recognise her own blind spots?
Hindsight is a great thing and even the most scrupulous and experienced can end up dealing with dilemmas such as this. Janet’s main concern appears to be the impact this will have on her supervisory work. Hopefully she will have a relationship with her supervisor where she is able and encouraged to bring such concerns. This will be an opportunity to talk through what has happened and to decide whether it is possible for the supervisory relationship to continue, as well as being a valuable piece of learning.
I do not think there is always a contra-indication to this type of dual relationship but it needs to be thought through very carefully – and I would probably want to err on the side of caution. After all, there was really no need for Alma to go into therapy with Janet’s supervisor.
In the end Janet’s primary responsibility is toward her clients and if she feels too uncomfortable in the current supervisory relationship she may need to move on.
Lynn Fryer (counsellor and manager)
My first response was to wonder about the thought processes behind the supervisor’s decision. Perhaps she did not consider the possibility of two connected people falling out with each other and the fact they might both wish to discuss the other in therapy/supervision. It might have been best to avoid the situation altogether by referring Alma to somebody else from the start (assuming the supervisor knew of the relationship between the two). At the very least I would have thought the supervisor would have established some boundaries when she agreed to take on Alma as a client, so all parties knew that to discuss the other would not be accepted within the therapy or supervision, regardless of their relationship.
Even with the best of intentions there is no doubt that situations like this can and do arise and sometimes can’t be avoided.
Really the only thing all three can do is agree not to talk about each other during their individual sessions and to hold those boundaries. Otherwise the relationship of trust between supervisor–supervisee and counsellor–client could erode, particularly as each might begin to wonder who the supervisor/counsellor really believes or whether his/her opinion of them has been influenced or changed in any way.
However, to have the freedom to say what is wanted or needed in supervision or therapy even slightly curtailed may mean that none of the three is able to be truly open or congruent, and that is a hugely important element in any therapeutic or supervisory relationship.
Even if all three agree to put boundaries in place, it may be that unspoken frustrations remain, and it is still detrimental to the therapy or supervision not to be able to talk about something that is obviously very important. This is exactly why every therapist I asked in my organisation agreed that it is a situation that should be avoided where possible.
Vernon Cutler (BACP accredited counsellor and psychotherapist)
Guilt or rather shame in this case, can be quite disabling. I remember early on in my own training being helped to discern the difference between guilt and shame; shame is what we are dealing with here.
Janet was perfectly happy to refer Alma to her supervisor when they were still friendly. In which case, what has changed from a professional standpoint? Where is Janet’s congruence? Is not the essence of a supervisory relationship the ability to share some of our more questionable and difficult decisions? If we do not experience ourselves or our supervisory relationship as sufficiently robust to enable that, I would question its value. I remember a lecture given by Professor Brian Thorne some years ago in which he said, ‘If you do not come away from supervision feeling supported, then ditch ’em.’ I have always been grateful for that advice.
If Janet has not acted unprofessionally, then her only other question is the professionalism of her supervisor. If she fears that her supervisor will allow her work with a client to interfere with the positive regard that we trust she also extends to her supervisee, then clearly Janet needs to discuss that in supervision.
Beyond that, given that in a relationship any problem will most likely be the product of the dynamic, then we may assume that Janet is not without blame, in which case what a wonderful opportunity for her to face her own shame and thus exercise congruence. If we cannot exercise humility and admit our own failings, especially in supervision, then how can we begin to ask our clients to do so?
Gaynor Boileau (MBACP (Accred) counsellor, psychotherapist and supervisor in private practice)
The situation is out of Janet’s control; she feels anxious and uncomfortable and wants to do something about it. Two people she knows, who hold many of her confidences, are now in conversation together. I could say that it was ill-advised to suggest her clinical supervisor as a suitable therapist for her friend and, with hindsight, perhaps it was not the ideal option. But would it have made better sense to recommend someone she doesn’t know or to refuse to make a recommendation when she believes that her supervisor is an appropriately skilled practitioner and able to help?
Alma, on the other hand, does not have a problem; at least, not one relating to this dilemma. She has a place to talk about her concerns and, if she does want to use therapy to reflect on her relationship with Janet, she can.
I have confidence in the unnamed person in this triangle. As Alma’s therapist, she will aim for professional distance, recognise anything shared as one person’s truth rather than the truth, and be bound to keep any disclosures confidential. As Janet’s supervisor, she will want to hear in general about any personal issues affecting Janet’s client work but she will not need to hear the details. If she is professional, she will curb her curiosity. In my practice, I suggest and prefer a ‘no names’ policy to protect boundaries and I hope that Janet would resist any urge to name Alma. However, I think Janet is doing her supervisor a disservice to suggest that she might not be able to offer sound supervision in these circumstances.
I would advise Janet to acknowledge the roots of her anxiety and the impact of her lost friendship and to share this anonymously in supervision. Her supervisor will encourage her to reflect on her experience of loss, suggest personal therapy if it seems appropriate, and help her to consider any impact on her client work.
Tibor Poór (psychodynamic counsellor in training)
This is a perfect example of the blurred boundaries that exist within the profession regarding referrals within circles of friends, colleagues and training organisations, and why ethical guidelines have been created and are given so much weight in professional training.
Although we know that the therapist–client relationship is not the same as the supervisor–supervisee relationship, confidentiality applies equally to both. I’m sure we would all agree that taking on friends of friends or family members as therapy clients is inappropriate and unethical, but does the same apply within supervisory relationships? I would like to think so.
The primary role of a supervisor is to ensure the clinical competence of the supervisee, modelling good ethical practice and, above all, mentoring. Our professional tools are our intuition and feelings as well as our cognitive processes. How could we or Janet not have an anxiety about that mentoring relationship being affected or threatened? The source of Janet’s anxiety is whether her supervisor can manage to contain both relationships without either of them being affected by the other. Although it is possible that she could, nonetheless I feel it was an oversight on Janet’s supervisor’s part not to discuss the potential repercussions that taking on Alma as a client may have on their existing relationship. It is Janet’s supervisor’s responsibility to uphold and monitor the frame and containment. There are no written rules about what is ‘too close’ in a relationship between three people in one therapeutic environment, and I do not suggest there should be. The supervisor is the only person in a position to decide whether there was a conflict of interest, but in any case it is wise to avoid any situation that may result in a breach or a cross-contamination of the therapeutic alliances.
I think Janet needs to reflect on what she imagines is being said about her, and why it is causing her such anxiety. What intolerable part of herself is she projecting onto Alma and why does she want to keep that hidden from her supervisor? I would say Janet’s best course of action is to bring her concerns to her supervisor. In the best case, her supervisor will be able to reassure her of her impartial and nonjudgmental attitude. If that is not sufficient to put Janet’s mind at rest, she may have to consider finding a new supervisor.
Gherado Dellamarta (counsellor in private practice)
This is an interesting case that raises issues of trust, confidentiality and boundaries. I wonder how many therapists have been faced with these factors in their practice. With all the social networking websites such as Facebook and Twitter, where do we draw the line between private and public domain and where do we stand as therapists? How much are we allowed to reveal to our friends about our work? How far are we allowed to go to help a friend? What is the difference between being friendly with someone and calling a person a friend?
Janet could have told Alma to look at the BACP website or other therapy websites before mentioning her own supervisor. The fact that Alma was looking for a specialist in a particular area might suggest that Janet has revealed too much information about her supervisor and her expertise. Is this a breach of confidentiality and trust? I am also concerned about Janet’s supervisor. How does she feel about this? What if she decides to stop seeing Janet or Alma or maybe both? It seems that it is the supervisor who may have to pay the price for Janet’s mistake and she will have to ‘hold’ both Janet and Alma. This can raise concerns about Janet’s practice and how much she discloses with her clients. Also, Janet seems to panic that Alma will reveal information to the supervisor. Does this raise concerns about their friendship and how much she trusted her friend?
Maybe this is a lesson for all of us on when it is safe to disclose to friends about our profession and what we can disclose. Having said that, I also think that Janet’s intention was to help her needy friend and that she acted in good faith, but without thinking about the consequences for the relationships with all the people involved.
Next month’s dilemma
Cameron is nearing the end of his two-year counselling training. He has been having therapy for the entire two years, which was a required part of his course. Cameron has found the therapy very useful, both personally and as part of his professional development, and in the process has developed a good relationship with his therapist. The therapist has occasionally suggested books or articles for Cameron to read and has helped him to think about his client practice in the light of his own personal history. Now Cameron is considering stopping therapy but wonders whether he might continue to work with his therapist as supervisor. After all, she knows Cameron so well and would be aware of possible pitfalls in his practice. What are the issues that Cameron should consider?
Please email your responses (500 words maximum) by 30 April to Heather Dale at firstname.lastname@example.org. Outline how you would manage the dilemma and make your thinking as transparent as possible. A selection of answers will be published in Therapy Today, with others appearing on www.therapytoday.net. Readers are also welcome to send in their own ethical dilemmas for consideration for publication, but these will not be answered personally.