|"Kenneth is waiting for his online supervision session to begin with Angela. She recently started working in a prison and Kenneth is very conscious that he has never worked in a prison setting himself. Nor has he previously supervised anyone else who was working in a prison. He is wondering what issues Angela will bring to supervision and whether his lack of experience matters. When they discussed this in their last supervision session, Angela was OK about his lack of experience but Kenneth is still worried" |
|"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?" |
|"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" |
|"A gay counsellor advertises for casual sex on the internet. Is this a potential personal disclosure too far?"|
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?
Dilemmas – Just the three of us
This month’s dilemma
Rachel is a therapist who has been working with her client, Satya, for some time. During the course of therapy Satya has discussed difficulties she has experienced with her partner, which were a large part of her reason for entering therapy. She feels that therapy has helped her to reach a good understanding of her issues. She now feels that it would be beneficial for her partner to attend a one-off session so she (the partner) can see for herself exactly what has been achieved. Satya is convinced that this would make a huge difference and help her to progress in her relationship. As it would be a one-off, Rachel is considering allowing Satya’s partner to attend. What issues should Rachel consider in making her decision?
Andrew Reeves (counsellor/psychotherapist, supervisor, trainer, editor and writer)
It is so tempting, following a positive experience, to want to share it with others and particularly with those we love. We might, however, speculate on Satya’s motives beyond sharing a good experience, including wanting to prove things are different; trying to engender change in her partner; wanting to show her partner the good relationship she has with Rachel, and so on. In making her decision, Rachel must keep in mind the potential for a myriad of dynamics hidden in Satya’s request.
Whether it is a single meeting or several, Satya’s partner would be brought into a relational dynamic between Satya and Rachel from which she was previously excluded. It is not uncommon for the partners of those in therapy to hold anxieties about the focus of therapy and project their worst fears onto the therapist/process. Rachel (presumably) knows a lot about Satya’s partner from discussions that might have taken place in therapy, all from Satya’s perspective. Satya’s partner might be very wary of what Rachel knows, and what Rachel then thinks of her. Satya’s partner might also potentially feel quite threatened by the existing relationship between Satya and Rachel, and might continue to feel excluded from it even though she would be physically present.
In short, Satya’s therapy was contracted to focus on Satya’s needs. To re-frame the relational dynamics at this stage by including Satya’s partner as, essentially, an ‘add on’ to the relationship has the potential to do more harm than good. It might not turn out to be positive for the partner, for Satya or for Rachel. Ultimately, it might also make it difficult for Satya to return to Rachel in the future, if needed. One-off or not, Rachel’s task is to explain this sensitively to Satya and to help her reflect on the dynamics behind her request.
Julia Segal (psychodynamic counsellor, trainer and author)
This is a more complicated issue than it appears on the surface. My rule of thumb as a relationship counsellor is: if a client comes on their own, keep them on their own; if they come as a couple, keep them as a couple, and if this requires working with each in separate sessions, keep the number of sessions as equal as possible. This rule would help me to think about and explore why Satya came on her own in the first place.
It would also depend on the contract. If I were working as a relationship counsellor, this would have been discussed from the beginning. If I were to see both parties, I would first make sure that both had a chance to make a relationship with me on their own, before meeting me together. Otherwise there is a risk of the new attendee feeling ‘ganged up on’. If Rachel were to meet Satya’s partner separately, it would set up all kinds of complicated relationships and feelings that I would not expect to be helpful. If Satya is unable to tell her partner ‘what has been achieved’, then I am not sure that this is the role of the therapist. It infantilises Satya and makes the therapist a supposedly more powerful extension of Satya. Is Rachel being called in as part of a complex power game? It might be more helpful to explore these issues.
In terms of specific considerations, I would wonder what Satya wanted Rachel to tell her partner, and whether it was what Rachel would want to say. Satya might easily feel betrayed. She might or might not be happy if she saw her partner and Rachel getting on well, or arguing or disagreeing. She would have to cope with complex jealousies and issues of separation as she realises that Rachel is not just there for her but is also someone ‘out there’ who potentially has a relationship with her partner. People can have complex feelings about the therapist of their partner, including destructive and angry ones as well as positive, hopeful ones, and these may have to be worked with if Satya’s partner attends a session.
I would only seriously consider going ahead with Satya’s suggestion if Satya had come to Rachel because she specialised in a particular condition (eg an illness) and the focus was on the illness and its effect on the relationship. Then it might make sense that the therapist should help the client to talk to significant others about the illness and its impact on their mutual lives after having first explored it extensively with the person who is primarily affected. There might be other exceptions, where the therapist is being asked to help a client to reveal something very difficult or frightening to a partner, but I would still want to consider very carefully the impact on the relationship between client and counsellor.
Helen Stangret (integrative/cognitive behavioural therapist)
My initial reaction to this dilemma is to want to ask Rachel and Satya some questions. Satya says she has reached a good understanding of her issues. I wonder how this understanding has affected her emotionally and the important relationships in her life.
I also wonder what exactly Satya hopes to gain from bringing her partner to a one-off session and how attending this session would help her partner to see what she had achieved. It seems that she may want the therapist to communicate something on her behalf. Does this mean that there is something she is unable to communicate to her partner?
Are there more direct ways that Satya and Rachel could work on improving this communication? Does Satya have shameful experiences/behaviours that are preventing her doing this? Does she feel scared, judged or angry?
As therapy has been ongoing for some time, Rachel and Satya are likely to have an understanding of Satya’s patterns in relationships. It may help to understand this dilemma in that context. I would also wonder about the partner’s thoughts and feelings. It is highly likely that she has her own needs and difficulties in the relationship that perhaps cannot be put to one side in order to understand what Satya has achieved.
This sort of exploration could open up different ways for Satya to deal with this issue. In future she and her partner might benefit from couples counselling with another therapist. I don’t think that the proposed meeting would benefit Satya, her partner or the relationship.
Anita Tedder (counsellor and supervisor in private practice)
There is no one right way to be a counsellor and sometimes a flexible response can be helpful. However, in this case, Rachel is faced with a scenario that has the potential to undermine all her good work and jeopardise her relationship with her client.
Satya is asking Rachel for a one-off session because she feels it will benefit her partner to see what has been achieved and that it will help her, Satya, to ‘progress’ in her relationship. This raises several questions. What is happening in their relationship that Satya’s partner can’t see what has been achieved in their day-to-day lives, but could if she came to a single counselling session? Why would meeting Rachel help their relationship progress?
It might help Rachel to understand the part she is being asked to play in the dynamic between Satya and her partner. She could consider whether this request resonates with a triangular relationship from Satya’s past, some kind of family triad, a sibling or love rivalry. Perhaps Satya feels she needs Rachel’s support and physical presence to be truly heard or understood in her partnership, but, in that case, Rachel’s role is to respect Satya’s autonomy and help her find her voice.
It’s possible that Satya may feel so helped and supported by Rachel that she simply wants her partner to come along and meet her. This simple request is full of potential pitfalls. Satya’s partner may not like Rachel. She may come to the session feeling nervous and stay silent; she may open up and talk candidly about her own difficulties. Does Rachel work with or ignore the partner’s problems? Satya would have to share what’s usually solely her time with Rachel and afterwards manage her partner’s positive or negative feelings. Whatever happens complicates the counselling relationship between Satya and Rachel.
Rachel’s role is to help Satya find out what she hopes the meeting will achieve that she feels she cannot enable for herself. With exploration, Satya’s personal power, autonomy or whatever it is that she feels unable to express to her partner – perhaps jealousy, anger or fears – can emerge.
Rachel could re-visit the contract she has with Satya, explain the differences between couples and individual counselling and, perhaps, suggest a couples practitioner. But in this case, in my view, she should hold the boundary and not agree to Satya’s request for a one-off session with her partner, simply because it is in Satya’s best interest as the client.
Amanda Parfitt (counsellor and supervisor in private practice)
This dilemma reminded me of a similar experience in my private practice. I would suggest that it would be useful for Rachel to explore with Satya why she thinks it would be helpful for her partner to attend a therapy session, and the benefits and the possible negative consequences of her doing so.
Rachel would need to make it very clear to Satya and her partner that Satya is the client; her partner would be coming into the session as Satya’s guest. It needs to be clear to all that this would not be a relationship counselling session: this is a chance for Satya to disclose whatever she chooses to her partner with the counsellor in attendance; an opportunity to discuss her counselling issues with her partner in a safe place. It is therefore also important for Satya to realise that it is only fair that her partner be given space and time to respond.
Rachel and Satya will have developed a close therapeutic relationship, which may be daunting for Satya’s partner to enter into. She may feel an outsider and quite intimidated. It is important that she is welcomed as Satya’s partner in the session and made aware that anything she may say is also confidential. Rachel would also explain that, although Satya is her client, the partner would be shown the same respect, confidentiality, non-judgment, congruence and empathy. Also, in line with the confidentiality agreement between Rachel and Satya, Rachel must state at the beginning of the session that she will not disclose anything that Satya has discussed with her in therapy. Rachel’s role in this session is to provide a safe, respectful space for both Satya and her partner.
Due to the sensitivity of the situation for all parties involved, it may be useful for Rachel to discuss this with her supervisor, preferably before she makes her final decision. If the session goes ahead with the partner included, it would be helpful for Rachel to discuss the outcome with her supervisor.
If Rachel and Satya have collaborated fully and the partner is in full agreement before the decision is made, I think it could further strengthen the therapeutic relationship. However, Rachel would have to prepare for possible pitfalls whichever way she decides.
Barbara Mitchels (counsellor in private practice)
Rachel will need to think about several legal and ethical issues, including her client contract, confidentiality, records, and the extent of her duty of care to her client. How will her existing therapeutic relationship with Satya affect the proposed joint session?
Satya is Rachel’s current client, with a contract for individual sessions. If Satya’s partner joins them, then that contract changes. They must agree who will be treated as Rachel’s clients for a joint session and negotiate a new confidentiality agreement.
Satya has probably been talking quite a bit about her partner in the course of her therapy. She and Rachel now have shared knowledge. Rachel cannot reveal issues and information from earlier sessions without Satya’s consent.
Will Satya expect Rachel to ‘be on her side’ in a joint session? How will Rachel handle things if Satya brings into the discussion issues from the past that may be a surprise to her partner?
Will Rachel (perhaps unintentionally) rush to protect Satya (or her partner) if one of them is confrontational in the session? Will Rachel be able to offer equal empathy to both persons in the room in a joint session?
What achievements does Satya want to ‘show’ her partner in the joint session? Is this the best way to do it?
Rachel owes a duty of care to Satya (and her partner in any joint session). She should consider the BACP Ethical Framework 2010, and the following issues in particular:
- client autonomy and the balance of power in the room – will the partner feel disempowered in a joint session with a counsellor in a therapeutic relationship with Satya?
- beneficence, and non-maleficence – Rachel should ask herself who will be helped by her seeing the couple together, rather than a different therapist. Can she help them more than another therapist might? If so why?
Will Johnson (counsellor in private practice)
I have found myself in Rachel’s situation more than once and have always said no. Rachel’s contract is with her client, Satya. If she allows the dynamic of the dyad to change even once, then her contract shifts to Satya’s relationship. Her partner cannot be treated as some sort of add-on who has been allowed the rare privilege of seeing how well Satya relates to her counsellor.
Rachel may well observe things in the relationship that completely up-end every confidence that Satya has shared with her. Not only may Satya lose confidence in Rachel; more seriously, Rachel may lose confidence in Satya. She has to be able to believe in her, and to live in her world. If that world is to be challenged, then this needs to come from within the client – those moments when there is a mismatch between two world views, as propounded by the client.
I recall a supervisor once saying to me that, if a client chooses to tell lies, then that is their privilege. It is only when the lies come into conflict with another reality within the client that the counsellor can claim any right to point out the contradiction.
Furthermore, confidentiality is to be maintained, even when the client asks for it to be broken.
I suspect that it is going to be far more fruitful for Rachel to invite Satya to explore more fully the reasons why she wants her partner to come to a session. What does she hope will happen? Does she want her partner to be a passive witness to the intimacy that she has with Rachel but doesn’t have with her partner? Whatever the reason, it is hard to see how her partner attending a session is going to achieve the breakthrough in communication that she may be seeking.
Next month’s dilemma
Aafreen is the manager of a busy voluntary counselling service. The receptionist, Ben, has been working there for several months. His work has been good, although Aafreen has found Ben’s manner with some of the clients to be rather abrupt. Ben has recently qualified as a counsellor, although on a course that demanded very little client contact. He has now suggested to the management committee that he could provide counselling one day per week while continuing to work as a receptionist. If he cannot do that, he is anxious that his counselling career may be held back. What are the ethical issues involved?
Please email your responses (500 words maximum) by 28 June 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 our website. Readers are also welcome to send in their own ethical dilemmas for consideration for publication, but these will not be answered personally.