Janine thinks two of her supervisees are both working with the same vulnerable client but that the client hasn’t told either of them. Should Janine reveal what she suspects?
Dilemmas: Caught in the middle
This month’s dilemma
Janine works in private practice as a counsellor and supervisor. One of her supervisees, Tiffany, who is nearing the end of the second year of her training, is discussing a client. Janine gradually becomes aware that the client must be the same person with whom another of her supervisees, Michael, an experienced counsellor who works in a voluntary organisation, is also working. The client is vulnerable, with suicidal ideation.
What should Janine’s role and responsibilities be in this situation?
John L Threadgold (focusing-oriented therapist and supervisor)
Does Janine know that the client is in dual therapy or has she jumped to conclusions? As a supervisor, I respect client confidentiality, to the extent that I do not know the names of my supervisees’ clients. If we assume that the details are identical, so that the answer is yes, the next issue is also a confidentiality issue. Janine would not normally talk about one supervisee’s client work with another supervisee. Should confidentiality be broken in this instance and if so why?
There is nothing in the BACP Ethical Framework that advises a therapist against working with a client who is receiving dual therapy. As long as the therapist’s assessment is that the client is not put at risk by having dual therapy or otherwise being overwhelmed by the experience, then client autonomy should be respected. Clients may have all sorts of legitimate reasons for dual therapy. For example, they may be a member of Alcoholics Anonymous, go to group therapy for anger management and have individual therapy for depression. They may decide to explore one set of issues with therapist A and another set with therapist B.
Let us suppose that Janine feels that the dual therapy is putting the client at risk of harm in some way. This raises a number of key questions. What is it about the dual therapy that is putting the client at greater risk of harm? What would be the impact on the therapeutic alliance between the therapists and the client if the therapists were informed about the dual therapy? It may be very disruptive and potentially dangerous, or it may not. Would passing this information on to the client and the client having to give up one therapist put him or her at greater risk than the dual therapy itself? Client welfare is paramount.
There is one other factor: do either of the organisations for which the counsellors work have a policy prohibiting dual therapy? If yes, then would Janine be bound to inform the supervisee who works at that agency? If the sole reason for informing Tiffany and/or Michael was the policy of their employing agency, then the answer would be ‘no’ – the BACP Ethical Framework should take precedence over agency policy.
Will Johnston (counsellor in private practice)
There is an odd symmetry here, which may (or may not) make it easier to make sense of the dilemma. Janine’s first responsibility is to the client, and it is the client who has set up the dilemma by consulting with two counsellors without telling them. Janine’s supervisees are the two ‘innocents’ caught in the middle.
Janine must not do anything that might damage the relationship between the client and either of the therapists – her two supervisees. If she tells either one what she knows, then she risks damaging the trust that the two counsellors have for the client. In my view, it is no less important for the counsellor to trust the client than it is for the client to trust the counsellor.
My own belief is that the client is perfectly entitled to have as many counsellors as he/she wants. It may not be wise, but it is his/her right, as is his/her right to be a different person with each and every counsellor. (The implication in this case is that the client is being reasonably consistent, otherwise Janine would not have come to her realisation.)
In any case, each counsellor will be bringing a different person to supervision, since their view of the client will be coloured by their own personality, style and way of relating. If her supervisees are any good at what they do, then both narratives will be valid. But can Janine bracket one off from the other? She cannot bring what she knows from one supervisee to her relationship with the other. Is there also a danger that she will tend to trust the narrative of the more experienced over the less experienced? If Janine’s first responsibility is to the client, then she owes equal responsibility (and respect) to her two supervisees.
The drastic solution would be to tell both supervisees, with a view to each confronting the client. It could work, but it could also be a complete disaster. If the client is very vulnerable, then this might well push him or her over the edge. The risk is far too great to be contemplated. I mention it only because this might be one of the possibilities that Janine could discuss with her own supervisor – to be rejected with a host of other equally impossible solutions.
There may, of course, be a powerful argument for Janine just to sit with the fact of not knowing, and this could turn out to be extraordinarily fruitful for everyone. The phrase ‘I don’t know what to do’ is often the best starting point towards a solution.
Mary Williamson (therapist and charity worker)
As a supervisor, one needs to think of the professional development of both the supervisees and the welfare of their clients. There are three people to think about in this situation. In principle, one needs to find the most honest approach while maintaining confidentiality. Any kind of fudging of the situation in order to spare hurt would do more harm than good.
Janine could keep her knowledge secret in the name of confidentiality, but I believe that her relationship with her supervisees would be affected. She needs, in individual supervision, to be open about what she has realised and offer a joint meeting, not to discuss the actual case but to discuss what they would like to do about it. It might be a good idea, if this were likely to be a long-term case and the client continues with both counsellors, for one of them to decide to find another supervisor but this would need to be thought through in the particular situation and in relation to the voluntary agency and training programme.
Fundamentally the client, whether it seems like a good idea or not, has chosen to have two counsellors. Has the client been upfront about this with the two counsellors or is he or she ‘splitting’? (Is she keeping Tiffany and Michael in the dark about this or openly mentioning one to the other.) As a psychodynamic counsellor, I wonder why the client has chosen to work with two counsellors. Is something being worked out from the past? Could the pattern be linked to adults in her past?
Does the client need to know about all this? The situation would be easier to resolve if she had already made one counsellor aware that the other exists. The situation could then be raised with the client and openly worked with. Unfortunately, as the dilemma has been posed, this is not clear.
Susy Churchill (counsellor, supervisor and trainer in private practice)
My first response is concern for the client: how did she come to be seeing two counsellors at the same time? Does this reflect a level of felt need: that she does not feel that she is being taken seriously enough? Or was she on two different waiting lists and felt too embarrassed to reveal this when the second contract became available?
My second response is that none of the above matters in the immediate context of the role and responsibilities of the supervisor. In Janine’s shoes, I would explore the training that both Tiffany and Michael have received about working with vulnerable clients, their level of knowledge and confidence about risk assessment and the steps they might take if the client disclosed, for example, an imminent plan to take her own life. This would fit with the formative and normative aspects of supervision, and talking through practicalities would probably help to avoid both Tiffany and Michael feeling overwhelmed.
My primary intention would be to give Tiffany in particular, as the less experienced counsellor, enough information and space to explore whether she felt it was appropriate for her to continue working with this client, or whether it would be more ethical to refer the client on.
If Tiffany decides that working with this client is outside her current competence, I would explore with her where she might refer the client and how to facilitate the referral, possibly role-playing how she might explain this to the client. This might lead to the client revealing that she is already seeing another counsellor, and it would be important in our next supervision session to explore with Tiffany how this referral meeting had gone, to process any feelings she may have of inadequacy or of abandoning/rejecting the client.
I might want to review with Tiffany’s agency and Michael’s organisation what policies they have in place to record whether a new client is receiving therapy elsewhere. I would keep this as a general enquiry; this specific client has not divulged that s/he is concurrently receiving therapy from two therapists and it does not feel right for me to override his/her autonomy.
Next month’s dilemma
Lloyd, an experienced counsellor, has been working with a couple, Julie and Tom, for around six weeks. The impetus for the counselling came from Julie, and Lloyd is aware that Tom only comes to please Julie. Lloyd has not found the work easy and has sometimes struggled to contain their aggression, some of which is towards him, particularly from Tom.
One day, when Lloyd is idly scanning the internet, he comes across a blog written by Tom entitled ‘Couples counselling – a true story’. Lloyd is very tempted but decides not to read further. However, he wonders whether he should tell Tom that he has seen it or wait for Tom to bring it up first.
What are the ethical dilemmas involved in this scenario and what should Lloyd do?
Please email your responses (500 words maximum) by 28 September to Heather Dale at firstname.lastname@example.org. Outline how you would manage the dilemma and make your thinking as transparent as possible. Readers are also welcome to send in their dilemmas for consideration for publication, but these will not be answered personally.