CBT Values and Ethics

Books

David Kingdon, Nick Maguire, Dzintra Stalmeisters & Michael Townend

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  • Front Matter
  • Back Matter
  • Subject Index
  • Copyright

    About the Authors

    David Kingdon is Professor of Mental Health Care Delivery at the University of Southampton, Clinical Services Director, Adult Mental Health, Southampton, and Honorary Consultant Adult Psychiatrist for Southern Health NHS Trust. He has previously worked as Senior Medical Officer (Severe Mental Illness) at the Department of Health and has participated in many policy initiatives over the past two decades. He chaired the Expert Working Group, leading to the Council of Europe’s Recommendation 2004(10) on Psychiatry and Human Rights (1996–2003). His research interests are in cognitive therapy of severe mental health conditions and mental health service development, about which he has published over a hundred peer-reviewed papers and many articles, chapters and books. He received the Aaron T. Beck Award for Exceptional Cognitive Therapy in May 2015.

    Nick Maguire is an Associate Professor in Clinical Psychology at the University of Southampton. He is currently the Deputy Head of Department responsible for Education, and has research and clinical interests in excluded populations. He teaches and researches psychological factors implicated in the causation and maintenance of social exclusion, and the implications for the adaptation of cognitive and behavioural therapies. He is a founder member of the Faculty for Homeless Healthcare and was on a support panel for the NHS Inclusion Health Board. He is passionate about enabling excluded populations with serious and enduring mental health problems to access health care, including much needed psychological provision.

    Dzintra Stalmeisters is a Chartered Psychologist and Associate Fellow of the British Psychology Society (BPS). She is trained in Cognitive Behavioural Psychotherapy, Gestalt Psychotherapy and holds a BPS qualification in Counselling Psychology. Dzintra is an Independent Practitioner and is also a Senior Lecturer at the University of Derby. She works on the MSc Cognitive Behavioural Psychotherapy (CBP) course as the Module Leader for Ethics, Law and Research in CBP. Dzintra is also a Doctoral Supervisor and is currently active in research. She is keen to engage students and therapists in conversations and discussion about ethical practice, and quintessentially to make ethics more accessible.

    Michael Townend is a Reader and Senior Lecturer in Cognitive Behavioural Psychotherapy at the University of Derby, where he teaches and researches cognitive behavioural psychotherapy. He also leads the Doctoral Programme in Health and Social Care Practice. He is a Consultant in Cognitive Behavioural Psychotherapy at the SPIRE Parkway Hospital Solihull. Michael was the Founding Editor of the BABCP journal, The Cognitive Behaviour Therapist. He is passionate about the development of values and ethical practice alongside evidence to underpin therapeutic work that has compassion, formulation and the therapeutic relationship at its heart.

    Acknowledgements

    There are a number of people who have contributed to the development of this book and whose interest, encouragement and support we wish to acknowledge.

    We would first like to thank everyone at Sage who have worked with us to bring this project to completion. Particular thanks go to Amy Jarrold, Kate Wharton and Edward Coats – our editorial team – and all at SAGE who have been such a solid source of support throughout the process.

    Beyond those directly connected with this project, we are deeply grateful to all those who, over the years, have shaped our understanding of our diverse professional fields and the values and ethics that we consider can underpin cognitive behaviour therapy alongside a research-based approach to practice. A particular mention goes to the many clients, teachers and supervisors, with whom we have had the good fortune to work and from whom we have learned so much. We also acknowledge our current and former students and colleagues, who continue to challenge us and who have in so many ways shaped this edition.

    David Kingdon wishes to acknowledge the influence of many colleagues he has worked with over the years, especially Douglas Turkington, Shanaya Rathod, Lars Hansen and Farooq Naeem, and most of all, Marie, who appreciated how important it was for this book to be written.

    Nick Maguire wishes to acknowledge Tess, Papa and Tanisha for their patience when dealing with a grumpy dad after a late night at the keyboard. He has learned an enormous amount from his Southampton Psychology Department colleagues about thinking ethically, and more from the homeless people who put up with him as their psychologist.

    Dzintra Stalmeisters wishes to acknowledge her husband Michael and their children, Matthew, Sinead and Ruairi, for their continued support and encouragement. She is also grateful to the students who have taken part in the MSc Cognitive Behavioural and Psychotherapy, Ethics, Law and Research Module at the University of Derby: their engagement with the ethics part of the module has stimulated thought, contributing to the completion of this book.

    Michael Townend wishes to acknowledge Jenny, his family and friends for their love, understanding and patience. His thanks also go to all his colleagues at the University of Derby, for their inspirational ideas and for helping to create the space to enable work on yet another book. Finally, he thanks his students and his clients, who, by their experiences and feedback, have contributed to this text. They also act as a continuous reminder that it is a privilege to be in a position to work with them all.

    List of Abbreviations

    • AACBT Australian Association for Cognitive and Behaviour Therapy
    • AaCT Acceptance and Commitment Therapy
    • ACT Academy of Cognitive Therapy
    • APA American Psychological Association
    • APS Australian Psychology Society
    • BABCP British Association for Behavioural and Cognitive Psychotherapies
    • BME Black and Minority Ethnic
    • BPD Borderline Personality Disorder
    • BPS British Psychology Society
    • CBP Cognitive Behavioural Psychotherapy
    • CBT Cognitive Behavioural Therapy
    • CEBT Cognitive Emotion and Behaviour Therapy
    • CICM Chronic Illness Coping Model
    • COPD Chronic Obstructive Pulmonary Disease
    • CPD Continuing Professional Development
    • CT Cognitive Therapy
    • DBT Dialectical Behaviour Therapy
    • DH Department of Health
    • DSM Diagnostic and Statistical Manual
    • EABCT European Association for Behavioural and Cognitive Therapies
    • EBMWG Evidence-Based Medicine Working Group
    • EBT Evidence-Based Therapy
    • EPR Electronic Patient Records
    • HSCIC Health and Social Care Information Centre
    • IAPT Improving Access to Psychological Therapies
    • ICD International Classification of Diseases
    • KSA Knowledge, Skills and Attitudes
    • ME/CFS Myalgic Encephalopathy/Chronic Fatigue Syndrome
    • MRC Medical Research Council
    • NHRA NHS Health Research Authority
    • NHSU National Health Service University
    • NICE National Institute for Health and Care Excellence
    • NIMHE National Institute for Mental Health in England
    • NPSA National Patient Safety Agency
    • OCD Obsessive Compulsive Disorder
    • OT Occupational Therapist
    • PORT Schizophrenia Patient Outcomes Research Team
    • PTSD Post-Traumatic Stress Disorder
    • RCT Randomised Controlled Trial
    • RFT Relational Frame Theory
    • ROMs Routine Outcome Measures
    • SCIE Social Care Institute for Excellence
    • SCMH Sainsbury Centre for Mental Health
    • T-FCT Trauma-Focused Cognitive Therapy
    • UNGA United Nations General Assembly
    • WHO World Health Organization
    • WMA World Medical Association
    • WRAP Wellness Recovery Action Plan
  • Conclusion: Ethical Decision-Making

    We have covered a lot of areas as the book has progressed and now want to pull these together in a way that allows them to be applied in day-to-day situations.

    Any therapist can become anxious and worried when faced with an ethical dilemma, whether they are a novice or experienced. Moreover, the therapist needs to be able to justify the action they take because this is a professional responsibility. Approaching an ethical dilemma in a systematic manner can help clarify thinking and help to reduce anxiety. Practice for therapists in working through ethical scenarios needs to be part of their continued professional development. Clinical supervision – both individual and group – is a useful place to do this. Although no two ethical dilemmas will be exactly the same, being familiar with the process of ethical decision-making is without doubt valuable.

    Using an ethical decision-making model or framework can help in this decision-making process. The rights and wrongs of behaviour are complex and the process of ethical decision-making reflects this. However, using an ethical decision-making model can help anchor the ethical decision-maker when they feel lost, concerned and drifting. The model that we have put forward is that of the Verb Model of Ethical Decision Making (Figure 10.1). We have called it the ‘Verb Model’ in order to emphasise that ethical decision-making is very much a ‘doing’ activity, ‘doing nothing’ – ‘ignoring dilemmas’ – is not an option, although there may be times when whether to act or not is a decision that has to be taken. It is a model that can reflect the complexity of the systems that the CB therapist works in. It takes into account legal and organisational requirements, whilst also being sensitive to the therapist and the client’s value system.

    Figure 10.1 The Verb Model of Ethical Decision Making

    Six stages are identified to work through:

    • Identifying
    • Contextualising
    • Reasoning
    • Consulting
    • Processing and reflecting
    • Deciding

    Again, each of the stages are labelled as verbs in order to stress the need to be doing – taking action. Questions are posed to the therapist to reflect upon at the Identifying and Contextualising stages. At the Reasoning stage, the therapist is asked to consider how the dilemma might sit with the ethical theories, for instance Deontology and Utilitarianism (see Chapter 1) or practical applications, for instance, safeguarding. Reflect on such questions as:

    • Are the persons involved being treated as a means to an end, or as an end in themselves?
    • Could following a particular action be transferred to other situations or not, is that important?
    • What are the long-term and short-term consequences for all those involved?
    • What ethical principles are activated?
    • Do the principles compete?
    • Which principle appears to be the most significant in this situation?

    The last three stages of the model are very much aimed to be interactive, where additional support to clarify thinking is sought before deciding on an action. Discussing the issues with clinical supervisors and/or senior members of staff is appropriate, mindful, too, that they will have boundaries relating to confidentiality that they will have to adhere to.

    Examples of worked scenarios

    We have worked through a few scenarios to help you understand the process. However, although we have tried to rationalise the ethical decision-making process by providing a framework for ethical decision-making, it is necessary to remember that this process is informed by values, and values are subjective. Therefore, the importance of discussing ideas with other professionals is essential in order to work out what the values leading the decision are. This said, in life-threatening situations, a rapid response will be necessary.

    Additionally, the necessity for clear contracting is highlighted in the scenarios. It is important to consider how we contract, as previously questioned, are clients really in a position to fully digest the contract at the beginning of therapy? As we are all probably aware, it is easy to agree to things or not read the small print when we really want something, or are not fully ourselves. What can we do to ensure that clients understand the contract? Also, how frequently should we remind our clients of this contract, given that as the therapeutic relationship develops, clients tend to feel more comfortable disclosing significant information, information that could have serious consequences?

    As you read through the worked scenarios, consider how your values might influence the decision-making process and how well your therapist–client contract would support you if faced with the ethical dilemmas. Remember too, that no two ethical dilemmas are ever the same, and that our worked examples here are no substitute for seeking appropriate legal advice.

    Scenario 1

    You work for an organisation that delivers CBT. The organisation has a long waiting list for clients seeking CBT. You discover that a colleague, another accredited CBT therapist, who is off work with stress, is currently seeing private clients. There is no doubt that this is happening. What do you do?

    Identifying

    What is the issue? Whistle-blowing.

    Whose problem is it? The therapist that discovers the problem, the ‘sick’ therapist and the organisation.

    To whom do I owe an obligation or alliance in this situation? The organisation, colleagues and clients on the waiting list.

    Contextualising

    What laws are activated? Money has been gained by deception from the employer, therefore gross misconduct has occurred. As the law works in the public interest, the therapist is unlikely to be prosecuted, but could be cautioned, if the employer pursues the care.

    What organisation policies are activated? Potentially, the contract of employment.

    Which ethical codes are activated? The BABCP section 1.5 code states:

    The safety of service users and others must come before any personal or professional loyalties at all times. As soon as you become aware of a situation that puts a service user or someone else in danger, you should discuss the matter with your clinical supervisor, a senior colleague or another appropriate person.

    You must behave with honesty and integrity and make sure that your behaviour does not damage the public’s confidence in you or your profession.

    You must limit your work or stop practising if your performance or judgement is affected by your health.

    Although the clients may not be put in danger, the therapist’s capacity to help clients may be limited due to her illness. Is the sick therapist acting with honesty and integrity?

    If a client is involved, what do I understand about their values? Unknown.

    What are my values, how are they affected, how do I feel? Honesty and trust are important to the therapist. With a strong work ethic, it is difficult to see colleagues work hard and the waiting list continue to grow.

    Reasoning
    Whistle-blowing

    In terms of ethical theories:

    • Deontology: We have a duty to be honest and act with integrity, this can become a universal law.
    • Consequentialism: Consider short-term and long-term consequences of whistle-blowing – the sick therapist might get the help she needs or conversely be disciplined. If she returns to work, interpersonal problems may develop. However, if she returns to work, the waiting list might reduce in size. If she is really sick and gets the help that she needs, clients would no longer be put at risk from any inappropriate decisions that she might make as a result of her own health issues.

    In terms of ethical principles:

    • Autonomy: Whistle-blowing without informing the ‘sick therapist’ does not respect her autonomy.
    • Beneficence: By whistle-blowing, the organisation will be able to sort out staffing – it could also mean less pressure on staff and more clients might be seen. Moreover, if the ‘sick therapist’ is ill, she might get appropriate support. Current private clients may be directed to another therapist, who is in a better place to help them.
    • Non-maleficence: The ‘sick therapist’ might be disciplined for breaching standards and regulations, therefore harm might come to her. If the therapist returns to work, there might be an atmosphere, particularly if she has been disciplined. The private clients whom the therapist is currently seeing might not be receiving the help they need because of the therapist’s own problem, harm may ensue.
    • Fidelity: Trust has been brought into question by the ‘sick therapist’s’ action. However, by whistle-blowing, the sick therapist or colleagues might not trust the ‘whistle-blower’ again.
    • Justice: Only private clients are being treated by the sick therapist not the ones on the waiting list of the therapist’s organisation – is this fair or correct?
    Consulting (clinical supervisor or appropriate senior members of team)

    The BABCP code notes that it is necessary to inform a supervisor if clients are put in danger, however the extent to which the clients are put in danger by this therapist is not clear.

    In this case, the clinical supervisor or a senior member might be duty-bound to inform management, because of this, moving to the processing and reflecting stage of the framework first might be helpful.

    Processing and reflecting (using the judgement and discretion to consider the gathered information)

    Whistle-blowing in this situation fits with the therapist’s value of honesty. However, the ‘sick therapist’ might be disciplined if she is found to be dishonest. Causing others grief is difficult: the sick therapist is already off with stress and, if this is genuine, reporting her could cause her more stress. It is not uncommon for individuals to ‘turn a blind eye’ to such activity and, indeed, there may be colleagues who are also aware of what is happening, and doing just that. However, if she is sick, she might get extra support.

    Here, then, the principles of beneficence and non-maleficence compete. However, clients may be put at risk because of the therapist’s potentially poor judgement. The BABCP code is supportive in this case.

    Deciding (a sensible, justifiable solution or way forward)

    After working through this process, the therapist felt comfortable that the best way forward was to disclose this information to her supervisor. The therapist felt that she could justify the actions using the ethical principles and felt supported by the BABCP code of practice.

    After discussion with the supervisor, the approach agreed is that the therapist informs her colleague, the sick therapist, that she is aware of the situation and allows the ‘sick therapist’ to report her situation to their employer. However, assurance is sought that this will happen and the colleague is made aware that if this does not happen, the therapist would feel obligated to report it.

    Scenario 2

    You work as a CBT therapist with a local charity that supports homeless people into secure accommodation. You work for an NHS Trust, with the charity buying out two days a week of your time for providing therapeutic support in a small hostel. Your supervision arrangement is within the Trust.

    You have been asked to see a resident who is under threat of eviction having made threats to kill another resident after drinking heavily. The hostel staff believe that you may be able to enable him to deal with this issue, to the extent that they can rescind the notice to quit. He is still drunk when you see him. You have a good relationship with him but are aware that he can become quite emotional, to the extent that he may self-harm. You have no immediate supervision available. Although this is your regular day with the charity, the session would be unplanned and is unscheduled.

    What do you do?

    Identifying

    What is the issue? The resident will be evicted if he doesn’t report some sort of insight into his actions to hostel staff. They have asked you to intervene as you have a good relationship. However, a psychological intervention may cause unmanageable emotions and further behavioural issues.

    Whose problem is it? The resident. They may be evicted or become more emotionally unstable.

    To whom do I owe an obligation or alliance in this situation? The individual, in terms of reducing the chance of eviction and rough sleeping with those inherent risks.

    Contextualising

    What laws are activated? None.

    Which organisation policies are activated? The risk policy of the charity, which stipulates criteria for eviction. Practice organisation risk policy.

    Which ethical codes are activated? No formal ethical code, but two questions around values are informed by the National Institute for Health and Care Excellence (2012).

    If a client is involved, what do I understand about their values? They do wish to engage in change in behaviour and are very aware of the link between drinking and problematic behaviours.

    What are my values, how are they affected, how do I feel? Support to marginalised people is important, enabling them to make changes in behaviour to reduce the possibilities of them sleeping rough, thereby putting themselves at more risk and contributing to negative psychological and emotional processes. Change and support in difficult circumstances are therefore important.

    Reasoning

    In terms of ethical theories:

    • Beneficence: We must always act in the best interests of the client. The BABCP ethics guidelines stipulate this and that you must always get informed consent for treatment (except in an emergency). Arguably, this person may not be in a position to give informed consent, given their heavy drinking, but likewise it may be considered some form of emergency even if it is not an acute medical one. The ethics issue here is that we may need to sacrifice structures and informed consent to serve and avoid the greater harm of rough sleeping.
    • Deontology: We have a duty to act in the client’s interest at all times. One action, to engage the client, may result in increased predisposition to self-harm and emotion dysregulation. It is also acting outside the structures of the agreed therapy, unless ad hoc time has been agreed in advance (e.g. DBT coaching).
    • Consequentialism: There are possible consequences for either course of action. If the therapist refuses to see the client because it is not a scheduled appointment, then the chances of eviction are high, meaning possible serious risk to the client (overdose, self-harm, assault, etc.). However, if the therapist agrees to see the client, it may be difficult to avoid an emotional exchange that results in little behaviour change due to alcohol use and emotional dysregulation. The urge to self-harm may increase. It may be that engagement is warranted, on a coaching, problem-solving level (e.g. DBT coaching), being careful not to invalidate or perhaps become dragged into an emotionally charged and uncontrolled exchange. This method would be best served if it was initially set up as part of the contracting process.

    In terms of ethical principles:

    The health of the client should always be paramount:

    • Beneficence: Either option is arguably in the best interests of the client. One has short-term costs but possible longer-term gains; the other has longer-term costs.
    • Non-maleficence: It would be important, if the intervention were to be engaged, that it should be conducted in a way that minimised emotion regulation for the client.
    • Fidelity: There is a departure from standard practice, both in terms of the structure of the therapy and the interventions used. The charity may start to do this more often, i.e. engage the therapist in ad hoc interventions, having been reinforced for this.
    • Justice: Arguably, social justice is being served by adapting protocols that were not designed for this group of people. It may serve as a useful case study if successful.
    Consulting (clinical supervisor or appropriate senior members of team)

    In this case, the supervisor was not available. However, it would be important to discuss the case at the earliest convenience to work out expert value-driven interventions with a clear rationale for departing from protocol.

    Processing and reflecting (using the judgement and discretion to consider the gathered information)

    The information would probably point to a need to predict such issues at the beginning of therapy. DBT proposes a useful model of coaching which is entirely problem-solving in nature and asks the person to reflect on the skills that have been taught so far in therapy. This would need to be considered as part of a review process, possibly with all clients who may risk eviction to the street. Work would also need to be done with the charity workers on how they refer for such ‘emergency’ interventions.

    Deciding (a sensible, justifiable solution or way forward)

    It would seem that a DBT-style ad hoc, but limited, coaching intervention may be the most appropriate. It addresses the need for an intervention, whilst minimising the risks of emotion dysregulation, although this would have to be skilfully done. It may be useful for staff to receive training in DBT-style coaching sessions, maintaining fidelity to a model.

    Charity staff could also be taught to understand the function of such behaviours. The risk policies could be adapted to include ‘cool-off’ periods in safe environments whilst individuals recover the capacity for thinking through these issues.

    Scenario 3

    You are working in an organisation that delivers high-intensity CBT. One of your clients, a 30-year-old woman reveals that she was sexually abused as a child by her stepfather. Her mother and stepfather no longer live together, in fact she has no idea where he lives now. She has never told anyone about this before. She does not want you to let anyone know.

    Identifying

    What is the issue? Breaching client confidentiality. Safeguarding children.

    Whose problem is it? The therapist, the client and the organisation.

    To whom do I owe an obligation or alliance in this situation? The client, the organisation, the profession and, potentially, children who might come to harm.

    Contextualising

    What laws are activated? Whilst there is no mandatory duty to breach confidentiality here, the organisation has opted into the ‘Working Together’ framework and adopted their abuse reporting procedures.

    What organisation policies are activated? Potentially, contract of employment related to sharing information in relation to the Working Together framework.

    Which ethical codes are activated? The BABCP code states in sections 1.1 and 1.3 that:

    • You are personally responsible for making sure that you promote and protect the best interests of your service users. You must respect and take account of these factors when providing care or a service, and must not abuse the relationship you have with a service user, sexually, emotionally, financially or in other ways.
    • You must not do anything or fail to do anything, or allow someone else to do anything that you have good reason to believe will put the health or safety of a service user or others in danger. This includes both your own actions and those of other people. You should take appropriate action to protect the rights of children and vulnerable adults if you believe they are at risk, including following national and local policies.

    If a client is involved, what do I understand about their values? Trust is an important issue for this client.

    What are my values, how are they affected, how do I feel? Trust and honesty are important. Breaching confidentiality here feels uncomfortable as the client has clearly asked not to share the information about abuse.

    Reasoning
    Breaching client confidentiality. Safeguarding children:

    In terms of ethical theories:

    • Deontology: We have a duty to be honest and act with integrity. Also, we have a duty to protect children. These can become universal laws.
    • Consequentialism: Consider short-term and long-term consequences of breaching confidentiality. If details were passed on, the client might have to look at issues that she had tried to avoid for some time, she might have to face the perpetrator. In the long term, though, this might help her resolve this issue:
      • The perpetrator may continue abusing others.
      • The therapist: Would be complying with her organisation’s policy and her professional requirements. However, she might lose the trust of her client, and therefore the opportunity to help the client would be lost. The client may consider that therapists cannot be trusted and therefore terminate therapy and not seek further therapy.

    In terms of ethical principles:

    • Autonomy: By breaching confidentiality the client’s wish for non-disclosure and thus autonomy will not be respected.
    • Beneficence: By breaching confidentiality, the therapist will be adhering to her organisation’s policies. Other children might be protected.
    • Non-maleficence: The therapeutic relationship might be harmed. The client might lose trust in therapy. The client may have to look at issues that she might not be ready to explore.
    • Fidelity: The extent to which the client can trust the therapist and any future therapists might be questioned.
    • Justice: The boundaries of breaching confidentiality are explained to all clients.
    Consulting (clinical supervisor or appropriate senior members of team)

    The clinical supervisor pointed out that as part of the contracting agreement, it is made clear to all clients prior to starting therapy when breaching confidentiality is necessary. This is one of those situations. However, it also noted that at the start of therapy, clients may be so desperate to start therapy and/or do not think clearly, that they might agree to a contract that they have not fully absorbed, and therefore might not understand its implications.

    Processing and reflecting (using judgement and discretion to consider the gathered information)

    Breaching confidentiality does not sit comfortably with the therapist’s values, particularly as the client has asked for confidentiality to be kept. Respecting the client’s autonomy is important and trust is fundamental to the therapeutic progress. The client has identified her need for therapy and this may stop her from getting her needs met. However, it appears that the perpetrator is still alive and might be abusing others, therefore harm might come to them. By breaching confidentiality in this situation, the therapist would be adhering to her employment contract, however deontology points out that it is important not to treat people as a means to an end. It could be argued that breaching confidentiality may result in the perpetrator being brought to justice, and thus potentially preventing harm to others, however it is questioned at what cost to this particular client.

    The BABCP code of ethics is not explicit in the specific situation of historic abuse, however it is clear about preventing harm from happening to others.

    Deciding (a sensible, justifiable solution or way forward)

    After working through this process, the therapist felt comfortable that the best way forward was to remind the client of their original contract regarding breaching confidentiality. The need to disclose this information to the person in the agency that deals with safeguarding, because of the potential serious harm to others, was explained. The therapist also reinforced that she understood the importance of trust and that she sincerely wanted to help the client work through her issues.

    Scenario 4

    You are working in a primary care setting with a severely depressed client who is not improving with CBT. He informs you that he is suicidal and has plans to take an overdose within the next few days. He has gathered together a large volume of painkillers. He expresses a profound sense of hopelessness and his score on the Beck Depression Inventory is 46. He asks you not to tell anybody that he is suicidal so that he can be at peace, he sees no other options. He has told you he is suicidal simply to say goodbye. What do you do?

    Identifying

    What is the issue? The client is at serious and immediate risk of suicide, within the context of a formally diagnosed mental health disorder.

    Whose problem is it? The therapist.

    To whom do I owe an obligation or alliance in this situation? In this case, an obligation to protect the client and respond, accordingly.

    Contextualising

    What laws are activated? Whilst the client would be acting within the law by taking his own life (Suicide Act 1961), this would be in the context of a person whose capacity to make such a decision is compromised by their mental disorder of severe depression (Mental Capacity Act 2005).

    What organisation policies are activated? Possibly contract of employment policies.

    Which ethical codes are activated? Section 1.5 of the BABCP code states that:

    You must protect service users or others if you believe that any situation puts them in danger. This includes the conduct, performance or health of a colleague. The safety of service users and others must come before any personal or professional loyalties at all times. As soon as you become aware of a situation that puts a service user or someone else in danger, you should discuss the matter with your clinical supervisor, a senior colleague or another appropriate person.

    If a client is involved what do I understand about their values? Respects authority. Does not want to be a burden.

    What are my values, how are they affected, how do I feel? Respecting the client’s autonomy is important, however this is based on their ability to make an informed, rational decision.

    Reasoning

    In terms of ethical theories:

    • Deontology: We have a duty to behave in a manner that develops trust and not to violate relationships, this could become a universal law. However, we have a duty to protect vulnerable clients, to help keep them safe.
    • Consequentialism: If no action is taken, the client will not survive. By taking action, the client may get the help he needs and eventually his depression should lift.

    In terms of ethical principles:

    • Autonomy: Respecting the client’s wishes means he won’t survive.
    • Beneficence: By breaching confidentiality, eventually his mood may improve and his quality of life may improve.
    • Non-maleficence: By doing nothing, harm will happen to the client.
    • Fidelity: By breaching confidentiality, trust will be breached, but this could be repaired in time.
    • Justice: You would treat anyone in such a situation, experiencing mental illness, in the same way.
    Consulting (clinical supervisor or appropriate senior members of team)

    This is a life-threatening situation and thus requires a rapid response.

    Processing and reflecting (using the judgement and discretion to consider the gathered information)

    Rapid response is needed, that places client safety as the main consideration. The issue is serious and immediate.

    Deciding (a sensible, justifiable solution or way forward)

    The decision is to inform the client that confidentiality will need to be breached and an ambulance arranged to take them to the local Accident and Emergency Department (A&E) for assessment. It is agency policy to engage the emergency services in this way. The client is also informed that his family doctor will be contacted, so that his doctor is aware of the active suicidal status.

    The client is reminded that this was discussed at the contracting phase of therapy. This information is shared in an empathic manner, and it is stressed that the client might think differently if he was not depressed and that, with the right treatment, he can still recover from his depression.

    Reluctantly, the client agrees to comply with the assessment through A&E. Later that day, communication is received that the client has been admitted to the local mental health unit under the Mental Health Act for assessment purposes.

    At the contracting phase of therapy, the client had been informed that in such situations, confidentiality would be breached. Although, even if this had not been done, a breach would be justified. The client’s capacity is compromised and thus the principle of autonomy does not apply. In this situation, the therapist, in order to do no harm, must act in a paternalistic way to protect the client and ensure their welfare.

    This is a medical emergency situation and no matter what the setting is, decisive and rapid action is necessary. Where possible, there is a need also to explain this decision to the client and try to engage them in the process.

    Scenario 5

    You work as a private therapist in a small town. A former client keeps requesting to be your friend on social media. She left therapy six months ago. The issues you worked with related to her low self-esteem and social anxiety. You developed a very good therapeutic relationship with her. You recall that rejection had been a significant theme in her life. What do you do?

    Identifying

    What is the issue? Boundary crossing.

    Whose problem is it? The therapist.

    To whom do I owe an obligation or alliance in this situation? The former client and the profession.

    Reasoning
    Boundary crossing

    In terms of ethical theories:

    • Deontology: We have a duty to behave in a manner that develops trust and not to violate relationships – this could become a universal law.
    • Consequentialism: Consider short-term and long-term consequences of boundary crossing. By becoming a friend on social media, the client may feel validated in the short term, however once a boundary is crossed, the relationship could not return to a therapeutic one. Therefore, she would lose future therapeutic benefits of this relationship. Short- and long-term consequences for the therapist: the therapist could lose a sense of privacy, but gain a friend, however she is content with the friends she has.

    In terms of ethical principles:

    • Autonomy: By making the client a ‘friend’ she would be respecting the client’s wishes.
    • Beneficence: The client’s self-esteem may be increased.
    • Non-maleficence: Boundary crossing can be problematic. The therapist might feel her privacy is reduced as the boundary between work and her private life cross over. If the therapist does not make the client a friend, the client may feel rejected.
    • Fidelity: The literature suggests that dual relationships can lead to problems that can lead to a reduction of trust in the profession.
    • Justice: All clients are made aware of the therapists’ boundaries around the therapeutic relationship at the start of therapy, thus promoting fairness and equality.
    Contextualising

    What laws are activated? None.

    Which organisation policies are activated? None.

    Which ethical codes are activated? The BABCP code states that you must keep high standards of personal conduct. Section 4.1 of the BABCP codes states that:

    You must keep high standards of personal conduct, as well as professional conduct. You should be aware that poor conduct outside of your professional life may still affect someone’s confidence in you and your profession.

    If a client is involved, what do I understand about their values? Respects authority and tends to put other people first.

    What are my values, how are they affected, how do I feel? Treating people equally and with respect is important. This situation compromises the therapist’s values of keeping work life and private life separate.

    Consulting (clinical supervisor or appropriate senior members of team)

    The supervisor and therapist considered the situation chiefly in terms of beneficence and non-maleficence. Attention was drawn to the therapeutic contract that had omitted boundaries in relation to social media.

    Processing and reflecting (using the judgement and discretion to consider the gathered information)

    Maintaining clear boundaries enables separation of the therapist’s private and professional life. It potentially keeps the client and therapist safe, as well as the reputation of the profession. Conversely, the client’s self-esteem might be negatively affected and she might feel rejected, therefore the principle of non-maleficence would be compromised.

    Although the BABCP code does not give clear guidelines regarding boundary crossing, they do support keeping high standards of personal conduct.

    Deciding (a sensible, justifiable solution or way forward)

    After working through this process, the therapist felt comfortable that the best way forward was to remind the client of the contract agreement, in which it was discussed what would happen if they saw each other outside of therapy. This was included in the contract as the therapist worked in a small town and was aware that she might bump into clients and former clients. However, it had not covered social media specifically.

    The client was again made aware that the contract reinforced the need for clear boundaries and is employed with all clients, it thus adheres to the ethical principles of justice and fidelity. Also, the client will be told that having clear boundaries meant that she would be able to return to therapy with the therapist if she ever felt the need to. The therapist emphasised that she valued the work they had done together.

    Additionally, the therapist amended her contract to include social media as well.

    Practice scenarios

    Now, have a go at working through the ethical dilemmas below. Remember that it is important to explore them with others in order to discover how your own values might be influencing the decision-making process.

    Scenario A

    A friend tells you that one of his friends, John, is very distressed. John has developed a close relationship with his therapist, May, whilst he was in therapy with her. John started seeing the therapist socially, however once the relationship became intimate, therapy stopped. The therapist moved in with John and lived with him for approximately a year. The therapist ended the relationship a few weeks ago and sharply moved out. John is devastated. Your friend is shocked by May’s behaviour, describing it as ‘selfish’. How do you react?

    Scenario B

    You are an accredited CBT therapist. One of the CBT students in your organisation with whom you are friendly needs to complete a case study. It is her final case study, however, she forgot to obtain written consent from the client to record the session. She tells you that she doesn’t have another recording that she can use, and that she can’t contact the client. She privately tells you that she intends to forge the client’s signature; she says that the university won’t find out. What do you do?

    Scenario C

    John, aged 34, has misused alcohol for many years but tells you that he is prepared to detox. However, he says that when he has done so in the past, memories of adverse childhood experiences come back that he can’t deal with. What do you advise him to do? What do you do?

    Scenario D

    Brian is a patient whom you have known for many years and have a good relationship with. He tells you that he has broken the joystick for his games console. You have a spare one at home and tell him that you will bring it in for him next time you meet. Are there any ethical considerations that you need to take into account? What if instead of giving it to him, you offered to sell it to him for a small fee?

    Scenario E

    Jenny has been seeing you for almost six months and has had 18 sessions of therapy. She has made slow but steady progress. Both of you think that she would benefit from continuing past the 20 sessions that you are allowed to offer her by your agency. What are the ethical issues involved? How can you resolve them? What do you say to her?

    Scenario F

    You work in a community team and have received a referral for a sex worker who has suffered multiple traumatic events in the last three weeks and has overdosed on paracetamol once. She refuses to be admitted and criteria for sectioning aren’t met. She has found CBT input helpful in the past and has asked for someone to see her. She lives in a homeless hostel, where there is a private room available. She won’t come to the team base and has no other mental health support other than sporadic use of a GP working in a homeless health care team. As an accredited CBT therapist, what do you do?

    Scenario G

    You have received a referral for a man with moderate learning disabilities who is reported as having problems with anger, sometimes lashing out at other service users. He doesn’t seem to understand why he is being taken to his room at such times and seems frustrated and anxious when this happens. Staff can seem to find no trigger for his outbursts, having already had some input from psychology. He is wary of professionals since the time of a set of difficult medical interventions. What do you do?

    Ethically developing as a CB therapist

    Finally, as part of their professional training and specialist training in CBT, therapists will have considered the ethical basis for practice. Yet, this formative training, no matter how well it has been internalised through deep learning strategies from a rigorous education curriculum, can endure without continuous professional development. Thus, it falls to the clinician to take responsibility for their own learning and development to revisit and reconsider the ethics and values of their work. This, in our view, is necessary in order to refresh, reconsider and revitalise ethical knowledge and skills. By doing so, the CB therapist will be able to continue to apply this knowledge in a reasoned way to everyday and increasingly complex ethical situations and dilemmas. Yet, the field of cognitive behaviour therapy – as we have discussed throughout this book – has been relatively slow to develop its ethical underpinnings whilst is strives to develop its evidence base. This is understandable in the context of policy-makers demanding evidence before they support service commissioning. Increasingly, then, it now falls to each of us to take responsibility for our own ethical learning and development so as to ensure that our knowledge and skills remain fit for purpose for the benefit of our clients (Corrie et al., 2016). It is hoped that this book will assist the trainee therapist and experienced therapist with this process.

    In order to conclude this text in a form that can be used for self-directed or curriculum learning, we recognise the value of using ‘reflective tools’ that have been extensively developed, described and used in their own work by Sarah Corrie and David Lane (Lane and Corrie, 2006, 2012; Corrie and Lane, 2010, 2015). Essentially, reflective tools, much like the therapy process of CB therapy, are based on a series of guided questions that relate to the different ideas covered in this book as well as the debates drawn from professional practice and the wider literature (Corrie et al., 2016).

    We recommend that you revisit the reflective tool and questions therein from time to time with colleagues, supervisors and trainers and with clients themselves. You can creatively open up your ideas and ethical reasoning to others for constructive discussion, debate and feedback, thus turning them into a form that has implications for your future values-based and ethical CB practice.

    Your reflective tool

    This reflective tool has been partly reproduced and partly adapted from Corrie, Townend and Cockx (2016) with permission:

    • Spend some time reflecting on what drew you initially to becoming a CB therapist and the values you now hold as a therapist? What are the factors from your personal and professional history that have shaped your values and how you approach ethical issues and dilemmas? Use the following questions to guide you:
      • What (or whom) has been most influential in shaping your values as a CB therapist?
      • What do you consider to be your most important values and why are they so important to you?
      • What have been the major ethical challenges that you have faced in your work as a CB therapist? How have you attempted to manage these and what have you learned from them?
      • In terms of values and ethics, what learning have you gained from formal training, experience and your colleagues?

    List any insights below:

    _________________________________________________________________________________

    _________________________________________________________________________________

    _________________________________________________________________________________

    _________________________________________________________________________________

    _________________________________________________________________________________

    • 2a. Reflect on your practice in relation to human and legal ‘rights’ (recap on Chapters 1 and 2 if you need to refresh your memory on any of the key points discussed). Having done so, consider your responses to the following questions:
      • Do you have a preferred set or bill of rights that you try to uphold in your therapy? If so, what is it and why is it preferred?
        • To what extent is your practice based on the rights of the client?
        • To what extent does your place of work influence how you enact those rights?
      • Review the rights in Chapter 1 and the rights that underpin ethical codes in Chapter 1. Which rights are incorporated into your professional practice? Are there any areas that would be useful to think about and develop more fully?

    List any insights below:

    _________________________________________________________________________________

    _________________________________________________________________________________

    _________________________________________________________________________________

    _________________________________________________________________________________

    _________________________________________________________________________________

    • 2b. Having responded to the questions in 2a above, and having reflected on the content of Chapter 1, what do you now know about your current level of capability and skill in the area of incorporation of rights and values into your practice?
      • What are your strengths/areas where you do best?
      • What are your current limitations/areas where you are least effective?
      • Which specific areas would it make most sense to work on for the immediate future?

    List your responses below:

    _________________________________________________________________________________

    _________________________________________________________________________________

    _________________________________________________________________________________

    _________________________________________________________________________________

    _________________________________________________________________________________

    • 3a. Reflect on your usual approach to ethical dilemmas (recap on the second part of Chapters 1 and 2 if you need to refresh your memory, and other chapters for specific applications on any of the key points discussed). Having done so, consider your responses to the following questions:
      • How or do you use deontological, consequential or virtue ethics in your practice?
      • Are there any typical problems, challenges or ethical dilemmas that you regularly encounter in your CB practice?
      • When attempting to reason through ethical problems, do you have a preferred way of understanding or formulating the issue?
      • For irregular ethical issues, whom can you discuss these with, how well developed is the support available to you? Are you able to approach the problem together?
      • Does the ethical problem-solving process outlined in this chapter help you to solve regular and novel ethical problems?

    List any insights below:

    _________________________________________________________________________________

    _________________________________________________________________________________

    _________________________________________________________________________________

    _________________________________________________________________________________

    _________________________________________________________________________________

    • 3b. Having responded to the questions in 3a above, and having reflected on the content of the different chapters, what do you now know about your current level of capability and skill in the area of using ethical theories to help you make reasoned professional decisions?
      • What are your strengths/areas where you do best?
      • What are your current limitations/areas where you are least effective?
      • Which specific areas would it make most sense to work on for the immediate future?

    List your responses below:

    _________________________________________________________________________________

    _________________________________________________________________________________

    _________________________________________________________________________________

    _________________________________________________________________________________

    _________________________________________________________________________________

    • 4. Having read this book, what do you now know about the values, ethical frameworks and ethical reasoning that underpins your professional practice in CBT? How ethical is your practice?
      • What are your strengths/areas where you do best?
      • What are your current limitations/areas where more attention to values or ethics would help you to become more effective?
      • Which specific areas would it make most sense to work on for the immediate future?

    In considering each of the above, spend some time reflecting on your responses and what you feel comfortable with and if anything has made you feel uncomfortable. This process is intended to help you to fully appreciate the implications for your work and professional practice. Is there anything that you would like to change in your CBT practice for the immediate future? Are there any learning needs which reading this book or engaging with these questions have alerted you to that you need to follow up on (e.g. with your supervisor, line manager etc.)?

    List your responses below:

    _________________________________________________________________________________

    _________________________________________________________________________________

    _________________________________________________________________________________

    _________________________________________________________________________________

    _________________________________________________________________________________

    • 5. Based on all of the above, what future direction do you wish your value and ethically based CBT-related professional development to take and what resources do you need to help you get there?
      • What supervision arrangements might need to be in place to help you take these next steps?
      • What training courses or workshops might be needed to top up your knowledge and skills?
      • What further reading is necessary?
      • Are there other forms of self-directed learning that might be beneficial?

    List your responses below:

    _________________________________________________________________________________

    _________________________________________________________________________________

    _________________________________________________________________________________

    _________________________________________________________________________________

    _________________________________________________________________________________

    Concluding remarks

    In this chapter, we employed the Verb Model to explore ethical dilemmas through a set of worked scenarios (with further examples to try) and a reflective tool to examine your own ethics and values. We have tried to emphasise that the ethical decision-making process is subjective whilst being based on statute, guidance and reasoning, and that because of this, discussing each dilemma with other professionals is essential. Not only should you be able to justify your decision, but it is necessary, too, that you feel as comfortable as possible with the decision made – you and your client will live with it.

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