Professionalism In Therapeutic Practice

Introduction

Professionalism within the therapeutic practice has generic understandings and situations which are not always easy to define (Mitchells and Bond, 2010). Sometimes grey areas arise and it may be difficult to determine the right course of action (Jenkins, 2017). So, how do we make sense of and evaluate what kind of a person and what kind of commitment is needed to support a person at a time when the ship of their life is foundering on the rocks? (Freeth, 2007) particularly, when the view of the wider society determines people’s emotions as objects to be managed, instead of experiences being tolerated and cultivated (Furedi, 2004).

How do we regulate what is right and how do we best become accountable to ourselves and others? Being accountable is a key aspect of professionalism (Bond, 2015). Bond (2015) argued that: ‘The group of people who have most at stake in the quality of service providers are the clients’ (Bond, 2015, p. 272). We can only begin with ourselves, with our own professional training and personal development and try to ascertain, what we are plugging ourselves into and be mindful, of the weight of conviction it imposes (Bates and House, 2006). Most counsellors believe that it is essential that the ethical codes and professional organisations they adhere to are clarified to the client (bacp.co.uk) (Sills, 2006).

Being a member to a governing body such as the British Association for Counselling and Psychotherapy (BACP) can help some aspects of professionalism in relating to psychological helping feel more solid, whilst standards of training and accreditation help further develop self-awareness and an ability of working and being in a therapeutic relationship (bacp.co.uk) (Clarkson, 1995). However, Whitton (2003) argued that: ‘There is a gap between any means of accreditation and competence’ (Whitton, 2003, p. 83). My placement organisation is accredited by the BACP and adheres to the BACP ethical framework (bacp.co.uk). I am provided with a group supervision (Creaner, 2014). This is a vital part of my professionalism… as it not only helps to filter through my own responses and feelings from the objective needs of my clients; it also allows for the understanding of the different perspectives on my client’s process and the methods through which I can ethically commit myself to meet their needs (Thistle, 1998) (See Appendix I).

Moreover, Bond (2015) argued that: ‘The ethical responsibilities to do good and avoid harm require carefully considered judgments’ (Bond, 2015, p. 273). These judgments should also include research evidence, where effectiveness of theory is considered, which can be ethically challenging when Humanistic counselling is primarily focused on the client and developing a healing relationship (Bond, 2015). Accordingly, Bond (2015) argued that: ‘Ensuring general principles should not override the specific needs and circumstances of individual clients’ (Bond, 2015, p. 273).

I have come to value the contextual setting where I see my clients and the agency’s protocols and regulations to which I adhere to (bacp.co.uk) and which I have moved across to perform private practice (Thistle, 1998).This structure not only holds me in my professionalism but also supports and maintains me in the development of my skills (Egan, 2010). Thus, it promotes courage to support clients to set themselves free from whatever may be holding their true selves as captives (Rowan, 1996). Accordingly, this also facilitates the clients to overcome incongruence and to encourage psychological well-being (Rogers, 1951). Jenkins (2017) points out that: ‘Counselling and Psychotherapy are intrinsically linked to ethical behaviour on the part of the therapist’ (Jenkins, 2017, p.131).

However, regardless of what measures are in place to protect the client, counsellors and organisation/law; there appears little guarantee in how effectively work is carried out (Bond, 2015). Helpful or unhelpful therapeutic work cannot always be determined and depending on the situation classed as professional or unprofessional (Jenkins, 2017). Wosket (2001) argues that there is a naivety around the protection of the public when the aim of professionalise counselling is combined with the intimacy and power of the therapeutic relationship and this could lead to the potential risk of abuse (Wosket, 2001). Yet, power and diversity will trickle down into the counselling relationship like rain coming through a mountain, where it may prove difficult to accept and actively challenge the messages the client gets from others (Whitton, 2003). Consequently, Bates and House (2006) critically review how professional codes could impose an antipathetic outcome compared to what may be desired (Bates and House, 2006). For example, autonomy may rest on an assumption of the normative centrality of autonomy (Christman, 2003). Thus, being mindful to how normative concepts of physical and social structures affect the client in the therapeutic space is crucial (Bates and House, 2006).

The predominant inquests in this context are how can a practitioner provide a clear and solid ethical framework when considering the variables of legislations, contextual settings, policies and research trials/evidence associated to the helping profession and how do we communicate that to other people without impacting or creating a shift in the therapeutic work (Jenkins, 2017). In addition, Freeth (2007) investigated the effects of a culture being infected by policies which discriminates between less value in the therapeutic relationship and a culture that challenges practitioners’ capacity to deliver cost-effective short-term work (Freeth, 2007).

In the past, the notion of becoming professional has been critiqued as what could be regarded as a form of mask which professionals sometimes wear; this almost constitutes a rigid separation between the professional role and the person (Furedi, 2004). Today, we are facing further uncertainties around seeking statutory regulation of the scope of practice and education (SCoPEd) (bacp.co.uk) and thereby, dissenting our professional role, which could deny our true ethical work commitment by opposing our counselling work and heighten insecurities to how we can prove ourselves (Therapy Today, 2019). Aldridge (2014, quoted in Jenkins, 2017, p.16) argues that: ‘These are insecure professions with weak occupational boundaries’ (Aldridge in Jenkins, 2017, p.16).

Ethics, codes of practice and supervision are some key aspects of what constitutes professional practice and what allows for the good enough counsellors to be able to demonstrate the necessary expertise of possessing and applying knowledge by working in a highly intuitive manner which is effectively grounded in their own learning and experience, without implementing a power dynamic (Proctor, 2017).

Having an awareness of what I do and how I articulate this is vital in my professional role (Jenkins, 2017). After holding the sessions, I check to see if I had missed anything or for resistance on my part. Generally, this constitutes checking if I have faithfully tracked the clients in their world of experience and not been blind to it. It is an affirmative practice to ascertain the counselling process and any phobia problems within society which may arise (Bates and House, 2003). Carroll and Shaw (2013) suggested that: ‘There are values which I think and say I that I believe and there is another invisible set that informs my decisions and actions’ (Carrol and Shaw, 2013, p. 15).

Freeth (2007) attempts to shed light on the humanising process without being blind to economic and political realities in the UK (Freeth, 2007). However, Wenger et al, (1998, quoted in Jenkins, 2017, p.16) argues the nature of moving away from a fruitless quest of professional status and suggested that: ‘it may be useful to look at groups of professionals, working together in shared culture, with common values and understandings, as constituting ‘a community of practice’ (Jenkins, 2017, p.16). Aldridge (2011) attempts to shed light on the risk of our profession becoming homogeneous (Aldridge, 2011).

Before entering into a mutually agreed contract between myself and my client and to try and bring direction in a disordered world (Sills, 2006); it is essential that the ethical codes of my professional organisation/private practice are clarified to my client (Sills, 2006). Sills (2006) stated: ‘The professional contract defines the purpose and focus of the counselling/psychotherapy and how it will proceed’ (Sills, 2006, p.12). Mitchell and Bond (2010) describe legal contracts as: ‘Legally enforceable contracts embody a number of essential ingredients which may be explicit or implied’ (Mitchell and Bond, 2010, p.45) (see Appendix II).

Whereby, I am following organisational regulations to help safeguard and provide guidance to acting ethically for the best interests of my clients and in any event, where agreements of confidentiality and the law may need to be acted upon (bacp.co.uk). The BACP Ethical framework is informed by human rights acts and what public services outline (bacp.co.uk) (see Appendices I,V).

Throughout my training, I have encountered challenging experiences which needed careful reflection on my client’s needs as these changed and evolved (Mitchell and Bond, 2010). Bor and Watts (2017) argued that: ‘The reflective practitioners incorporate the use of their personal qualities into the skills used in therapy’ (Bor and Watts, 2017, p.215). This has further developed my understanding in Humanistic Theory and altered/enriched my personal philosophy with a good flexibility to allow myself to consider the best therapeutic intervention for my clients (Cooper, et, 2013). Berne (1910-1970) devoted to the client’s autonomy by asking the client what they needed and wanted from the therapist to help change their lives (Sills, 2006). However, Tweedy (2017) argued that: ‘Because interest is repressed, they find themselves in systems in ways they would not fully understand and would – if they could understand it – undoubtedly deplore’ (Tweedy, 2017, p.29).

Recently, I have been working with clients with complex history, where I had to thoroughly examine my level of competence, which challenged me personally and professionally in what I could offer and how to keep myself and my client contained and safe within the therapeutic space (Wosket, 1999). Bates and House (2003) argued that: ‘If practitioners simply obey rules, endorsed by others, theirs may not be a truly ethical stance’ (Bates and House, 2003, p. 48).

My clients came to me from a psychiatry setting to find their own answers (Bentall, 2010).

My placement offers open ended counselling where I have been fortunate to have learnt to value the significance of the Person-Centred Theory’s (PCT) growth promoting and healing benefits (Cooper, et al, 2013). I believe that being an advocate of PCT has encouraged me to feel grounded in my counselling role and to create a safe containing therapeutic space (Merry, 2014). At times, my previous CBT supervisor (Beck, 1995), who was technical in their approach came to question the sufficiency of the Humanistic Approach and working with psychopathology (Bentall, 2010). I quiet enjoyed defending my Humanistic standpoint (Schneider, et al, 2015). However, Bentall (2010) provides an overview between a person’s normal functioning and severe mental illness and Bentall (2010) suggests that: ‘there is no clear dividing line’ (Bentall, 2010, p.108).

In addition, Bentall (2010) attempts to shed some light on the relationship between diagnostic criteria being reliable and accurate, yet also addresses the problem of appearing vacuous in the light of Bentall’s examination (Benttal, 2010). My supervisor came to admire my client’s growth and the therapeutic relationship which had been developed and which has shaped a secure base for the client where they have learnt to value themselves (Beckett and Taylor, 2016). Bental (2010) argued that: ‘What is needed is a more compassionate approach that places the therapeutic relationship at the centre of clinical practices’ (Bental, 2010, p.265).

However, a situation arose that challenged me and created a shift in the therapeutic work. My client expressed intrusive thoughts to kill her husband. These thoughts became incrementally severe which involved a thought-out plan. This then became serious for me to take action for the safety of my client, my client’s husband and possibly others – it also heightened my own sense of safety to an ebullient status, due to the severity of my client’s existing psychopathology, which was then inhibiting my Humanistic approach as I became focused on what was unhealthy in my client. Thus, diluting my ability to be fully present (Mearns and Cooper, 2005). Wosket, (1999) stated that: ‘It is essentially allowing ‘passivity’ and receptiveness, even of the desire to heal, to be present’ (Wosket, 1999, p.120). I was able to restrain my reservations of safeguarding issues and personal feelings until I spoke to my supervisor and provided a space to explore and normalise their defences of their core self (Merry, 2014). I kept my focus on metaphorically holding the client in their suffering (PCEPS 9) (see Appendix III). Thus, a Humanistic viewpoint brought implications to the therapeutic practice, where commitment to the ethical framework for counselling professions contradicted and encountered challenges within many of the qualities and the expert position of the mental health profession (Bond,2015). However, Thistle (1998) concluded that: ‘It is possible to integrate an ethical and caring approach to clients with a business like attitude’ (Thistle, 1998, p.2).

Sometimes we need to take a step back from our personal feelings and intellectual framework of attending to the therapeutic process by obtaining a more clarified view of the efficacy in how professional standards meet could attend to the client’s needs with consideration to ethical guidelines, socio-cultural perspectives, regulations of any organisation and the existing laws (Sills, 2006). The British Association for Counselling and Psychotherapy (BACP) has shaped six ethical principles that form our duty of care (see Appendix I). Hereby, respecting diversity and difference (Feltham, et al, 2017).

Through support in supervision, it was decided that I needed to break confidentiality in accordance with regulations and write to my clients GP services for shared support in accordance with the BACP ethical framework (bacp.co.uk) (see Appendix V).I felt reassured to have guidance and support from my supervisor. I also felt assured that this was the right course of action as it followed the protocol of the agency in guidance with the law and fell in line with my own judgments. This gave me a sense of working competently and ethical approach, which on the one hand felt empowering as I felt robust in being assertive in my actions and I felt assured that I had explored the best course of action for my client. However, when reflecting on how this may impact my client and the therapeutic relationship, I could not ignore the perception that I was betraying my client and worried about implications.

Taking the right course of action and abiding by the law felt essential (bacp.co.uk) (See Appendix IV). However, my Humanistic values were pulling at my heart strings… I felt a weighty burden to have to brake confidentiality and saddened that this may jeopardise the trust and core conditions built upon, from which my client had so whole heartedly valued and grown upon (Whitton, 2003). Suddenly my positive assumptions about humanity and my unconditional positive regard was less accepting and felt a reversal to how I intended (Schneider, et al, 2015). I was also aware that certain segments of my emotional expressions constituted reactionary measures to my own philosophy, which is embedded in me, whereby my catholic upbringing’s spirituality perpetrated an increased sense of ‘betrayal’. Thankfully, through careful considerations in supervision, I was able to explore with my client my reasons for breaking confidentiality and having the support from my client in this, restored trust and a sense of mutual understanding to the reasons for the actions taken coming from a place of duty of care for the client. Being able to explore with them collaboratively the course of action, this proved to be a valuable meaning making and we continue to work together reaching sixty counselling sessions. Cooper, (2008) found that: ‘A therapeutic relationship in which alliance ‘ruptures’ are experienced and repaired, may be of a particular value to clients’ (Cooper, 2008, p. 104).

There lies value in an ongoing and lengthened intimate relationship between two people (Smail, 2003). However, the relationship between counsellor and client is supported by a structure which holds mixed blessings. It is about having a clear understanding of organisational protocols, how this is improvised and how this may impact the therapeutic work. My learning enhanced my faith and brought further awareness to the benefits of the Humanistic therapeutic space, whereby, I and my client formed a willingness and commitment within the breadth, depth and bleakness of intimate human experience (Whitton, 2003). It could be argued that empathy without boundaries is unhelpful for the client (Clarkson, 1995).

Within the structure of our weekly sessions, the boundaries of the safe space provide me the opportunity to exercise my professionalism to constitute the levels of treatment and addressing of the problems of the client and this has been consistently confirmed by the client in the subsequent reviews.

As my client has been trusting the process, I am equally trusting the process, my skills, my ability in having an awareness of my own feelings’ on a moment to moment basis, which creates a fluid process and encourages the client to develop her own internal valuing process and trust her judgments more. A commitment and way of being with the client on a minutiae level as well as a level of how I make contact with a client to enable him or her to look more closely at painful feelings (Rowan, 1996). Feltham et al, (2017) argued that: ‘It also urges practitioners to work towards actively challenging and addressing inequality on micro (individual) meso (group or community) and macro (political and societal) levels’ (Feltham et al, 2017, p. 27).

I experienced further challenges when a client expressed suicidal intent mentioning the use of a gun. Within the moments that this was shared, I explored with my client safeguarding issues and established that the client was not in possession and I listened as tentatively as I could and metaphorically held the client in his/her despair (PCEPC 9). I felt torn between enhancing my client’s personal autonomy and respecting the client’s autonomy of wanting to end his/her life (Bond, 1997). This was my first experience of an intention of suicide with a plan. After our session, I was stood facing the sea which I felt to be important for me to reflect on the process of a client wishing to end his/her life. It did not fit with my personal philosophy and values (Schneider, et al, 2015). The sea reflected the storm within me which I was trying to unravel…Yalom (2015) concluded that: ‘At one’s core there is an ever-present conflict between the wish to continue to exist and the awareness of inevitable death’ (Yalom, 2013, p.5).

How could I best support my client at a time where their wishes may take a path which could have been prevented or should be respected? I gathered that through the time of further sessions these answers would be revealed, but even this brought ambiguity. I was trying my best to enter the client’s world and to work out if the client was coming from a too deeply depressed place which considered death as the only hope or had this been a cry for help etc.

I soon noticed a heightened sense of acceptance as I wrestled with my thoughts. I needed to respect the clients wishes if these deemed to be made under an adult mental capacity and in a sense that lifted my own desperation in sharing what meant to me a devastation. Yet, being mindful not to place my aspirations for living and influence my client in such a way which might create a power imbalance and an inability to empathically meet them which may help reduce the risk (Egan, 2010). Reeves (2015) concluded that: ‘As the clients are able to explore their feelings and fears and begin to address them fully’ (Reeves, 2015, p.49). Moreover, Bond (2017) argued that: ‘A counsellor is legally obliged to respect the wishes of an adult client with mental capacity who is contemplating suicide and actively forbids the counsellor to seek additional help’ (Bond, 2015, p. 177). Initially my supervisor had a sense of concern around the protection of myself working with complications of the client. Jenkins (2017) argued that: ‘Counsellors do not always pay enough attention to the risks which the client may pose towards them’ (Jenkins, 2015, p. 63).

My persistence and desire to continue working with my client was honoured by my supervisor by the belief that I was willing and able to manage the potential difficulties with this client (Reeves, 2015). However, without the support of good supervision and my Humanistic approach, I do not believe that I could have provided a safe therapeutic space whereby the client’s previous suicidal intent is now expressed as a suicidal ideation (Reeves, 2015). These have been challenging aspects of my professionalism within my Humanistic practice, from which I continue to learn and develop from by evaluating my weaknesses and strengths and by supporting my emotional well-being (Jenkins, 2017). Thus, empowering me to strive to work at high standard whereby I am ethical and principled in my approach that enables me to keep my client’s needs at the heart of the therapeutic work (Whitton, 2003).

In conclusion, the therapeutic process sits parallel to how professionalism in the therapeutic practice is shaped, identified and displayed in many forms that constitute of dynamic and fluid regulations that are constantly changing (Cooper, et al, 2013). It is essential to have expertise, though sometimes less knowledge may allow for more distinguishable curative factors in the helping profession (Egan, 2010). Thus, practitioners are picking up some responsibility for the client’s wellness and working in a joined-up way with other professionals and with a drive to provide a high-quality ethical commitment of promoting standards of care in professional practice, without subjugating an expert position. However, too much guiding us may act as distraction in allowing for a complete understanding and acceptance of the clients in their emotional needs which is essential to promote universally fundamental concerns and moral principles This could enable formulation of trust in our judgements by valuing and accepting the validity of one’s voice regarding where the client is at and having an overview of contextual and social influences (bacp.co.uk) (Schneider, et al, 2015). In this manner, we could better support our clients through the stages of the process with an aim for the client to be self-efficient, without needing the support of a counsellor (Rogers, 1961).

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(Appendix I)

BACP ETHICAL FRAMEWORK for the Counselling Professions (2016)

Ethics: Our Ethics are based on values, principles and personal moral qualities that inform and underpin the interpretation and application of our commitment to clients and good practice. (2016:2) (Jenkins, 2017, p. 131).

(Appendix II)

• A promise (e.g. to do or supply something)
• An agreement
• An exchange (e.g. of money in return for goods and services) (Mitchells and Bond, 2010, p. 45)

(Appendix III) (PCEPS 9) PC9. PSYCHOLOGICAL HOLDING:

How well does the therapist metaphorically hold the client when they are experiencing painful, scary, or overwhelmed experiences, or when they are connecting with their vulnerabilities? (Sanders and Hill, 2014, p.186-191) (Skills Feedback Form, 2014).

(Appendix IV)

BACP Core Curriculum (2009): (Jenkins, 2017, p.131)

10. Identify ethical and legal responsibilities with regard to potential risk, including critical decision making with respect to autonomy of the client and potential harm to self and others (2009:17). (Jenkins, 2017, p.131).

(Appendix V)

Confidentiality

55. (d) informing clients about any reasonable foreseeable limitations of privacy or confidentiality in advance of our work together, for example, communications to ensure or enhance the quality of work in supervision and training, to protect a client or others from serious harm including safeguarding commitments, and when legally required or authorised to disclose. (bacp.co.uk).