Boundary Issues in Therapy: Case Study

Critically analyse the actions of the therapist from the perspective of the BACP and BABCP codes of practice and from the perspective of boundary issues.

The initial assessment of S revealed the presence of depressive symptoms, alcohol and substance use and poor coping skills, characterised by a chaotic household routine and difficulties managing her two children. Although limited information is available regarding the development of S’s current problems, it would appear that predisposing factors may include a history of physical abuse in her own family and pre-existing “low mood and irritability”. During the assessment, S described a vicious cycle of depressive feelings, negative automatic thoughts and avoidance behaviours, which appear to have maintained and exacerbated her current state. In addition to the disordered domestic situation previously mentioned, S depicted her relationship with her two young children as being something of a struggle, as she found their fighting with each other problematic and she stated that she “sometimes loses control” and slaps them “hard on their legs and hands”. Furthermore, S stated that she leaves her 11 year old child daughter to look after her 5 year old daughter. Whilst professing her wish for help, S also acknowledged her fear of losing her children.

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The counsellor articulated their wish to help S with her depression. In doing so, the counsellor is complying with fundamental principles of both BABCP and BACP guidelines, in terms of “aiming to resolve problems and promote well-being” (BABCP, 2007) and adhering to the “beneficence” principle (BACP, 2007). However, the counsellor did not, at this stage, expand upon any possible interventions which may be employed for S’s depression, nor did they explicate a plan to manage S’s alcohol and substance use. At this stage of therapy, it would be useful to begin the process of establishing a therapeutic alliance (Derisley and Reynolds, 2000), in terms of introducing mutually agreed goals and a shared formulation (Kirk, 1989). Such an alliance has been demonstrated to be positively associated with treatment participation and outcomes amongst alcoholics (Connors, DiClemente et al., 1997). Furthermore, this is congruent with the BACP principle of “autonomy”, i.e. “the importance of the client’s commitment to participating in counseling or psychotherapy” and with the BABCP’s guideline of discussing and agreeing the aims and goals of interventions from the outset of therapy.

The quality of empathy, an attribute described in BACP guidelines as one which counsellors and therapists should “aspire to” is not manifestly portrayed in the case study. An empathic therapist style has been associated with low levels of client resistance and with greater long-term change amongst individuals with addictive behaviours (Miller, Sovereign and Krege, 1989 cited in Miller and Rollnick, 1991). Accurate empathy has also been described as facilitating further disclosure of feelings and cognitions and thus, therapeutic collaboration (Marshall, 1996).

Confidentiality within a therapeutic relationship is acknowledged as a crucial and implicit feature within BACP codes of practice. This is reflected in the principle of “fidelity”, i.e. “honouring the trust placed in a practitioner … confidentiality is an obligation ….. any disclosure is restricted to furthering the purposes for which it was disclosed” (BACP, 2007). The BABCP also lists confidentiality within its guidelines for good practice, but is slightly less robust in its communication of this, stating that “information acquired by a worker is confidential within their understanding of the best interest of the service user and the law of the land” (BABCP, 2007). The counsellor working with S made the decision to break confidentiality due to their concerns about the welfare of S’s children and informs S that she will be requesting a social services assessment of the home situation. In view of S’s previous expression of her fear of losing her children, this information is highly likely to reinforce her anxieties and potentially risks alienating her from the therapeutic alliance and disengaging from any intervention. However, the clear dilemma facing the counsellor was acting upon the perceived risk to S’s children, whilst maintaining confidentiality and trust. Both BACP and BABCP codes of practice affirm that confidentiality must be within legal constraints. When elucidating the principle of “justice”, the BACP refers to “remaining alert to potential conflicts between legal and ethical obligations” and further to “be aware of and understand legal requirements and be legally accountable”.

With regard to legal aspects of S’s case, the children’s act of 2004 continues to allow smacking as long as it does not cause visible marks. It is not clear whether S’s smacking of her daughters constitutes illegal activity, however of more concern is her admission that she “loses control” when slapping them. Also of concern is the information that S allows her 11 year old daughter to care for her 5 year old when she herself feels unable to cope. Whilst S does not actually leave the children alone in the house and therefore is not breaking the law, the emotional impact upon her children would be a potential issue requiring attention. Returning to the actions of the counsellor in this circumstance, it would be highly beneficial to obtain more information about the nature of S’s relationship with her daughters, including the frequency of her smacking them and a clearer impression of their routine, in order to establish the possibility of neglect. The BABCP code of practice states that the therapist should “minimize possible harm and maximize benefits whilst balancing these against any possible harmful effects to others” (BABCP, 2007) and this is echoed by the BACP, which draws attention to “situations in which clients pose a risk of causing serious harm to themselves or others… the therapist should be alert to the possibility of conflicting responsibilities between those of their client, others and society” (BACP, 2007). Whilst the decision faced by the counsellor was a difficult one, a possible course of action would have been to declare the potential need to break confidentiality from the outset. Good practice guidelines typically incorporate an initial statement which refers to disclosures remaining confidential unless there is a risk of harm to the self or others (Jenkins, 1997; Bond, 2000) and apprising S of this possibility from the outset may have attenuated, to some extent, the impact of learning that a social services assessment would be requested.

One alternative course of action for the counsellor in this situation would have been to postpone a social services assessment until S had had an opportunity to implement the contract of behaviour regarding her children and the counsellor had sought supervision. There did not appear to be any urgency in S’s home situation, therefore it would seem reasonable to seek supervision prior to taking any immediate action. Both BACP and BABCP codes strongly dictate seeking supervision if “faced with a situation outside their competence” (BABCP, 2007) and paying “careful consideration to the limitations of their training and experience” (BACP, 2007).

In terms of informing the GP of S’s overall problem issues, but keeping the substance and alcohol abuse confidential, this would appear to be consistent with guidelines of keeping communication between colleagues “purposeful” (BACP, 2007) and “relevant” (BABCP, 2007). The counsellor mentions working on strategies to reduce S’s behaviours around substance and alcohol abuse and, as previously mentioned, further clarification of this intervention would have been helpful. Cognitive therapy for substance abuse emphasises identifying and testing thoughts and images about using drugs, modifying beliefs that increase the risk of drug use, coping with drug cravings and providing relapse prevention (Beck et al., 1983; Marlett and Gordon, 1989). Illustrating this process with S may have ameliorated the formation of a working alliance, as well as providing her with greater information about the intervention process, thus increasing her “self-determination” and “autonomy” (BACP, 2007). Furthermore, as S appeared to be at the “contemplation” stage of motivation to change (Prochaska and DiClemente, 1982, cited in Miller and Rollnick, 1991), an informative approach may have consolidated this state and enabled S to further move around the “wheel of change” into a state of determination or action.

With regard to boundary issues in the case study, a clear example of how this may be problematic in the counsellor’s relationship with S is in the area of a dual relationship (Schapp et al., 1996). That is, the emergence of conflicting responsibilities relating to S being the client but her children’s welfare being a clear cause for concern contributed to a potentially disruptive, ambiguous boundary. In this case, the ethical dilemma was apparent and although the codes of practice referred to provide some guidance and principles for managing such difficulties, it has been noted that guidelines and standards inform rather than determine our ethical decisions (Gillon, 1986). As such, in dealing with a client with sole parental responsibility, this is the nature of the issues confronted by a counsellor.

References

Beck, A.T., Wright, F.D., Newman, C.F. and Liese, B.S., 1983. Cognitive Therapy of Substance Abuse. The Guildford Press.

Bond, T., 2000. Standards and Ethics for Counselling in Action. London: Sage.

British Association of Behavioural and Cognitive Psychotherapy, 2007. Guidelines for Good Practice of Behavioural and Cognitive Psychotherapy. Available from: www.babcp.co.uk [cited: 30 April, 2008]

British Association of Counselling and Psychotherapy, 2007. Ethical Framework for Good Practice in Counselling and Psychotherapy. Available from: http://www.counselling.co.uk [cited: 30 April, 2008]

Children’s Act, 2004. Chapter 31. London: HMSO.

Connors, G.J., Carroll, K.M., DiClemente, C.C., Longabaugh, R. and Donovan, D.M., 1997. The therapeutic alliance and its relationship to alcohol treatment participation and outcome. Journal of Counselling and Clinical Psychology, 65 (4), pp. 582-598.

Derisley, J. and Reynolds, S., 2000. The transtheoretical stages of change as a predictor of premature termination, attendance and alliance in psychotherapy. British Journal of Clinical Psychology, 39, pp. 371-382.

Gillon, R., 1986. Philosophical Medical Ethics. New York: Wiley.

Jenkins, P., 1997. Counselling, Psychotherapy and the Law. London: Sage.

Kirk, J., 1989. Cognitive Behavioural Assessment. In, Hawton, K., Salkovskis, P., Kirk, J. and Clark, D.M. (Eds), 1989, Cognitive Behaviour Therapy for Psychiatric Problems: A Practical Guide. Oxford: Oxford University Press.

Marlett, G.A. and Gordon, J.R. (Eds), 1989. Relapse Prevention: Maintenance Strategies in the Treatment of Addictive Behaviours. New York: Guildford.

Marshall, S., 1996. The Characteristics of Cognitive Behaviour Therapy. In, Marshall, S. and Turnbull, J., 1996. Cognitive Behaviour Therapy: An Introduction to Theory and Practice. Balliere Tindall.

Miller, W.R. and Rollnick, S., 1991. Motivational Interviewing: Preparing People to Change Addictive Behaviour. New York: Guildford.

Miller, W.R., Sovereign, R.G. and Krege, B., 1989. The Check-up: A Model for Early Interventions in Addictive Behaviours, cited in, Miller, W.R. and Rollnick, S. (Eds.), 1991, Motivational Interviewing: Preparing People to Change Addictive Behaviour. New York: Guildford.

Prochaska, J.O. and DiClemente, C.C., 1982. Transtheoretical therapy: toward a more integrative model of change, cited in Miller, W.R. and Rollnick, S., 1991. Motivational Interviewing: Preparing People to Change Addictive Behaviour. New York: Guildford.