Working Safely, Legally and Ethically in CBT
Many aspects of working safely, legally and ethically in CBT are the same as they would be when working in any other modality.
For example, it is good practice to belong to an ethical body and to adhere to its code of practice – such as the Ethical Framework for the Counselling Professions (BACP, 2018).
One of the ‘fundamental values’ in this framework is a commitment to protecting the safety of clients (both physical and clinical). This safety is supported by ensuring we have regular clinical supervision, appropriate insurance and continuing professional development (CPD).
Physical Safety of Clients
Physical safety and comfort in the counselling room has various aspects, including:
- adherence to the legal requirements for health and safety
- vigilance to spot any new physical risks to clients (e.g. any breakages or spillages)
- appropriate lighting
- comfortable room temperature and ventilation
- privacy (e.g. using window blinds and ensuring the room is marked as engaged).
While it is always important (in any modality) to set out two similar (or ideally identical) chairs for client and counsellor, CBT work is facilitated by both parties having access to a desk/table to lean on when writing (as this modality often includes written work).
With regard to clinical safety in CBT, it is usual to assess risk at the start of therapy (and on an ongoing basis, as necessary) using mental-health questionnaires.
These come in various forms, measuring depression (e.g. PHQ and Beck’s Depression Inventory), anxiety (e.g. GAD), stress (e.g. PSS) or overall mental wellbeing (e.g. CORE and WEMWBS).
Many of these include questions that relate to suicidality (e.g. in PHQ-9, there is ‘Thoughts that you would be better off dead or of hurting yourself in some way’, assessing suicidal ideation; and in CORE-10, ‘I made plans to end my life’, assessing suicidal planning).
There are then specific instruments available to measure suicidality – for example, the Beck Scale for Suicidal Ideation (BSSI)
Indeed, the key risk for which to assess clients in CBT (and other talking therapies) is suicide.
Actual suicide (i.e. the act of deliberately killing oneself) is typically preceded in time by three prior stages:
- suicidal ideation
- suicidal plan
- suicidal intent
At the stage of ideation, the client has thought about suicide in a theoretical/abstract way – perhaps as one option in eliminating the emotional pain they find themselves in.
If this progresses to suicidal plan, the person has thought about what method they might use to take their own life (e.g. overdose, hanging or jumping from a height).
If this continues to suicidal intent, then they have decided specifically where and when they will carry out this plan (e.g. at home next Saturday night).
Assessing risk allows us to differentiate between these stages, discovering whether any does apply and, if so, taking appropriate action to keep the client safe if at all possible. Different action is likely to be appropriate at different stages.
In the BSSI, the first five screening questions are initially asked; if the answers to these are all 0, there is no need to continue to the rest of the questionnaire (so reducing its length and intrusiveness for patients who are non-suicidal).
Sometimes, clients will unilaterally reveal suicidal ideation when talking to their therapist.
However, being willing to raise the topic ourselves as therapists is important, both to provide a specific opportunity for the client to tell us about any such thoughts/plans/intentions and also to show that we are not afraid to discuss this topic.
Death and dying tend to be seen by many people in our society as taboo topics and it can be a huge relief to a client to discover that here they have someone who will listen without changing the topic or judging them.
Assessing suicidality is important, and it is also a good idea to request GP details for all clients at initial contact, in case of any need to contact the GP.
If a client’s assessment reveals suicidal ideation only, without any history of suicide attempts, the therapist should consider encouraging them to contact their GP (possibly phoning together during the session), and ensure they know where to get urgent help if they ever feel they could not keep themselves safe (A&E, 999, Samaritans and local crisis/assessment team).
If there is also a plan and/or intent, it is important to discuss with the client whether and how they can keep themselves safe, and if necessary encourage them to go straight to A&E or contact – or consent to the therapist contacting – the local crisis/assessment team during the session.
Having contracted with the client that one of the limits to confidentiality is harm to self or others, if they refused to follow any of these courses of action, the therapist may need to break confidentiality and contact their GP or local crisis/assessment team without their consent.
If a client describes their intended method of suicide as being a harm risk to others (e.g. the public if the plan is to jump off a motorway bridge), it may be necessary to break confidentiality to the police too (by calling 999).
Referral and Signposting
Apart from helping the counsellor identify possible risk and so ensure clinical safety, the results of mental-health questionnaires can also inform the decision on whether CBT is an appropriate therapy for the client, and whether the practitioner has the competence to work with the person and their presenting issue(s) to an appropriate professional standard.
If CBT is not appropriate or the client appears to require input beyond the therapist’s competence and insurance, they can then be signposted on to an appropriate individual or organisation.
For example, if it seems that a client may have PTSD, they can be referred on for specialist trauma-focused CBT or for eye movement desensitization and reprocessing (EMDR), in line with guidelines from the National Institute for Health and Care Excellence.
In order to know where best to refer or signpost clients, it is useful to research relevant organisations. Some agencies have their own lists of local support services, and counsellors can add to this by online research and by networking.
It is helpful to ask clients whether they are already clients/patients of any other relevant health organisations, to inform possible referral routes.
If the counsellor believes that referral would be the best option for the client, it is important to share their reasons, encourage the client to participate in the decision, and ask their consent to transfer the relevant information to the other agency.
At the very beginning of therapy, before explaining the CBT model and completing the risk assessments, the counsellor should communicate to the client the personal and professional limitations of their practice, using the counselling contract.
Contracting is a vital part of entering into a therapeutic relationship, as it explains clearly the boundaries and how each party can work with the other safely and responsibly.
The very act of contracting establishes the relationship as professional, and allows the therapeutic work to get underway more quickly through building trust in the therapist’s professionalism.
A typical contract might include:
- information on the offering (including the session duration, and any limit on number of sessions)
- confidentiality (including in relation to supervision, where the client would not be identified but their material may be discussed as part of maintaining a high standard of practice)
- the limits to confidentiality (i.e. harm to self or others, drug trafficking and money laundering, in line with the law)
- professional-body registration and adherence to a relevant ethical code
- fees (if relevant)
- policy on cancellations and DNAs
- information storage/use/disposal.
It is also important to ensure the client is aware of the therapist being a student (or a qualified practitioner in another modality but student of CBT), if relevant.
It can be useful for both parties to sign and date two copies of the contract, the client keeping one and the other being placed in the client’s file for secure storage at the agency.