A Critical Evaluation of the Challenges in Professional and Ethical Practice for the Person-Centred
It could be suggested that from certain perspectives the person-centred practitioner is in the business of collaboratively healing the wounds left behind by an individual’s encounter with authority. The authority we place with our external locus of evaluation can leave us feeling not good enough as we are, and encourage us to become somebody we are not necessarily meant to be. The psychological and emotional implications for this could be considered massive, and, at times, it is the role of person-centred practitioner to assist their clients with getting in touch with their own authority again, found within their internal locus of evaluation. Yet can authority be confronted and obeyed at the same time? Within this paper we shall briefly explore whether the person-centred approach meets the expectations and needs of society. What are the implications for the person-centred approach operating within an evidence based climate. Whilst touching on some reflections around my competency and effectiveness as a counsellor.
Are individuals within this society enabled, encouraged even, to sacrifice their personal responsibility when in the presence of some perceived authority? Social experiments conducted by Stanley Milgram in the 1960s appears to support this perspective, which demonstrated that the majority of participants would electrocute a helpless victim when ordered to.
Subjects have learned from childhood that it is a fundamental breach of moral conduct to hurt another person against his will. Yet, 26 subjects abandon this tenet in following the instructions of an authority who has no special powers to enforce his commands. – (Milgram, 1963)
Yet other individuals defy authority even when it has come at great personal cost, consider the protesters currently protesting against the Dakota Access Pipe Line at Standing Rock for example. So not everyone obeys an external source of authority, yet it could be implied that authority has a direct impact on human behaviour, and is arguably an accepted and expected part of modern society.
When it comes to authority and human behaviour it should be explicitly stated that there are an immense amount of variables attached to both these concepts. For the sake of simplicity, authority is symbolic of power and human behaviour is reactive to this power. Sometimes authority can be considered helpful and supportive, other times it could be considered oppressive and controlling, and individuals react differently to authority dependent on their phenomenological perspective on any given situation and its implications.
It could be suggested that it is this expectation and somewhat passive acceptance of authority that defines the philosophy behind person-centred theory unique compared to other methods of problem solving found within society. Normally if we encounter a problem that we cannot solve ourselves we will seek out an expert of some description to provide us a solution. It could be suggested that person-centred theory is geared up to heal the wounds that are subtly and often implicitly inflicted by different sources of authority; termed conditions of worth.
The process of internalising conditions of worth results in the emergence not of a true or, in Seeman’s terminology, ‘organismic’ self, but of a false or conditioned self. This conditioned self is the self that operates in the world, and this is the self that continues to actualise. (Merry, 2002, p. 28)
A person’s truth is not reached by being symbolised as an expert on psychological/emotional wellbeing. This is achieved through developing a therapeutic alliance by utilising the core conditions which can enable the client to get back in touch with their truth, and as a result become more engaged with and responsive to their own authority, rather than maybe feeling committed to being reactive to the authority imposed upon them by others. So from this perspective it could be claimed that person-centred therapy might not meet the expectations of society, as in their problems will not be fixed, yet it could be addressing a social need that many of us may not be aware of. A need for individuals to take more personal responsibility for themselves, their actions and the impact they can have on others and the world. A need for individuals to become empowered.
If time limits did not constrain therapy, perhaps more individuals would question the world they live in, and in doing so challenge the status quo. The person-centred approach does not concern itself with therapy alone, but it is a vision of ‘being human’. (Macdonald, 2006, p. 41)
Due to its fluidic nature person-centred theory has the potential to meet a wide variety of human needs, yet will not claim to have the knowledge to fix anything, "The client is not only assumed to have an innate capacity for growth, but is also the expert on how to achieve this." (Bond, 2015, P. 41). This perspective on problem solving could appear quite alien to people who are conditioned to rely on the authority of others, as we all are to a certain extent. Yet although person-centred practice could be considered to be able to counteract the impact that authority has on individuals, the person centred practitioner still has to consider different authorities when practicing with their clients.
A counsellor needs to understand their own morality, have respect of their clients’ right to self-govern whilst also being mindful of any policies and procedures imposed on the therapeutic alliance by any organisations they might be working for, and also being aware of the impact other professionals might have if they work in a multi-disciplined setting. Then to be considered professional one must become a member of the BACP or another nationally recognised institution, and work within the provided ethical framework whilst at all times obeying the law. All these different facets to professional practice can at times appear to conflict and as a result create a lot of tension which is referred to as encountering an ethical dilemma. These moments can be very stressful so utilising a systematic approach like Bond suggests can be incredibly beneficial.
Whenever you are confronted with an issue or dilemma about ethical standards, it is useful to approach it in a systematic way. This maximises the likelihood of reaching a solution which you are confident is the best possible outcome. (Bond, 2015, p. 279)
I am currently working with a client who I am really struggling to understand due to his thick Caribbean accent. I was able to be real and congruent within my communication by acknowledging the stress and frustration I was experiencing in trying to understand what he was saying and how I felt resistance in repeatedly asking him to repeat himself. To which he responded by saying he would much rather I repeatedly ask than just pretend to understand. Which felt like a stressful proposition to me, I could maybe understand 25% of what he offered. I was not sure whether I should continue to work with this client or refer him on to another therapist within the service, this felt like an ethical dilemma.
On examination, this is my dilemma, yet the decision I make is consequential to my client. Referring him on could have implications upon my client that I am unaware of, yet continuing the work is having a detrimental impact on me, in the sense I experience deep stress and anxiety in relation to the thought of continuing our work. This implies that there is a conflict between self-respect and non-maleficence when the BACP’s 6 principles are considered. Autonomy is also challenged because referring him on could technically override his autonomy, dependent on how it is done. Trust worthiness and fidelity feel inert in relation to this dilemma yet justice would indicate I am unable to offer this client the same depth of therapy as I am able to offer other clients, and possibly suggests an incompetence in regards to working with this client. "A counsellor has the right to withdraw from counselling when they feel that counselling is beyond their competence and a client refuses additional assistance or referral." (Bond, 2015, P. 117). Yet referring him to another therapist could potentially clash with the law as well, specifically the equality act.
The Equality Act 2010 (applicable to England and Wales and adopted by Scotland) provides legal protection against discrimination for specified human characteristics, namely- age;- disability;- gender reassignment;- marriage and civil partnership;- race;- religion or belief;- sex;- sexual orientation. (Bond, 2015, P. 200)
Referring him on could be misinterpreted as an act of racial discrimination by my client or from another outside perspective. This is a situation that is best explored with my supervisor, to remove the stress of personal responsibility and share it with another source of authority, even if this is not objectively true. “When supervising qualified and/or experienced practitioners, the weight of responsibility for ensuring that the supervisee’s work meets professional standards will primarily rest with the supervisee.” (BACP, 2015)
My supervisor’s main mode of practice appears to be restorative, which I find incredibly rejuvenating and it often leads me to looking for normative/formative guidance. In regards to my client who is difficult to understand, from a normative perspective we explored the impact of referring this client to another therapist within our service, would another therapist necessarily understand him better than me, and what could the possible implications be? From a more formative perspective my supervisor educated me on other services and other potential resources that he was aware of that could help. I came to the conclusion that my client’s autonomy was incredibly important here and rather than explicitly encourage him to engage with another service I would carry on working with him and only suggest the other service if I hear him become frustrated within our therapeutic contact. This will enable the client to make a decision of what is best for him and minimise the risk of psychological and emotional damage, whilst also ensuring my practice is considered ethical and professional. I decided to value non-maleficence and autonomy over self-respect, which indicates an area of professional development. My clients’ needs always appear to come before my own, to the point I have found myself psychologically suffering before due to this imbalance of consideration. It has been suggested that I over identify with my clients, and take on too much responsibility on my clients’ behalf. This leads me to think about how can I hope to develop empowering relationships if I treat myself as an afterthought and actively disempower myself? Yet from another perspective it could be suggested that this area of development for me could be considered an area of competence. I am unlikely to practice in a way that makes my clients feel diminished by my authority, allowing their own sense of empowerment to develop by not putting any personal conditions on our therapeutic alliance. Yet there is a fine line here of competence and incompetence, if I allow myself to suffer too much it could have a negative influence on my practice. There is something here about boundaries, yet I am aware my boundaries are relational to what is presented to me. I might not have to put my needs before my clients, but it is ok for me to offer my own needs the same depth of consideration.
At another one of my placements if suicidal intent is discussed I am to break confidentiality and to make contact with my client’s GP, hopefully with the clients consent. Yet even if client’s consent is not offered this has been explicitly requested of me and I am to break confidentiality regardless. There is a whole procedure developed around this scenario with explicit instructions provided. My personal authority is technically superseded by the authority of my placement. Yet what about the BACP’s principle around being trust-worthy “honouring the trust placed in the practitioner” (BACP, 2015). It could be said that by breaking confidentiality I am in clear breach of this ethical principle, especially if I look at the client/counsellor agreement and the limits of confidentiality are not mentioned. This indicates that if I blindly follow the authority of my placement I could be operating outside the boundaries of acceptable practice of my governing body, whilst also finding myself breaching common-law in relation to confidentiality which could have a devastating impact on my personal and professional life. But UK law and the BACP hold autonomy in high regard so when it is disclosed that all the clients I work with are explicitly told about the limitations of the confidentiality that they are offered during their assessment session the picture suddenly changes. "There are no ethical or legal reasons which require that the therapeutic contract should be in writing. In many situations an oral agreement will be sufficient." (Bond, 2015, P. 99). So if the situation arises where suicidal intent is disclosed I am enabled to break confidentiality, even if that decision goes against my client’s personal wishes, and still consider myself as an ethical practitioner. Yet what about the ethical implications from a person-centred oriented perspective?
Our choice of therapeutic orientation will have ethical implications. Therapeutic models are usually produced to serve therapeutic ends rather than as exercises in secular ethics. Nonetheless, they incorporate ethical orientations and beliefs, usually implicitly. (Bond, 2015, P. 41)
Does communicating the limits of confidentiality and explicitly detailing the consequences of disclosing suicidal intent create the environment of a condition of worth to be implicitly internalised? I am worthy of therapy and confidentiality as long as I do not talk about my desire to kill myself? Desire does not mean intent and maybe by detailing the consequences of disclosing intent will create a block for the client to explore any hidden desire, possibly reinforcing incongruent communication. Is this therapeutic? Is this accepting a person for who they are, as they are? Remaining ethical in person-centred practice requires a deep level of awareness and a resilience to tension, because ethical practice is complex and very rarely is there a black or white perspective, so often different people will come to different conclusions (Cooper et al, 2013).
At the very core of person-centred philosophy is a faith in an individual’s tendency to actualise, which suggests person-centred therapy is not designed to work with problematic behaviour or psychological/emotional states, but to work with a person as a whole being. This perception appears to be reaffirmed by Carl Rogers himself in regards to his first published book, found referenced within the helping system: Journey and Substance.
In this book we shall work with the child, not the behaviour symptoms. One will look in vain for a chapter on stealing, thumb-sucking, or truancy, for such problems do not exist, nor can they be treated. . . . [In] each instance it is the child with whom we must deal, not the generalisation which we make about his behaviour. (Rogers, 1939: 3 – 4) (Barret-Lennard, 1998, P. 1)
Yet it would appear this basic philosophy has not been taken seriously and as a result the person-centred approach is being victimised by a condition of worth to be problem specific, I am to write a dissertation on the necessity and sufficiency of the core conditions in overcoming addiction and I am also aware of a book released in 2014 by Pete Saunders entitled Counselling for Depression: A Person-centred and Experiential Approach to Practice. This arguably takes person-centred theory away from its very core. Is this drive to provide results and fix problems a result of the evidence-based climate being more focused on fixing undesirable behaviours and emotional states, combined with the perception that problems can be solved under the authority of an expert of some description? When we consider that NICE has a lot of influence over the development of mental health services and as a result influence over financial investment (Bond, 2015), and its roots are found within the NHS, which heavily subscribes to medical model of recovery, this problem solution way of working and measuring of effectiveness becomes understandable. But it is this perspective which is unable to meet person-centred theory and the philosophy it has been built upon. That individuals are experts on their own experience therefor possess the internal resources to overcome their perceived difficulties, or deepen their levels of understanding and acceptance. To be an expert and tell the client what they should or should not do would be symbolic of creating a condition of worth which would be detrimental to the core philosophy at the centre of this approach.
The person-centred approach, then, is primarily a way of being that finds its expression in attitude and behaviours that create a growth-promoting environment. It is a basic philosophy rather than simply a technique or method. (Rogers, 1990, p. 138)
How can a philosophy be quantified and measured? Is there any accurate way to measure and put a value upon the core conditions? The very fundamentals of person-centred therapy are immeasurable and therefor are at a disadvantage when it comes to evolving within an evidence based climate.
Not everyone can afford therapy, many people who would greatly benefit from them are unable to access them. So the IAPT service has been developed as part of the NHS, which invests massive sums of money in improving access to psychological therapies, so those who are unable to afford therapy are still enabled a chance of accessing it. Which although appears very altruistic, the development of IAPT is largely accredited to the work of Richard Layard who explores the economic implications of mental health issues that impacts members of society, and basically how investment in better mental health services enables more people to return to work (Layard, 2006). Which is symbolic to a very subtle but incredibly powerful authority, economics; specifically money. Without money practitioners are unable to survive, and to seek investment in a service one has to be able to provide evidence that what they do is effective, which is arguably what has created this evidence based climate.
Evidence is acquired in numerous different ways from clinical RCTs to client and practitioner feedback. Client feedback is acquired through the use of forms that use scales in an attempt to measure an individual’s subjective experience. Yet what impact does asking a client to fill out a form have on the therapeutic alliance? I was once allocated a client who had been on a waiting list for a long time. She came to see me in relation to the traumatic experience of losing a child. The first thing she claimed when she sat in the room was that she did not think she needed therapy anymore and she scored incredibly low on the CORE-OM form which stands for Clinical Outcome in Routine Evaluation Outcome Measure. This suggests on paper that my client is in a good subjective place, but maybe from a person-centred perspective this is evidence of incongruence. So if we explore this traumatic experience there is a strong likelihood that score on the CORE-OM form is going to rise. Does this mean that I am going to be judged as a poor therapist by my counselling coordinator? Will this form then become evidence of the ineffectiveness of person-centred therapy in a study? Would it then be ethical me to reinforce this possible incongruent understanding of my clients sense of self to protect my own interests and the reputation of my modality? I would disagree that this would be ethical on any level, yet I was aware these concerns entered my mind, and the power of authority can have a heavy influence over the development of a therapeutic alliance, and therefor impact the therapeutic outcome.
By gathering research it could be implied that the intimacy of therapy is tainted in some way by the thought of an invisible force of authority monitoring our progress. Yet the forms can also help prepare the client to explore deeper parts of their process, whilst also providing further insight for the therapist to work with. For example a client might score high on the scale which measures suicidal intentions which then allows the therapist to facilitate an exploration of these feelings. Whereas without the form asking the direct question it is possible the client might not choose to discuss this part of their experience with their therapist for whatever reason. It could also provide a metric to which therapists can try to measure their effectiveness by, yet this is not something I do as I find there are so many other variables in life that can impact a score rather than just therapy. For instance I had a client whose father died unexpectedly during our therapeutic relationship. This experience had more of an impact on my client than therapy ever could.
I measure my effectiveness through reflecting on my experience with previous clients, and watching the personal development that unfolds in front of me with my current clients. Although practitioner experience is not highly regarded in the world of research (Bond, 2015), to me it is invaluable. I am aware that I have been experienced as an effective counsellor in the past, so I know others from my future could also consider my practice effective. Yet not necessarily everyone will. Research is beginning to indicate it is the quality of the relationship that is the important factor of therapeutic development, not the skill or modality of the therapist (Cooper, 2008). So I know I cannot claim to be an effective therapist in relation to every potential client out there.
Authority has a direct impact on human behaviour, and arguably distorts human development. Person centred therapy tries to work in a way where the sense of authority and the conditions that come with it are briefly removed for a small moment of time, so the client can explore their internal worlds in a way that allows them to get back in touch with their own values, rather than the values imposed upon them. So from this perspective it could be claimed that person-centred theory actually combats the effects of authority and tries to heal the wounds implicitly inflicted by this concept. Yet ironically, for person centred practitioners to be considered professional and ethical, they have to obey the expectations of other sources of authority. This can impact practice and influence practitioners to work in a way that conflicts with the person-centred perspective. The philosophy behind the person-centred approach and the method in which it is practiced is quite unique to the point it can feel like it does not quite belong in this society yet. The person-centred approach is not about working with problems, it is about working with people, and because this philosophy is not acknowledged or respected by the environment it is found within, there is the risk that the person-centred approach is being pressured to become something that it is not.
References
Barrett-Lennard, G.T. (1998) Carl Rogers’ helping system: Journey and substance. Thousand Oaks, CA: SAGE Publications.
Bond, T. (2015) Standards and ethics for Counselling in action. London, United Kingdom: SAGE Publications.
British Association for Counselling and Psychotherapy (2016) Ethical framework for the Counselling professions. Available at: http://www.bacp.co.uk/events/learning_programmes/ethical_framework/documents/ethical_framework.pdf (Accessed: 12 November 2016).
Cooper, M. (2008) Essential research findings in counselling and psychotherapy: The facts are friendly. Los Angeles: SAGE Publications.
Cooper, M., O’Hara, M., Schmid, P.F. and Bohart, A.C. (eds.) (2013) The handbook of person-centred psychotherapy and counselling. 2nd edn. New York: Palgrave Macmillan.
Layard, R. (2006) THE DEPRESSION REPORT A new deal for depression and anxiety disorders. Available at: http://cep.lse.ac.uk/textonly/research/mentalhealth/DEPRESSION_REPORT_LAYARD2.pdf (Accessed: 8 November 2016).
Mearns, D. Thorne, B. and McLeod, J. (2013) Person-centred counselling in action. 4th edn. London: SAGE Publications.
Milgram, S. (1963) Behavioural Study of Obedience. Available at: http://www.columbia.edu/cu/psychology/terrace/w1001/readings/milgram.pdf (Accessed: 6 November 2016).
Merry, T. (2002) Learning and being in Person-Centred Counselling. 2nd edn. London, United Kingdom: PCCS Books.
Pauline Macdonald. (2006). person-centred therapy and time-limited therapy. In: Proctor, G. Cooper, M. Saunders, P. and Malcolm, B. politicising the person-centred approach; an agenda for social change. United Kingdom: PCCS Books ltd
Rogers, C. Kirschenbaum, H. Henderson, V.L. (1990) The Carl Rogers Reader. London, United Kingdom: Constable and Robinson.