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Knowledge beyond words: confusion and ethics

In 2002 BACP published new ethical guidelines. Before publication, Ivan Tyrrell questioned the main author of the guidelines, Tim Bond, about what they actually mean.

TYRRELL: The British Association for Counselling and Psychotherapy (BACP) is one of the main trade associations for therapists, and it is very active in trying to set standards that it would like to see adopted nationally. You played a big part, I believe, in preparing its new Ethical Framework for Good Practice in Counselling and Psychotherapy?

BOND: Yes, I was the author of most of it, except a few specialist professional conduct procedures.

TYRRELL: The word ‘ethics’ comes from the Greek ethikos, which means ‘dealing with human nature’. So, my first question is where does BACP’s knowledge of how to deal with human nature come from that qualifies it to set out this framework?

BOND: There are two dimensions to your question: one is the general question about where we gain the knowledge of what is ethical. The other dimension is, what is BACP’s claim to have a voice, with regard to ethics and the profession?
   If I take the general point first, ideas about where one can get ethical knowledge from are changing quite rapidly. When I first started studying, moral philosophy was almost invariably linked to ideas about reason and analysis, and deducing practice from principles. Whereas now, because of cultural changes, and changes in academic understanding, there is a greater reluctance to rely exclusively on any one system of thought, particularly when you look at a professional practice. There are real risks working solely from principles, for example, because they tend to create a sense of disengagement from the people you are working with. That is both their value and their limitation. Their great value is in showing the need to step outside a complex situation to look at it afresh. Their limitation is that principles do not necessarily encourage an ethical way of being with the person you are working with.

TYRRELL: Can you define what you mean by an ethical way of being?

BOND: It is very much rooted in the quality of the relationship and the way in which, in the modern world, we interact with potentially different value positions. Respect for diversity and the quality of the relationship become more important than operating out of a single ethical perspective or belief.

TYRRELL: By that you would mean, for example, perhaps a religious framework …?

BOND: It could be a religious framework; it could be a cultural set of values; and of course cultural values are often deceptive because they go unquestioned.

TYRRELL: Well, they are usually conditioned-in.

BOND: Yes, they are within our ‘warp and weave’ and it is only when we are exposed to other cultures that we can become aware of them. 
   Nowadays, when people think about what it means to be ethical, the personal moral qualities have come more to the fore. Within the literature on talking therapies, these are often presented as ‘the personal qualities of the therapist’. We know from empirical studies of clients’ experiences that, very often, it is their sense of the personal qualities of their counsellor or psychotherapist which help them, which give them a sense of being valued and a feeling of safety. Very often, frameworks are secondary to that.

TYRRELL: Your stated aim in producing this document was to produce a framework that “provides the best possible protection of the public” — could you explain what that means and how you define protection?

BOND: There are several dimensions to protection. The first and most obvious one is that any profession should be able to assure the public that its members will not exploit, abuse or neglect them. Every profession needs safeguards in place to deal with those issues as they arise. Fortunately, they are relatively few in relation to the large volume of work that takes place within talking therapies. Once the safety net is in place, probably the more critical issue which would apply to the vast majority of encounters between clients and practitioners would be about enhancing the ethical quality of the relationship. That, in this context, means both addressing the way in which the relationship is established and managed, and also the quality of services provided.

TYRRELL: That is a key thing — the quality of service — but, before we talk about that, I would like to raise the stated second aim: that BACP wants this framework to encourage practitioners to consider the ethical basis of their routine work with clients, and “to embrace ethics as an essential integral part of their work”. How does one embrace ethics exactly? We can embrace a person, a child, or even a tree, if so inclined, but surely we cannot embrace ethics? 
   A big problem with a document such as this is that so many of the words used in it are what linguistic psychologists call ‘nominalisations’ [the term for an abstract noun which is produced by converting a verb into noun]. This makes this topic very, very difficult because one has to pin these words down. Just because one behaves ethically in a situation, for example, doesn’t mean one ‘has’ ethics. Ethics is not something that one can pick up, embrace and carry around. Similarly, one cannot ‘have’ counselling. Someone can be counselled, of course, but they don’t have it.
   Nominalisations are confusing slippery words of influence, dangerous almost, because they mean different things to different people. No one can give someone ‘joy’, ‘love’ or ‘enlightenment’ because these words mean different things to different people, even though we manipulate one another all the time by pretending they are concrete things that can be given. One can beenlightened about something but not given enlightenment. One can be made angry by something happening but not have anger inside, as if it was blood. In the same way, one cannot have values. I think your document represents a heroic endeavour, but, because there are a lot of nominalisations in it, it is probably going to cause some confusion in many people.

BOND: Yes …

TYRRELL: I must ask you about this as it is absolutely central to good counselling, yet so many counsellors are not aware of this. How does one embrace ethics exactly? This is your phrase, not my phrase.

BOND: No, it’s certainly my phrase. What it is driving at is that, for some practitioners, ethics have been, as it were, an afterthought — something that was bolted on. The notion of embracing, in this context, is actually drawing ethics closer into everyday practice. So it is actually trying to promote a sense of ethical mindfulness within practitioners which is not solely related to those difficult and tricky dilemmas that we all face – should I break confidentiality in these particular circumstances to prevent some other wrong to somebody else? Ethical mindfulness should run throughout all routine work, as well as the exceptionally demanding work.

TYRRELL: So, basically, you want people to think about the consequences of their actions in some kind of ethical way, as part of whatever they are doing?

BOND: Yes. It is particularly significant in the context of the change that this document represents because it is a deliberate move away from a ‘rule-based’ system of ethics to one which is drawing people’s attention more to the issues and the possible ways of responding to issues, and encouraging them to take greater responsibility for their practice, and develop a corresponding degree of accountability for the decisions that they make.

TYRRELL: What you have just said, using the word ‘issues’, illustrates a fundamental problem. When we use a nominalisation like ‘issue’, which sounds as if it refers to something specific, it actually hides the fact that circumstances always alter cases. In any point in question, which is what an issue is, you have got to look at the particular event in the round and consider everybody’s roles in that event and recognise that no two events are the same. Approaching an event in that way would be an ‘ethical activity’, as it were. When we use nominalisations like ‘human rights’, ‘values’, ‘principles’, ‘sense of self’ and so on, it is incredibly difficult to form a relationship in one’s own mind with what these words might mean to someone else.

BOND: Yes, I accept that that is a fair comment, and it is in the nature of these documents that they are written in fairly abstract and general terms. Therefore, it represents a sort of value commitment, rather than an absolutely prescriptive, tightly bolted down behaviour.

TYRRELL: The thing is, when you say we should respect human rights and dignity — on the face of it, no one is going to disagree with that. But what exactly does it mean? Nobody comes into the world with ‘rights’. Rights can be defined by law, but there has to be an agreed shared perception in a community to abide by such laws. So, what are these shared perceptions? Is a counsellor operating from an ideology infringing the rights of their clients or treading on their dignity without anyone realising it? Does a psychopath who obeys every impulse and does whatever he wants, have rights? If he wants something now, should he have it, whatever it is?

BOND: Whilst I agree that there is a range of views with reference to human rights, most of them would not countenance the psychopath’s.

TYRRELL: No, I was just using that as an example to illustrate the point. Someone said to me the other day, “I have a right to high self esteem!” — two nominalisations there — and this is an absurdity.

BOND: Yes, I would agree with you.

TYRRELL: So, when people talk about human rights, there aren’t shared perceptions about what is meant.

BOND: Well, in the context of BACP’s new ethics document, human rights lead to a point of reference which would actually be the legal definition. And clearly human rights would mean an awful lot to practitioners working with, say, refugees in various oppressive situations. In our current society, we have the luxury of looking beyond those basic human rights to more relational rights and quality of life type issues which often get merged in with human rights. 
   But certainly in the wider international context it is extremely important that practitioners using a talking therapy are committed to human rights and also avoid being used by authorities in ways which abuse people’s human rights. Of course, in the history of mental health there have been times when practitioners were either coerced or voluntarily got themselves involved in some very degrading practices in relation to their clients.

TYRRELL: Could you give an example?

BOND: Well, for example, where psychiatric patients were compelled to receive medications, which later on proved to be extremely toxic, without any opportunity to give or withhold consent. There have also been some very brutal behavioural regimes used at various times in mental hospitals.

TYRRELL: Another area which will be of particular interest to our readers is where you talk about “enhancing the quality of professional knowledge and its application”. This is listed as one of the ‘values’ of counselling and psychotherapy — a commitment to doing this — along with “alleviating personal distress and suffering”. Now these are vague statements and BACP seems to have no way of dealing with the practicalities of overseeing how people uphold this sensible requirement. 
   The problem seems to me to be that, even assuming that all counsellors and psychotherapists are in the business to alleviate personal distress and suffering, many of the ways they are trained to use to do this do not work terribly well, and some can actually maintain people in their suffering. There is a lot of research, for example, showing that psychodynamic approaches to treating depression make depression worse, as does any form of counselling that encourages introspection, because emotionally arousing introspection is what causes depression in the first place! And yet these practitioners would sincerely believe themselves to be committed to relieving distress, even though, because of their training, they are not relieving it.

BOND: Yes, I realise that this is one of your concerns.

TYRRELL: At a workshop yesterday, I met a counsellor, accredited by BACP, who thought it was not necessary to set clear goals with clients. She was telling us about a client she had been seeing every week for three years who came to her because he was depressed and needed help. He was still depressed. She confidently believed that the ‘therapy’ she was doing must be helping him because in their sessions together she was unravelling and exploring ever deeper reasons for his state of mind. In the light of what is known about depression this is clearly unethical. She had been trained at the Tavistock in a type of psychodynamic therapy.

BOND: This takes us back to why excessive reliance on any one principle or value, or human quality, is now being questioned. You can only, as it were, achieve the alleviation of personal distress and suffering, at a level that is more than rhetorical, if you are also asking yourself — very systematically — how effectively you are doing it, how safely you are doing it, and how you know that you are doing it effectively and safely. That is why throughout our document there is a great emphasis on developing professional knowledge, and on research.

TYRRELL: Yes, that theme runs right through it.

BOND: It is one of the big shifts in the talking therapies — that research is being increasingly recognised as important.

TYRRELL: However, it is not just research into the effectiveness of different types of therapies which is needed but awareness of research findings about the brain and about human nature. Therapy approaches need to be open and flexible enough to incorporate and act on this kind of information, on an ongoing basis.
   Moving on, though, to my next question. How is professional competence to be measured? In the framework you say, “All clients are entitled to good standards of practice and care from their practitioners in counselling or psychotherapy”. This is said a number of times. But how is professional competence to be measured? 
   It seems to me that no amount of ethics, agreement to commitments, particular therapeutic approaches or values have a meaning unless any given therapist can be shown to have a fairly reliable effect on getting people better. Are BACP-accredited counsellors, for example, getting people out of their depressions? Are they dealing well with anxiety disorders? Are they getting people over their addictions? Are they improving people’s relationships? Are they able to detraumatise people? In other words, does this ethical framework count for anything if that competence is not measured?

BOND: The broad drift of the document is in complete agreement with that point. It is laying stronger emphasis on the profession, and us individually, to look at what is the evidence for our claims, and is also therefore trying to create an infrastructure that will, over time, enable us to answer such questions much more effectively.
   You talk about what is measured. As you know, the evidence based movement, which has clearly had an influence on the document, can be defined very narrowly as being restricted to particular paradigms of knowledge and particular methods derived from the natural sciences or it can be viewed more broadly as encompassing a whole range of approaches. These are the sort of debates that we need to have continually within the profession in order to develop our own strategies and approaches which are appropriate to our practice. 
   It is quite reasonable that there should be a range of views on those sorts of issues. But what is really important is that, as a profession, we are committed to actually looking at the impact of our work and how we know.

TYRRELL: I couldn’t agree more! You say in the document that “fostering a sense of self that is meaningful to the person, or persons, concerned” is one of the values in counselling and psychotherapy. Could you just explain what you mean by a sense of self that is meaningful?

BOND: During the process of writing this I was strongly influenced by the experience of people in New Zealand, and my own work with people from Asian countries, which highlighted that not only do we have individually different understandings of what self means to each of us but also that there are strong cultural differences. Generally speaking, in western European society, ‘self’ is very much thought of as ‘the individual’. But that is not the universal frame of reference. 
  For instance, take the Maoris in New Zealand – their primary point of reference is their family group. The result of this, in the context of medical ethics, has quite profound significance. There have been examples of Maoris attending hospitals for investigations but, when their diagnosis is communicated to them and they are offered treatment, they run away from the hospital. This was a source of great concern and frustration for doctors and nurses involved in trying to treat them until they discovered that the individual did not have the authority, in their way of thinking, to make decisions about matters of life and death which would have an impact on the family. The fundamental unit for making those sorts of decisions was the family. Similarly, when you’re working with other communities, the notion of the detached, independent self is just not part of the mindset. So, if I was working from my rather westernised perspective with people with a different understanding, then I think there is an ethical requirement that I work in ways that are respectful of that understanding and try to engage with them.

TYRRELL: That’s fascinating. There is a lot of interest in low self esteem at the moment and the idea that we should all have high self esteem has really taken root in the west. But the idea of esteeming the self is actually repulsive because people who esteem themselves tend to be boastful and put their wants above other people’s needs and so on. So there are many ways to ‘sense the self’ from the anthropological point of view.

BOND: That sense of high self esteem replaces the one about humility to some extent, which originally, during a more traditional Christian time, was thought to be a more desirable virtue.

TYRRELL: In the document, you talk about the values of fidelity, autonomy, beneficence … What is the difference between values and principles in counselling or psychotherapy, as you see it?

BOND: ‘Values’ are a general ethical commitment. ‘Principles’ bring that commitment together with a commitment to action. It is almost inevitable that the principles are the dominant mode of expression within any profession, and most codes or ethical statements are expressed as principles. But one of the things we have tried to do is not to rely solely on principles because of the limitations of principles, particularly in a profession which depends so much on the quality of the relationship between a practitioner and client.

TYRRELL: One of the principles you talk about is autonomy. You say that “the principle of autonomy strictly prohibits the manipulation of clients even for beneficial social ends”. Now, on the face of it, that seems incredibly limiting and unrealistic in the sense that, in any interaction between people where attention is being exchanged, manipulation is inevitable. For example, people seek help when they are highly emotionally aroused and can’t think straight enough to sort out their difficulties on their own. They go to a counsellor because they are emotionally disturbed and so an essential step in helping the client begin to gain control is for the counsellor to relax them. Would you say that relaxing a client is manipulating them?

BOND: Not if you are relaxing them towards a goal to which they have agreed or are supportive of.

TYRRELL: So, manipulation from your point of view would be occurring only if they did not know that they were being manipulated?

How does one embrace ethics exactly? One can embrace a person, a child or even a tree, if so inclined, but surely we can't embrace ethics?

BOND: Exactly.

TYRRELL: Well, although on the face of it that seems to make sense, in practice it seems unrealistic to me and in need of more clarification. This is because, in a state of high emotional arousal, people cannot think straight, which they need to do in order to clarify goals. This means they first have to be calmed down and surely this is a necessary manipulative act on the part of a counsellor. Also, clearly, in any conversation, when we use a metaphor to reframe circumstances for someone, which we all do instinctively all the time, we are manipulating in order to help them enlarge their patterns of understanding of reality. Likewise, when we encourage a client to rehearse doing things in their imagination using guided imagery. Even when we use humour, to reframe a situation for someone, we can be said to be manipulating them if the joke expands their horizons or makes them see another point of view.

BOND: You are not alone in questioning the wording of this sentence. I’ll see if I can think of a better way of wording it – we are just at the point of doing the final revision.

TYRRELL: Oh good! It is just so very black and white at the moment where you say ‘strictly prohibits’. It just doesn’t seem a good approach – like when BAC (as it was called, before it became BACP) used to say that counselling is not advice giving, when the dictionary definition of counselling is to give counsel, to give advice. That is a real problem for a lot of the general public. They go to a counsellor because they are too emotional to think straight themselves and, in that state, need to borrow somebody else’s brain, as it were, and that is what they expect of counselling. Then they find, because some schools of counselling have taught that you must not give advice, that they can’t have a normal conversation. It seems inhuman!

BOND: Yes. Of course it’s different according to the school to which the counsellor belongs. Lots of cognitive behavioural approaches are advice driven, but even people who have done discourse analysis on person-centred approaches have found veiled advice being given by the counsellors. Clearly everyone, in some ways, is trying to influence their client, in a caring-type sense.

TYRRELL: Yes, absolutely. And some counsellors are much better at this than others. Elsewhere in the document, where you talk about self respect, you use the phrase ‘entitlement for self’. What does that mean exactly?

BOND: It was hard to find a phrase for that. I can’t remember what the original, early drafts said but they all raised howls of protest from colleagues. One of the difficulties within the talking therapies, where the emphasis on client autonomy has been dominant, for all sorts of historical reasons, is trying to determine what the appropriate ethical rights of the practitioner are in relation to the client. For example, what do you say to practitioners who have a client who is seeking to use counselling to undermine the values and autonomy of other people, or the practitioners themselves? Also, what do you say to practitioners who are being coerced by an agency to treat clients in ways which they believe are inappropriate or unethical?
  The principle of self respect is the one that we have selected out of the various options as a way of validating the practitioner’s place in the ethical context – that they too are entitled to be treated ethically. Whilst, to quite a considerable extent, they sometimes suspend their own values and their own rights in the interests of the client’s, they are entitled to say, “to this point and no further”.

TYRRELL: That brings me to a really important topic. My understanding of this subject is that ethics is a type of specialisation that requires objectivity which, necessarily, requires detachment. To be detached requires consciously achieved low emotional arousal, and that is something that has to be learned. When people are very emotional about something they think in more black and white terms and are, consequently, more simple-minded in that state. It does not matter what the emotion is – any kind of emotion, even happy emotions like falling in love – it is very all or nothing. Anger is very black and white, obviously; so is depression and anxiety. So strong emotions stop us from being objective and detached and thus able to take an ethical stance in situations.
   I would say that ethical behaviour stems from the proper working through of the process of getting individual needs met in a way that does not interfere with how the proper needs of other people get met. So, having a clear understanding of people’s physical and emotional needs – what we call the ‘givens’ of human nature – is a prerequisite before one can not only be ethical but even be a counsellor. In other words, ethical behaviour is indistinguishable from knowledge. So, would your ‘entitlements for self’ include the ability to be more detached and emotionally in control, so as to stand a chance of knowing how to know what to do?

BOND: Well, there is a danger in stressing detachment exclusively because the sense of ethical safety in talking therapy relies, in part, on the quality of engagement as well. So there are times, I think, in the lived experience of practitioners, when their ethical insight and sense of what is right or wrong is informed by their sense of emotional engagement with somebody. There are also other times when that is a very messy process and it is extremely valuable to be able to step outside that and to have a detached, independent review of what is going on; either/or, both need to be there.

TYRRELL: That is why I am saying that being detached whilst retaining empathy and closeness with the client is a specialisation, a skill. Detachment does not mean you are not in rapport with somebody, or not empathising with them. People need to know they are getting one hundred per cent attention but, as counsellors, we always need a part of our mind free to operate more objectively on behalf of our clients – who are by definition too emotional to be objective.

BOND: Oh yes! You need to be able to step outside the immediate engagement.

TYRRELL: If counsellors don’t have sufficient control over their own emotional arousal, they are in danger of pattern matching to their clients’ problems and getting emotional themselves – then both parties are in the soup!

BOND: Yes. It is trying to draw on the available ethical resources in ways that are creative and appropriate in the context in which you are working. So, some people reading this framework will see a challenge to their remoteness from their clients. Others will read it and will see it as a challenge to overinvolvement and loss of perspective. That will partly represent different challenges to different theoretical approaches to counselling and psychotherapy, but it will also reflect the individual states of mind and the context in particular relationships with particular clients.

TYRRELL: That’s a fascinating approach. You talk about wisdom at one point: “People need humility, competence, fairness and wisdom and courage”.

BOND: These are the personal, moral qualities.

TYRRELL: Yes. But what is wisdom? It is hypocritical to say we need wisdom if the person advocating it has no idea how to help people get it! And, if you have wisdom, do you need supervision?

BOND: Ah! It’s a good question! I think that a wise practitioner knows the value of supervision.

TYRRELL: Well, if you know how to change a car’s sparking plug, do you need supervision?

BOND: I don’t think that you are comparing like with like there. Changing a sparking plug is a technical exercise within an inanimate object while, when you are dealing with another sentient being, your self is also engaged and may be potentially touched. I think the case for supervision is still a strong one. Of course it varies as you gain in competence and experience and good supervision will vary …

TYRRELL: Yes, I am not anti-supervision; it is the word ‘supervision’ that is unfortunate. Peer group advisory sessions, or one-to-one advisory sessions with an experienced therapist, would sit better, I think. And the more effective one becomes as a counsellor, the less this is needed.

BOND: My basic point is that wise practitioners know the value of supervision, although they may wish to obtain it in different ways as their careers progress.

TYRRELL: Are you familiar with the checklist published by the European Therapy Studies Institute on what effective counselling should be?

BOND: No, I am not.

TYRRELL: It was prepared after 10 years’ research by a group at the Institute who were looking at what was needed by the public, service providers, GPs and so on, so that they could make sense of all the different models of counselling therapy you refer to. 
  The Institute felt a more unified approach to helping depressed and disturbed people was needed, so that we can get away from all these different models of counselling and psychotherapy. In other disciplines, like physics, for example, you would not say, “I am a Newtonian physicist” or “I am an Einsteinian”! You might have a speciality, but you would not say that you only see the material world through one such model. But, in counselling, there are hundreds of different single idea models – some short term, some long term, and their efficacy is incredibly variable. Yet they are all bundled together and called ‘talking therapies’.

BOND: Yes, and their appropriateness to particular situations is variable as well ...

TYRRELL: ... and that is very confusing for doctors and GPs, and also the general public, so we looked at the neuroscience behind why some forms of counselling are more effective than others and produced a checklist of what should be expected of an effective counsellor. (Tyrrell reads out the checklist – to read click here.)
  This is what counsellors ought to be able to do but many of them, because they have been trained in a narrow model, cannot. Would you say the way counsellors are trained creates ethical problems?

BOND: Yes, absolutely. And of course the framework has brought together the role of counsellors, psychotherapists, supervisors and trainers within a shared framework. That is certainly ahead of a large counselling programme – I am very well aware of the ethical dilemmas of training practitioners.
   In part, as I listen to your list, I see we need a greater degree of knowledge in order to move beyond the sort of founding stages of talking therapies, which are rooted in the visions of particular individuals …

TYRRELL: ... I am so glad you said that!

BOND: ... to something which is more informed by the outcomes for clients. I think that those of us who are trained in particular models need to have the courage to be open-minded, to learning from other approaches.

TYRRELL: You get my vote, Tim. I think that is absolutely a wonderful thing to say. At MindFields College, where I teach, we are often attacked by people who won’t budge from their particular model’s perspective when we advocate a more open, scientific and holistic view of what counselling and psychotherapy should be doing.

BOND: In part, that is also about where we are in relation to the development of our own profession. If you had looked at the medical profession in the 19th century, you would have found it divided around schools of thought and schools of training in much the way that we are at the moment in counselling.

TYRRELL: Let’s hope we can discard all of these models and all work together to pull counselling into the 21st century.

 

TIM BOND is reader in counselling and professional ethics at the University of Bristol. He is author of Standards and Ethics for Counselling in Action (Sage, 2000). He is on the professional conduct committee of BACP, which has been concerned with producing the ethical framework, ethical awareness-raising and training. He is a past chairman of BACP.

IVAN TYRRELL is an experienced psychotherapist. He a director of Human Givens College, was a founding member of the European Therapy Studies Institute (ETSI) and co-developer of the human givens approach. He is a Fellow of the Human Givens Institute.

 

"Human Givens Journal" Volume 9 - No. 1: 2002

 

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