by Gerry Myers
The role of supervisor in psychotherapy is an interesting one, with many layers. In this article, I’m going to write about one of those layers. Now at the outset, let me say that this is not intended as a learned article, full of quotes and references, it is more in the nature of a think piece. I am particularly interested in therapists who work in what could loosely be described as a non-counselling agency setting. I am hoping to spark a debate among supervisors, therapists, agency managers (and clients of agencies, if they get to read this article!). So please, if anyone wants to use a comment box or even write an article in reply to this, please feel free to bombard the editor!
From the early days of modern Psychotherapy, beginning with Freud, the therapy frame has been viewed as vitally important. In psychoanalysis most analysts set up elaborate procedures to protect the therapy frame. The 50-minute hour, for instance, was developed by Freud himself to protect patient confidentiality and keep clients well separated. In terms of protecting client confidentiality, we are all used to getting signed releases from clients when reports etc. are to be issued to solicitors or others who are outside the therapy frame. Supervisors frequently hear from practitioners of all persuasions about the distress that can arise when some key aspect of the therapy room, or its environs, is changed. During my training in London, I remember being thrown into a tailspin when my therapist sent his curtains for cleaning. His therapy room was on the first floor of a quiet suburban street and I’m sure nobody could see in, but I felt naked, exposed and very unprotected by my therapist.
Therapists tend to be very tuned to boundaries. As an example, if a practitioner is working at home and a house-guest, untrained in the rules of the house, accidentally intrudes into the therapy room; most therapists will see the incident as a very significant offence against boundaries. Let me give a further example: I practice with several colleagues in a rather busy part of Limerick called John’s Square. We occupy the ground floor of a building. We have very careful monitoring and electronic control of our entrance. But very occasionally some brazen kid, hoping to grab something of value, gets in when someone has accidentally left the main door open, and will try the handle of my therapy room door. Needless to say, in the very rare occasions it has happened, it has caused consternation and it has taken a couple of sessions to get things back on an even keel for both myself and my client. It is not enough for me to say to my client “This shouldn’t have happened”. I need to be able to look at door control arrangements and remedy the deficiencies as best I can.
Let me continue giving examples of therapists holding to boundaries and clear arrangements. Most of us will have encountered the situation where we get a referral, from a mother, of a nineteen year old son. If we take the referral, we will usually ask that he rings for an appointment himself. If the mother says she has to get the appointment for him, however, we usually make it abundantly clear to her that, once he starts therapy, he is the client and our contract is with him alone. Of course, this will be reinforced at the initial therapy session with the young man. However, have you ever had the experience of the mother ringing up after about a month asking how her ”John” is getting on? You explain that you can’t tell her anything, but she persists! Presumably, all of us would persist right back and hold to our ethical duty to preserve confidentiality with our client. And if, by chance, we ring “John” to confirm some arrangement about an appointment and, unfortunately, the phone is answered by her, we will not normally take it as gospel if she tells us that “John” is unlikely to be coming to therapy any more! Presumably we will try “John’s” mobile number, and speak with the man himself! Why? Because therapists tend to have very clear procedures around making appointments, charging for them, making and taking phone calls etc.
Those therapists who work in counselling agencies, such as the National Counselling Service etc. also tend to work quite hard at minding boundaries. They have clear rules about case material, devote a lot of time and energy to how case material is to be handled in team meetings, how notes are to be stored, how phone calls and reports are to be handled etc. Clearly, boundaries, including the boundary of the therapeutic frame, are very important in therapy!
As a supervisor I subscribe to the theory that supervisors have a multi dimensional role. Sue Wheeler, an internationally-recognised researcher in the field of psychotherapy supervision, at a seminar in London in July of this year, talked at length about the need for supervisors to take some responsibility for best practice on the part of those they are supervising. She indicated that legal judgements, in both the US and the UK, are swinging in the direction of therapists and their supervisors “being held to account” for exercise of their responsibility function. It is with an eye to the responsibility of supervisors that I find myself raising the problem that is at the heart of this article.
In my experience some therapists are making arrangements with organisations and businesses to provide counselling for agency clients or employees, without attending properly to best practice concerning boundaries and contracts. How can it be that some good therapists, who would freak it if their spouse knocked on the therapy room door at home during a session, seem willing to provide therapy in a school, EAP, etc without a detailed written agreement as to the nature of the therapy contract.
In work with agencies, key issues arise, such as:
- who has the right to refer (i.e. who is the gate keeper to the service)?
- how much freedom has the referred person to refuse the referral?
- has attendance at therapy any connection with disciplinary processes?
- who has the right to what information about the specific therapy process?
- who has the right and the responsibility to inform the therapist of the client’s intention to cancel a session (a key issue in prisons and schools – a warder may choose to interpret a prisoner’s behaviour as a decision not to go to a session – this does happen folks!)?
- who has the right to see reports?
- who has the right to authorise payment of report fees (and thus act as gatekeeper for reports)?
- what control exists over the allocation of the therapy rooms?
- what level of control exists over the physical frame?
- who has custody and ownership of records?
- in the case of minors, who has the duty to authorise the establishment of a therapy contract?
- Who pays for supervision and how does this affect the relationship between the therapist, the client, the supervisor and the agency management?
These are all large questions that, no doubt along with others, need to be addressed by therapists who undertake work for non-counselling agencies.
It is my belief that therapists who work with or in these agencies need to come to grips with establishing codes of practice to govern their therapeutic work. It is my experience that management in many agencies that do not specialise in counselling have little knowledge of the ethos within which counselling works. In such a situation, it is the responsibility of therapists to educate management within the contracting agency as to what is required to sustain ethical therapy practice within the organisation. Unfortunately, I notice that some therapists shy away from this. I have heard therapists say that they will raise various contractual, boundary and other ethical issues with managers, but only when they are more established with the agency. Yet in private practice, as I have already indicated, we are, correctly, very exercised about frame, boundary and contractual issues. Why should agency work be any different?
One possible reason why some therapists may be making inadequate arrangements with various agencies, is that these therapists feel in a weak position and may even be grateful for the chance to work in new settings. Maybe some therapists are not very political and see themselves as just wanting to get on with the business of meeting and working with clients. Whatever the reason, therapy operates in a complex social environment in which issues of power, rights, duties, and the shadow side of social structures, are in constant play. I contend that therapists who work with or for agencies simply must be willing to engage those agencies in negotiating appropriate codes of practice for the counselling or therapy that is to be provided. Perhaps other practitioners might be willing to write another article for Inside Out, giving a possible template for a generic code of practice that individual therapists might use when negotiating contractual arrangements with schools, prisons, care centres, EAPs, etc.
I do appreciate that many therapists who have contracts, in various ways, with organisations, have set up very tight arrangements with their contracting agency. I further appreciate that many therapists have set about educating managers, school principals, prison governors etc as to what is needed when you have a therapist on board. The truth is, however, that some therapists have been less than thorough on that score, and have accepted wishy-washy arrangements that do not fully address the ethical responsibilities of therapists to their clients.
Maybe you, as the present reader, find that you agree or disagree with me. Either way, I would welcome a debate on the issue of the practice contracts that therapists’ with agencies, particularly non-counselling agencies that have little expertise in the needs of therapy. I hope this article spurs some response from therapists and those who exercise a supervisor function.
Gerry Myers is a phenomenologically orientated psychotherapist and supervisor; he also jointly leads a postgraduate integrative psychotherapy training at UL.