Supervising Counsellors

Issues of Responsibility

Sue Wheeler, David King, Sue Wheeler, David King

• Publisher: SAGE Publications Ltd
• Year: 2001
• Print ISBN: 9780761964087, 9780761964070
• eBook ISBN: 9781446237267
• Edition: 1
• Topic: Psychology
• Subtopic: Education in Psychology
• Index: Psychology

Supervising Counsellors is a practical and insightful guide to the responsibilities facing all those involved in supervising practitioners and trainees. Drawing together contributions and new research from those at the forefront of supervisory practice, this book makes essential reading for both qualified and trainee supervisors.

Part One defines the supervisor?s clinical, legal and ethical responsibilities, and clearly sets out the law and professional codes relating to supervision. Part Two examines issues that arise for supervisors working in different contexts: organizations; training; primary care; and some of the wider issues concerning supervision, and highlights in particular the expectations of supervisees and the role of supervisors in ensuring that clients are not discriminated against.

Part One

PROFESSIONAL ISSUES FOR THE SUPERVISION OF COUNSELLORS: CLINICAL–LEGAL-ETHICAL

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1

Clinical Responsibility and the Supervision of Counsellors

David King

The purpose of this chapter is to examine the nature of responsibility within the counselling triad of client, counsellor and supervisor. The nature of clinical responsibility will be discussed, drawing on recent research in the British context of counselling and supervision. The extent to which supervisors of counsellors are clinically responsible for the work of their supervisees will be considered. The issue of risk assessment will be addressed and the extent to which counsellors and their supervisors should be informed about psychiatric issues will be examined. This chapter will focus on one-to-one supervision; the issue of responsibility for supervisors of groups is discussed in Chapter 9.

RESEARCH

As part of a research dissertation for a higher degree, I carried out a study (King, 1997) to investigate the extent to which counselling supervisors considered themselves to be clinically responsible for the work of their supervisees. This included which responsibilities they considered themselves to have for such work, and how they managed those responsibilities. The purpose of the study was to enhance the counselling profession’s understanding of the responsibility of supervisors and of the supervisory relationship. The study was confined to supervisors working in private practice. The research was a qualitative investigation in which ten experts in the field of counselling and supervision were interviewed.

In a book of this nature it is not appropriate to discuss or enumerate the research findings in detail. However, the research did produce interesting results not only on the notion of clinical responsibility but also on other issues salient to the counselling profession, and some of these will be considered in this chapter.

CLINICAL RESPONSIBILITY: WHAT IS IT?

The Code of Ethics and Practice for Supervisors of Counsellors (BAC, 1996b: B.1.2) requires supervisors to help supervisees reflect critically upon their work, but at the same time acknowledge that clinical responsibility remains with the counsellor. This is the only time that the term ‘clinical responsibility’ features in the British Association for Counselling and Psychotherapy (BACP) codes. Moreover, no attempt is made to define its meaning. Thus, there is an assumption that it is a term that is meaningful to counsellors and supervisors, which proved not to be the case with the experienced supervisors interviewed (King and Wheeler, 1999). The term ‘clinical responsibility’ is often used, but there is a lack of clarity about the nature of the responsibility it implies.

BAC, in its Working Party Report (1998), acknowledges that there is a need for an unambiguous policy statement about the clinical responsibilities of the counselling supervisor. What is also required is a clear and unambiguous statement about the purpose and value of supervision. Given the importance of supervision to the counselling process, the question of the nature and extent of the clinical responsibility of supervisors remains extremely vague.

I surveyed the current literature on counselling and counselling supervision in order to determine the meaning of the term ‘clinical responsibility’. Only one counselling text referred to contained the term ‘clinical responsibility’ in its index. Moreover, what definitions exist are largely derived from other disciplines and not from counselling. It is appropriate at this juncture to consider some of these.

The medical model adopts a paternalistic stance and assumes responsibility for the patient’s wellbeing (Higgs and Dammers, 1992). Hence, in applying this model counsellors are responsible for clients rather than to them (Daines et al., 1997). However, counselling is about personal change (Aveline, 1979) and the main aim is to empower clients rather than to take responsibility away from them (Mearns, 1993). According to BAC (1996a), counselling aims to increase a person’s ability to make choices and to facilitate a client’s self-determination. Thus, if a counsellor adopts the medical model then the practitioner becomes the expert, and this does not sit easily with some counsellors and counselling approaches (Mearns, 1993; Mearns and Thorne, 1988; Rogers, 1951). The medical model has been rejected by many counsellors and therapists for its hierarchical nature and its reliance on ‘power’ and ‘labelling’ (Dryden and Feltham, 1992). Moreover, there will be times when practitioners’ authority and client autonomy are not compatible (Beauchamp and Childress, 1983).

There is thus a tension between the two models: on the one hand concern for the patient’s wellbeing is paramount and on the other the client knows best (Higgs and Dammers, 1992). Counsellors are torn between adopting a medical model in order to gain objective support for their work and trying to persuade themselves and society that other criteria are more congruent with their kind of professionalism (Foskett, 1992). One of the challenges for counselling is how to be as systematic as the current practice of medicine but without taking on the worst excesses of professionalism, which could create a vast gulf between counsellor and client (Bond, 1993).

Evidence arising from the research mentioned earlier suggests that the term ‘clinical responsibility’ was not only inappropriate in a counselling context but also that there was no clear agreement as to its meaning. The participants in the research study felt at odds with the term ‘clinical’, and thought that it had medical connotations relating to treatment and illness, which accords with Daines et al. (1997) and as such was incongruous with counselling.

Indeed, the use of the term ‘clinical responsibility’ was seen as an attempt to add a gloss of medical respectability to counselling that was unbecoming. Moreover, it was argued that the term was currently fashionable yet there was a lack of clarity as to its meaning. This perhaps explains why a detailed consideration of the term is conspicuous by its absence in the literature, lending credence to the view of one participant in the research that the notion of clinical responsibility is ‘muddled and vexed’. Hence, the issue of responsibility is one that needs to be teased out and debated within the counselling culture (Mearns, 1993).

However, before examining this subject further it is important to consider the place of counselling within the societal framework.

COUNSELLING: THE SOCIETAL CONTEXT

During the last 50 years, there has been a rapid growth in the use of counselling, which has filled a vacuum created by the demand for therapeutic help and the lack of resources in statutory services to respond (Wheeler, 1999). This growth in counselling is matched by increasing public awareness of therapy and much media interest (Bond, 1993). Much of this interest has been highly critical. For example, Grant (1992) describes counselling as an industry that is completely unregulated and has no standard form of qualification, which therefore makes it difficult for the public to know if it is getting a quality service. Moreover, Wheeler (1999) has written that for the counselling industry to be regarded more seriously as a profession, stricter regulatory controls would be needed to protect the interests of the public. The public perception of the value of counselling depends to a large extent on how effective counsellors are at maintaining satisfactory standards of practice (Bond, 1993). Yet, Wheeler (1996) has produced evidence to suggest that counselling training programmes are not always successful in eliminating incompetent counsellors.

However, with the growth in counselling provision, there have been consequent calls for greater accountability and cost effectiveness, especially as British society is functioning increasingly on the basis of market forces (Cooper, 1992). With the growing popularity of counselling comes greater criticism. This can be seen as a healthy challenge to a largely unregulated profession. According to Palmer-Barnes (1998), however some believe that supervision alone ensures good practice, while others argue that registration and regulation are necessary to protect the reputation of the profession. Furthermore, codes of ethics and practice are not legally enforceable – they are only morally binding. Codes of ethics and complaints procedures have not, as yet, been tested at judicial review (see Chapter 2).

Whether counselling is obtained from private practice or through the publicly funded National Health Service (NHS) there is a cost dimension that needs to be accounted for (Higgs and Dammers, 1992). Yet few studies report on the cost-effectiveness of counselling. One study by Lave et al. (1998) showed that treatment for depression through psychotherapy was more costly than medication. Hence, interest in therapeutic accountability has arisen partly as a result of an increase in the accountability of the caring professions (McLeod, 1994), political reforms in the UK (Barker et al., 1994) and issues related to financial efficiency (Barkham, 1989). Evidence-based health care is high on the agenda at the beginning of the twenty-first century and mental health is no exception. In response to the need for a comprehensive research schedule that informs mental health provision in the UK, a health technology assessment programme has been established that aims ‘to ensure that high quality research information on the costs, effectiveness and broader impact of health technologies is produced in the most efficient way for those who use, manage and work in the NHS’ (Stein and Milne, 1999: 37). The efficacy of treatment is under the spotlight and counselling will also be subject to scrutiny. Accountability is no longer a topic that can be fudged and a need for clarity about responsibility is paramount.

CLINICAL GOVERNANCE AS CLINICAL RESPONSIBILITY

The growing trend of accountability is led by the government strategy to regulate practice in the NHS through a system of clinical governance. Set out in guidelines issued by the Department of Health (1999), the clinical governance framework makes numerous demands on practitioners, which include the following:

• evidence-based practice
• targeted research
• continuing professional development
• complaints monitoring and public accountability
• use of clinical indicators
• benchmarking
• monitoring of outcomes, including client satisfaction
• peer review, including peer supervision and professional self-regulation
• clinical audit
• guidelines and clinical/professional standards.

These initiatives and requirements will be promoted and monitored by the National Institute for Clinical Excellence (NICE), which will disseminate information and audit methodologies.

Clinical governance has already had an impact on the provision of counselling in primary care, as services have been under scrutiny, measured against the standards demanded. Accountability to a professional body, such as BAC, has been one of the problems that primary care counsellors have had to address. Although BAC does set a standard for practice through accreditation, it cannot claim to be a professional body that sets standards for all its membership because most members are not accredited.

Parry and Richardson (1996), in evaluating psychotherapy services in the NHS, argue that applied research has had insufficient impact on the organisation and delivery of psychotherapy services within the UK. If this is the case, then how much more is it so in the case of counselling, which is more fragmented than other types of care. Clinical governance within the NHS endeavours to overcome some of the shortcomings highlighted by Parry and Richardson and promotes greater clinical responsibility, matching patients to appropriate treatment, for which evidence of effectiveness is available. Clinical audit is a requirement, and peer monitoring and review should go some way towards ensuring that best practice is maintained. If the psychological state of clients is assessed with greater accuracy, individual bias and error on the part of therapists should be reduced. In terms of clinical work, a high level of skill is expected, informed by appropriate research evidence. It is anticipated that as a result counsellors and therapists will deliver better care (Owen, 1999).

Evidence-based practice attempts to discover if interventions that counsellors make with clients have had the effect intended. Ascertaining such cause and effect is not easy, and Rose (2000) suggests that some counsellors are more interested in cherishing their own beliefs, related to the theoretical orientation they adhere to, than taking into account the best interests of the client. If counsellors working in areas where service provision is publicly funded do not embrace the demands of clinical governance, their livelihoods may be in jeopardy. With such powerful and influential trends being set by the NHS, it is only a matter of time before other counselling service providers, whether in charitable and voluntary organisations or in private practice, will be affected, as these trends are sure to impact upon their clinical work at some point in the future.

CLINICAL RESPONSIBILITY AND COUNSELLING SETTINGS

Focusing once more on clinical responsibility and the work of individual practitioners, I will go on to examine the counselling settings in which counsellors practice.

The responsibilities of counsellors depend on the counselling context in which they work (Bond, 1993) and their employment status (BPS, 1995). In a hospital setting, the health authority will assume ultimate responsibility for patients in receipt of counselling (Higgs and Dammers, 1992). The liability of the employed counsellor is linked to the principle of ‘vicarious responsibility’ (Hall, 1983; Jenkins, 1997), which is a legal principle under which the employer of an individual who commits a negligent act bears an obligation in law.

In a general practice (GP) setting, the issue of who is responsible for the patient when referred to counselling is not always clear. A doctor who delegates treatment or other procedures must be satisfied that the person to whom they are delegated is competent to carry them out (Sharma, 1994). It is likely that a patient in receipt of counselling in general practice remains the ultimate responsibility of the doctor (Ball, 1995). (This issue is considered more fully in Chapter 6).

My research, referred to earlier, concerned itself with the context of private practice. According to Syme (1994), in private practice the most common employer is the client, and this poses difficulties for both the counsellor and client since there is no institutional buffer to absorb some of the liability. Thus, the counsellor in private practice has to carry the burden of responsibility for the way he or she works (see Chapter 7). My research findings suggested that counsellors in private practice should be cautious in their selection of clients. An agency provides a safer setting for both client and counsellor because an agency has a management structure that takes some responsibility for the work. This has implications for supervision in terms of the needs and expectations of supervisees and what in reality the supervisor can provide.

RISK ASSESSMENT: THE ANTHONY SMITH CASE

In the area of risk assessment, the Anthony Smith case is highly relevant to the notion of clinical and supervisory responsibility, and thus what has become a cause célèbre warrants a broad focus. In 1995, Anthony Smith, a man suffering from a severe mental illness, killed his mother and younger half-brother in a deranged episode of violence. Prior to his diagnosis as suffering from schizophrenia, the patient’s GP referred him to a counsellor based at her practice and he attended regularly from May 1994 until May of the following year before to his admission to hospital. In June 1995 he was referred to the Psychiatric Department of ...

Table of contents

• Cover Page
• Title
• Copyright
• Contents
• Notes on Contributors
• Acknowledgements
• Introduction
• Part One Professional Issues for the Supervision of Counsellors: Clinical-Legal-Ethical
• Part Two Contexts
• Part Three Wider Issues
• Index