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A Reformulation of ACAT Code of Ethics and Practice and Equal Opportunities Policy?

Helen Jellicoe, 2013. A Reformulation of ACAT Code of Ethics and Practice and Equal Opportunities Policy?. Reformulation, Summer, p.6,7,8.

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I would like to say initially, that I do not claim any special expertise in ethics, but as a clinical psychologist and a therapist, I am expected to adhere to professional codes of ethics. My interest in this subject was evoked when, six years ago, during my CAT practitioner training, we were asked to prepare a presentation on the professional ethical and social contexts in CAT. I took this opportunity to step away from my personal interface with CAT and to examine the model at a broader philosophical level.

I procured copies of the ACAT Code of Ethics and Practice and the Equal Opportunities Policy (ACAT, 2005). I noticed my negative reaction to it; I felt both disappointed and annoyed and that my opinions were challenging and critical – the guidelines and I were in some kind of negative reciprocal relationship! I felt like an indignant rebel - had this been elicited by the guidelines? Were they really written in a manner that could be said to be arrogant and bullying in places?

As a hardened consumer of various professional guidelines I was not altogether surprised that the ACAT guidelines seemed fairly tangential to my experience as a therapist, where such codes don’t usually begin to capture the complexity of the human encounter that is experienced in therapeutic work. I found myself irritated by the use of only female pronouns as this seemed to be merely cosmetic, rather than authentic. The ACAT guidelines appeared to have been taken ‘off the peg’, aping other codes of conduct, but not, it seemed, to fi t in with the model and ethos that I had assumed underpinned CAT and its practice. I had hoped for clarity and practicality rather than generalisations, which seemed to masquerade as modern but felt as if there was dogmatism lurking within.

Writers on ethics refer to four underlying principles: non- malefi cence, autonomy, benefi cence, and justice; and I wanted to refer to these in reviewing our own code. Here was my chance to inspect ACAT’s ethical code in more detail than I’d done for other therapies. So, for my 2nd year assignment, I acted on my own misgivings about the codes and decided to rephrase the guidelines in language that I felt was closer to the model and meaning of CAT. I wanted to propose codes that better represented what we were actually doing and provide practice guidelines that gave therapists and clients more meaningful protection.

Taking fi rst one of the guiding principles: ‘In her work, the therapist acts impartially, putting aside personal consideration and demonstrating respect for the client’s autonomy.’ The concept of autonomy didn’t seem to sit easily in a CAT model based on reciprocity, mutuality and collaboration; it seemed meaningless in a dialogical model where therapist and client exist in relation to each other and a wider community. Likewise, the concept of impartiality is ill-suited to a model where self-knowledge and self-awareness is an integral part of the therapeutic dialogue, and the therapeutic relationship. So the alteration I suggested was: ‘The therapist acts in relation to her / his client, and therefore has to be aware of her / his own personal considerations and how these might impinge on the client and their relationship.’

I also felt that there was a therapist- centric tone to most of the codes that again grated with a dialogic-relational approach. For example, Code 10 states: ‘The psychotherapist has obligations not only to her clients but also to her profession..... An obligation to act in accordance with an awareness of the standing of her profession.’ Here there is no mention of the client’s other obligations, roles, confl icts of interest and the like, so I re-wrote this along the following lines: ‘Both the client and psychotherapist have loyalties to other relationships in addition to their commitment to the therapeutic relationship. At times these loyalties may take priority.’

Similarly Code 8 hardly incorporated the notion of mutuality or collaborative endeavour: ‘Psychotherapists act within a network of services and need to act with respect for the services.’ A relational model needs to accommodate relationships beyond the dyad, and therapists need to be mindful of the climate in which they work. If, for example, they are working in an authoritarian or highly restrictive climate they might struggle to operate within the principle of benefi cence or non-malefi cence and he / she needs to be aware of this. Code 8 also seemed to raise issues around confi dentiality where, for example, the ‘network of services’ in which they work might be a multidisciplinary team, where strict confi dentiality is overridden by the policy of shared notes. So instead I suggested: ‘Recognition by the therapist and the client of their relationship to the wider systems to which they belong allows them to understand the effect these can have on the therapeutic relationship and mitigate any adverse effects on it.’

With it’s slight air of menace, Code 3 seemed to raise issues around the principles of non-malefi cence: ‘The psychotherapist should ensure as far as possible that the client is aware of the contractual boundaries of the relationship.’ A veiled threat - to fi t in…or what? It hardly describes or encourages refl ective practice; it provides no guidance as to what a CAT therapist actually does if ‘contractual boundaries’ are broken. Wouldn’t we call it a ‘rupture in the therapeutic relationship’ rather than ‘breaking the contract’? So my idea was: ‘The psychotherapist and client agree therapeutic aims and a programme of intervention which is usually thought to be optimally effective over a predetermined number of sessions and using a set of assessment and management procedures. If client or therapist are unable to execute this plan or it fails for some other reason then as far as possible the therapist and client can refl ect on the reasons for this rupture in the therapeutic relationship/process.’

I also took issue with other words and phrases that were sprinkled through the codes - ‘obligation’; ‘should not’; ‘it is essential’; ‘should be’; ‘should never’; ‘must take care’; ‘should take’ – all of which had a legal tone that seemed entirely out of place in a code that is supposed to underpin a therapy like CAT, or any therapy for that matter. My favourite was: ‘Social contact with clients should be avoided wherever possible’ with its overtones of the analytic couch, the silent expert at its head, but just out of sight. So in CAT speak I thought ‘obligations’ were better described as ‘loyalties and commitments’; ‘must take care’ becomes ‘takes care’; ‘should not’ becomes ‘endeavours not to’ and so on.

This allows a more accurate meaning to be expressed so for example, rather than dictating about ‘…..no social contact..’ we can raise the essential issue of boundaries in the relationship between therapist and client. So I suggested : ‘There are multiple relationships between therapist and client involving multiple boundaries and the potential for split loyalties. Clear and consistent feedback to the client helps the dialogue to focus primarily on the re-enactment of explicit interpersonal patterns in their relationship, but explicit recognition of other implied and potential relationships (professional, social, fi nancial, sexual) helps to maintain boundaries around these.’

I even put forward ideas for the Equal Opportunities Policy because I thought the tone was individualistic rather than relational: ‘We welcome diversity of backgrounds and lifestyle in our clients, our therapists, supervisors and trainers.... We recognise we exist in a society where discrimination occurs on the grounds of... We believe equal opportunities are best developed within the culture of the association valuing discussion, consultation, consensus, constructive action and relationships which respect the individual.’ I wanted this policy to express the relevance of ‘difference’ within the therapeutic relationship: ‘Where differences exists between therapist and client these are addressed because they are perceived within the relationship and therefore may be experienced as invalidating / endorsing the client’s / therapist’s identity.’

Such was my zeal, I decided to think about the ethical principle of justice; this I perceived was implicit in Code 4c: ‘In exceptional circumstances… there is serious concern about the safety or interests of clients… (and/ or others)… the psychotherapist may take such steps as are judged necessary to inform appropriate third parties without prior consent’. I tried to change this into the dialogic language of CAT so that the code might provide clearer guidance to practice: ‘When the therapist or client fi nds her / himself to be in a judgemental position in which the morality of the other is at odds with their own and / or that of wider society, and / or the law, this confl ict needs to be identifi ed in the therapeutic dialogue. Where violence or abuse is a likely response the interest of those most at risk takes priority, irrespective of any previous dialogue.’

And by way of fi nal example I wanted to include Codes 7a and 7b: ‘Clients should be seen in appropriate surroundings… providing privacy, security and comfort.’ Again the use of ‘should’ made me feel a bit scruffy as a therapist; the realities are that consulting rooms are scarce, we may work ‘at the bedside’, and whilst the room may be private, the notes are not necessarily so. I wanted to tone down the obligations on the therapist to provide these things, and to recognize the range and reality of the settings in which we work: ‘The therapist strives to provide the optimal surroundings that are available, providing as much privacy, security and comfort as possible in the circumstances in which therapy is to take place.’

I hope an adversarial tone hasn’t come across in this piece because my intention, and hope is to encourage a collaborative debate. Amongst my conclusions at the time, was the realisation that although CAT has creatively integrated various models and techniques, so that the whole has become greater than the sum of the parts, CAT’s coherence as a separate and worthwhile school of thought wasn’t represented in its own guidelines. Worse than that, it seemed to be undermined by them. So I have presented here my attempt to devise some codes of ethics and practice for CAT therapists that were semantically consistent with the CAT approach, provided relevant, open and honest boundaries for its practice and (within the assumptions of the models and theories on which CAT rests) were able to withstand more rigorous ethical analysis.

The process of doing this Year 2 presentation was helpful personally since I began to consider whether my own, sometimes incoherent, experience of CAT was perhaps in small part related to a therapeutic community that was, itself, insuffi ciently integrated as to be able to stand behind a code of ethics and practice that actually refl ected what CAT was all about.

Many thanks to Anne Crowley for her helpful comments on the draft.

Helen Jellicoe has recently retired from the NHS and runs a small independent practice in central London. Email: gpsy@hotmail.co.uk.

Full Reference

Helen Jellicoe, 2013. A Reformulation of ACAT Code of Ethics and Practice and Equal Opportunities Policy?. Reformulation, Summer, p.6,7,8.

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