The Autonomy Dilemma

One thing that being a client, a therapist and a student of therapy has taught me, is that when we are trusted, we can learn to trust ourselves. When we are allowed to make autonomous decisions, we can grow towards our authentic selves.

Of course, the ethical principle of autonomy is emphasised in the BACP ethical framework. We should, according to the BACP, “respect our clients’ right to be self-governing.”. How does this work in practice, and how do we manage the conflicts this principle raises in the work?

Recently I have been considering the ways in which the counselling profession manages the autonomy of clients, therapists and student counsellors, and where the balance lies between the philosophy of self-determination, and the expectations placed upon those groups.

My interest was recently piqued around a study from the University of Nottingham which found “serious ethical considerations” about mandatory personal counselling for counselling students. One of the prominent issues raised in the study was the conflict mandatory therapy raised with the ethical principle of autonomy. Most therapists would agree that clients get the most out of therapy when they come voluntarily, and that it is important that they seek therapy, and agree to therapy willingly. So it seems like a double standard when it comes to counselling students, with no easy resolution.

I want to qualify this by saying that I think that all therapists should experience counselling as a client. I think that trainee therapists should have a passion for self-exploration and growth, and that ascertaining and exploring this passion should be part of the selection process at universities and colleges. I might be idealistic, but I feel that if that philosophy is communicated and nurtured, we wouldn’t need to mandate therapy – students would feel compelled to sit in the client’s chair and learn about themselves!

I have two friends who went to university with established therapeutic relationships, only to be told that they would have to leave their current therapists and find new ones who had been accredited for a minimum of three years. This experience has been exceptionally upsetting and seems to me to defeat the object entirely. Are universities teaching students to value the therapeutic relationship by arbitrarily causing helpful, established therapeutic alliances to come to a premature and forced end? Where is the autonomy in that? And where is the non-maleficence? It seems that the decision-makers in these situations (at two separate universities) have chosen bureaucracy over common sense and the very values they are aiming to teach.

Many counsellors develop a policy whereby they will not see clients who are also seeing another therapist, even of a different modality. In the spirit of autonomy, I think the therapist has every right to manage their own policies and make their own best decisions about their practice, however I also wonder whether such a policy may miss opportunities for clients to develop their self-determinism and use therapy autonomously, and in a way that works for them.

If a client wishes to see two therapists at once, they may choose to simply not tell their respective therapists, out of fear of termination, which may limit the efficacy of the therapy. My view is that different therapists may be useful to clients for different reasons, and the client is the best person to make decisions about that.

It hasn’t escaped my attention that my philosophy around autonomy poses difficult questions about my pro-regulation stance. If we are to trust in clients to make their own best decisions for their therapy, if we are to trust in students to make their own best decisions about their engagement with therapy, isn’t it incongruent to imply that I don’t trust in therapists to make their own best decisions about their practice?

For me, this is where we have to look at a way to balance our ethical principles where we find them in conflict, and to balance the conflicting needs of clients and those within the profession.

When it comes to regulation, my first thought is the safety needs of clients, because clients are the people we serve, and when harm occurs in therapy, it can have a devastating effect. I feel that it is of paramount importance to mitigate risk of harm however we can without compromising the service we offer. Fears within the profession about regulation restricting the creative and diverse interpersonal way we practice need to be taken seriously in the regulation debate.

It is the danger of therapists losing more autonomy than is necessary to protect the interests of clients, which has led me to the conclusion that compulsory regulation by a range (and choice) of PSA accredited regulatory bodies would be preferable to statutory regulation. I feel that therapy needs to be kept in the hands of therapists, not government regulators.

Autonomy is a tricky issue, and runs through the very heart of our profession at all levels. I don’t have any definitive answers as to how we manage these conflicts, but I hope my thoughts on the matter can provide some platform for reflection and discussion.

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