British Association for Counselling and Psychotherapy
Action Taken
BACP conducted a thorough review of member resources relating to confidentiality, competence, and eating disorders, detailed in an attached spreadsheet. (AI summary)
View full response
Dear Mr Wilson
Re: the late Natalie Melissa Turner
I am writing to you in response to the Regulation 28: Prevention of Future Deaths Report which was received from your office on 28th March 2022.
I know that you will share a copy of this response with Natalie’s family, and I would first like to express my sincere condolences for their loss. Every death of a client is a tragedy and the safety of those in receipt of counselling and psychotherapy is my absolute priority. We welcome the opportunity to respond to the concerns you raise which are of utmost importance to our organisation, our members and their clients.
You expressed concern, following evidence heard at the inquest about several aspects of the private counselling that Natalie received from a BACP accredited member:
• That despite BACP’s guidance about when it is justified to break confidentiality the counsellor was unduly constrained from doing so to preserve the therapeutic relationship when in this instance breaking confidentiality might have saved Natalie’s life
• That clients with complex eating disorders might be at particular risk given their reluctance to engage with mainstream medical professionals or their families, despite the fact that medical intervention can keep a client safe
• That the counsellor had no experience of working with eating disorders which can be complex and potentially life threatening and that there did not seem to be much guidance from BACP on eating disorders
In response to your report, we have conducted a thorough review of our member resources relating to confidentiality and when to breach it (including safeguarding and duty of care), working within own limits of competence and guidance on eating disorders specifically.
These are detailed in the attached spreadsheet under three themes. You will see that we have also indicated where these are open access (to anyone visiting our website), where members have access as part of their membership subscription (a very substantial body of guidance), and where additional resources can be found if a member subscribes to the CPD hub for an additional £25 per year. Many of these resources will not have been accessible to you.
We also offer an Ethics Service which is freely available to members if they have any ethical queries. This service is staffed by a dedicated team who offer access to support, guidance and expertise especially regarding ethical dilemmas which often relate to boundaries, confidentiality and safeguarding issues. The service includes options to book a telephone session with one of our ethics officers and for supervisors to book an appointment with a specialist ethics consultant. We do not know if the therapist or their supervisor availed themselves of these member resources or the additional Ethics service.
In terms of the specific concerns relating to this case we would like to offer the following observations:
Working with eating disorders can be a complex area of practice. The level of knowledge and skill that the therapist needs will depend on the severity of the issues and a full consideration of the client’s individual circumstances including the immediate and on- going level of risk and self-harm. This can be on a wide spectrum especially given that disordered eating is often a behavioural response to an individual’s situation which may or may not put the client at immediate risk. In addition, clients don’t always divulge an eating disorder at the outset of therapy which means that conducting a risk assessment can be difficult.
Working with complex and severe eating disorders does require specialist training which not all therapists have acquired within core training or subsequent training. However, there is no doubt that it is the therapist’s responsibility to recognise their own limitations and consult with their supervisor to determine whether or not they have the right skills to continue working with a client and/or whether a referral to specialist services, or additional specialist support is needed. These can be difficult judgements. The BACP Ethical Framework makes it very clear that therapists must work within their limits of competence and keep their skills and knowledge up to date (Ethical Framework Commitment to Clients clause 2).
As a professional body rather than a training body we can and do offer guidance on specific client issues such as eating disorders and set standards for accredited courses, but we don’t directly deliver the training or monitor individual competence in specialist areas. We are, however, very clear that members should not work outside their limits of competence.
We offer considerable amounts of guidance, legal, ethical and practical, on when and how to make decisions about when to break confidentiality as this is a key dilemma for therapists. As you helpfully observe this can be a very difficult decision especially when one possible outcome is the breakdown of the therapeutic relationship which may be the only trusting relationship the client has because of the nature of their difficulty. Part of contracting with a client at the outset of therapy (again we have a lot of guidance on this) means being very clear about when and under what circumstances the therapist would break confidentiality. This is particularly important when working with clients who are at high risk of self-harm or suicide. Where confidentiality may need to be broken the therapist is expected to go through an ethical decision-making process with support and guidance from their supervisor and involving the client where possible. What is not clear however, is whether breaking confidentiality would have saved Natalie’s life given that her situation was already known to her GP and specialist medical services and known to her partner.
We will continue to keep our guidance and resources under review and to take every opportunity to highlight the critical importance of the professional points and draw them to our members’ attention through our different channels of communication which include
direct member bulletins, our Therapy Today magazine which has regular features on these issues, our website and at our member events including our ‘working with’ days which can spotlight specific practice or presenting issues.
In that respect we want to thank you for the opportunity to respond to the important issues you raise. Once again, we deeply regret that Natalie’s life was not saved.
Re: the late Natalie Melissa Turner
I am writing to you in response to the Regulation 28: Prevention of Future Deaths Report which was received from your office on 28th March 2022.
I know that you will share a copy of this response with Natalie’s family, and I would first like to express my sincere condolences for their loss. Every death of a client is a tragedy and the safety of those in receipt of counselling and psychotherapy is my absolute priority. We welcome the opportunity to respond to the concerns you raise which are of utmost importance to our organisation, our members and their clients.
You expressed concern, following evidence heard at the inquest about several aspects of the private counselling that Natalie received from a BACP accredited member:
• That despite BACP’s guidance about when it is justified to break confidentiality the counsellor was unduly constrained from doing so to preserve the therapeutic relationship when in this instance breaking confidentiality might have saved Natalie’s life
• That clients with complex eating disorders might be at particular risk given their reluctance to engage with mainstream medical professionals or their families, despite the fact that medical intervention can keep a client safe
• That the counsellor had no experience of working with eating disorders which can be complex and potentially life threatening and that there did not seem to be much guidance from BACP on eating disorders
In response to your report, we have conducted a thorough review of our member resources relating to confidentiality and when to breach it (including safeguarding and duty of care), working within own limits of competence and guidance on eating disorders specifically.
These are detailed in the attached spreadsheet under three themes. You will see that we have also indicated where these are open access (to anyone visiting our website), where members have access as part of their membership subscription (a very substantial body of guidance), and where additional resources can be found if a member subscribes to the CPD hub for an additional £25 per year. Many of these resources will not have been accessible to you.
We also offer an Ethics Service which is freely available to members if they have any ethical queries. This service is staffed by a dedicated team who offer access to support, guidance and expertise especially regarding ethical dilemmas which often relate to boundaries, confidentiality and safeguarding issues. The service includes options to book a telephone session with one of our ethics officers and for supervisors to book an appointment with a specialist ethics consultant. We do not know if the therapist or their supervisor availed themselves of these member resources or the additional Ethics service.
In terms of the specific concerns relating to this case we would like to offer the following observations:
Working with eating disorders can be a complex area of practice. The level of knowledge and skill that the therapist needs will depend on the severity of the issues and a full consideration of the client’s individual circumstances including the immediate and on- going level of risk and self-harm. This can be on a wide spectrum especially given that disordered eating is often a behavioural response to an individual’s situation which may or may not put the client at immediate risk. In addition, clients don’t always divulge an eating disorder at the outset of therapy which means that conducting a risk assessment can be difficult.
Working with complex and severe eating disorders does require specialist training which not all therapists have acquired within core training or subsequent training. However, there is no doubt that it is the therapist’s responsibility to recognise their own limitations and consult with their supervisor to determine whether or not they have the right skills to continue working with a client and/or whether a referral to specialist services, or additional specialist support is needed. These can be difficult judgements. The BACP Ethical Framework makes it very clear that therapists must work within their limits of competence and keep their skills and knowledge up to date (Ethical Framework Commitment to Clients clause 2).
As a professional body rather than a training body we can and do offer guidance on specific client issues such as eating disorders and set standards for accredited courses, but we don’t directly deliver the training or monitor individual competence in specialist areas. We are, however, very clear that members should not work outside their limits of competence.
We offer considerable amounts of guidance, legal, ethical and practical, on when and how to make decisions about when to break confidentiality as this is a key dilemma for therapists. As you helpfully observe this can be a very difficult decision especially when one possible outcome is the breakdown of the therapeutic relationship which may be the only trusting relationship the client has because of the nature of their difficulty. Part of contracting with a client at the outset of therapy (again we have a lot of guidance on this) means being very clear about when and under what circumstances the therapist would break confidentiality. This is particularly important when working with clients who are at high risk of self-harm or suicide. Where confidentiality may need to be broken the therapist is expected to go through an ethical decision-making process with support and guidance from their supervisor and involving the client where possible. What is not clear however, is whether breaking confidentiality would have saved Natalie’s life given that her situation was already known to her GP and specialist medical services and known to her partner.
We will continue to keep our guidance and resources under review and to take every opportunity to highlight the critical importance of the professional points and draw them to our members’ attention through our different channels of communication which include
direct member bulletins, our Therapy Today magazine which has regular features on these issues, our website and at our member events including our ‘working with’ days which can spotlight specific practice or presenting issues.
In that respect we want to thank you for the opportunity to respond to the important issues you raise. Once again, we deeply regret that Natalie’s life was not saved.