Before you start seeing patients, you will need:

1. Professional insurance, see https://www.psychotherapy.org.uk/join-us/joining-faqs/professional-indemnity-insurance/
2. Up to date professional registration/membership (Bowlby Centre membership and UKCP membership if you are a registered member)
3. Supervision, compliant with your level of training, how many patients you are seeing, and modality (see Student Handbook for further information).
4. A GDPR statement to be given and agreed with patients: see https://www.psychotherapy.org.uk/ukcp-members/standards-guidance-and-policies/gdpr/
5. Registration with the ICO (Information Commissioners Office) if necessary. To check this, see https://ico.org.uk/media/for-organisations/documents/2258205/dp-fee-guide-for-controllers-20180221.pdf
6. To be familiar with the principles of Ethical Practice (See https://www.psychotherapy.org.uk/media/bkjdm33f/ukcp-code-of-ethics-and-professional-practice-2019.pdf)
7. Be familiar with Ethical Principles: https://www.psychotherapy.org.uk/media/bzlpheqw/ukcp-ethical-principles-and-code-of-professional-conduct-2009.pdf
8. To consider drawing up a therapeutic contract or agreement which carefully set out your agreements with your patients covering things such as confidentiality (and limits of), fees, cancellation policy, holidays, endings.
9. To consider whether you may wish to use a risk assessment tool such as: https://www.coresystemtrust.org.uk/wp-content/uploads/2020/03/CORE-OM.pdf
10. To consider about what you say about risk in terms of how you advertise your practice, and how you may be accessible online. This may include a welcome letter which sets out how you work, what to expect in the first session, and possibly a map and instructions about how to access the practice.
11. A Therapeutic Will, to be shared with your supervisor.
12. To consider joining a peer supervision or a ‘home group’ and local (or even international) network of therapists to enable you to not become professionally isolated, and to share concerns that arise in the work in a protected professional environment.

 

Different types of risks

THINKING ABOUT RISK BEGINS AT THE FIRST CONTACT

1. Risk to self
2. Risk to others
3. Risk from others.

 

Assessing Risk

THE FIRST PHONE CALL:

Ask what their reasons are for seeking therapy? (Do they mention a psychiatric diagnosis, or risks such as self-harm? Are these current or historic?)

1. It may not be appropriate to work with an individual who is at active risk of harming themselves, others, or are being harmed by others for several reasons.

Consider whether therapy at the time may cause any harm. There is a very good chapter ‘On Iatrogenia: When the Wrong Clinical Intervention Causes Harm’ in Marrone, M. (2014). Attachment and Interaction: from Bowlby to current clinical theory and practice. London: Jessica Kingsley Publishers.

FIRST APPOINTMENT:

Ask for postal address, email and mobile number, date of birth, person to be contacted in the event of an emergency, and GP’s details. If there are concerns about this, explore what the concern may be. Reassure the patient that this information would be kept securely and only be used with their explicit consent in very unusual circumstances, and that you would not breach their confidentiality without justifiable reason to do so. This can be a useful opportunity to explore what feelings about this come up such as does it make them anxious or reveal that they may be socially isolated?

RISK TO SELF:

You may wish to ask questions such as:

• Have you ever harmed yourself?
• If so when?
• Have you ever made an attempt to end your life? When was that? What were the circumstances?
• Do you have any current plans or intention to end your life?
• What are your thoughts as to what may be behind these thoughts and feelings?
• Are you aware of particular triggers, such as an anniversary of a loss? Or ongoing risky behaviours such as excessive substance abuse, gambling, sexually harmful behaviours?
• Are there any things which would stop you acting on thoughts to harm yourself or end your life, (such as the impact that it would have on someone else)
• What are your feelings and thoughts about the future?
• Do you have support to keep you safe (such as being under the treatment of a mental health team? Trusted friends or family who are supportive?)
• Ask ‘Would it be useful for us to devise a crisis and contingency plan if you do have worries about how to keep yourself safe?’
• NB asking these questions is a matter of professional judgement, you can decide whether it is useful for yourself and your patient to ask these questions, and discuss this in supervision if you have doubts about whether and how to explore risk to self.

RISK TO OTHERS

• Keep in mind whether the patient may present a risk to others, and what sort of risk this may be.
• Have confidence to ask specific questions about these risks, similar to the questions above, such as whether there are known triggers which increase these risks (such as drug or alcohol or fears of abandonment).
• Consider whether there are practical steps you may need to take if you felt in danger during the session (do you need a way of accessing help?)
• Remember a therapist can only treat someone safely when they themselves feel safe. Remember to explore what counter transference comes up for you in supervision and the unconscious processes which may be at work. It is not a sign of weakness to feel afraid of a patient, but this does need to be explored and thought about.
• Take to supervision, and seek advice from the ethics committee immediately if you have any doubts about whether you have a professional responsibility to breach confidentiality and communicate risks you think that a patient presents to others due to their seriousness.

RISKS FROM OTHERS

• These risks can often be hard to detect, and even harder to reduce!
• Official statistics, and separate figures from Women’s Aid, show around 80 women were killed by their partner or ex-partner in the latest year they cover.
• It is important to explore whether accessing therapy leaves someone more at increased risk of harm from others.
• Women can be more at risk from harm from others and violence when pregnant, the violence is escalating or they are planning to leave a relationship.
• The complexities of these relationships will need exploring, and it may be useful to discuss if a patient is leaving a harmful relationship the sources of support they may leave, including safety planning, and crisis and contingency plan.
• Signposting to more formal sources of support may be appropriate in certain circumstances.

REMEMBER not all risks can be completely illuminated. Seek support and advice about anything that you are concerned about.

 

Ethical Considerations

• Best interests of clients
• Professionalism
• Communication and consent
• Records and confidentiality
• Professional knowledge, skills and experience
• Social responsibility
• Trust and confidence

 

Safeguarding Children.

Sorts of harm that may trigger a safeguarding referral or investigation:

• Physical abuse.
• Emotional abuse
• Sexual abuse
• Neglect

This list is not exhaustive and may involve reporting of historic abuse or current risk.

You can seek advice about whether to make a safeguarding referral from the Bowlby Centre’s safeguarding lead (Currently Sue Berger).

If you do decide to go ahead and be involved in a safeguarding referral, it is important to consider the cultural context of the situation and any unconscious biases that may be present.

Raising a safeguarding matter takes courage. If you feel fearful or isolated, it is important to acknowledge and explore this and seek support and advice.

Not all referrals to the safeguarding board of the local authority that the child resides meet the criteria for further action or investigation. There are sometimes high thresholds that are in place for situations in which further action is taken by the local authority. The outcome of referrals will also take into consideration protective factors which reduces the risks of harm the child may be exposed to. Sometimes these discussions can be highly emotive, and create many differences in opinion. It is important that a therapist is able to remain calm and regulate themselves if involved in these discussions and maintain a sense of perspective and their professional role.

Generally the only circumstances where a child would be referred to the local authority’s safeguarding board without a parent being informed of the referral is if there was an immediate risk to the child or when this may increase the risk to a child.

It is important when raising a safeguarding concern, to be open and transparent with all involved  Things can’t necessarily remain ‘secret’ if the risk of harm to a child or others is so great that it exceeds the usual professional obligation of confidentiality.

Always seek advice prior to making a referral.

 

Safeguarding adults

The following issues may impact a person’s ability to safeguard themselves:

• Physical disability
• Drug or alcohol use.
• Mental health problems.
• Learning difficulty
• Frailty caused by ageing.

The sorts of risk that a vulnerable adult may experience include:

• Physical abuse
• Emotional abuse
• Sexual abuse
• Neglect
• Coercive control
• Financial abuse

If considering making a safeguarding adults referral, consider very carefully what is in the patients best interest, and the patient’s wishes. Explore issues of consent (do they give consent for a referral to be made?) as well as the unconscious process which may be underlying the concerns.

Sometimes a capacity assessment (usually carried out by a social worker) may be needed which assesses whether a person has the capacity to understand the implications of their choices and decision.

Be open and transparent about the concerns, and support a patient to act for themselves as much as possible.

Always seek advice from safeguarding lead prior to making a referral.

 

Your role as a psychotherapist

Your role is to provide therapeutic treatment which increases the reflective capacity of the patients. On occasions, it may be necessary to consider the risks, ethical issues and making safeguarding referrals. However, our role is also to explore the conscious and unconscious processes and provide as much relational security as possible. We must be alert to being pulled into re-enactments of traumas from our patients past, and our own unconscious processes. This is balanced by the reality that no therapeutic work can develop without a certain realistic confidence in the process, occasional need for positive risk taking, and faith in ourselves and our support networks to be able to contain our patients distress. This happens in the hope that by talking about feelings and experiences, that these feelings become more manageable and bearable and the risks that may be present much reduced.

 

Things to keep in mind.

You are not alone. You are part of a community who can guide and give advice as needed. You have the training to draw from. You have your training therapy, peers, supervisor, seminar leaders and course tutor to seek advice from. You are also able to seek information you may need independently, and communicate what you have learnt to us as your community.