Fitness to practise - common factors
There is agreement across the different professional bodies that fitness to practise includes an emotional robustness and capacity to both contain and work with difficult emotional and cognitive states, and to be sensitive to the use of self within the work. It requires sufficient physical resilience in order for the client to experience a reliable and consistent presence in the therapist, and good cognitive functioning including the ability to reflect on what is being heard, make sense of it and consider how to use it for the client’s benefit. The symptoms of physical or psychological conditions that need to be considered in terms of fitness to practise arc those that affect this capacity to think, to feel, to be present and to communicate. The responsibility to recognise and address difficulties rests with the practitioner, the supervisor and their colleagues, not with the client.
Substance use
Alcohol has a depressive impact which overrides judgement and inhibition and should be avoided at times when it could affect practice. Even a small amount of alcohol can make a difference to perception and affect and the client may well recognise this even if the practitioner docs not. There should therefore be no client contact when alcohol has been consumed, being mindful that it can have an impact for several hours after consumption. Being very clear on what response the client can expect out of hours is important here.
Clearly the use of mood altering and hallucinogenic non-prcscribed drugs would be considered unethical, but prescribed drugs must also be considered as they too can have an impact on psychological awareness and mood. Practitioners must be able to monitor and account for any impact of their own medication, and crucial here could be openness in supervision and with medical and professional consultants.
Physical and mental health
Many illnesses arc temporary and the effect on practice may be profound but short lived. Other conditions may be on-going or fluctuating. Mental ill health can include long-term, transitory and recurrent conditions that may or may not have an impact on therapeutic practice and should be discussed in clinical and managerial supervision. Some conditions may be recognised as a disability under the 2010 Equality Act and for employers in particular consideration of reasonable adjustments for the employee should be made, to facilitate a safe and helpful therapeutic service to clients. This can present particular challenges in supporting both the rights of the practitioner and the needs of the client.
Stress
Ongoing and severe stress can be similar to illness in terms of symptoms, causing headaches, addictive behaviours, appetite changes, disturbed sleep, poor concentration and tiredness. These may become noticeable to clients, but for the practitioner there may be denial of the stress itself and therefore of the symptoms. Identifying the source and impact of the pressure is the first step to managing and ameliorating it (Thurgood & Crampin, 2009). Support mechanisms, personal characteristics, resilience and use of stress management techniques all come in to play when considering fitness in this situation.
Life events
Life events might include problems that affect the practitioner through concern for a third party, such as the illness of a dependent; or they may be directly affected, for example redundancy or relationship breakup. Whether the problem is predictable or unpredictable, progressive or static, permanent or transient, all arc considerations in the judgement of fitness to practise.
The question is not just whether someone is fit to practise, but also what they arc fit to practise. Work context, client profile and theoretical orientation all affect decisions about what to do if fitness to practice is in question, whose responsibility it is to act and what ethical courses of action arc open.
Fitness to practise - responsibilities
Alert and experienced practitioners who arc aware that their practice is suffering will want to take steps to protect their clients. Agreed best practice is for concerns to be discussed with a supervisor and/or professional colleague or consultant who can bring an external view to bear, and with an employer who may well be able to support changes to working practices for a period of time.
While this is unarguable, there is a problem in that the person who is most subjectively involved at that point, namely the practitioner, is being asked to make the first move in recognising their own vulnerability. A client may feel very unconfident in judging whether their support worker is fit to practise, particularly if it their first experience of seeking help and there is little to compare it with. Indeed, their inclination may well be to assume that the practitioner is the expert and to assess their own experience in the light of this assumption.
Dale (2010) stated that in questioning fitness to practise there is a need for a clear and open conversation with the supervisor. However, there arc barriers in honesty between supervisee and supervisor and the level of trust must be high for vulnerabilities to be disclosed (Webb & Wheeler, 1998), particularly where there is a managerial link. This is an argument that has been used against mixing the supportive and developmental with the monitoring functions of supervision. Barden (2001) argued that support and monitoring must be seen as a dual role of the supervisor as the monitoring function keeps the practitioner as well as the client safe, and it is false to create a division between the roles. Full monitoring is impossible in professions that work largely unobserved and depend on the honesty and awareness of practitioners. Indeed, if a practitioner is unable to be open about their vulnerability in supervision, it could be argued that they arc unfit to practise.
When working for an organisation some supcrvisory/consultancy contracts give clear indications of accountability; others arc less clear, and in some cases, there is no clinical contract, particularly where therapeutic practice is not the major function of the organisation. Supervisors may be expecting managers to assess someone’s capacity to work adequately; managers may assume supervisors will tell them if they have concerns. With trainees there is the added dimension of whether the contract is between the placement, the trainee or the course - preferably a clear agreement between all three, but this does not always happen.
The BACP Ethical Framework underlines that supervisees must:
be open and honest in supervision and ... draw attention to any significant difficulties or challenges that they may be facing in their work with clients. Supervisors are responsible for providing opportunities for their supervisees to discuss any of their practice-related difficulties without blame or unjustified criticism and ... support their supervisees in taking positive action to resolve difficulties.
(2018: 31)
This recognises that it requires the joint effort of both parties to protect the client if there are concerns about poor practice. Other professionals such as experienced colleagues or line managers who arc involved also carry responsibility. The unifying link is the protection of the client, which always comes first.
Notwithstanding all this, the primary monitor of fitness to practise remains likely to be the practitioner, with all the attendant complications. This raises issues for the training and selection of helping professionals and the importance of their personal qualities. There is a particular demand on private practitioners who may work largely in isolation and for whom ceasing to practise may have serious economic consequences. Practical steps like adequate insurance can be helpful here in making ethical decisions less distressing. Joining supportive practitioner groups and attendance at conferences and workshops can be essential sources of support and advice. The expectation that independent practitioners create a professional will outlining arrangements to care for the needs of clients in the case of their death, or accidcnt/illncss leading to incapacity to work, is now a requirement of registration with many professional bodies.
