Fitness to practise - taking action

The most frequent recommendation made across all codes is that the practitioner should consider refraining from working when their fitness to practise is impaired. Yet this is not as simple as it might at first appear. As has been noted, helping professionals work in a variety of contexts, with a range of clients and from a number of theoretical orientations. Whether the work they arc engaged in is long term or short term, in an agency where alternatives can be quickly offered or in a single person practice where onward referrals may be problematic, are all factors to be considered in deciding what is in the client’s best interests.

Having recognised that each situation is different, there are several options to choose from. Practice can be stopped, restricted, reduced or adapted. Technology can provide solutions in some cases, providing alternatives to face-to-face contact. The balance sought is between what the practitioner can manage and what the client needs. These variables arc examined through two vignettes.

Vignette I - serious illness

In a case recorded by Wheeler (1996) a trainee counsellor ‘Jane’ had a terminal illness that nevertheless allowed her to function well at the start of the training. The illness progressed more quickly than was anticipated and her therapist became concerned for the quality of Jane's work on her training placement. The therapist therefore was herself in an ethical dilemma, and pivotal was Jane’s difficulty in confronting the possibility that her condition could be affecting practice. At a counselling session not long before her death:

She (Jane) was carried into the room. She was painfully thin, pallid and drawn. She had, however, been to her training session the previous evening and was fully intending to see her clients the following day. I confronted her with her responsibility to take care of herself and not see them while she was so ill, but she rejected that totally, saying ‘My clients are my life'.

In a consideration of fitness to practise it is the client’s needs, not the practitioner’s, which come first. Jane had her life invested in her clients and could not admit to herself that she should not be seeing them. In not being able to process her own ending Jane was, at the very least, having to deny the possibility to the client of dealing with their ending too. This can be compared to Jeffries (2000) who, working in a university student affairs department, explored the management of her clients when she was diagnosed with cancer. I Icr treatment involved surgery, radiotherapy and periods of chemotherapy lasting two to four months, at unpredictable intervals depending on the progression of the illness. In explaining her absences and physical changes to her clients she encountered various reactions from distress and anxiety to guilt, anger and fear. How much she told each client depended on their reaction; it was done on a case-by-case basis rather than a single script, and always directly, as she felt emotionally strong enough to do this. Her strength was aided by a positive response from colleagues and strong personal support at home. Clients were given choices in how they wanted to go forward, for example changing counsellor, having an ‘interim’ counsellor, or waiting until the interruptions for treatment were over and then resuming sessions. Clients were naturally in different stages of neediness and dependency, and an individualised response respected this.

At the point at which she was cautioned by her oncologist that her life expectancy made it inadvisable to take on any long-term commitments, Jeffries restricted all new work to intake and short-term clients. The cancer remained a part of the work that required continuing attention.

Although I have been well since my return to work ... my prognosis has affected my practice in subtle ways. All the clients I have taken on this academic year arc new to me and I have not felt that it has been appropriate or necessary to tell any of them that I have cancer. But I think I am working more actively, setting a faster pace, holding back from offering myself as available for as long as I am needed.

(Jeffries, 2000: 481)

Jeffries’ own robustness on the subject of her cancer made making these arrangements a different experience to the case of ‘Jane’. However, it is worth reflecting that behind the scenes her decisions were unlikely to be reached without facing considerable amounts of ambivalence, fear and uncertainty in the process. Openness and ongoing support in supervision arc essential parts of any such process; practitioners should not take a position as sole judge of their fitness to practise. Management support can also make a difference to the case of decision-making, and managers should consider being proactive as well as sensitive in involving themselves in fitness to practice issues.

Vignette 2 - external demands

As Rosenberg attests,

Upset children, a nagging headache, uncertain finances, an argument with a partner, indecision about the weekend’s plans - these must somehow be held away during the session. That is the idea, at least, but the reality is that any number of these issues can and will push in, frustratingly.

(2016: 11)

For most practitioners there will be times when the focus on a patient becomes compromised by their own problems or experiences. Take, for example, the case below.

Aki was a practitioner whose mother, who brought him up as the only child of a single parent, was showing signs of confusion and forgetfulness. She lived alone close by and became increasingly more demanding and absentminded. Aki was concerned that she was not caring for herself and may not be safe at home.

He had not discussed his family problems with his supervisor as he did not believe that his ability to care for his patients was compromised. However, his supervisor noticed that he seemed on edge during their supervision session, though he denied that there was a problem. During the next supervision session Aki received a phone call. He excused himself and left the room to take it. This was highly unusual behaviour as Aki had previously switched his phone off at the beginning of every supervision session. On his return his supervisor pointed this out and alerted him to her concerns in this and the previous session. Aki apologised profusely for accepting the phone call and explained that his mother had been ill, and he was worried about her condition. Their session continued as normal and there were no signs that the supervisor could pick up that his patients were not getting his full attention. The following session Aki arrived unusually late, looking exhausted. He acknowledged that he had been experiencing a hard time. He had had to cancel some sessions when his mother had a fall, and she had returned to live with him until she became mobile again. On returning to her own home she had become confused, and he was now waiting to take her to hospital to be assessed and hopefully to find some support for her condition. The supervisor sympathised with these difficult circumstances but felt that there may be patient issues that needed exploring. At first Aki seemed to be defensive and denied that his personal circumstances could possibly have any impact on his relationships or work with his patients. The supervisor gently persisted, and Aki agreed that it felt extremely challenging to try to care for his mother, take part in family life and be fully present for his patients. He had not been sleeping well and had only eaten sporadically.

With the supervisor’s support Aki came to accept that his problems may be affecting his work and together they considered how he could deal with the issue including how he might support himself, and be supported by others, during this challenging time. They agreed to monitor this situation and discuss further help if or when required.

BACP describes supervisors as ‘key allies working “upstream” ... promoting an “ethics-aware” approach' (Jackson, 2018: 8). While a client’s needs must take priority, care and concern for the practitioner must also be expressed. The supervisor’s approach in this vignette was supportive rather than punitive, though it remained firm and focussed.

Conclusion

Larcombc pointed out that ‘As practitioners, it is the “duty to self’ that underpins our duty of care to our clients and to the profession’ (2008: 284). It will be clear that the concept of fitness to practise is not simple to define. Practitioners need to know that their work requires emotional robustness and a level of physical wellbeing. There is a need to be proactive in maintaining professional fitness, and reactive to situations that might compromise this. Having arrangements in place to support clients in the event of the latter may help to prepare for the unexpected.

Over the course of a long career it would be remarkable if life did not produce situations that challenged fitness to practise from time to time. Such challenges are not shameful but normal, and the simple guideline in facing them all is to make the first question, ‘What is in the best interests of the client?’ The ethical way forward will follow from that.

Reflective questions

• 1. How do you know if you are fit to practise?
• 2. How could you prepare for managing unexpected changes in your personal life that could impact on your practice?
• 3. What could interfere with your ability to make sound ethical decisions?
• 4. Who would you tell if you had concerns about your fitness to practise?

References

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