Good Practice in Action 063

Clinical Reflections for Practice

Equality, diversity and inclusion (EDI) within the counselling professions

Updated February 2019

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Updated Good Practice in Action 063 Clinical Reflections for Practice: Equality,
diversity and inclusion (EDI) within the counselling professions is published by the
British Association for Counselling and Psychotherapy, BACP House, 15 St John’s
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Contents

Context
Purpose
Using Clinical Reflections for Practice resources
1 Introduction
2 Therapeutic setting for vignettes
2.1 Referrals and service remit
3 Case studies
3.1 Vignette 1 – Bert
3.2 Vignette 2 – Lilly
3.3 Vignette 3 – Rani
3.4 Vignette 4 – Tanith
3.5 Questions for reflection
4 Observations for practice
4.1 Equality, diversity and inclusion (EDI)
4.2 Ethical Framework
Conclusion
About the author
Further resources

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Context

This resource is one of a suite prepared by BACP to enable members to engage

with the BACP Ethical Framework for the Counselling Professions in respect of
equality, diversity and inclusion.

Purpose

The purpose of this resource is to stimulate ethical thinking in respect of equality,

diversity and inclusion issues that may be encountered within therapeutic practice.

Using Clinical Reflections for Practice resources

BACP members have a contractual commitment to work in accordance with the

current Ethical Framework for the Counselling Professions. The Clinical Reflections
for Practice resources are not contractually binding on members, but are intended
to support practitioners by providing information, and offering questions and
observations practitioners may need to ask themselves as they make ethical
decisions within their practice in the context of the core ethical principles, values
and personal moral qualities of BACP.

Specific issues in practice will vary depending on clients, particular models of

working, the context of the work and the kind of therapeutic intervention provided.
As specific issues arising from work with clients are often complex, BACP always
recommends discussion of practice dilemmas with a supervisor and/or consulting a
suitably qualified and experienced legal or other relevant practitioner.

In this resource, the terms ‘practitioner’ and ‘counselling related services’ are used
generically in a wider sense, to include the practice of counselling, psychotherapy,
coaching and pastoral care. The terms ‘therapist’ or ‘counsellor’ are used to refer to
those trained specifically as psychotherapists and counsellors.

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1 Introduction

It may appear a simple task to define how equality, diversity and inclusion (EDI)
are encountered in practice, but EDI bring an expectation for us to not only be
mindful of the overall concepts, but also to develop a holistic view of the person we
are working with and the unique relationship which is being formed. If we as
practitioners want to avoid the risk that some aspects of our clients may go
unseen, we need to look beyond appearance and physical capacity, beyond
gender and cultural backgrounds as the concept of EDI genuinely encompasses all
our lives. For example, think back over your life, have you ever felt unseen by the
world around you? Or that you were being treated differently to others? Or blocked
from doing something you really wanted to do? While these are often normal
experiences of living they can also be the m. anifestation of discrimination and
exclusion.

In light of the Equality Act’s differing application across the UK, the following
vignette’s focus on two overarching themes: the protected characteristics, and our
obligation to make reasonable adjustment and what this may look like within
therapeutic relationships. This resource does not provide specific guidance, rather
its aim is to increase our awareness of how EDI can be present in practice. To this
end, these vignettes feature fictional composite characters drawn from the
experiences of a range of BACP members working in settings from private practice
to the NHS and voluntary organisations. They are all written from the client
perspective. All the therapeutic sessions take place in a fictional counselling
service and should not be perceived as the only way in which EDI may be
encountered in practice. Following the vignettes there are some questions which
you may wish to consider, together with some general observations which are
included at the end of the resource to support further reflection. Other resources in
respect of EDI include: Good Practice in Action 062 Commonly Asked Questions
about EDI, and 108 Legal Resource EDI.

The concept of EDI has been entwined within a changing society for decades, with
the pace of change slowly building as the structures needed to support an inclusive
society evolved and discrimination began to be challenged.
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While steps were taken to tackle discrimination in some specific contexts, it was
not until the Equality Act of 2010 was passed that a unifying piece of legislation
was instigated.

The Equality Act introduced a working definition of EDI with the aim of enhancing
inclusion within society through the identification of different specific characteristics
where discrimination could be experienced within society. These protected
characteristics of age, disability, gender reassignment, marriage and civil
partnership, pregnancy and maternity, race, religion and belief, sex and sexual
orientation are at its core and provide a clear scope of its application.

While these characteristics encompass the totality of life, it is important to

remember that their application and relevance will vary depending on the individual
concerned. For example, while age is a consistent characteristic its application will
vary depending on the age of the individual concerned, as the manifestation of
discrimination around children and young people will differ from people past
retirement. Additionally, while some of the characteristics have consistent
relevance others may vary depending on the events of a person’s life and their
choices. You can find further information about the Act’s definition and application
at the Equality and Human Rights Commission website:
https://www.equalityhumanrights.com/en/equality-act-2010/what-equality-act or the
Equality Advisory Service https://www.equalityadvisoryservice.com/app/help. Full
contact details can be found at the end of this resource.

The other key responsibility, which the Equality Act introduced was the obligation
to make reasonable adjustment to ensure accessibility for disabled people. In this
case the decision of what comprises a reasonable adjustment is not specified by
the legislation or determined by either party but is subject to negotiation if legal
precedent does not exist.

While these overarching themes cover the whole of the UK its application can vary
in England, Scotland, Northern Ireland and Wales and local guidance should be
sought where necessary.

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It should be remembered, however, that while the Equality Act has been an
imperative in enhancing awareness of EDI its structure around certain protected
characteristics does risk facilitating the development of a ‘silo approach’ where the
characteristics are viewed and addressed in isolation. This approach can result in a
presumed need and detract from relating to the person holistically. For example,
are we being genuinely mindful of EDI when engaging with a client who has a
physical disability, if we are unaware of their sexuality or gender? In addition,
focusing solely on the protected characteristics can result in other barriers to
inclusion and equanimity such as disparity in wealth or the availability of support
services going unseen.

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2 Therapeutic setting for vignettes

Fictional Charlotte House was built in the early 1920s as a care home for wounded
servicemen, surrounded by gardens and allotments to feed the home’s residents.
Since World War II, the outdoor space has gradually been reduced, being re-
developed to provide much needed local housing and only a small paved seating
area and six staff parking spaces remain. In the mid-1960s the building was
transferred to the NHS and had a variety of uses before becoming the local base
for mental health services in 1973.

In the years following the millennium, the local Clinical Commissioning Group has
implemented a rolling review of its service provision, and it was decided that it
would be more appropriate for mental health services to be contracted out to an
independent provider. As the staff were keen for the service to be retained, ABT
Community Engagement was created and secured the contract in 2005 at which
point management of the services 60 volunteers was transferred to ABT.

ABT became a social enterprise the following year and raised the funding it needed
to complete essential maintenance and modernisation works to ensure Charlotte
House would meet the needs of all service users and it now has two distinctly
separate spaces. The ground floor being the community space including a café,
large rooms for clubs and groups to meet in, along with the office space for ABT,
main reception, two rooms used by the Community Mental Health Team for mental
health assessments and ABT’s drop-in advocacy service along with stairs to the
first floor.

The first floor comprises the protected counselling space with four one-to-one
rooms, two couple’s rooms and a family room along with the private waiting area.
From the outset ABT’s fundamental goal was to make free counselling services as
accessible as possible providing open-ended interventions for adults. Sessions
could take place between 9am and 9pm Monday to Friday, 9am to 5pm on
Saturdays and Sundays, by appointment.

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In accordance with the terms of the original contract, the service provision has
recently been reviewed and following a reduction in funding it is no longer viable for
ABT to have these extended hours. Following an independent consultation with all
stakeholders a restructure in the service provision has had to be implemented. At
the start of the current financial year, services were revised and there has been a
reduction in ABT opening hours for counselling to 9am to 5pm Monday to Friday
and Saturday between 9am and noon, with free counselling capped at 18 sessions
per intervention; following objections from both clients and counsellors, it was
agreed that the 18-session limit could be exceeded but it was conditional on the
client making a contribution of between £5 and £20 per session depending on their
circumstances.

The service has also responded to requests from its counsellors and now makes
the counselling rooms available for rental on an hourly basis by private
practitioners in the evenings and weekends. In order to make the separation
between private and ABT clients clearer, a separate entrance has been created
providing direct access to the counselling rooms for private clients.

2.1 Referrals and service remit

Referrals to ABT can be made by any medical or social care professional within the
Clinical Commissioning Group’s geographic remit who considers that someone
they are working with would benefit from counselling. All ABT referrals are
assessed by one of ABT’s three paid counsellors before being allocated to one of
the volunteer counsellors primarily on the grounds of counsellor availability, unless
a specific type of intervention has been identified. Following allocation,
practitioners are given a summary of the assessment prior to seeing the client,
those counsellors who are either registered or accredited with BACP are able to
liaise directly with their clients to confirm appointments etc. but all client contact for
other counsellors (such as trainees) takes place via the office staff.

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Any requests for counselling which fall outside ABT’s service remit, such as self-
referrals, are referred to the ‘Other Services’ section of their website where clients
can register by providing basic details about themselves, availability and reason for
seeking counselling and they will be contacted by one of the private practitioners
registered with ABT to arrange an assessment.

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3 Case studies

The following series of fictional vignettes are intended to enable you to reflect on
how issues relating to EDI may present themselves in practice. As you read
through them, be mindful of the protected characteristics and the potential need to
make changes in how services are provided for the person. After you have read
the last vignette about Tanith, there are questions for you to think about (and for
discussion) in respect of all the vignettes.

3.1 Vignette 1 – Bert

Bert was referred to ABT by his GP following the death of his second wife, Dorothy
or Dot as her family always call her, shortly after celebrating their 30th wedding
anniversary. They met and married following the acrimonious break up of his first
marriage; when comparing his marriages Bert said ‘but it’s all right though, I loved
this one’. He asked to be referred to ABT at the encouragement of his children, as
he appeared unaware that his angry outbursts were becoming more intense and
being hurled at them, often in the presence of his grandchildren, and they felt they
were being pushed away.

The assessment was comparatively brief, confirming the above information, the
primary presenting conditions being sadness and loneliness, that he had no
specific access needs and that he had been made aware of the terms and
conditions relating to the service’s scope.

You have been working with Bert for three months and his attendance has
generally been good, but the reduction in the family income following his wife’s
death now means that he no longer drives and is dependent on public transport, or
community transport services, which he finds demeaning. In his early sessions he
was often angry in the room with you, focusing his aggression on the unfairness of
his life. Over time though he has begun to trust you, becoming slowly more candid
and you have formed an effective working relationship with him.

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It has gradually become clear that in addition to the loss of his wife, his anger is
stemming from his own practical struggles as while you were always aware that he
used a walking stick to get around he is now struggling to make his way up the
stairs when he thinks nobody is looking; he is clearly in pain when it’s cold, rainy or
windy outside.

In recent sessions Bert has been talking about how he now just feels lonely and
unhappy all the time and has picked up a couple of the leaflets for the groups
which meet on the ground floor; while accepting the possible benefit they could
bring he isn’t really sure whether he would want to be that involved as, ‘that was
Dot’s job’. He is also concerned about what people might think when it gets out that
he is coming to see you. Running in parallel with his loneliness, he has also
recently been acknowledging the benefit which talking to you is having for him but
he is starting to become anxious as to what will happen when his sessions run out.

3.2 Vignette 2 – Lilly

Lilly was referred for counselling by her Rehabilitation Worker as she is
experiencing growing anxiety over some unavoidable and significant changes in
her life.

At present, she still lives at home with her mother, her father dying before her first
birthday and she has no memories of him. She was born deaf blind as her birth
was extremely premature due to her mother’s severe pre-eclampsia. Her mother
has empowered her by making sure that all her close family learned to hands-on
sign to ensure her home life was as inclusive as possible. Sadly, her mother is now
developing dementia and as it is no longer felt safe for them to keep living together,
Lilly has decided its time to move out to supported housing but she is increasingly
anxious over the practical challenges this will present.

Despite her fears over what the future holds, Lilly sees the real benefit of
counselling and wants to come as she knows her life is changing forever. As this
was her initial assessment session, she brought her younger brother, Danny, to
‘hands on’ sign for her, but feels it would be inappropriate for her siblings to attend
her sessions.
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From the outset it was apparent that this style of communication would take longer
than usual and two further appointments were needed to complete her
assessment. Lilly was adamant that she doesn’t want to have any existing
connection with the translator and as the deaf blind community is comparatively
small it took two months to find somebody she felt able to work with.

The signer was articulate and engaging, but ‘hands on’ signing proved very time
consuming and tiring, sessions being broken into two 20 to 25-minute slots with a
short break in the middle. Lilly finds the interruptions irritating but her commitment
remains undimmed as she has begun to explore parts of her life she has always
felt unable to look at. Whilst progress is slow, Lilly begins to risk considering how
she sees herself, and the experience of being loved, but she also acknowledges
her fears that with only three sessions left, and without the financial resources to
pay for more sessions, she will not have enough time to think about it properly.

3.3 Vignette 3 – Rani

Rani was referred for counselling by her GP as her children were becoming
increasingly concerned over her reaction to the death of her first great grandchild.
The inference from the referral was that she had been able to spend time with the
baby but at assessment it was confirmed that the baby, a boy, was stillborn.

The GP’s covering letter confirmed that the referral was being made following a
discussion with her oldest son Belwinder, a doctor working in orthopaedics. Since
the baby’s death, he was aware that his mother had become less active and was
reluctant to engage with her family. In her assessment, it was noted that while she
easily communicated with the assessor, her son had also attended, often
interrupting to correct her response if he saw things differently; Rani always
deferred to his perspective.

While a family member would bring her to ABT for her sessions and take her home
afterwards, they always waited in reception. Rani focused in her early sessions on
the losses in her life starting with her parents’ deaths in India over 40 years ago;
whose funerals she was unable to attend, two miscarriages and her husband who
she described as being her support and protector.
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Rani is engaging in her sessions, welcoming any observations you make,
acknowledging them as being ‘so powerful in helping her understand and start
trying to change’; at the end of her fifth session you note that she has always
deferred to your perspective. As Rani’s sessions progress, she often ends her
sessions by commenting on how much better she feels from seeing you.

Unusually, Rani’s session was cancelled today but the clinical lead at ABT checks
in with you as Belwinder had called to express his, and his siblings concerns, that
despite seeing you for 12 sessions, their mother remains as detached as she was
prior to starting counselling.

3.4 Vignette 4 – Tanith

Tanith was referred to ABT by her GP to address her social dysfunctional
behaviours as she has been becoming increasingly detached from family and
friends, culminating in her recent separation from her partner of four years. Her
referral confirmed her medical history providing summary information across a
range of health conditions, including four counselling referrals during the last 15
years since coming under the remit of the adult mental health team.

Tanith carefully planned her lengthy journey to ABT for her assessment, but it was
less time consuming than she had anticipated and she arrived 30 minutes early.
While waiting in reception she became visibly uncertain and uneasy as it was busy
with excited people attending a community event and she struggled to access any
of the information displayed. Her assessment notes confirmed that throughout her
assessment Tanith was disconnected responding primarily mono-syllabically and
refusing to sign the contract provided saying ‘I can’t read that, don’t you know I’m
dyslexic?’ before threatening to leave; her referral had only described her as
having a learning difficulty.

Tanith cancelled her first session when she arrived and learnt that a contract,
which she could read, still hadn’t been provided and that no one was available to
work through it with her.

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Following a brief telephone conversation with the administrative team, a
reformatted contract was produced, which was discussed in detail at the start of
Tanith’s next session, as she focused on ensuring that she had correctly
understood the meaning of the language used.

During her first few sessions Tanith swayed from mono-syllabic responses,
avoiding eye contact and fidgeting, often crossing and uncrossing her arms and
legs, to a more relaxed posture with a continual, uninterrupted narrative being
recounted about all aspects of her life. She often appeared oblivious to your
presence. As she spoke Tanith often misinterpreted your observations and
interventions, necessitating clarification and re-phrasing a number of times to make
sure that the language meant the same to both of you. As her sessions
progressed, a reasonable working relationship started to form, and she began to
become more candid over some of the experiences of her life.

3.5 Questions for reflection

Some questions for you to consider when thinking about Bert, Lilly, Rani and
Tanith:

 which of the Equality Act’s protected characteristics is applicable to each of

them?
 do you think that any adjustments might be needed to make it easier for them
to attend their sessions with you?
 when you are in the room, might you need to make any changes to how you
work?
 is there anything which you feel may need to be considered/reviewed by ABT?

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4 Observations for practice

4.1 Equality, diversity and Inclusion (EDI)

When considering the vignettes, all the clients fall under the scope of a number of
the protected characteristics including age, gender and race but the profile and
potential issues do vary. For example, when considering age, the profile of
isolation and loss can rise due to Bert and Rani being older whereas the challenge
of independence has greater resonance with Lilly; while Rani’s acquiescing
demeanour is often manifest within relationships, it can have a higher profile within
some social and cultural settings. Equally, both Lilly and Tanith meet the definition
of disability, however, Bert is in that grey area of how a disability is defined, as the
practical struggles he is experiencing may not be classed as a disability since they
are not consistent.

Across Bert, Lilly and Tanith’s vignettes, there are differing levels of willingness to
acknowledge the need to request adjustment to improve service access. Lilly and
Tanith are both able to articulate what was needed in order for them to engage with
counselling, but Bert remains reluctant to acknowledge his challenges and
consider whether things can be improved; in this case a counsellor might need to
give some thought as to how to explore what changes may be appropriate with
him.

Finally, in the case of Lilly, it may be appropriate for further adjustment to be

considered, as on reflection: is it necessarily appropriate to apply the requirement
of payment for additional services to Lilly given that the slowing of progress has
stemmed from things beyond both the client and counsellor’s control?

In all these cases, the need to actively consider the totality of the client, and a
willingness to address possible changes to enhance the effectiveness of the
intervention, are essential in order to provide genuinely inclusive services.

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4.2 Ethical Framework
Throughout its evolution, an underlying theme of the Ethical Framework has been
to make service accessibility a reality. Historically, this has predominantly been
articulated through its ethical principles, values and personal moral qualities.
The Ethical Framework for the Counselling Professions (2018) however, commits
members to ‘respect our clients as people by providing services that:

a) endeavour to demonstrate equality, value diversity and ensure inclusion for all
clients
b) avoid unfairly discriminating against clients or colleagues
c) accept we are all vulnerable to prejudice and recognise the importance of self-
inquiry, personal feedback and professional development
d) work with issues of identity in open-minded ways that respect the client’s
autonomy and be sensitive to whether this is viewed as individual or relational
autonomy
e) challenge assumptions that any sexual orientation or gender identity is
inherently preferable to any other and will not attempt to bring about a change
of sexual orientation or gender identity or seek to suppress an individual’s
expression of sexual orientation or gender identity
f) make adjustments to overcome barriers to accessibility, so far as is
reasonably possible, for clients of any ability wishing to engage with a service
g) recognise when our knowledge of key aspects of our client’s background,
identity or lifestyle is inadequate and take steps to inform ourselves from other
sources where available and appropriate, rather than expecting the client to
teach us
h) are open-minded with clients who appear similar to ourselves or possess
familiar characteristics so that we do not suppress or neglect what is
distinctive in their lives. (Good Practice, point 22a-h).

The Framework goes on to commit members to:

…take the law concerning equality, diversity and inclusion into careful
consideration and strive for a higher standard than the legal minimum.
(Good Practice, point 23).
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And that:

we will challenge colleagues or others involved in delivering related services

whose views appear to be unfairly discriminatory and take action to protect
clients. (Good Practice, point 24).

This brings clear parameters to practice which all members need to be mindful of.
Some of these commitments have a clear resonance within the vignettes, such as
Lilly and Tanith’s need for adjustments to be made in order to make the service
accessible. However, is there a need for greater understanding of the possible
cultural foundation of Rani’s familial dynamics and should Bert’s increasing
struggles to move around the building be allowed to remain unaddressed?

Conclusion

These vignettes have been produced to illustrate how EDI can be evident in our
relationships with clients but they are by no means an exhaustive list. In order for
genuinely inclusive and accessible services to be provided, members all need to
ensure that they retain a willingness to make adjustments to how they work, where
necessary and reasonable, in whatever setting they are working. More importantly,
however, is that we consider our clients holistically and retain the integrity to raise
issues that we feel may be impacting on our interaction with them.

Further BACP Good Practice in Action resources are listed below along with other
organisations who can provide advice on the interpretation and application of the
Equality Act, which inform the need for an holistic view of our clients, whilst
acknowledging our individuality as practitioners. This should not be taken as an
inference that reading and development opportunities do not exist, rather that their
selection needs to be driven by the people we are and our experiences in practice.

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If this resource has highlighted an aspect of your client engagement that you would
like to increase your awareness of, a good first step would be to reflect on which
aspects of EDI you are most uncertain of before reviewing what publications exist
and what other developmental opportunities may be provided by organisations
focused on this area of public engagement.

About the author

Steve Rattray is a senior accredited counsellor and senior accredited supervisor of

individuals, working in an NHS Palliative Care Unit’s Bereavement Counselling
service and was a member of the BACP’s Professional Ethics & Quality Standards
Committee between 2011 and 2015. Away from his clinical practice, he works
collaboratively with a range of third sector organisations, health and social care
services to support the enablement, empowerment and rehabilitation of people
experiencing sight loss.

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Further resources

For information and confidential advice on the application of the Equality Act on an
individual level:

Equality Advice Service

Tel: 0808 800 0082
Web: https://www.equalityadvisoryservice.com

For advice on the interpretation of legislation and its application at an

organisational level:

Equalities & Human Rights Commission

Tel: 020 7832 7800
Web: https://www.equalityhumanrights.com/en

BACP Good Practice in Action resources are available at:

https://www.bacp.co.uk/gpia

BACP Ethical Framework for the Counselling Professions is available at:

https://www.bacp.co.uk/events-and-resources/ethics-and-standards/ethical-
framework-for-the-counselling-professions/

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