Who Knows Who? A Challenge to Primary Care Counselling

Richard Bryant-Jefferies

You are into your third session on counselling with a client in a Primary Health Care setting. All has been progressing well, the therapeutic relationship has developed and the client is clearly motivated to explore and understand themselves more fully. They mention a problem they are having with a friend who lives in another part of the village. At first, you think nothing of it, and then you gradually find yourself wondering if she is talking about the client you had been seeing a few months back. She describes an aspect of this friend, and you then know for sure that it is your ex-client. The client stops talking, looks at you and comments, somewhat accusingly: "You look as if you’ve lost me." You know she is right, you were dwelling on her friend, caught trying to match what you know to the person the client is describing.

This scenario is one that occurs in Primary Health Care settings. Counselling in surgeries, particularly small, village-based ones, are likely at times to lead to a situation where there is a ‘cross-over’ between clients. As a counsellor and supervisor of Practice within Primary Health Care, I have come across a number of scenarios in which clients have made reference to people also known to the counsellor through their counselling work.

Often it is obvious, a GP or other health care professionals not appreciating boundaries within counselling, and referring a family member to a counsellor who is already seeing, or who recently saw, another member of that family. Familial ‘cross-over’ can be avoided at the outset, particularly where Primary Health Care Team members are made aware of the boundaries that counsellors set on who they can work with in a family once someone else has already been seen for counselling. There is also a huge advantage now with the development of PCG-based counselling services. When in the past the presence of a lone surgery counsellor could mean the second patient does not get a service, this can now be dealt with more equably by exploring ways of offering counselling to that second person within a PCG counselling group. However, as the above scenario shows, the counsellor can still be caught out.

The counsellor working in a GP surgery needs to be alert to the possibility of ‘client-cross-over’, and to be clear in themselves how they will respond. Obviously, supervision will play an important part in enabling the counsellor to try and maintain clarity towards the client they are working with such that what they know about someone who is being talked about does not affect the content of the therapeutic relationship. You cannot drop a client simply because of who they are talking about. And to congruently reveal to the client the reason for their reaction to the situation arising will breach confidentiality with the earlier client. Counsellors can find themselves in a difficult position; their supervisor needs to be aware of this challenging and demanding aspect of counselling in Primary Health Care.

In my work as an alcohol counsellor, in one small single-GP practice, I had the situation whereby neighbours met in the waiting room, one having just seen me, the other waiting for her appointment. Whilst one knew that the other had an alcohol problem, the other (the second client) came into the counselling very anxious because her neighbour now knew she had a problem. (I was the only one working in the surgery and seeing clients at that time of day). For my second client, the secret was out and it took some time for her to come to terms with it, whilst I was left trying to maintain a singular focus on her without aspects of the other client getting in the way.

A counsellor could be faced with the situation where a client (or a couple) in their first session are discussing their marital situation and one partner accuses the other of having an affair; the person they cite is the counsellor’s next client! It is not impossible, I have not had this actually occur, but I have seen a variation of this and it. Suppose the next client is attending a first session. Is the counsellor going to be able to offer counselling to them? What if the second client has already been seen for 4 sessions, does the counselling have to be ended for the first client(s)? What impact might be had on the second client if they arrive early and because of the layout of the surgery see the first client(s) leaving the counselling session?

Another intriguing situation that I was faced with was a client telling me about an incident in which something had been stolen from them, an incident that the thief had described to me in a counselling session the previous week!

I am raising this issue of client ‘cross-over’ in order for counsellors who have not encountered these kind of situation to be aware of the possibilities and to offer them the opportunity to raise it themselves as an issue within their own supervision. Working in Primary Health Care does raise the possibility of situations arising that may be less common in other settings, particularly in the smaller Practices.

Richard Bryant-Jefferies has had a range of books published addressing alcohol use and other counselling issues that can be accessed at:  http://richardbj.co.uk/books/index.html