The therapist's duty of care versus client autonomy

Working with clients in the counselling context is a complex process. The ethical therapist must always hold the balance between respect for autonomy and the duty of care that arises when a client’s behaviour becomes self-destructive.

When working with a client who wants to pursue medical transition—and when we believe this may be harmful—it is imperative that we meet our professional responsibilities, even if this challenges the client.

We must trust in the therapeutic process we offer. Otherwise, what is the point in offering it? This may mean handling it professionally when a problem drinker becomes unhappy within the process and starts drinking again. In this context, we should not plead with the individual to return to sessions at any cost. If an anorexic client threatens to leave when difficult questions are asked, the skilful therapist treads a fine line; the measure of success often lies in balancing our skill with the client’s resistance. Similarly, when working with gender dysphoria, it is unethical to run a “peace at any cost” practice. Therapy should be challenging and meaningful, not a perfectly pleasant process with a kindly and benevolent old uncle.

Therapeutic neutrality is often misunderstood as detachment or passivity, but in reality it is a disciplined stance that allows the therapist to stay engaged without becoming enmeshed. Neutrality exists to protect the therapeutic process from the therapist’s personal values and emotional reactions, ensuring that the client’s experience remains central. By maintaining this balanced position, the therapist provides a reflective space where conflicting feelings and motives can be explored safely.

True neutrality does not mean ethical indifference or abdication of responsibility. It allows the therapist to respond appropriately when safety or coherence is at stake, without becoming caught in the client’s defences or external pressures. Neutrality in therapy is not absolute; it is shaped by a commitment to helping the client move toward recovery, autonomy, and a more fulfilling life.

We care about the outcome, but we do not impose it. A skilled therapist working with an anorexic individual who refuses to eat will care deeply about survival and health. However, the therapist avoids taking a directive stance (”you must eat”) because confrontation or coercion can deepen resistance and shame. Instead, understanding and internal motivation for change is built—helping the client want to live freely rather than complying out of pressure.

Likewise, when working with gender dysphoria we do not hold fixed goals such as “become gender conforming” or “accept your body.” Instead, we hold space to explore the meaning of the client’s wish to medically transition, seeking to understand what transition symbolises emotionally, psychologically, or socially. In both contexts, the therapist should remain alert to the danger of collusion or serious risk throughout the process, ensuring that empathy does not become avoidance.

A therapist’s duty of care is the ethical responsibility to take reasonable steps to prevent foreseeable harm to a client, whether through action, omission, or neglect. It requires balancing respect for client autonomy with the professional obligation to protect safety and promote psychological wellbeing.

Effective therapists can hold two truths at once. On the one hand, we know that medical transition carries tremendous physical and psychological risk. On the other, we respect that the urge to transition often represents issues such as loneliness, a desire for control, protection, identity or belonging. The challenge is to acknowledge the danger without collapsing the therapeutic relationship into a battle over identity. This entails gentle care and deep understanding.

Just as we would not collude with starvation by framing it as self-expression, we should not affirm a desire for irreversible and harmful medical interventions. Instead, we seek to understand the underlying motivation with questions such as:

• What does transition promise to solve?

• What fears or pains lie beneath this wish?

• How do you want your life to change?

• What are your impediments to a deeper understanding?

We acknowledge that the client’s distress is real while ensuring the client recognises that medical transition can carry lifelong consequences and profound regret. The stance involves holding the tension between empathy for suffering and awareness of potential harms—without adopting a position that affirms or prohibits.

However, it must be clear that having “no definitive outcome” applies to the therapeutic process, not to the overall treatment plan. The ethical therapist holds a clear treatment plan focused on healthy outcomes. We respect the client’s right to make choices, but when a client is in psychological crisis or acting under an extreme, overvalued belief reinforced by external influences, neutrality must be tempered by ethical concern. Our role is to help ensure that choices arise from integration and self-understanding rather than confusion, trauma, or social pressure. There are moments when we feel powerless before the depth of a client’s pain, yet that awareness of our limits grounds our integrity as therapists.

Ultimately, we aim to help the client understand why they have come to believe that transition feels necessary. The decision to transition should rest solely with the client—it undermines autonomy if we “approve” or “disapprove” of the choice. At the same time, we have a responsibility to ensure the client fully understands the physical risks and psychological burdens that accompany medical transition. We have a particular duty of care toward vulnerable clients who lack insight or are impeded by other co-morbidities, and we cannot neglect our responsibilities when we recognise that the client is avoiding reality. The process centres on fostering self-knowledge, coherence, and emotional resilience.

It is important to note that if the client is under 18, additional safeguards apply. Parents must be made aware of anything that poses danger to their child. The therapist’s role is to ensure we adhere to our duty of care by informing everyone involved about any potential risks.

These days, ethical therapists carry an unsustainable burden, as wider society is often profoundly uninformed about medical transition and the extreme beliefs that can underlie a person’s urge to transition. In this context, the therapist must maintain ethical practice, refrain from collusion, and work with the knowledge that some clients will pursue medical transition as a consequence of a deeply misguided social climate.

Our role often focuses on the psychological meaning of the distress while ensuring that medical safety is maintained. When a client’s health becomes acutely compromised, we have a duty of care that overrides neutrality. We can, for example, acknowledge when we feel out of our depth and refer to another clinician; we may recommend hospitalisation when a client appears unsafe; we may increase supervision when the work becomes complex. In this sense, therapeutic neutrality is always bounded by ethical responsibility.

If a client goes through a meaningful therapeutic process and still chooses medical interventions such as a double mastectomy or vaginoplasty, we must consider whether we have, in some way, failed the client. None of us is perfect, and it is more helpful to acknowledge mistakes than to repackage the event as “client autonomy.” The current climate also makes it very difficult for therapists to carry out ethical therapy.

In this context, we should become reflective rather than defensive. Supervision and self-reflection help us ask:

• Did I miss any signs of escalating risk?

• Did I collude with avoidance or misinformation?

• Did I underestimate the depth of the client’s despair?

This reflection should be grounded in compassion, not self-blame. The therapeutic task after medicalisation is not to start over but to help the client make meaning of what has happened. The question becomes, “Why did the client believe that extreme body modification was the most appropriate action?” Our attentiveness and care can help transform the crisis into further insight.

Recovery is rarely linear. We continue to hold hope for the client’s eventual integration while acknowledging the danger and grief of what has occurred. Many clinicians recognise that medicalisation can represent a turning point. The client’s system may reach its limit, requiring external containment through medical care while the psychological work continues. Sometimes hospital admission provides a boundary that reinforces the value of life and helps the client begin to integrate competing parts of the self.

In this context, we interpret the event as a painful but meaningful chapter in an ongoing process. Medicalisation can be seen as a testament to the power of the individual in the face of mental pain. It calls for renewed curiosity, collaboration, and compassion rather than a retreat into guilt or collusion.

Psychotherapy deals with forces beyond any one person’s control. The human capacity for self-destruction is, unfortunately, something I have known all too well in my own life. Some people seem driven to destroy themselves. I wish they weren’t, but some are. As Carl Jung observed, “The right way to wholeness is made up, unfortunately, of fateful detours and wrong turnings.”