I’ve known therapists who slept with their patients. I’ve known therapists who took “down on their luck” patients into their homes. I’ve known therapists who made friendships with their patients and socialized with them outside of the office. And, I’ve known therapists whose sense of their own value depended on their patients’ approval and improvement.
There are problems here and I hope that most of them are obvious. But, just in case, I will explain.
A therapeutic relationship involves unequal power. Authority figures, be they bosses, teachers, parents, clergymen, or therapists, usually have a power advantage. Patients assume that a therapist has only the patient’s best interests at heart. The patient might never previously have had someone in his or her life who seemed so interested, who listened so patiently, who seemed so caring. Under these circumstances, the patient is vulnerable if the therapist should pursue his own sexual agenda.
For a time, it might feel good to both parties, but it is a fundamental corruption of the therapist-patient relationship and, in the long run, can do extraordinary damage to the patient and add one more life-injury to the long list of hurts that the patient has already suffered. This is true even if it is the client who provokes or initiates the sexual contact, as sometimes happens.
Dual roles are generally a problem. Thus, a therapist is well-advised to avoid the complication of being more than a therapist to his patient. Meaning he shouldn’t be a therapist/lover or therapist/friend. To take on more than one role almost inevitably confuses both the therapist and the patient as to which role takes priority. And, it compounds the potential feeling of rejection, if the therapist should say or do something that seems critical or indifferent.
Expectations of friends, therapists, and lovers depend on which role you believe that person occupies in your life.
Even the anticipation of a possible future friendship or sexual relationship after therapy ends can change the therapeutic relationship for the worst if either the client or counselor harbors such hopes. Imagine a therapist who desires a patient who is considering a possible divorce; if he anticipates the possibility of “dating” the newly divorced woman once therapy ends, might he not be more likely to encourage her to end her marriage?
It is for reasons like this that the American Psychological Association’s ethical guidelines rule out any such contact between counselor and patient, during or after therapy, in virtually all cases.
None of this is to say that doctors do not, sometimes, have feelings of attraction to clients. We treat the beautiful, the charming, and the handsome, as well as the less than beautiful and less than charming. But all counselors should be trained about and reminded of the boundaries concerning therapeutic relationships, boundaries that must never be violated.
Therapists run other risks, as well. Among them, is the need for approval from their patients. Certainly, it is human to want such approval. But the therapist needs enough confidence to be able to withstand the inevitable fact that he cannot help everyone; and, that in order to help some people, it will be necessary to tell them painful truths that may cause the patient to end the therapy and reject the therapist.
If the counselor is too invested in the patient’s improvement for his own good, he can be laid-low if the patient does not get better. And, ironically, if the therapist is working too hard to help his client, harder (in fact) than the client is working, he is likely to steal the initiative of the client that is necessary for his or her improvement.
Anyone in a helping-profession faces a problem with respect to how close he should get to his patient. If he is emotionally distant from this person, his ability to help is compromised. Most people, after all, want a doctor who cares. If you think your healer doesn’t care, or is only in it for the money, you are likely (and correctly) guided to go elsewhere for treatment.
On the other hand, however, is the problem of the health-care-professional who cares too much; who feels your pain almost as much as you do; who suffers the ups and downs of your mood as if he is a passenger on the same roller coaster, sitting right beside you. He is in danger of giving too much of himself, to the point of burning himself out. Moreover, when you reach out to him in your sadness or confusion, you are not likely to find a “rock” upon whom you can rely, but instead someone who is just as pained or disoriented as you are over the reverses in your life. From that vantage point, no therapist can be of any use.
Therapists need to be solid, emotionally and physically, to take on the complicated emotional and intellectual lives of the people sitting across from them. They need to be involved, but not to the point that their own emotional well-being is compromised by the sadness or turmoil of the people who they are treating. They need to know their own limitations and set limits on the extent that they provide care, lest they be sucked-dry by the process and be unable to be of any use to anyone, including themselves.
It can be useful for therapists to receive their own therapy. But when the counselor’s world is rocked from the outside, or when he is unable to navigate the white-water of human emotion that he is attempting to traverse, sucked into whirlpools beyond his control, he is well-advised not only to seek supervision and treatment, but sometimes, to refer the patient or patients in question to those who do have the equanimity to be able to do good for those same people.
Nearly all therapists mean well. Nonetheless, as the saying goes, “The road to hell is paved with good intentions.” If you think your therapist is unstable, too involved, or in some way inappropriate, it is time to consider your options: there are lots of good therapists out there, but there is only one of you, one life to live and set on the best possible course that you can.
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The above image is Cropped Photo of 2007 KKC Participant with Self-made Custom-fabricated Crutches by Rich Cosgrove, sourced from Wikimedia Commons.
Thank you for taking up the subject of the pitfalls of therapy. I appreciate it and your generosity pointing out these issues.
Can I raise a couple of areas of discomfort in this?
One is the territory of a therapist telling people “painful truths.” I would think constructive dialogue would be geared toward LEADING to truths rather than TELLING someone else truths. Only the client knows what these truths are, as the only witness to life beyond the consulting room. Are the “painful truths” some sort of judgment or label? I feel those are limiting and don’t help a client live a more functional life.
There’s a danger to this “for your own good” philosophy. It was my experience, anyway. My therapist delivered what he thought were “painful truths.” In the real world, anyone would call them what they were–putdowns.
I do wish too that therapy could be delivered to mitigate this “authority figure” mystique which I feel reinforces powerless and causes more damage when a therapist errs. If a client could see a therapist realistically rather than magically, it might be healthier.
Your point is well taken and it is a fine line indeed. I agree that coming from “on high” is a problem for therapists. Sometimes, however, the Socratic method does not lead the client to all of the conclusions that might be useful to him or her. Certainly therapists can err and one must make a good assessment of what information will reveal itself in time and what has been missed by methods that perhaps have been too subtle and indirect. As you say, we have no “magic” and the best of us try to let our clients know that we do not offer only truths written in stone.
I understand what you’re saying. And as we’re discussing this, we’re obviously each mentally referencing back to very different scenarios. I experienced the abusive end of some “truth-telling,” but I can also imagine critical situations which might call for more direct interventions. My bottom line, if someone were to call me on something, is first the delivery and secondly can this jarring translate into immediate and concrete steps to correct/improve the problem.
The authority issue is a difficult because of so many factors before the client even arrives at your door. I’m sure my biggest problem years ago was idealization, and I hear it in that way people talk/write about their therapists. Indeed it’s something of a paradox to address this construct.
Again, thanks for your generosity.
As you say, this is enormously complex. But what you have to say is very important and unfortunately, based on some difficult experience with therapists. I’ve put you on my blog roll and hope that others who read my blog will benefit from your perspective. Thank you for taking the time to write.
I wrote because I feel a dearth of conversation about some of these issues, among professionals, to the public, and certainly between the two groups. I will add you to my blogroll as well.
Thank you very much for this post. As a therapist and as someone who was traumatized in therapy by a dual relationship with my therapist, I appreciate this post tremendously. I also find the discussion on “telling the painful truth” interesting, as I see it from both perspectives. I think that, even if there might be some objective truths in this world, our ability to know them is limited. We can, however, have our subjective knowledge and vision that, I think, is perfectly fine to share with others including our clients, as long as we present it as our vision and not The Truth. I personally always appreciated when others told me their perspective on my situation even if it was different from mine, as long as they did not insist that their vision was The Only Right One. Honesty for me is an essential component of any relationship, otherwise, the relationship doesn’t feel genuine. I especially value genuineness in the therapist-patient relationship, because I believe that if it is not present, then no real work can take place. I was actually harmed more by my therapist’s constant agreeing with me on everything and seeing everything from my perspective only. It felt good for a while that he could empathize to the point that he would cry with me and for me, but eventually it put me in a very dark place, where I could see no way out, no solutions for my problems.
On the other hand, giving people your opinion prematurely, before they were able to establish some basic level of safely with you could feel very invalidating, and I have had this experience as well. I needed to feel heard and understood on my own terms before I was willing to be receptive to the therapist’s input. It is also important how you deliver the message and what kind of intention is behind wanting to give the client an honest feedback. I know from experience that sometimes it feels like we want to do it for the client’s “own good” but, in fact, we might feel the need to impose our own agenda on them. I think, mindfulness and self-awareness is the key in navigating through these complicated situations, and in order to stay mindful we need to be brutally honest with ourselves.
Your very thoughtful comment — indeed, a mini-essay — is much appreciated. I expect that others who read it will benefit from your wisdom and the hard-won experience you describe.
Thank you. I am working on my own blog/website on therapy process in general and harmful therapy in particular. When it is ready I will put a link to your blog there among other resources.
I will look forward to seeing it. Thanks.
Gerald, I just wanted to share the link to my interview/article on yahoo associated contend regarding abuse in therapy. Here it is
http://www.associatedcontent.com/article/8269499/how_to_avoid_getting_abused_in_psychotherapy_pg6.html?cat=5
I happened to be one of the survivors of this kind of abuse. This is just the beginning of all my future attempts (articles, books, presentations etc) to raise public and mental health community awareness of this phenomena that is, sadly, not uncommon. This issue perfectly fits with the idea of your blog about therapists who need therapy. My therapist certainly needed it badly.
Many thanks for this, Marina. I’m sure that it will be useful to a great many people. While I can imagine that some of the warning signs you have listed will help people to detect possible therapist inappropriateness, I also believe that some of them may occur in patients who project many of their own feelings on to the therapist and may attach their emotional life to that of the therapist without the clinician having done anything inappropriate to encourage it. In any case, I think your point of view is an important one.
I am guessing that your are talking about patient’s transference here. From experience of being a therapy patient, who was abused by her therapist and listening to stories of other patients, who were abused in therapy and also being a therapist myself and knowing what patients could attach to you through transference, I can say that I don’t know of any single case, where therapist inappropriateness was imagined rather than real. Patients might sometimes falsely perceive you as non-compassionate, judgmental, uncaring, inattentive, but they don’t make up inappropriateness where there is none, as this is something that is impossible to make up. Transference does not cause trauma even though it could be intense and uncomfortable. Therapist’s exploitation of transference does. There is even a legal term that is used in therapy abuse cases “the abuse of transference” or “professional incest”. When my therapist/perpetrator and I saw two therapists together (after seeing each other outside of his office as “colleagues” for two years), they too implied that my trauma was self-created and had nothing to do with his behavior. When I pointed out to how he violated boundary on many occasions, they did not even respond to that. They just refused to talk about his behavior at all. I was the only one who was supposed to be under scrutiny, but he was off limits no matter what he did. It is interesting how therapists typically respond to those cases..The initial automatic reaction is to believe that the patient is making it up as opposed to believing that the therapist did something wrong..There are two websites that offer support and advocacy for those who were abused by therapists
http://www.therapyabuse.org
http://www.advocateweb.org
I think, it’d be educational and helpful for all therapists to browse through these websites and read their materials.
Very well put. My point is that I am simply disinclined to judge individual cases in the abstract. I do not question the data you site. However, having dealt with in excess of 3000 individuals (many of whom I was asked to evaluate by other therapists rather than treat), including many who were psychotic or had severe personality disorders which often produced idiosyncratic ways of looking at the world, I wouldn’t want to judge based on a presumption that the therapist must be in the wrong. God knows, usually that it the case, but you never know.
Speaking as a consumer, I fear it’s not uncommon for therapists hide behind their transference theories to avoid examining their role in a therapeutic impasse. Patterns of human interaction don’t suddenly change at the consulting room door. Therapists can do tremendous damage maintaining their pride, then attributing a breakdown to the client’s projections.
That’s not to say a client might have heightened vulnerability in an injury. If the therapist idolizes the therapist (that some therapists even encourage), or is otherwise dependent, a boundary crossing leaves her feeling quite fearful and adrift. But assuming a client reasonably sane and functional, I assume at least some provocation.
My point is different though. I think, psychotic people could be left out of this discussion, as they simply live outside of this reality. Everyone else, including those with severe personality disorders do not simply say “My therapist told me that he loved me and held my hand in session”, if the therapist didn’t do it. They have no reason to lie intentionally and consciously. In case when the therapist really did something inappropriate, the patient’s disorder or any psychological issues that she is struggling with are irrelevant. I was fortunate to find the third therapist, who my ex-therapist and I saw together, who clearly labelled his behavior as inappropriate and abusive, and to all his attempts to discuss my issues and my history she responded that my material was irrelevant, and that when the therapist behaves unethically, the patient’s issues cannot be held against her. After all, if I had not had any issues, I would not have been seeking help in the first place, and it was his job to deal with whatever I brought to the table. If he had felt that he was not able or competent to work with me, he should have referred me out. When patients project, demand, manipulate, provoke, they simply bring their material to us, and it is our job as therapists to deal with this material professionally instead of using patients’ disorders as an excuse for for doing something inappropriate. As one of my supervisors said: “It is your patient’s job to seduce you and it is your job not get seduced”. One of the things that I found on http://www.therapyabuse.org is the statement “You could be a prostitute and begging for sex and it is still the therapist’s responsibility to hold the boundary.” I think, this statement reflects the heart of the matter.
Disequilibrium1 adds to my point. My addition to her post would be that people with sever disorders are even more easily provoked than those who are reasonably sane.
My dispute involved the therapists (a team) behavior when I wanted to leave treatment. When I complained, they accused me of transference and distortion. Now to fabricate a story, I’d have to dig deep in professional texts to learn of clinician termination issues, then imagine a full scenario. If one is inclined to cry victim to get attention, wouldn’t she choose something a little more dramatic than a dispute around termination? It’s preposterous. I only understand the scenario–because I lived it.
Thanks to both you and Marina for adding to the discussion with your personal experiences. I agree with your characterization of the preposterousness of the scenario you lived through, and Marina’s statement that the therapist, regardless of provocation, must hold to the boundary.