Therapy: Staying Safe
Whilst talking therapies are commonly safe & effective, long lasting negative effects do occur in a small minority of cases. There are however things we can do, to improve our chances of a positive outcome.
It is helpful before we start therapy, to think about what qualities we would value in a therapist, familiarise ourselves with what, "good enough" therapy commonly looks like & learn about, "red flags" that may indicate questionable practice.
Identifying A Suitable Therapist
The titles, "psychotherapist" and "counsellor" are not protected in the UK. Anyone can use them, even with absolutely no training, or having undertaken a £10 course in counselling/neuro-linguistic programming on the internet! An impressive looking certificate may not mean much. One component of staying safe is therefore to ensure our therapist is suitably qualified & is registered with a governing body overseen by, or accredited with, the UK Professional Standards Authority (PSA).
All NHS (UK) therapists have completed (or are working towards) accredited training & the NHS has implemented many measures to safeguard patients. Whilst these measures may at times be imperfect, they confer a much greater degree of protection than is inherent in the UK private sector.
People undertake therapy privately for many reasons. Compared to NHS treatment, private therapy usually permits greater flexibility re timing of sessions, duration of treatment & choice of therapist/therapy. In addition, long waits for treatment can be avoided. Therapy is often covered in full by private health insurance & many highly skilled therapists work partly or solely in the UK private sector.
The PSA accredited registers for counsellors & psychotherapists are voluntary. Regulation is typically less stringent than for professions with protected title (for whom regulation in statutory). Protected title professions include: clinical/counselling psychologists, psychiatrists, social workers, occupational therapists (OT) & registered mental health nurses (RMN).
It is worth checking the professional register of any potential therapist, to ensure they are listed & not currently working under sanctions. Sometimes therapists state, "they abide by the code of ethics of X organisation", which sounds good, but which offers us zero protection, if the therapist is not currently on the register of that organisation!
Governing bodies overseen/accredited by the PSA require that their therapists: have undertaken a recognised training course, are insured, attend supervision, undertake continuing professional development (CPD) & have agreed to abide by their code of ethics/conduct. However, the UK regulatory system for talking therapists is fragmented, inconsistent & sometimes fails in its aim to safeguard those undertaking therapy. There has been reluctance from some voluntary governing bodies to sanction therapists in cases of misconduct. In addition, there is currently nothing stopping a therapist, struck off a register for intentionally harming patients/clients to continue to practice talking therapy & call themselves a psychotherapist or counsellor! Reform is needed.
What Typically Happens in "Good Enough" Therapy
There are many types of talking therapy & so a typical session/course of therapy will vary somewhat. However, there are many features shared by almost all talking therapies & it is important for everyone embarking on therapy to understand what to expect!
In the first session, the therapist usually discusses the type of therapy they offer & what it entails (contracting). This helps ensures mutual expectations. Contracting typically includes discussions regarding: frequency/times /duration & location of sessions, cost (if undertaken privately), session format, therapy type, cancellation policy, circumstances in which contacting the therapist between sessions is permitted & any consequences of missed sessions. The therapist should be professional, have a clear framework under which they operate & be happy to answer questions.
When deciding to see someone privately, it is often a good idea, if feasible, to meet with a few therapists for an initial session to find someone you feel really comfortable with. This is important because, a positive therapeutic relationship has been shown to be a major factor in therapeutic success. Whilst most of us benefit from the therapy we undertake, good therapists should inform us that negative effects can occur even with optimal treatment & provide information regarding their possible nature & frequency. This ensures informed consent. It also helps create an environment in which we may feel more able to voice concerns in future sessions, if it feels that things are not progressing as anticipated.
It is important that achievable goals are discussed, collaboratively generated & agreed. These help create a shared understanding of what progress will look like, which is very important!
Therapists should regularly “check-in”, to ensure therapy feels helpful & is leading to positive change.
Therapy can be tiring, difficult &/or bring up uncomfortable feelings; this is not necessarily a sign things are going wrong. In fact, these are common reactions to effective therapy! This is especially true for sessions addressing trauma. Negative effects should be temporary however & lead to subsequent improvement.
Sometimes therapists use written/computerised forms to check in on our well-being regularly. These can be an highly effective additional measure to monitoring change; they have been shown to pick up deterioration otherwise missed.
Strong Therapeutic Boundaries
Strong therapeutic boundaries are essential for safe therapy. Boundaries are rules/limits which ensure we & our therapist maintain a safe distance. Therapists help us, but they are not our friends. For example, therapists should not talk extensively about their own problems during our sessions, or EVER enter into a sexual relationship with us. There is an inherent imbalance of power in the therapeutic relationship. These rules are needed to help ensure the therapists power is used as a force for good & does not lead to exploitation or harm. These boundaries also keep the therapist safe. It is always the therapists responsibility to maintain boundaries, but it is helpful if we know about them & can thereby monitor their appropriateness ourselves! Further examples of poor boundaries are given below.
Recognising Unhelpful or Harmful Therapy
Research indicates approximately one in twenty people undertaking therapy with well-trained accredited therapists in the UK, experience long-lasting harm (which also means 95% of people undertaking therapy do not!).
The majority of harm is unintentional i.e. it occurs despite the therapist’s best efforts & good intentions.
If we feel therapy is not being maximally helpful, it is important to discuss this with our therapist & explore & mitigate this together if possible.
Sometimes our therapist is not a good fit (or our problems lie outside their area of expertise) & it may be that both sides need to acknowledge this so we can then find someone more suitable. Research has shown that if we have not established a good working relationship with our therapist by the end of the third session we are unlikely to subsequently, so this might be a good time to review!
There are instances. although uncommon, where therapists behave unethically & exploit clients to meet their own needs (e.g. sex, money, admiration or control). Exploitation typically occurs after boundaries are gradually eroded over time (called the "slippery slope"). It can be flattering for us to be apparently singled out for, "special treatment" by our therapist, but these behaviours are "red flags" indicating therapy is not safe.
If we have knowledge of these warning signs in advance, it can empower us to take appropriate action (e.g. terminating therapy) when things are not as they should be!
"Red Flag" Warning Signs Therapy May Not Be Safe
*NB* There may occasionally be circumstances in which a small number of the behaviours listed below may be considered to be okay.
These are only a selection of possible warning signs of questionable therapy.
1. Poor boundaries
-Shares lots of personal information about themselves/family/friends/other clients.
-Allows sessions to go on much longer than scheduled.
-Schedules sessions for when no-one else is around e.g. end of the day or mid-morning if working from home (alone during day)
-Regularly phones/texts/contacts us via social media between sessions (& requests we delete these exchanges).
-Discusses their problems in our sessions.
-Touches us (okay if a standard part of that type of therapy & fully explained/agreed at contracting).
-Behaves in a "creepy" manner or make odd comments that don't seem relevant to a current topic of conversation.
-Socialises with us/introduces family/friends/other clients outside of our therapy sessions.
-Gives us presents.
-Discusses going into business with us or offers employment.
-Suggests they/their family members babysit our children.
-Tells us we are "special" or their “favourite” client.
-Flirts, discusses problems in their current/previous relationships or expresses regret we did not meet years ago!
-Discusses their sex life/fantasies and/or asks about ours. Lends or gives us sexually explicit material.
-Asks us to sit on their knee or lie down together.
-Hugs, kisses or engages us in other sexual behaviour.
-Lends/gives us their belongings or buys us clothes/jewellery etc.
-Comments on our appearance or asks us to change it (lose weight/wear specific clothing).
-Advises us not to discuss our therapy/what happens in the therapy room with anyone.
-Negatively influences our opinion of loved ones (e.g. partner, family or friends) or encourages us to terminate contact (except in cases of abuse).
-Increases the number of sessions/week.
-Sees us for free or at reduced cost as a favour.
-Insists they are the only person capable of &/or interested in helping us.
-Suggests we cannot survive without them.
-Fails to refer us appropriately when our needs are beyond their capabilities or we have markedly deteriorated.
3. Discriminatory Practice
-Fails to respect social difference including: culture, sexuality, gender, SES, neuro-diversity, religion, physical diversity, class or ethnicity.
4. Failing To Gain Consent Or Ignoring Our Stated Preferences
-Undertakes hypnosis or other techniques without consent.
-Breaks confidentiality without consent or good reason.
-Lies or engages in gaslighting.
-Is unable to collaboratively engage with constructive feedback.
7. Undermines Our Well-being
-Ridicules/shouts/threatens/is contemptuous/expresses disgust/suggests or implies we have no positive qualities/engenders helplessness & despair/encourages risk taking or other unwise actions/endangers life or suggests suicide.
It is worth noting that when asked this question:
"Compared to other mental health professionals within your field (with similar credentials), how would you rate your overall clinical skills and performance in terms of a percentile (out of 0–100% : e.g., 25% = below average, 50% = average, 75% = above average)?"
Of a sample of 129 mental health professionals (a mix of psychotherapists, psychologists, psychiatrists & social workers), just 8% rated themselves as below the 75th percentile (!) & NONE rated themselves below average (50th percentile). It is statistically impossible that this can be true! So there is substantial bias in mental health professionals' perception of their own relative competencies & almost all think they are well above average or awesome at their job! This is an interesting finding & I am curious what impact these self-perceptions have on therapists' willingness to engage with the possibility of iatrogenic (caused by treatment) harm, especially given many currently refuse to even acknowledge it as a possibility.
If ~16 million people in the UK have ever been to therapy & of these at least 5% (as studies have found) suffer enduring harm, that is approximately 800,000 people in this country alone!
Any efforts we can make to increase awareness (on both sides of the couch) of therapeutic harm & abuse & consider way to reduce their likelihood, has the potential to positively impact the lives of people in distress seeking help in the future.