Approximately one in twenty people undertaking therapy, with well-trained accredited UK therapists in a recent study, experienced enduring negative effects.
Whilst harm probably lies on a spectrum of culpability, the majority is inadvertent & occurs despite the therapist’s best efforts & good intentions. If we feel we are not making the progress we hoped for, but that our therapist has our best interests at heart, then it is always worth discussing the issue with our therapist! There are often changes that can be made, so that the therapy is more effective for us.
The quality of the therapeutic relationship has been found to affect the chances of a successful outcome. Research suggests, that if we do not have a good working relationship with our therapist by the end of our third session, it is unlikely we will develop one later in the course of treatment. It may therefore be helpful, for us to reflect on our experience at this point. Sometimes our therapist is not a good fit (or our problems lie outside their area of expertise) & we need to move on.
Whilst the majority of harm is unintentional, some therapists are reluctant/unable to acknowledge that negative effects can occur. Studies suggests that therapist who discuss the possibility of negative effects at the beginning of therapy & check in regularly to obtain feedback on how therapy is going (& amend their practice as needed) may be less likely to harm patients. It may therefore be helpful for us to seek out therapists who are happy to engage in discussions on the topic. Informed consent is routine in many professions, but appears uncommon in talking therapies.
In addition to therapist who (sometimes profoundly) inadvertently harm people, there are also some therapists who exploit clients to meet their own needs/wants (e.g. for sex, money, admiration or control). Therapeutic harm likely lies on a spectrum of culpability from abuse/malpractice through poor practice & sub-optimal help to those harmed despite receiving the best treatment available.
Exploitation of clients/patients by therapists invariably causes profound & enduring harm. It is difficult to gauge how common this problem is, due to its covert nature & the silencing effect of shame.
Exploitation typically occurs after a gradual erosion of boundaries (the "slippery slope"). It can be flattering for us to be apparently singled out for special treatment, but these behaviours are "red flags" indicating therapy is no longer safe.
If we are familiar with warning signs in advance, it can empower us to take appropriate action (e.g. terminate therapy) when things are not as they should be!
"Red Flags" Therapy May Not Be Safe
Some "red flags" are far more serious than others. Whilst most are never part of ethical therapy, a few may be okay in specific circumstances, or if they happen very infrequently/to a limited degree.
The list is not exhaustive.
There is cause for concern if our therapist.............
Has poor boundaries
-Shares lots of personal information about themselves/family/friends/other clients.
-Allows sessions to go on much longer than scheduled or books them for when no-one else is around.
-Regularly phones/texts/contacts us via social media, between sessions (& requests we delete these exchanges).
-Touches us (okay if a standard part of that type of therapy & fully explained/agreed at contracting).
-Behaves in a "creepy" manner/makes 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.
-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 with them, hugs or kisses us or engages in other sexual behaviour.
-Lends/gives us their belongings or buys us clothes/jewellery or other presents.
-Comments on our appearance or asks us to change it (lose weight/wear specific clothing).
-Advises us not to discuss what happens in our therapy with anyone, requests we keep certain events a secret or claims other people would not understand our, "special" relationship.
-Negatively influences our opinion of loved ones or encourages us to terminate contact (except in cases of abuse).
-Increases the number of sessions/week without good reason.
-Sees us for free or at reduced cost as a favour.
-Insists they are the only person capable of &/or interested in helping us or suggests we cannot survive without them.
-Fails to refer us appropriately when our needs are beyond their capabilities, or we markedly deteriorated.
-Fails to respect social difference: culture, sexuality, gender, age, socio-economic status (SES), neuro/physical diversity, religion, class or ethnicity.
4. Fails To Gain Consent Or Ignores Our Stated Preferences
-Undertakes hypnosis or other techniques without consent.
-Breaks confidentiality without consent or good reason.
-Allows other people to, "listen in" to sessions or takes audio/video recordings without our knowledge/consent.
5. Is Dishonest
-Lies/engages in gaslighting.
6. Is Rigid
-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/provides unlicensed medication, alcohol or street drugs/ becomes physically or sexually abusive/ endangers life or suggests suicide.
We need to trust our instincts; if it doesn't feel right, find a different therapist.
Common Tactics of Abusers
Whilst probably uncommon, cases of therapists grooming and abusing clients/patients occur.
Perpetrators of abuse, across a wide range of contexts, often engage in a shared pattern of behaviour outlined below.
A. Identify A Suitable Target
Anyone can be targeted by an abusive therapist. However, a marked power differential between therapist & client/patient increases risk. Abuse is more likely if we: have low self-esteem, have severe mental illness (especially if detained), are female or non-binary & seeing an older male therapist, are less well educated than our therapist, have a history of childhood sexual abuse/other trauma, have learning difficulties, find regulating our emotions challenging, previously experienced abusive adult relationships, are incarcerated &/or belong to other marginalised groups.
Intersectionality (the interconnected/overlapping nature of social categorisation), can impact the size of the power differential, resulting in many of us entering therapy profoundly powerless relative to our therapist.
B. Build Our Trust
Effective therapy is unlikely if we do not place trust in our therapist. It is a risk we need to take to potentially bring about positive change. However, it leaves us vulnerable to abuse if our therapist is untrustworthy.
C. Gather Information About Our Interests/Unmet Needs
Therapists need to gather information about us so they can help. Abusers can however, misuse this information.
D. Meet Our Needs
Once our potential abuser has chosen us, built trust & identified our interests & needs (e.g. to feel understood/of value), they will step in to meet those needs, "share our interests" & shower us with positive regard in a bid to hook us.
Perpetrators may also promote our feelings of indebtedness & gratitude, for example undertake apparent acts of kindness to which they frequently refer.
More minor, "red flag" behaviours may start to occur at this point. If we spot them & take issue, they are likely to be minimised, denied or excused by the therapist or we will be blamed. We may then feel we are being unreasonable & apologise.
E. Separate Us From Other Support
The abuser-therapist encourages us to view those we love/value in a negative light & suggests we reduce/stop contact. Without their support it is harder to reflect skilfully (or possibly at all!) on what is happening. It also further increases our dependency on the therapist.
If groomed for abuse, there may be a limited time-period when we have sufficient resources to leave. Once ensnared, it is more challenging to disentangle ourselves from our abuser.
F. Start to Abuse Us
Abusers can start with small acts & escalate once they have determined how we react.
They may concurrently undermine our belief we possess any positive qualities. For example, if we value kindness, our abuser might question & devalue our actions every time we exhibit this trait. Subsequently, we might not believe there is any good in us at all, facilitating further abuse. Abusers are likely to encourage us to blame ourselves for what happens. We may repeatedly apologise for the harm done to us! Profound confusion is common. The finger of blame turns upon itself. Shame silences. We may cease to function effectively in any area of our life.
G. Employ Techniques To Evade Detection
Perpetrators commonly employ gaslighting (a form of manipulation aimed at making people doubt their own reality) & insist events/ conversations which occurred, never did. Additionally, abusive therapists may blame our poor mental health for our, "misconceptions" & we may end up believing them (especially if our ability to function is in free-fall due to abuse we have failed to identify or mistakenly taken responsibility for). These tactics promote further confusion & erosion of remaining self-esteem/belief/functioning.
Strong loyalty to our abuser is not uncommon. The intermittent acts of, "kindness", will be highlight as evidence when needed, of how they have gone above and beyond to help us. We may hold them in curiously high regard & go to lengths to explain away/justify their harmful behaviour.
Perpetrators, in many cases, collect information (easy in the role of therapist) in advance, to discredit us if ever needed. If the abuse does ever come to light, the abuser-therapist may claim we have been an impossible case. They may have tactically sought additional supervision (the process whereby therapists discuss cases with experienced colleagues -with the usual aim of helping us more effectively!) to recruit unwitting others to corroborate their story.
Abusers across diverse settings frequently use a tactic called DARVO (deny, attack, reverse victim & offender) to reduce the likelihood we are believed in the event allegations of their misconduct come to light. This tactic was first described by Jennifer Freyd (see publications page for references).
In DARVO, the abuser first vehemently denies any abuse ever took place. A recent well-known example would be, "Any allegations of non-consensual sex are unequivocally denied by Mr. Weinstein".
In the next step, the abuser (or his defence team in the example) mount(s) a blistering attack on the victim's credibility. A perfect victim does not exist, so there will always be leverage. For example, in a ~9 hour cross-examination, Mr Weinstein's defence pummelled a victim with relentless questioning & accusations, “You were manipulating Mr Weinstein so you’d get invited to fancy parties, correct?” “You wanted to benefit from the power, correct?”.
Finally, the abuser erroneously claims they are actually the victim of, "abuse" at the hands of the true victim(+/- their allies). This can have devastating psychological consequences for the genuine victim(s). In Mr Weinstein case, he responded to allegations in an interview, "“I feel like the forgotten man...I made more movies directed by women and about women than any filmmaker, and I’m talking about 30 years ago....I did it first! I pioneered it! It all got eviscerated because of what happened. My work has been forgotten". He then went on to highlight the $100 million raised during a charity concert for 9/11 first responders he helped organise. The abuser morphs skilfully into the, "good guy", falsely accused by (a) malevolent or delusional other(s).
We live in a world where victim blaming is endemic. Research has found DARVO is highly effective in further discrediting victims; people typically side with the abuser.
Encouragingly however, studies also reveal, that if people learn about DARVO, then they are likely to subsequently spot it & not be deceived in future. Education is therefore an important tool in helping ensure effective action is taken in all cases of abuse, including those that (probably infrequently) occur at the hands of therapists.