Some thoughts about working with clients who have experienced harm in therapy

A bad experience with a therapist can be painful, scary and traumatic. These feelings are often exacerbated by the client’s vulnerability in counselling and can leave the client suffering considerably and afraid to seek help.

At the time of writing this post, I am not aware of any specific training for therapists in working with the unique needs of this client group. I think that is a shame, and something I hope will change, not least because the client/therapist dynamic in the new relationship is central to the work and also likely to be heavily impacted by the client’s previous experiences. Both the client and the therapist are likely to be experiencing certain anxieties about the work. Here I am going to think about some possible feelings which could occur for both therapist and client:

Possible client concerns:

• I can’t start over again. There is a high possibility that the issues which first brought the client to counselling have not been fully addressed in their previous therapy. These might not be immediately apparent if the client is primarily expressing distress over their experiences in therapy. The client’s original issues may not be brought into the room for some time. The client is also likely to be ambivalent about disclosing upsetting details of their life again; the experience is difficult enough in itself, and is likely to be compounded by a damaged trust in the profession. The therapist must demonstrate patience with the client’s process, even if the client’s previous experiences in therapy remain present for many months or more after the start of therapy. The client must be allowed to process their negative experiences of therapy as much as, and for as long as necessary, just as they would with any other type of trauma, abuse or grief. I would suggest this is the key to the client experiencing the level of safety required in the relationship to ‘start over again’ with the issues that brought them to therapy.
• Will my new therapist report my old one? Some clients who have experienced poor therapy may be protective of their previous therapist. They may have some fear of getting their therapist into trouble, or equally, they may worry about the emotional stress of their traumatic experiences being aired in front of an ethics committee. It is essential for the autonomy of the clients that the limits of confidentiality are explained clearly at the contracting stage and the client feels confident about what would or would not be reported, so that they are able to make autonomous choices about what to disclose. The client may also fear their new therapist negatively judging their old one, and it is important that the therapist is validating of the client’s experiences and feelings, while remaining cautious of expressing their own frustration or anger towards the previous therapist. This is not to say it is always unhelpful to express your feelings about what has occurred, however it is important to be mindful of how this might be received by the client. It is a tricky balance and requires a degree of intuition and also meta-dialogue with the client about how they are experiencing the new relationship. Supervision provides a space to explore strong feelings which might be stirred for the therapist.
• What if the new therapist does not believe me? Clients, especially those who have experienced similar situations in their past, are likely to be very afraid of the feelings of rejection and disempowerment which come with not being believed. The therapist might feel tempted at some level to view the situation from the perspective of the previous therapist; after all, that is likely to be the frame of reference most familiar to them, and they may wonder or fantasise about how they would have responded in the situation the client is describing. I would suggest that the therapist needs to catch themselves if they find they are slipping into this way of thinking and remember that in the counselling room, the client’s frame of reference is the relevant one. Any intervention which appears to be missing the client’s experience may be received as a judgment or that the therapist is not taking the client at face value. If trust is damaged at this stage, effective therapy would be extremely difficult. Again, supervision is the appropriate arena for processing such thoughts and fantasies.

Possible therapist concerns:

• What if this client reports or complains about me? This is a valid anxiety and if the therapist ignores it, it may emerge in conscious or unconscious defensiveness towards the client which is likely to be damaging to the therapeutic relationship. The therapist must examine the origin of these kinds of feelings. They are likely to be triggered by some part of the therapist’s inner-process. Some self-doubt about their competence, perhaps?  A negative experience of disciplinary proceedings? A perceived existential threat to the therapist’s career, and therefore identity? This kind of anxiety is likely to be disproportionate to any actual likelihood of such an event occurring. By processing it earnestly in supervision and perhaps personal therapy, the therapist can ensure it does not impact negatively on the client work.
• What if I know the previous therapist? The counselling and psychotherapy community in the UK isn’t huge. There is a chance the current and previous therapists may know each other, and the chances are increased in a small town or rural area.  As with any potential conflict of interest, a judgement needs to be made by the new therapist as to whether they can work with this client or whether it would be better to refer them to another therapist. Factors to consider will include how well they know each other, how the situation is likely to impact on the new therapist, and what problems may arise as a result. Conversations with a supervisor are important, and the client’s best interests, as always, are paramount.
• I am tired of hearing about this therapist. Many feelings could be occurring for the therapist which lead to impatience with the client’s process around their previous therapy. The therapist might feel impatient to get to other areas of the work; they may feel ‘stuck’ and helpless in the work; or even jealous of the love and attachment the client may still hold for their previous therapist. It seems to me that being consistently self-reflective and separating their own material from their client’s is key for the therapist here. By bringing these frustrations into awareness, the therapist can examine what these feelings are saying about the work and the relationship, what transference and countertransference processes are at play, and this extra knowledge and understanding of the relational dynamic can facilitate rather than hinder the process. I think it is important to be aware that feelings around abandonment or childhood abuse may have been triggered by the client’s previous therapy experiences. In addition, a client reentering therapy may be still grieving the loss of their previous therapist. All these feelings are complex and need to be managed delicately.
• If this therapist can cause so much harm, so could I. This is unlikely to be a conscious anxiety, at least initially. It is my feeling that the profession as a whole shies away from confronting the great harm that can be done in therapy; having a clearly traumatised client in front of us forces us to face up to the power we hold, and the harm we can do. That is really scary. For this reason, I feel that great harm can be done by therapists who are unaware of, or in denial about the impact of their actions and words on clients – by those who would rather keep this aspect of the profession’s shadow deeply buried. Working with clients who symbolise this part of our shadow is deeply challenging at an existential level and this must be brought into our awareness both as individual practitioners and as a profession. We must not compound mistrust or trauma, we must seek to remedy it. I believe that to do this as fully as we can, we must acknowledge our potential to do harm.