Reflections on Unintended Harm in Psychotherapy

Yesterday evening I watched an hour-long Skype conversation between John Wilson and Philip Cox in the Onlinevents library (a UK based online learning platform). The topic of the conversation was ‘Exploring Unintended Harm in Psychotherapy’ and the discussion raised many interesting talking points, some of which I’d like to discuss in this blog post.

Firstly, Philip presents the following definition of harm, which will also be the definition I will adopt for the purposes of this blog post:  “Harm must be relatively lasting i.e. this definition excludes transient effects, such as in-session anxiety or between session sadness, and must be directly attributable to the quality of the therapeutic experience or intervention”.

With this definition in mind, Philip points to recent research suggesting that the figure for clients who feel they were harmed in therapy is as high as 10%, and that these figures become substantially higher when looking at clients from minority groups and clients who are therapists themselves. I have to confess that I am not surprised by these statistics at all. My feeling is that the more we listen to the experiences of clients, the more we will come to understand the scale of, and reasons behind this high level of harm.

I do not wish to make any assumptions about why minority groups and therapists report greater harm, but I find the fact that ethnic minorities, people with disabilities, and those who identify as LGBTQ+ are reporting higher rates of harm in therapy particularly concerning. Unless we begin to face up to these challenges and address them, I feel we are not fulfilling our ethical responsibilities of non-maleficence and justice as a profession.

Philip made a great point about therapist flexibility as a vehicle for positive therapy experiences and outcomes; as he explored, this is likely to be particularly important when meeting with a client with a different cultural frame of reference. When the therapist sticks rigidly to a paradigm which doesn’t meet the client where they are, they risk alienating the client, and ultimately damaging the relationship. Those statistics leave me with a renewed awareness of the importance of endevouring to understand the client’s frame of reference, and retaining a dialogue with each client about the relationship throughout the process. By having conversations with the client and checking in with their experience of counselling, I would hope that any issues could be caught and resolved more readily, reducing the risk of harm.

Philip highlighted the importance of the therapist’s openness to feedback. I would like to shout this point from the rooftops. My personal experience of therapy has shown me that when a therapist is willing to hear their client’s concerns and accept feedback non-defensively, the relationship can become stronger and more trusting as a result. It sounds obvious, however I think it can be difficult to keep that notion in our consciousness when faced with clients who may challenge us. For me, it is important to remember that I am, as a therapist, in service of the client; whether or not I recognise what the client is feeding back to me, it is my duty to reflect, both upon my actions, and the significance of what is occurring in the relationship in the context of the work. This can be explored in supervision and, where appropriate, brought into the counselling room. Philip described co-creating a relationship strong enough to withstand therapist errors, and I think a non-defensive attitude towards feedback is essential in creating the level of trust required for this kind of work.

John mentioned the idea of having a “fresh pair of eyes” on the relationship, which supervision offers us. Philip rightly pointed out that this objective input serves both the therapist and the client, and when issues occur, the Counselling and Psychotherapy Union can also offer non-judgmental support for therapists. These are undoubtedly excellent resources which benefit all parties, including the therapist’s caseload of other clients, whose counselling could be potentially affected by an unsupported practitioner going through the process of a disciplinary proceeding, for example.

Unsurprisingly, I find myself wanting to borrow the idea of a ‘fresh pair of eyes’ and make a shift of emphasis to what might be happening for a client in a difficult situation. Therapy can be an isolating experience for a client, as well as a practitioner, and as I have mentioned before, clients do not have the benefit of supervision or any objective voice which might be able to point it out if things go awry. How is a client even to know that things aren’t right?

Happily, there are more resources available today than there used to be. As I have previously discussed, the BACP offers a free and confidential advisory service for clients who are concerned about any aspect of their therapy. The international organisation Therapy Exploitation Link Line (TELL) also offers support, resources and advice for those who have been in exploitative or abusive therapy. In addition, online peer support forums and chatrooms exist where clients can check in with others about aspects of their therapy, usually anonymously, and hear different perspectives. I don’t think these resources are to be feared; it seems to me beneficial to the integrity of the profession that we welcome scrutiny and offer transparency.

I am encouraged and impressed by the way Philip has sought to address the problem of unintended harm in therapy. It seems vital that we as practitioners are having these kinds of discussions and looking at ways to reduce those worrying statistics.

So alongside working to avoid causing harm in therapy, for me the next logical step is looking at how we can best support those who have experienced harm. I feel it is important to acknowledge the fear that many clients are likely to experience around returning to therapy and becoming vulnerable again in a therapeutic relationship.

How can we meet these clients’ needs in a new therapeutic relationship? Perhaps more therapy won’t be the way forward for all clients – what do they need? What support do clients need when going through a complaints procedure? Are we doing enough? These are all questions which I feel require much more investigation. I am excited by the good work already happening, and I feel confident that client experiences will inevitably improve as long as we remain curious, and keep these conversations alive within the profession.

Reference:

Cox P & Wilson J (2017). Exploring Unintended Harm in Psychotherapy. [ONLINE] Available at: https://www.onlinevents.co.uk/exploring-unintended-harm-in-psychotherapy-philip-cox/. [Last Accessed 03/12/2017].

2 thoughts on “Reflections on Unintended Harm in Psychotherapy”

  1. Hello Erin
    I’m so glad that you are writing about this topic. As somebody with a niche speciality in working with clients who have had negative/abusive experiences in therapy, one of the potential issues is that therapy itself can be triggering. A very similar area is working with clients who have been abused and/or neglected by NHS Mental Health Services whether by overtly abusive behaviour by a single therapist or by perhaps a more insidious form of abuse through neglect (sloppy admin, booking errors, multiple cancellations etc), which might be paralleling Complex-PTSD inducing childhood neglect. I’d love for all in the profession to be more trauma aware and therefore sensitive to what can potentially be retraumatising for clients. Ignorance can lead to sloppy boundary keeping actually being traumatic for clients.
    I’m relieved that the issue of potential harm in therapy is being discussed. What sort of Dark Ages nonsense has prevented this from being an open discussion until now?

    Liked by 1 person

    1. Thank you for raising this important point, Amanda. I agree with you that therapists can unwittingly retraumatise clients by behaving inconsistently and unpredictably, Trauma awareness certainly seems to be key to avoiding harm in many cases. I have seen some of what you have written around the importance of trauma training in core training and I think you are absolutely right. These conversations have been a long time in coming but I am hopeful that a light is beginning to be shone on this important topic, and that is really positive.

      Liked by 1 person

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