harm in therapy – A Client First

Can Effective Supervision Prevent Harm in Therapy?

Philip Cox’s recent article on harm in therapy got me thinking about the value of the supervision I seek, and my relationship with my supervisor. I like the notion that the word supervision literally means “over-view” and I can picture my supervisor in a little helicopter, observing the wider picture as I manage the finer details on the ground.

So what is the purpose of supervision? For me, the supervisory relationship serves several functions.

Firstly, I have a trusted and confidential space to discuss my work with clients, which feels like an essential counterbalance to the isolating nature of the work which is so often talked about in the profession. It is in itself a form of self-care.

Secondly, I find the strength of the relationship provides a solid platform on which I know I can stand when I need to. I feel confident it will not break beneath me. This security gives me the courage to co-create new platforms with my clients, on which they too can stand and experience safety within the relationship. Being part of this solid base for my clients feels possible because I am anchored by my own firm footing in supervision.

Thirdly, the trust I have in my supervisor helps me in a number of ways. Through talking about client work and other areas of my process openly, I have allowed myself to become vulnerable, and at no point have I ever felt judged. This mirrors beautifully the function of the therapeutic relationship and allows me to bring whatever I need to discuss to supervision, even times when I feel I have made mistakes in my work. The transparency allows us to shine a light on areas of my work that we might otherwise miss, and to raise anything to my awareness which might impact on the work. I value my supervisor’s willingness to challenge me, and to be challenged; I find the parts of the work where we each hold different perspectives the most illuminating of all – there is always so much to learn and to take forward into my practice. Parallel process fits nicely into this area of working within the relationship; it is a fascinating phenomenon and, I find, rich with data about myself and my relationships with clients.

Do I disclose all my thoughts and feelings about the work to my supervisor? Well, I try to, but there will always be things outside of my awareness which don’t become immediately apparent. As my supervisor gets to know me better, he becomes even better placed to spot my shadow material as it emerges and bring to my attention anything I might not have seen. I try to make a point of accepting the observations he makes curiously and non-defensively, even if I do not recognise what he is saying. I find this work exciting and engaging.

A good supervisory relationship doesn’t make harm occurring in client work an impossibility. It would be arrogant and naive for any therapist to assume they do not have the potential to do harm for any reason. But I do think that supervision is an important safeguard against harm. When we have a trusted relationship, a space to explore every aspect of ourselves and our actions towards clients, we have a safety net – the opportunity to catch areas of the work which could become problematic before any harm occurs.

I think this is as true for very experienced practitioners as it is for those at the beginning of their career. Certainly the nature of supervision for a practitioner with forty years experience is likely to differ from that of a student or newly qualified therapist, but all therapists require support, and of course, we are all vulnerable to the emergence of shadow material – supervision is an important part of managing this throughout our career.

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.

A Client First

This is my first foray into blog-writing and in a strange way I feel very at home already. I am in the final year of training to become a counsellor/psychotherapist and I suppose I am already beginning to wonder if the world of the qualified therapist provides the same space for discussion and exploration of ideas that I enjoy weekly at university. Perhaps I am scoping out new territory in which to…well, I’m not sure…express? explore? ignite debate? challenge my preconceptions? Maybe all of these. I tread lightly as I take my first steps into this uncharted terrain and bring with me an open mind and enthusiasm to learn and grow.

The title of this blog alludes to my introduction to psychotherapy, which was (and still is!) to experience therapy as a client. As I move into psychotherapy as a career, I am sometimes uncomfortable with what I describe as an ‘us and them’ attitude I have occasionally experienced from practitioners. At the beginning of my learning, I witnessed a tutor declare to the students “All clients lie!”. As inexperienced as I was at the time, I found this sentiment jarring and frustrating. As a client I felt a real sense of the inherent power imbalance, as though I were stood at the foot of a mountain, vying to be heard by those at its summit.

My experiences in psychotherapy have not always been positive. My first therapist displayed a disregard for therapeutic boundaries which was not only unhelpful, but actively harmful. When I subsequently sought consultation with an excellent therapist, I noticed that even he sometimes struggled to know how best to work with the fallout from my previous therapist. I have found that almost no literature or research exists on working with clients who have been harmed in therapy and meeting the unique needs of this client group. I hope to be able to contribute in this area; I want the profession to be able to confront this aspect of its shadow and not to shy away from the harm that we can do as practitioners. I want clients who are wary of reentering therapy know that therapists want to help them. That we are by their side, that we want to understand what is happening for them, and that we do not fear working with them. I feel that an open conversation in the profession is essential to achieve this.

So, that’s a little bit about me and my interests. In this blog you can expect my thoughts and comments on all things psychotherapy, a strong leaning towards the rights of clients and the ethical responsibilities of therapists, and probably some poetry here and there too!