How to Recognize Abuse in Therapy and What to Do About It

May 25th, 2016   |  

The therapeutic relationship can be a very powerful relationship. In fact, power in this relationship is vital, and something ethical therapists should think carefully about. Ideally, the therapist uses the position of authority inherent to the role to empower people in therapy and encourage them toward wellness and autonomy. Unfortunately, this does not always happen. In some cases, therapists have been known to abuse the imbalance of power in the therapeutic relationship. This can of course be harmful to the people they are entrusted to help, who may not know exactly what is happening or what to do about it.

As a person in therapy, trusting your own experience and communicating about it are both essential to the outcome of therapy. If you have fears or doubts about something that happened or how you are being treated, in most cases you should speak with your therapist about these concerns. In turn, any such concerns should be taken seriously and addressed immediately by the therapist.

Some ways therapists may go astray in the therapeutic relationship include behaviors related to boundaries, to fostering dependence, to their duty of care to you, and to acting in hostile ways. A number of specific things would be red flags. While I will discuss some of them, please know this list is by no means exhaustive, nor can it possibly be. It is important to trust your instincts about how you are being treated.

Boundaries are extremely important in the therapeutic relationship, and many are outlined in the ethical codes mental health practitioners are bound by. It is incumbent upon your therapist to maintain appropriate and professional boundaries; this is one of the ways the therapist fosters trust in the relationship and in the therapeutic process. Maintaining boundaries means your therapist should neither cross boundaries nor allow you to cross them as part of the relationship. The therapeutic relationship should empower you and enrich your life.

Examples of boundaries being crossed include:

• Violating confidentiality: Sharing your information with others, or others’ information with you.
• Attending sessions while compromised: This includes being inebriated, or conducting sessions if the person in therapy is too inebriated to meaningfully engage the therapeutic process.
• Conducting sessions while distracted: This means doing other things, such as running errands, having meals, or answering phone calls.
• Not adhering to expected lengths of sessions: Sessions sometimes run a bit late, but consistently going long or cutting short, or if you don’t know how long sessions are supposed to be, is not respecting boundaries.
• Expecting, asking for, or accepting favors or gifts: Small gestures such as thank-you cards are okay if offered, but should never be expected, and the person in therapy should never feel pressured to give anything.
• Extending invitations or accepting invitations to social events: Your relationship is professional and should be conducted within the confines of professional contexts; while we, as therapists, do sometimes receive invitations to important social events involving people in therapy and generally are very touched and honored by this, we should decline them gracefully to preserve the integrity and safety of the professional relationship, which is our first priority.
• Requesting support for their business: Therapists should not ask for donations, contributions of time or money, or any other support of their business outside of what you owe them directly for your therapy. This includes soliciting reviews for use in their marketing or websites.
• Maintaining multiple relationships: Therapists generally should not be in a therapist role for people with whom they have other significant relationships, or for people with close ties to others the therapist is working with. In small communities with very limited numbers of therapists, this can be difficult, but therapists should work hard to find the best ethical balance they can while preserving the safety of the therapeutic space.
• Any sexual innuendo, requests, pressure, or behavior: Licensed therapists are prohibited from sexual contact with the people they work with in therapy. If your therapist makes sexual overtures to you or encourages them from you, this is a serious violation of trust.

Fostering Dependence

Therapists are ethically obligated to support people in therapy in living full, independent lives to the extent this is possible for them. In some (hopefully few!) cases, therapists have intentionally fostered dependence. As a therapist, my goal is always, as I say, to “work myself out of a job,” because this means the person in therapy has achieved the goals established at the outset and moved into a better space.

Some clues that your therapist may be fostering dependence in the relationship include:

• Pressuring you to cut off ties with important people in your life who support you.
• Encouraging frequent out-of-session contacts with no reasonable clinical justification.
• Responding negatively or dismissively to positive changes you make.
• Having excessive influence over your personal choices—leisure activities, relationships, clothing choices, career choices, etc.
• Pressuring you not to disclose your therapy work to others, or seeking to isolate you from other important people in your life.
• Offering or encouraging you to use illegal or potentially addictive substances outside the boundaries of appropriate prescriptions by a qualified physician or psychiatrist.

For what it’s worth, some of the signs above are hallmarks of emotional abuse. You don’t deserve such abuse from anyone, let alone your therapist.

Deviations from Duty of Care

Therapists have a specific duty of care to you. This includes a legal and ethical duty to work actively toward your welfare and to be responsive to your needs.

Therapists have a specific duty of care to you. This includes a legal and ethical duty to work actively toward your welfare and to be responsive to your needs.

Some specific deviations from a therapist’s duty of care to you might include:

• Failing to respond to suicidal or homicidal ideas you express during sessions, or encouraging such thinking or planning.
• Not listening to your concerns about your well-being or your priorities in this regard, or failing to respond when you voice such concerns.
• Being dishonest or deceptive in regards to the goals, process, or prognosis of your therapy.
• Abandoning you—suddenly terminating therapy without explanation or referrals to other qualified providers, or failing to respond to reasonable needs or requests for support.

Hostile or Abusive Behaviors

Therapists may sometimes need to confront problematic behaviors or hold reasonable expectations regarding behavior of the person in therapy. However, this boundary should never take the shape of openly hostile or abusive behaviors.

Some indications your therapist is engaging in hostile behavior include:

• Expressing excessive anger at you or your behaviors.
• Using language with you or about you that is insulting, demeaning, or inappropriate—using profanity in the therapy room is not particularly uncommon, but this language should never be directed at you in an insulting way or used in ways that are frightening or offensive to you. My rule of thumb is to follow the lead of the person in therapy; if the person chooses to use profanity to express strong feelings, that is fine with me, but I do not use such language outside the context of the person’s own use of it. Strong language, whether profane or not, should not be directed at you in insulting or abusive ways.
• Yelling at you—again, raised voices sometimes accompany the discharge of strong emotions, and this can be fine and even healing at times. However, your therapist should not be yelling at you in demeaning or belittling ways, or ways that feel frightening or upsetting.
• Violating your boundaries—if you set a clear boundary about something you don’t want to discuss, your physical space or touching, or language you find upsetting, this should be respected. It may reasonably happen that your therapist might express an opinion about the clinical benefit of talking about something that feels uncomfortable to you; however, this should be a calm expression that helps you understand and feel supported rather than an angry or confrontational demand.
• Threats—you should not feel threatened by your therapist. Threatening to disclose sensitive information to others, to use it against you inside or outside of therapy, or to terminate therapy if you don’t “toe the line” are red flags. A therapist may need to terminate therapy with you if they believe it is not benefitting you or for other reasons, but this should be handled in a sensitive way that helps you to understand the reasons for it and offers other options.

The scenarios above provide a broad overview of some behaviors that may be indicators of a problematic or abusive therapeutic relationship. In some of these cases, it is conceivable that there might be reasonable clinical justification for certain behaviors. However, if you feel uncomfortable about your therapeutic relationship, you should address that discomfort—it is real, valid, and deserves attention.

If You Have Concerns Regarding Therapy or Your Therapist

If you have concerns about the safety or appropriateness of your therapy relationship, in most cases the best first step is to bring these to the attention of your therapist. In many cases, there may have been a miscommunication of some sort and your therapist will be grateful to you for bringing this to their attention so it can be addressed. (Good therapists want to help you feel better!)

If this does not seem possible or reasonable in your circumstances, you are always free to seek a second opinion from another therapist. Although it’s rarely advisable to have multiple concurrent therapists, one session to consult with a different therapist about how your therapy is going and explore the possibility of changing to a therapist who may be a better fit for you is always a reasonable step.

If you have serious concerns about how you have been treated in therapy, you can contact the licensing board for the type of professional you are working with in your state and ask what your options are. A simple web search should help you find this body. For example, searching for “counselor board state of Indiana” should help you navigate to the relevant authority that can help you with your specific questions or concerns.