The role of ethics in therapy., a blog.When you seek support in therapy, you’re also opening yourself up and entrusting someone with your most personal thoughts and emotions. Therapy should be a safe, confidential, and professional space where you can heal and grow — that’s why ethics in therapy are so critical. Ethical therapists uphold high standards to protect client well-being, maintain trust, and ensure the best possible care.

But how can you be sure a therapist follows these principles? Not all therapists adhere to the same ethical guidelines, and without proper vetting, finding a truly qualified professional can feel like a wild goose chase. That’s where GoodTherapy comes in. Every therapist in our directory meets strict ethical and professional standards, so you can confidently connect with a therapist who prioritizes your well-being.

Why Ethical Standards in Therapy Matter

Ethics are the foundation of quality mental health care. Without strong ethical guidelines, clients could face breaches of trust, poor treatment, or harmful mental outcomes. Ethical therapists follow professional codes of conduct that prioritize:

Without these ethical safeguards, therapy can lose its effectiveness or worsen the mental health of the client. That’s why it’s so important to choose a therapist who follows these principles.

How GoodTherapy Helps You Find an Ethical, Qualified Therapist

While many therapists uphold ethical standards, it’s not always easy to verify their credentials, training, or commitment to ethical care. That’s why GoodTherapy is committed to taking the guesswork out of finding a professional you can trust.

Every therapist in our directory is thoroughly vetted to ensure they:

With so many therapy directories available today, it’s imperative to choose a platform that prioritizes ethical standards. At GoodTherapy, we make it easy for you to find a therapist who is not only experienced but also committed to ethical care of the highest quality.

Therapist Ethics Matter — So Does Where You Search 

The right therapist can have a profound impact on your mental health journey. By choosing a therapist who upholds ethical guidelines, you’re ensuring a safe, professional, and effective therapeutic experience.

Don’t leave your mental health to chance. Start your search with GoodTherapy today and find a therapist you can trust.

GoodTherapy | Truth in Advertising

by Connor D. Jackson, JD

Connor D. Jackson is a healthcare attorney based in Chicago who serves independent practices in several states. Visit his firm’s website here.

Truth In Advertising: Avoid These Land Mines When Marketing Your Therapy Practice

With the explosion of digital marketing, mental health professionals have more outlets than ever to promote their services. And when trying to drum up new clients, it’s natural to focus on using the medium, message, and imagery to stand out from competitors. 

But federal law and state practice acts don’t favor creativity or persuasiveness in marketing. Instead, they demand accuracy and transparency. We discuss the constraints that you need to understand when creating your public profile.

The Legal Definition of “Advertising”

Under the law, restrictions on advertising and marketing cover a broad scope of activities. Advertising refers to any public communication designed to attract business. Therefore, it includes websites, directories, author/speaker bios, business cards, online map listings, and everyday social media posts. In short, anything that potential clients can use to form an understanding of your services or qualifications falls under this term.

Representing Credentials

The American Counseling Association (ACA) Code of Ethics and American Psychological Association (APA) Ethical Principles prohibit members from directly or implicitly misrepresenting their qualifications. Counselors and psychologists cannot misstate their training, education, accreditation, or association membership status. Trainees and supervisees must disclose their status as such.

Though state practice acts vary in precise terminology, they mirror the ACA’s and APA’s prohibitions against false titles or credentials. It’s never acceptable to fudge your qualifications or imply that you have a degree or professional credential that you lack.

In California, for example, unless you are a Licensed Marriage and Family Therapist (LMFT), you should not advertise you can do “marriage consulting,” nor should you advertise you perform similar services to an LMFT.  Similarly, California mandates that unlicensed associates disclose that they are a supervised entity in all advertisements and not use any degree credentials.   

It’s crucial to stay abreast of your state’s most current terminology. Take Colorado’s nomenclature for unlicensed psychotherapists that are listed in the state’s registry. Until recently, they were called “registered psychotherapists.”  However, to potential clients, the term sounded like full licensure. In response, Colorado recently changed the title to “unlicensed psychotherapist” and sunsetted the older term. 

Washington provides a similar example of shifting terminology. In the early 2000s, Washington legislators created a “registered counselor” category as a catch-all for anyone who had not attained the master’s degree and thousands of clinical hours required for full licensure.

However, in 2008, after a Seattle Times exposé alerted the public to substandard care and sexual misconduct by untrained, poorly vetted Registered Counselors, Washington dropped the category. Today, anyone practicing therapy in Washington without full licensure must represent themselves as unlicensed and may not advertise or operate a “counseling” practice.

On the flip side, understating credentials also creates problems. For example, licensed professionals should never advertise clinical therapy as “coaching” to evade state laws. It doesn’t work — the laws will still apply!

Representing Products and Services

The Federal Trade Commission Act (FTCA) demands all claims be truthful and not misleading. In the context of health advertising, this means the Federal Trade Commission (FTC) will evaluate what express or implied claims are conveyed to consumers and whether reliable scientific evidence supports these claims. 

In evaluating the implied claims, the FTC looks to the “net impression.” The FTC asks, “Based on what the public generally understands the expressions in the advertisement to mean, is the ad truthful?”

The FTC also requires that information be presented clearly to avoid confusion. Thus, the FTC views omissions, such as not disclosing when clients receive payment for testimonials, as misrepresentations. Disclosures and disclaimers must be clear and conspicuous, not buried in the fine print or obscured by technical language that the typical consumer will not understand.

False, deceptive, or misleading claims are not solely the purview of federal law. Many state practice acts prohibit making scientific claims that are not substantiated by reliable, scientific evidence. 

To stay compliant with federal and state laws, 

Using Testimonials

Across all industries, testimonials serve as one of the most powerful, persuasive marketing tools. However, for mental health professionals, they require additional caution.

The American Psychological Association Ethics Code and the National Association of Social Workers Code of Ethics prohibit therapists from soliciting testimonials from current clients or anyone who may be vulnerable to undue influence because of their particular circumstances. The American Counselors Association goes further, prohibiting counselors from soliciting testimonials from former clients.

When a client independently volunteers to submit a testimonial, the therapist should explain all risks and obtain explicit, signed consent before publishing it. Moreover, the therapist must avoid violating the client’s confidentiality in keeping with the HIPAA Privacy Rule and state laws. 

As with all other advertising materials, the testimonial’s content must be truthful, including disclosing any compensation to the client. As the party benefiting from the testimonial, the therapist will likely be responsible for the content. 

The Keys to Compliance

In the end, compliant marketing boils down to four efforts:

  1. Recognize that restrictions on advertising and marketing apply to a wide range of public-facing activities.
  2. Disclose your education, training, license, and practice specialty areas with precision and according to your state’s regulations. Never inflate your credentials, even by suggestion.
  3. Be conservative with claims about what your practice or style of therapy can achieve. Refrain from making statements that you cannot support with reliable data, such as peer-reviewed studies.
  4. Tread cautiously with client testimonials by obtaining consent, protecting privacy, and ensuring that the content paints an honest picture.

Keep in mind that many marketing consultants and copywriters don’t understand the stringent guidelines surrounding healthcare. As a result, they may urge you to ask for testimonials or use language that skirts the truth. It’s also likely that you can find examples of competitors who appear to ignore the guidelines. 

Just remember that it’s your practice at stake. Ultimately, it’s you (and no one else) who bears responsibility for your advertising. With truth and transparency behind you, you’ll likely stay on the right side of the law and build more trust with potential clients. For help staying legal with your advertising, check out our advertising materials review services. 

Registries are an important part of any psychotherapist’s marketing strategy. Being listed on GoodTherapy lends you credibility and makes you easier for potential clients to find. Check out the whole host of perks that come with GoodTherapy membership and join today!

This article is made for educational purposes and is not intended to be specific legal advice to any particular person. It does not create an attorney-client relationship between Jackson LLP Healthcare Attorneys and the reader. It should not be used as a substitute for competent legal advice from a licensed attorney in your jurisdiction.

GoodTherapy | Ethics Training for Mental Health Providers

Ethics Training for Mental Health Providers

Ethics training is essential for mental health providers, helping you provide the very best help to your clients and patients. As laws, technology, and our understanding of people and the therapeutic relationship continue to evolve, ethics training keeps you and your practice up to date.

The theory and study of ethics stretch through every profession as the measure of quality in decision-making. Ethics play a vital role in how therapists and counselors choose to interact with their clients. For mental health providers, having a strong understanding of ethics is important for maintaining healthy boundaries with yourself, other professionals, and clients as you work through some of life’s more difficult topics. Keep reading for a brief explanation of ethics and an examination of how ethics training is important for therapists.

What Do We Mean by “Ethics?”

Ethics is a complex term that we use to talk about several different aspects of appropriate conduct. The most relevant definitions of ethics from Merriam-Webster for our purposes are “the discipline dealing with what is good and bad and with moral duty and obligation” and “the principles of conduct governing an individual or a group.”

According to the American Psychology Association, The Ethics Code “provides a common set of principles and standards upon which psychologists build their professional and scientific work.” Its goals are “the welfare and protection of individuals and groups with whom psychologists work and the education of members, students, and the public regarding ethical standards of the discipline.”

Ultimately, ethics training ensures that you know the ethical principles that govern psychotherapy and understand how to align your professional conduct with them.

Looking for ethics courses? Check out our lineup of ethics CE courses for therapists!

How Does Ethics Support Psychotherapy?

As mental health providers, you must frequently determine how to apply ethical principles in various contexts. That’s why many jurisdictions require psychotherapy practitioners to take continuing education courses in ethics. Through ethics training, you’ll grow in your understanding of how to weigh ethical issues in psychotherapy and what to do if you get stuck in the decision-making process.

Staying up to date with the ethical standards and best practices will help you practice psychotherapy in a way that avoids ethical violations. Providers who exhibit unethical behavior may can find themselves at risk of losing their license or ability to practice.

Examples of Unethical Behavior

Ethics violations include many different examples of poor decision-making. Here’s the scoop on four of the most common therapist ethics violations.

Dual Relationships

As a therapist, you should never have a client who is or becomes someone you share a personal relationship with (e.g.,  a family member, friend, or romantic relationship).

Breaking Confidentiality

Confidentiality is essential for building trust with clients; sharing private client information with another party without the client’s informed consent breaks that trust and violates ethical standards. Confidentiality has a wide scope, including what you tell a friend over coffee and how securely you keep your client files.

Failing to End Therapy

If you do not end therapy with a client you are not in a position to help, whether that’s because you cannot give them the attention they need, you do not have the knowledge or expertise to address their concerns, or the client is no longer benefiting from therapy, you are not serving the client.

Practicing Without a License

It is unethical to offer psychotherapy without the credentials, such as a license or certification, that are required in the jurisdiction where you’re practicing. Licensing boards are a great place to start. It is each therapist’s responsibility to know the requirements that govern their practice and follow them.

Impacts of Unethical Behavioral

Ethics training for mental health providers can help you avoid unethical behavior. This is crucial, as therapist ethical violations can have a lasting impact on you and your clients.

For someone who has come to you for help or attention to address issues and problem areas in their life, unethical behaviors can be damaging to their progress. Because of the inherent imbalance of power in the therapeutic relationship, clients are vulnerable. Your unethical choices can harm a client’s ability to trust (both in future therapy contexts and in their personal lives) and can cause them further psychological damage. Ethics training keeps you in the loop about how to act ethically and protect the integrity of the therapeutic relationship, ensuring your client is safe and supported.

Staying Compliant

While most mental health professionals took ethics courses in school or during their certification, it is important to refresh your knowledge and stay on top of new developments in ethical psychotherapy. Continuing education courses on ethics can be a fantastic way to stay fresh on the topic and stay up to date. Many jurisdictions require a minimum number of continuing education hours to be about ethics, and it’s easy to see why.

GoodTherapy offers ethics courses as part of our continuing education program. There are three ways to access our continuing education courses: CE Only allows you to purchase courses a la carte; CE Unlimited allows you to take as many courses as you want for a monthly fee; and Premium or Pro membership options include a profile in our registry, unlimited access to our CE courses, and other perks. Check out your options today!

Help for Helping Professionals: Risk Management Strategies for Stalking

by Dr. Jocelyn Markowicz, PhD, Psychologist

Help for the Helping Professional: Risk Management Strategies

The success of psychotherapy is correlated with the attachment between client and therapist in the therapeutic relationship (Farber, 2015). According to Dr. Farber, empathy and building the bond of attachment is our stock-in-trade as mental health practitioners. When empathy builds the bond of attachment with someone starved for connection, a therapist may inadvertently set themself up to become a victim of a stalker (Farber, 2015).

Safety Risks Often Discounted

When a therapist embarks on training, they are imbued with ethical principles to guide the delivery of services. One crucial ethical principle is to take reasonable steps to avoid harming their clients and minimize harm where it is foreseeable and unavoidable. However, training programs do not adequately equip mental health providers to take reasonable steps to mitigate the safety risks inherent in working within the mental health field. Unfortunately, therapists often lack support when they talk about the dangers faced in their profession. Therapist safety concerns are often met with the sentiment that “it comes with the territory.” Therefore, they must deal with and manage risks or even active threats alone. People often have the same view when nurses, physicians, firefighters, law enforcement officers, and service members talk about the risk they are managing. The dismissal of the severity of risk that mental health providers take on reduces their access to resources and tools to reduce that risk successfully. An industry designed to help individuals who struggle with the perpetration of harm against others does not negate the provider’s right to be free from harm. Stalking, in particular, has become a major concern for therapists in this technological boom.

Stalking and Therapists

Stalking is a prevalent phenomenon with significant negative psychological, physical, social, and financial consequences (Sheridan, Adrian, & Scott, 2019). According to the U.S. Department of Justice, Office of Justice Programs, Bureau of Justice Statistics (2015), a greater percentage of females experience stalking than males. Additionally, 2.2% of females compared to 0.8% of males experienced at least one stalking victimization within a 12-month period. Storey and Hart (2017) correctly documented that prevalence estimates are considerably higher for individuals holding certain professions. Mental health professionals (psychologists, psychiatrists, counselors) have higher rates of stalking than other professionals (Galeazzie & DeFazio, 2006; Store, 2012). Nearly 19.5% of psychologists report being stalked in the context of their professional lives (Lion & Herschler, 1998; Smoyak, 2003; Whyte et al., 2011). Additionally, 32% to 64% of counselors have been victims of some form of harassing behavior from a client (Romans, Hays, & White, 1996; Store, 2016). 

Health care workers and mental health care workers have been stalked by their clients, as documented in several studies from the United States (Romans, Hays, White, 1996; Gentile et al., 2002) and abroad (Galeazzi, Elkins, & Curci, 2005; Abrams & Robinson, 2011). In fact, research has demonstrated that co-workers also stalk service providers, but the percentage of stalking from service users is higher (Ashmore et al., 2006). This means that, although anyone can potentially be stalked within their professional environment, mental health professionals are at a higher risk of being stalked by their clients than others in other work environments.

Reducing the Risk

Specific risk reduction and threat management interventions are needed to ensure that therapists have effective risk management tools and risk reduction policies at their disposal. Why is risk reduction necessary for professionals in mental health? According to Galeazzi, Elkins, & Curci (2005), mental health professionals who have been stalked by their clients have left the field, reported lost time from work, and moved to a different state to escape their stalker. They have also carried weapons to work in response (Pope, & Vasquez, 2011). The impact of stalking on providers is substantial. There is limited training currently available about how to manage stalking in one’s mental health career. The call is to have adequate systems in place to reduce the likelihood of stalking and appropriately respond when it does occur. In the age of technology, stalking risks are increased due to clients having multiple ways to contact their practitioners and access their personal information online. Mental health providers may face online stalking or be stalked by phone or email in addition to unwanted physical presence in the professional or personal environment. Here are six risk management strategies: 

#1 Implement Client Consultations

Harm reduction involves the initial assessment of risk in your professional environment. Therapists are trained to assess risk for client harm to self and others but often do not view harm to themselves as a potential area to consider. Professionals working in a private practice setting, group forensic setting, or within a hospital setting will have different risk factors to consider. For example, a provider working in an independent private practice may wisely implement more stringent policies to reduce risk than a provider who works within a health system and has access to on-site security guards and other professionals that may serve as a risk management team.

When possible, all new clients should participate in an initial consult to determine if this treatment setting will offer the most effective treatment and evaluate any potential risk factors that the provider or system may have to manage. Clinicians are encouraged to refer individuals to a higher level of care and to agencies that can responsibly manage harm potential more effectively as needed. For example, a client with a history of stalking may need to work with a provider in a larger treatment agency versus a solo provider in private practice in order to minimize the risk of intimate attachment that may lead to stalking behavior. The risk assessment process can inform the policies a provider creates for the safety of everyone involved. 

#2 Provider-Client Technological Access

Therapists should use business phones and office email systems versus their personal cell numbers and email addresses to communicate with clients. At the beginning of treatment, therapists should outline communication policies, specifically what content is to be communicated electronically (i.e., scheduling new appointments of cancellations versus crisis intervention) and time parameters for communication with clients (e.g., during business hours only). One’s communication policy should, of course, contain a limits of confidentiality policy and discussion of how the professional will handle violations of the communication policy. A communication policy that outlines limits to professional responsiveness and limitations to the depth of electronic communication can minimize safety risk by establishing clear, professional boundaries.

#3 Maintain Communication Boundaries

Therapists should adhere to the communication policies they set forth for their clients. If a provider establishes that they will not communicate with clients after business hours via email, they must not violate their own policy. If a professional indicates that they will not address clinical issues via email, they must follow through on that commitment. Psychotherapists violating their own communication policy may condition their clients to violate the policy as well. Boundary violations from either party increase safety risks.

#4 Seek Support from Colleagues

Mental health providers have the privilege of helping individuals who struggle with a variety of emotional and behavioral concerns. Given the nature of this work, risk cannot be prevented, but it can be reduced and managed more effectively with support. Not unlike individuals seeking services for distress due to being threatened, clinicians also need support as they implement protocols to reduce their risk or manage active threats. The inherent risk of the mental health profession does not negate the need for support in the face of risk management or active threat reduction. I encourage therapy for therapists to help them manage the distress of working within risky situations or addressing active threats.

#5 Individualized Action

When therapists are managing an active stalking threat, they must take care of themselves the same way they take care of others. They must seek support from other mental health professionals to determine ways to work within the boundaries of ethical mandates while preventing harm to themselves. They may also need to seek the assistance of law enforcement to manage risk and prevent harm. The individual goals and efforts of mental health providers to manage the risk inherent in their position can make a significant difference in the outcomes they experience.

#6 Systemic Action

Training therapists to implement protocols to minimize their safety risks is vitally important to bringing about widespread change in risk management for mental health providers. Psychiatrists and psychologists are the professionals most likely to be stalked, possibly because aspects of the psychotherapeutic relationship can produce misunderstandings about the nature of the intimacy generated and appropriate boundaries in this type of relationship (Galeazzi, Elkins, & Curci, 2005). Mandating risk management continuing education for mental health providers to learn how to minimize their own safety risk should be encouraged. Consultation services for psychologists who are navigating managing active stalking threats should be more accessible. The impact of reduced safety for therapists comes at too great a cost to themselves and their communities. Mental health providers need systemic protection plans so that they can continue working hard to minimize distress and improve life functioning for their clients.

Got something profound or helpful to share with other mental health professionals on the GoodTherapy blog? We welcome content contributions from our members. Not a member yet? Explore GoodTherapy membership opportunities.

References

Abrams, K. M., & Robinson, G. E. (2011). Stalking by patients: Doctors’ experiences in a Canadian urban area. Journal of Nervous and Mental Disease, 199, 738-743. 

Ashmore, R. Jones, J., Jackson, A., & Smoyak, S. (2006). A survey of mental health nurses’ experiences of stalking. Journal of Psychiatric and Mental Health Nursing, 13, 562-569. 

Farber, S. (2015 ) My Patient, My Stalker Empathy as a Dual-Edged Sword: A Cautionary Tale. American Journal of Psychotherapy | Vol 69, No. 3, 331-355. 

Galeazzi, G.M., Elkins, K., & Curci, P. (2005). The stalking of mental health professionals by patients. Psychiatric Services, 56, 37-138. 

Gentile, S. R. , Asamen, J. K., Harmell, P.H.,, & Weathers, R. (2002). The stalking of psychologist by their clients. Professional Psychology, Research and Practice, 33, 490-494. 

Lion, J.R., & Herschler, J.A. (1998). The stalking of clinicians by their patients. In J.R. Meloy (Ed.), The psychology of stalking: Clinical and forensic perspectives (pp. 163-173). San Diego, CA: Academic Press.

Mark M. A. Bureau of Justice Statistics, January 22, 2015, NCJ 248470.

Pope, K. S., & Vasquez, M. J. T. (2011). Ethics in psychotherapy and counseling: A practical guide (4th ed.). John Wiley & Sons Inc.

Romans, J.S. C., Hays, J.R., & White. T. K. (1996). Stalking and related behaviors experienced by counseling center staff members from current or former clients. Professional Psychology: Research and Practice, 27, 595-599. 

Sheridan, L. North, A. C. & Scott, A. J. (2019). Stalking in the Workplace. Journal of Threat Assessment and Management. Vol. 6, No. 2, 61-75.

Smoyak, S. (2003). Perspectives in mental health clinicians on stalking continue to evolve. Psychiatric Annals, 33, 641-648. 

Storey, J.E., Hart, S.D., & Lim. Y.L. (2017). Journal of Threat Assessment and Management. Vol. 4, No. 3 122-143. 

U.S. Department of Justice Office of Justice Programs. Bureau of Justice Statistics, January 2015. https://www.bjs.gov/index.cfm?ty=pbdetail&iid=5217

Whyte, S., Penny, C., Christopherson, S., Reiss, D., & Petch, E. (2011). The stalking of psychiatrists. International Journal of Forensic Mental Health, 10, 254-26.

AdobeStock 198849313In the past month alone, I have had two new clients report egregious ethical violations from their previous therapists. In one case, a male therapist made repeated narcissistic advances toward a woman who came to him to unravel the trauma of her ongoing divorce proceedings. This therapist repeatedly told the client details of his personal life which had no bearing on her therapy, and which frankly shocked me both in their content and in the manner in which he presented the information. The client ultimately stopped the counseling relationship, which the therapist was reluctant to sever.

In the other, a female therapist repeatedly fended off efforts to discuss the client’s presenting trauma, sent the client a social media friend request, and invited her on a weekend getaway with no therapeutic agenda. This therapist then abruptly abandoned the client with no stated reason and no offer to refer to another counselor.

In both cases, the clients felt responsible for the well-being of their therapists. They both experienced the breach of the relationship as abandonment. Remember that these individuals sought counseling support for their own trauma and pain and were vulnerable and trusting of the professionals they chose as their therapists. Rather than being seen as individuals in distress by these therapists, they were grossly mistreated and re-traumatized.

My work with these individuals involves not only support in easing the original distress, but also creation of a strong therapeutic bond when both clients are ambivalent and defensive about exposing themselves vulnerably to another counselor.

This infuriates me, as it no doubt infuriates you. What can be done if you experience something that feels off in your relationship with your counselor?

First, trust your instincts. Trust the way you feel both during the session and particularly afterward, when you’ve had time to recognize and identify your emotional response to a conversation. Sometimes, during a session it is possible to feel flooded and overwhelmed, so your reactions may not be clear to you until later. This may be a subtle discomfort that you can’t seem to put your finger on, or a more specific discomfort about a particular comment or behavior from your therapist. You may feel misunderstood. You may feel “dirty” or shamed. You may feel confused after having asked questions that did not get answered to your satisfaction.

If you feel your therapist is behaving unethically, the first thing to consider is bringing it up in session. Express your concern. Ask for clarification of something that doesn’t make sense to you or doesn’t feel right. If you don’t feel confident in the response you get, please terminate the relationship.

Also, remember that you chose your therapist carefully. You therefore expected professional expertise and ethical behavior, so you may be holding a cognitive bias in favor of the therapist. This can lead you to doubt yourself and the validity of your reactions, instead of questioning the therapist’s behavior or treatment.

Skilled therapists can help you move forward in your life, which is the reason you seek counseling support in the first place. Most therapists are sensitive, competent professionals who hold your best interests and work conscientiously on your behalf. But every now and then, for whatever personal reasons, therapists depart from the norm into ethical violations that harm their clients.

If you feel your therapist is behaving unethically, the first thing to consider is bringing it up in session. Express your concern. Ask for clarification of something that doesn’t make sense to you or doesn’t feel right. If you don’t feel confident in the response you get, please terminate the relationship.

All licensed therapists are governed by the laws of the state that grants them the license to practice. You can file an ethics violation complaint with the licensing board. Sometimes, doing so may feel like adding more pain to your experience, which you may prefer to put behind you and move on. I understand this reluctance. But consider making an inquiry at the state board and at the therapist’s professional association (you can identify this by the letters after the therapist’s name—LMHC or LMFT, for example) to learn about the specific steps involved in submitting a complaint. Then you can decide whether to proceed. It is entirely up to you. Bear in mind, though, that if a therapist has behaved unethically with you, it is possible this is happening with others as well. Yours may not be the first complaint of an ethics violation.

One last word: Please do not let a bad counseling experience deter you from finding a skilled therapist. Search directories (such as GoodTherapy) for your specific geographical region and your specific concerns. Select a few therapists for contact, then request a brief telephone chat. Once you select a new therapist, please share your experience in session so you can get the relief you need from the burden of your previous counseling encounter, which you may still be carrying.

Author’s note: To protect the privacy of all concerned, I changed the client and therapist details while remaining true to the nature of the ethical breaches described.

Professional sitting at desk reads through papers with serious expressionSexuality is often a sensitive issue. In recent months, many people have come forward, speaking out about inappropriate, harmful, and abusive sexual behaviors and actions taken by people of positions in greater power. These abuses of power and their effects have too long been in the shadows of silence. The topic of sexuality deserves greater awareness from all of us. By taking the time for honest and open self-reflection, we can all help prevent the misuse of power.

What is inappropriate and harmful sexual activity? For the purposes of clarification, let’s say this includes any physical or verbal behavior that is suggestive, seductive, harassing, demeaning, or exploitative. When a person in therapy is attracted to their therapist, this can often be discussed in therapy without harm—as long as the therapist is not excessively affected by attraction or countertransference. The therapist must be able to focus on the sexual issues of the person in therapy only to the extent such discussion is based on their therapeutic process. It is also essential to establish and uphold boundaries, including an explicit agreement that there is no possibility of sexual relationship at the time or in the future.

Issues related to sexuality present enough challenges in ordinary relationships. When it comes to the therapeutic relationship, sexuality can be even more of a challenging and complex consideration.  Here are some things to consider when examining sexual feelings toward or from people in therapy.

Coping with Sexual Feelings Toward a Person in Therapy

It can first help to explore why you may be attracted to a particular person. Is there something about them that meets one of your needs? Perhaps it is a natural need, but it is one that must be met elsewhere.

  1. Talk to a colleague who can help you sort out what you are experiencing and take appropriate steps to keep the therapeutic relationship ethical. [fat_widget_right]
  2. Seek personal counseling. Working with your own counselor can help you resolve your feelings and uncover any issues in your life you may be struggling to deal with effectively.
  3. If you are unable to resolve your feelings, terminate the professional relationship and refer the person to another therapist.

Coping with Sexual Feelings from a Person in Therapy

A good first step here is to acknowledge the person’s feelings as normal. Appreciate their courage and vulnerability around bringing them up or having them named. Explain that although the intimacy that often develops within the therapeutic relationship is powerful, it is best described as a kind of contextual love that is specific to the power differential relationship. Sexualizing this kind of love is detrimental to your work in therapy.

  1. Make it very clear, with both words and body language, that a sexual relationship is outside the bounds of the therapeutic relationship. (Ethical codes vary in their statements of how long after termination it is considered ethical to begin a sexual relationship, if ever.)
  2. Make every effort not to shame or reject the person you are working with. Track for and attend to any signs of shame or rejection.
  3. If appropriate, look for therapeutic ways in which issue of sexuality can be addressed and explored.
  4. When sexual feelings are unspoken or unconfirmed, use your best professional judgment to determine what would best serve the person you are working with: naming the feelings yourself or waiting for them to make the choice to do so.
  5. Be prepared in advance. Consider how you might handle this kind of situation or how you might handle it with greater skill. Seek the support of supervision.

How Can We Deepen Our Understanding?

The issue of sexuality goes much deeper than simply understanding feelings and setting boundaries. These several questions, brought up by students, can help you explore this topic further in order to deepen your understanding.

Here are a few stories for further consideration:

These stories illustrate how important it is to both think proactively about how you will respond to sexual issues when they arise and to learn how to attend to and repair relationships when needed. When personal sexual desires get involved, thinking can become very warped.

It is especially important to seek out and use resources such as colleagues and supervision when faced with ethical dilemmas, things about which you feel ashamed, or mistakes you have already made or believe you may make. If you are unsure how to begin this process on your own, the support of a compassionate counselor can help.

Dear GoodTherapy.org,

Several years ago, my wife began seeing a therapist. After a year, she asked that I join her for a session. Afterward, I began seeing the same therapist frequently on my own and periodically with my wife (we were having marital issues). After about nine months of this, my wife terminated her relationship with the therapist because she didn’t feel her voice was being heard. She felt the therapist was constantly preaching patience and taking my “side” on most issues.

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I continued to see the therapist for what remained of our marriage (about a year) and beyond and indeed still see her to this day. I just found out that my now ex-wife (we’ve been divorced four months) has reengaged her relationship with this same therapist. Obviously, the divorce is still fresh, but I’m feeling a lot of emotions here and I’m frankly not sure they are justified. I feel betrayed. At a minimum, I think the therapist should have told me that she had taken on my ex as a client again. I also feel uncomfortable moving forward using the same therapist as my ex. Am I justified in these feelings? —Untold Anger

Dear Untold,

Your question raises a number of concerns. The short answer is that your therapist is ethically bound NOT to let you know she is working with your ex-wife. Part of client confidentiality includes not sharing the identity of a person in therapy with another person without the explicit permission of that client.

That said, the way your relationship with this therapist evolved sounds messy. The first moment that may have been confusing was when your wife’s individual therapist also became your individual therapist and also worked with the two of you as a couple. When a therapist works with multiple members of a family system, it is essential that boundaries are clear and all parties are comfortable with the situation. Exploring the benefits and risks prior to engaging in the work is essential. Checking in regularly to ensure everyone’s needs are being met is also important. Working with individuals and working with them as a couple can be beneficial at times, but it also runs the risk of one party feeling as if the therapist is more aligned with their partner and takes their side.

In individual therapy, the alignment between person in therapy and counselor is clear. In couples work, the relationship is the “client,” and it is imperative that neither individual feels marginalized. Managing that well and simultaneously meeting the needs of both individuals and the relationship can be challenging. It seems as if your wife began to feel as if her needs were not being met and took appropriate steps to terminate her relationship with that therapist.

Whether or not your feelings are “justified,” if you are feeling betrayed it is important that you address those feelings with your therapist.

It seems as if you felt aligned with and supported by this therapist until the recent revelation that she was working with your ex. Whether or not your feelings are “justified,” if you are feeling betrayed it is important that you address those feelings with your therapist. Having the opportunity to explore what is contributing to your discomfort could be helpful. You may ultimately decide you are not comfortable moving forward with this particular therapist, or you may discover that you are able to work together. Either way, having a conversation about trust and boundaries seems important.

I do wonder about some of the roots of your discomfort. In theory, your therapist is meeting with each of you as individuals; therefore, there should not be competing alignment concerns. Your sessions would focus on your needs, your ex-wife’s on hers. Given the history you’ve had with this therapist, however, I wonder if perhaps you are concerned about her ability to remain impartial and unbiased. Are you concerned that you may begin to feel the way your wife felt before she terminated their relationship? Might you be worried that this therapist will not be able to compartmentalize information from one of your sessions and bring that bias into the other’s session?

Whatever your concerns, without safety and trust, it is unlikely that your work together would be helpful or beneficial. If you are able to address your concerns, this might be an opportunity to deepen your trust. At the very least, this feels like important feedback for your therapist so she can understand how her choices are impacting your feelings of trust and safety.

Best of luck,

Erika Myers, MS, MEd, LPC, NCC

Thoughtful professional wearing sweater with short hair sits in comfortable office looking out windowOne challenge that can arise for therapists is the decision whether to disclose personal tidbits of information as they become potentially relevant during treatment with the people we help. I recently provided consult to a colleague who brought this dilemma to light and gave me the opportunity to contemplate all of the aspects involved in deciding whether to share information in our work.

In this particular scenario, my colleague was conflicted about whether to disclose to a woman she was working with that they shared the same medical practice. Normally, this piece of information might be an insignificant coincidence; however, this specific case was more complicated. A large focus of what the woman was discussing in the session involved decisions she was making regarding one of the doctors in the practice as it related to the future of her health care. My colleague, her therapist, had strong opinions about this particular doctor due to a very negative personal experience she had. As she listened to the woman explain her situation, she felt conflicted over whether to speak up about the fact she knew this doctor or stay quiet and focus solely on the woman’s experience.

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Both felt like no-win options. On the one hand, it felt awkward to take the focus off the woman’s experience by mentioning her own knowledge of the practice. On the other, she felt that simply listening and nodding without mentioning her familiarity with the doctor was like withholding a secret or being dishonest. And that felt like a threat to her credibility and to the therapeutic relationship.

As we contemplated her options, we discussed various questions, including: What if the two women ran into each other in the doctor’s office waiting room? What if the woman mentioned her therapist by name to the doctor and he revealed he knows her? If the woman somehow found out her therapist knew of this doctor all along with no mention, would she feel betrayed? Would it be a threat to their working effectively together?

I had a similar experience in the past in terms of feeling uncomfortable holding a “secret” from two people I was working with. I had a long-standing relationship with each individual. Well into my work with both, it became apparent the two had met and become friends. As the two talked about their budding relationship in their individual therapy sessions, I sat with the discomfort of being unable, due to confidentiality, to blurt out, “I know this person!”

Sometimes, obvious conflicts are apparent up front and we have the opportunity to inform an individual that, due to a conflict of interest, we are going to need to refer them to a colleague. But when coincidences and complications arise well into the course of treatment or are not obvious conflicts, our options and decisions as therapists become more complicated. We are often faced with navigating how to balance being transparent, open, and honest while adhering to boundaries, ethics, and legal codes.

When ethical or legal boundaries do not prohibit therapists from sharing information, appropriate self-disclosure can be incredibly useful in therapy. For one, sharing common experiences can strengthen the therapeutic relationship. Additionally, revealing limited personal information or mentioning mutual experiences can help make the therapist seem more “human” or “real,” which can increase the comfort level of the person seeking help.

When a therapist decides to disclose certain information, it’s important to keep in mind that the reason for doing so is to help support the person in therapy and advance the treatment. The therapist must ensure the disclosure is in the best interests of and for the benefit of the person they are helping and be careful not to turn the focus on the therapist.

A strong therapeutic alliance is one of the biggest factors in whether therapy is helpful, and some level of disclosure can help in developing this necessary rapport. Additionally, when therapists share that they personally relate to pain, struggle, or challenge, they can instill hope and help to reduce feelings of isolation or helplessness.

The key to disclosing lies in determining when it is appropriate. In line with most health care provider codes of ethics, the first obligation is to do no harm, so it’s paramount to think about the welfare of the individual in treatment and to contemplate all the ways they may be impacted by the decision to share or not share. In more complicated situations, it is important to seek outside consultation with other professionals or colleagues to ensure the therapist is looking at the situation from every angle and that personal needs, emotions, and biases are not clouding their judgment.

When a therapist decides to disclose certain information, it’s important to keep in mind that the reason for doing so is to help support the person in therapy and advance the treatment. The therapist must ensure the disclosure is in the best interests of and for the benefit of the person they are helping and be careful not to turn the focus on the therapist. The therapist should not disclose anything that may require the person they are helping to then be in a position of caring for the therapist. For example, it would not be appropriate to bring up unresolved grief or any other issues the therapist is wrestling with.

Disclosure is effective only when the person in therapy feels supported, understood, and validated, so care should be taken in the timing and delivery of the information. It is not helpful if the person feels the therapist is wasting valuable time with their own interjections or anecdotes, so therapists should consider whether disclosure can be summed up in a simple sentence or whether it would require a more in-depth explanation that takes up time and turns the focus away from the person’s experience.

Questions for Therapists to Consider Regarding Disclosure

Some questions therapists must ask themselves when deciding whether to share certain information include:

Apart from issues that involve clear legal or ethical guidelines, there is often no right or wrong answer as to whether disclosing certain information is appropriate or warranted. By considering the above questions, therapists may be better able to make decisions that are well thought out and upholding of their duty to act in the best interests of the people they help.

photo of therapist clasping hands of person receiving therapy. Physical touch has long been a controversial issue in psychotherapy. While some professionals consider touch one type of nonverbal communication that can have therapeutic value, it is also widely believed that touch in therapy can be too easily abused and that any value may be outweighed by the risk of harm to people in treatment.

The creation of an artificial mind-body split in psychotherapy began around the 1970s with the advent of cognitive-based therapies which, I believe, helped contribute to the divorcing of our emotions from their very real physical base—without our bodies there would be no emotions! Around the same time, controversy and publicity surrounding some approaches to sex therapy practices and an increase in risk management practices led to an emphasis on protecting people receiving therapy from abuse through inappropriate touch. Concerns continue today with the use of body-based therapies internationally, though in America, the level of concern about the use of touch in therapy appears to be much higher, as Courtenay Young points out in the article “About the Ethics of Professional Touch.”

Certainly anyone experiencing posttraumatic stress as a result of having been physically or sexually abused may be hyper-sensitive to any type of touch and/or issues of established personal space, with good reason. The impact of abuse, and the process of healing, is likely to have an impact on interpersonal relations throughout life. Therapists who work with people experiencing these and related symptoms need to be particularly sensitive, as it is possible for people healing from abuse to easily be re-traumatized by a careless touch or embrace.

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Touch and Talk Therapy: The Rosen Method

Techniques involving touch have been used as approaches to healing for many years. Some techniques, such as the Rubenfeld Synergy Method and the Rosen Method, combine touch with talk therapy. The Rosen Method, a combination of gentle touch and verbal feedback that reflects what the person in therapy is experiencing, was developed by Marion Rosen, a physical therapist who worked with individuals undergoing psychoanalysis in Germany in the 1930s. She drew on touch therapy as a way to help some individuals access unconscious memories and past events they had forgotten or suppressed.

At the heart of the Rosen Method is a belief that chronic muscular tension is a way of “holding against” feeling something we’d rather avoid, a belief that is in line with current thinking about trauma. Many individuals who have participated in the Rosen Method treatment report feelings of safety and support, along with deep relaxation.

The Use of Touch in Therapy Today

Many recently developed conventional therapy modalities fall under the umbrella of cognitive therapy. As this name implies, these approaches rely heavily on the thoughts of the person seeking treatment. In general these therapies would never involve the sensation of touch, as healing is considered to occur through cognitions: thoughts, observations, and verbal affirmations.

However, some older therapy practices do support the use of touch. Body-based psychotherapy, for example, which is taught by the Hartford Family Institute, has its roots in Gestalt therapy and Bioenergetic Analysis. Gestalt therapy, developed in the 1940s and 50s, emphasizes what is being done and felt in the present moment. Bioenergetic Analysis, developed in the 1950s by Alexander Lowen, is grounded in the idea that chronic muscle tensions in the body can serve as (often unconscious) blocks to emotional expression. Both of these therapies emphasize the experience occurring in the present moment, which includes both physical and emotional sensations.

The Institute provides for a therapist’s touch as a means of healing while still emphasizing the need to maintain appropriate professional boundaries, respect for the person in treatment, and a keen awareness of any individual’s personal history that might sensitize them to touch. According to Dr. Lubin-Alpert, one of the founders of the Institute, “Not to touch any clients at any time can be experienced as abusive as the original neglect to the … infant inside the adult client.” Touch might occur in the form of hands on the shoulders in support of a person imagining a confrontation with a childhood abuser or gently holding hands with someone grieving a personal loss.

In all cases permission is sought before the gesture is made, in order to maintain the empowerment and safety of the person in treatment. “Would it be okay to move a little closer?” and “Would you like to take my hand?” are typical questions a therapist might ask. In no case would a therapist proceed without a clear indication from the person being treated that it is acceptable for touch to be used.

The Ethics of Touch for Professionals

The question of appropriate professional standards is addressed by all professional organizations representing people who provide psychotherapy. The National Association of Social Workers, which represents most of the professionals providing behavioral health services in the U.S., explicitly addresses the issue of physical contact between therapist and person in treatment, mentioning “cradling and caressing” techniques. Such activities are prohibited when there is a chance of psychological harm to the client.

The American Psychological Association addresses the issue more narrowly in the context of sexual harassment, mentioning physical advances sufficiently severe or intense as to be considered abusive but not the broader issue of touch. The American Counseling Association has similar guidelines in its code of ethics.

In general, most therapists are very reluctant to use touch for both ethical and potential legal reasons. If you are comfortable with your therapist and feel that something like this might benefit you, you may wish to bring this up in session, as your therapist may be willing to discuss their feelings and concerns openly.

There are sufficient arguments both for and against the use of ethical touch in therapy. While the potential ramifications of the abuse of therapeutic touch must be considered, it’s also worth considering that most of us, from time to time, could use a hug or even just a pat on the back.

References:

  1. Alexander, B. (2009, March 26). ‘Sex surrogates’ put personal touch on therapy. NBCNEWS.com. Retrieved from http://www.nbcnews.com/id/29881206/ns/health-sexual_health/t/sex-surrogates-put-personal-touch-therapy/#.WVLjCGjyuCg
  2. Code of ethics. (2008). The National Association of Social Workers. Retrieved from https://www.socialworkers.org/pubs/code/code.asp
  3. Lubin-Alpert, N. (2015). The ethics of caring and touch from a mind, body, spirit perspective. The Door Opener. Jun-Aug, 222.
  4. History of the Rosen Method. (n.d.) The Rosen Institute. Retrieved from http://roseninstitute.net/about/about-rosen-method/history
  5. Kertay, L., & Reviere, S. L. (1993). The use of touch in psychotherapy: Theoretical and ethical considerations. Psychotherapy: Theory, Research, Practice, Training, 30(1), 32-40.
  6. Young, C. (2005). About the ethics of professional touch. European Association for Body Psychotherapy. Retrieved from http://www.eabp.org/pdf/TheEthicsofTouch.pdf
  7. Zur, O. (2017). Touch in therapy and the standard of care in psychotherapy and counseling: Bringing clarity to illusive relationships. United States Association of Body Psychotherapists Journal, 6(2), 61-93. Retrieved from http://www.zurinstitute.com/touch_standardofcare.pdf
  8. Zur, O., & Nordmarken, N. (2017). To touch or not to touch: Exploring the myth of prohibition on touch in psychotherapy and counseling. Retrieved from http://www.zurinstitute.com/touchintherapy.html

Pen lies on notebook on wooden table with rainy weather visible outside windowFor better or for worse, the holiday season is associated with the giving and receiving of gifts. Gifts are exchanged between those we are close with, including family members and friends. Gifts are exchanged between acquaintances, such as coworkers or local service providers (think mail carrier or hairdresser). Gifts may also be given or received among those with which we have no relationship, or anonymously (adopting a family, donating time or money to a charity).

With so many gifts being passed around in so many contexts, it’s an opportune time to talk about some of the potential issues one must be mindful of when considering gifting within the therapeutic relationship—be it during the holiday season or any other time of year.

It may seem only natural to exchange gifts in therapy. After all, in therapy, a close bond may be established, great care and concern are typically expressed, and when the rapport is strong, there may be a genuine like between the parties. The giving of gifts may also be thought of as a means to show appreciation or honor a special stage in therapy.

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But not so fast. Although gifts may seem appropriate between a person in therapy and their therapist, receiving and giving gifts can be a source of stress for the therapeutic relationship. It can hurt therapeutic progress, and it can have serious consequences. Professional ethics codes typically caution therapists from giving or receiving gifts within a therapy relationship. For example, the American Counseling Association Code of Ethics (2014) advises counselors to consider the therapeutic relationship, monetary value of gifts, and the motivation for accepting or declining gifts from people they serve, and the American Psychological Association Code of Ethics (2010) requires that psychologists avoid personal and financial situations that could create a conflict of interest.

Such standards are meant to protect people in therapy from exploitative or manipulative therapy tactics and relationships. These standards are also meant to protect therapists. For example, if a therapist was presented with a gift of value, they may feel pressured to give preferential treatment or refrain from challenging the gift giver. Exchanging gifts may also suggest or invite a change in the nature of the therapeutic relationship—from a professional relationship to a relationship that is too casual, too friendly, or potentially provocative.

Where some mental health professionals might draw a hard line on gifting in either direction, others may see a sliver of gray area. While there are possible pitfalls and ethical complications to consider, there are also ways in which gifts might legitimately be argued to be potentially helpful and culturally appropriate. For example, if a child draws their therapist a picture, it may be hurtful to the child if the therapist rejects the drawing. Another example: After visiting their homeland, an individual brings their therapist a small gift of tea from their country. It might be unnecessarily complicated to explain why accepting the gift is a bad idea, particularly if giving gifts is a meaningful part of that person’s culture and rejecting it would be counterproductive to therapy goals.

Any licensed mental health professional should be keenly aware of potential ethical entanglements involved in gifting, and it is up to the therapist to determine whether gifting a person in therapy may risk or promote therapeutic growth. Where there is doubt, caution is always the wisest path.

It might also be argued that there are benefits of therapists providing some people, in some circumstances, with certain types of small, symbolic, therapeutic gifts. Such therapeutic gifts might be intended to represent growth and provide ongoing motivation. At the completion of therapy, a small memento may go a long way in maintaining positive change, or serve as a reminder to reach out for help in the future. Additionally, some individuals may have difficulty affording the therapeutic tools, such as journals or books, that are sometimes recommended or assigned as therapy “homework.” In these cases, within reason, a therapist might decide that gifting the individual with a homework tool is justified and appropriate.

Of course, some therapists might reasonably feel uncomfortable providing even therapeutic tools, no matter the circumstances. It’s a position few could fault them for. When therapists do choose to provide people in or completing therapy with these types of small gifts, they must consider the potential ethical issues. Therapists should never give gifts that impede the therapy relationship or promote a harmful or unsafe environment, and must be mindful of issues associated with power and control.

Below are some examples of free or low-value gifts and tools that therapists, in an informal survey, reported having given to people they worked with in the therapy room. The reasons the gifts were deemed to be therapeutically beneficial are also summarized. The general theme was this: in each case, the gift complemented the therapeutic relationship and the journey of the person in therapy.

  1. Cards. At the end of therapy, some therapists may provide a card highlighting therapy progress and reminding people of the changes they have made. During a termination session, sharing with a person the changes their therapist sees in them may be considered a special and caring way to end the relationship.
  2. Stones. Some therapists may keep small stones in their office. Stones may be representative of strength, resilience, hardiness, or other qualities. Stones that have flaws may be seen as beautifully imperfect. Allowing people to choose a stone may serve as a symbolic reminder of the person’s strength and imperfect beauty.
  3. Mandalas. These spiritual or ritual symbols in traditional Indian culture represent wholeness and one’s relationship with the universe. The therapeutic benefits of coloring mandalas may include expanding creativity, building spiritual connection, and enhancing relaxation.
  4. Journals. Therapists may request that people maintain a journal while in therapy. Journaling can help to organize thoughts, decrease anxiety, and serve as a means for tracking change. Some therapists may provide a simple journal or use time in therapy to create a journal.
  5. Books. Self-help books can be used separate from therapy or in conjunction with what is being explored in therapy. Therapists may provide a person with a book that is already in their office, one they believe the person would benefit from. Or, as routine practice, therapists may supply books associated with the specific form of therapy being used.
  6. Metaphors, quotes, or poems. Metaphors or inspirational quotes and poems can be symbolic of the unique qualities or strengths people possess.
  7. Candles. Candles can inspire relaxation, meditation, and focus. Use of a candle can help people reproduce a space of awareness and insightfulness outside of therapy.
  8. Music or meditation. Playing a song in session or giving a person a meditation recording may be a special way to acknowledge and maintain clinical progress.

Ultimately, the decision whether to give or accept a gift rests with the individuals involved. Some therapists might not want any part of gifting, while others might leave room for unusual considerations. Under no circumstances should a gift be expected or rewarded. Any licensed mental health professional should be keenly aware of potential ethical entanglements involved in gifting, and it is up to the therapist to determine whether gifting a person in therapy may risk or promote therapeutic growth. Where there is doubt, caution is always the wisest path.

References:

  1. American Counseling Association. (2014). Code of ethics. Washington, DC: Author.
  2. American Psychological Association. (2010). Ethical principles of psychologists and code of c Washington, DC: Author.

Mannequins posed to appear as if they are having a chat over a fenceThe relationship a person has with a therapist is unique. Some people question why they should seek professional guidance when they can talk to their loved ones for free, while others who are already in therapy wonder about the unspoken etiquette, ethics, and rules of this special relationship. It is critical for those in or seeking therapy to understand the dynamics and boundaries of the therapeutic relationship. The distinction could mean the difference between a deeply healing experience and wasted time and money or, worse, retraumatization and new relational wounding for the person seeking help.

Dynamics That Bring About Healing, Change, and Growth

Unlike relationships with friends or family, the therapeutic relationship is a professional one that happens to be based on deeply personal material. Much like other health or medical professionals, therapists are bound by codes and ethics that not only lay out rules about confidentiality, but also ensure the relationship maintains the emotional safety and best interests of the person seeking help. This is different from the relationship with family and friends in that therapists have nothing to gain personally from the relationship. Any advice, questions, and even opinions expressed by a therapist are based solely on the best interests of the person in therapy. In return, people in therapy owe therapists only a sincere willingness to work toward their goals, basic relational courtesy, and previously agreed-upon fees. Although loved ones typically have your best interests at heart, they also often have their own biases based upon family traditions, cultural understandings, personal history, and the effects various outcomes may have on their lives.

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Additionally, while those closest to you may know you better than a professional therapist (at least at the beginning of a therapeutic relationship), this can be a drawback when it comes to getting clear or unbiased feedback. Those who have known you over a period of time may have preconceived notions of who you are, what you should do, or how you should behave.

In contrast, therapists endeavor to see people in therapy as clearly and objectively as possible, allowing for growth, change, and healing to occur in a way that best serves a person’s needs and well-being. Specifically, therapists are trained to maintain a nonjudgmental stance with unconditional positive regard for the basic humanity of the people who seek their services. Through skill, expertise, and their own self-awareness, therapists hone their ability to support and guide people so they may achieve their highest potential. Through the therapeutic relationship, people in therapy can experience a nurturing presence that helps them feel they are being seen, heard, and responded to appropriately.

Why Boundaries Within a Therapeutic Relationship Matter

In order for the therapeutic relationship to work, it is important the therapist maintain an unprejudiced stance by setting orderly boundaries. In the absence of such boundaries, it may be challenging for the therapist to maintain neutrality and for the well-being of the person in therapy to remain the priority over the duration of the therapy. Additionally, without clear boundaries it can be harder for people in therapy to feel safe, build trust, and focus on their needs.

Boundaries are based as much on judgment as they are on guidelines set forth by various professional codes of ethics. As such, it is less helpful to describe specific dos or don’ts here, as those can be found elsewhere. What should be understood here is the intent and effect of boundaries. Yet, anytime a person in therapy feels uncomfortable about boundaries, whether they consider them too strict or too lax for their needs, they should address their concerns with their therapist. In turn, therapists should respond to conversations about the therapeutic relationship in an open and non-defensive manner so the person in therapy feels their concerns or questions have been heard, answered, and addressed fully and respectfully.

When Boundaries Are Violated or Cause Relational Disconnect

Through the therapeutic relationship, people in therapy can experience a nurturing presence that helps them feel they are being seen, heard, and responded to appropriately.

While therapists are bound by codes of ethics, and must carry state licenses and malpractice insurance, some therapists may exhibit behavior that disregards best practices and violates boundaries to the point it can be harmful to the therapeutic relationship or to the emotional well-being of the person in therapy. If you have experienced therapy in which you felt misunderstood, upset, or used in any way, it is important that you tell your therapist. It may be a simple misunderstanding or feelings that are being projected onto the therapeutic relationship, providing a tremendous opportunity for a breakthrough conversation that leads to growth and healing.

However, if you do not get a genuine and satisfactory response from your therapist or your feelings continue over a period of time, you may choose to find a therapist who better meets your needs. Ultimately, the therapeutic relationship should be nurturing, fulfilling, healing, and reparative for you, the person in therapy, within the context of professional boundaries and mutual respect.

A Professional Relationship That Comes from the Heart

Finally, I want to make a note about the therapeutic relationship from the therapist’s perspective. Although it is a professional relationship and there are clear boundaries and parameters, the connection and desire to help is no less heartfelt or genuine than in any other relationship that exists outside the office.

Appropriate boundaries allow therapists to do good work in a safe manner, but they should not be a barrier to meaningful relational connection within the therapeutic setting. Ultimately, finding a skilled therapist with whom you feel safe and connected can provide the foundation for a powerful and life-enhancing therapeutic experience.

Silhouette of upset woman in open doorwayThe 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.

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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:

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:

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:

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:

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.

Important Notice

GoodTherapy is not intended to be a substitute for professional advice, diagnosis, medical treatment, or therapy. Always seek the advice of your physician or qualified mental health provider with any questions you may have regarding any mental health symptom or medical condition. Never disregard professional psychological or medical advice nor delay in seeking professional advice or treatment because of something you have read on GoodTherapy.