A Harvard professor of psychiatry and the law has published a pocket guide to help clinicians working in mental health avoid some common pitfalls.
It is possible to look at the guide from a patient’s point of view, and to deduce some warning signs of when therapy is going wrong.
In A “Pocket Guide” to Avoiding the Most Common Boundary Pitfalls, Thomas G. Guthell lists nine ways in which clinicians commonly stray outside the proper boundaries of therapy:
There are a variety of reasons for boundary problems; some may stem from the practitioner’s ignorance or exploitative character, others from moral weakness or emotional vulnerability, and so on. But what makes the matter even more distressing is the fact that some of the pitfalls I repeatedly observe, that often result in litigation or board complaints, could have been avoided with relative ease.
Advice to therapists: Stick to the therapeutic contract.
If you do not have a written contract with your therapist, setting out what you can expect from therapy, you should have. Ask for one.
It is no excuse that your therapist works in the NHS. The NHS is perfectly capable of providing written information that tells you exactly what to expect of the treatment you are having.
Do not agree to take part in any activity that appears to be for your therapist’s benefit rather than yours.
Do not ask your therapist to go beyond the contract by holding hands, sitting on his lap, going for trips together, and so forth.
Advice to therapists: Work in the office.
Do not have contact with your therapist outside the office, unless it is a specific part of your treatment written in the contract.
Of course, lots of medical care and support does take place in other settings, such as in hospital wards, at your home, and in other places if there is an emergency. But psychotherapy only takes place in a private environment without distractions. Care and support is not therapy.
Advice to therapists: Never worry alone.
If your therapist seems worried, confused, or unable to cope, consider stopping therapy until your therapist has consulted a colleague or supervisor. Properly qualified therapists are required to have regular clinical supervision. Management is not the same as clinical supervision, and is no substitute for it.
Unqualified therapists, especially psychologists, nurses and others in the NHS, often try to practise psychotherapy without supervision. If you feel your therapist cannot cope, insist on a referral to a qualified, supervised therapist.
Advice to therapists: Be emotionally present.
Expect your therapist’s full attention during therapy sessions. If your therapist seems distracted, consider ending the session early, and explain to your therapist why you are doing so.
But do not expect any attention from your therapist between sessions or after therapy ends, unless that is in your therapeutic contract. If your therapist suggests contact outside the boundaries of your contract, consider it suspicious.
Advice to therapists: Do not avoid personal questions from the patient.
Do not expect your therapist to reveal any personal information to satisfy your curiosity. If you feel you need to know things about your therapist’s life, that feeling you have is a symptom of your mental state.
It is not wrong to ask your therapist personal questions, because that brings your need to know out into the open where you can discuss it. Also, it is not wrong for your therapist to volunteer personal information — for example, to illustrate a point.
But if your therapist reacts to personal questions with hostility or by changing the subject, then your therapist is not recognising your feeling.
A competent therapist does not avoid your personal questions, but instead recognises your feeling and helps you to understand it. However, a competent therapist avoids answering your personal questions.
Advice to therapists: Know the protocol for gift giving and receiving.
Do not give your therapist gifts. If you feel you would like to, discuss that feeling in therapy instead of acting on it.
Do not accept personal gifts from your therapist.
Books and other media are not personal gifts if they are directly relevant to your therapy, but only if they are not personalized in any way. For example, it is reasonable for a therapist to lend you a book from the clinic’s library, but not for her to give you a signed copy of her latest novel.
Advice to therapists: When communicating with patients, be cordial and polite.
Expect respect and professionalism from your therapist at all times. Treat as suspicious any suggestion from your therapist of a personal relationship with you, including friendship, love, jealousy or hostility.
Advice to therapists: Do not use terms of endearment.
As above. Any suggestion of a personal relationship is suspicious.
Advice to therapists: Do not forget to document.
Expect what Dr Guthell calls the 3 Ds from your therapist: demeanour, documentation, and debriefing.
Demeanour means a professional and respectful attitude towards you at all times.
Documentation means written notes that include all the significant interactions with you. You are entitled to see your notes, and you are entitled to make a formal complaint if they are incomplete.
Debriefing means that you discuss significant things in your therapy sessions. If something happens that your therapist does not want to discuss, consider it suspicious.
What to do
When therapy starts to go wrong it can be difficult to know what to do. Imperfect therapy might be better than no therapy at all.
However, there are certainly many therapists who always work within professional boundaries, observing all the above guidelines. There is no reason why you should not be seeing one of those therapists.
In general, if something seems to be going wrong in therapy, bring it up at the next session. If it is not resolved to your satisfaction, or if it continues to go wrong, do not go back to that therapist. If you suffered actual harm or distress, consider making a formal complaint or taking legal action.
Some therapists who knowingly cross boundaries with their patients use the excuse that it is all part of the therapy. They might use technical terms like ‘transference’ to explain away their unprofessional behaviour. If that happens to you, think about whether the problem is just in the way you feel, or in the things your therapist actually says and does. If the problems is in things your therapist actually says and does, then there is no excuse.
In the NHS, people who complain generally get better treatment, although the process of making a complaint and following it through can itself be frustrating, difficult and lengthy. This looks set to improve over the next few years, as the NHS is increasingly held to account for its outcomes, and as advocacy services improve.
Also, the NHS is required to provide you with appropriate treatment. A therapist who behaves inappropriately is certainly not appropriate treatment. If your therapist is behaving inappropriately, regardless of how you might feel about yourself you deserve better.
If your therapist is private, do not pay for any session in which your therapist behaved unprofessionally, or which you wasted discussing your therapist’s behaviour. For treatment covered by health insurance, tell your insurer to withhold payment. In future this might also apply in the NHS, and your GP might be able to withhold payment for bad treatment, which will help to ensure that treatment providers maintain high standards.