Psychotherapy is Helpful...Except When It Isn't

It takes courage to enter into psychotherapy. You’re trusting private thoughts and feelings to someone you don’t know. You expect them to protect your privacy, treat you with respect, and have your best interest in mind. Ordinarily, this is exactly what happens, but sometimes it doesn’t.

What to Expect

At the beginning, a therapist should ask a lot of questions and listen attentively to understand what’s bringing you to them. They should encourage you to share your therapy goals, and you should have a sense that the work you’ll be doing is related to these goals. The focus should be on you and your concerns. A therapist may share something from their personal life if they think it will be helpful. For example, a judicious use of self-disclosure can be helpful. But they should be clear that the sharing is to help you, and then quickly return the focus back to your concerns.

You may feel you can be better understood by a therapist with a similar background. A therapist may share their culture, heritage, sexual orientation, ethnic or racial identity, or other characteristics that can inform a possible shared understanding or perspective. You may also find it helpful to know that a therapist has had similar lived experience, such as losing a loved one, parenting a child with disabilities, or struggling with infertility. A brief disclosure can be helpful for establishing a therapeutic alliance, which research shows is a large contributor to a good therapy outcome. A therapist, however, should communicate that they don’t assume that their experience means they know exactly how you feel.

If your therapist has a different background, you should feel their acceptance, openness, and understanding. Therapists shouldn’t discriminate based on age, gender, gender identity, race, ethnicity, culture, national origin, religion, sexual orientation, disability, or socioeconomic status.

How to Know if a Therapist is Working Toward Your Best Interest

You should be talking about what you went to therapy to talk about—talking about you, not the therapist or their areas of interest. It’s your agenda. And be open to being challenged by your therapist once trust is established. If you ever feel like something is inappropriate, talk to a trusted friend or family member about what’s happening to get their perspective. Potentially harmful ethical violations may need to be addressed.

A therapist should also be open to discussing the probable duration of the course of therapy, including at what point it will end. Therapy can range from one session to more than a year of every other week, weekly, or twice weekly sessions. If you’re seeking support around a recent stressful event, you may benefit from an hour of careful listening, validation, and support. In contrast, if you’re seeking help in healing from childhood abuse, you may need a few years to work toward healing, personality development, and improvement in multiple areas of life functioning. The APA Ethical Principles state, “Psychologists terminate therapy when it becomes reasonably clear that the client/patient no longer needs the service, is not likely to benefit, or is being harmed by continued service.”

When Things Go Wrong

One of the idiosyncrasies of a therapeutic relationship is that it’s inherently transactional and unidirectional. A client (or their insurance) pays money to a stranger who listens to their problems and helps find solutions (of course, it’s actually more complicated than that). The unidirectional relationship should remain intact. That is, the therapist is there to support the client, not the other way around. Also, the payment should be for therapy.

The APA Ethical Principles state that a psychologist may not engage in any multiple relationships with a client that could “impair the psychologist’s objectivity, competence, or effectiveness in performing functions as a psychologist, or otherwise risks exploitation or harm” to the client. A multiple relationship can be anything from planning a business venture together to seeing your best friend’s brother for therapy to developing a friendship or romantic relationship with one another.

Sexual intimacy between a therapist and client is always wrong. There’s an inherent power differential wherein the therapist has more power, making it impossible for the client to provide true consent. Sexual attraction within a therapeutic relationship happens and may or may not be addressed/discussed in the therapy depending on whether it’s clinically useful for the client. It may be useful to discuss if the client has challenges with keeping healthy boundaries or differentiating between appreciation and sexual attraction. A therapist will likely seek consultation or supervision from a colleague should they experience attraction toward a client.

What should you do if you feel you have been harmed by a therapist? If the harm is relatively minor (i.e. you were hurt by something your therapist said but have otherwise had a trusting and positive experience), you should bring your concern to your therapist. This is a good opportunity to discuss a harm and hopefully have someone you trust respond thoughtfully and respectfully. Give your therapist the opportunity to hear you and apologize or clarify.

If the harm was big, talk to a trusted friend or family member about what happened so you can have support. You have the option of reporting your therapist to the state licensing board to investigate your concerns. All mental-health professionals are licensed by the state and subject to state regulations and statutes.

Healing from harm done by a mental-health professional may involve trying again with another therapist. Each therapist will have their own reaction to harm done in the context of a therapeutic relationship. A new therapist may feel anxiety and shame when hearing about the harm done by a fellow mental-health professional, and may not know what their responsibility is in terms of reporting the professional. Once the therapist has worked through their own feelings with the assistance of colleagues, they should be able to use their skills to help you.

Possible explanations for what happened include that your therapist was untrustworthy, motivated by self-interest, and exploitative. This is terrible and should be reported. Another is that they were experiencing a major stressor or change in cognitive status (i.e. major depression or dementia) that rendered them incapable of providing competent services. In this case, your report could help them get the help they need. For example, a professional I know was engaging in odd behaviors during a couple’s therapy session—repeatedly checking the time and playing with his phone. The couple reported it to his family, and he was soon diagnosed with a degenerative neurological condition.

Another possibility could be that you’re engaging in such a way that you perceive exploitation or harm when there’s none. This is more likely if you tend to perceive these dynamics in other relationships outside of therapy, if you have certain types of personality disorders, or if you’re very suspicious or paranoid. If any of these describe you, you may want to choose a therapist who comes highly recommended by a trusted source, or bring a friend or family member to therapy with you.

Most mental-health professionals are drawn to the profession because of a deep and abiding sense of wanting to help others—invested in reducing harm, and healing and helping others live their lives on their terms and to the best of their abilities. As in any profession, there are bad actors out there. Please don’t let these few dissuade you from getting the help you need.

Elizabeth H. Winston, PhD, is a licensed Madison psychologist who provides psychotherapy, psychological assessment, and consultation to businesses and organizations. Find her at shorewoodpsychology.com and consultingcollaborative.org .