What Psychotherapists Need to Do to Prevent Harming Clients

7 Ways Clinicians Miss the Mark and Their Patients Pay the Price

When I was training to be a Gestalt psychotherapist, we covered ethics, empathy, transference and counter-transference, the field and contact boundary, presence, the impasse, Gestalt cycles, and much more, but many things are learned through experience, not education. That’s inevitable.

This piece is about sharing some of my hard-earned wisdom to prevent clinicians and clients from learning the hard way. It’s written to psychiatrists, psychologists, psychotherapists, and all mental health practitioners, but is also recommended reading for those of you who are clients, or considering therapy.

If there’s one thing mental health practitioners should hold as sacred, it’s putting the clients’ best interests first. Opening your eyes to what is often hiding in plain sight will save unnecessary heartache all around. Let’s look together.

The following are seven ways clinicians miss the mark and their clients pay the price.

1. Veteran Therapists Believe They No Longer Need Supervision

Complacency is the devil. As a therapist, it is part of your job to seek supervision on a regular basis. Who are you to think that you don’t need to bounce ideas off anyone else? You’re in a room, alone, with people sharing their hearts, secrets, and emotional wounds with you everyday.

In order to stay positive, energized, and open to new approaches, therapists need supervision. It’s too easy to avoid facing counter-transference, and to act out on clients, when you forgo feedback from experienced supervisors. In addition, bounce your cases (anonymously, of course — always maintain confidentiality) off your peers, your fellow therapists who have distance from your case and your issues, and possibly a worthwhile, fresh perspective to share.

Don’t be so arrogant as to assume you have nothing more to learn and have no need of feedback. If reading this makes you feel angry or squirm a little, please, that’s a telltale sign that you should get yourself a supervisor or a supervisory group immediately.

2. Therapists Stop Their Own Therapy Too Soon

We’re therapists. Let’s face it, most of us got into the field to improve our self-esteem. And we have. We’ve been in therapy ourselves, including the radical exposure of group therapy. We’ve worked on facing the worst in ourselves, and finding the best in ourselves. But everybody has low self-esteem in some area. Clients trigger all sorts of feelings in therapists, and one of our greatest challenges is to stay self-aware. When you brush uncomfortable feelings under the rug, you’re doing your client a tremendous disservice.

The point is, the therapist’s low self-esteem makes you forget or overlook the impact you have on clients. You don’t realize how much your clients look up to you; how profoundly you affect them. There’s a fine line between feeling that your client is your equal (essentially, all humans are equal), and feeling like a peer with your client. Your client doesn’t hire you to be a peer, e.g., parents and children are equals, but they are certainly not peers. Children rely on their parents for guidance and wisdom. Well, clients rely on their therapists and hold us in high regard. They take what we say very seriously.

If your self-esteem is low, you will not fully embrace your authority. In fact, you will feel afraid of the influence you have on clients. Therapists are not supposed to give advice, but we do point people in a better direction for themselves. This takes self-confidence. The kind of confidence that can tolerate being idealized by clients (comes with the territory) without getting self-important, and then being thrown off the pedestal as the client comes into her own. In other words, don’t people-please your clients. It does not serve their best interests, and you become a model of dishonesty, compliance and fear-based relationships. Not a healthy model. Time for you to go back to therapy and build some more emotional muscle.

3. Unwillingness to Discuss Money Matters

It’s awkward but necessary. When Freud started the psychology biz, it was built on sex. Ever since, therapists are trained to deal with sexual issues. But money? That’s a relatively new frontier. Traditionally, therapists bill clients at the end of the month. Resentment can build when clients do not pay on time. And guess what? Therapists have a hard time bringing up the subject. This, of course, taints the therapeutic process because it flavors the clinician’s listening. During the session, a voice in your head is saying, “Why doesn’t this client bring up payment? Why do I have to mention it? It’s so unpleasant having to ask for money. What! Did she just say she’s planning a vacation to Thailand?!*#@!”

Transparency around money is liberating. Just like sex is a microcosm of a person’s entire relationship with their significant other, finances are indicative of much deeper issues of security, freedom, generosity, stinginess, poverty, abundance, and how that affects the client’s approach to life in general. If you, as the therapist, enable the client in not talking about money, you prolong the underlying issue. Because of your own discomfort with the subject, you allow a fissure in the clinician-client relationship. If this is you, nowadays there are coaches who address this issue. Find one and liberate yourself from your own limitations, and become a better therapist in the process.

4. An Inflated Sense of Importance

People in need of therapy want to feel that their therapist is confident that the treatment will work. Understandably so! But these same people are vulnerable and may mistake arrogance for confidence.

Therapists who have an inflated sense of self-importance are arrogant. They believe they know what’s going on inside the client without thorough exploration or truly empathizing. I’ve seen therapists use active listening to stroke their own egos (they love the sound of their own voice repeating back to the client what was said), rather than to grasp what is really going on with this unique individual. Initially, clients may feel understood, but eventually, the client goes unseen because a self-important therapist is a self-centered, not client-centered, clinician. Psychologist and author Alice Miller, put it this way:

“The grandiose person is never really free; first because he is excessively dependent on admiration from others, and second, because his self-respect is dependent on qualities, functions, and achievements that can suddenly fail.”

A self-centered mental health practitioner at any level (psychiatrist to social worker) is more interested in career kudos, and the flattery of a private fan club, than helping clients heal and, eventually, outgrow the therapist. Great clinicians want to makes themselves obsolete. They don’t assume they know what’s best for a client without genuine partnership; they don’t stretch out treatment longer than it is needed in order to line their pockets. When you have the client’s best interests at heart, you provide a safe haven until they heal — and then you support them in leaving the nest.

5. Reducing Clients to a Diagnosis

We’ve learned all sorts of methods to help people mitigate anxiety, depression, and the many other disorders listed in the DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, fifth edition). Not to mention what we affectionately call “garden variety neurotics,” people who negotiate life on a daily basis with functional doses of anxiety, depression, perfectionism, paranoia, and such. As Woody Allen put it, in Annie Hall, “Well, that’s essentially how I feel about life — full of loneliness, and misery, and suffering, and unhappiness, and it’s all over much too quickly.”

Objectifying clients is downright inhumane. Too often, diagnosis limits the way we see the person. In Gestalt therapy, we look at defense mechanisms as brilliant creative adjustments. It’s a client-centered, relational, humanistic approach. Fritz and Laura Perls were focused on what was arising in the present moment and the rich, fertile ground provided in the here and now. Integrating appreciation for an individual’s coping style opens up the possibility for raising their self-esteem instead of being locked into a pathological view.

Clearly, diagnosis has a place, but far too often it reduces people to an inferior status. On the positive side, diagnosis can be a relief for a client. Knowing that what they are suffering from has a name, healing measures, and many others who have dealt with the issue, can be comforting and reassuring.

Unfortunately, there are many psychiatrists, psychologists and psychotherapists who objectify the person when they diagnose. Such therapists are dinosaurs, subscribing to the notion that they are superior to their client and playing God with diagnosis. A person with a heart and soul, who is hurting, becomes a personality disorder to be medicated and fixed.This is so dehumanizing! What’s worse is that it’s done by people who are supposed to be insightful and empathetic. To quote Irvin Yalom from his book, Lying On the Couch:

“What? ‘Borderline patients play games’? That what you said? Ernest, you’ll never be a real therapist if you think like that. That’s exactly what I meant earlier when I talked about the dangers of diagnosis. There are borderlines and there are borderlines. Labels do violence to people. You can’t treat the label; you have to treat the person behind the label.”

Client be warned: if you feel the person who is treating you is not on your side … get a second opinion; interview another therapist; find someone you feel is truly interested in understanding you and supporting you, while also challenging you to get out of your comfort zone.

6. Playing Favorites

This can happen in group settings. Therapists work with client groups and supervisory groups. In either scenario, the group leader who has a “class pet” needs to examine this with his or her supervisor. Which means she or he must first be aware that they are playing favorites. This is not so easy, given that often group leaders work solo and have no feedback from their peers. The clients or therapists in the group are usually reluctant to point out favoritism.

So what to do? How about videotaping a group session and watching yourself in action? You will have to get permission from the group members, of course. Be transparent and explain you want to show it to your supervisor as a way of you keeping yourself accountable and delivering excellent guidance to them.

Watch alone in private and notice what you feel as you see yourself in action. Take notes, write down questions, and then ask your supervisor to watch the tape. After she does, you will have one of the most productive coaching sessions of your professional life. Of course, you will pay your supervisor for the time spent viewing as well as meeting with you, but if athletes and musicians do it to improve their performance, why shouldn’t therapists?

7. Denial, Complacency & Collusion

Therapists are not immune to being in denial about themselves and others. Although we’re in the profession of being insightful and empathic, we all have blind spots. It cannot be said too many times: we need supervision. We need to be challenged. We need help seeing where we can make adjustments and grow. We need help appreciating our flaws and the beautiful humility they give us … a humility that makes it safe for our clients to trust us.

“Only the wounded healer can truly heal.” ~Irvin Yalom

This holds true only if we do not act our wounds out on another, but use them to form responsible, reparative bonds with our clients. Transparency with a supervisor helps us know ourselves; then we can help clients know themselves.

Clients do not need us to be perfect — how can we truly empathize with them if we have no issues of our own? They need us to be trustworthy, great listeners, and have resources to suggest to them. They need us to have integrity, humility and to be role models of emotional and psychological health. Again, that does not mean perfection. It means the ability to be self-aware, not take ourselves too seriously, have resilience, and inner strength.

I’ve seen therapists in positions of authority overlook blatantly unprofessional behavior because they assessed an on-staff therapist as brilliant (and the person in question was brilliant … in some ways). This is a form of complacency. But brilliant work does not excuse chronic lateness, sexual misconduct, hubris, and other uncaring and self-serving behavior.

Unfortunately, mental health practitioners are not always compassionate; they can be narcissistic. Predatory is a strong word to use, but, regrettably this is a field in which a predator can thrive. We need, as a community, to hold ourselves and each other to a gold standard of integrity. People come to us when they are at their most vulnerable. We need to honor their trust.

If a supervisor, manager or team leader minimizes, overlooks or fully denies unprofessional behavior in a staff member/fellow therapist, the team tends to go along with this. Collusion is cowardly, dishonorable, and happens more than we, as a community, would like to admit. I hold therapists to a higher standard: we’ve worked on our personalities, our defense mechanisms, our character structure. We should have a higher level of self-awareness and integrity than most people. It’s our job!

One of the founders of humanistic psychology, Carl Rogers said, “The degree to which I can create relationships, which facilitate the growth of others as separate persons, is a measure of the growth I have achieved in myself.”

To be honorable clinicians, we must achieve personal growth.

We must expose ourselves to scrutiny and subject ourselves to the same demanding work we facilitate in our clients. Do the right thing and find yourself a good supervisor, a good supervision group, and perhaps a peer supervision group or colleague with whom you can exchange peer supervision. Hold yourself to a high standard of integrity, self-awareness and honesty. Be kind. Be trustworthy.

Don’t ever make a client pay the price for your self-indulgence. Mistakes are forgivable. But superiority and self-importance are not, especially in our profession. Be more than professional — be honorable.