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Is This Ethical?

In the article “When the Therapist’s Behavior Is Confusing”  I talk about situations when people aren’t sure if their therapists are being helpful or if they even know what they are doing. Other common scenario is when the client starts questioning the therapist’s actions beyond the areas of competence or professional judgment. They start questioning ethics and even lawfulness of what the therapist is doing, because some of the therapist’s actions strike them as being so outside of how they normally see a professional service. I often read the descriptions of blatantly unethical behaviors of professionals that aren’t recognized as unethical by their clients.

Excessive self-disclosure with no justifiable therapeutic purpose, hiring the client to do certain tasks for the therapist, a sudden fee increase without an advance notice, talking to the client’s family without their permission – those are just a few among many examples of obviously unprofessional and unethical actions of therapists that many clients have to deal with because they are unfamiliar with therapists’ professional code of ethics.

When the service you are seeking is related to your health care whether physical or emotional/mental, the basic wisdom would suggest doing a little research into the professional ethical code of your health care provider.

Unfortunately, there are virtually no consumer related available and easily accessible public resources that explain in plain English what type of therapists’ actions should not be accepted as normal by clients. The formal ethical codes for various types of professional licenses can be found online but their wording is not consumer friendly and requires further explaining and interpreting even for professionals (this is why professional laws and ethics take an entire course in professional training).

While the absence of consumer oriented information on professional ethics is frustrating, the good news is that in many situations all you need is your common sense to decide if your therapist’s actions are acceptable to you or not without trying to define them in terms of ethics, legality or professionalism. There is no need for you to label the behavior of your therapist in any way in order to decide if it serves your needs and your best interests. After all, everything comes down to you achieving your personal goals in therapy and if the therapist’s behavior doesn’t seem to be aligned with working on your goals, this needs to be addressed and resolved promptly, and if it doesn’t get resolved promptly, there is no reason for you to keep seeing that therapist. Simple as that. Or not?

As simple as it sounds, I understand that this is easier said that done because often people don’t know what their therapy goals are because they don’t even know they need goals in order for therapy to work. But being clear about what your therapy is for and what you are trying to achieve is a must in order not only to make the best of it but also in order to protect yourself from possible harm. Your goals and whether you are moving in the right direction is the ultimate measure of everything that happens in your therapy including your therapist’s behavior.

When you know what you want and your attention is focused on clear objectives, it would be much easier for you to see that when your therapist talks about him(her)self too much, when they become flirtatious with you or try to be chatty, when they are often late for appointments, when they unexpectedly raise their fees and are inconsistent with their business policies, when they are disrespectful, when they talk to your family members about you without your permission – all that doesn’t serve your needs and your best interests.

It is much easier to decide for yourself what you do and don’t need and, consequently, what you are and aren’t willing to accept from the therapist if you think consciously about the purpose of therapy and your specific personal goals than to figure out if a particular action the therapist takes is ethical or not.

Unlike laws, ethics are mostly a grey area and cannot be ensured by the manual of precise instructions that would cover every possible therapy scenario. Therefore, trying to create a checklist of what therapy consumers should watch for is a futile task. The same action that could be appropriate and even therapeutic in one case, could become a slippery slope in another case and outright unethical in yet another case. That’s why professional ethics are set as guidelines rather than strict rules and that’s why professionals are advised to be guided by the general principle of thinking of their clients’ best interests when they face ethical dilemmas.

The same general principle can be used by you, a consumer, when trying to understand if your therapist’s way of working and interacting with you is what you need. While the therapist is obliged to think of your best interests, you don’t have the same obligation towards the therapist. All you need to think of is your own interests, needs and goals and when you are committed to doing that you’ll be better able to understand if your therapist is fulfilling his or her professional role.

That being said, some behaviors of some therapists are so blatantly unethical and even illegal that they need to be pointed out in a separate article, because, sadly, despite their obvious inappropriateness, many people are unable (and somewhat unwilling) to see them for what they are and they get victimized and traumatized as a result.

 
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9 Comments  comments 

9 Responses

  1. G

    Hi Marina,

    I hope you enjoyed your spring break last month! I agree with your thoughts on the unfortunate minimal amount of sites that are client oriented and provide sound perspective on what to look for in a healthy therapeutic relationship. Yours is one of the few and one of the most comprehensive and thoughtful.

    Learning about ethics was eyeopening for me. It is indeed a grey area as you mentioned. Ethics are worded in a way that can leave too much to interpretation, rendering them vague. The discovery that ethics existed was at first comforting to me, but learning that they are in fact just aspirations for therapists was very disillusioning. Ethics is a thought. Like a serving suggestion on a box of cereal. Nothing more. There is no way to monitor it, except for the client having some knowledge of it.

    The harm that my therapist caused left me devastated. I exhausted both the malpractice lawsuit option and ethical complaint option (with the state licensing board). I was left with the realization that in real world practice, little exists that is in place to actually deal with emotional abuse in therapy. I was left feeling there was no way to go. You have listed the additional avenues towards healing and action that are available with great consideration, including blogging, writing, etc. I started thinking, would there be a way to have something positive come out of my experience. My thought is about the idea of a checklist that you mention. I agree that it cannot be a checklist in the strictest form, because therapy is not so black and white. There are some posts online that list things to look out for that can be an indication of bad therapy, or unproductive therapy. I would like to reframe the naming of this tool, and think of it not as a checklist, but a list of occurrences or interactions for the client to be aware of. To try to use them as a guide, like we do with so many things. I would have liked to have had it years ago. One of the reasons I was in therapy was that I had difficulty standing by my convictions and instinct. And my therapist was very savvy in knowing just how easy it was for her to divert attention from the concerns of lack of progress that I brought up to her by instilling fear or blame in me, and how little she needed to say to get me to stay. A list would serve the client. one could ask oneself how many of these are occurring in my therapy, are they upsetting to me, is there sufficient discussion about it with my therapist if they are upsetting to me, is it interfering with progress. It would reinforce instincts. I think it would help both client and therapist in the long run. The better understanding the client has of the work, then the more likely the client would stay, or would find a better fit, without wasteful months or years. I love your thought that there need not be a label of the therapists behavior. That idea might make the process of leaving less intense or fraught with emotion or guilt or blame. Your suggestion of focusing on the goals is simple yet profound. Is the therapy working or isn’t it? The most important factor is the clients quality of life.

    When I started with my psychoanalyst, I had no idea there were different modalities. She was very rigid and narrow-minded, and her treatment was not appropriate for me. My instincts were telling me that I needed something different, and even generally what changes to make. But I didn’t know at the time those therapies existed. (in reality, anything else would have been better for me). I think with some knowledge and reinforcement, I would have been able to leave earlier than I did.
    What do you think?

    • Marina Tonkonogy

      Hi G,

      I had enjoyed my vacation break, thank you!

      To answer your question, yes, it would certainly be much easier for clients to leave harmful situations in therapy and unethical practitioners if there were consumer information sources where therapy was described in a real way, exactly how many people experience it instead of portraying it as something that doesn’t reflect clients real experiences and doesn’t speak to their real needs.

      Right now people have virtually no point of reference to evaluate their current therapy in terms of its effectiveness, practitioner’s competence, professionalism, ethics and so forth. If they have doubts about where their therapy is heading, they are left with no help, no independent, impartial third party to help them evaluate their therapist’s performance. All they can do is to address their concerns with their therapists who are often far from capable of engaging in a constructive conversation about it, as your own experience and experiences of many other people show. So, yes, absolutely, independent educational sources like this website are desperately needed to empower people to trust their instincts, common sense and to exercise their independent judgment. I hope there will be more people, professionals and consumers alike, who would step forward and start an honest conversation about what’s going on in our mental health system.

      As far as the “check-lists”, I don’t philosophically oppose the idea of listing some indicators that could show that something in your therapy is off. The problem is that when you try to make those indicators about something specific then, first of all, the list would never end and, also, each item on the list could be debatable because the same behavior that may be inappropriate or questionable in one case may be perfectly benign under different circumstances. This kind of things are always contextual, they come with the territory and cannot be judged one way or another on their own. For instance, giving client a hug at the end of the session may be inappropriate and unprofessional under one set of circumstances, mindless under other circumstances and quite therapeutic and perfectly within professional boundaries in some other cases. That’s why if I were to make a list of things people should be mindful of while in therapy, I’d make it about how their therapy works in general. I’d put together a set of questions one needs to ask themselves to determine if this particular practitioner and the methods they practice is what they need or if they need something different, which is kind of what I am doing on this website.

  2. E

    Hi Marina
    My experience happened years ago, so I am speaking from hindsight. G describes how her therapist was able to to “instill fear or blame” in her for lack of progress, and I think that something like that happened in my case as well. Or perhaps, the therapist used his awareness of my affection for him to manipulate me to stay in an unproductive relationship.

    My relationship with this therapist began as a very professional one. He was someone I was paying for a service which was to help me with anxiety and some other life occurrences.
    Somewhere along the way the relationship became more personal than professional – some of the things that happened might or might not be on a checklist of signs of poor therapy.
    Finally, because of the accumulation of behaviors and statements that made me worry about his attachment to me, as well as my own dependence upon him, I left.

    While many professional relationships do have some personal element to them, this was more that I had ever experienced with a professional or in a professional context.

    Once feelings have become personal, there is no “reset button”. I was able to tell myself that I came to his office with certain professional expectations, and he did not live up to some of them. Labeling the strong type of feelings that can occur between and therapist and patient as “transference” and “countertransference” is not a “reset” either. He tried to do this at some point, and so did at least one subsequent therapist. These were feelings, whatever label is given to them, and whatever the genesis of them.

    So, as you have stated, the decision to file actions is very complicated in some cases. It is difficult to go back to the start when the relationship was nothing more than professional.

    Thank you.

    • Marina Tonkonogy

      Hi E,

      Thank you so much for sharing your experience. What you have described is very important because this is such a common scenario in therapy. The specifics may be different but the general occurrence is the same every time and that is when the professional nature of the relationship with the therapist transforms into the personal one. This happened to me as well, and this was the major precursor for the subsequent traumatic experience and the major factor that made the emotional damage so massive.

      I really want to congratulate you on your strength and wisdom that allowed you to leave the unhealthy situation before it caused you too much damage. I can tell you from personal experience and from what I know from others that this is not an easy thing to do. I couldn’t do it and many other people couldn’t do it either. Even though you have been hurt from the professional service turning into something it is not supposed to be, the harm could’ve been much greater had you not left immediately when you became aware of the problem.

      I can also understand very well why you and many other people have such a distaste for the terms “transference” and “counter-transference”. I can clearly see how labels like those could feel like they are delegitimizing real feelings that people develop for each other, both therapists and clients. When someone gives your feelings the label of “transference” it sounds like they don’t accept them as real feelings that are natural and, therefore, healthy, but, instead, this “clinical” term implies that your feelings are some sort of a medical “condition” that needs to be “treated”, which is pathologizing and, as such, insulting.

      There is no question that many therapists use the term “transference” to pathologize normal, natural feelings, but this doesn’t have to be the case, and this is very important for people to understand. It is important to understand that the label “transference” doesn’t have to be an insulting dirty word that pathologizes and invalidates that which is natural and essentially healthy, because, as a matter of fact, most of what we feel towards other people in the moment can be called transference, as transference doesn’t only apply to a therapy situation.

      Transference is a phenomenon that exists far beyond and outside of therapy situation. It is simply a projection of our past situations to the present ones. That’s all it is, and, as such, this is something we do all the time, with many people, every day, many times a day. And, vice versa, other people do this to us on a regular basis.

      To explain it further, transference is a perception of a person that is based on what we BELIEVE them to be, as opposed to who they really are, and, in turn, the beliefs that give rise to our perceptions have come from what we have learned about people from our past life experiences.

      Since we look at other people through the lenses of our experiences, it is virtually impossible for us to see anyone for who they are and we see them how we want to see them. Outside of therapy, however, there is more opportunity for us to see people more realistically because we see them in different context. We see them interacting with others, they may share personal stuff with us as much as we share with them, we see them doing different things and this gives us a lot of information about them. So, we have many opportunities to get objective information about people outside of therapy. Therefore, when we develop feelings for them, those feelings are much more based in the reality of who those people are than the feelings we develop for our therapists.

      With therapists, on the other hand, there is not much chance to see them for who they are because the therapy situation doesn’t allow it by design. That’s why the feelings we develop for the therapists are the feelings for the persons we imagine them to be as opposed to who they really are.

      Therefore, in both cases, the feelings are real, but the objects of our feelings are much more real if they exist outside of the therapy context and much more imaginary if they are therapists. So, it is the therapist, as the object of love, that is more imaginary than real, but the feelings for the therapist are just as real as the feelings for someone outside of therapy. The feelings are always real simply because we feel them regardless of who the object of the feelings is and in what situation they arise.

  3. E

    Marina,
    Thank you for your answer. I understand the idea that the feelings we develop are not based on the real information that we would normally gain from someone interacting in the real world. For example, I was once at lunch with a person who belittled a waiter for some minor misstep. That incident gave me a lot of information and a warning about that person.

    In my situation, the therapist shared quite a bit of personal information with me, much of which was not related to my issues He may have filtered things to present himself in a more positive light, but not everything was positive, and some things were actually sad. I think I knew very real things about him, but I knew at some point, that this was a red flag. While I don’t believe that he gave me the kind of information we get about someone in the real world, I dd come to know more than I needed to or wanted to.

    On a slightly different note and not related only to this therapist, I have wondered if many therapists truly know much more about us than we know about them. Rarely do they talk to people who are the main players in our lives, and rarely, do they observe us in our professional and personal situations. So, their impressions of us may be less than exact. For example, a client who is doing outstanding work in a difficult field may feel inadequate, and yet, be too modest to express or even see the success. Or the reverse. Another example might be that a person may feel unpopular, in spite of having many friends who would say he/she is liked or loved by many. A person who seems nervous in therapy may appear very calm to others and relative to many other people. Without seeing us in the real world, therapists rely on us to tell them about ourselves.

    And it is even more complicated than that! I think that my parents who saw me everyday described me very differently.

    Some therapists venture forward to criticize, judge, diagnose a client without ever once having observed us outside the office. They may encourage us to change, without really knowing what about us is truly working for us. A person’s unique strengths could be transformed into liabilities based on therapist perception.

    When a client is able to work with a therapist to express something that he/she truly wants to change about himself, I think that might be a good plan to work on. But I would rather have short term goal oriented therapy with the therapist as a coach. To me this would be more useful than talking for a long time waiting for the therapist to “discover” what he/she thinks the problems are.

    • Marina Tonkonogy

      E,

      Your insight about therapists being just as unable to see clients for who they are as clients are unable to see them is right on the money. This thought has crossed my mind as well occasionally and I believe this is an important topic in and of itself that deserves a separate article.

      You are right, we have to see people functioning in different situations and interacting with other people in order to get a better idea of who they are in addition to talking with them and listening to their stories. The behavior often reveals much more about the person that what they tell about themselves. After all, we all tend to present ourselves in a certain way when we talk to others and that includes when talking to a therapist. We mostly do it unconsciously but we all do it to some extend. We can’t even be completely open and authentic with ourselves because we all carry traits and qualities we don’t like and don’t want others to see. Again, we are not aware of what we are doing most of the time but we are doing it. It’s in the human nature to project a certain self-image outside for the purpose of hiding and protecting some vulnerable parts of ourselves or parts that we consider unattractive so others won’t see them and won’t reject us. And, so, unless a therapist has an opportunity to observe a client outside of therapy, they won’t be able to get a sense of a client as a real person. That’s not to say that seeing people in various situation is a guarantee that we will know everything there is to know about them, but, I think, when we can actually observe how people live their real life, that gives us a sense of their “realness”, otherwise, if they just come to see us in a closed room for 50 min or so to talk about what is bothering them today then what we know about them is their story, not who they are as a person.

      And that immediately leads to the conclusion that long-term therapy that assumes that my therapist will eventually “figure me out” is a futile adventure, as it is impossible to figure anyone out. The entire premise that a therapist possesses some special magical powers to dissect or deconstruct a client’s mind, as if it were a piece of machinery, to see how it works and what needs to be “fixed” is rooted in extraordinary arrogance and sheer ignorance.

      A coach-like type of work, when the guidance is given for achieving a specific goal, sounds much more realistic, and it’s really funny you mentioned it because it is exactly what I’ve been thinking about for a long time in terms of how I would prefer to work as a therapist. I decided a while ago that I would feel most comfortable directly sharing my insight on a person’s situation and ways of finding solutions than just sitting there week after week listening to their ever changing circumstances, moods, wishes, hopes, dreams that to me are just the surface that doesn’t change the core issues they struggle with, which could be accessed and worked with directly.

      I have to say though that I really dislike the term “couch”. To me, it also carries some arrogance and ignorance because it implies that the human mind and behavior can be “couched” just like a personal trainer couches you in the gym. I do believe people can be guided in some general way in terms of getting a fresh perspective, acquiring some knowledge they didn’t have before that they could apply to their situation. But I don’t believe in “couching” a.k.a advising or instructing them on what to do. That’s because I don’t believe that any human being can understand another human being well enough to know how to “couch” them. Every individual is unique and their internal emotional process is unique and no one except them can know the best way to get where they want to get. As a professional, I can only educate them on the workings of the human mind as it applies to their circumstances, but it is up to them how to apply that knowledge to find solutions. So, I see this type of work as more educational in nature than “clinical”.

      Another problem I have with couches is that most of them don’t come from psychology background and have no knowledge of psychology, mental health and trauma research findings. They take brief 2-3 months of life couching courses that are quite questionable IMO in terms of their scientific foundation and that’s enough for them to start seeing clients. I think, it’s insane, frankly. As flawed as psychotherapy practice is, couching is much less legitimate IMO, especially given that it’s completely unregulated. That’s not to say that there are no gifted individuals who work as couches who are naturally good at “getting” what people need. But, the occupation as a whole seems a bit suspicious to me.

      To me, the best name for brief, goal-oriented or specific issue oriented work would be “short-term counseling”, not “coaching” and not “therapy”.

      Last, but not least, I am sorry for what you went through in your therapy. Your therapist has clearly violated professional boundaries with unnecessary excessive self-disclosure. Once again, I admire your strength and wisdom that allowed you to cut the cord immediately when you recognized his behavior as a red flag. Not many people are able to do that, so you have every reason to be proud of what you did.

  4. E

    Marina,
    Thank you so much for this post and for the ideas you are developing that may be of help to many. I think “short term counseling” would be a good label for clients who function relatively well in their lives most of the time. I don’t have the background to speculate about what would be appropriate for people who really do need long term support to mange their lives, but I know that many therapists deal with more severe cases as well.

    To return to “transference/counter transference” feelings that develop in therapy, I wonder if there is really a good way to let them deflate. In real world relationships, as we observe people we may adjust our feelings negatively or even positively as we see them interact with others, solve problems, as you have said. This type of experience is absent as therapy ends.
    Explaining to a client that they don’t really know the therapist is helpful, but when feelings are strong, that may not be enough. Time does help and so do other relationships and life interests. But…

    I am wondering about positive therapy endings. Have you heard of ways that therapists have ended therapy in a way that was positive for the client? Clearly, instilling fear and guilt in a client is not a good ending. But what makes a good ending?

    I did have one good experience with an ending with a therapist I saw years prior to my difficult experience. At some point, she said to me something like this. “I think there may start to be a time when something comes up that you would rather do than coming to see me, so just let me know.” Actually, it was almost self-fulfilling because about two weeks later, I was invited to do something at my appointment time, and my work with that therapist wound down on a very positive note. Any transference, counter transference was not as strong in that case, but I still think that was a good ending for me.

    With “short term counseling” the ending might not be so difficult, but closure and good endings help.
    E.

    • Marina Tonkonogy

      Hi E,

      Tons of good questions in your post, as usual. I am leaving the house in a few minutes so I will respond later when I am back. Your post deserves a mindful response and it’s not possible to do in a few minutes. Will talk later. Thanks.

    • Marina Tonkonogy

      E,

      I’d like to address some interesting thoughts you expressed, as well as to answer your questions, in the sequence in which they appear in your post.

      So, first, in regards to short-term counseling vs. long-term counseling or “therapy”, and the idea that short-term counseling would only or mostly work for people who function relatively well makes sense, as I understand the logic behind it. I, however, look at it differently.

      When I propose short-term counseling as just ONE of the possible alternatives to the status quo, I don’t suggest that short-term counseling has the capacity to completely resolve whatever specific problem the client brings to work on. I don’t believe any of our psychological or situational problems can be completely resolved either through short-term or long-term counseling. The human mind is not like a clock mechanism that could be completely deconstructed and where the problem could be precisely detected and then “fixed”. The human mind is infinite and, to be completely honest, is still largely mysterious despite the bold claims of the mental health profession that they have figured it out already. There are so many big and small factors involved in each case scenario that I wouldn’t even attempt to deconstruct any particular person’s psychology and life situation regardless of how mild or small the problem may appear on the surface, let alone try to solve their problems.

      So, when I talk about short-term counseling, I don’t think of it as something that would or could solve the specific problems the client brought in, but rather about suggesting to the client to consider some tools and strategies with which THEY might approach solving their problem, explaining some possible ways of working on their problems and/or coping with them. There is no guarantee that those strategies would work, and if they don’t, they should be re-evaluated and the new ones should be mapped out . But the client is the one who ultimately is supposed to figure out each step in each given moment. It is not the therapist’s job to supply them with the precise manual on what to do. The client walks on their healing path by themselves and if they get stuck the therapist can give some guiding suggestions on how to get unstuck, but the therapist cannot tell them how exactly to get to their destination.

      It cases of serious trauma like PTSD and others, I don’t believe any kind of counseling alone, whether short or long term would be enough. Trauma operates deeply on the physiological level in addition to psychological and merely talking about it and getting support, even if it’s long-term, is not enough. Those cases IMO require some direct brain/body interventions like EMDR, yoga, bodywork and many other alternative modalities. However, short-term counseling in those cases can also be helpful if it’s used in addition to the above mentioned modalities. In short-term counseling of someone who has been severely traumatized the therapist can help by helping the person to get a different perspective on their life and what happened to them, a perspective that gives hope and shows that everything is not as doomy and gloomy as it might seem.

      Now to your question about whether feelings caused by transferences on both the therapist’s and the client’s parts can be deflated.

      I think, those feelings can be PREVENTED from being developed in the first place. I honestly believe that when a therapist is crystal clear about their professional role and responsibilities and if they are honest with themselves and with their clients about their limitations, the intense emotional entanglement created by transference processes on both sides won’t even take place. Moreover, I believe that in this case therapy won’t last for years as it often happens.

      In my professional experience I never had a case when a client had an intense debilitating transference towards me, the kind of transference I and many other people had towards their therapists. I believe it’s because I never tried to use them to fulfill my emotional needs because I knew that this was not a part of my professional role. People had experienced transference when they worked with me and I did too, but it was never intense to the point that it created conflict and prevented us from focusing on the work. I am certainly not saying that I was perfect of even good enough. Some people didn’t like what I was doing and it is what it is. Sometimes it happened because of my limitations, sometimes the client and I were simply not a good fit. Usually in those cases they’d express their anger and terminated the work immediately. I never took it personally and I never blamed either them or myself. I always saw it as a positive thing because they took care of themselves and, hopefully, found some other practitioner who could help them better than I did. For myself it was also a positive thing because they freed their time slot for someone else for whom I was a good fit.

      And, as to the good ending in therapy, YES there are good endings in therapy, absolutely. I’ve heard about them from other people, I’ve had a couple of them myself and the majority of my clients had good ending with me, which I am proud to say. In all those cases, however, therapy was rather brief than long and the transference was not strong, which, I think, is very telling.

      But when I talk about good ending, to me this implies that the entire therapy experience was good. In cases with some of my clients, the endings were abrupt, which was not by their or my choice. It was because the agencies where I worked directed me to terminate the work for one reason or another. Normally, abrupt endings aren’t good endings, but in those cases when the relationships were good and collaborative and we were satisfied with the work that was done to that point, we were still able to make a good closure.

      I hope this adequately responds to your thoughts and answers your questions.

      I will be on vacation until Sep 9th and won’t be able to respond to comments until Sep 10th. You can still post comments any time, but my response will be delayed until the 10th.

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