As therapists, each of us would like to do exactly the right thing in each and every session. However, given the stressful nature of our work, the lengthy and sometimes sporadic hours, the occasional inability to feel secure in our continued income, and even our own not-yet-totally-resolved issues, we sometimes fall a bit short of this lofty goal. Simply put, despite our good training, supervision, and continuing education, we occasionally make errors. A few of the more common therapeutic missteps are discussed below, along with suggestions on how to avoid them. That said, professional organizations have guidelines that are (and always should be) a therapist’s first line of defense in this regard. Plus, without doubt I’ve missed a few things. If so, please add your thoughts on those issues in the comments section. That way, anything I’ve overlooked will still be discussed.
- Following Our Own Agenda and Timing (Rather Than the Client’s). This is a difficult pitfall to avoid. After all, we are trained to observe and identify, quite early on in therapy, which client issues are primary and which are secondary. Additionally, we are trained to pursue these concerns effectively and efficiently. And most of the time we can quickly envision useful interventions that might jumpstart a client’s healing. Nevertheless, the issues that stand out for us as clinicians may not be the issues that brought the client into therapy. In fact, the client may not be ready to hear about or even consider those subjects. In such cases, timing is everything. If your initial assessments are correct then you will probably need to eventually steer the client toward his or her primary underlying issues, but pushing for that before the client is ready is more likely to engender resentment than recovery.
Sometimes a client’s presenting issues can lead us into an agenda-driven choice of treatment methodology, regardless of the client’s current needs and/or ability to receive that particular methodology. For example, most of my work is with addiction and related issues, so I’m a big fan of cognitive behavioral and social learning models, which are without question the most effective approach for early addiction intervention and treatment. That said, some individuals will dig their heels in and rebel against the reading assignments and homework that are typically called for when providing CBT. In such cases, despite what I think and want, I must follow the pace and reality of the client. Most of the time I end up switching to a softer, more interpersonal approach. Later, after a solid therapeutic alliance has been established, I can switch back to more direct interventions.
Typically, agenda related issues arise because a therapist is feeling impatient, seeing the client’s issues and a series of potential solutions and wanting to solve things right away rather than allowing the client to experience his or her individual healing journey. As such, even when we know that certain forms of treatment and therapy are typically the most useful with a particular pathology, we must be willing to relinquish that agenda and our need to fix the problem as quickly as possible.
- Not Allowing Sufficient Time for Processing. It can be incredibly difficult and sometimes even damaging for a client to visit his or her therapist, open up about something incredibly painful, and then have the therapist say, “I’m sorry, but our time is up. I’ll see you next week.” This can be especially problematic when treating clients with a deep trauma history. Even without a significant trauma history it’s never a good idea to send clients back into the world less put-together than when they arrived. When that occurs, bad things can happen. If a client is dealing with addiction, for example, he or she might be leaving your office emotionally primed for relapse. Not cool. It is much better to sense that a client is open to sharing about something painful and meaningful, but time is running short and you won’t be able to sufficiently process by the end of the session. In such cases, you can make a note of where things were heading and pick up at that point in a future visit. At times, this hurrying can be a finance-driven issue, with therapists hoping to move a client forward through his or her therapeutic work rapidly because the client has limited insurance coverage and/or financial resources.
- Unintended Boundary and Ethical Violations. Accountability is a two-way street. Just as we should not have to tolerate poor boundaries acted out by clients, we must respect and role-model proper boundaries ourselves. For example, temporarily lowering our fee for a long-term but recently unemployed client = compassion. But allowing a perpetually out-of-work client to run up a huge bill even though they’ll probably never have the resources to pay it = borderline unethical. Of course, boundaries extend well beyond the financial. For starters, barring an unexpected emergency or illness, our showing up late for sessions and/or cancelling sessions at the last minute is bad form. Falling asleep during sessions is completely unacceptable. It is also unwise to bring our cultural and/or religious views into the therapy room unless we are clearly doing so in direct service of the client. No matter what, we must keep ethical rules active and present in the therapy office, remembering that we do not become friends with our clients, we do not barter with them for therapy, we do not enter into dual relationships with them, etc. All of these rules are in place for a good reason: to keep the client and the therapist safe.
- Being Unaware of How Our Cultural/Moral/Religious Beliefs Affect Our Work. Usually this issue manifests as a lack of acceptance by the therapist, and it may occur with a wide variety of issues – homosexuality, addiction, sexual abuse, polyamory, having seven cats, or whatever. Certainly if clients are acting out in ways that harm themselves or others we are obligated to address this in therapy, but we must do so as nonjudgmentally as possible. (If there are reporting requirements – as with child abuse, suicidal/homicidal ideation, and similar issues – we should make sure the client understands this up-front, and we must be diligent about our paperwork.) Yes, therapists tend to be very open-minded and accepting about most issues, but no one is perfect in this regard. We all carry our personal beliefs and values into the therapy room. If/when you have a client who presents with issues that make you personally uncomfortable, it is best to either seek consultation or refer that client to someone else. In other words, if your natural inclination when you meet a sex offender is to punch that person in the mouth, you’re probably not the right clinician for that client. Similarly, you shouldn’t treat an alcoholic who wants to get sober if you think the concept of addiction is a crock; you shouldn’t treat a gay person with reparation therapy if you believe that homosexuality is a sin; etc.
- Not Allowing for Silence. More often than not our clients need us to just shut up and listen. Despite our “useful insights,” interrupting them, cutting them off, finishing their sentences, and/or pushing for a response rarely leaves them feeling heard or safe. Simply put, our job as therapists is to listen and empathize and then, when appropriate, to reflect and potentially give direction. Sometimes this means we just sit quietly with clients while they feel and experience whatever it is that they need to feel and experience. At worst, clients may have to ask us to give our insight and support (which is always a useful skill for them to practice).
- Not Seeking Consultation When Unsure About or Unfamiliar With a Client’s Issue(s). As mental health clinicians we are neither expected nor required to be all-seeing and all-knowing. We are, however, required to seek help from our peers and colleagues when presented with an issue or client concern that is either unfamiliar, beyond the scope of our practice, or evoking ethical/moral/religious concern. This is especially important when facing a potentially litigious client. Remember: Your best defense against a malpractice lawsuit is documented proof that you sought consultation from a specialist.
- Making Inappropriate Referrals. As much as we want the best for our clients, it is not in our best interest or theirs, nor is it ethical, for us to recommend specific professionals in other disciplines such as law, medicine, or finance. The reason is simple: No matter how highly we regard a particular professional, if our client’s relationship with that person goes south it could undermine or even destroy the therapeutic alliance and, therefore, the clinical work. Beyond referring clients out for psychotherapy-related issues, we should avoid specific professional referrals – though we may safely refer to nonprofit professional organizations (who can, in turn, provide our clients with specific referral options). One more thing about referrals: Never refer your client to a friend or family member. It will end badly, I promise.
- Not Keeping Good Records. Malpractice lawsuits are as high as you can go on the list of psychotherapist fears. Of course, none of us entered this field thinking we would ever have legal action taken against us, and hopefully none of us ever will. Nevertheless, being human and busy, we are bound to make clinical errors. And even when we do everything right there is always the chance that a random client will take legal action against us. After all, we work with an emotionally disturbed population that may love us one minute and hate us the next. The most effective and inexpensive way to protect yourself from such situations is to document, document, document. Having been trained well and early in both hospitals and residential treatment centers, it is second nature to me to keep clear records of all client visits, and all calls and consultations with others made on a client’s behalf. It is also second nature for me to maintain and track a useful treatment plan. Unfortunately, these are not natural activities for every therapist, and many end up regretting that fact. So regardless of whether you are doing daily psychoanalysis or the occasional crisis intervention, you need to keep detailed, up-to-date, accurate records. Admittedly, no clinician that I have met enjoys keeping client records. None of us looks forward to the extra hour per day this activity requires. Sometimes a useful way to think about client record keeping is to view it as a form of self-care, much like exercise or eating right. The simple truth is that if you accurately document your client interactions and clinical choices, your chances of successfully being sued by a client diminish exponentially.
- Not Getting Proper Written Releases (to Discuss a Case with Others). In our concern for a client’s welfare and needs, it can be so simple and easy to skip the necessary and essential step of getting that individual’s permission in writing when we wish to speak to someone else – anyone else – about that person’s case (legal reporting requirements excepted). Yes, bringing a spouse or family member into a client’s session can be productive and also offer collateral information, but it is unethical for us to talk to that person without a release. Period. Nor can we talk to doctors, lawyers, other clinicans, treatment centers, family members, or anyone else without a written release. This is a simple and straightforward rule, yet easy to overlook. And the consequences of ignoring it can have far reaching consequences for both your work and your license.
- Viewing Continuing Education Requirements as an Obligation, as Opposed to an Opportunity. Would you want to be operated on by a surgeon who’s not up-to-date on the latest techniques? Me neither. Well, the psychotherapy profession is no different. For those of us who have them, continuing education requirements exist for a reason, and that reason is that our field is constantly changing and we need to keep up. New research, new technologies, and new methodologies emerge almost continually. Sure, you can skate through your CE requirements with “easy A” online courses, but are you actively learning or are you just meeting a deadline? Admittedly, going to conferences and sitting through sessions can be expensive (and sometimes not very exciting), but it’s near always worthwhile. Keep in mind that getting a degree doesn’t make you a good therapist. Our academic degrees are merely a start. The best therapists build and rebuild their knowledge-base through experience and relentless learning. (If you’re reading this, you’re probably pretty good about your CE stuff, so kudos to you!)
Something many therapists find useful when starting work with new clients who’ve been in therapy previously is to ask, point blank and very early on, what they liked about their previous therapist and what they got out of their previous therapy sessions (and, conversely, what they didn’t like and didn’t accomplish). At the very least this information gives you a few guideposts toward a useful working treatment plan. Many therapists also find it helpful to do a quick check-in every month or so with each client, asking questions such as:
- Is there something you’d like to talk about that we haven’t addressed?
- Do you feel comfortable talking about difficult topics in this room?
- Do you think you are developing a better understanding of your issues and how to overcome them?
Obviously there are many other questions you can (and should) ask, depending on the client and how you work. Sometimes clinicians will periodically bring out a copy of the client’s written treatment plan – and yes, you should have mutually determined, written, and signed plan in the chart of every client – to ensure that you are both still on track and/or to see if new goals need to be written. It is important to not take it personally if a client gives honest answers to your questions that don’t reflect well upon you or the service you are providing. If an individual doesn’t feel comfortable with you or doesn’t feel that he or she is making progress, it doesn’t mean you’re a failure as a therapist. It may, however, mean:
- The client’s dissatisfaction and unhappiness is a reflection of his or her pathology (i.e., the client tends to complain but is actually quite happy).
- You need to try a different stance/approach to work with that particular client.
- The client needs to work with someone else, in which case you should provide a referral.
In such instances it is nearly always useful to check your assumptions and judgments about the situation with another professional, and even with the client, keeping in mind that at the end of the day if the work doesn’t feel productive, changes need to occur, and those changes may involve referring the client to another therapist.