I would like to start by telling you how I came to consider emotional abuse in therapy and what has happened to me during the process of writing this paper. I first applied the label 'abusive' to a therapist's actions when I heard a client relate to me what occurred in her therapy hour. She had been dealing with the effects of long standing sexual abuse by her brother who was twelve years older than her. As a result of these sessions with her therapist she had started to doubt herself and what she had experienced. She questioned the validity of her feelings, thinking that her response to a history of recurring sexual abuse was exaggerated and inappropriate. She was suicidal.
It was my last session on a Friday afternoon. It was nearly the end of the session (our fifth) when she told me her therapist's response to her fear of being abused again when she was next visiting her family abroad. The therapist had said: "The fact that it was your brother meant that it wasn't as awful as if it had been your father ... he wasn't so old and he probably had an athletic body, so it wasn't so bad,” and then later, “If you can't stop it happening again, it’s not the end of the world, it would be just one more time.”
My instant response was' “You must be joking.” She wasn't. Somehow we continued and finished the session. After she left, I didn't write up my notes straight away. I felt a bit spaced out, but I didn't know exactly why. For the rest of that evening I felt empty. Blank. And so I let the night pass away. Three days later, it dawned on me. I realised that since that session I was in a state of shock. I had split off my inner self so I couldn't fully realise the impact of what I had heard that Friday afternoon. I couldn't take on what the other therapist had said and so had numbed myself. As a result, I was not fully available to feel and think empathically. I hadn't realised the impact of hearing what another therapist had said and how I would feel listening to it. I felt like someone had used a razor blade on me and had ever so carefully started slicing me open.
Later I felt overwhelmingly angry and a great deal of pain. My inner voice kept saying “It's wrong, it's wrong, it's wrong.”
In the next session I discovered that the client had felt numb after telling me what had happened. This reaction is very understandableshe wouldn't have been wise to show her true feelings on the matter after her last therapist's reaction. I told her my reactions during the week and how I had realised what had happened to me. "Did it really affect you that way?" she asked. She started crying.
Not long after this, another person rang seeking therapyand then anotherand then another all telling stories of their previous experiences with therapists. I find it very painful to hear what they have experienced. I find that I get angryvery angry at what I hear. And upsetlistening to their experiences and feeling their pain. And shame. Shame because I believe that what they have experienced at the hands of other therapists is uncalled for and wrong.
I thought about what I could do. I could sit on it and just feel upset and angry or I could talk to colleagues about what I was hearing and experiencing. I chose the latter. In truth, I was needing to unburdento tell someone else, to share what I had experienced and what had happened. I needed some validation of my reactions. I needed to know whether they would feel as I had. To my dismay, I discovered they were also dealing with clients who had been abused emotionally by their therapists. We started to share what it was like for us to hear what our colleagues were doing and not doing. I found to my relief that they felt similarly.
We started listening more acutely when clients started talking about their previous therapy experienceswe reflected on what our past and current clients had said. And slowly the words emotional abuse were used to label therapists' abusive actions.
I decided to discuss these experiences so that we can consider what we are doing to other people in the name of counseling and therapy, in some sense to break a silence that I think has been pervading our profession. In doing so I've had some strong reactions. I found it hard to sleep. I was going over in my mind what I could say and how to say it. I felt anxious and slightly giddy. On reflection, I was scaredand I still am. You may well ask what I would be scared about. I asked myself that. I realised that my anxiety was similar to that of a survivor of childhood abuse who tells their story and breaks the silence in their family. They fear the reactionthat they will not be heard, that they will be dismissed, the painful story of their experience denied and their feelings ignored, trivialized and laughed at. I fear that pain of not being heard and these events trivialized as I tell you what clients are experiencing. However, my desire to tell you what is happening has not gone away.
I invited those who have experienced abuse in their counseling to share their experiencestell their story of what occurred and what they feIt. I wrote to them and said: “I have been increasingly aware over the last few years of the increasing incidence of abuse in therapy. By abuse I mean intentional and unintentional conduct by therapists towards their clients that is not in the best interests of the client. Abuse can be of a sexual and emotional nature. Although situations of sexual abuse are becoming more visible to the public and therapists are being prosecuted as a result, emotional abuse has been hidden. When I mean emotional abuse, I think of situations where the therapist is ‘not there’ emotionally for the client, where the therapist uses therapy jargon to deal with the relationship issues between them and their clients, misuse of psychological testing, inappropriate assessment and therapy and inappropriate use of languagefor example metaphors and stories. I don't believe that emotional abuse is a new problem in therapy. Generally when we have experienced abuse at the hands of people we trust, we doubt ourselves, lose our voices, feel dreadful, bad, angry and worthless inside. Often we do not seek therapy after this experience. However, I think clients are becoming braver to voice their experiences with other therapists.
"I want to open this area up to other therapists and trainers of future therapists for them to consider their practices and start considering what they are really doing with the people who come to them. In September, 1990, the XIth Australian Family Therapy Conference will be convened in Adelaide. At this meeting there will be practising therapists and trainers in counseling and therapy. I want to present a paper to define and discuss emotional abuse to challenge this helping profession to clean up its act and start treating the people it sees with respect, dignity and integrity.
"I invite you to consider whether you would like to contribute to this paper. I am available to discuss your experiences with you, include any information you choose to have included, with respect to the abuse you have incurred and the effects on your person and self. If you would like to join with me in this venture I would be very honoured. At any time you have the freedom to withdraw any comments you have made about your situation. If you do not feel comfortable about contributing to this paper but would like a copy of the paper, please feel free to contact me or speak with your therapist.
"Thank you for reading and considering my ideas.”
Everyone who received a copy was enthusiastic about the idea. Seventeen people were contacted. They all were currently in therapy and had been or were currently dealing with their previous therapists’ actions as part of the therapy process. Of the seventeen, seven people were able to write their own account of what occurred, five started writing and could not finish due to the pain it was causing them. Three said they couldn't write about it but gave their permission for their experience to be told, and two said that it was not right for them at this point.
These people who have been clients are women and men, both young and older. Some are counsellors and therapists themselves, some are in training to be in our helping profession, and some are members of the public. Their abuse has been at the hands of experienced women and men therapists. The abuse is not specific to a model or approach to therapythe counsellors and therapists used the psychodynamic, the systemic and strategic, the experiential, the behavioural and cognitive modelsand this abuse occurred in individual, couple and family therapy.
I am writing on behalf of thembeing their voice to inform you they have experienced abuse at the hands of therapists. In sharing these experiences, I want to acknowledge three vital points:
Clients can be and are being abused in therapy;
Abuse experienced in therapy is life threatening; and
Healing therapist abuse is on par with healing childhood sexual, physical and emotional abuse and requires the same sensitivity and advocacy on the part of the therapist.
To do this I will explore how emotional abuse in therapy can be defined, what is abused, and how clients are affected. Finally, I will set out my ideas on helping clients who have been abused in therapy.
In discussing emotional abuse in therapy, I want the 'therapy' profession to consider ways of stopping this painful and uncalled for trauma. I will make recommendations for practising therapists, professional development and training courses, setting of standards of behaviour and the review of the procedures of ethical committees.3
Defining Emotional Abuse
When I use the words ‘emotional abuse’what is it I'm saying? Let us go back to the first example where the therapist said: “The fact that it was your brother meant that it wasn't as awful as if it had been your father ... he wasn't so old and he probably had an athletic body, so it wasn't so bad.”
Implicit in this statement is that the brother's abusive sexual behaviour is not physically repulsive and somehow acceptable and will not be harmful to the client's well-being if she is unable to stop the sexual abuse recurring.
I believe this to be wrong. She would have to tolerate someone using and abusing her body without consent. It means that her body is not her own, she would have to tolerate an invasion of her body and person by emotionally disassociating or splitting off. She would question whether she is responsible for what has occurred and whether her feelings of self loathing and disgust are justified.
This client reported leaving that session with her therapist in a blank fognumbly putting one foot forward before the other as if she was going towards her deathwaiting for it to occur. She was not armed with the facts and strength from her therapist saying, “It’s not o.k.it's never o.k. and it wi1l not occur-again or ever. " Instead, she felt she had been given away by her therapist to her brother.
What has happened here in this therapeutic exchange? In order to answer this, I feel we must start at the beginning and consider why clients seek help. They come asking for help by telling the therapist what they feel, what others have done, and how they have responded. Clients hopefully yet silently seek acceptance, wanting their feelings acknowledged and validated as real and rightful.
In seeking help, clients put their trust in us by the very fact of coming to speak with a counsellor or therapist. In seeking out help, they are saying that something is not right for them in their lives. They are looking for ways of changing their situation. Some people may be looking for new ideas the therapist may have as a result of their experience and expertise, some seek an opportunity to discuss different courses of action, and some are looking for encouragement to be different. In this way, the aim of therapy is to provide a certain type of environment-safe place, a safe environment. There a client can express their experiences, express their inner self which has been held away in safety for fear of rejection, abandonment and annihilation by those who have professed their love or who should have been responsible for their safety and growth.
In this example, the therapist has minimalised what occurred to the client. Her experience has not been taken seriously and the effects of continued abuse have not been considered. It is my opinion that the therapist has made an inaccurate assessment of the situation. The situation has been misdiagnosed. In addition I believe that the therapist's subsequent actions were inappropriatethat their 'treatment' was wrong. In effect, the client has now been abused by the therapist in their assessment and treatment.
From this, the question we must ask is, is this abuse? And to do this we must consider what is abusewhat is emotional abuse in therapy? The professional community accepts as given that there are many forms of abuse, for example, childhood abuse, spouse abuse and employer abuse in the areas of verbal, physical, emotional and sexual abuse. This being the case, it would be naive of us to assert that the therapist relationship is exempt from such trauma.
I contacted the Australian Psychological Society, the Australian Association of Social Workers and the Medical Complaints Tribunal. I asked what are the nature of complaints they receive and what are the categories they use to define and label them. All groups indicated that the complaints that are dealt with relate to therapist sexual and physical abuse. In asking whether they receive complaints about emotional abuse by therapists, originating from incorrect assessments and inappropriate treatment, they thought they might but none had been fully explored or documented. I asked whether these complaints could be lost at the initial point of inquiry because of the current focus on sexual abuse. All groups thought that this could be the case. When I asked them what they would say would be abuse in terms of diagnosis or treatment, they were at a loss to say.
I went to the legal field to explore what was being said about malpractice and professional misconduct in the medical field. Again the cases that have been before court and those cited as precedents relate to sexual abuse. Some of their arguments about professional misconduct can be applied to the area of emotional abuse in therapy.
The legal definition of abuse is broad. The Medical Practitioners Act (1938) as amended provides for only one general form of charge, namely Section 27(1)(d) of professional misconduct. Professional misconduct includes: Any conduct that demonstrates a lack of adequate
- skill; or care, by the practitioners in the practice of medicine or any other improper or unethical conduct relating to the practice of medicine. (Section 27(1)).
I believe this definition can be applied to therapy such that professional misconduct including emotional abuse is: Any conduct that demonstrates a lack of adequate
- skill; or care, by the practitioners in the practice of medicine or any other improper or unethical conduct relating to the practice of therapy.
For the purposes of considering what is abuse in therapy, I will consider lack of knowledge and experience, then skill and care in the practice of therapy.
1. Lack of Knowledge and Experience
The question arises as to whether lack of knowledge or experience constitutes abuse in therapy. For example: A woman sought help from a therapist because of a marital breakdown. The therapist suggested that she invite her husband in for the next session and gave her two forms to complete. They were forms with questions about their relationshipa type of marital satisfaction inventory.
The couple duly came to the next session with their forms completed. After the therapist briefly introduced herself to the husband, she asked the couple to give their completed form to each other to read. Again the couple did this.
The effect was devastating. Both parties had been as honest as they could be, thinking that this would help the therapist help them. They had not answered the form thinking their partner would read it. They could not talk much for the rest of the session. So the therapist finished the session early.
The couple left and managed to get home. The woman was extremely upset and her partner could not console her. They rang a friend who knew a counsellor to seek help.
After hearing what happened and the couple saying not only would they never go back but that each were wanting to kill themselves, an emergency session with another therapist was organised.
This couple are now in individual and couple therapy dealing with the long standing problems in their marriage. However, during this time, there has been a traumatic separation and fears of suicide as a result of the initial therapist's actions.
The guide-lines in the Code of Professional Conduct for Psychologists clearly state: “Psychologists must supply clients and persons being assessed with explanations of the nature and purpose of the procedures used in language the recipient can understand.” (Code of ethics, Section A, Assessment procedures)
This particular therapist's actions are a departure from this and are contrary to a recognised code of behaviour relating to the use of assessment materials. It is clear from this example that the therapist did not give the couple complete instruction about the use of the forms. In fact, the forms were given to the woman in her individual session. The woman took these forms home for her partner to complete.
Does this demonstrate abuse as defined by a lack of knowledge and experience in the practice of therapy? I believe it does. The couple completed the forms in good faith, believing they would be read by the therapist. The result was a marriage collapsing, devastation and threats of suicide. After ten months of pain and hard work, this couple is still trying to heal the wounds from two therapy sessions and rebuild a new relationship. They are currently struggling with repairing the damage of those sessions and questioning whether they can.
With respect to this abuse and others, we need to ask ourselves is “what occurred improper or unethical?" "Improper meaning wrong, by the usage of the community standard and unethical meaning not fitting with the rules, written or unwrittenof recognised conduct." (Ramsey, 1989)
As practitioners, we have accepted procedures in the actual practice of therapy. We gather information in the first and subsequent sessions to make an assessmenta diagnosisof what the problem is and how we understand it. Assessments are based on a therapeutic approach the therapist is working with and the values contained within. Each therapy approach has written and unwritten standards and rules.
Based on the assessment, we map a treatment process. The map of treatment is generally hoped to be consistent with the therapeutic approach we follow.
Using Ramsey's (1989) legal 'test' for misconduct or malpractice, the question is: “Is the therapist's conduct a deviation from the accepted procedures in the actual practice of therapy? If the answer is yes, would their behaviour attract the strong reprobation of the therapy community?”
In the two examples, one which minimalises recurring sexual abuse and the other which misuses psychological tests, it is my opinion that not only were the clients abused but that the therapist's actions would attract the strong reprobation of the therapy community.
2. Professional Conduct
The second point in considering what is abuse in therapy is professional conduct. Ramsey (1989) comments that the operative phrase in the legal definition of professional malpractice for medical practitioners is "the practice of medicine," i.e., that any matter in question needs to relate to the practice of medicine which in turn relates to the doctor/patient relationship. What Ramsey is underlining is crucial for therapy. In therapy, the therapist-client relationship is an important and integral ingredient. Again I consider the client coming to see a therapist. They come to tell us their concerns, and they seek our reactions both emotionally and intellectually. The guidelines relating to client/therapist contact and client welfare in the Code of Professional Conduct for Psychologists (APS, 1986) state: “The client is in a unique position of vulnerability in any therapeutic relationship. Vulnerability may stem from uncertainty about the differences between propriety and impropriety; the criteria for efficacy or harmfulness; what constitutes accepted practice as compared with irresponsible or unusual therapy.
Clients' ability to make judgements about their welfare are potentially lessened by the wish to succeed in therapy; the belief that the psychologist will always act in the client's best interest. It is therefore incumbent upon the psychologist to be constantly mindful of the responsibility for protection of the client's welfare and rights, and for the rigorous maintenance of the trust in the client-psychologist relationship.”
It is incumbent upon therapists to be cognisant of the vulnerable position the client occupies and consider carefully the duty of care accompanying our position. By this I mean the care inherent in our position as therapists to give serious attention to, to be protective of, and to be concerned about the client's emotional well-being. In this matter, we are required to consider how we do care for our clients and are we truly caring of them. Peter Lomas (1987), in his book, The Limits of Interpretation, said: “The richness and complexity that is often engendered when two people meet regularly over a long period of time and speak of matters of personal importance cannot be encompassed by a formula which focuses on certain patterns of functioning.” (Lomas, 1987, page 47).
Let us consider this example:
“She was a traditional therapist, detached, impassive. I thought, in spite of this, I would keep an open mind. I was at the stage that I needed to do some more work on issues relating to my early childhood experiences, particularly with my relationship with my mother, something I had been avoiding as I knew it was going to be very painful. I had been recently coming to terms with the extent of emotional abuse that had gone on in my relationship with my mother. Her abuse had been much more subtle in many ways than that of my alcoholic father; he was the obvious "baddy" in the familyhis abuse had been much easier to identify and deal with in the past.
We had five sessions. On session three, she asked me if it would be okay if she took notes. The next three sessions she did almost nothing else but write. It felt like she was just sitting back uninvolved, her professional mask firmly in place, saying very little. I was able to rationalise my feelings of discomfort and fear. I was able to ignore how unsafe I felt. I kept thinking, it will change, surely it can't stay like this, she is supposed to be a "good therapist." It’s my fault that I feel like this. I should be able to handle this.
During session five I experienced an enormous feeling of grief and aloneness. I became overwhelmed with these feelings and began to sob uncontrollably. It was as if I had fallen into the abyss and was going deeper and deeper. She just sat there writing, then she said “Time is up. If you need some time to get yourself together you can sit in my front room.” Nothing more was said.
The session was over. I sat there for a moment in disbelief, confused, disoriented. feeling out of control. Somehow I got myself out of the building and to my car. I felt abandoned, abused. I never went back.”
In this situation, we have a client who was experiencing enormous feelings of grief and aloneness, being overwhelmed with her feelings and knowing she was falling deeper and deeper in the abyss she so greatly feared. And the therapist continues to write and the client continues to fall into the depths of her aloneness.
The therapist, in declaring the session is over, offers no acknowledgement of the client's pain, does not help her with any way of coming back and finding her adult person before she leaves the therapy room. The only advice is that she can wait in the next room and get herself together. Using Ramsey's (1989) legal 'test' question again, i.e., “Is the therapist's conduct a deviation from the accepted procedures in the actual practice of therapy? If the answer is yes, would their behaviour attract the strong reprobation of the therapy community?”
I believe that the therapist's actions reflect a lack of care. What care is caring enough in therapy? What type of caring do we need in therapy to heal our past wounds? Alice Miller succinctly says that it is not intellectual insight that helps a client deal through their childhood and adult pain but someone who acts as the advocate for the client, allowing them to re-experience their pain in an environment of unconditional caring and acceptance (Miller, 1984). In her most recent book, Banished Knowledge (1990), she says: “It is not possible for someone really to clarify their situation and dissolve their fears until they can feel them rather than discuss them. Only then is the veil lifted and they realise their true need: not a tutor, not an interpreter, not a confuser; they need space for their own growth and the company of an enlightened witness on the long journey on which they have set out.” (Miller, 1990. page 184)
If an approach to therapy, in this case a seemingly orthodox analytic stance, does not provide the basic consideration and duty of care, then it cannot make claims to help people. It was poor judgement on the part of the therapist who abandoned her client to another room. There was an abuse of power by the therapist's actions in allowing the expression of pain but not dealing with it. It just pushed the client to re-experience abuseabuse at the hands of the therapist which parallels the abuse at the hands of the parent. I believe this would attract the strong reprobation of the therapy profession.
Therefore in answering the question "What is abuse in therapy?" it is my opinion that the lack of judgement and care and the misuse of therapeutic power is abusive in therapy. It is in the nature of the judgements we make and the care we take and the way we deal with a client that affects them. In not seriously attending to these matters, therapists' actions become abuse.
What is ‘abused?’
The question that arises is "What is being abused?" By this I mean what aspect of the client is abused in therapy? We need to think of each client as a person with an inner self and ask ourselves what do we attribute to them? Rather than label clients with obtuse terminology as narcissistic, grandiose, passive aggressive and hostile dependent, it is more helpful to describe them as a sensitive, caring, thinking, spiritual and feeling human being. It is a person with feelings and sensibilities that gets abused in therapy. Abuse occurs when people do harmful things to others without their consent. Violations physically, sexually, emotionally and spiritually occur, when people in positions of privilege use their power through words and actions to overwhelm the other's expression and being. As a result, the victim, being in a less powerful position, is less likely to challenge the other and so goes along with what is said. As a result of this, they spin out in confusion or become numb by disassociating or splitting off.
This principle applies to therapy. The very nature of therapy and how this relationship comes into existence means that one person is more powerful than the other. The person as client comes to another as therapist to tell them how they feel and what has happened. It is a goal oriented relationship and the aims of this relationship for the client are not reciprocal for the therapist. Therefore, it is a situation where the therapist holds greater power than the client. In accordance with their model of therapy, therapists tell clients to take certain action, to do something this way and not another. Silences are also powerful as they are another way of acknowledging one situation and not another. Couple therapists intervene in interactions by encouraging one to continue talking and helping another not to. By their actions, a therapist is saying do what I sayI know best. They determine what will and won’t be discussed. The whats, the hows and the whens of discussion are all wrapped up in fancy labels like interpretations, reframing, contextualising, re-authoring, and such. In the example of the very distressed client, the therapist had said nothing about her distress. What is the client to think? I shouldn't be getting upset? Something is wrong with me? I should be able to get myself together? And what does the client think? At the time, the client can't think. They are feeling. Feeling disbelief, confused, disoriented and out of control. With respect to the therapist, they feel abandoned and abused.
Clients do credit therapists with the power they have inherent in their position and they try to do what they are told. No one would go to a therapist if they did not think they had something to offer. People go to a doctor with a medical problem they hope they will fix. They go to a therapist hoping they can help them fix the emotional ones.
So the difficult question is, what do therapists do that is abusive? I believe that therapists are abusive when their actions are not caring, when their actions are misjudged and wrong, and when they are not respectful of the client.
I believe that as therapists we can know when our actions have not been caring or have been misjudged by listening to our inner voice. One of the ways we have of caring is to listen, honestly and painstakingly (and sometimes painfully), to our inner voice. That voice which tells us or feels for us when something is not quite right. The great difficulty is listening for and paying attention to that voice even in the face of the many approaches to therapy, our training and our personal biases. It requires us to acknowledge what we have done without dismissing it by labeling a client's complaint as transference, projection and resistance.
Some clients are able to tell us when they feel that something is not right and when they feel unsafe. I believe that clients give us every opportunity to mend that wound. Some clients are not able to challenge their therapists directly but they are able to show their reaction in a multitude of ways. Their response in the next session, their anger, their ‘closed-downness,’ their forgetting the next appointment and prematurely terminating indicates something has happened. Take this example:
“My partner had been seeing a therapist for several years. It was acknowledged that there were difficulties in our relationship, so I went to sessions from time to time when requested. The therapist eventually admitted a lack of perception about the basis of our difficulty and suggested we see another therapist whom she referred to as a "good systems man.
The systems man (called X) affected a casual air. We met in his living room. My partner and I sat there while he carried out an extended coffee-making ritual in the kitchen. The session was also interrupted twice by telephone calls which he also took in the kitchen. We were both uncomfortable waiting while X went in and out of the room. In this and other ways he effectively established his territory and asserted his authority.
He informed us of the method by which he would conduct this initial session, getting right down to business by asking us questions in turn. He started with my partner. First general background questions: why she was here, what kinds of things bothered her, her relationship with her family. I stuck by the rules and kept silent while my partner dealt with the questions often with versions with which I disagreedseveral times making statements which I knew she knew weren't true (she had previously admitted to both me and her own therapist that she would frequently lie). Nonetheless I maintained silence, relatively comfortable in the knowledge that soon it would be my turn. Finally my partner made a disturbingly misleading statement not about me but about her relationship with her daughter.
I was surprised (1 suppose even offended on the daughter's behalf) and opened my mouth and said, "But that is not true." X turned to me and said, ‘Who are you, her secretary?’which certainly put me in my place and shut me up.
How did I feel? My face went hot and my insides went cold. I shriveled.
I quickly assessed my transgression. What did he mean? I had been wrong to openly question my partner. It was wrong for me to ‘tell’ on someone. I had betrayed her. I should be more supportive and not contentious. I thereafter responded inoffensively, innocuously and compliantly during that and the several other sessions we had with X.
It was another year before my partner's therapist took a long look at me one day and suggested I see a therapist on my own.”
Here we have a client who has complied with what the therapist in his position of authority requested, i.e., to wait her turn to tell her story, until it got too much and she had to disagree with what her partner was saying. The therapist's very strong rebuke silenced her and made her feel bad and guilty for interrupting. This client was verbally slapped by the therapist. We can see that the client complies with the therapist after that and the result is unproductive therapy. What we have is a client who is being abused by a therapist.
The therapist's response seems stronger than a similar intervention, "Excuse me, but are you the spokesperson for the family?"and "What! I asked him to talk, and you're talking again?" in an account of 'useful' family therapy published in the Family Therapy Networker. (1988) Does this mean that such comments are legitimised as helpful by publication? I don't believe it does.
I am not saying that a therapist needs to be perfect. I am saying that therapists are required to make sure their comments fit with their clients, to ask openly for comments, to invite feedback on what has been said. It is my belief that we can take better care with what we say and how we say it. We are working with people who honour us with trust and faith by allowing us to know their inner world of feelings and thoughts.
This brings us full circle to ‘What is abused?’ What gets hurt? I hold a view that clients are more than the sum of their behaviours and they are more than the sum of their thoughts. As with all people, they have an inner self with an outer persona which operates to shield and protect their inner self. The inner self feels and is represented by the ‘am,’ and the persona by the ‘doing.’ Traumatic experiences (from birth to adulthood) are repressed from the conscious memory of the inner self. People survive trauma by incorporating their response into their way of relating. In the Drama of the Gifted Child (1983), Alice Miller says: “This person develops in such a way that they reveal only what is expected of them, and fuses so completely with what they reveal that until they come to therapy, one could scarcely have guessed how much more there is of them, behind this 'masked view of themselves.' (Miller, 1983, page 27)
It is the 'am' in the client, the inner self that gets abused in therapy.
A number of approaches to therapy don't hold my view about the inner self and making feelings more important than thought and action. As therapists we need to address these philosophical and psychological questions about who our clients are.
The Effects of Abuse
Let us now turn to the effects of emotional abuse in therapy. In reconsidering the client whose therapist said, "Are you her secretary?" and the couple who showed each other their assessment form, it is clear that these people have been hurt by their therapy experiences. To understand the havoc that is caused when therapy becomes abuse we are required to consider what happens when trust is broken. Clients, by trusting their therapist with their private feelings and thoughts, believe what they say and do. When the therapist's actions seem to go against the client's inner sense, it is understandable that the first person they will doubt is themselves. As one person reported when she was writing of her experiences: “It was often on my mind in everyday activity taking my son to kindergarten, driving the car. But I have found it very difficult to know how and where to begin. On reflection I think the reason it has been so difficult is because the experience was so painful and confusing that a part of me has repressed it and I am finding it hard to unearth it again.”
“What was missing for me in our experience of couple therapy was that I never felt the therapist ever got my story, that he never really heard or acknowledged me. I never felt any empathy from him towards the difficulty of my situation and the pain I was experiencing.
"He made remarks which demonstrated to me a lack of empathy and sensitivity. For example, one day I was talking about how devastated I felt when my husband left, how I felt hurt, alone, totally abandoned and betrayed, that my world was falling apart. I spoke of how difficult it was with the children and some financial difficulties I was also experiencing. I was in tears.
"The therapist's response was, ‘So you see your husband as the big bad wolf,’ and invited my husband's comments. That was it, I could not believe it.”
Seven months later, after the woman had many individual sessions with another therapist who acknowledged her distress and validated her right to be heard, the couple jointly decided to quit therapy. She says: “We both felt devastated: We had invested so much emotional energy, effort, time, not to mention money. We had believed in him, trusted him with our fragile relationship believing in his expertise.
We were like two individuals adrift in a raft in mountainous seas reaching for the rope from a rescue helicopter. The therapist was the pilot of the helicopter but he had no rope to throw us. He had no map to guide us out of trouble. It was entirely up to us. The longer we stayed with him, the greater the tempest became. Therapy had been working against us rather than for us for a number of reasons, but primarily because of the therapist’s insensitivity to my feelings and his inability to allow me to express them and to deal with us as a couple on an emotional level.”
When a therapist exercises the authority of their position and says or does something, clients will believe them before themselves. As in this case, the woman needed many individual therapy sessions before she believed in herself, that what was occurring was damaging and abusive.
When self doubt increases, vulnerability increases and a kind of hopelessness prevails. Rather than challenging the therapist, the client is more likely to go quiet, become numb, and feel despair. These are all the conditions necessary for feeling suicidal, not only physically but emotionally. By this I mean giving up on their inner self.
With the first example, where the therapist minimalised a recurring episode of sexual abuse, the client did become numb and felt like they were going towards their inner death. The client whose therapist said she could go to the next room to get herself together was devastated and took six weeks to regain her balance.
In one situation a client attempted to argue with her therapist: “We were seeing a well-known male therapist for couples work. In session three, the discussion centered on our sexual relationship. My partner was saying how difficult it is for him when I tell him what to do or not to do sexually. On my part, I felt that if I didn't tell my partner I would just be put off and turned off by things he was doing which I didn't like.
The therapist gave us an anecdote about when he was learning sailing. How nervous it made him when the instructor instructed him and how well he learned to sail the boat when he was left with minimal or no instructions.
Also in the same session there was a lengthy discussion between the therapist and my partner about me being a damaged person. The therapist asked him ‘Do you see her as a damaged person?’ My partner said yes and then they discussed me for about twenty minutes.
I waited expecting the therapist would draw me into the discussion. But this never happened. The therapist then gave his ideas about people not really being damaged but because they think they are, then they are on some level.
I felt very angry, upset and abused in this session and although I was not given speaking time, I took a few minutes at the end to disagree with him. I pointed out that I felt that with my individual therapist labeling what had occurred to me as abuse in my life, I was healing and repairing the damage that had occurred to me. The therapist said that maybe he hadn't made himself clear to me. But I felt he had. He and my partner had sat there for twenty minutes discussing whether I was damaged or not as if I was an object in the room. That he felt that there was no such thing as a damaged person. To top this all off at the end of the session, he said that I should learn to be less instructive.
What I know that I was unable to say to him, which I could in my individual therapy, is that I'm not a fucking sailing boat!”
Here we have a situation where the client attempts to challenge the therapist to no avail. She reported feeling patronised and objectified. She never returned to the next appointment.
Every client who wrote of their experiences on abuse in therapy clearly indicated that they were hurt, damaged and abused. Some were not able to return to the therapy while others kept going. Clients are often not able to say directly to their therapist that what they are doing feels wrong, patronising, or abusive. These clients, by understandably privileging the therapist's actions and doubting themselves, give over themselves in the way they learnt from childhood.
Healing Therapy Abuse
In working with abused clients, therapists need to treat therapist abuse like any other abuse. This means that a therapist must hear the client's experience, help them stop it recurring, label the actions as abuse and allow the client to experience fully their pain, grief and anger.
To be truly empathic a therapist needs to feel their client's experience. It is most helpful for clients when therapists tell them how they feel on hearing the story.
The client whose therapist minimaIised recurring sexual abuse by her brother was recommended by another therapist. This therapy had been going well before a lengthy break. When the sessions resumed, the client again felt that she wasn't safe. The client was at a crucial part of her healing where she was dealing with how the sexual abuse had continued into adulthood. She was starting to feel very angry towards the perpetrator and was expressing her desire to kill him and expose him by writing to both him and the other members of the family.
In response to these matters, her therapist said: “Yes, you may feel like you want to write to your family and expose the abuse. You might feel this, but you shouldn't act on it. If you do, there is no going back. You should hang onto it and talk about it next sessionand with respect to the long standing nature of the abuse, Maybe we have to look at your part in it!”
This particular client felt that the therapist was telling her to be silent and that her anger was unacceptable. She felt smothered by the therapist in a similar way to the smothering she felt with her previous therapist and her brother.
This matter was not mentioned by the therapist in the next session. Time in the session was spent talking about the break, the summer sales and other miscellaneous topics. In the following sessions, the client repeatedly raised her concerns and felt that she wasn't heard. She had attempted to discuss with her therapist what had been said, how she felt the therapist 'wasn't there' and that she was feeling unsafe. Her therapist responded to her by saying, "I wouldn't have meant to do that."
In the next session the therapist said she had been thinking about the client's comments: “I've thought about it and I've decided I didn't do that,” and “I think this is a case of transference. So what is it about you that makes you have this reaction to me?”
It is my opinion that the therapist did not hear the client's experience of the sessions and that the client's voice was dismissed and her feelings denied by the therapist's reaction. After knowing what happened in the first therapy and now listening to was happening in this therapy, I said: “So she was not able to say I'm sorry. She missed you and she hasn't owned her part in it. I wanted to cry when you were talking. I think it is unfair. I feel really angry for you. You have struggled, struggled and then struggled again with your therapist. Your therapist knew about you and what had happened before in therapy and she is now repeating it with you.”
I continued: “I know for myself I have found it hard when my clients tell me when I do something that is not right. I needed to look at it myself, to feel it and not close down. My sadness is for you. I'm also angry that your therapist is not prepared to do this.”
This client bravely went on to a third therapist after her emergency sessions with me and is now successfully dealing with the abuse she had incurred at the hands of her brother and the two therapists.
In situations of therapy abuse, therapists need to treat the situation seriously and believe what the client is saying. Therapists need to show how they feel. This helps the client get back in contact with the feelings they had which they have denied and repressed.
Alice Miller, in her books Thou Shalt not be Aware and Banished Knowledge, and Ellen Bass and Laura Davis in The Courage to Heal, clearly state how believing and validating the client helps them discover and express their feelings about childhood abuse. These ideas hold for therapist abuse and can be summarised as:
1. Believe the client.
2. Join with them by labeling the abuse and damage.
3. Clarify the therapist's responsibility and clear the client of blame.
4. Be real and share your feelings and validate theirs.
In the example when I told the client how I felt listening to the second episode of abusive therapy, the client said, “I'm desperate for this not to be happening. I would do anything for it not to be happening. I'll try to deny my own feeling if I could make it not happen. Maybe I’m trying to make her unsafe.”
In this instance, the client was considering how she was to blame for what had occurred and was trying to find any clue to that effect. It is important in those situations to challenge the client's inclination to self-blame and observe the facts of the matter.
The same applies to ourselves when our clients inform us of our abuse with them. In one situation, I knew as I stood up at the end of the session that something was wrong, that what I said to my client was inappropriate. In the next session I talked about feeling uncomfortable and bad about what I had said. My client said she had not reacted to my comments. I persisted saying that if I had been in her shoes I would have felt angry and upset. Later in our sessions, when she felt my comments were inappropriate, she told me. She reported feeling encouraged and safe by my earlier conversation to discuss the matter. By accepting responsibility for what we say and do, I believe that, as therapists, we release clients from a burden of protecting us which they learnt to do with their parents. This frees the client from doubt and helps them trust their own inner voice.
It is not acceptable for a therapist to say they had no intention to be abusive. The client feels and judges our actions. After discussion with colleagues, it became clear that we had similar ways of avoiding abusive behaviour in our therapy. These are:
1. Listening to what they and the clients are saying;
2. Watching how the client is reacting;
3. Asking for the client's response to what they've said;
4. Listening to their inner voice. I believe that therapists can know intuitively that their inner voice alerts them to the fact that something is not right. When I feel unsettled, heavy and tired, I know that something is happening that doesn't fit for me on an inner level.
It is incumbent upon all therapists to consider how they see therapy and what their roles are within the therapy process. The creators of the many models or approaches to therapy appear to spend little time reflecting on who the client is in a psychological and philosophical sense. The literature is crowded with examples of interventions and technical know-how. Regardless of whether we are talking about counseling, individual and couple therapy or psychotherapy, Peter Lomas's comments still apply: “It is not obvious psychotherapy needs a model. However, the search for an appropriate metaphor can extend our understanding of its nature and may also expose limitations of the model on which it is at present based. Once we take seriously the emotional dimension in therapy, the technical paradigm is revealed as inadequate and any alternative model will have to be of a personal nature.” (Lomas, 1987, page 70)
The paradigm that he proposes is that of parenting. The therapist acts as an unconditionally nurturing and accepting person creating an environment for the client to feel safe so they can express feelings that were judged as inappropriate and bad. The therapist's aim is to provide a more appropriate response to the client's experience by recognising the original parent's failed interactions and responding to the client with the necessary understanding, confidence, hope and love. (Lomas, page 70) I believe that this is a paradigm that requires serious examination.
The parenting metaphor enables both the therapist and the client to relate emotionally in a real and honest way. Each can express how they feel about matters that occur outside the therapy session for the client and between them in the session. When feelings are accepted as real and important, there is the opportunity for a corrective emotional experience. A client feels what they felt in the past with full acceptance by the therapist that their experience was real and important. The therapist's action provides the comparison for the client which helps them address how others have treated them in the past and present situations. Then the client is able to grieve for the silencing they experienced by parents and partners.
In dealing with how previous therapists have harmfully treated clients, therapists are required to address confidentiality. The question we must all ask ourselves is whether we as therapists tell the other therapist who has been abusive. It is my opinion that confidentiality precludes us from ringing the therapist. I consider that in our duty of care our primary responsibility is to the clients to help them heal from their experiences. Ten people in this study were not able to complete or write about their experiences. They are still at a stage where this is not possible for them. They have not been able to contact their therapist and inform them of their reason for terminating therapy.
Therefore, these therapists and others are unaware at a conscious level of why their clients finished. This means that they will continue to use the privilege of their position and act abusively.
In considering what the helping profession can do in this matter, I recommend that:
1. All practising therapists:
(i) reflect on the nature of therapeutic power; (ii) be required to have a professional supervisor with whom they can discuss and consider issues relating to the process of therapy; and (iii) attend workshops on abuse as part of compulsory continuing education.
2. All training courses:
(i) have the subject of abuse in therapy in the course for discussion and reflection.
3. All standards committees:
(i) review their procedures for accrediting therapists; (ii) examine the advantages of video and audio assessment; and (iii) incorporate compulsory personal work, demonstrated emotional relating, ability to accept challenges, and acknowledge therapeutic errors.
4. All ethical committees:
(i) review their categories of abuse; and (ii) devise ways of dealing with the trauma of emotional abuse.
5. All professional associations:
(i) develop a comprehensive list of client's rights; and (ii) publish and advertise these to the public.
In this way, therapists can reassess and develop new ways of dealing with their therapeutic power and examine ways of helping clients heal from therapy abuse. In addition, therapists will feel confident to consider advising clients to lay a complaint against the offending therapist.
Until these matters are addressed in an open forum and emotional abuse acknowledged as occurring in therapy, I believe emotional abuse in therapy will remain a silenced activity.
I ask you to consider these issues fully before you deny or judge those clients who have been brave enough to voice their experiences. I believe that by listening to them we can learn. For myself, it has made me question what I do and how I go about my work. I fully accept that as a therapist I hold a privileged position, a position of power in relation to my clients and therefore hold a power which can be abusive. And that finally it is incumbent on me to know my duty of care towards my clients by providing them with a safe environment and a real relationship in which they can grow and heal.
Australian Psychological Society, 1986. Code of Professional Conduct.
Bass, E. & Davis, L., 1988. The Courage 10 Heal, Harper and Row.
Lomas, P., 1987. The Limits of Interpretation, Hazel Watson & Viney.
Miller, A., 1983. The Drama of the Gifted Child, Basic Books.
Miller, A., 1985. Thou Shalt Not Be Aware, Pluto Press.
Miller, A., 1990. Banished Knowledge, Virago Press.
Morley, D., 1988. "What! You're Talking Again Already?" Family Therapy Networker, MarchI April, pages 55-59.
Ramsey, M., 1989. "Professional Misconduct," unpublished paper, Tress Cocks & Maddox, Solicitors and Notaries.
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