There is a mantra in the mental health field, a code of ethics that we all live by: “first do no harm.” This seems like an obvious idea but, in truth, the definition of “doing harm” may not be universally understood and agreed upon. The relationship that is forged between a client and his or her therapist is an extraordinarily emotionally intimate and vulnerable one. There is an inherent expectation that the client will, in time, disclose deeply personal thoughts and feelings, as well as allow us to bear witness to past and current behaviors that may be quite shame-based for them. It is our ethical responsibility to create and maintain an environment of emotional and physical safety for clients so they are able to reveal, process, and transcend their most difficult memories and experiences in ways that feel reparative and never re-traumatizing.
In the earliest stages of treatment the onus is on the therapist to appropriately establish boundaries and clearly articulate the parameters of the relationship. In this day and age that includes whether or not e-mails, texting, after hour phone calls, doing sessions by Skype, meeting you outside of the office, or connecting with you on Facebook are going to be an allowable part of the therapeutic alliance. When it comes to these issues, we shouldn’t assume clients understand what is and is not appropriate. Our job is to model what is appropriate, and then maintain consistency. Blurring or crossing boundaries, engaging in a dual relationship or continuing to work with clients when there is a conflict of interest, repeatedly going over the allotted session time, making the agenda for therapy ours and not the clients, or fostering co-dependency, are often therapy missteps that have their roots in the clinician’s own unresolved issues.
It is also essential for us to keep in mind the potential feelings of inadequacy, shame, confusion, and incompetence that clients struggle with when they enter treatment. They often don’t understand why they have their symptoms or untenable thoughts and feelings, and mistakenly believe that their struggles represent “evidence” of being crazy, damaged, broken, or bad. The extent to which we, inadvertently, reinforce these ideas by pathologizing, blaming, or shaming our clients, goes a long way towards either helping them to heal or solidifying and deepening their trauma. Even when we simply suggest possible theories about why clients have somatic complaints, engage in a certain behavior, remain in an unfulfilling relationship or job, we must remember that our theories and suggestions carry tremendous weight and are often taken as gospel, especially by young or vulnerable clients. It is far better to invite the client to be curious about their issues and struggles, in a non-judgmental and compassionate way, and to help re-frame the cognitive distortions they propose in a therapy session, so our silence is not mistaken for agreement.
Some therapists believe that maintaining total neutrality and an almost disengaged or highly intellectualized stance is a good way to “do no harm.” This can actually backfire when clients experience it as a lack of attunement, warmth, or concern for their feelings and their circumstances. Conversely, the therapist who cries alongside their clients and becomes overtly distressed, angry, dissociative, or overwhelmed, is operating from a place of emotional disequilibrium that can lead to role reversal or the client’s fear that they are “too much to handle” and irreparably “broken.” The challenge for us as clinicians is the balancing act of dual awareness. It’s being “present” enough to simultaneously ask ourselves during the session, “what’s going on for my client AND what’s going on for me?” When we lose sight of the client’s process or we lose sight of our own counter-transference, there is the potential for deviations in the standard of care, a loss of safety in the room, a breach of trust, a rupture in attachment, blaming the victim, missing critical information that is being communicated verbally or non-verbally by the client, an abrupt termination, or therapist burn-out. The notion of “doing no harm” is an important concept. However, we should operate from a much higher credo that pushes and encourages us to be supremely sensitive to the emotional vulnerabilities of our clients, and to make the therapeutic relationship and environment conducive to ego-strengthening, personal growth, and true healing.
Have you found yourself caught up in this type of experience? Share your experience and solutions to the problem in a comment.