What is considered unethical by a therapist?

I love stories. I love ethics. And I especially love good stories about ethics and ethical issues. As a psychologist who has had experience with psychotherapy in multiple ways (as a client, a practitioner, a supervisor of practitioners, and an author who writes about the topic) I have lots of good stories about ethical issues and have seen many examples of ethical and unethical psychotherapist behavior. So, how would I answer the question above? I'd answer with-- (c) aspiration of or desired outcome of most practicing psychotherapists.

My experience as a psychologist and a supervisor of practitioners tells me that most psychotherapists don't enter the profession to be unethical. They enter the helping professions to do good by their clients, to treat them with respect and dignity, and to make the world a better place for human beings. In short, most individuals who enter the helping fields do so with the aspiration and desire to be competent and caring psychotherapists. But let's face it: Therapists like everyone else are human beings with the capability of losing perspective, of doing harm and /or of being self-serving. Many of us have probably heard or read about (or experienced) a therapist who acted unethically: was sexually involved with a client, violated a client's confidentiality, or was incompetent in their practice.

Unethical behaviors by psychotherapists happen for multiple reasons. Sometimes they don't take care of themselves and find themselves using their clients to meet their personal needs. Or sometimes they might not stop and think about what they are saying and end up sharing information about a client. These ethical errors or unethical behaviors are usually accompanied by what Mitch Handelsman and I (in Ethics for Psychotherapists and Counselors: A Proactive Approach) call "red flags" or warning signals that indicate to the therapist the aspiration or desire to be ethical is likely to be compromised. We wrote about these red flags to encourage psychotherapists to build self awareness about themselves as persons who have great impact on the lives of others. We also wrote about "green flags". Mitch and I describe green flags as therapist behaviors that go above and beyond the minimum requirements and show that therapists really do aspire to good work.

Over the next several blogs we (my co-writer, Dr. Mitchell Handelsman, and I) will share our thoughts about "red flags" that indicate trouble ahead, and about "green flags" that signal ethical behavior by psychotherapists.

Most people assume that most therapists are well-trained, knowledgeable and competent professionals. They expect when they go to a therapist, they will receive the right care to address their deep-seated emotional issues. And a large percentage of therapists embody these attributes. But not all.

Anyone seeking a therapist is encouraged to be a critical thinker and careful consumer. Unfortunately, not all are as well-trained, competent and capable of providing adequate services as is needed for effective therapy to occur.

I had an experience years ago that left an indelible mark on understanding, statistically, how many therapists actually are ineffective. The psychiatrist I was working for shared a report from the American Psychiatric Association that was shocking. The research showed that one third of people going to therapists or psychiatrists were actually harmed by the experience. For another third there were no changes or healing, and only one third improved. Imagine if these statistics were true for physicians! How safe would you feel?

Choosing A Therapist

What do we need to know in choosing a therapist other than considering the specific type of therapy they offer? In my last blog I shared the research from Cozolino’s book The Neuroscience of Psychotherapy: Healing the Social Brain in which he stated that researchers found that… “the quality of the emotional connection between patient and therapist was far more important than the therapist’s theoretical orientation.” How does one assess the competency of their therapist so they can indeed have a high-quality emotional connection with them?

Less effective therapists may do things like talk too much, tell a lot of their own personal stories, incorporate religious or political perspectives, are inattentive, appear bored, disinterested, even exhausted. You don’t want your therapist to fall asleep on you! Some base their therapy only on providing education about emotional health without incorporating opportunities for their clients to explore the emotional side of their pain. Certainly, many therapists do include a psychoeducational component in their therapy. But, intentionally balance providing this kind of information with a focus on processing the feelings and sensations of clients coupled with an exploration around past life experiences that continue to haunt a person’s current life.

What Makes a Therapist Unethical

Then there are highly unethical and even dangerous therapists. At the extreme there are therapists who actually are sociopaths. For chilling descriptions of such therapists, read The Sociopath Next Door by Martha Stout, PhD where she describes how sociopathic therapists find joy in manipulating the lives of their patients.

While certainly not in the same category as sociopaths are the therapists who misuse their power in the therapeutic relationship by giving advice in an attempt to direct a client’s decisions. A quote from a February 2020 article by MedCircle entitled Seven Things to Therapists Should Never Do: “… the therapeutic process isn’t about advice. It isn’t about therapists telling clients what they should or should not do. Instead, therapy is about exploration. That may entail processing the risk and benefits of particular patterns or choices. It may include goals related to increasing decisiveness and harnessing a sense of personal autonomy….  . If the therapist rescues the client every time, the client does not grow. Likewise, clients become dependent on someone else telling them what to do.”

Therapists And Their Own Beliefs

Another clear and firm statement about counselors advising clients based on their own values, attitudes, beliefs and behaviors is found in The American Counseling Association’s Code of Ethics where they state “Counselors are aware of—and avoid imposing—their own values, attitudes, beliefs, and behaviors. Counselors… [should] seek training in areas in which they are at risk of imposing their values onto clients, especially when the counselor’s values are inconsistent with the client’s goals or are discriminatory in nature.”

According to the website TalkSpace advice in which the therapist tells the client what to do “… goes against the nature of therapy, a practice meant to empower clients with the cognitive and emotional skills to make great decisions without someone explicitly telling them what to do. It can rob a client of his or her autonomy…”

Why is it so unethical for a therapist to give advice? The problem has to do with a very important dynamic that occurs during therapy: transference. According to Cozolino in The Neuroscience of Psychotherapy, “… psychodynamic therapists … allow the client to project onto them implicit unconscious memories from past relationships. This form of projection, transference, results in the client placing expectations and emotions from earlier relationships on the therapist, which allows the client’s implicit beliefs to be experienced and worked through firsthand. It is through this transference that early relationships for which we have no conscious recollection are brought fully into therapy.” In many ways this therapeutic alliance is similar to the experience someone has when hypnotized and put into a mild trance: suggestions can become commands.

The Therapeutic Relationship

As the therapeutic relationship continues to grow, it is often through transference that the therapist activates unconscious memories of childhood experiences, with a parent or significant caregiver that gives the client a safe space to address deeply held unconscious beliefs. Advice-giving therapists interfere with health processes of transference.

In my next blog I will invite my readers to consider some very specific unethical behaviors especially around advice giving to enhance your abilities to recognize when these are occurring in therapy.

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