Abuses of Power - When Therapy Harms (Part 1): Five Warning Signs of Abusive Therapy

Abuses of Power: Power Differentials in Professional Relationships

Power differentials exist in many professional relationships.  In professional relationships (with therapists, doctors, supervisors, teachers, clergy, etc.), the power differential can feel overt or subtle.  Generally, being a client, patient, or student means that you have entered into a professional relationship with someone you are hoping to learn from - whose expertise, experience, and/or training in a particular area will benefit you in some way.  When you seek help from any professional, there is a sense of vulnerability (to varying degrees) required for you to learn, grow, and/or heal. 

Today’s post focuses on power differentials in therapy, and how to recognize the misuse or abuse of power by a mental health professional.

When Therapy Harms (Part 1)

When you decide to seek out therapy, you are looking for someone to help you with a particular struggle, problem, or concern.  It's similar to going to a doctor when you don't feel well, with the hope that your doctor will listen to you, identify the problem, and offer an appropriate treatment.  You are counting on the doctor's expertise, experience, and training to help you feel better.  In much the same way, most people attend therapy because, in one or more ways they don't feel well.  Therapy is an investment aimed at moving you toward mental wellness, with the therapist utilizing their expertise, training, and experience to help you achieve the goal of feeling better.  

It’s always disheartening to hear a client talk about how they’ve had negative experiences with therapists. Some negative experiences are normal, if you happen to be working with a therapist who just isn’t a good fit for you in their personality or style of counseling.  Finding a good therapeutic fit is important, and when styles or personalities don’t mesh, it’s time to seek someone with whom you feel more comfortable. 

Harmful therapy experiences are different than a mismatch of personality or style, though.  If you’ve never been to therapy before, you might not yet be familiar enough with the process to determine good therapy from bad.  You might not know what therapy is supposed to look like.  Making things more complicated is the fact that therapy can look vastly different from one experience to another.  This is good news in that you can find a therapist with a style of counseling that fits well for you.  On the other side of the coin, though, there is no 100%, clear-cut, same-across-the-board picture of what good therapy looks like.  It can look different from one therapist to another, or one therapeutic technique to another.  However, there are licensing boards with rules and ethical guidelines that therapists must follow.  These guidelines can help you decipher a healthy versus unhealthy therapeutic relationship.

5 Warning Signs of Abusive Therapy:

  1. Breaches in confidentiality - what you say in therapy should remain confidential. There are exceptions to this rule, some of which include if you are a danger to yourself or to others, or if you report a child or an elderly person is being abused. In general, though, the therapist should not talk about you or what you say in therapy with their friends, family members, other clients, etc.

  2. Breaches in privacy - therapist are legally required to keep your health information private in a variety of ways. Without your express permission, your therapist is not allowed to even acknowledge that you are a client. There are exceptions to this rule, as well, but in general - your therapist should not disclose that you are a client without your express, written permission. Generally speaking, if you see your therapist out in public, your therapist should not approach you, wave, say hello, or in any way acknowledge that they know you. They aren't being rude - they are simply protecting your right to privacy! It is up to you whether or not to disclose that you are in therapy.

  3. Blurring relationship boundaries - though a therapist might feel like a friend, the therapeutic relationship is a professional relationship. It is generally unethical for a therapist to engage in any kind of relationship with you outside of therapy. This means that a therapist should not hang out with you outside of the therapy setting. There are few exceptions in which a therapist may engage with you outside of the office when it is clearly therapeutically beneficial, but these exceptions are very limited and aimed toward achieving very specific therapeutic outcomes, and for very particular sets of problems or issues. It is always unethical, and never okay, for a therapist to enter into a romantic or sexual relationship with you!

  4. Fostering dependence - when you are just getting started, or doing really hard work in therapy, you might start to feel dependent on the therapist. This is completely normal and natural. However, it is the therapist's job to empower you over time, to learn skills and techniques that help you to manage symptoms, and function independently. The nature of a successful therapy relationship means that it will eventually end, and empower you with skills and resources to function independently, and in more healthy ways. Some people spend longer in therapy than others, and some issues require more time to resolve, but therapy is not intended to last forever. If a therapist says things like, "you need me," or, "you can't get better without me," - these are both red flag statements that the therapist is misusing their power in the therapy relationship.

  5. Withholding information - you should understand what is happening in therapy, and your therapist should be open to answering your questions about how you are working toward goals, and what techniques are being used and why. Therapists are trained specialists, and exploration of your history and concerns, as well as challenging the way you look at things, is part of the process. However, you are the client (or the customer), and you are in charge! You have every right to know and understand about your treatment options, and understand what is happening in therapy.

Potential Effects of Abusive Therapy:

1.      “It’s my fault” – (guilt/shame/misplaced responsibility). While I do understand where this belief might come from, it simply is not true.  I’ve heard clients say things like, “I’m an intelligent person. I should have known better.”  The truth is that, yes, you are an intelligent person – but you entered into a professional relationship with a therapist who is responsible for practicing ethically, legally, and working to “do no harm.”  You should expect to be able to trust in a therapist to use their knowledge and position of power to help you, not to hurt you. 

2.      “I’m so confused” – (confusion/ambivalence), Most of the time, therapist misconduct evolves over time, and is not overtly obvious.  As with almost everything, there are exceptions here, as well.  I will write more about additional warning signs of abusive therapy in Part 2, but for now, I want to help to normalize your experiences of confusion.  When you start out working with a therapist, have spent time building rapport and trust, and then eventually that source of support becomes hurtful– the result is lots of confusion and ambivalence in remembering when the therapist was trustworthy and kind, mixed with remembering when the therapist was hurtful and abusive.

3.      “I can’t trust anyone. I can’t trust myself” – (mistrust). Trust in therapy, especially for those of you who experienced trauma and abuse before entering therapy, can be very difficult to achieve in the first place.  When a therapist proves untrustworthy or abusive, it solidifies those beliefs that you might have had in the first place – that people cannot be trusted, and trusting people can only lead to more pain.  Furthermore, abuse by a therapist leads to doubt in your ability to trust yourself.  “How can I know that this won’t happen again?”

4.      “I want to die” – (despair/hopelessness). You entered into therapy to feel better, and perhaps to recover from prior experiences of abuse, neglect, or harm.  An abusive therapist, instead of inspiring hope, has instead shown you that there is only more pain.  If you are thinking about suicide, I want to encourage you to do something totally counterintuitive – give it one more try and reach out for help!  While there are therapists out there who abuse their positions of power – there are far more therapists out there who want nothing more than to help you regain a sense of hope, see that there is still good in the world, and help you to heal. 

While I do not have any magical words that will help you to trust that there is real, healthy, and sincere help available, I do hope that by writing this series about this little-talked-about form of abuse of power will give you a sense that you are not alone, that this has happened to other people - and that there is a way to heal from the pain of the past, reclaim your sense of self, regain your ability to trust, and to find your own infinite possibilities for a happy and meaningful life beyond therapist abuse.

Kristen Henshaw, a Licensed Professional Counselor (LPC), specializes in helping those impacted by misuses and abuses of power – including, but not limited to emotional, physical, and sexual abuse by parents, therapists, clergy, teachers, physicians, and others in positions of power. For a respectful and gentle approach to healing, contact her for your free thirty-minute consultation.

The Impact of Emotional and Narcissistic Abuse

The impact of emotional abuse is devastating, though it is often minimized by others, and by the survivors of the abuse themselves.  Many emotional abuse survivors say things like, “I didn’t have it so bad. It could have been worse!” Many survivors attempt to shrug it off, stating that they are (or were) too sensitive, or that the mistreatment either didn’t matter, or that they deserved it.

The thing is – emotional and narcissistic abusers intend for you to feel that way! If you feel as though your experiences are your fault, or that they just don’t matter, then the emotional abuser has you just where they want you – stuck, and often blaming yourself or minimizing your experiences. The abuser has taught you, through chronic invalidation of your feelings and experiences, to invalidate yourself.

If you’ve experienced emotional or narcissistic abuse as a child, or as an adult, the abuse can result in many current day struggles – even if you’ve been able to remove yourself from the abuser. Some of these issues include:

Perfectionism:

You seem stuck on the idea that, if you just do things better, then the belittling, invalidation, and insults will stop. You work to perform to perfection, thinking that if you can just be perfect, then you can earn the love of the emotionally or narcissistically abusive person.

Giving Up:

On the opposite side of the coin – if you have done your best to be perfect and discovered (as inevitably one will) that perfection is impossible, you may stop trying altogether. You find yourself saying, “What’s the point?”

Trust Issues:

Your reality has been questioned or manipulated so many times, that you start to have difficultly trusting others, and trusting yourself. When you cannot trust others, you start to feel isolated and afraid to let your guard down enough to develop friendships or relationships. When you cannot trust yourself, you also isolate out of fear, feeling unable to trust your own judgments enough to protect yourself from more hurt.

Indecision:

You have extreme difficulty when trying to make decisions. This stems from being constantly told that you were not good enough, or that you could not trust your own perceptions.

Hypervigilance and Anxiety:

Living with an emotionally or narcissistically abusive person often results in the feeling of having to walk on eggshells constantly. You never knew when the next explosion would occur, so you learned to be on guard all the time. Not only is hypervigilance physically and mentally exhausting, but leads to long-term struggles with anxiety, and an inability to relax.

Dissociation:

When you feel trapped, and forever in no-win situations, sometimes the only thing left to do is to mentally check-out. Overwhelming feelings become too burdensome, and you do what you have to do to keep going through the motions of life. You might find yourself on auto-pilot, feeling disconnected from yourself or the world around you, because your experiences have become too overwhelming to consciously acknowledge.

Fear of Abandonment:

Especially if you experienced emotional or narcissistic abuse as a child, you may have developed a heightened fear of people leaving you, or abandoning you.

Low Self-Esteem:

The more you heard that you were unworthy, the more you started to believe it. You might now feel inferior to others, like your needs don’t matter. You might go so far to say that you don’t have needs at all. Low self-esteem has a list of symptoms of its own: depression, anxiety, fear, hypervigilance, self-sabotaging behaviors, social withdrawal, sensitivity to criticism, and difficulty living in the moment.

Symptoms of Posttraumatic Stress (PTS) or Posttraumatic Stress Disorder (PTSD):

As much as people still want to believe that emotional abuse is somehow less significant than physical trauma, emotional and narcissistic abuse is traumatic. Many of the issues listed above coincide with symptoms of posttraumatic stress including: hypervigilance, dissociation, detachment, self-blame, and isolation. In addition, other symptoms of posttraumatic stress include: intrusive thoughts, flashbacks, nightmares, avoidance, and difficulty with sleep or concentration. 

Physical Ailments without Medical Cause:

The stress of living in an emotionally abusive environment takes its toll on the body, as well. Some common physical symptoms are headaches, stomach problems, weight gain or loss, fatigue, insomnia, and lowered immunity to illness.

Recovery

If you grew up in an emotionally abusive environment, or if you’ve found yourself on the receiving end of narcissistic abuse as an adult – you may relate to one or all of the above mentioned effects. You might feel a bit lost, wondering if you will ever find your way back to the person you once were.

There is help and hope. When people have been traumatized in any way, sometimes their experiences can feel incoherent or jumbled. Seeking counseling can help you put the pieces back together in a way that makes sense, and frees you to live your life fully once again.

The truth is, you can recover. You can find your way out of the madness. You can learn to trust yourself and others, and regain your sense of self. You never deserved to be on the receiving end of emotional or narcissistic abuse. You DO deserve to be treated kindly, and with respect. 

Kristen Henshaw, a Licensed Professional Counselor Intern at Counseling South Austin under the supervision of Ann Stoneson, LPC-S, specializes in emotional and narcissistic abuse recovery, as well as high sensitivity and dissociative disorders. She offers sliding scale counseling and EMDR. Contact her for your free thirty-minute consultation.

My Answers to Frequently Asked Questions for DID Therapists

Last month, I wrote a post addressing some concerns of people with Dissociative Identity Disorder (DID) who are trying to find a therapist to work with.

As promised, these are my answers to some of the questions that folks with DID are often curious about when interviewing a potential therapist.

Didn't find the answer to your question?  Feel free to contact me with your specific question, to learn more, or to set up your free consultation.

-          How long have you been working with DID?

I started working clinically with DID and other dissociative disorders in May 2015, before I graduated and while completing my master’s level internship.  I have been independently researching trauma and dissociative disorder treatments since 2000, and have spent several years with people who have Dissociative Identity Disorder.  Since graduation, I have continued to work with people struggling with trauma-related issues including: dissociative disorders (including DID), post-traumatic stress disorder (PTSD), complex post-traumatic stress disorder (C-PTSD), anxiety, and depression.  I have gained clinical experience in both supervised private practice, Ross Institute's inpatient program (now located in Denton, TX), and partial hospitalization and intensive outpatient programs.

-          Where did you get your DID experience or training? 

-          How have you continued your education or training?

Part of my master’s level internship was completed at the Ross Institute, then housed at Timberlawn in Dallas, TX.  The Trauma Program is now operating out of UBH Denton (http://ubhdenton.com/trauma-program).  I have continued to study and/or obtain Continuing Education Units (CEU’s) in Trauma Model Therapy, Ego State Therapy, the Structural Dissociation Model, Attachment Theory, neurobiology of trauma and PTSD/C-PTSD, Eye Movement Desensitization and Reprocessing (EMDR), and various treatment models for dissociative disorders and PTSD/C-PTSD.  I am also a member of the International Society for the Study of Trauma and Dissociation (ISSTD). To find out more about ISSTD, visit their website at http://www.isst-d.org/.  ISSTD provides access to some of the most up-to-date research in the field. 

-          How well do you understand PTS/PTSD/C-PTSD?

I have a firm understanding of PTSD versus Complex PTSD, as well as PTS.

PTS: Post-Traumatic Stress

Post-traumatic stress occurs when a person has witnessed or experienced a traumatic event, and exhibits symptoms of PTSD, but does not meet the diagnostic criteria for PTSD.  The symptoms are the same, but they do not last as long (they may diminish or lessen after a few days, and typically do not last longer than a month or so).  If the symptoms do interfere with your day-to-day functioning, they don’t interfere for an extended period of time. 

Symptoms of PTS include:

-Feeling anxious or uneasy

-Shakiness

-Increased heart rate

-Feeling distracted

-Sweatiness

-Nightmares about the experience

PTSD: Post-Traumatic Stress Disorder

PTSD is caused by experiencing or witnessing one or more traumatic events, or learning that a loved one has experienced a trauma.  First responders and other professionals who hear details about traumatic experiences can also develop PTSD.  These events include, but are not limited to a car accident, rape, assault, or combat.  Symptoms of PTSD last for more than a month, are ongoing and severe, and significantly interfere with functioning in one or more areas of your life (occupational, social, etc.). 

Symptoms of PTSD include:

-Nightmares

-Flashbacks

-Intrusive Thoughts

-Hyper-vigilance

-Exaggerated startle responses

-Isolation

-Decreased interest in activities

-Negative mood

-Difficulties with feeling positive

-Difficulty concentrating

-Difficulty sleeping

-Engagement in risky behaviors

-Inability to recall key aspect of the trauma

- Amplified blame of self or others for causing the trauma

-Avoidance of trauma-related thoughts, feelings, or reminders

-Emotional distress or physical reactivity after exposure to reminders of trauma

-Derealization (feeling that things are not real, distorted, or distant)

-Depersonalization (feeling detached from oneself)

C-PTSD: Complex Post-Traumatic Stress Disorder

C-PTSD is not an official diagnosis, but a well-known type of PTSD caused by interpersonal or social, ongoing traumatic experiences.  These can include experiencing childhood abuse, physical abuse, sexual abuse, emotional abuse, exposure to gaslighting, domestic violence, a history of being bullied, torture, and/or ritual abuse.  C-PTSD develops when a person experiences multiple, chronic, inescapable traumas.

Symptoms of C-PTSD include symptoms of PTSD, in addition to:

-Emotional dysregulation

-Inhibited or explosive anger

-Chronic sadness

-Suicidal thoughts

-Feel easily overwhelmed

-Helplessness

-Worthlessness

-Guilt and/or shame

-Fragmented sense of self

-Intimacy issues

-Trust issues

-          How do you feel about or view DID?

I feel like I could write an entire, separate blog post on this topic.  In a nutshell, I view dissociation as a protective factor that ensured survival, and an ingenious way to cope, and a creative means to manage in completely overwhelming circumstances.  I understand where the “disorder” part of DID comes into play, as well, because for many folks it starts to get in the way of functioning or one’s ability to experience joy in their lives.    

-          Do you work with all of the parts of a DID system?

Absolutely, yes!  Any and all parts of any and all systems are welcome, and encouraged to participate in the counseling process.  To me, stating that I only work with the “host,” or the "ANP," or any other particular part of a system would be like saying to a “singleton” that I am only willing to work with one aspect of their personality.  It doesn’t make sense for “singletons” in counseling to not work on themselves as a whole, and it doesn’t make sense for someone with DID either, in my opinion. 

-          Do you consult with other professionals when needed?

Absolutely, yes!  I network with local professionals, attend additional trainings, and consult with other professionals who specialize in dissociative disorders on a regular basis.

-          How frequently are sessions scheduled, and how long do they last?

This depends completely on the client’s individual needs.  Typically, 1-2 sessions per week at either 50 or 80 minutes per session.

-          What is your fee, and do you accept my insurance?

My current fee can be found here.  I do not accept insurance, but am happy to provide receipts for reimbursement for the client to file for out-of-network reimbursement.  I always encourage clients with insurance to interview with clinicians who accept their insurance, or check with their insurance provider to determine if they can be reimbursed for out-of-network therapy with me. 

-          What is your policy regarding emails? Phone calls? Crises?

Email is not a secure form of communication.  There is no way to 100% ensure that emails, which are stored on servers, will not be read by third parties.  I have a conversation with potential clients regarding email, privacy, and confidentiality.  Clients are then free to decide if they want to email personal information.  I will generally respond with non-clinical information to let them know I received the email, encourage them to bring their emailed concerns to the next session to discuss, or if necessary, I will follow up with a phone call.

Occasional phone calls between sessions are fine within the function of needing some encouragement or help with grounding.  If the return phone call goes beyond a certain time frame, I charge additional fees.

I am always sure to explain that I do not work in an environment conducive to responding to crises, as it sometimes may take me 24 hours to respond.  I develop a crisis plan with clients, listing emergency numbers, contacts, and suggestions for coping.  If repeated crises are occurring several times per week, and the client is frequently unable to regulate or keep themselves safe, I might suggest a higher level of care until they are able to stabilize.

-          How do you feel about integration as a counseling goal?

A goal of full integration (or fusion of parts) is completely up to the client, and completely respected as a decision that only the client can make.  Integration of information, including access to one's own adaptive neural networks is helpful in resolving trauma.  I do not push clients toward integration as a goal, as most of my experience involved DID goals of cooperative functioning.  Again, I’ve known many unintegrated folks with DID who are extraordinarily high functioning, and living happy, balanced, and productive lives.  I have known others who wish to fully integrate, and I respect each client’s decision.

Kristen Henshaw, a Licensed Professional Counselor Intern at Counseling South Austin under the supervision of Ann Stoneson, LPC-S, specializes in trauma recovery, dissociative disorders, and supporting those who have experienced chronic invalidation, manipulation, or gaslighting in relationships. She offers an affirming environment and welcomes diversity. Contact her to schedule your free thirty-minute consultation.