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Consumer Protections In Psychotherapy Reduce Access to Care

A while ago these two things happened on the same day: 1) I read about a psychiatric patient who had just gunned down his doctor and whoever else was nearby. 2) A prospective client accused one of our intake workers of horrible untrue things, in response to the form e-mail introducing our treatment program.

I do not equate getting insulted with getting shot. Still, I felt stressed out and vulnerable — like a target.

It should be obvious that working with highly distressed people can be dicey. But I managed to get through the first couple of decades of my career feeling reasonably secure. I used to believe that as long as I was conscientious and did good work, it would be okay.

I no longer believe that. I have seen too many instances of therapists who were conscientious, who did good work, and who nonetheless were harmed by their clients. Here are some examples – disguised, of course – that I have learned about from therapists in the community.

1. An older teen with a history of psychosis went to therapy for seven months, proclaimed that she was better, and discontinued treatment against the therapist’s advice. She actually was at least somewhat better, and the improvement persisted for almost two years. Then new life stressors led to another psychotic episode as well as more general deterioration. She blamed the therapist for this and demanded a million dollar settlement. The therapist demurred, but did offer to either resume treatment or make a referral; these offers were declined. The client then created a facebook page “to inform and protect the public” by maligning the therapist with a number of false and outrageous allegations. The therapist’s attorney advised that the therapist could easily win a libel suit – extensive documentation clearly disproved the allegations – but doing so would cost an estimated $60,000, which would not be recovered from the penniless client.

2. A recently divorced couple was court-ordered to therapy for co-parenting. In the first session, the therapist remarked on her observation that the ex-husband had just stood up and yelled, and the ex-wife cowered. The ex-husband then yelled at the therapist, “I didn’t come here to be ganged up on!” and stormed out of the room. An hour later, he posted a negative review online, accusing the therapist of being a man-hater and unfairly ganging up with his ex-wife against him.

3. The court had found that a 5 year old boy had been abused by his father, put a hold on visitation, and required the mother to take the child to a therapist. After six months, the court asked the therapist for an update, and the therapist advised that the child should continue to be protected from any contact with his abuser. The abuser filed a complaint with the licensing board, claiming that the therapist “implanted” false memories of abuse in the child’s mind. It cost the therapist about six weeks of her time, plus about $100,000 in legal fees, to defend her license from the complaint.

These rather typical examples represent two main types of situations: mental health issues and abuse tactics.

     Mental health issues. Clients whose mental functioning involves distortion of reality – such as the teen in the first example – may sincerely believe what they are saying. This happens not only when a client or former client is delusional, but also when they are prone to misinterpreting and then not able to recover. For example, a client told their therapist about a restaurant they particularly liked, and the therapist mentioned another restaurant that he thought the client might also like. This offense led to the premature termination of treatment. As the client explained, “The restaurant I like to go to is really good about not serving me anything I’m allergic to. But you obviously don’t care if I’m safe, you want me to go to some other place where I could end up in the hospital.” And even though the therapist actually did care about the client’s safety, no matter how he explained that, the client’s misperception persisted.

     Abuse tactics. When a person who is abusive is challenged or held accountable, the typical response is to DARVO: Deny, Attack, and Reverse Victim and Offender. This tactic was used in the second and third examples.

Parents who abuse their children routinely use this approach by accusing the non-offending parent of “alienating” the child from the abuser via bad-mouthing, coaching the child to lie, and brainwashing the child. Abusers also commonly target anyone else who stands up for the child’s safety, as allies of the supposed alienator. This tactic has been devastatingly effective in pathologizing the non-offending parent (and other child allies), neutralizing the (true) allegations of abuse, and maintaining the abuser’s access to their victims – despite the fact that the parental alienation hypothesis has been definitively debunked as junk science. In this environment, courts and licensing boards often take the DARVO complaints (against therapists) seriously enough that therapists have to devote enormous amounts of time and money to defend themselves.

Short of a suit or complaint, negative online reviews and “gripe” web sites can also cause considerable stress as well as lost business. And therapists cannot easily defend themselves. We can’t post a reply to the review because of client confidentiality. We could sue for libel in some circumstances, but the legal fees are prohibitive. It can take a lot of time and money to get a smear off the internet.

It’s so easy nowadays for a client, former client, or related party to do harm. The internet is easy to access, and so are guns. A therapist experiencing harm is no longer a rarity; to the contrary, it’s commonplace. We never know when someone is going to lash out with a negative review, a complaint, a law suit, or even a fist or a gun.

So what to do about this? I hesitate to propose special rights or immunities for therapists, because there are therapists who do harm, and clients must have recourse in such cases.

On the other hand, therapist vulnerability has led to lack of care for certain types of clients. Because we therapists vote with our feet. We try to protect ourselves by avoiding those clients or situations we perceive as dangerous. Just for one example, on several occasions I have tried to make a therapy referral for an abused child who is the subject of a custody battle. Most therapists won’t go near it. Because they know that when an abusive, litigious parent is involved, therapists get harmed. And the child who may desperately need help cannot get it.

I could give other examples but they would all make the same point: that we try to protect ourselves by refusing to get involved with certain types of clients or situations. Individual therapists draw the line in different ways, but we all make choices that balance our desire to help people with our need for personal safety and security.

This is an unfortunate choice to have to make. If therapists were safer from unwarranted attacks, we would be more willing to help those people with qualities and/or in situations we may now perceive as dangerous.

In other fields, we are better at taking risks into account. For example, the danger in police work is recognized, so police officers may work in pairs or teams, they can radio for back-up, they are trained in de-escalation tactics, they wear video cameras to record their appropriate behavior, and they carry weapons which they have the right to use when necessary for personal safety (or for the safety of others). Police officers are not required to be defenseless, and this empowers them to do their jobs.

Psychotherapists should also not be required to be defenseless. For example, perhaps if a client maligns a therapist in a public manner, that could be considered a waiver of confidentiality so the therapist would be allowed to defend themselves in a public manner. Perhaps the role of licensing boards could be modified from the current consumer protection orientation to the dual orientation of protecting both consumers and professionals. I have not thought these proposals through, and do not specifically endorse them. I’m just giving examples of the kinds of possible solutions that we should at least be considering.

Please note that I do not intend this as a rant against therapy clients, the vast majority of whom manage to get through their treatment without being aggressive or threatening towards those trying to help them. Nor am I asserting that therapists do not, on occasion, deserve a negative review, complaint, or law suit. My intention here is to highlight the problem of therapists’ systemic inability to protect themselves from unwarranted harm. This leads therapists to avoid those clients/situations perceived as dangerous or risky, so certain types of clients are unable to access the treatment they need.