A Probabilistic View of Therapy Harm
I’ve thought about clinical boundaries often over the past couple of years, despite not being a clinician myself.
My very tentative conjecture is that therapy harm and therapy abuse may be more probabilistic than we realise.
Namely, if all harmful boundary crossings or dual relationships in therapy had a purely negative impact, I think that (paradoxically) rates of therapy harm would probably be significantly reduced. It would likely be much easier for patients (and therapists) to realise that an unhealthy situation is developing – and address it– if blurred boundaries were having a clear, immediate negative impact with no other complicating factors.
Instead, it seems like removing part or all of a boundary results in more intense fluctuations– both positive and negative – in ways that can be harder to detect initially, but more destabilising over the long term. To give a couple of examples:
1. Suppose a clinician relaxes their typical boundary on self-disclosure. In doing so, they’ve opened up a greater range of possibilities– after all, they can respond to the patient in all of the ways that they typically would, and now additionally can respond in new ways that involve sharing more information about themselves or their life. At times, this extended set of possibilities might lead to additional warmth or positives (at least in the short term.) Perhaps the therapist shares something about themselves that the patient relates to, and which genuinely helps the patient. Or perhaps the level of disclosure makes the patient feel trusted or cared for, even if in the long run this feeling may be a sign of an unhealthy dynamic developing.
And at other times, this extended set of possibilities might lead to stress, confusion, etc. What if a therapist shares something about their life that causes the patient to feel anxious about them? What if they share a perspective that the patient fundamentally disagrees with? What if something they share makes it difficult for the patient to be forthcoming? This could happen if a patient learns about key stressors or traumas in their therapist’s life and is hesitant to share challenges or traumatic memories from their own life that may overlap too closely. It could also happen if something a therapist shares makes the patient afraid of being judged (e.g. if the therapist says they had a negative experience with veganism and believe it’s an unhealthy lifestyle, the patient may be much less inclined to share that they are vegan.)
2. Suppose a clinician has a dual relationship with the patient, such as being their therapist and also being their friend. At times, these relationships may amplify each other in a positive way– the patient may feel they have all the joy of connecting with a friend, but with the added deep understanding and (relatively) unconditional care for their mental health that can occur in therapy.
On the other hand, if anything difficult occurs in the friendship, such as a disagreement, the patient now may have several layers of stress to contend with:
The direct stress of a disagreement or difficulty in the friendship
Potential concern about what this means for their therapy relationship going forwards
Potential stress/uncertainty from having to reconceptualise the therapist’s role (i.e. if they are used to the therapist being a supportive person in their life focused on understanding their perspective; it may be jarring to suddenly have the therapist be more focused on proving their perspective)
Essentially, therapy is typically a highly boundaried environment, and while these boundaries may be constraining in some way, they also may provide stability and sustainability. While this is all conjecture and very much an oversimplified model, I would imagine:
“Boundaried therapy” to draw from a sort of truncated Gaussian (below in green)-- namely, the patient may feel supported in a professional sense and may feel some warmth or positive emotional impact, but may be less likely to feel intense euphoria or overwhelmingly positive feelings or, conversely, intense devastation or stress. In the plot below, this would be the green distribution.
“Flexible therapy” (intermediately boundaried therapy) to draw from a slightly broader Gaussian– there may be more risks and rewards. In practice, creating a more flexible boundary could be helpful for an individual. For some neurodivergent or marginalized clients, strict clinical neutrality can feel distancing or even retraumatizing – so flexibility isn’t inherently problematic. But flexibility without mutual clarity or structure may still carry risk of stress or confusion. In the plot below, this would be the yellow distribution.
“Blurred boundaries” to draw from a bimodal distribution where patients may alternate from feeling high highs to low lows in a way that is likely destabilising.
Unfortunately, this may lead patients to take on more guilt or confusion over their experience with therapy as pain or hurt may be mixed with gratitude or feeling like they “should have known” earlier.
And I think it also highlights why intentions and impact can be so different in therapy harm. I believe that many therapists genuinely have good intentions (even if they may have also have subconscious motivations that they are not aware of) and I think it is rare that they consciously remove a boundary with the overt intention of hurting or confusing a patient. Rather, they may find it easier to justify increasingly blurred boundaries to themselves by focusing on the highs while disregarding the lows or framing the lows as the patient being difficult.
(I am not saying that this makes therapy harm okay at all, or that it removes responsibility from the therapist! The discussion of intentions versus impact is worth its own article at some point. But I think better understanding how therapy harm occurs may help everyone create safer therapy.)
