Can a "Mostly Well-Intentioned" Person have Abusive Behaviour?
(content note for discussion of abuse, conversion therapy, ABA, etc. In particular, the essay may be stressful to read for others who have experienced therapy abuse or harm, as it discusses at length potential intentions of the clinician.)
Yesterday, I had the chance to read a fantastic article on someone’s Substack called “Can Therapist Abuse Be Unintentional”. After reading it, I began thinking more about the topic myself (and of my own situation, where I believe my therapist had mostly good intentions despite behaving in ways that could be considered clinical abuse). Below are some stream-of-consciousness style thoughts on the topic.
Are there ever cases where abusive behaviour could be purely unintentional?
I believe this is possible in theory, although the examples that come to mind are essentially edge case hypotheticals.
For example, suppose the clinician has a sudden medical or mental health condition (e.g. a head injury, brain tumour, or psychosis causing them to believe the patient is not actually a patient but rather out to get them) which both:
Leads them to lash out at the patient in a way that is fundamentally incompatible with their core self
Impacts their reasoning so that they aren’t able to self-reflect on their current state (e.g. to realize that they shouldn’t be seeing patients at the moment)
(Side note – I definitely do not believe that people with these conditions are inherently harmful or likely to cause harm, quite the opposite! My choice of these examples comes from thinking about how, in my own life, times of attenuated psychosis or concussions have sometimes complicated my decision making in a way that likely could have been challenging to navigate if I were a therapist.)
Aside from these “edge cases”, is it possible for a clinician to be well intentioned and still have abusive behaviour?
This is a fascinating question, and I think much of it comes down to how one defines intentions. By definition, I believe abusive behaviour is morally wrong (assuming the person has reasonable control over their behaviour), and that is true regardless of what other thoughts or emotions the person may have had during the process.
At the same time, I think it can be helpful to distinguish between surface intentions and underlying motivations or attitudes. A clinician may consciously feel warmth toward the patient or believe they are helping, while still relying on the patient in ways they do not fully recognize, or having assumptions that distort how they interpret the patient’s needs.
Because of this, I believe that it is virtually impossible for abuse to occur without some kind of harmful attitude, distortion, or justification somewhere in the clinician’s thinking. In some cases, this may be overt and conscious (e.g. a clinician who deliberately enters the field to have power over vulnerable patients). In other cases, the clinician may consciously feel a certain amount of affection or warmth for the patient – or a desire to see the patient be happy – but be subconsciously relying on the patient for support or warmth or gratification.
As a bit of a tangent, I am a transgender man who grew up in an extremely conservative environment. While I never personally went to conversion therapy, the environment I was in did sometimes have “ex gay” speakers and similar figures, which provided me a small glimpse into a mindset that likely exists to a much more amplified extent in conversion therapy.
Unfortunately, I believe that some people who push for us to become “ex gay” or “ex trans” (sometimes with extremely harmful approaches such as conversion therapy) genuinely believe that they are saving us from hell, perhaps because they themselves grew up with deep indoctrination on the topic. It is hard to say that they are truly “well intentioned”, as I believe that if someone was truly open to others’ perspectives and self-reflective, they wouldn’t be practicing conversion therapy. However, I do view it as an example of how someone can believe they are doing a good or even noble act while actually traumatising the person they believe they are helping.
It also taught me that people who otherwise might deeply care for my well-being (e.g. go to great lengths to help me if I am physically ill, be incredibly kind in many ways) can simultaneously fundamentally try to change me as a person in deeply painful ways.
In short, I believe that clinicians who engage in abusive behaviour can, at times:
Feel warmth for their patient
Not want to see their patient in distress
Consciously believe they are helping their patient (even if they are actually causing significant harm)
In some ways or situations, be willing to put in time or energy with the goal of benefitting the patient
(Though I also believe there are clinicians who have none of the above.)
However, I generally believe that – even if a clinician does have some of the elements above – underlying this there will be some combination of:
Using the patient to meet their own emotional or other needs (with or without consciously realizing it)
Wanting the patient to make progress in a certain way in order to feel effective as a therapist
Defensiveness or unwillingness to listen to difficult feedback from the patient, or unwillingness to fully realize the degree of harm they caused
Not fully accepting all aspects of the patient’s experience or identity, or having a distorted view of the patient
Inadequate follow through (e.g. having well wishes to the patient in theory but being neglectful or careless in practice)
The clinician’s own burnout, overwhelm, etc.; especially if they don’t recognise it or take adequate safeguards for it
My own experience illustrates what I mean by these kinds of mixed intentions.
Why do I keep emphasizing that I think my own therapist was well-intentioned?
Firstly, I think at times I haven’t been very careful in framing my discussion of her intentions, and in hindsight wish I had approached it in a slightly more nuanced way.
I don’t actually think my previous therapist was perfect in her intentions – I believe there were times where she was defensive and also (a bit more speculative here) perhaps she was relying on me for emotional support at times without fully recognising it, or at least wasn’t adequately reflective about how the trauma in her life was spilling over into her practice.
But when I say she had “good intentions”, I mean the following:
I believe she is overall a kind and self-reflective person
I don’t believe she ever consciously meant to cause me harm, and at times she seemed to take efforts to provide care even in ways that were likely inconvenient for her
She also had multiple major, consecutive traumas in her life during the final period of working with her. I don’t want to treat her as completely helpless or unable to take responsibility for her own actions, as I don’t think that is true. At the same time, I also don’t know if she was “fully herself” (for lack of a better term) during that time period, which was when the significantly blurred boundaries occurred. She seemed to be struggling greatly overall in her life.
In that way, the situation seemed different from a clinician who has more calculated abuse of vulnerable patients behind closed doors, while otherwise appearing to “have it together” in public.
I also believe that she had reasonably good clinical ethics and a great deal of openness to feedback prior to the final couple of years of us working together, and noticed a few ways in which she seemed very thoughtful about boundaries at the time.
In other words, I think it is possible for someone to be broadly kind and reflective as a person while still having specific needs or defensive reactions that lead to harmful therapeutic dynamics.
Why do her intentions matter?
I guess that the simplest reason is that they matter emotionally to me. I don’t think it erases the wrongness of the clinical abuse or the harm. However, I almost view intentions as being a separate dimension, and I draw a small amount of comfort from believing that she didn’t want me to be hurt.
More generally, there are two other reasons that intentions might matter.
1.) Tentatively, I believe that intentions can be relevant in the repair process. For example, a clinician who is actively malicious toward their patient may be more likely to retraumatise the patient in the process (and may use any termination session or other process to retaliate against the patient). A clinician who has more mixed intentions (e.g. some care but also some defensiveness and other motivations) might still cause further harm to the patient in the process, and I believe that any interactions after therapy abuse should be treated with extreme caution. However, I believe that my therapist’s intentions did play a role in her offering some acknowledgement of harm and a willingness to have a facilitated meeting; and I doubt it would have been healing at all if her intentions had been primarily exploitative.
Likewise, I imagine that intentions may be relevant in processes like supervision, particularly after harm or ruptures in therapy (e.g. in an ideal case, the supervisor might take into account the therapist’s intentions to more effectively work with them on lowering their defensiveness and understanding the impact on the patient).
2.) Finally, and as a key point to me – I actually view my case as a cautionary tale. Maybe part of the reason I keep emphasizing her good intentions is that I would love for more clinicians to become aware that – even if they are genuinely kind people who care about their patients and their work – there may still be a possibility that their boundaries could gradually slide under pressure, burnout, or stress. Without adequate self-reflection and support, they too could be at risk of causing significant harm.
Sometimes I worry there is a risk that clinicians might hear about clinical harm or abuse and think something to the effect of: “oh, that’s terrible, but I guess that probably only happens to a few therapists who are fundamentally bad people,” when I believe the problem is broader and more complex.
Finally – do I believe that patients should feel an obligation to understand their therapist’s intentions after abuse?
No. I don’t believe any of the above should ever be used to pressure patients to be more understanding or softer on their therapists after abuse.
