Mediation after Therapy Harm
by Sam Brandsen, with acknowledgements to David Meer and Natalie Russ for sharing their incredible insights on this topic
I would also like to acknowledge Drs. TC Waisman and Kristen Gillespie for their support on a related (ongoing/upcoming) manuscript on mediation in autism research, as some of those discussions have shaped my perspective on mediation more broadly.
This document is very much a work in progress! If you have thoughts or feedback, please feel welcome to contact us at hello@allneurotypes.com
What is mediation and why pursue it? An introduction.
After harmful or traumatic experiences in therapy, patients/clients often are left in a vulnerable state and may be experiencing several conflicting emotions (e.g. attachment, confusion, hurt, anger, sadness, gratitude) towards their therapist. Unfortunately, patients often have few resources (if any) that allow them to gain closure from their therapist.
We believe it is important for patients to have access to a process that is focused on their well-being and healing. In the context of therapy harm, mediation often involves an independent, trained third party who acts as the mediator. In some cases, mediation may consist of the mediator facilitating a joint meeting between the patient who was harmed and their clinician. While mediation can take on several different forms depending on the specific situation and needs of the patient, the main goal is to provide patients with external support as they seek healing and/or closure from their therapist.
The goal of this article is to propose a model for the use of mediation when therapy harm has occurred. In particular, our aim is to maximise the potentially supportive qualities of mediation whilst trying to mitigate potential risks.
Mediation may have significant potential to offer additional, valuable support to patients who were harmed. Ideally, the mediation process can be set up to:
Encourage clinicians to take accountability for harm caused to the patient and to acknowledge the impact of their actions on the patient (as this is often a vital part of supporting patients in healing)
Assess the needs of the patient and provide support based on those needs
Provide the patient with an opportunity to give specific feedback or suggestions to the clinician (if they wish)
Provide private support to the clinician in working through any complicated feelings (e.g. defensiveness, shame, sadness, frustration) as well as suggestions for additional support
Mitigate potential risks of therapist-patient interaction (e.g. further harm from defensiveness, coercion, or gaslighting of the patient)
Critically, mediation is not a legal process. Currently, our systems are better equipped to adjudicate liability or fault than to facilitate healing. Our mediation model draws on restorative justice principles and prioritises the client's autonomy, emotional safety, and relational accountability over legal resolution. We recognize that healing from therapy harm—particularly when it involves identity-based or systemic oppression—requires not only acknowledgment that harm happened, but an intentional process of repair defined by those impacted.
The goal of this article is to discuss ideas maximising the potentially supportive qualities of mediation whilst trying to mitigate potential risks. With that said, we realise that there is not one “right” way to approach mediation and that each situation is likely going to be unique and complex. While this article focuses on practical ideas for mediation in the “real world”, in time we hope to explore what mediation might look like in a more ideal setting.
In case it is helpful to contextualise our manuscript – Sam Brandsen is an autistic autism researcher who had an extremely stressful experience in therapy. He was grateful to have the opportunity to receive mediation for it, which prompted his broader interest in the topic. David Meer is a therapist, clinical supervisor, and advocate for neurodiversity-affirming care. David is based in the US and Sam is based in Canada, but his experiences which motivated this essay happened in the US. Any feedback on this essay is welcome– our hope is that it can be an evolving document as we continue to learn more about this topic.
Liability and Considerations when Finding a Mediator
In practice, therapists may be hesitant to participate in mediation due to fear of professional repercussions or liability. For example, if a therapist has engaged in illegal or egregious misconduct with a patient, they may worry about legal implications of admitting fault in mediation, may worry about the mediator reporting them to the Board, or may worry that the patient could use any documentation (e.g. emails) from the mediation process as evidence in a Board report.
We fully support patients’ rights to utilise the Board and do not think that patients should ever feel obligated or pressured to waive their right to contact the Board when seeking mediation. However, we also believe it is important for patients to have access to at least one resource where they can communicate openly without any worry about that information being shared with the Board (i.e. potentially triggering a mandatory/automatic report). And – even if this ideally wouldn’t be the case – we also believe that patients are much more likely to receive supportive mediation if the therapist can be open and reflective without worrying about mediation itself carrying direct professional or legal consequences.
There are several practical considerations when finding a mediator, namely:
How to find someone who doesn’t have a conflict of interest (e.g. a close relationship with the therapist or patient) but who is a good fit?
Will the therapist pay for mediation, or is the mediator volunteering their time?
How to find a mediator that the patient is comfortable with?
In some cases, the patient may feel most comfortable with a mediator who has a particular area of expertise, communication style, or who shares an area of identity with them (e.g. a patient who felt harmed by their therapist’s racial microaggressions may be most comfortable with a mediator who shares their racial identity.) More generally, a patient who has just been harmed by therapy may be hesitant to quickly trust a mediator (who, even if not a clinician, may be perceived as being in a similar role in the mediation process.)
We plan to write a subsequent article that discusses these topics, and particularly steps to reduce liability/legal concerns, in detail. For now, the guide presented below may be most appropriate/effective in situations where:
the clinician is not worried about liability or legal concerns (e.g. forms of therapy harm such as repeated microaggressions, dismissive reactions, or limited dual roles that are unlikely to present a liability risk for the clinician despite potentially being highly damaging for the patient.)
and/or the therapist and patient both feel comfortable with the structure of mediation
Intake sessions/Pre-mediation
The first step to mediation is ensuring that both the client and therapist opt in without pressure and fully consent to being part of the mediation process. The rest of this article will be based upon the premise that both client and therapist have agreed to preliminarily enter the mediation process.
Ideally, the mediator can meet with both the patient and clinician separately before potentially moving on to a joint meeting.
Pause on Communication Between Therapist and Client
While the ideal approach will probably be highly situation dependent, prompt and timely mediation services combined with a temporary pause on communication between patient and clinician may be a good “default” setting. Correspondence between the patient and therapist may be overwhelmingly stressful if the relationship is already frayed. Even in situations that don’t involve acute distress or discomfort, there may be some risk that the rupture would deepen by delaying mediation.
When meeting with the patient, the mediator can learn about:
The patient’s experience with therapy and therapy harm
Whether this is meant to be a final session for closure or to repair a rupture in order to continue therapy
What they are most hoping to get out of a mediation session (e.g. acknowledgement of harm, change in therapy approach going forwards, emotional closure, something else)
What type of meeting format would be most comfortable for them (see Table 1 for more options), any accessibility needs (e.g. desire to have an agenda ahead of time to know what to expect.)
Any concerns about mediation or other considerations, such as:
Topics they hope to avoid
Anything they are worried might happen (e.g. the therapist invalidating or blaming them)
Any signs they are becoming overwhelmed in mediation and what would be most helpful if they are overwhelmed
Anything they would like to share privately with the mediator that is not to be shared with the clinician
The mediator can also offer the patient the option of sharing any documentation of their experience in therapy (texts, emails, etc.) with the mediator. This can be especially helpful if the patient expects that their therapist will try to deny or has forgotten certain events.
The mediator can also share with the patient their rights during the mediation process. Namely, the patient is welcome to withdraw from the mediation process (either entirely or in part) at any time or to ask for a pause. It is also okay if their goals or needs shift throughout the process of mediation– for example, a patient might initially want to restore the clinical relationship but may realise partway through the mediation process that ongoing communication with their clinician would be too overwhelming. Additionally, the patient does not have to waive any of their other rights – including the right to utilise separate processes such as the Board – in order to participate in mediation. The mediator can also outline potential risks of mediation and acknowledge that, while potentially a powerful tool for healing, full closure may not be possible and even the most effective mediation won’t be able to completely erase harm caused.
The mediator can then meet with the clinician and try to understand:
Their perspective on therapy and response to the patient’s perspective/concerns
Whether this is meant to be a final session for closure or to repair a rupture in order to continue therapy
Whether there are any areas where the clinician could use private support
Any other considerations
In many cases, the mediator may find that the clinician is experiencing complicated emotions about the situation and/or is expressing significant defensiveness. In Appendix B, we outline different stages of defensiveness and accountability, and how a mediator may best support a clinician in moving towards increased accountability in a non-shaming way. In Appendix A, we outline additional considerations regarding different types of support clinicians may need.
Choosing a Mediation Format
In some cases, if the patient and clinician have relatively shared goals and perspectives and if there are no major complications, proceeding to a joint mediated session might be a clear next step. In other cases, there may be risks to joint mediation.
Perhaps the most serious “red flag” would be if the therapist and patient have fundamentally different perspectives about what happened (e.g. complete denial from the therapist of the patient’s concerns). In this case, proceeding with mediation could leave the patient feeling gaslit, more uncertain about their perspective, and deeply hurt by the lack of clinician accountability.
And while we believe it is likely extremely rare for a patient to lie about a harmful experience in therapy and try to obtain mediation for this, it is technically possible. In these rare situations, mediation could also be harmful to the therapist by encouraging them to take responsibility for something they didn’t do.
Below are some “red flags” that there may be additional risks to joint mediation or that additional caution is needed:
Disagreement between patient and therapist over what happened (with increasing caution warranted based on degree of disagreement)
Different goals: e.g. the patient wants to continue therapy but the therapist wants mediation to be a final meeting or vice versa
Defensiveness from the therapist, excessive focus on their intentions or justifying their approach
Any indication that the therapist may use mediation to coerce or pressure the patient (to not report them to the Board, to not tell others, etc.)
The patient feeling afraid or overwhelmed by therapist
Any indication that the therapist wants to rush a resolution (e.g. if their perspective seems to be “how soon can we move on from this” or something similar)
Egregious harm (i.e. sexual abuse or financial abuse in therapy, a therapist providing the patient with illicit substances, etc)
Extenuating factors- this could include anything from the therapist having external stress/trauma, the patient feeling conflicted about what they want, etc.
Indications that the therapist stepping back into a more “clinical role” may be confusing or stressful for the patient (e.g. if a patient is used to casual communication or having “dual roles” with their therapist; sudden withdrawal or formality can feel punitive or disorienting.)
One final consideration is whether there are strong indicators of potential reactive harm. A client who has been deeply hurt or impacted may be in a vulnerable or chaotic state by the time they reach out for therapy mediation. We believe that it is generally best to keep the focus on the patient’s well-being and to recognise that expressions of deep hurt and confusion can be messy. Sadly, many personal essays on therapy abuse include patients having their “messiness” held against them. Therapists may focus on brief moments of patient distress or imperfection and use them to undermine the patient’s credibility or shift blame. If the mediator has additional concerns about proceeding after the pre-mediation meetings, they may wish to schedule another pre-mediation meeting with the patient and/or clinician to discuss further.
With that said, if there are indications that a patient is likely to interact with the therapist in a way that is truly hostile or abusive, joint mediation may not be appropriate or effective.
Some possibilities for mediation are outlined in Table 1 below. Ideally, this decision will be based on the patient’s wishes, the therapist’s willingness, and the mediator’s judgment.
Our hope is that choosing a suitable mediation approach will not only help the patient find healing, but also may help reduce trauma from the mental health field as a whole. For example, even if the therapist is unwilling to proceed with mediation or is more defensive than expected during joint mediation, having others show care for the patient’s situation and validate their perspective (where appropriate) may show the patient that there are still people who genuinely care for their well-being.
We include in Appendix B additional ideas for the mediation itself. More specifically, we include a list of questions that may be helpful during mediation. We also discuss potential ways to structure live meetings that may
facilitate human connection
help both the patient and therapist feel secure enough to be vulnerable
help de-escalate as needed (e.g. potentially re-traumatising patterns start to emerge)
Closing the Mediated Meeting and Follow-Up
It may be beneficial to help the client and therapist find one concrete step that symbolises repair (even if this is a symbolic step). If appropriate, the mediator can also encourage the therapist to name their commitment to doing better publicly or with peers. For example, if a key cause of therapy harm was the therapist’s lack of familiarity with autism, the therapist could share with their supervisor, peers, or others that they have realized this is an area where they need more growth and how they plan to pursue it. The goal is not to publicly shame the therapist, but rather to provide a form of accountability and also normalise ongoing learning and accountability in the therapy community.
In many cases, there will not be a quick “fix” for the therapy relationship, especially if the harm was egregious or systemic and even in cases where the goal is closure rather than repair, there likely will not be a perfect closure. We suggest that the mediator check in with both parties weeks later to reflect on the impact and, if applicable, discuss next steps.
Finally, whilst this article has been largely constrained by the “real world”, we are planning to write a subsequent piece exploring a theoretical nonprofit structure for a Mediatory Body. This model could include various branches or teams focused on mediation, training, research, and advocacy and would be based on a co-leadership model where those with lived experience, advocates, and disability justice leaders have shared governance with clinicians. We believe such an entity would have the potential to support both individual healing and initiate broader systemic change.
Appendix A: Support for the Clinician
Note – this section is based on the idea of a Mediatory Body that has the bandwidth and capacity to provide relatively extensive support for clinicians. However, even though an individual mediator may not be able to provide as extensive of support, we believe that the suggestions below may still be helpful.
Support for the clinician/therapist can entail several different things.
Practically, it may mean providing resources on relevant topics. For example, if a re-occurring cause of harm was that the clinician had gaps in knowledge regarding a marginalised identity and therefore was inadvertently dismissive of the patient’s experiences, the Mediatory Body could provide the clinician with resources for ongoing education. Likewise, if the clinician has been impacted by major stressors or traumas in their own life, it may entail finding support for the clinician and helping them honestly reflect on whether they have capacity to serve their current patients well. If a clinician is experiencing a major mental health crisis of their own, the Mediatory Body can help connect them with additional support and care. In some cases, the clinician may identify a need for temporary supervision, which the Mediatory Body could provide support for.
The Mediatory Body could also cultivate knowledge on identifying “early warning signs” of ruptures in therapy as well as signs of burnout and could share these with clinicians for their future use. This may include adjustable templates for checking in with patients periodically to obtain feedback, and the Body could work with the therapist to tailor these templates further. For example, if a clinician knows that they struggle with excessive self-disclosure (or alternatively if they frequently receive feedback that they are too much of a blank slate), the Body may have feedback prompts tailored to each area.
In some cases, support may involve helping the clinician come to terms with potential consequences. For example, a clinician may be worried about being reported or more generally may worry about reputational damage, such as a patient giving them a negative online review or something similar. While this stress or anxiety can be very real for the clinician, it’s important that the clinician not make the patient responsible for managing stress. Namely, patients should be able to honestly talk about their experience in therapy with others (including friends, family, other clinicians, etc.) without fear or pressure from their therapist. This holds true even when the patient is discussing negative experiences in therapy or sharing feedback, such as via an online review, where the clinician disagrees with the patient’s interpretation. While there are some rare legal exceptions such as defamation, these are very much outliers.
Therapy ruptures can also be difficult or confusing for the clinician. The blurring of therapeutic boundaries can sometimes (perhaps even often) start with good intentions, or at least without conscious malintent. Traditional discussion on therapy harm sometimes presents a dichotomy where there is a small portion of therapists engaged in actively predatory behaviour and a larger majority of therapists who are “mostly good”. However, our perspective is that everyone has the capacity for great good and also great harm. Care and harm are not mutually exclusive. A clinician may truly care about a patient, and still act in ways that cause distress, confusion, or trauma; especially if the clinician themselves is under-supported or experiencing external stressors.
In some cases, therapists may struggle to come to terms with the fact that they harmed a patient and may instead shield themselves from this realisation by redirecting to their intentions, any extenuating circumstances, perceived “difficulty” of the patient, etc. Therapists may experience any range of emotions such as shame, guilt, frustration, defensiveness. More generally, if the therapist places great value on being supportive to their clients or on being a “good” therapist, they may struggle with this self-concept as they begin to acknowledge their role in therapy harm or abuse.
And as with any relationship that has been ruptured (or shattered), there may be complicated feelings. Therapists may feel confused, sad, rejected, or otherwise impacted at the loss of a relationship with their patient or at seeing the distress their patient may be experiencing as a result of therapy harm. In some cases, therapists may struggle to mentally undo unsustainable or unhealthy expectations towards their patient– for example, a therapist who developed a dual “friendship” with a patient may (even without realising it) be expecting emotional support or reassurance from their patient.
Perhaps most fundamentally, the Mediatory Body can help support clinicians in their internal process of taking accountability and adjusting to the impact of therapy harm on their patient and on themselves. For example, a therapist who keeps focusing on their intentions (rather than the impact on their patient) may be more open to accountability and hearing their patient’s perspective during mediation if they are reminded of the difference between intention and impact prior to mediation. Just because their intentions were good doesn’t mean the patient wasn’t harmed and vice versa. Likewise, these pre-mediation meetings may help therapists identify and work through areas where they are still holding unhealthy expectations of their patients.
The Mediatory Body can privately help clinicians assess the degree of harm caused and what that means for their practice – for example, while the Mediatory Body will not force any decision, they can suggest time away from practice in cases of severe harm and/or can suggest continuing education and other next steps.
Appendix B: Potential questions for mediation
Below are a list of questions that may be a helpful starting point:
Category #1: Understanding the impact of therapy harm:
How did that impact you?
How have you been feeling recently? Is there anything that you are particularly struggling with?
Are there any areas or conversations where you felt especially hurt, shut down, or invalidated by me?
Are there any emotions (e.g. frustration) that you haven’t felt safe sharing with me?
Is there any feedback or challenge that you’ve been hesitant to share with me that you would like me to know?
Are there any areas where you are feeling conflicted/have mixed emotions and would like support working through them?
Category #2: Identifying the patient’s need for support:
Is there a topic or area where it would be especially helpful for me to provide validation?
How can I help support you in healing from therapy harm?
What would be the most helpful for you right now– would you like me to lead the conversation, would you like to lead it, would you like to pause and think for a bit, or something else?
Category #3: Feedback for the clinician. The first step is to see whether the patient would like to give suggestions to the therapist – in some cases, this may be healing for the patient while in other cases it may feel like an unnecessary burden or responsibility. While we certainly don’t expect the clinician to automatically implement every suggestion from their patient, we do believe it is important for suggestions to be heard and considered.
If the patient would like to provide suggestions, below are some guiding questions:
Are there topics that you would like me to seek supervision and/or additional trainings on?
Are there approaches that you would like me to implement in my practice (with you and/or with others) going forwards? (For example, periodically checking for feedback.)
Do you think I need to take a complete pause from therapy and re-evaluate my practice?
Is there something specific I can do that would be restorative? Potential examples:
The clinician stepping back from activities or groups where they overlap with the patient
The clinician offering support in finding a new provider or other services that the patient needs as a result of therapy harm
The clinician making a donation to a group of the patient’s choosing
The clinician taking specific steps towards accountability (e.g. letting their workplace know that they need support in a certain area or taking an appropriate, non-shaming shift in how they describe their practice)
