Stages of Accountability: Towards Healing
Below is a list of steps that clinicians may progress through when taking accountability for harm caused by their approach to therapy. While this list is geared towards clinical harm and/or abuse in particular, my hope is that it may be helpful for reconciliation processes more generally. The goal of accountability here is not to increase self-blame or shame for the clinician, or even to push the clinician to completely agree with the patient’s perspective– but rather to promote healing (for the harmed party), self-reflection for the clinician, and restorative justice.
These steps are based on anecdotal evidence, in particular:
Reading several articles on patient’s perspectives on clinical harm
One article of a therapist deeply reflecting on the harm they caused to a patient when they let go of boundaries
My own highly stressful experience in therapy (with a generally very kind clinician), which led me to think more deeply about the difference between intention and impact when it comes to therapy harm
And my own experience reflecting on times where I’ve been defensive in my own life and how I was able to (at times) internally progress from defensiveness to a more complete accountability (while I’m not a clinician, I would imagine that there may be some overlap in the process as we are all human!)
This article is meant to be a living document, and we truly welcome any feedback/suggested updates. You are welcome to email us at hello@allneurotypes.com– unfortunately, our response times may be quite delayed/variable, but we do value thoughts and feedback and will eventually read every email!
It’s worth noting that the stages outlined below are not fixed or linear– people may oscillate between them or hold multiple perspectives simultaneously. For example, a clinician may find it easy to take full responsibility for one area of therapy harm but may be very defensive for another area. While many of the suggestions here are written with the possibility of a mediator in mind, the general themes may also be useful in other settings (for example, by clinical supervisors, mentors, or by clinicians themselves during personal reflection.)
Stage -1: Patient-Blaming and Harm Reversal
Key Characteristics:
Denial or distortion of events.
Clinician implies or explicitly states that the patient is too sensitive, unstable, manipulative, difficult, or states the patient is misremembering (even when they aren’t)
Apologies, if given, shift emotional labour back onto the patient. For example, "I’m sorry I’m such a terrible therapist, you must hate me" may cause the patient to feel guilt or an obligation to reassure their clinician.
Accountability Level: None or reversed accountability (i.e. shifting blame to patient).
Curiosity About Patient: None
Acknowledgement of Power Dynamics: None or reversed (e.g. may make patients feel like it is their responsibility to not “jeapordise the therapist’s career”, report the therapist, etc.)
How can one go from "Stage -1” to "Stage 0”?
A mediator or third party might remind the clinician that even if the patient was “difficult” in some way, that doesn’t mean the patient wasn’t genuinely hurt. In fact, the perceived difficulty may be an expression of hurt or pain.
Likewise, the mediator can encourage the clinician to not automatically deny or dismiss the patient’s perspective. This could involve:
Going through supporting documents provided by the patient (e.g. text/emails/etc.) with the clinician if applicable
(Initially) focusing on areas where the clinician does agree with the patient’s perspective
Reminding the clinician that the patient is allowed to have a different perspective– just because the patient and clinician may emphasize different things doesn’t mean the patient is “taking things out of context” or “distorting” things. Likewise, just because a patient may occasionally paraphrase or misremember a minor detail doesn’t mean the patient’s overall point isn’t real or important.
Note: Clinicians may – even if unconsciously – interpret the patient’s distress as manipulation, “being difficult”, etc., particularly if the clinician feels guilt or shame they cannot yet process. It can be easier to think “My patient is being difficult” than to think “My patient is in an immense amount of pain that I contributed to.” This harmful pattern can be fueled by the clinician’s position of power relative to their patient (in particular, the fact that the clinician has or had at one point the ability to diagnose their patient; to document their patient’s mental health state and have it be presumed to be an objective expert opinion, etc.)
Stage 0: Complete Deflection
Key Characteristics:
The therapist frames harmful dynamics as the patient’s initiative or desire or, alternatively, frames harmful statements (such as microaggressions) as a misunderstanding.
E.g. “I just did (action) because you asked” or “You said you wanted (action)”
“I didn’t mean (microaggression) that way” or “I’m not (racist/sexist/ableist/etc.)”
Boundaries framed as accommodations rather than the clinician’s responsibility
While the clinician may not be personally criticising the patient or questioning their memory, there is no validation offered to the patient’s perspective
Accountability Level: None
Curiosity About Patient: Minimal or none.
Acknowledgement of Power Dynamics: None
How can one go from "Stage 0” to "Stage 1”?
A mediator or third party might remind the clinician that even if a patient initially asked for something, it’s still ultimately the clinician’s responsibility to uphold boundaries. The mediator can validate that the clinician may feel caught off guard by unexpected distress in their patient; while emphasizing that it is also understandable for patients to have a “delayed response”. In some cases, it may take patients a while to realise they were harmed by something or to understand how it impacted them.
Potential guiding questions could be:
Even if you don’t think what you said was hurtful, can you see any reason why your patient may have felt frustrated/hurt/confused?
Even if your patient initially asked for something, can you see how the power imbalance may have impacted their ability to fully consent?
Stage 1: Focus on Justification/Clarifying Intentions
Key Characteristics:
Clinician begins to acknowledge the situation was complex or stressful for the patient, but centres their own reasoning, intentions, or external circumstances
May have a lot of statements that combine partial acknowledgements with justifications:
“I’m sorry it bothered you, but my intentions were (justification of intention).”
“I can see where that might have been confusing, but you seemed okay with it at the time/you asked for it.”
Accountability Level: Low to emerging.
Curiosity About Patient: Likely limited or surface level
Acknowledgement of Power Dynamics: May be present, but in a limited or self-focused way
How can one go from "Stage 1” to "Stage 2”?
The mediator can gently remind the clinician (ideally prior to mediation) that the main goal of the meeting is to help the patient in healing; and that will require a deeper focus on and curiosity about the impact of one’s actions (regardless of intention).
The mediator can continue to encourage the clinician to reflect on why and in what ways the patient might feel hurt. One exercise would be to ask the clinician to describe (in as much detail as they can):
Different ways their patient may have been impacted by therapy harm
How the therapy dynamic may have compounded existing stressors or experiences of trauma in the patient’s life (e.g. excessive self-disclosure from the therapist may exacerbate previous trauma from a patient who was parentified growing up; microaggressions in a therapeutic setting may add to harm from a lifetime of bias/stigma)
The mediator could potentially share key quotes or statements about the impact of therapy harm from the patient. It may also be helpful to share essays from other patients with the clinician; particularly if the essay has similar themes or types of harm, as clinicians may have less defensiveness when reading external material.
Stage 2: Emerging Accountability
Key Characteristics:
Open to acknowledging some of the impact, even if they struggle to acknowledge the overall level of harm or how the power imbalance played into it
Open to hearing the patient’s perspective, even if they aren’t actively asking many questions to learn more
Still may focus on clarification, but emotional tone is less defensive and there is less emphasis on justifying their intention. Examples:
“I may have been (insert intention/context), but I see now that it hurt you regardless of my intention”
“I didn’t realise how much it affected you.”
Accountability Level: Moderate. At this stage, mediation is less likely to retraumatise the patient.
Curiosity About Patient: Emerging, may be a passive curiosity.
Acknowledgement of Power Dynamics: Emerging
How can one go from "Stage 2” to "Stage 3”?
Firstly, the mediator may want to provide additional support to the clinician as this stage may be correlated with increased feelings of sadness, guilt, or shame. While I’m not a clinician, in my own anecdotal experience, this stage is often the most emotionally difficult (as it is when one is beginning to more fully realise the impact of their actions on others).
As such, the mediator may want to balance supporting the clinician and affirming the accountability they have taken so far; with encouraging them to deepen their understanding of the patient’s perspective and to begin thinking about steps for repair.
Stage 3: (Mostly) Full Accountability
Key Characteristics:
The clinician acknowledges broader, harmful patterns in the therapy relationship and takes responsibility for their own contributions.
“I may have relied on you more than I realized, and that wasn’t fair to you. Our meetings should have been a place for you to receive support for your life, not for you to hear about challenges in mine.”
“I can see now that (action) was wrong given the power dynamic, and I’m sorry you were harmed as a result of that”
Clinician begins to reflect on how choices may have been shaped by stress, need, or blurred roles; but only discloses their intentions/external factors when it seems likely to help the patient in their healing
The clinician is likely very open to hearing the patient’s perspective; willing to warmly validate the patient’s perspective (as appropriate)
Accountability Level: Strong acknowledgement of harm
Curiosity About Patient: Present.
Acknowledgement of Power Dynamics: Clear.
How can one go from "Stage 3” to "Stage 4”?
Trust in the mediator/mediation setting can help the therapist move towards Stage 4. Clinicians at this stage are likely to be quite open to doing what they can to make mediation supportive for their patient. However, they may still hesitate to actively invite their patient to share more (especially on topics/experiences that are likely to bring up grief, frustration, etc.) or may be hesitant to offer steps towards restoration.
The mediator can potentially offer to support the clinician again privately after mediation in processing anything difficult that may have come up (e.g. intense sadness or frustration from the patient). Likewise, the mediator can remind the clinician that – while they don’t need to agree to or immediately decide on any steps towards restoration suggested by the patient – openness to hearing and genuinely considering suggestions can be an important part of mediation.
Stage 4: Accountability with Curiosity and Restorative Intent
Key Characteristics:
Full acknowledgement of power imbalance and harm caused
The clinician invites patient to share more about their experience and is genuinely open to listening:
“Would you be open to sharing more about how this impacted you?”
The clinician remains open and supportive (without defensiveness) when their patient expresses ambiguity, grief, frustration, conflicting emotions, etc.
The clinician is willing to explore what restoration might mean/whether there are specific actions they can take (such as supervision, seeking out additional training on a specific topic, or others) that would be restorative or meaningful for their patient
Accountability Level: High.
Curiosity About Patient: Deep and non-controlling.
Acknowledgement of Power Imbalance: High
Sustainability:
Mediator support and a good support system/support in self-reflection may help clinicians reach and sustain this stage
In some ways this is an ideal stage that may only rarely be fully obtained – and some might reach this stage of internal accountability only once the therapeutic relationship has long been ruptured. But steps toward it can still meaningfully support healing for both patients and clinicians
Notes for Mediators or Peer Supports:
Do not pressure clinicians toward Step 4 if they are at Step 0 or -1, as this can backfire or entrench defensiveness.
A clinician’s ability to move forward is often supported by reducing shame and increasing compassion-based insight.
Patients are not obligated to wait for a therapist to reach these steps, but may benefit from knowing that movement is possible (even if it is invisible to the patient).
