Why is My Patient So Hurt? A Tentative Therapy Rupture Guide for Clinicians
Introduction
I imagine it can be challenging for therapists to realise that a patient feels hurt by something they said or did. While I aim to be a reflective and generally accountable person in my own life (as a non-clinician), I also know that critical feedback is rarely easy to digest and it can be difficult to disentangle from defensiveness completely. Therapists, too, may feel a complex mix of emotions in the face of rupture – sadness, confusion, defensiveness, worry about professional repercussions, or even the sense that the patient is being unreasonable. These reactions may be especially strong if the rupture is major, unexpected to the clinician, or if the patient expresses feeling deeply harmed.
I don’t believe that accountability necessarily requires agreeing with the patient completely or apologising for everything the patient found harmful. Nor does accountability need to be a punitive process. Yet it’s easy, often unintentionally, for people to short-circuit the process of taking accountability before it has the chance to truly begin. For example, a therapist may shift their focus to perceived flaws in how the patient communicated distress (too indirect, too sudden, too intense) rather than on the distress itself.
This pattern of unintentional defensiveness seems particularly relevant in therapy, where patients are often vulnerable, likely have already experienced stress or trauma, and may not even realize they’re being harmed until the impact accumulates. Patients who have been harmed by therapy may be feeling significant confusion or conflicting emotions, and may express this in ways that appear sudden or “messy” to the clinician. Therapy is also structurally unequal, which means that even when something looks mutual, such as significant self-disclosure between therapist and patient, it rarely is.
Given this, I think it’s critical to aim for understanding rather than judgment whenever possible– why is the patient in pain? What is causing the confusion? How can we help them heal?
The main goal of this resource is to address common thinking patterns that clinicians might have after a therapy rupture, for example: “but my intentions were good”, “I only made that exception to try and help”, “I feel like my patient is leaving out a lot of context/remembering things selectively”, “this came out of nowhere”, etc. Where possible, the resource will pair each point with a potential patient perspective (to give a simplified example, something that seems to have “come out of nowhere” might have actually been affecting the patient for a long time– they just may not have realized it initially or may have felt conflicted or confused about how to bring it up.)
Unfortunately, this resource is not able to cover every possibility. Likewise, this resource is not equipped to provide a full roadmap towards accountability– in some cases, especially where substantial harm was done, accountability may involve additional steps such as consultation or supervision, third-party involvement with the patient, or other reparative steps. Still, reflection is a critical first step, and I hope this resource can support clinicians in beginning that process.
While small ruptures are quite common in therapy and absolutely deserve their own protocols as well, this guide focuses more on situations where the patient has experienced substantial hurt or confusion
Disclaimer: I am not a clinician! While all the material here was developed by me, I have used ChatGPT to format portions of it given my tendency to create incredibly lengthy drafts.
Thought Pattern #1: Intentions versus Impact
I think one of the most human reactions to any rupture is to default to our intentions. After all, I would imagine that vanishingly few clinicians are actively sitting there and consciously planning how to cause harm to their patient– namely, I think it’s highly unlikely that anyone’s internal monologue reads “I will now dissolve this boundary and increase my self-disclosure in a way that will cause long-term confusion for the patient, because in the moment it feels nice and I appreciate the warm and sometimes idealistic responses my patient gives me conversationally.” However, that doesn’t mean that this isn’t the impact on the patient.
Many clinicians may struggle to see themselves as capable of serious ethical harm. They may recognise small mistakes or be open to minor feedback, but view “egregious concerns” as strictly the purview of other therapists with worse intentions. The truth is more complex: good, caring, competent therapists can still cause serious harm. Recognising that possibility may be difficult but necessary– and I think recognising harm will be easier for clinicians who are comfortable with this complexity and don’t view themselves or their capability in all or nothing terms (e.g. either a “good” or “harmful” clinician).
Defensiveness pattern:
“If they only knew my intentions were good, they wouldn’t feel so hurt.”
Hidden blame:
“The client is misjudging me — their hurt comes from misunderstanding rather than from what actually happened.”
Possible client reality:
Clients don’t have access to your inner world. They live with the impact of what was said or done, not the full complexity of what you meant.
Intentions are rarely singular. A clinician might consciously intend to comfort, while also (less consciously) meeting a need for closeness, soothing guilt, or avoiding discomfort.
“Good” intentions are not always pure, and “bad” intentions are rarely cartoonishly malicious. Most are mixed.
Clients may actually assume you meant well — but what matters most to them is whether you can recognize and take responsibility for the harm they felt.
Reflective prompts:
Am I clinging to my stated intention to protect myself from feeling responsible for impact?
Can I acknowledge that my intentions may have been layered — partly caring, partly self-protective — without spiraling into shame?
What if my intentions, however mixed, don’t need to be proven or justified right now? What if what matters most is how I respond to impact?
Thought Pattern #2: I Was Trying To Do A Favour
Defensiveness pattern:
“I only made this exception or loosened my boundaries as a favour, and now they’re turning it against me.”
Hidden blame:
“The client is ungrateful or fickle.” or “Maybe the client was trying to trick or manipulate me all along”
It’s worth noting that there are certain things that patients simply can’t consent to. Even if a patient technically asked to date their therapist, the onus is on the therapist to maintain that boundary. It simply isn’t possible to enter a mutual social or romantic relationship with a patient after a therapeutic relationship, and while patients aren’t responsible for knowing the ethical implication of dual relationships, therapists are. The power imbalance of therapy– where the therapist knows many or all of the patient’s vulnerabilities and traumas, has been given a clinical role in the person’s life, and may be viewed as a sort of authority figure by the patient – simply can’t be erased by declaring the relationship to be a mutual one.
In other situations, a patient may have requested something more feasible (e.g. slightly increased self-disclosure from the clinician) but not have anticipated the exact form that it would take or how it would impact them or may not have anticipated the degree to which the clinician increased self-disclosure. In short, there are several reasons for patients to feel understandably hurt or confused regardless of whether they initially asked for a certain arrangement, and holding that initial request against them may add an additional layer of guilt to their confusion.
Possible Client Reality:
Blurred boundaries can feel warm and special at first, especially for clients longing for closeness.
The “highs” may mask the discomfort until later, when the “lows” (confusion, fear of withdrawal, loss of safety) surface.
Even if a client does realize they are starting to feel uncomfortable or harmed, they may be hesitant to express it due to fear that the therapist will suddenly withdraw or think that they are over-reacting. Some may hope that being closer to the clinician will eventually fix things.
A fawn response or fear of conflict can also play a role in patient hesitancy.
Even if a patient/client truly was trying to trick a clinician in an intentional way (which would be very uncommon), they still may be hurt and still deserve care
Reflective Prompts:
Can I understand how something might feel good and harmful at once? (Or might have initially felt good only to later become harmful?)
How might power dynamics have made it difficult for this client to say “no” or voice distress earlier?
Might I be inadvertently overlooking my responsibility in the initial request? E.g. did I treat the request as if it was coming from a peer rather than carefully thinking about power dynamics?
Is it possible that – even if the patient did ask for something initially – they weren’t prepared for the form it would take or potential risks of a change (e.g. the intensity of a certain modality of therapy, potential stressors of self-disclosure, etc.)
Thought Pattern #3: My Patient Is Blowing Things Out of Proportion
Defensiveness pattern:
“I can see why they didn’t like [XYZ], but this is really getting out of hand.” or “I said sorry, I don’t know what more they want from me.”
Hidden blame:
“The client is over-reacting, misrepresenting things, or perhaps being overly punitive.”
In some cases clinicians may understand to some extent why their patient/client is bothered by something, but feel surprised, frustrated, or tired by the intensity or duration of their client’s reaction to events. It may also be easier to think that the patient is over-reacting than to realize that the patient is potentially deeply hurt.
Possible Client Reality:
Something which overlaps with a patient’s trauma history or vulnerability may have a greatly amplified impact on the patient. For example, a dismissive comment from a therapist may be much more painful if the patient e.g. had dismissive parents growing up.
In some cases, the patient may be remembering things that the therapist may have forgotten or the patient may be reacting to something which feels like a pattern to them (e.g. a pattern of dismissive reactions from their clinician) even if they are only describing one instance to the clinician.
You may not be fully responsible for causing their pain– it is possible that several factors in their life have combined to amplify it. But the pain is real and still needs care, so it is important to take it seriously.
Reflective Prompts:
Am I minimizing this because I feel shame?
If I heard this story about someone else who I don’t know, would I potentially be able to see it differently? (For example, could I have more curiosity about the patient’s perspective and their pain if I wasn’t tying it to my own clinical actions?)
Is the harm perhaps repeating another pattern or trauma in the patient’s life (even if not completely)?
Thought Pattern #4: My Patient Is Leaving Out Context
Defensiveness pattern:
“If they told the whole story, it wouldn’t sound so bad.”
Hidden blame:
“The patient is deceptive, unfair, inaccurate, or trying to get me in trouble.”
This pattern is somewhat related to the above. Clinicians may find themselves wanting to stop or interject as a patient is explaining their experiences in order to “add context”. In some cases, it may genuinely be helpful for a patient to understand a broader context that they weren’t aware of or didn’t pick up on– e.g. maybe an appointment that was cancelled at the last minute wasn’t due to the clinician forgetting them or not valuing them, but due to a truly unavoidable emergency. However, in some cases pushing the patient to add specific details or put things in a broader context (especially if that is defined by the clinician) may be counterproductive.
Possible Client Reality:
Clients often filter or simplify experiences because of shame, confusion, or fear of disbelief.
Context is somewhat subjective– your patient is likely telling you the parts of an interaction that were most important or harmful to them, and being pushed to give a longer backstory may be overwhelming if they are already struggling
“Missing context” may reflect their attempt to make sense of overwhelming feelings or focus only on the most important parts.
Likewise, clinicians may be missing context as well (of what else was going on in the patient’s life at the time, how the patient felt or thought about something, etc.)
Just because a patient is temporarily focusing on something that felt harmful or challenging to them doesn’t mean that they aren’t aware of other neutral or more positive parts of the relationship
Reflective Prompts:
Am I focusing on context as a way to (even if inadvertently) discredit their perspective?
Even if I feel like their perspective is a bit one-sided or misleading, what can I take away from it? Are there any parts of it that I can empathise with or understand as a starting point?
What might their telling reveal about how they experienced it, regardless of my intent?
