Hurt people hurt people? When Good Therapists Cause Harm

In working with a diverse range of helping professionals, including undergraduate psychology students, fellow counselors (and other mental health professionals), and law enforcement personnel, a common thread keeps showing up: many of us seek out these careers because of a deep desire to serve others. This desire often stems from intrinsic personality traits and/or frequently our own encounters with hardship.

Regardless of the source, we enter practice as beacons of hope, armed with empathy and a fervent desire to alleviate suffering. The very notion that we, the healers, could be the source of harm to our clients can feel like a betrayal of our calling. It can go against everything we believe about who we are. We cling to the adage "hurt people hurt people," a comforting belief that only those currently wounded themselves inflict pain. But the therapeutic landscape is far more intricate. Research suggests that well-intentioned therapists can cause harm, and not just those who haven't grappled with their own emotional baggage (e.g., Arora et al., 2022; Teachman et al., 2021; etc.).

The truth is, healed people also cause harm.

Through our graduate training we are frequently asked to explore our complex experiences, biases, and blind spots as a way of knowing how they show up in the therapy room. We are told we may unintentionally project onto clients, get triggered by their stories, or simply miss the mark on what they truly need. We're told it isn't a sign of failure; it's the inevitable dance of vulnerability inherent in a deeply personal field.

This work of self-exploration doesn't end when we graduate grad school. It also doesn't end when we become fully licensed, not when we achieve the career success we are aiming for, and not even when we approach retirement. While implicit biases, venturing outside our scope of practice, microaggressions, and outdated knowledge (among other issues) can all lead to unintended harm, therapists have a fundamental responsibility to continuous improvement. Continuing education (CE) credits are a valuable tool for this, but navigating the practical options can be challenging. Focusing solely on cost, convenience, or personal interest might not always align with our clients' needs or the latest advancements in the field. And there's another issue that gets in the way of improving and leads to client harm:

We don't know what we don't know.

Consider the following: one in five people fall within the neurodivergent spectrum, encompassing conditions like autism (ASD) and ADHD. These individuals often have unique needs in therapy that can be missed by therapists unfamiliar with neurodivergent presentations. A therapist accustomed to working with neurotypical clients might misinterpret stimming behaviors in an autistic client as anxiety, leading to interventions that feel alienating or even punitive. Therapists working from a traditional Cognitive Behavioral therapy foundation may push clients to behave in ways that increases masking, leading to long-term physiological and psychological damage.

Here are some ways even well-intentioned therapists can cause harm:

• Unchecked Expertise: Believing competency with certain issues or diagnoses can lead therapists to assume that what they do (based on what they have been taught or what they have historically done) is the best course of action. This happens frequently when consulting with clinicians about neurodivergent clients.
• Cultural Insensitivity: Unconscious biases can lead to a "one-size-fits-all" approach that fails to consider a client's cultural background, values, and lived experiences. This can create a sense of alienation, distrust, and ultimately, impede progress.
• Misunderstanding or Minimizing Intersecting Identities:  A misunderstanding or lack of awareness of the racial/ethnic, gender, and sexual identities of clients may lead to minimization, misdiagnosis, and harm. What it means to be a white Autist, for example, is completely different than what it means to be a homosexual Black Autist.
• Neglecting Power Dynamics: The therapeutic relationship inherently has a power imbalance. The therapist holds the expertise, sets the agenda, and interprets the client's experiences. Failing to be mindful of this dynamic can lead to therapist dominance and a stifling of the client's voice. Being unaware of the potential issues related to trusting our interpretation of the client and their experiences leads to a false sense of rightness or a false certainty.

Facing the Demons

Bridging the gap between our good intentions and the positive outcomes we strive for has to begin with full acceptance of a few key concepts:

• Acknowledge our Limitations: We must start with the recognition, acceptance, and acknowledgement that we do not know what we do not know. This changes our perception of the feedback we receive from our clients and from fellow therapists.
• Embrace that Healed People Harm People: Once we become aware that we do not know what we do not know, we also become hungry to learn. It is no longer scary to learn new and different ways of being and working with clients. It's also no longer scary to learn about our harm to others and our less than healthy ways of being.
• Value Lifelong Self-Awareness: Regular therapy, consultation, continued learning, and personal growth work are essential for staying attuned to our own emotional baggage and potential blind spots and for engaging with greater empathy and presence. Seeking out continuing education that is on topics unfamiliar to us, unrelated to our clinical interests, and from presenters who are different from us becomes exciting and meaningful.
• Center Cultural Competence Training: Continual education on diverse cultural experiences and perspectives is paramount. This includes understanding the impact of race, ethnicity, religion, sexual orientation, gender identity, neurodiversity, and socioeconomic status on mental health presentations and treatment needs.
• Settle into Authentic and Effective Practice: Acknowledging our limitations and being open to feedback from clients and peers demonstrates respect and fosters a collaborative therapeutic environment. Studies have shown that authenticity and therapist transparency lead to stronger therapeutic alliances and improved client outcomes.

A Brief Primer on Doing No Harm: Neurodiversity and the Therapeutic Relationship

As discussed previously, neurodivergent clients require considerations beyond what we have been taught to do with neurotypical ones. Therapists unfamiliar with the ways that neurodivergence presents frequently misinterpret stimming behaviors, sensory processing issues, or social communication differences. Neurodivergent clients are more likely than neurotypical ones to have treatment-resistant anxiety, obsessive-compulsive symptoms, disordered eating, substance use, and life-long suicidality. When therapists see and treat those symptoms through an allistic framework, clients frequently do not improve. This can lead to clients being perceived as having treatment-interfering behavior or being noncompliant. Clients coming to KDH Counseling frequently report that previous counselors misunderstood them, and they often report long histories of going from counselor to counselor without finding relief.

Here are some additional ways therapists can create a safe and supportive space for neurodivergent clients:

• Education on Neurodiversity: Investing in training on neurodivergent conditions like autism, ADHD, OCD, and more equips therapists to understand the unique challenges faced by these clients and develop appropriate interventions.
• Sensory Awareness: Creating a therapy space that is mindful of sensory sensitivities can be crucial for neurodivergent clients. This might involve offering noise-cancelling headphones, fidget toys, or allowing clients to adjust lighting.
• Alternative Communication Strategies: Some neurodivergent clients might find written communication or visual aids more helpful than traditional talk therapy. Being flexible with communication styles allows clients to express themselves more effectively.
• Collaboration with Specialists: In some cases, collaborating with other mental health professionals specializing in neurodiversity can provide valuable insights and support for both the therapist and the client. Occupational therapy, prescription medication, feeding therapy, and neurodiversity-affirming support systems/programs are highly recommended for neurodivergent clients. There is also a need for understanding employment assistance, disability, and more, none of which is typically discussed in counseling graduate programs. Knowing when and with whom (neurodiversity affirming professionals) to collaborate is essential.

Next Steps

For Therapists:

At KDH Counseling and Collective, our passion for learning fueled our desire to create a space for therapists and clients alike to explore cutting-edge research and best practices. Whether you're seeking a casual conversation, focused consultation, or continuing education opportunities, we welcome you to join us. Ready to learn more about our team and specialties? Check out some of the following recommendations and reach out to see how we can support your journey.

• Check out Monet David, MS, LPC's blog, The Potential for Harm: Ethical Considerations for Counseling, in which she offers an honest exploration of her own capability to unintentionally cause harm and offers an invitation to explore what that means for us as we read along.
• To learn more about neurodiversity and working effectively with neurodivergent clients, check out our ND continuing education content.
• To learn more about sex and sexuality, check out our Sex Ed continuing education content.
• To learn more about trauma and how it interacts with and affects the function of neurotypical and neurodivergent clients, explore our Trauma continuing education content.
• The KDH Collective therapists also share more on these topics in other blogs, so be sure to explore those here.

For Clients:

This blog post highlights the importance of ongoing education and self-reflection for therapists, values we hold dear at KDH Counseling and Collective. If you're a potential client, this commitment translates into a safe space for growth and exploration in therapy. Curious to learn more about our therapists' expertise in these areas? Head over to the "Blog" section on our website to see their unique perspectives on these topics.