The big issue: The truth about harm in therapy
Therapy Today, April 2025

When Jessica Wing* started seeing her new therapist she was just a trainee. ‘I’d seen a few therapists by that point, all women,’ she says, ‘and felt that I knew what to look for and ask.’ But when Wing opened up to the therapist about her experience of sexual violence he undermined her. ‘I spoke about a few of the events of rape I experienced,’ she recalls. ‘He responded by saying, “you feel like you’ve been raped”. This small adjustment in language took me from feeling believed and validated, knowing I had been raped, to questioning and blaming myself. He even asked whether I said “no”.’

In a later session the therapist crossed a physical boundary: touching her shoulder as they said goodbye. In the moment, she froze. Afterwards she ruminated on whether she invited the touch, whether he was ‘testing’ her, and whether he would escalate boundary crossing as the therapy went on. 

Wing discussed what had happened with her supervisor, stopped working with her therapist, and stopped therapy altogether for several years. Wing also wrote her therapist a letter about her experience of harm, but not every client can voice their concerns – some may even struggle to name it. Studies show harm is underreported and remains poorly understood. As long as the profession resists the question of harm, the problem remains corrosive. 

Not every client seeks redress for a problem but some do. In 2023 BACP received 511 complaints, in the same period 29 cases were allocated to a practice review hearing (also known as the practice review process track),¹ and 14 were allocated to a disciplinary hearing. Although they involve less than 1% of BACP’s almost 75,000 therapist membership, the risk of doing harm – and its consequences – is rightly a serious concern for the profession. Although complaints are still rare, they have risen yearly since 2020, increasing by 26% from 406 in the report for 2022, outpacing growth in BACP membership (up just 6%). Given that not every client harmed by therapy makes a complaint, it may be that the rarity of complaints belies the true prevalence of harm. 

Last summer the lack of regulation of counsellors and psychotherapists was in the headlines again when a high-profile therapist was found guilty of sexual assault in a civil claim and his victim was awarded £200,000 in damages.² The reports from the courtroom are likely to have disturbed both clients and therapists. But most harm in therapy is far less headlinegrabbing than cases that involve sexual conduct or dual relationships – harm can also come from lack of awareness, a gap in knowledge or competence, or lack of attunement to a client’s needs. We spoke to key stakeholders to build a true picture of when therapy is most likely to harm clients, and how prevalent it is. 

Therapy Today, April 2025

Boundaries 

One of the key issues underlying harm in therapy is a lack of knowledge among clients of what ‘good’ therapy should look like. ‘I always felt like it was really hard for me to know whether or not what I was experiencing was OK, or to explain why, when I felt that it wasn’t,’ says Erin Stevens MBACP, a humanistic, integrative therapist and supervisor whose experience of harm in therapy motivated her to train as a therapist and specialise in working with clients who have also experienced harm. 

‘It wasn’t until two years after termination, when my former therapist began to break boundaries more explicitly, that it became clear. When he did that, I could go, “See, this is what I was talking about the whole time”. It took something obvious for everyone to go, “Oh, yeah”. All the other stuff was just so hard to articulate,’ she says. 

During therapy, the practitioner would do things such as use jargon, change session duration and selfdisclose. ‘At the time I was not a trained therapist myself, and I had no frame of reference for knowing what was OK in therapy and what wasn’t,’ she explains. ‘When I questioned what was happening, my therapist would tell me that he was “congruent” and I was “incongruent”, further leading me to doubt my experience. He controlled much of the narrative and context in a way that was confusing and painful for me. 

‘He would often allow sessions to go on for much more than the designated hour, which was difficult to challenge – it felt good to have more time. However, he completely controlled the terms of the time boundaries, which was ultimately disempowering. 

‘I felt similar ambivalence about his overdisclosure regarding his personal life, and his expressions of feelings towards me, which would range from awe and admiration to announcing that he felt I had “stabbed him in the heart” by questioning an approach he used. Due to my attachment and love towards him, I felt completely powerless and beholden to his whims, which was frightening.’ 

Stevens eventually took a break from her therapist to see a second therapist. ‘It would have been very difficult for me to walk away without support,’ she says. ‘Clients can become stuck in harmful dynamics for years due to a sense of isolation and an absence of other options. Ultimately the therapist’s refusal to talk about the feelings that were happening in the relationship led me to take a “break” while I worked out what was happening, with a second therapist.’ 

After two months Stevens made a decision about the first therapist. 

‘Noticing the sheer difference that a boundaried and calm therapy space made to my nervous system, I decided not to go back. At first there was nothing but grief in this for me, but I then stayed with the second therapist for over nine years. The first year or so was almost completely focused on recovering from the first therapy, and we returned to processing it intermittently throughout the work.’ 

Betraying trust 

Clara** was a trainee therapist when she too experienced harm in therapy as a client. ‘I had been working with my therapist for several months and felt we had a good rapport,’ she says. ‘I trusted her, so it was quite a shock when months in she revealed that she’d spoken to some of her therapy colleagues about an issue I was grappling with and had picked their brains for advice on how to work with it. With complete conviction she proceeded to relay the advice they’d given her: “They told me to tell you... And they told me to ask you...” 

‘I was in such shock I disassociated. I felt heartbroken and unable to explain to my therapist why this felt like a betrayal. I believe she really thought she was helping, and I believe she did it out of care. But it destroyed me.’ 

Clara says she wasn’t far enough in her training to be able to challenge her therapist, or understand what was happening: ‘Looking back I can see my therapist repeated a relational pattern with me that was familiar – having my confidences betrayed – but it’s not enough to excuse it. The experience harmed me and I never really recovered.’ 

Stevens says that the thing that some therapists don’t realise is that harm may be caused in incremental degrees. ‘Harm doesn’t have to be some kind of headline event,’ she says. ‘It can happen gradually. I think this is why a lot of the time when clients leave a harmful therapeutic relationship, they’re asking the question, “Was this harmful?” Sometimes it’s difficult to pinpoint and articulate. 

‘Sexual or financial abuse can sometimes happen in therapy, but they are relatively rare compared to other types of harm. It’s easy to think, “Harm is abuse” or “I’m not going to abuse a client, therefore I don’t have to worry about harm”, to other the “bad” therapists.’

Research 

As well as being too little discussed, ‘harm’ in therapy has long been a struggle to define. The process of every therapy is likely to include difficulties such as missteps, mistakes and distress, but while every harm done in therapy is a mistake, not every mistake is harmful. 

A definition may be difficult to come by, but given how common harm can be, clarity is urgently needed. One of the most recent studies into ‘lasting negative effects’, focusing specifically on therapy for anxiety and depression in NHS trusts, found that 14% of 662 participants, one in seven, reported them.³ The study authors concluded that, going forward, clients should be prepared for ‘negative experiences of treatment’, and that progress should be reviewed regularly, both ‘to identify and prevent’ negative effects. 

Experts who have been in the field for some time also warn that lessons have not yet been learned. Professor Glenys Parry was the chief investigator for AdEPT, a landmark study into harm that received funding from the UK’s prestigious National Institute for Health and Care Research in 2014.⁴ In 2019 she co-authored another paper to develop a model of process factors that might lead to harmful therapy.^5,6 ‘I’m amazed at how few people actually have a formal informed consent process telling people what the risks are,’ she says. 

A decade on from AdEPT, Parry says she remains shocked by the relative scarcity of information that some clients receive before contracting. ‘It’s so important for clients to be aware that therapy can be distressing. It’s a collaborative relationship, and the client should know that they’ve got the power to raise a concern or to seek external support. I really don’t know how many therapists do that.’

Retraumatisation 

There is still much to be learned about the nuances of harm in therapy, but one area that has come under the spotlight in recent years is the risk of retraumatisation. In 2020, in their study on psychotherapy for children, Dr Daniel Hayes and Barbara Castro Batic developed the research on this topic by creating a distinction between clinical deterioration and retraumatisation as two separate types of harm.^7,8 The authors said further research into harm in therapy may benefit from research into specific settings, especially to explore retraumatisation as a new research subject. 

They also recommended future studies might be able to identify harmful experiences that are currently ‘out of the awareness of particular stakeholder groups’, especially since clients and therapists were shown in the 2019 AdEPT paper as having different understandings of ‘negative effects’. 

Hayes is now working on a project with UCL’s Social Biobehavioural Research Group to improve outcomes in CAMHS. ‘This study came out about four or five years ago now,’ Hayes says, ‘and since then there’s been a greater focus on trauma-informed care. Things such as therapists having training in traumainformed care and cultural competence can definitely help mitigate against retraumatisation within therapy for young people.’ 

Preventing harm 

There are simple but effective ways that every therapist can reduce the risk of harming clients, says Sarah Millward, BACP’s Client Ethics Manager. ‘I strongly believe that therapists should be encouraging regular feedback from their clients, and that when they do receive feedback, that they work with their clients through their concerns in an empathic and non-defensive way,’ she says. ‘Doing so can often forge a stronger therapeutic relationship with that client.’ 

It’s also important to be familiar with the Ethical Framework. ‘When you sign up to be a member of BACP, you don’t sign up just to have the letters behind your name,’ she explains. ‘You sign up to adhere to the Ethical Framework, to work with it and work to high standards. That’s our expectation.’ 

Part of Millward’s role is to run the Get Help with Counselling Concerns service, a free helpline for any client who has questions about their therapy. In 2023 it answered 1,390 public queries. The biggest cause for calls is, as many might guess, boundaries. ‘Issues around professional boundaries come up the most, perhaps because it covers so many different aspects of therapy,’ says Millward. ‘Without professional boundaries it’s like the Wild West out there.’ 

Endings are another common cause for concern for Get Help callers. ‘Endings are such an important part of the therapeutic process itself,’ she says. ‘I talk about endings an awful lot with clients, and what good practice around endings looks like. It’s important for a therapist to actually be aware of their own competence, being honest about the work rather than just ending the therapy. An abrupt ending can be hugely damaging for a client.’ 

Another common theme is that clients find it difficult to talk to their therapist about concerns or questions they may have about their work together. ‘If it’s difficult for clients to talk to their therapist about what’s bothering them, I might suggest to a client that they could put something in writing and send it to them before the session to say, “This is something that I would like to talk to you about in the next session”, or take something that they’ve written into the session to read out,’ says Millward. 

Cultural competence 

BACP’s Public Protection Committee’s annual report in 2023 included a list of common themes in types of concerns and complaints at the Investigation and Assessment Committee; concerns categorised as ‘equality, diversity and inclusion’ represented just 1% compared with boundary issues (14%) and ‘abrupt endings’ (10%). Nevertheless, lack of cultural competence is emerging as causing a significant risk of harm in therapy. 

Myira Khan, a BACP counsellor, author and founder of the Muslim Counsellor and Psychotherapist Network, warns that a lack of cultural attunement by the therapist runs many risks. 

‘Working with clients who are culturally distant from the therapist may result in the use of an “outsider” lens by the therapist, which brings into the room their bias, projections and assumptions about the client’s lived experience,’ Khan says. ‘The “distance” creates unfamiliarity and unsafety for the client and/or therapist, and the client feels unseen and unmet by the therapist.’ 

Khan says that she has worked with clients who have been set directive goals by the therapist that clash with the client’s own wishes. ‘Trends in harm that I have seen in my clinical practice revolve around the cultural misattunement between an individualistic-cultured counsellor and collectivist-cultured client she says. ‘The client may be presented with choices or goals in therapy which sit outside their cultural values and context.’

Rotimi Akinsete, BACP counsellor, author and member of the Black, African and Asian Therapy Network leadership team, adds: ‘As outlined in the Ethical Framework, it is our duty to facilitate a sense of self that is meaningful to the person within their personal and cultural context. In my professional experience as a counsellor, supervisor and course tutor, I have worked with clients and students who have been deeply harmed by a lack of cultural sensitivity in previous therapeutic relationships. For example, I have supported clients who felt their cultural identity was dismissed or pathologised, leading to a breakdown in trust and a sense of being misunderstood. These experiences often compound existing trauma, making the therapeutic journey longer and more complex.’ 

Complaints 

Every client of a BACP registered therapist has a right to make a complaint and have it investigated. Our complaints system is designed to protect both individual clients and the public perception of our profession. Most therapists agree it’s important to have a robust complaints system in place, but the fear of a client taking out a complaint can be a constant worry for many. 

Susie Jamieson MBACP was subject to a complaint in 2021. She says the process cost her ‘a significant amount of money’ in lost earnings, despite her insurer funding her solicitor’s fees. ‘It tore my world apart’ and ‘I took to my bed for days at a time’, she says. ‘Sometimes I was able to cope because I have the luxury of working from home, but what if I was hiring a room two days a week, for example, and had clients back to back? Where’s the space for falling apart?’ 

Jamieson first spoke publicly about her experience at the BACP Private Practice Conference last September, and today around a quarter of her caseload now comes from therapists who have received a complaint. ‘I haven’t come across anybody yet who’s come to me and said, “Look, I’ve harmed a client. Can you help me?”,’ she says. 

Complaints seem to have a devastating effect on therapists who seek her help, she says, causing many to abandon their work: ‘A therapist may decide to wrap up their entire practice after a complaint. Some seek work elsewhere. I remember wanting to work in a supermarket.’ 

Jamieson says she would like to see more clarity around what constitutes harmful behaviour but says we also need to acknowledge that not all complaints or allegations of harm are justified. ‘A client is under no obligation to tell us if they have a mental health diagnosis,’ she says. ‘We could be working with people with quite severe mental health issues and be somewhat oblivious to it. We don’t get access to medical records, and we don’t even really know that the client is using their real name. Even if we are doing all the things that we’re supposed to be doing, that’s no guarantee that a client is not going to be upset about something.’ 

Interventions 

BACP continues to invest in and develop its public protection function, and arguably the low rate of complaints among a growing membership suggests that the profession overall is wellresourced to prevent and address harm directly with clients. 

Therapists can also point to specific preventative interventions when discussing overall professional risk of harm: BACP’s current review of the Ethical Framework, cross-partnership work like the Memorandum of Understanding, which protects clients against homophobia and transphobia, and the introduction of the Get Help service in 2012. 

But Stevens says there is still reluctance among many professionals to acknowledge that as well as helping clients we have the potential to harm them, something that became apparent when she started training in 2015. ‘I felt shocked. As a trainee I was at a loss as to how somebody who’s been harmed in therapy is supposed to re-engage. I had been lucky. My subsequent therapist was very, very open to learning from me about what I needed, and keen for us to work on that collaboratively and figure it out together. Now I think that few people have that experience when they go back into therapy, if they go at all. A lot of people who have been harmed in therapy aren’t able to re-engage.’ 

Interventions rely on the therapist’s own willingness to prevent and recognise harm in the therapy room, she says. She now leads independent training on preventing harm in therapy, and says in her experience, the hardest part for therapists is often simply recognising what’s happening. 

‘It’s surprising to therapists to learn that a lot of harm, and in my experience the majority of harm, is nuanced and difficult to spot,’ she says. ‘It’s an erosion of boundaries, or a kind of relational enmeshment re-enactment – an enactment that we might not spot readily. [The challenge is] how we can approach it, and how we can use supervision and self-inquiry to prevent that descent, which is often shrouded in denial.’ 

Jessica Wing wrote about her experience in a member blog, 4 February 2025. Name has been changed 

For information about Erin Stevens’ training courses for therapists working with clients harmed by therapy.