Courtney thought it was strange when her therapist asked her to follow him on Instagram. She had begun seeing Michael – a psychoanalyst who has written books and appeared on television – to treat her fear of flying in 2018 (both of their names, and those of all the patients in this article have been changed). After a few sessions, he suggested the pair connect on Instagram, where he posted everything from mindfulness tips to topless gym selfies. As she didn’t use the app much, Courtney shrugged off her concerns and continued therapy, discussing her childhood abuse, depression, anxiety and sex life. Then, around five months after she had begun seeing him, Michael asked if she had been offended by a message he had sent. What message? Courtney hadn’t seen one, so Michael demanded that she check her Instagram inbox then and there. “All this sex talk has got me gagging for it,” his message began, “I can’t wait to get home and sort myself out.” Michael called himself a psychoanalyst and had training in hypnotherapy, but Courtney didn’t scrutinise his credentials when she found him by searching online. “I just assumed that all therapists had more or less the same capabilities,” she says now. In fact, psychotherapist, psychoanalyst, therapist, hypnotherapist and counsellor are all unprotected terms in the UK, where there is no statutory regulation of therapists. You can legally call yourself any of these titles without any training. Courtney terminated her sessions with Michael shortly afterwards, and last autumn self‑published a book – under her pseudonym – about her experiences, When Therapy Goes Wrong: A Personal Examination Of An Unregulated Industry. In it, she discusses a number of ways in which therapists can be harmful: from inappropriate comments and gaslighting to drinking with clients and telling them they are beyond help. Before publishing her book, Courtney complained to the association Michael was registered with. The complaint was closed by the committee due to “insubstantial evidence” and Courtney later pursued legal action against him (the case is ongoing). “Once I released the book, so many people came forward and said, ‘I’ve had a similar experience and nobody believed me.’ I just think: how many people are there who nobody’s listening to?” More than 1.69 million people in the UK were referred to NHS talking therapies between April 2019 and March 2020, while countless more sought help from private practitioners (the NHS website says “most” of its psychotherapists are clinically qualified). There is now a widespread acceptance that therapy can change lives: a 2020 survey from YouGov and the British Association for Counselling and Psychotherapy (BACP) found that 86% of people believe it’s better to talk about your problems than take medication. Yet there is very little mainstream discussion about transgressive and abusive therapists, and even less about well-meaning therapists who are inadvertently damaging. In such a unique and emotional relationship, how can you tell when a therapist has crossed the line? What should you do when something goes wrong? Glenys Parry is an emeritus professor of psychological services research at the University of Sheffield, and the author of a number of papers about therapy risks. “I think the most common ones are therapists getting out of their depth, working with a complexity and severity of problems that they are really not trained to do,” she says. Some therapists can be too rigid or don’t listen enough. “Another reason therapy can be harmful is that the therapist is actually psychotoxic – this is where a therapist’s behaviour directly harms a client’s mental health or wellbeing, for example by undermining their confidence or self-esteem, or fostering unhealthy dependency.” Courtney says she experienced a number of red flags during her sessions with Michael. First, he liked to make the therapy about himself – when Courtney told him about a 3km run she had done one week, he replied: “I can run a 5k in 23 minutes – quite impressive for a man of my bulk.” He would often eat during sessions, and never took notes. When Courtney’s mental health deteriorated and she began self-harming, he asked to see her cuts. His reaction was shocking: “That’s not so bad, I’ve seen much worse.” Parry says experiences like this can cause lasting harm. “Some people have a very negative relationship with a therapist, which can put them off therapy for life, or it can make them quite ill.” One 2016 survey led by the Royal College of Psychiatrists found that one in 20 people reported “lasting bad effects” from their therapy, with people from minority-ethnic and LGBTQ+ backgrounds more likely to encounter these problems. Kyle was experiencing depression and anxiety when he sought help from an NHS therapist in 2019. Six sessions were booked, but Kyle left after four. In one incident, Kyle’s therapist used “she” and “her” pronouns to discuss Kyle’s partner – he corrected her; his partner was a man. The therapist then declared she had “felt” that Kyle was gay in their first session. Kyle believes she drew on stereotypes to reach this conclusion. “It made me feel very self-conscious and question what it was about me that had made her sense my sexuality,” he says, “and why she thought this was an appropriate thing to say.” Kyle’s therapist also asked him why he was scoring poorly on the depression questionnaire he completed before each session, with his symptoms worsening each time. When Kyle mentioned that a former acquaintance had recently taken his own life, the therapist said: “I don’t care about that.” Kyle believes she was more focused on his score than his actual emotions – she needed a concrete reason to give her supervisor for his declining mood. “It was quite an extreme example of the general lack of care that I felt from her,” he says. Kyle and Courtney have since had positive experiences with other therapists, but Courtney believes Michael caused lasting damage to her mental health. “I tried to kill myself. I was in an inpatient facility. I had to leave my job,” she says. “I couldn’t even get out of bed. It was totally devastating to my life.” Courtney believes this damage was partly caused by Michael’s insistence that she “relive” her childhood sexual abuse via a 40-minute hypnotherapy session, during which he wanted explicit details and asked her to witness the scene from the abuser’s perspective. She recognises that there is a place for recall in trauma work, but felt the way Michael did it was gratuitous. He rarely revisited the topic after forcing her to open up, and in a later session he appeared to have forgotten about her abuse entirely. Parry says that discomfort and facing up to traumatic memories can be a necessary part of therapy, but a good therapist should always explain this to the client. “In good therapy, the therapist checks regularly: ‘Is this helping? Do you feel this is what you need?’” she says. Parry has done a lot of research on the “psychotherapeutic alliance” – a good alliance means there is a bond between patient and therapist, an agreement on what the goals of therapy are, and how to reach those goals. “The problem comes when the therapist and the client haven’t got enough trust or enough psychological safety to be able to say, ‘This is very hurtful. I just don’t feel I’m getting anywhere. I feel worse.’” For eight or nine months, Imogen had a good therapeutic alliance with her therapist, whom she started seeing via Zoom after experiencing psychosomatic stomachaches. (Thousands have transitioned to virtual therapy in the pandemic, but Parry says there’s no evidence online therapy is any less effective or more harmful.) After Imogen began feeling better and tried to end the sessions, her therapist became angry. “It was childish,” Imogen says now, describing how the therapist said she would rather write her book than continue to see Imogen anyway, and also referenced an email from an anorexic patient (“It felt like she was just trying to prove herself”). Imogen paid more than £400 a month for therapy; her therapist used to say that people who couldn’t afford treatment should “eat a bit less”. Imogen is conflicted about her experiences because she believes her therapist truly did help her before things broke down. Therapists are human, and Parry notes that sometimes ruptures in the therapeutic alliance can be fixed (provided it is just a relationship problem and not malpractice). “We’ve done studies where a rupture is repaired, and that is very good, because you learn that you can speak your mind. It can be a therapeutic moment when you’ve managed to work through a difficulty.” How can you tell what qualifies as a rupture that you can overcome, as opposed to something that’s crossed the line? The BACP’s ethical framework provides a comprehensive list of expectations for therapists, ranging from protecting client confidentiality and keeping accurate records, to not abusing clients “financially, emotionally, physically, sexually or spiritually”. But Parry stresses that determining harm can be complex – partly because some discomfort is a necessary part of therapy, partly because some patients have existing difficulties with relationships, and partly because some clients and therapists simply aren’t a good fit, personality-wise. She says: “A rupture can occur because of misunderstandings on either side.” Parry advises talking to a friend or another therapist to get a second opinion before confronting your therapist, either in person or, if you feel unable to do that, via letter or email. The rupture itself is one thing, but what happens when you try to bring it up can often be most revealing. Parry says your therapist should address it in an “open, non-defensive, compassionate” way. “If the therapist isn’t doing that – if you’ve raised an issue and they’re silencing you – that isn’t good. If you don’t feel they’re working with you, if they’re overruling you, this is a bad sign.” If your therapist is unresponsive to your concerns or continues to behave transgressively, you may be able to report them. With NHS therapists, you can complain directly to the practice or hospital, or you can contact your local clinical commissioning group, which you can find on the NHS website. With private practitioners, there are a number of registers a mental health professional can belong to, the largest of which is the BACP. In 2020, the BACP took forward 193 complaints about its members and responded to 1,361 concerns via its Get Help With Counselling Concerns service (the BACP currently has 57,000 registered members). Fiona Ballantine Dykes, the BACP’s chief professional standards officer, says the association works on “upstream prevention”, looking for “themes” in complaints and issuing extra guidance to members. If someone is removed from the BACP register because of transgressions, that information is publicly available on its website and is shared with other accredited registers. To become a member of the BACP, therapists need to pass a certificate of proficiency or undertake a BACP-accredited course. But many people are unaware that therapists don’t have to belong to a register to practise. (Anyone can call themselves a psychologist, but the terms clinical psychologist, health psychologist, practitioner psychologist, registered psychologist and counselling psychologist are protected.) Parry advises asking your therapist outright about their credentials: “It’s perfectly acceptable to ask. I would say it’s essential.” Because of her experiences, Courtney is pushing for greater regulation in the industry: she would like to see a central register of complaints against therapists, akin to the Solicitors Regulation Authority, which allows the public to search for complaints made against a solicitor. She is also undertaking a master’s degree in counselling and psychotherapy. “I think there needs to be more training around the dangers,” she says. “I mean, even in my own training course, we were told you can’t really do much damage to clients. I sat there thinking, ‘I think you can!’”