Therapist Red-Flags

Finding harmony in a flooded market

Everyone has a right to quality therapy for their struggles or suffering. However, I don’t necessarily agree that everyone is inherently ready for therapy because the wider societal conversation pressures it. There are definitely ways to ensure that you are more prepared for the process of therapy. In fact, read Dr. Devon Price’s recent piece on how to get the most out of therapy before this piece here. 

I aim to create a simple list of potential red flags in a provider based on my training and expertise. This is not meant to be a slander piece. Instead, I intend this as a resource to help you think differently about the relationship that you have with your counselor. There needs to be more information about how therapy works, what it works toward, and what the process looks like. I hope to provide some therapist behaviors that make me think twice about the health of their practice alongside information that you may not have known about therapy generally. 

It is not your fault that you may not know how to approach the therapeutic process; good clinicians are meant to explain your role as well as theirs at the beginning of treatment. However, both clinicians and clients allow these myths to be perpetuated. This list is meant to provide you the tools to advocate for yourself and recognize the signs of a potentially misaligned therapeutic relationship.

Myth 1: There’s one right way to do therapy

We’ve known for a while that “common factors,” such as a client’s positive expectations in therapy and the warmth of the therapist, are valuable in treatment. Current research effectively says that we cannot pull apart whether specific factors or common factors (probably both) create change in treatment. Common factors are categorized broadly under umbrellas of support, learning, and action. Some examples of common factors that may predict how well someone does in therapy are things like 1) how much the client respects the therapist and their modality, 2) how warm and genuine the therapist appears, 3) how much someone’s feelings of capability change, 4) how much the client is encouraged to face their fears. These are only a few examples, but hopefully, you can see how these factors could be applied in therapy regardless of the specific clinic, focus of treatment, or modality of treatment. 

However, this is not to say that specific treatment techniques or approaches are pointless. There’s a term used in clinical work called Evidence-based practice (EBP). The “evidence” in this phrase is usually scholarly research that provides information regarding the utility (or lack thereof) of specific treatments. EBP is often used as a noun, where a treatment or approach is considered “evidence-based” in itself. For example, Cognitive Behavioral Therapy (CBT) may be called evidence-based because research has demonstrated its efficacy and effectiveness for different problems and populations. This often leads to therapists or organizations providing a single solution for a single problem. For example, any client dealing with substance abuse issues is given the same treatment of motivational interviewing.

This is, perhaps, a bastardization of how EBP is intended to work. EBP was originally developed as a verb, a process consisting of 5 steps: 1) Ask the client about their views and preferences for treatment, 2) Acquire evidence to help you understand the problem and possible treatments for it, 3) Appraise the quality of the evidence and the appropriateness of the treatment for the problem, 4) Apply the intervention that is best suited for the client and their problem, and 5) assess how well the treatment worked, preferably through formal measurement. Steps 1 and 4 highlight EBP as a client empowerment process. In fact, in step 4, if you bring a well-researched option to the client and they don’t want it, you should go back to the drawing board. Yet, how many of you readers have received clinical treatment that looked like this? I’m willing to bet it is few to none. 

Red Flag 1: My Way or the Highway

The first red flag to be aware of is when the clinician you are working with is inflexible to a variety of treatment options. If their therapist profile online states that they are an expert in CBT and that is the only option that they are willing to provide you even after you express interest in other options, that is a red flag. It is important to note that the client has responsibility in the negotiation of treatment. This point will reappear throughout each of these sections. Your therapist should be willing to adjust their treatment as needed for your initial problem, your change over time, and in response to different experiences throughout the process. Most clinicians are not going to immediately tell you they only provide one type of treatment. During your first session, you should feel comfortable assessing your clinician’s fit for your services. Explicitly discussing treatment approach is one way to assess how flexible they can be with their techniques and modalities. 

For best outcomes, there are some steps you can take. First, be familiar with different modalities. There is a lot of material online regarding different common approaches (CBT; DBT; Generalist; EMDR; etc.) but you can also use information regarding what has been helpful for others in similar situations to you. Second, explicitly ask your clinician to describe their treatment approach or modality. Be wary if they generalize one treatment option to all of their clients, or do not relate their approach to your specific issue. For example, they may say, “with my clients I use CBT to approach the unhealthy thinking patterns that lead to emotional dysregulation.” This tells you that there is one option that they have already decided and plan to fit you into. Your therapeutic modality should be tailored to your needs, not the other way around. Finally, openly express interest or concern regarding treatment approaches. Explain to them what you’ve heard about, what you would consider to be helpful, or treatments that you are not willing to explore. If you are not willing to try medication alongside therapy, for example, speak up! Therapists are service providers, they work for you! 

Ultimately, remember: good clinicians will be able to find multiple potential solutions to each client problem and can adjust as needed. 

Myth 2: TikTok Clinicians are Giving You Something for Free

Now, time to address the elephant in the room: TikTok. Although I am a TikTok user myself, there are some critiques that must be raised in this discussion. I have personally seen the rise of the self-marketing of private practice therapists on TikTok. Briefly, I want to distinguish between TikTok Clinicians and TikTok Scholars. There are plenty of scholars using the platform to disseminate good information about mental health. However, there are perhaps even more private practice therapists who are sharing information as self-marketing. Look out for any private practice therapist who is following content trends and has their practice linked in the bio or link tree. Basically, if you can access their private practice from their TikTok page then it’s a marketing option for them. I want to be clear, I don’t blame any of these therapists because that usage makes sense. 

My fear, however, is the ethical implications don’t bode well for them or their clients. For example, I have seen popular therapists with extensive demand in their comments sections. The ethical question is: if they have a three-year waitlist because of TikTok success, will they refer out or make them wait? Ethically, each therapist should close their books or refer their waitlist out to other qualified clinicians. However, it’s a lot of work to guarantee the quality of the alternative clinician and to formally refer the clients out. For many of these TikTok clinicians, you are a dollar sign and they are satisfied to make you wait. How long can your mental wellbeing wait? 

Red Flag: I’m not a Regular Therapist, I’m a Cool Therapist

It may be difficult to tell when someone is a well-intentioned clinician trying to educate versus someone who is selling your something. I will provide an example. I saw a video once of a therapist who was using a trendy content template to gloat about being the type of therapist who allows you to wear a bonnet and curse during a session. Of course, this implicitly says, unlike those other (hypothetical) therapists. I want to be very clear that the issue with this is that any therapist that doesn’t allow you to wear a bonnet or curse during a session is not meeting the bare minimum requirements. This should not be a selling point, it is your right to show up as you are in session. When a video implies that they are a better therapist than some hypothetical other who is not there to defend themselves, it’s a sale. A video that says, “these are your rights as a client,” is different from, “here’s how I respect the rights of clients in ways that others don’t.”  

For best outcomes, take all TikTok content with a grain of salt. You have heard this before, I’m sure. A practical step you can take is to check the licensure of any potential therapist whether identified through TikTok or otherwise. You can search “(your state name) therapist license lookup” and typically find the licensing agency’s search website. Additionally, ask yourself after a video about mental health, “am I being sold something?” 

Myth 3: Therapists are your friends

This one may hurt a bit. Therapists are not your friends. The therapeutic relationship has features that are friendly, warm, and unconditionally supportive, and it should. Therapists are meant to provide you a confidential place to work out ideas and behaviors in safety and non-judgment. However, the therapeutic relationship has a power differential which means that you are not friends. In fact, most licensed fields have stipulations regarding dual relationships. Psychology requires that it is 7 years post-treatment before a therapist and client can be friends or more. Some fields say once a client, always a client. The important thing to consider is that there are no healthy friendships that look like a therapeutic relationship should. Most people are meeting their therapist on one of the worst days of their life. Clients also share their truth with a complete vulnerability that is not reciprocated. If it is reciprocated, that is a problem. 

Red Flag: Personal Disclosures

Oh, but Dawson, what’s the harm?! My therapist bestie and I talk about how hard life is all the time! Trust me, I hear it all the time. I promise you, though, it limits the quality of your treatment. Some passive disclosures, such as photos of loved ones on their desk, are minor and potentially benign. Even an occasional disclosure that is used intentionally for therapeutic purposes can be okay, but they all come with risks. The first thing we need to talk about is how to identify a self-disclosure. The only things that you need to know about your therapist are related to your treatment. Their credentials, their treatment approach, their ideological approach, and the insurance that they accept. A good therapist should earn your respect and provide you unconditional support without you having to know much more than that. A good therapist should be differentiated from who they are as a person. If normal conversations and relationships were enough to solve all mental health and behavioral issues, we wouldn’t need therapists or special training. 

Although healthy relationships are one key to wellbeing and in an ideal world would be all that is needed, that is not what you are paying them for. Clinically, I never arrived as just my full Dawson-self. That’s because Dawson is a person who gets their feelings hurt, has anxious thoughts, and has trouble setting boundaries. My clients would have suffered for that. Clinician Dawson is a strong advocate, can set boundaries with authority when necessary, and understands that I represent a role and my clients may occasionally need to vent. 

Ultimately, if you know who your therapist is (truly) then you can hurt them in a way that does not allow them to be good clinicians. If you know Dawson the person, you can call me names that actually hurt me when you lash out because you’ve had a hard day. I have been on the receiving and delivering end of many lectures about the harms of self-disclosure. I will spare you the tuition fees. Here’s the short list of how personal disclosures from a therapist can harm a relationship. 

The first risk is that a disclosure will activate bias within a client. All of us have biases because it is human nature. Our brain takes shortcuts to try to keep us safe. It generalizes from one experience to all of them. So let’s say you’re an agnostic client and your therapist starts sharing about what a great time they had over the weekend at church. Even if you have no judgment towards someone with religious faith, you cannot unknow that about your therapist. An easy result of knowing something like this is an unconscious (or conscious) filtering of your thoughts based on what you’ve learned. In this example, perhaps you start filtering out any thoughts you might’ve shared about your agnosticism or any fears of death. 

The second risk is unclear boundaries. If you think of your therapist as a friend, you may start treating them the way you treat your friends. This limits the therapeutic possibilities. For example, if you “people-please” or prioritize other people’s needs instead of your own, it may show up in session. For example, you may not share something that is really weighing on you because you are worried about the weight that thought might have on your therapist. I hear about this one often. If you start worrying about your therapist’s wellbeing, the relationship has skewed too far. You may be more inclined to buy gifts, text or call late at night, or even seek their approval rather than their guidance. A therapist’s role should be clear and designated. You shouldn’t worry about hurting your therapist’s feelings, but that’s appropriate for a friend. 

Additionally, if your therapist says, “well when I was in a situation like that…” you are going to be more likely to try to do what they would do rather than what is good for you. It is not hard to say, “I’ve had other clients who have done…” to achieve the exact same communication with less risk. Your therapist should be willing and able to do those mental gymnastics to help you reach your goals. 

This brings me to the next risk, loss of respect or competency. If your therapist shares anything that speaks to their personal wellbeing, you may start to view them as someone needing support not providing it. I’ve heard of therapists sharing about their substance use recovery during sessions with clients. Those clients then worry about their therapist’s possible relapse. How could you share explicit details about your usage and how it affected you, if you view your therapist as vulnerable to those details? In order to be able to have healthy confrontation, authority for safety, and other therapeutic skills, then there needs to be a level of respect that is outside of “friendship.” 

Additionally, self-disclosures are distracting from therapeutic work and progress. Talking about your therapist’s dogs, weekend plans, or previous experiences sure is a great way to waste time in a session. This can distract intentionally or unintentionally from the important work that needs to be done. Would I rather talk about my therapist’s recent wedding or do emotionally draining role plays where I have to practice advocating for myself? I would definitely prefer the first one, but I would be paying to do the latter. 

Finally, dual relationships are the one of the most common reasons that therapists are investigated and have their licenses removed. This includes sexual relationships between client and clinician, as well as other dual conflicts like your therapist convincing you to buy their book or get coffee with them. 

If you want or need new friends then set a goal with your therapist to help you strengthen your social health - don’t let your clinician be your friend. 

Myth 4: Therapy Forever

Depending on the specific modality of treatment, the “optimal range” of treatment length is four to twenty-six sessions. Some treatments, such as solution-focused brief therapy (SFBT) is designed to be delivered in less than eight sessions. Even generalist practice with “eclectic” techniques, should have an end date. Now, I know many people who see the same psychiatrist for over a decade. I want to be clear that there is a difference between prescribers and counselors. If you are in sessions with your therapist for years and years, you are either not getting better (because of poor practice) or you are being financially exploited (because of malicious practice.) 

Red Flag: Not Discussing Termination ASAP

No matter the practice approach, therapy should have clear goals and a deadline. That end-date can be changed, extended, or shortened. However, if your therapist is not discussing termination with you at all, there is a problem. The goal of therapy is for you to develop better behavior that is a lasting change without the need for a therapist to coach you through practicing that behavior forever. Multiple goals is fine, as long as there is progress toward each. Even “talk therapy” should have a clear purpose and a threshold where you know that your goals have been reached and it is time to end the relationship. When starting a new therapeutic relationship, your clinician should initiate a conversation about when it will end. However, you have the right to initiate that conversation if they do not, as early as the first session. Please feel confident asking the question, “how will you measure that I am meeting my goals and how will the decision be made that it is time to end therapy?”

If you are already in a long-standing therapeutic relationship, here are some questions to ask yourself to determine if quantity and quality are at odds:

• What was my original goal when I entered therapy? Has it been reached? Has a new goal been set?

• Has my clinician been measuring my progress? What has changed since we started treatment?

• Has my behavior changed? Am I able to sustain those behaviors without treatment?

• Do I still need specific support or am I afraid of not having the possibility of support?

• Has this relationship caused any financial strain for me?

• What is being provided for me that has not previously been given, demonstrated, or practiced?

• How will I know when I am ready to end therapy? Was this discussed with my therapist? 

A really important consideration is that if you feel that you are not getting any better or your behavior is not changing, you need to tell you therapist that. I will discuss this more in Myth 6. 

Myth 5: You Don’t Want Your Records

There is a bit of mystery that exists in a clinical room. One thing that shouldn’t be a mystery is what is going into your records. In fact, the 21st Century Cures Act (CURES) now requires that any requests for mental health records are provided electronically, for free, within 30 days. You have a right to your records. One of the reasons that this policy was passed was because there have been real attempts by clinicians to interfere with accessing records. I have personally been told in previous years by supervisors to make the client not want their record. In fact, it used to cost $1 per page for each page and that was stressed to every client to try to interfere with their access. This new law means that there are real repercussions for that type of behavior. 

Red Flag: A Secret Permanent Record

There are different types of records in therapy and it would be a lie to say that there are no downsides to receiving all of your records including your notes. It can feel personal to read your notes or they may include terminology that is only meant for clinicians. It is possible that seeing your records, no matter how great the clinician, can damage your relationship and make it harder to progress. 

However, even without copies of your files, there should not be questions about what is being recorded about you, generally. A non-negotiable is that confidentiality, and the limits of it, should be discussed in the very first session. For example, disclosures of active abuse of a child, an elder, or a person with a disability must be reported. Suicidal or homocidal intent must also be reported. There are also occasions, where your records can be subpoenaed by a court. However, your clinician should advocate for as much privacy as possible. Additionally, in some states, if a child dies due to neglect per an autopsy, any records on the parent or guardian become public record. These are discussions that should happen during the intake and first session with a new clinician. Additionally, although many aren’t told this, you should be informed that if you are accessing services through health insurance, a diagnosis is required for treatment after the first session. Medical records, including psychotherapy notes, must be filed within 24 - 48 hours after services. So, each session you have has a paper trail. In some fields, collaborative notes are gaining popularity. Collaborative notes are defined by the client and clinician working together to decide what is filed after the session. 

Ultimately, you don’t need your records but you do need transparency about what they include. Any evasiveness from a clinician regarding discussing the facts above, should raise concern. 

Myth 6: Your Therapist Knows Best

Finally, although the clinical role comes with authority and expertise, there is a myth that your therapist always knows what is best. The number one mistake I hear in therapeutic experiences is that the client is unable to have healthy conflict. If your therapy experience isn’t challenging, I question its efficacy. Since you are meant to have a safe space to practice new skills and you are entrusting another person with your full vulnerability, there are going to be ugly moments. 

Remember earlier when I said that you should be explicitly and loudly telling your therapist if you’re not progressing? If you would not feel comfortable telling a clinician that you don’t feel like you’re getting better, then your therapist has failed or you are not ready for therapy. I mean this with complete non-judgment. Although current society has made it a moral issue if you are not in therapy, it is okay to not be ready for it if you are not going to benefit. 

Red Flag: Giving Advice 

The biggest and quickest red flag regarding therapist guidance is if they are giving advice. Now, giving advice differs from helping you work out the logic of an action or sharing approaches to healthier choices. Therapists should be helping you work through your logic through questioning. Handing you answers is not what therapy is about. Therapy is a lot like teaching, if a school teacher only ever gave you answers, you wouldn’t learn anything. One of the most pervasive myths is that therapists give you the answers when they are actually supposed to give you the tools. 

I have heard of therapists encouraging clients to break up with their romantic partners. Even in domestic violence situations, therapists need to consider their client’s choices and desires. For example, we know that the risk to someone escalates when they leave a violent relationship. Imagine the consequences of a therapist blindly advising someone to leave their partner if they haven’t yet shared their violent history. 

This also relates to therapists not being your friends. Friends give advice, and they are often trying to tell you what they think is best. Therapists give guidance by helping you find what you think is best and then helping you have the skills to execute it. Additionally, when you think your therapist is your friend, you are way less likely to question bad advice. I have heard repeatedly of therapists giving advice like, “you should tell your mom to back off.” Then, a client obliges, follows the advice, and then when it ultimately backfires, the clinician is to blame. 

So instead, you should be working through it to find what you think is best. Questions you should be hearing are: 

• What have you tried already? 

• What worked at all? 

• When was the issue at its worst?

• When was the issue better?

• What are you able to change? 

• What is outside of your control?  

When working with a client, a therapist could assume that anything that they could theoretically recommend is something the client has already thought of because they live in that situation. The clinician simply visits it with them for a limited amount of time. Make sure they understand that you are the expert. 

As always, there are exceptions to each of these assertions. This is not objective truth but general information to help you better understand the complex relationship that is therapy. Not radical but refreshed.