Subsequent Therapist Reconsidered

It is a natural tendency of professionals to want to be helpful, to protect their clients from incompetent or predatory therapists, to establish themselves as experts. When hearing what they consider to be wrong, unethical or harmful behavior of another (potentially competing) professional, a therapist quickly wants to protect their clients and become an expert on what is right and wrong. But does this get in the way of acting ethically? Further, does this jeopardize therapists’ ability to provide a quality service to their current clients?

I have coined the term Subsequent Therapist Syndrome (STS) to mean:

Circumstances where the subsequent therapist (ST), current, next or new, may act unethically or even illegally when providing an “expert opinion” regarding a former therapist’s (supposedly) unethical or illegal conduct. These are the cases where the subsequent therapist’s evaluation and judgment are solely based on their theoretical bias, rigid view of therapeutic boundaries, and/or a client’s self-report. These are the situations where the ST arrives at firm and clear conclusions without reviewing the psychotherapy records or other relevant collateral evidence, or without consulting with the former therapist (of course, with client’s permission). Then the ST, based on insufficient knowledge, encourages the client to file a licensing board complaint or, with the client’s permission, files a board complaint himself or herself.

Here is an example:

Sally is a 45-year old mother of three going through a tough divorce who begins work with a licensed clinical social worker. On one particularly challenging visit, the social worker reaches out and takes Sally’s hands in hers, reassuring her that “she can get through this.”

Unfortunately, quite unexpectedly, Sally’s social worker must go on a medical leave and gives Sally three referrals to fellow clinicians. Sally finds a clinician she feels comfortable with and begins work. She tells her new therapist about her work with her social worker and how it meant so much to her when she took her hands in hers and reassured her. Feeling as though Sally’s social worker overstepped boundaries by touching Sally, Sally’s new therapist explained to Sally that what her former therapist did was “unethical” and should be reported to the licensing board. Her new therapist then got her permission and proceeded to report the prior therapist to the state board of licensed clinical social work.

At the heart of the “Subsequent Therapist Syndrome” is the disturbing realization that many psychotherapists and counselors do not know how to simply say “I disagree” but instead claim “It is unethical”.

Here are several areas where Subsequent Therapist Syndrome may rear its head:

• a therapist uses ethical and clinically effective physical touch to soothe a distressed or anxious client;
• the therapist makes a clinically appropriate home visit, such as to an agoraphobic or home-bound client;
• the therapist uses clinically beneficial, extensive disclosure of personal information with a client;
• via text messaging, a therapist engages with a young suicidal client late into the night in order to prevent the client from hurting himself or herself;
• the therapist signs an e-mail to a long-term-intermittent client of 20 years with “Love, Xxx”;
• the therapist goes for a walk on a nearby trail with a client who loves the outdoors or prefers ‘side-by-side’ type communication as opposed to face-to-face communication;
• the therapist is in a small town and, therefore, is unavoidably involved in shared, social, and multiple relationships with the client.

Psychotherapists have the clear duty to protect their clients in particular, and the public in general, from incompetent, predatory and harmful therapists. In doing so, we need to act responsibly, being very careful not to draw premature, unsupported or unsubstantiated conclusions based solely on a client’s self-report, without a review of records, consultations or discussion with the former therapist (of course, with client consent).

In my (Dr. Zur) experience, sadly, a significant percentage of board complaints are inappropriately initiated by subsequent therapists.

One helpful step is peer consultation or consultation with an ethicist. Instead of immediately concluding that the actions of another were unethical, a prudent clinician can consult with peers or experts to review the actions of the former therapist, and overcome any biases that may preclude judgement.

Getting the client’s permission to discuss the concerns with the former therapist is generally a good idea. It can be clinically helpful as it helps shed clearer light on the former therapist’s interventions and clinical rationale as well as of client’s response to different interventions.

In summary, do not fall into the trap of the Subsequent Therapist Syndrome. If you have a concern regarding the former therapists’ action, be thoughtful and act in an ethically and clinically responsible manner.