Funder by the Department of Human Services Auspiced by Our Community


Many of us develop useful, even life saving, therapeutic alliances. Nonetheless, the relationships we develop with mental health clinicians are unusual and artificial in many ways.

Here we outline 10 issues that can be relevant to relationships, and offer some thoughts about how we can consciously shape these formal exchanges (as much as we can).

1. Dependence

Many people understandably fear becoming dependent. Often to some extent we are, and this is not necessarily entirely a bad thing, or entirely our fault. Many of the clinicians we see are also dependent on us - some are certainly dependent on our money.

Some of us are so determined not to become dependent that we completely shut off from developing meaningful relationships. This is understandable, as the risks are relatively one-sided. However this can hinder opportunities for personal growth.

2. Boundaries

Boundaries are an important concept for professionals, although sometimes over-stressed.

Mental health professionals tend to believe that 'professionalism' demands that they create and maintain boundaries, and that this protects their clients.

However, consumers who have had multiple clinicians know that boundaries are drawn idiosyncratically. We can experiment by pushing boundaries to better understand them.

Also, different consumers have different ideas about boundaries (and these can change over time). For example, glimpses into a therapist's private life can be very helpful, frightening or annoying.

Some of us like to maintain distance, or even try to make ourselves less likeable to avoid developing overly 'touchy-feely' relationships.

On the other hand, some of us strongly prefer that these boundaries are looser - if boundaries are too tight and rule-driven we might feel controlled, undignified and unhappy. Our own boundaries need to be self-defined.

At their extreme, therapeutic arrangements are governed by a 'Contract of Therapy' (particularly associated with some forms of psychotherapy) which gives us little or no room to move once it is signed.

Depending on our communication preferences these documents can either reassure us or scare the living daylights out of us. Once signed, it is part of the therapy. It won't go away. Decide early whether you're going to leave.

3. Boundaries as excuses

Like confidentiality, boundaries can be used as an excuse for poor communication.

Flexibility is essential, allowing sensitive professionals to explore boundary issues with consumers in an open, safe and transparent environment, free from any games.

4. Malpractice

Sometimes boundaries are shattered by the party which has the most power in the relationship - in this context, the mental health professional.

It's important to know that if we are touched inappropriately, sexual advances are made, or sexual images are used unsuitably, for example, we should be concerned, no matter how 'nice' and 'caring' the person might seem.

We need to be clear that none of this is our right and none of it is our fault. If we are uncomfortable with anything to do with personal boundaries we must try and find support to confront these issues and remove ourselves from the relationship. This is a big decision to make and some people do not follow through with a complaint. Unsupported it will be extremely hard.

5. Political views and moral imperatives

Some people believe that anti-psychiatry is a moral imperative for consumers whilst others perhaps once thought this way and have moved on to a more accepting stance. Others still are perfectly comfortable with psychiatry, and happy about campaigns that promote compliance within a medical agenda.

People hold a wide range of views. It is not weak-willed to seek out help from psychiatry/psychology or counselling. Nor should it be seen as wrong to seek and promote information from the consumer/survivor movement. We need to be encouraged to talk to others who have travelled the same paths and enabled to think well of the choices we make.

6. Ethics and professionalism

There is often a difference between the patient/client code of ethics and the professional code to which clinicians ascribe. Sometimes these differences compromise practice and communication.

Issues around confidentiality, duty of care, being competent and in control, and detailed record-keeping are part of the fabric of clinical ethics and professionalism. For us, however, ethics might include the requirement for clinicians to listen to us respectfully at all times, adhere to our advance directives, practice in a way that enables the dignity of risk, challenge the social structures that protect perpetrators of abuse and trauma, and make a stand on behalf of their clients/patients around the social issues that often have determined our lives.

7. Intelligence

Often people say that they can't bear being 'in therapy' with clinicians who are not as intelligent as they are. When they find it easy to 'read' the clinician, second-guess their next move and manipulate the therapy, they are not satisfied and become pessimistic about anything changing in their lives.

In the public sector this can be diabolical because there is almost no opportunity for changing your primary worker.

8. Inexperienced practitioners

Most people practicing psychotherapy attend regular supervision from more experienced practitioners. This is like having a mentor and has proven to be imperative for the survival of many young practitioners in a harsh environment.

Sometimes, however, it can be like learning the 'sins of the father'. All apprenticeship models hold risks of some young clinicians copying bad practice.

9. Referring friends

Take care. Some of us have done this and it has gone pear shaped.

It's imperative to remember that we all appreciate different approaches to clinical practice: different theoretical underpinnings, different ideas about medication, and so on.

If you have found a therapist/clinician who is useful, write down what they do which works for you. Think it through carefully on several axes of importance. For example: 'politeness, non-patronising and good bedside manner' or 'knowledge of the most up-to-date psychotropic medication' ... then, instead of recommending her/him per se, say, "This is what my therapist's practice includes ..." or, "This is what I appreciate in my clinician's behaviour/practice ..." then people can make up their own minds.

10. Ending a therapeutic relationship

Concluding long-standing relationships with a therapist IS difficult. After all, we have invested a large part of our lives in this transient, strange relationship which is disconnected from the fabric of the rest of our lives.