How to Sit with Patients and Do No Harm

Psychotherapist’s Oath

As a Psychotherapist:

I must first do no harm.

I will promote healing and well-being in my patients and place the patient’s and public’s interests above my own at all times.

I will respect the integrity of the persons with whom I am working, and I will remain objective in my relationships with patients and will act with integrity in dealing with other professionals.

I will provide only those services for which I have had the appropriate training and experience and will keep my technical competency at the highest level in order to uphold professional standards of practice.

I will not violate the physical boundaries of the patient and will always provide a safe and trusting haven for healing.

I will defend the profession against unjust criticism and defend colleagues against unjust actions.

I will seek to improve and expand my knowledge through continuing education and training.

I will refrain from any conduct that would reflect adversely upon the best interest of The American Psychotherapy Association and its ethical standards of practice.

*https://americanpsychotherapy.com/about/oath/

I must first do no harm.

Harm = Physical or mental damage or injury; something that causes someone or something to be hurt, broken, made less valuable or successful (Britannica dictionary)

When people are seeking therapy, they are, at best, conflicted and vulnerable, and, at worst, desperate or close to it. Much has to occur to take the step to initiate getting help, and entering into the therapeutic relationship either for the first time or the 5th time is a plea for an end to suffering, a longing to be taken seriously, and a desperation to be validated. Before the moment a patient comes to you for help, your job is to know your role in this relationship, the power that you hold, the inherent inequity between patient and therapist, and the fragility of this relationship. Doing no harm starts and ends with you as the keeper of the boundaries. Acknowledging that is not enough.

When a trauma survivor comes to you for help, they have already had a trust that has been ruptured, boundaries that have already been crossed, and harm that has already been done. It is likely they have been harmed during a time of vulnerability, possibly by someone they loved and trusted, and most assuredly in a dynamic in which they experienced themself as helpless and incapable. There is always shame in not being able to keep oneself safe. These people come to you with this rooted inside of them. Often trauma survivors have been in some kind of treatment before they have arrived to you, and it is your duty to get clarity on why that wasn’t helpful and why they are seeking you out. This patient is still questing for a witness and a chance at a better life. If they have found their way to you, be certain that they have not found it yet. You will quickly feel inclined to be the savior, but do your part by having humility, being inactive, being curious, listening, and doing your work to learn this person fully before thinking you know what is in their best interest.

I will promote healing and well-being in my patients and place the patient’s and public’s interests above my own at all times.

Translation: Do your own work.

You are only as available to your patients as your ability to look internally and uncover your conflicts. You will not be able to recognize patterns of suffering if they resemble your own and you haven’t made good sense of them yourself. You will not be able to impart the true exhilaration of self discovery and awareness if you have not ventured down that path yourself.

If you deem yourself the expert on this person, you will fail. You are a novice with this new life before you. You both have a lot to learn together. Yes, you are in charge, and you bring with you skills, education, and experience that this person before might not have. Yes, you are in a position of power, but your patient does not want your workbook exercises or medication referrals or best evidence based anxiety reducing techniques, even if they say they do.

What patient’s want and need is to borrow your good, stable, boundaried ego strength so they can do their own work and make sense of their lives and feel empowered doing so. You are the container. And likely, if this person has a trauma history, they have never had a container before. This person is yearning for a space to hold them, a person to pronounce their story real, and to finally make meaning of their pain.

I will respect the integrity of the persons with whom I am working, and I will remain objective in my relationships with patients and will act with integrity in dealing with other professionals.

Remaining objective = YOU ARE A RED DOT.
 

Here, you are not a representation of all your years of experience or your professional degree. You are not all your trainings. You are not the expert on this person. You are human, you are love, you are containment, and you are neutrality.


For this person, you offer to them something they might have never had in their lifetime, which is a chance to take a good, hard look at themselves. This is so incredibly hard for clinicians, especially newer clinicians who feel helpless when faced with big, often messy feelings. When meeting a patient, sometimes the person is flalling…they might not be attached in any way to the story of their lives yet, so sometimes all you have are the free floating feeling states before you. It can feel unruly. These are the times clinicians want to get active and hyper manage the symptoms. This might seem like you are being helpful, and your good, kind intent might be to do anything you can to put an end to their suffering urgently, but the urgency to do so is actually motivated by a quiet calling of your own helplessness and fears of inadequacy. These symptoms are not your problem to fix, but instead the beginning of the story that you are gifted with listening to and understanding.

This is not an operation, but a collaboration.

Be the red dot so that it is only the patient’s conflicts and pain that is front and center in the room. Your good, hard self analysis will be the only avenue for this to happen.

I will provide only those services for which I have had the appropriate training and experience and will keep my technical competency at the highest level in order to uphold professional standards of practice.

Training and experience does not mean: Permission to proceed without consent.

Anyone can become a therapist. Anyone can get training. Anyone can get experience, but not everyone can help. Know your limits, don’t have all the answers when you don’t have all the answers. Be steeped in your lack of knowing and take ownership of it. Know the uniqueness of each patient that sits before you. Know that all the patterns or behaviors you might have observed throughout your years in practice, all the specialties you might possess, and all the credentials that follow your name means nothing in this moment relative to the clinical material unfolding right before you.

Your protocol needs to be secondary to your good gut.

If your niche is working with trauma, and you encounter a patient with a significant dependency issue with alcohol, it is your responsibility to not overlook the obstacle that a substance abuse issue poses to an effective, insight-oriented psychotherapy. Honor what you are seeing, speak to what is real, and assist this patient to get to where they need to go. This is primary before they can benefit from the good work that you can offer them.

Know who you are, know what you do best, and know what you don’t do. Be up front. Be realistic, it is the kindest intervention you can do.

I will not violate the physical boundaries of the patient and will always provide a safe and trusting haven for healing.

Physical boundaries = All boundaries, visible and invisible.

The only way to adhere to boundaries is to know what the boundaries are. And the only way to know what the boundaries are are to be intune with your own relationship with boundaries.

Safe and trusted haven for healing = Doing your own work.

A person can only feel safe if you do your own work. A person can only feel safe if you remove your agenda, your helplessness, your need to be the expert, your need to be active, your bottom line (receiving payment, meeting a patient quota for a fee split, trying to be heroic by treating someone you are not qualified to treat, fulfilling your protocol or expertise on a patient who isn’t giving consent to receive it, feeling the need to diminish symptoms because they activate your discomfort).

Haven = A place of safety or refuge.

This needs to be a place where a patient can have permission to be completely raw and broken down. This can only happen if you have established the trust and respect of your patient and the sanctity of the space between the two of you. It is your job to protect the patient’s vulnerability by confirming their reality. People with trauma histories may have never known the experience of having someone confirm the reality of what is happening from moment to moment, let alone corroborate the story of their lives.

People with trauma have a familiarity to feeling unsafe everywhere: in a family where they were supposed to experience only love and support and might have not, in a home where they were supposed to have felt protected and understood and they might have not, and in their own body where they were supposed to feel trust, reliability, and connection, and they might have not.

It is your job here to foster the reparation of a history of broken relationships. The correction will not just occur in the therapeutic relationship, the correction will be the therapeutic relationship.

I will defend the profession against unjust criticism and defend colleagues against unjust actions.

The profession = Helping.

Helping = An absence of interfering in the process of the true intention of the therapeutic relationship.

The true intention of the therapeutic relationship = A temporary loan of your good gut, your presence, your affirmation and confirmation of reality, your containment of all affective states, your declaration of what is real in the consulting room and what was real for this person back then, until they are able to connect the dots themselves, make meaning of their lives, and test this out in the world.

Any criticism is vaporized, because the beauty of what you can offer and do speaks for itself.

Any unjust action towards your role as the helper reveals its own absurdity (*this is conditional to your adherence to appropriate boundaries and the integrity of the profession.)

The profession stands on its own, as the proof lives in all the people who have felt the shedding of their skin and the release from their own mental cages.

If you have been in a good psychotherapy, you know exactly what this means.

I will seek to improve and expand my knowledge through continuing education and training.

To improve = Never be content enough to rest on your good work.

Never get so comfortable that you become complacent and forget the value in learning something new. Never underestimate how enlightening a new perspective is. Read a new paper, hear a new speaker, take a new workshop. Grease your mind, shift your focus, go deeper. There is always a new lesson to learn, there is always an opposing angle, there is always the meaning underneath the meaning.

Knowing is just a resting place.

Continuing education and training = You are never done growing. Ever.

I will refrain from any conduct that would reflect adversely upon the best interest of The American Psychotherapy Association* and its ethical standards of practice.

The best interest (of anyone or any organization) = The best interest of your patient = the best interest of yourself.

As long as:

• You are constantly aware of what entering into psychotherapy means = A binding negotiation of care, trust, and vulnerability.
  
  

• You do not shift your focus from the constant inequality between you and the patient that sits before you and honor the sacred nature of relationship dynamic.
  
  

• You show up to your work with an open, curious mind, and a dedication to helping your patient seek the truth.
  
  

• You are conscious of your strengths and limitations, your own biases, your achilles heel, your blindspots, your calling to do your own work, your tendencies, your deep desires, and your uncertainties…

You will thrive.

And when you thrive, your patients will thrive.

There is electricity in the power of collaboration. Change will happen. Pathways will be broken down and rebuilt. At the end of a good psychotherapy your patients will still recognize themselves, but the transformation will be enormous. From here on out, going inside their mind will become a place they can rely on, invest in, and enjoy. And without even realizing, you, as the clinician, will have grown tremendously through this cherished exploration; a mutual flourishing of two people that quietly unfolded, separately, together.

If you are interested in learning about psychotherapy or clinical supervision services, please feel free to reach out. I would love to talk to you.

*Marla Garmo, LMSW is not a member or an affiliate of the American Psychotherapy Association, and is not speaking on the behalf of or representing their organization. This blog is for informational purposes only.