10 Guidelines for Mental Health Care Providers

By Darlene Lancer

Healthcare providers are natural caretakers and often are codependent. Codependency is perhaps even essential to being a good therapist. On the other hand, if their codependency is unchecked, mental health care providers risk not only harming themselves but also impairing the therapy. Consider the following guidelines, which highlight areas of concern and offer suggestions to put into practice:

  • Do take care of yourself. Denial of needs is typical of codependency. When you disown your dependency needs, you can develop a negative countertransference toward needy clients and think, “What about my needs?” This is a clue to your and your clients’ painful past and might also signal that you’re neglecting boundaries or self-care. You also risk experiencing burn-out or resentment toward clients. Instead, empathic inquiry into clients’ negative feelings and their self-perception models compassion for their needy child-self.

  • Do heal your codependency. Denial and repression of feelings can limit your capacity to help others. Unresolved feelings about your past trauma might compromise your objectivity regarding a client’s experience. You might avoid issues with clients, using defenses of denial, intellectualization, distraction, and detachment in contrast to being present and engaged. When this happens, data about the client is lost. You may even cause a client to react to your denied feelings.

    If you’re in denial about an addiction in yourself or your family, you risk ignoring it in a client. In denying your codependency, you might perpetuate your clients’ codependency by aligning with the client to change someone else.

    By not confronting clients’ caretaking patterns and helping them build a separate self, you enable their sense of powerlessness and dependency.

  • Do heal your shame and fears. Typically, therapists fear anger, intimacy, failure, and abandonment. This shame and fear can result in the following:

    • When you haven’t resolved issues around the expression of anger or past experiences of abuse, you may become rigid or reactive to clients’ anger and unable to be calm.

    • Fear of anger may paralyze your ability to appropriately investigate reasons for clients’ anger, to empathize with their unspoken pain, to share your reaction, and to confront them.

    • Intimacy with a client can stimulate your fear of intimacy, suffocation, or loss of the control. Your countertransference may take the form of detachment or rigid boundaries, possibly enacting the client’s earlier emotional abandonment.

    • Unhealed shame can make you react to a client’s shame and hopelessness. The client’s disappointment in the therapy and feelings of failure or inadequacy can be taken as a sign of your failure and inadequacy and limit your ability to explore and empathize with the client’s feelings. You might attempt to contradict the client instead — as his or her dysfunctional parent once did.

    Termination often elicits clients’ conflicting feelings about attachment and letting go. It can activate your dependency needs and abandonment fears, making empathy with a client’s position difficult. When you remain emotionally neutral, however, you allow your clients to experience their ambivalence about autonomy and dependency, which you can then explore.

  • Do maintain your boundaries. Your damaged boundaries, dependency needs, and fears of rejection and abandonment challenge your ability to uphold boundaries and can lead to rigid enforcement or nonenforcement of them. However, maintaining appropriate and comfortable limits empowers clients to do so. It teaches them that, despite their childhood wish that people meet all of their needs, two adults can have conflicting needs and that both you and they can say no and still care about the other person.

    You also risk invading clients’ boundaries when you depend upon them to satisfy your business or social needs or unmet childhood needs for attention and approval. Examples of crossing clients’ boundaries are initiating hugs, inappropriate touching or self-disclosing, meeting clients socially, and requesting favors, referrals, or use of clients’ resources. This behavior creates a role-reversal, allowing your clients to take care of you, often re-enacting a parentified role that may have led to their codependency.

    Clients often request hugs, reminder calls, extra time when they’re late, to use the phone or copy machine, to borrow books, or to bring food, animals, or others to the session. You may experience inner conflict when clients challenge your boundaries — the codependent dilemma of feeling resentful if you grant a client’s wish or feeling guilty if you don’t.

    Your resentment can damage the therapy if you allow clients to violate policies or exploit your time or resources. This is a common issue at the end of each session or if a client makes frequent contact between appointments. Stopping on time can lead to a discussion about the client’s boundaries in other relationships and associated feelings of rejection, abandonment, and even despair of ever getting his or her needs met.

  • Do relax. Many codependents are uncomfortable playing, yet playfulness helps equalize the therapeutic relationship and allows for an authentic connection with clients. Anxiety, fear, and perfectionism can be stultifying and restrict spontaneity. Often, the best learning happens during play and creativity.

  • Don’t be a people-pleaser. Does a desire to be liked by a client influence your behavior? Does your self-esteem rise or fall with clients’ successes or failures? When your self-esteem depends on clients’ approval or appreciation, you may become hypersensitive to their criticism or rejection. You risk indulging them to avoid disapproval, and you become susceptible to manipulation, potentially forfeiting their trust. You also miss opportunities to address their exploitative or accommodating intent and behavior. Additionally, they might not express their anger at you if you need to be liked, perpetuating the “false self” they’re working to eliminate.

  • Don’t avoid confrontations. Most codependents dislike confrontation. Fear of rejection and abandonment can inhibit therapeutic confrontation of acting-out behavior, lateness, late payments, verbal abuse, and issues regarding boundaries. Fear can make you uncomfortable enforcing policies, such as payment for missed or late-canceled sessions, especially when clients object.

    Setting limits and letting clients know the impact of their behavior conveys that you care enough to be honest. A client might test your ability to set limits in order to create a sense of safety and demonstrate that you can take care of yourself. Feedback informs the client how he or she is perceived by others. When clients blame you to avoid responsibility for their behavior, you can point out their pattern of abdicating responsibility for their own behavior.

  • Don’t enable your client. Weak emotional boundaries are problematic for codependent therapists who have a misplaced sense of responsibility for others’ feelings and behavior. They may feel impelled to gratify and nurture clients and be reluctant to challenge, confront, or allow them to feel discomfort.

    Maintaining clear boundaries shifts to clients the responsibility for meeting their own needs. For example, a client may want extra time because he got a speeding ticket or because she “couldn’t” leave work on time. The issue is who should take responsibility for the client’s behavior. Appeasing such a client infantilizes and enables him or her, since you suffer the consequences. By discussing the client’s disappointment and ending on time, you support the adult in the client, not the child, and exemplify boundary-setting with others.

  • Don’t try to fix your client. It’s tempting to rescue clients, especially when your personal issues parallel those of your client. Instead of helping a client think for himself or herself and find his or her own solutions, you may feel compelled to do something, like give advice. This enables both your and your client’s codependency.

    If you’re newly in recovery, you may unwittingly project your experience onto clients and not see them as unique individuals. You can become overly involved with their trauma or choice of path and progress. If they repeatedly relapse, are abused, are self-destructive, or get into desperate situations, you might become easily disappointed or disagree with their choices and be frustrated that they’re not following your suggestions. Your countertransference may lead to lecturing, judging, or scolding them. According to psychiatrist Donald Winnicott, your therapeutic role is “not a rescuer, a teacher, an ally, or a moralist.”

  • Don’t react out of guilt. Shame and low self-esteem lead to self-judgment and guilt and overreacting with guilt about real or imaged mistakes. Quickly apologizing or accepting a client’s forgiveness for lateness, mistakes, or lapses, such as falling asleep, or even forgotten appointments, preclude understanding the client’s feelings and the reasons for your behavior. For example, sleepiness may be a reaction to projective identification of a client’s disowned feeling.