Risky business

Ours is a risky business. This may be felt even more acutely by those working in private practice than by colleagues in organisational settings, where systems of support, policies, procedures, and management structures offer a degree of containment. In private practice, much of that containment is absent. We may have supervision, of course, but the clinical responsibility for our clients ultimately rests with us alone.

Risk is an ever-present feature of therapeutic work, and it takes many forms. We sit, often with limited power, alongside vulnerable clients who may be at risk of harm to themselves or others. This includes those considering suicide or living with suicidal ideation, as well as those in the grip of addiction – whether alcohol or substance use, disordered eating, chemsex dependency, or other self-harming behaviours. In these situations, the potential risk to clients’ emotional, psychological, and physical wellbeing, as well as to those around them, can be significant and complex.

We also work within the relational field of transference and countertransference, where we inevitably become the recipients of both positive and negative projections. Clients may unconsciously position us as idealised figures, longed-for reparative parents, or, at times, as neglectful or even harmful others. We may be held in states of love, hatred, fear, or suspicion, shaped by their histories and internal worlds. For some clients with traumatic backgrounds or severe psychopathology, these projections can become particularly intense, occasionally leading to ruptures that extend beyond the consulting room. In rare but serious cases, this can include complaints, boundary testing, or even stalking behaviours, placing therapists in positions that feel personally exposing and professionally challenging.

It is also unavoidable that we will, at times, fail our clients. We may say something that lands badly, misjudge timing, or challenge a defence before sufficient safety has been established. We may forget something of importance or take a break at a moment when separation feels intolerable for the client. Rupture, in this sense, is not only inevitable but also part of the therapeutic process. When it can be recognised and worked through with sufficient care, it may deepen the work. Yet this is not always possible. Endings are not always repairable, and therapeutic alliances are not always successfully sustained.

Alongside this, we must also acknowledge that most of us have been drawn to this work, in part, through our own wounds. The extent to which we have engaged with these in personal therapy or other forms of self-reflection will inevitably shape our capacity to sit with the pain of others without either retreating into avoidance or moving too quickly into rescue. It also helps guard against the misuse of power – against the subtle or overt positioning of ourselves as the ‘healthy’ party in relation to those we perceive as ‘ill’.

Given all of this, it is perhaps surprising that anyone remains in this profession at all. Many therapists will recognise the experience of only fully understanding the emotional and ethical weight of the work once they are well into it. With time, practice does not necessarily make the work easier. Instead, it often brings a deeper awareness of its complexity and of the limits of what can be known or resolved.

Paradoxically, it may be this very recognition – that we do not and cannot know enough – that sustains the work. Rather than fostering certainty, experience tends to cultivate humility. And it is perhaps this humility, more than anything else, that protects against the illusion that we hold answers for others or possess the capacity to save anyone other than ourselves.

 This is an edited extract from an editorial first published in Private Practice, December 2024, published by BACP©