When Therapeutic Relationships Harm:

A Framework for Recognising Covert Exploitation in Healthcare Settings

A Clinical and Ethical Analysis for Patient Safety and Self-Advocacy

David Humble
Sovereign Integrity Institute (SII)
April 2026

Abstract

The therapeutic relationship is grounded in trust, professional responsibility, and the expectation that practitioners will act in the patient’s best interest. However, a subset of clinical interactions may result in harm that is not attributable to technical incompetence alone, but to problematic interpersonal dynamics within the practitioner–patient relationship.

Drawing on literature related to subclinical dark personality traits, medical gaslighting, boundary violations, and patient–provider communication, this paper proposes a structured framework for identifying potentially harmful therapeutic dynamics. It examines (1) personality traits associated with exploitative or counterproductive professional behaviour, (2) interactional patterns such as dismissal, coercion, and boundary ambiguity, (3) systemic factors that may enable such dynamics, and (4) patient-centered strategies for risk recognition and self-protection.

A single-case narrative is included as an illustrative example; it is presented as subjective report rather than verified fact. The paper does not seek to diagnose individuals or generalise prevalence, but to support patient awareness and informed decision-making in healthcare contexts.

Keywords: medical gaslighting, boundary violations, therapeutic alliance, dark tetrad, patient safety, healthcare ethics, informed consent

1. Introduction

Healthcare interactions are characterised by an inherent asymmetry: practitioners possess specialised knowledge, while patients often seek care in states of vulnerability. This asymmetry necessitates strong ethical safeguards, including informed consent, professional boundaries, and patient-centered communication.

While most clinical encounters are beneficial, a subset may result in iatrogenic harm—harm arising not from the underlying condition, but from the clinical interaction itself (Illich, 1976). Such harm may be overt (e.g., negligence) or subtle, including dismissal of concerns, coercive communication, or boundary ambiguity.

This paper examines the latter category. It proposes that certain interactional patterns—particularly when persistent—may undermine patient autonomy, distort informed consent, and negatively affect both psychological and physiological outcomes.

The aim is not to pathologise practitioners, but to provide a framework for recognising potentially harmful dynamics, enabling patients to make informed decisions about continuing or terminating care.

2. Personality Traits and Professional Risk Factors

Research in personality psychology has identified a cluster of traits—commonly referred to as the Dark Tetrad (narcissism, Machiavellianism, psychopathy, and sadism)—that are associated with manipulative, self-serving, or low-empathy behaviour (Paulhus & Williams, 2002; Furnham et al., 2013).

Importantly, these traits exist on a subclinical spectrum. Individuals may function effectively in professional environments while still exhibiting behaviours that negatively impact others.

In healthcare contexts, these traits may correlate with:

Reduced responsiveness to patient feedback
Increased likelihood of counterproductive work behaviours (Abbas et al., 2020)
Strategic interpersonal manipulation (Jones & Paulhus, 2009)
Emotional detachment or low affective empathy (Blair, 2005)

It is essential to emphasise that the presence of such traits cannot be inferred from isolated interactions, nor does this framework diagnose individuals. Rather, it highlights risk patterns that may become clinically relevant when expressed consistently within therapeutic relationships.

3. Interactional Mechanisms of Harm

3.1 Medical Gaslighting

Medical gaslighting refers to communication patterns in which a patient’s concerns are dismissed, minimised, or reframed in a way that undermines their credibility or self-trust (Sealey et al., 2023).

The ECRI Institute identified medical gaslighting as a significant patient safety concern, noting behaviours such as:

Interrupting or dismissing patient narratives
Minimising symptom severity
Attributing responsibility for illness to patient behaviour without adequate basis

These dynamics may contribute to delayed diagnosis, reduced adherence, and diminished trust in healthcare systems.

3.2 Boundary Ambiguity and Violations

Professional boundaries are central to ethical care. As outlined by the American Medical Association and the Health and Care Professions Council, practitioners must avoid relationships or behaviours that exploit patient vulnerability.

Boundary concerns may include:

Personal disclosures not relevant to care
Probing into non-clinical aspects of a patient’s life
Attempts to create social or emotional familiarity beyond the therapeutic role

While not all boundary crossings are harmful, repeated or ambiguous boundary behaviour may shift the relationship away from a clinically grounded framework.

3.3 Guilt Induction and Coercive Framing

Patient-centered care requires that treatment decisions be collaborative and voluntary (Epstein & Street, 2011). However, some communication patterns may implicitly pressure patients, including:

Suggesting that outcomes depend primarily on patient compliance
Framing increased service use as a prerequisite for effective care
Implying that questioning treatment reflects lack of commitment

These dynamics may reduce patient autonomy and contribute to dependency.

3.4 Somatic and Psychological Indicators

Patients frequently report subjective responses to clinical interactions, including:

Fatigue or depletion following sessions
Increased confusion or self-doubt
Heightened stress or discomfort

While subjective, these experiences align with research on stress physiology and clinician–patient interaction quality (Halpern, 2014; Porges, 2011). Such responses may serve as early indicators of relational mismatch, even in the absence of overt misconduct.

4. Structural Contributors

4.1 Information Asymmetry

Differences in knowledge between practitioner and patient can limit a patient’s ability to evaluate care quality. This asymmetry may inadvertently enable problematic dynamics if not balanced by transparency and communication.

4.2 Regulatory Context

In Thailand, oversight of medical professionals is conducted by the Medical Council of Thailand under the Medical Council Act B.E. 2525 (1982). Patients have formal channels for complaints; however, barriers such as procedural complexity and cultural factors may affect utilisation (Chantavanich, 2017).

Regulatory systems are typically reactive, addressing issues after harm has occurred rather than preventing them.

4.3 The Therapeutic Alliance

The therapeutic alliance is a well-established predictor of positive outcomes (Frank & Frank, 1991). However, the same trust that facilitates healing may also delay recognition of problematic dynamics, particularly when patients attribute discomfort to their own condition rather than the interaction.

5. Patient Rights and Protections

Under the National Health Act B.E. 2550 (2007), patients in Thailand are entitled to:

Informed consent
Access to information about treatment options
The right to refuse or discontinue care
Non-discriminatory treatment

Patients may also submit complaints to relevant regulatory bodies and pursue civil remedies where appropriate.

6. A Practical Framework for Patient Self-Advocacy

6.1 Monitor Subjective Experience

Patient perception is clinically relevant. Persistent discomfort, confusion, or perceived lack of alignment with a practitioner warrants evaluation.

6.2 Identify Recurrent Patterns

Rather than focusing on isolated incidents, patients may benefit from observing patterns over time, including:

Repeated dismissal of concerns
Lack of treatment individualisation
Communication that induces guilt or obligation

6.3 Exercise Informed Consent

Patients are entitled to ask questions regarding:

Rationale for treatment
Alternatives
Risks and expected outcomes

Resistance to reasonable inquiry may indicate poor alignment with patient-centered care principles.

6.4 Maintain Records

Documenting appointments, recommendations, and personal responses can:

Support clarity in decision-making
Provide evidence if concerns escalate

6.5 Discontinue When Necessary

Patients have the right to terminate care at any time. Discontinuation may be appropriate when:

Trust cannot be established or maintained
Communication is persistently ineffective
The patient experiences consistent negative outcomes

7. Discussion

This framework does not assert that harmful dynamics are widespread, nor that they are attributable to identifiable personality types in any given case. Rather, it emphasises that:

Harm can occur through interactional patterns, not only technical error
Patients benefit from tools that support independent evaluation of care quality
Ethical practice depends not only on competence, but on relational integrity

Future research should incorporate prospective designs and objective measures (e.g., patient-reported outcome metrics, physiological indicators) to better understand the prevalence and impact of such dynamics.

8. Conclusion

Healthcare systems rely on trust, but trust must be supported by transparency, accountability, and patient autonomy.

This paper proposes that certain patterns—such as dismissal, coercive framing, and boundary ambiguity—may indicate a breakdown in the therapeutic relationship, regardless of practitioner intent.

By recognising these patterns and exercising their rights, patients can take an active role in safeguarding their well-being. The goal is not adversarial engagement, but informed participation in care.

A functional therapeutic relationship is collaborative, respectful, and adaptive. When these conditions are not met, reassessment—including discontinuation—is a legitimate and often necessary course of action.

Institutional Note

Published by the Sovereign Integrity Institute (SII) as part of its research into patient safety, therapeutic dynamics, and self-advocacy in healthcare systems.

Citation: Humble, D. (2026). When Therapeutic Relationships Harm: A Framework for Recognising Covert Exploitation in Healthcare Settings. SII Working Paper Series, 2026(08).