David Humble<\/strong> The therapeutic relationship is grounded in trust, professional responsibility, and the expectation that practitioners will act in the patient\u2019s 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\u2013patient relationship.<\/p>\n\n\n\n Drawing on literature related to subclinical dark personality traits, medical gaslighting, boundary violations, and patient\u2013provider 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.<\/p>\n\n\n\n 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.<\/p>\n\n\n\n Keywords:<\/strong> medical gaslighting, boundary violations, therapeutic alliance, dark tetrad, patient safety, healthcare ethics, informed consent<\/p>\n\n\n\n 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.<\/p>\n\n\n\n While most clinical encounters are beneficial, a subset may result in iatrogenic harm<\/strong>\u2014harm 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.<\/p>\n\n\n\n This paper examines the latter category. It proposes that certain interactional patterns\u2014particularly when persistent\u2014may undermine patient autonomy, distort informed consent, and negatively affect both psychological and physiological outcomes.<\/p>\n\n\n\n The aim is not to pathologise practitioners, but to provide a framework for recognising potentially harmful dynamics<\/strong>, enabling patients to make informed decisions about continuing or terminating care.<\/p>\n\n\n\n Research in personality psychology has identified a cluster of traits\u2014commonly referred to as the Dark Tetrad<\/em> (narcissism, Machiavellianism, psychopathy, and sadism)\u2014that are associated with manipulative, self-serving, or low-empathy behaviour (Paulhus & Williams, 2002; Furnham et al., 2013).<\/p>\n\n\n\n Importantly, these traits exist on a subclinical spectrum<\/strong>. Individuals may function effectively in professional environments while still exhibiting behaviours that negatively impact others.<\/p>\n\n\n\n In healthcare contexts, these traits may correlate with:<\/p>\n\n\n\n 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<\/strong> that may become clinically relevant when expressed consistently within therapeutic relationships.<\/p>\n\n\n\n Medical gaslighting refers to communication patterns in which a patient\u2019s concerns are dismissed, minimised, or reframed in a way that undermines their credibility or self-trust (Sealey et al., 2023).<\/p>\n\n\n\n The ECRI Institute identified medical gaslighting as a significant patient safety concern, noting behaviours such as:<\/p>\n\n\n\n These dynamics may contribute to delayed diagnosis, reduced adherence, and diminished trust in healthcare systems.<\/p>\n\n\n\n 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.<\/p>\n\n\n\n Boundary concerns may include:<\/p>\n\n\n\n While not all boundary crossings are harmful, repeated or ambiguous boundary behaviour may shift the relationship away from a clinically grounded framework<\/strong>.<\/p>\n\n\n\n Patient-centered care requires that treatment decisions be collaborative and voluntary (Epstein & Street, 2011). However, some communication patterns may implicitly pressure patients, including:<\/p>\n\n\n\n These dynamics may reduce patient autonomy and contribute to dependency.<\/p>\n\n\n\n Patients frequently report subjective responses to clinical interactions, including:<\/p>\n\n\n\n While subjective, these experiences align with research on stress physiology and clinician\u2013patient interaction quality (Halpern, 2014; Porges, 2011). Such responses may serve as early indicators of relational mismatch<\/strong>, even in the absence of overt misconduct.<\/p>\n\n\n\n Differences in knowledge between practitioner and patient can limit a patient\u2019s ability to evaluate care quality. This asymmetry may inadvertently enable problematic dynamics if not balanced by transparency and communication.<\/p>\n\n\n\n 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).<\/p>\n\n\n\n Regulatory systems are typically reactive<\/strong>, addressing issues after harm has occurred rather than preventing them.<\/p>\n\n\n\n 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.<\/p>\n\n\n\n Under the National Health Act B.E. 2550 (2007), patients in Thailand are entitled to:<\/p>\n\n\n\n Patients may also submit complaints to relevant regulatory bodies and pursue civil remedies where appropriate.<\/p>\n\n\n\n Patient perception is clinically relevant. Persistent discomfort, confusion, or perceived lack of alignment with a practitioner warrants evaluation.<\/p>\n\n\n\n Rather than focusing on isolated incidents, patients may benefit from observing patterns over time<\/strong>, including:<\/p>\n\n\n\n Patients are entitled to ask questions regarding:<\/p>\n\n\n\n Resistance to reasonable inquiry may indicate poor alignment with patient-centered care principles.<\/p>\n\n\n\n Documenting appointments, recommendations, and personal responses can:<\/p>\n\n\n\n Patients have the right to terminate care at any time. Discontinuation may be appropriate when:<\/p>\n\n\n\n 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:<\/p>\n\n\n\n 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.<\/p>\n\n\n\n Healthcare systems rely on trust, but trust must be supported by transparency, accountability, and patient autonomy.<\/p>\n\n\n\n This paper proposes that certain patterns\u2014such as dismissal, coercive framing, and boundary ambiguity\u2014may indicate a breakdown in the therapeutic relationship, regardless of practitioner intent.<\/p>\n\n\n\n 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<\/strong> in care.<\/p>\n\n\n\n A functional therapeutic relationship is collaborative, respectful, and adaptive. When these conditions are not met, reassessment\u2014including discontinuation\u2014is a legitimate and often necessary course of action.<\/p>\n\n\n\n Published by the Sovereign Integrity Institute (SII) as part of its research into patient safety, therapeutic dynamics, and self-advocacy in healthcare systems.<\/p>\n\n\n\n Citation:<\/strong> Humble, D. (2026). When Therapeutic Relationships Harm: A Framework for Recognising Covert Exploitation in Healthcare Settings<\/em>. SII Working Paper Series, 2026(08).<\/p>\n\n\n\n A Framework for Recognising Covert Exploitation in Healthcare Settings A Clinical and Ethical Analysis for Patient Safety and Self-Advocacy David HumbleSovereign 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\u2019s best interest. However, a subset of clinical interactions may result […]<\/p>\n","protected":false},"author":1,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[5],"tags":[],"class_list":["post-203","post","type-post","status-publish","format-standard","hentry","category-research-and-development"],"yoast_head":"\n
Sovereign Integrity Institute (SII)<\/em>
April 2026<\/p>\n\n\n\n
\n\n\n\nAbstract<\/h2>\n\n\n\n
\n\n\n\n1. Introduction<\/h2>\n\n\n\n
\n\n\n\n2. Personality Traits and Professional Risk Factors<\/h2>\n\n\n\n
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\n\n\n\n3. Interactional Mechanisms of Harm<\/h2>\n\n\n\n
3.1 Medical Gaslighting<\/h3>\n\n\n\n
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\n\n\n\n3.2 Boundary Ambiguity and Violations<\/h3>\n\n\n\n
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\n\n\n\n3.3 Guilt Induction and Coercive Framing<\/h3>\n\n\n\n
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\n\n\n\n3.4 Somatic and Psychological Indicators<\/h3>\n\n\n\n
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\n\n\n\n4. Structural Contributors<\/h2>\n\n\n\n
4.1 Information Asymmetry<\/h3>\n\n\n\n
\n\n\n\n4.2 Regulatory Context<\/h3>\n\n\n\n
\n\n\n\n4.3 The Therapeutic Alliance<\/h3>\n\n\n\n
\n\n\n\n5. Patient Rights and Protections<\/h2>\n\n\n\n
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\n\n\n\n6. A Practical Framework for Patient Self-Advocacy<\/h2>\n\n\n\n
6.1 Monitor Subjective Experience<\/h3>\n\n\n\n
\n\n\n\n6.2 Identify Recurrent Patterns<\/h3>\n\n\n\n
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\n\n\n\n6.3 Exercise Informed Consent<\/h3>\n\n\n\n
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\n\n\n\n6.4 Maintain Records<\/h3>\n\n\n\n
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\n\n\n\n6.5 Discontinue When Necessary<\/h3>\n\n\n\n
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\n\n\n\n7. Discussion<\/h2>\n\n\n\n
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\n\n\n\n8. Conclusion<\/h2>\n\n\n\n
\n\n\n\nInstitutional Note<\/h2>\n\n\n\n
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