Living with Mental Illness as a Therapist: Ethical Challenges in Psychotherapeutic Practice

Introduction

Psychotherapy centres on the healing relationship between the patient and the therapist, with the goals of every interaction remaining identifying, working through, and ultimately alleviating the patient’s distress (Flückiger et al., 2018). However, the focus of the professional relationship and therapeutic process extends beyond the patient, as it also encompasses the therapist’s mental health and psychological state, and the implications this may have for their functioning and ability to carry out their professional role to the best of their abilities. This is especially true for therapists such as myself, who live with a chronic mental health condition and may experience unpredictable shifts in mood, cognition, and behaviour, with direct consequences for personal, social, and occupational functioning. Alongside the numerous ethical issues encountered in day-to-day practice, I have found that little guidance is available regarding how one is expected to navigate the therapeutic process as an unwell therapist, particularly in matters relating to boundaries, competence, and self-disclosure. Through an arduous process of reflection, self-discovery, and, admittedly, the occasional unintended letting down of both myself and a patient, this article seeks to shed light on ethical approaches to understanding and working through such challenges from the therapist’s perspective.

A therapist’s lived experience of seeing and treating patients is far from easy. Alongside requiring immense emotional labour, successful therapeutic work depends heavily on cognitive processes such as attention, concentration, attunement, and intellectual responsiveness. Ironically, it is these very capacities that are often most affected during periods of distress and psychological ill-health (Guy et al., 1989). In the context of mental illness, such impairment can be intense, prolonged, and unpredictable, often lasting days, weeks, or even longer. Unsurprisingly, diagnostic criteria for many mental disorders explicitly recognise the impact such conditions can have on social and occupational functioning (Üstün et al., 2003). This is particularly important when working with vulnerable individuals who live with mental health conditions and may rely heavily on their therapist for emotional comfort, reassurance, validation, and healing through communication and human connection. Such individuals are often highly attuned to the presence or absence of these qualities within the therapeutic relationship. Ordinarily, a trained therapist is skilled at facilitating such an experience. The question remains, however: can a therapist experiencing active psychological distress consistently provide the same level of care, presence, and responsiveness? Emerging research suggests that the answer may not always be straightforward (Zerubavel & Wright, 2012). Yet simply avoiding clinical work during periods of psychological ill-health, while appearing to be an obvious solution, is often far more complex in practice. For many therapists, symptoms may fluctuate over extended periods, raising difficult ethical questions regarding professional competence, continuity of care, self-disclosure, and the balance between therapist wellbeing and client welfare. These dilemmas can further be understood through the ethical principles outlined in the APA Ethics Code, each of which highlights a different aspect of balancing therapist well-being with patient care (American Psychological Association, 2002; Barnett, 2008).

Ethical Analysis Through the APA Ethics Code

Principle A: Beneficience and Nonmaleficence

Beneficence requires therapists to act in the best interests of their patients, while non-maleficence emphasises the importance of avoiding harm. During periods of psychological ill-health, however, these principles may come into conflict. Continuing therapy may support continuity of care while risking a reduction in therapeutic effectiveness, whereas taking a break may support therapist wellbeing while disrupting treatment.

Principle B: Fidelity and Responsibility

This principle focuses on therapists’ responsibilities to maintain professional competence, uphold trust within the therapeutic relationship, and navigate difficult decisions regarding disclosure, boundaries, and continuity of care during periods of mental ill-health.

Principle C: Integrity

Integrity requires therapists to communicate honestly and transparently while carefully considering how, when, and to what extent personal information should be disclosed. This raises important questions about authenticity, self-disclosure, and maintaining appropriate professional boundaries.

Principle D: Justice

Justice emphasises providing fair and equitable care while recognising that therapists living with mental illness should not face discrimination or assumptions about their competence solely because of their diagnosis. It also highlights the importance of balancing patient needs with fair treatment of clinicians.

Principle E: Respect for People’s Rights and Dignity

Respect for people’s rights and dignity requires therapists to recognise patients’ autonomy in making informed decisions about their care while ensuring that discussions around therapist mental health are handled sensitively, collaboratively, and with respect for individual preferences and values.

Navigating Therapist Competence During Psychological Distress

In my experience, the ethical complexity of this issue begins the moment symptoms start to emerge. I often find myself questioning whether I should take a scheduled session at all and, if not, what explanation I should provide to the patient. A common misconception that may arise in certain contexts is that therapists should not experience mental illness themselves, or at the very least should be able to “cure” themselves as evidence of their professional effectiveness. Although similar assumptions may occasionally arise in relation to physical illness, mental illness carries additional stigma for mental health professionals because it directly concerns the very domain in which they are expected to possess expertise. Therapists may therefore be perceived as less competent, emotionally stable, or professionally credible if they experience the same conditions they are trained to treat, leading many clinicians to conceal symptoms or delay seeking support (Moll et al., 2013; Zamir et al., 2022). While this belief is largely inaccurate, it can make communication regarding the existence of a problem significantly more difficult. Further, unlike many forms of physical ill-health, which often follow a relatively predictable course in terms of onset, progression, and recovery, mental health distress tends to be far more non-linear.

The Burden of Clinical Decision Making

Even when I recognise the onset of an episode of psychological ill-health, I am often left with a number of unanswered questions. If I reschedule a session for the following week, will I feel well enough by then? Should I be honest with my patient and disclose that I can feel a depressive episode emerging, or should I simply state that I am unwell? If more than a week passes and I still do not feel capable of conducting a session, what happens to the patient in the meantime? These are questions that arise repeatedly and are often difficult to navigate, particularly in relation to self-disclosure and determining what constitutes fairness to the patient. At the same time, I find myself questioning my own effectiveness and competence as a therapist during such periods. Active phases of mental illness can reduce one’s ability to function as efficiently as one normally would, leading me to worry about the quality of care my patients are receiving. Compounding this issue is the possibility of a vicious feedback loop. During periods of psychological distress, I often become increasingly critical of myself and my performance within sessions. This can result in heightened feelings of shame, disappointment, and frustration, which in turn may worsen my symptoms and further undermine my confidence in my professional abilities. It often feels like a Catch-22 situation: whether I decide to conduct the session or cancel it, the resulting sense of guilt and perceived failure becomes an additional burden, one that does little to support my own recovery and healing.

Self Care vs. Patient Care

Therapists are aware of, and are trained to practice, self-care. This is done to ensure that the quality of services they provide remains unaffected, and that they are able to remain relatively healthy and functional despite the emotional demands of their work (Barnett et al., 2007). However, we are often taught to view patient care and self-care as two distinct processes, each capable of occurring more or less independently of the other. During periods of mental illness, though, I am frequently faced with the dilemma of needing to choose between the two. At such times, caring for myself and caring for my patient do not feel as though they can occur simultaneously. From an ethical perspective, I often find myself questioning where my primary duty lies. No matter which option I choose, it can feel as though one party may suffer at the expense of the other, with there being no true “win-win” outcome. Taking time away from clinical work may support my own recovery, but may also leave a vulnerable patient without the support they were expecting. Continuing to provide therapy, on the other hand, may allow for continuity of care while raising concerns regarding my own wellbeing and professional effectiveness. An obvious solution might appear to be referral. However, as therapists know, this is often an oversimplified and impractical answer. Referring a patient to an unfamiliar therapist for one or two sessions is rarely feasible, particularly when a therapeutic relationship has already been established. The alternative is for the patient to go without support for a week or more, which is equally undesirable. As a result, the ethical dilemma remains unresolved. Caring for myself becomes significantly more difficult when accompanied by concerns about whether the other person is struggling, suffering, or feeling unsupported in my absence.

Strategies for Managing the Dual Role of Therapist and Patient

In all of my reflection regarding this issue, I have found no easy answers and continue to struggle with navigating this dilemma. However, over time, I have developed certain ways of addressing and coping with these challenges that I have found extremely helpful. A few of these techniques have been discussed below:

• The importance of supervision: This involves not only discussing my feelings regarding the process itself, but also seeking support from the very emergence of symptoms and the first signs of a potential episode. Rather than solely bearing the burden of deciding whether I am “capable” of conducting sessions during a period of distress, I rely on the perspectives of others as well. Together, we formulate a plan regarding the extent to which I can continue seeing patients and identify the point at which stepping back may be necessary. In many ways, I have learned to apply to myself the same principles that we teach our patients: monitoring symptoms, recognising warning signs, and seeking support when difficulties begin to escalate.
• The benefit of initial disclosure: Another strategy pertains to being open with patients about the possibility of such situations from our very first session together. Without engaging in excessive self-disclosure or placing an emotional burden on them, I provide a brief explanation of the condition I live with, the steps I take to manage it (including medication, therapy, and supervision), and the implications it may have for our work together. While some may question whether such disclosure is appropriate, I have found that limited and carefully considered disclosure can promote transparency and prepare patients for future disruptions in care.  For example, I might say: “I want to share something with you that I believe is important for our therapeutic work together. I live with bipolar disorder, and while it is well managed through medication, therapy, and regular supervision, there may be rare occasions when I experience an episode that affects my ability to work. If that happens, I will let you know as early as possible. During any period of leave, my priority will be to recover so that I can resume our work together as soon as possible. Together, we can develop a plan in advance to ensure that you have access to appropriate coping strategies, emergency helplines, and other sources of support should you need them. We can also discuss how we will reconnect once I return, so that you are not caught off guard by an unexpected interruption in therapy. I recognise that this information may influence your decision about whether you would like to work with me, and I welcome any questions or concerns you may have so that we can make this decision collaboratively.” I have found that this approach helps establish realistic expectations and ensures that, should I need to take a break during a future episode, patients are aware of the possibility of the same.
• Co-development of regulation techniques: I make it a point to develop certain therapeutic coping tools with mypatients, that they can draw upon in my absence between sessions. The contents vary depending on the individual, but often include increased social support, emotional first-aid strategies, coping skills, and resilience-building techniques. Where possible, I also make it a point to check in with patients during my own episodes, even when conducting a full session is not feasible. In addition, I provide information regarding emergency helplines, crisis services, and other psychological resources that they may access if needed until I am able to resume our work together. While none of these strategies completely resolve the ethical tensions associated with being both a therapist and an individual living with mental illness, they have allowed me to navigate these challenges in a manner that feels more transparent, responsible, and compassionate toward both my patients and myself.

Conclusion

As a psychotherapist, living with a mental illness is enormously emotionally taxing and affects far more than just my personal life. It raises a number of ethical challenges that often remain overlooked and insufficiently addressed, despite their direct implications for both therapists and the patients they serve. These are conversations that need to be acknowledged, explored, and discussed more openly within the profession. Given the number of therapists who may live with, or develop, a mental health condition at some point in their lives (with a survey highlighting lifetime rates of depression exceeding 60% among psychologists), this should not become a barrier to their aspirations, professional goals, or ability to practice (Pope & Tabachnick, 1994). Instead, we need to create space for difficult conversations not only about our patients, but also about ourselves. Just as our patients may require support, understanding, and compassion during periods of distress, so do we. Just as impairments in their functioning are met with empathy rather than judgement, the same consideration should be extended to therapists facing similar challenges. Ultimately, recognising the humanity and vulnerability of therapists does not weaken the profession; rather, it strengthens it. To truly advocate for mental health, we must be willing to acknowledge, discuss, and support the mental health needs of clinicians themselves, regardless of the discomfort such conversations may generate within the professional community.