I read recently about a couple of therapists in the town next to mine who were arrested for insurance fraud for bilking the Medicaid system. They got caught in part because they were bragging that they had found a way to “get paid for work they hadn’t performed,” namely billing for sessions that didn’t occur, and using the licensed provider’s credentials to bill for work that an unlicensed social worker performed. One of the many charges they are facing is “defrauding a public community,” a class-B felony. Since reading about this story, it’s weighed heavily on my mind. You see, as therapists, whether we like it or not, we are held to a much higher standard of behavior in the community than folks working in many other professions. And there are important reasons for that. As professionals who create space for people to share their most closely held, often shameful secrets, we, simply, must be trustworthy. If your therapist (or a therapist you see on the news) is defrauding the system, engaging in inappropriate relationships, lying, cheating, or otherwise behaving badly, how can you trust that person? Some might ask how can anyone trust any therapist? I’ve had two conversations this week that further disturbed me and led me to write this post – one with a person who described a long history of feeling emotionally abused by healthcare providers, and another who quit therapy after finding that her therapist wouldn’t entertain the idea of being friends outside of therapy. It made me wonder what people think ethical therapy is, and if perhaps a little bit of education is in order. I’m curious what you think – feel free to let me know in the comments. In the meantime, here’s a primer on ethical counseling.
1. Your therapist is not and cannot be your friend, love interest, exercise buddy, financial advisor, babysitter, travel companion, or, as you might have guessed, anything but your therapist. Any relationship outside of therapy is considered to be a “dual relationship,” and is ethically forbidden. In order for us to do our best work, we have to have some space from your life. It helps us to maintain objectivity. There are also power dynamics in the therapist-client relationship that are all too easily (and too often) exploited. Having very clear boundaries is incredibly important to being able to help you, and to avoid exploiting our clients for our own emotional or financial gain. It doesn’t mean we don’t like you. We do. We just can’t be your friend.
2. You shouldn’t know a whole lot about your therapist. In the same vein, your therapist should be mostly a mystery to you. Small talk happens, of course, and if it seems appropriate or if asked directly, I’ll share my marital status or that I have children, etc. But I try very hard to not use situations in my own life as examples, or as a way to connect with my clients. Therapists need to be somewhat of a blank canvas on which you can try out and expose your hopes, dreams, fears, and shame. This is why a good therapist often will, when presented with a personal question, ask you why you want to know, what the answer would mean to you, etc. We’re not being cagey or coy. Essentially it’s more helpful for you to be discussing you than it is to be discussing me. I know sometimes this can feel uncaring, but believe me, we care about you very much and yet are modeling good boundaries. We have to. That’s part of ethical counseling.
3. Your therapist should hold up her end of the bargain in any and every way possible. This means calling you back when she says she will, explaining and acting on her policies, staying awake during sessions (the #1 complaint I hear about ex-therapists is that they fell asleep on the client), and showing up for sessions. This may also mean things like charging you for late cancellations, ending sessions on time, reflecting back to you things that might be uncomfortable to hear, and refusing to meet several times per week, for example. All of this boundary-setting is necessary in order to provide you with the best counseling possible, and to avoid misunderstandings and ethical pitfalls. If you’re ever wondering if your therapist is setting boundaries because she doesn’t like you, ASK. Have a discussion about the therapist’s policies. Good therapists apply the same policies uniformly and don’t play favorites.
4. Your therapist should behave ethically when it comes to money. He shouldn’t bill insurance fraudulently (that’s a given), but also should give you plenty of notice before raising his rates, and communicate clearly about money issues, including not allowing you to carry an unmanageable balance on your account, resolving money issues with compassion and clarity, and sending out clear billing statements.
5. Your therapist sometimes can and should refer you to someone else. This can sometimes feel like abandonment, and as a therapist, I typically don’t enjoy the process. But the truth is that I can’t help everyone. It doesn’t mean that the people I refer out are “worse” or “sicker” than others; it simply means that the issues they are bringing to counseling aren’t within the scope of practice that I feel comfortable providing. As a therapist who works with individuals, and is transitioning to health coaching, I will often refer people with issues far outside that scope, and, as my practice is only for individuals, I will always refer couples and families. Sometimes it’s apparent at the first phone contact that I’m not a good fit, but sometimes it takes time (or perhaps your circumstances change) and it’s a parting that occurs after we get to know each other. A good therapist will handle a referral with compassion, and will provide you with information about how to find a new therapist, as well as offering to communicate with your new therapist if that’s helpful.
I’m curious what you think and if you have any stories of your own to share. Feel free to share this article and comment below.