From students and colleagues alike, I often hear statements to the effect of “There are a lot of bad therapists out there.” As I understand it, “bad” in this context has a variety of meanings, ranging from ineffective to unethical. At either end of that spectrum, though, the next question is usually the same: How do they stay licensed?
Let’s start at the ineffectiveness end. No therapy is 100% effective, so providing therapy that doesn’t work with some clients is normal. I’ve had my share of cases that did not go as well as I would have hoped. A therapist is violating professional standards if they make false claims about the likelihood of success with a particular treatment, or if they keep clients who aren’t improving engaged in a treatment process they don’t genuinely believe will be helpful. But believing, with good cause, that a treatment will work and then being proven wrong is hardly a crime. It’s a risk that both therapists and clients take in any form of therapy.
It could be argued that a therapist is behaving unethically if they are a great deal less effective in their work than the average therapist. But at present, there is no reasonable way for a licensing board to gather that kind of information. So they attempt to ensure effectiveness by proxy, through such requirements as ongoing continuing education.
For therapists who are unethical in their practices, it may take years before unethical practitioners are investigated and their licenses disciplined. Even when a complaint is not just made but is successful, only the most egregious acts — like sexual relationships with clients, insurance fraud, or repeated and knowing violations of confidentiality — actually result in a license being revoked. Reasons for this include that (1) licensing boards rarely can act in the absence of a complaint coming directly from an impacted client, and even clients who have suffered great harm are reluctant to complain; (2) because effective psychotherapy is so dependent on the protection of privacy between client and therapist, investigations are lengthy and costly, and may fail to find a pattern of therapist behavior even when it does exist; and (3) standards of the profession, including ethical standards and disciplinary guidelines, are predominantly set by members of the profession.
What mental health consumers can do
1, Caveat emptor. Licensure ensures that a therapist met minimal state standards for independent practice — it is by no means a guarantee of effectiveness or up-to-date knowledge. Clients should ask lots of questions of prospective therapists, and if you do not feel fully comfortable with the person you are seeing, find someone else.
2, Demand accountability for effectiveness. The first session should focus on setting clear goals for therapy. From that point forward, you and the therapist share responsibility for getting there. It is not in your interest to continue spending time and money on methods that are not making a difference. Therapy does not always work quickly, but this is why it is so important to set clear and achievable goals, including some early-stage goals: You will have a quick yardstick of your ability to succeed with this therapist.
3, If you have been the victim of an unethical therapist, file a complaint. It is not especially unusual for colleagues to have a sense that a particular therapist is violating the law or professional standards, but licensing boards cannot investigate a feeling. They need to hear directly from someone who has suffered because of the unethical therapist’s actions. For a variety of (understandable) reasons, many clients who have been victimized in this way never do make a report.
What therapists and counselors can do
If you have a client who tells you about a bad experiences with a prior therapist, a couple of things to remember. 1, Remember you’re hearing one side of the story. While it’s unfortunately true that some clients have negative experiences in therapy, it’s also true that client stories about prior therapy are often skewed. It’s sometimes helpful to give other therapists the benefit of the doubt, understanding that you would want the same from them if one of your current clients becomes their client in the future, and speaks equally ill of you. 2, If your client had a prior experience where you do genuinely believe the therapist acted illegally or unethically, it may be worth it — both for your client and for the well-being of the profession — to spend some time with them talking through their options for filing complaints. Yes, the process can be arduous. But wheels of justice do turn, even if slowly. And the process only works when people who have been harmed file complaints. Without them, the whole licensing system becomes a pointless artifice. 3, If you have firsthand knowledge of a colleague’s inappropriate behavior, address it directly. Yes, the conversation may be tense, even conflictual. But if you approach it in the spirit of wanting to help a colleague, and assume good intent even in the presence of what appears to be bad behavior, you might be surprised at how much good you can do.
It isn’t good for consumers or for the field when therapists who willfully harm clients get to remain in business for years. We have a whole system in place designed to remove the proverbial bad apples. But, to answer the question in the headline pragmatically, the way bad therapists stay licensed is by trusting that complaints won’t catch up to them.
Ed note: This post originally published March 11, 2009. Edited and re-published May 28, 2018.