Guidelines to finding a competent and ethical therapist

Except for one client, not one has ever asked me if I’ve ever had therapy. That question is too ridiculous for words. Of course I have. While there are many reasons a therapist can fail at their work, or not reach their potential in this field, a therapist that doesn’t have their own run of therapy is simply an inadequately trained clinician. And as I engage in various training of different modalities of work, in order to truly immerse myself and acquire expertise in a specific modality, I will not only obtain supervision specific to that modality of therapy, but also individual therapy.

My clients may not know this about me (although now they do!), but they can feel this in the quality of the therapy they are experiencing.

I believe that therapy has become the mainstream in our community because of a variety of factors. The Yitty Leibel Helpline, now defunct but a continued legacy notwithstanding, was manned for many years by competent therapists who fielded calls from anonymous callers. The Eitzah hotline was probably the single most powerful influence in the charedi circles as it recruited mechanchim and mechanchos from many of the biggest mainstream yeshivos and schools who respond to callers. And when they responded to calls from students and parents from a different perspective, they responded admirably by not only becoming better mechanchim but by realizing the imperative of therapy for many of these terrible predicaments. RELIEF OR REFUAH HELPLINE made the process easier by giving referrals to therapists and working within our community, easing and normalizing the process. Shalom Task Force opened the door on domestic violence and as a Kallah teacher for many years, I appreciated their excellent offering of free training to make me aware of what I should be aware. I don’t mean to leave any other organization out of this picture, such as AMUDIM which has been invaluable in addressing abuse and addiction, but as a sheltered Bais Yaakov student, and then later as an equally sheltered wife and mother, these were the organizations that filtered into my consciousness before becoming a therapist as a second career.

When I entered my first year of school to become a social worker, I was fortunate to immediately learn about NEFESH International and attend a 4-day conference still as a student.            NEFESH is an organization, founded in 1992, whose goal is to bring Orthodox Jewish professionals and rabbis to address mental health issues on a professional and communal level. At this time, members are worldwide, including USA, Canada, England, Brazil, Belgium, Israel, and Argentina. They offer annual conferences, training, a listserv in which we can connect and discuss present issues, and various opportunities for professional development. NEFESH’s morah d’asrah is Rabbi Dovid Cohen, and included, until his recent petirah, Rabbi Abraham (Shea) Twerski M.D a”h.

Recently, some of my colleagues went a step further, and incorporated into the Agudah Convention a Mental Health Professional Track that allows frum therapists to receive guidance, clarity and halachic direction from rabbonim, Rebbes, and poskim.

Recently the Board of NEFESH has drawn up competency guidelines to inform both professionals and potential clients of what would be considered ethical practice specifically in private practice. As many of my articles have discussed aspects of these guidelines, I was motivated to publicize these guidelines altogether so that anyone contemplating seeking professional help should be savvy enough to know what they should be looking for when contacting a private practitioner (in contrast to a clinic or agency in which these guidelines are not applicable or are already in place).

You may be referred to a therapist by your rav, rebetzin, friend, parent, or even RELIEF OR REFUAH HELPLINE and think that is a good enough reason to accept their advice. But I cannot stress enough that you should know these guidelines and ask your potential therapist each and every one of these questions to ascertain for yourself if they abide by these guidelines. Any therapist who either cannot respond to your questions about these guidelines, become defensive about your questions, or says it is not relevant to your therapy is someone who you should steer far away from!

So are you ready?

There are 8 areas of personal responsibility NEFESH advises for a therapist going into private practice. And NEFESH advises consumers to be aware of areas of personal responsibility when seeking therapy from a privately practicing clinician. These 8 are:  Education. Licensure. Insurance. Experience. Supervision. Competence. Personal psychotherapy. Rabbinic consultation.

A note to my readers: This article is geared for clinicians practicing in New York and New Jersey and their clients, and may differ slightly for therapists practicing in another state or country. If you are out of these two states or in a different country, there may be some different legalities and ethics involved.

Let’s elaborate on each one.

1.A therapist in private practice must have, at minimum, a Masters Level graduate degree in a clinical mental health field from an accredited school. This means that someone who has a Masters level degree in occupational therapy or education is NOT considered a mental health therapist and should not ethically be treating mental health. A clinical mental health degree would include a social worker (LCSW) , psychologist (or PsyD), and mental health counselor (LMHC), among others. Psychiatrists are doctors and usually dispense medication for mental health issues more than engage in actual therapy.

In addition, whether or not legally required for continued licensure, an ethical therapist will seek ongoing education, essential for maintaining and increasing competence in their work.

Ask your therapist, “What is license? May I please see it?” Therapists are supposed to have their licenses displayed in their office in some capacity. Ask, “What additional training do you have? How often do you seek training?” Don’t be afraid to ask! Don’t forget that you are the customer and the customer deserves to know what they are buying!

2.A therapist must be licensed in the state in which services are offered. Which means if you live in Canada, there are different legalities to have video-conference or phone sessions with a therapist licensed in another country. In addition, the license needs to include independent practice. For example, there are nuances to a social work degree. Only an LCSW (licensed clinical social worker) is allowed to practice privately, not a BSW (Bachelors in social work) or even an LMSW (licensed Masters in social work) who is only allowed to practice under supervision. In Israel or Europe, therapists don’t need a license at all to practice which complicates these ethical considerations; although English-speaking therapists are often trained in American institutions and have obtained their completes licensures. Ask!

3.Private therapists must hold professional liability insurance to protect himself and his client. Make sure your therapist has insurance and you can even ask what his insurance covers.

4.The amount of experience needed to go into private practice firstly should be dictated by the licensure the therapist has. For example, a social worker can only go into private practice after working a minimum of 2,000 hours and 3 years under supervision in an approved facility, taking another exam, and obtaining a second license which puts the C into the initials of LCSW.

However, NEFESH recommends at least 3000 hours and 5 years of post-Masters work before entering private practice and those with doctoral degrees at least 3 years post licensure. Many of these degrees are versatile, meaning a therapist can be engaged in social work or mental health but not necessarily doing psychotherapy. Thus, when a therapist goes into private practice, their experience should be specifically in psychotherapy hours, not case management, advocacy, administration, or psychological testing.

5.Make sure your potential therapist is in ongoing supervision with a licensed supervisor with extensive experience. NEFESH recommends that a therapist less than 10 years in private practice be in weekly, individual supervision. After that, obviously every therapist should continue to be in supervision but the logistics of how often and with whom may range throughout a therapist’s career appropriate to experience and competence. For example, a more experienced clinician may only be engaged in monthly individual supervision, or seek supervision on an as-needed basis, or only attend an ongoing peer-led supervision group; or some hybrid of all of these.

Again, don’t be afraid to ask about your potential therapist’s supervision. What type, how often, and how long. A therapist who does not have adequate supervision is not an adequate therapist. If you are paying the steep price of private therapy, your therapist owes it to you to pay the steep price of supervision!

Personally, I would not share my supervisor’s name with a client or potential client early on because of the borderline nature of some clients in which my supervisor may have his/her privacy violated. However, once I get to know a client better, I have no problem sharing this information in context.

6.There is a very important concept of therapy being delivered within a therapist’s scope of practice. This means that a therapist should only treat clients for issues in which s/he is competent to treat based on education, training, supervised experience, and study. Obviously, a therapist is continuously being faced with new situations and learns based on these new situations more and more. It’s impossible to become experienced without expanding one’s practice. In this case there are two things to keep in mind. Most of these new situations may actually go under one umbrella of treatment. Say, relationship issues. The situations may vary with a parent, child, co-worker etc, but they all fall under a similar umbrella. Secondly, a therapist in ongoing supervision and training is ethically abiding within his scope of practice. A therapist who is confronted with a situation outside his scope of practice either must obtain careful supervision whether or not it is ethical to accept this case altogether; if yes, whether or not to disclose lack of experience in this area. Of course, if it is deemed ethical to work with this situation, ongoing study and supervision is mandatory.

Sometimes, this situation occurs in the course of treatment. For example, although I specifically do not work with eating disorders or addictions, it has happened that a few months into treatment about another issue, a client reveals that there is an addiction or an eating disorder. Again, careful supervision is mandated to know whether this warrants a referral to another therapist or for the therapist to continue and commit to continued education in this area and supervision.

7.Unfortunately, there are few mental health programs that require hours of personal psychotherapy as part of graduating and licensure. But as a therapist I can assure you that for the most part, therapists who don’t commit to their own work, convey this lack to clients who leave dissatisfied in some way without being able to articulate their dissatisfaction. Fortunately, many post-masters training require personal hours of psychotherapy, even if it’s specifically in the training modality, to acquire certification in that training.

It’s tricky asking a potential therapist in our orthodox community if s/he has been in therapy. It would have been awkward for me to respond to this question as a new therapist; although it is such a given in the mental health field. My own supervisors talk about their own therapy freely, setting an example for their supervisees. It’s normal conversation at any mental health training. I know how funny it is to me when I have clients who years into therapy with me go into the field and become therapists; and how during this transition I know it suddenly dawns of them that their therapist who has always seemed so perfect and as having it all together (me!) must have been in therapy too; and their reaction to that realization.

8.Because we are religious therapists working within a religious community, NEFESH advocates very strongly that a therapist must have a rav with whom s/he feels comfortable consulting concerning halachic issues.

I often have potential clients ask me which rav I consult with and I am happy to respond. In addition, I also find that because I am religious Jew, if it is within my client’s best interests, we can also discuss how to approach their rav about halachic concerns. I do not ask my rav halachic questions for my clients; that is their domain with their rav. At most, I will help my client find someone they can ask. But it is important that a religious therapist be cognizant of the role of a rav; both in her life and in that of her client.

Unfortunately, even with all these guidelines in place, a therapist may not be a good match for you, or effective. The same way no brain surgeon has a 100% success rate, but yet you would only consider a board-certified doctor; so too shouldn’t you go to an unlicensed or inexperienced therapist, even if you have heard of therapists with less than a 100% success rate. At least if there is licensure, there is accountability.

(Need a good therapist? Good, enter the field and become one!)

Knowledge is powerful. Empowerment to use your knowledge to care for yourself is even more powerful. Clip this article, take notes, and even better, go to the NEFESH International website to read more. Therapy is powerful experience. It is within your power to choose the right person.

Originally published in Binah Magazine