The Psychotherapy Client’s Bill of Rights and Responsibilities
Rabbi Simcha Feuerman, LCSW-R
Chaya Feuerman, LCSW-R
Going for therapy means different things for different people. For some, it is a dreaded last resort measure, only to be used when a person’s life or marriage is utterly falling apart. For others, it is less stigmatized and more routine – almost like going for physical therapy, not so convenient but necessary. And then there are those who really enjoy therapy and the opportunity for support, feedback, insight and healing. Regardless, especially for a newcomer, there are often misconceptions about what psychotherapy is and is not, what is okay to ask for, and what are the ground rules. With this in mind, we drafted a Psychotherapy Client’s Bill of Rights and Responsibilities and also circulated it amongst some of our colleagues and clients for feedback. This is the result of this collaborative effort and we hope it serves as a helpful guide.
1. You have the right to ask about your therapist’s credentials, training and supervision. Many people do not realize that good therapists, no matter how many years they have been in practice, still engage in what is called “clinical supervision.” This involves meeting regularly with a supervisor or participating in a supervisory group where case material is discussed (without identifying information). This may seem strange to a non-clinician, and perhaps might make you feel even somewhat uncomfortable that your therapist may be discussing you, albeit anonymously, with others. It may even seem to you like a sign of the therapist’s inexperience. However, the opposite is actually the case. A therapist who is not in supervision is in danger of losing perspective and somehow becoming part of the client’s problem instead of the solution. The emotional intensity of a therapeutic relationship necessitates obtaining feedback from colleagues so that the therapist does not lose track of personal and professional boundaries, or lose objectivity. It is interesting to note that in Talmudic parlance, a scholar is referred to as a “Talmid Chacham”, a “wise student”, which implies that one who is constantly learning and studying is the true expert, not one who sits on his laurels and is satisfied with his current knowledge, wisdom and expertise.
2. You have the right to ask what your treatment plan is, and what the rationale is for various interventions and suggestions. Your therapist should be able to explain to you in plain English, without clinical jargon, what he or she sees as the problem what the treatment process entails.
3. If you do not feel like you are making progress, you have a right to challenge and question the efficacy of the treatment. Keep in mind, often the therapeutic relationship involves nuances such as working through feelings and fears about emotional dependency and attachment, and it is reasonable for your therapist to suggest that you “trust the process” and “give the therapy some time to work.” Indeed, many times, the difficulties and complaints about the therapy represent the client’s way of acting out how he or she handles (or mishandles!) other relationships, and thus to stick it out and work through the relationship can be an important part of the treatment. However, as true as this may be, therapists can also use this as an excuse to defend an ineffective mode of treatment. The bottom line is that a good therapeutic relationship is a collaborative effort between therapist and client, and a good therapist will not be defensive and have no problem with your wanting to explore if the treatment is working or not, and why.
4. You have a right that whatever you tell your therapist will be kept confidential from others, including family members and clergy, no matter how well-meaning they may be. HOWEVER, under circumstances where you make a serious threat to harm yourself or another person and in those instances only, the law requires mental health professionals to act to protect you or that other person. This could include contacting emergency personnel, a friend, a family member or appropriate professionals. It is important to understand that a “serious threat” is not a casual half joking statement such as, “I’m so angry at my husband, I could just kill him.” Rather, it is when there is clear and immediate intent, such as “I am so angry at my husband I could just kill him, and I am going to buy a shotgun and blow him away.” Of course there are times where a client makes an ambiguous statement, and the therapist may contact you for further clarification after making statements that appear to be dangerous but are not 100% clear. Ultimately, it can boil down to a judgment call. A therapist should have a good judgment and not become panicky or over-reactive to threatening statements.
5. While therapy may often involve discussing very private matters, and can necessitate encountering painful emotions and ideas about yourself and others, you should never feel personally violated by the process. You have every right to tell your therapist that you are uncomfortable with a particular topic or line of inquiry. While your therapist may gently encourage you to overcome your fear or shame because it may eventually free you from some internal torment, you never should feel undue pressure, coercion or as if your privacy is invaded. As an example, it is certainly good clinical practice for the therapist to take a sexual history, HOWEVER if it does not feel comfortable for you to discuss this you shouldn't feel any undue pressure from the therapist, nor should you get a feeling of unusual and inappropriate interest on the part of the therapist. If something feels wrong about the therapy relationship, maybe there is. Trust your gut. It is important to share these concerns with your therapist. If you do not feel respected or your therapist is continuing to make you feel uncomfortable, you should seriously consider seeking consultation with another therapist and, if necessary, ending treatment with your current provider.
6. You have a right to make technical requests such as insurance receipts and other correspondence to be responded to within a reasonable time frame. On the other hand, requests for phone, email, or text guidance on clinical matters in between therapy sessions are different and dependent on the style of practice that your therapist employs and should be discussed in advance to understand the ground rules. So for example, some therapists are ok with clients texting or emailing and some are not. Some therapists are willing to take brief phone calls and some will ask for compensation for phone time if it is longer than a few minutes.
7. You have the right to your feelings about your therapist and a right to express them respectfully without feeling that the therapist is defensive or dismissive of these feelings. It is not uncommon to develop feelings of love or rage toward your therapist, regardless of gender, and it can become a part of the treatment to appropriately discuss and deal with the meanings of these feelings. A good therapeutic relationship can function as a laboratory for your other relationships and allow you to mindfully and reflectively explore how you manage conflict, attachment and dependency. This is why you and your therapist should be welcoming and respectful of all your feelings and allow you to voice them without shame. Of course, discussing feelings of rage or love must be conducted in a context that feels safe in that that boundaries will be maintained. This is achieved via a collaborative discussion about the ground rules of therapy, and the professionalism of the therapist. The point is, you should not feel fear of expressing your deepest thoughts and feelings because you are worried about how your therapist will react, although you might still feel discomfort or shame for your own internal reasons. It is your right to share these thoughts and feelings. If you do not feel safe doing so, it is equally your right to discuss it and move toward this level of therapeutic process.
8. It is your responsibility as a client to respect your therapist's privacy. Of course it's natural to be curious, and you won’t be the first person to Google about your therapist. Feelings of curiosity are natural and may be a by-product of a developing therapeutic attachment. However, be mindful that your therapist should not feel like he or she is being stalked. What your curiosity means to you and what you are imagining about your therapist is fair game and often important to discuss in the therapy as we explained in item 7.
9. You have a responsibility to pay your therapist promptly at the agreed upon rate of compensation. It is important to understand that the therapy relationship works best when the therapist's objectivity and concentration is not impacted by concerns about not being paid. Once in a while a person might forget a checkbook and that's often just normal, but if you allow the balance to build up to high amounts, that can become destructive and disrespectful. Of course, therapists should endeavor to be professional at all times, but it is a basic human need to receive compensation and it is most unfair to have trust violated by delays in agreed upon payment. Therapists are human beings too!
You might wonder, "What about chessed? Why can't my therapist be available just for the mitzvah?" While there are therapists who reduce fees in hardship situations and others who don't, this situation is different, as you already agreed upon a price. Therapists may try to keep their emotions objective, but it is not impossible that feelings of resentment or anxiety about not getting paid can get in the way of treatment.
It is worth noting two Jewish sources that pertain to this matter:
(A) If there is a basic understanding that a professional is to be paid at the time of service or within some accepted time frame, to delay payment beyond sunset of that day may be a violation of a Biblical prohibition. See Shulchan Aruch Choshen Mishpat (339) for details.
(B) The Talmud states: "A physician who heals for nothing is worth nothing.×´ (Bava Kama 85a.) It's important to keep in mind, this is no mere aphorism. The rabbis used this assumption as a means to extract payment of medical costs from the defendent in a civil damages case even when he insists that he can find a physician who will offer treatment for free. In Talmudic logic, this means that there is a powerful estimation of human nature ("chazaka") that certain services which require a heart and soul dedication and attentiveness simply cannot be performed adequately as a mere favor.
10. You have a responsibility to keep your appointments and should offer compensation if you cancel or simply do not show for a meeting without adequate time for the therapist to fill that time slot. Sometimes people think of therapists as doctors who may double and triple book patients in a room. However, therapists can only see clients, couples or families, one at a time, for fixed appointment times. If you cancel a session you create a gap in the schedule which could have been used by another client. You might even have caused him or her to lose a client because without an available session, a potential client might have elected to choose another therapist rather than wait for an appointment. And even if your therapist has not lost a client, s/he might have turned down personal opportunities such as time with family and friends in order to be available for you, and your cancellation, especially with short notice, may not allow for enough time to reschedule.
11. You have a right to your religious beliefs and practices, or to your lack thereof. Psychotherapy is not mussar. Psychotherapy helps a person correct pathologies, change attitudes and behaviors that one assesses and targets with a therapist in a collaborative manner. At times, a client may ask a therapist if a particular behavior is normal or even moral. The therapist may or not offer his/her opinion based on the modality he/she uses, clinical approach, understanding of the client’s ego functioning and his/her training, however a therapist should not be shaming, criticizing or even advising a client about religious matters. At times, healthy and adaptive functioning can help encourage moral behavior, and the reverse is true as well, that moral choices and attitudes can help a person function in a more adaptive and healthy manner. Nevertheless, therapists should not preach. Instead, therapists hold a mirror to the client, helping him or her better understand his behavior, motivations, the impact of his behavior on himself and others, and other possibly more adaptive choices.
In summation, the client-therapist relationship, like all relationships thrives when everyone has a clear sense of the boundaries, rights and responsibilities and a commitment to honor them.
2015 Rabbi Simcha Feuerman, LCSW-R Chaya Feuerman, LCSW-R Previously published in the Jewish Press
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Translations Courtesy of Sefaria, (except when, sometimes, I disagree with the translation .)