Ethics Consult: Should I Write Letters on Behalf of Clients?

Dear Ethics Consult,

I’ve been practicing psychotherapy for seven years now. In the past couple of years, I’ve gotten more and more requests from clients to write letters on their behalf—letters to court, letters to employers, letters about emotional support animals, and on and on. I want to help my clients, but these requests always make me nervous. What should I be keeping in mind when writing letters for clients?

Sincerely,

Fully Enveloped

What to Know About Writing ESA Letters, Legal Letters, or Employment Letters on Behalf of Clients

Dear Fully Enveloped, 

I understand where you’re coming from. Despite how it may appear, I actually both enjoy and dread writing in general. Thankfully, I’ve had the benefit of some amazing editors who filter out my bad ideas, and make the good ones much better. 

Writing letters for clients, though? I don’t have an editor for those. So when a client asks me for a letter, part of me is terrified. And that part very much wants to talk them out of the letter request, rather than just writing the dang thing.

It sounds like you wrestle with a similar anxiety. Thankfully, it also sounds like you wind up in the right place. Writing letters on behalf of clients is often a powerful way that we as providers can use our knowledge and position to advocate on clients’ behalf. 

So, with that as framing, here are some things to consider as you weigh whether to write a letter on behalf of a client.

Are You Qualified to Write the Letter?

There are both legal and ethical components to this question.

Legally, it’s worth considering whether you’re even allowed to write the letter, given your particular license. Here, where I’m based in California, licensed master’s-level professionals can’t certify a client’s disability claim, even when that claim is based on a mental disorder that we have diagnosed. 

Ethically, do you have the relevant training and expertise to write the letter your client is requesting?

Subgroups of the APA and ACA have both developed position statements actively discouraging most clinicians from writing emotional support animal (ESA) letters, encouraging us instead to refer to experts on the subject.

How Might the Letter Benefit the Client?

Our licensure and expertise often provides us with a great deal of influence on outside systems—when we’re willing to use it.

Letters from mental health professionals are often necessary to ensure that trans clients receive gender-affirming medical care. We can significantly influence court cases in which our clients are involved. And even where schools and employers may not be legally obligated to act in accordance with our recommendations, our letters can and often do still significantly impact their treatment of our clients.

If we’re keeping clients’ best interests centered, that tilts the scale toward providing letters where clients request them. There may even be times where we proactively mention the possibility that a letter from us might be useful.

At the other end of the spectrum, I’ve occasionally gotten requests from clients to write letters on their behalf that wouldn’t have helped them achieve their stated goal.

One client asked me to write a letter in hopes of getting them out of a parking ticket. Alas, I discovered that the city in question did not make exceptions to their parking rules for mental health care.

In that case, consequently I couldn’t, in good conscience, accept the client’s money in exchange for preparing a letter I was aware would have no impact.

Can You Stand Behind the Content of the Letter?

Here’s the thing that makes me the most nervous about letters written on clients’ behalf: these letters are, by definition, going to outsiders who may or may not understand the therapy process.

The letter may wind up in the hands of people for whom it wasn’t initially intended. It could even be drawn into a legal dispute, or a licensing board complaint. 

So, it’s essential to make sure the content of that letter is airtight.

As with any time you share otherwise-confidential information—even at the client’s request—you should share no more than what is necessary to achieve the purpose of the disclosure. Every factual statement in the letter should be fully defensible, based on your existing documentation of the case. 

Consider ESA letters as an example. Requests for these letters appear to have meaningfully decreased since airlines banned ESAs in early 2021, but therapists do continue to get them, primarily from clients wanting an ESA in a housing situation that doesn’t typically allow pets. 

Again, subgroups of the APA and ACA discourage most clinicians from writing ESA letters. And California in 2022 enacted significant restrictions on therapists writing ESA letters. But if you’re going to go forward, you would want to make sure that the letter is about the client, and not the animal.

The point of an ESA letter is simply to attest to the fact that the client has a diagnosed mental disorder and that an ESA is likely, in your professional judgment, to be beneficial to them.

Typically, ESA letters don’t include information about the specific animal. Most mental health professionals are in no place to comment on or attest to the safety or behavior of any specific ESA.

Will Writing the Letter Leave You Resentful or Fearful?

In your case, you’ve noted getting letter requests with increasing frequency.

You don’t specify whether you charge fees for letters. If you don’t, I think you should.

Writing strong letters on clients’ behalf can take significant time, and in some cases, additional research or consultation. While I think we all should make conscious choices about how we charge fees, I also know that giving away this much time can leave some providers feeling resentful.

If you intend to (or already do) charge fees for letter-writing and other administrative functions, make sure this is in your initial informed consent documents.

And then there’s the gut-check moment. If a client asks you to write a letter that you don’t feel comfortable writing, listen to that reaction. See whether you can pinpoint what it is about the request that makes you uncomfortable. If it’s simply that it’s an unfamiliar process (as is often the case for therapists writing their first letter in support of a trans client), then the best choice may be to get consultation and learn the process, to overcome your own anxiety.

On the other hand, if the client is asking you to make statements that you don’t agree with or don’t feel like you can stand behind, that should be a red flag. 

A certain baseline level of anxiety—or to put it in a more useful way, caution—about letter-writing is fully appropriate.

Letters therapists write on clients’ behalf are often used as evidence in licensing complaints or lawsuits. They’re different from the usual process of healthcare, where clinical decisions can be debated, but courts and boards routinely defer to clinical judgment. And even when the clinician’s judgment is questionable, it can be difficult to prove a client’s accusations about something that may or may not have happened in session. But letters? Those are clear, specific statements that have your signature attached to them. They’re not hard to prove. 

Here’s another way to think about it. Our letters often have a high degree of influence, one that aligns with our roles as health care providers. With that high degree of influence comes a heightened level of accountability. Growing comfortable with both sides of that is part of owning our roles. 

Letters represent concrete ways we can support and advocate for our clients. You shouldn’t fulfill every such request. But you also shouldn’t let your own anxiety stand in the way of doing something powerful and positive on a client’s behalf.

Good luck,

 

Ben Caldwell, PsyD

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