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The Legal Department articles are not intended to serve as legal advice and are offered for educational purposes only. The information provided should not be used as a substitute for independent legal advice and it is not intended to address every situation that could potentially arise. Please be aware that laws, regulations and technical standards change over time. As a result, it is important to verify and update any reference or information that is provided in the article.
In this article, Bradley J. Muldrow, JD, discusses key legal, ethical, and clinical issues therapists should consider prior to soliciting testimonials and reviews from their patients.
by Bradley J. Muldrow, JD
The question of whether it is appropriate for therapists to ask patients to offer testimonials or leave reviews regarding the therapists’ services has been the subject of much debate over the years. Patient reviews and testimonials can serve as effective marketing tools that empower patients to share their stories and encourage individuals facing mental health challenges to get the help they need. However, therapists should bear in mind that in certain instances asking patients for reviews and testimonials may exploit their vulnerability and trust.
This article will provide an overview of important legal and ethical issues therapists should consider before asking patients to offer reviews and testimonials.
Understanding Patient Testimonials and Reviews
Generally speaking, a patient testimonial is a statement in which the patient describes their therapeutic experience with a particular therapist or their experience as a patient of a therapy practice or agency. Therapists typically use patient testimonials for marketing purposes (e.g. a written patient testimonial appearing in print or web advertisements, a video-recorded patient testimonial posted on a treatment center’s website, etc.)
Alternatively, popular websites such as Yelp and Google allow people to post reviews detailing their experiences with businesses, including therapy practices and counseling agencies. These websites often allow people to give businesses numeric ratings (e.g. one star through five star ratings from worst experience to best experience) that the sites use to create average ratings for each business. Patients often use these websites to publicly discuss their experiences with their therapists.
However, the practice of therapists soliciting reviews and testimonials from their patients presents multiple legal, ethical, and clinical questions for practitioners to consider.
An Updated Ethics Approach for Soliciting Testimonials
After a multi-year process of review and revision by CAMFT’s Ethics Committee and outside consultants, CAMFT released its revised Code of Ethics on December 7, 2019. One of the most notable changes was its approach to the issue of MFTs soliciting testimonials from their patients. Although previous iterations of the ethics code prohibited this practice, the revised ethics code allows MFTs discretion to solicit testimonials from patients in appropriate circumstances. CAMFT Code of Ethics Rule 13.6 provides:
Marriage and family therapists do not solicit testimonials from those clients/patients who, due to their particular circumstances, are vulnerable to undue influence.
A wide range of legal, ethical, and clinical issues MFTs should consider prior to soliciting patient testimonials will be addressed in greater detail later in this article. However, at this point it is sufficient to acknowledge that, pursuant to CAMFT’s revised Code of Ethics, MFTs are generally permitted to solicit testimonials from patients who are not vulnerable to undue influence.
Note: The ethics code does not specifically address the issue of therapists soliciting patient reviews. However, the legal, ethical, and clinical issues presented when therapists solicit such reviews are nearly identical to those presented when therapists solicit patient testimonials. Accordingly, it is generally prudent for therapists to follow legal, ethical, and clinical principles for soliciting patient testimonials when determining whether to solicit patient reviews.
For additional information regarding the revised CAMFT Code of Ethics’ updated rule for soliciting patient testimonials and other issues, see CAMFT staff attorney and ethics committee supporting staff member, Michael Griffin’s articles, A Closer Look at the Revised CAMFT Code of Ethics Part I, Part II, and Part III.
Potential Benefits of Soliciting Patient Testimonials and Reviews
For many MFTs, the idea of asking a patient to leave an online review or offer a testimonial regarding the therapist’s services evokes feelings of discomfort. Such reactions are understandable given that ethical approaches for engaging in these practices have only recently become available. As will be discussed later in this article, in some cases it may be inappropriate for an MFT to ask their patient to leave a review or offer a testimonial. However, it may be helpful for practitioners to consider why some MFTs choose to solicit testimonials and reviews in appropriate circumstances:
Testimonials and Reviews Offer Patients the Opportunity to Use Their Positive Therapy Experiences to Help Others
Sometimes patients who have had positive therapy experiences feel empowered when given the chance to discuss their mental wellness journeys and provide inspiration to people struggling with clinical challenges they have worked hard to address. For example, consider a patient who found therapy to be an important part of their recovery from substance use disorder (“SUD”). This patient may experience catharsis if given an opportunity to offer a review or testimonial encouraging others struggling with SUD to benefit from the services that changed their life.
Soliciting Patient Testimonials and Reviews Can Help Therapists Reshape Their Online Narratives
CAMFT staff attorneys frequently field calls from members who have received negative online reviews from their patients, their patient’s representatives or, in some cases, people falsely claiming to be their patients. The challenge therapists face in these situations are: 1) companies that allow people to review businesses do not always allow business owners to delete reviews; and 2) unlike other business owners, therapists are typically unable to post responses challenging false or even defamatory reviews without breaching confidentiality. As a result of this dilemma, individuals leaving negative or defamatory reviews have significant influence over the online presences of therapists while the voices of patients who have had positive therapy experiences often remain unheard.
In clinically appropriate circumstances, asking patients to offer reviews and testimonials can allow prospective patients to gain a more complete perspective of an MFT’s services.
Patient Reviews and Testimonials Can Be Effective Marketing Tools
Many prospective patients identify potential therapists by checking the ratings and reviews of therapists in their area on websites such as Yelp and Google. Similarly, encountering a video-recorded patient testimonial posted on a therapist’s social media page may motivate an individual struggling with mental health challenges to find out information about the therapist’s services. When used appropriately, patient reviews and testimonials can significantly benefit a therapist’s marketing efforts.
The Ethics of Soliciting Patient Testimonials and Reviews
As previously discussed, under the revised CAMFT Code of Ethics, an MFT is generally permitted to solicit a testimonial, and impliedly a review, from a patient so long as the patient is not “vulnerable to undue influence.” Accordingly, MFTs should assess on a case-by-case basis whether it is appropriate to solicit patient testimonials or reviews. The following sections will cover key issues MFTs should consider when making these assessments, beginning with the most obvious question: what does “vulnerable to undue influence” actually mean?
Assessing Patients’ Vulnerability to Undue Influence
The term “undue influence,” as used in the therapeutic context, is not defined by California law or the CAMFT Code of Ethics. However, the concept of undue influence is frequently discussed in the legal arena. Although courts adjudicating contract and probate disputes have offered multiple ways of understanding undue influence, perhaps the most helpful definition of this concept, for purposes of the present discussion, comes from the California Court of Appeal in Estate of Sarabia (1990). Per the court:
Undue influence…is the legal condemnation of a situation in which extraordinary and abnormal pressure subverts independent free will and diverts it from its natural course in accordance with the dictates of another person.
Understanding Undue Influence: Extraordinary and Abnormal Pressure
Most practitioners would agree that a therapist who threatens to terminate treatment with a patient for refusing to leave an online review or berates a patient into offering a testimonial is exhibiting “extraordinary and abnormal” pressure. However, in some cases, what a therapist sees as a benign request for a patient to offer a review or testimonial can leave the patient feeling significant pressure to take an action they are not comfortable with. For instance, a patient struggling with attachment-related clinical concerns or people-pleasing behaviors may experience significant stress if asked to write a testimonial discussing their experience with their therapist. The prospect of disappointing or being rejected by their therapist for turning down the request may cause the patient to experience such extreme distress that they feel pressured or forced to write the testimonial despite their severe discomfort.
To avoid engaging in undue influence, MFTs should consider the experiences of their patients in addition to their own actions and intentions.
Understanding Undue Influence: Patients’ Independent Free Will
Clinical concerns and other circumstances can make it difficult for patients to make decisions reflecting their independent free will as opposed to the will of other people. For example, a patient with an intellectual or developmental disability who does not fully understand what a patient testimonial is or how they are used may not be able to make their own independent decision to provide such a testimonial. Similarly, a 12-year-old patient may not feel free to turn down requests for online reviews or other requests made by adults with authority over them, such as their therapists.
Requesting reviews or testimonials from patients who are not able to fully consider, and make independent decisions regarding the requests may result in undue influence. Therapists should also consider power imbalances and other potential dynamics within therapeutic relationships that may hinder their patients’ abilities to make decisions regarding reviews and testimonials that reflect the patients’ independent free will.
Practice Pointer 1: Empowering Your Patients to Make Independent Decisions
When asking a patient to leave an online review or provide a testimonial, an MFT may wish to consider assuring the patient that declining the request will not impact the therapeutic relationship. Additionally, offering to answer any questions a patient may have regarding how a testimonial will be used (e.g. where it will be posted, whether the patient can opt to keep their identity anonymous, etc.) may help the patient to feel empowered to make an informed, independent decision.
The Key Word is “Vulnerability”
Practitioners should note that the ethics code does not simply prohibit MFTs from actually obtaining patient reviews and testimonials through undue influence. Pursuant to CAMFT Code of Ethics Rule 13.6, MFTs may not solicit testimonials, and impliedly reviews, from patients who are vulnerable to undue influence. Therefore, it is not sufficient for an MFT to solicit patient reviews and testimonials without applying extreme pressure or violating patients’ independent free will. Prior to soliciting a patient testimonial or review, an MFT must determine whether the patient is vulnerable to undue influence. If the therapist determines a patient is vulnerable to undue influence, it would not be appropriate to solicit a testimonial or review from that patient.
In some cases, therapists should consider consulting with other practitioners to properly assess a patient’s vulnerability to undue influence.
Practice Pointer 2: Document, Document, Document
Before soliciting a patient review or testimonial, an MFT should consider documenting their clinical rationale for believing the patient is not vulnerable to undue influence. In this way, should an MFT face an allegation that they solicited a patient review or testimonial inappropriately, the MFT’s record will clearly demonstrate that they assessed the patient’s vulnerability to undue influence and came to an appropriate clinical judgment on that issue.
Furthermore, prior to utilizing a patient testimonial containing identifiable patient information on their website or in marketing materials, a therapist must obtain written authorization from the appropriate party or parties (e.g. the patient(s), the patient’s parent(s) or guardian(s), the patient’s conservator, etc.).
Note: Some online review websites have policies prohibiting business owners from soliciting reviews from customers / patients. Be sure to review such websites' policies and guidelines before asking patients to post reviews on the websites.
Additional Clinical Considerations for Soliciting Patient Testimonials and Reviews
Assessing Impact on the Therapeutic Relationship
MFTs should also consider the impact that testimonial and review solicitation may have on their therapeutic relationships. For example, even if a patient is not vulnerable to undue influence, would they experience a testimonial or review request from their therapist as an imposition or burden? If the patient agrees to offer the testimonial or review, would they feel as though their therapist owes them a favor? Alternatively, would the patient feel that the therapist is attempting to “use” them?
For many patients, the answer to these questions will be a solid “no.” In our current age of online reviews and social media marketing, many people view requests for reviews and testimonials as perfunctory, low-pressure asks that can easily be declined with little thought or effort. However, receiving such requests from their therapists may leave certain patients feeling uncomfortable. Prior to asking patients to offer reviews or testimonials, it is imperative that therapists consider the impact these requests may have on their therapeutic relationships.
MFTs should also consider whether soliciting patient reviews and testimonials would compromise their objectivity. For instance, would a therapist be upset or offended if a patient refused to offer a testimonial or left a negative online review of their services? Conversely, would the therapist feel indebted to a patient who left them a positive online review or offered a testimonial that garnered significant social media buzz? Therapists should be mindful of how soliciting patient testimonials and reviews can impact their own feelings and interactions with patients.
Considering When to Solicit Patient Testimonials and Reviews
Although the ethics code does not expressly prohibit MFTs from asking current patients to offer testimonials and reviews, many MFTs err on the side of caution and solicit testimonials and reviews from former patients rather than current patients to avoid any potential exploitation. Soliciting a testimonial or review from a current patient significantly increases the risk that the request will negatively impact the therapeutic relationship or exploit the patient’s trust and vulnerability. That said, MFTs requesting testimonials and reviews from former patients or current patients during their last sessions should still consider: 1) whether the former patient is vulnerable to undue influence; and 2) the likelihood of the patient resuming treatment in the future. If a patient is likely to resume treatment with their therapist in the future, the therapist should consider how soliciting a review or testimonial may impact the patient’s future course of treatment.
Practice Pointer 3: Inform Patients About How Their Testimonials Will be Used
Patients leaving online reviews are typically aware that the reviews will be publicly displayed on the review website which allows them to determine what they feel comfortable disclosing in the review, whether they wish to leave the review anonymously, etc. However, patients do not have control over their therapists’ posting protocols for patient testimonials. Prior to posting patient testimonials, MFTs should apprise their patients of pertinent information, including where the testimonials will be posted (e.g. the therapist’s website, the therapist’s social media pages, both, etc.).
Practice Pointer 4: Using Patient Reviews in Marketing Materials
In some instances, a therapist may wish to incorporate a particularly positive or impactful patient review in their marketing materials or post the review on their website or on their social media pages. Prior to taking such actions, therapists should obtain patient permission (and document having obtained such permission) to ensure that their patients are comfortable with their reviews being used in these ways. Additionally, practitioners must also remember to obtain written authorization from patient(s) or other appropriate parties if they will be utilizing reviews that include identifiable patient information.
Considering Patient Confidentiality and Anonymity
In some instances, it is possible for an MFT to utilize a patient testimonial that does not reveal the patient’s identity. For example, a written testimonial on a therapist’s website may identify the patient via their initials or a pseudonym. Alternatively, an MFT may post a patient testimonial on their Instagram page that only features the patient’s voice and does not reveal their name. MFTs are not required to obtain signed releases of information to post testimonials that do not reveal their patients’ identities. However, it may be wise for therapists utilizing such “anonymous” testimonials to obtain some form of written consent from patients prior to posting the testimonials. At the very least, therapists should consider documenting that they have received permission from their patients or other appropriate parties to post anonymous testimonials.
MFTs who are interested in utilizing anonymous testimonials should also take care to ensure that the testimonials do not reveal personal stories or other information that would identify their patients even to the patients’ close friends, relatives, coworkers, etc. A practitioner is generally permitted to utilize a patient testimonial containing information that would reveal a patient’s identity so long as the patient or other appropriate party signs a release of information authorizing the disclosure of that information. However, some information, such as a patient’s address, employer, contact information, etc. may not be appropriate to include in a testimonial even with appropriate authorization.
Practice Pointer 5: Releases of Information Are Not Required for Patients to Post Online Reviews
Therapists do not need to obtain releases of information for patients to post online reviews so long as the reviews are posted by the patients themselves.
Prior to posting patient testimonials, MFTs should discuss with their patients how they intend to attribute the testimonials to the patients (e.g. first name and last initial, initials only, a pseudonym, etc.). This will ensure that their patients are not surprised by the manner in which their therapists choose to identify them (or by the fact that the therapists did not identify them).
MFTs should also be mindful that it is possible to edit recorded testimonials or paraphrase written testimonials in ways that patients may find inaccurate or misleading. Accordingly, practitioners should take care to ensure that patient testimonials they utilize accurately reflect their patients’ statements.
Soliciting Testimonials and Reviews from Minors
CAMFT’s Code of Ethics does not expressly prohibit MFTs from asking minor patients who have consented to their own treatment to offer testimonials and reviews. However, CAMFT strongly recommends that therapists exercise serious caution when considering whether to take such an action. Although minors who consent to their own mental health treatment may be mature enough to participate in psychotherapy on their own, they generally present a greater risk of vulnerability to undue influence. Moreover, many minors may not fully comprehend all the ways in which the information they share about themselves, particularly online, may impact their lives and futures. Accordingly, MFTs should carefully consider the potential clinical and ethical implications of soliciting testimonials and reviews from minor patients before making such requests.
If a therapist believes it would be appropriate to ask a minor who has consented to their own treatment to offer a review or testimonial, the therapist should still consider the following issues (in addition to the minor’s general vulnerability to undue influence):
Patients who have offered reviews and testimonials regarding their therapists’ services may feel less comfortable with the public nature of those postings as they start new jobs, enter into new relationships, or experience other life changes. Although patients typically have the ability to delete online reviews they have posted at any time, therapists should be prepared to take down patient testimonials should their patients request them to do so.
That said, certain testimonials, such as those printed in books or on flyers, cannot be retracted once they are published. Prior to publishing a testimonial that cannot be retracted, an MFT should advise their patient that it will not be possible for them to withdraw their testimonial once the book, flyer, etc. has gone to print. The therapist may also wish to have the patient sign a document acknowledging their consent for the testimonial to be published despite their awareness that it cannot be retracted post-publication.
Providing patients with the opportunity to offer testimonials and reviews presents numerous pros and cons for practitioners to consider. Prior to asking patients to offer testimonials or reviews, therapists should: 1) carefully consider the legal, ethical, and clinical issues discussed in this article; and 2) make these determinations on a case-by-case basis. In coming to such decisions, therapists may benefit from obtaining clinical consultation from colleagues or calling CAMFT’s legal department to discuss relevant legal and ethical issues.
Brad J. Muldrow, JD, is a staff attorney for CAMFT. Brad is available to answer member calls regarding legal, ethical, and licensure issues.
1. CAMFT Code of Ethics Rule 13.6
2. See e.g. In re Marriage of Starr (2010) stating “Undue influence is a contract defense based on the notion of coercive persuasion. Its hallmark is high pressure that works on mental, moral, or emotional weakness, and it is sometimes referred to as overpersuasion.” (In re Marriage of Starr (2010) 189 Cal.App.4th 277, 284 (citing Odorizzi v. Bloomfield School Dist. (1966) 246 Cal.App.2d 123, 130).)
3. See e.g. Estate of Baker (1982) stating “Undue influence consists of conduct which subjugates the will of the testator to the will of another and causes the testator to make a disposition of his property contrary to and different from that which he would have done had he been permitted to follow his own inclination or judgment.” (Estate of Baker (1982) 131 Cal.App.3d 471, 480 (citing Estate of Franco (1975) 50 Cal.App.3d 374, 382).)
4. See Estate of Sarabia (1990) 221 Cal.App.3d 599, 605.
5. In some instances, a patient’s consent for their therapist to use an anonymous testimonial may be implied by the patient’s decision to offer the testimonial.
This article is not intended to serve as legal advice and is offered for educational purposes only. The information provided should not be used as a substitute for independent legal advice and it is not intended to address every situation that could potentially arise. Please be aware that laws, regulations and technical standards change over time. As a result, it is important to verify and update any reference or information that is provided in this article.