Suppose a current or former client asks you to write a letter on their behalf when they need special accommodations, an excuse from work, character reference, and the like. From their perspective, since you have in-depth knowledge about them, you're the logical person to write such a letter.
But before you agree to do so, you need to consider both clinical and ethical factors:
- Will such a letter be in the person's best interests in terms of emotional stability and/or mental health progress?
- Would the letter compromise privacy issues that the client might not be aware of?
- Would the contents of such a letter conflict with your professional ethics code?
Here are some hypothetical scenarios...
1. Ms. A. asks you to send a summary of her treatment to her psychiatrist or other medical professional, and signs a release form authorizing you to do so.
This type of letter is almost a no-brainer, because it will serve to co-ordinate care, which is in Ms. A's best interests. I say "almost" because the contents of your letter should be based on a need to know. For example, you would provide much more detail about personal and family history of mental illness to a psychiatrist than to a podiatrist. It's also a good idea to discuss in advance with Ms. A what information would be shared, and why.
2. Mr. B. planned a vacation with his girlfriend, paying $1200 in advance for the trip.
Unfortunately the couple has broken up. He asks you to write a letter to the airline and cruise company saying that due to emotional problems he needs a medical excuse, which would qualify him for a refund.
If Mr. B. is weathering the breakup in a normal way (i.e., highly stressed, but coping) it would probably be unethical for you to write a letter claiming that his emotional condition precludes his ability to go on the cruise. To help him save $1200, you might be committing fraud.
Thus, you should decline, and give your reasons for doing so.
3. Ms. C. is in the midst of a child custody conflict with her ex-husband.
For the past year and a half, you have heard her describe situations in which he was verbally abusive to their two children. She now asks you to write a letter to the court, stating that her husband's visitation with the kids should be cut back, because contact with him is detrimental to their mental health.
Although you might sympathize with Ms. C., it would be unethical for you to give any professional opinion about someone you've never met, no matter how compelling the story sounds. This situation calls for a formal assessment by an independent custody evaluator who has no previous acquaintance with the any of the family members.
When you refuse to write the letter, Ms. C. will probably not be happy, and you may need to apply your clinical skills to help her manage her emotional reactions.
4. Ms. D. is applying to an MBA program, and needs to include three letters of reference by people who know her well.
Naturally, she thinks of you.
While you do know her well, neither of you can predict how a letter from a therapist will be received by the school's admissions committee. Would they view it as a plus, demonstrating that Ms. D. is the type of person who uses resources well? Or might they view her being in therapy as indicative of emotional fragility? Even though mental health treatment is more common and less stigmatizing than it used to be, stereotypical assumptions have not gone away.
Thus, a character reference from you might hurt Ms. D's chances of being admitted to the program, and you should decline.
5. For the past few weeks Mr. E. has been seeing you because of problems with sleeping, focus and concentration, related to a recent diagnosis of cancer.
He is employed as a warehouse foreman. He has gone to work every day, but recently was given a warning for lack of attention to safety issues. The disciplinary action has magnified his stress, and he strongly feels that he needs some time off work. The company HR manager told Mr. E. that they require a doctor's letter documenting the necessity of a leave of absence.
If you presume that removing the daily stress of his job would help Mr. E. make more rapid improvement, then it is reasonable for you to recommend a leave of absence for a specific length of time. After Mr. E. signs a release form, ask the HR manager what specific information they need in order to authorize the leave. Don't give any more than necessary. For example, if all they require is a diagnosis and documentation of dates of treatment, there's no reason to offer any additional details.
6. Eight years ago Ms. F. brought her 10-year-old son to you for an evaluation of ADHD.
You wrote a report at that time confirming the diagnosis, and you made some recommendations to the school. Now the boy is 17 (almost 18) and starting college. Mrs. F. calls you, asking you to write a letter to the college stating that her son needs extra time to complete assignments.
While ADHD doesn't disappear, it affects people differently at different ages and in different circumstances. Given that you have not seen the boy for several years, you are not in a position to render a professional opinion about his educational needs in college.
In this situation, you might offer to do an evaluation update, but with no guarantee that you will write the letter that Mrs. F. requests.
The examples above illustrate the potential implications of what may appear to be a simple request to write a brief letter. Consider the purpose of the letter - What is it intended to accomplish? Will it help your client's progress, or hinder it?
Also consider whether you are qualified - both professionally and ethically - to write the letter requested by your client. Is the subject matter within the scope of your competence and expertise? Would your writing the letter compromise your professional ethics or licensing laws?
Finally, be conservative in how much information you share in your letter on behalf of the client. While legally the client can authorize you to share "my whole file," it is your professional obligation to explain the risks to their privacy.
Disclaimer: The above is for informational and illustrative purposes only. It is not intended as legal or professional advice. If you have a specific question about a specific case, you are advised to consult a mental health practice attorney, or risk management consultant with your malpractice insurance carrier.