Therapy with Esther was anything but safe. The groups were based on fear and shame. We would get called out if we didn’t share all our information.

She was the self-proclaimed authority. If you questioned or argued with her, she chastised you. You were labeled an authority problem, one who was showing resistance to the work.

She made us think her space was the only one offering emes. The world was full of sick people, and she and the women of her therapy group were the only ones who were authentic.

While under Esther’s influence, I had no intention of ever leaving her care — and she was fine with that. Her patients saw her on average for two to three hours a week, plus group sessions. Some women in the group also saw her with their spouses, and there were therapists seeing her for supervision on top of those three hours. One person I knew was seeing her four days out of seven.

But the reality was that no one ever got well enough to leave. No one got better. Marriages were either destroyed or compromised. If you aren’t moving forward in therapy, learning more with each mistake and growing more empowered, it’s not healthy. But I only learned that when it was all over.

In a sad twist of irony, Esther became my savior; she had all the answers. As time progressed, her therapy group became my family and my refuge. I isolated myself more and more — from family, friends, neighbors. I couldn’t make a decision on my own and called her for everything. If I did brave making an independent choice, I was called out for my resistance.

Was I happy for the almost six years I surrendered to therapy with Esther?  I thought I was getting better. And in certain ways I was — which is why it was so confusing. The bottom line is that I was brainwashed. Even my kids tried to tell me that, but I couldn’t hear it.

I feel like I was plucked out of danger (albeit, kicking and screaming) by Hashem. It was only a year after leaving the group that I started to understand what had really happened to me. I studied up on it and realize now that the setup had all the signs of a cult.

I’m grateful every day to the brave relative who practically locked me in my room and talked to me for hours. She made that first crack in my armor, and started me on my road to freedom.

Sometimes, when someone lives through a challenge, they look back and are grateful for the hardship they endured, because it brought them growth and understanding. I don’t feel that way. This was a ruinous period in my life — one I wish I had never lived through.

Currently, there is a criminal complaint lodged against Esther. I hope it will stop her from destroying other lives.

Red Flags and the Therapeutic Experience

While Perel’s story was particularly nightmarish, there are a host of nuances that provide clues that something is going wrong in the therapy room. And while the red flags may be subtle, an educated client will be much more likely to pick up on them. Professionals in the field share how some common red flags would present, so clients can find healing safely.

Rabbi Binyamin Babad is the CEO of Relief Resources, a nonprofit organization that helps the frum community access and evaluate appropriate mental healthcare services. He says the minimum a potential patient should expect from a therapist is that he or she be vetted, licensed, and reputable; honor confidentiality; and engage with professionalism and a high standard of ethical behavior. “The heimish world is open to do-gooders,” he says. “But in that sense we open ourselves up to danger.”

Finding an appropriate therapist is complex. While your neighbor may be a competent referral source for a good mechanic, you’re more likely to hit trouble when you trust him to refer a good therapist. Compounding the problem is that most often, a person seeking counseling is already in a susceptible, compromised place. Their decision-making skills may be impaired, and it’s likely not the best time for them to go with their gut in choosing a therapist.

How can a potential patient be assured that a clinician is safe, skilled, and effective? What are the warning signs that signal danger?

Red Flag 1: No license? Beware!

Age, frumkeit, and personal style all play a role in the therapeutic alliance or relationship. But the feel-good factor should not be the first thing on the agenda when  seeking a clinician. “Licensure is a must,” Rabbi Babad emphasizes. “Never see an unlicensed therapist. If they dishonestly represent themselves as professionals, what else are they lying about?”

Katharine L. Loeb, PhD, is a member of Relief’s Advisory Board. She is a licensed clinical psychologist and professor who specializes in the research and treatment of eating, feeding, and weight disorders and has taught medical ethics on the graduate level.

“Professionalism begins at the start of treatment with informed consent,” she says. The therapist must disclose his or her credentials. Evasiveness is a bright red flag. If the clinician is still in training, he or she must disclose this fact and share the identity of their supervising professional.

Working under a supervising professional is a mandatory requirement for therapists-in-training, and that supervisor not only guides and oversees the treatment plan, but also shares the novice therapist’s liability. The fact that the supervising professional has a stake in the success of the treatment builds patient protection into the process.

Red Flag 2: Breach of Confidentiality

A professional mental health practitioner will always treat anything that the patient shares in therapy with complete confidentiality, and in fact, US law obligates them to do so. The Health Insurance Portability and Accountability Act of 1996 (HIPAA) is the federal law that prevents information from being disclosed without a patient’s knowledge or consent.

A mental health practitioner may only disclose a patient’s private information without their consent if it will protect them, or others, from harm. If, for example, a client would threaten to harm himself or to act violently toward someone else, the mental health professional is obligated to share that information with the appropriate people.

Barring that exception, a lack of confidentiality, like the one in Perel’s case, is a major ethical violation.

Red Flag 3: Stay in Your Lane

Cheryl Friedman, LMSW, is a therapist in private practice and specializes in treating traumatized and abused adults and adolescents. She works in the Mount Sinai Beth Israel Victim Services Program and was a key player in reestablishing the SOVRI Helpline, a call-in center staffed by Orthodox volunteers that provides assistance and referrals to abused women.

She shares that a red flag specific to her area of expertise is if a therapist demands to hear the details of the offense from the client. “The details don’t matter. What matters is that the person feels violated and the work that needs to be done so the victim understands that she or he was not at fault and should not feel ashamed.”

A related impropriety is where a client comes to consult with a therapist about a problem, and the therapist responds by delving into other unrelated topics in the client’s life. “If I come to a therapist to talk about my fear of public speaking, and the therapist wants to talk about personal aspects of my marriage, that’s a very bad sign,” Rabbi Babad points out.

On the flip side, though, Dr. Loeb notes that a skilled therapist must recognize when a patient comes to talk about a problem but is unaware of — or withholds — the underlying issue. She offers the example of a man coming to discuss his bad marriage, complaining about how unreasonable his wife is and describing all the fighting they do, without revealing that his substance abuse problem is the basis of their marital discord.

Cheryl concurs and shares that very often when there is trauma there are additional diagnoses that emerge because of that trauma. “I have clients who have worked on getting their eating disorders under control, and then they come to me when they are ready to address the trauma that triggered that eating disorder.”

Red Flag 4: Crossing Boundaries

All the professionals contributing to this article agreed that professional and ethical behavior on the part of the therapist comes down to one word: Boundaries.

A therapist who presents unprofessionally, overshares personal details in a deep or uncomfortable way, or texts and calls a patient inappropriately has breached the boundaries of ethical behavior. Whereas a good therapist may find it helpful to share personal anecdotes with the client if they perceive that it is beneficial, “Too much self-disclosure is a red flag,” says Rabbi Babad. “A therapist should not be sharing his or her life circumstances with the patient.”

In general medicine, a doctor won’t examine a patient without a nurse in the room. Therapists can’t avail themselves or their clients of that protection but can instead build strong boundaries — and those boundaries are both physical and mental.

In Cheryl Friedman’s practice, she will always sit across the room from her patient and will only move her chair closer if the client expressly permits it. She allows her clients to call and text her, but with the firm understanding that she will not respond right away and may even wait until their next session to respond. If it is an emergency, they are advised to call Hatzolah.

She deals with many troubled adolescents and admits that sometimes she would love to take them home to nurture them back to health — but that is not the role of a therapist. “I’m not their friend. I’m very real with my clients, but I maintain a distance,” she clarifies.

Sometimes it is the client who lacks boundaries in the therapeutic setting. They may call their therapist frequently or attach themselves to the therapist in an inappropriate way. Is this a red flag for the therapist?

According to Dr. Loeb, a red flag, a phrase which implies danger, is not applicable to a patient. Whereas the patient’s behavior can guide treatment decisions, the obligation to establish and maintain appropriate boundaries falls exclusively on the therapist. The therapist holds the ethical responsibility to act in the patient’s best interest, not vice versa.

If the patient challenges the therapist’s boundaries, the therapist must build that into the process. What is the patient trying to convey with his or her behavior? How might these behaviors affect the patient’s day-to-day, interpersonal functioning outside of the office? “Think of it as a diagnostic red flag. The behavior is something that needs to be treated; it’s not an ethical issue.” Patients are not bound by the ethics of the profession as is the therapist.

Dr. Loeb sums up the therapist’s primary obligation by paraphrasing the bedrock principle of medicine: “First, do no harm.”

“All of ethics code is designed to maximize beneficence and minimize maleficence,” she says. “Don’t do harm. Do what’s best for the patient.”

Red Flag 5: Therapists of the Opposite Gender

The therapist-patient relationship is private, personal, and often intense. Should a frum person consult with a therapist of the opposite gender? Rabbi Babad finds that this is a question most people don’t think about. He conjectures that because it’s a health concern, people feel they have an automatic dispensation. “But people often suspend common sense as well as halachah when it comes to mental health.” Over time, Relief has seen many complications and inappropriate scenarios crop up in these kinds of therapeutic alliances.

Generally, in therapeutic relationships, the therapist assumes the role of the expert, while the patient begins the process exposed and sensitive. When the therapist is female and she is seeing a male patient, the disparity in their roles tends to be weaker. Conversely, when the therapist is male, and the patient is female, it makes the therapeutic alliance very sticky.

Rabbi Babad advises women to consider this issue before they begin therapy. A woman must first question: Should I be seeing a male therapist?

While he admits that sometimes there is no alternative available and that it’s necessary for a female patient to see a male therapist, because he may be the only professional skilled in her specific area of need, he says that “99 percent of the time there are other qualified female therapists who can address the issue at hand. Women outnumber men two-to-one in the field.” Aside from the serious yichud issues that must be addressed, experience has shown that it isn’t recommended.

There are also inherent challenges for the therapist seeing a client of the opposite gender. Dr. Loeb comments that if the therapist notices that he or she is dressing more carefully for a particular patient, scheduling the patient for the end of the day so they can walk out together, or asking questions not relevant to the treatment, there is trouble brewing. “This is where the professional needs to seek consultation — don’t wait till it goes downhill.”

An ethical, frum practitioner will set up preventatives to ensure a proper, tzniyus therapeutic setting. Those preventative measures could include setting up cameras, leaving the door of the office open, or having a spouse accompany and wait for the patient outside the therapy room.

Red Flag 6: Abuse of Power

There is a natural power differential in therapy. A therapist enters the relationship in the position of power, and that power can be used in the patient’s best interests or, as in Perel’s case, it can be abused. Dr. Loeb explains that the source of the therapist’s power is in his or her knowledge and education.

“We do have a broader knowledge than the patient. But a part of that power differential is also that we, as therapists, have a fiduciary responsibility to the patient.” The therapist may have to make judgment calls that the patient doesn’t like or want but are nevertheless for the patient’s good.

Nevertheless, the therapist can never impose a course of action on a client. When a therapist abuses his or her position of control, the process changes from “beneficence to maleficence.” In Perel’s case, the power differential morphed into features resembling a cult. Compelling this level of control on a patient under care is contradictory to the goal of the ethical therapist who works, says Dr. Loeb, “to instill independence in the client, not dependence.”

Esther’s therapeutic environment was one of fear and shame, where the patients became so dependent on their therapist that they were unable to make decisions on their own. A therapist who creates an unsafe environment for the patient is never an ethical practitioner.

Red Flag 7: When Duration and Progress Don’t Match

A therapist who maintains a client for her own personal benefit, or who is unwilling to explore other options with a patient when therapy is failing, breaches professional ethics. In Perel’s case, Esther encouraged her patients’ commitment and unscrupulously held them in therapy.

But what is the normal duration for therapy? Dr. Loeb explains that there is no one answer, although most evidence-based interventions are designed to be short-term (6–12 months). The patient and therapist must consistently move forward and achieve measurable change. The ratio between progress and duration doesn’t have to be even, but it must be balanced. If consistent progress is being made, the pace is not that significant a factor. Each person’s healing trajectory is unique.

Rabbi Babad agrees that there is no hard and fast rule regarding the therapeutic timeline but says, “We certainly don’t believe in therapy as a lifestyle.” He says the proper duration can best be expressed as, “as long as necessary and as short as possible.” He recommends that anyone who feels unsure about the efficacy of their experience — whether because of its duration or for any other reason — should consider consulting with a second professional to sound out whether their situation is normal and appropriate.

Appropriate mental health care can save lives, and caveats notwithstanding, anyone who is experiencing a troubling mental health issue or has a debilitating problem that they cannot resolve should not hesitate to seek appropriate help. But, as in any service offering, the onus is on the consumer to vet the provider. Though most therapists are professional, ethical, and care deeply for the welfare of their patients, every profession has its miscreants.

Look out for red flags, use your common sense, and avail yourself of credible resources to achieve a meaningful refuah sheleimah.

*names have been changed

(Originally featured in Mishpacha, Issue 968)