What's up with all the unlicensed queer sex therapists?

September 20, 2024 2:50 PM

I've been looking on Psychologytoday for a new therapist to help with trans/sex issues and I see that a lot of the listed practicioners are unlicensed.

I talked to a couple on the phone, these are the only people who've gotten back to me. An acquaintance told me a few years ago that they were seeing an unlicensed therapist and the concept sketched me out, but now I'm considering it. They seem very nice and thoughtful, and have relevant graduate degrees, but they can't take insurance and don't use the DSM in their work. The latter is fine with me and the former is workable, but I still find the whole thing weird. Some of them also mention sex-positive coaching or group classes on their website, and most offer sliding scale payment. They also seem more likely to do somatic work.

I'm curious if:
1. You are a mental health industry professional with an opinion on this type of therapy, or a perspective on why this seems to be increasingly common, especially for queer/sex/nonmonogamy therapists?
And!
2. If you have seen a therapist like this do you feel that they were as helpful as someone licensed?

I grew up with an antivaxxer parent so I've pendulum swung to be pretty suspicious of alternative health trends. I definitely do need outside help and I'm past the point where I can put up with a therapist misgendering me and have an effective therapy experience, so if these folks can help then I'm interested. However, it kind of feels like taking advantage of a marginalized group with specific therapeutic needs. Do unlicensed therapists spring up along racial/disability/other marginalizations as well? I'm very curious about the whole situation.

posted by Summers to Society & Culture (11 answers total)

Best answer: I'm a licensed therapist who's doing a lot of study and discussion about the ways in which the mental healthcare industry can cause harm and has historically caused harm, with racial and gender/sexual minorities generally being the most harmed. I've talked to a lot of trained therapists who either gave up their licensure or stopped pursuing licensure because they felt like they could not do ethical practice given the legal mandates in our field for things like mandated reporting, given the pathologizing required to be paid by insurance companies (that is, having to prove/document that the client is "sick" or "disordered" as opposed to, say, dealing in a completely normal way to the horrors of White supremacist cisheteronormative patriarchal capitalism), and given the increasingly impossible conditions of most workplaces (low reimbursements from insurance, higher and higher caseloads, etc.). There are also sometimes considerations for people practicing alternative healing modalities and worrying about getting censured by licensing boards for not doing therapy in the approved White European way.

I don't think any of them are wrong about the ethical compromises we often need to make as therapists, and I can't speak to their work with clients (since I haven't experienced it) but they've all seemed like people with knowledge, skills, and integrity. And I see a lot of licensed therapists saying things like, "Well, I know involuntary hospitalization can be traumatizing but I didn't want to risk my license so I sent him to the hospital anyway."

"I didn't want to risk my license" is a pretty common refrain among therapists who want to ignore ethical conundrums.

I obviously can't say that all the therapists you're looking at are choosing not to pursue licensure for those sorts of ethical reasons, but those sorts of ethical reasons definitely exist, are valid in my opinion, and seem to be most common among practitioners who are societally marginalized and/or work with clients who are societally marginalized. (Most do talk about the fact that capitalism has warped things and made the financial aspects another ethical concern, but obviously they generally feel the other factors outweigh that aspect.)
posted by lapis at 3:03 PM on September 20 [22 favorites]

I just saw you specifically asked about sex therapy -- a lot of insurances won't cover sex therapy at all, so that's another reason that people practicing it may not feel like licensure is helpful.
posted by lapis at 3:05 PM on September 20 [8 favorites]

I don't pursue this sort of work or call myself a therapist. But online and IRL friends have reached out to me asking if I'll work with them, because there aren't a ton of licensed therapists who understand non-monogamy really well. So it could be that they're filling a gap.
posted by metasarah at 4:04 PM on September 20 [3 favorites]

I have paid out of pocket for therapy in the past decade, and I know a bunch of people who engage in various activities like therapy but they call it coaching or somesuch because they don't want to participate in licensing, and some of them are pretty woo, but I'm not convinced that any of them are less effective at doing what they're selling than the licensed therapy I've paid for.

So, yeah, licensing won't be a concern in my future pursuit of such services, next time I feel like I need it.
posted by straw at 4:59 PM on September 20 [3 favorites]

Best answer: As a licensed therapist, I am aware that the mental health system has perpetuated a lot of harm and medicalized/pathologized lots of things that shouldn't have been. And I really don't blame people when they want to seek out non licenced providers for very rational reasons, including cost and availability.

I think that there are lots of things that non licenced people can do and do well. In addition, people who don't have "clinical" things going on can still need a space to talk about life and explore themselves.

In the US we already culturally allow for pastoral/religious counseling ( in general when employed by a church counseling licenses aren't required but in other cases are) that is widely accessible and not that regulated. But as a whole it has helped many people and has perpetuated lots of harm to marginalized groups who don't fit the norms of those religions. I also think that people offering services as a person from a marginalized groups to other people in that group are fulfilling a role similar to pastoral counseling.

My biggest concern about non licensed counseling is what to do when something becomes out of scope which for many many people it isn't applicable for but when it is applicable those people need a competent response and quickly.

My second concern is that there isn't a way to report behavior if it is terrible while with licenced providers you can report to insurance companies, licensure boards etc. But honestly even pretty egregious behavior can go undisciplined even when reported for very long times, and most of the time with no result at all.

Both regulated and non regulated providers can engage in nonethical or straight up malpractice and the quality can vary dramatically between one person and the next. They are just people.

Personally, I use a licenced provider for my own therapy needs. I worry about vulnerable people self selecting non licensed providers, but I also don't believe everyone who wants to talk to someone else needs to have a clinical license to talk with to get benefit.
posted by AlexiaSky at 6:05 PM on September 20 [9 favorites]

Licensure means some things, but it should not necessarily be taken as an indicator of quality, imo. I say this as a licensed psychologist who practiced for many years and trained and supervised people who were working on getting licensed.

In my experience, graduate schools in the mental health professions are quite deficient in their understanding and training about queer and alternative sexualities. Some people who I think of as excellent therapists in many areas don't have a lot to offer about sex, and may even do harm, for example by considering trans identity as indicative of pathology, aka "something to fix." Don't forget that homosexuality was a diagnosable mental illness not that long ago.

Given this context, you can imagine why some queer/alternative folks decided to skip the professionalized track and go into business as "coaches" which is an unregulated term. I personally know of at least two people who work in this area as coaches, and I have no hesitation recommending them to people who need help. They are kind, knowledgeable, ethical, sensitive, have received lots of training, and just decided to not go through all the rigamarole of getting licensed. It's true, you do have to pay out of pocket, but that's increasingly true for many licensed therapists I know of who don't want to fight with insurance companies.

Also, there are associations, such as the Kink Aware Professionals who can serve as a resource for finding people who have interest and expertise in these areas.

Just note that not being licensed means that they don't necessarily operate within the laws that regulate licensed therapists, so if you do pursue working with someone in this way, ask about concerns you have, particularly about confidentiality.

Feel free to MeMail me if I can answer other questions you have.
posted by jasper411 at 6:38 PM on September 20 [5 favorites]

Just for some background on the licensure process: in order to get a clinical license, a therapist needs to complete a few years of counseling hours (professionally, paid) under a licensed supervisor. Many of the unlicensed therapists out there are receiving supervision and are in the process of accusing their hours for licensure. I know that doesn't answer your question directly, but it's some background that therapists may be "not licensed yet" vs. Just practicing without a license.
posted by bearette at 8:28 PM on September 20 [2 favorites]

Best answer: And as said above, a license does not a good therapist make.

One therapist I saw, who was fully licensed: the first session went well, as she was taking the psychosocial. Her responses were gentle and kind.

But in the second session, she said she wanted me to try an antidepressant. When I told her I couldn't afford that, she wrote the name of the drug on an index card and told me you wear it under my shirt, next to my skin. Some sympathetic magic bullshit.

I never went back, obviously.

Otoh, the counselor who really saved my life when I was in deep crisis was in the first part of her supervised counseling training. She was young and not licensed yet, but she gave me some coping strategies that I use to this day, 30+ years later. Part of what she did that was very helpful was being clear with me about the limits of her expertise.


I can't speak to the specific kind of therapist you seek - my issues that I need help with are more in the mainstream of trauma. But I'd recommend heavily first asking them about what training they have, and what they would do if an issue came up that they weren't trained for. I don't know that there's a single "correct" answer to that, but trust your gut there - if they evade or seen unwilling to admit a lack of expertise, get out fast.

I did see an unlicensed "Bodywork" coach to try to resolve some of the physical touch issues I have. It was helpful, until it got too intense for me. I might have done well by continuing, but I feared going deeper without true professional support for aftercare.

I don't regret that experience at all. I guess what I'm saying is if you find someone that is helpful to you, go to them as long as you feel like your boundaries are respected and you are seeing progress. The license means there's been a certain kind of training, but it doesn't really say anything about how well you will be able to work with them.

Of course, ymmv. Im a blue collar guy who doesn't necessarily trust that a certificate implies competence, nor that the lack of same implies incompetence.
posted by Vigilant at 9:31 PM on September 20 [1 favorite]

"Pre-licensed" and "unlicensed" are really different things. Pre-licensed therapists have to register with the state licensing agency and are supervised by a licensed therapist, and are working on accumulated supervised hours in order to qualify for licensure (most states require 2000 or 3000 post-grad school pre-licensed supervised hours to qualify to take the licensing exam). Unlicensed providers aren't part of that system at all. People are giving you answers for both, but it's worth distinguishing what category your potential providers are in.
posted by lapis at 9:50 PM on September 20 [4 favorites]

Response by poster: Thanks everyone! This has been really helpful and interesting context. I'll discuss the topic at the intake I have next week. I'm interested in more answers if people have thoughts or experience to share but I'm going to mark this as resolved.

Thanks again!
posted by Summers at 3:49 AM on September 21

I think only one person mentioned the right/duty of confidentiality with a licensed therapist. I think it could potentially be very relevant to understand whether someone you're seeking a therapist-relationship with can be required to testify under oath about their conversations with you. I hope that someone offering that service would have the knowledge to be clear with you up front about that and provide guidance as to how to protect yourself.
posted by Salamandrous at 5:15 PM on September 28