Who Wrote the Rules Your Therapist Has to Follow?

Hint: It wasn't your state legislature — and no one voted on it.

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“I am embarrassed to open up about some of my issues. The thought of sitting in front of someone who is analyzing me and hearing all of my deepest secrets terrifies me. I’m not even sure where to begin…” The feelings the Reddit poster was sharing are common among first-time clients and highlight the necessity of developing public trust in any talk therapy profession.

For therapy professions, like every line of work that can have a profound and lasting impact on someone’s life, establishing confidence that the person doing the job will reliably put the client’s well-being above their own is critical.

Similar to the law, Codes of Ethics were a human invention built to improve cooperation through building trust. The ancient Hippocratic Oath, as an example, is a short pledge of healers, promising to do no harm, even if that means doing nothing.

But a code of ethics is only as trustworthy as the body that writes it, and most clients seeking therapy have no idea what that body actually is.

What most clients don’t know is that when it comes to licensed professionals, Codes of Ethics are most often the product of distant professional organizations, which themselves may only represent a tiny fraction of professionals working in a given field.

How Association Rules Become State Law

Most states have approached licensing in a rather hands-off way. When a new licensing board is established, it is populated with current local leaders in the field who are then tasked to build the full architecture for the license, such as deciding what educational background, certification tests, and practical experience are required.

This same group will choose and oversee a code of ethics and enforce those standards going forward. The board will then continue in perpetuity, periodically changing board members and adjusting standards as time goes by.

While States take a variety of approaches in how they manage licensing bodies and Codes of Ethics, it’s common for boards to either lean heavily on Codes written by professional organizations or adopt those codes in their entirety. Currently, 21 states have adopted the American Counseling Association (ACA) Code of Ethics, and as of 2019, well over half of all states use the American Medical Association’s (AMA) Code of Ethics for Medical Doctors.

For states, like Tennessee, which have adopted the ACA Code of Ethics as part of licensing state counselors, every time the ACA updates its code, so does Tennessee. And while the state General Assembly could vote to disband the counseling licensing board, as apparently they nearly did in March, as so often happens, the saber rattling didn’t lead to foundational change. Lawmakers make threats, but taking action that could be painted as costing the state jobs is very hard to pull off.

That is because the public is unaware of just how insular licensing boards have become. While there is much to be written about that subject, suffice to say Rebecca Haw Allensworth’s research has shown that licensing boards are not the neutral referees they were sold to the public as. Rather, they function as economic and ideological actors, run by other competing professionals in the same field. Even with the best of intentions it can’t be neutral.

And if the board isn’t neutral, neither is the code it adopts.

The Open Gateway

When the state adopts a professional association’s code of ethics wholesale, it is buying into a worldview. If that worldview is based on something like “using the profession and practice of counseling to promote respect for human dignity and diversity,” as seen in the American Counseling Association’s (ACA) Code of Ethics, you might be getting more than you bargained for.

For example, look carefully at that quote above, which comes from the ACA’s mission statement. It specifically says that the purpose of the profession is to ‘promote respect for dignity and diversity’, rather than saying something like, “support and inform counselors as they work to support and improve their clients’ mental health.”

The mission of the profession has a profound impact on a code of ethics. The mission is the seed, and the code is the enforcement branch.

States vary on how they both choose and manage their governing code of ethics, but it’s not something they revisit every month. Once agreed upon, a specific code of ethics can be active for a decade or more. While some states, like Tennessee, have instituted a process where the general public can comment on such details when they do come up in the administrative cycle, others, like Pennsylvania, don’t.

Sunset clauses, public votes triggering updates, or options for the public to do more than comment if they don’t like what they read in a code of ethics are rarities, if they exist at all.

Effectively, the vote to create a licensed profession is, in many states, a one-time transfer of ongoing regulatory authority to an autonomous group that is populated by industry insiders.

Voters may have approved of the profession being licensed, but they didn’t agree to the Code of Ethics listing “promoting social justice” and “honoring diversity and embracing a multicultural approach” among its core professional values.

So what happens to the practitioner whose values conflict with the code? Those therapists are faced with a choice between their license and their honest professional judgment, and clients don’t even know this tension exists.

The ACA Code of Ethics is currently being revised with a projected completion announcement in the fall of 2026, and the pattern of past revisions suggest the ideological content will expand, with practitioners required to abide by the new regulations as a condition of their license.

What This Means For Clients

The Reddit poster’s fear is legitimate. The profession’s response to that fear was supposed to be a set of rules that define ethical behavior in a way we can all agree on, and an enforcement arm for practitioners who break those rules.

What the system actually delivers is the enforcement of rules written by private organizations, which are enforced by a board of competitors, and updated with little, if any, public input. And all of this has the force of state law behind it.

Few clients are aware of this.

In Closing

When a state votes to license a profession, it’s creating a legitimacy that is supposed to protect client safety and ensure practitioners meet a standard.

But when that standard is determined by a private body, revised at will, and enforced by insiders, who is actually making a promise to protect client safety?

The Reddit poster deserves a real answer about what risks come with therapy. So far, no one with authority is really answering that question.

Further Reading

The Licensing Racket: How We Decide Who Is Allowed to Work, and Why It Goes Wrong by Rebecca Haw Allensworth

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About

Diogenes in Exile began after I returned to grad school to pursue a master’s degree in Clinical Mental Health Counseling at the University of Tennessee. What I found instead was a program saturated in Critical Theories ideology—where my Buddhist practice was treated as invalidating and where dissent from the prevailing orthodoxy was met with hostility. After witnessing how this ideology undermined both ethics and the foundations of good clinical practice, I made the difficult decision to walk away.

Since then, I’ve dedicated myself to exposing the ideological capture of psychology, higher education, and related institutions. My investigative writing has appeared in The Federalist, Real Clear Education, Heterodox STEM, Minding the Campus, The College Fix, and has been republished by the American Council of Trustees and Alumni. I also speak and consult on policy reform to help rebuild public trust in once-respected professions.

Occasionally, I’m accused of being funny.

When I’m not writing or digging into documents, you’ll find me in the garden, making art, walking my dog,