A note before this week’s essay:
A new piece in The New York Times discusses the neuroscience concept of predictive processing—how our perceptions are actually predictions determined by early experience—as a unifying concept underlying all effective psychotherapy. Highly recommended. (And yes, I’m quoted in it.) I share some additional thoughts here.
Legitimate mental health professionals don’t respond to strangers on social media as if they were patients. We are psychotherapists in our offices, in the context of a professional therapy relationship. That is where psychotherapy happens.
Steer clear of anyone who responds to you “like a therapist” on social media. They are showing you their lack of understanding and boundaries.
What would you think of an attorney who gave legal advice to a stranger based on a tweet? A physician who made a diagnosis or wrote a prescription? Most people would recognize it as a red flag.
Yet some people seem to expect mental health professionals to engage with people online as if they were clients or patients.
It doesn’t work that way, and it can’t.
Case in point: if a patient of mine were rude or antagonistic, I’d likely get curious about their thoughts, feelings, and experience, including their experience of me and our interaction. I’d hold as an open question whether I had done something to offend or whether their perception of me was colored by a past relationship, or perhaps some of both. This would occur in an ongoing relationship in which we had established some mutual trust, with a shared understanding that discussing our interactions is part of the work.
It would also be a relationship in which I give the patient my full, undivided attention for the duration of our sessions, hold in mind why they came, think about our immediate interaction in the larger context of their personal history and psychology, and use my clinical expertise to the best of my ability to provide the help they came for. That’s work, and I’d be getting paid for it.
Online interactions are not psychotherapy.
There is also professional responsibility and accountability. A psychotherapist who accepts a patient for treatment assumes professional and legal responsibility for the treatment. It’s not a game or a popularity contest for clicks. It’s people’s lives.
No one can know in advance what will come up in psychotherapy once you begin. It’s opening Pandora’s box. People come asking for help for seemingly circumscribed, ordinary things: workplace stress, trouble sleeping, help resolving something with their spouse. It sounds simple.
Then you find out that the person is spiraling toward divorce. Involved in domestic abuse. Decompensating into psychosis. Suicidal. Dealing with the after-effects of severe trauma.
What’s on the surface is not all there is, and few things are as simple as they seem. So-called presenting problems are often the tip of the iceberg. The person asking for help may not recognize that.
But a mental health professional must know it is a possibility. They know how to do a comprehensive evaluation, and that’s where skilled psychotherapy starts—and where a professional is obligated to start. They don’t fall into the trap of thinking they can address concerns piecemeal, without knowing the patient and their history. They are prepared for the unexpected, and they know how to handle emergencies when they arise.
Skilled professionals also know when they are outside their area of expertise and how and when to refer to other professionals—when, for example, a patient needs a medical evaluation because what looks like a mental health concern may be a medical problem.
A therapist who gives advice to strangers on the internet assumes responsibility for nothing. They borrow the authority of psychotherapy while accepting none of the professional responsibilities that justify that authority.
A therapist who gives advice to strangers on the internet assumes responsibility for nothing.
This is why legitimate professionals are psychotherapists in their offices, in the context of a professional treatment relationship, and never on social media.
That is the minimum standard we owe people who seek our help.
Related Essays
How to Choose a Psychotherapist: A Guide to Recognizing Competence (September 11, 2025)
The Slow Decline of Psychotherapy (April 6, 2026)
50 Therapy Red Flags (November 24, 2025)
Therapist Ethics Isn’t About Following Rules (May 8, 2026)
For Paid Subscribers
Eavesdropping on a Psychotherapy Session (May 11, 2026)
That Was Then, This Is Now: An Introduction to Contemporary Psychodynamic Psychotherapy (March 30, 2026)
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