Friendships with Ex-patients: Why I Say “No”

The_Friends_Stage_cropped

I recently received an invitation from a former patient to meet for coffee. This warm-hearted offer came from a man who is as principled and decent as anyone I know. What’s more, he is funny and bright — just the sort of person I’d enjoy having as a friend.

I said no.

Now you might ask, why did I make this decision? This was not the first such request since I retired over two years ago and not the first from a person I thought companionable. I’ve said no to all of them. What I’m about to do is explain how I reasoned this out. I’ll finish with my response to this terrific guy.

First, nothing in the American Psychological Association’s Ethical Principles of Psychologists and Code of Conduct forbids me from having communication with former patients. Nowhere does it say I can’t be friends with them. We are, however, governed by the same overarching principle any medical practitioner is expected to live by: first do no harm, an idea going back to Hippocrates. Here is what the APA Ethical Principles says:

Principle A: Beneficence and Non-Malfeasance
Psychologists strive to benefit those with whom they work and take care to do no harm… Psychologists seek to safeguard the welfare and rights of those with whom they interact professionally and other affected persons… Because psychologists’ scientific and professional judgments and actions may affect the lives of others, they are alert to and guard against personal, financial, social, organizational or political factors that might lead to misuse of their influence…

In anticipating retirement I realized my obligation to former patients still required me to “take care to do no harm.” I imagined some number might wish to continue a relationship as friends, serious or casual. I told them all I was available to give them referrals and to be contacted by email if they just wanted to say hello or let me know how they were doing. I subsequently received both types of communications and always responded to them. Indeed, I enjoy hearing from people who I had the privilege to serve and hope their lives are turning out well. In many cases, they have my continuing affection.

Here is another section of the Ethical Principles I considered:

3.05 Multiple Relationships
(a) A multiple relationship occurs when a psychologist is in a professional role with a person and (1) at the same time is in another role with the same person, (2) at the same time is in a relationship with a person closely associated with or related to the person with whom the psychologist has the professional relationship, or (3) promises to enter into another relationship in the future with the person or a person closely associated with or related to the person.

A psychologist refrains from entering into a multiple relationship if the multiple relationship could reasonably be expected to impair the psychologist’s objectivity, competence or effectiveness in performing his or her functions… or otherwise risks exploitation or harm to the (patient).

Multiple relationships that would not reasonably be expected to cause impairment or risk exploitation or harm are not unethical.

256px-Francisco_Goya_Self-Portrait_with_Dr_Arrieta_MIA_5214

Careful readers will note nothing above tells me about associations with former clients or those close to them where no promise of such contact has been made before the end of therapy. Having a dual (multiple) role exists, for example, if I am simultaneously a psychologist/lover, psychologist/friend, psychologist/business associate; or involved with someone close while the treatment is ongoing. Yet, to me, the words at the end the second paragraph remain weighty, where the psychologist “…risks exploitation or harm to the (patient)…”

How would such harm occur if I were no longer the individual’s therapist? Here are some examples:

  • I begin a non-therapeutic relationship with an ex-patient and discover he wants more of my time or intimacy than I want. I have the delicate task of setting limits and perhaps hurting feelings.
  • I am still thought of as the “therapist.” Now, however, I am doing informal counseling at Starbucks or in my home or the ex-patient’s residence. Without injuring him, I must try to tell the former patient I will not continue this role, even though he already knows I am not his current psychologist (or, in my case, am retired from practice).
  • Should the ex-client still need to improve his social network, my continuing presence in his life might reduce his incentive to meet new people, take social risks, improve social skills, etc. Simply put, with me as his friend he needs one less relationship.
  • Perhaps my former patient and I don’t get along as well in the new form of our association as in the old one. I decide I need to “break up.” How might my new friend feel if he were “dumped” by his ex-therapist?

Remember the coffee invitation with which I started? Now, in light of all of the above, here (in a revised version) is my response to the emailed invitation:

Thank you for your kind invitation. Here is my dilemma. Prior to my retirement I expected some people might request social contact with me. I had to decide how I would handle this. As you can imagine, the APA essentially forbids “dual relationships” (therapist/lover, therapist/friend, therapist/employer) for the protection of the patient. At the end of treatment, however, the rules change a bit (still no sex) but are less explicitly defined with respect to other kinds of interactions.

Anyway, I had to consider what I would say to anyone who wished a post-therapy relationship. “Why not?” someone might ask. Since no absolute and unconditional prohibition exists, no such reason could be given. Three statements were possible in trying to explain why I was saying no:

  • “I don’t want to be your friend. Beyond therapy, I doubt we have much in common.” Surely, saying this might injure all but the most bulletproof among us. Regardless of its social clumsiness, with some people it would be the truth. Even phrased in a more delicate way, the message is potentially problematic, in part because of imaginary comparisons the rejected client could make to those with whom I was willing to attempt friendships.
  • “I won’t meet with you because I’m afraid that would not be in your interest. It is impossible for us to have a clean slate. I’d be afraid our history would color your expectations for the relationship even if you said to me you were sure it wouldn’t.” Many patients put the therapist on a pedestal. Any subsequent relationship begins on unequal footing, with the former counselor perhaps having unequal power or influence.
  • “Even if I thought you and I could be friends without doing you harm, I wouldn’t be able to guarantee the relationship would always remain harmless. For example, were I to end the contact at some future time, I’d put you in the position of having been dumped as a friend by your former therapist.”

As a result, I decided to make a firm rule: no relationships under any circumstances. While some people would be disappointed, I hoped they wouldn’t experience the sense of personal rejection they might otherwise.

Indeed, some people did want to meet, take me out to dinner, etc. I refused every one.

I am telling you this for two reasons. First, I’d enjoy seeing you if we didn’t have a treatment history. Second, I don’t want you to be hurt by not accepting your invitation. You are a good fellow, but I just can’t. I’m not assuming any desire on your part except for a single cup of coffee. At the same time, the rule I set takes the potential complications out of such things. I miss out on some neat relationship possibilities, but I think it is the best way to avoid damage to people I tried to help.

That said, occasional emails or requests for referrals or reading my public blog posts and commenting on them are fine.

I’m sorry to disappoint you and, as I mentioned, I’m sure I’d have enjoyed the time.

All the best, etc.

My ex-patient’s response was very gracious and understanding.

If I lived in a small town, my car broke down, and a patient were the only auto repairman, things would be different — at least as far as the therapist/auto repairman relationship. Chicago, on the other hand, is no small town. You, dear reader, might not agree with my decision about post-therapy contact, but I hope you understand how I made the decision.

The top image is a cropped version of the “Friends” stage plaque, outside of Stage 24 at Warner Brothers Studios in Burbank, CA. It was uploaded by Nijilravipp. The self-portrait is Francisco de Goya with Dr. Arrieta, photographed by XgHysMjXb5u2eA at Google Cultural Institute. Both are sourced from Wikimedia Commons.

34 thoughts on “Friendships with Ex-patients: Why I Say “No”

  1. Dr. Stein, the fact that you say ‘no’ to all invitations for friendships with ex-patients should ease or eliminate any pain of rejection on their part.

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  2. This is a question clients frequently ask on psych discussion boards. I appreciate your well-thought-out explanation which foresees the situation from the client’s viewpoint. Some therapists express contempt that those dusty all rules apply to them. I see think seeing oneself as the exception, or believing both sides perpetually will benefit from the shifting ground of a relation is hazardous thinking.

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    • drgeraldstein

      This is a situation where there really are two sides to the story. It is clearly one you have also considered carefully, so I am especially grateful for your appreciation.

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  3. Maybe it’s because my therapist is 30 years older than me and a man that I find it strange to envision asking him to coffee post-treatment, but your reasons for having a hard policy against such a practice make perfect sense to me. I thought it was pretty standard. Likewise, it’s difficult for me to imagine getting together socially with a former student.

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    • I’m sure that many of my patients would feel exactly as you do. I made the policy decision based on those who would feel differently, as indeed, some have. Thanks for your perspective, which is an important one.

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  4. I admire that you have an across the board response and are sticking to it. I have a problem, however, with some of your reasons. You make it clear that the prior clients may not be able to handle a friendship. That they may not be able to take you off a pedestal (IF they ever had you on one, not all do), that they may continue to treat you as a therapist and want listening and advice in a Starbucks, or that they may not understand you aren’t available for friend related things as often as they may like. I don’t think you give very much credit to your prior clients. And I don’t know them. I’m sure some really would not benefit from a friendship. But I’m sure you have some that are perfectly stable and have many healthy relationships in their lives already and therefore adding you would be merely a nice extra friend, NOT their ONLY friend.

    Also, ANY friendship risks finding out you don’t have as much in common as you thought, or one party wanting to lessen time together, or one party wanting to end contact. That is not exclusive to post therapy friendships. Again, I would give the client more credit, as well as yourself, to have the ability and mental health to handle it.

    As for saying yes to some and no to others and therefore harming the ‘no’ people, I see that point. However, you’re not supposed to be treating friends and relatives anyway, so I’m not sure how the information would get out.

    Again, I admire your firm across the board stance, but you, yourself, admit you are missing out on some nice relationships this way. I wouldn’t take your route, personally, due to the missing out. But I’m glad it’s working for you.

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    • As I stated in my reply to A., I did not assume that large numbers of my patients would request a continuing relationship as a friend or that all those who so requested it would be unable to manage it. Nor did I assume that I would be unable to manage friendships with some of them. Rather, I tried very hard to respond to the APA’s ethical guidelines in such a way as to reduce, minimize, or limit damage to people I’d tried to help. You are absolutely right in saying many did not have me on a pedestal, wouldn’t have sought further informal counseling in the new friendship, etc. I absolutely give those people credit for being perfectly companionable, as I stated with respect to the particular person who served as an example of how my policy worked. As to your question of how some ex-clients might find out I was open to having some ex-patients in new friendships, but not others, I can think of at least two ways. First, some, upon being refused the opportunity might ask me whether this was my policy for all ex-patients or not. I would answer them honestly, of course, and then they might well have followed-up with questions about why they were excluded. As you have stated, the “no” people might well have been harmed by the knowledge or belief they were deficient in some way. Second, it is not unusual for patients to refer friends or relatives. The APA ethical guidelines only exclude treatment of such people if they are “close” and if treating one might reasonably be expected to do harm to one or both. If, for example, a previous patient referred a friend or relative, I could imagine the following scenario. The previous patient might eventually hear that her friend, once treatment of her friend ended, had also become my friend. Perhaps the previous patient now decided to call me and invite me to coffee. I think you can see where this is going. I would agree my approach to this issue is cautious. The APA ethical guidelines give much more emphasis to doing harm via multiple relationships than any possible benefit or happiness ex-patients or therapists might derive from these new friendships. If you read what the APA guidelines say about sex with current or former patients, it is clear where their concerns are focused. In any case, as you say, I’m comfortable with my stance and I believe it is for the best for the people I treated. There are also many friendship possibilities for them other than with me. Thank you for your comment, Katherine.

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  5. Dr. Stein,
    I have been very much enjoying your posts, but this is the first time I have commented. I wanted to thank you for such a thoughtful explanation of how you handled this situation. I am a long time client of psychotherapy and have been working for around seven years with my current therapist. He has very clear and consistent boundaries for which I am very grateful as I have experienced some very intense transference in the relationship, ranging from romantic/erotic to paternal to mentoring. Actually, you name it, I think I have felt. 🙂 This becomes even more complicated when you factor in that my reason for therapy was childhood sexual abuse by my father. I have been very open with my therapist about these feelings and he has handled them flawlessly. He has made it clear that any, and all, of my feelings are welcome for discussion and that he has control and responsibility for the boundaries so that I am assured of my safety while being free to explore these feelings. Because of this I have experienced an extraordinary amount of growth and healing while working with him, and lead a much fuller life. The intensity of my feelings have been very tied into my early attachment injuries, sometimes having a life and death quality to them. So part of what I have felt is an intense longing to go beyond the boundaries in an attempt (futile, I know, but it doesn’t stop you from wanting to try) to get now what I didn’t get then. There has been a lot of pain associated with learning to respect the necessity of those boundaries.

    Which is all my long way of saying that I think I am exactly the kind of client to whom you are striving to “do no harm.” My therapist also has a “once a client, also a client” approach and I am guessing will handle the issue in his retirement in much the same fashion as you. And in my more honest moments, although I do recognize that there is a genuine adult component to my desire to have a friendship based on very real respect and wanting to know him more fully, I also know that what is operating is a desire to have 24/7 access to that wonderful, warm, focused person I see each week. Which doesn’t really exist. I do not mean that I am not seeing a real person, I know the relationship is very deep and very real. But no one can constantly, nor should they, put aside their own needs in a peer adult relationship. Which therapy is not. And again, being painfully honest, I don’t know how well I would make that shift. Not because I did not understand or even because I do not have other friends. I am actually quite blessed in my friendships. But the truth is that we have had to go so deep in order for me to heal, that my therapist carries a heavy symbolic weight that I know from an emotional standpoint, I would struggle to put aside, no matter how well I understand cognitively that things would have to change to continue in relationship with him.

    So thank you for realizing that for at least some of your clients, you fulfill a very important role in their lives and carry a commensurate responsibility. A responsibility that you take so seriously that you are willing to make those client’s safety a priority even in your retirement, placing their well-being above your desires. I deeply admire your stance on the issue and having it so well explained makes it easier for me, as a client, to recognize the value of that boundary despite the fact that it can be painful on occasion. ~ AG

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    • drgeraldstein

      I rarely say I am humbled, but I will say it now, after having read your comment twice. You write beautifully and thoughtfully, just to begin. I am impressed by the growth you describe and which is reflected in your perspective on the therapeutic process. Moreover, as was true with my own patients who survived abuse, you have admirable and rare courage. You are spot on about the human flaws of therapists, who only appear larger than life (occasionally) in the consulting room. Outside of it, none of us are. Finally, you are very welcome for that which you found useful in this post. And thank you for everything you wrote, as well.

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    • AG, how I admire your way with words.

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    • I can only echo Dr Stein’s and Spacefreedomlove’s comments about your way with words – beautiful beautiful writing, flawlessly flowing and crystal clear. And true, so very true, for me at least – every point chimes with how I feel….

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      • Life,
        Thank you, I have just been browsing around your blog and can say the same for your writing. I very much appreciate how thoughtfully you reflect on your own processes and how honest you are. I’m looking forward to reading more of your stuff. It was very kind of you to take the time to say this. Yet one more thing I am grateful to Dr. Stein for, leading me to you. 🙂 ~ AG

        Liked by 1 person

  6. I really enjoy your blog. I’m going through and reading every post right now. I also like the story with the genie in the bottle!

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    • drgeraldstein

      Ah, the genie story. One of my rare attempts at fiction. I’m happy to hear you enjoyed it and my other posts. Thanks, too, PJ, for attempting the rare feat of reading every one of them! One piece of advice: take lunch breaks!

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  7. Reblogged this on Tales of a Boundary Ninja and commented:
    I thought this was an excellent, compassionate explanation of why a therapist might choose to not have a personal relationship with you. I very much respected his stance of continuing to care for his clients even after they were no longer his clients. I thought this might be helpful for a lot of people to read.

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    • drgeraldstein

      Thank you for reblogging the post. I hope your followers find it useful.

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      • I think a lot of my readers would benefit from reading it! Although I also forsee it upsetting some. 🙂 Such is blogging! And thank you for your earlier reply, I really appreciated the kind words about my writing (I sometimes have difficulty taking in compliments and am never sure how to reply).

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  8. Dr. Stein,
    When I read the title for your topic, I thought, “How cruel!” But, once I read it, I understand completely. I have been in a situation where my therapist of 25 years took an unexpected retirement. (He had a stroke a couple months before he was going to actually retire.) He is a lot older than myself, so he was very much a father figure to me. He has since moved out of state and moved back to his home state, along with his wife. But, I still feel the need to connect with him. Every year on his birthday (he, irronically shares the same birthday as myself) I send him a birthday card and wish him well. I don’t expect anything from him, not even a reply. I just want him to know that I still think about him and let him know that all of the hard work we did together is not forgotten. I certainly don’t want to be a burden to him, I just want him to know that I care.

    LJB

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    • I’m glad you read the essay despite your initial reaction. I know I appreciate being remembered and I wouldn’t be surprised if your retired therapist feels the same way. Some people live inside of us for as long as we live. Thank you for your thoughtful comment. By the way, I love your email address!

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  9. Thank you for writing about this. I have had experience with a few therapists and ending with them. I have only kept in contact with one, but this was purely a ‘checking in’ on both sides perhaps 3 times a year. She was an incredibly important part of my life, and we ‘clicked’, so it was good to connect in that way. We are actually now back to client-therapist again, and I am glad we didn’t let boundaries slip into friendship or I would have lost out on the beneficial therapeutic relationship I now have with her again.

    I worry constantly about what will happen when my (other) current T retires or I leave. Because of my attachment issues, our relationship has been very different to with other professionals I have worked with. She is old enough to be my mother, and I guess I have absolutely no interest in being her friend after therapy, but I do want to believe that she would want to check in occasionally and keep some connection with me. I certainly would with her, particularly as therapy has been a little like redoing my childhood, and my leaving I am sure will feel somewhat like leaving home or flying the nest. I would hate to think of a cut off with absolutely no further contact.

    This topic is frequently discussed all over the internet, so it will definitely help a great many people. Thank you so much for writing this.

    x

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    • Thank you for describing your own situation. I think the point you made — that some people will want to return to seek additional therapy — is extremely valuable. Shifting from being a patient/client to a friend and back again — would, as you say, be difficult, if not impossible.

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  10. Wow, you’re really arrogant. Did it ever occur to you that a patient might “dump” YOU after attempting a friendship? Especially if their encounter with you knocked you off your pedestal. Sheesh. Isn’t it okay to have sex with a former patient after two years?

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    • I will deal with the two substantive questions you raise. My essay focused only on the possibility of injury to my client, not any injury to myself. As you say, I might have been rejected by a former client in any new friendship we might have attempted. I was more concerned with their well-being because that is what my position as their former therapist demands of me from an ethical standpoint. With respect to your second point, here is the relevant quote from the Ethical Principles of Psychologists and Code of Conduct:

      “10.08 Sexual Intimacies with Former Therapy Clients/Patients

      (a) Psychologists do not engage in sexual intimacies with former clients/patients for at least two years after cessation or termination of therapy.

      (b) Psychologists do not engage in sexual intimacies with former clients/patients even after a two-year interval except in the most unusual circumstances. Psychologists who engage in such activity after the two years following cessation or termination of therapy and of having no sexual contact with the former client/patient bear the burden of demonstrating that there has been no exploitation, in light of all relevant factors, including (1) the amount of time that has passed since therapy terminated; (2) the nature, duration, and intensity of the therapy; (3) the circumstances of termination; (4) the client’s/patient’s personal history; (5) the client’s/patient’s current mental status; (6) the likelihood of adverse impact on the client/patient; and (7) any statements or actions made by the therapist during the course of therapy suggesting or inviting the possibility of a post-termination sexual or romantic relationship with the client/patient. (See also Standard 3.05, Multiple Relationships.)”

      I have never met a single colleague or expert on the subject of ethics who has endorsed the idea of a sexual relationship with a present or former patient under any circumstances. In the State of Illinois, we are required to have at least six hours of instruction in ethics every two years. My most recent such instruction was entirely consistent with the idea of an absolute prohibition.

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  11. Thank you for this excellent post, which I have just discovered. Yet again, I can only have sympathy with every reason given, and admiration for the stance you have taken, despite the fact this too, is a source of pain in my therapy relationships. I think your response to your ex-client was very very kind, thoughtful, genuine and considered, and just the sort of reply I would have very much appreciated, had I been in their shoes. I am so glad they responded well! As well as explaining your position, I think it was wonderful to have told the individual that you would have enjoyed that friendship – I know that to me, that would have meant a very great deal. The more read about the therapist’s side of things, the more I respect and admire what it takes to do the job (and I admired it a very great deal to start with!). In some ways it makes it that little bit easier to deal with the pain of not ‘getting what we want’ in terms of ongoing or deeper relationship – the knowledge that part of what our therapists so very special, is also part of what makes those things that we want, impossible to have.
    Now, what I really need is a win in the lottery I don’t play, and a long period without work so that I can actually go back through all your archives and read what I am sure are the many wonderful posts I have missed over the years!

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    • Thank you very much. The task of taking on my blogging history is not a small one, but it is much appreciated by this author! As for the lottery, do remember that the research says after the passage of six months or more, than aren’t any happier than they were before they won. Of course, that does not include you, because you will be the first person ever to win without playing:)

      Liked by 1 person

  12. Reblogged this on Life in a Bind – BPD and me and commented:
    Although this post by Dr Stein was written last year, it feels like a logical conclusion to the series of posts I recently shared (both his, and my own), on the topic of feeling excluded from your therapist’s life, and the related question of whether a friendship between therapist and client would be possible. Even for clients who are persuaded (though painfully) by the reasons behind this ‘exclusion’, the question remains – why should a friendship be prohibited once a client becomes an ex-client? And if there are reasons for prohibiting it for a period of time, why should such a friendship not be permissible at a later point?

    As with the reasons behind why therapists and clients would find it very difficult to maintain a ‘dual’ relationship, the reasons in this post are also very persuasive. I wish it were not so, because everything within me dreads and fears the day (hopefully far far in the future) when I will come to the end of my current therapeutic relationship. But I have been fortunate to have received an email from my ex-therapist, following a desperate plea from me for ongoing contact, that was kind and compassionate, and made the ‘no’ slightly easier to bear. I hope that if you too are in a similar position, the response that you receive is as honest but compassionate and caring, as the one described by Dr Stein above….

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  13. Thank you Dr. Stein for your realistic explanation of why I can’t wishing to be friend with my doctor. I know I can’t have any relation outside the office, but I want to make absolutely sure that there is NO WAY AROUND that I can pursue my wish and stop my daydreaming to be with him even after 2. 3, 5 years, I can wait. It is so much pain than what my own problems are as I spent most of my time thinking any kind of possibilities to see my doctor in person.( we are not in the same city) Now that I read all above and they shine light on me. I hope I will be able to adjust my thoughts and focus on my real issue. Thank you very much.

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    • You are welcome. Sometimes what seems impossible is only a matter of allowing time to pass, as difficult as that is. I hope it works that way for you.

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