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

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.

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.

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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.