Over the past three decades, researchers have examined multiple relationships between psychotherapists and their current and former clients, and boundary issues have been explored in the ethics literature. In day-to-day practice, multiple relationships (also known as dual-role relationships) with current clients are commonplace for some practitioners. In some instances, these relationships can be unavoidable and even beneficial. For example, it is not uncommon for a school counselor to also be the coach of a sports team, thus filling both a counselor and a coach role for students.
Discussions of multiple relationships with former clients have been relatively scarce until recent years. In the late 1980s and early 1990s, research began regarding the ethics of counselors entering sexual relationships with former clients, culminating with the ACA Code of Ethics prohibiting sexual relationships with former clients for a period of at least five years post-therapy (see Standard A.5.c.). More recently, studies have examined how therapists view nonsexual relationships with former clients. Interestingly, research suggests that therapists feel less ethically conflicted about entering these relationships with former clients than they have in the past. For example, in 1989, Debra Borys and Kenneth Pope reported that 46 percent of therapists thought that becoming friends with former clients was ethical under some conditions. In a 1996 study, William Salisbury and Richard Kinnier found that 70 percent of counselors held this belief. In 2004, Tracey Nigro and Max Uhlemann found that a whopping 83 percent of counselors thought that becoming friends with former clients was ethical at least some of the time.
So, what about clients’ perspectives of friending a former counselor? My colleagues Sharon Anderson, Jim Banning, Suzan AlDoubi and I took a mixed-methods approach to study former clients’ experiences of nonsexual post-therapy relationships with their therapists (the research was inclusive of psychologists and counselors).
In the first phase, Sharon collected and analyzed data from a questionnaire. The questionnaire asked former clients to provide demographic data (e.g., their gender, the former therapist’s gender, their ethnicity, the former therapist’s ethnicity, age while in therapy, reason for therapy, estimated time between therapy termination and post-therapy contact, and who initiated contact). In addition, participants were asked to:
1) Describe the post-therapy relationship
2) Indicate whether they thought the post-therapy relationship was positive, neutral or negative for them
3) Explain why they thought the relationship was positive, neutral or negative for them
4) Indicate whether they would be willing to be interviewed about the post-therapy relationship and its impact on them
In the second phase, Sharon conducted interviews with nine former clients who responded to the questionnaire. Participants were interviewed one at a time, and the interviews ranged from one hour to 90 minutes each. Prior to beginning the interview, informed consent was discussed and obtained. A debriefing sheet listing referral for counseling was provided. Participants were informed that the research findings might be published but that their names and identifying information would be altered to protect their confidentiality. All interviews were recorded and transcribed.
Of the nine clients interviewed, eight were female. All participants identified themselves as white or Caucasian. Their ages while in therapy ranged from 16 to 56. Reasons for being in therapy included couples work, grief and loss, self-esteem, anorexia, depression, suicide in the family, suicidal ideation, sexual abuse, family-of-origin issues, transitional issues, dissociative identity disorder and posttraumatic stress disorder. Time in therapy ranged from seven months to five years. The estimated time between therapy termination and post-therapy contact ranged from a few weeks to two years.
Former clients and former therapists were almost equally responsible for initiating post-therapy contact, with five clients initiating contact and four therapists initiating contact. Regarding the former therapist’s gender, there were five males and four females. The ethnicities of the former therapists were reported as African American, German, Jewish, Irish and white.
Our findings examined the following five variables:
1) The type of post-therapy contact between the former client and therapist
2) Which party initiated post-therapy contact
3) The transition between therapy and post-therapy relationship
4) Power issues in the post-therapy relationship
5) The impact of the post-therapy relationship on the former client
Quotes from the former clients (using pseudonyms) are included to highlight these results.
Type of post-therapy contact
We identified three different types of post-therapy contact that participants described with their former therapists.
Simon: “I’ve only seen her in class. I think maybe I’ve stopped by her office once or twice just to say hello, but it’s just been in a classroom where she’s like a TA [teaching assistant] now and I’m a student.”
Jewell: “We are in the same field. She had developed some workshops. Then as I moved into private practice, I began wanting something for my clients that I knew she had to offer. So I began to do some training with her, so there was a process of not therapy anymore, but more training and mentoring.”
Lacey: “Me and my husband have done a couple things with her and her husband, like dinner and things like that. I talk to her on the phone maybe once a month. … I call her, she calls me. It’s not just a one-way thing.”
Alice: “So I went to workshops with her, and I think part of us becoming friends was that I cleaned her house to pay for therapy. And so I kind of got to know her a little bit better that way, and then after, we just hung out. She had been friends with my mom some, but then she got to be closer with me, and we talked on the phone and we were like friends and went out quite a bit, and I went to workshops that she did. I also took a psychology class from her later.”
Jeg: “I wouldn’t really call it a friendship like my other friendships in my life. It’s not the kind of friend that I would call and shoot the breeze with and tell the latest news to. It’s a friendship in the sense of … it’s two-sided. I tell her how I am doing now, and she also shares with me what’s going on in her personal life. Again, I don’t think she shares great intimate details like really close friends might. There’s just a real warm regard and mutual interest.”
Lanette: “I think to me the post-treatment contact … has been kind of leveling, kind of humanizing. [It] kind of keeps things for me in perspective, in terms of ‘you’re a person, I’m a person,’ and even though we have had this very intense and sometimes traumatic contact, basically, we’re just people muddling along the best we can. … I guess what I am saying is, to me, it sort of makes them like friends, although they are not friends in the way most of my friends are my friends. They’re something between a friend and an acquaintance.”
Flo: “I knew he loved me … and his wife loved me as well. I was friends with him, and I was friends with his wife. I’m an artist, and he loved my work and he came to all my openings. … We did some neat things together. It was great.”
Initiator of post-therapy contact
We asked participants to recall who initiated the contact after therapy. Was it the former client, or was it the former therapist who made the first move? Four responses came out of the analysis:
1) Former therapist
Leni: “So, I had initiated the termination in February after we had the discussion about it for about six months, and then I didn’t have any contact with him until June. He wrote me a letter saying that he would be willing [to see me] if I needed anything.”
2) Former client
Lanette: “We moved from _____, which is just so different. We’ve gone back for each vacation, and last summer we saw him … and this summer I expect we will also. I went back by myself in December and arranged to meet with him.”
Jewell: “As I moved into private practice and I began wanting something for my clients that I knew she had to offer, I started calling her to ask her about ‘What do you do in this workshop?’ and ‘What has been helpful?’ and ‘What’s the theory base?’ [and] ‘Whose work have you drawn on for that?’”
Jeg: “When I go to town, we get together and have lunch. We send Christmas cards. … She sends birthday cards, Christmas cards. A couple of times she sent me a short letter with an article or something like that.”
Alice: “She had been friends with my mom some, but then she got to be closer with me, and we talked on the phone and we were like friends and went out quite a bit, and I went to workshops that she did.”
Simon: “The person I had been in therapy with is a doctoral student here at ___. I’ve only seen her in class.”
Transition between therapy and post-therapy relationship
We wondered how the therapist handled this transition. In analyzing this part of the interviews, we found two themes: 1) the termination of the therapy relationship was not clear and 2) the termination was clear, with the termination process being clearly discussed.
1) Unclear termination
Leni: “He had some formula, being psychoanalytically based, that if you were in therapy this number of years, termination equaled that amount of time. And up to a year of termination was the thought. I was feeling like that would be dragging it on, and we discussed the issue … but he said that would not feel like it was a termination. So I had struggled with that sort of wanting to be successful in treatment but yet not being able to afford it and feeling like it just kept going on and on. He wrote me a letter saying that he would be willing [to see me] if I needed anything … and I saw him one or two times. … It was basically that I still had some wish to sort of bring closure more successfully than it had been done.”
Lacey: “I don’t really remember a termination process. I knew when I was going to see her for the last time [that] it would be the last time … but nothing really was said. Actually, I know there wasn’t any [termination process]. I would have remembered that.”
2) Termination process clearly discussed
Simon: “Our schedules were changing. I had kind of gotten to a place where I didn’t feel like I was making any more progress, so I said, ‘Well, this has been real helpful, but I’ve gotten what I needed to get out of this,’ and so we … did go through what felt like a real formal termination.”
Lanette: “There was a winding down. We’d already gone through a winding down emotionally, and he had preferred to see me once a week until the day that I left. … We talked a lot about termination, which was extremely difficult for me, extremely painful.”
Jewell: “It was gradual in that I probably went fairly regularly to her — maybe every other week. Then it got less frequent, sometimes once a month. … And when my family moved, we talked about it, that phase was ending, and that phone contact would be available if I needed it. I’m not sure what to say about termination except that it was pretty clear, pretty gradual: ‘Call me if and when you need to, but you’re doing well and don’t need it.’ So it was seen as an achievement. It actually was not painful. That was really nice.”
Power issues during post-therapy contact
A power differential exists in the therapy relationship. The therapist is there to offer expertise, and the client is there as a customer who pays for the service rendered. Thus, the counselor is seen as having more power in the therapeutic relationship. But what happens to the power differential in the post-therapy relationship? Two participants saw the power within the post-therapy relationship as being more or less equal. The other seven participants described the power differential as remaining unequal, with the therapist continuing to hold more of the power in the relationship and, at times, transference and dependency continuing.
1) Equal power
Simon: “Toward the end, I felt when I left that she was not like the almighty therapist like when I had originally started therapy a number of years ago. When I first started, I used to think, ‘This person’s like next to God or something.’ [Then I] was able to see her as a real genuine person. I think I still do.”
Flo: “Well, now that I think about it, part of getting healed is getting to feel good about yourself. As the relationship progressed and I got better, that [feeling of being equal] would transpire. … I think it was a combination of his trusting me and my expertise and his openness. He told me … some of the things he was dealing with.”
2) Unequal power
Jeg: “I initially saw her as the person with the answers, a person who was going to tell me what to do so I could make it all better. And a lot of times I was real pissed off at her because she didn’t do that, so in that sense, she was a sort of parent figure for a while. And even now, I think that’s why I would probably say we may not ever be friends in the sense as regular friends are.”
Jewell: “I think power differential in the therapy and supervisory relationship of course are there, though she worked very intentionally on not being the all-knowing, all-powerful person. So I would say there was, in a sense, a power differential, however unintentional, [and] I think it’s been a little tricky … to go into more of a mutual, really truly mutual relationship. I think the fact that I have trouble calling her or taking the initiative has to do with the fact that she is about the age of my mother and some of the difficulty of relating to my mom. I assume that she is not going to be really present, even though she always has been. I sort of think, ‘Well, I don’t want to bother her,’ so I think some of that is still there. Do I mention it to her, set it aside and say, ‘This isn’t my mother’? I think there’s a piece of it that is just there and the relationship is just too big of a trigger for it.”
Lacey: “When I go see my family in the summer, they live in the same town. Should I call her and let her know I’m in town? Should I just wait to see if she calls me before I go? Maybe I should just forget it, but then what does that mean? Can I still call her as a therapist or not? It’s kind of confusing. I don’t sit and ponder those thoughts very often. But you better believe, driving to Texas, I’ll think about that a lot, thinking maybe I should call her. I don’t want her to get mad if I don’t call and she knows I’ve been in town. It’s one of those kind of bitchy friendships a little. It’s just confusing.”
Impact of post-therapy contact
We were interested to hear participants’ assessment of the impact of the post-therapy relationship. We identified four themes, ranging from harmful to beneficial.
1) Definite harm: To these former clients, post-therapy contact was extremely confusing. Interactions with former therapists were disorienting and harmful, compromising the work accomplished in therapy.
Lacey: “If I was a counselor, I would never do it. I just kind of think … ‘I wonder if she is going to call? Well, should I call her? Well, I’m just kind of confused. This sucks.’”
2) Possible harm: To these former clients, post-therapy contact was conflicting and confusing. Participants were in post-therapy relationships, yet preferred to be completely done with the therapist and on with life. The former therapist continued to encourage connection.
Leni: “When I got the letter, it felt like I was valued and that I was important, and that felt good. At the same time, it felt like I had to read between the lines. … So, I remember carrying the letter around for a long time [because] that gave me some sense of security. But at the same time, [it was] frustrating because it continually sort of challenged me to call him or not call him … call him or not call him … call him or nor call him. Sort of perseverating on that unfinished feeling.”
3) No benefit, no harm: The post-therapy interactions occurred because of external circumstances.
Simon: “I know she works here on campus, and I have stopped in and seen her. It felt real reassuring just to stop in and say hi and touch base. I did that a couple of times and it was like, ‘I can let this go.’”
4) Beneficial, yet confusing: These former clients initiated the post-therapy contact. Participants talked about the good connection with their therapist. At the same time, their statements at times suggested confusion about the relationship.
Lanette: “I always tell them in our Christmas letter when we’re coming out there. … It’s just kind of nice to lay eyes on them again … see that they’re still walking around, kicking, doing the
Jeg: “The whole experience of working with her I wouldn’t trade for anything. I might put it up there with the most important thing I’ve ever been through. And even now, I think that’s why I would probably say we may not ever be friends in the sense as regular friends are. It is hard for me to completely not have her in that role.”
Jewell: “I don’t want to bother her, and I didn’t know if I would be bothering her or not with that. She said that she wished I would sometimes. That she is an old woman and would welcome it, having that connection. I said, ‘Well, you know you don’t call me.’ She said, ‘I have followed your lead on that part.’ There’s still some of that transition. However, it’s probably been much harder for me than her (laughs). It may sound a little crazy. It is not neat and tidy.”
Standard A.6.e., Nonprofessional Interactions or Relationships (Other Than Sexual or Romantic Interactions or Relationships) of the ACA Code of Ethics states: “Counselors avoid entering into nonprofessional relationships with former clients … when the interaction is potentially harmful to the client. This applies to both in-person and electronic interactions or relationships.”
The central theme inherent in all the interviews we conducted was confusion. Is confusion potentially harmful to former clients? We believe it is. Thus, we suggest if there is the potential for a role change to a nonsexual post-therapeutic relationship, then the potential for confusion should be an ongoing discussion in counseling.
Standard A.6.d., Role Changes in the Professional Relationship, states: “When counselors change a role from the original or most recent contracted relationship … clients must be fully informed of any anticipated consequences … of counselor role changes.” Again, we believe the potential for confusion as a result of changing roles should be a part of this conversation.
Finally, we suggest that all nonclinical, post-therapy contact should be initiated by the client. Standard A.4.b., Personal Values, says, “Counselors are aware of — and avoid imposing — their own values, attitudes, beliefs and behaviors … onto clients, especially when the counselor’s values are inconsistent with the client’s goals …”
If clients want to return to counseling, or to transition from a therapeutic relationship to a friendship, the right and responsibility to renew or reinvent the relationship should be theirs alone. Overcoming the power differential inherent in therapy is tricky. Giving clients the power to decide if and when to pursue a post-therapeutic relationship is but one step in acknowledging their autonomy and effort in becoming happier, healthier people.
We believe counselors seeking therapy would expect nothing less from their own therapists.
Knowledge Share articles are developed from sessions presented at American Counseling Association conferences.
Allison L. Kramer is associate professor and program lead at Johnson & Wales University in Denver. She is a licensed professional counselor and a level-two certified addiction counselor in Colorado. Contact her at email@example.com.
Letters to the editor: firstname.lastname@example.org