By: John A. Riolo, Ph.D.
If you’re in a partnership, you can dissolve it. In a committed relationship, you can break up and go separate ways. You can divorce your spouse and start fresh. However, does your client ever stop being your client, no matter how much time has elapsed since the end of treatment? Ask your colleagues and co-workers, and see what they say. Many, if not most, will tell you “once a client, always a client.” Some might go so far as to say that treatment doesn’t actually end after you stop seeing the client, but continues perhaps indefinitely. This way of thinking is intended to be protective of clients and can help prevent various kinds of abuses, up to and including taking advantage of clients sexually. Among students, senior clinicians, and many faculty, this is a near universal opinion. To challenge it can bring some negative reactions from peers.
But is it a valid premise? Is it always helpful to think that way?
Before you read further, let me be absolutely clear. In no way am I supporting or encouraging any activity with a client or former client that would be exploitive. This includes sexual relations with clients, as well as any situation in which we exert undue influence over a client for our own benefit.
The issue here is whether or not the therapist/client relationship truly lasts in perpetuity. And if so, what are the logical ramifications or consequences? If, in fact, “once a client, always a client,” then we would run into some interesting situations that create ethical dilemmas with no easy solutions. In small rural communities, this situation would be more acute, but the principle would be the same in big cities, too.
Imagine these scenarios: You are interested in politics in your community and decide to run for school board. You find out a former client has also announced his or her candidacy. Do you campaign against your former client, or withdraw because it would be a conflict?
Our clients are often free to join many, if not most, of the organizations where we are members. Do we withdraw if they join our groups? Do we bar their membership if we can? This could include online networks, as well.
You provide therapy to a child. Ten, fifteen, or more years later, that patient becomes a prominent, top in their field, attorney, surgeon, or other highly specialized professional. You discover that you need someone with those highly specialized qualifications. If the client is still a client even after all those years of no contact, is that a conflict of interest and a prohibited dual relationship? If it is an issue of power, who is in the position of power? Is power in any relationship always static, or is it variable and subject to change based on the circumstances?
Dual or Sequential Relationship
When a therapist and client enter into a relationship that is outside of or in addition to the therapeutic relationship, it is generally referred to as a dual relationship. Dual relationships are discouraged by most professional organizations. However, not all experts in the field believe that all dual relationships are necessarily harmful. It would depend on the context. (See Dual Relationships and Psychotherapy, edited by Lazarus and Zur, [2002]).
However, when a therapist and long past patient enter into a relationship separate from the therapeutic one, is that actually a dual relationship? Would it be more accurate to call it a sequential or serial relationship? Is there a difference? If one believes that our patients grow mature and sometimes surpass us in knowledge, wisdom, and power, then it is a significant difference. However, if one truly believes “once a client, always a client” and that clients are always dependent on us, then “former clients” would mean a distinction without a difference.
Of course, of all the dual or sequential relationships that are potentially possible with patients and former patients, when the issue of sex comes up, most all therapists of all disciplines react forcefully. Having sex with a current patient or even a recently discharged patient is not only unethical—it is illegal. It is truly a betrayal of the trust the patient places in us. However, over time (as in years), can that change in some very special circumstances to allow exceptions to the rule?
If a therapist and former patient meet some 10 or 15 years after the last therapeutic session and develop a personal relationship, get married, and have children, can we say that an ethical violation or a crime has been committed? If we believe “once a client, always a client,” then that logically follows. However, our ethical codes don’t go that far, for good reason.
The American Psychological Association Code of Ethics, Section 10.05, states that psychologists do not engage in sexual intimacies with current therapy clients/patients. The American Counseling Association Code of Ethics, Section A.5.b, prohibits intimate relations for five years. The NASW Code of Ethics, Section 1.09(a), prohibits social workers from engaging in “sexual activities or sexual contact with current clients, whether such contact is consensual or forced.” Section 1.09(c) states that “social workers should not engage in sexual activities or sexual contact with former clients because of the potential for harm to the client.” However, it further states, “If social workers engage in conduct contrary to this prohibition or claim that an exception to this prohibition is warranted because of extraordinary circumstances, it is social workers—not their clients—who assume the full burden of demonstrating that the former client has not been exploited, coerced, or manipulated, intentionally or unintentionally.” Of course, this would be a difficult—if not impossible—burden to meet if it came before an ethics committee. Nonetheless, it leaves open the possibility, as rare as it may be, and does not claim that “once a client, always a client.”
In most all states, laws prohibiting sex with clients are limited to current or recent clients. Washington State is one exception. However, assuming the former client does not file any complaint, how enforceable would such laws be? For example, what if the former therapist and patient got married, were in a committed relationship, and had children? Would or should an ethics committee have the authority to interfere with a marriage or union among consenting adults? What about our belief in the right to free association?
What is the rationale for the prohibition against sex with patients? Many believe it is the power differential. However, Dr. Stephen Behnke, APA Ethics Director (2006), says otherwise. Behnke points out that many relationships have significant power differentials, including partnerships and marriages, and that we often do in fact put our own interests above those of clients when we charge fees, for example. So, neither a power differential nor putting our own needs first is in and of itself unethical. Rather, Behnke says, it is because we have a fiduciary relationship that is compromised and creates additional risks that are not a necessary part of the therapeutic relationship, making psychotherapy impossible. But fiduciary relationships are not static and change with time and circumstances. What makes the therapist/client fiduciary relationship any different from any other fiduciary relationship?
So, how did so many of us come to the belief that “once a client, always a client” and that virtually all dual relationships are harmful? Some would argue it is based on psychodynamic theory, and perhaps those who practice psychoanalytically have a higher standard. But interestingly, there is nothing in psychodynamic theory or psychoanalysis that would state such. In fact, as Fredric Reamer points out in his book Tangled Relationships, Freud himself and other early founders of modern psychotherapy engaged in behaviors that by today’s standards would be unthinkable and could result in ethical charges. This would include taking patients on vacation and conducting analysis in hotel room beds. Many clinicians are shocked and dismayed to learn that people we revere and respect would have acted in a way that would be unthinkable by today’s standards. We tend to forget that that was a different time with different standards. Therefore, perhaps, our reactions could possibly be a way of denying and reacting against the behaviors of a previous era we find frankly embarrassing and indefensible.
Another possibility is that, whereas all of us require structure of some kind, some of us need more structure and clear inflexible rules more than others. Some fear that if they bend the rules just a little, they may go down a slippery slope and cross all reasonable bounds. To therapists who believe they are just one rigid rule away from harming their patients, I say maintain all the rules you need. However, not everyone requires such inflexibility. Attempting to impose such rigidity on everyone is not good practice. It is not good for our clients or the field.
Although many therapists across disciplines will hold onto the view that “once a client, always a client,” it is not without serious unintended negative consequences. If we hold that belief to be literally true, then it would not apply only to sex. We are responsible to protect our clients from harm to self and others. But if we make no distinction between current and long past, can we in this litigious society be sued for the actions of a long past client?
Perhaps the strongest argument against the “once a client, always a client” notion that many of us have is that it does not conform to reality and it infantilizes our clients. Our clients grow mature and often leave us behind. If we do our jobs well, we have given them the tools to move on. It is unrealistic to think that, after several years, we mean the same to them as when they came to us for help. It is not like a parent/child relationship, although even in a parent/child relationship, roles often equalize and even reverse. It is more like a mentor/mentee relationship, in which one expects in time that the mentee will catch up to, and perhaps even surpass, the mentor.
References
Behnke, S. (2006, June). The discipline of ethics and the prohibition against becoming sexually involved with patients. APA Monitor, 37 (6). Retrieved online at http://www.apa.org/monitor/jun06/ethics.aspx.
Lazarus, A. A., & Zur, O. (Eds.). (2002).
Dual relationships and psychotherapy. New York: Springer.
John A. Riolo, Ph.D., is a retired private practitioner who operates a number of educational Web sites and blogs on mental health issues. His Web sites include Civil Discourse Blog, The Insider, Your Advocate Online, Law and Ethics in Mental Health, and Listen to the Insider Podcast Series.