Making friends as an adult can be weirdly difficult. So, when you really connect with someone, you might hope that bond blossoms into “I’m definitely texting you all my thoughts during Big Little Lies” friendship. But…what if that person you feel a connection with is your former therapist?
In my time as a psychiatrist on a university campus, I’ve had more than a few patients ask if we can keep in touch on a regular basis after we end our formal therapeutic relationship. I get why. My job is to be a good listener who respects and empathizes with the person sitting across from me. As patient and therapist, we work hard for months, sometimes years. We share deep conversations and maybe even a few laughs. I’m also usually close in age to my patients, as my population of choice is college and graduate students. (Basically, I’ll actually understand a lot of my patients’ pop culture references, Big Little Lies and otherwise.)
Even though I see why some of my patients want to be friends once our sessions are over, I wouldn’t actually let it happen, and neither would most of my peers. Here’s why the prospect of becoming friends with your former therapist is so much more nuanced than “I like you, you like me, let’s hang out.”
There aren’t official guidelines about this for therapists.
You might be wondering if your former therapist would even be allowed to be your friend, given how ethically rigorous the mental health field is. The answer is technically yes, but it’s generally inadvisable. (To be fair, I’m not talking about sending an old therapist an update on how you’re doing every once in a while. Many former therapists very much welcome those updates, me included. I’m talking about being friends friends who really share the ups and downs of life.)
The professional organizations of psychology (the American Psychological Association) and psychiatry (the American Psychiatric Association) offer no explicit rules about friendships with former patients. Their directives about “multiple” or “dual” relationships, as they’re called, explore friendships with current patients (don’t do it), along with sexual relationships with current and former patients (again, don’t do it).
Friendships with former patients are a bit more of a gray area, so I made a few calls for clarification. Dual relationships “are not disallowed as long as the client is not being hurt, [however], most of the psychologists I know would choose not to do it,” David Palmiter, Ph.D., a professor of psychology at Marywood University and fellow of the American Psychological Association, tells SELF.
Rebecca Brendel, M.D., J.D., chair of the American Psychiatric Association ethics committee and director of the Masters of Bioethics Program at Harvard Medical School, had a similar take. “While there is no hard and fast rule … it is important as a psychiatrist to think about anything that could be exploitative of prior or ongoing relationships,” Dr. Brendel tells SELF. “It is not unethical for there to be more than one dimension to a relationship, but the primary focus must always be on the patient’s interest.”
OK, so it’s not expressly forbidden, so why can’t you just make it work? Well, there’s the huge and inconvenient fact that the former patient-therapist relationship is pretty incompatible with the dynamics of a good, healthy friendship.
Therapeutic relationships are grounded in power differentials.
I asked fellow mental health professionals to share their thoughts about being friends with former patients, and wow, did they ever. The consensus? Most who responded to my social media call-outs said they would never even consider it and instead follow the “once a patient, always a patient” rule. That might be disappointing, but hear us out.
“Therapy does have elements that are common to friendship, like positive regard and wanting the other person to do well,” Aditi Ahlawat, Ph.D., a staff psychologist at Washington University in St. Louis, tells SELF. “However, the focus is still on the client and their well-being. There is an intrinsic power difference in a therapeutic relationship that is not an issue in organic friendship.”
In order for therapy to work, you need to be vulnerable enough that your therapist can explore what makes you tick, usually on a much deeper level than you would with a new friend. “We are privileged to the most intimate details of other humans’ lives,” Erin Fulchiero, M.D., a psychiatrist at Case Western Reserve University, tells SELF. Meanwhile, your therapist is keeping all of their dark and twisty personal stuff to themselves, not expecting much more from you than payment, showing up on time, and being willing to work. You spill your soul to them, and they respond from a professional distance.
This is an inherently imbalanced power dynamic that, in the vast majority of cases, can’t easily translate into a balanced, healthy friendship—even after you’re done with therapy, even if you only saw them a few times, even if you were seeing them for something that seemed pretty minor, or whatever the case may be.
Also, it could be really hard for them to shake a feeling of duty to you that would go beyond a typical friend’s. “I would always feel obligated,” Anna Borisovskaya, M.D., a psychiatrist from the University of Washington, tells SELF. “I would have to respond to every worrisome status post on Facebook. I would have to worry if I didn’t call them often enough—they might take it as a rejection on a variety of levels.”
On the flip side, if your former therapist were a friend, your gratitude and admiration could make it hard to stand up to them, say no to a favor they ask, or weigh in honestly about their life.
Therapy is also meant to have a beginning, middle, and end.
That’s generally speaking, of course. But in most cases, the goal is to end therapy so the patient learns how to process loss in a healthy way. Many patients start treatment to deal with some type of loss in the first place. Ending the therapeutic relationship properly can allow them to practice coping with fresh loss with the new skills they’ve learned. Even if you’re not in therapy to deal with loss, having a practice run for handling it can always be helpful in the future.
Beyond that, ending your relationship with your therapist when you’re ready can bolster your self-confidence. You might realize that, wow, you’ve actually poured a ton of work into this process and don’t need the constant presence of your therapist in order to achieve happiness or success. Keeping your therapist around as a friend wouldn’t allow you the distance to come to that realization. And, over time, that distance might help you realize your warm and fuzzies about that therapist weren’t even fully about them.
Transference can blur your feelings about your therapist.
Transference happens when you unconsciously redirect feelings about someone else, typically someone from your childhood, to your therapist. These can be positive or negative feelings, but the positive ones might help explain why you’re itching to invite a former therapist to happy hour.
For example, you might really like the way your therapist interacts with you because, without you realizing it, she reminds you of your mother. Or maybe you get easily annoyed at the way your therapist asks questions because…again, she reminds you of your mother.
Therapists can also redirect their unconscious feelings about someone else onto their patients, which is called countertransference. In “positive” countertransference relationships, a therapist might really like you and have the desire to be overly supportive, share more about themselves than they should, or break boundaries to support you in some way. The thing is that, as professionals, we’re trained to identify these feelings for what they are and still maintain therapeutic boundaries. Without training, you can’t as easily figure out how much of you liking your therapist is actually about them.
This isn’t to say there’s no way you like a therapist or former therapist for who you perceive them to be. (Because, remember, they’re probably getting your most authentic self and you’re getting them at work.) But it can be harder for a patient to know the difference between genuinely liking a therapist and transference.
Also, you may eventually need your therapist again.
Your mental health will ebb and flow throughout your life, so you might benefit from therapy again at some point in the future. Between how difficult it can be to find a new therapist and how exhausting it can be to brief them on your whole life story, going back to an effective former therapist can be a great option when possible.
“Every week, I have at least one patient who wants to re-enter treatment with me,” Naureen Attiullah, M.D., clinical associate professor in the department of psychiatry and human behavior at The Alpert Medical School at Brown University, tells SELF. Becoming close friends with a former therapist would pretty quickly make them off-limits for future treatment.
As always, there are some exceptions.
In general, yes, it’s best to keep your friends and former therapists in separate categories. But sometimes it’s not always that easy.
My social media call-out opened my eyes to a few special cases of unavoidable dual relationships. They all hinge on running into each other a lot socially. Early on in your therapy sessions, it’s always smart for you or your therapist to bring up what you’ll do in these situations—do you ignore them, do you casually acknowledge them, or do you actually stop to talk to them? If you agree that you’re both comfortable engaging in conversation when you run into each other, you might start wanting to be friends in situations like these, especially after you stop your therapy sessions:
- There’s only one therapist in your tiny, rural town who takes your insurance, so you’re inevitably going to be in social situations with them at some point.
- You’re a mental health professional yourself, so you turn to a colleague or someone in your network for therapy, meaning you see them a lot at work or work functions.
- Your child or teenager is in therapy and you hit it off with their therapist. This can still be a difficult boundary, but child and adolescent mental health professionals can be scarce in some areas, and this dual relationship can feel more ethical since you’re not technically the patient.
- You’re seeing a therapist who shares an important facet of your identity, like being of the same race, religion, culture, or ethnicity, so you may run into them at a lot of those community events.
In these kinds of situations, it’s completely natural to want to be friends with a former therapist. This is always going to be case by case, but it will unfortunately most often make sense for a former therapist and patient to keep any friendliness pretty surface-level. Ultimately, as Palmiter notes, “It is easier to find a good friend than a good therapist.” I would have to agree with that one.
Jessica A. Gold, M.D., M.S., is an assistant professor in the department of psychiatry at Washington University in St Louis. Find her on Twitter @drjessigold.