Navigating confidentiality when former client wants to join your friend group

[truthtopower]

Let's suppose you are in the following hypothetical situation. How would you handle this?

I have a lovely group of friends.

One of them (let's call her "Susan") has come into contact with a former patient of mine (let's call him "John").

My friend ("Susan") is considering inviting ("John") to our friend group. "Susan" does not know that "John" was my former patient.

"Susan", however, is aware that "John" knows me.

"John" has told "Susan" that he and I were previously "colleagues" -- and that this is how he and I know each other.

(He was my patient; he was not my colleague.)

"Susan" has, separately, asked me in casual conversation how I know "John" -- and asked me how I would feel about "John" joining our friend group.

I did not tell "Susan" how I knew "John" and avoided her question.

She asked if she could invite him into our friend group and I felt some reluctance to have him join or friend group, because of our prior therapist-patient relationship -- it would just make things a bit more complicated.

However, I also don't feel like I can disclose this information to "Susan" because it violates my ethical responsibility to confidentiality.

Any thoughts would be very welcome! Thanks!

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[SomeGreatNotion]

Thus far, I think you are navigating this quite well. That you are not overwhelmingly endorsing the former client's entry into the friend group should allow Susan to register your reluctance without it being made explicit. In these situations, I think it common to operate off of a "you first" principle; "John" needs to disclose the relationship first before you can acknowledge it. If asked explicitly by Susan, refer to John's explanation. I'm not sure there is much else you can do.

How long ago was "John" a patient? Not that it changes anything but more recent I think would increase my discomfort.

 

[WisNeuro]

Either way, I would do a quick consult with liability carrier's ethics line and/or state board ethics consult and document just to have that paper trailed laid out.

 

[Sanman]

How long ago was John your patient? What was the duration of the professional relationship?

If it was more than two years ago, APA ethics code allows for romantic relationships after this period. So, from a professional perspective letting someone into a friend group after this point certainly would meet the most basic of ethical standards. However, this would also depend on the answers to the questions above.

Either way, I would consider contacting John and making him aware that you cannot see him in a professional context in the future if you would be in the same social circle. I would also discuss how he would like to proceed regarding confidentiality (colleague story?). I would document this in some way in case there are problems in the future.

 

[BuckeyeLove]

APA ethics code allows for romantic relationships after this period.

This legit always astounds me. Like where did they get that number? It's so weird to me that someone would even entertain the notion of doing this, so the fact that they had to put a timeframe on it clearly shows it has been (and apparently always will be) an issue. I know it's still like the number one board complaint issue.

 

[MCParent]

Like where did they get that number?

it’s probably the min length of time the people writing the policy at APA had between seeing someone as a patient and dating them.

 

[MCParent]

There’s a big subfield of professional ethics, small world ethics, that addresses this and even more complex things. Eg you are a psych in a small town and see a teacher at the school. Your kid is about to enter that teacher’s grade. You don’t have to bus your kid an hour to go to a different school.

Also worth noting that the ethics code doesn’t forbid dual relationships. We have dual relationships with most people (eg therapeutic and financial). The ethics code warns about *problematic* dual relationships. The distinction is important; I’ve had grad students who lost their minds when they realized they were in the checkout line at the grocery store where their former patient was bagging customer food.

 

[ClinicalABA]

If it does work out that he is in your group, you might want to reach out to him to let him know that you will/have to respect his privacy regarding your previous relationship. I'd also address the extent of the "ruse" regarding you guys being "colleagues" as that puts you in a position of being deceitful with your friends. He's already felt the need to be untruthful about your relationship, so clearly he has concerns.

What is the nature of this friends group? Is it IRL, or purely online? Online or occasional get together is a different beast than regularly get together/get drunk/get high. Also important is the nature of your clinical relationship and presenting issues- how difficult will it be for you to not use or consider privileged information in your "friend group" relationship?

 

[AcronymAllergy]

There’s a big subfield of professional ethics, small world ethics, that addresses this and even more complex things. Eg you are a psych in a small town and see a teacher at the school. Your kid is about to enter that teacher’s grade. You don’t have to bus your kid an hour to go to a different school.

Also worth noting that the ethics code doesn’t forbid dual relationships. We have dual relationships with most people (eg therapeutic and financial). The ethics code warns about *problematic* dual relationships. The distinction is important; I’ve had grad students who lost their minds when they realized they were in the checkout line at the grocery store where their former patient was bagging customer food.

This is an important point. This exact wording (3.05) is:

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 as a psychologist, or otherwise risks exploitation or harm to the person with whom the professional relationship exists.

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

I agree with the suggestions above, including to potentially have a private discussion with the former client, and reaching out to your malpractice/liability carrier for a consult (or even your state psych association, if you're a member and they offer that service). IMO, it also matters that the former client is the one actively choosing to enter the friend group knowing you're already a member, as opposed to you being the one to reach out to them. I don't think it's reasonable to automatically expect a psychologist to uproot their life because a former client chooses to become a part of some aspect of their non-professional sphere. Imagine how that could play out with a potentially vindictive former client, for example.

 

[MCParent]

I don't think it's reasonable to automatically expect a psychologist to uproot their life because a former client chooses to become a part of some aspect of their non-professional sphere.

I’ve seen students and trainers who do seem to think this. This (I’d say mostly totally inconsequential) overlap happens really often in college towns where trainees work at the campus counseling center (as well as psychs working at a military base, border town, etc etc). It’s compounded for people with minoritized identities in smaller places, where their clinical interest population, research interest population, and friend/possible dating groups might be even more prone to overlap. When I was in grad school there was a trainee who exhibited mild psychic shock that a former patient was in the same yoga class as them, and the advice they got from a trainer was to quit yoga (or maybe to pay a ton to do private yoga, I forget now). I think that’s ridiculous.

In the original post, context matters. If the clinical issue was that the client was having sex with as many people as possible while not disclosing their untreated HIV+ status, that’s pretty different from you doing a WAIS as part of their ADHD battery. Part of a thorough understanding of ethics is grasping that there aren’t clear rules to apply to everything all the time.

I do a super fun ethics talk on navigation of dating apps for grad students that touches on this topic, fyi
Based on this paper: https://www.researchgate.net/public...d_health_service_psychology_graduate_students

 

[PsyDr]

“I can’t talk about that”

Repeat anytime someone asks a related question.

 

[cara susanna]

I've done a LOT of trainings on dual relationships lately for licensure CEUs, and generally the question to ask is: who stands to benefit from the relationship? Basically, you don't want the answer to be "me," lol. You also want to consider potential harm to the (former) patient.

 

[Shiori]

I've done a LOT of trainings on dual relationships lately for licensure CEUs, and generally the question to ask is: who stands to benefit from the relationship? Basically, you don't want the answer to be "me," lol. You also want to consider potential harm to the (former) patient.

TMS has a pretty good one for VA folks!

 

[cara susanna]

TMS has a pretty good one for VA folks!

I did all of the ones on TMS, lol

 

[ccpsych16]

.When I was in grad school there was a trainee who exhibited mild psychic shock that a former patient was in the same yoga class as them, and the advice they got from a trainer was to quit yoga (or maybe to pay a ton to do private yoga, I forget now). I think that’s ridiculous.

From what I remember, the most “correct” answer would be for the psychologist to remove themselves from the yoga class. This came up during EPPP practice in grad school (I think we reviewed retired questions). If that was an answer choice, that was the “correct” one EPPP was looking for. I think that’s ridiculous, too.


In the OP’s example, I personally would be pondering a way to say NO to my friend. I would also be weirded out with a client knowing I’m in this friend group and still pursuing it. Context matters as far as what *kind* of group it is, but I wouldn’t want a former client in ANY of my friend groups. Way too close for comfort. The average age of my clients is significantly older than me, so I haven’t had to worry about yet.

 

[MCParent]

From what I remember, the most “correct” answer would be for the psychologist to remove themselves from the yoga class. This came up during EPPP practice in grad school (I think we reviewed retired questions). If that was an answer choice, that was the “correct” one EPPP was looking for. I think that’s ridiculous, too.

You ever been to one of the big ethics seminars at APA? Let’s just say it won’t instill faith in your supposed peers.

 

[ccpsych16]

You ever been to one of the big ethics seminars at APA? Let’s just say it won’t instill faith in your supposed peers.

I haven’t, but now I’m morbidly curious

 

[foreverbull]

The LGBT community is small in my area, and well, as a therapist who sees mostly LGBT clients......you see how this might go, and that's just ONE area of overlap in a small town. Another example is when therapists live near clients and see them on walks, etc. If you join community groups in a small community, you'll experience this overlap very quickly. My grad program taught me to be terrified of this and pull out of every community group/group situation just to avoid this happening (i.e. extreme response), much like @MCParent is saying. That said, we don't HAVE to leave advocacy groups or social interest groups we belong to just because a former or even present client decides they suddenly want to be a part of them. It depends on the situation. Generally a good rule is to keep distance as much as possible, and if the person is a current client, discuss boundaries clearly in session to minimize confusion and minimize contact in public spheres. We also have a right to live our lives and I don't think it's fair to be expected to have to leave all groups and shy away from our communities because of one person or the possibility of one person becoming involved in those areas.

In your case, OP, some lying was involved on the case of the former client, which has set up a really weird situation that made it much harder to navigate, because if Susan knew the truth from John, she'd back off of inviting him to the friend group and the problem would be resolved. I'd tell Susan to talk to John if she asks and repeat it as needed--Susan may glean what that means if she's savvy to therapy ethics, but that's not the therapist's problem. Then, if John reaches out to the therapist about the situation, boundaries can be discussed openly, but I agree with @ClinicalABA that this might be a situation in which it's okay to contact a former client to discuss boundaries and get stories straight, especially because it's the therapist's friend circle Susan is trying to invite a former client into. I would make sure to document WHY that was necessary from an ethics standpoint (i.e. clarification of roles/boundaries to avoid harm, perhaps?).

As others have said, context also matters quite a bit--these are just general thoughts.

 

[MCParent]

The LGBT community is small in my area, and well, as a therapist who sees mostly LGBT clients......you see how this might go, and that's just ONE area of overlap in a small town. Another example is when therapists live near clients and see them on walks, etc. If you join community groups in a small community, you'll experience this overlap very quickly. My grad program taught me to be terrified of this and pull out of every community group/group situation just to avoid this happening (i.e. extreme response), much like @MCParent is saying. That said, we don't HAVE to leave advocacy groups or social interest groups we belong to just because a former or even present client decides they suddenly want to be a part of them. It depends on the situation. Generally a good rule is to keep distance as much as possible, and if the person is a current client, discuss boundaries clearly in session to minimize confusion and minimize contact in public spheres. We also have a right to live our lives and I don't think it's fair to be expected to have to leave all groups and shy away from our communities because of one person or the possibility of one person becoming involved in those areas.

In your case, OP, some lying was involved on the case of the former client, which has set up a really weird situation that made it much harder to navigate, because if Susan knew the truth from John, she'd back off of inviting him to the friend group and the problem would be resolved. I'd tell Susan to talk to John if she asks and repeat it as needed--Susan may glean what that means if she's savvy to therapy ethics, but that's not the therapist's problem. Then, if John reaches out to the therapist about the situation, boundaries can be discussed openly, but I agree with @ClinicalABA that this might be a situation in which it's okay to contact a former client to discuss boundaries and get stories straight, especially because it's the therapist's friend circle Susan is trying to invite a former client into. I would make sure to document WHY that was necessary from an ethics standpoint (i.e. clarification of roles/boundaries to avoid harm, perhaps?).

As others have said, context also matters quite a bit--these are just general thoughts.

I always told me trainees to start first sessions with covering what happens if we see each other in public & what happens if social circles overlap, also a good time to cover social media policies (wont friend/follow clients). Way easier to handle all these things before they happen.