Treating a former student: A dual relationship?

[compassionate1]

---

Members don't see this ad.

I am in a unique situation and would appreciate advice : I am currently a PhD student / teaching fellow in a research psychology program. However, I am also a licensed mental health counselor ( completed MHC program, plus completed all post graduate clinical hours and passed the licensing exam in my state).

A year ago, a student who had just taken one of my courses contacted me via email and asked if I would see him / her as a client. I explained that there may be a conflict of interests involved and referred elsewhere. I just recieved another email from the same student requesting, again, that I take him / her on as client.

Here is my question: I am aware of several professors in my university who do see former students but I do not know whether this is legal and/or ethical. I wonder if it makes a difference that a year had passed, and whether or not the student has graduated since ( Hence, no possibility of taking another course I am teaching, passing each other in the hallways etc).

I appreciate your thoughts and guidance,

Thanks,

Compassionate1

 

[EmotRegulation]

I personally feel that this direction (student to client) is much less of a problem than the other way around (client to student).

There's nothing illegal about this arrangement....but most of psychotherapy ethics don't have anything to do with legality. I personally wouldn't have a problem seeing a former student as a therapy client if it were completely clear up front that by entering into this arrangement, the client should not sign up for any of my courses and if he/she were to do so (since I can't technically stop anyone enrolling in my classes) we'd likely have to terminate the therapy relationship. I'd also set some clear guidelines about how you would interact with the person (e.g., let him/her greet you first) if you ran into each other in the hallways.

 

[CheetahGirl]

This would be experienced as a dual role and I would transfer the client to someone new. There was already a power differential established, not in favor of the client, and from this, it would be difficult to move past (i.e., the elephant in the room).

IMO it would be unethical.

 

[compassionate1]

I personally feel that this direction (student to client) is much less of a problem than the other way around (client to student).

There's nothing illegal about this arrangement....but most of psychotherapy ethics don't have anything to do with legality. I personally wouldn't have a problem seeing a former student as a therapy client if it were completely clear up front that by entering into this arrangement, the client should not sign up for any of my courses and if he/she were to do so (since I can't technically stop anyone enrolling in my classes) we'd likely have to terminate the therapy relationship. I'd also set some clear guidelines about how you would interact with the person (e.g., let him/her greet you first) if you ran into each other in the hallways.

Thanks for your input, EmotRegulation. I don't think the code of ethics covers this particular situation so perhaps it is a matter of comfort level and what feels right? I was also wondering about one direction vs. the other ( Student - > client vs client - > student). And yes, also thinking about the possibility of a student signing up for my class without my knowledge. Having a student who was previously a client would inevitably impact the instructor - student relationship. I think finding out that she / he had graduated would alleviate some of my concerns. Another area to consider is whether the terms of university employment / fellowship have any rules about this, so that even if it is OK from the clinical aspect, perhaps it is still problematic from that other end. I contacted some people in academia but received mixed answers ( and some absence of responses as well which may indicate that this is a grey area that not everyone is willing to openly discuss and disclose their own practices...)

 

[Therapist4Chnge]

Unless this was in a place w very limited services (i.e. no other providers in the area) I would pass on the case. There are too many (admittedly mostly minor) issues that may present.

 

[compassionate1]

This would be experienced as a dual role and I would transfer the client to someone new. There was already a power differential established, not in favor of the client, and from this, it would be difficult to move past (i.e., the elephant in the room).

IMO it would be unethical.

Cheetah, I definitely hear you about the power differential. It just so happens that the person was a strong student and we had a very pleasant relationship. And yet -- it is still a power differential, and something to think about.

 

[CheetahGirl]

I will PM you b/c my terse response comes from personal client experience and much practicum discussion about this case.

Cheetah, I definitely hear you about the power differential. It just so happens that the person was a strong student and we had a very pleasant relationship. And yet -- it is still a power differential, and something to think about.

 

[compassionate1]

Unless this was in a place w very limited services (i.e. no other providers in the area) I would pass on the case. There are too many (admittedly mostly minor) issues that may present.

Therapist4change. I was considering this fact that she / he could have contacted any other therapist, and there are plenty of clinics where I live as well. Yet, the fact that the student was seeking me out, in particular, and had felt a certain connection had meant something to me. And also that he / she was not deterred by my first refusal, and had waited a year to contact me again. This could be the beginning of a wonderful therapeutic alliance ( or transference...)

 

[compassionate1]

I will PM you b/c my terse response comes from personal client experience and much practicum discussion about this case.

Thanks very much ( and I did not experience your response as "terse" -- at least not in the negative sense of the word.).

 

[Ollie123]

Therapist4change. I was considering this fact that she / he could have contacted any other therapist, and there are plenty of clinics where I live as well. Yet, the fact that the student was seeking me out, in particular, and had felt a certain connection had meant something to me. And also that he / she was not deterred by my first refusal, and had waited a year to contact me again. This could be the beginning of a wonderful therapeutic alliance ( or transference...)

The latter is what worries me. The context (waiting a year and still emailing you) suggests to me this person already formed some sort of relationship with you based on your teaching. To me, it would actually raise a huge red flag if a person asked once, I explained I can't and refer them elsewhere and they come back and ask me again a full year later. A therapeutic alliance is not synonymous with "We like each other and get along" so I think anytime you are trying to build one from a prior relationship of any kind it is going to be murky. However, there is always going to be some grey area with these sort of things (otherwise its not really ethics by definition). I agree that student > client would be somewhat less worrisome to me than client > student. I do also think it somewhat depends on the nature of the class (TA for a 400 person class and you had no idea who they were beyond a name in the books vs. a small discussion-based seminar), though its not like its "fine" in either circumstance.

I don't think there is a right or wrong answer in this circumstance - in some communities it is unavoidable but that doesn't make it ideal (and it doesn't sound like the case here). If you do pursue it, I would proceed very cautiously at first (i.e. we can meet in a VERY time-limited manner to see if I'm the right therapist for you), consult with others about it and perhaps even speak with an ethics board to get advice on how to proceed. Were it me, I'd likely refer elsewhere but I'd strongly urge proceeding cautiously if you do not.

 

[compassionate1]

Thank you, Ollie. I certainly hear your concern. Although there may have been another reason ( for contacting me again after a year): Perhaps the person had already tried another clinician and was dissatisfied for whatever reason. She / he then recalled that she / he took a class with a professor they appreciated, and decided to check in again to see if something had changed ( perhaps due to passage of time which would make it less of a conflict).

Having said all of that, I do realize I may have a blind spot right here, and that it is a somewhat of a nice ego stroke, as surely -- he / she can do well with another therapist as well. And especially since I have primarily seen clients in a clinic setting, and this would be a private client -- probably not wise to start a private practice on murky grounds... Thanks everyone.

 

[Ollie123]

A red flag does not definitively mean the worst possible scenario...just that there is enough evidence that you should probably be thinking twice about something. The situation you describe is entirely possible...its just a BIG question you don't have any way of knowing at this point and jumping into therapy without that knowledge would be a risk for the client, hence my recommendation. Agree though that particularly if this would be your first "private" client, its probably not the best way to get started.

 

[testifeye]

While the issue of legality is probably based on state statutes that you can look up, it's clear that there's an ethical issue at play. There are definitely dual roles between you and the potential patient. What if they ever needed a letter of recommendation based on their performance in the class, but now you are their therapist? I think that it is our job as psychologists/clinicians to take on ethical responsibility *beyond* the letter of the law and *for the benefit of the client, not for our own benefit*. In your posts you communicate a feeling of specialness that this person has decided that they like *you* and want to work with *you* despite your initial push to refer him/her to another provider. They want *you* even though there are many other competent providers available in the area. To me, your posts sound like you want to work with this person, at least in part, because of this potential special connection.

I think that the feeling of specialness we get when a client likes us/wants us has the potential to cloud our judgment. You clearly have doubts about this decision or you wouldn't have posted on this forum to get feedback. That's a good sign - it means in your gut you had a reaction to moving forward without question. Some part of you thought something could be wrong and you knew to ask others. That is a good thing, and a sign of an ethical provider.

My inclination is that unless there is imminent need (i.e., person must have care immediately or you're located somewhere that dual roles are impossible to avoid at the cost of not providing care) you should avoid the dual role. Why take a risk ethically? Why start a therapeutic relationship without solid boundaries?

What are you communicating to the patient when you start the relationship by making an exception for them? You communicate to them that they are special, and different, and because they wanted *you* that you bent your rules and this sets a precedent. It means that when you say no, you don't really mean it if the patient persists. In therapy it's so important for us to model solid boundaries, especially if the patient doesn't always have them. In this case, s/he pursued you even after you sent appropriate messages refusing to treat them, and provided them with resources to meet their needs.

It's unlikely anyone will sue you over this, and you can probably go ahead and choose to take the patient and maybe nothing bad will happen. Maybe it will even be a useful and functional therapeutic relationship. Based on your posts and the information you disclosed, I can't see any important reason that you should take on the case, and you do communicate many reasons why you shouldn't.

 

[CogNeuroGuy]

Just curious...if this former student of yours ends up becoming your client, what would prevent them from recommending this same avenue to their classmates/friends? I would think that this could be a can of worms that could potentially spiral in that direction.

 

[compassionate1]

While the issue of legality is probably based on state statutes that you can look up, it's clear that there's an ethical issue at play. There are definitely dual roles between you and the potential patient. What if they ever needed a letter of recommendation based on their performance in the class, but now you are their therapist? I think that it is our job as psychologists/clinicians to take on ethical responsibility *beyond* the letter of the law and *for the benefit of the client, not for our own benefit*. In your posts you communicate a feeling of specialness that this person has decided that they like *you* and want to work with *you* despite your initial push to refer him/her to another provider. They want *you* even though there are many other competent providers available in the area. To me, your posts sound like you want to work with this person, at least in part, because of this potential special connection.

I think that the feeling of specialness we get when a client likes us/wants us has the potential to cloud our judgment. You clearly have doubts about this decision or you wouldn't have posted on this forum to get feedback. That's a good sign - it means in your gut you had a reaction to moving forward without question. Some part of you thought something could be wrong and you knew to ask others. That is a good thing, and a sign of an ethical provider.

My inclination is that unless there is imminent need (i.e., person must have care immediately or you're located somewhere that dual roles are impossible to avoid at the cost of not providing care) you should avoid the dual role. Why take a risk ethically? Why start a therapeutic relationship without solid boundaries?

What are you communicating to the patient when you start the relationship by making an exception for them? You communicate to them that they are special, and different, and because they wanted *you* that you bent your rules and this sets a precedent. It means that when you say no, you don't really mean it if the patient persists. In therapy it's so important for us to model solid boundaries, especially if the patient doesn't always have them. In this case, s/he pursued you even after you sent appropriate messages refusing to treat them, and provided them with resources to meet their needs.

It's unlikely anyone will sue you over this, and you can probably go ahead and choose to take the patient and maybe nothing bad will happen. Maybe it will even be a useful and functional therapeutic relationship. Based on your posts and the information you disclosed, I can't see any important reason that you should take on the case, and you do communicate many reasons why you shouldn't.

Hello, Testifeye. Thank you for your very thoughtful response. I agree that there may be a "specialness" trap here. And as I wrote in my response to Ollie, I am wary of the (perceived) flattery involved -- and especially as a relatively new therapist, and I do not wish to fall into that. I do want it to always be first and foremost about my patients, and perhaps I am kidding myself when I am thinking that it is about this person primarily, and that it would be in her / his interest to see me since they feel a connection, and that it would be a missed opportunity if he / she does not. Without disclosing details on this individual, I think that my attraction to this case is that the person appeared stable, insightful and highly functioning -- someone who strived for meaning and self - growth. This is a profile of the client load I would love to have in my private practice. However, this discussion with all of you has helped me realize that I want to do things the right way, and starting a private practice working with a client with whom I already have some ethical dilemma is probably not the way to go. So now, taking care of things as I still have to answer back to this student: I do not currently have a specific clinician I feel comfortable referring people to. Is it sufficient to refer the student to the school's counseling center as they can provide further referrals? Thanks again.

 

[testifeye]

Hello, Testifeye. Thank you for your very thoughtful response. I agree that there may be a "specialness" trap here. And as I wrote in my response to Ollie, I am wary of the (perceived) flattery involved -- and especially as a relatively new therapist, and I do not wish to fall into that. I do want it to always be first and foremost about my patients, and perhaps I am kidding myself when I am thinking that it is about this person primarily, and that it would be in her / his interest to see me since they feel a connection, and that it would be a missed opportunity if he / she does not. Without disclosing details on this individual, I think that my attraction to this case is that the person appeared stable, insightful and highly functioning -- someone who strived for meaning and self - growth. This is a profile of the client load I would love to have in my private practice. However, this discussion with all of you has helped me realize that I want to do things the right way, and starting a private practice working with a client with whom I already have some ethical dilemma is probably not the way to go. So now, taking care of things as I still have to answer back to this student: I do not currently have a specific clinician I feel comfortable referring people to. Is it sufficient to refer the student to the school's counseling center as they can provide further referrals? Thanks again.

I think it's great that you're opting toward not taking on this patient as your first in a new practice that you are building. In terms of referral, I don't think you need to have a specific person to refer him/her to - as long as you have the school counseling center, and perhaps a county help line - I think that is sufficient. I'm unaware of laws or ethical policies that require you to refer to a specific known provider.

In my job I work with a specialized population, so perhaps this is just my bias - but having someone stable, insightful, and highly functional as a patient is atypical for my caseload and for many others that work in mental health. We are often in this role to help people that do not have these qualities, or at least do not have them at the present moment. I might just be having my own reaction to your post - so I want to own it if this is just me - but to intentionally plan a practice designed for allowing the highly functional of our society have a window for self exploration... comes across as convenient for you (and them) but not the primary purpose of mental health care or psychology practice in general.

 

[compassionate1]

I think it's great that you're opting toward not taking on this patient as your first in a new practice that you are building. In terms of referral, I don't think you need to have a specific person to refer him/her to - as long as you have the school counseling center, and perhaps a county help line - I think that is sufficient. I'm unaware of laws or ethical policies that require you to refer to a specific known provider.

In my job I work with a specialized population, so perhaps this is just my bias - but having someone stable, insightful, and highly functional as a patient is atypical for my caseload and for many others that work in mental health. We are often in this role to help people that do not have these qualities, or at least do not have them at the present moment. I might just be having my own reaction to your post - so I want to own it if this is just me - but to intentionally plan a practice designed for allowing the highly functional of our society have a window for self exploration... comes across as convenient for you (and them) but not the primary purpose of mental health care or psychology practice in general.

Thanks for your comments. I understand your reaction and thank you for specifying it as such . I worked for several years at a community clinic with a wide range of populations and issues. Many of my clients were high - risk / low functioning. I worked per diem while being expected to be on call 24/7 and respond to emergencies at all times ( without being compensated). This may sound bad, but I am going to be honest and realistic: I feel that I had done my share of volunteering earlier on in life. I have a family to support and I( like most people here, including you I am sure) have invested many years in my education and will likely continue to do so for the rest of my life, in one form or another. Clinical work is hard work, and I need to be able to help my clients while also feeling intrinsically as well as extrinsically rewarded. To me, doing relational existential work with people feels rewarding. It does not mean that this is elitist and precludes people with "real problems". High functioning individuals struggle too, and deserve to get helped. And truck drivers, sanitary workers and fire fighters can be very insightful. I do not intend to limit my practice to the wealthy either but rather, I am committed to running a sliding fee scale practice, while also taking care of myself and my family. I commend you for having the generosity of heart to work with difficult, specialized populations. It is not for everyone.

 

[AcronymAllergy]

Personally, as T4C mentioned, unless there's a shortage of therapists in the area, I'd pass. You can certainly work with the person to make appropriate referrals and help them get in touch with a provider whose skills you trust, but that's personally as far as I'd go.

 

[compassionate1]

Personally, as T4C mentioned, unless there's a shortage of therapists in the area, I'd pass. You can certainly work with the person to make appropriate referrals and help them get in touch with a provider whose skills you trust, but that's personally as far as I'd go.

Thank you, AcronymAllergy.