It is ironic that while most therapists champion the role of the therapeutic relationship in the success of therapy, there has been little research on how the transfer process and prior therapy relationships may have an impact on the therapeutic relationship. Clients are often transferred from one therapist to another in clinics when therapists-in-training leave at the end of their training, or when therapists retire, can no longer help a client, or take a leave due to health reasons (Penn, 1990; Super, 1982; Wapner, Klein, Friedlander, & Andrasik, 1986). Clients also stop working with therapists when they have achieved their goals, move or have financial issues, or do not feel a connection to or find the therapist helpful. In my adult practice (BT), over half of my clients have had at least one prior therapist, with several having had as many as four prior therapists.
In our recent study of therapists-in-training working with transfer clients (Marmarosh et al., in press), almost all of the trainees reported that they had been provided little to no training in how to work with clients who have had prior therapists. This is consistent with our personal training experiences as well. The purpose of this short article is to identify some potentially important considerations for both new and experienced therapists working with clients who have had prior therapy relationships.
There has been some research indicating a dropout rate as high as 69% following a transfer (Tantam & Klerman, 1979; Wapner et al., 1986). Keith (1966) coined the term “transfer syndrome” to describe the difficult emotions and behavioral changes experienced by clients who end treatment with one therapist and begin treatment with another. Others describe clients’ feelings of abandonment, grief, and loss when transferred (Clark, Cole, & Robertson, 2014); anger/rage towards the transferring and new therapists (Penn, 1990); and feelings of unworthiness (Penn, 1990). Despite the literature describing negative client experiences after being transferred, studies by Clark, Robertson, Keen, and Cole (2011) and Wapner et al. (1986) found that clients with a long prior therapy relationship or prior experience of being transferred were less likely to drop out of therapy after a transfer compared to those who did not. In essence, the prior therapy relationship and the experience of surviving a transfer can bolster clients through the transfer process.
The way the new therapist helps the client cope after the transfer can also minimize negative effects. In a qualitative study, Clark et al. (2014) found that clients often reported feeling anxiety, fear, sadness, and anger about the transfer. These clients also reported that it was helpful when the new therapist and clinic helped them cope with these feelings. Clients who felt their transfers were “successful” reported that their therapists had helped them deal with their reactions to the transfer.
Not only do clients struggle through the transfer; therapists, too, can experience challenges working with transfer clients. There is some indication that therapists have difficulties dealing with clients’ emotions about their prior therapists. Boyer & Hoffman (1993) found that while some therapists reported being able to tolerate clients’ experiences of termination and loss, other therapists, specifically those who had prior personal losses, struggled with the termination process.
In a study looking at psychiatric residents’ experience of transfer clients, Schen, Raymond, and Notman (2013) found that some transferring residents felt guilty, sad, anxious, and even relieved to transfer their patients. In contrast, transferred-to residents felt badly about being compared to prior residents, felt overwhelmed when patients were grieving the loss of their prior clinicians, and feared transfer patients’ negative emotions about repeating an intake, re-hashing the past, or starting over.
In our qualitative study (Marmarosh et. al., in press) many important aspects to the transfer experience emerged that were different from seeing a client for the first time, and trainees revealed factors that both hindered and facilitated the transfer process. These factors included client past experiences of being transferred, client characterological issues, and termination of the prior therapy (e.g., whether the ending was processed). When trainees were more comfortable themselves discussing loss issues and more secure about their own competence as therapists, it seemed easier to help the client through the transfer process. When the new therapist felt the termination with the prior therapist was addressed and processed, the new therapy relationship developed more smoothly than when it had been avoided.
Other practice issues such as unclear or inconsistently followed clinical policies and payment policies seemed to also impact the transfer process. For example, when there was a large debt accrued in the prior therapy, it impacted the new therapist, who had to start off the new relationship addressing issues about payment. In addition, therapist race, class, gender, and cultural background had an impact on the new therapy relationship, especially if client expectations or preferences for certain therapist characteristics were not met.
Based on our own experience as therapists, our research, and other research findings, we offer four important considerations that may facilitate working with clients who come to you after having had a prior therapy relationship. While there is likely some difference between immediate transfers versus delayed transfers (i.e., when a client ends treatment and starts again at a later date), we believe that there are enough common characteristics to warrant similar considerations.
Important Considerations in Working With Transfer Clients
1. Recognize that the relationship with the prior therapist will likely influence the client’s expectations about you and the therapy you will have.
For some clients, the loss of the prior therapist may have been experienced as a significant loss, even abandonment. These unresolved feelings will impact the development of the new relationship with you. For other clients, negative experiences with the prior therapist or treatment (e.g., therapist falling asleep in the session, not remembering pertinent information, having unclear or overly strict boundaries, no change in symptoms) will likely influence expectations of you. Positive past experiences will also influence the new relationship. In our experiences, positive prior therapy experiences helped clients be more open and able to trust us and the therapy and work through issues. Given the prior relationship is alive in the new relationship, it is important to explore this with the client, including the experience of loss or absence of loss toward the prior therapist, expectations (both positive and negative) about how you might be similar or different from the prior therapist, and to openly clarify expectations and differences in styles and practice up front.
2. Be aware that client history, psychopathology, and interpersonal style will likely influence how the client reacts to a different therapist, mourns the loss of the prior therapist, and compares you to the prior therapist.
Although the research on attachment style as it relates to therapy relationships ending is minimal, some preliminary findings indicate that attachment style might influence how a client “attaches” and “detaches” from therapists (Mallinckrodt & Jeong, 2015). We know that therapist attachment style is related to their perceptions of ruptures in the new treatment after a transfer (Marmarosh et al., 2014) with more anxious therapists noting more ruptures and more effort in repairs compared to less anxious therapists. We also know that clients with different diagnoses may experience endings or transitions differently. For example, clients with borderline personality disorder or severe histories of interpersonal trauma are more likely to struggle with abandonment or emotional deregulation during and after a transfer.
3. Be willing to initiate the conversation about the prior therapy experience with the client.
Rather than waiting for clients to bring up feelings of loss from their prior therapy—which they may be hesitant to do—invite clients to share their thoughts and feelings with you. For example, consider initiating the discussion of the transfer by asking clients what was helpful and less helpful about the prior therapy. Over time, as you learn more about the prior therapy, it may be important to delve more deeply into the past therapy and therapy relationship. If there are signs that the loss of the prior therapist was difficult or challenging to the client or the client’s history identifies potential loss or abandonment issues, it is often helpful to gently push the therapy toward what the client may be avoiding or minimizing. If you sense the client is struggling with gender or cultural differences between you and the prior therapist, you may need to slowly introduce conversations about race, ethnicity, gender, class, or religion. For beginning therapists, this may mean overcoming insecurity about being a “new” therapist, saying the “right thing” or not being “good enough” when comparing themselves to the prior therapist. The more comfortable and secure you are as a therapist, the easier these discussions will be.
4. Periodically check in with the client about how things are going between the two of you as the new relationship is developing.
If the client expresses concerns about some aspect of the prior therapy (e.g., the client didn’t like that the other therapist didn’t challenge enough), it can be beneficial to use this information directly to get feedback on how the client is experiencing that in you. Do not assume that “givens” in your practice will have been the same givens in the client’s prior experience. For example, therapists may differ around abuse reporting practices, payment of fees, keeping secrets, and missed sessions. When certain issues surface, it is useful to ask about prior therapy experiences around those issues to allow you an opportunity to explain or address those differences directly. It is also important to pay attention to what clients do and do not say. If the client comes late to sessions, cancels sessions, or does not show up to appointments, it is important to wonder with the client about how the client is experiencing the new relationship with you. Many times, clients will avoid difficult conversations and it is important for therapists to openly talk about these issues to prevent premature dropout.
The reality seems to be that as therapists we will all work with clients who have had experiences with other therapists. This can be challenging, yet this factor can also lead to potentially valuable therapeutic opportunities. Clients can address their experiences of loss, ways of coping with transitions, and implicit relational strategies that protect them from being hurt. Therapists can also gain something from these experiences. They learn to tolerate their own feelings of insecurity, cope with feelings of competition, and become more comfortable sitting with uncertainty and loss. Being aware of and addressing the possible positive and negative influences of prior therapies will likely help you become a better therapist, improve your work with the client, and help your client develop more satisfying relationships.