Have you ever considered what might happen to your practice, your clients, and files when you retire or if you suddenly became ill, or died? Do you have a plan? This article will help you formulate the plan you need. Of course, we all think such a plan is a good idea, but few therapists have thought through what would happen, let alone developed a simple, doable plan of action. This article introduces a nuts-and-bolts toolkit that you can print out and complete on your own computer. It includes step-by-step guidelines for designing your own system to help you and your clients in the event of planned and unplanned absences from practice. The first section provides an overview of the advantages of writing out how you want your clients handled if you have to be out of the office. The second section helps you decide who you want to have cancel your appointments and deal with clients if you are unable to. Recommendations and experiences of other therapists will help you create your own plan. Lastly, the Blueprint for Therapeutic Continuity, sample letters, and forms that you can copy and print are provided for your personal use.
Thinking about illness, disability, death, retirement and disruptions in our work is uncomfortable. It makes us squirm. As therapists we are not immune to denial. This is especially true when it comes to planning for our own absences from work. In the 20 years that I have supervised and taught therapists, this has been the most difficult area for therapists to deal with and manage. In fact, most just don't deal with it.
"You will never die." Is that what you were told when you applied to graduate school? That is one theory I formulated when I began asking colleagues and workshop participants how they handle their absences from work and what plans they have for retiring or dealing with medical emergencies. The level of denial about mortality and limitations among therapists is impressive. Many therapists even talk about how fortunate they feel, because they can work well past normal retirement. A shocking number of therapists have not written a will, much less filled out a Durable Power of Health Care Decisions, a document that spells out your wishes about life-support systems and whether you want "comfort care" if you have a medical crisis, are in an accident or are unable to make your preferences known. In addition to the independence afforded by private practice, many therapists prefer not having to deal with mandatory retirement. Underlying our denial is the common sentiment, "They'll have to take me out of here on a stretcher." When I give workshops I jokingly repeat the sentiment "Therapists never die." Unfortunately we do, and we need to help our clients cope with that final separation and the smaller ones that occur along the way. “If you find yourself being scheduled for immediate bypass surgery tomorrow do you really want your spouse or partner to call your clients to cancel your appointments?”
Well, maybe you do, maybe you don't, but let's remember our obligation to make rational decisions that are in our client's best interests. Denial is sometimes so much easier! Yet how we plan or don't plan ahead for predictable and unpredictable, normal life changes will affect our clients, colleagues, friends and family members.
In Florida, or course, it is different. Relocated and retiring therapists who live in Florida are not allowed to indulge in such denial. Instead, their state laws are light years ahead of the rest of the country. Florida law requires therapists to place a newspaper ad announcing their upcoming relocation or retirement, as well as where former clients can get their records. Heirs to deceased therapists are required to place a similar ad, making public the fact that the therapist has died and providing contact information about how clients can obtain their files. Florida is one of the only states that mandates this system of public notification and transferring of client records.
It is uncomfortable to consider one's present and future vulnerabilities. Yet by investing the time in the unpleasant task of writing out your Therapeutic Continuity Blueprint, composing letters to be sent to clients in the event you are unable to do so, and drafting a script for your outgoing answering machine message, you will find unexpected relief. Knowing that you have tackled these uncomfortable yet important issues is surprisingly comforting.
Literature in this area is sparse. This paucity reflects our profession's discomfort with the topic. Psychoanalytic authors were the first to write about illness or death of the therapist and its impact on clients. This was followed by a growing, though small, body of literature addressing the effects of pregnancy on treatment. Since then there have been only a few articles that advise clinicians on how to prepare clients for their retirement or unexpected absences. (See references at end of this article.)
There are many forms of termination: planned, unplanned, and temporary. It is the most important, most often overlooked, phase of treatment. A healthy termination process allows time for goodbyes and cleaning up unfinished business. The safer a therapist makes this process for his or her clients, the greater the chance that clients will feel comfortable seeking treatment when they need it in the future.
One of the most curative aspects of any therapy is for clients to learn to speak the unspeakable. Unwanted terminations are a time when we (therapists) need to explicitly invite clients to discuss or ask questions about our absences or termination. Having a plan in place ahead of time can also drastically reduce the stress of dealing with the complex issues that can arise when we are most vulnerable. Do you really want your colleagues to have to do damage control for you, without knowing your wishes, if you are in a car accident, have a family emergency or die?
Why We Need to Plan for Unexpected Absences
Denial of our own fragility and mortality is surprisingly pervasive among mental health professionals. As therapists, we are unaccustomed to revealing much of our private lives. Changes in our appearance, such as those due to pregnancy, illness, or disability, may force us to deal with clients' reactions. If we are in denial or conflicted about our situation, clients are likely to sense this and may be put in the all too-familiar, unhealthy position of protecting the person whose responsibility it is to protect them. Our own countertransference issues and resistance to telling clients about our medical situations may also impact continuity of treatment, creating unnecessary psychological damage.
There are several reasons why it is important to address these issues while one is in good health. Taking a proactive stance and preparing documents to be used by your Emergency Response Team, or ERT, will enable you to work these issues through in advance, better preparing you to make difficult choices about changing your practice due to health or other reasons. Taking on the challenge of creating an ERT is also a way of modeling good self-care and direct communication to your clients.
Thinking through and writing out a plan for how you want your colleagues to handle your clients in your absence is a big undertaking. Most therapists are overwhelmed when they consider planning for their retirement or unexpected absences from work. This article presents an ideal system. Only you can decide the types of information that are most important for your ERT to know about your practice. The samples are intended to help you prioritize the information that you believe will allow your ERT to be maximally effective.
To get a flavor of the importance of starting this project, it may be helpful to put yourself in a client's shoes for a moment. For example, “imagine the trauma of coming home from work to find a message from a friend asking whether you were going to attend a memorial service for your therapist.” The last you heard from your therapist was a message canceling your appointment. You had no idea that your therapist had been ill.
The following example is typical of the problems created when therapists have not planned ahead for unexpected personal crises and absences from work.
Darlene, a management consultant who had been working on early childhood trauma issues, learned of her therapist's life-threatening illness by mail. She was upset to learn that he would be unable to work for an indefinite period of time and hurt that the brief letter she received included a request for payment. This excessively considerate woman had difficulty believing she had the right to information about her therapist's condition. Her efforts to take care of herself were further hindered when she had to deal with her therapist's wife, who was, herself, in crisis. The result of this unskillfully handled crisis was that Darlene was re-traumatized, and her work and marriage suffered. The trust issues that motivated her to seek treatment were recreated, and she once again felt that no one was safe to trust. After months of disruptions in her home and work life, she was able to start therapy with a new therapist. It took her a year of treatment before she could deal with her feelings about her previous therapist. She was one of the fortunate ones. There are no statistics on how many clients are unable to risk starting over with a new therapist.
The next example involves my father, a psychiatrist, who had a clinical psychotherapy practice:
When my father, a psychiatrist in private practice, became critically ill, I was asked to take over his psychotherapy client load. Since he did not have an Emergency Response Team, I was forced to assume the roles of both personal gatekeeper and Bridge Therapist, a colleague designated to serve a transitional function for clients during a therapist's absence. The final termination session I arranged for him with his long-term outpatient group was one of the most difficult and enriching experiences of my life. Nevertheless, it was a salvage job that could have been avoided had there been adequate planning and preparation on my father's part. My personal experiences taking over his long-term therapy group when he became terminally ill are presented in "When the Therapist Has to Cancel," The California Therapist, January, 2001.
Our responsibility as therapists is clear: to provide the best possible care and to do no harm. Whether you view transference as an important part of clinical work or not, many of our clients develop close attachments and benefit from being able to "count on" our consistency and continuity of treatment. Often, we are the first dependable, consistent relationship they have experienced.
Further, some clients have never experienced the safety of successfully testing another human being's willingness to hear their pain and anger. Though a client may become unreasonably angry upon discovering we are ill, it is our duty to be there for him or her, to tangibly demonstrate that, within reason, his or her anger won't push us away. Weathering a client's anger and pain can be a major curative factor in their treatment.
The purpose of the ERT and the Therapeutic Continuity Blueprint is to protect and respect the needs of our clients. It also helps clinicians in a number of significant ways. First, it serves as a reminder that we are neither invincible nor immortal. Thus, we can be more realistic about our own personal needs as well as those of our clients. Additionally, by planning ahead, we can minimize the potential damage and disruptions caused by all kinds of absences, from vacations to retirement.
When exploring the uncomfortable topic of becoming ill or having to cancel sessions unexpectedly, it is helpful to consider your therapeutic style and values. Therapists who view their role as that of a coach or teacher will have a different perspective on the type of arrangements they feel are appropriate if they are unable to say goodbye to clients in person. For example, in preparing for their deaths, some psychodynamic therapists may prefer to plan a memorial service designed exclusively for their clients with a specified colleague present. However, a more eclectic therapist might prefer a public memorial service that is open to his religious community, family, and clients. Still others may prefer no formal service. By taking charge of how we want these difficult issues addressed, we can better serve our clients and preserve energy to care for ourselves in the future.
Borrowing Someone Else's Brain
In my writings about coping with illness, I refer to "Borrowing Someone Else's Brain," a process where, when one is ill, one needs to have someone else help think through difficult decisions. Borrowing someone else's brain is a temporary process that does not mean relinquishing permanent control or admitting defeat. Having a few trusted colleagues with whom you can discuss the emotional topics of retirement, leaves of absence, and significant medical problems is a true gift.
When a Bay Area therapist died without an ERT in place, Mardy Ireland, Ph.D. and Kathy Mill, LCSW, formed a group of mental health professionals who met over the course of two years. In these meetings they dealt with the aftermath of this clinician's death and created a plan to protect themselves and their clients in a similar eventuality. Their plan lists several important functions that the ERT can serve. They suggest that the ERT can administer your practice in your absence and can serve as a consultation and support group for one another. (Personal communication, Mardy Ireland, May 2000.)
Ireland's group also introduced the concept of a Bridge Therapist, a colleague who would serve a transitional function for clients during a limited period of time to assist with such crises as:
- Deciding whether and when to end therapy with you if you become seriously ill or unable to work.
- Mourning and reminiscing about you after you have stopped practicing.
- Helping to promote resolution and closure on a therapy that has ended through your illness or death.
- Discussing a treatment plan and possibly making a referral to another therapist.
There are a number of reasons to pick your ERT and your Bridge Therapist with care. Both you and your clients will rely on these trusted people when you are incapacitated. Additionally, they are being entrusted to protect you and your clients if your clinical judgment becomes impaired.
Words of comfort: “This is a big project, emotionally and physically. You need not do it all at once.” But you do need to do it. Unfortunately, few among us received training in how to handle disruptions in our practice due to our own personal emotional and medical crises. By simply taking this process one step at a time, you will make quick progress.
The Nuts and Bolts of Creating Your Own Emergency Back-up Plan
Suggestion: Take big breaths as you read this article. Remember that the Therapeutic Continuity Blueprint and the other materials you will write are best viewed as works in progress. The most important thing is that you start now. Why not take 10 minutes and start a temporary folder labeled "In Case of Emergency"? What follows is a step-by-step plan designed to move you through the process of designing your own plan:
Step One: Selecting your Emergency Response Team (ERT)
Consider the person or people who cover for you when you are unavailable (i.e., on vacations or at professional conferences). Here you have the foundation for an ERT. If your current back-up system works, consider making it more formal. Ask your current back-up people to be your ERT members and consider developing a system in which you serve as ERT members for each other. Select who you want to be your Bridge Therapist. The next step is to write out important information about clients that may be at risk or have special needs.
Step Two: Drafting the Information for ERT
Start writing a rough draft of the information your ERT will need in order to make covering your practice in the event of an emergency less overwhelming. Begin talking to colleagues you are considering having be part of your ERT. The process of setting up your ERT and filling out the Blueprint will be easier and more enjoyable if you work on it with trusted colleagues. Once you have formed a formal or informal group, make a plan for how often you want to meet. Consider scheduling meeting times more frequently while you are in the planning stages. Once your "system" is up and running, you may decide to only meet occasionally. Consider scheduling time to initially meet on a monthly basis while you are in the planning stages. The following is a list of critical clinical information for your ERT:
Checklist for Creating Your ERT
- Latest copy of your Blueprint for Therapeutic Continuity.
- List of active cases, updated when necessary, include supervisees, consultees, and appointment times.
- Brief client and group summaries, vital information about each client and or group.
- Where to leave a confidential message for each client (their preferred home and work numbers.)
- Recommendations for interacting with specific individual clients and group members.
- List of former clients from the prior year and significant former clients.
- Two sample letters for ERT to send clients to inform them of your death or temporary absence (templates available at end of this article).
- Location and instructions for disposition of manuscripts, teaching files, lectures, books, journals, or tapes.
- Directions for retrieving and changing the outgoing message on your office answering machine.
- Suggested outgoing answering machine message.
- Detailed directions regarding location of keys, computer passwords, burglar alarm and other codes.
- List of preferred referral therapists.
- Wishes and directions regarding memorial, including suggestions for groups.
Step Three: Creating Client Contact Summaries
When your Bridge Therapist goes to your office, the last thing he or she needs is to have trouble finding information like phone numbers and which clients may need extra follow-up. By taking time to put this information together now, you will be reducing stress for your ERT and increasing their ability to be helpful to your clients. The ERT can operate most effectively if you keep a file containing a one to two page summary about each client. (See the sample Client Contact Summary Sheet at the end of this article, which will be enormously helpful to the Bridge Therapist.) Clients with a history of suicidality and those who may have significant difficulty coping with your absence need to be identified and recommendations should be made for helping them. Using this form will cue you to provide the necessary information in your practice. This form is designed to make it easy for you to list information your ERT will need in your absence to provide quality follow up care for your clients.
Realistic Maintenance Plan for Client Summaries
Once your ERT plan and Therapeutic Continuity Blueprint are written, take a moment to determine, realistically, how often you will update your client summaries. Ideally, client summaries should be updated yearly. These summaries need not be longer than a few paragraphs. They simply need to be clear and concise. You may decide to mark this task on your calendar as part of preparing for vacations. Try scheduling it a few weeks before your vacation so you can do a few each week.
If you don't already have a central file that lists all your clients and their contact information, start one now. Consider including a cover page that lists client names and phone numbers, highlighting any clients that are particularly vulnerable or at high risk for suicide. The Client Contact Summary Sheet provides a place to note whether the client might be at risk or is likely to have special needs when contacted about your absence. If there are major changes in the nature of the treatment relationship, or other significant events, add a brief note about these changes to the summary page. Add updates more frequently for those clients that are higher risk or who have special needs. By including these updates in this form you can avoid writing more frequent summaries. You could also keep backup summaries in your computer making it easy to make any changes or additions.
A copy of this summary should also be kept on the inside cover or back of each client's file. The anxiety you may feel at the prospect of doing this work now is minimal in comparison to the stress you and your Bridge Therapist are likely to feel when these forms are needed. Knowing that you have done the best you can to make it as easy as possible for your ERT is an investment in having more peace of mind.
Step Four: Using the ERT
When the Therapist Becomes Cognitively Impaired
The possibility that therapists may become impaired, either as a result of a medical or substance abuse problem, is another taboo topic that has only recently been addressed. The Blueprint for Therapeutic Continuity presented in this article includes a section about the help you want in the event that you develop a chemical dependence, organic illness, or mental illness that interferes with your judgment and/or jeopardizes your clients' well-being. The section entitled In the Event of My Mental Incapacitation spells out specific steps the ERT should take if they have reason to believe your clinical judgment is impaired.
Illness and Death of a Therapist
Jacques Rutsky, in his article, "Taking Care of Business: Writing a Professional Will" (The California Therapist, April, 2000), points out that, “if you are ill, both you and your family may need to be shielded from clients' well-intentioned, yet possibly unwelcome, curiosity, concern and questions”. Thinking through, and spelling out your preferences while in good health will make dealing with illness or death less traumatic for everyone concerned, particularly close family members who may already have enough on their hands.
The Blueprint for Therapeutic Continuity includes a section in which you may indicate your wishes about a memorial service. Depending on your theoretical orientation, you may be more or less comfortable encouraging your family to allow clients to attend or participate in a memorial service. As with the majority of the questions raised in this article, therapists need to tailor these documents and memos according to their theoretical beliefs, as well as the nature of their practice and personal references.
If you run groups, work in an agency setting, or other organization, you may have specific preferences and recommendations for how to best allow the members to grieve together. The clearer your directions are, the better prepared the designated facilitator of your memorial will be. An example of the Blueprint for Therapeutic Continuity can be found at the end of this article.
Step Five: Gathering all your Information
Creating Your List of Referral Therapists
This is a list of colleagues whom you would recommend as long-term therapists for your clients after the Bridge transition. In addition to their clinical skills, you might consider the following:
- Whether the therapist is too close to you to be comfortable encouraging clients to discuss their anger about losing you, and other painful emotions.
- Whether your clients may have had social contact with either your ERT or therapists to which you plan to refer them.
- Where appropriate, include a list, in the Client Contact Summary Sheet, of clinicians that are less likely to have potential dual relationships.
Contents of File for Executor and Attorney
- Copy of your license and your malpractice insurance face sheet.
- Contact information for professional organizations and colleagues you want notified about the changing circumstances of your practice.
Financial Records and Collections File
The Blueprint for Therapeutic Continuity states that only people who are trained to handle confidential client information are to have access to client's financial records. Your letter to the ERT should include directions for how to handle outstanding balances due and insurance bills that have not yet been submitted for reimbursement.
Sample Documents
The Blueprint for Therapeutic Continuity and letters presented here are designed to be used as templates, or guides. Each clinician should modify the sample documents to fit the needs of his or her particular style and treatment population. It may also be beneficial to consult an attorney.
Sample Memos and Letters to your ERT
Your ERT needs two letters in draft form that can be mailed to clients if you are incapacitated or have died unexpectedly. It bears repeating that it is best to prepare these letters while you are in good health, rather than waiting for an emergency.
The Blueprint for Therapeutic Continuity requests that a member of the ERT put a note on the office door, notifying clients that you have cancelled appointments and to expect a phone call with further details. Depending on the type of practice, you may want to ask that an additional note be posted with the name and telephone number of the ERT Bridge Therapist and suggest that clients call with questions.
Make three copies of each of these letters and the Blueprint and memos and distribute them in the following way:
- Put one in a safety deposit box, or other safe, secure location.
- Keep one in your locked file cabinet
- Give copies to each member of your ERT, your attorney and executor of your personal will.
In addition to the "Instructions for the ERT," it is important to think through, in advance, how you want your clients to be informed of unanticipated temporary or permanent absences. The last thing one ought to have to think about when in crisis is what to put in a letter for clients. So, draft a letter now. Feel free to use any or all of the samples on the next page.
The 3-Step Quick Plan of Action
If you are not ready to make a complete plan yet, don't let it stop you from getting started. Complete just the following three steps and you will be far along the path.
- Choose three colleagues to cover your practice in your absence.
- Fill out the sample forms at the end of this article.
- Write out how your Bridge Therapist and ERT can find essential client contact information.
Viola! You have practiced what you preach about good self care! You have prepared for and protected your colleagues, clients and family from unnecessary trauma when you are gone. You have planned ahead for everyone's peace of mind. They will appreciate it more than can be imagined.
Conclusion
Reading this article is a step toward dealing with one of the more difficult aspects of being a therapist. Merely considering these issues is deserving of a healthy dose of self-congratulations, and once you've completed the ERT preparations, you might consider formally recognizing your effort with some kind of celebration. After all, the challenging work you've done has built a quality safety net for you and your clients.
The samples on the next page are designed for you to copy and paste into your word processor where you can make modifications that meet your specific needs. Feel free to copy the following materials onto a clearly labeled document. Fields which need your attention are identified by "angle brackets" (<>). Fields which are in italics provide instructions to you. Underlined fields identify information which you must provide. To fill in your information, highlight the entire field, i.e. <name/address/telephone>, then type in your information.
Download Forms and Letters: For your convenience, these forms may also be downloaded here.
FORMS and SAMPLE LETTERS
EMERGENCY RESPONSE TEAM PREPARATION PACKAGE
Memo to ERT
You may want to write a sample outgoing answering machine message for the Bridge Therapist. Example:
You have reached the office of <Therapist's Name>. You may or may not have heard that your therapist is ill. My name is <Covering therapist>, <Therapist's Name> has asked me to handle her professional affairs in her absence. If you would like to speak with me in person or would like further information or help, please call me at <phone number>. Thank you.
Sample Letters to Executor and Attorney
Date_______
Dear Executor and or Attorney,
Thank you for helping with these matters. Enclosed please find a copy of my Blueprint for Therapeutic Continuity. In addition you will find a copy of my malpractice insurance information. If it is necessary to protect my estate in the event of legal action arising after my death, please contact each insurance company with whom I have a policy to arrange for additional coverage. Please be sure to bill my estate for your time and any other expenses that you incur in executing these instructions.
With many thanks,
____________________________
<signature>
Sample Memos and Letters to your ERT
Include two letters in draft form that can be mailed to clients if you are incapacitated or have died unexpectedly. It is best to prepare these letters while you are in good health, rather than waiting for an emergency. Take a few minutes to write some notes about the amount and type of information you routinely disclose to your clients. This will help them in deciding what to tell clients when they call to cancel your appointments. For example, if you routinely tell all your clients where you are going on vacation and have family photographs in your office, you may want your ERT to give more detailed information about the reasons for your absence than if you have a more analytic approach to self- disclosure.
The following forms are intended to be used as samples. Please make modifications that take into account your personal and professional situation as well as the relevant state laws and regulations.
In The Event Of My Unexpected Absence From Clinical Practice:
Date ______
Dear Client,
If you receive this letter, it is because I have become temporarily incapacitated and am unable to call you myself. <Covering therapist> , has mailed this letter, using my stationery, in accordance with an agreement we made in <Month, year> . If you are currently in therapy with me, regretfully, this letter is to let you know that I am unable at present, <either to continue my psychotherapy practice or keep any further appointments>. <Covering therapist> , will be handling my clinical practice. Please cal
