The Therapist's Professional Will TM: If Not Now, When?
by Ann Steiner, Ph.D., MFT, CGP, FAGPA
- Have you ever considered what might happen to your practice, your patients, and your files when you have a family emergency, retire or if you suddenly become ill, or die?
- Do you have a plan?
It is never too early to plan for the unexpected. Everyone gets sick, has family emergencies, and eventually will need to stop practicing.
I became aware of the need for a therapist’s professional will fourteen years ago after witnessing the damage done to patients whose therapist died without terminating. Stories like these prompted me to research and create a comprehensive system for expected and unexpected disruptions in treatment. Having a written plan reduces your stress. And allows you to follow the ethics guidelines of your profession.
This article gives you a jump start. It guides you in thinking through your unique situation – and to begin your own therapist’s professional will, TPW. You’ll find advice for protecting your patients, colleagues and yourself in the event of unexpected absences from practice. This sample is not intended to replace legal advice. You are encouraged to work with an attorney before or in conjunction with completing your actual professional will, preferably one familiar with the professional and business needs of mental health providers. This will help you make sure the wishes you spell out in your professional will meet your needs, and are compatible with other legal documents you may have already created. You may be advised to also develop an estate plan to protect you and your heirs.
In the twenty years that I have trained therapists, this has been a difficult area for therapists to deal with. Once they realize what could happen without a professional will, they understand how important it is to have one. And yet, they put off doing even a rough draft because they find it too difficult to start on their own. So I created an easy-to-follow, fill-in-the-blanks downloadable system available at:www.PsychotherapyTools.com.
Most of us were not taught techniques for skillfully handling our expected or unexpected absences. The TPW is not just for therapists who are aging; each of us, regardless of age, needs to ensure continuity of care for own patients. We need to have a back-up team as well as a TPW. The concept of creating a TPW resonates with most psychotherapists. Surprisingly few of us have actually done even a rough draft. Have you done yours?
Thinking about illness, disability, death, retirement and work disruptions makes us squirm. As therapists we are not immune to denial. This is especially true when it comes to planning for our own absences.
Did you know that you are REQUIRED to have a Professional Will?
Most clinicians aren’t aware that their Ethics Codes require them to have a plan for continuity of patient care during the therapist absences. Every guild and professional organization for mental health professionals expects its members to have at least the equivalent of a professional will.
What is the Therapist’s Professional Will?
The therapist’s professional will, the TPW, is a document that outlines how you want your practice handled in your temporary or permanent absence. “The Therapist’s Professional WillÔ: Guidelines for Managing Planned and Unplanned Absence,” the system I created, provides a downloadable format and necessary paperwork to spell out where the covering therapist can find essential information in an emergency.
DISCLAIMER: This article is written for informational and planning purposes. The information included is not to be relied upon as a legal document, or viewed as legal advice. You are advised to consult an attorney in your state to make sure that decisions you spell out in your professional will are compatible with your personal will and other estate planning documents.
The TPW includes places to list current patient phone numbers, diagnostic and risk-related patient information, office and file cabinet keys, burglar alarm codes, crucial passwords, etc. It also includes templates for good-bye letters and describes your wishes for a memorial service (Steiner, 2001 and 2002 -2013, etc.).
The TPW 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 patients. By planning ahead, we can minimize the potential damage and disruptions caused by all kinds of absences, from vacations to retirement. Note: The information in this article is not intended to replace legal advice.
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 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.
Introducing the Emergency Response Team
The cornerstone of the TPW is the creation of what I refer to as an Emergency Response Team, or ERT. This is a team of trusted colleagues who agree to perform a triage function for each other in the event of expected and unexpected absences from practice. Having your ERT in place before you have an emergency benefits everyone.
Your Emergency Response Team, a team of trusted colleagues, helps you think through what is in both the patient’s and your best interest. For example, they can assist you in making decisions when you get ill, if you are injured in a car accident, have surgery, or need to be on pain medication. These situations may effect your ability to be objective and provide high quality care. In addition, your ERT can cancel appointments when necessary, and be an ongoing support team you can turn to during challenging times.
Information sharing about your medical situation and availability to often falls to nonclinical family members or the therapist’s colleague. This person, also stressed and unprepared to cope with the crisis, not only has to hunt for crucial patient contact information, answer patient inquiries. Again, your ERT will protect you, your family and colleagues from unnecessary stress. It is especially helpful when therapists are temporarily absent, become terminally ill, or die. How about scheduling time to discuss this article with a colleague within the next few weeks?
When a therapist died without an Emergency Response Team in place, her colleagues 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 patients for 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 serves a transitional function assisting patients with such crises as:
- Helping to promote resolution and closure on a therapy that has ended through your illness or death.
- Mourning and reminiscing about you after you have stopped practicing.
- Discussing a treatment plan and possibly making a referral to another therapist.
Chose your ERT and your Bridge Therapist with great care. Both you and your patients will rely on these trusted people when you are incapacitated. Additionally, they have agreed to protect you and your patients if your clinical judgment becomes impaired.
“It takes a village.” As a group psychotherapist, I see the value of group support in many situations. Consider this project from a group perspective, with your ERT in the role of a trusted support group. Doing so creates a powerful antidote to isolation. When Dr. Cecil Rice and others had to deal with the death of an admired group therapist, they formed the equivalent of an ERT. “We were mindful of creating an emotional container for each other-because we too had suffered a loss.” [Rice, C., Shapiro, E., Shay, J., (2011) Death of a Group Therapist and the Survival of the Group International Journal of Group Psychotherapy Association 61 (2) p. 178.]
Why We Need to Plan for Unexpected Absences
It is difficult enough for us to deal with our own fragility and mortality. Balancing information that patients need about our ability to be there for them, and our privacy often requires consultation.
It is important to address these issues while one is in good health. Your ERT can also serve as a consultation group when you face 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 patients.
History
Our profession's denial of death is so profound that literature in this area is sparse. Few articles advise clinicians on how to prepare patients for their retirement or unexpected absences. (See references at end of this article.)
Florida was the first state to handle this differently. Florida law requires therapists to place a newspaper ad announcing their upcoming relocation or retirement, as well as where former patients 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 patients can obtain their files. Florida was the only state to mandate this system of public notification and transferring of patient records. Oregon law now requires psychologists not only to have a professional will, but to keep their licensing board informed of who has custody of their records and the name and contact information for that person. Other states are likely to make it a legal and ethical requirement to have a professional will.
Termination Matters
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 good-byes and cleaning up unfinished business. The safer a therapist makes this process for his or her patients, the greater the chance that they will feel comfortable seeking treatment in the future.
As I tell patients, “Leave-taking involves some pain.” By allowing ourselves and our patients adequate time to say goodbye, we make room to identify accomplishments and areas that they wish to work on in the future. Your ERT can help you think through these issues.
The Value of Termination
One of the most curative aspects of any therapy is for patients to learn to speak the unspeakable. Unwanted terminations are a time when we (psychotherapists) need to explicitly invite patients 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? How we plan or don't plan ahead for predictable, normal life changes will affect our patients, colleagues, friends and family members. Not to mention that our ethics require that we have the equivalent of a Professional Will.
Thinking through and writing out a plan for how you want your colleagues to handle your patients in your absence is a big undertaking. I have created a system designed to help you prioritize the information that you believe will allow your ERT to be maximally effective.
“This is Difficult!”
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. 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."
It is uncomfortable to consider one's present and future vulnerabilities. Yet, by investing the time in the unpleasant task of writing out your TPW, composing letters to be sent to patients in the event you are unable to do so, and drafting a script for your outgoing answering machine message, you will find unexpected relief. Our responsibility as therapists is clear: to provide the best possible care and to do no harm. Knowing that you have tackled these uncomfortable yet important issues is surprisingly comforting.
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 patients in person. For example, in preparing for their deaths, some psychodynamic therapists may prefer to plan a memorial service designed exclusively for their patients 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 patients. Still, others may prefer no formal service. By taking charge of how we want these difficult issues addressed, we can better serve our patients and preserve energy to care for ourselves in the future.
Think about your patients’ histories, especially their experiences and response to: Abandonment, trauma, endings, deaths, co-dependency, etc. We know that stress usually makes it harder to function effectively and often stirs up old losses. Treatment disruptions of all kinds can elicit trauma reactions. It is the ERT’s responsibility to minimize the negative impact of these reactions. Having a plan in place in advance of your expected and unexpected absences is crucial.
Planning For Patients In the Event of Your Unavailability
In addition to the ERT, it helps to have letters that can be sent to patients when you are absent temporarily or permanently. I have created templates for these letters including a “Letter to be Sent in the Event of My Unexpected Death” and a “Letter to Patients In the Event of My Unexpected Absence.” These sample letters summarize what I would have wanted to say to patients, given the opportunity. These letters will be sent by a member of my ERT. In these letters, I encourage patients to accept support from a colleague I have chosen in advance to help them deal with my not being available. The sample letter included at the end of this article is designed to be used as a template, or guide. Modify it to fit your particular style and treatment population. It is best to prepare these letters while you are in good health, rather than waiting for an emergency.
Clinical Implications
Some patients have never experienced the safety of successfully testing another human being's willingness to hear their pain and anger. Although a patient 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 patient’s anger and pain can be a major curative factor in their treatment.
Whether you view transference as an important part of clinical work or not, many of our patients 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.
The following example is typical of the problems created when therapists have not planned ahead for unexpected personal crises and absences from work.
A patient 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 the patient was re-traumatized. Her work and marriage suffered. The trust issues that initially motivated her to seek treatment were recreated, and she once again felt that no one was safe to trust. It took her a year before she was able to start with a new therapist. After a year of treatment she began to deal with her feelings of abandonment. She was one of the fortunate ones. There are no statistics on how many patients are unable to risk starting over with a new therapist.
Are You in the “It Won’t Happen To Me” Mindset?
Just as groups are often the most powerful antidote for isolation, so too consultation or ERT groups are a rich way to create and maintain support for yourself, your practice and your TPW/ back up system.
This is a big project, emotionally and physically. Before reading further it may help to take a break. You don’t have to do it all at once. But you do need to do it. Unfortunately, few among us were trained to manage disruptions in our practice due to our own personal, emotional and/or medical crises. By simply taking this process one step at a time, you will make quick progress.
The Nuts and Bolts of Starting Your Own Emergency Back Up Plan
Remember that doing your TPW is best viewed as a step-by-step work in progress. What follows is an overview of the essential tasks:
Step One
o Create a group of at least four trusted colleagues for the core of your Emergency Response Team, ERT. This is where most therapists get stuck and stop. Who covers for you when you are unavailable i.e., on vacations or at professional conferences? If your current back-up system works, consider making it more formal. Make sure that at least one member who is younger, perhaps an early career therapist. Here you have the foundation for an ERT. Talk to them about serving as ERT members for each other. These clinicians will serve as your consultation/support group. They will need to be willing to cover for you temporarily or in case of your permanent absence.
o Some ERT members decide to offer initial pro bono sessions following the death of the therapist. Other clinicians are more comfortable if each member takes out a term life insurance policy naming one or more members of your ERT as beneficiaries. It is important to make sure that directions you have spelled out in your estate plan are consistent with those you list in your TPW. Agreeing on how you want financial matters handled in your absence usually eases concerns about the large amount of time and effort required for closing a practice.
Step Two
o Write down a short list of colleagues you would trust to be your Bridge Therapist. This is who you call in the even to of an emergency and then becomes the Team Coordinator. He or she is the one who has the keys to your office, locked file cabinets, etc. Avoid chosing a close family member of friend for this role.
Step Three
o Make a list for your ERT: location all your essential practice information, how to get access to patient contact information, where you keep your appointment list, who has access to this data, etc. Then, list who you would want to refer each patient to when you are unable to continue in practice. Note whether they have agreed to take your referrals.
Step Four
o Keep a file in your locked file cabinet for your ERT including a treatment summary for each patient. 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.
Step Five
o Create a list of active patients that includes their preferred method of being contacted, treatment modality and whether they are “high risk” or have special needs. If you use a computerized billing program, use it’s patient list to simplify this task. This way, when your Bridge Therapist goes to your office, he or she will be able to find necessary information like phone numbers, etc.
Step Six
o Be sure that your office policies are updated. They should at least mention that you have a trusted group of colleagues who have agreed to serve as back ups in the event of your absence. It is important that your TPW is compatible with your estate plan. You may want to check with your attorney or state mental health association about your TPW. Provide a copy of your completed professional will to your accountant, a family member and your attorney to be kept with your personal estate plan.
Take ten minutes after you finish this article and start a temporary folder labeled "In Case of Emergency."
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 "Therapist’s Professional WillÔ: Guidelines for Managing Planned and Unplanned Absence” 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 patients' well-being.
Assemble all your malpractice insurance and practice-related legal documents in one place so you have easy access to them when you work on your TPW.
How About Now?
Creating your own TPW builds connection and belonging and eases the stress and burden on your family members, colleagues, and others during a time of crisis or loss and grief. Your TPW reduces the guesswork, confusion, and headaches that often accompany unexpected events that make you unavailable to your patients.
By creating your TPW, you and your ERT will be better prepared to help patients manage unwanted treatment disruptions. This project is beneficial for senior psychotherapists, trainees, early career psychotherapists and health care providers. Starting this project will bring you closer to creating one of the best gifts you can give your patients, loved ones, and yourself. Planning ahead is an investment in everyone's peace of mind. They will appreciate it more than can be imagined.
How about starting now? Take 10 minutes to list 3 colleagues with whom you would be comfortable discussing these ideas. Commit to scheduling meetings to keep yourselves on track.
For more information about The Therapist’s Professional WillÔ: Guidelines for Managing Planned and Unplanned Absence, see www.PsychotherapistTools.com.
As Groucho Marx said “We should learn from the mistakes of others. We don’t have the time to make them all ourselves.” When can you start this very do-able project? You’ll be glad you did!
Disclaimer: The information in this article does not represent legal advice and should not be relied upon as such. As with all matters, check with an attorney practicing in your state to ensure that information you want to include in your professional will does not run contrary to your state’s laws and is consistent with your personal estate plan.
About the Author:
Ann Steiner, Ph.D., LMFT, CGP, FAGPA* The author of “The Therapist’s Professional WillÔ: Guidelines for Managing Planned and Unplanned Absence,” a downloadable guide for psychotherapists, is in private practice in the San Francisco Bay Area, and is a pioneer in creating, developing and teaching the Therapist’s Professional Will.Ô She provides continuing education, presents programs, consults to psychotherapists, and has published articles about the therapist’s professional will for over 12 years. She delivers keynotes and workshops for national and international societies, including the American Group Psychotherapy Association, the International Human Learning Resources Network.
Dr. Ann Steiner served as an Associate Clinical Professor, Dept of Psychiatry, UCSF, for 14 years, is on the faculty of the Psychotherapy Institute’s Group Therapy Training Program, is a Fellow* and Board Member of the American Group Psychotherapy Association, and was President of the Northern California Group Psychotherapy Society.
Further information, updates and resources for developing your professional will are available at Dr. Steiner’s website: www.PsychotherapyTools.com Discounts are available for multiple orders. She may be contacted at
Her Medical Information Form is an easy-to-use computer record that anyone taking medication can carry with them at all times. It is available free to the public at www.DrSteiner.com. She is currently writing a self-help book about dealing with chronic medical illness.
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Selected References
Becker, E. The Denial of Death, The Free Press, New York, 1975.
Johnson, W. B., Barnett, J.E. (2012) When Illness Strikes You: What are Your Ethical Obligations as a Practitioner in the Face of a Life-Threatening Illness? American Psychological Association Monitor on Psychology, (43)10, 50-57.
Chernin, P. (1976) Illness in a Therapist-Loss of Omnipotence, Archives General Psychiatry, Vol. 33, Nov., p. 132.
DeWald, P. (1982) A Serious Illness in the Analyst: Transference, Countertransference, and Reality Responses, Journal of Psychoanalytic Association. Vol. 30, No 2, p. 347.
Fieldsteel, N. (2006) When the Therapist Says Goodbye. International Journal of Group Psychotherapy, 55 (2), pp. 245-279.
Gerson, B. The Therapist as a Person: Life Crises, Life Choices, Life Experiences, and Their Effects on Treatment, The Analytic Press, 1996.
Gold, J.H., Nemiah, J.C. (eds) Beyond Transference: When the Therapist's Real Life Intrudes, American Psychiatric Press, Inc. Washington, D.C., 1993.
Guy, J., Souder, J. (1986) Impact of Therapist's Illness or Accident on Psychotherapeutic Practice: Review and Discussion, Professional Psychology: Research & Practice, Vol. 17(6) p. 509.
Halpert, E. (1983) When the Analyst is Chronically Ill or Dying, Psychoanalytic Quarterly, 1.1.
Ireland, M. Plan for a Professional Will in the Event of Illness, Disability, or Death, unpublished manuscript, 1998.
Kahn, F. (1998) Ending A Clinical Practice in The Event of Disability, Retirement or Death, California Psychologist, April, p. 89.
Levin, D. (1998) Unplanned Termination: Pain and Consequences, Journal of Analytic Social Work. Vol. 5(2) p. 35.
Rauch, E. (1998) A One Session Memorial Group Following the Death of a Therapist, International Journal of Group Psychotherapy, 48 (1) p 99-104.
Samuels, L. When the Analyst Cannot Continue, The San Francisco Jung Institute Library Journal, Vol. 10, No. 4, 1992, pp. 27-38.
Schad-Somer, S. (1985) Situational Countertransference, Journal of Contemporary Psychotherapy. Vol. 15(2) p.156.
Schwartz, H., Silver, A. Editors, (1990) Illness in the Analyst: Implications for the Treatment Relationship,
Madison, CT, International Universities Press.
Steiner, A. (2001) When the Therapist Has to Cancel, The Therapist, Jan/February, p. 52-54.
Steiner, A. (2002) The Emergency Response Team: A Back Up Plan Every Clinician Needs, The California Therapist, April/May, p. 69-77.
Steiner, A, (2007) The New Therapist “The Empty Chair: Making Therapist Absences Less Traumatic for Everyone.” 48,11-21.
Steiner, A. (2011) Preparing Your Clients and Yourself For The Unexpected: Therapist Illness, Retirement, and Death, The Therapist, (23) 6, 47-56.
Steiner, A, (2011). Therapists Need a Strong Back-Up Plan, The National Psychologist, July/August, 20-21.
Steiner, A. (2011) The Therapist’s Professional Will™: A Back-Up Plan Every Clinician Needs, GROUP. (35)1, 33-39.
© Copyright Ann Steiner, Ph.D. 2000-2013. All Rights Reserved.
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The Therapist's Professional WillÔ: If Not Now, When?