The Plan

(or How to Call a Minga)

I have something I want to say to all the therapists out there, novice and experienced alike.  Perhaps this message will fall on deaf ears and go unheeded, much less unread.  But I still feel the need to put it out there, just in case someone is listening.

So here’s the thing: you have to have a plan.

I know it’s easier to think that you are the omnipotent being you undoubtedly project onto your clients. But I’m here to remind you that you are not.  And that while you may try to promise your clients (and probably yourself) that “you’re not going anywhere,” life happens and you need a plan for when it all goes careening off the rails.  You are not immune just because you are a therapist.  And I would argue that you have a responsibility, a moral and ethical imperative set higher than many other professions, because of the work that you choose to do.  If this seems like too much to reconcile, I would ask that you give serious thought to your current career path.

I’m not saying that this will be easy (it won’t) or pleasant (it won’t) but it must be done.  Make a plan.  Not a theoretical hypothetical plan.  An actual plan based on real-world scenarios.  What happens if you get sick?  What if the illness forces you to go on short-term disability?  Long-term disability?  What if you need to retire (for whatever reason)?  What if you burnout?  What if your kids get sick or your parents need care?  What happens if you die?  Immediately or after a long illness?

Then what?  You have to think about this.

No one likes to think of death or their own mortality or irreversible outcomes that forever change the course of life.  Drawing up a personal will is a most unpleasant experience, one where you have to picture a world without you in it and how you want to handle all that is most dear to you.  It is jarring and unsettling.

This idea of a “clinical will” seems to make so many people uncomfortable that I could only find two references online (here and here).  You are entrusted with people’s hearts and souls and lives and there are only two Google results giving any kind of guidance in how to plan ahead in case bad things happen?

All have to enter into therapy with a kind of blind trust, until real trust can be created.  So even clients who are just starting out on this journey are vulnerable, having had to give away parts of themselves on good faith alone.

Sherry Amatenstein, a therapist and writer, said this in an article in yesterday’s New York Times on the importance of writing a will: “I think it’s an act of love to do a will, because you’re trying to make life easier for those we leave behind.”

The first thing to decide is an executor for your plan.  Just like with a non-clinical will, you need someone to be able to execute your plan should it be needed.  This person needs to know where you keep this plan and how to contact your clients.  Ideally, you will have a team of clinicians who can come together to help, but every team needs a leader and this is no exception.

As part of this plan, you need a profile on each client in your current caseload.  This should be a brief summary, with the intent to give your support team just enough information to understand the client: backstory, current goals, unique qualities, 1 or 2 clinicians with whom you feel this client would have the best chance of connecting with in the event of needing to transfer care.  Potential clients often have to make decisions about therapists based on the minimal information provided in a Psychology Today profile – so it doesn’t need to be a comprehensive report, just enough for the team to get a feel for the client and a sense of what will be best moving forward for each individual.

And yes, you need to keep these profiles updated as your caseload changes.  You need to add profiles for new clients, archive ones for graduated clients and even update the summary and referee suggestions for those in your care, as needs may change as growth (or setbacks) occur.

Just like we review wishes in a non-clinical will to make sure it is in alignment with our current state of affairs, so must you too.  We ask questions like: are we still comfortable with our choice of our executor?  Guardians?  Trustees?  Has anything changed in the lives of those people that would cause us to reconsider our choices?  Have the needs of our children changed?  What is in their best interest, at this point in time?  It’s one thing to think about a guardian for a child you only wish for, another for a child here, growing and changing before your eyes.

During this time of intense disruption, it is important to keep clients up to date as best you can, either personally of through your support team.  Clients need some information, but not necessarily all the gory details.  The worst thing to do is to just disappear.  The lack of information only compounds the inevitable loss your clients will be experiencing.  They have a right to know why there has been a sudden interruption in their therapy and what they can reasonably expect, given what is known and understood about the situation, in order to re-calibrate as needed.  Is this a permanent interruption?  Temporary?  For how long?  I know that sometimes the answers to these questions are unknown, but your clients will probably be feeling lost and confused and the knowledge of what might come next can be anchoring and comforting if such information is available.

Perhaps the best thing your support team can do is to reach out to your clients.  Let them know what is happening, that they care and are here to help.  Perhaps this is considered taboo, but your support team might need to reach out to clients, who might be in a state of shock, more than once.  They might need to check in a few times to assess how people are doing, who is moving on and who is stuck and might need some extra support.  I never said this would be an easy or quick task.  Signing up to help support a fellow colleague’s caseload in a time of crisis will take dedication, time, energy and effort.  Perhaps without financial compensation.

And finally, you must provide an opportunity for closure, to the best of your ability.  Even most employees in “at-will” employment give employers the courtesy of a two week notice.  An article in Counseling Today issues this stern warning: “Holding a professional license means that you might have to place the needs of others before your own.  Therefore, leaving a job or otherwise ending a therapeutic relationship requires planning.  […] To ensure compliance with laws and rules, these referrals should be legitimate referrals to other competent professionals. Directing the client to call his or her insurance company is not sufficient.”

In another article in yesterday’s Times, Paul Moon shared his own reflections on being the son of a funeral director.  These thoughts most resonated, as he spoke of trying to persuade relatives to attend a viewing for the author’s deceased grandfather: “I tried to convince them that seeing a loved one for the last time is an essential human tradition.  […] I’ve found it to be extremely helpful in getting the closure to begin grieving.”

There is a reason that “termination” of therapy is such a weighty topic, even under normal, non-emergency circumstances.  I know that events that may trigger the execution of such a plan may not allow for such pre-planning but if the fates allow, a client should always be given an opportunity for adequate closure, a final loving gesture to help that person move on.

As a therapist, you make a pledge to safely ferry your clients from one side of the emotional chasm to the other.  Just like the captain of a ship says, “I will get you there safely, and if we hit an iceberg, I will make sure you are safe before I jump.”  So too must you consider the welfare of those in your care.

I’ve heard several anecdotes of therapists who found themselves facing an illness, but even so, managed to stay.  One even continued to practice for two years, wig and all, as she slowly weaned her clients away from her.

If this all feels too overwhelming for you, then perhaps simply think about what you would want to happen if something suddenly happened to your therapist (and yes, you should have a therapist of your own).  What would you hope to happen?  What would you need?  How would you feel if that person suddenly disappeared from your life?  What would help ease the shock and transition?

I was recently introduced to the concept of a minga.  A minga is a South American term (specifically from the Quichua language) that roughly translates as “a coming together for the collective good.”  Notice that we can only translate the concept of a minga, as there is no such word in the English language.  But in these remote Andean communities, when a minga is called, everyone stops what they are doing and the villagers come together to solve the problem at hand.  In addition, the minga is sent to neighboring villages, and they too come together.

When my ex(?)-therapist got sick, this is what I wish had happened.  Maybe this is all impractical, but it’s still how I wish things had played out, instead of the way that they did.  A group of trusted colleagues would have been convened, maybe even in my therapist’s office all crammed together on the couch and chairs and maybe even some sitting on the floor.  Together they would have reviewed the current case load, one by one.  Clients would have been divvied up as best as possible based on individual needs, personality, potential match to another therapist – all in the very best interest of that particular client.  The group would have then dispersed, each with names and contact details for clients to contact.  Follow-ups would occur as needed.  No one would be left behind.  And as talk shifts to her coming back to work, I wish she would take care of her current clients before taking on any new clients.

Maybe this is all just a fantasy, with no rooting in reality.  Still it’s how I wish things had played out, my own wish for a better ending.  A minga for me and for heartbroken clients everywhere – because, sadly, this happens more than you would expect.  All the more reason to have a plan at the ready.  Do it for your clients.  Do it for yourself.  Who will call your minga?  And what will it be?

 

One thought on “The Plan

  1. Mallory Kates

    Great job. Maybe you ought to send this to Psychology Today. And as an aside — there really ARE protocols that therapist organizations advise their members to adhere to. Most therapists don’t of course.

    Like

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