Dear Young Therapist: Allow for the Unexpected

Dear Young Therapist:

No graduate program can prepare you for everything that is going to happen in your career. As you embark on your journey as a therapist you'll want to be sure you make allowances for the unexpected to happen. It will--in ways that you'll never expect. 

My training did not prepare me for what happened on April 15, 2013. Bombs went off just two and a half miles away from my office in Cambridge. While I could not hear the explosions, I could hear sirens and helicopters as the day progressed. My heart sank hearing the news between my appointments: my city--my home--was under some sort of assault. 

I reached out to friends and family. I was safe. They were safe. 

My mind quickly turned to my patients--some forty people scattered across the Boston region who call me their psychologist.

Were they safe? 

Some volunteer every year at the finish line of the Boston Marathon. Others live or work within the area of the blasts. Some, experienced survivors of all sorts of trauma, were likely to be stimulated and flooded with fear. I worried about them reliving their own personal hell from the past.

I wasn't trained to reach out to patients when I think they might be in distress. I wasn't trained to know what to do when bombs exploded just a couple of miles away from my office. What teacher could anticipate such a thing?

You'll learn in your practice that sometimes the right answer to the situation isn't the thing that your supervisors taught you. Ethics are important. It's important that you spend years studying your ethical code so you can develop a deep understanding of the complexities of being ethical in your practice. You'll need lots of colleagues to talk things over with. You also need to learn how to be responsive in ways that codes and protocols cannot teach you.

You've got to make allowances for the unexpected and know how to make decisions when the world around you has fallen apart. Days will come when you'll have no supervision, guideline, or protocol to follow. You'll be on your own. You'll know you've finally earned your license when you know how to make a path of your own that's strong, clear, ethical, and wise. 

I end each appointment with the same phrase: Call me if you need me. Some have taken me up on my offer, others have wondered for years what I mean by that phrase, and some others roll their eyes at my predictability  My intentional predictability.

After the bombs went off I could have easily just waited for patients to call me if they needed me. If they did, that's fine. I would know what to do. If they didn't, that's fine too. I'd wait to see what they brought up in their next appointment. That's what I was trained to do. That's what my supervisors told me to do. 

Sometimes, young therapists, you have to set aside rigid ethics, protocols, and supervision. There are times when the right thing to do is to reach out to your patients like a fellow human being. Sometimes, you have to listen to your heart and trust your training and experience will guide you through difficult uncharted territory.

I  was trained to ask myself why I wanted to do any particular activity that I was considering. Was I reaching out to my patients to satisfy my own personal needs? Yes. Of course. I wanted to be helpful, useful, and to ease my fear that some of my patients might be maimed, dead, or terrorized. I felt very helpless and wanted some magic balm to make myself feel powerful.

It's not the job of my patients to easy my fears. I can be afraid. I can tolerate it. I can let my fear stand without forcing it to be bigger or smaller than it is. There was no need to reach out to my clients to assuage my fear. My helplessness is also something that I can withstand and tolerate. I don't particularly like the feeling, but it comes with the territory of being a psychologist. As with fear, I can let that feeling be what it needs to be without trying to change it (with varying degrees of success). 

So no, it wouldn't be right to reach out to my clients to manage my own fear or feelings of helplessness. I'd have to deal with those on my own. There was, however, another reason. It was the reason I ended up listening and responding to: I wanted to give each of my patients a gentle reminder that I am here. I am present. I am witnessing these events, these bombings, just the same as I witness every other event shared with me in my office.

That's what my work is about: noticing all the ways in which patients announce their presence to me (or hide from me) and noticing all the ways in which I announce my presence to my patients (or hide from them).  We can dress it up with fancy terms (Gestalt, CBT, DBT, hypnosis, etc.) but therapy is really just an elaborate game of peek-a-boo.

I took an unprecedented step--not done a single time in my twenty plus years of clinical practice: I reached out to every one of my patients. One by one I checked in with my patients by text, phone, or email. It was the right thing to do. It was the human thing to do. 

The content of these contacts, and the responses, are private. They belong inside my consultation room: not in the outside world. The process of why I did it is what is important to share.

A supervisor once taught me about the difference between human errors and technical errors. Patients, she said, generally have endless forgiveness for technical errors. Appointments that start late, therapists that get sick, and other technical details like that can be worked through. Human errors--neglecting the care of another human being--are generally never forgiven.

I felt that had I not contacted my patients, I would have engaged in a human error that I could not recover from. I would have been neglectful of my patients and would have violated everything that I believe in about the therapeutic enterprise. 

I would have missed my patients--dropped them--and had not been present at an important time in the world. I would have been hiding at a time that I needed to be present. 

Four days later the bombs came again. 

This time the danger was at my doorstep. Places I had walked with Maggie just a few hours earlier were crime scenes. Our city was on lock down and I was reaching out to my patients again. 

Crazy times. No supervisor gave me a roadmap for this. I found one of my own and hope it helped my patients find their own roadmaps through this uncharted territory.

I hope you never have bombs go off around you, young therapist. I know the unexpected will happen and nothing I can do will shield you from that. Hopefully these words will come to mind as you chart your own course through the difficult terrain you find on the road ahead.

For more letters to a young therapist see Dear Young Therapist: Don't Be Afraid of the Dark; Dear Young Therapist: That Time My House Burnt Down; Dear Young Therapist: Cultivate Patience and Listen to the Music; Dear Young Therapist: Consider Your De Rigueur Requirements | The Post-Doctoral Tie Incident; Dear Young Therapist: Are You Ready to Jump; Dear Young Therapist: Perspective is Everything; Dear Young Therapist: Sometimes We Can't Put Humpty Back Together Again; Dear Young Therapist: Sometimes Race and Sex Matter; Dear Young Therapist: Don't Be Afraid to Love; and Dear Young Therapist: Allow for the Unexpected.