Sunday, April 28, 2013

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.


  1. This is such wonderful advice, especially when we feel paralyzed by ethics or law even though we know what the helpful thing to do would be. Thank you!

    1. Thanks for stopping by and commenting, Roy.

      I remarked once to someone that I supervised that it was important to follow ethics rigidly when working as a student and first starting out in practice. The codes--and rigidity of the codes--are helpful in forming a shape of what will be a very ethical career. Over time, with lots of experience and consultation, there grows room for flexibility.

      There are things that I do now that I would never have dreamed of doing when I was a 25 year old therapist. The accumulation of supervision and experience has allowed me to be comfortable and knowledgable about the contours of my practice.

  2. I can't say that I've stretched the grey areas of my ethical boundaries much. The only times that I can remember is sending sympathy card(s) to family after my client(s) passed away(of course the family knew me, and were often part of tx). This post encourages me to reconsider what my boundaries are and why. Things to think about

    I also enjoyed your thoughts on therapy being an elaborate game of peek-a-boo how clever/playful :)

    1. Hi John--it too me a long time to enter into the grey areas of ethical boundaries. I once had a supervisor tell me that if I was contemplating something I should ask myself if I've every had training and supervision in it.

      Give a graduation gift to a client? As a student, I had no prior training or supervision in gift giving to a patient. Years later, such things came up many times, and I was comfortable giving a small token of recognition to someone completing a very long journey in school.

      It makes me feel very long in the tooth to think about all the experience that my accumulated hours of supervision, training, and clinical work has provided me.

      A sympathy card, by the way, is a lovely gesture. I think our training programs forget to teach young clinicians that it's okay to be human, with feelings, and that there is plenty of room to express those feelings.

      I've been meaning to write a blog post about love. In one of my practicums there was a particularly strong lecture one day about expressing love in the context of therapy. It was a powerful lesson I still think about.

  3. Such an excellent post - thank you for writing this. I won't forget what I've read here.


    1. Thank, Alannah. I'm so glad you found this post helpful.

      I hope you enjoy the journey your practice brings you.