When the Therapist is in Crisis: Personal and Professional Implications for Small Community Psychotherapy Practices

Introduction

Most of us will face personal crises at some points in our lives. Going through personal crisis as a psychotherapist, especially in a small community, can present special challenges. This article addresses the issues that arise in the course of facing personal crisis and is based on our experience and those of some of our colleagues. Some issues are practical: how clients are contacted to cancel appointments, how much information to reveal about the crisis, how to arrange for coverage, and when to return to work.

Other issues stress therapeutic skills—coping with difficult clients when we ourselves are in pain, handling client anxiety, anger and dependency, plus managing our own reactions as we strive to do our jobs while grieving and being vulnerable.

My husband and I have been psychotherapists in a small community for the past 30 years. David is a social worker, treating individuals and couples, and has worked in several community agencies, including at our local hospital as Director of Social Work.

I am a psychiatric nurse practitioner in a full-time private practice, providing talk therapy and psychopharmacology. My practice is based on a bio-psycho-social model and clients entering treatment are evaluated not only for their presenting problems, symptoms, and history, but also for thorough medical history, assessment of current physical problems and medications. If necessary I order blood tests and encourage up-to-date physicals as needed.

In therapy sessions the focus is as much on a client’s current social context, nutrition, substance use, exercise, as it is on other coping strategies, past traumas and family history. My training and clinical experiences are within a psychodynamic framework. I work within the context of an Interpersonal Psychotherapy model, initially developed by Gerald Klerman and Myrna Weissman (1993) for clients with depression. This fits well with my practice population. I engage each client in an empathic relationship that promotes trust, self-awareness of moods and behaviors, and positive change. Treatment is “solution focused,” using the “possibility” approach of therapy as developed by Bill O’Hanlon and others (1999), which emphasizes problem-solving in the here and now.

I see clients with depression or other mood disorders more frequently at the beginning of treatment and then less frequently for maintenance and relapse prevention. I view my role as an educator and collaborator with my clients; we partner in planning their treatment and improved well-being.

Because my therapeutic role with many of my clients focuses on being a health educator, my small-community based practice is not quite as impacted by boundary keeping as a practitioner providing long-term psychotherapy, yet keeping boundaries is always an issue. I have experienced many of the privacy issues common to therapists in a small town, where it can be next to impossible to keep a clear separation between one’s private and professional lives, and where the overlapping of personal and professional roles is often unavoidable. The small-town practitioner is routinely challenged by personal and clinical situations involving a loss of privacy and anonymity that the therapist in a large urban center may never have to face. We vigilantly guard confidentiality at all times because we frequently see clients and former clients at community events, meetings, parties. We may exercise with them in the gym and attend the same yoga class. Some clients want to share personal information when meeting us in the grocery store. Often, clients are friends of our friends, are invited to the same social events, are parents of our children’s friends, or teachers of our children. At times, in a complete role reversal, clients have provided healthcare or some other service to our family. This can cause complications for therapists trying to work through transference issues with their clients because in a small community practice, a therapist is not able to present as a “clean slate”. Much information about the therapist may already be known to the client and vice versa.

For the most part, however, we have learned to balance our roles as professional and private citizens and to raise our four children to adulthood. We have not hesitated to voice our opinions (political and otherwise), participate on boards and community events, and lead active social lives. In fact, the balancing act has probably become easier as we have aged because we became more flexible and comfortable with dual relationships. Our sense of privacy about our own family, however, has always been a priority, in large part because of our role as psychotherapists, but also owing to whom we are as individuals—a (usually) self-reliant and self-contained couple.

Crisis: Immediate Response, Communication, Coverage

Nothing could have prepared us for the event that changed our lives nine years ago when our oldest son was injured in an automobile accident and suffered a severe traumatic brain injury. He was initially given a 50/50 chance of surviving through the first night. But he was medically stabilized in the ICU, spent three weeks in that hospital, and was transferred to a rehabilitation hospital 300 miles from our home.

News traveled fast, not only because of our place in the community, but also because our son was well known and loved as a friend, musician, and community service worker. Within 72 hour of the accident, a large portion of our village and the larger community were aware of our circumstances. Instantly, the crisis made our lives an open book and we became dependent on the assistance and good will of others.

From Private Provider to Public Persona

At first a good friend served as a gatekeeper to control both information sharing and visitors; another friend started an e-mail listserve, providing updates on our son’s condition and the effects of the accident on our family. The e-mails served the very useful function for us by disseminating information and protecting us from well-meaning, but intrusive, questions and weary repetition. However, we had no control over who received these e-mails nor to whom they were passed on to—including our clients. We very quickly went from having a low-key private life to “living in a fish bowl”. We were too preoccupied with our son’s condition to be very concerned about privacy. Still we wondered who was receiving information about our son’s medical status and other details about our family life.

A Practice on Hold

In addition to the overwhelming outpouring of support we received from our close circle of friends, the psychotherapy community responded as well. Colleagues made phone calls to our patients, put signs on our doors advising of our absence, provided clinical coverage, and fielded questions from clients and other providers about what had happened.

Still, there were the practical matters of trying to run our practice for an indefinite amount of time from 300 miles away. By the end of the rehabilitation, we were away for nearly 11 months. In the first five or six weeks, our practices were on hold, with colleagues seeing our clients when necessary and providing prescriptions. For the next three to four months, both David and I attempted to maintain limited practices, with one of us working two or three days every other week, so that one parent would always be at the hospital with our son.

This worked relatively well for a while, providing each of us with a distraction from life in a rehab hospital. It also allowed us to keep our connection to our friends and our professional lives at home. However, the traveling back and forth and squeezing a workload into a couple of days was exhausting and began to take its toll, emotionally and physically, on us. As our son’s progress continued with many ups and downs and uncertainties, we had to reassess our capacity to be in practice and meet our family’s needs. My husband put his practice on hold first in the spring and remained with our son. By mid-June, I also decided not to return to my office for the summer and handled prescription requests and medication questions by e-mail, which felt less intrusive and more manageable than the telephone. Obviously, this could only work for my clients who were stable enough to get by with this limited supervision. Those with greater requirements were referred to other colleagues. Some chose to leave on their own, others chose to stay in treatment with us despite our limited availability and the unpredictability of our absences. Some clients did not seem to know anything about what had happened, others appeared insensitive to our situation and focused on their own needs, but most of those clients who knew, were very concerned and supportive.

Views From the Therapeutic Community

Immediate Responses

After the initial crisis passed, we discussed our situation with other therapists and found amongst our colleagues who faced their own personal crises many similarities in struggling with vulnerability, obtaining practice coverage, revealing information to clients, and determining when to return to work. Irene, Janis, and Paula are all experienced therapists in our community. In addition to their commentary, I have included commentary from my husband and myself.

David

I found that it was initially very hard for me to listen to, let alone accept, what were often genuine expressions of concern from my clients. At first I had the urge to minimize or dismiss the impact of the trauma on me to my clients. Outside the office I was constantly preoccupied with the state of my son’s condition and so in the office I felt myself directing the focus back to clients’ issues. I was aware of what I was doing, but felt so vulnerable that I could almost not bear to attend to the relevance my situation might hold for some of their lives. I was still too much in the “eye of the storm”.

Prior to private practice, I had held a number of local agency positions and was a well-known presence in the community. When I came home for these brief work periods, I tried to avoid being seen in public as much as possible, going to the post office during off hours and driving everywhere instead of walking around downtown. It was too difficult to face the concern and questions of strangers or casual acquaintances, to face the psychodynamic material too close to my open wounds. Eventually I needed to be full time at the hospital and to narrow my focus and my strengths to be a constant and driving part of my son’s recovery. This clarified for me that I had been spreading myself too thin. It became clear that I needed to stop my practice temporarily and be available only to my family.

Irene

A little more than two years ago my husband died suddenly from a heart attack. On the night he died, very close friends came over to the house. My son and I were in a terrible state of shock. Later in the evening I remembered that appointments for the following day had to be cancelled. My friend made the phone calls to my clients with me sitting next to her. The following day I arranged coverage with two colleagues and gave them a list of my active clients. I believe they split the list in half and contacted everyone, offering their services as needed. I was home for six weeks before returning to my practice on a limited basis.

Janis

Two years ago while away on vacation I had a serious medical emergency, which involved emergency surgery and three weeks in intensive care. Because I was on vacation, I already had a colleague covering my practice and she continued to cover for me in my absence. I missed a total of five weeks from my practice. While I was incapacitated, in order to cancel the appointments I had made, my husband and a colleague were able to access my client list from my computer and appointment calendar and make calls to my clients. Also, a friend put a sign on my office door that said “Closed due to family emergency”. Later, I was able to leave a message on my answering machine stating that I would return to work on a certain date and reiterated the contact information about my covering clinician.

Paula

My most recent crisis was my husband’s serious illness this past year. I was only out of work for two weeks and then returned on a limited basis. I took my own calls and responded to client calls, which felt all right because my practice is made up of fairly high-functioning people.

Self-Disclosure and Other Communication

Therapist self-disclosure has been an issue of controversy in the psychiatric literature and can be an especially difficult strategy when we ourselves are suffering (Tsai, Plummer, Kanter, Newring, & Kohlenberg, 2010). There is general agreement, however, that self-disclosure must serve the clients’ best interests and be thoughtfully done (Tsai et al, 2010). Bram (1995) spoke of keeping a balance between beneficence and truth telling, being honest yet not over-revealing nor burdening clients with too much information. In our case, in such a small community, disclosure was often made for us, but how much else we revealed was our decision.

Denise

The message that was conveyed to David’s and my clients was that we were away indefinitely for a family emergency. The names and phone numbers of covering colleagues were given. However, much information— both accurate and rumors—circulated within our community. In addition, we had little control over the e-mail distribution. Although clients’ expressing concern and asking questions about a therapist’s private life is not a usual topic for therapy, once I had returned to work this came up frequently and often revealed insight about my clients’ emotional stability, needs, and sometimes transference issues. In each session I had to make decisions about how much information to give in response to their questions. I sorted out whether to use their feelings about our situation and our very limited availability as grist for the therapy mill. I was often surprised by how much knowledge some of our clients already had, usually due to their connections to others who knew us or our son, or because they were receiving the e-mails.

Many clients had very limited understanding of our son’s injury and its consequences. Some were in hopeful denial about the seriousness of the injury, others overly pessimistic. Some clients wanted to be reassured that our son would be “all right” and reach a full recovery. Most clients who were aware of our situation would inquire at the beginning of sessions as to our son’s status. I would usually give a brief response depending upon my relationship with the client, his or her interest or need to know information, and how much I felt comfortable revealing. Most were satisfied with brief feedback and then moved on to their own therapy issues.

Irene

I’m still not sure exactly what information was shared by my covering colleagues. Some clients learned that there had been a death in my family, and others learned that it was my husband. Many read his obituary in our local newspaper so that the information was very public. Once I was working again, I approached each inquiry on an individual basis. I tended to keep my responses simple and to follow the client’s lead.

Janis

I initially did not intend to give a lot of information to clients, but several revealed to me that they knew some very detailed information via the grapevine, either through colleagues who gave out information about me without consulting me, or through contacts of my husband’s, who were quite free with information. Once I actually got back to work, several factors led to my divulging more information to my clients. When people asked, or when they had received incorrect information about me, I told them the essentials about my diagnosis, recovery and prognosis, partly to reassure them that I was safe and competent to be working. After a few weeks, I began to see that most of my clients who knew of my absence had received or inferred information, or had formed a hypothesis about me. At that point I felt free to give them clarifying information, after ascertaining that they actually wanted to know.

Paula

I just told clients it was a family illness, and for the most part, I was brief and nonspecific. Most of them said “I hope it gets better” or something like that and did not pry as I was obviously not telling them what it was. I reassured them that I would be available by telephone and scheduled their next appointments. For a very few, who were long-term clients and who I knew had strong boundaries, I said “My husband has some health issues but is getting better.”

Deciding to Return to Work

Bram (1995) wrote that the therapist’s desire to return to work can be a reaction formation against feeling weak and vulnerable and may arise from one’s need to feel competent and to maintain a sense of identity. A therapist must be continually aware of how personal needs and limitations affect the ability to work effectively.

Denise

As I mentioned before, after six weeks away, I tried working for a few days every other week, traveling back and forth. Once I recognized how stressful that was on me, I took the summer off and then returned to work part time in the fall as our son was recovering. Work definitely was a distraction from my own difficulties. But … it was not helpful if it put more stress on me or if I could not be fully present and competent for my clients. I felt the dilemma that Irene and Janis also experienced: how to ease back into working by seeing one’s least difficult clients at first, when it was the most difficult ones who may need to see us the most. I decided that my clients who were really in crisis would be better off seeing another clinician. Plus, I had to go easy on myself. For me, deciding when I was ready to return to work was a process based on my son’s condition, my own emotional health, financial needs, the desire to re-engage with and help my clients, and to resume a professional life. Since much of my practice is medication management now, it was easier to transition to seeing these kinds of clients rather than doing intensive psychotherapeutic work.

David

My son’s injury and recovery process was a transformation for him and our whole family. None of us would ever be the same again. I did not return to work until January, a full year after my son’s accident. When it came time for me to return to my practice, I was both excited and cautious. I was eager to return to the comfort and familiarity of my office where I “knew my stuff”. While I thought I was prepared for the reactions and transference issues that new and returning clients brought to my door, I was still surprised when new clients sought me out because of what they had heard about our lives, while some former clients could not cope with returning and seeing me.

Irene

After a few weeks, I felt the need and desire to return to work. Being self-employed, and now a widow, finances were a concern. Also there was the need to be productive and to have structure in my life. One afternoon I was out kayaking with a friend who began to talk about his mother’s illness. It occurred to me that I was able to concentrate on what he was saying, as opposed to constantly thinking about my own situation, and that felt like a relief. When I was trying to figure out how to make the first phone call, a client who had sent me a card, contacted me at home. She thought she had dialed my office number and was looking to make an appointment. So, I really didn’t have to think about where to begin, and I also knew that this woman was someone whose needs were manageable. In general, I was careful initially to make contact only with clients whose situations would not overwhelm me. I eased back into my office very gradually. The first week I maybe saw two people, the second week, a few more. . . . I didn’t go back to full-time practice for more than six months.

Janis

I was told that I should take about a month off to rest before returning to work. The main impediment I noticed after returning home from the hospital was muscle weakness, making it painful to sit for extended periods. But once I could sit comfortably, I felt that I was ready at least to see my most stable and least challenging clients who would require the least out-of-the-office effort (weekly appointments already in place, rare after-hours phone calls, etc.). However, once my answering machine reverted back to me and not my covering clinician, I received many calls from clients claiming an “urgent” need to see me. I began to feel that it was arbitrary and unfair to see some, but not all, of my clients, even though this was the plan I had made for a gentle re-entry. I did not keep to my plan but instead attempted to see clients who themselves appeared to be in crisis. A concern to provide care overrode taking care of my own needs in a better way.

I had a need to be productive again. It was emotionally trying to be lying around the house all day. I was physically weak and in moderate pain, so I was limited in my activities. That left me a lot of time to feel useless. I am usually a fairly low-energy laid-back person, but after my illness, there was a particular need to feel like I had a reason to be alive, having had a near-death medical problem. I felt that somehow being back to work would justify my existence and give my life more meaning. Beyond that, I wanted to get out of the sick role. I felt like my identity was merging with my diagnosis, and I needed to get back to being a person. I wanted to get the focus off me and my problem and my work is well suited to that. Somehow this fed into my pressure to get back to work in two weeks upon returning home, rather than the recommended four weeks. Colleagues had also advised taking more time off but I did not take their advice. Being a money earner was mixed in with that too. But the recognition of the need to make money to make ends meet was not as pressing to me as the feeling of not wanting to be “useless”.

Paula

After two weeks I felt okay to return to work part-time—once my husband was safe to be home alone or someone was coming over to spend time with him. I live near my office so could check in on him easily. The decision was also made mainly due to my need to be productive and useful again.

Difficult Issues in Therapy: Client and Therapist Reactions

It is generally more anxiety provoking for clients when a therapist’s absence is sudden rather than planned and expected (Dewald 1994, p. 222). Psychotherapy rests on a foundation of interpersonal trust and any deviation in the therapeutic relationship can temporarily or permanently undermine this trust (Counselman & Alonso, 1993, p. 592). Therapists dealing with personal crises can expect a wide range of client reactions— sympathy, care taking, excessive concern, anger, guilt, denial, reactivation of trauma, as well as other forms of “acting out” behaviors (Tsai et al, 2010, p. 8). Still, a tragedy can offer the opportunity to deepen therapeutic collaboration and enhance the capacity for flexibility in client-therapist boundaries. (Mendelsohn, 1996 in Gerson, p. 26).

Denise

For the client, having a therapist who is vulnerable—whether due to divorce, medical illness, or the illness or death of a family member—can bring up many issues of transference, particularly abandonment fears, as well as concerns about practical issues, such as having regular sessions and getting prescriptions filled. Certainly, when our crisis first happened and we had to cancel appointments, many clients were quite upset (some believed something had happened to one of us), confused, and unsettled about when we would be back. Our return was so uncertain and made for higher anxiety and frustration. The different reactions we encountered had much to do with the personality structure and emotional stability of each client, history of loss, the therapeutic relationship, and the length of time in treatment. At times, not knowing exactly how much information each client had obtained made it difficult to sort out facts from their transference fantasies. Some clients were barely aware of our problem or acted oblivious to it. Clients who were just seeing me for medication management often were less aware and less affected by my vulnerability than clients who were engaged in long-term therapy with me. Many of the latter were sensitive to my hurt and worried state of mind, and some tried in their own ways to “take care of me” by checking in to see how I was doing, or by not wanting to “burden” me with their own problems. I had been their caretaker, and now my caretaking ability was in question. Sometimes this presented an impediment to clients feeling free enough to talk about their own issues because of their concerns about my feelings. I often had to reassure them that I was there to work with them on their problems. I realized that for some clients a therapist dealing with her own serious family crisis could generate fear—an injured child could happen to anyone. Clients might feel embarrassment that the issues presented in therapy would seem trivial by comparison. It was possible for positive identification with the strengths observed in the therapist and might possibly lead to an idealization of these strengths. These reactions can be catalysts in the therapy process.

I, of course, had my own reactions to clients’ behaviors. Some reactions were the result of being tired, stressed, and grieving. Some, however, may have crossed the line into countertransference when I had unrealistic reactions to clients based upon my own feelings and needs. I wanted to appear strong and available to my clients, but as contradictory as it might seem, I also expected them to be sympathetic and to go easy on me. I must admit that it often was extremely difficult to listen to some of the problems clients talked about while our son lay helpless in a hospital bed. Many of my clients’ problems were trivial by comparison.

On the other hand, I had become much more aware of and understanding about the effects trauma has both on an individual and on a family. Our trauma was recent and at least could be buffered because as care providers we understood “the healthcare system”. We also had a strong marital relationship and family ties, and community support. Many of our clients had been traumatized most of their lives, without the resources we had, and I was able to empathize more experientially with their pain and its aftermath. Alternating with my understanding, however, was irritability about how easily some clients tossed the word “trauma” around and how they used it as an excuse for an inability to change or take control over their lives. For a brief period of time, my anger about the injustice of my son’s injury and what had happened to us got the best of me and resulted in countertransference reactions with several clients. I was agitated and became too impatient and confrontational with some of my more resistant clients and yet foolishly believed for a time that I was a more effective therapist. My sense of helplessness in my personal life was causing me to become over-controlling as a therapist. I felt particularly angry at a client who, indignant about not being called back immediately for a prescription refill, cancelled her appointment at the last minute with the phone message “What’s wrong with you people over there anyway? I’m taking my business elsewhere!” I recognized then that I was not in good control as a professional, needed to take time off, and decided to spend that summer with my family. I knew that therapists should be open to all kinds of client reactions (including anger), and that I should utilize these reactions in the therapy. However, for a while, I was just feeling too raw and vulnerable. Also, some clients (like the woman on the phone) left treatment abruptly without the opportunity to explore and process their feelings. I was able to explore transference issues with some of my long-term clients, but not the majority of them for whom I was mainly prescribing medication.

David

I experienced several comments from clients that were particularly difficult to hear and were a real challenge to my feelings and reactions:

“I hear that everything is fine now with your family. How great for you.”

“You folks are so strong. I don’t think I could handle it.”

“I shouldn’t trouble you with my problems.”

“You guys are lucky that you work for yourselves and can take this time off.”

These kinds of comments left me feeling bewildered and frequently angry. I recognized that some were simply awkward attempts to express compassion while also expressing anxiety that I could no longer provide the care and attention which they felt they needed. Yet I felt too vulnerable, exhausted and distracted to really deal with these comments in any effective way and to challenge them would have meant revealing more personal information than I was comfortable with. So I mostly just did not respond. I quickly realized that it was too early in the crisis of my own life. If I was going to proceed with my practice, I needed to maintain a constant and vigilant awareness of both the possible impact of my own counter-transference and general fragility. I needed to allow my own healing to take place and not keep dividing my psychic energies. I made the decision to put my practice on hold for several months and attend to being an advocate for my son and a support for my family.

Irene

I appreciated and was surprised by the many cards I received from clients. But it felt awkward to be accepting condolences from people I was supposed to be helping. It was quite a role reversal. I felt sometimes that clients were going too easy on me, and I worried about my affect and how I was appearing to them.

One client in particular had a big fear of how she’d manage if she did not have her husband, so she didn’t return to treatment, even though we had worked together for quite a while. There were a couple of clients who did not return my phone calls.

The first year, many clients wanted to make sure I had plans for the holidays. One woman made me a CD of sad songs, “in case I needed to cry”. A friend who works in a different business told me that a mutual client reported to her that she was “taking care of Irene”, a very embarrassing thing to hear, especially since it was not true. Another client said she felt uncomfortable speaking to me about her problems because my situation was so much worse. Trying to offer reassurance around that issue was challenging. I had to emphasize time and time again that, while I was experiencing a loss, I had returned to work because I felt able to help others again and that everyone’s problems are significant to them.

One big challenge has been listening to individuals’ complaints because the people in their lives are imperfect. In the midst of my own frustration, I couldn’t very well say “If that person were gone from your life, you’d miss the way he/she didn’t take out the garbage!” Those can still be difficult moments for me. My loss of my spouse had generalized to other losses. Recently I was working with a middle-aged couple. They basically love each other and are good together. Yet it frustrates me to see (in my mind) that they don’t appreciate what they have together. I probably became a bit more forceful in getting them to focus on the positive aspects of their relationship. I might have had a little trouble staying neutral with issues like these. That may or may not have been useful with certain clients.

Another example, that is more specific was the client who was discussing a possible cardiac issue: I suddenly felt overheated, like having a hot flash, and my demeanor changed in some way. The client knew about my husband and noticed my discomfort. I explained my response and hoped she did not feel too burdened by it. There was much to keep track of: be present and authentic, think of the clients’ needs, maintain composure and remember to breathe, and still balance the framework of professional boundaries.

Janis

I did feel that some of my clients acted out their difficult feelings on me. . . . I had decided in consultation with four colleagues and my husband, that it would be easiest to start back to work with clients who were more stable and in weekly therapy The organizational logistics were also easy—call each of them, say that the following week I would resume the usual appointment schedule, and ask them to call me if they could not come.

I had a clerical assistant make the actual calls because I wanted to keep the calls short and let any questions come up in the sessions (I decided I would rather not risk the possibility of hours of discussion on phone calls meant just to set up appointments.) About sixteen people were called, and I was set to start up work the following week. One client called back asking if the appointment call had been a “prank call” because she didn’t believe I would have had someone else make the call for me. No one called to cancel or reschedule, but in the first week, six clients did not keep their appointments, including two who had called so urgently needing to see me. Were these clients acting out? Were they feeling alienated by my having a clerical assistant call them since this was something I normally did not do in my solo practice. Were they angry with me? Had they given up on me?

At the beginning I did feel mistreated by my clients. Perhaps I expected to be given a pass or a little sympathy. I was not aware of it, but in retrospect that might explain what was difficult for me at that time: I wished I had not bothered to try so hard figuring out the best thing to do. I wished I had not been thinking about my clients’ interests so much, that I had been able to be more “selfish”. But I also felt guilty about having hired an assistant to make those calls so that no solution felt quite right. I felt cornered with the threat of having too much work to do and no good option to hire assistance. I had established myself as a one-person office and people liked it that way so that I couldn’t change it. Yes, I know those thoughts were distortions, but that was what it was like returning to work, and it was the most difficult part. There were other instances of feeling taken advantage of—people making demands for urgent appointments and then having nothing urgent going on, only what seemed to me like trivial demands. It felt as if clients were acting out their dependent fears and grief about my illness by being inconsiderate, entitled, and dissatisfied with me. I see it now clearly, and even at the time I recognized that possible interpretation. What was difficult was how hurt and angry it made me feel. I’m not sure if my feelings showed during my sessions but I worried about this, felt guilty about my countertransference, being exposed, and then may have tried harder to meet clients’ needs, causing more resentment . . . a vicious cycle. There were two times that I revealed more personal information than necessary. I had two clients who in the aftermath of my illness were unusually demanding of me after I returned. One demanded frequent lengthy evening phone calls with repetitive complaints about what had gone wrong in her life during my absence. The other sent a letter to another health professional complaining about my lack of availability. I felt hurt and misunderstood and got tired of apologizing and trying to compensate. I finally decided that I would tell them that I had been extremely ill and unable to work during the period of my absence. I thought a little realism would be helpful rather than apologizing to excess about something I had no control over. I did not do this in anger, but I have to admit that my intention was to get them to back off the emotional pressure they were putting on me. I think that having been ill and temporarily disabled left me particularly vulnerable to feelings of inadequacy that I had not felt since the very first years I was in training. Thank goodness that was over two years ago, and I am no longer offended by my clients’ behaviors. I do not strictly adhere to a no-personal-disclosure policy and occasionally may tell an anecdote from my personal crisis. Sometimes, when I think it may be useful, I share my experience of being temporarily disabled from work but having recovered.

Paula

I had one client who was about my age and had a husband who had been chronically ill for about twenty years. He worked every day but was not a “supportive husband” in that he was uncommunicative and had no empathy for her or gratitude for what she did every day for him. We were working on her having more of her own life and her relationship with her grown daughters. The client was ambivalent about her devotion to her husband. She is a nurse and, if not for her care, her husband probably would have died long ago. Ours is such a small community, she knew who my husband was and what was going on. I knew that she envied me because I had a “supportive husband” and she was angry with me about that. After I returned to the office, she acted out by being a “no show” for our first appointment. As for myself, I did feel a little guilty that my husband was so kind, that we had a good marriage, and that taking care of him was not something I resented, as did she in her marriage. We wrestled with her jealousy and anger by focusing on how long her care-taking had been going on and how much a chronic illness can wear down both ill person and caregiver. I tried to help her see that chronic stress can sometimes cause displacement of negative feelings onto others and eventually she seemed to come to grips with how she was hanging on to those feelings and that they were not serving her well.

Coping Strategies

Therapists pride ourselves on being competent, giving, and useful. We often cope with anxiety by being caretakers and are not so comfortable with being on the receiving end of care giving (Counselman & Alonso, 1993). When in a crisis, therapists behave according to their personality styles, residual internal conflicts, adaptive and defensive coping strategies, and past history of trauma (Dewald, 1994).

Livingstone (2007) has written about therapists questioning the ability to function as caregivers when feeling raw with grief, because they are worried that they might break down in sessions. Andrew Morrison (1996 in Gerson, p. 43) stresses the importance of monitoring the “self-state” of the therapist on an ongoing basis and believes that if self-awareness and consultation with colleagues is present, even a suffering therapist can still be helpful. Indeed, a therapist may role model how one can cope with what is unbearable.

During the acute crisis, there is the adrenaline rush, and providers are able to do whatever is needed, but, for the long term there have to be other strategies for self-care. During the early stage of our crisis, a hospital staff member had warned us that dealing with our son’s recovery would be “not a sprint but a marathon”, and that we would need to find ways of taking care of ourselves. David and I not only had mutual, but also individual ways of coping with our crisis as it went on for many months. Music, spirituality, and my dog were comforts in my sadness and anxiety. I became absorbed in the 2004 Presidential election and immersed myself in becoming somewhat of a family advocate at the rehab hospital. My family had difficulty understanding why I was involved in these other issues, but these somewhat helped take me out of myself and my problems.

Practical Preparedness: Advice for Private Practice Therapist

Every therapist with regular psychotherapy clients needs to be prepared ahead of time for illness or unavoidable absence (Counselman & Alonso, 1993). This should be within our standard of practice, yet how many of therapists actually are prepared?

Being a private practitioner can be rather isolating work, especially following personal tragedy, crisis or trauma. I believe that one is at risk to feel even more isolated under the scrutiny of other professionals and others in the community. Many people do not want to get “too close to trouble”. My husband and I felt the support and connection to the small number of colleague/friends who shared our workspace and stepped in during our long absence to carry our practice and meet the needs of our clients. These colleagues continued to be emotionally, physically, and clinically available to us, assisting in our return to our practice routine.

The other therapists contributing to this article agree that adequate clinical coverage and support from colleagues was essential in allowing time for recovery and appropriate timing for return to work.

Based on the experiences of the five therapists in this article, some suggestions for preparing a course of action follow:

Conclusion

Self-awareness is crucial, especially when the therapist is in crisis and vulnerable to countertransference reactions. Therapists in crisis need access to supervision and often therapy. At times of crisis utilize colleagues for their guidance in assessing one’s capacities and deciding when to return to work, especially when dealing with difficult client situations. This is especially helpful if the therapist is not receiving supervision or therapy.

Therapists have an ethical obligation to ensure clients are provided for when we cannot do so. Life is unpredictable, crises even more so, and it is human nature to be somewhat in denial about something tragic ever happening to us. Although no one can ever be truly prepared for a crisis, try to set up the best plan possible, and hope never to have to use it.

A therapist’s crisis can take many forms. Some have a one-time, circumscribed crisis; others have chronic, repetitive problems that hamper the ability to provide regular appointments and reliable treatment for our clients. We have colleagues who will experience family emergencies— divorce, the death of a loved one, physical or mental illnesses, addictions. In a small community it is difficult, if not impossible, to keep these private. These therapists have had to deal with unwanted publicity and embarrassment as well as their own vulnerabilities while trying to care for their clients and keeping their practices afloat. It can feel overwhelming to balance one’s own needs with the needs of clients, and it is especially difficult to listen to our clients’ expressions of disappointment and anger when we are not always available to them. For the wounded therapist to be able to not only survive the crisis, but also to move beyond it and to grow, means working through our own stages of denial, anger, grief, depression, and, hopefully, acceptance. Doing so can present opportunities for growth in the therapeutic relationship which can help our clients heal from their own traumas.