Friday, September 30, 2011

Guest Blogger Dr. J: The Well-Planned Unexpected Retirement


 Dr. J wrote an article for a shrinky publication about how she was carefully planning her retirement with a one-year lead time.  Things did not go quite as expected and she wrote a sequel detailing all the distress of her well-laid plan going totally awry.  Dr. J kindly agreed to let Shrink Rap re-run the second segment of her story.
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I find it an ironic and even embarrassing fact that my prior article was mailed out on the very same day on which, instead, I abruptly announced my permanent retirement . I retired five months earlier than my patients and I had expected, and much earlier if you count the many prior absences that occurred in the Fall.  After a full year of working on terminations, my hopes and plans for that year, my high clinical expectations. This is what really happened.
This is definitely an odd little autobiographical piece following my own recent medical history, which, unfortunately, is necessary to understand the quality and prematurity of my retirement, and the consequent effects on my patients and me. Just before Labor Day, I suffered a surprise episode of severe atrial fibrillation, caused by a ruptured mitral valve chorda.  I was out for most of a week for a fast work-up, and then out again just before the planned but postponed  surgery for over a week in September, in the hospital for a near-sepsis severe abscess at the coronary angiogram site. That was followed by being in and out for pre-surgery-related reasons. I was away from early October through mid-November for the successful mitral valve repair, but it was complicated by a horrifying post-op delirium/reactive paranoid psychosis.
I learned, in a personal way, a lot from that all-too-common post-op experience- things that patients had told me about psychosis in so many ways in the days when I treated psychotic people. These words are carefully and precisely chosen by me: By being told that I was wrong about my memories of what happened, what I had perceived to be absolutely true, I was relinquishing memory ownership, and that is a very, very bad thing. It costs, deeply. It shakes you to your bones, especially since nothing in my mind has yet changed about those memories of mine feeling correct. Post-op delirium or psychosis occurs up to 50% of the time after major invasive surgery, especially cardiac, and yet it usually goes undetected unless it is the noisy kind, as mine was not. It very often evolves into PTSD, as mine did. It became part of the weave of my early retirement.   
In early September, to quote one very perceptive soul, I had been “la-dee-da” about my impending leave for open heart surgery. Such serious crises were in some patients’ lives, dying loved ones, children plunging into mental illness, marriages falling apart, so much  demanding direct attention.  My surgery was mostly a lousy time for me to be disappearing on them, though all wished me well and expressed concern. My planned retirement was also a lousy time to be disappearing, as it was beginning to feel closer now, and this was a clear deletion of time and a harbinger. The leave coverage I arranged was of little comfort. At that point I didn’t feel my work was out of whack, my denial intact and working for me. An impending long leave was all new stuff to me, never having been away for more than a two- or three-week vacation, never more than two days out for illness in all these years. It seemed that my surgical leave could be a trial termination, leading to more productive work afterwards about inevitable change and loss. However, with each leave before surgery, I felt less sure of my tidy wish. 
Instead, when I came home to bed four days after heart surgery, no la-dee-da affair at all, with too little energy to do more than lie there, an effort to produce sound bites, PTSD came roaring in behind the untreated post-op paranoia. In spite of depletion of all energy, my body had not lost the capacity to experience terror, day and night. I made a truly desperate phone call to a Baltimore psychiatrist whom all of us here know and deeply admire. He could hear all he needed to know in my voice. The kind man arrived that same evening, came to where I was bed-bound and listened patiently.  He returned until I was able to drive to his office, and I’ve been seeing him since. He has been, as I had experienced in my analysis with a very special woman, useful beyond description. I underline this important revelation because of that despicable New York Times front page article of 3/6/2011 by Gardiner Harris, the one about psychiatrists giving up doing therapy. It deeply offended me, saddened me, and left me feeling that maybe it’s a good time to “get out." It so minimized the incredible need for psychiatrists to remain extremely capable, compassionate and wise psychotherapists, because I have also needed his medical expertise.
Sometime in early November, overlapping cardiac recovery, I developed inexplicable atypical, severe bilateral leg pain at night, resulting in terrible insomnia with sleep-deprivation and/or grogginess from meds meant to alleviate those. I had increasing difficulty with concentration, memory, and attention as the psychological sequelae of both sleep deprivation and PTSD, which I definitely had. Nonetheless, I soldiered on and then returned to practice. I was limping along as a therapist, occasionally looking puzzled when there was nothing puzzling. At times, I said things that were misworded or syntactically upside-down, without enough awareness except for the consequent expressions on my patients’ faces. I looked exhausted and was. I was beginning to scare patients about my health, I think. They were worried now, and some would say so. One woman opined that I had underestimated what this surgery would take out of me. (That was certainly true.)  When asked, when there was a clear need to explain my inexplicable degree of exhaustion, I did, and one patient suggested Ambien, which of course has a humorous side to it. I didn’t know the cause of my pain-generated insomnia, so I couldn’t give my patients very helpful answers. In total, given all the interruptions, I was at work for about eight or nine scattered days after September 1st  until January 1st.

I too was seriously worried, eventually becoming flat-out desperate, since none of the specialists that I was seeing urgently,  knew what was wrong to cause such intolerable leg pain at night. Though never my very kind and talented choreographing internist (to whom I am forever indebted) nor my psychiatrist, some specialists diagnosed psychogenicity. Two very bright others worried about a possible paraneoplastic syndrome. Patients were aghast that I’d cancel again and again for more testing, with less and less time left for our treatment. Some were getting almost frantic about these appointments of mine, and most had a hopeful suggestion, a theory, a favorite doctor. Those who really needed to be seen regularly, I tried hard to persuade them to transfer to new therapists at that time, with limited success.
I realized things were subtly turning upside down in my office. Those few patients I saw during those remaining days were trying to help me now.  Therapy was about anticipated loss, no doubt including loss of control over my help and presence. My desperate effort was to be the kind of therapist I’d “always” been, wanting so much to go out with my vision of helpfulness and my self-respect intact, with a sense that my thirty-five year career had ended well. I wanted to make it to the finish line that I had chosen, with the final work I had hoped for with each patient. There were so few actual patient sessions that this was mostly wishing, not occurring, in my office, but my head was swirling with how to do it. The Thanksgiving holidays fouled up my office scheduling again. 
Then, having had pain-related insomnia all night for days, with so many patients still unseen or seen only once since August or September because of all my leaves, I fell asleep on two longstanding patients. I apologized profoundly and explained. I knew then, really knew, that I must simply stop.
I went straight home and called a very dear friend and colleague who came over to help me make a plan, advised me with her ever-present wisdom. Afterwards I called every patient to say that I was taking yet another leave until mid-January, unable to say to them, or definitively to myself yet, that this would be a final leave, and certainly unwilling to do so right before the holidays. But I did know, and couldn’t stand to feel it all at once. My explanation to my patients was uncharacteristically vague because in fact my malady was. Sometimes I had to communicate my “leave” on answering machines, giving my news and saying I’d call back, a brutality of modern electronic life. I always left my home phone and home email for them to contact me. I worked on a list of therapists whom I thought would be good matches, leaving preliminary queries for those psychiatrists and non-psychiatrist therapists, all of whom responded so generously, giving of their tight practice time, such gifts
With no progress in diagnosis and treatment for my unusual and intense leg pain, with so many tests and consultations ahead, with my insomnia unremitted, I faced calling every patient to say that there had been too many leaves, so that in fact I was retiring early, as of now. That was an indescribably horrible week in my life. Most of them had wondered if that was coming, so not a great surprise, but instead they were shaken, very disappointed, wondered if I was dying of something- no matter how I tried not to be alarming, up against this abrupt loss due to an unknown, without any control at all over the matter. I gave each my specific referral. I invited each patient to think about whether he/she would like to come by my home at some future point for a brief good-bye in person. I moved my office furniture out. Only in mid-March, with the help of my psychiatrist’s medical acumen, was my pain diagnosed as originating from an unusual configuration of lower back spinal disease sites, with fairly extensive lumbosacral surgery. Relief came in between diagnosis and surgery with those lovely steroid injections in the spine and through the foraminal canals by a menschy ace needler. After surgery, I just might have made it back to work by the original retirement week.   
Such truly chaotic endings for my patients, and retirement for me, after knowing a few of my patients for almost twenty-five years. I had never imagined becoming ill in a way that made for such a scheduling mess, mystery, and ultimately trouble working. It grieved me so much that I kept plugging along until the worst of all insults, falling asleep with those two patients, patients who were sharing their secrets and their vulnerabilities. I have always been merciless in my mind when patients have told me about former therapists who did this with them. I have seen the cost of that rejection to them. I am deeply fortunate that these two were so healthy as to understand what this was about, and that I had long track records with them. But who knows if that day will be without any consequence to them, last sessions that they were? Both chose to come say good-byes at my home and both expressed gratitude for our work. They seemed free of such consequences, but the psyche runs so deep and their need to protect me so probable.
When I had invited each one to come say good-bye if they so chose, I made it clear that either way was fine, something to think about. Every one wanted to, though some wanted to postpone it until they didn’t feel so raw, until I was better, until the flowers were up, until they felt their new therapist could be a cushion, and so forth. Since then virtually all contacted me, patients whom I was actively seeing when I retired and many who only very occasionally still came in from the past, who asked to come for these brief visits. What I hadn’t anticipated was how powerful these meetings would be, then ending when we both felt it was a natural moment, when we both could tell we’d said what had been important to say, when we both stood up together. Inevitably each recently seen patient commented on their relief that I looked so much better, i.e. that I didn’t look like I was at death’s door, as I had.  Each had their individual things that they wanted to say, realized that they’d needed to say, and sometimes saved questions too. These were intense, condensed opportunities to put their questions and thoughts right into context, to give them historical meaning, because of our years of relationship. I hope and believe that many left with something useful to think about.                                                                                                                           
I saw how very brave these fine people are when they chose to come here and handle the finality of these good-byes with such focus, direction, and emotional candor in a different setting. They wanted to tell me how far they’ve come, what they had accomplished, what they are still working on and probably always will be. Most told me that they had felt cared about and could hear my “helpful voice” internally. As they said that, they patted their chests, not their heads, every one of them. They wanted to thank me, and I certainly wanted to thank them too, hand automatically going to my heart too, for the privilege of watching their growth, their hard work, for sharing themselves with me and more than that. They gave me the chance to say good-bye, some aware that they were doing that for me too.
It certainly has been useful for me to see them, a way to offer small amends for such a desperately awful ending, to be reassured myself, and for me to have my opportunity to grieve after each visit. I am infinitely grateful to all of them for their enormous patience , their genuine good wishes, their willingness to try new therapists and usually connect well with them, their courage, and these not-so-easy good-byes in person. They have been heroic. My gratitude for my surgeries by talented surgeons had been overshadowed by the black dust of this forced retirement. Thanks to my former patients and my own psychotherapy, I am now able to feel fortunate about that and my career again, in spite of the robbery of my tailored retirement plan and my lost absolute insistence on control over that. We do know we don’t have that, then we learn that we don’t have that, and then we learn that, and then learn that again, and then I suppose one day we may get that.
Reprinted from The Maryland Psychiatrist.

25 comments:

Anonymous said...

Certainly a moving story. It is not surprising that the patients were "heroic". They saw it coming well before the doc. If a doc manages 8 or 9 days of work in several months, people start preparing themselves in one way or another, at least on some level. That a patient suggested Ambien has a funny side, I suppose, but it also demonstrates, aside from caring about the doc, caring for the doc. It must have been clear to most patients that the doc probably needed more caring for than they did. Perhaps some were returning the favor of her years of care. Others my have been acting out the old script of care taking. Whatever unfinished business any of them may have had, most people are going to feel sympathy for the doc and express that. Most people won't burden the doc with any feelings of abandonment. True, she had begun the process of termination already (hate that word; it sounds like an abortion. Other relationships end. Psychotherapeutic relationships terminate) but it is a good bet that they spent a good lot of time with their new therapists dealing with the feelings this ending stirred up. Everyone will retire, unless they die first. The unexpected happens. I probably was not great to allow her patients to take care of her for so long. Lots of docs practice while in some degree of denial. Everyone does.

Daniela said...

Thank you so much for sharing this incredible post by Dr. J. Dear Dr. J: I'm so moved: by the courage it took to share your vulnerabilities and foibles, by the integrity of it and by the compassion implicit in it, for yourself, for patients and for peers. For as physicians, we often treat ourselves far less well than we do our patients. We get into the habit of soldiering on, for the sake of others. Into the habit of thinking we're in control, when we're not. Into the habit of ignoring the warning signals.... Thank you so much for the reminder that the weakest link in the chain of service is taking care of ourselves. That's why flight crew instruct passengers to first put on their own oxygen masks before assisting others with theirs. My original plan after sending off this comment was to go do x, y and z, but you've made me rethink that. Think I'll go lay down for a little rest instead. Get well soon and best wishes for an enjoyable and refueling retirement.

Anonymous said...

Beautiful. Heartfelt. Raw. That relationship with a psychiatrist is a unique one. I loved how she described her patients giving back in their own way.

Liz said...

just wanted to let you know that i have posted your blog on my blog...maybe some of my readers will come your way.

http://pocketshrink.blogspot.com

Anonymous said...

I'm really not quite sure what to think about this post. On one hand, yes, clearly it was moving and courageous and deep. On the other hand, as a patient, what am I supposed to take from it? At the very least, I feel vaguely uncomfortable. I respect and like my therapist very, very much and deeply hope that if a similar experience were to happen to her, I would behave similarly "heroically." On the other hand - do I need to know all the info in this article? How is this helpful? I agree wholeheartedly with anonymous 1 that most (if not all) patients would not burden their dr with feelings or concerns of abandonment, etc. - even though in this situation they would truly be genuine and reasonable! To assume otherwise is to really do your patients a disservice. Like I said, I'm just not sure what was supposed to be taken from this article.

I know this is a blog "by psychiatrists for psychiatrists" but you guys know well that you have a large readership from the patient side. I am not critiquing. I am just not certain what exactly you hoped those of us on that end would take from this. Or, for that matter, on second thought, what anyone is supposed to take from this. That it's okay to go on indefinitely while you're not capable of working? I am not a shrink but work with a vulnerable population. For me to do that would be absolutely wrong. What makes it okay for a shrink to do the same?

I don't know....This is a nice and moving story, but after reading it several times I'm less and less sure what's meant to be taken from it - whether as clinician or patient.

Antoinette said...

As a trainee psychiatrist , I thank you for taking the time to write that . You have given me much to think about , and I can hopefully learn from your experience in the future . The message for me, is you need to care for yourself first , before you can efficiently care for others.

Dinah said...

Anons (especially the one who wants to why this was posted or what to take from it):

I posted it because I've never seen a psychiatrist write such a raw (to borrow Jesse's word) and revealing article. It seems to aim for exactly what's in her heart with very little held back and very little censure, and this piece was written for a venue that is read exclusively by psychiatrists-- So Dr. J told all to all her colleagues and as well as several hundred professional strangers. It took guts. I think it was good for other professionals to read-- because 'stuff' really does happen to us, good or bad (illness,moves, death, retirement, maternity leave, deaths of family members) and getting it exactly right so that you leave or take off in a way that is optimal for everyone is hard--and here Dr. J tries so very hard, with a one-year lead time-- to do it so perfectly and life just doesn't comply. Of course no one thinks that a psychiatrist should fall asleep, but clearly, Dr. J also thought this wouldn't happen and was surprised herself (I am assuming she didn't fall asleep during 3 sessions one day, then work the next day anyway...). We all know retirement and illness and death are hard on our patients, but she details this in a way and with an honesty that I haven't seen, so I wanted it on Shrink Rap.

You're supposed to take from it that Shrinks are human, vulnerable, and often struggling, too. Maybe she did work too long or try to go back too soon-- it sounds like an absolutely horrendous stream of events in her life, and I was amazed that she was thinking so hard about her patients and worrying so much about not being there for them when she was in pain and concerned that she might imminently die.

To anyone who is very invested in seeing their psychiatrist as being "all about the patient, all the time" or to anyone who would like to hold their psychiatrist in some idealized form, maybe Shrink Rap isn't the best read?

I'm moderating the comments because I wanted to shield Dr. J from any serious negativity (shrinks are people, too, and this one has clearly struggled)...so far I've let them all through, but I've hesitated here....

Anonymous said...

As Dinah wrote:
"To anyone who is very invested in seeing their psychiatrist as being "all about the patient, all the time" or to anyone who would like to hold their psychiatrist in some idealized form, maybe Shrink Rap isn't the best read?"
Anon 1 here. I do not hold to either of these ideas. I think the story highlighted how the patients did not hold their psychiatrist in some idealized form or as all about the patient all the time. I think that it is possible for patients to take very good care of their doctors feelings and to be acutely aware when the doctor needs care taking. I think the doctor had the best of intentions and was blindsided by all that happened to her. I am sure she was a wonderful therapist but probably not during that time. I had an experience with a therapist whose own life was falling apart. I stuck around for the falling apart, tried not to stress the therapist out, expressed concern for them. I also had a final meeting after an extended time during which I expressed my gratitude etc and then began seeing a new therapist, spending a very long time dealing with the issues I dared not bring up with the ill therapist. My point is that if it does not make sense to idealize the therapist, and it does not, it makes no sense to believe that all these patients, seeing a therapist for a reason, would not be activated into the care taking mode and would not have feelings to work with through that they felt they could not burden the sick therapist with. While Dr J wanted to avoid an abrupt termination her own idealization of her abilities or power to bounce back, which I called denial, put her patients in an uncomfortable spot for a longer time than needed to happen had she been more willing to let go. The story highlights the fact that the therapist was as human as any other person but at some point it may be fair to say that rather than being all about the patient all the time it was much more all about the therapist's own needs, which the patients continued to fulfill. No offense intended. To err is human.

Anonymous said...

Re the comment about this blog being by psychiatrists for psychiatrists and patient voices perhaps not being wanted, many of the psychiatrists and other therapists I have known have been or are in therapy and do go back at times of crisis in their lives. Dentists get their teeth cleaned, too. Why do we have to feel pitted against one another. When the doc is in therapy, they act like patients and they are patients.

Sunny CA said...

I am a patient, and appreciated reading this. I found it a touching story that I could relate to, and could put myself into both her shoes and those of her patients while reading it. I am also one who soldiers on despite illness, and could understand that aspect, yet also understand the impossibility of fighting one's body and mind, at times.

My own psychiatrist is 70 and appears healthy, but just decided to cut his practice down to 3 days a week (from 4) and it is the first ramp-down towards retirement. I feel very well at present and have been debated whether I should end treatment now, or continue, but at longer intervals between sessions, hence termination has been on my mind also.

Bill Clinton suffered noticeable cognitive and emotional effects from heart surgery also. I think it is much more common than acknowledged.

Anonymous said...

it terrifies me that god forbid something like this could happen to my beloved, well-liked, trusted and respected psychiatrist. Terrifies me for her and for me.

jesse said...

This is a wonderful article. Thank you Dr. J. for writing this. You have a great deal of courage and wisdom. Your patients were very fortunate to have been able to work with you.

Carrie said...

I find this to be such a beautiful example of narrative ethics. To tell one's story, no matter who you are, can be both challenging and a catharsis. It's so important that in our fast-paced, 140 character lives, we remember the story. Her writing was very moving, and you can definitely feel the emotion within it. I do believe that Dr. J demonstrates that all psychiatrists are people too. We're all patients at some point in our lives.

Imagine what life would be like without stories? In some ways, we've already come so far from storytelling that the art is lost. But - our lives are so enriched by them. The anger or negative feelings against someone may sort of dull or fade completely away once we know their story. When you drive in a car and get angry at other drivers, it's natural because everyone is anonymized. But when you know the stories of all of those around you, you may feel quite differently.

Regarding staying longer than you should - this is a problem in so many walks of life. It is SO hard to give up what you love and what you have done for so long. I've watched people in various places of my life stay past the point where they should, and it's never easy. One of my preceptors for my current job has an autoimmune illness that has severely disabled her life. Before she stopped working, she was using oxygen to get from the car to the hospital unit - and took it off when she got to the unit. She didn't want to stop working. Why? The moment her sister stopped working with the same disease, she declined rapidly and died. So she soldiered on - in a way that was heroic to me and to all of us. Eventually she had to stop once she was being evaluated for a lung transplant. I think of her all the time and miss the chance to talk to her about so many things.

In all the rush of life, we need to appreciate stories. We can all learn something from them - be it more compassion, more humanity from psychiatrists, or other things - it's important to stop and listen to each other.

Dr. J: Thank you for writing such a beautiful post. I wish you the best as you continue on life's journey.

jesse said...

Dr. J.'s story reminds me of that famous remark by Phineas Fogg in Around the World in Eighty Days: "The unforeseen does not exist." Well, we all know what happened there. Despite Dr. J.'s efforts and intelligence, nothing went exactly as she hoped. Yet due to her caring, sensitivity and maturity, it all worked out for her patients for the best.

dr. j. said...

At this point, reading all of these very thought-full comments, I am touched by the efforts so many have taken to respond as they see it. Naturally the compliments make me feel such gratitude and fortune, but I have learned more from the people who have strong feelings that I essentially used my patients at the end. There is truth to this, and were it a trajectory that I could have seen from above, that I knew where my body would take me next (when it was supposed to be Okay Now), I hope that I would have retired earlier. Instead, I took small leaves to try to get myself rested and in shape to work, only to get exhausted again. I think that falling asleep on a patient is one of the worst things we can do, leaving a patient feeling profoundly rejected. I did fall asleep twice, in a row, then cancelled and went home, my last day in my office. It is a sort of amazing "luck" (an odd term, for which I apologize for the way it felt to me, and not to them), that I had known both patients for years, they both KNEW that I treasured them, and both asked immediately whether I was going to be okay, what they could do. I explained fully, heavens knows they deserved it, and felt such gratitude to them for their instant appreciation that this truly was not about them, as I also said aloud. This is no defense. I did wait too long to "shut down", but it is a statement that we can and should have such important relationships with our patients that they understand when they see such a real life medical situation in play.

These comments have given me enormous food for thought, and have taken on the job that my patients didn't take on: taking me to task for my acted-upon wish to go on longer than I reasonably could.

The kindness of some comments makes me virtually weak in my knees. Kindness has been hard to take when there is so much room for criticism. I am very grateful to Jesse, Daniella and Carrie in particular because they mounted defenses of me that I could see and feel as particularly true, as well as comforting and kind, obviously. Yes, narrative is the center of being, and we are, inevitably, the hero of our own tale. The best I ever knew how to do was Try to hear my patients' tales, as thoroughly as they could manage, which is no small act of heroism on their parts.
Dr. J.

Dinah said...

Oh, my-- it's like you've tried so hard to retire and I've dredged everything up all over for you and dragged you back to work!!!

Too much weight in all this. It seems we've bought in to this concept that the psychiatrist has to be absolutely perfect --for everyone, somehow colluding with the idea that one must never feel abandoned by or disappointed by their psychiatrist who must--even in death or near-death--never ever rekindle the momentary pain of past distresses. I would be shocked if patients who knew you well and saw that you were sick felt rejected by your illness. Yes, time to go home, but to beat yourself up for a misjudgement about your health?

Sunny CA said...

when I read tonight that Andy Rooney, age 92, just retired from his thirty-three years with 60-Minutes, it reminded me of this post. Did Andy stay too long? Who knows?

From your narrative, Dr. J., it was clear that you were trying to bring your practice to an appropriate ending point before retiring, but illness stopped you. I am sure psychiatrists die and abruptly leave all their patients and the difference is merely one of degree. You did not cause your illness. The fact that you were not able to overcome the illness and keep working was not your fault any more than it would have been your fault if you had died in the same time period.

If my psychiatrist fell asleep in my appointment, now, after knowing him for so long, I would not think it was because he was bored or disinterested, because he has shown clearly in our meetings that he is interested and does care. please don't beat yourself up over this. It sounds like you had successful relationships with your patients and helped many people in your career. That is what is important to remember at this point, not the one day when you were working when you ought to have been at home.

Anonymous said...

I greatly respect and appreciate Dr. J's response. My point was, and is, that sometimes the therapist does use the patient. In the best case scenario, this is not out of any intent to harm or abusiveness on the part of the therapist. It happens out of some sense that one is more powerful than is realistically so. Dr J appears to understand this. She seems like an amazing therapist,yet, even such people can make mistakes. Dinah, do you feel that Dr. J is so fragile that you must protect her from any criticism, including that which she seems to take as food for thought as opposed to a personal attack, which it most certainly is not?No one is saying that the therapist must always be perfect in order to protect their patients. And yes, patients may be adversely affected by the best intentioned therapist, in the short term.No therapist is super human. Mistakes will be made. That is not a personal affront. So long as the relationship was "good enough "the patient will be fine in the end. So long as therapist/doc is remunerated for services rendered, it behooves them to consider how much of a help they are or can be. Dr. J. can hear this. Perhaps, in the thick of things, it was difficult for her to determine what was best, for her or her patients. Whether or not she continued too long is not for me to determine but, again, there are times when unwittingly, perhaps on both parts, patients pay to help the therapist feel better. I wish Dr J. the very best. I am certain her patients were lucky to have know her. We can all learn a great deal from her experience, whether as patient or as therapist. An open mind is key.

dr. j. said...

Another Dr. J. response: Dinah, I have actually been enriched by this blogging idea of yours. No, not transported backwards except as I read them, and that is a good thing, to continue the ongoing process of making sense of our lives as we go along, and not just in a convalescent home one day! It is what therapists innately do, I think: put it all together as best that can be done, and it is a kind of inborn reflex that leads us into this kind of privileged career. I have been very grateful for the effort of all the responders, all of them even when negative. I'm afraid that my prior response gave the impression that I still feel guilty or regretful, and infact that black dust settled months ago, as I saw each patient and could see that the dust didn't cover them, that they were there to say good-bye in some meaningful way, without ever feeling that the final sessions that we had had weren't useful, and knowing that the ending was beyond all of our control, itself a natural thing. We could talk about what therapy had meant and what was still ahead for them with their new therapists. Many brought gifts that they'd know I'd accept (small enough!) but absolutely dripping with thoughtfulness in their choices. They were so pleased at my pleasure, which was very real, of course. This is a time when we can accept the small gift of thanks that patients so want to give, and the pleasure that they too received created an atmosphere of bittersweetness that is hard to describe, but captured something very dear at the heart of our relationships. So, this is fascinating to me, so often a gift to me (Jesse Hellman, what a mensch you are!!), and I thank you Dinah for the experience and continuity offered.

Jen said...

I was touched by your responses, Dr. J. You remind me so much of my therapist in how you look at things. From my end, as a patient, I wonder at how it could be really a clean, good ending - both from your end and from your patients'. Not that there is care and respect and compassion and kindness on each end, because it's clear that there is, but that there isn't still an unfinished end. It's easier for me to imagine that clean, finished end from a patients perspective, and I'll readily admit it's uncomfortable to me to think that such a messy (a wrong word here, I think, but not sure which could be better - uncomplicated perhaps?) end could be so complete and clean - not black dust-covered - for you.
Can you talk about that a little?

Tigermom said...

Isn't even a "bad" ending to therapy still grist for the mill and therapeutic?

dr. j. said...

Dr. J. responding to Jen's direct question.: Messy is a fine word. But with time, I felt the bulk of my long career far outweighing the ending, because my former patients are all right now with their new psychiatrists (to my knowledge), because I am well and loving retirement, so I have moved on in life. It's been awhile. But mostly because there were no sources of enduring guilt, having done the very best that I could at the time with life's inevitable "bad patches" which were beyond my control. We all carry regrets, but their residual intensity and demanding conscious persistence can vary with whether we caused them or not.

And last but certainly not least, I had good therapy to help me through, to help me with clarity about the experiences! I firmly believe that there is no substitute for that, and it grieves me to see high quality therapy becoming less common in this world of insurance coverage and training.

Anonymous said...

Thank you for sharing this story. I read it with great interest and some amusement as I have been someones patient a very long time. I wonder if the good doctors see themselves as needing to appear to be perfect and have perfect lives to be good therapists. I see this as a distancing technique and it makes me feel unsafe with the therapist. I have seen my psychiatrist fall asleep in our session. I sat there quietly and waited for him to wake up. He had shingles and was on narcotics. His humanity and his desire to soldier on made him more human to me. I did tell him to take a few days off since he was such a lightweight about narcotics. He did. I have heard my psychiatrist say when he thought I could not hear" that he "didn't feel like being therapeutic today" because he had just been robbed. He was embarrassed but I was entertained and was happy to be supportive in the face of his distress. I have been hurt and felt loss when a psychiatrist moved on to a different practice but I learned why and how to deal with it, to say goodbye and was stronger for it.

Personally I can't really trust the "perfect Dr" presentation. I want a heart and soul behind my care provider. Part of being a good caregiver does include some self disclosure, an entering into community with the client.

Dr. J. said...

I couldn't agree more and lived my career with that basic philosophy.
Dr. J.

Liz said...

beautiful and inspiring....many, many thanks.

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