In the “helping profession,” it is easy to talk about how we handled our successes, but seldom do we openly speak about the failures, the ones who got away. The people who leave treatment and don’t come back, or the ones who take their own life. How do you reconcile this?
The Ones Who Come and Go or Don’t Come Back
Over time, I have reframed my perspective from “What did I do or say wrong?” to the social work principle of client self-determination and come to accept it. I have done what I can do. I view therapy as a process and a series of stair steps on the client’s journey. Some clients may take the steps rapidly while others pause to practice along the way and return to a new and different therapist later to move forward. It is amazing how this concept, when presented to someone considered “chronic, repeater, or a therapist shopper,” helps them feel better.
On the Death of a Coworker
At the time of that training, I had only experienced the death of a coworker who shot himself — a young man, a recent college graduate who had volunteered and completed an internship in the mental health clinic. He fit the 1980’s Emergency Service Image of the day: suit, white shirt and tie for the guys; heels and hose and three-piece suit dress for the women. This nothing-out-of-place look was advanced by the department manager which, if you ask me, was designed to make the population we serve uncomfortable. He was working in rehab and pulling shifts in emergency services after hours. I was temporarily acting as program supervisor while the regular supervisor was on maternity leave, so his supervision was my responsibility.
Nothing is more unnerving to a new clinician than to be on the telephone in the wee hours of the morning talking to a military veteran in possession of a gun telling you they are going to kill themself, or who is seeing the enemy coming through the window to kill them. His speech was broken. His lips trembled. His body trembled as he spoke. It was clear to me that this novice clinician was not ready to clinically deal with the after-hours crisis. I went to my superiors and the department manager and asked them to remove him from after-hours work, but they ignored me.
Then one day, our executive director called us to an all-staff emergency meeting. He said this young man had shot himself in his home and was dead. I was shocked, sad for the young man and his family. and angry that management had not respected me clinically and listened, but I never felt responsible. Documentation supported me. I had done what I could do.
On the Death of Clients
True to prediction during my career, two mothers with young children have died while in treatment with me. While I was on vacation, the mother of an eight-year-old put a note on the door for the neighbor to care for her son, took his teddy bear, and used carbon monoxide poisoning. When I came into work on that Monday following my vacation, my supervisor called me into the office and said, “While you were gone…” I felt no accountability. A QA chart review did not find any clinical culpability. It revealed hundreds of times when I had asked her to enter inpatient treatment for substance abuse or depression and she declined. I was sad for the child and the family. I wrote what I called “The Alphabet” for the service and gave a copy to the guardian for the day that the child asked, “What was my mother like?” The Alphabet was a commemorative of his mother, with one of her positive qualities attached to each letter of the alphabet.
The aunt raised that little child and gave him everything his mother wanted him to have — life in a small town, school, freedom from the stigma of his parents’ substance abuse and repetitive domestic violence, sports, scouts, activities, friends, a college education, and a good job. His aunt and I have corresponded over the years. He got married last September.
In the second case, the mother of an eleven-year-old experienced a heart attack from the abuse of multiple prescription medications from multiple doctors in conjunction with illegal drugs. I was sad. I felt no guilt or responsibility because the clinical record was in order. I had done what I could do. I helped the family clean out the apartment with the blessings of my supervisor.
The family were like dispassionate machines which angered me. With their permission, I took a cookbook and kitchen knives that symbolized the child’s mother for the day that she asked, “What was my mother like?” I attended the service and took one of her friends.
I wrote “The Rose,” and shared it with the family at the luncheon following the service. One of the family members said to me, “If we had known, we would have had you read it at the service!” Instead, they had a priest offering words of comfort about someone he didn’t know. “The Rose,” like “The Alphabet,” was a tribute to the child’s mother (whose name was Rose) using metaphors of the flower to describe her.
The child was raised by her father. I used to see them when he would come by to pick her up for her visitation. It was clear he found it difficult to deal with her mother, but he adored his daughter as she did him. Her life has been a little harder. I found some of her mother’s old friends. They told me she was a mother, but the grandparents were raising the children. As a child, she tested “gifted.” Currently, she is using her artistic ability as tattoo artist. She still lives in the area, but our paths have not crossed. The cookbook, the knives, and “The Rose” await the day our paths cross again. I have done what I can do.
I still use what I call “The Alphabet” and “The Metaphor” technique in my professional life as one of my techniques to help clients with grief issues bring closure. In my personal life I have used it many times for family and friends and seen it in a time of sadness bring a smile, laughter and, “Oh, I remember” that warms the heart of a grieving face!
Questions for Reflection and Discussion
How have you dealt personally and professionally with losing clients?
How might you have avoided a particular client’s unexpected departure from therapy?
What are your thoughts about attending a client’s or their family member’s funeral?
File under: The Art of Psychotherapy, Musings and Reflections
Losing Clients in Therapy
I remember sitting in a training group run by one of my mentors — the topic was treatment failures. He said clients come and go, and that few therapists get through their career without experiencing the death of a client.Like what you are reading? For more stimulating stories, thought-provoking articles and new video announcements, sign up for our monthly newsletter.
The Ones Who Come and Go or Don’t Come Back
Over time, I have reframed my perspective from “What did I do or say wrong?” to the social work principle of client self-determination and come to accept it. I have done what I can do. I view therapy as a process and a series of stair steps on the client’s journey. Some clients may take the steps rapidly while others pause to practice along the way and return to a new and different therapist later to move forward. It is amazing how this concept, when presented to someone considered “chronic, repeater, or a therapist shopper,” helps them feel better.
On the Death of a Coworker
At the time of that training, I had only experienced the death of a coworker who shot himself — a young man, a recent college graduate who had volunteered and completed an internship in the mental health clinic. He fit the 1980’s Emergency Service Image of the day: suit, white shirt and tie for the guys; heels and hose and three-piece suit dress for the women. This nothing-out-of-place look was advanced by the department manager which, if you ask me, was designed to make the population we serve uncomfortable. He was working in rehab and pulling shifts in emergency services after hours. I was temporarily acting as program supervisor while the regular supervisor was on maternity leave, so his supervision was my responsibility.
Nothing is more unnerving to a new clinician than to be on the telephone in the wee hours of the morning talking to a military veteran in possession of a gun telling you they are going to kill themself, or who is seeing the enemy coming through the window to kill them. His speech was broken. His lips trembled. His body trembled as he spoke. It was clear to me that this novice clinician was not ready to clinically deal with the after-hours crisis. I went to my superiors and the department manager and asked them to remove him from after-hours work, but they ignored me.
Then one day, our executive director called us to an all-staff emergency meeting. He said this young man had shot himself in his home and was dead. I was shocked, sad for the young man and his family. and angry that management had not respected me clinically and listened, but I never felt responsible. Documentation supported me. I had done what I could do.
On the Death of Clients
True to prediction during my career, two mothers with young children have died while in treatment with me. While I was on vacation, the mother of an eight-year-old put a note on the door for the neighbor to care for her son, took his teddy bear, and used carbon monoxide poisoning. When I came into work on that Monday following my vacation, my supervisor called me into the office and said, “While you were gone…” I felt no accountability. A QA chart review did not find any clinical culpability. It revealed hundreds of times when I had asked her to enter inpatient treatment for substance abuse or depression and she declined. I was sad for the child and the family. I wrote what I called “The Alphabet” for the service and gave a copy to the guardian for the day that the child asked, “What was my mother like?” The Alphabet was a commemorative of his mother, with one of her positive qualities attached to each letter of the alphabet.
The aunt raised that little child and gave him everything his mother wanted him to have — life in a small town, school, freedom from the stigma of his parents’ substance abuse and repetitive domestic violence, sports, scouts, activities, friends, a college education, and a good job. His aunt and I have corresponded over the years. He got married last September.
In the second case, the mother of an eleven-year-old experienced a heart attack from the abuse of multiple prescription medications from multiple doctors in conjunction with illegal drugs. I was sad. I felt no guilt or responsibility because the clinical record was in order. I had done what I could do. I helped the family clean out the apartment with the blessings of my supervisor.
The family were like dispassionate machines which angered me. With their permission, I took a cookbook and kitchen knives that symbolized the child’s mother for the day that she asked, “What was my mother like?” I attended the service and took one of her friends.
I wrote “The Rose,” and shared it with the family at the luncheon following the service. One of the family members said to me, “If we had known, we would have had you read it at the service!” Instead, they had a priest offering words of comfort about someone he didn’t know. “The Rose,” like “The Alphabet,” was a tribute to the child’s mother (whose name was Rose) using metaphors of the flower to describe her.
The child was raised by her father. I used to see them when he would come by to pick her up for her visitation. It was clear he found it difficult to deal with her mother, but he adored his daughter as she did him. Her life has been a little harder. I found some of her mother’s old friends. They told me she was a mother, but the grandparents were raising the children. As a child, she tested “gifted.” Currently, she is using her artistic ability as tattoo artist. She still lives in the area, but our paths have not crossed. The cookbook, the knives, and “The Rose” await the day our paths cross again. I have done what I can do.
I still use what I call “The Alphabet” and “The Metaphor” technique in my professional life as one of my techniques to help clients with grief issues bring closure. In my personal life I have used it many times for family and friends and seen it in a time of sadness bring a smile, laughter and, “Oh, I remember” that warms the heart of a grieving face!
Questions for Reflection and Discussion
How have you dealt personally and professionally with losing clients?
How might you have avoided a particular client’s unexpected departure from therapy?
What are your thoughts about attending a client’s or their family member’s funeral?
File under: The Art of Psychotherapy, Musings and Reflections