A few years ago, a colleague called to tell me our friend and fellow psychiatrist had collapsed at home and died of a cardiac arrest. She was in her early 70s, without any previously known medical illness. Within hours, a group of shocked and grief-stricken psychiatrists gathered at her home office, faced with a predicament: We had no idea who her patients were, much less how to contact them.
When we finally managed to get into her computer with the help of her husband and some luck, one of her long-term patients had just signed into Zoom for a scheduled appointment. “Oh, my God. Where is she? What happened?” the person asked when she saw me instead of her psychiatrist. Holding back tears, I told her that her therapist died suddenly that morning.
It’s hard enough for patients to lose their therapists, but the loss is compounded by a glaring lapse in our field: Therapists are largely unprepared for the impact of their death or sudden incapacity.
For a profession that prides itself on insight and self-understanding, this is a curious oversight. Then again, psychiatrists are probably like everyone else. Who wants to think about their own infirmity or mortality?
Psychiatrists and psychologists tend to have high career longevity. Nearly two-thirds of active psychiatrists are 55 or older, while just under half of family practitioners are that old. I have colleagues well into their late 80s who are mentally sharp and still taking on new patients. So if you’re a patient, you are far more likely to lose your therapist than, say, your family doctor.
Imagine losing the very person you count on to help you deal with loss. One of my colleague’s patients told me that it felt incomprehensible that she did not have her therapist around to help her deal with her grief. Another patient reacted to the loss as an abandonment, saying, “It’s like she was abducted.” This patient lost his father in a car accident as a child, and the feeling of being left to fend for himself brought back this trauma.
Some patients experience the sudden unexpected death of their therapist as a betrayal of sorts, a violation of the trust that they will be cared for. There’s a risk that it could trigger a relapse and acute distress or even suicidal ideation in vulnerable patients, including those with a history of major depression, bipolar disorder or personality disorders.
Unlike with the death of a spouse or family member, the grief over the loss of a therapist is private, often unacknowledged by a patient’s social network, which can be particularly painful. Because of this, my colleagues and I made sure to give our fellow psychiatrist’s patients information about her memorial service. We wanted to give them the opportunity to be included in a public ritual of mourning. Her patients would get a glimpse of their clinician’s personal life, but we thought it would be OK if they saw that their therapist, too, was human and mortal.
Every licensed therapist should have a will for their professional life, updated at least twice a year, that sets out provisions to care for his or her patients in the event of death or sudden incapacitation. The will should make specific recommendations about next steps and contain basic clinical information about the patients, deputizing a colleague to contact them. Patients should be notified at the start of treatment about the will and asked for their consent to share their medical records with their therapist’s chosen colleague.
Professional organizations, like the American Psychiatric Association, recommend that mental health professionals designate an executor with access to their patients’ medical records if they are no longer able to, but these guidelines are not binding. They also appear to be little known. None of the dozens of colleagues I’ve asked had considered a will, though they all thought it was a good idea to have one.
It’s true that a patient’s electronic medical record contains some clinical information, but in the case of psychiatry, this is typically the bare minimum to protect privacy. For example, you can easily learn about a patient’s symptoms of depression — like their sad mood, insomnia, social withdrawal and suicidal ideation — but the record is usually shorn of the rich details of their lives that are essential for continuing their care and finding the right new therapist for them.
As a psychiatrist, I have to pass an annual hospital training course that covers a wide range of topics, including confidentiality, infection control and fire safety. But there is nothing about how I should prepare my patients for when I’m gone. There should be. I would not have a professional will if it hadn’t been for my disturbing experience. For our patients’ sake, we need to fix this omission.
Richard A. Friedman is a professor of clinical psychiatry and the director of the psychopharmacology clinic at Weill Cornell Medicine.
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