Contemp Fam Ther (2012) 34:313321 DOI 10.

1007/s10591-012-9181-y ORIGINAL PAPER

Death of a Clinician: The Personal, Practical and Clinical Implications of Therapist Mortality
Emily H. Becher Tomoko Ogasawara Steven M. Harris

Published online: 16 February 2012 Springer Science+Business Media, LLC 2012

Abstract Death is inevitable and yet in US culture the discussion of death is somewhat taboo. Marriage and Family therapists are trained in the implications of grief and loss for clients who lose loved ones and yet examination of the impact of therapist mortality on clients is lacking in the clinical literature. This article examines ways that private practice therapists can both protect their clients condentiality and mitigate the impact of therapist sudden death on their clients with planning and forethought. In addition, the factors inuencing the lack of empirical research on this topic is discussed in the context of social mores on death and how therapists own denial of mortality may impact their ability to connect with clients through the pain of grief and loss. Recommendations are made for therapists to evaluate their own attitudes towards mortality and develop a plan for client care in the event of their death. Keywords Therapist death Therapy Clinician death Death denial Professional will

Marriage and family therapists (MFTs) are often called to respond to concerns regarding the death and untimely passing of clients family members. Our identied core competencies include prociency with issues related to death, dying, and the grieving process (AAMFT). However, little attention is paid to the death and untimely passing of the therapist. The purpose of this article is to summarize current thinking on the topic of therapist death and its implications for client welfare. We will highlight the ethical implications for not planning for ones own passing and point readers to a potential resource for clinicians, especially those in or those intent on pursuing private practice, to help them plan for this event. To provide context, a rationale for interest in this topic regarding two of the authors experiences will be offered. We will then report on a review of the literature to see what research has been done in this area, including implications for therapists and therapy. We will also discuss cultural beliefs surrounding death and dying in
E. H. Becher (&) T. Ogasawara S. M. Harris Department of Family Social Science, University of Minnesota, MinneapolisSaint Paul (Twin Cities), MN 55108, USA e-mail: bech0079@umn.edu

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the United States and conclude with suggestions for training and research on the topic of therapist death. For each of the lead authors, this subject has both a personal and a professional history. In 2009, two of the authors experienced the sudden loss of a shared supervisor and teacher. One of the authors experienced a second loss of a supervisor within the same period of time. The time after these losses was lled with shock, disruption and seeking to connect with others who had known these individuals. In addition to the sadness and regret, there were the ripple effects of chaos and uncertainty in the surrounding systems. Logically, these ripple effects could have been anticipated, but these were not times to consider professional practicalities or logistics; we were focused on grieving. While these particular professionals who had died were working in group practice settings and therefore had systems of built-in coverage for this type of eventuality, there are many clinicians in private practice who do not have these built-in systems of coverage. Although MFTs are trained to acknowledge the meaning of loss and grief that our clients experience in their lives, therapists own mortality or possible incapacitation is rarely brought up in training. Garcia-Lawson et al. (2000) state that there is a silence around the issue of death and dying, viewing it almost as a taboo among mental health practitioners. In their small survey study, some respondents expressed their discomfort or even hostility toward the questions around the death of a therapist. Yet what does this mean for us ethically as a eld? We are encouraged to examine our personal blind spots with vigor in order to limit any negative impact these may have on our clients and yet the subject of our own mortality seems to be a signicant blind spot that we may be conspiring to ignore.

Literature Review A multi-step review of the literature was conducted which began with searching for peerreviewed articles containing the subjects therapist death and client records, death and therapy, client grief and therapy, therapist attitudes and death and professional wills using the academic search engines Google Scholar, Psych Info, and Pub Med housed at a major research university. The searches were limited to the past 25 years and were conned to journals connected to any clinical profession that maintains condential records including physicians, social workers, psychologists and marriage and family therapists. Because of the limited body of work found in our initial search, we expanded the search to include state-dened codes of ethics for Marriage and Family Therapists, as well as codes of ethics for the American Psychological Association, the National Association of Social Workers and the American Medical Association. Searches were also conducted for case law examples addressing condentiality and therapist death as well as any books or websites that addressed the topic of therapist death. The review revealed a paucity of peer-reviewed literature on the topic. The limited body of articles available focused on how a therapists sudden death affects his or her clients, including their relationships with inheriting therapists (the therapist who might see a client immediately after that clients therapist dies) (Beder 2003; Garcia-Lawson et al. 2000). There were no empirical articles relating to therapist preparation for death in terms of long term protection of clients condentiality and wellbeing. In short we know very little about how a therapists untimely death specically impacts his or her clients, supervisees, and colleagues.

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Codes of Ethics In their codes of ethics, many mental health professional organizations seem to think of the death of a therapist primarily from the perspective of an interruption of psychological services (American Psychology Association, code of ethics, 3.12), or an issue related to the maintenance, dissemination, and disposal of condential records (APA, 6.02). In a similar manner, the American Association of Marriage and Family Therapy (AAMFT) mentions the death of the therapist only once related to protection of condentiality of clients, in parallel with situations where a therapist is moving or closing a practice (2.5). Yet in a recently proposed revision of the AAMFT code of ethics, new language has been added to section 2.5 that puts death as another event for which a therapist must prepare in order to maintain client condentiality (AAMFT, code of ethics proposed revisions). The National Association of Social Workers (NASW) also discusses protecting clients condentiality in the event of the social workers death, incapacitation, or termination of practice (1.07). While those national-level professional organizations briey mention the case of therapists death from the perspective of the best interest of clients, certain state-level law and codes of ethics for mental health professionals require or advocate for further action. For example, Florida is the only state that mandates providing public information when a therapist dies, including how his or her clients can obtain their records (Steiner 2007). In fact, the California Association of Marriage and Family Therapists (CAMFT) has proposed writing a professional will as part of their Code of Ethics: Marriage and family therapists, therefore, maintain practices and procedures that assure undisrupted care. Such practices and procedures may include, but are not limited to, providing contact information and specied procedures in case of emergency, or therapist absence, conducting appropriate terminations, and providing for a professional will. (Code of Ethic, 1. 3; TREATMENT DISRUPTION). Preparing a professional will is discussed in detail in a later section. It is clear from these documents that therapists have an ethical duty and responsibility to acknowledge and plan for their death as it relates to their client records, relationships they have with clients, and their associates who stand to inherit clients after a therapist dies. Current Empirical Studies As several empirical studies indicate (Beder 2003; Garcia-Lawson et al. 2000) clinical effects of a therapists death on clients are clearly different from other occasions, such as a therapist moving or simply closing their practice. Especially in the case of a therapists sudden death, the clinical implications can be alarming. Clients can exhibit more intense grief and loss reactions, which seem to be carried over to relationships with their inheriting therapists, compared to those clients who had planned for termination (Garcia-Lawson et al. 2000). It is possible that in the case of a sudden death of a therapist, the clients initial presenting problems may get sidetracked or subsumed within the loss. There also exist a few studies with conicting results that look at the question of therapist attitudes around death and if those attitudes impact their ability to be effective with clients. Kircheberg and Neimeyer (1991) found that beginning counselors were more uncomfortable than experienced counselors with issues related to death and the discomfort that beginning counselors likely feel was associated with their own levels of death anxiety. Following the previous study, Kircheberg et al. (1998) found that new therapists with higher levels of death anxiety had higher levels of distress, discomfort, and were less able to be empathetic with their clients around issues of death. Carr (2007) attempted to

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examine the link between personal death anxiety of psychologists and professional death anxiety in the context of working with clients. The instruments Carr developed ultimately lacked statistical reliability but the question is certainly a valid one which should be explored further. In contrast by the ndings of Kircheberg and colleagues, Terry et al. (1995) examined clinical attitudes of experienced grief and loss therapists who had high degrees of empathy and experience and found that their levels of personal death anxiety were not signicantly associated with clinical responses to death related issues. The limited body of research on this topic presents mixed results as to whether ones clinical skills are related in any signicant way to ones attitudes toward mortality and what role experience plays in the equation. Much more work is needed in this area to know for sure how clinicians and clients think about the death of a therapist and if therapist attitudes around death impact their ability as clinicians. Legal Aspects From a strictly legal perspective, the review of literature revealed that cases have been seen before the Supreme Court around the issue of condentiality surviving the death of a client or patient (Swindler & Berlin vs United States), but no cases could be found that examined the issue of condentiality of records surviving the death of the clinician, doctor, or attorney. The Health Insurance Portability and Accountability Act (HIPAA) of 1996 contains provision 164.508 that discusses the use and disclosure of psychotherapy notes and conditions where authorization is and is not necessary. No language exists for provisions to be made for those notes in the event of the death of the psychotherapist. Death-Denying Culture The notion that American society is a death-denying culture has attracted the attention of sociologists, psychologists, practioners, and journalists (Leming and Dickinson 2002; Durkin 2003). The scholarly literature highlights that the view on death in modern American society stems from irrational anxieties about death, death as a culturally pervasive taboo, and a fear of being out of control in the industrialized world. Kellehear (1984), a sociologist, structured a death denying social thesis around the arguments of medicalization of death and dyingor a view of death and dying circumscribed by medical values, rules, accepted practices, and the controlling role of the physician (Connelly 19971998; Abstract)fear of death, and the twentieth century crisis of individualism. Focusing on medicalized and institutionalized death in the twentieth century, Zimmerman and Robin (2004) redene this sociological view of death-denial into ve clinically relevant spheres from a palliative care perspective: (1) The taboo of conversations on death; (2) Medicalization of death; (3) Segregation of the dying from the rest of society; (4) Decline of mourning; (5) and death-denying funeral practices (p. 122). In particular, the authors emphasize that difculty in conversations about death come from death-avoidance attitudes of health care professionals, which reinforces and collides with the societal denial of death. On the other hand, the authors contended that an avoidance of, or a fear of death, is not a new psychological phenomena, and in fact, the isolation of the dying and institutionalized death stirred the arguments which promoted modern palliative care as we know it. However, Henig (2005) in the New York Times describes current hospice care as becoming more inclusive and providing a variety of options for how to die, and speculates that this might be a new replacement for medicalized deaths in American society.

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The underlying belief being that societys deep ambivalence about dying is perpetuated through the fantasy that dying is somehow optional (p. 1). This trend, according to the author, was tersely reected when hospice workers started to use the term end of life care, rather than death and dying. The author points to this as a subtle but signicant shift from death to life which is language that could be less anxiety provoking for members of a death denying society. Conversations about Death with Clients Reecting on clinical practice begs the question of how therapeutic work is impacted by therapists who are immersed in a death-denying culture. Feinsilver (1998) discusses his journey as a psychoanalyst dying of metastatic cancer, seeing clients with the knowledge of his impending death. It is a poignant piece regardless if one identies with psychoanalytic principles or not, but what is powerful for the purposes of this discussion is how Feinsilver talks about his death with his clients. He tells them each about his ambiguous medical status and that because of the nature of disease we could not know for certain whether this [his death] would be sooner or later, or even before we nished our work together (p. 1132). The authors of the current article believe that this is true for every therapist. Yet it seems that only in situations where the imminence of death cannot be ignored, whether on the part of the therapist or the client, that we are able to open the conversation about our own mortality. In fact, the eld of psychoanalysis has several articles about dying therapists and the impact on their clients and their therapeutic work (Silver 2001; Pinksy 2002; Traesdal 2005; Vlachos 2011). Vlachos (2011) names the limited body of work about the death of therapists across therapeutic elds as the cultural tendency of our time to deny death and dying, reected in an omnipotent attitude which masks fear on the part of the analyst (p. 94). Many of these psychoanalytic articles decry the fact that so limited a body of work exists in their eld on the dying therapist yet compared to other therapeutic paradigms, they appear to be far more willing to engage in a discourse about their own mortality. Professional Wills In the face of a death-denying culture, the potential impact of therapists death anxiety on working with clients grief and loss concerns, and the risk to condentiality for clients of therapists in private practice, there is strong argument for therapists to explore their own mortality and the practical implications of it. If working in private practice, and adopting the ethical standard of rst doing no harm a sensible place to begin for the eventuality of ones death would be to create a professional will. A professional will could outline stepby-step instructions for the care of ones practice and clients in the event of ones death and can alleviate some confusion and chaos for clients and family members. The most helpful and pertinent information we found about this topic was in the form of advice books geared toward the private practitioner and more specically, chapters and websites presenting ideas about professional wills. McGee (2003) and Walsh and Barnett (2009) both recommend that psychotherapists create professional wills in the event of their incapacitation or death. Pope and Vasquez (2005) outline several steps in developing a professional will and indicate that our professional responsibilities include preparing for the possibility that something may happen to us, taking away our ability to function adequately, at any time without warning (p. 57).The rst step they describe is to designate an executor to conduct the business of the

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will and how to contact them as well as a list of backups in cases where people might not be reached. Pope and Vasquez (2005) further suggest meeting with these individuals and walking them through the details of ones professional will; where things are located, including keys and security related information (i.e., passwords, codes, and account numbers). In addition, they should know where the clinicians weekly schedule is, how to access it, where client records are kept and how to reach clients. The will should outline who will handle and maintain the records as well as instructions for advertising this information in some public venue. Access to the client information by the executor and whoever will be maintaining the condential les should be included in the informed consent document signed by the client at the intake session and maintained in the le itself. Pope and Vasquez (2005) include several other useful and important pieces of information about what to include in a professional will that are beyond the scope of this article. Ballard (2005) and Luepker (2003) are other useful sources which outline specic steps in preparing a professional will. Steiners (2007) proposal on creating an Emergency Response Team (ERT) and a Blueprint for Therapeutic Continuity for a therapists unexpected absence or death is another practical application of the idea of a professional will. She encourages professionals to start the plan by selecting a team of their colleagues who will work together in the event of the therapists sudden death or incapacitation, including a designated Bridge Therapist who will initiate actions on behalf of the therapist. Information for the ERT includes client contact summaries, instructions for disposition of manuscripts, directions for phone messages, or a list of preferred referral therapists for clients (see: pp. 1419). The author also details how to develop the Blueprint for Therapeutic Continuity, which is a comprehensive document that species the therapists intent and wishes concerning the best interest of his or her clients. The document contains the therapists personal will, instructions for the ERT, power of attorney, how to notify clients and maintain their condentiality and records, and wishes for the therapists memorial services. The plan is followed by client contact summaries that the ERT can use to provide ethical and supportive transitions for clients. As Steiner (2007) points out, preparing professional wills is not a pleasant task for any professional. We believe, however, it will contribute not only to client welfare, but also modeling good self-care before the therapist is too vulnerable to uphold his or her professional responsibility. The Steiner (2007) model demonstrates one way of being proactive for unpredictable life events that could impact our clients. The authors of the current article encourage interested readers to follow up with Steiners recommendations by reviewing her template on how to prepare a professional will (see: pp. 1419: http://www.psychotherapy.net/ article/ psychotherapist-retirement#section-blueprint-for-therapeutic-continuity). Implications for Future Research It is clear that the idea of professional wills or contingency/emergency planning for ones clients and practice has been given scant attention in the literature. Despite existing recommendations, there will be many therapists who choose not to engage in thinking about their own mortality and will not create a professional will. Future research in this area is critical and it could move in two directions: (1) The impact of mortality acceptance/ awareness on self of the therapist and (2) How death preparation or lack thereof can impact clients and therefore be an issue of ethics and professional practice (i.e., therapist competence).

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Because of the level of research currently available, we propose that the rst stage of investigation should be one of exploration, through preliminary investigations and qualitative interviews. Many clinicians have experienced losses similar to those of the authors and have also inherited clients from colleagues. It would be useful to interview such clinicians about what was unique and was similar about the clinical experience of working with a client who lost their previous therapist and perhaps factors such as how formal or informal the inheritance process was. Is the inheritance process impacted by how well the inheriting therapist knew the previous clinician or what the quality of their relationship was? Additionally, a second line of investigation can focus on the many clients who have lost their therapist in the midst of treatment by interviewing them with the intent of knowing more about their experience. How exactly does loss of a therapist impact initial presenting problems? What is the impact of confounding factors such as the stage of the therapeutic relationship prior to the death, the length of treatment and what presenting problems a client came to treatment with? Is the impact of therapist death mediated by the amount of other signicant relationships a client has? These are just a few of the important questions that need more empirical exploration. In addition to exploratory interviews, some basic quantitative research should be conducted. It would be important to know if by simply making a professional will, do therapists work better with issues of death, dying, grief and mourning than those who do not? How do therapists attitudes on this topic impact their ability to be present with clients who are struggling with these concerns? Therapists working in clinical contexts with high degrees of grief and loss could be recruited and randomly assigned to one of two conditions, one condition where therapists are asked to write a professional will compared to a control group of therapists who have not written one. Therapists could then be videotaped and coded by independent raters on the level of empathy, comfort, and follow up to issues of grief clients display in addition to having therapist and clients ll out session by session self report measures. Another question that could be asked is; Do clients whose therapists have professional wills do better clinically with an inheriting therapist than those whose therapists die without one? Obviously, random assignment to a particular condition in this case would not be possible but certainly following up clients and interviewing them and their inheriting therapists about this process and perhaps following them longitudinally would benet the profession. These are just a few of the important questions that could easily be explored to help us know more about how therapist mortality and an examination of this mortality may impact our clients. The questions posed here are challenges to the eld to engage in an empirical and personal discourse about death. The absence of research in this area may indicate an isomorphism within the eld of what is occurring in society around our collective denial of death. For that issue alone, every therapist should seriously consider exploring their thoughts about their own mortality if only to be more aware of potential blind spots and areas of growth. They should consider what will happen to their clients in the event of their death in order to be as mindful as possible about client care.

Conclusion Death comes to us all. It is not necessarily a happy topic; it is not pleasant but it is inevitable. In therapy, we encourage our clients to explore topics about which they may have limited insight or interest, but have signicant impact on their relationships with others. Similarly, as MFTs, we are encouraged to be aware of our own issues so as not to

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put those onto our clients. Within the elds of psychotherapy in general there seems to be a broader denial of how therapists own mortality affects their clients across various dimensions, which is interesting for a eld that promotes clear-sighted exploration of the self of the therapist (Baldwin 2000). However, in looking at the broader literature on attitudes toward death, it is not just therapists who are aficted with this attitude, but society as well. As systems therapists, we are trained to examine the broader context of any particular behavior and therefore in this article the authors wanted to explore the questions of; Why are more therapists not talking about this important issue? And, what are the implications for self of the therapist and therapeutic practice related to the death of a clinician? We believe MFTs should begin to engage in the same type of introspection we ask of our clients who exhibit personal blind spots. We should examine our own death-denying tendencies in order to have greater clarity and understanding about who we are and how we engage with others. All therapists will die. Realistically, most will probably die when they are not actively practicing. However, the fact is that very few of us are prepared for a death that is professionally appropriate and honors our relational connection with clients and colleagues. In that sense, this article is a call to action for therapists and the eld as a whole to engage in conversation about the taboo topic of death both at the personal and the professional level. It is only through such conversations that we can continue to enhance our self awareness and protect and care for our clients in the most ethical ways possible.

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