To Reveal or Not to Reveal

Ten years ago, I was diagnosed with breast cancer. I had an active therapy practice and initially chose to keep this news from my clients. It took me months of tests to get an accurate diagnosis before it was time for my surgeries and chemotherapy, and I frankly thought they wouldn’t notice.

But I was also protecting myself. These were vulnerable days, and I didn’t want to have to worry about how to talk about my experience of this frightening new reality with them. I struggled with whether it was fair to burden my clients with knowledge that could interfere with their ability to speak freely about their own less-than-life-threatening issues, or make them feel even more distraught about the uncertainty of life.

Eventually, my client Beth, who had a history of traumatic attachment injuries and had begun therapy weeks after her husband had died of melanoma, noticed that something seemed off with me. When I’d first mentioned I was having minor surgery and would be gone for a few days, she’d nodded and wished me well. I had no plans to explain further, so Beth caught me off guard when she plopped down on the couch for our next session and immediately asked, “How did it go?”

My lengthy pause instantly flooded her with panic and tears. In that moment, it felt utterly clear that being truthful was the only right choice: for her, for me, for the therapy. “I have early-stage breast cancer and just had a lumpectomy,” I told her. “My doctor says I have an excellent prognosis.”

She instinctually put a hand to her heart at the news, showing her compassion, but she was also noticeably calmer. My telling her the truth allowed her to feel my caring for her.

After that, at the beginning of each session, Beth would ask how I was, and I’d answer simply and honestly. To my great surprise, I discovered that despite her frightened-young-girl-take-care-of-me presentation, she showed a capacity for genuine concern and caring. With her trust in me restored, we were able to resume her therapeutic work.

Much later, I was surprised when Beth told me that before I’d come clean and told her about the cancer, she’d sensed that I wasn’t myself. I was convinced that I’d been fully present, despite the extended period of stress that accompanied all the scans, testing, surgeries, and recuperations. In retrospect, I realized this attempt at working hard to pull it together and get on with life as usual was not only an unnecessary burden I’d put on myself, but a burden for my clients.

Each therapist who becomes seriously ill faces a weighty choice between silence and disclosure. This choice is even more fraught for those dealing with a terminal condition. Since my own illness, I’ve reached out to ill or dying therapists, their clients, colleagues, and family members—more than 100 people in all—and conducted in-depth interviews about what it’s like to face a therapist’s death or diagnosis, or be kept in the dark about something you can sense but haven’t been told about. As a result, I’ve found several common factors that go into therapists’ decisions about when and how to tell their clients that they’re sick or about to die—and to my surprise, I learned that some therapists never do.

The stories I heard have a recurrent theme: those who disclose early and allow it to be explicit in the therapy room cause the least disruption to therapy and their clients’ well-being. The realization that one’s therapist is a human being with her own vulnerabilities is a huge reckoning for clients, one they’d prefer not to have to face alone. Being able to take time in session to process this news and prepare them for the various eventualities seems to help everyone.

Clients Know When We’re Not Well

When Simone, a trauma therapist in her mid-50s, was starting to show early signs of Parkinson’s disease, she felt ambivalent about disclosing her diagnosis. After all, she told herself, therapy is about what’s happening to my clients, not to me.

However, her hypervigilant client Tara, who had a history of being lied to and abandoned by significant people in her life, sensed the subtle changes in Simone’s movements. She noted that when they’d meet at the door, Simone would steady herself on the knob before walking slowly to their chairs. Throughout the session, as they sat across from each other, she’d see Simone cover one hand with the other if it began to shake. When Simone called to shift her schedule unexpectedly for a medical appointment, Tara was deeply disturbed. “What’s going on?” she asked, her voice rising. “I know there’s something you’re not telling me.”

Hearing Tara’s distress, it dawned on Simone that because her symptoms were starting to show, she was already disclosing in sessions, even if she wasn’t doing it with intention. She immediately apologized to Tara, told her the truth—that she was in the early stages of a progressive disease that has no cure—and took full responsibility for her silence. As Tara struggled to speak, Simone clarified that the illness wouldn’t get in the way of her ability to be present for Tara for quite a long time to come, and that she had good doctors and a close support system helping her. Tara’s agitation subsided before they hung up, and after a person-to-person check-in when they next saw each other, she was able to focus again on her work.

Being Honest Every Step of the Way

As we see from Tara’s experience, therapists are often misguided to assume that what they’re going through isn’t apparent or doesn’t affect the client. While it’s true that the client is and should remain the focus of treatment, the way a therapist’s needs and dilemmas are handled can either enhance therapy or derail it, especially in the case of illness.

While in treatment for pancreatic cancer, Lauren spoke to her clients with the same courage, integrity, clarity, and humanity she showed each time I interviewed her. We talked first in the early, hopeful days of her treatment, again when her cancer returned, and finally, as her health deteriorated, when we discussed how she was handling ending her practice.

After Lauren’s original diagnosis, she underwent extensive Whipple surgery, a major procedure that involves slicing and attaching together three different organs to take over pancreatic functions, which seemed to have been successful. From the beginning, she’d kept her clients in the loop about her diagnosis and the treatment for it. “I knew it would be in the room, whether I spoke about it or not,” Lauren said. “And it was my duty to prepare them for my recuperation from the surgery, which would keep me home for two months.”

When the cancer returned, almost two years later, Lauren disclosed it again, inviting her clients to be with her in the uncertainty about her future. She welcomed their questions while reserving the prerogative not to answer if she felt uncomfortable. Some clients chose to start sessions with a simple “How are you?”—and Lauren responded honestly with however she was feeling in the moment. Regularly, she’d ask them, “How is this illness of mine affecting you?” This ritual gave the clients permission to be open and honest and to feel that, even while ill, Lauren was still very much present as their therapist.

One client, Brenda, also a therapist, who has strong caretaker instincts of her own, initially wondered to herself, “How can I talk about my own issues when Lauren is going through so much?” She reported that she was able to because Lauren didn’t shield her from what was going on. “It made it so I could relax and do my work,” she said. “Had she kept things from me, I wouldn’t have felt comfortable enough to focus on myself.”

That her needs could continue to be met while her therapist was meeting her own became a corrective emotional experience for Brenda. Lauren’s honesty created an opening for reparative healing of earlier losses, in which Brenda hadn’t had a chance to tell people what they meant to her.

For Lauren, her ability to live with her illness in an upfront and authentic manner allowed her to continually and honestly assess her capacity for working. Five months after the cancer came back, when it became clear that treatments weren’t working, she could feel her capacity to be present for clients starting to fade. She believed deeply that they had to be kept informed, even if they worried, felt burdened, or wanted to take care of her.

She decided to close her practice over a three-month period. During those months, she and her clients cried together in their final sessions as they talked about the work they’d done, the personal growth they’d experienced, the changes they’d have to endure ahead, and how much the relationship mattered in both directions.

Not a single client left therapy before Lauren’s practice ended. Not only that, but the open and respectful way Lauren handled her illness created trailheads for therapeutic paths with many clients, and several did deeply meaningful work because of it. Some were able to grapple with dynamics in the therapeutic relationship that echoed those in their personal relationships, wrestling with questions like, “What do I deserve?” “Is it ever okay to put myself first?” “Is it possible to care without being a caretaker?” “What’s a good goodbye?”

Handling a Final Ending

Stacey, a client in northern California, had therapy sessions over the phone with Anne, who lived in another state. They’d worked this way together for more than three years. When Anne was diagnosed with a rare form of cancer, she immediately shared the news with Stacey, explaining that she’d need more tests to know what the next steps in her treatment would be. “For now,” she said, “we’ll need to stop working together for the time being.”

Their next phone session, a day or two later, was their last. In it, Anne said, “I’m investigating treatments and trying to be hopeful but also realistic. I’m just taking it one day at a time.”

Stacey had already researched the cancer and knew no one survived more than five years after surgery. She told Anne she wanted to say something but didn’t want to upset or offend her. Anne answered, “Don’t be afraid to say whatever you’re thinking and feeling. You don’t have to hide anything in this relationship.”

Stacey told her that she knew the outlook was bleak and expressed a desire to meet in person at any point Anne felt up to it. It would be their first face-to-face meeting. Anne was enthusiastic about the idea because she, too, felt that after all the work they’d done together, it was important for Stacey to have the kind of closure she needed. So after Anne’s surgery, Stacey got on a plane to meet her. They talked and walked and had some lunch. “I got to see her seeing me in person,” Stacey said. “I got to hug her and thank her for helping me find compassion for myself, something I sorely lacked before our work together. I can think of no greater gifts she could’ve offered me.”

Although we can’t know Anne’s thinking in choosing to end therapy with Stacey as she did, it seems she was acting in accordance with what she knew about Stacey’s history and wanted this ending to be as different, nontraumatic, and mindful of their attachment as possible. “She was so thoughtful,” Stacey said. “I’d lost two previous therapists. I’d lost a boyfriend in a horrifying accident, and I grew up in a family where I wasn’t safe. There was real love and affection in our therapeutic relationship, and that was where all the healing came in. She taught me to be with what is—or at least to practice getting better at being with what is.”

The Repercussions of Holding Back

Unlike Anne, Simone, and Lauren, plenty of therapists I spoke with were not keen on sharing news of their illnesses with clients, even if they suspected clients might be able to sense something going on. That made me curious. What’s the effect on treatment when a client has to risk naming something that the therapist won’t, or when no one names anything at all?

I’ve learned that clients’ observations and intuitions about the therapist are often remarkably astute. And why wouldn’t they be? Their sense of safety and trust in this deeply intimate relationship depends on the therapist’s reliability and authenticity. A therapist trying to hide health issues that may be outwardly apparent, or soon will be, puts a client in a serious bind: how do you cross a boundary the therapist has wordlessly put in place? Further, not acknowledging what’s happening may make it seem that what the client is sensing is unspeakable, and it may sit in the middle of the room like an invisible pane of glass, obstructing the therapy process.

Clients I interviewed described the activation of previous attachment injuries or traumas. They described feelings of deep betrayal cropping up when what had seemed true and reliable in the relationship suddenly became suspect. It led one client to wonder, “Was she keeping me attached for her own needs, or for the income?”

The underlying premise of therapy is that clients are free to speak their truth—that this is one place where honesty won’t have negative repercussions. But some therapists struggling with illness told me they responded to clients inquiring about their health with the “therapeutic stance” of turning the question back on the client. Certainly, being genuinely curious about the client’s observations is one thing, but using this stance to avoid being forthcoming is another. When it happened, clients reported feeling shut out, infantilized, and sometimes even crazy. Often they blamed themselves for the therapist’s reluctance to be open about the truth of what was really going on.

It goes without saying that therapists have their own histories of trauma, attachment injuries, abandonments, and loss—experiences that influence their ability to self-disclose. Rationalizations, denial, avoidance, and isolation are often part of the therapists’ struggle to regain stability and balance. Here are some things my therapist interviewees told me about their decision not to self-disclose: “I don’t want to be seen as weak.” “I’m overwhelmed and don’t want to convey that to my clients.” “It’s private; I have good boundaries.” “I don’t want to endanger my chance for referrals.” “Therapy is about the client, not the therapist.” “Hearing how my clients feel would be too much for me to bear.” “I need to keep the shame I feel about my illness at bay.” “My clients won’t notice.” “I need to keep working as long as possible to support my family and maintain my identity.” “I’m a fighter. I’ll keep a positive outlook, show a strong face, and beat this illness.” “My clients will get over it (my death).”

How can therapists facing a serious or life-threatening crisis even consider disclosing to clients when holding so much fear and terror of their own? The importance of timely consultation with one’s trusted colleagues or a therapist about the psychological crises these medical situations evoke is absolutely necessary. Once therapists have attended to themselves, they can have a healthy centeredness and awareness of the effects their illness is likely to have on clients.

Ending Well?

If therapists do share their diagnosis with clients, there are often other conversations that need to take place to prepare clients for the future and offer them an opportunity to say goodbye.

Decades ago, Barbara, a somatic-­based practitioner in Chicago, received an impersonal form letter from her therapist stating that she suddenly had to close her practice due to a medical situation. Barbara was concerned and sad for her therapist, but she was also angry. She told me, “I spent years in intensive treatment with her, sharing my innermost world, and this is what I got? I felt like I didn’t matter. There was no follow-up, not even one last session.”

A few months ago, Barbara called me about Pam, her friend and colleague who’d recently been diagnosed with advanced ovarian cancer, a terminal illness. Barbara wanted to have an honest conversation with her about ending her practice. When they spoke, Pam gave lip service to accepting her offer to help her transition clients. But ultimately, she stayed in touch with them by text and email, and then declined so quickly that she was unable to end with them in person, or even in writing.

Though Barbara had composed a letter for Pam to send to her clients, describing the extent of her illness, explaining her inability to meet them in person, and emphasizing the importance and value of the work they’d done together, Pam never got to send it. Two months after Pam’s death, I interviewed Joan, one of her clients and also a therapist. Joan, who’d worked with Pam for a year, had noticed that in addition to using a cane, Pam hadn’t seemed herself for several weeks.

Pam finally explained in a single session that she’d been diagnosed with stage-four ovarian cancer and had started chemo. “I’m thinking positively,” she said. “I’ll beat this.” Joan felt Pam was in denial about her prognosis, but believed she had to appear to take Pam’s lead and appear upbeat.

Pam recommended that she consider looking for another therapist, but at the same time made an appointment for Joan two weeks out. Joan said, “Although we had another scheduled appointment, that one session turned out to be our last. Before I knew it, Pam had just stopped working, without any real ending.”

When Joan and I talked, it was clear she was still a bit stunned by it. There were long pauses as she struggled to express what she was feeling. She understood that Pam had been overwhelmed, but she told me that a young part of her had felt abandoned. “I found myself in a bad space. I started having panic attacks, about not only Pam’s passing, but the lack of process around her dying. I’m a caretaker in my own life. Therapy was a place for me to be taken care of. Even a phone call explaining what was happening would’ve helped.”

Barbara, too, had been frustrated in her interactions with Pam. She knew that Pam had too much to handle for one person, and she could see how crucial it was to have a professional will in place, where plans for medical illness, an accident, or death are spelled out well in advance. Professional wills include directives on how therapists want their clients to be notified and who should be on a prearranged emergency response team to follow through. Along with details about safeguarding records and managing any required business notifications, they contain the therapist’s client list and provide for clients’ temporary or permanent transfer to other therapists. All therapists, not just sick ones, should consider putting a professional will in place for situations of sudden incapacitation or death.

After these kinds of losses, some clients resume treatment with a hypervigilance that the new therapist would do well to anticipate. My interviews in cases where the ending was poorly handled, or the illness was never disclosed at all, show that clients’ capacity to trust in the authenticity and reliability of a therapist’s caring was badly shaken or seriously ruptured—as was, for some, their trust in their own ability to perceive reality accurately. For many, the process of repair took a very long time.

Honesty May Mean Losing Clients

Maya’s therapist, Alison, was diagnosed with uterine cancer. When she needed to take time off for surgery, she told Maya about it. While Maya valued their relationship and the meaningful work they’d done together, she didn’t believe she could deal with her own past losses on top of the potential loss of her therapist. Alison respected Maya’s decision to terminate therapy. She died a year later, and Maya knew she’d made the right decision.

Sherry consulted with me about her practice because of her diagnosis of metastatic breast cancer. Though she still felt healthy, she did have physical symptoms. So when a prospective client came in for a consultation, having shared in the initial call that she was a two-time cancer survivor, Sherry decided to be upfront about her condition. Her intention was to make this a shared decision, with each of them being able to discuss the implications and the pros and cons of working together. Although she felt somewhat torn, this prospective client decided that, given her history, entering treatment with Sherry wasn’t in her best interest.

Given the potential impact of our illnesses, it’s critical that our clients have the right to determine whether they want to start or continue therapy. If we withhold our medical status, aren’t we interfering with their right to self-determination?

As I interviewed all these therapists and clients about therapists’ illnesses, I realized that my own attempt to get by with keeping my diagnosis a secret had been a burden that I’d put on both myself and my client Beth, who’d been struggling to contain her fears about me. I’d never considered at the time that my attempts to keep myself together was a hurtful act: I’d been protecting myself, but not the relationship. And had I not acknowledged the truth, I have no doubt that I would’ve created another attachment injury for Beth.

I’ll never forget my true crisis of authenticity, which came when I was told to practice wearing a wig before my hair fell out. After consulting with colleagues about how phony I felt wearing it, I decided to tell everyone the truth. Once I did, I immediately relaxed. I could be myself with no energy wasted on the stress of keeping a secret. I had a beginning script, and the conversation had a life of its own with each client. All wished me well. I wore colorful scarves, which acknowledged not only what was going on, but that I was able to embrace it with flair.

At the end of chemo, my face was puffy, and I know I looked tired. I was. I was also relieved and grateful that I hadn’t kept my treatment hidden any longer than I had. When the whole experience was over, many of my clients told me they were grateful and relieved that I was okay. But what resonated most deeply was hearing from those who, in addition to whatever else they’d gained from therapy, had discovered something about handling the often dark and uncertain journey through major illness that, sooner or later, many of us must face.

PHOTO © ERIK RANK/PHOTONICA COLLECTION/GETTY IMAGERS