Weighing Your Clients’ Needs Against Your Own

Q: When dealing with an ongoing personal crisis or medical emergency, how do I know when it’s too much for me to simply “carry on” with my regular practice?

A: Let me start by sharing what I learned when I was faced with a family emergency while managing a full caseload in private practice.

It was January 2021, and my husband and I were relieved to be on the other side of a busy holiday season. As we were putting away the holiday decorations, he suddenly turned to me with a stricken look on his face and said, “I’m having chest pains. I think I need to go to the hospital.”

He’d had heart trouble in the past, but this caught me off guard since he’d been doing well on his medications. I was terrified as I drove him to the hospital. This was midway through the pandemic, and I couldn’t go in with him.

“I need triple bypass surgery,” he told me later that day over the phone.

The thought bubble over my head read: Oh my God!

Over the next few days, although I often felt panicked, everyone assured me he’d only be in the hospital for five days at most. At that point, the thought bubble over my head read: This will be okay. I can manage this. And for a while, I was right.

The operation went well, but each time I talked to the ICU nurse, she said things like, “I don’t know why he’s still giving off so much fluid,” and “He’s not really coming back the way we like to see.” My husband stayed in the ICU a day and a half longer than expected. He was puffed up from the fluid they’d pumped into him for the surgery and had tubes coming out of his chest. Although it was scary to see him that way, I tried not to let my anxiety get the better of me. But once he was in a regular room and still not back to his old self, I had to come to terms with what was happening.

“He’s not healing properly,” his post-op nurse told me.

Because of covid concerns, I initially kept my visits to an hour a day, but ended up missing most of the doctors’ rounds, no matter when I showed up. I realized I needed to spend more hours at the hospital, and that my regular schedule of seeing clients three days a week for six to seven hours a day needed to be temporarily adjusted. So I canceled my afternoon clients, rescheduling people with flexible schedules into morning slots.

But after my husband had been in the hospital for 10 days with no end in sight, I found that even seeing just a few clients in the mornings felt like too much. During one session, a client told me of her father’s recent heart attack, and I got distracted wondering if he’d end up on the same floor as my husband. But the pivotal moment came early one morning when I went to the hospital and found that my husband hadn’t been given any breakfast. I wandered the hallways for several minutes in search of a nurse who was willing to order him some food. When one finally assured me that food was on the way, I rushed home to see a few telehealth clients. Afterward, I returned to the hospital and was shocked to see that although my husband’s food tray was now in front of him, the small bowl of oatmeal, the size and consistency of a hockey puck, hadn’t been touched. No one had taken the time to help him eat it. I felt sad, angry, scared, and helpless.

At this point, the thought bubble over my head read: Oh, forget it! I can’t pretend I’m able to see clients. I need to stop, at least for a while. I was finally ready to let go of any pretense that I could manage my life and my practice in the same way I had before my husband’s surgery.

Ethical Considerations During Personal Crises

During a personal crisis like this, we often end up weighing the risk of client abandonment against possible therapist impairment. Looking at these situations closely, we’re talking about the collision of the ethical principles of beneficence and nonmaleficence. Beneficence is the ethical mandate to do good, while nonmaleficence is about avoiding harm. Both of these principles derive from bioethics, and together constitute Principle A in the 2017 APA Code of Ethics. The good you need to do for your family member or yourself (beneficence) conflicts with wanting to make sure you do no harm to your clients (nonmaleficence).

Two ways you might harm clients when you’re trying to manage a personal crisis are by being emotionally unavailable and depleted or by reaching a point where, as a result of the sequelae of your own overwhelm and stress, you abandon your clients altogether. When caring for your clients interferes with caring for yourself, your priorities conflict. This can be confusing during a personal crisis. So it may help you to think about the situation using the following steps.

Evaluation: Ask yourself, Can I do this now? In other words, can you see yourself sitting with clients and being able to give them your full attention? If the answer is yes, then go ahead with your regular schedule. If the answer is no, proceed to the next step.

Reflection: Ask yourself, What’s coming up for me? Do you suspect you’ll be distracted during your sessions? Are you finding that your mind strays as you sit with your clients? If so, then practicing staying steadily present with clients, moment to moment, can actually be a way of coping with your personal crisis, as long as it doesn’t become an ongoing form of avoidance. This kind of focused attention can be a lifesaver if you’re not able to do anything to help resolve your personal crisis immediately. If you can do something or feel you must do something, then proceed to the next step.

Triage: At this point, it’s probably become clear to you that there’s something more you need to be doing to take care of yourself or someone else. So it’s time to think about doing triage with your clients. Which clients do you think would be impacted the least by having their session put off for a few days or weeks? Which would suffer harm from not seeing you?

Figuring this out can be tricky. For example, I worked with one long-time client who had significant boundary and abandonment issues. With her, the question became “What do I tell her about the reason I need to reschedule?” and “How will it land with her if I don’t have a specific reschedule date?” As always, consulting with colleagues or supervisors can be helpful in these situations, because it’s your ethical obligation to do your best to assess the impact of your hiatus on each client.

In my case, because the hospital was nearby, I had some leeway when it came to timing sessions with clients I’d already scheduled. I could call the nurse early in the morning and then see a few clients before going to the hospital, where I stayed until 8 p.m. If making best-guess calculations when it comes to taking care of your own situation and your clients seems impossible or too stressful to think about, proceed to the next step.

Telling Clients: Depending on your level of comfort with self-disclosure and the clinical issues your clients are dealing with, you may decide to tell your clients something like, “I’m so sorry, but I have an emergency to take care of, so I’m afraid I must reschedule our appointment. I’ll get back to you as soon as I can with another time.” Most clients show concern in these situations and hope things turn out okay for you. If you know your client needs support when you won’t be available to them, you could offer a referral. One place I recommend to clients (when I’m on vacation, for example) is a free walk-in clinic where I did many of my postgraduate clinical hours. Otherwise, it’s a good idea to ask a trusted colleague or two if they’re willing to be a backup for you while you’re away. This gives your clients somewhere to go, even when you’re not able to be there for them.

Once things have gotten back to some semblance of normal (we had in-home care for my husband after he finally came home) and you’re able to start seeing clients again, proceed to the next step.

Returning: After the emergency has abated, you may decide to tell all your clients the same brief story about what happened, or you may decide to disclose more to some clients and less to others. Keep in mind that some may not want to know what happened, and the ones who do may be unsure about whether it’s okay to ask you about it.

As you figure out how much to disclose, think about what each of your clients might need from you. Will they benefit from your authenticity in this situation, or will it unsettle and distress them to know details? I had an experience with a client in which self-disclosure opened a deeper level of understanding between us.

“I’m so sorry I had to reschedule,” I told her in our first session after my time away. “My husband had emergency open-heart surgery and there were complications afterward.”

She looked at me closely. “Oh, I know exactly what that’s like,” she said. “My husband had quite a few of those.”

Although I knew she’d lost her husband several years earlier to a heart attack, I hadn’t known the details. “Wow, I had no idea,” I said.

“He was pretty ill for the last 10 years we were together,” she told me, “so I know what you’re going through and how hard it can be.”

Tears welled up in my eyes as we looked at each other, sharing a moment of connection, human to human, around what it’s like to suffer through the worry and fear of having a loved one on the brink of death.

Being therapists doesn’t protect us from experiencing stressful situations and events we can’t control. When we find ourselves trying to move through a crisis, rather than pushing ourselves to power through, a better choice involves attuning to our changed needs, considering our clients’ needs, and making temporary adjustments. Although I’d never wished for the distressing disruption that shook up my life and my practice for a few months, truly being in the moment with my worry, grief, and loss helped guide me to make sound decisions with my clients, and act in a grounded, ethical manner. This is what our clients need and deserve most from us.

Photo @ Pexels/Andrea Piacquadio