I retired a 2 years ago After 28 years as a private practice LCSW. The career was interesting, challenging and wonderful...honoring to have have so many trust me for so many years. The practice wind down took years as I took no new clients and then, narrowed my available hours. Then, the final office closure unfolded unexpectedly but, naturally. Now, ( at 65). I maintain my license and work a bit for Critical incident companies, do sage like things, hang in my garden, enrich my soul and play with friends, kids and grandkids.

Thank you so much for this article. It is much needed. While I deeply appreciate your appeal to therapists to be self-aware and monitor whether we really are fit to practice, whether the way we are truly serves our clients, this still requires a level of consciousness about our performance and a level of self-awareness that might be bypassed altogether by cognitive decline. Hard as it is to admit, our fitness to practice may be affected by our mind no longer working as sharply as it did or needs to, and this being much more significant than we might be aware of or admit to ourselves. If we don't realise it's happening, how do we address the issue of cognitive decline? Some years ago (about 6), when I had a supervisor whom i regarded very highly, saw as very wise, and had benefited immensely from seeing in supervision for some years, I had experiences when I noticed her having moments of not being 'with it' cognitively during our sessions. At times, her mind would wander, her sentences might not make sense, or she would ramble in a tangential way to the topic at hand. Such moments would leave as suddenly as they had arrived, and our work would continue. At that time, I was 54 yrs old, and she was 72 yrs old, a long time practitioner in the field and highly regarded in her specialty. I found those moments very disturbing and distressing. I didn't know how to raise these experiences with her, whether I should, even. I didn't want to shame her, didn't want to scare her, didn't want to hurt her, and had no idea how she might receive such challenging feedback. She had always prided herself on being self-aware, as well as having a very sharp mind. I didn't want to be the first person to raise a question on her cognitive fitness to practice. I also didn't want to lose her regard for me, or lose her as a supervisor. It was particularly difficult for me because we had negotiated a contract of radical honesty between us - I could be myself, warts and all with her, and I was. Except for this. This was the one secret I kept from her and it didn't sit well with me to withhold it from her, but I didn't have the courage to do anything else. It felt like a betrayal of our agreement. As it happens, life took care of things for me. She died of a stroke 2.5 hours after our last supervision session about a year later, and that was that. In the lead up to her death, however, I searched for articles on this very issue: how do we know when we should stop as therapists/ supervisors? How can we monitor our fitness to practice? What would such metrics be? What protocols do professional organizations have in place to monitor this? I found NO articles on this matter anywhere. My professional association, the Australian Association of Social Workers, had nothing to say on the matter when I contacted them. I was astounded at the dearth of ANY in depth, frank discussion on this important issue in the literature. I drew some comfort from the fact that, in addition to client feedback and retention rates, I use a session by session evaluation tool in my practice which evaluates my effectiveness as a therapist over time. I keep an eye on the figures and my Effectiveness Rating score, and watch any movement in the average score over time. It's my hope that this will be one way I might see a change in my fitness to practice beyond whatever my own self-awareness might track. After her death, when I negotiated a new supervision contract with another practitioner I held in high regard, i shared my story with him. I told him I want him to track whether he has any concerns about my mental fitness to practice over time, and I want him to tell me if he has such concerns. In turn, he asked me to tell him if I ever have any such concerns about him and how I experience him in our sessions over time. Hopefully, we will both be brave in this regard and this time, honor the radical honesty I so prize. I hope I will be brave enough to listen if he tells me he is concerned about me. And this time, if I have concerns about him, I hope I will be brave enough to say it to him. I think our professional associations need to look at this issue in depth and institute measures to regularly monitor practitioners' fitness to practice. It's essential from an ethical point of view for client service delivery, but also for the practitioners' sake. Thank you for opening up a thorny topic.

The issues you raise are crucial, particularly because, as you point out, our competence is essentially based on an "honor system" of self-awareness. Having experienced the descent of a dear friend and colleague into early-onset dementia and witnessed both her ability to mask her problems until they were glaringly obvious and the truly devestating effect on her clients, I feel that we need something more than a self-monitoring process. Had she been in her right mind, this very ethical and smart therapist would never have left her clients in the predicament in which they found themselves - without referrals and without records. Working solo gives us too much freedom in some cases.