Vacations should be care free. I suspect they were in the days before therapists and portable phones. Now, if you want some freedom from responsibility, limits must be set on how much of your “work” you take with you. Therapy patients, however, have little choice in the matter. After many years of hearing my clients’ concerns about my departures, I realize to some of them my farewells sounded as if I were saying, “Goodbye and good luck.” Today I shall address the problem of vacations from the therapist’s side of the treatment process.
I saw those interruptions as both essential to my well being and as an opportunity for therapeutic growth in my clientele. You might not agree with how I approached the issue while I was in practice, but I hope you understand my reasons.
The blogger What It Takes To Be Me, explains the client’s dilemma in this excerpt from her post, Reconnecting:
Regular readers of this blog will know that psychotherapy breaks is a topic I have written about a lot over the years, because it brings to the fore all of my fears about being abandoned and forgotten. It is also one of those things that people who haven’t been in therapy never seem to fully understand or appreciate. And, to me, that is also part of what makes breaks in therapy difficult; the sense that others don’t understand how hard they really are. Whenever I mention to ‘non-therapy’ friends that I feel really anxious about an upcoming break, I always get the feeling that they are thinking that I am worrying over nothing. And if I, during the actual break, say something along the lines of finding it hard that my therapist is away, the immediate response is invariably ‘When will she be back?’ followed by an equally predictable ‘Well, it’s only X weeks left’. This, of course, feels terribly invalidating, since a therapy break isn’t really about length of time at all, but about strength of emotions and how to cope with them in the absence of a safe place to explore them.
I was “forgotten” on the first day of kindergarten at Avondale School. I recall all my classmates being picked up by their moms. I was alone but for the teachers. Indeed, the school janitor, push broom in hand, was already making his rounds before my mother showed up. She misunderstood when school ended. The event did nothing to cement my own sense of security!
Much more serious and repeated abandonment issues fuel counseling sessions. Trust builds gradually, if (a big if) the therapist is sensitive to the kinds of feeling so well described by What It Takes To Be Me. Nonetheless, vacations are tricky.
The issue of credibility is near the heart of the problem. The people you treat are asking themselves an essential question: will this guy do what he says he will do? To fulfill the implicit or explicit promise of therapy, you must listen carefully to what people say to you, remember what they report from week to week, show up on time, be available by phone to a limited extent, and not be overwhelmed by the harrowing, heartbreaking stories you hear. Judging is not permitted either. Regardless of whether the client is aware of his motives, a part of him is testing you. Given his history, this kind of appraisal is more than fair. The vacation is one of the bigger tests.
I always tried to prepare clients by announcing my vacation schedule weeks in advance. Those who were in therapy for a considerable time knew when I predictably took off. Not all holidays, of course, were predictable. When I began outpatient practice I usually took four weeks vacation. Closer to retirement, respites from work were at least double the time, with roughly thirty years in between. Indeed, the need for more breaks signaled work-caused depletion and aging. Retirement beckoned.
The need for refueling is one of the funny things about doing therapy. The psychologist or other “provider” (as the insurance companies like to call all healthcare professionals) just sits, listens, and talks. A pretty soft life, eh?
If, however, you take it seriously, it is not. You must listen with intensity: hear, understand, and interpret the words; the tone of voice, watch the facial expressions and body language. To find out more about what is going through a therapist’s mind during the session, read What is Your Therapist Thinking?
I have written the above to enable you to understand what I am about to say, even though many of you already know: therapy is hard work and vacations are necessary if you are to perform a desperately important task without burning out, becoming resentful of clients, and using yourself up so as to be of no value to yourself, them, or your family. I was privileged to do therapy, permitted access to secrets never told, and to know some amazing and courageous people almost as well as they could be known.
The practitioner must also present a model of self-care, an ability many of his clients lack. A counselor who is overwhelmed, preoccupied, or exhausted, benefits no one. Your offer of yourself as a human sacrifice is a well-intentioned mistake. A portion of the good people you treat have lived in the same self-effacing style for years and are searching for another way. You are exhibiting all the wrong things about how to lead a life. Such a therapist is not a rock to hold on to in a torrent, but himself adrift.
Just so, you are giving an unfortunate impression if you do not take enough time or interest in your own family. This is complex. You do not wish patients, about whom you care, to experience guilt because you are taking time from your spouse or children. Some clients want as much of your presence as you can give, but you will almost always be respected more if you are good to yourself and your family. Your behavior, more than words, demonstrates sincerity and balance in the way you manage and (usually) do justice to the competing interests.
That said, by the time I was taking eight or more weeks off, I had accepted as patients only those people who could withstand my absences. Remember what What It Takes To Be Me wrote, “…since a therapy break isn’t really about length of time at all, but about strength of emotions and how to cope with them in the absence of a safe place to explore them.”
A therapist needs to put off very sensitive issues in the few weeks before his vacation. Just as a surgeon does not want to leave an operation before suturing the incision, a counselor shouldn’t leave anyone wide-open emotionally as he heads out the door for a holiday. Consultation with the client about what is safe to discuss is essential.
Part of a healer’s job is to factor in every conceivable variable in approaching his client, including his own mental and physical health. As Hippocrates wrote, “First do no harm” and he might have added, “to anyone, you and your family included.” I tried to be as thoughtful as possible. Young therapists, in particular, need to experiment to find an approach honoring their ethical responsibilities to others and their private needs.
I found out what worked best for me and my patients was not what I did early in my career when I took less vacation or, in a certain sense (as I will soon describe), none at all. A practitioner risks becoming too responsible as much as he risks being careless of others’ needs. One does not want to assume everyone you see requires access to you at every moment, thus stealing the initiative needed for them to grow. This is similar to an overprotective parent’s hovering over a child.
I recall one patient in particular to whom I gave my private phone number with the instruction to call if she were in crisis while I was taking time off. She did, although I can’t remember how often. What I do recall is the effect on me: I was unable to unwind because I anticipated the possibility she might call. As a consequence of my decision, at vacation’s end, I felt as though I had not been away from my normal work routine. I soon ended this permission and discovered that she and others survived my absences and eventually grew from them.
That left the problem of how to best create the circumstances for such growth. I needed to stay bonded to those individuals who feared I would forget them or never return, or believed I was refraining from scheduling only them and not my entire clientele.
Therapists have many ways to approach this. The patient and I worked on my upcoming time away and how he might find support elsewhere. We talked, too, of the “transference” of his abandonment fears: parental figures who had been undependable, indifferent, or who disappeared during childhood create expectations of similar behavior by the healer.
Who was “covering” for me in emergencies was another important topic. If the colleague was in the building, I sometimes made sure there was a meeting between my client and this stranger before leaving.
I also used what are called “transitional objects.” Just as children will hold fast to a doll or a blanket to mediate the time until a parent returns, so do therapists offer tangible items for patients to take home while he is away. I sometimes employed a stuffed bear to maintain the connection between me and the person who was afraid of being abandoned again. A recording of my voice was another such device.
Ideally the client discovers, over many therapy breaks and an equal number of reunions, the healer is not identical to whomever abandoned him previously. In this way, the patient can begin to prevent his past from recreating a sense of anxiety in the present. Eventually, he sees the relationship-portion of the life project from a more hopeful perspective. In therapy and out, parting is inevitable. Treatment will end one day. A vacation by the therapist is a step in preparation for such a time.
Healthcare professionals are notorious for taking off during the holiday season. I was guilty of this, as well. These periods are often a temporal reminder of many of the worst experiences in a client’s life. The healer must help develop an adequate plan to get beyond the holidays. If the patient has supportive relationships outside of counseling he is well-positioned. Finding these is easier said than done, but with time it can be done. Without such people, activities (for example, working at soup kitchens for the down-and-out) are crucial to avoid the despair of a season that contributes to the unhappiness of many. The joyful images of TV programs and commercials are not a commonplace reality. Inevitable comparisons with idealized lives make us less than thrilled about our workaday existence.
There you have it. I do not mean to suggest I discovered the secret to perfecting a challenging part of being a clinical psychologist, and the potentially frightening and dangerous aspect of trusting a person like me. I am friendly with at least one psychiatrist who takes calls from his patients while on vacation. He is a conscientious man, but also one who doesn’t treat the phone as a burden to himself or his family. My hat is off to him. I did not have his magic formula within me, much as I searched early in my practice. Yet I believe I served my clients honorably and well within my limitations.
Remember, the Temple of Apollo at Delphi was inscribed with the Greek aphorism, “Know thyself.”
The top photo is a Surfer at the Beach of Costa da Caprarica, Portugal by Alvesgaspar. Next comes a Beach Sunset, Newport Coast by Axion23. Finally, more of Axion23’s work: Crystal Cove Beach Sunset. All are sourced from Wikimedia Commons.
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