Psychotherapist Professional Wills: Easy to Avoid, Crucial to Address

Importance of Creating a Professional Will

As therapists, we take time, intention, thoughtfulness, and care in developing our relationships with clients. Many of us see this bond as a vehicle for change. We may acknowledge our clients’ attachments, sometimes even dependency, on us at certain stages of treatment, and we strive to operate with integrity and beneficence as our ethics codes demand. However, we often avoid an important ethical duty to our clients, i.e., planning for their wellbeing if the worst were to occur to us. Consistent with our therapeutic efforts, we owe it to clients to consider how they would be impacted if faced with such a sudden loss. While statistically unlikely that a tragedy would befall any one of us, we have the responsibility to face our discomfort with mortality and to plan for the needs of those in our care. 

Consider the impact of a sudden termination. At a recent state psychological association convention where I was promoting professional wills, a colleague teared up remembering her anger and confusion banging futilely on her therapist’s office door 25 years ago, only to learn two months later that her therapist had died. Now, as a clinician herself, she prioritized creating a detailed and comprehensive plan for patient notification and continuity of care, in case the unexpected happens. She vowed she would never leave her patients in the position of feeling abandoned.

Some patients are at heightened risk for regression or decompensation. When I notified the patients of a colleague’s incapacitation, most people expressed grief, but some reenacted trauma.  One woman told me, “What a waste of a decade of spilling my guts, only to be screwed over by the one person I trusted. Well, I’m done for good now. I have lost all trust.” This same person shared six months later, “I was heartbroken when Dr. B was sending me somewhere else after going to her for a dozen years…. I am sorry.”

Colleagues shared their work with patients who had come to them in great distress following the sudden death of a previous therapist. Still, others spoke of rummaging through a colleague’s office, basement, or garage, trying to find files and patient contact information to notify them following a death. The practitioners I spoke with who have personal experience with unexpected therapist loss appreciate the importance of a professional will, and while they do not intend on leaving this for others to handle, they still procrastinate their initiation of this process. In fact, at the recent conference I attended, many therapists gave a range of responses, with some muttering as they passed by, “No, no, no,” while shaking their heads. One elderly man would not make eye contact but joked, “If I drop dead, you can take over.” Another woman stated, “I’m leaving it all to my daughter to figure out! I know that’s terrible!”

As a Maryland psychologist in private practice for almost 25 years, I have learned from personal experience that appointing a close colleague as a Practice Executor is not best practice, though it has been the standard way of handling this. In days past, a neighboring colleague was the best option because someone would need access to paper calendars and files, typically locked in the therapist’s office. While these arrangements were made with the best intentions, a colleague has her own full set of professional and personal obligations and cannot come close to meeting all the urgent demands of clients and the practice. Clients would likely not be well-served, and having a close colleague serve is likely to place an unintentional emotional and practical burden on your loved ones.

Considerations for Clinicians When Creating a Professional Will

Many therapists are aware that creating a Professional Will is a way to document your plan and intentions, carefully specifying details about your practice and instructing a qualified individual on how to resolve your practice. In order to construct an adequate Professional Will, you should contemplate the following questions:

• How do you want clients to be notified of your death?
• Who will reach out to your clients?
• How will you protect their confidentiality?
• To whom do you want to refer them? How will available matches be identified?
• Where are your passwords located to access client contact information?
• Where are confidential records stored? How should they be transferred or retained?
• How will your estate collect payment for services rendered by you?
• How will clients get the statements they need for insurance?
• What will be demanded of your family in their time of grief as clients are looking for you, for information, for their records?
• Will your estate face a financial liability to pay your Practice Executor?
• What will happen with your office? Your automatic bill payments? Your license and malpractice insurance? Your website?
• How will your colleagues be impacted? How will they manage their personal grief while shouldering the professional burden?  How will they cope when calling your patients or greeting them in the waiting room?
• Who can you ask to take care of this job for you as your Practice Executor?
• How long will this job take? Who will have the time?
• How long will it take for your clients to be reached and assisted with referrals?
• How much detail is ok to share with clients who ask about your condition?
• Would clients be welcome to attend a memorial service if they ask to?
• Which clients should have a specialized plan due to the potential of your loss being particularly destabilizing for them?

The Dilemma of a Professional Will

Our field has a Professional Will dilemma. Through conducting trainings, surveys, and consultations, I have learned just how overwhelming it is for clinicians to think through the above questions. Not only is it upsetting to consider the possibility of your sudden incapacitation or death, but it is also difficult to contemplate the impact that your sudden absence would have on those charged to your care. Most psychotherapists understand the obligation as outlined in our ethics codes, but many do not know how to fulfill the responsibility. Moreover, even if a therapist creates a comprehensive Professional Will that lays out a succession plan, it is often not clear how this plan will be carried out. Practice Executors are not under any legal obligation to comply with Professional Will instructions and may not be available to do so. Unless the Practice Executor also signs your Professional Will, it is not considered a contract but only an expression of your wishes. For colleagues who do try their very best to step up and serve, there is little guidance or support in the literature or trainings as to how to perform these duties. And now that you may understand the complexities and time required to serve as a Practice Executor, it becomes even more difficult to identify who you can ask to take on this responsibility.   

Lawyers will tell you that a Practice Executor is an administrative job. If you are a fellow psychotherapist, you will understand that this is a clinical job, as you will face grieving individuals who feel bereft and adrift. Depending on the executor’s relationship with the deceased, they may be deep in mourning as well. The job, on behalf of the absent therapist, is to gently bring their clients to shore by sharing the terrible news, listening to their shock, responding to questions about the therapists’ condition, and fielding inquiries about memorials.  The Practice Executor will identify referral sources, maintaining contact with clients to facilitate their transfer of care and records. This emotional and draining process is then followed by many more duties that may fall under an administrative category, but which also rely on clinical judgment regarding confidentiality, risk assessment, and anticipation of the impact on clients and on the therapist’s family as matters of the practice are resolved.

Each and every time a therapist is suddenly incapacitated or dies, we recreate the wheel and there is no telling what gets overlooked or slips through the cracks. This emphasizes the need for a better system. Here are some suggestions based on my experiences:

We need an easier means to comply

Instead of having therapists research Professional Will templates on the internet to best suit their practices, we need to offer assistance and provide a service to guide the creation of individualized plans. We need expert consultants available to assist with the clinical and business elements of this arduous task.

We need ways to outsource this duty

Similar to the outsourcing that is done with many other aspects of practice that require professional expertise (i.e., insurance submission, billing, electronic health records, administrative assistance, legal and accounting services), this is a necessary condition for practicing ethically and with integrity.  

We need to create a mandate for Professional Wills

State Boards of all disciplines of psychotherapists need to mandate that therapists create a Professional Will as a way of protecting the public. Despite most therapists’ best intentions, it is too difficult to overcome our intrinsic avoidance of mortality to really think about and allocate resources for the possibility of our untimely demise. While we understand this, it cannot be an excuse. It should not take a psychotherapist’s exposure to the chaos and crisis following a colleague’s sudden death to appreciate the need to act.

Conclusion

With patient care as our priority, psychotherapists need to better understand the impact of traumatic terminations and the importance of the ethical obligation to plan for continuity of care in the event of the therapist’s emergency. Psychotherapists are burdened with the complexity of this duty, as we are asked to contemplate mortality in a way that challenges human defenses. The status quo for fulfilling this responsibility calls on psychotherapists to draft documents with legal intent, and to seek ad hoc arrangements with colleagues to fulfill crucial clinical services for patients. As a field, we need to do better. Psychotherapists strive to operate with integrity and want to comply with ethical standards. There needs to be a more reliable and efficient means to do so in regard to creating a Professional Will and naming a qualified and available Practice Executor. Additional resources for professionals are included below.

Additional Resources

For recommended readings and resources, see here.

For a Professional Will template, see here.