When acute illness strikes, how can this affect a therapist’s work and clients?
Last Easter, I went on holiday in Africa for two weeks. I prepared my clients in good time, knowing that some of them would struggle with the break no matter how well signposted. It was on the flight back that I started to feel unwell and when I got home I went straight to bed. Later that night I realised I was too ill to see my clients the following day. It felt like I had a flu-like bug that would burn itself out after 24 hours. However as each 24 hours passed, and I didn’t feel any better, I had to cancel the following day’s clients. Arguably in denial about the seriousness of my illness I ended up cancelling one day at a time thinking each day, surely, I must be getting better by now?
After seeing my GP, followed the next day by a visit to A & E, I was admitted onto the infectious diseases ward at University College Hospital on day six of my illness.
Without exception everyone who looked after me was compassionate and professional; it really was the NHS at its best. On the one hand it was a great relief to be told that my symptoms did indeed mean that I was very ill and not imagining it; I could surrender to the men and women in white coats who promised to get me well again. But I also experienced waves of fear, worrying that I might actually have something seriously wrong with me. In my listless and febrile imaginings another worry that wouldn’t go away was, “What am I going to do about work?” I remember tearfully asking the lovely young Danish registrar what I should do. She explained simply that I was ill and I needed to take time to recover. I felt like a child, but it was such a relief that another person could make that decision for me and to be told specifically to cancel work for the following week (by this point it was Friday).
I sent out more individualised texts saying:
Apologies but I will need to cancel again next week as it turns out I picked up an infection while abroad. I expect to be fine for our session the following week.
Looking back I remember the huge relief I felt being given permission to cancel work for a week, but also I can now see how unrealistic it was to think that I would be back at work so quickly. I wonder whether the doctor thought if she told me to cancel for any longer it would have made me panic about my illness? Of course she wouldn’t really have known the trajectory or timescale as at that point it hadn’t been diagnosed, but it does make me think about how doctors manage their patients’ expectations and anxieties. In her case, whether she was aware of it or not, I think she handled my anxiety just right.
It was very surreal lying in my isolation room, looking at The Post Office Tower and the surrounding sky as it changed from pink and grey into blues and back into that particular shade of London night, grey tinged with sulphurous yellow. My spiking fevers, sweats and headaches meant I didn’t have the desire to do anything, not even read or watch TV.
After five days the doctors were able to confirm that I had an amoebic liver abscess and it was agreed that I could go home the following day, leaving with a big sack of drugs on the understanding that I would return as an outpatient for scans, blood tests and meetings with the doctors. I was still experiencing fevers and torpor, but even then, I was in denial about how long the recovery would take. When I saw one of the registrars the following week I asked with trepidation how much longer he thought I’d have symptoms and then how long it would take to fully recover. In the forefront of my mind was worry about missing so much time off work, but also concern for myself as I still felt so unwell. He suggested I needed a month to really recover, but three weeks minimum. I could barely take it in. I’d already had a two week planned break for my holiday, which now seemed eons ago, another two weeks to get to this point, and now he was suggesting three more weeks. I broke down in tears – surely a clear sign if ever one was needed, that I was no-where near well enough to see clients!
I felt overwhelmed with feeling both responsible and worried about what my clients would make of me having all this time off. Competing with these concerns was the shameful acknowledgement that actually I didn’t want to go back to work – I couldn’t face it. I’m sure I am a typical therapist, in that an interest in and compassion for other people is central to how I see myself. So it was strange indeed to observe how little I cared about anything much beyond my immediate family, and if I’m really honest, I didn’t much care for them either. I literally had no energy for anyone else. I didn’t have the capacity, or shockingly, the desire, to care for my clients. I wasn’t fit for purpose.
However, I was able to recognise that the doctor giving me a time-frame meant I could surrender to the process of recovery and trust that although I didn’t want to work now, when I was better my desire to work would return.
A few days later I spoke to my supervisor to get some guidance navigating this unchartered territory, as it was the third time I’d had to send out a cancellation text. This is what she suggested I wrote:
Hi. Just to up date you on my current situation. I’m now on a course of treatment and have been instructed not to work for the next two weeks. Our next session will be on xxx.
I look forward to seeing you then.
Much of my time was spent in bed, alone, filling my days with the ritual of regular small meals, administering drugs and sleeping. It’s extraordinary how quickly one can adapt to the life of the convalescent. I could sense how all too easily I might allow myself to indulge in feeling totally dependent…and all the while an uneasy thought kept resurfacing – “I can’t work. I can’t face those people and their needs.”
This discomfort let me to wonder whether I would have the capacity to work as a therapist if I ever developed a long-term chronic disease. I have heard of therapists closing down their practices practically overnight, leaving clients confused and feeling abandoned. Would I do that? I got a clear realisation that our physical health is one of the most important aspects of our lives, particularly as we age. I am young enough, and my illness obscure and acute enough, to warrant lots of kind interest and concern, but as we age our fragile health becomes more mundane. Who will visit me bearing gifts of bath oil, candles and copies of Grazia when we are all old and struggling with arthritic hips, weak hearts and dementia?
When the convalescence period was drawing to an end I started to re-orientate myself back towards the outside world and my client work. As part of this process I met with my supervisor to discuss the specifics of how I’d handle this unique situation. Although she had recommended that I kept details about my illness to a minimum, I found each client’s reaction to my absence to be different and required a different response. My experience was that the clients with the most complex presentations were the least interested in what was wrong with me. They were much more preoccupied with the impact of me not being around for them and what that meant – which of course is as it should be.
I lost one client. I think my absence had come at a very difficult time in the work we were doing and she found the two-week holiday break hard enough, but after I had to cancel for another four weeks it was too much for her. In turn she cancelled appointments in advance, on the day, and didn’t attend others, eventually leaving, but without seeing me, nor coming to a final session. This process took the same amount of time as my illness had, a pattern that echoed all the holiday breaks I’d had with this client. I was sorry about ending our work in this way, but if I’d been asked to predict which client would most likely leave because of my absence, it would have been her.
Another client told me he thought that I’d made the time to see all my other clients in the week before I returned to work, and that I’d not prioritised seeing him. He also told me that while I had been away, he’d often composed texts to end therapy, but never sent them. We had previously discussed how he felt marginalised, an outsider and forgotten. In his fantasy I favoured my other clients over him. I was able to say to him, very congruently, “Maybe this has been your reality in the past, and continues to be your reality sometimes, but in this case, although I can see why you imagined it might be like that, it certainly wasn’t the case. You are in fact the first client I am seeing since my break.”
I can now use the concrete reality of our relationship as a way into his inner world. My absence turned out to be quite pivotal in the end and he has really shifted in his understanding that this is sometimes what he does (imagine he’s marginalised), rather than what always happens to him. From the outset, this client was very ambivalent about therapy but since this episode our work has been much more productive and committed.
My supervisor was sure that most clients wouldn’t be interested in what was wrong with me, and indeed believed it wasn’t their business to know. However I was curious to see if clients would ask me questions about my time off sick, and if so, which ones.
One had made it clear from the outset of our work that he didn’t want to know anything about me (he’d had had some blurred boundaries with other therapists), and I respected that. Surprisingly, he did want to be told enough to know that I was OK. I was careful to discuss why he wanted to know, and how much, beforehand. We discussed how different this was for him therapeutically – to ask me for what he needed and to receive the right amount of information that wasn’t overwhelming.
If I put myself in the client’s shoes, I know I would have fantasised about my therapist being mortally weakened and vulnerable. I would have asked myself questions such as, “Am I going to have to look after her now?” and “Is she going to be strong enough?” Something similar happened to me in the early days of having my own therapy, and with that therapist I felt our roles had been irrevocably shifted so that I became the ‘concerned child’ to her ‘damaged mother’. Perhaps I am oversensitive to this possibly coming up for my clients as it did for me, and it hasn’t actually come up at all – directly at least. Maybe it will at some point in the future. So I found myself disagreeing with my supervisor about disclosing details about my illness. I saw the needs of my clients individually and in relation to why they wanted to know and what answers they wanted to hear. Maybe that cut off their possible fantasies, maybe it was not the right thing to do, but I tried to go with what they said they wanted from me.
I started to feel ‘normal’ as a therapist after about another three weeks. I had worried about going back to my fifteen clients a week but by completely prioritising work and nothing else, I made sure I was well enough to see them all. Luckily, almost everyday I was able to have a nap and I ignored everything that wasn’t essential while I got back into a routine. I still do far less than I did before my illness, but that is a conscious choice now as I am enjoying the space it’s created in my daily life.
As far as my practice goes, the lack of empathy for my clients that I experienced while ill revealed something perhaps we therapists take for granted. I didn’t anticipate feeling so guilty or anxious either about my own health or my clients’ concerns. I also did not expect to feel so readily dependent upon others for my wellbeing. It’s a timely reminder of how stressful this work can be, and how much energy empathy requires.
Four months after my illness and happily back at work, a client sent me a link by email of an article in the journal Nature entitled ‘Over half of psychology studies fail the reproducibility test’. This of course raises a whole load of questions about technology and boundaries in therapy, but I’ll save that for another article. Suffice to say that it prompted an interesting discussion about the efficacy of therapy. My stance on this has become much clearer over the years – I have an MA in psychotherapy, which I believe indicates that the work I do is a creative process, an exploration without a clear direction or predictable or reproducible outcomes.
But I am sensitive to the prevailing cultural demand that our work should be supported by evidence. Fair enough. With this in the back of my mind I went along to my signing-off appointment at the hospital. I was greeted by the familiar, friendly face of my registrar, who introduced me to a taciturn young doctor as “one of the patients we managed to get better.” Evidently in a good mood, he asked me if I liked to be interesting, to which I replied, “Sure, I’m a therapist. It makes a change for me to be interesting instead of my clients!”
He then explained how his team had been in contact with another London hospital where I’d been seen eight years previously with a serious gastro-enterological complaint. Their brilliant pathologists re-examined my paraffin blocks (FYI – bits of my colon preserved in resin – amazing isn’t it that this stuff is sitting for years somewhere in London’s labyrinthine NHS?). They discovered that I’d been misdiagnosed at the time and I’d actually had amoebic colitis. This means that my recent illness had not been contracted in Africa at all (pure coincidence), but had been in my system for at least eight years and probably contracted many years before that. This I was told is extremely anomalous – it does not fit the expected trajectory of an amoebic infection. It doesn’t really make sense. My doctor was palpably excited and I was too. The taciturn young doctor however didn’t seem that bothered…
I walked away from that meeting thrilled for many reasons. Being well again of course, but also to have made some sort of sense of the illness I’d had almost a decade previously, while at the same time noting how this wasn’t a predictable, linear, logical-making sense. It was unique to me, to my body, to my history. This didn’t fit the scientific model, and I thought, if a commonplace infection doesn’t follow a predictable trajectory, what hope the complexity of the human mind?
For me this episode serves as a reminder that we can make maps by all means but don’t expect to always be able to follow them. Detours are often so much more interesting, and we should remain humble enough to not know where we might end up.
(Details have been changed to respect client confidentiality).
Jane Edwards is an integrative therapist working in North West London. She suggests reading Gut: The Inside Story of our Body’s Most Under-rated Organ by Giulia Enders (Greystone Books, 2015). It’s about the link between the gut, the immune system and depression.k
Image: Sheila Sund – The Doctor’s Desk