Ethical and Intrapsychic Issues in Ending a Practice

After many years of fulfilling work with psychiatric patients, one of the hardest things to contemplate is the process of retirement. Yes, we may look forward to freedom from long hours, emotional challenges, and continuous responsibility, but we dread the loss of close relationships with patients as well as our professional persona and standing in the community. After so many years, how will we adapt to such a different way of life? And how will we fulfill our responsibilities to patients?

The freedoms and new opportunities in this life cycle transition outweigh the losses, but one goes through a lasting process of mourning. The fact that one’s patients are also working through a realistic loss and experiencing anxiety, veiled anger, and feelings of abandonment complicates the process. This is especially true for patients in intensive psychotherapy, who mount their usual defenses, providing grist for the mill. However, the patients with more severe illness whom we maintain with supportive therapy and medications often have a stronger attachment than we realize, which deserves time and therapeutic attention to help them avoid a relapse. Though we and the patients are both dealing with separation and loss, and we may even acknowledge this to our patients, we are doing so in parallel, not conjointly; therapy time is for our patients, not us. Peer consultation can be very helpful in sorting out the issues.

Ethical and intrapsychic issues are involved whether one retires at 65, 75, 85, or at death. Psychiatrists tend to retire considerably later than most other physicians, and psychoanalysts go on even longer. Such continued service is noble and generally fulfills a need, but in going on, are we really doing what is best for patients? The ethical requirement of competence requires that we regularly observe closely our physical, cognitive, and emotional status and get objective verification of that status, that we be honest with ourselves about how we are doing, and that we act accordingly.

That rational course of conduct may not be so easy. Like any big upheaval, withdrawing from practice makes us anxious. So does the evidence of aging. We unconsciously reduce the anxiety with defense mechanisms, such as denial (“I’m not slipping,” “80 is the new 70”), projection (“my patient is trying to confuse me,” “Dr. X just wants my job”), rationalization (“an error here or there is normal at this age”), displacement (“I’m really sad about giving up that sailboat”), somatization, and so on. We may reduce the emotional impact through intellectualization and isolation of affect, or through turning passive into active—taking charge proactively through preparing a retirement that allows patients and us to deal with termination therapeutically.

A major internal struggle for us occurs because our personal needs and wishes are part of why we retire, especially if we are still doing pretty well physically and cognitively. Being conscientiously inclined, we feel this as an aggressive act that conflicts with the needs of patients, both individually and collectively, at a time when the profession is so short-handed. This may result in feeling guilty or unprofessional. Yet one is acting professionally by carrying out termination consistent with the principles of effective therapy

Regarding competence, we also have an ethical responsibility to the profession. This includes helping colleagues who are visibly declining in function. The perception can be subtle, but glaring difficulties can easily escape notice because of everyone’s denial, rationalization, passivity, uncertainty about the validity of the observation, and reluctance to intervene with a respected or even idealized senior colleague. Further complications arise because of confidentiality issues if we learn of the difficulty from a patient in therapy. Intervention may range from personal advice to the colleague or confidential counseling by a professional society’s assistance committee to a complaint to an ethics committee or state licensing board. The colleague deserves respect, understanding, and support, but the priority is to protect patients.

Confidentiality issues also pertain to our management of patients’ protected health care information. The retiring psychiatrist must carefully guard the security of patient records and arrange secure disposal after the legally required period for their retention, if there is no longer any risk of exposure to liability. Psychotherapy notes should remain totally inaccessible pending destruction.

It is neither respectful to patients nor good psychotherapy technique to spring on them one’s departure from practice with no advance preparation. If a therapist is dealing with a progressive or terminal illness, sad experience with colleagues teaches us that the ethical course is to prepare the patient for what is coming and terminate while one can help him or her with it. Working through an approaching termination with ample time is often therapeutically productive, allowing the patient to deal with it in a manageable way. In so doing, both therapist and patient resist the ordinary human tendency to avoid dealing with loss and the finiteness of all human relationships. Often it leads to deeper reworking of prior losses in the patient’s life. Recognizing and working through ambivalence are essential, as we know from the role of ambivalence in prolonging depression following loss.

The ethical principles of honesty and full disclosure pertain here. Usually we do not introduce our personal life into the treatment process, but this is a necessary exception to a degree based on need to know. Tact and discretion are essential. If possible, disclosure by the therapist should leave ample time to work with the sadness, anger, fear, anxiety, love, hate—and possibly relief or pride in accomplishment—that come with preparing to say goodbye. In the process, one often revisits important work that took place earlier in the therapy and the patient leaves with a sense of closure. So too may the therapist.

Closing a practice is a major life-cycle turning point for the therapist, as is termination for the patient. With forethought, care, attunement to our patients, and working through of our own ambivalent grief and guilt about asserting our own needs, it can be like any other developmental crisis and open the door to new fulfillments. ■