The lifelong learning of saying goodbye

By David Kopacz, MD, Clinical Tele-Psychiatry Practice

 

I’m in the process of leaving my 10th job in almost 30 years of clinical psychiatry practice. It never really gets easier saying goodbye to patients I’ve been caring for. There are often a mix of emotions for both me and for patients. I feel sadness, guilt, and selfishness, but also joy for the changes patients have gone through and gratitude for having been part of their journey. For patients there can be shock, anger, sadness, grief, and frustration at having to start over with a new doctor, but there also can be happiness for me, for the new job I’m taking, as well as gratitude for the help and support I’ve given. Complex emotions!

 

I’m leaving a tele-psychiatry position that I’ve had for less than a year to take a mostly remote position. I put in my 60-day notice, which goes fast and is full of emotions in saying goodbye to patients I’ve come to know well. Saying goodbye is a time to reflect on the work we’ve done, and it’s also a time where I feel more exposed with my personal life intruding on a patient’s treatment.

 

The challenge of one-sided endings

It’s exhausting work, “terminating,” as they say in psychoanalytic and psychotherapeutic psychotherapy. In contrast to a natural stopping point based on the patient reaching a transition point that makes sense to stop treatment, when I leave a practice, treatment is interrupted one-sidedly.

 

Notifying a patient I’m leaving a practice, planning the logistics, and beginning to say goodbye can be tough to fit into a session which a patient has already planned to fill with urgent or deep business. When I’m seeing a patient weekly, there’s always the possibility of not bringing up my departure that session and postponing it for the next week. Sometimes this is because of a pressing crisis on the patient’s part, but sometimes it’s that I’m just emotionally exhausted and need a break from every session being a goodbye.

 

Finding meaning in goodbyes

I remind myself that goodbyes are part of being human. They give us an opportunity to practice working with sadness and grief. Goodbyes are times to reflect on a shared journey. They’re also times to think about the future, see if there are any last minute, pressing topics a patient wanted to bring up in therapy, and also a time to look for resources that might be helpful for their continued journey.

 

Some patients will need another psychiatrist for their medications or another psychotherapist to continue therapy. Some patients might be stable enough to go back to their PCP for maintenance medications, and still others might not be on medications at all and decide to take a break to see how they feel.

 

Opportunity for growth

There’s also an opportunity for growth in the closing sessions. Internalizing a sense of empowerment and self-trust, internalizing problem-solving skills, and practicing mindfulness techniques—these can all be done in a different way after finishing therapy.

 

When a patient expressed how much they appreciated the opportunity to work together, I asked if he’d heard the saying, “When the student is ready the teacher will appear.” He had. I asked if he’d heard another saying that comes after that one—“When the student is really ready, the teacher will disappear!” We both laughed at that.

 

The nature of the therapeutic bond

It feels good to be able to help people and it’s a privilege and responsibility to have someone trust you with their joys and sorrows, their traumas and successes. It can be a close bond, the patient-clinician relationship. It’s similar to many other relationships, but also unique—a mentor, a guide, a coach, and a technician. It’s a serious business and it can also be light-hearted at times.

 

It can feel like a kind of love that I have for patients—in the sense that Dr. M. Scott Peck defined love in “The Road Less Traveled”: “[The] will to extend one’s self for the purpose of nurturing one’s own or another’s spiritual growth.” Except that for a psychiatrist, it’s not just spiritual growth, but psychological and personal growth as well. The Greeks had a number of words for love, including “eros” (erotic), “agape” (affection), and “philia” (friendship).

 

Dr. Jean Watson, a nurse, author, and founder of the Watson Caring Science Institute wrote in “Unitary Caring Science: The Philosophy ad Praxis of Nursing” about caritas as a basis of nursing, and it can apply to all within the caring professions:

 

“As a given, caring must be grounded within a set of universal human values—kindness, concern, and Love of self and others. . . . Caritas in its original and evolved sense honors the gift of being able to give and receive with a capacity to love and appreciate all of life’s diversity and its individuality within each person.”

 

Affection, affiliation, friendship, caritas, caring, a kind of love—all these can be elements of the therapeutic relationship—and a goodbye ends the therapeutic relationship that has been a source of meaning for both patient and clinician. Before the word “therapeutic” meant “curing or healing,” it came from the root, “therapon,” meaning “attendant.” We attend to patients, we care for them, and yet that contract is time-bound and leaving a practice interrupts that relationship.

 

How strange life can be—the comings and goings, the tragedies and joys, and the power of human relationship to transform suffering.

 

Pearls for saying goodbye:

 

1. It’s emotional work—care for yourself, get enough rest, take it easy after a long day of goodbyes, and do something relaxing.

 

2. Pace yourself and stagger goodbyes when possible so that you don’t go into emotional overload and detachment.

 

3. Work on the range of your own emotions through reflection, journaling, paying attention to your dreams, and talking with friends, family, and colleagues. This will better allow you to be present for patients’ emotions.

 

4. Be open to a range of emotional reactions from your patients and support them with the transition.

 

5. It’s ok to share some of your own feelings, as long as you’re doing it in a therapeutic way to support the growth of the patient.

 

6. Be human.

 

7. It’s ok to say, “I’m sorry that we won’t be able to continue working together,” or “I’m sorry that my job opportunity is interfering with your treatment.”

 

8. Remember to watch boundaries—goodbyes are liminal transition zones, and remember that the patient-doctor relationship is always first and foremost for the growth and healing of the patient—you are in the session, but it isn’t your session.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

This piece expresses the views solely of the author. It does not necessarily represent the views of any organization, including Johns Hopkins Medicine.