The last time Jeff Axelbank spoke to his psychoanalyst, on a Thursday in June, they signed off on an ordinary note.<\/p>\n
They had been talking about loss and death; Dr. Axelbank was preparing to deliver a eulogy, and he left the session feeling a familiar lightness and sense of relief. They would continue their discussion at their next appointment the following day.<\/p>\n
On Friday morning, though, the analyst texted him to cancel. She wasn\u2019t feeling well. Dr. Axelbank didn\u2019t make much of it \u2014 over years of long-term psychoanalysis, each had canceled on occasion. But the following week, he still hadn\u2019t heard from her, and a note of fear crept into his text messages.<\/p>\n
\u201cCan you confirm, are we going to meet tomorrow at our usual time?\u201d<\/p>\n
\u201cI\u2019m concerned that I haven\u2019t heard from you. Maybe you missed my text last night.\u201d<\/p>\n
\u201cMy concern has now shifted to worry. I hope you\u2019re OK.\u201d<\/p>\n
After the analyst failed to show up for three more sessions, Dr. Axelbank received a text from a colleague. \u201cI assume you have heard,\u201d it said, mentioning the analyst\u2019s name. \u201cI am sending you my deepest condolences.\u201d<\/p>\n
Dr. Axelbank, 67, is a psychologist himself, and his professional network overlapped with his analyst\u2019s. So he made a few calls and learned something that she had not told him: She had been diagnosed with pancreatic cancer in April and had been going through a series of high-risk treatments. She had died the previous Sunday. (The New York Times is not naming this therapist, or the others in this article, to protect their privacy.)<\/p>\n
Dr. Axelbank hung up in a state of shock \u2014 heartbreak, confusion, but mostly shock. He pored over their final conversations in search of signals he might have missed. He cycled through anger and self-recrimination. Should he have pressed her harder for details about her health? Did she think she was protecting him by keeping her illness secret?<\/p>\n
He had encountered a thorny problem for those in the mental health professions. Ethics guidelines require psychologists to make preparations in case they become incapacitated or die, appointing an executor to break the news to their patients and find them new care.<\/p>\n
But it is a chore that many of them push aside, and none of the major professional associations monitor compliance. Lynn Bufka, head of practice for the American Psychological Association, said she had no idea what percentage of members had a plan in place.<\/p>\n
Even if that data were available, she said, pressure to comply would have to come from licensing boards or insurers, since, as she put it, \u201cwe cannot process an ethics complaint against someone who has passed away.\u201d<\/p>\n
As the mental health work force ages<\/a>, a handful of activists within the profession are urging their colleagues to confront their own frailty and prepare patients for what is to come.<\/p>\n \u201cOf course the patients are distressed when they lose their analyst, but the real anger and pain, about having been essentially lied to, is really quite awful,\u201d said Dr. Robert Galatzer-Levy, who has published studies<\/a> of patients whose therapists died during treatment.<\/p>\n Dr. Galatzer-Levy, 80, a senior analyst at the Chicago Psychoanalytic Institute, became interested in the subject after he was referred a dozen patients whose analysts had died. Often, he found, they were left traumatized, mistrustful of the whole endeavor of therapy.<\/p>\n Their analysts had been colleagues of his, well-respected and senior figures. But they seemed, he said, \u201caround their own mortality to become really quite inept, and did not do obvious things, such as simply being straightforward with patients about what was going on.\u201d Frequently, the patients learned about their death in the newspaper, or from a note attached to their analyst\u2019s door, or through word of mouth.<\/p>\n \u201cThere\u2019s a lot that therapists and analysts can\u2019t do,\u201d he said. \u201cThe one thing we can do is be honest. When one is basically being untruthful about something as important as whether one is going to be around to do the work \u2014 that is an enormous breach.\u201d<\/p>\n \u2018She was kind of orthodox\u2019<\/p>\n Dr. Axelbank, who lives in Highland Park, N.J., saw his analyst three times a week, settling himself on a plush brown couch while she sat behind him in an armchair. From the outset, she had turned a \u201claser-focused\u201d attention on him, making it clear that she was fully devoted to his needs, a feeling he said he had never received from his mother.<\/p>\n Asked how the analyst made him feel, Dr. Axelbank searched for words, and finally retrieved a line from an old love song \u2014 \u201cI\u2019ve been waiting since I toddled \/ For the great relief of having you to talk to.\u201d<\/p>\n The work with her changed him, he said. He no longer stutters. The \u201cmalignant, toxic\u201d internal voice he had carried around since childhood was replaced by something gentler and more benevolent. It made him a better husband. It made him a better parent.<\/p>\n \u201cI just lost the person who knows me better than anybody else,\u201d he said. \u201cBetter than my wife, better than my family, because I\u2019ve talked to her about everything. And so, to be without that is \u2014 it\u2019s a terrible loss.\u201d<\/p>\n And yet there was no shiva, no wake, no funeral. The week he learned of her death, he had a houseguest visiting, and he felt obligated to keep up a cheerful, lively demeanor. \u201cWe still had to walk the boardwalk, and play some Skee-Ball and go to the Phillies game,\u201d he said. He compared her death to a miscarriage, or the death of a beloved pet: a profound loss that is unrecognized by society.<\/p>\n He was also angry. He couldn\u2019t believe that she hadn\u2019t told him. He tried to give her the benefit of the doubt: Maybe she needed time to come to terms with it. Maybe she was worried about hijacking their final months of treatment by shifting the focus away from his concerns. She was \u201ckind of orthodox, old school,\u201d he said, always brushing away his questions about her life.<\/p>\n But he also worried that maybe he was the one who screwed up, by allowing her to maintain that distance.<\/p>\n There was only one person in the world who he knew could help him untangle all these strains of dark feeling. And she was gone.<\/p>\n He found himself longing to return to her office, a place where he had spent some of the richest and most comforting hours of his life. From her couch, he looked up at a glass dream-catcher and a heavy, acorn-shaped lantern hanging from the ceiling. Maybe seeing those things one more time would help him let go.<\/p>\n \u201cThat makes it real,\u201d he said. \u201cThey\u2019re gone. You\u2019re kind of putting all the pieces together.\u201d<\/p>\n Other patients, recalling the sudden death of a therapist, described the same lack of resolution.<\/p>\n Eric Hensal, 58, a Washington-area political consultant, knew his analyst had cancer and had agreed to continue their sessions as his condition deteriorated. That wasn\u2019t the problem. What bothers Mr. Hensal, 13 years later, is that no one called him when the analyst died. He found out when he showed up at his office for a session and the door was locked.<\/p>\n \u201cNo note, no nothing,\u201d he said. \u201cIt\u2019s just like, Oh, that\u2019s it. You turn around and walk down the hallway and go to the elevator and leave. It\u2019s sad. I mean, I still get sad when I think about it, because it was just so abrupt.\u201d<\/p>\n Meghan Arthur, 45, has played and replayed her final exchanges with her analyst. The analyst\u2019s cancer was not a secret \u2014 for months, they scheduled their sessions around her chemotherapy. But the analyst told Ms. Arthur she was going to beat it. She talked about the future, maybe renting a cottage in Scotland to plot out the next stage of her career.<\/p>\n It was confusing. Toward the end, the analyst sent a warm, affectionate note to all her patients, explaining that she was going to a hospice \u2014 but only for the weekend. \u201cIf we can get an appointment on the calendar, we should do it, and then see how things pan out,\u201d the analyst wrote. \u201cOne never knows.\u201d<\/p>\n Then a week passed, and another week, and Ms. Arthur got a terrible feeling in the pit of her stomach. \u201cI wanted to trust her,\u201d she said. \u201cAnd I don\u2019t think she was lying. I think that\u2019s what she really believed.\u201d Three weeks after her last appointment, a family member shared the news that the analyst was dead.<\/p>\n Years have passed, and Ms. Arthur has not quite shaken off a feeling of abandonment. \u201cThis woman helped me so much, for so long, and then, at the very end, she couldn\u2019t be clear to me about what was actually happening,\u201d she said. \u201cShe kind of put that on me \u2014 which is not, I mean, as the patient, that is not supposed to be my job.\u201d<\/p>\n An honor system<\/p>\n In 1999, a prominent young San Diego psychologist died suddenly, leaving her family to manage a legal and logistical nightmare: reams of sensitive case files and an appointment book full of long-term patients who had to be informed of her death right away, lest they simply appear in her office to find her gone.<\/p>\n Her colleagues at the San Diego Psychological Association, agreeing that this should not fall to her family, divided the work among themselves. Soon they had a template for a \u201cprofessional will\u201d \u2014 a document<\/a> identifying executors and the steps they should take to terminate a practice.<\/p>\n The idea spread quickly, and it began to appear in professional ethics codes. But writing a will made many members uncomfortable, said Linda Altes, who served on the association\u2019s PRID committee, which stood for Psychologist Retirement, Incapacitation and Death. (\u201cWe just shortened it and hoped nobody knew what we were referring to,\u201d she said.)<\/p>\n \u201cJust getting people to write an acknowledgment that it could happen, that was quite an accomplishment,\u201d she said. And it remained, as she put it, \u201can honor system.\u201d<\/p>\n Robyn Miller, a therapist in Bethesda, Md., began studying the problem seven years ago, after she served as an executor for a colleague and close friend who died of cancer. She was taken aback by the emotional intensity<\/a> of the task, she said, counseling \u201cpatient after patient who was shocked and bereaved,\u201d and some who felt \u201crejected and abandoned.\u201d<\/p>\n And she began to doubt that the honor system was working. When she surveyed 114 colleagues, they agreed overwhelmingly that a professional will was a good idea \u2014 but 68 percent of respondents did not have one<\/a>. She began to compile accounts from patients who learned of a clinician\u2019s death in unsettling or impersonal ways.<\/p>\n \u201cIt\u2019s really because we are human, too,\u201d Dr. Miller said. She concluded that therapists could benefit from the services of a professional executor, much as they outsource marketing or accounting. Last year, she started TheraClosure<\/a>, which steps in after a clinician\u2019s death to manage records and counsel patients. Doing so swiftly and sensitively, she said, could be \u201cthe difference between loss and traumatic loss.\u201d<\/p>\n And it is true: The way a patient learns of a therapist\u2019s death seems to make a difference. Laura Robinson, 56, a psychologist in Ann Arbor, Mich., spoke warmly of how her own therapist had handled it. <\/p>\n When the therapist went into hospice, she delivered the news in a long, personal letter, recalling specific things about Dr. Robinson and the time they had spent together. Dr. Robinson was so moved that she spent two weeks composing a response that \u201creally conveyed what she meant to me.\u201d When she sent it, it bounced back.<\/p>\n \u201cI know she knew the things that I said in the letter anyway,\u201d Dr. Robinson said. \u201cIt was out in the universe.\u201d<\/p>\n When Leilani Crane received word that her therapist had died, she was in the middle of moving, and a ring \u2014 something she had long ago given up for lost \u2014 had dropped out of a drawer and bounced on the floor.<\/p>\n It was clear that the therapist had prepared for this moment. The colleague calling on her behalf seemed to have plenty of time to talk, offering help with referrals and inviting Dr. Crane to attend the funeral. She remembers listening and gazing down at the ring, whose reappearance felt supernatural.<\/p>\n \u201cThe fact that she was thoughtful enough to do all this, and take care of us, in case she died,\u201d she said. \u201cReally, really, I didn\u2019t expect it.\u201d<\/p>\n Returning to the scene<\/p>\n