So, as a psychotherapist in private practice you are self-employed. That means you pay your own office rent, liability insurance, malpractice insurance. You pay for your own sick days, and vacation days. You fund your own retirement plan. You have no flex-spending account. It means that you, for decades, self-purchase a private medical insurance plan, out of pocket as well a short term disability plan (which reimburses you for less than 10% of your earned income but better than nothing) and a more expensive long term disability plan, and a long term care insurance plan (which you hope you will never have to use.) If you are fortunate, your income is enough to own a home and subsidize your kids’ needs. You feel better off than most people, and the precariousness and variability of the work is outweighed by its meaning and sacredness.
You can’t really imagine not being able to work. It is a profession you don’t plan to retire from, even if you can imagine seeing fewer clients and writing more and maybe going to seminary for no good reason at all. You can imagine your work life adjusting and changing, but you can’t really imagine it being disrupted.
You know, you see those articles about 102 year old therapists and you think: “Yep, I’ll just keep hobbling into the office because our culture needs wise old crones.” I mean you save for retirement because you know you won’t be able to earn your full income but you don’t really plan on retiring.
You probably won’t be able to afford to retire any way because you don’t earn all that much. And kids are expensive. And college is coming up – and of course you’ve tried to save for that too – but none of it can be enough, it will be tight, and you’ll sell the house and downsize again and live simply and you’ll get through.
And you’ll keep working.
I mean you’ve worked through and around migraine, and flu, and fever, months of sleeplessness as a new mother, and the death of loved ones and sick kids, and family emergencies – and all of your extended family is dead now – and you’ve made it through some really bad shit and been able to compartmentalize and still show up as a therapist even when your own world was on fire or collapsing, you have been able to cancel and reschedule at worst and still be there, and still listen – sometimes to crises far more minor than the ones you are negotiating and sometimes to crises far greater – and yes, it can be really really hard, sometimes an unfathomable strain, sometimes it takes the energy of every mitochondria of every cell in your body to sit there in that chair and stay alert and stay present and stay connected.
And at the end of the day you may be wrung out, a near zombie, but you did it, and offered value, and maybe even coughed up moments of crystalline insight, and no matter how fucked up you felt in your own skin, or even when you’ve needed to take medication for migraine and were a little altered neurologically, there were moments when you know you nailed it, and transformative moments, and moments of closeness and intimacy, and moments of acknowledged failure and you may be fucking tired but at the end of the night you get to ride home with truth in your pocket.
And people pay you for this. And some people can’t pay you for this. And some people could pay you for this and can no longer and you aren’t going to abandon them and some people couldn’t pay you at all for a long time and then they could. And some people always can pay you for this and do. And some people come and go and you hold your door open for them, and maybe they can’t pay your full fee but you’ve known them for so long and you trust your caseload- in its distribution along the entire socioeconomic scale – that they pay you what they can and you receive it and are grateful. And there are times when you wish you were one of those independently wealthy therapists or were married to someone who was an investment banker so you could just pursue this as a jobette, and set out a collection bowl on the coffee-table and have people leave whatever they thought the hour was worth to them and not have to think about this stuff at all.
But you are married to someone who does the same work you do, and has similar values, thank god, and who understands and supports you and sometimes peer-supervises you and calls you on your shit better than anyone else. And between the two of you, you accept the variability, and precariousness of your income stream – as full fee clients fall into crisis that make them suddenly no fee clients, or as you pass through an under-booked season, or an over-booked season the other one is there to stabilize your fluctuations and you do the same for them.
And its been this way for decades. Getting by. Pursuing meaning. Earning a living. Scraping along. Getting through. Downsizing. Negotiating financial crisis and hard times. Seasons of prosperity. Seasons of scarcity.
Not so different from what you learned on your grandparents’ farm, the only and most noble work model available to you: Dependent on fate and fortune and weather and politics and the good will of the community and your own resourcefulness and generosity through bountiful harvests and years of drought.
And then you find out on a Monday that you have cancer and you cancel your work week and they start giving you huge doses of steroids which change your thinking and you are processing the fact that they see this as an emergency and you are admitted to the hospital on Thanksgiving Day for your first cycle of chemotherapy and that makes you nauseated and the medications you take to control that make you feel even more altered and the chemo itself seems to effect your thoughts – make them move more slowly and strangely. You notice a difficulty retaining certain kinds of logistical information – and don’t know if that is because you are still in psychological shock that you are very ill, if the cancer itself is effecting your energy and perceptions or if the meds you have to take to control the nausea from the chemo change your thinking or if this is an effect of the chemo itself.
And you are home by Monday and you know there is no way you are going to be able to work – even though the doctor said you could – because you are not present, the first two days home you are actually a fetus, and are not able to be present even for loved ones that you miss terribly and most want to be connected to. You can’t think clearly. Your thinking and feeling functions are altered and impacted and untrustworthy. When you feel optimistic you don’t know if you are in denial or responding to the data that the doctors have laid out in front of you. When you are afraid you don’t know if you are being hysterical and catastrophizing and succumbing to irrational fears. And you suspect that much if this is neurological response to all the toxicity that has just run through you. And you suddenly can’t trust that you have anything to give anyone and you can’t tell how contaminated your thinking is and you don’t know how much energy you have to “go over” into anyone else’s world and you wonder if you can work at all through these chemo cycles – if it is even ethical to do so, and you realize once you ask yourself that question: “Is it ethical for me to work in this state?” that the answer is obviously “No.”
So unless things shift, or maybe in the second week after chemo your thoughts will clear up as the nausea and the meds that go with it recede – and you might be able to get a day’s work in. (right before you have to go back into the hospital for another chemo cycle) you may not be able to work through this at all.
And maybe it will only be two cycles. But the nurse practitioner said to prepare for four.
And the people who love you, your primary family and friends don’t want you to work at all and want you to tolerate being cared for, for god’s sake, you have a crazy rare cancer – you are the only one in the world known to have this cancer in this way – and you need to rest and focus on getting better and getting through this.
And you gather your colleagues and you ask them if they can see your clients and you encourage them to seek ancillary support from from other therapists because you don’t know what you will be able to offer or not but it probably won’t be much for a while.
But the “low balance” banking alert on your phone keeps pinging and you see the strain in your husbands face and he would like to protect you from this reality too but he really can’t because what he has to do is work extra, and take on more clients – to try to expand his income as much as possible even though he cannot possibly double or triple himself but knowing him he will try.
And worse, cancer has not just erased a full one half of your household income you now embody a new list of expenses as copays and especially pharmacy charges explode and you haven’t even seen your share of the first hospital bill yet and there are 3 or 4 more to come. And your previous “privately purchased” insurance was folded into the exchanges and downgraded and then downgraded again a few months later to an HMO, and now they are even holding up on approving a game-changing life saving medication which is known to eradicate your type of cancer (even though you are still the only one who has ever gotten it in this order, in this part of the body) and the doctors want you to take like triple the standard dose and you can’t even imagine what they are going to make you pay out of pocket for that since just your migraine pills cost you, personally $40 per pill.
And you still have childcare, and office rent to pay if you are to return to work, and all your insurances -and your medical insurance – which in this new Trumpified world has to be maintained at all costs because you now have a life threatening pre-existing fucking condition.
And your daughter who has always been fashion fixated is excited about a new dress for her first middle school “semi-formal” and your son, who has been a largely unmotivated student began suddenly working his ass off in Spanish class last year animated by a chance to earn through grades and hard work, a spot on the school trip to Spain and he did it and he even improved his grades across the board – and you want to make sure more than anything that he can still go and if your cancer fucked this up you will hate yourself forever.
And you know that your household expenses were just barely covered before.
And that you are heading into deep shit now.
And you want to work when you can because it will be good for you and good for others and you look for opportunities to do that.
But mostly, people keep telling you not to worry about all this and just get better but you aren’t just sick, you are in harms way, and you are putting your family in harms way. And you can’t ignore that.
And you realize that you have given a lot of yourself away for free, in lots of spheres, charitable work, community organizational work, pro bono work, and that you give your writing away for free too, because you don’t really think of yourself as a writer and people keep telling you that you are but you don’t really know what that means.
If you are a psychotherapist in private practice, this is a potential reality too. This precariousness. This fiscal danger.
Impossible things can happen. And they can change everything.
This is the nitty gritty that catches in the drain pan under the shadow of your profession:
It can stop taking care of you in an instant.
I realize I have to reexamine and reorganize my inherent sense of expansiveness. I am being taught new experiential lessons about limitation.
But now I can’t give away anything, even words, because it will cost the people I love, and myself too much. Perhaps now have to consider all the ways in which I give too much away, undervaluing myself.
So: I’m adding a donate button to this blog.
I since writing this I have completed my inpatient chemo therapy and here is information about my current status. I hope to be back to a modified work schedule in late January or early February.
And, in the meantime, I’ll research and get real about professionalizing myself as a writer and pursue getting paid for writing in formal, more explicit ways.
If reading my writing has been of value to you – please consider making a donation which reflects that value. Perhaps what you might have been willing to pay for these essays had they been for sale in book form.
If you can’t and don’t click on the button – all these words are still here for you and if you can please just find a way to make it of use in your own life and make a commitment to pass that value on to someone else that will mean the world to me.
And if you do click on the button:
More than words can say.