Why I Told My Clients I Have Cancer

Self-disclosure–what to share about yourself with a client, and how–is a big topic of debate among therapists. Some old-school psychologists think that you should share as little as possible, and be a “blank slate” to avoid distracting the client from “the work.” Other therapists, especially those who operate within a feminist or relational lens, tend to believe that appropriate self-disclosure can strengthen the professional relationship and move the work along.

Most agree on a few things, though–don’t share personal medical details with your clients, and don’t share anything that you haven’t fully worked through already. It’s one thing to mention to a client that you went through a divorce years ago and that there’s no shame in it and that healing will come; it’s another to tell a client that you’re actually on your way to the attorney’s office after work.

I was, until recently, completely on board with these general guidelines. Then I got diagnosed with cancer, and suddenly they didn’t work for me anymore.

Almost immediately, I dreaded having to explain my absence to my clients somehow. I didn’t know anyone in my field who’s ever gone through anything like this. Neither of my supervisors at work did, either. Most of the time when something medical interferes with work, it’s rather more straightforward than cancer treatment–for instance, a surgery. You tell your clients, coworkers, and supervisors varying degrees of detail about the fact that you’ll be out for 6 weeks, and gently shut down any inappropriate questions.

I, however, was about to start chemo and I’d be working through it. I wasn’t sure how much, and I knew that might change as I went through treatment. As it turns out, it’s uniquely impossible to be vague or coy about cancer treatment. I knew right away that if I tried to spin some bullshit about how I’d be off a few days every other week for “my treatment” and then start showing up in wigs, I would come across like I’m either ashamed of it, or think my clients are children. People know what it means when you miss work every two weeks and lose your hair.

Unable to get any clear direction from professionals with more experience, I went next to Google. Here I found a number of articles by therapists who’d had cancer. They all told their clients that they’d be “leaving this position” and referred them to other therapists. I was confused. Were they not planning on returning to work? Would they have to just build up an entirely new client base? That sounds like a lot of fun on top of recovering from chemo.

One article described a therapist processing her imminent departure with her clients and having to pretend that she was moving on to another job, and reassure her clients that it wasn’t because of them and that she really valued working with them.

Later, she received an email about her own former therapist, who had terminated treatment with her the same way. He’d died of cancer.

Ultimately I decided that this level of deception and fakery not only goes against my ethical values, but would literally be impossible for me to manage. Telling my clients I had cancer was painful enough; I couldn’t imagine having to also pretend that the cancer was actually a cushy new job. Having to apologize to my clients for leaving our work unfinished as if it had been my decision, rather than a horrible thing that happened to me.

So I went for the opposite extreme. I told every single one of my clients that I’ve been diagnosed with breast cancer and would be undergoing chemo followed by surgery. I invited them to ask me any questions they wanted about it and reassured them that I wouldn’t answer anything I truly felt uncomfortable with. Some didn’t ask for any details at all. Most asked if I felt okay to be at work. (I did.) A few wanted to know more–what stage, what type of surgery, what chemo feels like, if cancer runs in my family.

Was it awkward? Sometimes. Did it distract from the client’s therapeutic needs? Maybe, in some ways. Is that ideal? No.

The problem, though, is that therapists are in fact human, and we have human bodies that fail in the same glorious ways as everyone else. I don’t believe I could’ve continued to do this work effectively throughout my chemotherapy while actively deceiving clients about what I’m going through. I also don’t think that would make me a very good role model.

A lot of surprising conversations came out of it. One client revealed his own battle with cancer, years ago. He’d never talked about it. A few mentioned that they really ought to be doing breast self-exams because it runs in their families; I told them where to get more information and explained that when caught early, breast cancer is extremely treatable. One client, surprisingly, brightened and smiled when I told her. She explained that a beloved relative is a survivor of breast cancer several times over and that this relative is her mentor and source of inspiration.

Another client said she was glad I told her. “I’ve been working on being more vulnerable and open with the people in my life,” she said. “If you’d tried to hide this, it would’ve sent the wrong message.”

That conversation was a reminder that while therapists often keep personal information from clients in order to “protect” them or to avoid distracting them, clients may interpret this secrecy as a product of shame, callousness, or both.

That’s not to say that my transparent approach hasn’t had its downsides. It does sometimes make my clients feel awkward about sharing their own problems; cancer tends to be that thing people remind themselves at least they haven’t got, so it can be weird to vent about your shitty job when someone’s just dropped cancer into the conversation. But I always reassure my clients that 1) I’m here because I want to be, and 2) I still see their problems as valid and important even though I have cancer now. The awkwardness usually doesn’t last.

It does sometimes make things harder for me, though. When I was first diagnosed and didn’t know the staging or prognosis, I could hear the unasked question on many of my clients’ minds. No, I didn’t know if I was going to survive or not. (Even now, with chemo going swimmingly, I can tell you that I’m pretty unlikely to die of cancer, but recurrence is a thing and it could happen anytime.) I could only tell my clients the same thing I could tell myself–that I had no reason to expect the worst, so therefore I’d hope for the best.

Sitting with uncertainty is one of the most difficult things in life, and probably the most difficult thing about cancer especially. Yet it’s also one of the most important skills to develop, for me and for my clients too.

As treatment went on, I often found myself having to be a bit performative when clients asked how I’m doing. It’s true that chemo isn’t too bad and that I feel okay most of the time. But some days are very hard. Yes, there were days when I wished I’d stayed home from work, but I didn’t because I wanted to be as consistent as possible with my schedule. (There were other days when I called off even though I’d planned to be there.)

Most days, I’m not my best self at work. I’m just not. It’s just impossible. The only other option would’ve been to take all four months of chemo off work entirely, but that would’ve been worse for my clients, worse for me, and ultimately impossible. I don’t have enough medical leave for that.

So although I don’t tell my clients many details about treatment, I continue to be transparent. I’ve told them that I feel tired a lot. I’ve mentioned that chemo sometimes leaves me with bone aches, which is why I stay home a few days after each treatment. I keep a positive attitude and tell them that many chemo side effects are very well-managed with medication and that chemo isn’t what it used to be. My hope is that if any of them end up being diagnosed with cancer, or having a loved one who is, they’ll remember that, and they’ll remember not to be afraid and to ask the doctor for help if they need it.

Disclosing this to my clients a week after diagnosis–telling 40 or so people that I have a potentially lethal illness and then taking care of them around that disclosure–is the most difficult challenge I’ve faced in my professional career so far. I found myself having to reassure people about something happening to me, something I found (as most people would) horrible and terrifying.

This situation turned the usual ring theory inside out. Normally the person at the center of a trauma or tragedy is the one who gets taken care of by everyone else. But as a therapist, it’s my job to take care of my clients. Which is probably why the conversations were sometimes so raw and awkward–my clients sensed that they “should” be the ones comforting and reassuring me, but they also understood that that’s not their role. And because of the strong therapeutic relationships we’ve already cultivated, we were able to talk about that directly.

I had my last chemo treatment this past Monday, so things are going to be more straightforward from here on out. But that doesn’t mean I’ll be able to stop having conversations about this with my clients. I have multiple surgeries and other procedures in my future and it could drag on for years. I may not be able to be at work as much as my clients (or I) would like, but I hope that by being open and honest I can reassure them that help is available even when I’m not there and make sure they know how much I wish I could be there with them.

Over the past four months, I’ve had to radically redefine what professionalism and appropriate self-disclosure mean to me. As it turns out, vulnerability isn’t just good for my friendships and partnerships; it’s good for my professional relationships too.


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Why I Told My Clients I Have Cancer
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Trump’s Mental Health Diagnosis is Irrelevant

Donald Trump’s mental health diagnosis, if he even has one, is almost entirely irrelevant to any of the questions we are trying to answer about our future and is a pointless and dangerous distraction that we cannot afford.

I regularly diagnose people with mental illnesses. I am myself diagnosed with a mental illness. As far as I can tell, these diagnoses have a few main functions:

  1. Insurance billing. Your insurance company needs to see something from the doctor justifying the money they’re spending on you.
  2. Research. Participants in studies have to be systematically categorized somehow, because a treatment for depression symptoms may not work for eating disorder symptoms and we need to know which it works for.
  3. Treatment. You and your therapist or doctor can use diagnoses to figure out a course of treatment that’s most likely to be effective, and to know what to try next if that doesn’t work. You can also use it on your own to find books and other resources that might help you or a loved one with coping skills and self-acceptance.
  4. Community. When people know what their diagnoses are, they can use those labels to find others who have very similar issues and build solidarity with them.

Notice what’s not anywhere on that list? Predicting a stranger’s future behavior.

Suppose you know that Donald Trump qualifies for the DSM criteria for narcissistic personality disorder. What exactly does this knowledge change? How does it impact your predictions of Trump’s future behavior or your decisions about your own behavior? How is a world in which Trump technically fits those criteria different than a world in which he doesn’t technically fit those criteria?

The only halfway-reasonable answer I’ve ever seen anyone give to any of these questions is that maybe if a fancy doctor examines Trump and concludes that he fits the criteria for some or other mental disorder, then people will finally realize that he’s unfit to be president.

First of all, that’s just false. Trump has been accused of sexual violence by numerous women, saluted by actual Nazis, and implicated in numerous cases of fraud. A bunch of clinical jargon isn’t going to change anyone’s opinion on anything if none of those things have. And given what I’ve gathered from Trump supporters by actually listening to them, many of them don’t recognize the validity of psychiatry, the DSM, or mental healthcare in general.

Second, Donald Trump is going to become president on January 20, 2017. Do whatever you need to do to cope with that knowledge, but it’s going to happen no matter which billing codes his doctors send to his insurance company.

Third, if–after the sexual violence and the fraud and the nepotism and the tax evasion and the naked racism and the probable interference of Russia in the election–it’s mental illness that makes people finally see Trump as unfit for office, that is horrifying.

What that says is that our unjustified, irrational fear of people with mental illnesses is more powerful than the collective evidence of someone’s past behavior.

That being a person with a mental illness is worse than being a rapist.

Worse than stealing the labor of working class people who need that income to put food on the table.

Worse than threatening to imprison and deport innocent people, and having the power to actually do it.

Worse than pandering to Nazis and dictators.

What does that say about the millions of people who share Trump’s supposed diagnosis?

And as awkward as I find it to disagree with a bunch of Harvard psychiatrists with much more experience than I have, we don’t need an expert neuropsychiatric evaluation to tell us that Trump is unfit for office. We already know because he provides evidence of this daily and has been doing so since he first emerged in the public spotlight. We elected him anyway.

And there’s both the bad news and the good news. The bad news is that you can never predict with anywhere near-certainty what someone will do in the future, especially if it’s not someone you know personally. People surprise us every day. It would be nice if we could magically divine a complete catalog of the disasters that Trump will cause while in office, but we can’t. Knowing which DSM criteria he fits will not help with that, and it may even obfuscate it even further.

The good news is that there is one fairly effective way of predicting someone’s behavior, and that is by observing their current behavior and reflecting on their past behavior. Trump has a long and clearly-evident record of dishonesty, boundary violations, fraud, discrimination, nepotism, harassment of journalists and other critics, conservative politics, and other things that most of us generally dislike. It’s a safe assumption that he will continue to do these things in the future.

Mental health diagnoses, on the other hand, are very poor predictors of behavior because the causative link between mental illness symptoms and outward behaviors is much more complicated than simple cause-and-effect. Diagnoses mostly describe internal processes, such as feeling hopeless or thinking everyone’s out to get you, and not outward behavior (although outward behavior can help identify internal processes). Someone who really wishes they were dead may or may not ever attempt suicide or even self-harm. Someone who is scared of elevators may or may not choose to use them anyway for any number of reasons. Plenty of people with depression hide it perfectly even from people who know them well. Someone experiencing hallucinations that tell them to jump out a window may or may not realize that the voices are a symptom of psychosis, and may or may not be able to ignore them and stay away from windows.

Personality disorders, which is what people typically associate Trump with, are an even more complicated thing. For starters, many professionals are skeptical of their validity as diagnoses in the first place because they’re extremely subjective and based much more on local norms of social behavior than on what is actually harmful or distressing for the patient. Regardless, we typically do not diagnose something as a personality disorder unless it’s maladaptive for the individual being diagnosed or they’re unhappy with the way they are. That others are unhappy with the person’s behavior doesn’t count. Trump does not seem to be unhappy with his behavior and you could hardly argue with a straight face that it’s been maladaptive for him.

In any case, I work with individuals with personality disorders on a regular basis and while knowing their diagnosis certainly predicts some of their symptoms–that’s literally the point of a diagnosis–it doesn’t necessarily predict their outward behavior, especially not when it comes to complex roles like running a government. That’s because, as I wrote above, diagnoses mainly describe internal processes.

Having a few random experts declare that Trump officially has a mental illness will not remove him from office or undo any of the harms he has already done or will do by that time. If it could, then we’d have to have a difficult conversation to have about just how badly we want to fuck over ordinary people with mental illnesses for the sake of removing from office someone that we elected in the first place, because that would mean that nobody with a history of mental health treatment will ever be able to hold elected office in this country again.

But it won’t, so the conversation we should be having instead is whether or not we will continue to attribute everything we don’t like in ourselves to mental illness, or whether we will stop demonizing those of us who suffer from it and instead aim our arrows at the proper targets.


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Trump’s Mental Health Diagnosis is Irrelevant

Why We Should Ban Conversion Therapy

[Content note: suicide, transphobia, abuse]

I wrote this article for the Daily Dot about conversion therapy. Please note that I did not write and do not endorse its headline as it appears at the Daily Dot.

At the close of a year that saw both incredible gains for transgender people and a number of tragic acts of transphobic violence, 17-year-old Leelah Alcorn, a trans teen from Ohio,committed suicide on Sunday. In a note that she had preemptively scheduled to post on her Tumblr, she described the bigotry she had faced from her parents, who tried to isolate her from her friends and the Internet as punishment. They also sent her to Christian therapists who shamed her for her gender identity.

In response, the Transgender Human Rights Institute created a Change.org petition on December 31. The petition asksPresident Obama, Senator Harry Reid, and Representative Nancy Pelosi to enact Leelah’s Law to ban transgender conversion therapy. Less than two days later, the petition has already gained 160,000 signatures and made the rounds online. It may be the most attention that conversion therapy has gotten outside of activist circles for some time.

Aside from LGBTQ activists, secular activists, and mental healthcare professionals seeking to promote evidence-based practice, not many people seem to speak up about conversion therapy, or understand much about it. Most discussions of it that I come across deal with therapies that attempt to “reverse” sexual orientation from gay to straight or to eradicate same-sex attraction. However, conversion therapy also includes practices aimed at transgender people with the goal of forcing them to identify as the gender they were assigned at birth.

In her suicide note, Alcorn wrote, “My mom started taking me to a therapist, but would only take me to Christian therapists (who were all very biased), so I never actually got the therapy I needed to cure me of my depression. I only got more Christians telling me that I was selfish and wrong and that I should look to God for help.” Although she did not elaborate further about her experience in therapy, it’s clear that the treatment goal was not to help Alcorn reduce her risk of suicide, accept herself, recover from depression, or develop healthy coping skills that would help her stay safe in such an oppressive environment. The treatment goal was to force Leelah Alcorn to identify as a boy and to fulfill her parents’ and therapists’ ideas about what being a Christian means.

This is not mental healthcare. This is abuse.

Read the rest here.

Why We Should Ban Conversion Therapy