Announcer:
This episode is sponsored by DSM-5-TR Insanely Simplified, a new book from Chiron Publications.
Elisabeth LaMotte:
From the National Association of Social Workers, this is Social Work Talks, and I'm your host, Elizabeth LaMont.
Today we're going to be talking about something that's not necessarily uplifting, but it's incredibly important. We're going to be talking about why social workers, especially those of us in private practice, really need to have a professional will. In the Social Work NASW Code of Ethics, Section 1.15 explains that social workers have an ethical obligation to plan for unexpected interruption of services due to illness or death. So this is an ethics issue, and it's one that is incredibly overlooked in the literature, in the academy, and in spheres of continuing social work education. Now with more than a million lives lost to COVID, it highlights all the more that it is necessary for us to face that unexpected illness and death happens, and we must have a professional will in place for our clients. But if you're listening right now and you don't have one, you are not alone.
And that's why I am so pleased to welcome today to Social Work Talks, dr. Ann Steiner. Dr. Steiner is a pioneer in this area. She has published over 20 articles on the topic of professional wills. For 14 years she taught at UC San Francisco and she is on the diversity, equity and inclusion task force of the American Group Psychotherapy Association. In addition to all of this, Dr. Steiner is in the process of publishing an ebook that you can download to create your own professional will, so we'll talk more about that later. Dr. Ann Steiner, welcome to Social Work Talks. Thank you for joining us.
Dr. Ann Steiner:
Thank you for having me. This is exciting that you have this topic being addressed today. It's great.
Elisabeth LaMotte:
As we get started, could you please walk us through the nuts and bolts of a professional will?
Dr. Ann Steiner:
Okay. Well, first I want to echo what you started with, which is that many people don't realize that this is an ethics requirement and it's actually an ethics requirement for every single mental health discipline, so that when you renew your membership, at the bottom it will say, "I agree to abide by the ethics." And most of us just sign that, assuming we know what the ethics are. And in fact, there is this section that NASW has had for years that says that there's an ethical mandate in essence to have the equivalent of a backup system so that you provide for continuity of care in the event of your expected and unexpected absence. So that's the overview. Then in terms of the nuts and bolts, the bottom line is to really understand what the reasons are for having a professional room.
This is essentially a system to protect you, your practice in your community. It's a system I've worked, on creating it so that it's a little easier for people to put together, but in essence it's having a team of people that you pick by hand that you trust to take over your practice if you get COVID, if you get the flu and lose your voice. Right now, if something happened to either of us, who do we have that we could send one text to, to say, "Please contact my patients and cancel them for the next week, because I don't feel well enough to be able to do that."
Elisabeth LaMotte:
Well, thanks to you, who I have is a bridge therapist, because I took your ethics workshop at the AGPA conference, not once, but twice, to make sure that I had this in place. So thank you. I happened to have the plan, but I didn't always have the plan. For many years I didn't.
Dr. Ann Steiner:
And for most people when they understand the idea, they think it's great, but it's a little bit like thinking it's a great idea to buy a burial plot, but nobody does. Most people don't do it, and one out of three Americans have a will. Everybody wants one. Everybody wants to have their wishes followed by their family, but the majority of us don't do it. So what I've been working on is trying to make it easy for people to set up a system. So going back to your question about the nuts and bolts, you referred to the bridge therapist. I think of it as having an emergency response team, like first responders in essence. That's a team of maybe five, depending how many people you want, but at least four of people that you trust, clinicians. And at the head of that is your emergency response coordinator or contact person, and that's the person you mentioned that I call the bridge therapist.
That's the person that if I'm in a car accident or I lose my voice, I call my bridge therapist and he or she knows where my calendar is, is able to cancel my patients for that week, has the keys to my... Right now, I'm now doing everything online out of my home office. So it has the keys to my locked file cabinet that has all the information that's spelled out in the actual professional will, and then you've got a system that's put together. So it's a team, I'm a group oriented person and I've found over the years that it works much better if you have this emergency response team that can then double also as a consultation group for you. If you're having knee surgery, you can talk to them and say, not can but is best, once you put them together, which is the hardest part of putting your team together, to be honest.
Elisabeth LaMotte:
Well, what would you say to somebody who says, I think I can identify a bridge therapist, but I'm not so sure about a team. I'm a solo practitioner. I've worked this way for years. Is it good enough if your practice is a manageable size to have one key bridge therapist?
Dr. Ann Steiner:
Great question. The issue is, when you say your practice is manageable enough, the question is, the bridge therapist is going to have to call all of your patients. So how many people in a week do you see? And this is looking at it being at a short term thing, so asking one therapist to call 25 patients...
Elisabeth LaMotte:
It's a lot.
Dr. Ann Steiner:
... in a week, in a day or two, is a lot. So why I like the idea of a bridge therapist with at least two people on your emergency response team, is that person can call the team together and then delegate out who's going to call who.
Elisabeth LaMotte:
That makes sense.
Dr. Ann Steiner:
And now that everybody is so accustomed to Zoom, they don't have to be in your same town.
Elisabeth LaMotte:
Such a good point.
Dr. Ann Steiner:
It really makes it easier. So what used to be really hard, people said, "Well, there's nobody. I don't know the people in my community." Well, you can find them, and you can put together a temporary team just to have it going.
Elisabeth LaMotte:
As we reflect on this Dr. Steiner, and we talk about how important it is to have the professional will in place, to have the bridge therapist, and to have the emergency response team, could you share with our listeners what led you to become interested in this topic, and in fact, to become a real pioneer on this issue of professional wills, not just for social workers but for all clinicians?
Dr. Ann Steiner:
Well, there were several different paths. One was that I've had arthritis most of my life and it got worse after graduate school. And while I was in graduate school and during my postdoc, I got interested in the question of illness in the therapist. So I started researching it, and at that time, because I am a little bit old, at that time there was almost nothing. There was the very, very analytic, wonderful article by De Waal, which is a classic about illness in the therapist, but they're from a very analytic perspective. So there was almost no literature, and there was somebody who had written a professional will that was one or two pages, really didn't address all the little details that need to be addressed.
And so, that was the first part that led me, so I got familiar with it at that point. And then when my father, who was a psychiatrist, became ill, he wanted me to take over his practice. I'm a big person about termination, and he was a 60s therapist, which meant he ran his practice with very few boundaries. His patients...
Elisabeth LaMotte:
It was a different world then.
Dr. Ann Steiner:
Another world. I mean, I grew up knowing them they, because they would barter and work in the garden. I mean, it was another world. And so, when he was terminally ill, I put together a group of people to say goodbye to him, and these were the people he was still seeing. And the problem I had was finding somebody that would be willing to be a co-therapist with me for that goodbye group session. And that was really eye-opening. So I had two senior clinicians say, "Oh, of course I'll do that for Marty. I would love to help out." And then two people bailed at the last minute. I talk about this when I do the six-hour law and ethics workshop, but in essence it was very eye-opening. I was glad that I had a goodbye letter I'd gotten him to write that was tailored to each person, and able to do that. And it made me realize, that was just too much for one person to do.
Elisabeth LaMotte:
Of course it was.
Dr. Ann Steiner:
It was just too much. And then there was an article in the Family Therapy Networker about the professional. Again, a very small article. And I was in a monthly networking group, and I brought that to the group. Again, this is classic, everybody thinks it's a great idea. Every month I asked people, has anybody else done it? Nobody else had done it. Within a year I realized nobody's going to do it. And then I realized that this was a broad multidisciplinary networking group, and in fact there were people in that group that I wasn't comfortable referring to. So I think that's why it fell apart. People on your team need to be people you trust and that you will be comfortable referring to or having take care of your practice and your absence.
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Elisabeth LaMotte:
Well, as you talk about people saying it sounds like a great idea and then not following through, I have to admit, that sounds a little bit like me more than 10 years ago when I found myself in your training. And I'm curious if you could speak to, as a trainer now on this topic, doing ethics workshops really around the country and around the world, what you see from clinicians that surprises you, and if you could just tell us a little bit about this pattern that I think I have where I'm not alone.
Dr. Ann Steiner:
You are completely not alone, you're in the majority on this. Is that especially when I was doing it about 10, 15 years ago, the common experience, because every year I would teach it at the American Group Psychotherapy Association, or every other year, and people would love it. And then I would get in the elevator and I would see people that looked familiar and there would be no exchange. And I always like, I don't respond unless somebody initiates. And then a year or two later, people would then say to me, "You know what? I was too embarrassed to say hello to you, because I had all these wonderful papers you'd given me. And I know where they were, they were on my desk and I hadn't done it yet. And now I've done it, so I'm happy to share I feel so much better." But the frequency with which people would avoid me was really startling, because this was an annual thing.
Elisabeth LaMotte:
I was one of those people and I didn't look familiar to you probably, but I saw you and I walked the other way. And that's when I realized, I think I have to take this workshop a second time and force myself to do it, because the first time I was somewhere in my earlier 30s, but by my later 30s I realized it was time and then I took care of it, and then I had the confidence to engage with you, knowing that I had taken this step. Could you tell us what else you would notice as common mistakes that people make on a professional will, in addition to simply not having one?
Dr. Ann Steiner:
Okay. There are a number of them. One that jumps out at the moment is, one of the most frequent common questions people ask about the bridge therapist is, "Can it be my husband or my partner or my best friend, because they know me best?" And I strongly advise that people not have their best friend or their partner do it, because there're going to be possible time-
Elisabeth LaMotte:
Distraught.
Dr. Ann Steiner:
Yeah. Well, there're going to be times when it's a temporary thing when you're just out of the office with something not at all life-threatening. But for the final time when you might need it, as you said, that person is going to be dealing with their own grief, and then to be dealing with your patient's grief at the same time, is just too much. So you want that person to not be that close to you. And that's where the emergency response team is helpful, because they can step in and do some of the chores for the bridge therapists. That's the key thing on that. The other thing is that people tend to automatically start working on it, and then put it aside.
Elisabeth LaMotte:
Interesting.
Dr. Ann Steiner:
What I encourage people to do is to do a quick and dirty first draft, quick and dirty, and have that in your locked file cabinet. That's better than nothing.
Elisabeth LaMotte:
Exactly.
Dr. Ann Steiner:
But the key is when you do that, make sure you tell the people who you put on your team that you're doing it, and send them a copy of it, because it will have the names and phone numbers and contact information of the other people on your team. Well, I had somebody recently that told me that she thought she was on maybe four people's team, but she wasn't sure and she couldn't figure out how to find out who those people were. So she literally went on to that particular organization's LISTSERV and said, "This is embarrassing, but I was at an event with everybody, and a bunch of you asked me to be on your team and I agreed. I don't know who you are, so please contact me offline to let me know if you still want me to be doing that, serving in that role."
Elisabeth LaMotte:
And did people contact her?
Dr. Ann Steiner:
No. I think some of them had already gone passed, to be honest. But she heard from one person. But the key is to follow through and to set up a realistic timeline. And that's hard, and that's part of why I said that-
Elisabeth LaMotte:
And would you suggest when you send people the quick and dirty version of the will, do you also send the goodbye letter, which we haven't yet touched on today, but which I as your trainee was so impressed by, and I changed it to make it my own, but I'm so glad to have it. And I'll mention just one other thing about you, that in your trainings you, in order to make it easier for people, you give them materials including, I'll explain to the listeners that right now I'm holding up a red folder that says, "In case of emergency", and inside is my will and the letter. So would you suggest sending a draft of the letter in addition so that your team has it?
Dr. Ann Steiner:
Yeah.
Elisabeth LaMotte:
Even if you're going to change it?
Dr. Ann Steiner:
Definitely. The workshop you took is the cliff notes for the six-hour workshop, and the material that I gave there is the samplers of the larger piece in the full package, which has three sample letters and really encourages people to use them as a template and do what you did, which is to do use your own language, but it was structured to follow and then make into your own language and the way you work with people.
So yes, I encourage you to have a copy of the sample draft letter that can be then emailed or not, or mailed, and a list of closed cases. Fortunately, a lot of people are getting more and more comfortable using electronic records. I was not originally, I'm now a fan of it because of the way Zoom makes it easier for emergency response teams to work together. You can meet in an emergency, go over the list of clients and patients, and divvy up who's going to with who.
Elisabeth LaMotte:
Part of what I've been thinking about on this topic is the potential isolation of the solo social work practitioner. And I do think this whole topic taps into that on different levels, and I'm just curious for your thoughts on that topic.
Dr. Ann Steiner:
I think that one of the key obstacles, is that most of us who went into private practice did so because we liked the idea of being our own boss and being able to schedule, be our own boss basically, and have that independence and freedom. And COVID has really shown those of us that were aware that solo practice is isolating, that we have to be really deliberate and cautious about working against being in isolation and being too isolated. And this team can really counteract that if you put your team together and you plan to use it as a way to touch base and do that maybe a couple times a year, and in the beginning to help each other get this project done. Because to be honest, it is a big project to eventually have an easy way for people to find where all your patient files are, and tips and things like that. So yeah, we can learn a lot from each other, and having a team matters. The solo practitioner-
Elisabeth LaMotte:
I think it really does. And thinking more deeply about this topic, especially in the context of the pandemic, really highlights that. Another thing that it crosses over into, which you've referenced today, is group work. And as a member of the American Group Psychotherapy Association task force on diversity, equity and inclusion, can you speak to our listeners about how group therapy overlays onto this topic in your experience?
Dr. Ann Steiner:
Sure. Well, there are two different pieces. One is, being aware of sociocultural differences, is really important for all of us. And I think for many people, the past few years, that's been an eye-opening awareness and reminder that we need to be clear about our socioeconomic privilege and our power and the role that, that has and the impact it has on our group members. The way in which I see them connecting these issues, is the beliefs and values about death and dying and talking openly doesn't fit with every culture. And so, we need to be sensitive to, and aware of those differences. An example is that when I knew I was going to have a surgery coming up and I told all my groups, I'm going to be going out for this surgery, it's not a life-threatening surgery, but I will be out of the office for that period of time, what does that bring up for people?
So I'm psychodynamic in the core just to first invite people's reactions, and then I'll tell them what the realities are. But that brought up all kinds of stuff, including I learned that somebody else had lost a therapist I didn't know about, and it had taken them five years to go back to therapy after that therapist went into the hospital and never came out, and nobody contacted that person. So I mean-
Elisabeth LaMotte:
Oh wow.
Dr. Ann Steiner:
... the horror stories I have, I try not to share, because there're too many of them, and I don't believe in scare tactics. But the benefit of it was, we found out that some people really wanted to know why I was going to have surgery, and then there were one or two people really didn't want to know. So flushing that out and understanding what those differences were, and [inaudible 00:23:21] each person's perspective and figuring out how we were going to negotiate that as the group, really made a difference.
Elisabeth LaMotte:
Right. And then that allows the group to go deeper, and everybody gets something clinically from this experience, which could be something that is just denied and avoided, and then you miss an opportunity.
Dr. Ann Steiner:
Right. Right. The other thing is that most groups have what we used to think of as the class clown, and one time when I was going to be out, the class clown said, "So are we going to get a substitute?" And I said, "Well, what do people think about that?" And he was shocked that I was taking this seriously. This was many years ago, before people thought about doing that when they would meet groups. And everybody liked the idea. That person was going to be in touch with me, would be able to give them feedback that I was fine, and it was going to be a long break, two months, and they wanted to meet. So I found a substitute and put that person in, and it worked great. Now, there are two thesis about that. One is that I think that if you do a lot of groups, it helps to have one group therapist on your emergency response team, and at least if not on your team-
Elisabeth LaMotte:
That makes sense.
Dr. Ann Steiner:
So they could manage your groups. And then if not, at least a group therapist that could be willing to step in that's on your referral list. And again, please be sure to ask people permission to be referred to. The numbers times I've heard that people just assumed and then wrote, told the patient, "Susie so-and-so will be taking over if I'm not here", and that person didn't know. So these are things we can do proactively.
Elisabeth LaMotte:
We're going over some examples of things going wrong. Could you share an example of something going really well with respect to somebody being planned and prepared with a professional will in place?
Dr. Ann Steiner:
Yeah, great point. Because the ideal, I think, from many therapists is they think they want to die with their shoes on, that they feel like they don't need to retire, they can cut back. But it really helps if we're more mindful of our cognitive limitations as we age. So the example is, somebody who has a professional will and has a very well thought through, and I don't mean careful, careful about it, but has a plan about they're going to retire at a certain age, lets their practice know, "I'm planning when I hit 70, that's when I'm going to retire", and they do a long wind down with people. That gives people the opportunity to transfer and they can do some overlap. So that's where it's the most successful, is where somebody successfully closes their practice and says goodbye and doesn't need their emergency response team to take care of anything, because they can't.
Elisabeth LaMotte:
So by long wind down, what you mean? I have a couple questions about that, but describe what you mean, and that may answer my questions.
Dr. Ann Steiner:
Okay. Well, it's interesting, because it used to be an intellectual question for me, the long wind down. I'm going to be 69 in October, as I get older, I'm getting closer to when I said I was going to retire, and I now realize that to walk the talk, anybody that I take on now in any capacity, group or individual, I have to tell, "I will probably be retiring within the next few years. Let's think about whether this is a good thing for you to start with a therapist who will be retiring, and I will do my best to work with you and help transfer you to somebody else when that time happens and I'll give you as much notice as I have." But there are many people for whom, because I do long-term work, it's probably better for them to not start with me. So that, to me, is a long-
Elisabeth LaMotte:
It's an interesting question, because again, the very topic of professional wills touches on the question of, when should a social worker retire? And we do have cognitive changes as we age, but my mom would say, she's a social worker as well, that we gain wisdom. And I do experience you as a wise practitioner. So has your thinking about retirement changed as you get closer to retiring, and could a long wind down be a much smaller practice that's more manageable?
Dr. Ann Steiner:
Well, that's what it's going to be for me. Yeah, it's going to be smaller and much more selective, because I will be wanting to take more time off, and some people don't do well with long breaks. So that's going to be part of the conversation.
Elisabeth LaMotte:
Interesting.
Dr. Ann Steiner:
So the advantage of your emergency response team, the way I recommend that people design it, is that you get people you really trust so that if there are signs of cognitive impairment and slippage, they will say to me, "You know what, Ann? Look, I noticed this. I think you need to think about doing things differently and maybe cutting back even more." And I need to trust them enough that they will have that conversation with me.
Elisabeth LaMotte:
That's a really powerful thought, Ann. Thank you for describing that. I just have a few more questions with the time that we have. What, if anything, do you have to say to social workers who are based in an agency with respect to this topic?
Dr. Ann Steiner:
Often people in agencies think that they don't need a professional will. The version that you need is different. But I would encourage anybody in an agency to find out what the system is for saying goodbye and closing down patient practices, your work with people. In many agencies it's short-term work, so it's easier. But often, I'm in California, we have a big HMO here, very powerful. It started out believing in preventive medicine, and then they now offer therapy every six sessions, every six weeks at the most. So who would say that's not real therapy, it's a bit... Right?
Elisabeth LaMotte:
Right.
Dr. Ann Steiner:
Often I would have people whose psychiatrist or a group or a class who was through that HMO, and they would get a cancellation notice. They would get no information that the therapist had either transferred, left or died. No opportunity to say goodbye.
So this is my main concern for agencies is that, please advocate for your agency that there be a way for you to have at least, what I call a salvage job of one wrap up session where you go over what worked, what progress the person made, and what you wish for them, and what supports you might hope that they would continue getting, whether it's 12 step or whatever. But to have a goodbye, and sometimes to have a actual ceremony, and this is one of the things I encourage people to do in their professional will is to spell out whether they want a memorial, and if so, whether they want their family included or keep it private, which is for most people better. But sometimes an agency will have a celebration of life for a practitioner who has pass, and for people have the option to go. And then to have clinicians available for triaging, is useful. It's a complicated concept, but there are reasons why I think agencies should have some form of a system in place.
Elisabeth LaMotte:
It's a very good point. And as you encourage agency-based social workers to advocate on this issue, I'm thinking about how advocacy is such a centerpiece of what it means to be a social worker. I am honored to be on the Private Practice Specialty Practice Committee at NASW, and what I have really focused on there is highlighting social workers who've made a tremendous difference in the field. And now, Dr. Steiner, you are not a social worker, though I experience you as very social work like. And I'm wondering, having done trainings for the California chapter of NASW, could you just speak to your observations of the social work field, and what it's been like to work with so many social workers in your career?
Dr. Ann Steiner:
Thank you. I'm touched that you think I'm social worker like, because the value-
Elisabeth LaMotte:
I'm serious about it.
Dr. Ann Steiner:
I get that, and it makes sense, because I mean, I used to be viewed that way, because I have that orientation and those values that social workers have as part of your priorities. And that's part of why, I'm going to take a side step on that one, that's part of why in the professional will I encourage people to think about describing your practice, your orientation so that the people who cover for you in the event of an emergency, know how you relate to people. That you do in fact advocate for people more than non-social workers, for example. And that you do maintain boundaries very carefully and respectfully, and yet you possibly would have more contact with their rheumatologist than a non-social worker. So those are some of the unique qualities. And the level of dedication has been really, really special to witness and be part of when I work with social work groups. It's really been an honor.
Elisabeth LaMotte:
Thank you for explaining that. And before we say goodbye, could you tell our listeners about your new ebook that is up and coming and how it's different from what you've done thus far?
Dr. Ann Steiner:
Okay, thank you. This is an exciting project that I'm working on so far that the system that I have has been editable, and it is in essence like a PDF that you would now purchase it from me, and I mail you the PDF. This is going to be an ebook where it will be the equivalent of all the topics that I addressed in the six-hour law and ethics workshop. So what I liked about the original system that I'm going to be able to continue with this is, you can jump from one section to the next. You can say, okay, I want to learn more about self-disclosure and how that relates to doing my professional will, and you can read that section.
If you've already got your bridge therapist, you can skip the section about how to find one and what the good criteria would be for finding and selecting a trusted bridge therapist. So those are the main features of it is that it'll have sections that they call editable, and sections that are not, because while it sounds like a legal document, it's not written to be a legal document, it's written to be aspirational and clinical.
Elisabeth LaMotte:
We will be having material about how to contact you on the section notes of our website, which you can visit after this podcast. And through that we will share your website, which again is www.psychotherapytools.com and your email address as well, so that people could reach out to you about that. Any other thoughts that you want to share with our listeners today?
Dr. Ann Steiner:
I guess the main thing is, as you know personally, because you've been there, it sounds like a daunting project. And it is a big project, I don't want to minimize it, but the sense of freedom and comfort and peace of mind that you can have when you do it, and that it gives your community, is very difficult to convey without more discussion about it. It's that it really provides more peace of mind, and that's the benefit for everybody.
Elisabeth LaMotte:
And I think through your conversation today, you have conveyed that to us very well, and I really appreciate it. Thank you for listening to Social Work Talks today. Thank you Dr. Steiner so much for joining us. Listeners, if you go to the show notes section of the website, you can learn more about Dr. Steiner and her wonderful work, her upcoming book. Also, if you are a social worker in private practice, please consider joining the Specialty Practice section of the Private Practice Committee. We have lots of articles there. One coming out about Dr. Steiner, many others. And again, thank you so much for listening today. And Dr. Steiner, thank you for joining us at Social Work Talks.
Dr. Ann Steiner:
It's been a pleasure working with you.
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