Re-certification is mandatory is many professions. As I have shown in Part 1, airline pilots are required to continually undergo and pass stringent tests to demonstrate their ongoing fitness for the role.
In this piece, I propose that addressing the circumstances we face in our own lives and how we conduct ourselves therein provides a valuable lens through which to gauge our fitness to practise. Continuing my thought experiment on re-certifying, Re-certifying for therapists, I put forward an assessment and reflections from a recent challenge in my own life, using myself as a case study.
The challenge
In 2023, I fell in the carpark at my local shopping centre and broke two bones in my wrist. From that moment, the process commenced. I first went through a month of conservative treatment (manipulation under anaesthetic and immobilisation in a cast). When this did not succeed, I underwent surgery, and a plate was fixed with pins to one of the bones that was not healing correctly. I was then put into a cast for 14 days, then given a splint for a further four weeks to immobilise the area.
Bio-psychosocial assessment
Realistically, every crisis point impacts people differently, depending on their starting position at the time. Doing a quick biopsychosocial audit of the person’s circumstances before they are faced with some life event is a useful way to identify strengths, resources, and challenges, and can be highly predictive of how they’ll navigate the path ahead. The more privileged the person – situationally, materially, physically, social/emotionally and (for some) spiritually – the more pathways they will have available to them to buffer the impact of the crisis.
Whether it’s health reserves, knowledge about systems, unimpeded access to care, quality social support, or having money to pay for services, how anyone responds to a new life demand will be significantly determined by how they are faring in these areas at baseline. This is before new demands are added to their load.
It’s worthwhile doing an audit to gauge the level of strengths/resources and points of vulnerability we have before a crisis point. Below is mine.
Living situation: I live alone with my dog in a house with steps.
Health: 63 years old, active woman. Prior to the injury, I was fit, in reasonably good health, give or take age-related arthritis. No significant pre-existing health conditions.
Work: I work from a home clinic. I’m self-employed in private practice—I have all the autonomy, all the responsibility. I have some financial reserves I am able to draw on.
Setting: I live in an urban setting, very close to shops, essential services and medical care. Everything I need medically, or for my daily needs, is easily accessible to me.
Psychosocial support: Over the ten years since moving to this area, I have deliberately cultivated community ties with my neighbours and in local places. An ethic of care and looking out for one another characterises many of the relationships among my neighbours.
Social ties: I have a reasonably solid network of neighbours, though not overly close, and I’m linked into the local community social media page. I have a network of very close friends (local and remote) with whom I share strong ties and am in regular contact.
Personal resources: I’m privileged to be educated. In addition, through therapy and personal growth, I have developed a healthy sense of entitlement in terms of how I expect to be treated when I need treatment. I am good at advocating for myself and others. I am proactive, and usually skilled at anticipating, planning for, and managing problems. Living alone, and working for myself for over 35 years, I’ve had to be independent and resourceful. I also know when to outsource.
Like all who get to live long enough, I’ve had to face and manage challenges. With support, I’ve been resilient, bounced back from challenges and grown. Overall, I’d say I have an optimistic outlook and a growth mindset that have set me up to expect things to turn out okay and that I understand I’ll need to learn to do things differently to resolve or manage challenges. I think I am better equipped to face life challenges than before I developed those resources, or if I were someone who had never acquired them.
My ‘re-certification process’ assessment
Here are some of the questions and reflections that I consider were relevant in assessing my own fitness to practise as I went through each day’s challenges.
In this analysis, I consider there were two phases to my process: the acute phase (the first two weeks) and the ongoing phase—the immediate six weeks following the accident and then the months thereafter.
Acute phase
Right after the fall, did I think to call for help, to seek assistance?
In truth, no. My default survival response based on old childhood beliefs kicked in (‘I’m on my own, I have to sort this out myself’). So, I got up, finished packing the car, and drove myself home. In French we say, under crisis, the bad habits always come back first.
Once I got home, did I think to ask for help and support?
As the pain and swelling worsened, I realised I needed help and reluctantly phoned a friend.
Was I able to ask for care and support as needed, or did I place obstacles in the way of receiving the assistance I needed?
At first, my concerns were affected and shaped by my family of origin-derived training to not intrude on/inconvenience my friend on a weekend. So, at first, I worded my inquiry carefully, making it clear I did not want to impose on her plans. My friend saw through this and responded as a caring, competent adult would—she dropped everything and came around. She argued for the importance of us going to hospital there and then, framing the situation as urgent. Shock was slowing down my ability to accurately assess my situation and see it for what it was: a medical emergency. My friend took over the task of driving me to hospital for treatment and she stayed with me. My conditioning kept returning, with repeated expressions of discomfort at my friend being put out.
Was I able to put my own needs first, and accept that others might be inconvenienced, miss out, in the process?
In the early phase, yes and no. I accepted my friend’s unobtrusive, quiet supportive presence for the first five hours of navigating the emergency department process. Then, when I realised that she might miss out on seeing a show we had tickets to see that night, I insisted that she go. I had bought the tickets for her birthday. I wanted one good thing to come out of this shambles of a day. I then navigated the rest of the night alone. I don’t think that was conditioning – ‘Don’t be a burden’ – as I did ask her to go to my home and tend to my dog. I still asked for what I needed.
Was I able to advocate for my needs in t he face of the hospital emergency process?
Overall, yes. As a health care worker, I clicked into colleague/consumer mode and I was able to ask about diagnoses, treatment options, and make choices for myself. Despite the shock, I was able to successfully advocate for my specific treatment needs rather than fall back on my childhood defaults: put up, shut up, do what the adults say. It paid off.
In this phase, was there any intrusion from past trauma experiences? If there were, how did I manage that?
I was aware of previous experiences of physical/medical trauma arising. I could feel myself feeling young, alone, and scared, and on the verge of overwhelm. Memories of past medical trauma arose, making me prone to expect uncaring, indifferent conduct from treating personnel. In adulthood, memories of not having symptoms taken seriously and being treated in a dismissive, ridiculing manner arose.
Knowing I needed to compartmentalise the past from my present experience, I deliberately talked to myself internally as a soothing, open, loving, limit-setting adult might when accompanying an injured child or dear friend through an emergency process. I kept up this adult/child, adult/friend sense of myself throughout, attending to my vulnerable feelings.
Due to a previous bad hospital experience, I initially chose to go to a smaller hospital, hoping for better care. While I was cared for well there, I needed to return to the larger hospital where I had previously been treated poorly as the smaller place did not have the equipment needed to fully assess the extent of my injuries.
In my adult mode I ensured that, going into hospital, I had packed and wore warm clothes to layer (for shock). I drank water. Mentally, I kept refocusing my mind on key things to distinguish my experience as it was happening as present moment experience. Looking at staff and patients around me, I made myself look for and focus on warmth, care, respect, kindness, presence, and compassion. I particularly focused on kindness, grace and presence. I found this practice very helpful in both keeping overwhelm in check, and allowing me to function as an adult advocate for my own care, able to ask about and clarify treatment issues, advocate for adaptation where I knew it would be needed.
At various points, I gave myself permission to name out loud to attending personnel that I was in shock, that I was not processing information as fast or effectively as I might usually, and I asked them to repeat, explain and clarify when I felt I had lost the thread. This meant I felt like an active participant in my health care decisions and not a hapless, helpless victim.
I used various techniques learned for emotional regulation when I felt my mind catastrophising or my emotions spiralling. This helped contain my overwhelm and enabled me to keep returning to the here and now, the immediate priorities, compartmentalise and chunk down what I needed to attend to and what could wait and, in doing so, hold onto a sense of myself as a grown woman and not a helpless child.
Ongoing phase
Initially, this involved four weeks of conservative treatment in a cast. When pain increased after two and a half weeks, I sought a review and was sent to have corrective surgery. This then set a new course for recovery.
What factors led to a change in course of treatment?
I can clearly say that I accessed my adult/professional mode in tracking my progress and my pain, and in my determination to advocate for myself, be taken seriously, and not be dismissed. This was instrumental in my treatment as, while I didn’t know what to expect in terms of post-fracture discomfort, I tracked my own pain levels and considered that increased pain might signify that one bone may have moved.
Previous experience of treatment at the hands of arrogant dismissive practitioners who missed a significant critical diagnosis at the time it occurred, made me determined to be taken seriously this time. I advocated for my own care. I asked lots of questions. I asked to have scans explained to me. Where staff thought I should be fine to wait four weeks for a final review, I insisted on a review at two weeks. When I came for the review appointment, I held my ground in the face of what felt like disbelief and irritation from reception staff. I calmly asked for another X-ray and to have treatment discussions based on that. The X-ray showed one bone fragment was sitting at an 11° angle, explaining my significant and increasing discomfort. I was then recommended for surgery which happened three days later.
Since the acute phase, have I been able to accurately assess how help I need, realistically gauge what I can and cannot do for myself, problem-solve what kind of assistance I need and how I might source it?
On the whole, yes. This came from a combination of becoming self-reliant out of necessity, learning in childhood that aid could sometimes be sought from adults outside of my direct family, and subsequently choosing to live for substantial lengths of time in my adult life on my own. These factors have meant I have cultivated the skill of learning what I can do for myself, and when and how to outsource. I think that has served me well in the post-acute phase.
I practised what I preach. I drew on all sorts of knowledge and skills learned in training as a therapist about problem-solving, asking for help from my community, and making choices relevant to need, capacity and context. My years of therapy paid off in my knowledge that I deserved and was entitled to such care. Those years also gave me the skills I needed to regulate my emotions, even as I found myself in the eye of the storm as my situation unfolded.
I drew on my own coping ability to manage what I can myself, but also thought about my capacity when it changes (e.g. when I came heavily down with a cold after surgery). From the start, I identified what might be done by others, and sought additional support where I could, leveraging strong as well as weak ties, and my material privilege. I benefited from generosity from a colleague (a week of cooked meals), neighbours helping with food and groceries (even filing and household tasks) and friends taking me shopping. I hired a local worker to prepare my meals, make my bed, and hang out my sheets each week. A dear friend contributed to the cost of the home-care worker. I paid for a cleaner and to get my hair washed each week, and for countless Ubers to get me to and from appointments. Without the kind of material privilege I have, I can see I would have drowned.
Resilience: how did I cope with my reduced mobility and capacity?
That was a learning curve—a very steep, challenging one at that. Dealing with the fact I had to learn how to do almost everything one-handed, which had its own biomechanics, balance/fall risks, and logistics, was a big deal. I had to think about all sorts of things I don’t usually ever pause to think about. I was practising a level of mindfulness that was exhausting—in the physical execution of a myriad of daily tasks, in my constant planning and managing of logistics and resources to get things done, and in my inner world as I lived my life. This sense of hyper-awareness, of needing to be ‘on’ all the time, was exhausting and took its toll as bandwidth tax.
As a single, self-supporting person who lives alone, I know my mental health is paramount. Just as I can’t afford another injury on top of what I’m already dealing with, I can’t afford to crash mentally—I must be in reasonably good mental shape to sort things out as I go if I’m going to get through this as well as possible.
Some days, some moments, I didn’t cope at all well with my circumstances. I catastrophised. I imagined the very worst future for myself. Sometimes, I was scared. Very scared. Mostly, at things my mind imagined.
I noticed that pain and the spectre of surgery or permanent impairment could quickly bring me into a spiral of dread and negativity. Then, I practised emotional regulation, and I brought myself back to the present and what was right in front of me, chunking things down to smaller units of time to make things more manageable in the moment. Interestingly, once my feeling that I needed a different course of treatment was confirmed, the meaning I attached to surgery changed. It went from something I wanted to avoid to a welcome option, preferable to being left with chronic pain and restricted movement.
I noticed I was nowhere near as overwhelmed coming out of surgery as I was after the initial break and treatment. Knowing I had all sorts of supports already in place made a huge difference to my ability to deal with the new course of action. Surgery just became another milestone on the path to my recovery, not a complete return to the beginning, as someone told me they had experienced it.
Frustration: how do I deal with not getting things done as, and when I want, or at all?
As a person who is used to a lot of autonomy over her own life, suddenly being unable to make things happen as and when I chose was a major challenge. Having to ask, source, wait for, and rely on others, was a very different world to the one I usually inhabit, and I realised it had fostered a level of illusionary omnipotence. In this new world, I was confronted with my dependence on others in a direct way. The everyday minutiae of my life reflected just how limited, conditional, and precarious my self-reliance and independence really are.
I was frustrated. Often. Really frustrated.
I hated that it felt as though everything took five times as long. Even for the simplest of things — like putting socks on, or pulling my underpants up.
I was frustrated that I had to work out the logistics of almost everything and make sure I had considered the biomechanics of what I needed my body to do in attempting any goal.
Of course, inevitably, as I balanced on one foot, or reached at an awkward angle, wrestled a stubborn container lid open with my knees, inner thighs, teeth, elbow, or chin, I knocked things over, lost balance and had to catch myself, or I created more issues (e.g. spills) to then deal with. The domino effect of things taking five times as long, having to navigate literal obstacles that don’t exist for a two-armed person, plus the additional challenges that happen just because things go wrong led to more frustration and brain strain. All of this required constant emotional resetting and regulation to avert unwanted outcomes.
This frustration meant I had to learn to let go of my demands that things be done in a certain way – my way, to be precise – in a certain order, in a certain time frame. I asked myself over and over: what do you make it mean that things be done this way, right now? Often, once I’d considered that question, I could let go of my demand criteria and let things be. I was reminded of a colleague years ago who playfully mocked her own ability to let go. She added, ‘Everything I’ve ever let go of has claw marks all over it.’ I can relate.
Life as a complex system
I remind myself that the situation I found myself in is most usefully approached as a complex system. By that I mean one that has many interacting parts – many of which I cannot know about or predict, nor necessarily control – that impact how things unfold.
When I switch to this way of thinking, I can more readily give up delusions of control where there are none to be had, linear-causal thinking, and trying to have all bases covered. I get more philosophical about the fact there are many unknowns, that whatever I decide can only be decided on the basis of imperfect and incomplete knowledge, that there will certainly be unexpected twists and turns. I practise planning but only holding loosely to any plan I make, being willing to quickly change directions as needed as the situation unfolds.
When I forget to approach my situation in this way or try to force things to be as I want instead of as they are, I end up with more optional suffering and I feel more unsettled for longer. But knowing this intellectually and living it, applying it to my circumstances as they unfold and how I approach them, is a daily, sometimes moment-to-moment, practice.
The life challenge I was presented with showed me that acceptance of reality as a complex system is probably going to be a lifelong journey for me. Sometimes I would do things pretty much as and when I needed them done. At other times, factors played out such as tiredness, old conditioning, being attached to having things a certain way/doing them myself, having ego tied up with doing them, insufficient information, old trauma, assumptions, and accordingly more importance to particular outcomes rather than maintaining steadiness of being. At those times, I would find myself far more frustrated and overwhelmed with little perspective. Problems would seem much bigger, if not insurmountable.
When other factors intrude
Sometimes, I would think I was doing well when I was actually playing out my family’s conditioning. For instance, I broke my wrist on a Saturday, I was at work at 8.45am on the following Monday. After my surgery on a Friday, I was at work with clients on the following Monday. I had a massive bronchial infection after surgery but I kept working until I lost my voice! Then, and only then, did I give myself permission to stop work, reflect, and really attend to myself. I hadn’t realised I was playing out my family of origin training for how I’m supposed to be, and how I’m cared for when I’m sick or vulnerable.
Yet at the time, my focus was all about coping and ‘dealing’. I didn’t realise I was lost down an old familial rabbit hole of having to do, be responsible, work, and keep going no matter what. It was a blind spot aided by the fact I did a great ‘job’ of putting my skills in service of my old programming. Work-wise, I didn’t miss a beat. But at what cost? And to whom? Whose interests were being served?
When I finally stopped working and reflected on how I’d treated myself, I saw that my predicament challenged me to consider: will I choose to put myself first and foremost as a life form that needs care, instead of seeing myself as a work unit that must function, bring in money and has responsibilities to others?
I realised that this continues to be a learning edge for me. I nearly missed it!
Progress notes
In my work, I often talk with clients about how we humans want to hold onto illusions of certainty, predictability, continuity and control. I talk about how tightly we cling to those despite the fact, in life, it is change, uncertainty and the unknown, rather than certainty, that are the ground of reality. I remind them that fighting reality won’t change it — it merely adds more optional suffering to the presenting load we’re dealing with.
Over the six weeks in the post-acute phase, and beyond, as I faced each day’s new and ongoing challenges, I saw how much I, too, wanted things to be knowable, predictable, controllable. Which is fine when they can be, but just makes things worse when they can’t.
Over and over, I saw how, as my day-to-day reality changed, as my capacity changed, as opportunities closed, as new challenges came to light, the single biggest predictor of how much optional suffering I was going to have to deal with on top of the immediate difficulty, was the balance of my capacity to accept against my capacity to be flexible.
Post-accident, I try to remind myself that, like every other person who walks the earth, my challenge is to look at what is and look for how I might respond with both more and less: more flexibility in my capacity to accept what’s okay and how to get there, and less rigidity, less insistence on having to have things my way, on my timetable.
What does this mean for ‘re-certification’?
I have observed that my own blind spots about my own life and circumstances can also translate into blind spots about how I approach my clients’ situations.
I can see why airline pilots are required to do their ‘sims’ regularly. The rigour of deliberately reflecting on how we deal with challenging circumstances, tracking and assessing how we handle ourselves when faced with predicaments in vivo could be a tool to let us know whether we are fit to practise. I used a ‘sim’ (breaking my wrist) as an opportunity to refresh my grasp on much of my knowledge. I might know a lot of theory but when I found myself in a challenging situation, how well did I remember what skills I needed and when to implement them? How well did I execute them?
Outrageous and unrealistic as it might seem, I think there could be merit in having us therapists regularly engage in processes of re-certifying by submitting for assessment and training our in-depth reflections on current life challenges we are facing and the degree to which we draw on and implement the skills, knowledge, perspectives and wisdom we so readily dish out to our clients.
In Part 3: Foundations for re-certifying, I present the underpinning practices that I drew on when facing my own challenging circumstances. In doing so, I reconfirmed my own fitness to practice. I propose these practices as the foundation of any re-certifying process.
