In psychiatry, we are trained to prepare our patients for the end of treatment. Treatment planning focuses on goals and strategies to help the person eventually end their need for therapy and external interventions. Interestingly, even with this anticipation of ending our relationship as part of the focus, it is not unusual for patients to disappear.

Ghosting doctors and treatment personnel is sadly commonplace in the mental health space. I have been in this business for too long to take the behavior personally. I have tried various techniques to avoid it. I developed a membership-based practice partly so that people who choose to partner with me as part of their treatment journey would have to let me know they are ready to move on when they end the membership. But even with this monthly reminder in place, I still see workarounds to engaging in that last conversation, such as late-night membership cancellations or requesting breaks from which there is no return.

With my years of training in human behavior and decades of experience with last sessions, you would think I would be skilled in anticipating the various behaviors seen when relationships end. Any thoughts of expertise in this area were put in their place once I entered the business side of medicine.

Contracts are entered in good faith, with verbal promises not always fully reflected on paper. All good things must end, and contractual arrangements are no different. Contractually, even with what seems to be favorable closing terms, it can be worked around. Recently, I was blessed to partner with a team that I felt was in complete alignment with my values and passion as an integrative medicine psychiatrist.

Initially, the working relationship evolved in exciting ways, and I saw real change in my patients and among team members as we learned from and with one another. But, alas, as with many work relationships, the team changed its focus, and sadly, because I was contractual, my contributions became less and less valued. I viewed myself as savvy enough in business and relationship dynamics to put on my big girl pants and anticipate the end of this contract.

But the goodbye never came. Instead, over weeks, which extended into months, I was slowly left out of crucial team meetings. Conversations seemed to be happening, and decisions were made without my input, though the results directly affected my practice and ability to interact as a part of the team. This was because, unbeknownst to me, I was no longer considered a team member.

As a female physician and business owner, I am the first to look in the mirror and wonder aloud, “What did I do?”

“I wanted to call back when you described what was happening,” a fellow woman psychiatrist familiar with the organization said. “I knew it wasn’t good – they are freezing you out.”

Months before my contract officially ended, the team’s leadership changed, and with that, the focus moved from patient care to keeping the budget within new parameters. In hindsight, I know I did nothing wrong – my values and my why never changed – but the team no longer shared my views, so I was no longer a good fit. And, if I’m honest with myself, the team was no longer a good fit for me either.

“Just keep your head down and finish it out. Get your money and move on.” The advice is sound, but the actions feel insincere. I enjoyed the early days with the team and have developed valuable relationships because of my time there. My personal practice and lifestyle were both enhanced.

As the end of my contract nears, I reflect on other goodbyes left unsaid. My father thanked me for visiting the weekend before he took his last breath. My friend Orlaith spoiled my children with gifts as we shared a meal in Dublin while she mentioned that her cancer had returned. She left this earth before our next visit. That colleague who just stopped coming to work as he retired without a word. The abrupt email notifying us of another’s last day.

So many farewells. So many endings. Why do we fear acknowledging what is felt and what we intuitively know? Our journeys overlap with others in work and in personal life. Those overlaps bring lessons through joy and loss. A moment, a pause to show gratitude, can only help us heal and move forward. Instead, we walk forward and away without acknowledgment. Leaving with an unspoken goodbye.

Holly MacKenna is an integrative psychiatrist.