No therapist enters the field of mental health believing that being a psychotherapist will harm him or her. The work of psychotherapy brings both costs and benefits to the therapist as a person. Too often the very factors that allow a therapist to be helpful are those that also put the therapist at risk.
Many, if not most therapists are profoundly changed, for better and worse, by the work they do. Several bodies of literature address the occupational hazards of doing psychotherapy. There is a general recognition of the interaction between the situational demands of the work of psychotherapy and the unique aspects of a particular therapist. This interactive model is essential; such a model suggests that an individual therapist’s vulnerability to the negative consequences of his or her work is variable over time and life circumstances.
Because a therapist’s self is both an inherent part of his or her professional identity and a tool for the work of psychotherapy, any change in the therapist’s personal life can affect his or her professional well-being. Resistance and denial are powerful forces in the profession. Resistance means we don’t want to know that psychotherapy can be harmful to the therapist.
Denial means we want to say that psychotherapy is not harmful to the therapist. (unless the therapist is doing something wrong). These erroneous beliefs are what most of us have been taught implicitly or explicitly in our professional training: the former by the absence of the topic in our curricula (including, often, our ethics courses) and the latter by the implicit or explicit message that any therapist in distress is unfit or flawed.
In fact the work of psychotherapy is demanding and uniquely stressful work, and practitioners need safeguards to protect themselves. Also, every clinician is at risk at some time in his or her practice simply because the work is endlessly challenging and because personal life events, past and present, will inevitably influence the therapist’s work at some time in an individual’s career.
Situational Factors: The Stress of the Work Itself
A psychotherapy relationship is a uniquely boundaried and intimate relationship. By theory, a therapist is to offer a neutral (nonjudgmental), compassionate relationship within which a patient (client) is invited to speak freely. A psychotherapy office is seen as a place in which it is appropriate for a client to express strong or unacceptable feelings that cannot be spoken in most social venues. As therapists we convey our willingness to hear stories that carry deep emotional significance to our clients. Some of these stories are poignant, some are painful. Some stories are horrifying, some are enraging. Some stories are heartbreaking, and some are uplifting.
As therapists listen, they may be transported to extreme states of feeling and sometimes crises of faith. But the therapist is not free simply to tend to his or her own emotional experience; rather he or she must first attend to the needs of the client within the boundaries of the therapeutic frame. The therapist is further constrained by confidentiality; the foundation stone of the therapeutic relationship. The therapist is therefore greatly limited in where to discuss the strong reactions stirred by clients, their material, and their symptoms and interpersonal style.
This fact is a contributing factor to the extreme isolation within which so many clinicians practice. Therapist’s isolation is further increased when they have few or no opportunities for consultation, supervision, or other venues within which to discuss their clinical work and their feelings about that work.
The acuity of one’s clients’ symptoms and distress, the nature of the therapeutic work (crisis, short-term, long-term, individual, group, family, case management), the age and number of clients, and the clients’ current levels of functioning and crises all shape the cumulative stress level represented by the therapist’s workload.
A significant source of stress for clinicians comes from the real and perceived levels of responsibility and liability they carry. This source of stress is increased for clinicians working with clients who are suicidal, self-injurious, volatile, violent, or otherwise engaging or likely to engage in dangerous behaviors. An ethical, licensing complaint or lawsuit creates extraordinary distress and hardship.
Clinicians may come to live in fear and anxiety about complaints and try to second-guess their decisions through a legal lens. Working from a position of defensiveness also can interfere with connection to one’s clinical instincts, one’s clients, and oneself. As you assess your own vulnerability to occupational stress, consider your work setting and level of professional support. Do you work alone or with others? If you work with others, do you share a common approach and value system about the work you do? Do you feel respected and valued for your work? Do you have specific sources of support for your work (e.g. places to talk about it, opportunities for continuing education, reasonable pay and benefits?)
It is very difficult to work in systems that are overtaxed or indifferent to the needs of the clinicians. In our psychotherapy work we try to provide a holding environment for our clients; in order to accomplish this goal, clinicians need a secure and supportive environment. Too many clinicians are either isolated or work within unresponsive work environments; both situations create stress and increase the vulnerability of the therapists to unhappiness, burnout and professional distress.
“Pull yourself up by your bootstraps” and “Get over it”
do not support the
central goals of psychotherapy: recognizing the influence of the past on
the present and increasing self-awareness and self-understanding.
Psychotherapists hear that which society wishes to silence. Within
medicine, the field of psychiatry has defined itself as the science of
treating incurable illnesses through managing symptoms. It is difficult
working in a field that is devalued and often ridiculed. The most
common popular images of therapists are caricatures. When therapists
are not ridiculed, they are often portrayed as unethical or predatory in
the film and television industry. Few people who have not received
psychotherapy have a good understanding of what psychotherapy is and how
it can help. This climate affects each therapist’s experience of his or
her work and profession.
Each therapist brings to his or her work a unique personal history, personality style, and set of life circumstances (which change over time). Over the course of professional development, we each develop a “therapist-self,” that is, a professional identity and familiar way of working. Aspects of the therapist’s personal life, past and present, are woven together to create this self. Significant events that occur in the therapist’s personal life will further shape the therapist-self. The interaction between these personal factors and the situational variables listed previously create the current vulnerability to occupational stress for a given therapist.
Therapists enter the field of mental health for personal as well as professional reasons. Research shows that therapists are more likely to come from family circumstances that include childhood abuse, alcoholism, and other family crises. Certain clients or circumstances can bring up issues from our past in ways that are challenging.
Current Life Circumstances
Health and Vulnerabilities
Therapists have bodies that are vulnerable to illnesses ranging from minor to life threatening. Therapists are also vulnerable to psychological distress and mental illnesses, including depression, and other mood disorders, addictions, P.T.S.D., and anxiety etc. Because of the (painfully ironic) stigma in the field, it is even harder for therapists to seek psychological or psychiatric services for themselves.
Personal Psychotherapy, Training, and Clinical Supervision
A mediating factor for therapists’ stress is the support they have. Three major sources of support for clinicians are effective personal psychotherapy, sufficient training, and adequate ongoing clinical consultation (or supervision). When any of these resources are inadequate or nonexistent, stress and distress for practicing clinicians can be increased. Ideally, every therapist should have adequate and sufficient training, helpful personal therapy, and appropriate ongoing case consultation.
Vicarious Traumatization (VT)
Clients who have experienced traumatic life events evoke strong reactions in therapists. Outside of the therapy context, therapists may experience intrusive imagery, cognitions, or unbidden waves of emotion related to their clients’ traumatic experiences. The stories these clients tell or struggle to tell us may challenge our beliefs about people, children, and the way the world works. Therapists are not allowed the same protective veil of denial as people in other professions. We must face the fact that bad things do happen to people, too often at the hands of other people – or risk failing our clients and ultimately the profession. At the same time, we must not abandon hope for relationships, hope itself, or compassion; in fact these are the key tools of our trade. Clients who have experienced horrific life events often have made extreme adaptations to these experiences and thus present with severe symptoms and dangerous or disturbing behaviors or lifestyles. The therapist is then further challenged to make sense of and tolerate emotionally the client’s current adaptations, presentation and behaviors. Therapists may experience intense anxiety and struggle with concomitant feelings of helplessness, responsibility, and rage.
Why Do We Do This Hard Work?
Individuals who practice psychotherapy need to ask themselves this question from time to time. Listen carefully to your answers. What do the answers tell you about what your work means to you. The meaning your work has for you will offset the nihilistic impact of VT by providing a context for the pain and grief that work can evoke. Some answers will connect you to aspects of yourself, your value system, spiritual beliefs, and passions. Practical answers do not imbue the work with meaning in a way that can transform the negative impact of the work e.g. “I do it to make a living.” Pragmatism is not a sufficient antidote to the negative impact of the work of psychotherapy.
The Interaction of Personal and Professional for Therapists
Because the personal self of the individual therapist is a defining part of professional identity, each therapist must track the interaction between personal and professional identity, responses and beliefs. This self-awareness is both a preventative tool and a helpful intervention when a therapist is grappling with the stress of his or her work. All therapists enter the field for deeply personal reasons, some conscious and others not in our awareness. Our understanding of those motivations and drives often deepens over the course of our work and life events. Sometimes life events change the reasons why we do the work. Helping others in pain can help us manage pain in our own lives.
Protecting the Self of the Therapist
The steps for self-protection involve awareness, balance and connection. The first step of awareness requires a therapist be aware of his or her occupational vulnerability and maintain a commitment to be self-aware. Maintaining balance among work, rest and play is a recipe for resilience and health. Attending to balance within your practice is essential as you fine-tune your personal protection plan. Consider what kind of balance you need of clinical work to other kinds of work (administrative, consultation, teaching, writing, political, research.) Consider what kind of balance you need within your clinical work, of treatment modalities and of intensity of clinical need. Finally, your connection to yourself, to professional colleagues, and to intimates all serve to create a safety net that protects you from isolation, over commitment, and from overlooking early warning signs of stress and distress.
Addressing the Stress of Our Work
The first line of defense against occupational stress is self-care; it is important to take care of your physical and psychological well-being. These kinds of stress management techniques are well known. Because much of the clinical work we do is with clients’ experiences of deprivation and symptoms of pain and self-punishment, it is especially important that therapists actively pursue those things that give them comfort and allow them to experience pleasure. Therapists have as much right as any human to escape to whatever fantasy or venue that allows them to find comfort and respite.
Transforming the Pain of Our Work
The most precious aspects of a therapist’s self that are at risk are in the realm of meaning. Specifically, the risks are to his or her capacity for hope, optimism, joy and wonder, love and idealism. The signs of danger are cynicism, pessimism, nihilism, despair, and disconnection. The primary approach to transformation is through meaning – specifically, finding meaning in your actions and imbuing everyday activities with meaning. An additional strategy is to challenge your own over generalized negatively. For example, when you find yourself always assuming the worst, remember a time when the worst did not happen. Consider that kindness and love are as true as cruelty and hate.
Guidelines for Healthy Practice
Respect: Respecting yourself as a person and as a therapist includes addressing the question of balance, practicing self-care, and validating your own experience and needs.
Limits: No therapist can treat all clients. Each of us has strengths and weaknesses as a therapist. Even within one’s area of expertise or specialty, one cannot be the right therapist for all clients. The “fit” between therapist and client reflects many factors, including interpersonal style and temperament.
Needs: “What do I need to do this work?” Try to meet or tend to these needs. Therapists need to pay ongoing attention to their physical, emotional, spiritual, and professional needs in order to pace themselves and to be reliable over time.
Experience: The profession of psychotherapy is an apprentice profession. We learn it largely by doing. One is a novice therapist for a period of years before gradually becoming an experienced therapist. Even so, the field of knowledge is so large and the variety of individuals so infinite that one is always learning. What have you learned about yourself in this work? What have you learned about yourself from your mistakes and your successes?
Be Informed About Your Work: One protection to the stress of the work is staying informed about relevant theory and methods and staying connected to others working with similar clients and approaches. Isolation is an occupational hazard for psychotherapists. Clinical consultation is an invaluable resource and safeguard throughout one’s clinical career. It is simply not possible for any individual clinician to maintain objectivity about all his or her psychotherapy relationships.
Connection: Connection allows us the secure base from which we can offer security and a holding environment. Connection is a matter of concentric circles; we need connection to ourselves (intrapersonal), we need connection to others (interpersonal) and we need connection to community (belonging).
Stay Connected to All of Yourself: No matter how committed we are to our work as psychotherapists, each of us is much more than our therapist-self. We are children of our parents, parents to our children, partners of spouses, sisters or brothers. We are artists, musicians, and athletes. We are lovers, clowns and dreamers. We have a myriad of talents, interests, and experiences. We need to stay connected to the many aspects of ourselves and our lives. Be complicated and multidimensional. Stay connected to that which makes you smile, laugh, and relax.
Stay Connected to Others: Because the nature of psychotherapy is about intense dyadic relationships, it is important that our clients not become our most intimate relationships. There is a danger of using clinical relationships to meet the therapist’s need for intimacy. A therapist needs relationships that allow him or her to be in different roles – not always the caretaker. Most therapists can benefit from opportunities to be in situations in which they are neither in charge nor the expert.
Stay Connected to Community: Allow yourself to belong. A community is larger than the group of people that comprise it. A community is a group with shared goals and principles. Belonging to a community reminds us all of the power of shared visions and the power of collaboration.
Hope : Hope is the backbone of our profession. Fundamentally psychotherapy is built upon the hopeful premise that people can change, heal and grow across their life span. Hope is our most essential commodity as therapists. Yet what do we do to nurture hope? Hope reflects realistic optimism. In the face of daily contact with despairing clients, cynical mental health systems, and critical popular culture, therapists cannot afford to take their hope and optimism for granted. Hope needs nourishment. Bolster your hope with your own evidence of success from your experience as a therapist and client, and as a colleague or consultant to other therapists. Hope is meant to be shared. With our clients, we may have to hold hope when they cannot bear to do so. With each other, we need to share and receive hope. Living your hope means knowing why you are doing this work.
Information Be informed about the risks of psychotherapy. Be informed about yourself: Be self-aware.
Adapted by J.Kuryk M.A. from: How to Avoid the Occupational Hazards of Being a Psychotherapist by Karen W. Saakvitne PhD (Sock-quit-knee). Reproduced from: Innovations in Clinical Practice: A Source Book (Vol.20) by L.VanderCreek and T.L.Jackson (Eds.), Sarasota, FL: Professional Resource Press. Copyright ©2002