Self-Care for Therapists
For a pdf of this article, please click here Self-Care for Therapists
Self-Care for Therapists: Prevention of Compassion Fatigue and Burnout – Vivian Baruch B.A., M.Couns.
The helping professional, who is mindful that compassion fatigue and burnout are givens in therapeutic work, rather than indicators of personal inadequacy, is well-placed to recognise and respond effectively when they experience the impact of these stressors. Therapists and counsellors are able to see what clients need to do to care for themselves, but at times become blind to their own needs to do the same. Self-care needs to be an area of primary concern for counsellors and therapists. Some even suggest that it be viewed as a moral imperative and be included in all training and on-going professional development programs. VIVIAN BARUCH provides a practical, challenging and compassionate consideration of these issues.
Charles Figley (1995) suggests that work with clients who have suffered traumatic experience has specific occupational health risks: ‘…there is a cost to caring…the most effective therapists are most vulnerable to this contagion effect…those who have enormous capacity for feeling and expressing empathy tend to be more at risk of compassion stress…’ (p.1).
He defines ‘secondary traumatic stress’ as ‘…the stress from helping or wanting to help a traumatized or suffering person’ (p.7) and uses the term ‘compassion fatigue’ interchangeably with the term ‘secondary traumatic stress’. Secondary traumatic stress is distinguished from burnout by its rapid onset and the extent to which the affected therapist presents with similar symptoms to those affected by post traumatic stress disorder.
Gilroy, Carroll & Murra (2002) stress that the key to prevention of burnout lies in the establishment of a professional ethos in which self-care is viewed as a moral imperative. In such a scenario, self-care would be stressed as a priority in our work as counsellors by training bodies as well as professional organizations. Self-care strategies would be included in the training and on-going maintenance regimes of therapists.
My interest in the area of counsellor and therapist self-care arose for two reasons. First, as a result of the failure for self-care to be addressed sufficiently in any of the counselling and therapy trainings I have attended. Where it was addressed, the only recommended methods were supervision and personal psychotherapy. Second, since my own brush with compassion fatigue twenty years ago, three years after I began to practice as a therapist, it has been important to me to ensure that I pursue de-stressing and healthy diversions to balance work and study.
Yoga and meditation form a significant part of my self-care programme, and I continue to benefit from their harmonising and integrating effects, as well as their ability to gently expand my sense of self and meaning frameworks. Holistic methods of healing emphasise prevention, which is generally regarded as necessary to maintain and develop the health of body, mind and spirit. The potential for compassion fatigue is often not considered, to say nothing of methods to prevent the condition in the first place. It seems straightforward that as counsellors and therapists we should attempt to practice for ourselves what we encourage our clients to do for themselves.
Not only is it important to model authenticity, as any good therapist may be expected to do (Walsh & Vaughan, 1993:161), but it is also important to pay continual attention to our own inner work and spiritual practice. In this way we can highlight our own shadow aspects, develop ethical sensitivity and develop an appropriate sense of responsibility. Of course, at times of increased stress, it becomes more difficult to maintain such self-care regimes. However, it is at precisely these times that we can draw on the reserves gained through an established self-care programme.
A search of the literature on counsellor and therapist self-care found:
- psychological principles, methods and research are applied rarely to therapists themselves. It’s interesting that we help clients to change in ways we don’t always practice ourselves.
- there is a paucity of systematic study on therapists and self-care.
- it appears that counsellors and therapists feel great shame around being impaired by our work. This is unrealistic given a growing body of empirical research attesting to the negative toll exacted by a career in counselling (Norcross 2000:2), as well as the effects of compassion fatigue.
- prevention is better than cure. Studies of those who have managed with success to navigate years of working with distressed clients can be of vital assistance to the field. (Coster & Schwebel 1997 & 1998; Dlugos & Friedlander, 2001; Norcross 2000).
- common themes have been identified in therapists who function well and their self-care methods. Recognition of and emphasis on these common themes are needed in training and continuing professional development.
The important themes that appear in the literature around therapists who function well with regard to self-care and prevention of burnout focus on the various methods used by experienced therapists that contribute to successful maintenance of well-being. These include:
- self-awareness and self-monitoring, which requires attention to interpersonal feedback from significant others (Norcross 2000); support from peers, spouses, friends, mentors, therapists and supervisors; personal values that help the practitioner to observe ethical standards of practice; a balanced life that incorporates vacations and stress-reducers, and continuing education to ensure that the practitioner diversifies their work and keeps abreast of changes (Coster & Schwebel 1997; Dlugos and Friedlander 2001; Norcross 2000; Guy 2000; Jennings & Skovholt 1999; Kramen-Kahn & Downing 1998; Mahoney 1997; O’Connor 2001; Skovholt et al 1997, 2001).
- embracing multiple strategies for self-care. Norcross (2000) suggests that possession of one particular skill is less valuable than a variety of self-care skills. Other researchers, some of whom incorporated cross-cultural studies on the impact of meditation and mindfulness, found empirical evidence that these methods show a marked influence on general well-being (Brown & Ryan 2003; Dluglos & Friedlander 2001; Mahoney 1997; Zetter 2003).
- diversity and synergy of professional activities such as: conducting multiple forms of therapy (individual, couples, group); engaging in a range of activities (e.g. therapy, assessment, research, teaching, supervision, consultation); work with a variety of clients and problems (age, ethnicity, disorders); continuing education; and balancing professional responsibilities with personal needs (Dluglos & Friedlander 2001; Guy 2000; Kramen-Kahn & Downing 1998; Mahoney 1997; Norcross 2000).
Other important concepts were:
- the need to recognise the hazards of psychological practice. Empirical research attests to the negative toll exacted by a career in therapy. The literature points to depression, mild anxiety, emotional exhaustion, and disrupted relationships as the common residue of immersion in the inner worlds of distressed and distressing people (Brady, Healy et al 1995, cited in Norcross 2000). The imperatives of confidentiality, the realities of isolation, and the shame felt when we experience the negative impact of our work, along with a host of other considerations, lead us to overpersonalise our own sources of stress, when in fact they are a given in psychological work (Farber 1983; Figley 1995; Geldard 1993; Gilroy, Carroll & Murra 2002; Kramen-Kahn & Downing 1998; Mahoney 1997; O’Connor 2001; Skovholt, Grier & Hanson 2001; Norcross 2000).
It is essential, and indeed therapeutic, that we disconfirm our individual feelings of unique wretchedness and affirm the universal nature of the hazards in psychological work. (Guy 2000; Norcross 2000).To do so leads us to corrective action and informs preventative measures.
- current policies in relation to distressed and impaired practitioners tend to be inconsistent and incomplete, and focus on code enforcement rather than on prevention efforts (O’Connor 2001, cited in Gilroy, Carroll & Murra 2002).
- it is difficult to estimate the overall prevalence of burnout in counsellors and therapists as unknown numbers leave the profession, or move towards teaching and administration rather than frontline therapy (Warnath and Shelton 1976, cited in McLeod 2003:429).
It seems straightforward that as counsellors and therapists we should attempt to practice for ourselves what we encourage our clients to do for themselves.
Outcomes from embracing self-care methods as a standard means to ensure that the practitioner functions well were: high levels of personal accomplishment, general well-being, enhanced self-awareness, openness to experience and appreciation of the rewards of care-giving, which all led to increased job satisfaction (Brown & Ryan 2003; Dlugos and Friedlander 2001; Guy 2000; Jennings & Skovholt 1999; Kramen- Kahn & Downing 1998; Mahoney 1997; Norcross 2000; O’Connor 2001; Skovholt et al 1997 & 2001). In addition, an ‘enduring quality in an individual’s functioning over time in the face of professional and personal stressors’ was found (Coster & Schwebel, 1997:11).
Research clarified a sequence of steps taken by therapists when they sensed their functioning was compromised: they asked for help, cut back on caseloads and sought to focus on relaxing and diversionary activities. Overall the research information contradicted the belief that well-functioning ‘just happens.’ These therapists were pro-active in their self-care (Coster & Schwebel 1997 & 1998; Dlugos & Friedlander 2001; Jennings & Skovholt 1999; Norcross 2000; Skovholt et al 2001).
As stated earlier, Gilroy, Carroll & Murra (2002) claim that the key to burnout prevention lies in the establishment of a professional ethos in which self-care is viewed as a moral imperative: ‘At a systemic level, the inclusion of guidelines regarding the practice of self-care needs to be incorporated within professional codes of ethics…Other recommendations include the regular provision of continuing education credits for participation in a variety of self-care activities, such as personal therapy, peer supervision, meditation, and so forth…At the institutional level, the current focus in universities and professional schools of psychology on clinical skills is not enough. It is imperative that personal psychotherapy be mandated… Although the curricula in professional psychology programs may mandate courses in legal, ethical, and professional issues, risk management, and so on, more attention is needed in terms of self-care and education concerning possible risk factors associated with such problems as compassion fatigue, distress, and impairment’ (ibid). ‘…those who are introduced to self-care and personal therapy early in their professional lives are more likely to undertake such means continually throughout their careers’ (Pope & Tabachnick, 1994 cited in Gilroy, Carroll & Murra, 2002).
‘It is important that such self-care action plans be comprehensive in nature and include attention to the physical, cognitive, emotional, recreational, and spiritual dimensions’ (Carroll et al. 1999, cited in Gilroy, Carroll & Murra, 2002).
Dlugos and Friedlander (2001) suggest that for the field to retain motivated, competent professionals, training and education programmes need to emphasise balance, integration of work with the rest of life, and the spiritual and transcendent nature of therapy. Their research showed that ‘passionately committed psychotherapists’ experienced a strong sense of spirituality. They found that an interest in activities unrelated to work as therapists, and attention to spiritual disciplines and development were as crucial, if not more crucial, than the pursuit of professional avenues of achievement.
Research on the regular use of spiritual practice, in particular meditation, has shown the following benefits: provision of meaning frameworks for the human condition; beneficial effects on the physical, emotional, mental and spiritual aspects of being; provision of social support networks and relationships; clarification and development of personal values and ethics; enhancement of the capacities of self-awareness, self-monitoring and altruism, and the capacity to act on these in a realistic manner (Vaughan 1989, 1995a & b, 1999; Walsh & Vaughan, 1993; Walsh 1999; Wilber 1989, 2000; Wilber, Engler & Brown 1986, Zetter 2003).
We all have times when the stress of our clinical work causes us to become exhausted, anxious and agitated. Some of us are suffering now, or have suffered, from distress, compassion fatigue or burnout. All are occupational hazards. We’ve discovered that our inner reserves of empathy aren’t infinite. Becoming more self-aware helps us to know the limits of what is possible in our own lives as well as in the lives of our clients.
As therapists, we face the challenges of a dwindling future, the struggles with managed care, and the need to work harder with minimal institutional support for supervision and continuing education. More than ever, we are isolated individuals who operate behind the closed doors of our practices. And while the resources and organisational support dwindle, we hear more traumatic stories from clients than we did years ago. Repeatedly we find ourselves experiencing distress, faced constantly with our own helplessness and inadequate recognition of the limits of what we can do to help clients bear the unbearable (Treadway, 1998:57).
The plethora of today’s theoretical and clinical approaches can leave many of us bewildered and confused about the nature of counselling. How do we sort out what is truly therapeutic in any given case? All these factors contribute to compassion fatigue and burnout, and we experience these in unique ways. Sometimes we don’t even recognize the danger signs. Conscious burnout drains us; unconscious burnout is often taken out on the people we love (Treadway, 1998:58). Our challenge is to do everything to prevent burnout, and should it happen, to handle it well when it comes. This involves development of our own survival strategies.
Empirical research attests to the negative toll exacted by a career in therapy. The literature points to depression, mild anxiety, emotional exhaustion and disrupted relationships as the common residue of immersion in the inner worlds of distressed and distressing people.
Strategies for prevention
The following suggestions are drawn from Treadway (1998):
Don’t go it alone
Many of us practice in too much isolation. We often feel ashamed when we experience any of the signs of compassion fatigue, such as feeling inadequate and overwhelmed. Often this shame causes us to retreat further. Prevention of isolation requires that we have a sense of community – be it through a peer group, supervision, attendance at conferences and so on. In addition, we need a sense of belonging through family, friends, hobbies and other means to ensure that we have a sense of self that is not just based on our occupation. ” Maintain beginner’s mind” Cultivate passionate involvement in learning something new, such as a hobby, a sport, a new discipline, a language, a new therapeutic model and so on. This relieves us of the burden of having to be an expert and gives us the freedom to not know the answers. No matter how experienced and knowledgeable we are, it is always good to have a teacher of some sort as a way to be nurtured and to stay ‘open’. Beginner’s mind is not only a basic stance from which to do the best therapy, but it is one to incorporate into the rest of our lives. Remember to let our clients teach us – they are the experts in their own lives.
Through increased economic fears, we work harder for longer hours. However, we must identify what materialistic needs are realistic and essential, as opposed to what we want. The voluntary simplification of our lives is a good thing to aim for, before it is forced upon us. Richard Gregg eloquently stated a rationale for voluntary simplicity: ‘Voluntary simplicity involves both an inner and outer condition. It means singleness of purpose, sincerity and honesty within, as well as avoidance of exterior clutter, of many possessions irrelevant to the chief purpose of life. It means an ordering and guiding of our energy and our desires, a partial restraint in some direction in order to secure greater abundance of life in other directions. It involves a deliberate organization of life for a purpose…’ (Gregg, cited in Walsh & Vaughan, 1993:248).
Therapist, heal thyself
It is the general nature of life that a sense of mastery is elusive and inconsistent. One of the most acute manifestations of compassion fatigue is the loss of confidence in our own work. This can re-activate ‘old’ issues, which we feel we have dealt with many times before. Many of us resist the recognition of when it is time to go back to therapy. It is also important to remember the possibility of medication (which we encourage our clients to take), as well as the wide range of alternative healing methods available, like nutritional supplements, herbs, acupuncture and so forth.
Stop for a refill
We need to be mindful of numbing out activities that don’t replenish and restore us. Utilise alternatives like exercise, healthy eating and sufficient sleep, plus hobbies that give a genuine recharge. Find your own methods, such as affirmations, prayer, massage, yoga, journaling, support groups, spiritual direction or meditation and use them regularly.
You are not It
Treadway (1998) reminds us that all we require in order to have the healing presence of the Higher Power in our life is to know that we’re not it! Repetition of this, or any other prayer, puts us in the right relationship with the universe. Ultimately, the root cause of burnout is to lose touch with our own spiritual centre. We all need to connect our individual lives to a pattern of purpose and meaning in the universe, in whatever way we understand it. This sense of place and belonging allows us to continue in our daily work, to remember that to be responsive to our clients’ suffering can make a difference, and that we are not responsible for their lives.
In the end, below the theory and technique, being a therapist challenges us to be open to letting our clients touch our souls, just as we touch theirs. Self-care is essential for stability, and to do so is to embrace mindfulness and compassion towards ourselves. These qualities allow us to develop an effective presence to the suffering of our clients. Such a delicate balance requires constant maintenance and adjustment because it is common knowledge that the beliefs and state of mind of the therapist – both conscious and unconscious – determine to a great extent the nature of the therapy and, in particular, its outcome. (Wittine, cited in Walsh & Vaughan, 1993:165)
It is this appeal to fulfill our calling in increasingly responsible ways which reminds us that ‘…the roots of modern psychology lie in spiritual traditions, precisely because the psyche itself is plugged into spiritual sources. In the deepest recesses of the psyche, one finds not instinct, but Spirit – and the study of psychology ought ideally to be the study of all that, body to mind to soul…’ (Wilber, 2000:ix). This lofty invitation that Wilber extends and calls being ‘integrally informed’ in our work, comprises a need to be mindful of integrating body, mind and spirit in self, culture and nature. It suggests that we attend to these aspects of being – not only in our clients, but in our own selves as well. Self-care, in this way, becomes a far more holistic moral imperative. It is only with the ethical intention toward continual development of psychic wholeness based on the integration of our body, shadow, persona, ego, existential self and spirit that we as therapists can assist our clients to do the same.
Brown, Kirk Warren & Ryan, Richard M. (2003) The Benefits of Being Present: Mindfulness and Its Role in Psychological Well-Being. Journal of Personality and Social Psychology. Vol. 84 (4) April 2003, pp. 822-848.
Coster, Janet S. & Schwebel, Milton. (1997) Well-Functioning in Professional Psychologists. Professional Psychology: Research and Practice. Vol. 28 (1) February 1997, pp. 5-13.
Coster, Janet S. & Schwebel, Milton. (1998) Well-Functioning in Professional Psychologists: As Program Heads See It. Professional Psychology: Research and Practice. Vol. 29 (3) June 1998. pp. 284-292.
Dlugos, Raymond. F. & Friedlander, Myrna L. (2001) Passionately Committed Psychotherapists: A Qualitative Study of Their Experiences. Professional Psychology: Research and Practice. Vol. 32 (3) pp. 298-304.
Farber, B.A. (1983) Stress and Burnout in the Human Service Professions. Pergamon Press, New York.
Figley, C.R. (1995) Compassion Fatigue- Coping with Secondary Stress Disorder in Those Who Treat the Traumatised. Brunner/Mazel, Bristol.
Geldard, D. (1993) Basic Personal Counselling. A Training Manual for Counsellors. Prentice Hall of Australia
Gilroy, Paula, J., Carroll, Lynne and Murra, Jennifer. (2002) A Preliminary Survey of Counseling Psychologists’ Personal Experiences With Depression and Treatment. Professional Psychology: Research and Practice. Vol. 33 (4) August 2002, pp. 402-407.
Guy, James, D. Holding the Holding Environment Together: Self-Psychology and Psychotherapist Care. Professional Psychology: Research and Practice. Vol. 31 (3) June 2000, pp. 351-352.
Jennings, Len., Skovholt, Thomas, M. The Cognitive, Emotional, and Relational Characteristics of Master Therapists. Journal of Counseling Psychology. Vol. 46 (1) January 1999, pp. 3-11.
Kramen-Kahn, B. & Downing, Hansen, N. (1998) Rafting the Rapids: Occupational Hazards, Rewards, and Coping Strategies of Psychotherapists. Professional Psychology: Research and Practice. Vol. 29 (2) April 1998, pp. 130-134.
Mahoney, Michael, J. (1997) Psychotherapists’ Personal Problems and Self-Care Patterns. Professional Psychology: Research and Practice. Vol. 28 (1) February 1997, pp. 14-16.
McLeod, John. (2003) 3rd ed. An Introduction to Counselling. Open University Press, Buckingham, Philadelphia.
Norcross, John. C. (2000) Psychotherapist Self-Care: Practitioner-Tested, Research- Informed Strategies. Professional Psychology: Research and Practice. Vol. 31 (6) December 2000, pp. 710-713.
O’Connor, Michael, F. (2001) On the Etiology and Effective Management of Professional Distress and Impairment Among Psychologists. Professional Psychology: Research and Practice. Vol. 32 (4) August 2001, pp. 345-350.
Skovholt, Thomas M., Grier, Tabitha, L., Hanson, Matthew R. (2001) Career counseling for longevity: Self-care and burnout prevention strategies for counselor resilience. Journal of Career Development, Vol 27 (3), Spr 2001. Special Issue: Career centers. pp. 167-176.
Skovholt, Thomas, M., Ronnestad, Michael Helge, Jennings, Len. Searching for expertise in counseling, psychotherapy, and professional psychology. Educational Psychology Review, Vol 9(4), Dec 1997. pp. 361-369.
Skovholt, Thomas M., Rønnestad Michael H. Learning Arenas for Professional Development: Retrospective Accounts of Senior Psychotherapists. Professional Psychology: Research and Practice. Vol. 32 (2) April 2001, pp. 181-187.
Treadway, D. (1998) Riding out the Storm: A Therapist’s Guide to Surviving Burnout. Networker, January/February 1998. pp. 55-61.
Vaughan, F. (1989). Awakening Intuition. Anchor Books, New York.
Vaughan, F. (1995a). The Inward Arc: Healing in Psychotherapy & Spirituality. Blue Dolphin, CA.
Vaughan, F. (1995b) Shadows of the Sacred – Seeing Through Spiritual Illusions. Quest Books, USA.
Walsh, R & Vaughan, F. (ed) (1993) Paths Beyond Ego: The Transpersonal Vision. Penguin Putnam Inc, N.Y.
Walsh, R. (1999) Essential Spirituality. John Wiley & Sons, USA.
Wilber, K; Engler, J; Brown, D. (1986) Transformations of Consciousness: Conventional & Contemplative Perspectives on Development. Shambhala, Boston & London. Wilber, K. (1989) The Spectrum of Consciousness. Quest, Illinois, USA.
Wilber, K. (2000) Integral Psychology: Consciousness, Spirit, Psychology, Therapy. Shambhala, Boston & London. Zetter, K. (2003) Keep taking the meditation. Good Weekend. The Sydney Morning Herald Magazine, August 30. 2003.