The practice of psychotherapy can be highly rewarding and gratifying. Psychotherapists regularly make a significant positive impact in the lives of those with whom they work. Yet, this endeavor can also be emotionally demanding and challenging; if we do not attend to our own functioning and wellness, we can be at risk of developing problems with our professional competence (Elman & Forrest, 2007).
Despite its many rewards, the practice of psychotherapy may cause us to experience feelings of distress. Distress is described as the subjective emotional reaction we each experience in response to the many stressors, challenges, and demands in our lives (Barnett, Johnston, & Hillard, 2006).
Distress is a normal part of life and we each experience it, whether in response to working with difficult clients, coping with insurance paperwork requirements, caring for an ill loved one, experiencing financial concerns, and myriad other acute and chronic challenges and stressors in our lives. While distress is a normal part of life, distress left unchecked over time can lead to burnout, what Baker (2003) describes as “the terminal phase of therapist distress” (p. 21).
Burnout, a term first coined by Freudenberger (1975), has three components:
- Emotional exhaustion,
- Depersonalization (loss of ones empathy, caring, and compassion), and
- A decreased sense of accomplishment.
Each of these components fall along a continuum and one may experience varying amounts of each at different times during one’s career. While there is not a specific agreed upon point where one is classified as “burned out,” it is vital that we each are self-aware and monitor ourselves for these signs of burnout. While of course, prevention is always best, when signs of burnout begin to develop it is hoped that we each will take a step back, reassess our current situation, and make the needed changes in our lives to help us get back on track.
Another important component of this distress – burnout continuum is vicarious traumatization (also at times referred to secondary traumatic stress or compassion fatigue). When treating clients who were victims of trauma, psychotherapists may themselves be traumatized by the emotionally intense experience of engaging in this type of psychotherapy. This may result in the psychotherapist developing many of the same intrusive and debilitating symptoms for which the client was being treating (Figley, 1995; Pearlman & Saakvitne, 1995).
Symptoms of vicarious traumatization include:
- intrusive thoughts and images related to the client’s disclosures
- avoidant responses
- physiologic arousal
- somatic complaints
- distressing emotions
- addictive or compulsive behaviors that may adversely impact one’s competence
The Ubiquitous Nature of Distress and its Impact
Yet, distress is not only a concern for psychotherapists who treat victims of trauma. As has been highlighted, distress is a universal phenomenon.
Key points about distress
- Distress left unchecked may result in an impaired ability to effectively utilize and implement our knowledge, skills, and abilities.
- Its development may be a gradual process and fall on a continuum.
- The line between distress and impairment may only be seen in the rearview mirror.
- We are all vulnerable to some form of distress-related problems with professional competence at some point(s) in our lives and careers.
- Distress and problems with professional competence are not discrete entities. They fall along a continuum.
More importantly, how we respond to the experience of distress is key, along with preventive steps we take and strategies used to minimize its deleterious effects.
Guy, Poelstra, & Stark (1989) found that 75% of psychologists surveyed acknowledged experiencing distress in the previous three years, 36.7% acknowledged that it adversely impacted the quality of care provided to clients, and 4.6% acknowledged that care provided was inadequate as a result of distress experienced.
Pope and Tabachnick (1994) found that 29% of those they surveyed acknowledged having felt suicidal in the past and that almost 4% reported having attempted suicide. Similarly, Deutsch (1995) found that 2% of mental health clinician respondents in her survey reported having attempted suicide in the past. Similarly, Pope, Tabachnick, and Keith-Spiegel (1987) found 59.6% of mental health clinicians surveyed to acknowledge working when too distressed to be effective. Yet, 85% of these clinicians acknowledged that doing so was unethical.
The Role of Balance and Self-Care in Avoiding Therapist Burnout
There are many aspects of the work of being a psychotherapist that may contribute to the distress – burnout continuum.
Work related factors
- Setting, client type, lack of progress, chronic conditions and relapses, on-call schedules, emergencies and crises, suicide attempts, violent and aggressive clients, professional isolation; fear of malpractice claims, ethics complaints, and licensure boards complaints; difficulties collecting fees, etc.
- Focusing on others’ needs; often neglecting our own.
- Being on call; long work hours; the unknown; inability to make plans.
- Administrative responsibilities, paperwork, insurance and managed care, lower reimbursement, utilization review, staff cutbacks, and lack of resources.
- Lack of immediate feedback; receiving negative feedback; not feeling appreciated.
- Time demands and pressures – not enough time to get everything done.
Additionally, it is important to note that there is no real line of demarcation between our professional and personal lives; each impact and influence the other (Pipes, Holstein, & Aguirre; 2005). Failure to adequately attend to and address these factors may result in decreased clinical effectiveness and emotional wellness.
- Personal Factors: Family, health, financial, relationship, mental health, substance abuse, and related issues.
- Examples include: caring for an ill family member, getting married, going through a separation or divorce, having a child, experiencing depression, etc.
There are challenges we each will face during different times and phases in our lives and careers. Each life and career stage and transition brings with them their own unique challenges and stressors. Considering where you are in your life and career at present and developing a plan to proactively address the most commonly occurring challenges will assist you to engage more in prevention activities.
Challenges throughout your career
- Graduate students: The impossible situation. Practice good self-care, but do a great job on every assignment, turn them in on time, do research, see clients, make money, have a life…
- Early career: Starting a practice or career and starting a family. Expectations and time pressures.
- Mid career: Raising a family, finances, running a practice, seeking tenure, (divorce, remarriage, blended families?), etc.
- Later career: Raising a family, caring for aging parents, retirement planning, declining health, etc.
Thus, it is vital that each psychotherapist participate in the ongoing practice of self-care. Self-care includes those activities we may engage in to promote our emotional, physical, relational, and spiritual/religious wellness. In fact, one may consider the ongoing practice of self-care to be an ethical imperative.
What the APA Ethics Code has to say about self-care and the promotion of wellness (APA, 2010):
- Principle A: Beneficence and Nonmaleficence: “Psychologists strive to be aware of the possible effect of their own physical and mental health on their ability to help those with whom they work” (p. 3).
- Other principles and virtues: Fidelity, Justice, Autonomy.
- 2.03 Maintaining Competence: Psychologists undertake ongoing efforts to develop and maintain their competence (p. 5).
- 2.06 Personal Problems and Conflicts:
- (a)Psychologists refrain from initiating an activity when they know or should know that there is a substantial likelihood that their personal problems will prevent them from performing their work-related activities in a competent manner.
- (b) When psychologists become aware of personal problems that may interfere with their performing work-related duties adequately, they take appropriate measures, such as obtaining professional consultation or assistance, and determine whether they should limit, suspend, or terminate their work-related activities. (p. 5)
- Standard 3.04, Avoiding Harm, states: Psychologists take reasonable steps to avoid harming their clients/patients, students, supervisees, research participants, organizational clients, and others with whom they work, and to minimize harm where it is foreseeable and unavoidable. (p. 6)
- Standard 2.03, Maintaining Competence, states: “Psychologists undertake ongoing efforts to develop and maintain their competence” (p. 6)
Self-Care Activities and Strategies
Self-care can involve so many different activities. It may include getting adequate sleep each night, maintaining a healthy diet, engaging in regular exercise, spending time with family and friends, participating in various forms of relaxation to include meditation or yoga, attending to your spiritual and/or religious side, playing with your pet, engaging in artistic expression, doing pleasure reading, and so much more. It also involves setting limits, saying ‘no’, maintaining healthy boundaries, and knowing your limits. Self-care also involves maintaining a healthy balance between various professional activities as well as between the professional and personal parts of our life.
Kramen-Kahn (2002) suggests the following 15 questions to determine ones current level of personal self-care.
- appear competent and professional?
- appear warm, caring, and accepting?
- regularly seek case consultation with another professional while protecting confidentiality.
- at the end of a stressful day, frequently utilize self-talk to put aside thoughts of clients?
- maintain a balance between work, family and play?
- nurture a strong support network of family and friends?
- use healthy leisure activities as a way of helping yourself relax from work? If work is your whole world, watch out! You do not have a balanced life.
- often feel renewed and energized by working with clients?
- develop new interests in your professional work?
- perceive clients’ problems as interesting and look forward to working with clients?
- maintain objectivity regarding clients’ problems?
- maintain good boundaries with clients, allowing them to take full responsibility for their actions while providing support for change?
- use personal psychotherapy as a means of maintaining and/or improving your functioning as a psychotherapist?
- maintain a sense of humor? You can laugh with your clients.
- act in accordance with legal and ethical standards? (p.12)
Blind Spots, Warning Signs, and Self-Assessment for Therapist Burnout
The practice of self-care is an ongoing endeavor. We are never done with self-care; it must be engaged in throughout our careers. As our life circumstances change over time, so too should our self-care practices. Additionally, we should each engage in ongoing self-reflection and self-assessment to ensure that our self-care needs are adequately being met. Along these lines, we should each become aware of and pay attention to our personal warning signs that tell us that we may not adequately be meeting our ongoing self-care needs. Examples may include being in session with clients and experiencing boredom, feeling anger or resentment toward clients, daydreaming while in session, wishing you were somewhere else, watching the clock and counting down the minutes until the session ends, ending sessions early, missing or canceling appointments, feeling fatigued, loss of enjoyment, low motivation, impaired sleep, and self-medicating.
Assess your warning signs:
- I have disturbed sleep, eating, or concentration.
- I isolate myself from family, friends, and colleagues.
- I fail to take regularly scheduled breaks.
- I enjoy my work less than in the past.
- I find myself bored, disinterested, or easily irritated by clients.
- I have experienced recent life stressors such as illness, personal loss, relationship difficulties, financial problems, or legal trouble.
- I feel emotionally exhausted or drained after meeting with certain clients.
- I find myself thinking of being elsewhere when working with clients.
- I am self-medicating, overlooking personal needs, and overlooking my health.
- I find my work less rewarding and gratifying than in the past.
- I am feeling depressed, anxious, or agitated frequently.
- I am enjoying life less than in the past.
- I find myself experiencing repeated headaches and other physical complaints.
- I sit staring into space for hours and can’t concentrate on my work.
Each psychotherapist should make a concerted effort to integrate ongoing self-care activities into our daily lives. That doesn’t mean that we engage in every possible self-care activity every day, but that we are mindful of our self-care needs and actively work to address them on an ongoing basis.
Checklist for positive coping behaviors
- I take regularly scheduled breaks.
- I take vacations periodically and don’t bring work with me.
- I have friends, hobbies, and interests unrelated to work.
- I exercise regularly, have a healthy diet, and maintain and appropriate weight.
- I limit my work hours and caseload.
- I participate in peer support, clinical supervision, personal psychotherapy, and/or journaling as preventive strategies.
- I attend to my religious and spiritual side.
- I regularly participate in relaxing activities (e.g., meditation, yoga, reading, music).
- I regularly participate in activities that I enjoy and look forward to.
This also means that we consciously work to avoid engaging in negative or maladaptive behaviors that are likely to contribute to increased distress and not likely to promote effective self-care.
Checklist for negative or maladaptive coping practices
- I self-medicate with alcohol, drugs (including over the counter and prescription), and food.
- I seek emotional support and nurturance from clients.
- I keep taking on more and try to just work my way through things.
- I try to squeeze more into the day, get more done, and measure success by how many tasks I complete and by how much I can accomplish in a day.
- I isolate, avoid colleagues, and minimize the significance of stresses in my life.
- I know that distress and impairment are for others and don’t take seriously the warning signs I experience.
- I believe that everything will turn out fine just because I say so! (Barnett, 2008)
Common Self-Care Strategies
There exists a wide range of self-care activities we each may engage in. In a study of 400 practicing psychologists, Case (2001) found the most commonly used self-care strategies to include the use of meditation and prayer, socializing with friends, maintaining a diversity of professional roles, maintaining relationships with one’s family of origin as well as with friends, and engaging in relaxation activities to promote one’s well-functioning.
More recently, Cooper (unpublished dissertation) found psychologists using the following strategies to engage in self-care: Use of humor (91.4%), relaxing activities such as meditation, yoga, and reading (85.6%), taking vacations (82.9%), exercise (75.2%), scheduling breaks throughout the day (67.6%), engaging in positive self-talk (66.7%), and use of listservs and professional affiliations (61.3%).
To Integrate Self-Care into your Daily Life, Barnett and Sarnel (2003) recommend:
- Make adequate time for yourself. Schedule breaks throughout the day.
- Do things you enjoy. Engage in hobbies.
- Take care of yourself physically and spiritually.
- Take care of the relationships in your life.
- Say NO!
- Don’t isolate yourself.
- Keep in mind that self-care is a good thing.
- Watch out for warning signs, such as violating boundaries, self-medicating, wishing patients would not show up, finding it difficult to focus on the task at hand, boredom, fatigue, and/or missing appointments.
- Watch out for distress, burnout, and competence problems in your colleagues.
- Conduct periodic distress and competence self-assessments and seek help when it is needed.
- Focus on prevention.
- Make time for self-care!
- Seek out personal psychotherapy.
- Use colleague assistance programs.
- Participate in peer support groups.
- Accept that you’re human, in need of assistance, and a work in progress.
- Don’t try to be perfect, to have it all, or to do it all. Know your limits and be realistic.
It is hoped that all psychotherapists will heed the call to practice ongoing self-care. Its importance cannot be overstated. But, what about for graduate students and other trainees? Regardless of where you are in your training and professional development, now is the time to begin the ongoing practice of self-care. You are currently developing your professional identity; the practices you engage in now can last throughout your career (both positive and negative practices). Also, failure to engage in adequate self-care now can have a deleterious impact on the services you provide to your clients right now. So, it is never too soon to begin these important self-care habits. I can assure you, you’ll be glad you did!
Dr. Jeffrey Barnett is affiliated with the Department of Psychology at Loyola University Maryland. He is also Chair of the Publications Board for the Society for the Advancement of Psychotherapy. Read about more of Dr. Barnett’s research and clinical interests on his website.