Distress, Therapist Burnout, Self-Care, and the Promotion of Wellness for Psychotherapists and Trainees
Issues, Implications, and Recommendations
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!
Cite This Article
Barnett, J. (2014, December). Distress, burnout, self-care, and the promotion of wellness for psychotherapists and trainees: Issues, implications, and recommendations. [Web article]. Retrieved from: http://www.societyforpsychotherapy.org/distress-therapist-burnout-self-care-promotion-wellness-psychotherapists-trainees-issues-implications-recommendations
American Psychological Association. (2010). Ethical principles of psychologist and code of conduct. Retrieved from http://www.apa.org/ethics
Baker, E. K. (2003). Caring for Ourselves: A Therapist’s Guide to Personal and Professional Well-Being. Washington, DC: American Psychological Association.
Barnett, J. E. (2008). Impaired professionals: Distress, professional impairment, self-care, and psychological wellness. In M. Herson & A. M. Gross (Eds.), Handbook of clinical psychology (Volume One) (pp. 857-884). New York: John Wiley & sons.
Barnett, J. E., Johnston, L. C., & Hillard, D. (2006). Psychotherapist wellness as an ethical imperative. In L. VandeCreek & J. B. Allen (Eds.), Innovations in Clinical Practice: Focus on Health and Wellness, (257-271). Sarasota, FL: Professional Resources Press.
Barnett, J. E., & Sarnel, D. (2003). No time for self-care? Retrieved October 26, 2014 from http://www.division42.org/StEC/articles/transition/no_time.html.
Case, P. W. (2001). Spiritual coping and well-functioning among psychologists. Journal of Psychology & Theology, 29(1), 29-41.
Elman, N. S., & Forrest, L. (2007). From trainee impairment to professional competence problems: Seeking new terminology that facilitates effective action. Professional Psychology: Research and Practice, 38, 501–509.
Figley, C. R. (1995). Compassion fatigue: Secondary traumatic stress from treating the traumatized. New York: Bruner/Mazel.
Freudenberger, H. J. (1975). The staff burn-out syndrome in alternative institutions. Psychotherapy: Theory, Research, and Practice, 12, 73-82.
Guy, J. D., Poelstra, P. L., & Stark, M. J. (1989). Professional distress and therapeutic effectiveness: National survey of psychologists practicing psychotherapy. Professional Psychology: Research and Practice, 20(1), 48-50.
Kramen-Kahn, B. (2002). Do you “walk your talk”? The Maryland Psychologist, 44(3), 12.
Pearlman, L. A., & Saakvitne, K. W. (1995). Trauma and the therapist: Counter-transference and vicarious traumatization in psychotherapy with incest survivors. New York: Norton.
Pipes, R. B., Holstein, J. E., & Aguirre, M. G. (2005). Examining the personal-professional distinction: Ethics codes and the difficulty of drawing a boundary. American Psychologist, 60, 325-334.
Pope, K. S., & Tabachnick, B. G. (1994). Therapists as patients: A national survey of psychologists’ experiences, problems, and beliefs. Professional Psychology: Research and Practice, 25(3), 247-258.
Pope, K. S., Tabachnick, B. G., & Keith-Spiegel, P. (1987). Ethics of practice: The beliefs and behaviors of psychologists as therapists. American Psychologist, 42, 993-1006.
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Im a preaccrediaited counsellor after completing Masters in Counselling and Psychotherapy and would welcome any literature , strategies to look at to minimise any stress to myself and increase my awareness in difficult situations especially grief/loss of loved person
thanks Mary T
One of the best, most concise articles that I have read on the subject. As a clinical psychologist myself, I am looking to assist other mental health professionals improve their self-care routine. Thanks so much!
Matt, Thanks so much for your feedback. I am glad you found the article helpful. I think we are each always a work in progress, but that by focusing on self-care and making an ongoing effort to practice it, while we’ll never be perfect at it, it will always be a lot better than not making the effort. I also think that it is vital that we look out for and support each other, not trying to go it alone. Thanks again and best wishes – Jeff
Excellent article. I can relate to a few of those points (unfortunately). However, a great reminder to make changes so we can provide the best services to clients.
Thanks, Kristine. We all need to work hard to address these issues on an ongoing basis and throughout each phase of our lives and careers. The challenges will always be there; it is how we respond that is key. Also, we are each human and each of us is vulnerable to the many challenges and stressors in our professional and personal lives. It is those who can’t relate to the issues raised that I am most concerned about. We are each a work in progress and we each should remain cognizant of these issues and keep working at them throughout our careers – for our clients’ benefit, for our own benefit, and for the benefit of all those who we care about . Thanks again – Jeff
I am a residential care associate in a facility working with mentally ill clients. I am not a therapist or a caseworker. I also work the night shift. There have been times when a client is up much of the night, yelling, screaming, using foul language, to name a few of the behaviors. There are a lot of tools available to staff for how to calm the client down, but very little in the way of how to keep ourselves from reaching a breaking point while in the middle of the crisis. This is not about job stress or burnout in general, but what to do in specific situations so that I don’t cross the line and wind up doing or saying something that will get me fired. Any tips would be greatly appreciated.
Hi Marie. It sounds like a very challenging situation. I do not know what is done at present and what can be done at your work setting, but here are some ideas that I have: If possible, can there be team meetings among you and others who are in similar positions but who work different days or shifts? Hosting some sort of a peer support group can be helpful. Participants can provide mutual support and to share about challenges and stressors. together as a group you all can request needed changes and additional support or resources from the administration if any are needed. It also will be important that you take care of yourself outside of work to include good sleep, diet, exercise, and desired leisure time activity. Showing up for work rested and relaxed definitely is better than showing up tired or stressed. A related issue is how you use your time at work during free time (if that exists) to do relaxation, stress management, etc. Also, after an incident with a client it is important to process it with a colleague or supervisor to talk through what happened, see what changes/additional resources may be needed, and to receive support. On a separate but related note, when I worked on a inpatient psychiatric unit I found it helpful to keep reminding myself that these are psychiatric patients and their behaviors are their mental illness coming out and that I shouldn’t take anything they say or do personally. That didn’t change their behavior necessarily, but it was helpful to me in how I reacted and handled it. I hope this is of some help.
How many hours per week in actual sessions is “healthy”? My employer is pressing for 6-7 sessions per day and this seems unreasonable for own mental health. Thoughts?
Hi Tricia. This will vary for each person and each work setting. Other factors to take into consideration include the mix of clients you have, how many are high risk or otherwise very difficult clients, how many days each week you are working, the ability to schedule time between sessions to complete documentation and to check phone messages and e-mails, and other requirements on your time. You also should be able to have the time to schedule and take a lunch break in the middle of the day. Other demands in your life will be relevant as well. I think we should look at the big picture in our lives. Also, how much self-care you are practicing and how effective it is will make a difference as well. It is also important that you receive emotional support and are not isolated personally or professionally. I recommend participation in a peer support group on an ongoing basis and personal psychotherapy when it would be helpful. I hope this is of help. Jeff
I used to do that, 7 clients daily until I got burned
I usually have 8-10 clients scheduled . I’m exhausted .
Indeed a well written informative much needed article. Thank you for the checklists especially!
I am a person with lived experience and it is vital that the people I trust to help with my recovery journey look after themselves.
This is a very good concise document with great practical tips and checklists.
The work you do is important , but not as important as you.
I am peer counselor.
I really appreciate this article and have shared it with my collogues. I would love to get information on how the structure of mental health and external factors contribute to burn out. So often the therapist is responsible to prevent their own burning out and its hard to believe that that is not without constant environmental pushes.