‘You must be OK, you’re a therapist.’ Over the years, I’ve heard this numerous times from friends, family and even clients, reinforcing the belief that once you become a therapist, your life is magically trouble free.
I confess that I have, at times, perpetuated this myth. ‘How are you?’ ‘Yes, fine thanks.’ Or perhaps I could tell them about the time when I couldn’t get the image out of my mind of my client being subjected to horrific sexual abuse? Or how l scrutinise interpersonal relationships around me for signs of domestic abuse? Or how I avoid watching certain programmes in case they remind me of client issues that I want to keep as separate as possible from my personal life? Or how I’ve seen in colleagues and myself the early signs of burnout or compassion fatigue? ‘I’m fine, thanks.’
Personal wounds
It’s very likely that therapists are wounded healers. We often come into this work because we’re familiar with the need for emotional support for our own issues and traumas. Therefore, we may have an unconscious drive to process our own experiences vicariously through our clients.1 We may find ourselves drawn to a particular specialism because it resonates with our own wounds. We can explain that this gives us an insight into the client’s experience. But, this can also be a maladaptive coping mechanism, as well as a form of a cathartic, healing experience for us.2
But when is close, too close? I recall a colleague who had a historical severe eating disorder, which, while she was technically ‘well’, always remained close to the surface. She specialised in working with eating disorders and there was one particular client who resonated with her own issues deeply. When we‘d meet for a coffee, I’d notice she was losing weight and had begun to look unwell. I became increasingly concerned for her wellbeing. We had a difficult but essential conversation and she vehemently denied there was an issue. Unfortunately, she eventually became so unwell she had to take extended leave to recuperate and become well again enough to work.
We’re not infallible, and when we work with issues akin to our own wounds, we need to be particularly vigilant as to the potential risk to our own vulnerabilities. We all have our own emotional needs in our personal life, such as mental and physical health issues, relationship problems, or financial difficulties. We are human too, remember.2
However, we can struggle with the belief that self-care is selfish.3 Yet, attending to our own emotional needs contributes to modelling of self-care to our clients, colleagues and those closest to us. It also means that we recognise that we are the main tool in our work. The venue of where we work can change, but the consistent factor within our work is ourselves. If we were professional violinists, we would take great pains to make sure that we looked after our violins. We would avoid temperature extremes and regularly replace and repair any early signs of wear and tear to avoid long lasting damage. As therapists, we are the violins; but I’m sceptical as to how well we look after our instruments.
In addition, while we may acknowledge that we too have our fair share of life’s ups and downs, we’re often reluctant to share our internal worlds and external pressures with other therapists.2 Why is this? Shame and fear of judgment, perhaps? Are we buying into the myth that we’re ‘OK’? No matter how much we would like to convey an image of competency – that we’re a safe pair of hands and have a level of resilience and robustness to do the work – life throws its curveballs. So, part of being a self-care-aware practitioner is recognising when we need to attend to our own needs. I fear that we often fai to practise what we preach, and thereby fail to uphold the duty we have to the profession.2
Working in private practice holds particular issues when it comes to attending to our self-care. I’m not aware of any practitioner in private practice who opts for a duvet day when they feel run down. The financial pressure of working privately can mean that we often continue to work when we’re unwell, rather than taking the days off we need to become well again – sometimes to levels of illness that we would actively discourage in others. Please be under no illusion that our clients aren’t aware when we’re unwell. The scrutiny we afford to our clients – the non-verbal signals we read as to their wellbeing – is a two-way process. I would suggest that I’m not alone in feeling dismayed if I have to cancel a session due to illness, with this being the absolute last resort, and then returning to work as soon as possible – perhaps too soon. This could be due to an obligation to clients but also to the financial pressures of being in private practice: if you don’t work, you don’t earn. But it could also be at the higher cost of our wellbeing, which comes in other guises.
Professional wounds
One of the most deeply felt costs of engaging empathically happened to me some time ago as a relatively new therapist. My client had disclosed domestic abuse at the hands of his father, abuse that was directed towards him, his siblings and mother. His father kept a roll of old carpet in the shed and my client described repeatedly being wrapped up in this so his father could kick, punch and hit him with a length a wood so that it would minimise the bruising. He would be left for hours rolled up, upset and scared, and no other family member dared to unroll him for fear of reproach.
His description of the detail of the abuse, the specifics of the carpet design, the smell, the power of the physical abuse, the muffled sounds of his father’s anger and swearing have stayed with me to this day, and when I recall them it can sometimes feel as if I’m describing it having happened to myself rather than to my client. It is forever vividly etched into my memory. It’s as if once the tap of trauma is turned on, it can only be turned down, never off.5
The literature on the negative impact of engaging empathically with our clients is vast and I will not attempt to cover it here. This has been described in terms such as vicarious trauma, secondary traumatic stress, compassion fatigue and burnout.4–6 The terms are often used interchangeably to cover the negative impact of engaging with clients, although not all relate to working with trauma. The terms vicarious trauma, secondary traumatic stress, compassion fatigue and countertrauma encapsulate the result of being exposed to traumatic material. The impacts of these are changes to the therapist’s thoughts, frame of reference, and understanding of the world. In such instances, therapists can be plagued with intrusive images, can be hypervigilant, feel unsafe and have an exaggerated startle response, for example. There is a risk that the therapist begins to see the world through the distorted lens of trauma, detecting harm where there may be none.
Burnout often sits alongside these terms and is used to describe the impact of working with trauma as the result of feeling overwhelmed and exhausted, losing role satisfaction and having increasingly negative perspectives towards clients.4–6 Furthermore, working in private practice may again be an exacerbating factor regarding wellbeing in regards to vicarious trauma; as not only can it be an isolating role, whereby we have limited daily contact with other professionals to help mitigate the impact of the work, but it’s also unlikely that we’re able to process our day with a loved one at home.
Many of our clients will have experienced trauma.5 In my practice, I have noticed an increasing number of client enquiries regarding working with trauma, and also clients disclosing earlier traumatic events, although their presenting problems are not explicitly trauma related. Because of this, it can be a challenge to actively limit the number of trauma clients we work with. However, it can also mean that we avoid asking clients about previous traumatic events, or unintentionally communicate unease about an issue that signals to the client that they’re not ‘allowed’ to discuss it.5
Protective factors
We have an ethical duty to look after ourselves. BACP’s Ethical Framework7 states that we will undertake self-care in order to be a resilient practitioner and work ethically with our clients. While I’m not aware of any research on the subject, I wonder how many of the ethical complaints received by BACP could be traced back to therapists’ wellbeing? My assumption here being that a ‘well’ therapist is more likely to make sound therapeutic decisions and therefore be practising safely and ethically.
So what can we do to manage the impact of our work? There are a number of factors that can help:
- There has to be an honest recognition that working empathically with clients can have a significant impact on us, and this needs to be addressed in therapy trainings.
- We can arm ourselves with activities that replenish. I suggest devising an easily accessible list of 10-minute, 30-minute and one-hour activities that can be chosen from and undertaken daily to help balance our perspective. A colleague of mine uses her artwork to rebalance. I read, use aromatherapy, go to martial arts classes and sing in a choir.
- Clinical supervision will help, so long as you have a trauma-aware supervisor and are able to disclose and describe your internal process and external pressures to them without fear of your competency or fitness to practise being questioned. Peer support can also be invaluable, particularly for those in private practice. Personal therapy, of course, can be a vital area of support.
- As with the aforementioned violin, we need to regularly conduct a wellbeing maintenance check. There are a number of assessment measures that can be used to determine levels of the negative impact of our work.8 I’ve found that the ProQol questionnaire9 can be a helpful tool in identifying whether changes need to be made in order to address practitioner wellbeing. This self-report measure can be used to evaluate and track wellbeing. It could form part of self-care-focused supervision sessions.
Final thoughts
We can’t ignore the personal and professional need to be well in order to work with our clients. Practitioner self-care may not be a new issue but I wonder if, over the years, we’re more astute in recognising the symptoms of the detrimental impact of the work? Or could it be that as the therapeutic relationship has evolved into being explicitly relational, this has made us more emotionally vulnerable as professionals? Perhaps we’re now recognising these issues emerging in the work as the rise in clients seeking help with trauma increases?
Whatever the reasons, I would urge all practitioners to honestly assess and attend to their own wellbeing, to look to peers and colleagues and start a dialogue about self-care. And I would recommend that supervisors should uphold self-care as one of the cornerstones of supervision sessions. Furthermore, I suggest to those responsible for teaching new therapists, that this issue become an integral part of the training programme, as, unless we take care of our instrument, it may become unplayable.
Michelle Seabrook is a practitioner-researcher in the first year of a doctorate. She is interested in trauma and practitioner wellbeing and works in private practice offering psychotherapy to young people and adults, and counselling to children within primary schools. She is also a clinical supervisor.
References
1. Sussman MB. A curious calling: unconscious motivations for practicing psychotherapy. Lanham MA, US: Aronson; 2007.
2. Adams M. The myth of the untroubled therapist. London: Routledge; 2014.
3. Thériault A, Gazzola N, Isenor J, Pascal L. Imparting self-care practices to therapists: what the experts recommend. Canadian Journal of Counselling and Psychotherapy/Revue Canadienne de Counseling et de Psychothérapie 2015; 49(4): 379–400.
4. McCann L, Pearlman L. Vicarious traumatization: a framework for understanding the psychological effects of working with victims. Journal of Traumatic Stress 1990; 3: 131–149.
5. Gartner RB. Trauma and countertrauma, resilience and counterresilience: insights from psychoanalysts and trauma experts. London: Routledge; 2016.
6. Iliffe G, Steed LG. Exploring the counselor’s experience of working with perpetrators and survivors of domestic violence. Journal of interpersonal violence 2000;1 5(4): 393–412.
7. BACP. Ethical Framework for the Counselling Professions. Lutterworth: BACP; 2016.
8. Bride BE, Radey M, Figley CR. Measuring compassion fatigue. Clinical Social Work Journal 2007; 35(3): 155–63.
9. Stamm BH. The concise ProQOL manual. Pocatello, ID: proqol.org; 2010