This is a beginning to intermediate course. Upon completion of this course, mental health professionals will be able to:
Mental health professionals, by definition, study and modify human behavior. That is, we study and modify other humans. Psychological principles, methods, and research are rarely brought to bear on psychotherapists ourselves, with the probable exception of our unsolicited attempts to diagnose one another (Norcross, 2000).
Although understandable and explicable on many levels, this paucity of systematic study on psychotherapists’ self-care is unsettling indeed. It is certainly less threatening, individually and collectively, to look outward rather than inward. Anna Freud once made the telling observation that becoming a psychotherapist was one of the most sophisticated defense mechanisms, granting us an aura of control and superiority, and avoiding personal evaluation of ourselves. This state of affairs strikes us as backwards. We should be studying ourselves and then others.
Consider that psychotherapists are amongst the most highly trained and experienced change agents. Yet we know relatively little (at least publicly) about how we cope with our own distress, change our own behavior, or struggle with the hazards of the craft. The tendency to view psychotherapists as not having lives outside the consulting room apparently afflicts us as well as our clients.
This CE course – and psychotherapist self-care – starts with the premise of valuing the person of the psychotherapist.
Portions of this course are adapted from chapters from the book Leaving It at the Office: A Guide to Psychotherapist Self-Care, Copyright © 2007 by John C. Norcross, Ph.D. and James D. Guy, Jr., Ph.D. and reprinted by arrangement with the Guilford Press.
Note: you do not need to purchase the book to complete this course. If you wish to purchase the book for supplemental reading, click on it and you will be sent to the publisher's web page.
Every ethical code of mental health professionals includes a provision or two about the need for self-care. The American Psychological Association’s Ethical Code (2002), for example, directs psychologists to maintain an awareness “of the possible effect of their own physical and mental health on their ability to help those with whom they work” (p. 1062). One section (2.06) of the code instructs psychologists, when they become aware of personal problems that may interfere with performing work-related duties adequately, to “take appropriate measures, such as obtaining professional consultation or assistance, and determine whether they should limit, suspend, or terminate their work-related duties” (p. 1064).
The American Counseling Association’s (2005) Code of Ethics, for another example, enjoins counselors to “engage in self-care activities to maintain and promote their emotional, physical, mental, and spiritual well-being to best meet their professional responsibilities” (p. 9). Further, the Code states “Counselors are alert to the signs of impairment from their own physical, metal, or emotional problems and refrain from offering or providing professional services when such impairment is likely to harm a client or others. They seek assistance for problems that reach the level of professional impairment….” (p. 9)
Without attending to our own care, we will not be adequately able to help others and prevent harm to them. Psychotherapist self-care is a critical prerequisite for patient care. In other words, self-care is not simply a personal matter but also an ethical necessity – a moral imperative (Carroll, Gilroy, & Mura, 1999). We gently urge you to challenge the morality of self-sacrifice at all costs and to consider the indispensability of self-care.
This course covers three crucial self-care methods: Recognizing the Hazards, Setting Boundaries, and Restructuring Cognitions.
For each, we summarize practitioner-recommended and research-informed methods of psychotherapist self-care. Unfortunately, the research on psychotherapist self-care has not progressed to the point where randomized controlled studies have been conducted. This course thus synthesizes clinical wisdom, research literature, and therapist experience on self-care methods from disparate theoretical traditions. We also offer illustrative examples from our own practices and lives, as we struggle to practice what we preach (and research). Each section concludes with a Self-Care Checklist.
Our ardent hope is that our course will gently, collegially remind you that our lives are works in progress and that you can practice self-care wholeheartedly, bringing yourself fresh to each moment and each patient.
with Joan Laidig
It almost looks as if analysis is the third of those “impossible” professions in which one can be sure beforehand of achieving unsatisfying results. The other two, which have been known much longer, are education and government. Thus wrote Freud (1937/1964) in Analysis Terminable and Interminable. The lack and uncertainty of therapeutic success is typically cited as the single most stressful feature of conducting therapy. Almost 75% of practitioners highlight it as a significant hazard (Farber & Heifetz, 1982).
So, let us begin by saying it aloud: practicing psychotherapy is often a demanding and grueling enterprise. Freud correctly characterized it as an “impossible” profession. Mental health professionals are regularly engulfed by their clients’ pain and disability, are routinely confronted by conscious and unconscious hostility, and are ethically bound to secrecy about the most troubling confessions and occasionally the most heinous of crimes. All of this is accomplished under unremitting pressure in frequently less than humane working conditions with interpersonally disturbed patients. Emotional depletion, physical isolation, and psychic withdrawal seem natural responses. Throw in the inescapable disruptions to our personal lives and one is tempted to accept the dramatic assertion that “If we ever really considered the possible risks in getting involved with a client, we would not do so for any price. Never mind that we will catch their colds and flus, what about their pessimism, negativity, and psychopathology?” (Kottler, 1986, p. 8)
Psychotherapist self-care begins with recognizing and preparing for the inevitable hazards of the undertaking. Understanding its various liabilities demystifies the process and enables us to cope effectively with its downside. Those who understand the etiology and impact of these liabilities are most effective in minimizing their negative consequences, and thus more successfully “leave it at the office” at the end of a long workday.
Table 3.1 offers a summary of the most prominent hazards associated with clinical work. This nonexhaustive list of stressors is culled from the vast literature on the topic, which interestingly enough is at least twice the size of the literature on the benefits of clinical work. Please minimize your exposure to this frightening list, lest you stare at it for hours and put in for early retirement! In actuality, we believe a little stress inoculation is effective, and, in any case, we will not get to all of the items in the listing. In this section, we have set for ourselves the ambitious task of summarizing the vast literature on psychotherapist stress and extracting its recurrent themes. Our integration begins by reviewing six overlapping burdens rooted in practice itself—physical isolation, emotional isolation, patient behaviors, working conditions, therapeutic relationships, and the industrialization of mental health—and then a series of interactive hazards centered on the person of the psychotherapist—motivations for becoming a therapist, the fusion of work stress and therapist personality, and intercurrent life events. We conclude with multiple methods to anticipate, master, and, when necessary, accept these hazards.
TABLE 3.1. Prominent Hazards Encountered in Conducting Psychotherapy
Few rookies are prepared for the gnawing effects of physical isolation on their inner world. The need for complete privacy with no interruptions is simply accepted as a requirement for conducting psychotherapy’s private journey. Isolation is regarded as essential in order to provide the context needed for in-depth exploration. However, no matter how necessary it may be, isolation comes at a price. The paradox of being so alone in the midst of this most intimate of interpersonal encounters is perhaps one of the least understood hazards of psychotherapy (Guy & Liaboe, 1986; Hellman, Morrison, & Abramowitz, 1986).
In contrast to the camaraderie and teamwork characteristic of clinical training, the practice of psychotherapy over the course of a career is basically a solitary task. While some therapists participate in treatment teams and co-therapy, most clinicians are forced by economics of time and money to go it alone. Treatment is typically provided by a single therapist who works throughout the day in consecutive sessions interspersed with occasional breaks. Short of considerable effort, the practitioner moves throughout her day alone, with minimal contact with associates. For those in hospital or clinic environments, group meetings and in-service workshops provide interruptions in the physical isolation. For those in private practice, even when associated with a larger group, there are few breaks in the physical isolation of the typical workday. It comes as no surprise that isolation is a leading complaint of experienced independent practitioners (Tryon, 1983).
It logically follows that physical isolation from friends and family also characterizes the practice of psychotherapy. We all know that most psychotherapists cannot be reached during a therapy session. Some have joked that even God cannot reach the dedicated clinician without an appointment! Although access can be gained in an emergency, the more serendipitous, casual contacts by friends and family during a workday are quite limited. Visitors cannot stop by for an unscheduled greeting or lunch. Friends cannot call during sessions to share a few moments of contact.
Even more unusual is the deficient access to news of daily local, national, and international events. Since our primary or even exclusive interpersonal contact is limited to therapy clients, it is possible to remain uninformed of recent events. Unless a client announces an assassination, military initiative, or natural catastrophe, it may be hours before we learn of a major event. One of our master therapists related the following illustrative story:
I had a full schedule of consecutive clients on the day that the United Nations forces attacked Iraq. I had no idea what had happened until several hours later, when a client mentioned it as she walked in for her session with a television in hand for us both to watch. Needless to say, I was surprised at her news, and I had to smile at the irony that my three previous clients had not thought it was appropriate, or a good use of their time, to inform me that U.S. military forces had attacked another country!
Such occurrences are the rule – what happens in the world outside of the office is oddly separate from the world inside the therapy session.
The isolation of the consulting room and the paucity of physical movement can lead to an unusual kind of environmental deprivation. Therapists report struggling with sleepiness or recurrent daydreams while trying to concentrate on clinical material. Even the content of the sessions themselves can develop a numbing similarity, causing a mental dullness to creep over us during the course of a long day. Therapists may begin to treat all clients in parallel ways using similar techniques and similar words. Eventually, the authenticity and creativity of the therapist become circumscribed (Freudenberger & Robbins, 1979). The result is a clinician who fulfills her role mechanically, producing a sense of boredom and isolation. Conducting a therapy session involves relatively little physical activity. Many therapists sit for eight or more hours a day in the same chair and room, rendering them physically exhausted from immobilization (Will, 1979). We rarely walk, stretch, or exercise. Such sedentary days suppress physical releases of stress after continued exposure to emotional pain. The research indicates that those who do not take time out from their busy schedules to exercise and participate in outside activities are more likely to suffer from fatigue and emotional exhaustion (e.g., Hoeksema, Guy, Brown, & Brady, 1993).
Unfortunately, therapist isolation is not limited to the physical realm. The isolation pervades our psyches. Despite the intense relational contact of psychotherapy, many practitioners feel alone emotionally. One study (Thoreson, Miller, & Krauskopf, 1989) revealed that 8% of the psychologists reported significant distress during the preceding year due to recurrent feelings of loneliness. The exclusive focus on our patients’ psychological world leaves little room for the expression of the clinician’s feelings and needs, particularly as they relate to her life. The role of the psychotherapist requires a self-imposed limitation on self-disclosure. The criterion becomes “what is in the best interests of the client.” Even in the most active treatments, clinicians exercise considerable restraint in keeping feelings hidden. We, as clinicians, set aside the personal concerns of the day, such as disputes with loved ones, financial problems, or even an upset stomach, in order to focus on the client—even when our own worries seem more serious than those of the patient. The therapeutic process further requires a great deal of emotional discipline on the part of the practitioner. We need to mute or restrain feelings in the name of competent treatment. And psychotherapists do experience strong emotions in their work; in one study, approximately 80% of therapists experienced fear, anger, and sexual feelings in the context of their work (Pope & Tabachnick, 1993). The constant emotional regulation isolates the therapist from others and possibly from her own feelings.
Patients’ reactions to the clinician compound the psychic isolation (Freudenberger, 1990a). For example, overly idealizing the therapist hinders attempts at a genuine encounter. Therapists can become burdened with unrealistic expectations that leave them little room to be themselves (Goldberg, 1986). Even worse, some therapists actually accept client idealization as warranted, leading to a sense of omnipotence that isolates them from their true feelings. In other cases, devaluing and attacking the therapist can result in her feeling discouraged, humiliated, or rejected. In fact, competent treatment may require that therapists absorb these projections rather than defend against them.
The ethical and legal requirements of confidentiality result in a tendency for psychotherapists to split off the emotional impact of their work from the rest of their lives (Spiegel, 1990). While many practitioners seek emotional support from family and friends to alleviate feelings of alienation, the confidentiality requirement impedes using such support except in certain circumstances (Tamura, Guy, Brady, & Grace, 1994). Therapists must monitor closely any self-disclosure of their workday to avoid inadvertent domestic violations of confidentiality, making the venting of frustration or the sharing of a therapeutic success a complicated matter (Spiegel, 1990).
Such secrecy conflicts with the need for open communication among family members (Kaslow & Schulman, 1987). The family may perceive confidentiality as a rule that shuts them out from the therapist’s world, engendering jealousy and resentment from those who might otherwise help ease the isolation. Is there a psychotherapist alive who has not experienced the disheartening duplicity of one moment being the attentive, empathic psychotherapist and the next moment the tired, preoccupied family member (Brady, Healy, Norcross, & Guy, 1995)?
All these factors converge and contribute to the “one-way” intimacy of conducting psychotherapy (Guy, 1987). The client is asked to share himself in great detail, while the clinician responds with little disclosure. Thus, the therapist experiences a sense of intimacy with many people, but with little personal risk or expressed vulnerability; true mutuality is lacking. Often the seasoned veteran has no one with whom to share deeply meaningful moments in the private journey of a psychotherapy client. The more intense the psychotherapy-related experience, the more difficult and unnatural it becomes to withhold it from a loved one. Therapists wind up habitually suppressing intense feelings, leaving them unprocessed and unresolved.
Since the treatment contract requires that the relationship eventually end, psychotherapists find that they are in the business of saying repeated good-byes to individuals they have come to value. The cumulative effects of these terminations on the emotional life of psychotherapists are just beginning to be understood (e.g., Guy & Brown, 1993; Guy, French, Poelstra, & Brown, 1993). Some find it difficult to let go of these meaningful relationships, particularly when they have been the source of considerable satisfaction and meaning (Brady, Guy, Poelstra, & Brown, 1996). The hurt is often a private loss unvoiced and unshared with friends. Over time, these repeated losses can beget reluctance to attach, and a disinclination to care deeply. We hate to lose contact with some patients; we miss them, we think about them periodically, and we wonder whether they will initiate contact with us again.
Planned terminations are necessary losses and a legitimate source of mourning endemic to the profession. Even relationships with colleagues can have an isolating component in them. Therapists have a strong desire to appear emotionally stable and clinically expert to peers (Guy, Poelstra, & Stark, 1989). The increased competition for patients and referrals associated with managed care adds fuel to the perceived need to always be at the top of your game. “Top Gun” rivalries—therapists competing with one another in a hostile manner—can become common (Persi, 1992). It is difficult for clinicians to share concerns openly if they perceive that doing so might put their livelihood and professional standing at risk. Rivalry and resultant isolation often follow from ideological schisms. Raised and socialized in a “dogma eat dogma” environment that pits one theoretical orientation against another (Norcross & Goldfried, 2005), therapists tend to avoid colleagues of differing persuasions and professions. Divisions between, say, psychoanalysts and behaviorists, or psychopharmacologists and psychotherapists, generate the ironic feeling of being alone among colleagues.
Male psychotherapists typically experience even more difficulty cultivating relationships with peers, since most men are socialized to inhibit expression of many emotions and to interact competitively with other men, thereby avoiding emotional closeness with male colleagues (Brooks, 1990). Their disinclination toward emotional support and honest communication may perpetuate relationships among men characterized by competition and homophobia. All told, secrecy inhibits sharing among colleagues and breeds loneliness.
Finally, some psychotherapists find it difficult to set aside the interpretive observer role when leaving the office (Zur, 1993). While at home, they may find that the practiced restraint and reflective treatment posture make it difficult for them to be themselves. Such detached expertise hinders the therapist from responding in a genuine, spontaneous way, leading to artificial interactions (Freudenberger & Robbins, 1979; Guy, 1987). In short, it is difficult to leave the psychodynamics at the office and “turn off” the therapeutic role while at home. This loss of spontaneity and genuineness may make the therapist seem aloof outside of the office. Family and friends may find it difficult to get us to self-disclose. Worse still, the emotional depletion after a long, exhausting day may kill any motivation for the therapist to reach out and make emotional contact with loved ones. Instead, she may withdraw and remain isolated, even when physically surrounded by those who wish to interact. Emotional isolation is more frequently reported by inexperienced clinicians who have not yet mastered the skill of removing the “therapeutic mask.”
Our colleague Gerry Koocher (1999), who works with children and families confronting life-threatening illnesses, has written movingly of his work-related nightmares. One recurrent dream is that Gerry is in line for a roller coaster theme park:
As the line winds down slowly toward the start of the ride, I notice that I’m standing among friends, relatives, and dozens of bald-headed or bewigged children, several of whom I recognize as patients I treated before they died from cancer. Suddenly we are on the leading platform, and I notice a sign with large red letters: “WARNING! Up to 40 percent of riders fall to their deaths. Check your safety bar.” I find myself seated in the last seat of the back car. I pull the safety bar toward me and hear a reassuring “click,” as it snaps into place. As I look up, the car begins to roll down the chute, and I notice that many of the riders in front of me have not secured their belts. I feel a desperate urge to reach out and help, but am locked in my seat and cannot help. We plunge into darkness that is broken by the flash of a strobe light. With each flash, I see more empty seats in front of me. There is nothing I can do. (Koocher, 1999, p. 25)
This disturbing dream encapsulates what many psychotherapists feel when they are unable to reach a patient, or when a patient disappears, dies, or suicides. One need not be an expert on dream interpretation to see that our rational desires to help and comfort are trumped in sleep by the magical wish to cure everyone and to stave off death. The dream powerfully reminds us of the stressful contacts and despairing lives that some patients share with us. We try to insulate ourselves from such disappointments, but some losses are like sandpaper on the soul. Psychotherapists work with emotionally distressed and conflict-ridden patients. The natural consequence is that we rarely see people “at their best” (Guy, 1987). Dealing exclusively with pathological populations begins to color our perceptions of society and humanity. For instance, a clinician who works with sexual abuse victims day after day can easily form a skewed perspective of the world (Pearlman & Saakvitne, 1995). Continual immersion in a world suffused with psychopathology and dysfunction isolates the clinician and constitutes an occupational hazard (Freudenberger & Robbins, 1979).
Not only are we as susceptible to clients’ contagious emotions as anybody else, but we also possess certain vulnerabilities unique to the profession (Schwartz, 2004)—a double whammy of sorts. We are supposed to be perfect—empathic, mature, selfless, kind, hopeful, and wise—no matter how the client is. Despite intense provocations on the client’s part, we are supposed to avoid pejorative remarks, wisecracks, or bitter complaints to the person/patient precipitating our distress. An impossible profession, indeed!
Most empirical research on the stressors of psychotherapy practice has been conducted on specific client behaviors. In general (e.g., Deutsch, 1984; Farber, 1983a; Kramen-Kahn & Hansen, 1998), specific patient presentations found to be the most distressing are suicidal statements and acts, aggression toward the therapist, severely depressed patients, premature termination, profound apathy, and the loss of a patient. Let us consider these and other patient behaviors in turn.
Of all the patients who test our patience, the suicidal top the list (e.g., Chemtob, Bauer, Hamada, Pelowski, & Muraoka, 1989). Jeffrey Kottler (1986) describes the challenge of treating suicidal patients on four levels. First, therapists may feel terrified at the knowledge of being so close to someone so desperate that nothingness seems like a viable option. Second, therapists feel immense responsibility to help a suicidal patient. The moral and professional obligations are extraordinary, and any mistake may prove to be lethal. Third, once a patient is assessed as suicidal, the entire therapeutic process is altered. Extra precautions on the part of the staff must be made, and everything must be done “by the book.” The margin for error is small, and the pressure on the therapist profound (Kottler, 1986, p. 74). Fourth, it is particularly difficult to leave the problems of dealing with a suicidal patient “at the office.”
Sadly, the probabilities of mental health trainees and professionals having a patient commit suicide are fairly high. More than one-quarter of psychologists and one-half of psychiatrists will experience a patient’s suicide (Chemtob et al., 1989). More than one in four interns/trainees will encounter a patient suicide attempt, and at least one in nine will experience a completed patient suicide (Brown, 1987; Kleespies, Penk, & Forsyth, 1993). In the event of a patient suicide, the psychotherapists involved will probably experience substantial disruptions in their personal and professional lives. One-third of psychotherapists who experienced a patient’s suicide subsequently suffer from severe mental distress (Hendin et al., 2004). Several factors contribute to the severe distress: failure to hospitalize an imminently suicidal patient who then died; a treatment decision the therapist felt contributed to the suicide; negative reactions from the therapist’s institution; and/or fear of a lawsuit by the patient’s relatives (Hendin et al., 2004).
Trainees who experienced a patient suicide, as compared to trainees who had patients only express suicidal ideation, felt greater shock, disbelief, failure, sadness, self-blame, guilt, shame, and depression (Kleespies et al., 1993). Patient suicide may represent the ultimate failure for a psychotherapist, who is left to deal with sadness, anger, self-doubt, confusion, and the fear of it happening again. The American Association of Suicidology has a Clinician Survivor Task Force to help practitioners who lose a patient to suicide.
Also high atop the lists of stressful patient behaviors is aggression. An early psychiatrist (Freeman, 1968, p. 286) declared dramatically that “the major occupational hazard of psychiatrists is being shot by former patients.” No one agreed with him literally then or now, but his forceful statement underscored the wide prevalence of physical attacks, threats, and stalking directed at therapists.
Reviews of the literature reveal that nearly half of all psychotherapists are threatened, harassed, or physically attacked by a patient at some point in their careers (Guy, Brown, & Poelstra, 1992; Haller & Deluty, 1988; Pope & Tabachnick, 1993). Therapists are more likely to be attacked in hospitals and clinics than in private practices (Tyron, 1983). The most frequent negative effects of actual physical attacks are an increase in personal vulnerability, escalation of fearfulness, decrease in emotional well-being, increase in a loved one’s concern for the clinician’s personal safety, and diminution of perceived competence (Guy, Brown, & Poelstra, 1990a, 1990b, 1991). Intense anxiety, fatigue, headaches, hyperactivity, nightmares, flashbacks, and intermittent anger are also common consequences of patient violence (Guy et al., 1990a, 1990b; Wykes & Whittington, 1991). Those clinicians expressing the most worry were those who had been previously attacked, those working in hospitals, and those physically injured in prior patient assaults.
Patient aggression manifests itself even beyond overt physical attacks, of course. Unwanted phone calls to the home or office, verbal threats against one’s personal safety and that of one’s family, and threats of destruction to the office contents or home all represent violence (Guy et al., 1992). Approximately 5–15% of psychotherapists have been stalked by current or former clients (e.g., Gentile, Asamne, Harmell, & Weathers, 2002; Purcell, Powell, & Mullen, 2005; Romans, Hays, & White, 1996), largely motivated by anger or infatuation. An illustrative example:
A female psychologist in private practice was forced to obtain two restraining orders against a former patient. The woman followed the therapist’s car on numerous occasions, tried to stop her in the middle of the street, kept her home under surveillance, made telephone calls to other professionals defaming the psychologist, and made verbal and written threats.
Severely apathetic and depressed clients are bound to evoke anxiety in a psychotherapist. A continuous string of “uh,” “um,” “yes,” or “no” can generate frustration in the best of us. A patient who is totally withdrawn and nearly silent can make a single hour seem endless; time seems to stand still. Eventually, therapists may begin to suspect that they must be doing something wrong. Sometimes, they even begin talking and answering for the client, in which case the whole process breaks down. Whenever this happens, the therapist feels under tremendous pressure to “get” the client to speak and make the treatment “work” (Corey & Corey, 1989).
Extensive work with trauma survivors, which involves listening to a litany of detailed descriptions of atrocities and constantly empathizing with clients, can also take a high toll on clinicians. Many experts believe that the most effective therapists ironically are also the most vulnerable to this hazard, as those who have the greatest capacity for empathy are at greatest risk for compassion fatigue (Miller, 1998). In this condition, described variously as vicarious traumatization (Pearlman & Saakvitne, 1995), compassion fatigue, or secondary traumatic stress (Figley, 1995), therapists repeatedly exposed to graphic trauma material via their clients’ personal accounts can develop mild PTSD-like symptoms and experience changes in their frame of reference. Such distressing responses tend to be even more stressful to practitioners who (1) conduct a lot of treatment with survivors, (2) have a personal trauma history, and (3) endure higher levels of exposure to graphic details regarding sexual abuse (Brady, Guy, Poelstra, & Brokaw, 1999; Little & Hamby, 1996). Further, clients with histories of abuse or interpersonal violence are more likely to engage in self-destructive behaviors, dissociation, and acting out (Gamble, Pearlman, Lucca, & Allen, 1994). Trauma work produces a soul weariness that comes with caring.
Virtually all patients experiencing interpersonal difficulties will bring those problematic relationship patterns into the consulting room with them. Perhaps the patients who are most difficult to manage are those suffering from personality disorders. Passive–aggressive and covertly resistant behaviors, for example, are special challenges. The most notorious signs of passive–aggressiveness include late arrival, minimal disclosure, and a hollow assurance that all is well. Accentuating the distress is that these behaviors are so hard to deal with directly—they evince an “elusive” quality, not always amenable to firm evidence or confident interpretation.
A common passive–aggressive manifestation in psychotherapy is premature termination, which frequently results in relatively high levels of psychotherapist stress (Farber, 1983b). A meta-analysis of 125 studies (Wierzbiciki & Pekarki, 1993) found that the average dropout rate for patients in mental health agencies is a whopping 47%! Many of our clients terminate before meeting their therapeutic goals, leaving us all feeling confused, uncertain, and disappointed with treatment outcome.
The ultimate test of stress management may well involve patients suffering from borderline personality disorder. In one person, the therapist may encounter scores of distressing patient behaviors: recurrent suicidal threats, self-mutilating acts, intense anger alternating with chronic dysphoria, identity disturbance, vicarious exposure to trauma material, and the worst elements of histrionic and passive–aggressive disorders. The therapist may be so busy extinguishing weekly brushfires attributable to “acting-out” behavior that attending to the underlying forest fire in the patient’s identity may go undone. Patients suffering from borderline traits and other characterological disorders are also prone to litigation.
The threat of malpractice or ethical complaint is omnipresent in health care professions, and psychotherapy is no exception. Approximately 10–12% of mental health practitioners will need to respond to a licensing complaint during their careers, all the more so if you are male and a psychiatrist. But only about 2% of practitioners end up being a defendant in a malpractice suit during their careers (e.g., Dorken, 1990; Pope & Vasquez, 2005; Schoenfeld, Hatch, & Gonzalez, 2001). The prevalence is rising but it is important to remember that it is still relatively low.
We suffer from not only an actual lawsuit but also the potential risk of such a suit. The threat of malpractice can paralyze us and cause us to practice too defensively. Lawyers and risk managers repeatedly warn us to consider every patient who walks through the door as a potential adversary. It is a chilling and disconcerting quandary for all of us—being advised to behave like adversaries in the non-adversarial, collaborative enterprise of psychotherapy (Kaslow & Schulman, 1987).
Studies of psychotherapists (e.g., Guy et al., 1992; Knapp, VandeCreek, & Phillips, 1993; Wilbert & Fulero, 1988) consistently find them actively worrying about malpractice—both their committing it and patients suing them for it. Between 8 and 23% of clinicians worry about it often although, again, only 1–2% will actually be charged with malpractice in their careers. In extreme cases, practitioners may develop litigaphobia – the excessive, unreasonable fear of litigation by a patient. Approximately one-quarter of psychologists reported being in a situation—suicide, homicide, child custody evaluations, or fee disputes, for example—that caused them to fear an ethical complaint or a malpractice suit (Knapp et al., 1993).
However, receipt of a malpractice suit or a licensing board complaint is only the beginning of a protracted, hellish story. The majority of complaints to a licensing board are ultimately determined to be unfounded, but the investigation process is rough on the psychotherapist nonetheless. A yearlong investigation may eventually bring out the truth, but not before the therapist has had to fight for her reputation, defend herself to peers, and survive the mental anguish involved (Kottler, 1986). Most therapists are patently unprepared for the painful consequences and expenses of defending themselves against a complaint (Lewis, 2004). A few therapists even decide to surrender their licenses and retire rather than face the agony of the investigation.
Coming full circle, we return to Gerry Koocher’s nightmarish dream that began this section. The range of stressful patient behaviors seems infinite at times. Our core being is touched again and again—working with terminally ill patients and facing with them their fears of death, or counseling patients with chronic pain caught in a web of hopelessness. Working with physically disabled patients can activate nightmares of our own old age as well as terrors of being confined to a wheelchair. Those conducting family therapy will invariably confront physical violence and emotional abuse in families as well as residual pain from their own family of origin. Independent of the demographics and disorders of the particular client, the core of the therapist as a person is indeed touched again and again.
Ideally, a practitioner’s workplace is a holding environment or a safe haven for the psychotherapist perpetually confronted with this laundry list of conflict-ridden patient behaviors. Realistically, however, the workplace often represents an additional source of stress. Organizational politics, managed care, excessive paperwork, demanding workloads, and professional conflicts lead the list of complaints of experienced practitioners (e.g., Farber & Heifetz, 1981; Nash, Norcross, & Prochaska, 1984; Norcross, Karg, & Prochaska, 1997). The excruciating slowness of the system, persistent resistance to new ideas, and unrealistic expectations are the key stressors of students entering the helping professions (Corey & Corey, 1989). The cozy setting of psychotherapy—the comfortable armchairs, the warm relationship, intimate engagement—often obscures its hazardous working conditions (Yalom, 2002). Virtually all healing contexts are dominated by a sense of damage, despair, and disease. And that’s only with the patients! Once you add in the bureaucratic nonsense, colleague misbehavior, inadequate resources, onerous paperwork, and assorted organizational and peer problems, one begins to recognize the potential damage of “working conditions” in the helping professions.
To be sure, different contexts make for different patterns of stress. Virtually every study (e.g., Farber & Heifetz, 1982; Hellman & Morrison, 1987; Orlinsky & Rønnestad, 2005; Raquepaw & Miller, 1989; Rupert & Kent, 2007; Snibbe et al., 1989) finds that psychotherapists employed in institutional and HMO settings experience more distress and burnout symptoms than those employed in private practice. Psychotherapists in private practice, on the other hand, find patient behaviors and financial concerns comparatively more stressful.
The major stresses attending independent practice tend to be, in descending order, managed care, time pressures, economic uncertainty, caseload uncertainty, business-related duties, and excessive workload (Nash et al., 1984; Norcross et al., 1997). Recurrent themes distinctive to independent practitioners include frustrations with insurance companies and third-party reimbursers, and unrealistic demands for superhuman feats from clients, insurers, and the court system (Nash et al., 1984). The financial instability and risk associated with full- or part-time private practice is a huge source of difficulty (Guy, 1987). Moreover, in the absence of firm criteria for client success, therapists are left to define their own terms for success, which often prove to be unrealistic or overly idealistic (Raider, 1989).
Even mental health professionals in administrative positions encounter their own varieties of stress from working conditions. Residency directors experience unique pressures and difficulties—having to select residents, struggling to assure that the faculty provides adequate care, contending with bureaucratic hassles, being overloaded with tasks, and warily monitoring residents released to function independently, to name but a few (Yager & Borus, 1990). Clinical supervisors, similarly, must attend to multiple and occasionally conflicting constituencies – student learning, client welfare, program requirements, and so forth.
We extract three evidence-based conclusions from the research on therapist working conditions. One is that each work setting comes equipped with generic stressors as well as its own unique pressures. A second conclusion is that we must guard against over-generalizing group differences in work settings to individual practitioners; for example, there are many contented practitioners in agencies and many dissatisfied practitioners in private practice. A third conclusion is that we must adopt a more nuanced perspective on the person–environment interaction. It is not the general work setting or environment per se, but the particular characteristics of that setting, such as low autonomy and low support in some agencies, that pose the greatest hazards. This latter point is covered more completely in our book Leaving It at the Office: A Guide to Psychotherapist Self-Care in Chapter 9, entitled, “Creating a Flourishing Environment.”
The therapeutic relationship constitutes both the agony and the ecstasy of our work. It is, at once, the most significant source of pleasure and displeasure in psychotherapy. We alternate between sleepless nights fraught with recollections of hostility and anxiety incurred from characterlogically-impaired patients and fleeting moments of realization that we have genuinely assisted a fellow human being (Brady, Norcross, & Guy, 1995).
Among the most widely reported stressors associated with the therapeutic relationship are the responsibility for the patients’ lives, the difficulty in working with disturbed patients, and the lack of gratitude from patients (Farber & Heifetz, 1981). The very process of working intimately with human suffering presents the practitioner with psychic discomfort (Goldberg, 1986). If we are not careful, we wind up carrying around the weight and pain of every single patient, as though we were a mama kangaroo.
An empathic relationship with patients will necessarily activate the pain of countertransference. Ever since Freud identified this phenomenon, overidentification and overinvolvement with the patient, manifested through countertransference, have plagued psychotherapists. Countertransference is often invoked when the practitioner recognizes within herself the client’s experience and is caught in the dilemma of trying to empathize with the client’s feelings while, at the same time, avoid being adversely affected by them (Goldberg, 1986). Countertransference reactions include the arousal of guilt from unresolved personal struggles, inaccurate interpretations of the client’s feelings due to therapist projection, feeling blocked and frustrated with a client, and boredom or impatience during treatment.
Which of us has not been repulsed by the actions and attitudes of a child molester, rapist, thief, or murderer? Of course, not all patients stimulate these feelings; only certain clients evoke such stressful reactions. As psychotherapists, we still struggle with distortions, unconscious reactions, unresolved conflicts, misperceptions, and antagonism in relation to particular clients (Kottler, 1986). Each client rubs the therapist a different way, bringing about different reactions. Clinical interactions are typically characterized by constant emotional arousal (Raider, 1989). This arousal is simultaneously a curative agent for the client and a damaging one for the therapist. Here lies a recurring irony of clinical work – empathy with the client’s distress deepening the therapist’s pain. The proper therapeutic relationship demands a delicate balance, namely, remaining open to anguished feelings while retaining a modicum of self-preserving distance.
Lastly, fear of psychopathology as a result of intense contact with disordered individuals may cause a psychotherapist, and particularly a trainee, to experience continual fear and intermittent symptoms (Greenfeld, 1985). Constant exposure to conflict is traumatic, even when it is not your own conflict. Constant exposure reactivates our own personal conflicts, or at least poses the fear of reactivating those conflicts. Examining the psychological disorders of others fosters a great deal of morbid self-examination and symptom overidentification. Identifying with the patient’s psychopathology while simultaneously striving to maintain the necessary psychological mindedness can pose significant challenges to our own mental health (Doyle, 1987).
Had we written this section in the 1980s or early 1990s, we would have apprised you of the classic stressors confronting the mental health practitioner – demanding patients, organizational politics, emotional exhaustion, and professional isolation. However, during the past two decades, new and evolving stressors have appeared, namely, increased demands for speed, numbers, and paperwork. The typical practitioner is now threatened with being overwhelmed by the escalating number of patients per day, the 30- to 40-minute sessions, an average of three to eight sessions, the mounting paperwork for diagnoses, treatment plans, and accountability. There is no longer a threat of professional isolation; on the contrary, the real threat is frenetic overinvolvement with patients, colleagues, insurance carriers, and administrators. All this represents a sea change not only in mental health treatment but also in the stressors endured by the terribly human clinician. The angst and disillusionment practitioners feel toward managed care are almost palpable. Many speak of the “catastrophe that overshadows our profession” and, after careers dedicated to the profession of psychotherapy, find themselves “reduced to numbers in corporate computers” (Graham, 1995, p. 4). The shadow of health care industrialization is looming: many practitioners are losing money, patients, and, perhaps most urgently, autonomy.
Health care has manifested the two cardinal characteristics of any industrial revolution (Cummings, 1986, 1988). First, the producer—in our case, the psychotherapist—is losing control over the services as this control shifts to business interests. Control of psychotherapy is shifting to the payer, with associated shifts in goals and toward limits in reimbursable treatments. Second, practitioners’ incomes are decreasing, because industrialization minimizes labor costs. Not surprisingly, income surveys consistently demonstrate that, as a group, psychotherapists are indeed losing income, when adjusted for inflation. Beginning around 1995 doctoral-level psychotherapists averaged 2–5% less net income per year; adjusting for inflation, they lost even more (e.g., Psychotherapy Finances, 2004; Rothbaum, Bernstein, Haller, Phelps, & Kohout, 1998). Managed care plans now cover 80%+ of the Americans who receive their health benefits through their employer. The practice patterns of psychotherapists and the income trends are thus evident, at least for the 75– 80% of licensed mental health practitioners who accept some managed care insurance. In a study of 487 psychologists, for instance, the median percentages of managed care patients in psychologists’ caseload increased tenfold—from 5% to 50%—over a 4-year period during the mid-1990s (Norcross et al., 1997).
The strain on psychotherapists is immediately linked to managed care—or managed costs and mangled care, if you prefer—but the overarching stress lies in the industrialization of mental health care. Managed care is not a monolithic entity, but most of us know the symptoms of “managing” psychotherapy (Norcross & Knight, 2000):
The restrictions of managed care affect all mental health professionals, but especially independent practitioners. The external constraints, additional paperwork, and lower reimbursement rates are the most highly rated stressors (Rupert & Baird, 2004). In contrast to colleagues with low managed care involvement, practitioners with high managed care involvement worked longer hours, received less supervision, saw more clients, experienced more stress, reported more negative client behaviors, and scored higher on emotional exhaustion (Rupert & Baird, 2004). This is a recipe for burnout and diminished self-care. Fully 80% of 15,918 psychologists responding to a survey (Phelps, Eisman, & Kohout, 1998) reported managed care as having a negative impact (26% high negative, 37% medium negative, and 17% low negative impact). When asked to endorse the top practice concerns from a list of 18, the psychologists most frequently nominated concerns related to managed care: managed care changing clinical practice; income decreased due to managed care fee structure; excess precertification and utilization review requirements of managed care panels; and ethical conflicts raised by managed care. The rhinoceros is in the house, friends, and its name is “managed care.”
Most of the aforementioned hazards “come with the territory.” They are part of the world of the psychotherapist. We find ways to minimize their impact, but few of us can avoid them altogether. At the same time, some practitioners create additional hazards that undermine their satisfaction and well-being over the course of a career. These are rooted in the therapist’s personal history and earlier life experiences, factors that may have led to the vocational choice of psychotherapy and that interact with ongoing life events (Freudenberger, 1990b; Keinan, Almagor, & Ben-Porath, 1989).
Several of the characteristics that attract individuals to a mental health career—commitment to altruism and self-knowledge, for instance—lay the foundation for later disappointments and problems. The source of our success can also be the root of the problem.
It is widely joked that some of the strangest individuals select psychotherapy as a career. Behind this humorous stereotype lies some truth. Many entering the profession are understandably motivated by curiosity about their own personalities. They hope to find solutions to personal problems or some resolution of underlying conflicts (Elliot & Guy, 1993; Goldberg, 1986). If the personal distress motivating this career choice is serious enough, the pressures inherent in conducting psychotherapy will exacerbate emotional problems (Overholser & Fine, 1990). Pursuing a career as a psychotherapist primarily out of a desire to relieve emotional distress is a venture likely to lead to disillusionment.
A related characteristic is a tendency to be drawn to the intimate encounters of psychotherapy out of a desire to combat loneliness. As a group, psychotherapists had relatively few friends before adulthood and tend to be loners (Henry, Sims, & Spray, 1973). The reality of practitioner isolation and artificial intimacy found in the work does little to satisfy interpersonal longings and attachment needs. If anything, the intense encounters with clients may serve to heighten rather than lessen the desire for love and understanding in a person who has yet to find satisfying relationships in her personal life.
Some psychotherapists are motivated to enter the profession in part because it provides the chance to exercise influence or vicariously live through patients. Therapeutic practice offers the temptation to vicariously act out personal fantasies, conflicts, and desires by encouraging clients toward a particular perspective (Bugental, 1964). Psychotherapists indeed want to “make a difference,” but this motive can possibly deteriorate into a god-like position of control for a charismatic individual (Guggenbuhl-Craig, 1971). The psychotherapist’s power can be considerable, and the resultant sense of self-importance can be intoxicating for those who secretly worry about their own competence as professionals and effectiveness as people. Arrogance and grandiosity are occupational hazards that can also transfer to the home setting.
Some individuals are drawn to this career due to the unspoken belief that their caring has special curative powers. In a near messianic fashion, they feel compelled to pour out their love on others with the expectation that it will serve as an emotional salve or balm. Such uber-altruism leads them to ignore their own needs—caring for others but not for themselves. It is easy to see how this motivator can lead to a false sense of omnipotence or, on the contrary, an enormous sense of disillusionment when the truth becomes known.
Some clinicians were born into or assigned the role of caretaker at an early age in their families of origin. The resultant career motives can be less than ideal (Dryden & Spurling, 1989; Guy, 1987). Whether assigned or naturally predisposed to the role of “helper,” such therapists find little reason to continue if personal growth leads to new interests and roles. Of course, there are likely to be some who have looked to a career in psychotherapy in order to resolve personal needs related to family dysfunction. This motivation is also likely to lose its relevance over time. Systemic changes are likely to be very modest, if they occur at all, and the need to rescue/repair these relationships eventually diminishes as the therapist resolves her conflicts regarding the family of origin.
Stressors in the therapist’s life outside of the consulting room receive too little attention (Guy, 1987). Life has an uncanny knack of interfering with our plans to create the ideal clinical encounter that reflects only the client’s need. In truth, the clinical encounter reflects the combined reality of both the client and therapist.
Life events can cause considerable distress in the therapist’s inner world. In several of our studies (e.g., Guy, Poelstra, & Stark, 1989; Norcross & Prochaska, 1986a; Prochaska & Norcross, 1983), between 75 and 82% of psychotherapists reported experiencing a distressing episode within the past 3 years, and more than one-third of these respondents indicated that these personal problems diminished the quality of their patient care. In another study (Pope, Tabachnick, & Keith-Spiegel, 1987), 62% of psychotherapists admitted to working when too distressed to be effective. The most common precipitating events of distressed psychotherapists are disruptions in their own lives—dysfunctional marriages, serious illnesses, and other interpersonal losses—as opposed to client problems (Norcross & Aboyoun, 1994). Our emotionally taxing profession frequently places stress on the marital or partner relationship (Freudenberger, 1990b). The therapist’s psychological mindedness may cause her to respond to a partner in a “therapeutic” manner, leaving the partner feeling estranged and misunderstood. In one survey of therapists’ personal problems (Deutsch, 1985), over three-fourths of the respondents reported having experienced relationship difficulties. Another study (Thoreson et al., 1989) found that over 10% of psychologists experienced high levels of distress due to marital or relational dissatisfaction. Several studies (e.g., Wahl et al., 1993) have found correlations between psychotherapist stress and marital dissatisfaction, suggesting that increased work stress is related to decreased marital satisfaction.
Pregnancy is another significant life event that has ramifications for both male and female therapists. The first pregnancy brings profound changes in roles and lifestyles as well as the therapist–patient relationship (Guy, Guy & Liaboe, 1986). For female therapists, pregnancy is a nonverbal communication to patients, destroying any anonymity (Paluszny & Poznanski, 1971) in that it becomes obvious that the therapist has a personal life that involves sexual activity and family ties (Ashway, 1984). Many pregnant therapists fear being less attentive to patients and becoming increasingly self-absorbed with thoughts and fantasies about the baby (Balsam & Balsam, 1974; Bienen, 1990; Fenster, Phillips, & Rappoport, 1986). Some therapists may feel guilty for becoming pregnant and abandoning their patients to care for the newborn. The growing sense of physical vulnerability, hormonal changes, and fatigue also influence the female therapist’s effectiveness (Guy et al., 1986). Male therapists with pregnant partners may experience many of the same role changes, conflicts, and emotions as the female therapist (Guy et al., 1986). The male therapist may become increasingly preoccupied with concerns for the mother, baby, and his own ability to be an adequate father.
Increased financial concerns may heighten his sensitivity to premature terminations and canceled sessions. He may also find himself more reactive to patient disclosures involving pregnancy, parenting, or abortion. Parenthood supplies an assortment of disruptions in the therapist’s relationships with clients. Children become ill, break limbs, and need their parents in emergencies. These realities of parenting increase the complexity of our professional role and necessitate a precarious balancing act to meet the fluid needs of both children and patients (Freudenberger & Robbins, 1979).
Common patterns for parenting therapists include allowing the therapeutic role to impinge upon family life by overanalyzing and over-interpreting children’s behavior (Freudenberger & Kurtz, 1990), pressuring children to appear emotionally healthy at all times (Japenga, 1989), permitting patients to intrude into the home life, and being too tired and emotionally drained to engage in family relationships (Golden & Farber, 1998; Kaslow & Schulman, 1987). In fact, 75% of psychotherapists complain that work issues spill over into their family life (e.g., Farber & Heifetz, 1981; Piercy & Wetchler, 1987). The therapist’s family may come to resent the energy and caring that seems more available to patients. Exhorting clients to devote more time and energy to nurturing their own family may take on an empty, even hypocritical, ring to many therapists neglecting their own.
Personal disruptions frequently take the form of loss—divorce and the empty nest being two of dozens of examples. Divorce may precipitate the therapist’s anxiety over its possible discovery by patients or cause doubts concerning competency since her marriage has failed (Guy, 1987). Children “moving out” may precipitate feelings of abandonment, despair, and depletion. Therapists who experience these losses may find terminations with their patients especially difficult (Kaslow & Schulman, 1987). In a study of terminations, we found that therapists significantly affected by the recent departure of children from their home reported a desire for more gradual terminations with their clients (Guy et al., 1993). Similarly, the study found that those therapists substantially affected by divorce were more likely to maintain social contact with clients after termination. Therapeutic relationships may thus be (mis)used to compensate for the losses in therapists’ personal lives. Dissatisfaction with their personal lives is the leading precipitant of psychotherapists engaging in sexual relationships with patients. Feeling lonely or alienated, moving through a divorce or a dying parent, enduring relationship crises, and financial concerns lead the list (Lamb, Catanzaro, & Moorman, 2003). Some 2–6% of psychologists (overwhelmingly male) report sexual relationships with clients (during or after treatment), behavior that is prohibited by ethical codes (Lamb et al., 2003). These sexual boundary violations are tied directly to both intercurrent life events and past personal vulnerabilities.
As a psychotherapist ages into late adulthood, it becomes increasingly difficult to keep personal concerns from influencing professional practice. The death of loved ones, the physical and mental effects of aging, and personal illnesses all exacerbate the depletion of the therapist’s abilities (King, 1983). Aging or ailing psychotherapists often experience anxiety as they confront, perhaps for the first time, the reality of their own mortalities (Guy & Souder, 1986a, 1986b). Some therapists feel guilty about becoming ill and having to temporarily “abandon” their patients (Schwartz, 1987). Others experiencing vulnerability and helplessness increase their desire to be cared for by their clients. This sense of weakness can be quite disturbing to the therapist who typically perceives herself to be strong and competent (Dewald, 1982).
In the opening section, we argued that striving to prevent burnout is a more pathological and less effective strategy than cultivating self-care. Nonetheless, no discussion of the occupational hazards of psychotherapists would be complete without a few paragraphs on burnout.
Burnout has been defined in a variety of ways (e.g., Freudenberger & Richelson, 1980; Perlman & Hartman, 1982; Guy, 1987), but it always links directly to emotional depletion. We endorse the definition of burnout as “physical and emotional exhaustion, involving the development of negative self-concept, negative job attitudes, and loss of concern and feelings for clients” (Pines & Maslach, 1978, p. 233). Thus, when the emotional drain from work-related factors is so great that it hinders personal and professional functioning, the therapist is likely suffering from burnout. Solid research indicates that approximately 2–6% of psychotherapists are experiencing burnout at any one time (Farber, 1990; Farber & Norcross, 2005). However, 32% of the therapists experience symptoms of burnout and depression to a degree serious enough to interfere with their work, and a similar 26% believe their colleagues suffer from symptoms related to burnout and depression (Wood, Klein, Cross, Lammers, & Elliott, 1985). Thus, while the vast majority of psychotherapists are emotionally “good enough” at any given time, periodic “brownouts” and instances of clinical burnout are prevalent.
There is no need here for an extensive summary of the mounting literature on psychotherapist burnout; however, we would like to punctuate three critical points. First, one should fully appreciate the interactive effects of occupational stress and psychotherapist personality. It is not simply the stressful environment nor solely the vulnerable person, but truly the interaction between the environment and person. The upshot – each psychotherapist must sort through the unique array of environmental work stressors that confront her and then address the iterative, idiosyncratic impacts on her own world. For example, the two of us experience physical isolation very differently. It troubles one of us not an iota, the other quite a bit. Surely, this says something important about our personality and predispositions. Surely, too, this says we must individually tailor our self-care to these personality predispositions.
A second critical point – burnout is not a unitary or global disorder; there are distinct subtypes of burnout with attendant different self-care strategies. Several subtypes have been empirically delineated (Farber, 1998): “wearout” or brownout, in which a practitioner essentially gives up or performs in a perfunctory manner when confronted with too much stress and too little gratification; classic or frenetic burnout, in which the practitioner works increasingly hard to the point of exhaustion in pursuit of sufficient gratification to match the extent of stress experienced; and under-challenged burnout, in which a practitioner is not faced with work overload but rather with monotonous and unstimulating work that fails to provide sufficient rewards. Each type requires a different self-care solution.
Our third and final critical point is that the probability of burnout is reliably associated with several identifiable risk factors (Guy, 1987). Here is a brief summary of the lengthy literature on these elements:
What a staggering list of hazards and burdens! Are we trying to drive you out of the profession and into real estate sales? Not hardly. So, here are the tradeoffs, and here are the ultimate purposes of this section.
Our selves are our therapeutic tools. To put the problem in a nutshell (Lasky, 2005) – Is there any kind of work in this world where the tools never get dull, chipped, or broken?
We began by saying it out loud and will do so again – Psychotherapy is often a grueling and demanding calling. Be aware of the occupational hazards inherent in the work and those unique to your work setting and personal vulnerabilities. Establish realistic expectations. Expect to feel overwhelmed and drained at times. Beware of what pushes your button, rings your bell, and activates your neuroses.
When recognizing the stresses you encounter as a psychotherapist, keep in mind that virtually all of your colleagues experience similar kinds of pressure. Confidentiality, isolation, shame, and a host of additional considerations lead us to over-personalize our own sources of stress when in reality they are part-and-parcel of the “common world” of psychotherapy. Disconfirming our individual feelings of unique wretchedness and affirming the universality of stresses are in and of themselves therapeutic.
Although we psychotherapists face the same trials and tribulations, we are hesitant to admit it publicly. The autobiographical accounts of experienced psychotherapists (e.g., Burton, 1972; Dryden & Spurling, 1989; Goldfried, 2001) make it painfully clear that they have endured many of the same personal tragedies, failures, and stressors as the rest of us. Despite our secret fantasy that prominent therapists may have discovered a way to inoculate themselves against the ravages of distress, experience proves otherwise. In the words of Freud (1905/1933), “No one who, like me, conjures up the most evil of those half-tamed demons that inhabit the human breast, and seeks to wrestle with them, can expect to come through the struggle unscathed.”
Appreciating the universality of these hazards and accepting some of their inevitable distress contribute to the creation of corrective actions. Speaking of corrective actions, let us accept from the outset that our positions exact considerable demands for high-quality work. Acceptance is a crucial mindset, as our cognitive-behavioral colleagues have learned in terms of treatment methods and our psychoanalytic colleagues have informed us in terms of a tragic view of human nature. Acceptance is an active process, not a passive resignation.
Here is how we personally think about it – clinicians already have two strikes against them. Freud, as you will recall, christened psychotherapy an impossible profession. However, it was only one of three that he identified; the others were education and politics (or governing, depending on the translation). Thus, clinicians are daily practicing two of the impossible professions—psychotherapy and politics —depending on your involvement in agency politics, professional organizations, and administrative responsibilities. That’s our acceptance strategy—we are involved in highly gratifying but impossible pursuits, and keeping our nose above the waterline is doing well under the circumstances.
Another place to begin is to Start Where You Are, the title of a book by the Buddhist nun, Pema Chodron (1994). “Our first step is to develop compassion for our own wounds. . . . It is unconditional compassion for us that leads naturally to unconditional compassion for others. If we are willing to stand fully in our own shoes and never give up on ourselves, then we will be able to put ourselves in the shoes of others and never give up on them.”
In appreciating the universality of occupational hazards and in cultivating self-empathy, you will probably discover that high-stress clinical situations require a team approach. The death of a child, severe PTSD, and suicidal borderline pathology, for instance, require multiple professionals working together (e.g., Kazak & Noll, 2004; Linehan, 1993). It is too much for a single clinician; it is inhumane for one person to go it alone. A team can better share the burden, process the pain, manage countertransference, and support one another.
Your team comes in many guises. The team may be an interdisciplinary cadre working directly with you on a particular case. The team may be supervisors, peers, and personal therapists. Your team may be researchers publishing on the disorder or dilemma you are confronting, your profession advancing your cause for equitable reimbursement for your services, or colleagues (like us) offering workshops and books on replenishing yourself. We devote several chapters in our book to self-care via nurturing professional and personal relationships, but did want to highlight here that you need not be alone and need not go it alone clinically.
In this section, we have followed the conventional typology of therapist stressors in terms of sources—physical and emotional isolation, patient behaviors, working conditions, therapeutic relationships, and so on. Another scheme is to conceptualize therapists’ practice difficulties in terms of three types:
Here’s the payoff of this typology – different types of difficulties call for different responses. Transient difficulties call for improved knowledge, training, and wider experiences; situational difficulties require tolerance, support, and acceptance; and paradigmatic difficulties call for enhanced self-awareness and countertransference measures.
To disentangle the three types, ask yourself questions: Have you come across such a difficulty outside of the practice setting, or with other patients? How are other therapists experiencing the situation? Would training and skill enhancement solve the problem? (Schroder & Davis, 2004)
As you assess your own difficulties, attend to the types you experience and then develop a corresponding self-care plan. Some difficulties call for peer acceptance and colleague support (“That damn supervisor!”, “I can’t understand this new form.”), some call for training (“I need to learn more about treating trauma.”), and still others for supervision or personal therapy (“It’s happening with another patient, just as it does in my personal life.”). Different folks need different self-care strokes.
The hazards of psychotherapeutic practice must be reconciled and balanced with its privileges. Our work’s frustrations are only half the story. As in the lyrics of Jackson Browne’s (1974) song, our work is “fountain of sorrow, fountain of light.” Our esteemed colleague, Jim Bugental (1978, pp. 149–150), put the tradeoffs beautifully. His 40+ years of practicing psychotherapy have profoundly changed him:
My life as a psychotherapist has been . . . the source of anguish, pain, and anxiety—sometimes in the work itself, but more frequently within myself and with those important in my life. Similarly, that work and those relationships have directly and indirectly brought to me and those in my life joy, excitement, and a sense of participation in truly vital experiences. As with most meaningful endeavors, a career as a psychotherapist is a mixed bag of benefits and liabilities. Few careers offer the rewards experienced by the dedicated clinician. Yet, most psychotherapists discover that encounters with distressed individuals and repeated confrontations with the painful aspects of human existence can undermine vitality and optimism. The therapist who denies that clinical work is grueling and demanding is, in Thorne’s (1988) view, mendacious, deluded, or incompetent.
We concur wholeheartedly, but would add that the therapist who claims not to have personally benefited from this grueling and demanding work is also likely to be mendacious, deluded, or incompetent. Without trivializing the enormous strains associated with this impossible profession, we would conclude that most of us feel enriched, nourished, and privileged in conducting clinical work.
To avoid the impression that psychotherapy is indeed an impossible profession, it is important to place the content of this section in perspective. Most psychotherapists enjoy long, successful careers during which time they experience only a relative few of the hazards we have discussed. When they do encounter these challenges, they are typically able to overcome them. This reflects the quality of their personal awareness, support network, and resilience. It also reminds us that practically all of us use several of the self-care strategies described throughout this course.
If you—like us—have recognized ways in which you have been harmed by the practice of psychotherapy, please be concerned but not alarmed. The liabilities associated with clinical practice can be reduced by a variety of concrete and creative measures. The remainder of this course specifically addresses skillful self-care mindsets and methods that have emerged from the recognition of occupational hazards.
Our genuine hope is that this material, although temporarily disconcerting, will assist you in summoning the conceptual and experiential tools required for a long, satisfying career as a mental health professional. In the remainder of this course, our aim is to share what our colleagues, experience, and research have taught us about overcoming the distress of conducting psychotherapy.
Dryden, W. (Ed.). (1995). The stresses of counseling in action. London: Sage.
Freudenberger, H. J., & Richelson, G. (1980). Burn out: How to beat the high cost of success. New York: Bantam.
Schaufeli, W. B., Maslach, C., & Marek, T. (Eds.). (1993). Professional burnout: Recent developments in theory and research. Washington, DC: Taylor & Francis.
Sussman, M. B. (Ed.). (1995). A perilous calling: The hazards of psychotherapy practice. New York: Wiley.
“How can I cut my hours down to 40 and walk away feeling justified?” This really nails the dilemma for most of us. How to hold the line, shorten sessions, just say no, and the like. In a nutshell, I think it requires a profound cognitive-emotional shift—helpers have needs, too. Can I say “no,” “enough,” or “good enough for now,” and still feel professional, effective, and ethical?” How do we balance the needs of patients with the needs of ourselves? How do we set consistent boundaries that humanely serve the interests of all involved?
The process of clarifying and balancing interpersonal relationships lies at the heart of the psychotherapeutic endeavor. Regardless of theoretical orientation, this process is one of the most complex and challenging of conducting psychotherapy. It can also become a primary source of distress among psychotherapists, particularly when confusion exists regarding roles and expectations. Psychotherapists who have difficulty establishing clear, reasonable boundaries will almost certainly have trouble leaving it at the office.
In a general sense, boundary implies a limit or territory that is not to be violated. In a psychological sense, boundary denotes maintenance of a distinction between the self and the other—what is within bounds and what is out-of-bounds. Some psychotherapists, especially those of psychoanalytic origin, prefer the term therapeutic frame. By whatever name, the primary function of boundaries is to provide a safe and predictable environment in which the patient can work and the therapist can render effective care.
We are in the mainstream in suggesting that therapists manage daily boundaries of psychotherapy for the benefit of their patients and for themselves. Being regular, predictable, and punctual does not replicate the chaotic life history that many patients bring to treatment. The holding environment and the comforting structure of office policies reassure patients. Boundaries serve to maintain safety and integrity in the psycho-therapeutic process (Epstein, 1994).
At the same time, we are mindful that efforts to consistently manage boundaries can deteriorate into rigid, even punitive, behavior that causes ruptures and threatens the therapeutic alliance. While we advocate in this section for setting boundaries, we also advocate for reasonable flexibility. The results of survey research indicate that most patients make relatively few requests about extending boundaries and that psychotherapists accommodate the requests most of the time (Johnston & Farber, 1996). Such practice suggests a spirit of good will, flexibility, and collaboration. We try to allow flexibility within limits—the “bend but don’t break” rule. Accordingly, in the following pages, we hope that our insistence on setting and maintaining boundaries is interpreted as consistent and predictable, yet flexible.
Not surprisingly, research bears out the self-care value of clear yet flexible boundaries. Psychotherapists who maintain clear boundaries feel less stressed by patients’ psychopathology and suicidal threats. By contrast, therapists with greater fusion tendencies experience more stress from patients’ pathology and suicidality, and report more professional doubt about maintaining the therapeutic relationship (Hellman, Morrison, & Abramowitz, 1987a). Again, we encounter the inescapable interaction of the therapist’s personality and the hazards of the work. Setting boundaries consistently emerges in the research as one of the most frequently used and one of the most highly effective self-care principles. In one study of boundary behaviors used to prevent distress and impairment (Sherman & Thelen, 1998), 72% of psychotherapists scheduled breaks during the day, 59% kept their caseloads at a specific level, and 56% refused certain types of clients. These are impressive numbers, but in an ideal self-care future, we hope these numbers would top 90%!
In this section, we consider the self-care imperative of setting boundaries both at the office and away from the office. On this point, there is universal agreement. A common thread among both passionately committed (Dlugos & Friedlander, 2001) and master (Skovholt & Jennings, 2004) psychotherapists is their insistence on creating boundaries between their professional and nonprofessional lives. The master clinicians interviewed for this book are unanimous in declaring that boundaries must be established to ensure the well-being and relationships of the psychotherapist. In fact, establishing clear boundaries was the most frequently cited self-care strategy of our master clinicians.
Boundaries at the office encompass an intersecting network of role definitions – what is in bounds and what is out of bounds for the psychotherapist, the patient, their therapy relationship, colleagues, family, and friends. Let’s consider each in turn with an eye toward psychotherapist self-care.
It is of paramount importance that the psychotherapist understands her role. She must recognize personal strengths and limitations and establish clearly defined boundaries (Gregory & Gilbert, 1992; Pope, 1991). This is done in a number of ways, but begins with, and requires, self-awareness.
For starters, how do you characterize your role in the treatment process? This is largely an expression of the practitioner’s theoretical orientation and personal style. Some psychotherapists see themselves as educators who seek to instruct clients in the complicated nature of human relationships and the process of behavior change. If so, this will partially determine your style within the context of the treatment relationship. The educative psychotherapist will most likely be quite active, freely self-disclosing, and instructing the client by providing content and skills. Psychotherapists who see themselves as “prophets” in the lives of clients will exhort and encourage them to higher levels of functioning, convincing and confronting them when necessary. Supportive clinicians who view their role as that of comforter and facilitator will probably listen more, talk less, and seek to understand and nurture the inner worlds of the clients. Analytically- inclined psychotherapists will engage in reconstructive work that requires a more reflective style of observation and interpretation.
The psychotherapist who understands her role, as defined by theoretical orientation and personal style, will have an easier time clearly communicating this personal and professional service to the client. This process will help shape expectations and reduce misunderstanding and disappointment. This may be as basic as deciding how many total hours the psychotherapist will work each week, which nights (if any) she will be available for appointments, and how many breaks will be necessary throughout the day to ensure quality care. It will also be important to decide how available the clinician will be for telephone contacts, crisis sessions, and multiple appointments per week. All of these decisions require an awareness of the overall relationship between the psychotherapist’s professional practice and personal life.
The more the psychotherapist can establish necessary boundaries, the easier it will be for her to commit to their maintenance. A master therapist put it this way:
I make it clear that I keep clinical work in my office during my workday and try not to bring it home with me. My family time is family time, leisure time is leisure time, and work time is work time. I set those boundaries in my own mind to try to keep clinical work in the office. I have to make a decision to not worry about a client who is telling me he or she is doing something that is putting them at risk.
Consider the number of hours a practitioner is willing to work each week. The goal of some therapists is to do as much psychotherapy as possible per week—that is, until they begin to “drift away” during sessions, offer mechanical responses, or are unable to physically tolerate another session. We suggest that the goal should be doing as much therapy as you can do well. Everyone has a different limit; Albert Ellis, one of the fathers of cognitive-behavioral therapy (CBT), famously does 60 hours a week, while others “max out” at about 30 contact hours. The goal is not more psychotherapy but better psychotherapy. Determining your own workload should be made by observing and honoring your feelings. If you find yourself becoming irritable, distracted, and exhausted during many workdays, then please honor those feelings and take corrective remedies.
Most of us are socialized to work to capacity (100%) or above capacity (110%). We recommend working under capacity (90%) so that emergencies, family demands, and self-care can be accommodated and, indeed, built into the weekly schedule.
Those of us who measure our “success” by the fullness of our appointment book and the number of sessions scheduled per day can come to regard unanticipated or unscheduled free time as a blemish to be hidden as quickly as it appears (Penzer, 1984). How easy it is to skip lunch in order to see another patient! Overwork is a curse of our time and simultaneously a badge of honor (Grosch & Olsen, 1994). Listen to a busy practitioner “complain” about her full schedule and overwork – it is a mix of grumbling and bragging. “What an important, esteemed healer I am!” Here is where the masked narcissism of many psychotherapists reveals itself.
This is a paradox of self-care; as we noted earlier, many of us embark on helping careers out of a genuine concern for others but also a need to be appreciated by them (Grosch & Olsen, 1994). We must realistically assess and continually monitor our need for appreciation, the deep desire to be liked and admired. Such motives may easily drive us to overwork.
Consider, too, the nature of session fees. In the ratio of length of professional training to average income, mental health professionals occupy the bottom rungs. Conducting psychotherapy as a licensed professional requires at least a master’s degree. How many MAs and MSWs out-earn MBAs? Or PhDs out-earn MDs? Psychologists, in particular, are at real risk of becoming the health care professionals with the longest training (an average of 6 years post-baccalaureate) but the lowest incomes. We are in real danger of becoming a masochistic profession in which we take care of the legitimate needs of others but not of ourselves.
The psychotherapy literature has been hesitant to talk about money (Rappoport, 1983). The profession has come out of the dark more recently, given the ravages of managed care, but money remains a deeply ambivalent subject to most mental health professionals. We suffer from moral uneasiness about profiting from the emotional distress of others.
Still, boundaries demand livable wages and a reasonable return on the investment that is required to become a psychotherapist. Income deserves to be addressed for the major dimension and reality element it is. None of us enters the profession solely for the money; most of our occupational rewards are nonmonetary (see the previous section, Recognizing the Hazards). However, we deserve a “good enough” income.
Consider how some psychotherapists deal with patients late for their scheduled appointments. We frequently encounter therapists who will see patients for their entire scheduled time (30 or 50 minutes, for instance) even if the patient (or couple) has arrived late for the appointment. As a result, subsequent appointments are pushed back for the remainder of the day. These therapists seem to be always running late and perpetually exhausted (Boylin & Briggie, 1987). Our advice is to maintain the time boundaries; see patients for only their scheduled time, and only extend appointments on the rare occasion it is warranted.
Consider as a final example of psychotherapists’ role definition the matter of availability outside of sessions. Each therapist must decide what she can realistically offer, keeping in mind how committed one is to her personal needs versus those of the client. The following disclosure by one of our master clinicians demonstrates one way of handling this conflict:
“I encourage people to contact me only in true emergencies. Sometimes we talk specifically about when it is appropriate to call my beeper. When there are clinical issues that require their calling me, I label it clearly. I try to be prompt and clear about telephone calls that I get and return. I also try to be on time with sessions. I let [clients] know that I don’t give extra time in sessions unless there seems to be an extraordinary reason.”
Practitioners naturally differ in their policies for out-of-session contacts. On one end, some of our colleagues maintain only a telephone answering machine with a message advising their patients to go to the emergency room in a crisis. In the middle are those who maintain a beeper, cell phone, or answering service but are clear that they frequently cannot be reached. On the other end are those who take calls 24/7.
We offer no self-care advice on which of these policies is optimal for your particular circumstances, but would offer four self-care caveats. First, it is a decision that should be made by you, not your patients. Second, it is a decision that should be clearly communicated to patients and potential patients. Third, when possible, limit your out-of-session exposure to crises by minimizing on-call circumstances, referring patients to the emergency room, and dividing calls among fellow professionals in your agency or in your office. When on your own time, surrender the beepers and the cell phones at the door! Fourth, thoughtfully select patients and clinical circumstances that fit with your on-call availability. Practitioners who are not generally available and who do not have backup arrangements should not be taking on chronically suicidal patients in their practices, for one obvious example.
Exceptions are the rule in clinical practice, of course. Circumstances may occasionally demand that the clinician extend herself beyond stated limitations in order to assist a client undergoing extraordinary difficulties. Sliding-scale fees, pro bono sessions, extra sessions, late-day appointments, and telephone contacts may be necessary from time to time. However, in such situations, the therapist should remain in the position of deciding the appropriateness of the exceptions and should clearly demarcate them as exceptions.
Combining your personal style, theoretical orientation, and individual resources into a clearly-defined persona as a psychotherapist is a gradual process. It is important to repeatedly assess your needs and priorities in order to be clear with your clients as to what you offer—and do not offer— as part of the treatment contract. Establish a personal policy and a method to determine whether a particular boundary has been crossed. Boundary violations are frequently realized only after the fact; this is a recursive process of trial and error that requires vigilant self-monitoring on your part. By understanding, monitoring, and maintaining your boundaries, you will be better able to communicate them unambiguously and unapologetically to your clients.
Few would disagree that there must be a clear set of expectations established for psychotherapy clients (Gutheil, 1989). Ethical principles governing the practice of psychotherapy require informed consent, which includes discussing the role of the client and securing agreement on terms mutually before commencing treatment.
For the psychotherapist, however, the fecal matter hits the boundary fan in trying to honor both patients’ desires and self-preservation. The decision to give 15 extra minutes to a patient means you leave 15 minutes late from the office or arrive 15 minutes late for your child’s piano recital. Research has no easy answers here, other than that achieving the right balance is an ongoing process requiring continuous self-monitoring, judicious compromises, and consistent boundaries. Good practice demands that psychotherapists help clients verbalize their role expectations early in the treatment process and then reach an explicit consensus. Goal consensus and collaboration do contribute to effective psychotherapy (Tryon & Winograd, 2002).
At the same time, good self-care demands that psychotherapists communicate and maintain their boundaries. For example, one’s fees for services always need to be defined. Is the fee to be paid in full at the time of the session? Should the fee be paid at the beginning or end of the session? Is it allowable for the client to carry a balance in his account? If so, is there a limit to how much the client can owe the therapist before treatment will be discontinued? How will insurance reimbursements be handled? All these arrangements should be specified in advance of commencing services.
Similarly, policies regarding the scheduling of sessions are discussed at the outset of treatment and maintained throughout unless mutually revised. Will the sessions be weekly? What will be their length? Will they include anyone besides the client, such as might occur in couples, family, or group psychotherapy? How will late arrivals be handled? The cancellation policy must be discussed so that the client knows the expectations of the psychotherapist regarding missed sessions, rescheduling, and breaks due to illness or vacations. The psychotherapist’s policy regarding telephone contacts between sessions must be explained, including any associated costs to the client.
Increasingly, psychotherapists are gravitating toward the use of informed consent forms that contain many of these important policies. The forms may be handed to clients to read, discuss, and then sign as a written treatment contract or, alternatively, may be used by practitioners as a template for topics to be covered during the initial sessions (see Pomerantz & Handelsman, 2004, and Harris & Bennett, 2005, for sample forms). We have used both methods in our practices with success. In both methods, the form contains information regarding appointments, fees, cancellations, billings, payments, extra-session contacts, crisis contacts, release of information to third parties, managed care reimbursement, HIPAA regulations, exceptions to confidentiality, and so on. Preliminary research shows that informed consent forms yield many practical benefits to the patient—more information, more comfort, a more favorable impression of the therapist—and to the therapist—feeling more thorough in covering essential topics, and feeling more protected in a legal and ethical sense (Sullivan, Martin, & Handelsman, 1993). Despite these findings and despite our positive experiences with them in our own practice, we are concerned that lengthy, legalistic forms may misconvey the essence of psychotherapy.
At the conclusion of the therapy relationship, expectations for the future must be discussed. In particular, what, if any, contact will be permitted between the client and the therapist? Who will initiate the contact? It should not be assumed that there is a mutual understanding and agreement on this issue until it has been discussed. One of our studies revealed a great deal of variation on post-termination contact (Guy et al., 1993). Although 86% of psychotherapists surveyed avoided social contact with former clients, 78% allowed the exchange of letters, 79% permitted telephone contact, and 93% encouraged future therapy sessions when needed. In nearly all of these cases, the subsequent contact was initiated by the client. For the conscientious psychotherapist, there are ways in which treatment relationships never really end. A meaningful discussion of these issues at the time of termination will lessen the possibility of unrealistic expectations or patient disappointment.
Having clarified the respective roles of the psychotherapist and the client, it is essential to delineate the nature of the psychotherapy relationship early in the treatment process. This helps to focus psychotherapy in order to foster the alliance, to increase its effectiveness, and to reduce misunderstanding regarding the boundaries that are to be a part of this intimate encounter.
One prevalent assumption of clients, particularly clients new to the process, is that the psychotherapist is going to fix, heal, or “treat” them. Patients who are overly socialized in the medical model expect to be the relatively passive recipient of services unilaterally dispensed by an expert doctor who is largely in charge and responsible for the outcome of treatment. Such a patient perspective unfortunately fits with a conventional view of therapist distress and burnout as caused by the grueling nature of the work and the experience of failure. The emotional exhaustion and intrapsychic depletion characteristic of burnout can result from over-responsible therapists who too readily assume responsibility for their clients’ lives or feel they need to save or rescue them. Therapists quickly become drained, overburdened, and soon feel underappreciated by all. This often represents a boundary (and thinking) problem – over-responsibility.
An alternative view is that we become dispirited, not because we are failures, but because our hierarchical view of therapy emphasizes our ideas and actions while according little attention to our clients’ perspectives. When we assume the one-up position of expert, then we become responsible for change.
As a alternative, we emphasize early in therapy our mutual responsibility for both the process and the outcome. Psychotherapy demands a highly collaborative process, beginning with our thinking and ending with behavior within session. We discuss shared responsibility for change. Yes, we are experts in some respects, but a “fellow traveler” in most respects.
One technique for facilitating shared responsibility is “transparency” (White, 1997), in which the therapist owns personal ideas and communicates possible frailties and empathic lapses to clients. We (the authors writing this course, for example) might acknowledge to the patient “our backgrounds as heterosexual white men may not allow us to fully appreciate your experiences as an African-American woman. We may convey feelings or share ideas that make more sense to a man than to a woman. Should that occur, please let us know” (McCollum, 1998). Active collaboration sets boundaries and reinforces mutual responsibilities for the change process and treatment outcomes.
An administrator made several boundary commitments following our self-care workshop, “I will stop ‘fixing’ everything. Let other people make mistakes, and don’t engage in prevention or fixing if they do. Don’t do everything I know how to do, even though it’s not my job, just because others know I know how to do it. It’s the only way for people and institutions to learn.” Sharing responsibility with patients (and with colleagues) is a boundary fix.
Once the relationship is defined as a shared responsibility, the challenge is to protect that relationship. To do so requires a mutual commitment to its maintenance and integrity. Specifically, psychotherapy must not be compromised by blending it with other possible interactions. For example, the psychotherapist and client must not enter into other types of relationships together. They are not free to become business partners, professional colleagues, friends, or lovers (Pope, 1991, 1993; Pope, Sonne, & Holroyd, 1993; Stake & Oliver, 1991). It is not appropriate for them to meet in other contexts that require additional roles that may conflict with those of client and psychotherapist (Borys & Pope, 1989; Pope, Tabachnick, & Keith-Spiegel, 1988). To work, play, study, or live together would most likely undermine the nature of the psychotherapy relationship. There is wide recognition among mental health organizations that it is necessary to avoid multiple role conflicts that would prove detrimental to the patient. The clearer the boundary is in this regard, the more effective the treatment will be.
Our master clinicians were nearly unanimous in communicating often with clients about the boundaries to be respected. Numerous personal examples were given regarding the importance of keeping the professional roles separate from personal roles outside the office. The following is typical:
“I had a patient who was celebrating a birthday. She wanted to invite me to the party, and she was hoping that I would go. We talked about it, and what it would mean to her if I did go. By helping her describe what it would mean, she got to issues that were important to her in the therapeutic process. It reminded her of things that she needed from her mother and father and did not get. By keeping myself in the room with the patient rather than going to a social event, it was a useful therapeutic re-doing. Had I gone to the party, it would have been a therapeutic disappointment. It helps me to set boundaries with patients, and it gives me more confidence in the treatment. I don’t touch patients, talk much about myself, or talk to family members of patients. I don’t socialize with patients. I have a whole constellation of boundaries that I set.”
This advice converges with the research on extra-session contacts with our psychotherapy patients. For example, about 60% of psychotherapists never accept an invitation to a client’s party or social event, and about a third rarely do so (Pope et al., 1987). We fall squarely between the never and rarely camp. Frequent social excursions can contaminate the therapeutic relationship, violate a nonsexual boundary, and interfere with the sanctity of a therapist’s private life. At the same time, we do make exceptions when the patient’s health and circumstances seem to require it.
In essence, maintaining boundaries entails saying “no” when it is deemed to be in the interest of the patient’s treatment and/or in the interest of the psychotherapist’s effectiveness. Herb Freudenberger (1983), father of the term “burnout,” has written eloquently of the need for health practitioners to say “no.” Protect yourself from the high cost of success; strive not to be perfect or to cling to the ego ideal of perfect, compulsive caregiver. It is not your job to meet everyone’s needs. Your goal is always to get people to push their own wheelchairs, even if they are never able to walk again (Berkowitz, 1987).
Saying “no” will necessarily come in many guises. These include:
Say “no” as a matter of integrity. The cost to your soul of doing otherwise is simply too high.
Many psychotherapists experience difficulty in asserting themselves in professional settings, particularly with their clients. Table 6.1 presents eight professional rights that assertive therapists take to heart (Janzen & Myers, 1981). While we would phrase some of these rights differently, their principal value is in reminding us of our inherent right – our perfect right – to say “no” at times.
TABLE 6.1. A Professional Bill of Rights for Psychotherapists
Based on and adapted from Janzen and Myers (1981). Copyright 1981 by the American Psychological Association. Adapted by permission.
Phrased more positively, assertively maintaining boundaries means remaining true to yourself, your moorings, and your vocation (Norcross, 2005a). Relentlessly define who you are and what you do. Know and accept your limits.
Speaking of limits, we enthusiastically recommend that psychotherapists more frequently transfer difficult cases—either for a second opinion or for the entire treatment—to a colleague (Kaslow & Schulman, 1987). A transfer is indicated whenever the case becomes prolonged, inefficacious, a poor client–therapist match, a shaky therapeutic alliance, or simply outside of one’s competence. Such a transfer can be interpreted as a sign of strength and wisdom, not failure. Moreover, all ethics codes prohibit us from practicing beyond our sphere of competence and remind us to consider transfer whenever services are not proving beneficial. In addition, transfer should be considered when the patient’s struggles and circumstances are too similar to the therapist’s life. The terminal illness of a close family member, a recent death or divorce, or the chronic illness of a child are prominent examples. Non-acceptance or transfer of patients at such times “represents a sensitive and humble awareness of one’s limitations and the placing of the patient’s needs for efficacious treatment above one’s own for a busy therapy schedule” (Kaslow & Schulman, 1987, p. 92). Maintaining proper boundaries means not only saying “no” but also saying, “I don’t know.” It is honest, avoids defensiveness, and confronts your perfectionist tendencies head-on. We simply cannot know everything!
Just as it is essential to understand, communicate, and maintain the boundaries of the treatment relationship, it is also useful to clarify the relationships that exist among colleagues (Tabachnick, Keith-Spiegel, & Pope, 1991). The psychotherapist will experience a number of potential role relationships with her colleagues. In some cases, she may assume the role of peer, with all the mutual respect and support that this implies. In other relationships, she may behave more like a parent, rival sibling, or friend. Obviously, this process is not restricted to psychotherapists; it is true of all work relationships. However, the emotionally rich and psychologically potent world of the psychotherapist seems to exaggerate the problems normally encountered with colleagues in a work context.
This phenomenon becomes particularly acute when the roles are compromised by a blurring of boundaries (Slimp & Burian, 1994). For example, it is universally recognized as unethical for a clinical supervisor to become a lover of his supervisee (Tabachnick et al., 1991). The role of supervisor or colleague also generally precludes the formation of a personal psychotherapy relationship with supervisees. In some cases, the administrator of a clinic may find it difficult to assume the role of peer and friend as a result of the power differential associated with his “parenting” role.
Psychotherapist–staff relationships also become tricky and strained if boundaries are not maintained. Staff are part friends to psychotherapists, part of the clinical team, and yet frequently employees or direct reports to psychotherapists. The blurring of roles and the relationship elements frequently confuses staff members not formally trained in graduate coursework. It can be useful to take an hour periodically to discuss openly the therapist–staff relationship.
Such relationships can be further strained when psychotherapists delegate non-clinical duties to staff, who frequently experience it as “getting more work dumped” on them. Psychotherapists are wise to delegate such tasks in order to free up their time and energy to concentrate on what they uniquely do best. Indeed, we encourage you to delegate all non-clinical work such as filing, Xeroxing, word processing, scheduling appointments, billing, and related office tasks. Even if you personally pay for it, delegate to others whatever runs counter to your skills and interests. See an extra patient per week and eliminate 3 hours of drudgery!
We urge you to monitor and maintain your boundaries with colleagues. Defining the nature of these professional relationships will help you negotiate the complexities related to boundaries and expectations.
Family and friends are not usually direct participants in the professional world of the psychotherapist. They are not present during psychotherapy sessions, they do not meet clients, and they do not assist with the delivery of services. Confidentiality requires that the clinician not share the identities and disclosures of clients with them. This leaves family and friends outside of the clinical experience of the practitioner. One of our master psychotherapists described it this way:
“My kids don’t really know what I do for a living. It’s hard to explain it to them, and I can’t really show them. They’ve seen the office. They know I talk and listen to people who are unhappy or have problems. But they really can’t understand why I get paid for this. After all, I do the same for them at home all the time ... and not always very effectively!”
Without considerable effort, there is little opportunity for spontaneous phone calls, personal visits, and short breaks with friends and family during the typical workday. The clinician spends most of her time with clients, many of whom are in distress. Moreover, since the focus on the client is often intense and engrossing, there is little opportunity for the therapist to think about personal relationships during a long day at the office. Find ways to bridge this gap. Deliberately schedule lunch appointments and visits with friends and family during the workday. When possible, telephone loved ones between appointments.
In order to effectively disengage and leave work at the office, the psychotherapist must realize that clearly defined boundaries are also necessary outside of the office. One of our master clinicians commented in an interview:
“I make it clear that I keep clinical work in my office during my workday and try not to bring it home with me. I avoid talking about what’s happening in my clinical work with my family or with other people, feeling that family time is family time, leisure time is leisure time, and work time is work time. I set those boundaries in my own mind to try and keep clinical work in the office.”
Establishing secure boundaries is essential in maintaining some distance between a therapist’s personal life and professional practice. Doing so will require a thoughtful attempt to define the roles of several significant people who populate the world of the psychotherapist, beginning with the therapist herself.
It is not enough to know “who you are” at the office, you must also know who you are when you’ve left and gone home. In order to be a friend, spouse, parent, or lover, you must be able to set aside the interpretive stance—the sometimes aloof and distant perspective of the “observer”— and enter into relationships with genuineness. You must also set aside the travails of conducting psychotherapy. Those working with patients suffering from severe psychopathology, in particular, struggle to leave it at the office, although their patients remain imprinted in their memories and may even intrude into their personal lives through emergencies and patient-initiated contacts outside of the session. Thus, it is probably not realistic to speak of always “leaving it at the office.” Instead, it is more realistic to set boundaries and to modulate the intensity of therapist response to such work (Kaslow & Farber, 1995). A thoughtful attempt to define yourself outside of the office, therefore, entails creating boundaries and establishing a meaningful life sufficiently separate and rewarding to be a viable alternative to clinical work.
For many of us, this is easier said than done. Most of us admit that we are prone to overextension of work, and we need to make conscious efforts to construct boundaries to help us help our patients. To some extent, this is the price of socially-defined success in our culture, but it also reflects some clinicians’ characterological vulnerabilities. Those suffering from the central character trait of the selfless caretaker (Barbanelli, 1986) minimize their emotional needs in deference to the needs of others. As discussed earlier, some psychotherapists “need” to be needed. The approval-seeking preoccupation with recognition from significant others and the suppression of anger are typically manifest. They’re always giving, but in the end, they typically feel deprived, isolated, underappreciated, and lacking a meaningful life outside of the office.
Significantly, the work-related distress of psychotherapists is not necessarily related to the number of their client contact hours (e.g., Firth-Cozens, 1992; Kramen-Kahn & Hansen, 1998; Sherman & Thelen, 1998). Thus, the common suggestion to cut back on the number of clients or reduce patient contact is not a panacea. Instead, one needs to selectively cut back and diversify one’s activities by doing other things. The second course in this series will traverse the variety of healthy escapes and creative activities outside of the consultation office available to the psychotherapist. All activities create stimulation, variety, and fresh challenges. Teaching, supervising, consulting at nearby agencies, conducting research, writing articles and books, or working in entirely different settings—all allow practitioners to define themselves as someone other than simply a psychotherapist. This same outcome can also be accomplished by pursuing parallel career interests outside the field – related or totally unrelated – to psychotherapy.
Creating a broader definition of who you are as a professional can enable you to perceive yourself as more than a psychotherapist. Many colleagues acknowledge that doing so makes it easier to set aside the role when they leave the office (Guy, 1987). In fact, several of our master clinicians enthusiastically shared the value of pursuing other interests and activities, including teaching, research, media appearances, and writing. Out of our list of 19 self-care strategies, pursuing interests outside the consulting office ranked as the fifth most important. Clearly, many of the happiest and most successful psychotherapists have found that it is best to define themselves professionally rather broadly by pursuing a host of roles in addition to that of psychotherapist. One master clinician related the following during an interview:
“Other professional activities help alleviate the stress of my practice. They take me one step back from the therapy process, and I can then see the big picture without getting lost in the details. It’s also nice to function as a professional without feeling the pressure to do something about an urgent problem. I find that this helps to clarify my thoughts and provides a more relaxed opportunity for me to be creative.”
In order for you to successfully set aside the role of the psychotherapist, your personal life must have meaning and joy outside of the healer role. Give careful consideration to your investment in pursuits that are independent of your work as a psychotherapist.
Earlier, we discussed the need to carefully define the relationship between the client and therapist within the psychotherapy encounter. The focus then was primarily on the contacts that would occur within the context of the consulting office. We now consider contacts between client and therapist that might occur outside the office.
A concrete start in demarcating work from home is by developing a transition or decompression ritual. It convincingly marks the transition from work to non-work. Representative rituals include sitting quietly for a minute before leaving for the day, saying a brief prayer, listening to relaxing music on the way home, spending some time alone reading, meditating for several minutes, changing clothes, and exercising (Mahoney, 2003; Neumann & Gamble, 1995). This sort of ritual formalizes the physical and emotional transition.
Most ethics codes explicitly acknowledge that not all multiple relationships are unethical; however, multiple relationships that would reasonably be expected to cause impairment or risk exploitation or harm are deemed unethical (e.g., American Psychological Association, 2002). The intent is to strike a fair balance between benign and potentially therapeutic dual relationships, on the one hand, and blatantly exploitative relationships, on the other hand. The ethical line is that psychotherapists refrain from entering into a multiple relationship if it could reasonably be expected to impair the psychotherapist’s objectivity, competence, or effectiveness in performing her function. The exact line here is murky and mired in professional controversy (see, e.g., Epstein, 1994, and Lazarus & Zur, 2002), but the essential point is that most dual relationships must be avoided in order to protect the client and the integrity of the treatment relationship.
Concretely, this means that the client and therapist will not pursue a relationship beyond the professional one already established. They will not meet together for other purposes, such as friendship, business, or romance. Having agreed upon this fact, there are still matters to discuss. Can the client call the therapist at home? Can she appear there for assistance? Will she meet individuals from the psychotherapist’s personal life, such as a spouse, children, or friends? If the therapist and client should meet inadvertently outside of the office, should they acknowledge each other and visit together? (Sharkin & Birky, 1992) To what extent will the client have access to the personal life and relationships of the psychotherapist? These and similar concerns need to be discussed within the therapy relationship, keeping in mind the priority that is of paramount importance – protecting the integrity of the psychotherapy relationship (Fremont & Anderson, 1988).
Interestingly, some clinicians have trouble maintaining appropriate boundaries. They may be tempted to cross the boundaries themselves by making unnecessary phone calls to clients, sending letters or notes that are only vaguely related to the therapeutic work, or arranging to meet outside of the office for supposedly “psychotherapeutic” reasons. These behaviors can blur the roles and boundaries, with detrimental consequences for both the client’s treatment and the private life of the psychotherapist. Of course, more times than not, patients initiate the multiple relationships outside of the office. For patients with mild or solely Axis I disorders, gentle but firm reminders about the treatment contract will suffice to stop future contacts. However, for patients with severe and Axis II disorders, more persistent efforts may be required. One of our studies focused on protective measures taken by psychotherapists to ensure their safety and that of their loved ones (Guy et al., 1992). The top five measures were to decline to treat certain clients, refuse to disclose personal data to patients, prohibit clients from appearing at your home, locate the consultation office in a safe building, and specify intolerable patient behaviors. Other measures, as needed, should also be considered – avoid working alone in the office, install an office alarm system, obtain training in handling assaultive patients, and so forth as needed. The objective is to protect yourself and your life outside of the office.
The practice of psychotherapy can easily absorb the entire life of the practitioner. It is a job—but much more than a job. Some psychotherapists prefer to “live” the job without interruption. In effect, they lose themselves in the persona of the psychotherapist or hide themselves in their patients’ lives. They are always “on duty.”
These individuals blur their life outside the office with their professional work. Social events typically center around conventions, workshops, retreats, supervision groups, and book discussion groups that focus on psychotherapy. Gatherings become meetings rather than parties. Colleagues become the primary, if not the only, friends of the practitioner. This blending of worlds is complete when the psychotherapist never has to stop being the clinician. Although an exaggeration, this characterization is frighteningly too close for comfort. Consider whether colleagues in the profession have become the primary players, or even sole participants, in your private life outside the office. It will be extremely difficult to alleviate the distress of this profession, or maintain a balanced life, if there is no escape from professional colleagues who have become your only friends.
At the beginning of this section, one of our workshop participants captured the essence of the dialectic between therapist self-care and clinical responsibilities. “How can I cut my hours down to 40 and walk away feeling justified? . . . Can I say ‘no,’ ‘enough,’ ‘good enough for now’ and still feel professional, effective, and ethical?” The incontrovertible answer is “Yes!” but it takes considerable work to establish and maintain that delicate balance.
We advocate a mature synthesis to the dialectic of selfishness versus responsibility (Gilligan, 1982). Namely, define yourself, acknowledge your limitations, take control of your life, balance competing demands, and take an active stance toward your choices. In two words: “set boundaries.”
The observation that therapists do not necessarily practice what they preach also applies to boundaries. One therapist (Penzer, 1984, p. 52) whimsically observed:
We [psychotherapists] seem to possess our own unique brand of craziness seemingly endemic to and epidemic in our profession. Although not clearly identified in DSM-III, our dysfunction involves the promotion of wellness philosophies, goals, and strategies, while imbibing homemade anti-wellness potions.
Top among these potions are short-lived boundary commitments, such as “I’m only going to work two nights a week,” which have as little chance of implementation as a New Year’s resolution. Like the diabetic physician who repeatedly fails to take her insulin, many of us fail to implement our own boundary advice. Some observers (e.g., Gladding, 1991) go so far as to label these boundary problems as therapist “self-abuse.” Examples are practitioners who schedule too many clients in one day or who let clients consistently run over the allotted session time.
The probability of therapist impairment, particularly as it relates to client exploitation, is decreased by the clarification and strengthening of therapist boundaries (Skorupa & Agresti, 1993). The clinician who understands her role, and that of the client, will make better decisions regarding contacts both in and outside of the office. She will be better able to resist compromising the treatment relationship by encouraging other agendas, such as profit, companionship, or romance. Close relationships with family and friends assist the psychotherapist in confronting any growing tendencies toward substance abuse, suicidal behavior, or mental disorder. Honest scrutiny is more likely to occur within caring relationships with loved ones than within the work environment, where clients and colleagues have a wide variety of motives that make total disclosure difficult or unwise.
Our ardent hope here has been to canvass the multifarious manifestations of boundaries in and outside the office in a manner that informs, fuels, and guides your own self-care. Such boundary work takes considerable energy and deliberate commitment on your part. And it will entail careful attention to the nature of your relationships inside the office—with patients, colleagues, staff, and family—as well as outside the office with those same groups of people. Realistic boundaries are assuredly one key to successfully leaving it at the office.
Epstein, R. S. (1994). Keeping boundaries: Maintaining safety and integrity in the psychotherapeutic process. Washington, DC: American Psychiatric Press.
Johnston, S. H., & Farber, B. A. (1996). The maintenance of boundaries in psycho-therapeutic practice. Psychotherapy, 33, 391–402.
Knapp, S., & Slattery, J. M. (2004). Professional boundaries in nontraditional settings. Professional Psychology: Research and Practice, 35, 553–558.
Pope, K. S., Sonne, J. L., & Holroyd, J. (1993). Sexual feelings in psychotherapy. Washington, DC: American Psychological Association.
with Maria A. Turkson
Cognitive restructuring for psychotherapists is steeped in ironies. Although intellectually aware of the irrational beliefs explored in rational-emotive therapy and the depressogenic assumptions of cognitive therapy, we therapists all fall prey to these cognitive errors. A predilection for dispassionate examination does not immunize us to the perils of the secular world. We are blissfully human, and, as such, we are subject to the same corrosive logic as our fellow humans.
Indeed, the father of cognitive-behavioral therapy, Albert Ellis, writes (1987, p. 364) that irrationalities “persist among highly intelligent, educated, and relatively little disturbed individuals” and “seem to flow from deep-seated and almost ineradicable human tendencies toward fallibility, overgeneralization, wishful thinking, gullibility, and short-range hedonism.” Assuming too much responsibility for our patients, catastrophizing over a case, and thinking dichotomously about the outcome of psychotherapy plague us all at times. Ironically, we engage in the very dysfunctional thoughts that we desperately teach our clients to avoid.
It is hard to be dispassionate about a subject when it’s yourself. Nonetheless, identifying and challenging our faulty assumptions are keys to therapist self-care. The focus here has been on cognitive restructuring – identifying and challenging problematic thinking that serves to maintain negative feelings and self-defeating behavior. We explore and consider the remediation of prevalent “musturbations” (Ellis, 1984) and cognitive errors (Beck, Rush, Shaw, & Emery, 1979) that psychotherapists inflict upon themselves. In a significant way, both of our courses are devoted to remediating the cognitive errors of psychotherapists; however, in this initial course we focus on specific examples and methods of cognitive restructuring.
We employ the cognitive-behavioral term of cognitive restructuring, but intend it in a transtheoretical manner. We use it as a broad process across theoretical orientations rather than a specific cognitive-behavioral method. Cognitive therapists are not the first or only ones to identify perfectionist strivings and cognitive errors. Psychoanalysts, in particular, have written extensively about the persistence of unrealistic and unrealizable analytic ideals of patient outcomes and therapist methods. One author (Abend, 1986, p. 566) reminds us that, although experience certainly dictates that perfectionist goals are all but impossible to attain, they continue nevertheless to influence both theory and aspirations. Most therapists try to live up to the inflated ideals of the masters, from Freud on down.
Solution-focused therapy, too, reminds us to re-author our own narratives. Consider these examples of cognitive restructuring via rewriting our stories about clients (based on Clifton, Doan, & Mitchell, 1990):
Solution-focused therapy underscores the difference between the therapist’s approach to a session with a “problem” versus a “solution” mindset. Just as clients often become “stuck” in their emotional experience, therapists can become mired in their negative reactions to clients or fixated on labeling the client’s problematic way of being (e.g., resistance, intellectualization, transference). This change to “solutions” can empower therapists by focusing on what is controllable and changeable (i.e., themselves!).
Similarly, humanistic therapists remind us to “cognitively restructure” our reactions to clients via empathy. When sitting with a client who criticizes your skills as a therapist, or projects anger toward you because she is not “getting better,” you can grasp those responses from an empathic place (e.g., “The client is experiencing a great deal of pain”). It is more difficult to feel anger when you hear her message as one of helplessness and pain rather than filtering the message through your own experience (e.g., “I’m annoyed that the client is calling me a lousy therapist,” or “The nerve of her to become angry at me when I’m working so hard!”).
In our interviews, one of the master clinicians bluntly stated:
“Stress is always self-created. Stress means that it is difficult, and when you do not have cognitive restructuring, you define the difficulty as awful, horrible, that it shouldn’t exist. When you do cognitive restructuring, then you define it as a pain in the ass, period, and you don’t get depressed about it. For example, when the clients are a pain in the ass then you define it as a pain in the ass, instead of horrible and awful.”
By heeding this candid redefinition of stress, you can transform, in Freud’s terms, neurotic misery into ordinary annoyance.
Cognitive restructuring starts with self-awareness and self-monitoring. We begin by recognizing what we tell ourselves, explicitly or implicitly, regarding our performance and identity as psychotherapists. A few minutes of thoughtful reflection, collecting data to test our assumptions, or concerned sharing with significant others—all of these alert us to the self-deceptions that creep into our thinking and eventually into our practice.
As therapists, our introspective skills allow us to monitor internal dialogue. For example, a client relates an experience in session, and you cannot conjure up a compelling or accurate empathic reflection. You demean yourself, “Why can’t I feel or resonate today?” After a few moments, your self-monitoring may recognize this instance of faulty logic. There is no singular interpretation or reflection, and even if there was, there is no reason to expect perfection in each clinical transaction. Or perhaps there is no need to analyze or comment at that moment.
Self-monitoring permits us to recognize our cognitive errors, determine our faulty assumptions, and prescribe an alternative. If our irrational thinking is not immediately apparent to us, it very likely will stick out (like a neon light in the darkness) to others, especially our coworkers. All for the better! Another therapist’s viewpoint may provide a new spin on our thinking. One of our clinical colleagues, for example, artfully points out our heavy sighing between sessions, a guaranteed tip-off that our perfectionistic expectations are getting the best of us that day. A little collegial prompting begets self-monitoring and disputations.
We consider self-monitoring internal dialogue to be the indispensable first step in battling our cognitive errors. Awareness alone, of course, is insufficient in combating the therapist’s “musturbations” and shoulds. Intellectual insight by itself, as Freud reminded us, is about as efficacious as providing a starving person with only a dinner menu. But awareness and insight begin the process of cognitive restructuring.
“What do I do to keep from obsessing about a woman whose husband has just speculated on what knife he would use to kill her; a borderline patient who is chewing me out for not immediately returning her nonemergency phone call; or a staff member who has neglected to arrange for a repair, resulting in the ceiling falling in during a rainstorm?” So begins rational-emotive therapist Janet Wolfe’s (2000, p. 581) “A Vacation from Musturbation,” an article appearing in the Self-Care Corner in Professional Psychology, which one of us co-edited a few years ago. Her answer,: “I try as much as possible to practice what I preach during the work hours and to take my philosophy with me when I leave the office.”
Over the years, Albert Ellis (1984) has gathered the common irrationalities or lies we psychotherapists tell ourselves. His list of five “musturbations”—things that therapists tell themselves they must do— includes several corollary irrationalities. The following are extracted from his “How to Deal with Your Most Difficult Client—You.”
The corollary musturbations include (1) “I must always make brilliant interpretations or empathic responses,” (2) “I must help my clients more,” and (3) “I must not fail with any of my clients, but if I do, it is my fault and I’m a lousy person! “ After our putting in years of graduate training and after our best empathic efforts, some patients have the audacity to get worse. Shouldn’t they have the common courtesy of getting better?!
The reality of psychotherapy, of course, is that success is neither automatic nor universal. Any therapist who assumes she has to succeed every time will eventually find great disappointment. We will not be successful with every client for multiple reasons – to say that you must always do so is completely contrary to the definition of being human.
We are reminded here of a particular case, involving a schizophrenic woman, that personally affected Carl Rogers enough to impair his own functioning as a therapist and as a human being. This case is an example of how psychotherapists, believing success will come with every patient, can mistakenly ignore their own problems for the sake of their client. Before treating the woman, Rogers “had come to understand the importance of the client’s feelings in the relationship, [but] his own personal background [suppressing feelings as a child] still held him back from giving due attention to the therapist’s feelings” (Kirschenbaum, 1979, p. 191). Difficulties began when Rogers, the paragon of empathy, substituted apathy for his traditional warmth whenever the woman’s disturbance and dependence threatened him.
Although not succeeding with the patient, Rogers continued treatment. In his own words, “I started to feel it was a real drain on me, yet I stubbornly felt that I should be able to help her and permitted the contacts to continue long after they had ceased to be therapeutic, and it involved only suffering for me.” Moreover, recognizing “that many of her insights were sounder” than his, Rogers lost confidence in himself. Although Rogers suffered deep distress as a result of this experience, he worked through it and eventually liked himself more. Even the most eminent therapists, like the rest of us mortals, are often blindsided by impossible expectations.
What are adaptive alternative cognitions? That psychotherapy succeeds with most, but not all, patients, and that we are human and will make errors. Yes, it would be highly preferable to always make brilliant interpretations and always have good judgments, but that is unrealistic and unobtainable.
Two corollary musturbations are that “every therapy session with clients (including difficult clients) must be good” and “I must be an eminent therapist.”
In a self-care symposium we organized a few years back, Judy Beck (1997) spoke movingly of her travails when comparing her clinical and scholarly performance to her father, Aaron T. Beck, one of the founders of cognitive therapy. She was bound to feel inferior, as we all would, given the impossible standards. It is a constant struggle to make realistic comparisons instead of perfectionist evaluations. Judy Beck advises us to compare ourselves to same-aged peers in similar circumstances.
As Ellis ardently puts it in “How I Manage to Be a ‘Rational’ Rational Emotive Behavior Therapist” (1995, p. 4):
There is no damned—or undamned—reason why I absolutely must be an outstanding therapist, colleague, socialite or anything else! I am determined to always give myself unconditional self-acceptance (USA) whether or not I perform well and whether or not I am loved and approved.
The resultant internal dialogue might be “I would like to be an outstanding therapist and have good sessions with all clients, but if I cannot, I can still be a competent therapist and enjoy doing therapy.” Moreover, “Why do I have to be a well-known therapist? Am I afraid that if I do not work so ardently and compulsively, that I might not be a good therapist?” We do not have to be labeled as “the best” to perform well. If in the process of establishing a distinguished career we succeed in making ourselves disturbed with our own stringent, absolutistic views, haven’t we sacrificed too much?
Several related fallacies frequently follow: “I must like all my clients, but if I do not, I must not allow myself to have negative feelings toward them;” “I must not insist my clients work too hard in therapy;” and “I must avoid sensitive issues that might disturb or upset my clients.”
Many of us erroneously conclude that a patient’s liking us is equivalent to good psychotherapy. Yet, gentle confrontation is the other side of caring. We need to be caring, but we also need to be tough (Whitaker & Bumberry, 1988). The therapeutic relationship parallels good parenting. Just as a good parent provides a child with nurturance and discipline, to help a patient grow you provide support and honestly address problem areas.
Ideally, conducting psychotherapy should be pleasant. However, unpleasantness is sometimes a reality, a part of the vicissitudes of life. Asking patients to address difficult topics, pushing them to work harder, and recommending that they expose themselves to previously avoided situations will make the pathway to healing bumpy. During these potentially stressful times, patients may retaliate by becoming angry, canceling sessions, or even changing therapists. Just because you are a helper doesn’t mean the transactions between you and your client will always feel comfortable.
Corollary musturbations concerning the anticipation of cooperative patients include: (1) “My clients should be tractable, not impossible;” (2) “My clients should always have their homework assignments done on time;” and (3) “I should only have YAVIS (Young, Attractive, Verbal, Intelligent, and Successful) clients! Don’t hard-working, successful therapists deserve hardworking, successful patients?”
Is there a healthier alternative? Perhaps there is – “It would be ideal if all my clients were hard-working, but if they aren’t, I will still accept and try to help them despite their imperfections.” We all feel occasionally frustrated by our patients’ lack of motivation and further nettled by their apparent unconcern or lackadaisical attitudes. This comes with the job description. Your client is paying you to do your job—who says she must do hers? You? For a therapist, detached compassion is sometimes the way of survival. We can pitch the benefits of change, but we can’t make the client buy it.
Corollary thoughts might be (1) “I must use therapeutic techniques that I enjoy regardless of their benefit to the client;: (2) “I must use only simple techniques that will not drain my energy;” (3) “My sessions can be used to solve my own problems as well as the client’s problems.” These thoughts converge on the entitlement or grandiosity afflicting some psychotherapists after many years of practice.
Creeping entitlement can be met with cognitive restructuring. “I would be overjoyed if my therapy sessions helped me to solve some of my own problems; however, my job is to help my clients, not me.” Work is called work for a reason. It’s not necessarily fun, exciting, or simple, but it is often arduous.
To mentally combat the hassles at work, Ellis (1995, p. 4) recommends his musturbatory-busting rationale:
The conditions that often prevail in therapy don’t have to be always easy, comfortable, and enjoyable. In fact, they often aren’t. Unfortunate! Inconvenient! But not the end of the world. Just a royal pain in the ass! Now how can I do my best to improve them—or unwhiningly accept what I can’t change? What’s my alternative? More silly whining!
As every half-conscious psychotherapist knows, awareness alone is insufficient in rectifying such musturbations and shoulds. Instead, irrational beliefs are often deep-seated—tenaciously implanted at the core of our personality—and require vigilance in identifying and disputing them. Just as we do in our clinical work. We alleviate our emotional distress only by practicing rational beliefs, practicing appropriate emotions (such as annoyance instead of misery), and practicing desirable behaviors.
Experienced therapists benefit from many of the same cognitive therapy methods as their patients (Beck, 1997). For example, monitoring one’s overly busy schedule and rating pleasure and mastery of activities can help the therapist discover what changes need to be made. As another example, uncovering one’s expectations of self and others and assessing the advantages and disadvantages for holding such standards can lead to a more functional reassessment. Recognition and modification of a dysfunctional comparison set—such as Judy Beck’s earlier example of comparing herself to higher achieving mentors instead of similarly situated peers—often improves self-confidence.
What follows is a medley of cognitive errors frequently committed by psychotherapists and a compilation of potential cognitive solutions.
A patient in psychotherapy with you for 3 months is not getting better. You tell yourself you have done everything possible thus far. You listened attentively and resonated with the patient’s experience. You conducted treatment in accord with the research evidence. You tried several treatment approaches. You have prescribed (or referred for) psychotropic medication. Nothing seems to work. Yet twinges of guilt and doubt pass through your mind – “I’m a failure as a therapist!” and “I should have listened to my mother and become a lawyer!” Several other failure cases from the past invade your consciousness. Suddenly you are feeling worthless and inept; to compound your self-doubts, you realize that your patient is the one who is suffering the most here, and maybe, just maybe, it’s your fault.
Sound familiar? We are so accustomed to perfection. Our work means so much to us; we have devoted a substantial part of our lives educating ourselves for the work. And to get this far in the profession, we needed excellent grades and work habits—not average, but excellent.
The point is this – we are accustomed to being competent and successful. “The absolutely perfect practitioner is, of course, a misguided and misguiding illusion, but it still operates in the tacit life ordering that goes on in psychotherapists’ lives” (Mahoney, 1991, p. 352) Expecting perfection in practice contributes to our own mental suffering.
We can be like Winnicott’s (1958) good-enough mother. Even when we make mistakes in therapy or disappoint the client in some way, we can process these empathic failures. It’s not the end of the world. For example, one of us was on vacation when a client was going through a particularly difficult time. The next post-vacation session provided what Winnicott describes as an opportunity to re-experience the failure situation. Acknowledging that the client felt abandoned furthered the work of therapy and increased the relational bond.
Selective abstraction, as you may recall, is the mistake of believing that the only events that matter are failures and that you should measure yourself by errors (Beck et al., 1979). You probably also recall several ways to minimize selective abstraction, track your experiences to determine successes and failures, accept the inevitable limitations of your therapeutic skills, and distinguish between case failures and yourself as a failure. More simply, rejoice in your successes, accept your human limitations, and offer yourself unconditional acceptance. Just because you have failed does not mean you are a failure.
Consider the exemplar of negative outcomes in psychotherapy. Approximately 5–15% of patients will experience increased distress and deterioration while in psychotherapy (not necessarily because of psychotherapy). We conveniently forget the 75%+ who are successes and preoccupy ourselves with the failures. This is not to suggest, of course, that we should dismiss the failures as inconvenient artifacts; rather, it is to suggest a psychological re-equilibrium. We recommend that you track or “log” your success experiences.
Once they are tracked, remember those successes. As we recommended earlier, whenever you begin obsessing about a recent difficulty or failure, remind yourself of the scores of successful cases in which you have genuinely assisted people. Savor your successes and acknowledge your contributions to bettering the human condition.
We can also measure success differently than complete remission of symptoms and total patient satisfaction (Edelwich & Brodsky, 1980). We can focus on the process and our efforts rather than solely on the results; we can set more modest or achievable goals for patients, and not expect immediate results.
In the movie It’s a Wonderful Life, the guardian angel Clarence tried to comfort George Bailey, who was dissatisfied with what seemed like a failure-filled life. Clarence said, “You just don’t know how much you’ve done.” We must be our own “Clarence” and force ourselves to see all the good we have accomplished. While we cannot turn back time and observe our patients’ lives without our help, we can imagine it. There surely are many cases where our clients’ lives were significantly improved through our presence and intervention.
Just as patients may be distressed because they take on more work or responsibility than is expected of them, psychotherapists are susceptible to the same mistakes. We can fall prey to a messianic complex and take on too many patients, too many projects, or too many particularly disturbed clients. As we know from cognitive therapy (Beck et al., 1979, p. 188), our impression of the world must be re-conceptualized from “it is overwhelming” to (1) “What are the specific problems?” and (2) “What are the specific solutions?” The motto might be – Define and solve in an orderly, rational way.
You might counter that real-world problems are not so easily operationalized or solutions so evident. You could protest, “John and Jim, I am working in an overwhelming, understaffed public agency” or “I simply cannot do less or make less money.” That may well be, but we can break large, vague problems down into workable parts that can be more easily solved. If this sounds like advice you frequently give your patients, it probably is.
For starters, we are probably accomplishing more than we realize. By recording our actions in a log or diary, the record will show that we are accomplishing something. Cognitive therapists wisely maintain that taking some action represents a partial success. The cognitive distortion represented in the statement “The task is so problematic it cannot be done” is incorrect. The cognitive model of distress further holds that many people take on more work than they need to. For example, therapists typically think “I must see at least seven patients every day” or “I must allow at least 50 minutes for a session.” Still others wrongly think they are expected to do more than they need to do. For example, “I must practice full-time and teach a course at night plus be a great parent.” People who think this rigidly, according to cognitive theory, actually believe they cannot withdraw from any of their endeavors.
For people to obtain a realistic view of their workload and others’ expectations, Beck and other cognitive therapists suggest disputing unrealistic expectations, constructing boundaries, and assertively protecting those boundaries. For instance, “My private practice and children assume priority. Thus, I will continue the practice and be a good parent. However, there is no law stating that I have to teach in the evening.” In our own lives, we periodically enter a “just say no” stage. Say “no” to new patients, say “no” to writing offers, and say “no” to additional workshops. Of course, we must then cognitively tackle the emotional effects of saying “no” – the mild guilt in disappointing people, the potential regret in not making extra money, and the nagging doubt that we may not have similar opportunities in the future. We have found cognitive restructuring to be effective in reducing the emotional effects during such moments.
Psychotherapists often incorrectly assign the blame or responsibility for adverse events to themselves—assuming personal causality. The misguided, self-referencing belief is that we are to blame for all misfortune. If a client succeeds in therapy, it’s her responsibility; if a client fails in therapy, it’s my responsibility (fault). Attributing most adverse occurrences to a personal deficiency, such as a lack of ability or effort, is assuming personal causality.
As we write this course, hundreds of subscribers to the e-mail network of the Society of Clinical Psychology were mistakenly removed because of a hardware error. Dozens of these doctorally-trained psychologists posted their beliefs that they were omitted from the subscription list because they thought they had annoyed the list manager or had committed a grievous insult. They were, in short, assuming personal causality for a random technical error. In medicine, physicians are trained early and well to realize that some patients, such as those in end-state terminal cancer, will probably never improve, but they try to help nonetheless. In psychotherapy, we intellectually acknowledge these constraints but have not yet learned to accept our limits openly.
One of us painfully recalls conducting therapy with a couple who decided amicably to get divorced. I took it hard until my wife reminded me, in simple and caring words, that I did not create the relationship difficulties. This simple observation exploded my largely unconscious belief that somehow I was responsible for reversing time—like Superman circling the planet Earth to turn back the clock—and for fixing their extensive problems. We all struggle not to feel responsible for solving and eradicating our clients’ problems, however vexing and longstanding.
The weight of self-reproach can be lifted and some objectivity gained through the disattribution technique (Beck et al., 1979, p. 158). The disattribution technique is a simple yet powerful method. It entails recognizing that you impose excessively stringent standards on yourself and disputing the belief that you are entirely responsible for negative events.
Consider the case of Dr. G, a conscientious and scrupulous practitioner who entered personal therapy with one of us because she felt responsible for the suicide of a 27-year-old patient. Some of her self-blaming statements were “If my schedule wasn’t so booked, I could have seen her more often” and “I should have been more observant during that last session—I could’ve noticed some sign of her self-destructive intent.”
After several sessions and grief work, Dr. G related that she had actually taken considerable care with this difficult patient: she had revamped her schedule to accommodate additional sessions, carefully monitored the patient’s medications, sought the counsel of the patient’s two previous therapists who also had little success, and had taken other measures to safeguard herself and her quite disturbed patient. After applying the disattribution technique, Dr. G gradually realized that not only did she conduct “good-enough” psychotherapy but she also went beyond her customary duty. Finally, Dr. G recognized that she was not responsible for this woman’s death. Neurotic guilt gave way to understandable loss and pain—a tragically common occupational hazard of working with severely disturbed humans.
In addition to assuming personal causality—“I am responsible for these bad things”—psychotherapists often assume temporal causality— “Bad things happened in the past, so they will happen in the future.” Consider these negative prophetic statements: “My last two long-term cases never improved, so this one probably won’t either”; and “Another depressed person. Therapy will now be difficult because it’s hard to change the negative thinking. This process is draining and monotonous. Therefore, I won’t be doing my best therapy.” How do we know these predictions are true? We don’t.
When you catch yourself making doom-and-gloom statements, you may profit by carefully analyzing your assumptions. Making them explicit, writing them down, or sharing your arguments with a colleague may sound ridiculous. You will probably protest initially, “For heaven’s sake! I’m a therapist, I don’t need to express my thoughts in writing—surely, I’m more sophisticated than that! And share my irrational thoughts with colleagues? They’ll think I’m an idiot!” This resistance frequently betrays another belief commonplace among self-sufficient therapist – the fear of appearing incompetent.
Taking a few moments to contemplate your internal talk, what you have written, or a colleague’s comments may bring to light your own overly pessimistic reasoning.
Also, instead of treating past events as totally predictive, you can list other factors influencing the outcome. For example, there are a number of patient and environmental variables that have an impact on the outcome of psychotherapy. Two patient characteristics that predict slow or little success are high functional impairment and low readiness to change (see Norcross, 2002). Perhaps the patient’s environment, your clinical setting, or the available resources simply do not offer the number of sessions or intensity of services needed. Taking the time to identify other factors that may influence the outcome will eliminate using past experience as the sole predictor of future events.
Anticipating the worst outcome protects us; at least we won’t be surprised when it happens. However, doomsday prophecy also contributes to therapist decay. At lunch the other day, one of our colleagues, a counselor employed at the local community mental health center (CMHC), acerbically insisted that “no one comes out of the partial hospitalization program better than when they came in.” After empathizing with his difficulties in battling chronic disorders with severely underfunded resources, we gently chided him to reevaluate whether catastrophizing his program’s outcomes did anything to improve the situation.
There are at least three salutary cognitive strategies for treating catastrophizing: (1) show that the worst did not actually happen (“Did that really occur?”), (2) determine the actual likelihood that the worst may happen (“What are the real probabilities?”), and (3) evaluate the consequences should the worst scenario improbably occur (“What would be the worst that could happen?”). With our frustrated CMHC colleague, respectful inquiries revealed that the worst did not actually happen—the partial hospitalization program surely does have successes. If the worst did occur for certain patients who deteriorated, then they were immediately referred to the inpatient unit, a real probability for many of these chronically and severely disturbed patients. When the worst did occur, the patients underwent a brief inpatient stay and then returned to the partial hospitalization program. While our colleague’s emotional frustration in working with such a difficult population is readily understandable, his cognitive distortions unfortunately reinforced our collective susceptibility to negative thinking. We—all of us—are certainly human.
How many times have you said, “I got nothing done today,” or “All my sessions were tough”—or even “Managed care is destroying my private practice”? Dichotomous (“either–or”) thinking is both a cause and a result of psychotherapist distress. A related attribute of this dysfunctional mindset is viewing negative consequences as irreversible.
Evaluating events on a continuum is an effective antidote for dichotomous thinking. Speaking in quantitative terms may seem like a mechanical exercise, but it pays off. For example, instead of “I got nothing done today,” perhaps “I accomplished a few minor tasks today and a small portion of a major task.” Rather than “all my sessions were tough,” perhaps “50% of my sessions were trying and 50% were moderate” would be a more accurate description of your day.
To modify extreme thinking and to view negative consequences as both reversible and only temporary, look for partial gains in reversals (Beck et al., 1979). What positive element can you find in a day that was otherwise “a complete disaster”? If you were not performing well, perhaps you made some mistakes while conducting therapy. “My day was a total mess!” might be mentally transformed into “Now that I know what mistakes to avoid, I will conduct better therapy next time.” In fact, these struggles do make us better psychotherapists. In On Being a Psychotherapist, Goldberg (1986, p. 109) maintains that if the practitioner regards her own struggles not as signs of weakness and shame, but as pangs of passion, caring, and concern, then the practitioner is more likely to offer clients a more meaningful therapeutic experience. Dichotomous thinking is a fitting example of rigidity. To place all of your experiences into two groups (e.g., good and bad) is unrealistic. As we have seen, there are positives even in “bad” clinical situations.
A pervasive struggle for all psychotherapists is thinking “straight” about their countertransference – those internal and external reactions in which unresolved conflicts (usually but not always unconscious) are implicated (Gelso & Hayes, 2002). How do we think through our client-induced rage or dysphoria or sexual arousal? Countertransference requires all of the self-care methods in our arsenal including a few words here on cognitive restructuring.
The nascent research on managing countertransference highlights five interrelated skills: self-insight, self-integration, empathy, anxiety management, and conceptualizing ability (Gelso & Hayes, 2002). Four of these attributes directly concern the cognitive operations of the therapist, whereas self-integration refers to the therapist’s possession of an intact, basically healthy, character structure. These serve as a cognitive roadmap.
Self-insight refers to the extent to which the therapist is aware of her own feelings, including countertransference feelings, and understands their basis. Empathy permits the therapist to focus on the patient’s needs despite difficulties she may be experiencing with the work and inclinations to attend to her own needs. In addition, empathic ability may be part of sensitivity to one’s own feelings, including countertransference feelings, which in turn ought to prevent the acting out of countertransference. Anxiety management refers to the therapist allowing herself to experience anxiety but also possessing the internal skill to control and understand anxiety so that it does not bleed over into responses to patients. Finally, conceptualizing ability reflects the therapist’s ability to draw on professional theory and to comprehend the patient’s dynamics in relation to the therapeutic alliance.
All of these skills are brought to bear on understanding the patient’s dynamics, your response to them, and then acting constructively despite your anxiety. When a patient screams at you, your awareness and interpretation of projective identification enable you not to scream back. When a patient argues incessantly with you, perhaps rekindling parental or sibling conflicts, your cognitive restructuring and anxiety management help you label it as enactment of old relational patterns, and you do not argue in return. Identifying, labeling, and managing your intense affective reactions all require advanced cognitive restructuring. These skills increase your capacity for affect regulation and demarcating the boundary between your emotional life and that of your patient. In this way, your cognitive self-care is crucial to remaining present, supportive, and effective with patients.
We end this section – perhaps we should have begun it—with the ultimate psychotherapist fallacy – “I should have no emotional problems. After all, I am a therapist!” We all chuckle appreciatively at this palpable nonsense— but also at the self-recognition that a small part of us secretly clings to it. Most psychotherapists suffer from idealized perfectionism and outrageous expectations; then, to top it off, they feel ashamed and guilty for acknowledging their perfectionistic expectations. Take comfort in Freud’s (1937/1964, p. 247) early recognition that “analysts are people who have learned to practice a particular art; alongside of this, they may be allowed to be human beings like anyone else.”
Yes, if therapists were not human, we’d be able to transcend dysfunctional thinking and avoid the occupational hazards. This lament reflects, in itself, wishful thinking instead of cognitive restructuring. Just as industrial workers must undergo safety training in working with heavy machinery, therapists must practice cognitive restructuring as a sort of mental safety, self-maintenance routine.
While we are on the topic, let us be sure to create realistic expectations of self-care. If they are not careful, some of our workshop participants transfer their perfectionism to their self-care. One of our participants wrote that the lasting lesson of the workshop for her was “To be more realistic about what’s doable in a certain time period. I am not setting myself up for a feeling that I have failed.” Please practice cognitive restructuring against unrealistic self-care expectations. If only we took our advice more seriously! (Kottler, 1993) It is poignantly ironic that the skills we teach our patients seem like foreign concepts when we combat our own difficulties. It is easy to discern someone else’s difficulties when you are an objective observer; it is hard to observe yourself objectively.
Assuming too much responsibility for our patients, catastrophizing over a case, and thinking dichotomously about the outcome of psychotherapy are just a few examples. Some empathic but persistent disputations help. Who is responsible for our patients’ psychopathology and decisions? How many cases are truly outstanding successes, on the one hand, or spectacular failures, on the other? Not many; it is always a continuum of outcomes.
Recognizing and managing our own musturbations, cognitive errors, and countertransference reactions are paramount to leaving it at the office. If we can offer ourselves the same empathy and cognitive restructuring we strive to provide to our patients, then we will indeed count ourselves among the successful patients we have treated.
Beck, J. S., & Butler, A. C. (2005). Treating psychotherapists with cognitive therapy. In J. D. Geller, J. C. Norcross, & D. E. Orlinsky (Eds.), The psychotherapist’s own psychotherapy. New York: Oxford University Press.
Ellis, A. (1984). How to deal with your most difficult client—you. Psychotherapy in Private Practice, 2, 25–35.
Wolfe, J. L. (2000). A vacation from musturbation. Professional Psychology: Research and Practice, 31, 581–583.
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