This is a beginning to intermediate course. Upon completing this course, mental health professionals will be able to:
Our first CE course on psychotherapist self-care covered three self-care methods: Recognizing the Hazards, Setting Boundaries, and Restructuring Cognitions. In this second course, we consider another three crucial methods: Minding the Body, Nurturing Relationships, and Sustaining Healthy Escapes. Together, we categorize them as Leaving It at the Office.
Our ardent hope is that your spirit and practice will be touched as you complete this CE course. The Self-Care Checklists at the end of each segment can help you individualize a personal action plan. These self-care strategies, we hope, will re-awaken and redirect sensitivities to the person of the psychotherapist. Leaving It at the Office can only exert its rightful purpose if you are embracing each moment with eager self-care abandon. If our course has ignited your ability to do so, even by just a little bit, then our efforts will have been amply rewarded.
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.
Paradoxes abound when considering strategies to relieve the stress of conducting psychotherapy. Paradoxically, one way to leave distress at the office is to enhance functioning at that same office. Not to frantically squeeze 10 hours of work into 8 hours and then expect to retreat peacefully to a safe haven elsewhere, for instance. Paradoxically, too, one way to leave distress at the office is to enhance one's life outside the office: Enjoying your relationships, minding your bodies, and participating in healthy escapes, for instance, so that you are fully charged for the onslaught of intense contact with disturbed clients.
The upshot of these paradoxes is that a balanced and comprehensive plan for your self-care as a mental health professional will require a dual focus—in your workplace and outside your workplace. Accordingly, we address self-care "at the office" as well as "away from the office."
Patients frequently act, for defensive purposes, as though psychotherapists do not have lives outside of the consulting room. We shall not commit the same error.
Suppose you were to come upon someone in the woods working feverishly to saw down a tree. “What are you doing?” you ask. “Can’t you see?” comes the impatient reply. “I’m sawing down this tree.” You exclaim, “You look exhausted! How long have you been at it?” The man replies: “Over five hours, and I’m beat! This is hard work.” You inquire, “Well, why don’t you take a break for a few minutes and sharpen that saw? I’m sure it would go a lot faster.” The man emphatically replies, “I don’t’ have time to sharpen the saw; I’m too busy sawing!”
That is the first paradox of self-care: no time to sharpen the saw! The story, incidentally, comes from Stephen Covey’s The 7 Habits of Highly Effective People (1989, p. 287). It is so easy to see and diagnose it in other people; it is so hard to get off the treadmill ourselves.
Existential–humanistic psychotherapists Sapienza and Bugental (2000, p. 459) put the self-care paradox bluntly: “Many of us have never really learned how to take the time to care and to nourish ourselves, having been trained to believe that this would be selfish…. Nor have most psychologists taken the time to develop compassion for themselves, and compassion for their wounds.”
Not that psychotherapists are opposed to self-care—far from it. Instead, we are busy, multitasking professionals dedicated to helping others but who frequently cannot locate the time to help themselves. Clients, families, paperwork, colleagues, students, and friends seem to always assume priority. The ideal balance of caring for others and for ourselves tends to favor the former. At the risk of redundancy, we believe it begins with prioritizing the value of yourself as a person/psychotherapist.
This point segues into another paradox of psychotherapist self-care—not availing ourselves of what we provide or recommend to clients. Often, we feel hypocritical or duplicitous – suggesting to others that they work less, exercise more, renew themselves, and so forth – while we do not take our own advice. How often do we sit with patients encouraging them to “relax and take a vacation,” while calculating our lost therapy revenue and airfare and concluding we can’t afford to take the time away from the office right now? (Penzer, 1984)
A recurrent theme of this course is the acknowledgement that it is easier to be wise and mature for others than for ourselves. If you are still feeling a little hypocritical, sheepish, or guilty about not practicing what you preach, then join the crowd and us. We are far more adept at recommending self-care to others than practicing it ourselves, as our families and friends will readily attest. Until quite lately in our own lives, self-care was regrettably more of a research proficiency than a personal success. We are in no position to moralize.
In fact, we take seriously an early lesson of folks traveling to Esalen, the human potential center in California. Although the trainers at Esalen were teaching other people how to relate to themselves and other people in optimal ways, they themselves had serious difficulties in their own lives and relationships. This lead Richard Price to popularize what he called Esalen’s Law: we always teach others what we most need to learn ourselves. A corollary is that each of us is our worst student. (Thanks to Ken Pope for reminding us of the law’s origins.)
Just as being a lawyer does not necessarily make one more honest and being a physician does not necessarily make own healthier (Goldberg, 1992), so too does being a psychotherapist not make one automatically more proficient at self-care. In fact, it is frequently the converse in a profession that people enter “to help others.”
Psychotherapists are so intent and focused on sophisticated self-care methods that we frequently overlook the biobehavioral basics of self-care: adequate sleep, rest, nutrition, exercise, and human contact. Do you subsist during the practice day, as did one of us for years, on diet soda and pretzels between appointments? How many hours of sleep do you need versus what you typically get? Do you sit all day, major muscles stiffening, while your facial muscles work overtime expressing emotions? Let’s not neglect the fundamentals of self-care.
As authors, we half apologize for reminding a sophisticated audience of these basic needs. Yet, the biology is elemental and demanding. The body in psychotherapy has become marginalized; many therapists have historically practiced from the head up. We need to take our bodily reactions more seriously, as the body constitutes the fountainhead of human experience. As Freud repeatedly reminded us, being a psychotherapist does not make us any less human.
In this brief but necessary section, we mind the body of the psychotherapist—sleep, bodily rest, nutrition, exercise, and human contact (including sexual gratification). These, quite literally, embody our energy and sense of engagement.
In our interviews with master practitioners, a recurrent self-care theme is obtaining ample sleep—a simple but powerful solution to occupational distress. Said one, “I have really made an effort, though not always a successful one, to get 8 hours of sleep a night. It makes a huge difference.”
Our watchwords as psychotherapists should be mens sana in corpore sano (a healthy mind in a healthy body). It is extremely shortsighted to see sleep as an obstacle to productivity. A nightly investment in sufficient rest leads to greater resilience and accomplishment.
The research literature attests to the value of maintaining a standard sleep window to secure sufficient sleep. Some call this sleep hygiene and others label it sleep stimulus control, but whatever name is used, many meta-analyses support its efficacy for obtaining sleep and treating insomnia (Morin et al., 1999; Smith et al., 2002). Those same meta-analyses further demonstrate that sleep stimulus control typically results in a shorter sleep latency (the amount of time needed to fall asleep) and in fewer negative side effects and addictive consequences than sleep medications. Stimulus control instructions mesh well with our emphasis in this course on the superior self-care effectiveness of harnessing the power of both the person and the environment.
Consider adopting the following sleep rules or instructions (Bootzin, 2005):
One of us (JCN) has been impressed in his own life with the results of rising with the sun and sleeping with the stars, from 10:00 P.M. to 6:00 A.M. It is a highly natural, in tune with nature, sleep pattern. It also gets one to the office early for concentrated stress-free work.
Let’s start comprehensive self-care by tending to your sleep, thereby recharging your battery. A body in motion deserves predictable rest.
The lyrics of Jackson Browne’s song, “Running on Empty,” warn us that running on empty, without rest or restoration, means pushing harder and enduring more pressure. Running on empty frequently means “running blind” and “running behind.” Psychotherapy consists of two or more physical presences in the consulting room. Interviews with experienced psychotherapists reveal that they suffer physically in a number of ways from the craft (Shaw, 2004). When we are empathic, we respond physically to patients, such as an anorexic or bulimic patient talking about vomiting and diarrhea. We vicariously feel anxiety as patients describe a panic attack or physical abuse. The body is a receiver.
The stress associated with conducting psychotherapy is often manifested in muscle tension, particularly in the jaw, neck, and back. As a result, many of us find massage to be an effective and pleasurable method of treating muscle discomfort. Facial massages are natural antidotes to experiencing and expressing strong emotions through the major face muscles. Massage not only helps muscles relax but also clears away waste products and the assorted pain that comes with tight muscles. Physiologically, it stimulates blood flow, improves muscle tone, and enhances the immune function (Field, 1998). Psychologically, a course of massage therapy reduces anxiety and depression almost as psychotherapy, according to a meta-analysis of 37 studies (Moyer, Rounds, & Hannum, 2004).
Our muscles stiffen when we sit for such long hours. In the office, we have learned to take short walks between sessions, even if only within the office or to the bathroom, and to give ourselves facial massages to ease the tension in the jaw. Outside the office, we have learned to schedule full-body hour-long massages.
Massage offers a recuperative rest from the turbulence of stress (Cady & Jones, 1997; Field, 1998). As stated by one master therapist: “I go to a professional massage therapist once a month or more. It helps keep me in touch with my body. It also reverses the roles; I am in the position of receiving rather than giving the care.” Another master clinician used massage in a creative and specific manner:
I was doing marital therapy with a couple, and they were really struggling with some issues that were difficult for me to be emotionally present to. What I did during the course of seeing them in therapy was set up a weekly session of massage for myself. I experimented with having my massage session before seeing the couple versus after seeing the couple. Although it felt good afterward, it seemed to be more helpful ahead of time. It helped me be centered and balanced and emotionally present in terms of what they were experiencing and my being moderator and counselor.
Different massage techniques are readily available from professionals in virtually all localities: deep muscle, Swedish, hot stone, acupressure, and Rolfing, for example. Taking a class or receiving individual treatments can be most useful, both for immediate stress reduction and for ongoing body self-care. We urge you to try it, if you haven’t already. It is simply invaluable.
During sessions in the office, try to keep your body straight and sit erect. Some therapists appear to flop around or remain off-kilter. The therapist’s physical posture is a crucial indicator. Sitting with a good posture throughout the session helps you give clients your full attention and preserves your energy. Be balanced and flexible, always gravitating to your center (Rosenbaum, 1999).
Move your body often to counteract the sedentary nature of your workday. Go for brief walks between appointments or during lunch. Learn to massage your own feet between sessions. Make sure you stretch your shoulders, neck, and legs now and then. Avoid a motionless sitting position that reduces your circulation and energy. In sum, give your body a rest between the relentlessly emotional but sedentary sessions.
In one of our first workshops on self-care, we quizzed the participants privately and anonymously about their nutrition during the workday. Only a quarter of psychotherapists thought their nutritional intake was healthy and adequate; three-quarters thought it was unhealthy, inadequate, or both. Since that inauspicious discovery, we always take a few moments to address nutrition and hydration.
Up until the past 10 years, our own performance in this domain of biobehavioral self-care was dismal. We subsisted throughout the day on coffee, sodas, and quick finger foods, only to become ravished and eat one enormous unhealthy meal at 9 P.M. We have become more mindful of our nutrition of late—perhaps because we are heeding our own advice, perhaps because we are in middle age, or perhaps because our caring spouses are determined to improve us. (Our money is on the latter.)
One of our psychotherapy patients was a registered dietician who helpfully suggested that we monitor our fluid intake during the workday. After thanking her for the recommendation and commenting on her reenactment of devoting more time to others than to herself (her presenting problem for treatment!), we gratefully did so. We were consuming about 60% of the recommended daily intake of 3 liters (13 cups) for men (2.2 liters for women). (Institute of Medicine, 2006) Losing just 2% of your body’s water will result in you feeling tired and weak. You might want to monitor your own hydration for a few clinical days.
The self-care imperative is to eat balanced nutritious meals and to hydrate oneself adequately during the day. Following a self-care workshop, one of our participants wrote, “I’ve begun by addressing some basic thing and have made a commitment to myself to do something not spectacular but something no matter how small but that builds on my daily self-care. Today it was getting breakfast, listening to relaxing music, and massaging my feet. And so it begins.”
Surveys involving thousands of psychotherapists discover that 71–78% engage in regular physical exercise (Barrow, English, & Pinkerton, 1987; Mahoney, 1997; Sherman & Thelen, 1998). Jogging, walking, workouts, tennis, racquetball, swimming, and bicycling lead the list of favored activities (Barrow et al., 1987). Here are 10 verbatim testimonials from our master clinicians and workshop participants:
A tenth and final illustration comes from Jeffrey Kottler in his book, On Being a Therapist. (1986, pp. 138–139). Here is his personal testimony on the salubrious effects of exercise:
When I ride my bike, the wind washes me clean. Everything I have soaked in during the previous days oozes out through my pores, all the complaints and pain and pressure. I feel only the pain in my legs and lungs as I climb up a hill pumping furiously. And then I coast down as fast as I can, never knowing what is around the next turn. For an hour or two, I am no longer a receptacle for other people to dump their suffering. Nobody catches me on my bike. There is no chance to think, or I will miss a pothole in the road. And it takes too much concentration watching for traffic, pacing my rhythm, switching gears, working on technique, saving my strength, breathing slow to consider anything outside my body. After a ride through the country, I feel ready again to face my clients, my past, and my uncertain future.
Associations between exercise and well-being have been documented repeatedly for decades. Such exercise most positively affects the therapist’s physical stamina, emotional mood, and mental stamina. The affective beneficence of exercise in psychotherapists converges, of course, with the empirical research attesting to the link between exercise and decreases in depression, anxiety, and body hatred (Hays, 1995). A meta-analysis (Stathopoulou, et al., 2006) of 11 treatment outcome studies demonstrates large effects for the efficacy of exercise. We suspect exercise may be even a more powerful benefit for psychotherapists—whose jobs are typically highly verbal, sedentary, and nonphysical—than for people in general.
A few cautionary words about exercise for the idealistic, perfectionistic practitioner (that’s 94.3% of us)—please keep your exercise expectations realistic. Heed the sage words of one of our master practitioners, “While my exercise is modest (20–25 minutes of Nordic Track or stationary bike with sit-ups) every other day, I am realistic that I will be more likely to succeed at this level rather than if I set myself impossible goals. Since I am always encouraging my clients to assess both their confidence and their competence when they set goals, I am trying to take my own advice.”
Psychologist Harry Harlow (1958) was amongst the first, and inarguably the most memorable, to experimentally demonstrate the inborn need for human contact that clinicians have witnessed for centuries. You may recall that Harlow took infant monkeys away from their biological mothers and gave them instead to two artificial, surrogate mothers, one made of wire and one made of cloth. The wire mother was outfitted with a bottle to feed the baby monkey. Nevertheless, the babies rarely stayed with the wire mother longer than it took to get the necessary food. Babies strongly preferred cuddling with the softer cloth mother, especially when they were frightened, even though it/she did not offer milk.
Such contact comfort is of overwhelming importance in the development of affectional response. Certainly, we cannot live by milk alone. We all need contact comfort, a little cuddling.
Some clinicians keep a favorite pillow or afghan nearby during sessions, to hold or touch. Others allow for time for phone calls to close friends and family members in the midst of a busy day. One master clinician schedules a weekly lunch with his spouse and small children, providing an opportunity for physical affection and meaningful contact, between psychotherapy clients.
Of course, the need for contact comfort can be partially satisfied in sexual relationships. Saul Bellow’s Herzog (1964, p. 166) goes so far as to argue that “the erotic must be admitted to its rightful place, at last, in an emancipated society which understands the relation of sexual repression to sickness, war, property, money, totalitarianism. Why, to get laid is actually socially constructive and useful, an act of citizenship.” We would not go that far, but Herzog vividly makes the case for sexual gratification.
The next section is devoted in its entirety to nurturing relationships for psychotherapists. Our intent here is to collegially remind us all of the biological need for contact comfort and sexual gratification.
Psychotherapists, being more human than otherwise, are subject to the same biological needs and amenable to the same physical releases as other humans. In this chapter, we hope to remind you to reconnect to the body, that thing below your neck, in your self-care.
All health care practitioners assuredly know the preceding material and routinely encourage their patients to mind their bodies. But if there is a first-place, blue-ribbon award for the disconnect between psychotherapists’ practices with patients and those same psychotherapists’ practices with themselves, then it is certainly in the realm of satisfying biological needs.
We trust that this section has neither belabored the obvious nor insulted your intelligence. Although we have been intentionally brief, let not this brevity be misconstrued. Sleep, bodily rest, nutrition, exercise, and human contact are indispensable to well-functioning psychotherapists. Get real, get basic, and get bodily self-care.
Dement, W. C., & Vaughan, C. (2000). The promise of sleep. New York: Dell.
Hays, K. F. (1995). Psychotherapy and exercise behavior change. Psychotherapy Bulletin, 30(3), 29–35.
Scott, C. D., & Hawk, J. (Eds.). (1986). Heal thyself: The health of health care professionals. New York: Brunner/Mazel.
In Flannery O’Connor’s short story “The Lame Shall Enter First,” a psychologist appropriately named Sheppard is dedicated to reforming troubled boys. However, the story ends with the devastating realization that, in trying to “save” a particularly hardened boy, Sheppard has neglected his own son and his own soul. “He had stuffed his own emptiness with good works like a glutton,” as O’Connor described it. The call to care for others may be taken to overzealous proportions—and with dire consequences (O’Donnell, 1995).
We need to take care while giving care; we need to nurture ourselves while we are nurturing others.
As psychotherapists, we work in a world of intimate relationships. The intense emotions experienced during these encounters seep into our private lives and relationships. As we have discussed before, the isolation, introspection, and restraint characteristic of the healer role can reduce our spontaneity, vitality, and spirit. A clinician may notice in herself a growing awkwardness with casual conversation or a tendency to be withdrawn or quiet at parties (Freudenberger, 1990a).
Insofar as intimate treatment relationships can deplete our inner resources, restoration of our resources can also occur within the context of meaningful relationships. Psychotherapists as a group have been described in classic research as independent, socially withdrawn individuals who spend considerable time alone (Henry et al., 1973). Therapists often have the image of a “loner” who restores inner resources by withdrawing into a cocoon of isolation and peace. Indeed, one of our master clinicians described just such a pattern in herself: “After working closely with clients all week, I really look forward to spending time by myself during the weekend. I don’t really want to talk to anyone. I’d rather go off alone to hike or bike. Physical recreation, by myself, raises my spirits and gives me back my energy for the next week of appointments.”
Despite the occasional need for psychotherapists to recharge their batteries through time spent alone, the clinical and research consensus is that we are best able to restore inner strength and regain emotional balance in the context of meaningful relationships (Medeiros & Prochaska, 1988). In fact, our survey of master therapists for our book found that they relied most heavily on nurturing relationships. As one master clinician put it simply: “I really rely on my most important relationships for personal encouragement. My friends and family give me the love and support I need for dealing with patients all day long.”
Nurturing relationships reliably emerge as effective self-care in the psychotherapist research (Norcross & Aboyoun, 1994). In several of our studies, mental health professionals consistently report greater use of helping relationships than educated laypersons in dealing with their own distress. In related studies, increased use of helping relationships correlates positively with psychotherapist well-being—just as use of social support typically does with laypersons (e.g., Pearson, 1986). Expectedly, psychotherapists find helping relationships to be both satisfying and efficacious for themselves.
Of course, psychotherapists find nurturance from their relationships in a multitude of ways. In this section, we review advice and examples from a number of these, both in the office (e.g., colleagues, staff, supervisors, sometimes patients) as well as outside the office (e.g., friends, family, consultants).
The clinical world is frequently populated with individuals capable of providing support, concern, and assistance. Psychotherapists find that they can be replenished by encounters with a variety of people during the workday who give to them the very same expressions of support that they regularly give to clients. This is not to imply that the psychotherapist’s role entails an equal share of nurturance for herself; we rarely receive the same amount of caring that we give at the office. Nonetheless, that nurturing moments can come for the therapist within the context of clinical work is indeed a welcomed realization.
Clinical colleagues are an important means by which to replenish our emotional reserves (Gram, 1992; Lewis, Greenburg, & Hatch, 1988; Menninger, 1991). Because they understand the world in which psychotherapy operates, they are able to appreciate the feelings, reactions, and concerns of fellow psychotherapists. By sharing their perspectives on treatment methods, diagnostic questions, ethical dilemmas, and practice challenges, they become partners who support and advise. This can be quite encouraging and reassuring to the practitioner, who otherwise feels alone with the challenges inherent in her work. Within the defined limits of confidentiality and ethical practice, other psychotherapists are a valuable self-care source.
Most of our master clinicians found it helpful to discuss clinical problems and difficult clients with colleagues as a means of lessening the distress of practicing psychotherapy. Some found it helpful to limit contacts with colleagues to informal encounters in the hallway or casual conversations over lunch. One master clinician described his experiences as follows:
I use casual conversations with colleagues to cathart and ventilate my frustrations. It’s comforting when one of them says, ‘Gee, I am glad to see that that happens to you also and not just to me.’ Just the fact that I’ve shared my complaints makes me feel better . . . simply being able to get if off my chest. It’s also helpful to get direction and guidance from colleagues. I walk away fortified by their input.
The authors (Coster & Schwebel, 1997, p. 10) of a study on well-functioning psychologists unambiguously conclude their study by stating, “If you do not have a close, cooperative, trusting relationship with one or more colleagues, we advise you to establish one. Such a relationship is a powerful resource in coping with the inescapable practice, management, and ethical problems.”
Other psychotherapists prefer to formalize nurturance from colleagues by organizing peer supervision/support groups that regularly meet to discuss professional issues of concern. The best estimates are that 10–25% of practitioners attend a peer support, supervision, or consultation group on a regular basis (e.g., Lewis et al., 1988; Sherman & Thelen, 1998). In the words of one of our workshop participants: “I do a lot of self-care, but the best way to handle stressful situations created by encounters with difficult therapy clients is consultation with peers. That extra perspective and support usually means a lot.”
Peer groups among clinicians have multiple advantages over mentor–protégé relationships (Gram, 1992). For one thing, they are often more readily available than seasoned mentors. For another, they are likely to be less expensive, if payment is expected of supervision. For still another, peer groups are advantageous in their implicit mutuality and nonhierarchical structure.
Moreover, peer groups typically serve multiple functions. These include providing a sense of community with other professionals, addressing unmet needs for appreciation, learning about practice management, sharing difficult cases and feelings, and receiving the support of fellow travelers. The content depends upon the goals of the group and the composition of the members but converges on providing mutual support in dealing with problematic cases, sources of stress, personal conflicts, and ethical matters. Research indicates that top expectations for peer consultation groups are to consider problem cases, discuss ethical and professional issues, and share information (Lewis et al., 1988).
All agree that peer groups must be carefully selected and structured to ensure trust and confidence. Confidentiality is the sine qua non for a successful group. “What is essential is that the group offer a safe, trusting arena for sharing of the stresses of personal and professional life” (Yalom, 2002, p. 254).
With or without a leader, peer groups are relatively easy to begin and nurture. You need a few dedicated members, a confidential setting, and a regular meeting time. Most groups contain 4 to 10 members and meet every 2 weeks to once a month for 2 hours per meeting. In rural or isolated areas, peer support is available via telephone or videoconferencing.
A specific form of peer supervision is the Balint group, named after the British psychoanalyst Michael Balint (1957). Here, a small group of clinicians creates a safe and structured opportunity to explore what it is about a particular patient that touches the psychotherapist in certain ways. In an hour every other week, psychotherapists take turns presenting a patient and the dilemmas that treating them invoke. Then, colleagues take turns asking clarifying questions—not questioning your diagnostic or treatment decisions, but about how the psychotherapist experiences this particular patient. Thereafter the group offers, ideally in a nonjudgmental manner, a wide range of possible thoughts, conjectures, and feelings about what may be transpiring between the psychotherapist and the particular patient (Sternlieb, 2005).
The Balint group is a form of peer consultation, but differs from it as well. There is an identifiable group leader who facilitates the process and ensures that individual members are not challenged or criticized for their treatment decisions. The group’s purpose is not to find solutions, offer advice, or present formal cases, as many peer consultation groups do. Instead, the Balint group strives to increase understanding of the patient’s disorder and to offer divergent views on the therapist’s response to the patient. In this respect, Balint groups are a hybrid of group therapy and peer consultation.
There are advantages and disadvantages to having peer groups meet at one’s workplace. On the plus side, during work hours group members are all aware of the oppressive situation and demands of the setting, are familiar with each other, can provide on-site support, and can congeal the staff. On the downside, group meetings at the workplace can deteriorate into gripe sessions, can threaten confidentiality, might intensify existing rivalries, and can feel a little too close to home. We have been involved in and led both types of peer groups, some in-house and some from mixed-practice settings; we can recommend both.
The family therapy pioneer Carl Whitaker started “cuddle groups” for psychotherapists out of the recognition that peer support was invaluable. Therapists come together and support one another in their personal and professional growth. In fact, toward the end of his life, Whitaker participated for years in a cuddle group, exercising care to be just a member and facilitator, not the leader. One of the participants in our self-care workshop summarized the results of her workshop experience like this: “I was inspired to get more strokes from work relationships. I talk to colleagues more during lunch instead of doing paperwork. I have also talked to my colleagues and supervisor about cuddle meetings to decompress. They received the idea warmly.”
Peer groups are powerful vehicles; avail yourself of the opportunity or create your own group, if possible. Peer groups for practitioners serve as a personalized source of information and a forum for resolving specific ethical, legal, financial, and professional issues (Greenburg et al., 1985). To the extent that the psychotherapist can set aside concerns regarding professional reputation and competition, colleagues are an excellent source of encouragement and nurturance. One of our master clinicians described his group in this way:
Our leaderless group of psychologists provides a format where each of us can express feelings and deal with life and work without trying to solve any specific problem or task, and without competing. It provides a point of balance for much of the rest of my life. We’ve been meeting for 90 minutes a week for several years. We deal with all kinds of stuff from the world of practice as well as personal things. All the way from which software to use for your practice to whether or not to take on a psychological assistant, the problems we face with bringing in a new psychologist into your practice, trying to build a career, what happens when people go out on their own and attempt to take clients with them whom you perceived as a part of your practice.
Can you imagine any health care treatment for a serious illness conducted by a single isolated practitioner? Neither can we. Serious disorders and intractable problems require multiple professionals working in coordination. Psychoses, borderline personality disorder, and similar impairing disorders call for a team approach.
Working as a clinical team cannot only improve the patient’s outcome but also nurture the psychotherapist. Team members may provide different services, be it individual therapy, group therapy, occupational therapy, pharmacotherapy, or residence supervision, thus sharing the burden. Teams can provide support, avoid insularity, and generate a sense of “we-ness.” One of our colleagues, Marsha Linehan (1993), specializing in the treatment of borderline and parasuicidal patients, likes to say that psychotherapists are not practicing her approach if they are not doing so as a team.
In this regard, we are ardent proponents of conducting cotherapy on occasion. It helps us remain fresh, avoid isolation, maintain contact with another therapist, and keeps us creative and challenged.
We are reminded here of an old Hasidic tale of the rabbi in a conversation with the Lord about heaven and hell (Yalom, 1975):
“I will show you hell,” said the Lord and led the rabbi into a room in the middle of which was a very big round table. The people sitting at it were famished and desperate. In the middle of the table, there was a large pot of stew, enough and more for everyone. The smell of the stew was delicious and made the rabbi’s mouth water. The people around the table were holding spoons with very long handles. Each one found that it was just possible to reach the pot to take a spoonful of the stew, but because the handle of the spoon was longer than a man’s arm, each person could not get the food back into his or her mouth. The rabbi saw that their suffering was terrible.
“Now I will show you heaven,” said the Lord, and they went into another room, exactly the same as the first. There was the same big round table and the same pot of stew. The people, as before, were equipped with the same long-handled spoons—but here they were well nourished and plump, laughing, and talking. At first, the rabbi could not understand. “It is simple, but it requires a certain skill,” said the Lord. “You see, they have learned to feed one another.” Whether in a dyad or in a larger team, let us learn to feed and nurture one another.
The physical and emotional isolation from colleagues, particularly in private practice, may be partially offset by nurturance from staff. Depending on the work site, psychotherapists may interact frequently with other staff—a receptionist, secretary, intake worker, or bookkeeper. They can provide an important source of contact and encouragement. They are often willing to partake in a few moments of casual conversation and shared humor that refreshes the psychotherapist between appointments. Even those of us who work alone in the consulting office report that regular encounters with maintenance people, parking attendants, and other building tenants give us a chance to visit and build casual friendships that balance the intensity of a day filled with multiple therapy sessions. Don’t overlook nonclinical people who physically surround you. They remind us that interpersonal interactions are more often about the price of tires than about existential angst!
Professionals located outside of the office are also vital sources of guidance and encouragement to psychotherapists. Physicians, lawyers, accountants, and the like not only provide professional advice but also are often willing companions for lunch and available partners for quick phone visits between sessions. Rely on them for business consultation, tax planning, legal advice, marketing, and so on. Those in allied helping professions offer mutual support in part because of the shared understanding that exists for what it takes to work with people—a mutual respect and care felt for other helping professionals, a kind of shared membership that creates natural ties. We suggest that you build relationships with professionals in the community who will assist and support you through a day of appointments. You will find that they can be a meaningful source of nurturance.
What do psychotherapists rate as the most positive influences on their career development? Experience with patients, getting formal supervision or consultation, and getting personal therapy. Together, these three constitute what has been described as the major triad of positive influences on career development and on current development (Orlinsky & Rønnestad, 2005). Therapists accord more value to these interpersonal influences than to academic resources, such as taking courses, reading books or journals, or doing research.
Psychotherapists who regularly participate in formal supervision typically find it to be very helpful. One of our esteemed colleagues noted: “Anything that I have a question about I know I can discuss at my next supervision appointment. It’s helpful to have the chance to discuss issues with another therapist and get another opinion from someone with more experience that might see things differently. It’s nice knowing that I always have some sort of safeguard. It increases my confidence a lot.”
Supervision provides essential and realistic feedback. It is probably more important for those in solo practices, but also useful for those practicing in agencies and institutions.
It may sound obvious, but we argue not simply for supervision, but for effective supervision (Grosch & Olsen, 1994). Marginal supervision may be worse than none at all, and, in our experience, much agency-based supervision of seasoned practitioners is fairly unsatisfying. Supervisors are assigned (not chosen), are selected on the basis of administrative talents (not necessarily clinical acumen), and may have a dual relationship (supervisor as well as evaluator). “How many people are going to reveal how stuck they feel with certain clients, or acknowledge that they are
attracted to a client, to a supervisor who is then going to write their evaluation and has the power to fire them?” (Grosch & Olsen, 1994, p. 125). Simply put, the odds of getting quality clinical supervision at work may be slim.
If effective supervision is not available in house, then we heartily recommend that you (1) seek it privately and usually for a fee. Seek it from a seasoned and talented psychotherapist with no connection to your agency and with a compatible theoretical orientation and personal style. (2) Contract with a supervision group led by an experienced psychotherapist. (3) Join or create a peer supervision group. Or (4) do some combination of the preceding options.
In all instances, clinical supervision should address not only invariable case problems but also you as a person. What are the recurrent themes in difficult cases for you? Who do these patients remind you of? How do stressful clients leave you feeling? Good supervision is a safe haven for review of all that transpires in psychotherapy: problem cases, ethical quandaries, transference, countertransference, practice management, and reactivated conflicts from your personal history. Get what you need.
There remains at least one more individual who can supply a nurturing relationship—the professional mentor. In that the practice of psychotherapy is a skill acquired through experiential learning, trainees quickly accept the need for mentoring during their training years (Betcher & Zinberg, 1988). Most realize that they will learn by “doing” under the oversight of a skilled, senior clinician who teaches the nuances of the psychotherapeutic encounter that cannot be learned from reading. What is not as widely recognized is the ongoing benefit of maintaining a mentoring relationship during later years of practice (Guy, 1987).
Virtually all surveys and interviews of successful psychotherapists wind up discussing the profound influence of professional elders or mentors (Rønnestad & Skovholt, 2001). The descriptions are powerful, passionate, and appreciative. The internalized influence continues in a contemporary and active way. We strongly recommend that each practitioners cultivate a strong attachment and positive investment with a professional mentor.
A mentor can offer guidance that is tailored to your individual personality and clinical needs, providing confrontation, nurturance, and direction in a manner that is more personal and informed than might be provided by a colleague. Contacts with the mentor can be conducted in person or by telephone as regularly scheduled events, or they can occur on a less frequent “as-needed” basis that is more like a consultation than a supervision appointment. In some cases, the mentor need only serve as a “touchstone” who is contacted primarily at times of critical career decisions or professional crisis. A trusted mentor serves an invaluable role throughout the professional life of the psychotherapist. It is regrettable that relatively few of us invest the time and energy necessary to maintain these mentoring relationships.
And now to a controversial source of nurturance for psychotherapists—clients. Few experienced practitioners are willing to divulge openly what most have actually experienced; clients can be powerful sources of support and encouragement in their lives.
Before we can comfortably consider this matter, let’s first acknowledge the obvious concerns. Everyone agrees that the purpose of psychotherapy is to facilitate the client’s relief and growth. The treatment contract specifies that the needs of the client take precedence over the needs of the therapist, at least to a reasonable extent. Professional ethics, legal precedence, and civil codes dictate the limits within which psychotherapists must operate. The therapy relationship exists to assist and support the client while enabling the psychotherapist to function in an effective, ethical manner.
At the same time, clients do provide therapists with special moments of nurturance and appreciation within a relationship that remains focused on the client’s needs. It is simply not an either–or situation. It is essential, however, to be certain that this occurrence is not initiated, consciously or unconsciously, by therapist need. Simply put, clients are not there to meet the emotional needs of the psychotherapist. But respecting this fundamental principle does not prevent some clients from providing deep satisfaction to the psychotherapist.
A few examples will illustrate our point. Recall the discussion of intercurrent life events that bring the person of the psychotherapist into closer contact with the person of the client, as presented earlier. Research findings suggest that some clients discover and react to personal events in the life of the psychotherapist, such as marriage, pregnancy, divorce, loss of a loved one, illness or disability, and emotional distress (Guy, 1987; Guy et al., 1986; Guy, Poelstra, & Stark, 1989; Guy & Souder, 1986a, 1986b; Wahl et al., 1993). On some occasions, of course, patients react in hurtful, confused, or ambivalent ways. On other occasions, they respond with touching concern, care, and support. An appreciation of transference and the need to refocus on treatment goals may require that such expressions be thoughtfully scrutinized and interpreted. Nonetheless, there are real-life aspects to the treatment encounter, and client expressions of caring occasionally touch the soul of the psychotherapist in tender ways.
Two comments by master clinicians illustrate this thesis. One observed:
I was really surprised by the concern and love expressed by some of my clients during my first pregnancy. Some of the women wanted to mother me, and some of the men became quite protective. We explored these feelings, and of course many were related to their own histories. Yet, I still appreciated their care; some of it seemed genuine, and that felt good to me.
Another told us of the “deep appreciation” for the cards and comments from patients when the local newspaper published an obituary of his father’s death. “We only spent a few minutes of the session on their condolences—it is their therapy, not mine, after all—but their care was real and obvious. Moreover, it opened fruitful discussions about losses in their lives and about their feelings toward me. It was a pivotal moment for them and me.”
Let us accept and be grateful for those moments when a client makes a comment, gives a compliment, smiles with gratitude, expresses concern, or even gives a touching (and appropriate) gift. In addition to its transferential elements, psychotherapy is at root a human relationship. It is permissible to acknowledge that the satisfactions resulting from conducting psychotherapy include the nurturance that comes from certain clients.
It’s difficult to advise psychotherapists how to increase the nurturance that they receive from clients, since it is necessarily an occasional by-product of the practice of psychotherapy rather than a deliberate goal.
The need for nurturing relationships must be met in other ways, some yet to be described in this section. Nonetheless, we advise psychotherapists to accept the reality of this occurrence so that, despite the need to explore, interpret, reframe, or deflect many of the solicitous behaviors of clients, it is permissible to accept those few moments of genuine care and support expressed for the therapist. To graciously receive and gratefully acknowledge these moments reinforces a healthy reality for both therapist and client. These precious moments stand on their own merit and deeply touch the spirit of the psychotherapist.
Some psychotherapists confide that they structure their schedules with an eye toward alternating replenishing sessions with those that are more draining. To put it more bluntly, they intersperse their favorite or more satisfying clients among those who are more demanding, challenging, or deflating. This scheduling balance helps to avoid emotional exhaustion and overload. Patients should not be retained in treatment merely to support the practitioner; however, common sense forces us to recognize that some clients will be more enjoyable to work with than others will. The psychotherapist intent on being effective and satisfied in her work will create a caseload mix that helps her remain focused, energetic, and optimistic throughout most of the day.
Now, we’re on more comfortable ground. Most of us expect that our primary supply of nurturance will come from close relationships with people unrelated to the practice of psychotherapy. Spouses/partners, family, and friends provide our love and support. Love—both receiving it and giving it—heals. In Winnicott’s sense, the therapist strives to create a holding environment for herself outside of the office where she can be soothed and nurtured (Kaslow & Farber, 1995).
Regardless of one’s marital status or sexual orientation, each individual feels a deep need to be known and loved by others. For many, this longing becomes focused on a particular individual or series of individuals, leading to lasting commitment and long-term relationships. Psychotherapists are no different. They marry at about the same rate as the general population (Wahl et al., 1993). Freud said long ago that the right marriage was an excellent alternative to a successful psychoanalysis.
The single highest rated career-sustaining behavior among psychotherapists is spending time with one’s partner and family. It receives a mean rating of 6.15 on a 7-point scale (Stevanovic & Rupert, 2004). The second highest rated career-sustaining behavior is maintaining a balance between professional and personal lives. The highest rated self-care method among interns? Yep, you guessed it: close friends, significant others, and family as sources of support. It receives a mean rating of 4.3 on a 5-point scale (Turner et al., 2005).
In the best of situations, many emotional needs are met within the context of committed, loving relationships. A partner is able to provide near unconditional love and acceptance, deep understanding, and genuine encounter. When occupational hazards related to emotional constraint, isolation, and psychological mindedness are overcome, the clinician is finally free to participate with complete freedom in an intimate relationship of paramount importance. A spouse is able to keep the clinician in touch with inner needs, feelings, and longings that are set aside during a day of therapy sessions. Partners affirm our worth and dignity.
A mate is often best able to counter the assorted struggles of psychotherapy practice. On the one hand, for example, a mate can confront the grandiosity and sense of omnipotence that can grow over years of clinical work. This helps to prevent the therapist from accepting the distorted idealizations of clients as actual reality. On the other hand, a mate can provide a firm foundation of support and acceptance of the worries and struggles of clinical work. This helps the therapist to express hidden fears and hopes related to the “impossible profession.” A nurturing partner has a significant impact on the professional confidence and competence of a psychotherapist.
Confidentiality must be considered here for a moment. We must remember that clients have the right to expect that their confidentiality will be protected by the psychotherapist (Pope et al., 1987). This includes preventing any inadvertent domestic slips of confidentiality, such as disclosing information to a spouse, unsecured documents at home, shared fax machine, or accidental revelation at the dinner table. Research suggests that, despite these ethical strictures, some psychotherapists do discuss job-related concerns with their partners (Tamura et al., 1994). Regrettably, this occasionally includes identifying details that violate client trust and risk accidental exposure of clinical material. Thus, limit discussion with your partner to feelings and thoughts that emerge in your inner world as a result of a psychotherapy session. This need not include any information about a client, nor need it involve a violation of professional ethics. Instead, the therapist shares her own internal process only as it relates to personal history and concerns.
Before leaving this topic, we would observe that psychotherapists tend to marry other psychotherapists at a surprising rate. In one national survey, about 20% reported that they married another psychotherapist (Guy, Tamura, & Poelstra, 1989). This pattern was even stronger among those married a second or third time. One is left to wonder whether such relationships increase the amount of understanding and nurturance that is shared between spouses, due to a commonality of experience. Several therapist couples (e.g., Weiss & Weiss, 1992) enthusiastically report that this has been the case for them during their careers. On the other hand, could it be that it is more difficult to reorient and re-enter the “real world” when both spouses spend considerable time in the world of multiple clients?
Like many of life’s adventures, a marital relationship between two psychotherapists must certainly be a mixed bag of assets and liabilities (Guy, Souder, Baker, & Guy, 1987). The first author of this course (JCN) has been happily married to another psychotherapist for more than 25 years, and the second author has remarried to a psychotherapist. So it can certainly be done!
As in the case of a spouse/partner, there is something basic, something fundamental, about being known in a genuine fashion, unfettered by clinical distortions, by family members. Most psychotherapists appreciate their honest relationships with children, siblings, parents, and extended family. Within this world, she is known as someone other than a psychotherapist. It’s refreshing to get together with family who insist that the psychotherapist stop sounding so “therapeutic.” They force us to come out from behind our clinical mask, prioritize life goals, and be genuine as humans.
A workshop participant reported, “I spend time with my grandson every week now... It allows me to get in touch with what is really important. The ladybug that rests on the window in my bathroom, which keeps us from taking our evening bath on time—or are we on time? Life seems just a little bit better now.”
One of our master clinicians tells us: “My favorite way to decompress after psychotherapy is to play and exercise with my dog. In addition to providing a great workout and release of energy for both of us, spending time with a cherished dog can be an emotionally uplifting experience. The warmth and consistency of our relationship provides a wonderful antidote to the shifting emotions elicited during psychotherapy. My dog is always on time, willing to work, and gets along well with his family of origin.” Such self-care usefully reminds us that not all family members are human, nor even members of our biological family.
Children and pets have impressive ways of deflating the self-importance that results from spending many hours with clients who value our advice and opinions (Japenga, 1989). It is humbling indeed to be ignored, teased, disobeyed, and challenged by children who are all too familiar with our personal weaknesses. Yet, few have the ability to provide more meaningful moments of tender love and satisfaction than one’s own children.
The research demonstrates that female therapists, compared to male therapists, tend to spend more time with families and friends (e.g., Coster & Schwebel, 1997; Kramen-Kahn & Hansen, 1998; Stevanovic & Rupert, 2004). Many factors probably account for this robust group difference, but we are concerned about men’s tendencies to be less expressive or relational.
Many practitioners try to abide by the Family First rule—“All others get in line.” But most of us slip, if not fall, in implementing the rule. In the interest of full disclosure, we two authors usually slip as well. One of us was fond of saying for years that there was an “unspoken” family rule of not traveling away from home more than once a month. The spouse, on more than one occasion, quipped that the rule was “unspoken and unkempt.”
Even when home and not traveling, it is often difficult for psychotherapists to be good listeners after lengthy days of listening to patients. We are tempted to seek mostly admiration and appreciation from the family, as opposed to a healthy mix of admiration, criticism, and teasing. In the short run, we want others to listen to us; in the long run, we want the honesty of loving concern. If not, we begin to leave too much at the office and not bring enough of ourselves home.
Siblings, parents, and extended family can dole out steady supplies of nurturance throughout a lifetime. These are people who have known us perhaps since birth, including many years prior to our entry into the profession.
This world of relationships is ideally a safe harbor of refuge in the midst of a busy career. Relatives are usually not invested in our particular clinical successes. In spite of the tendency of some to seek our advice on personal concerns or family conflicts, most family members continue a pattern of relating that predates the commencement of our psychotherapy career. This allows us to drop the role and accept the support of family members as genuine and without ulterior motives. There is purity to this nurturance that we intuitively understand. Within the limits imposed by family pathology, few people can make us feel as confident or secure. (Yes, we hear you . . . and few people can make us feel as crazy as well.)
Friends are good medicine. They share our deepest fears and most embarrassing foibles, hopefully with loving regard for both. Friends enjoy feelings of connection and acceptance, feelings not contaminated by the complications of marriage and family ghosts. One master clinician expressed it this way: “I find that my friends help me to lighten up. They make me set aside my role and be myself. They accept me for who I am, not for what I can do for them. My closest friends will always be there to help.”
We bid you to keep your old civilian friends. Nonclinical friends offer a wider and healthier perspective on life. Fellow therapists can make fine friends, but having too many of them leads to equating life with “the job.” Leave most of it—and them—at the office.
We all need friends, of course; yet, psychotherapists tend to have fewer and fewer friends over the course of their career (Cogan, 1977). This has led to speculation that perhaps, for better or worse, some affiliation needs are met through the practice of psychotherapy (Guy, 1987).
Friendships outside the office also tend to be more difficult for male therapists who were raised to respect the male stereotype of the strong, solitary oak tree. “Real men don’t need anybody” goes the common refrain. If you are tempted to rebut with the assertion that “male psychotherapists are different,” please think again. Our culture rarely encourages intimate friendships among men.
As we discuss in our first course, the reactions and expectations of casual friends sometimes make it difficult for the psychotherapist to escape the role of clinician. These individuals may not be a source of genuine encouragement, and interactions with them may be tainted by their expectations of psychotherapist rather than the actual person. It is the closer friend, committed to our well-being, who encounters the true person of the psychotherapist as a friend and companion.
These meaningful friendships are central sources of our strength. They remind us that most of life takes place outside of the consultation office. They help put things in perspective. Most people are not suicidal. Most people do not abuse children. Most are not crippled by anxiety and depression. Friends serve as reference points for this “normal” world, the world of which we are members. When invited, friends give honest feedback about the changes they note in the life and demeanor of the psychotherapist. As time passes, it is harder to find people who will be as honest as a true friend. Good friendships are worth the effort.
Should things turn nasty for your practice or career, reach out to spouses, family, friends, and, in addition, to organized state programs for assistance. Colleague Assistance Programs (CAP) provide resources for distressed clinicians and promote well-being. In the past, CAPs were designed for professionals in serious trouble; in the present, CAPs offer support and facilitation of professionals, including proactive self-care.
Approximately half of state psychological associations, for example, offer CAPs (American Psychological Association, 2006). Self-referrals are welcomed. All in the field agree that it is in the best interests of the public and the practitioner that we intervene early and often, before problems escalate into unmanageable monsters. We can help one another outside of the office instead of relying solely on punitive licensure boards or ethics bodies.
CAP programs offer multiple benefits to practitioners. These include advocacy, case monitoring, educational workshops, intervention/ rehabilitation, liaison, outreach to professionals and students, peer support programs, referrals, consultation, support/information hotlines, and training workshops (Barnett & Hillard, 2001). If trouble should come calling, please proactively consider CAP.
Psychotherapists are meaning makers. We try to understand the derivative meanings associated with experiences, encounters, and events. This is usually true in the psychotherapist’s personal life as well. We seek to make sense and meaning out of our own lives.
Most healers learn from mentors more experienced and powerful than themselves. We want to achieve the highest level of interpersonal effectiveness possible; we seek the nurturing direction of those who are successful and satisfied in their lives.
Psychotherapists often feel deeply committed to their lifelong growth. One path is to find a “life mentor” to support and guide us over many decades of life. Although this mentoring may include professional development, as discussed earlier, the primary focus here is upon the development of a person, who happens to be simultaneously a psychotherapist. The life mentor may be a clergyperson, personal psychotherapist, favorite teacher, special relative, neighbor, or older friend or colleague. The role is gradually defined over time and usually acknowledged by both parties. Contact may be infrequent, but it is always meaningful.
The nurturance provided by a life mentor serves a unique purpose in the life of the psychotherapist. It is reassuring, curative, and motivating. It comes from a special person who is genuinely committed to the well-being of the psychotherapist, often without motive or guile. It is a gift that is thoughtfully given, and the spiritual aspects of the mentoring give a richness and depth of meaning that anchors the psychotherapist.
One of us (JDG) treasures a mentoring relationship with a favorite graduate professor that spans 30 years. This caring person has generously supported me through every major (and many minor) life challenges and career changes. It is invaluable self-care.
Few have as strategic or vital an impact on the psychotherapist as her personal therapist. This individual alone has access to our most secret needs, fantasies, and experiences. The nurturance and insight gained from a personal psychotherapist is often without equal. .
One compelling reason for seeking personal therapy or professional consultation away from the office is when confronting a potentially litigious situation at the office. Whatever is said about such a legal matter might be used against the psychotherapist in subsequent legal proceedings (Ellis & Dickey, 1998). An expert on risk management in patient suicide (Bongar, 1991, p. 192) writes of the stark restraint of peer consultation in these situations:
We must caution the reader—any discussion with a colleague, or even with one’s own family or friends, of the deceased patient’s care is usually considered non-privileged information that is open to the legal discovery process. That is, the plaintiff attorneys will subpoena colleagues and ask what was told to them about your concerns regarding the patient’s suicide.
Thus, discussions of your feelings about potential misdiagnosis, treatment errors, or case mismanagement are best confined to the legally privileged contexts of legal consultation or personal psychotherapy. Be careful not to discuss your feelings about role or responsibility for any malpractice case or likely litigious case with colleagues or peers unless you are comfortable with those discussions becoming prosecution fodder in the courtroom.
Psychotherapists are people too. We are relational beings who find close, loving connections the most effective source of support, trust, and distress relief. The person of the therapist requires emotional nurturing, inside and outside the office, to avoid being a toxic sponge filled with clients’ suffering. When confronted with occupational stress, our research-grounded recommendation is to tend and befriend, not fight or flight (Taylor et al., 2000). Notice it is the use of nurturing relationships. Not simply having relationships available to you but actually using them for self-care. We have encountered the litany of psychotherapists’ rationalizations for not using relationships—“I don’t need to be pampered or nurtured,” “I’ve worked though my oral dependency needs,” or “No one truly understands my grind as a psychotherapist”—but find them unconvincing and transparent defenses. Of course, we need loving relationships. Psychotherapists are people too. The question is whether you give yourself the permission to be cared for, loved, and nurtured.
In her moving memoir An Unquiet Mind, psychologist Kay Redfield Jamison (1997) writes convincingly of the power of nurturing relationships in the treatment of her bipolar disorder:
For someone with my cast of mind and mood, medication is an integral element of this wall; without it, I would be constantly beholden to the crushing movements of a mental sea; I would, unquestionably, be dead or insane” (p. 215). And yet something more powerful was also operating in her life. She continues: “But love is, to me, the ultimately more extraordinary part of the breakwater wall: it helps to shut out the terror and awfulness, while, at the same time, allowing in life and beauty and vitality.
Following one of our self-care workshops, an experienced psychiatrist wrote of its effects on her, “I realized that all my self-care was solitary. I am a rather reclusive person anyway. The demands of psychotherapy combined with my personality have made for all solo activities—getting away from it all, so to speak. That is changing now.” She allows herself to receive (as well as give) at home: “I’m off with my spouse and friends to dance and listen to music.”
In our early years of presenting on psychotherapist self-care, we were disappointed with the specificity of what we were recommending. We felt that we were not concrete or specific enough in our recommendations. Perhaps you occasionally experience that feeling as you are reading this section. However, over time, we have become convinced that presenting anything more specific is not only bad science (since the research does not indicate that any single method is more effective than another) but also disrespectful and presumptuous in addressing mental health professionals, who are themselves experts in behavior change. Yes, we know that the research on psychotherapist self-care indicates that the routine and sufficient use of nourishing relationships correlates with self-care effectiveness. But neither the research nor we can honestly tell you which path to nourishing relationships is available or preferable to you. Just be certain you are securing nurturing relationships in your life, somewhere, somehow.
So, follow the research evidence—the very same evidence you probably faithfully recite to your patients. Research documents that your age, gender, income, job title, and even your health have small effects on your life satisfaction or happiness (Myers, 1993, 2000). The largest determinant of happiness appears to be a supportive network of close relationships. Luxuriate in your relationships, feel the connection, and pursue the reciprocity of nurturance.
We need an array of relationships outside of the consulting office to ensure a balanced, satisfying life. Not only is a full complement of trusted friends and family desirable for a fulfilling existence, but psychotherapists rely on these relationships when assessing their clinical competency. Our research shows that clinicians expect family and friends to identify professional impairment or incompetence related to emotional distress or advancing age well before patients or colleagues become aware of their existence (Guy, Poelstra, & Stark, 1989; Guy, Stark, et al., 1987). Clinicians expect these individuals to confront them, and they report that they rely on their judgment and feedback when deciding to reduce or terminate clinical practice. Families and friends are the therapist’s primary sources of nurturance and support; their impact on both personal life and professional practice is beyond measure.
We recommend that you give careful thought to the sources of nurturance in your life. Are they adequate? Is there variety and balance? How can they be utilized more effectively? These are among the most critical self-assessments that you can conduct when evaluating how to become more effective at “leaving it at the office.”
Coming full circle, we conclude with a reminder from Flannery O’Connor’s short story, “The Lame Shall Enter First,” that began this section. We implore you to become a good Sheppard, not a sacrificial lamb. Become the bounty-ful and boundary-ful clinician devoted simultaneously to self and to service.
American Psychological Association. (2006). Advancing colleague assistance in professional psychology. Washington, DC: Author. Available at http://www.apa.org/practice/acca_monograph.pdf.
Balint Groups. (2006). Available online at americanbalintsociety.org.
Guy, J. D. (2000). Holding the holding environment together: Self-psychology and psychotherapist care. Professional Psychology: Research and Practice, 31, 351–352.
Norcross, J. C. (Ed.). (2002). Psychotherapy relationships that work. New York: Oxford University Press.
Scott, C. D., & Hawk, J. (1986). Heal thyself: The health of health care professionals. New York: Brunner/Mazel.
Yalom, I. D. (2002). The gift of therapy. New York: HarperCollins.
with Rhonda S. Karg
“True happiness, we are told, consists in getting out of one’s self. But the point is not only to get out—you’ve got to stay out; and to stay out you must have some absorbing errand.”
Escapism is one of the most effective and popular methods of psychotherapist self-care. As part of our human nature, we clearly want to escape; as part of our healing burden, we may even need to get away periodically to minimize the corrosive effects of conducting psychotherapy. Occasional escapes allow us to temporarily separate ourselves from our professional identities and activities as we submerge our awareness in another experience.
The common thread among the diverse escapes considered in this section is occasional release from professional responsibilities and the concomitant immersion in alternative outlets. Escape can denote many behaviors. We are all familiar with the unhealthy escapes or false cures—alcohol abuse, isolation, sexual acting out, self-medication—that ultimately multiply the very sources of distress that they were intended to ameliorate. Like healthy diversions, maladaptive escapism provides a source of gratification and relief but exacts a cost—physically, psychologically, spiritually, and interpersonally. As we have all repeatedly witnessed in our patients, unhealthy escape itself becomes a new burden.
In contrast to unhealthy avoidance, healthy escapes denote embracing balance and wellness. They encompass constructive behaviors that invoke and blend diversion, self-nurturance, and relaxation in ways that balance work with respite. Healthy escapism, as we define it here, means taking breaks during our workday and leaving the office altogether, so that we may shortly return to our personal and professional lives with renewed energy and a fresh perspective. In this section, we explore healthy escapes in and outside the office, after a brief consideration of the dark side of unhealthy escapes.
We psychotherapists, being more human than otherwise, are not immune to mistreating our distress. In fact, the research indicates that psychotherapists are at high risk for being seduced by the lures of unhealthy escapes (e.g., Kilburg, Nathan, & Thoreson, 1986; Mahoney, 1997; Sussman, 1995; Thoreson, Bud, & Krauskopf, 1986). Flight from reality in the arms of unhealthy diversions is a form of the neurotic paradox: avoidance brings short-term relief but long-term misery. False cures do more than just make you feel good; they also provide a temporary escape from feeling badly about yourself (Baumeister, 1992).
Studies on psychotherapists’ personal problems yield the following top 10: irritability, emotional exhaustion, insufficient or unsatisfactory sleep, loneliness, isolation, depression, anxiety, relationship conflicts, concerns about caseloads, and self-doubt about therapeutic effectiveness (Mahoney, 1997). Sound familiar? Given these difficulties, it is not surprising that any of us would be vulnerable to unhealthy escapes.
Of the infinite number of ways we can mistreat our distress, three seem to capture an inordinate number of mental health professionals. With no claim to exhaustiveness, let us briefly review substance abuse, isolation, and sexual acting out. In each case, please perform an honest appraisal of your own self-care and identify whether the problem applies to you. Our aim in this section is to help you identify and begin altering unhealthy escapes that might hurt you and your patients.
Arguably the most prevalent self-destructive escape among psychotherapists is substance abuse (Guy, 1987). The incidence of alcohol and drug abuse among psychotherapists is alarmingly high, according to even the most conservative estimates (Kilburg et al., 1986; Thoreson et al., 1986; Sussman, 1995). While substance abuse results from multiple causes, Thoreson and colleagues (1986) found that several practice factors relate to its development:
Risk factors for developing substance abuse are aggravated by psychotherapists’ perceived barriers to care. Psychotherapists who think they may have a problem with alcohol, illicit drugs, and/or prescription drugs are often resistant to seek substance abuse evaluations, formal treatment, or 12-step programs. Perceived barriers to care include inflated fears of harming their professional reputations once the shameful secret is shared with others. As one psychotherapist argued, “What if one of my colleagues or patients saw me at an AA [Alcoholics Anonymous] meeting? I know so many people, it is bound to happen!”
Psychotherapists are often physically and psychologically isolated—we are alone with our clients in a small soundproof room, separating ourselves from the outside world during the workday. No visitors, no phone calls, and no interruptions during sessions. In between sessions, we remain physically isolated as we write notes or dictate reports in a quiet office. We have also fine-tuned the skill of psychic isolation—being emotionally subsumed in our clients—and are committed to protecting their secrets.
Even when we are not working, the long hours spent conducting assessments and therapy can breed further isolation outside of the office. How easy it is for this self-segregation to spill over into our personal lives (e.g., Farber, 1983b; Mahoney, 1997). Perhaps the most serious result of physical and psychic isolation is the therapist’s increasing inability to overcome these restraints in her own private life. In other words, the very factors associated with the healer role that promote a sense of loneliness and separation in professional relations carry over into personal interactions as well. This is often due to the fact that the practicing psychotherapist finds it difficult to set aside the professional role outside of the office (Guy, 1987).
If we are not on guard against the tendency to isolate ourselves, we quickly begin avoiding contact with family and friends as a way of coping (Margison, 1987). As one psychotherapist described it:
After listening to patients and staff talk to me all day, when I leave the office, the last thing I want to do is listen to my family or friends. I understand they all have something they want to discuss with me, but by the time I get out of the office, it’s like my brain has reached maximum storage capacity for verbal input, and I have no space for anyone else to “download” onto me. The only way I can get some quiet time to decompress is to isolate when I get home.
While the lure of isolating to cope with feeling overwhelmed or overstimulated is certainly understandable, too little time with our family and friends places our well-being in harm’s way.
Stop and ask yourself the following questions. Are you becoming less inclined to watch local or national broadcasts? Do you make an effort to listen to contemporary music? Watch new feature films? Read popular books? How isolated have you become?
Literature reviews point to a disturbingly high incidence of sexual acting out among therapists (Sussman, 1995). Coupled with the alarming percentage of psychotherapists, overwhelmingly male, having sexual relations with patients or students (e.g., Pope & Bouhoutsos, 1986; Pope, Sonne, & Holroyd, 1993), the research strongly suggests that sex is a powerful temptation for the distressed or impaired therapist. Sexual activity has all of the reinforcing effects created by recreational drugs—physical pleasure, exhilaration, tension release, relaxation, a temporary flight from reality, and ego enhancement. However, as indicated by a growing body of literature, sexual activity with clients is also a dangerous escape from emptiness, unresolved conflict, or a need for power.
Why are psychotherapists easy candidates for sexual acting out? For one thing, checking our professional hat at the door is often a difficult transition, thus requiring a certain degree of deliberation. Since we spend the majority of our professional time in the role of healer, it is not surprising when this role contaminates our romantic relationships. And reciprocally, romantic relationships can contaminate our therapeutic relationships. For another, many of us enter the profession out of an altruistic desire to eradicate mental health suffering, that of our patients and ourselves. Sometimes these desires can manifest themselves in sexual responses and rescue fantasies. Support for this phenomenon comes from the high percentage of therapists reporting fantasies about their patients—sexual and rescue-oriented in nature—at some point in their careers (Edelwich & Brodsky, 1991; Kottler, 1993).
Sexual feelings often arise in psychotherapy relationships, occasioned in the patient, the therapist, or simultaneously. Since this remains a taboo topic in training and supervision, therapists often miss the early warning signs that boundary violations with patients are looming or occurring. Many psychotherapists are simply not trained to effectively intervene before sexually acting out has taken place (Pope, Sonne, & Greene, 2006). Whatever the confluence of causes, it is ultimately the therapist’s choice and responsibility, not the other person in the dyad. Simply stated, we must guard against acting on such feelings with our patients.
It behooves us all to complete a self-assessment of unhealthy escapes and to participate in supervision and treatment, as needed. In the spirit in which Leaving It at the Office was written, you can approach these tasks in an unabashedly human and accepting fashion. As a psychotherapist, if you are engaging in these or other destructive escapes, we implore you to search within yourself to discover what you are experiencing internally, what you are avoiding, what you need to address. Please seek the assistance of your peers, supervisors, and personal therapist. Once you have determined your unmet needs, then you can take measures that will eradicate the symptoms instead of masking them.
Adaptive escapes from the burdens of the office begin, paradoxically, at the office. Brief renewing escapes can be blended into your day, in between patients or between professional responsibilities. There are dozens of healthy paths to escaping the strains of our impossible profession; here, we offer a variety of self-care methods designed to assist therapists during the workday by engaging in good, clean escapism.
In the busy-ness of our day, it might seem counterproductive to slow down or to take a break. On the other hand, as we frequently remind our patients, it is no more a waste of time than stopping to put gas in our car when the tank is almost empty. It is both necessary and beneficial. Taking breaks can create more time and energy. A growing body of research underscores the imperative of creating time for periodic escape in order for us to maintain psychological equilibrium (Carroll et al., 1999; Kottler, 1993; Ryan, 1999; Shoyer, 1999).
Most of us have made great strides in our career by overextending ourselves—holding 10 therapy sessions back-to-back, skipping lunches, and working 12-hour days. Most of us hear a little voice in the back of our heads saying, “Me? Take a break? What a joke! I don’t have time to take a break!” Such beliefs may be driven by our overachieving heritage and the implicit assumption that putting the patient first means putting ourselves last. We routinely encounter colleagues who insist that they cannot possibly take a 2-hour lunch break with colleagues, go to the gym after work, or schedule a 2-week vacation. We collegially disagree.
In a job as absorbing and demanding as ours, we need periodic relaxation during the workday—not simply after the workday. Relaxation reciprocally inhibits (or counterconditions) anxiety and tension. Some form of anti-stress restoration is particularly indicated for therapists who have habituated themselves to hectic schedules, physiological arousal, and overactive minds.
Relaxation at the office demonstrably improves the energy, empathy, and attention of psychotherapists. In his Principles of Psychology (1910, p. 424), William James writes, “the faculty of voluntary bringing back of a wandering attention over and over again is the very root of judgment, character, and will. . . . An education which should improve this faculty would be the education par excellence.”
Our master clinicians assuredly concur. One observes:
I am involved in many types of meditation, including tai chi and yoga. Probably my favorite is tai chi, because it is very fluid and involves motion rather than just quiet sitting. The important factor when you do tai chi is to focus on your breath and to move in concert with your breath. As a clinician we are always focusing on others. We are supposed to be the mirror who shows them who they really are. Taking that stance all day leaves us little room to know who we are, how we feel, and what is important to us. Through focusing on my breath [during the workday], I become more aware of who I am and that I am a vital living being. [Meditation in the office] helps me to feel closer to humanity, and this helps me develop empathy in my practice.
Relaxation takes many forms. The most common among psychotherapists in the office are brief meditations, muscle relaxation, and deep breathing. But any activity that reduces our autonomic and mental activity—music, imagery, or a few moments of pleasant reading—will certainly invoke a relaxation response. Make relaxation part of your work.
Laughter is a universal elixir—it helps us recover from physical maladies, mental distress, and emotional pain. In one study of psychotherapists (Kramen-Kahn & Hansen, 1998), maintaining a sense of humor was the most frequently endorsed career-sustaining behavior (82% endorsement). As Mark Twain, one of the world’s most celebrated humorists, said in The Mysterious Stranger (1897):
The human race, in its poverty, has unquestionably one really effective weapon: Laughter. Power, money, supplication and persuasion . . . these can lift a colossal humbug, they can lift poverty a little, century by century. . . . But only laughter can blow it to rags and atoms at a blast. Against the assault of laughter no evil can stand.
The utility of humor in therapy began with Freud, who wrote extensively on the subject (Barron, 1999). In the past 25 years or so, an increasing number of psychotherapists have been seeking both theoretical and empirical evidence to support incorporating humor into the psychotherapeutic transaction (Bloch, Browning, & McGrath, 1983; Goldstein, 1982; Heuser, 1980). Humor is typically used in stressful workplaces to counter anxiety, frustration, fear, and puzzlement. Common antecedents for practitioner use of humor are novel behaviors, bizarre thoughts, negative evaluations of self and role, and perceived threats to physical well-being (Warner, 1991). The growing body of empirical research supports the nation that humor in psychotherapy is decidedly beneficial (Cann, Holt, & Calhoun, 1999; Goldin & Bordin, 1999).
Humor in therapy profits both the therapist and the client. Beyond providing us with entertainment and allowing us to share the joy of laughter, humor also reduces tension, discharges energy, lifts affect from despair and suffering, provides intellectual stimulation, puts events in perspective, stimulates creative thinking, deals with the incongruous, the sublime, the awkward, and the nonsensical, broaches difficult subjects in less threatening ways, expresses exuberance and warmth, and creates a bond between those sharing a joke.
In addition to the benefits of using humor during the therapeutic process itself, a sense of humor outside of therapy sessions can assist the therapist in coping with painful sessions and frustrating patients (Parrish & Quinn, 1999). A master clinician, who directs an agency, offers examples:
Something that really helps is to find ways to build humor into your work. One thing that we did all began with the purchase of the book The Little Brown Dictionary of Anecdotes, which was edited by Clifton Fadiman. We rotate who runs staff meetings, and everybody takes their turn. When you run the staff meeting, you get to pick a couple of anecdotes to read. People can’t wait for us to get to the anecdotes, moving through the business items quickly to get to them. [Another] thing all of our staff try to learn is to tell a few jokes and cut the edge of the thing, whether it be a staff or clinical issue. We’ve also taken highly stressful or confusing events and changed them into skits. We sometimes play one out of something that at the time was not real funny but in retrospect is.
Sometimes we laugh with our clients, sometimes we laugh privately afterward, and sometimes we share the laughter with our colleagues. Another master clinician offered this illustration:
I am blind and use a seeing-eye dog. I was counseling a shy young guy, probably about 18 years old. He was talking about how hard it was for him to make contact with people. We were doing okay, but you could tell he was really struggling to talk. Then he got an itch in his private parts, which all of us do from time to time. He assessed the situation and figured that, since I was blind, I would not know what he was doing, and he took care of his itch. He sat there and scratched his itch. My ears really localize sound, so I knew exactly what he was doing. But I knew that, if I even smiled, he would be out of there because he was so shy. I was biting my lips to keep a straight face. He finishes the session, and I go running down the hall to tell one of my colleagues.
A therapist’s sense of humor is a reflection of her joyfulness, passion, creativity, and playfulness. It allows us to cope more sanely with such intensely serious subjects. A good laugh may be the best tool available to help us let go and put our current situation into perspective. And, as one of our master clinicians put it, “If you are not having fun or if you’re not able to laugh at yourself, you’re in trouble.”
Healthy escapes at the office are not limited to solo pursuits. Inviting your colleagues, staff members, friends, or family members to join you serves several functions. First, it allows you to socialize, to share stories and life events, to laugh, or to just hang out. Your workplace becomes associated not only with the grueling work but also with fun and socialization. Second, group activities allow many to reap the rewards of taking time off for frolicking. Third, due to the structured nature of our work, getaways help break up the routine of our day. They are vital breaks in the day, as discussed earlier in the course. Spontaneous escapes are sometimes the most rewarding. Consider the following from one of our master therapists:
We will take the staff out to fun events. We’ll pick some place to go out and take an excursion. For example, one afternoon, we had a succession of difficult client situations in which you know you just can’t win. Also we had a stretch where everybody had very busy schedules and a number of staff members had things go wrong in their families and personal lives. They were coming to work a little bit down to start with, and then all this stuff was happening, and everybody was feeling overwhelmed. There was a sense that no one was on top of their game. We basically just said let’s get the hell out of here. Sometimes the best time to shut down is when you’re busiest. We went to get some tea. It was just a very nice break.
Such retreats from the office can also be planned in advance, as another testimonial attests:
We make it a point to try to celebrate accomplishments or people’s time here. While that doesn’t sound like a big deal, what I have found over many years is that in mental health services, if there is any area people are deficient in, it’s how to celebrate and how to do positive things. The other day we took the whole staff to a new art exhibit. In the winter we have had fun in the sun parties. The staff will set up a fake beach and a heat lamp. Then we’ll play Hawaiian music, and people will come in costumes like wetsuits and skin-diving outfits. It’s meant to get rid of winter at its worst part.
Vital breaks, relaxation, humor, and get-togethers are healthy escapes at the office that allow us to decompress. Along with nurturing relationships and diverse professional activities, such self-care at the office is precisely what the psychotherapist ordered after a long day, during a hectic week, or amid a busy season.
Research has identified the broad strategy of counterconditioning—what we characterize as healthy escapes—as a reliable predictor of effective self-care among mental health practitioners. Whether you directly ask clinicians to tell you what maintains their well functioning or indirectly correlate their in-session behavior with their subsequent mood, healthy escapes are always popular. Classic modes of escape include humor, vacations, relaxation, self-assertion, cognitive restructuring, exercise, and diversion—all action-oriented activities incompatible with occupational anxiety. Here we focus on examples and advice related to other escapes outside of the office. In this section, we enjoin you, quite literally, to leave it at the office.
Any strenuous or absorbing activity, in principle, can serve as an effective means of escape (Baumeister, 1992). Literally “letting go” of the burden of one’s professional self, to escape the tyranny of work-related burdens, and to be liberated from the fetters of selfhood are a beneficial respite. In other words, one can escape from the burdens of the impossible profession and escape to absorbing errands, as Henry James advised at this section’s opening.
The research supports the obvious: “Any group of people whose selves are linked to high standards or expectations, or who are constantly threatened with loss of face, will tend to be exposed to greater ego stress and will therefore have a greater need of periodic escapes” (Baumeister, 1992, p. 34). Sound familiar?
Here are a dozen quick examples of healthy escapes away from the office from our workshop participants and our therapist colleagues:
Such examples can serve as portals to sensitivity and depth—or can confine us to meaningless particulars if pursued to obsessional lengths (Sacks, 1985). In the following pages, we endeavor to synthesize the ideographic with the nomothetic, the particulars and the general, in developing healthy escapes outside of the office.
We all require a Shabbat—a regularly scheduled day of rest and respite from the week’s demands. This is a day designed for peace and spirituality, a separate time to focus on family, friends, relaxation, and spirituality. It need not be a Saturday or Sunday, but it needs to be a genuine day off.
One of our master clinicians offers this remedy:
Despite, or perhaps because of, our hectic schedules, my family and I enjoy taking quick mini-vacations on the weekends. As luck would have it, these getaways are usually located on the beach—one of my favorite places to escape from the stressors of life. Sometimes we have a destination in mind, but at other times we just throw a few things in a bag, load up the car, and drive south. This is always an adventure!
Many psychotherapists are on call 7 days a week. We strongly advise them to reconsider this policy, to give themselves a Shabbat. If you are available 24/7 to your patients, you are never truly available to yourself and your significant others.
American workers generally get a measly 2 weeks of vacation per year, among the lowest of all industrialized nations. Even so, many Americans do not use all of their vacation time or days. To complicate matters further, we are sometimes actively discouraged or prohibited from taking the entire 2 weeks at the same time. Then, we are frequently asked to be accessible during the vacation!
Follow Freud’s example: take a month of vacation per year, away from the office, and largely out of contact. Be away—physically, mentally, and emotionally. As one colleague confessed, “It took me a day or two to remember how to play!” Many of us do not even begin to relax on vacation until 3 days into it and then begin to worry about our awaiting workload 2 days before the end of vacation. The restorative function of vacations may take a full 2 weeks.
For those who immediately protest “But I can’t afford it!” we offer the wise words of distinguished psychologist Arnold Lazarus. He (2000, p. 93) pointedly argues that “avarice and greed are responsible for most of the stressors that beset many professionals.” He—and we—know that far too many psychotherapists are greedy, working more than 60 hours a week, mainly for the money. Lazarus, by contrast, deliberately allows time for leisure and vacations. “A basic goal in my life has never been to make money—only to earn a decent living. My bank account may have suffered, but my psyche has been enriched.”
If longer vacations are not feasible, we highly recommend taking mini-vacations throughout the year. Imagine all the places that you can escape to within just a few hours. Take advantage of your location and the many places that remain unexplored.
When we get away from our offices, our patients, and our colleagues, we regain a perspective on what is truly important in our lives. And, as Kottler (1993) points out, “Eventually there comes a time when we grow tired of living out of a suitcase and feel ready, if not eager, to return to that which we call work.”
Two of the most frequent ways in which psychotherapists attempt to prevent distress are to take periodic vacations and to participate in non-work related activities (Sherman & Thelen, 1998). About 9 in 10 of us do so.
In one of our studies (Hoeksema et al., 1993), as should come as no surprise, psychotherapists’ satisfaction with their leisure activities was significantly correlated with decreased burnout. In fact, about 10% of burnout symptoms could be accounted for by respondents’ paucity of leisure activities.
The range of therapists’ non-vocational leisure activities is impressive (Burton, 1969, 1972). Whether it is reading, creative outlets, hobbies, or travel, the vast majority of psychotherapists enjoy getting away from it all, both figuratively and literally.
In our self-care research and workshops, we have been impressed with the ubiquity of psychotherapists gravitating to simple and concrete leisure activities. “I really enjoy cutting the lawn,” “Working in my woodshop is a pleasure,” or “I love puttering in the garden” are frequent refrains. Psychotherapy is a sedentary, diffuse activity with ambiguous indicators of delayed outcomes. The ideal counterweight is concrete physical activity with clearly visible and obvious outcomes. Many of us have taken to heart Chop Wood, Carry Water (Field, 1984)—a famous Buddhist book. The chores get us out of our heads, thus balancing and centering us.
Novelty also figures prominently into leisure activities. A master clinician offers this advice, pointing out that she prefers:
. . . novel activities, like go on a mystery night on a cruise ship, have a theme party at the house, travel to unusual places, go out with the most interesting people I can find who are not in psychology (so I don’t hear psychology talk). I might do some unconventional things where I don’t have to act professionally. Because of the small town I live in, people always know who you are. Spending time away from where I practice so I don’t always have to be at my most professional always helps.
Take music, for a prominent example. Music is one of the most effective escapes known to humankind. A number of clinical and experimental studies show that music has many therapeutic benefits (Sloboda, 1999), such as greater positivity (e.g., more happy), greater arousal (e.g., more alert), and greater present-mindedness (e.g., less bored). Better still, music can also be combined with many other healthy escapes—exercise, relaxation, play, and solitude.
One master therapists tell us:
My favorite way of escaping is through listening to music. The music I listen to can facilitate the release of most emotions—from sadness, remorse, frustration, and anger to happiness, joy, optimism, and acceptance. When I leave a day of conducting therapy, I typically experience some combination of these feelings. I listen to music and sing in my car on the way home, and it helps me work through these feelings before I get home. I find it very easy to escape into music.
I love music. It is one of the easiest ways for me to immerse and cleanse my mind throughout the day. I listen to it most of the time that I am alone, whether I am writing or running or cooking dinner. I might also jump up and do a little dance if I am alone. It gives me a boost in energy and lifts my mood like nothing else. It is also a hobby of mine. As a result, I have quite an extensive collection of music to choose from to fit my current mood and activities.
Thoughtfully chosen music can indeed be restful, relaxing, and renewing. Find which kind of music works for you for specific occasions. Do you need more energy or motivation? Try playing music with a fast beat, dramatic pieces, or something from your youth. Want to lift your mood? Listen to songs or tunes that trigger memories of your most positive experiences or of other carefree eras in your life. Need to wind down? Try putting on something with a slower melody. Need something conducive to being totally present in the moment? Try Eckhart Tolle’s Gateways to Now or other CDs that focus our minds and help us meditate.
Lest our examples appear to focus on social activities, let us be clear about the balance between socialization and alone time. After taxing days filled with demanding interpersonal interactions with patients, students, and administrators, many of us crave solitude.
When was the last time you were away by yourself—truly alone—for 24 hours? Forty-eight hours? Ever? We are in almost constant contact with others—and need to be for emotional and practical reasons. Yet, time spent alone is an essential biological and developmental need for all of us to maintain our mental health (Buchholz, 1997; Hoff & Buchholz, 1996). In fact, some argue that a lack (not an abundance) of solitude leads to maladaptive behavior.
Of course, the optimal balance between interpersonal contact and restorative solitude is an individual matter, affected by our personality style, work demands, and so on. One of us prefers little socialization after lengthy clinical days; the other prefers non-demanding fun after lengthy clinical days. Psychotherapists working in a hospital or community setting where face-to-face contact hours are greater, and opportunities for breaks are fewer, seem to favor more solitude away from the office.
We are avid practitioners of double-dipping on healthy escapes. We exercise with friends, we vacation with family, and we engage in a multitude of “twofers” escapes. In this respect, one added benefit of solitude is that it can be combined with other forms of healthy escapism—exercise, hobbies, relaxation, meditation, and traveling, to name a few.
Hours of restorative solitude can be extended into personal retreats. Retreats promise geographic, emotional, and interpersonal solace. One of our colleagues took a ferry from southern Rhode Island to Block Island in the morning, spent the night in a local hotel, and devoted the day and a half to himself, before returning to a delicious lobster dinner seaside with his family. It was an opportunity for dedicated reflection, discernment, and renewal.
During retreats, some colleagues prefer directed exercises, such as the spiritual exercises of St. Ignatius, while others prefer stream-of-consciousness journaling and meditation. Some prefer established retreat centers with fellow travelers on similar journeys, while still others prefer the anonymity and separateness of a Holiday Inn 80 miles from their home. The external attributes of the getaway are not nearly as important as the internal process: dedicated reflection and renewal as a person and, thus, as a psychotherapist.
“Human kind cannot bear very much reality,” as T. S. Eliot (1992, p. 118) reminds us. A psychotherapist (Fox, 1998, p. 104) relates:
I go into the desert to get lost. And lately, I can’t get lost often enough. I long for the moment when I can get behind the wheel of my four-wheel drive and aim the tires for a spot out there where my body runs on automatic pilot, and the dust of the desert clears my brain of city dust and haze, of tobacco and caffeine, and all the things that therapists absorb from their environment.
. . . Here [in the desert], I don’t spend time, I have time; for the days in the desert are longer, the nights are real nights when I can lie back and count stars the way an insomniac counts sheep.
On such retreats or vacations, we encourage you to leave your professional role at home by avoiding requests to talk shop or proffer advice. In fact, when one of us vacations and travels, he fudges and characterizes himself as a “consultant” or a “teacher” to avoid the ubiquitous requests for psychological information or assistance. Politely responding with “I don’t practice outside of the office” rarely suffices; a bit of dissembling is required to stop the assaults on our personal time. It’s a small white lie of omission but a small moral price to pay for self-care and renewal.
We are enthusiastic about personal retreats, but ambivalent about mandatory all-office retreats in which all clinicians from the same agency or clinic take a day or weekend together. First, such retreats tend to be mandatory and thus another imposition of control. Second, the retreat agenda is typically the administration’s or management’s, not that of the clinicians. Third, it intrudes into personal time. Of course, these concerns can be rectified if practitioners run the retreat, collaborate on the agenda and goals, and are paid for work time. In general, we advocate personal retreats, not office retreats, or organized retreats for renewal of health care professionals, which we see advertised and offered all around the country.
Personal retreats can be lengthened into clinical sabbaticals (Freudenberger & Robbins, 1979), taking a month, or a couple of months, away from clinical responsibilities. The disadvantages are obvious—interruption of patient care, loss of income, disruption of referrals, and so forth. Nonetheless, we are among those who favor clinical sabbaticals every 3–5 years.
One of our favorite questions in self-care workshops is “How do you play?” How do you step away from a busy life, have fun, and find renewal?
The emerging answers come in two varieties. The first answer, from about three-quarters of psychotherapists, is that they play in a multitude of ways impossible to catalogue. They play as hard as they work at every imaginable activity. They paint, write, sing, dance, fish, watch movies, exercise, and perform as clowns at birthday parties (we kid you not). Many point to their hobbies as self-nourishing, playful escapes from work and into their passions. We distinctly recall one workshop participant who proclaimed that his 2–3 hours a week at his potter’s wheel was his “salvation.”
These non-rational and creative pursuits counterbalance the typically serious and rational nature of conducting psychotherapy. Such pursuits free the therapist from the burdensome compulsion of attempting to understand patients and solve problems (Boylin & Briggie, 1987).
The second answer to “How do you play? (from the remaining one-quarter of psychotherapists) “is that “I don’t.” A typical response is “Well, I don’t really play. I used to, but then work, kids, mortgages, and life took my time and energy. It’s tough enough just working.”
Our immediate response is profoundly empathic. Life in general, and the practice of psychotherapy in particular, can certainly rob us of the inclination to play. We have all been confronted with these strains and can all feel the burden. At the same time, we cannot help but feel a sadness that once vital people are stagnant, that they and their loved ones are robbed of joyful vitality. Our next response is to gently inquire how we might get that playful feeling and commitment back into their lives.
What ways did you used to play? What sports are fun and remind you of the carefree days of your youth? Some ideas come readily to mind: amusement rides, water slides, water-gun fights, hide-and-seek, blowing bubbles, catching fireflies, playing horseshoes, volleyball, basketball, or baseball. Or building structures out of clay, sand, or dirt. Perhaps running through the pouring rain—and jumping in the mud puddles; playing board games— especially the ones that include acting, drawing, or building; playing a musical instrument; dancing around the living room; or singing in the car. The possibilities are limitless!
For the three-quarters or so of you, please keep playing and playing hard! Feel rejuvenated without the professional burdens. For the other one-quarter, please learn to turn off the professional role so that you can be spontaneous, joyful, and even immature at times. Relearn the power of play.
Most psychotherapists have several books in them—books about their clinical experiences, interesting patients, life lessons, and messages of renewal, as well as fictional works that might capitalize on their keen observational skills, writing ability, and creative imagination. We love writing and reading for fun.
Some of us record our dreams, others journal as self-care, some write fiction, and some carry notebooks and jot down phrases and quotes. The writing genre is probably not as important as the act of creative expression itself. Find a writing outlet for self-care.
Few pleasures rival curling up in a comfy chair with a good book after a draining workday. Lost in fiction or reading biographies, psychotherapists revel in the sheer pleasure of ideas, narratives, fantasy, and adventure. Some of us prefer trashy, I-don’t-have-to-think novels and others like the intellectual challenge of mystery. In all cases, reading gives us pleasure and respite.
Humor is used not only to facilitate the therapeutic process but also to nurture the individual clinician. Humor is a perfect antidote for the stresses of the occupation, the crippling disorders of some of our patients, and our occasional pomposity. Serious humor researchers find that it is powerful medicine that offers a panoply of health benefits. Laughter increases oxygen flow, elevates mood, encourages relaxation, provides an analgesic effect, and likely has a detectable beneficial effect on immune functioning (Martin, 2001). A sense of humor has been shown, in rigorous prospective analyses (e.g., Nezu, Nezu, & Blissett, 1988), to serve as a stress buffer. It is an effective, mature coping mechanism that prevents distress.
Consider the following two pieces of levity, shared repeatedly in private conversations or faxed repeatedly from one clinician to another:
A single-frame cartoon shows the stereotypical male psychotherapist, with a couch in the background, slapping the hapless patient across the face and ordering him to, “Snap out of it!” The caption reads Single-Session Therapy.
The second item is the following joke. A wealthy and aggressive managed-care executive meets with his demise and finds himself standing in front of St. Peter at the pearly gates. The executive is understandably consumed with anxiety and apologizes profusely. St. Peter looks benignly upon the man and renders the verdict “You may enter heaven . . .” The managed-care executive, relieved and overjoyed, runs through the pearly gates into his heavenly reward. But then St. Peter finishes, “but just for 3 days.”
In these two pieces of lightheartedness, we find classic expressions of aggression sublimated into mature humor. In the case of the cartoon, feeling pressured by the finances of short-term treatment, psychotherapists chuckle appreciatively at the potential horror and downright violence they envision for the ultimate in single-session psychotherapy. In the case of the joke, feeling displaced as arbitrators of patient health care and contemptuous of the unconscionable salaries of managed-care executives, psychotherapists revel in the “just desserts” of the executive’s receiving the same (limited) treatment afforded to many of our valued clients.
Of course, humor can be misused, as in attempts to dominate, evade, or laugh at—instead of with—others. It must be sensitively and properly applied. And when it is, humor is as restorative as sleep, in which we “burst into” health-giving benefits.
Earlier in this section, we discussed brief relaxation and meditative escapes at the office, but here we underscore the point that many mental health practitioners have adopted meditation as a lifestyle outside of the office.
Meditation is a simple process, if one can set aside the need for accomplishment and goals. Meditative escapes bring relief by rejecting ordinary thoughts and adopting a serene observational stance. The various meditative techniques disrupt the mind’s tendency to jabber on about everything that happens and to analyze it ad infinitum. Meditation involves letting ordinary thoughts come and go without judgment, interference, or disruption. By abandoning egotism and adopting a pervasive attitude of modesty, practitioners can avoid the burden of having to keep an overgrown, overvalued self up to inflated standards (Baumeister, 1992). The broader philosophical-cognitive shift that life is suffering—the first of Buddha’s Four Noble Truths—can help us abort the extended “pity parties” we throw for ourselves. Meditation clears the mind, refreshes the spirit, and centers us through close connection with the physical world.
One of our master clinicians describes his meditative escape this way:
About 6 months ago, I realized that my ambitious and driven behavior was taking a toll on me—physically, emotionally, and spiritually. I knew that I had to find some way to slow myself down. I wanted to find something that I could do just for myself—not for my family, not for my clients, and not for my vitae. So I began meditating. Each day, I make the time to meditate. Periods of sitting motionless and intensely focusing my mind calm my thinking, lift my mood, and soothe my soul.
Our research studies have identified not only what predicts effective self-care but also what predicts ineffective self-care—the “to do” as well as the “not to do.” This chapter has been occupied almost exclusively with the former, so before we close we should attend to the latter.
Two strategies are reliably associated with self-care ineffectiveness among psychotherapists (Norcross & Aboyoun, 1994) and among the population at large (Penley, Tomoka, & Wiebe, 2002): wishful thinking and self-blame. By focusing on not being able to change and relying on wishing rather than acting, the frequent use of wishful thinking probably accentuates distress and reduces problem solving. In a similar way, the negative preoccupation of self-blame may distress the therapist further and paralyze adaptive recourses. The moral is simple: avoid wishful thinking and self-blame.
In our experience, many psychotherapists suffering a paucity of healthy escapes may wind up engaging in wishful thinking and self-blame after listening to their colleagues in self-care workshops or reading this section. “My colleagues got their self-care acts together. What’s wrong with me? I’m not nearly as creative or resourceful as my peers. I wish I could do those things too!” And, as workshop leaders, we are humbled and more than a little envious of the superstars of healthy escapes that we encounter.
When these and related thoughts happen to you, we would offer four collegial directions. First, please do not compare yourself to the glowing exemplar of self-care highlighted in a workshop or this chapter, but to the typical practitioner struggling to remain sane and solvent in a busy life. Second, remind yourself that healthy escapes are merely one strategy of self-care, and some of our colleagues who excel at leisurely diversions do little else for self-care. There is no single self-care strategy so outstandingly effective that its possession alone ensures health.
Having a particular hobby or leisure pursuit is less important than engaging in a variety of self-care strategies. Third, transform the wishful thinking into action—perhaps you are, in fact, in need of more escapes away from the office. Mobilize the self-blame in order to take constructive action. Fourth and finally, if chronically plagued by self-blame and wishful thinking, then please consider peer consultation and personal therapy. This may well represent an enduring personality pattern, as opposed to a transient reaction.
How, exactly, do psychotherapists manage to take their minds off their professional identities and leave their distress at the office? The self cannot simply be turned off like a lamp (Baumeister, 1992). Creating healthy escapes requires a skillful attitude, an abiding commitment, and absorbing errands.
Healthy escapes must be defined and discovered individually; what one clinician classifies as self-care may be a stressor for another (Williams-Nickelson, 2006). For example, sports participation may be relaxing for some, but the competition is stressful for others. Some of us appreciate at least an hour of solitude each day, while others pursue interpersonal contact with non-clients. Taking a family vacation may be relaxing for most, but not if you are the person responsible for coordinating everyone else, and are then stuck with the extra work when you return. Determine what escape keeps you in touch with yourself.
Finding balance among love, work, and play is indispensable, and yet probably overprescribed, in the self-care literature. The advice is fine and well-intentioned but results in little permanent change unless combined with some candid assessment of what purposes and meanings overwork has for you (Grosch & Olsen, 1994). If you exchange a few hours of compulsive overwork for a few hours of competitive exercising or compulsive hobbies, little has been accomplished. So, as we conclude this topic, bear in mind that the advice must be combined with your own dynamics and vulnerabilities.
In this section, we offered a variety of healthy escapes to renew and energize you. To be sure, there are hundreds of other means not mentioned that you may find helpful in nurturing yourself. Our abiding hope is that this sampling will lead you to seek out or continue those escapes that work best for you.
But the greatest challenge in healthy escapism is not learning what works for you. The greatest challenge is building the practice into your daily life with regularity—both in and away from the office. As Henry James correctly observed at the beginning of this chapter, “The point is not only to get out—you’ve got to stay out; and to stay out you must have some absorbing errand.”
Baumeister, R. F. (1992). Escaping the self: Alcoholism, spirituality, masochism, and other flights from the burden of selfhood. New York: Basic Books.
Fields, R. (1984). Chop wood, carry water. New York: Penguin.
Pope, K. S., Sonne, J. L., & Greene, B. (2006). What therapists don’t talk about and why: Understanding taboos that hurt us and our clients. Washington, DC: American Psychological Association.
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