This is an intermediate course. Upon completing this course, mental health professionals will be able to:
This is the second course in a three-part series. Portions of this course are adapted from the book, Leaving It at the Office: A Guide to Psychotherapist Self-Care, © 2018 by John C. Norcross and Gary R. VandenBos and reprinted by arrangement with Guilford Press.
The information in this course is based on the most accurate information available to the authors at the time of writing. Self-care research and practice grow continuously, and new information may emerge that supersedes these course materials. This course will provide clinicians with an understanding of self-care and equip them to experiment with additional self-care methods. Doing so may provoke novel feelings or unsatisfying results for some readers. There are no known severe risks of engaging in clinician self-care.
Note: While you may choose to read the courses in this series singly or in any order, we believe it will prove important to complete them in sequential order. The first course in this series, Ethics of Self-Care: Where the Personal is the Professional, serves as the foundation for all three courses. This second course covers self-care at the office as well as away from the office. The third course, Mindful Self-Care: Your Internal and External Environments, offers a wide range of mindful related practices for the self-care of the therapist. We hope that your spirit and practice will be touched as you study the information provided here and that these self-care strategies will awaken and direct your sensitivities to your personal and professional identity as a psychotherapist.
Research has consistently identified healthy relationships, adaptive cognitions, and productive escapes as the most frequent and the most effective methods of psychotherapist self-care. This course canvasses these three foundations for successful self-care, providing research-supported examples, sharing examples from master therapists, and concluding with practical checklists.
The cognitive section begins with the need for self-monitoring complemented with external feedback; we then consider rampant therapist “musterbations” and cognitive errors, along with means to counter them. We cover self-care at the office as well as away from the office; for instance, nurturing relationships at the office with colleagues, peer groups, clinical teams, staff, supervisors, community colleagues, competence constellations, as well as away from the office with partners, family, friends, colleague assistance programs, practice consultants, and personal therapists. Likewise, we highlight the self-care research that supports healthy escapes at the office (e.g., vital breaks, relaxation, humor, get-togethers) and those away from the office (e.g., vacations, leisurely diversions, restorative solitude, nature, retreats, play).
We are all in the same boat in a stormy sea, and we owe each other a terrible loyalty.
– G. K. Chesterton
In Flannery O’Connor’s 1965 short story “The Lame Shall Enter First,” a psychologist appropriately named Sheppard is dedicated to reforming troubled boys. But 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.” 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 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 interpersonal relationships. The isolation, introspection, and restraint characteristic of the healer role can reduce our spontaneity and vitality. 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 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 alone, the clinical and research consensus is that we best restore inner strength and regain emotional balance through meaningful relationships (Medeiros & Prochaska, 1988). In fact, our survey of master therapists found that they depended 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 and popular self-care in the psychotherapist research. Across multiple studies, more than 90% of mental health professionals say they seek support from family, friends, and peers. In several of our studies, mental health professionals consistently report greater use of helping relationships than educated laypersons in dealing with their own distress (Norcross & Aboyoun, 1994). In related research, increased use of helping relationships correlates positively with psychotherapist well-being – just as social support does with laypersons (e.g., Chu et al., 2010; DiMatteo, 2004). Expectedly, psychotherapists find helping relationships to be both satisfying and efficacious for themselves.
Without getting too technical, helping relationships (or social support) exercise a threefold effect on work stressor–strain relations, according to the meta-analyses (Viswesvaran et al., 1999). Social support (1) reduces the actual strains experienced, (2) buffers or mitigates the stressors of work, and (3) moderates that stressor–strain association. In other words, nourishing relationships protect us from the ravages of our impossible profession in several ways.
Psychotherapists find nurturance in their relationships from a multitude of sources. In this section, we review advice and exemplars from a number of these, inside the office (e.g., colleagues, staff, supervisors, mentors, sometimes patients) as well as outside the office (e.g., friends, family, practice consultants, personal therapists). Since supervision and consultation can occur both in and away from the office, we consider the former in the office section and the latter in the outside section to avoid redundancy.
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, starting with peers.
Colleagues are an important means by which to replenish our emotional reserves (Gram, 1992; Johnson et al., 2013; Menninger, 1991). Because they understand the world in which psychotherapy operates, they appreciate the feelings, reactions, and concerns of fellow mental health professionals. By sharing their perspectives on treatment methods, diagnostic questions, ethical dilemmas, and practice challenges, they become allies. This can be quite encouraging and reassuring to the practitioner, who otherwise feels alone with the challenges inherent in her work. Within the limits of confidentiality and ethical practice, peers prove a valuable source of self-care and ongoing competency (Neimeyer et al., 2012).
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.”
Some psychotherapists prefer to formalize nurturance from colleagues by organizing peer groups that regularly meet to discuss professional issues of concern. The best estimates are that 60%–70% of mental health practitioners receive some form of peer supervision or consultation, while 10%–25% attend a formal peer support, supervision, or consultation group on a regular basis (e.g., Goodyear et al., 2016; Knapp & Sternlieb, 2016; Mahoney, 1997; Martin, 2010; 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–protege 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 at all. For still another, peer groups are advantageous in their implicit mutuality and nonhierarchical structure. And groups can offer you multiple perspectives on a clinical challenge you’re facing, as well as peer interactions.
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. Clarify the group structure early, and agree on membership rules (e.g., size, new members, and attendance frequency). 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 four to 10 members and meet every two weeks to once a month for two 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 create 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, healthcare professionals take turns presenting a patient and the dilemmas that treating him or her invokes. Then, colleagues take turns asking clarifying questions – not questioning 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 predictable 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 demands of the setting, are familiar with each other, can provide on-site support, and can congeal the staff. On the minus side, 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.
In many cultures, healing is never an individual task or duty. It is an emergent relational property and collective responsibility. It takes a healing circle; it takes a village.
Can you imagine any healthcare 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, personality disorders, severe traumas, and similar impairing disorders call for a team approach.
Working as a clinical team not only improves the probability of a patient’s successful outcome but also nurtures the psychotherapist. Team members may provide different services, be it individual therapy, group treatment, 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), who specializes in the treatment of borderline personality 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 co-therapy 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 the 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, more than enough 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 worksite, psychotherapists may interact frequently with other staff – a receptionist, secretary, intake worker, or bookkeeper. They can provide a central source of contact and encouragement. They can partake in a few moments of casual conversation and shared humor that refresh the practitioners 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 the workday. 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 also prove vital sources of guidance and encouragement to psychotherapists. Lawyers, physicians, accountants, and the like not only provide professional advice but also are often willing companions for lunch and available partners for quick phone visits. Those in allied helping professions offer mutual support in part because of the shared understanding for what it takes to work with people – a mutual respect and reciprocal 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.
For those in full-time independent practice, we recommend that you locate and build a relationship with an accountant, an attorney, an insurance agent, and a computer specialist/web designer. They will bill you for their professional services, of course, just as you bill your clients. Don’t go it alone when it comes to legal, financial, insurance, and computer matters. Knowing that they have your back provides comfort and succor.
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 (Orlinsky & Ronnestad, 2005). Therapists ascribe 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; Norcross & Popple, 2017). Marginal supervision may be worse than none at all, and much agency-based supervision of seasoned practitioners is fairly unsatisfying, in our experience. 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:
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? What awkward or clumsy situations have you encountered of late? What happened in your most successful cases of late? Good supervision is a safe haven for review of all that transpires in psychotherapy: problem cases, ethical quandaries, good moments, transference, countertransference, practice management, and reactivated personal conflicts. Get what you need.
There remains at least one more individual who can supply a nurturing relationship: the professional mentor. 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 (Ronnestad & Skovholt, 2001). The descriptions are passionate and appreciative; mentors leave an indelible mark on our personal and professional development that reverberates today. We strongly recommend that each practitioner cultivate a strong attachment with and a positive investment in a professional mentor. Ideally, maybe two or three mentors with disparate skill sets – practice, ethics, marketing, writing, professional organizations, for example – would form your mentor network.
A mentor offers guidance tailored to your individual personality and clinical needs, providing confrontation, nurturance, and direction in a manner that is more personal and informed than usually 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. In some cases, the mentor need only serve as a “touchstone” who is contacted primarily at times of critical career decisions or professional crisis.
We, the coauthors of this course, can personally attest to the soothing and inspiring roles played by mentors in our development. Knowing that a mentor is available with support and advice on sticky ethical matters (e.g., an elderly patient dies with a will leaving the practitioner money, unbeknownst to the practitioner) or clinical quandaries (e.g., the psychotherapist’s son becomes friends with a patient’s son) has proven invaluable. It is regrettable that relatively few of us have the opportunity and energy to maintain these mentoring relationships. Be a Telemachus seeking Mentor through your training, community, and professional organizations.
In time, you will give back when assuming the mentor role yourself. Check in with a colleague about her self-care and how you might assist her. Be available when others contact you. Like the final step in 12-step groups, you will try to carry the message forward to others. You can sequentially or simultaneously serve as mentor and mentee. In both capacities, you ensure the future success of psychotherapists and will be nurtured.
All of these in-office sources of nurturance – colleagues, peer support/consultation groups, clinical teams, office staff, community professionals, supervisors, mentors – can converge into competence constellations, clusters of relationships that take an active interest in and engage in action to advance a professional’s well-being and professional competence (Johnson et al., 2013). It is a communitarian approach for ensuing optimal functioning and protecting therapists from unrecognized problems of competence. These constellations shift the emphasis from individual to community responsibility for competence, like social healing circles, and from punishing impairment to ensuring well-being. Such shifts are long overdue.
Part of the impetus for the communitarian emphasis is the scores of research studies that demonstrate that clinicians are not particularly adept at assessing their own competence (e.g., Waltman et al., 2016). In one representative study (Walfish et al., 2012), 25% of mental health professionals rated their skill level at the 90th percentile compared to peers and none viewed themselves as below average! This self-assessment bias is known as the Lake Wobegone effect (named in honor of Garrison Keillor’s 1985 fictional home town in which all the children were above average). Healthcare practitioners need objective evidence of patient outcomes, independent review of work samples, multisource feedback, and especially peer review to increase the accuracy of our competence assessment. Psychotherapists can, and should, turn to each other to identify blind spots and unintended gaps in their abilities.
Individual practitioners or group practices can intentionally construct these consortia or networks. Alternatively, organizations can provide the time and space to develop them as ways to sustain individual and organizational health. Your constellation members can be the first to recognize when you’re experiencing personal difficulties or confronting competence limits. In the future, we shall see more explicit creations of these constellations along with communitarian concepts infused into ethic codes, training programs, and licensing regulations. The self-care lesson we learn and continually relearn: Don’t go it alone.
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 clinical practice. Spouses/partners, family, and friends provide our love and support. Love – both receiving it and giving it – heals. In Winnicott’s sense, the therapist creates a holding environment for herself outside of the office where she can be soothed and nurtured (Kaslow & Farber, 1995). In Flaubert’s words, be orderly and loved in your private life, so that you may be vital and original in your work.
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 long-term commitments. 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 in that same study 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 provides nearly unconditional 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 in an intimate relationship of paramount importance. 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. On the other hand, a mate can provide a firm foundation of support and acceptance of the struggles of clinical work. This helps the therapist to express hidden fears and hopes related to the “impossible profession.”
In private conversations and public presentations on self-care, we frequently hear colleagues lament the family spillover into their work performance, especially during marital discord and family disruptions. Research confirms these intercurrent life challenges, of course, but at the same time documents that psychotherapists report significantly higher incidence of positive spillover than negative spillover (Stevanovic & Rupert, 2009). That is, families tend to enhance professional functioning more than they detract from it.
One of our master therapists reported:
“I am more involved in doing professional activities through associations, beyond my psychotherapy practice, because my husband helps to make it possible. He encourages my professional involvement, he takes pride in it, and he tells his colleagues about what I am doing. He also does more around the house and with the kids than do the husbands of most of my colleagues. My children also take pride in my broader professional efforts in the community, and they tell their teachers and friends about what I am doing and what initiatives I am involved in.”
Confidentiality must be maintained in this context. This includes preventing inadvertent domestic slips of confidentiality, such as disclosing information to a spouse, leaving unsecured documents at home, sharing a fax machine, or making an 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. Therefore, limit discussion with a partner to your reactions that do not threaten confidentiality. This need not include any information about a client, nor need it involve a violation of professional ethics.
Before leaving this topic, we should observe that psychotherapists tend to marry fellow mental health professionals 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 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 prove more difficult to reorient and reenter the “real world” when both spouses spend considerable time in the clinical world? Like all of life’s adventures, a marital relationship between two psychotherapists must certainly be a mixed bag of assets and liabilities (Guy et al., 1987). The two authors of this CE program have both been happily married to fellow psychotherapists for more than 35 years. So it can certainly be done!
As in the case of a spouse/partner, there is something basic, something elemental, 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 one is known as someone other than a psychotherapist – Mom, Dad, daughter, son, aunt, uncle, and cousin. It’s refreshing to get together with family who insist that the practitioner 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 told us: “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. So, a self-care shout-out to valued pets!
Children have impressive ways of deflating the self-importance that results from spending many hours with clients who value our advice and expertise (Japenga, 1989). It is humbling indeed to be ignored, teased, disobeyed, and challenged by kids 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, namely, “All others get in line.” But most of us slip, if not fall, in implementing the rule. And, in the interests of full disclosure, we two authors usually slip as well. Both of us have publically remarked for years that there was an “unspoken” family rule of not traveling away from home more than once a month. And, both of our spouses have, on more than one occasion, quipped that the rule was “unspoken and unkept!”
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 and reciprocity of 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. This world of relationships is ideally a safe harbor in the midst of a turbulent career. Relatives are usually not invested in our clinical successes or failures. In spite of the tendency of some to seek our advice on personal concerns, most family members continue a pattern of relating that predates the commencement of our clinical career. This allows us to drop the healer role and accept the support of family members as genuine and without ulterior motives. 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!
Friends are good medicine. They share our deepest fears and most embarrassing foibles, hopefully with loving regard for both. Friends enjoy 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. As one of our master therapists described,
“I have had a friendship circle of six to eight friends, all in other fields, in both places in which I lived. Each group existed for over 10 years. We meet once a month for 90 minutes, usually for a late afternoon tea or coffee, but occasionally for lunch. We talk mostly about life. We have supported each other through all of the normal life events, challenges, and transitions. It is great to share and be supported like that, by gifted individuals going through similar experiences.”
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; 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 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.
Meaningful friendships remind us that most of life takes place outside of the consultation office and 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. When invited, friends give honest feedback about the changes they note in the life and demeanor of the psychotherapist. “There is nothing on this earth more to be prized,” wrote Saint Thomas Aquinas, “than true friendship.”
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 (CAPs) provide resources for distressed clinicians and promote their 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), and about 5% of practitioners have contacted one (Martin, 2010). The Social Workers Assistance Network and Social Workers Helping Social Workers, for two more examples, provide support and assistance to social workers experiencing personal distress and substance abuse. 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. CAPs are in a unique position to offer assistance and early intervention that could prevent the progression from distress to impairment. We can help one another outside of the office instead of relying solely on punitive licensure boards or ethics bodies.
CAPs 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). Please proactively consider a CAP, should trouble come calling or should you need additional sources of self-care.
Supervision and consultation overlap in their activities, but they differ in who is primarily responsible for clinical care and decision making. Depending upon your state licensure laws and regulations, formal supervisors are generally responsible for the patient care you render, whereas consultants are not. That’s why “peer supervision” is not technically supervision in most jurisdictions and why you should understand how those terms are defined where you practice.
We addressed community professionals providing your legal, financial, and computer services earlier in this course, so here we advocate for a clinical or practice consultant who will enrich your skills, process your work, and help you thrive as a psychotherapist. You may prove one of the fortunate souls who receive this nurturance from peers for free, but those instances prove rare as peers understandably expect reciprocity in satisfying their own needs. By contrast, practice consultants are, by design, there for you and only you.
A colleague wrote that, after attending one of our workshops:
“I contacted a group therapist colleague and convinced her to offer a peer consultation and support group for therapists. I have been in full-time private practice for four years and have meant to organize peer consultation all that time, but couldn’t get beyond feeling overwhelmed by the organizational tasks and anxiety about who to invite. So I decided to pay someone I trust to do all that. I have broken through the impasse and am very pleased with how it is going.”
The informal consensus is that such meetings ideally occur outside of your practice location. It is time to nurture you and your clinical competencies away from the office.
Psychotherapists are inveterate meaning-makers. We seek to find and make meaning out of our experience. Most healers learn from mentors to achieve the highest level of effectiveness and to create a larger purpose in life.
“Life mentors” support and guide us over many decades of life. Although this mentoring may include professional development, as discussed earlier in this course, the focus here is upon the development of a person who happens to be simultaneously a mental health professional. The life mentor may be a clergyperson/spiritual advisor, favorite teacher, special relative, cherished neighbor, or older friend. Contact may be infrequent, but invariably proves meaningful. Try to secure a life mentor genuinely committed to your well-being; it is invaluable self-care.
Few have as strategic or vital an impact on the practitioner 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.
But let us here briefly present one compelling reason for seeking personal therapy or professional consultation away from the office 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 nonprivileged 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 and 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 expectedly find close, loving connections the most effective source of buffering support 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 clinicians’ 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 understands my grind as a psychotherapist” – but find them unconvincing and transparent defenses. Of course, we need loving relationships. Psychotherapists are people too.
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 metal 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.”
So, follow the research evidence, the 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 (Lyubomirsky, 2007; Myers, 2000). The largest determinant of happiness appears to be a supportive network of close relationships. Luxuriate in your relationships, feel the connection, pursue the reciprocity of nurturance.
Not only is a full complement of trusted friends and family desirable for a fulfilling existence, but healthcare practitioners 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 (Guy et al., 1989a; Guy et al., 1987b). We also hope that you have developed peer relationships and competence constellations who would offer you feedback when you are deciding to reduce or terminate practice. Families, friends, peers, and mentors pull double duty in nurturing and cautioning.
We recommend that you give careful thought to the sources of nurturance in your life. Are they adequate? Is there variety and balance? Identify who has your back at the office. Pinpoint who supports you outside the office. (Consider sending them a thank-you note, by the way.) Calculate the discrepancy index: what you realistically desire versus what you have. How can your social support be utilized more effectively? These are among the most critical self-assessments that you can conduct in 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 1965 short story “The Lame Shall Enter First” from early in the course. We implore you to become a good shepherd, not a sacrificial lamb. Become the bounty-ful and boundary-ful clinician devoted simultaneously to self and to service.
What you put in your head is there forever.
– Cormac McCarthy
Cognitive restructuring for psychotherapists is steeped in ironies. Although intellectually aware of the irrational beliefs explored in rational-emotive therapy and the depressogenic assumptions of cognitive therapy, we therapists fall prey to these same cognitive errors. A predilection for dispassionate examination does not immunize us to the perils of the secular world. We are blissfully human; as such, we are subject to the same corrosive logic as our fellow humans. As Cormac McCarthy (2006) memorably put in The Road, “What you put in your head is there forever.”
Indeed, a father of cognitive-behavioral therapy (CBT), Albert Ellis, wrote (1987, p. 364) that irrationalities “persist among highly intelligent, educated, and relatively little disturbed individuals” and “seem to flow from deep-seated and almost ineradicable human tendencies toward fallibility, overgeneralization, wishful thinking, gullibility, and short-range hedonism.” Assuming too much responsibility for our patients, succumbing to the demands of perfectionism, catastrophizing over a case, and thinking dichotomously about the outcome of psychotherapy plague us all at times. Ironically, we engage in the very dysfunctional thoughts that we teach our clients to avoid.
It’s hard to be dispassionate about a subject when it’s yourself. Nonetheless, identifying and challenging our faulty cognitions are keys to therapist self-care.
This section focuses on cognitive restructuring: identifying and challenging problematic thinking among mental health professionals that maintains negative feelings and self-defeating behavior. We explore and consider the remediation of prevalent “musturbations” (Ellis, 1984) and cognitive errors (Beck, 2007; Beck et al., 1979) that psychotherapists inflict upon themselves. We also feature several of the assumptions underlying negative countertransference and underscore the role of therapist choice. In a significant way, this entire program is devoted to remediating the cognitive errors of psychotherapists; however, in this course we focus on specific examples and methods of cognitive restructuring.
We employ the cognitive-behavioral term of cognitive restructuring in this course, but intend it in a pantheoretical manner. We use it as a broad process across theoretical orientations rather than a specific CBT method.
Cognitive therapists are not the first or only ones to identify perfectionist strivings and cognitive errors. Psychoanalysts, in particular, have written extensively about the persistence of unrealistic and unrealizable analytic ideals of patient outcomes and therapist methods. One author (Abend, 1986, p. 566) reminds us that, although experience certainly dictates that perfectionist goals are all but impossible to attain, they continue nevertheless to influence both theory and aspirations. Most therapists try to live up to the inflated ideals of the masters, from Freud on down.
Solution-focused therapy, too, reminds us to re-author our own narratives. Consider these examples of cognitive restructuring via rewriting our stories about clients (based on Clifton et al., 1990):
Similarly, humanistic therapists remind us to “cognitively restructure” our reactions to clients via empathy. When sitting with a client who criticizes your skills as a therapist, or projects anger toward you because she is not “getting better,” you can grasp those responses from an empathic place (e.g., “The client is experiencing a great deal of pain”). It is more difficult to feel anger when you hear her message as one of helplessness and pain rather than filtering the message through your own experience (e.g., “I’m annoyed that the client is calling me a lousy therapist” or “The nerve of her to become angry at me when I’m working so hard!”).
In our interviews, one of our master clinicians bluntly stated:
“Stress is always self-created. Stress means that it is difficult, and when you do not have cognitive restructuring you define the difficulty as awful, horrible, that it shouldn’t exist. When you do cognitive restructuring, then you define it as a pain in the ass, period, and you don’t get depressed about it. For example, when the clients are a pain in the ass then you define it as a pain in the ass, instead of horrible and awful.”
By heeding this candid redefinition of stress, you can transform, in Freud’s terms, neurotic misery into ordinary annoyance.
Cognitive restructuring starts with self-awareness and self-monitoring. We begin by recognizing what we tell ourselves, explicitly or implicitly, regarding our performance and identity as psychotherapists. A few minutes of thoughtful reflection, collecting data to test our assumptions, concerned sharing with significant others – all of these alert us to the self-deceptions that creep into our thinking and eventually into our practice.
As therapists, our introspective skills allow us to monitor internal dialogue. For example, a client relates an experience in session, and you cannot conjure up a compelling or accurate empathic reflection. You demean yourself: “Why can’t I feel or resonate today?” After a few moments, your self-monitoring may recognize this instance of faulty logic. There is no singular interpretation or reflection, and, even if there was, there is no reason to expect perfection in each clinical transaction. Or perhaps there is no need to analyze or comment at that moment.
Self-monitoring permits us to recognize our cognitive errors, determine our faulty assumptions, and prescribe an alternative. If our irrational thinking is not immediately apparent to us, it likely will stick out (like a neon light in the darkness) to others, especially our coworkers. All for the better! Another therapist’s viewpoint may provide a new spin on our thinking. One of our clinical colleagues, for example, artfully points out our heavy sighing between sessions, a guaranteed tip-off that our perfectionistic expectations are getting the best of us that day. A little collegial prompting begets self-monitoring and disputations.
Graduate admissions in healthcare (especially doctoral programs) tend to select for high-achieving,2 competitive, and perfectionistic students. Then, grueling graduate training itself strengthens the notion that feeling overwhelmed and exhausted is “normal” and a feeling we must work through. Schooled in self-denial (Koven, 2010), mental health professionals frequently internalize the perfectionistic, work-through-the-pain traits that enabled us to get into graduate school in the first place.
Consequently, these originally adaptive traits fuel many therapist “thinking errors” – my personal worth is equal to my professional achievements, I should cure every patient, always put patient needs before my needs, fun and leisure are nonproductive activities, work even when ill. Over decades working with and supervising mental health professionals, we have concluded that this constellation of perfectionistic, self-denying traits is behind many of their (and our) impairing expectations. Keep this probability in mind as you self-monitor your internal process.
We consider self-monitoring internal dialogue to be the indispensable first step in battling our cognitive errors. Awareness alone is insufficient in combating the therapist “musturbations” and “shoulds.” Intellectual insight by itself, as Freud reminded us, is about as efficacious as providing a starving person with nothing more than a dinner menu. But awareness and insight begin the process of cognitive restructuring.
“What do I do to keep from obsessing about a woman whose husband has just speculated on what knife he would use to kill her; a borderline patient who is chewing me out for not immediately returning her non-emergency phone call; or a staff member who has neglected to arrange for a repair, resulting in the ceiling falling in during a rainstorm?” So begins rational-emotive therapist Janet Wolfe’s (2000, p. 581) “A Vacation from Musturbation,” an article appearing in the “Self-Care Corner” in Professional Psychology, which we coedited a few years ago. Her answer: “I try as much as possible to practice what I preach during the work hours and to take my philosophy with me when I leave the office.”
Over the years, Albert Ellis (1984) has gathered the common irrationalities or lies we psychotherapists tell ourselves. His list of “musturbations” – things that therapists tell themselves they must do – includes several, corollary irrationalities. The following are summarized from his “How to Deal with Your Most Difficult Client – You.”
The corollary irrationalities include (1) I must always make brilliant interpretations or empathic responses; (2) I must help my clients more; and (3) I must not fail with any of my clients, but if I do, it is my fault and I’m a lousy person!
“After putting in years of graduate training and after my best empathic efforts, some patients have the audacity to get worse. Shouldn’t they have the common courtesy to get better?!”
The reality of psychotherapy is that success is neither automatic nor universal. Any therapist who assumes she has to succeed every time will eventually find great disappointment. We will not be successful with every client for multiple reasons; to say that you must always do so is completely contrary to the definition of being human.
We are reminded of a particular case, involving a schizophrenic woman that personally affected Carl Rogers enough to impair his own functioning as a therapist and as a human being. This case is an example of how practitioners, believing success will come with every patient, can mistakenly ignore their own problems for the sake of their client. Before treating the woman, Rogers “had come to understand the importance of the client’s feelings in the relationship, [but] his own personal background [suppressing feelings as a child] still held him back from giving due attention to the therapist’s feelings” (Kirschenbaum, 1979, p. 191). Difficulties began when Rogers, the paragon of empathy, substituted apathy for his traditional warmth whenever the woman’s disturbance and dependence threatened him.
Although not succeeding with the patient, Rogers continued treatment. In his own words, “I started to feel it was a real drain on me, yet I stubbornly felt that I should be able to help her and permitted the contacts to continue long after they had ceased to be therapeutic, and it involved only suffering for me” (quoted in Kirschenbaum, 1979). Moreover, recognizing “that many of her insights were sounder” than his, Rogers lost confidence in himself. Although Rogers suffered deep distress as a result of this experience, he worked through it and eventually liked himself more. Even the most eminent therapists, like the rest of us mortals, are often blindsided by impossible expectations.
What are adaptive alternative cognitions? That psychotherapy succeeds with most, but not all, patients. That we can develop reasonable standards of success. Collect outcome data on all patients to determine your actual performance compared to peers with similar patients. That we are human and will make errors. Yes, it would be highly preferable to always make brilliant interpretations and always have superb outcomes, but that is unrealistic and unobtainable.
Two corollaries are that “every therapy session with clients (including difficult clients) must be good” and “I must be an eminent therapist.”
In self-care symposia we organized a few years back, Judy Beck (1997, 2007) spoke movingly of her travails when comparing her clinical and scholarly performance to that of her father, Aaron T. Beck, one of the founders of cognitive therapy. She was bound to feel inferior, as we all would, given the impossible standards she faced. It is a constant struggle to make realistic comparisons instead of perfectionist evaluations. Judy Beck advises us to compare ourselves to same-age peers in similar circumstances.
As Ellis ardently puts it in “How I Manage to Be a ‘Rational’ Rational Emotive Behavior Therapist” (1995, p. 4): “There is no damned – or undamned – reason why I absolutely must be an outstanding therapist, colleague, socialite or anything else! I am determined to always give myself unconditional self-acceptance (USA) whether or not I perform well and whether or not I am loved and approved.”
The resultant internal dialogue might be “I would like to be an outstanding therapist and have good sessions with all clients; but if I cannot, I can still be a competent therapist and enjoy doing therapy.” Moreover, “Why do I have to be a well-known therapist? Am I afraid that if I do not work so ardently and compulsively, that I might not be a good therapist?” We don’t have to be labeled as “the best” to perform well. If in the process of establishing a distinguished career we succeed in making ourselves disturbed with our own stringent, absolutistic views, haven’t we sacrificed too much?
In our self-care workshops, we ask mental health professionals if they can publicly declare themselves as “average” in terms of their clinical effectiveness. We have encountered only two such therapists in 40 years! The typical practitioner believes her efficacy, if not the most outstanding, to be at the 75th percentile, better than three-quarters of her counterparts. The workshop participants soon howl in laughter as they realize it is logically and statistically impossible for all of us to be above average, as in Garrison Keillor’s 1985 fictional Lake Wobegon “where all the women are strong, all the men are good looking, and all the children are above average.”
But that’s precisely the crux of the matter: By disposition and training, most of us are physically repulsed at the thought of being at the 50th percentile on any measure of effectiveness. Dare you set your expectations to be a “good-enough psychotherapist?”
Corollaries concerning the anticipation of cooperative patients include (1) My clients should be tractable, not impossible!; (2) My clients should always have their homework assignments done on time; and (3) I should only have YAVIS (young, attractive, verbal, intelligent, and successful) clients! Don’t hard-working, successful therapists deserve hard-working, successful patients?
Is there a healthier alternative? Perhaps. “It would be ideal if all my clients were hard-working, but if they aren’t, I will still accept and try to help them despite their imperfections.” We all feel occasionally frustrated by our patients’ lack of motivation and further nettled by their apparent unconcern or lackadaisical attitude. This comes with the job description. Your client is paying you to do your job – who says she must do hers? You? For a therapist, detached compassion is sometimes the way of survival. We can pitch the benefits of change, but we can’t make the client buy it.
To mentally combat the hassles at work, Ellis (1995, p. 4) recommends his musturbatory-busting rationale:
“The conditions that often prevail in therapy don’t have to be always easy, comfortable, and enjoyable. In fact, they often aren’t. Unfortunate! Inconvenient! But not the end of the world. Just a royal pain in the ass! Now how can I do my best to improve them – or unwhiningly accept what I can’t change? What’s my alternative? More silly whining!”
As every half-conscious psychotherapist knows, awareness alone is insufficient in rectifying such musturbations and shoulds. Instead, irrational beliefs are often deep-seated – tenaciously implanted at the core of our personality – and require vigilance in identifying and disputing them. Just as we do in our clinical work. We alleviate our emotional distress only by practicing rational beliefs, practicing appropriate emotions (such as annoyance instead of misery), and practicing desirable behaviors.
Experienced therapists benefit from many of the same cognitive therapy methods as their patients (Beck, 1997). For example, monitoring one’s overly busy schedule and rating pleasure and mastery of activities can help the therapist discover what changes need to be made. Or, for another example, uncovering one’s expectations of self and others and assessing the advantages and disadvantages for holding such standards can lead to a more functional reassessment. Recognition and modification of a dysfunctional comparison set – such as Judy Beck’s earlier example of comparing herself to higher achieving mentors instead of similarly situated peers – often improves self-confidence.
Following are a medley of cognitive errors frequently committed by psychotherapists and a compilation of potential cognitive solutions.
A patient in psychotherapy with you for three months is not getting better. You tell yourself you’ve done everything possible thus far. You listened attentively and resonated with the patient’s experience. You conducted treatment in accord with the research evidence. You tried several treatment approaches. You have prescribed (or referred for) psychotropic medication. Nothing seems to work. Yet, twinges of guilt and doubt pass through your mind: “I’m a failure as a therapist!” and “I should have listened to my mother and become a lawyer!” Several other failure cases from the past invade your consciousness. Suddenly you are feeling worthless and inept; to compound your self-doubts, you realize that your patient is the one who’s suffering the most here, and maybe, just maybe, it’s your fault.
Sound familiar? We are so accustomed to perfection. Our work means so much to us. We’ve devoted a substantial part of our lives educating ourselves for the work. And to get this far in the profession we needed excellent grades and work habits – not average, but excellent.
The point is this: We are accustomed to being competent and successful. “The absolutely perfect practitioner is, of course, a misguided and misguiding illusion, but it still operates in the tacit life ordering that goes on in psychotherapists’ lives” (Mahoney, 1991, p. 352). Expecting perfection in practice contributes to our own mental suffering.
We can be like Winnicott’s (1958) good-enough mother. Even when we make mistakes in therapy or disappoint the client in some way, we can process these empathic failures. It’s not the end of the world. For example, one of us was on vacation when a client was going through a particularly difficult time. The next post-vacation session provided what Winnicott describes as an opportunity to re-experience the failure situation. Acknowledging that the client felt abandoned furthered the work of therapy and improved the relational bond.
Selective abstraction, as you may recall, is the mistake of believing that the only events that matter are failures and that you should measure yourself by your errors (Beck et al., 1979). You probably also recall several ways to minimize selective abstraction: track your experiences to determine successes and failures; accept the inevitable limitations of your therapeutic skills; and distinguish between case failures and yourself as a failure. More simply, rejoice in your successes, accept your human limitations, and offer yourself unconditional acceptance. Just because you have failed doesn’t mean you are a failure.
Consider the exemplar of negative outcomes in psychotherapy. Approximately 5%–15% of patients will experience increased distress and deterioration while in psychotherapy (not necessarily as a result of psychotherapy; Lambert, 2010). We conveniently forget the 75%-plus who are successes and preoccupy ourselves with the failures. This is not to suggest that we should dismiss the failures as inconvenient artifacts; rather, it is to suggest a psychological re-equilibrium. We recommend that you track or “log” your success experiences.
Once they are tracked, remember those successes. Whenever you begin obsessing about a recent difficulty or failure, remind yourself of the scores of successful cases in which you have genuinely assisted people. Savor your successes and acknowledge your contributions to bettering the human condition.
We can also measure success differently than complete remission of symptoms and total patient satisfaction (Edelwich & Brodsky, 1980). We can focus on the process and our efforts rather than solely on the results, set more modest or achievable goals for patients, and not expect immediate results. And, as we have emphasized, focus on the successes and not just the failures.
Just as patients may be distressed because they take on more work or responsibility than is expected of them, psychotherapists are susceptible to the same mistakes. We can fall prey to a messianic complex and take on too many patients, too many projects, or too many particularly disturbed clients. As we know from cognitive therapy (Beck et al., 1979, p. 188), our impression of the world must be reconceptualized from “it is overwhelming” to (1) “What are the specific problems?” and (2) “What are the specific solutions?” The motto might be: Define and solve in an orderly, rational way.
You might counter that real-world problems are not so easily operationalized nor solutions so evident. You may well protest, “John and Gary, I am working in an overwhelming, understaffed public agency,” or “I simply cannot do less or make less money.” That may well be, but we can break large, vague problems down into workable parts that can be more easily solved. If this sounds like advice you frequently give your patients, it probably is.
You probably also advise your patients to reflect on and prioritize their values. What exactly do you prize from your life and for yourself?
For starters, we probably accomplish more than we realize. By recording our actions in a log or diary, the record will show that we are accomplishing something. Cognitive therapists wisely maintain that taking some action represents a partial success. The cognitive distortion represented in the statement “The task is so problematic it cannot be done” is corrected.
The cognitive model of distress further holds that many people take on more work than they need to. For example, therapists typically think “I must see at least seven patients every day” or “I must allow at least 50 minutes for a session.” Still others wrongly think they are expected to do more than they need to. For example, “I must practice full time and teach a course at night plus be a great parent.” Folks who think this rigidly, according to cognitive theory, actually believe they cannot withdraw from any of their endeavors.
For people to obtain a realistic view of their workload and others’ expectations, Beck and other cognitive therapists suggest disputing unrealistic expectations, constructing boundaries based on prioritized values, and assertively protecting those boundaries. For instance, “My private practice and my children assume priority. Thus, I will continue the practice and be a good parent. However, there is no law stating that I have to teach in the evening.”
In our own lives, we periodically enter a “just say no” stage. Say “no” to new patients, say “no” to writing offers, say “no” to additional workshops. We must then tackle the emotional effects of saying “no”: the mild guilt in disappointing people, the potential regret in not making extra money, the nagging doubt that we may not have similar opportunities in the future. We have found cognitive restructuring to be effective in reducing the emotional effects during such moments.
Psychotherapists often incorrectly assign the blame or responsibility for adverse events to themselves – assuming personal causality. The misguided, self-referencing belief is that we are to blame for all misfortune. If a client succeeds in therapy, it’s her responsibility; if a client fails in therapy, it’s our responsibility (fault). Attributing most adverse occurrences to a personal deficiency, such as a lack of ability or effort, is assuming personal causality.
Hundreds of subscribers to the e-mail network of the Society of Clinical Psychology were once mistakenly removed because of a hardware error. Dozens of these doctorally trained psychologists posted their belief that they were omitted from the subscription list because they thought they had annoyed the list manager or had committed a grievous insult. They were, in short, assuming personal causality for a random technical error.
In medicine, physicians are trained early and well to realize that some patients, such as those in end-state terminal cancer, will probably never improve; but they try to help nonetheless. In psychotherapy, we intellectually acknowledge these constraints but have not yet learned to accept our limits openly.
One of us (JCN) painfully recalls conducting therapy with a couple who decided amicably to get divorced. I took it personally until my wife reminded me, in simple and caring words, that I did not create the relationship difficulties. This simple observation exploded my largely unconscious belief that somehow I was responsible for reversing time – like Superman circling the planet Earth counterclockwise to turn back the clock – and for fixing their extensive problems. We all struggle not to feel responsible for eradicating our clients’ problems, however vexing and long-standing.
The weight of self-reproach can be lifted and a modicum of objectivity achieved through the dis-attribution technique (Beck et al., 1979, p. 158). It entails recognizing that you impose excessively stringent standards on yourself and disputing the belief that you are entirely responsible for negative events.
Consider the case of Dr. G., a conscientious practitioner who entered personal therapy with one of us because she felt responsible for the suicide of a 27-year-old patient. Some of her self-blaming statements were: “If my schedule wasn’t so booked, I could have seen her more often” and “I should have been more observant during that last session – I could’ve noticed some sign of her self-destructive intent.” After several sessions and grief work, Dr. G. related that she had taken considerable care with this difficult patient: She had revamped her schedule to accommodate additional sessions, carefully monitored the patient’s medications, sought the counsel of the patient’s two previous therapists who also had little success, and had taken other measures to safeguard herself and her quite disturbed patient. After applying the dis-attribution technique, Dr. G. gradually realized that not only did she conduct “good-enough” psychotherapy, but she also went beyond her customary duty. Finally, Dr. G. recognized that she was not responsible for this woman’s death. Neurotic guilt gave way to understandable loss and pain – a tragically common occupational hazard of working with severely disturbed humans.
In addition to assuming personal causality – “I am responsible for these bad things” – psychotherapists often assume temporal causality – “Bad things happened in the past, so they will happen in the future.” Consider these negative prophetic statements: “My last two long-term cases never improved, so this one probably won’t either” and “Another depressed person. Therapy will now be difficult because it’s hard to change the negative thinking. This process is draining and monotonous. Therefore I won’t be doing my best therapy.” How do we know these predictions are true? We don’t.
When you catch yourself making doom-and-gloom statements, you may profit by carefully analyzing your assumptions. Making them explicit, writing them down, or sharing your arguments with a colleague may sound ridiculous. You will probably protest initially: “For heaven’s sake! I’m a therapist, I don’t need to express my thoughts in writing – surely I’m more sophisticated than that! And share my irrational thoughts with colleagues? They’ll think I’m an idiot!”
This resistance frequently betrays another belief commonplace among self-sufficient therapists: the fear of appearing incompetent and exposing weaknesses. Taking a few moments to accept your own humanity, contemplate your internal talk, review what you have written, and chat with a seasoned colleague will likely bring to light your own overly pessimistic reasoning.
Also, instead of treating past events as totally predictive, you can list other factors influencing the outcome. For example, a number of patient and environmental variables have an impact on the outcome of psychotherapy. Two patient characteristics that predict slow or little success are high functional impairment and low readiness to change (see Norcross & Lambert, 2018). Perhaps the patient’s environment, your clinical setting, or the available resources simply do not offer the number of sessions or intensity of services needed. Taking the time to identify other factors that may influence the outcome will eliminate using past experience as the sole predictor of future events.
Anticipating the worst outcome protects us: at least we won’t be surprised when it happens. However, doomsday prophecy also contributes to therapist decay. At lunch the other day, one of our colleagues, a counselor employed at the local community mental health center (CMHC), acerbically insisted that “no one comes out of the partial hospitalization program better than when they came in.” After empathizing with his difficulties in battling chronic disorders with severely underfunded resources, we gently chided him to reevaluate whether catastrophizing his program’s outcomes did anything to improve the situation.
There are at least three salutary cognitive strategies for catastrophizing: (1) show that the worst did not actually happen (“Did that really occur?”), (2) determine the actual likelihood that the worst may happen (“What are the real probabilities?”), and (3) evaluate the consequences should the worst scenario improbably occur (“What would be the worst that could happen?”). With our frustrated CMHC colleague, respectful inquiries revealed that the worst did not happen – the partial hospitalization program surely does have successes. If the worst did occur for certain patients who deteriorated, then they were immediately referred to the inpatient unit, a real probability for many of these chronically and severely disturbed patients. When the worst did occur, the patients underwent a brief inpatient stay and then returned to the partial hospitalization program. While our colleague’s emotional frustration in working with such a difficult population is readily understandable, his cognitive distortions unfortunately reinforced our collective susceptibility to negative thinking. We – all of us – are more human than otherwise.
A pervasive struggle for all psychotherapists is thinking “straight” about their countertransference, that is, those internal and external reactions in which unresolved conflicts (usually but not always unconscious) are implicated (Gelso & Hayes, 2002). How do we think through our client-induced rage or dysphoria or sexual arousal? Countertransference requires all of the self-care methods in our arsenal (and in this course), but we will offer a few words here on cognitive restructuring.
The research on managing countertransference highlights five interrelated skills: self-insight, self-integration, empathy, anxiety management, and conceptualizing ability (Hayes et al., 2011). Four of these five directly concern the cognitive operations of the therapist, whereas self-integration refers to the therapist’s possession of an intact and basically healthy character structure. These serve as a cognitive roadmap.
Self-insight refers to the extent to which the therapist is aware of her own feelings, including countertransference feelings, and understands their basis. Empathy permits the therapist to focus on the patient’s needs despite difficulties she may be experiencing with the work and inclinations to attend to her own needs. Also, empathic ability may be part of sensitivity to one’s own feelings, including countertransference feelings, which in turn can prevent the acting out of countertransference. Anxiety management refers to the therapist allowing herself to experience anxiety but also possessing the internal skill to control and understand anxiety so that it does not bleed over into responses to patients. Finally, conceptualizing ability reflects the therapist’s ability to draw on professional theory and to comprehend the patient’s dynamics in relation to the therapeutic alliance.
All of these skills are brought to bear on understanding the patient’s dynamics, your response to them, and then responding constructively despite your anxiety. When a patient screams at you, your awareness and interpretation of projective identification enable you to not scream back. When a patient argues incessantly with you, perhaps rekindling parental or sibling conflicts, your cognitive restructuring and anxiety management help you to label it as enactment of old relational patterns, and you do not argue in return. Your empathy transforms negative reactions to clients from frustration to compassion (Wolf et al., 2012).
Identifying, labeling, and managing your intense affective reactions all require advanced cognitive restructuring. These skills increase your capacity for affect regulation and demarcating the boundary between your emotional life and that of your patient. In this way, your cognitive self-care is crucial to remaining present, supportive, and effective with patients.
Self-care research and experience punctuate two other useful cognitive restructurings to “stupid therapist thoughts.” The first of these involves embracing complexity. When asked how they sustain their well-being while working with seriously traumatized clients, peer-nominated master therapists said that they challenged their negative cognitions to expand their perspectives (Harrison & Westwood, 2009). They purposefully reminded themselves to encompass wider horizons of possibility, embrace complexity, and tolerate ambiguity. These therapists acknowledged the horrific trauma and suffering of their clients, and simultaneously accepted life’s potential for joy and growth. In one sense, they maintained optimism; in another sense, they avoided all-or-none (dichotomous) thinking; and in still another, important sense, they experienced life in broader, more complex, and mixed terms. The therapists cued themselves to think in these ways through self-talk, imagery, metaphor, spirituality, and time in nature.
The second useful restructuring, not yet explicitly addressed, concerns the realization that it is a choice. You need not commit to existentialism to appreciate that practically all of our behavior is the result of volitional choice, as much as we would prefer to act in “bad faith” and convince ourselves that “we have to do” things. When you get into the space where you feel like your practice, agency, and clients are happening to you beyond your control, you become disempowered and despairing. Take a breath, recapture your intentionality, and remind yourself that you chose to enter this profession, you chose to enter graduate training, you chose this job. When you connect to those choices, you reconnect to freedom and agency (Venieris, 2015).
In the words of two workshop participants: “I now make my choices more consciously,” and “My work is by choice rather than by force.” You assume ownership of what is yours; you steadfastly decline to assume responsibility for what is not. Embracing complexity and choice become cognitive-existential corrections to our misguided thoughts.
We end this section – perhaps we should have begun it – with the ultimate psychotherapist fallacy: “I should have no emotional problems. After all, I am a mental health professional!” We all chuckle appreciatively at this palpable nonsense – but also at the self-recognition that a small part of us secretly clings to it. Most psychotherapists suffer from idealized perfectionism and outrageous expectations; then, to top it off, they feel ashamed and guilty for acknowledging their perfectionistic expectations! Take comfort in Freud’s (1937/1964b, p. 247) early recognition that “analysts are people who have learned to practice a particular art; alongside of this, they may be allowed to be human beings like anyone else.”
Yes, if therapists were not human, we could transcend dysfunctional thinking and avoid occupational hazards. But the lament reflects, in itself, wishful thinking instead of cognitive restructuring. Just as industrial workers must undergo safety training for working with heavy machinery, therapists must practice cognitive restructuring as a sort of mental safety, self-maintenance routine.
While we are it, let us create realistic expectations for self-care. If they are not careful, some of our workshop participants transfer their perfectionism to their self-care. One of our participants wrote that the lasting lesson of the workshop for her was “to be more realistic about what’s doable in a certain time period. I am not setting myself up for a feeling that I have failed.” Please practice restructuring against unrealistic self-care expectations.
If only we took our advice more seriously (Kottler, 1993)! It is poignantly ironic that the skills we teach our patients seem like foreign concepts when we combat our own difficulties. It is easy to discern someone else’s difficulties when you are an objective observer; it is hard to objectively observe yourself.
Empathic but persistent disputations help. Who is responsible for patients’ psychopathology and decisions? How many cases are truly outstanding successes, on the one hand, or spectacular failures, on the other? Not many; it is always a continuum of outcomes.
Recognizing and managing our own musturbations, cognitive errors, and countertransference reactions are paramount to leaving it at the office. If we can offer ourselves the same empathy and cognitive restructuring we provide to our patients, then we will indeed count ourselves among the successful patients we have treated.
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.
– Henry James
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 probably need to escape periodically to minimize the corrosive effects of conducting psychotherapy. Regular diversions allow us to temporarily separate ourselves from our professional activities as we direct our awareness and actions to another experience. The common thread among the diverse escapes considered in this course is 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 sources of distress that they were intended to ameliorate. Like healthy diversions, maladaptive escapism provides immediate 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 embrace 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 mean it in this course, means taking breaks during our workday and leaving the office altogether, so that we may return to our professional lives with renewed energy and a fresh perspective. In this CE program, we explore healthy escapes – “absorbing errands” – in and outside of 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. Flight from reality into 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 many of us prove 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. Our aim in this section is to help you identify and begin altering unhealthy escapes that 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; Merlo et al., 2013; 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 may have a problem with alcohol, illicit drugs, and/or prescription drugs often resist seeking 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 – alone with our clients in a small soundproof room, separating ourselves from the outside world during the workday. No visitors, no interruptions during sessions, few phone calls. In between sessions, we remain physically isolated as we write notes or dictate reports in a quiet office. We have 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 private life. In other words, the very factors associated with the healer role that promote loneliness and separation in professional relations carry over into personal interactions as well. Healthcare practitioners find it difficult to set aside their professional roles outside of the office.
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.”
Stop and ask yourself: Are you becoming less inclined to watch local or national broadcasts? To join friends and groups for fun? Do you make an effort to listen to 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 mental health professionals (Sussman, 1995). Longitudinal data on the most frequent causes of disciplinary action show sexual relationships with patient and students, overwhelmingly by male professionals, to be at or near the top of the list (e.g., Pope et al., 1993; Pope & Vasquez, 2005). The research strongly suggests that sex is a powerful temptation for the distressed therapist. Sexual activity has all of the reinforcing effects created by recreational drugs: physical pleasure, exhilaration, tension release, relaxation, flight from reality, and ego enhancement. But, as indicated by a growing 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, checking our professional hat at the door is often a difficult transition. Since we spend most of our professional time in the healer role, 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 sometimes ourselves. Frequently, 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 sexual acting out has taken place (Pope et al., 2006). Whatever the confluence of causes, it is ultimately the therapist’s choice and responsibility, not that of the other person in the dyad.
It behooves us all to complete a self-assessment of unhealthy escapes and to receive peer supervision and personal treatment, as needed. You can approach these tasks in an unabashedly human and accepting fashion. 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 therapists.
Adaptive escapes from the burdens of the office begin, paradoxically, at the office itself. Brief renewing escapes can be blended into your day, in between patients or between professional responsibilities. Dozens of healthy paths enable us to escape the strains of our impossible profession. Here, we offer a variety of other self-care methods designed to assist therapists during the workday by engaging in good, clean escapism.
In the busyness of our day, it might seem counterproductive to slow down or to take a break. Yet, 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. Taking breaks creates 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; 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. Many of us hear a little voice in our heads protesting, “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 two-hour lunch break with colleagues, go to the gym after work, or schedule a two-week vacation. We collegially disagree.
Take detachment breaks throughout the workday. Our mental focus and energy cycles typically last 90–110 minutes each, so we need to step aside for a few minutes at regular intervals to restore our energy and reset our attention. In the office building housing his private practice, one of us (JCN) was frequently asked if he suffered from a prostate problem or a small bladder since he was frequently going to the bathroom. That’s because the bathroom was a refreshing two-minute walk away from the office for a detachment break.
Our workshop participants have learned to take 10-minute breaks between sessions. One writes that such breaks “give me time to talk to other people, make some calls, buy a coffee, and walk for a while. I feel much better going back to work after these mini-breaks.” Another “steps outside for a quick minute to enjoy the heat/sunshine and fresh air” or “walks through the halls to get out of my stuffy office.”
In a job as absorbing and demanding as ours is, we need periodic relaxation during the workday – not simply after the workday. Relaxation reciprocally inhibits (or counterconditions) anxiety and tension. Some form of antistress 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” (italics in original).
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 seem to be brief meditations, muscle relaxation, deep breathing, and centering exercises. Some colleagues have adopted technology to bolster their relaxation at the office. CDs of autogenic training, handheld biofeedback devices, electronic relaxation systems, and inner harmony apps structure and guide the relaxation response.
But any activity that reduces our autonomic and mental activity – music, imagery, 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 several studies of psychotherapists (e.g., Kramen-Kahn & Hansen, 1998; Rupert & Kent, 2007), 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 35 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 et al., 1983; Goldstein, 1982; Heuser, 1980; Michel, 2017). 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 research supports the notion that humor in psychotherapy is decidedly beneficial (Goldin & Bordin, 1999; Sultanoff, 2013).
Humor in therapy profits both the therapist and the client. Beyond providing us with entertainment, energy, and the joy of laughter, humor also reduces tension; discharges energy; lifts affect from despair; 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.
At the same time, humor in psychotherapy requires sensitivity and a strong bond so that the patient does not feel hurt or put down; the therapist’s goal is to laugh with, not laugh at. Therapist humor is often triggered by other feelings, including anxiety and embarrassment. Humor can fail to be humorous. Attempts at humor based on gender, cultural differences, sexual orientation, and other such sensitive topics are likely to be experienced as veiled criticism and cultural incompetence, rather than attempts to laugh at common human struggles.
Sometimes we laugh with our clients, sometimes we laugh privately afterward, and sometimes we share the laughter with our colleagues. A 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 OK, 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 multiple 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 enable taking time off for frolicking. Third, due to the structured nature of our work, getaways help break up the routine of our day.
Spontaneous escapes are sometimes the most rewarding. Consider the following example from one of our master therapists:
“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 or absorbing errands – as a reliable predictor of effective self-care among mental health practitioners. Whether you directly ask clinicians to tell you what maintains their well-being or indirectly correlate their in-session behavior with their subsequent mood, healthy escapes prove efficacious and popular. Classic modes of escape include humor, vacations, relaxation, self-assertion, cognitive restructuring, exercise, and diversion – all action-oriented activities incompatible with occupational anxiety.
Any strenuous or absorbing activity, in principle, can serve as an effective means of escape (Baumeister, 1992). It’s important to “let go” of the burden of one’s professional self, to escape the tyranny of work-related burdens, to be liberated from the fetters of selfhood. In other words, to escape from the burdens of the impossible profession and to escape to absorbing errands, as Henry James advised earlier in this section of the program.
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 several 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 idiographic 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. The Hebrew word for rest derives from the word for soul; in the resting of Shabbat, our souls are renewed (Mogel, 2008). 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 seven 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 fully available to yourself and your significant others.
American workers generally get a measly two weeks of vacation per year, among the lowest of industrialized nations. Even so, many Americans do not use all of their vacation time or days; in 2012, Americans left an average of 9.2 vacation days unused (Schwartz, 2013). To complicate matters further, we are sometimes actively discouraged or prohibited from taking the entire two weeks at the same time. Then we’re 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, 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 several days into it and then begin to worry about our awaiting workload two days before the end of vacation. The restorative function of vacations may take a full two weeks.
One of our master therapists reported:
“Vacations had an important function in our family when the children were young. We mostly went to one of the coastal beaches four to five hours away. It was the only time in the year when we had prolonged time alone, just as a family without responsibilities. Now, with the kids out of college and with their own families, we have a new family vacation ritual. Every Christmas, right after Christmas, we all go away together to some location to which we have never been. We select the location over the course of the year, as a group, with everyone, including the youngest child, having input.”
When we say vacation, we mean a nonbusiness, leisure vacation. To be sure, most healthcare professionals combine business with leisure travel – “bleisure” as it’s known in the profession – but that rarely affords deep, restorative renewal.
For those who immediately protest “But I can’t afford it!” we offer the wise words of the late 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 mental health professionals are greedy, working more than 60 hours a week, mainly for the money. Lazarus, by contrast, deliberately allowed 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. Small towns just an hour or two away can prove more interesting and relaxing than you imagine.
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 (Rupert & Kent, 2007; Sherman & Thelen, 1998). About nine in 10 of us do so. In one study (Hoeksma et al., 1993), as should surprise no one, psychotherapists’ satisfaction with their leisure activities was significantly correlated with decreased burnout. In fact, about 10% of burnout symptoms could be accounted for just by therapists’ 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 practitioners 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,” “My escape is working in my wood shop,” 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 (Fields, 1984) – a famous Buddhist book. The chores get us out of our heads, thus balancing and centering us.
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 (Crncec et al., 2006; Sloboda, 1999), such as greater positivity (e.g., being more happy), greater learning (e.g., developing more focus), and greater present-mindedness (e.g., becoming less bored). Better still, music can also be combined with many other healthy escapes – exercise, relaxation, play, and solitude.
A master therapist tells 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.”
Thoughtfully chosen music can indeed be restful, relaxing, and renewing. Find which kind of music works for you for specific occasions. 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 tunes that trigger memories of your most positive experiences or other carefree eras in your life. Need to wind down? Try putting on something with a slower melody and calming influence.
Lest our examples appear to focus on social activities, let us be crystal 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.
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. Health professionals 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 “twofer” escapes. In this respect, one added benefit of solitude is that it can be combined with other forms of healthy escapism – exercise, hobbies, relaxation, and traveling, to name a few.
A ubiquitous healthy escape for mental health professionals involves returning again and again to nature (vitamin N), for restorative solitude or for fun with significant others. A bit of ecotherapy produces huge benefits in lifting mood and lowering tension.
One of our international master therapists speaks passionately about friluftsliv, a Nordic term for “free air life” and “freedom to roam.” It is the notion that being in the outdoors is good for one’s mind and spirit. Appreciating nature and, in turn, reaping the benefits of doing so. Our colleague makes it a point to routinely walk in nature and, as we say in the States, smell the roses. Frilufsliv is a perfect antidote to sitting inside an office all day; returning to nature is returning to home base. And it is a clear self-care method for those who enjoy gardening and mowing their own lawn.
Hours of restorative solitude can be extended into personal retreats. Retreats promise geographical, 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 (1992/1943, p. 118) reminds us. A psychotherapist 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” (Fox, 1998, p. 104).
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 (JCN) 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 the day or weekend. 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 clinicians’. Third, it intrudes into personal time. These concerns can be rectified if practitioners run the retreat, collaborate on its agenda, and are paid for work time. In general, we advocate personal retreats, not office retreats, or organized retreats for renewal of healthcare 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 on. Nonetheless, we are among those who favor clinical sabbaticals every five to seven 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? It proves a foundational, penetrating question for many healthcare practitioners.
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 two – three hours a week at his potter’s wheel was his “salvation.” These nonrational and creative pursuits counterbalance the typically serious, emotionally draining, soul-sucking work 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.” The conjured image reminds us of a Dementor attempting to suck the soul out of Harry Potter’s mouth.
Our immediate response is profoundly empathic. Life in general, and the practice of psychotherapy in particular, can 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 that come to mind: amusement rides, water slides, water-gun fights, hide-and-seek, blowing bubbles, catching fireflies, and playing horseshoes, volleyball, basketball, or tennis. Building structures out of clay, sand, or dirt. 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. Singing in the car. A carefree day in nature. The possibilities are limitless.
For the other three-quarters of you, please keep playing and playing hard! Feel rejuvenated without the professional burdens. For the one-quarter, please learn to turn off the professional role so that you can be spontaneous, joyful, even immature at times. Relearn the monumental 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 capitalize on their keen observational skills, writing ability, and creative imagination. A colleague attending one of our workshops prescribed this self-care remedy: five pages of Proust every morning. 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. (How did you think all of these found their way into this course?!) The writing genre is inconsequential; it is the act of creative expression itself. Find a writing outlet for self-care. It may be a family history, the history of your hometown, or the art of touching and assessing a good cup of coffee. Go to wine tastings, and write notes on the wines from different countries or regions.
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 the intellectual challenge of mystery. In all cases, reading gives us pleasure and respite.
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 et al., 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 e-mailed 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 a 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 three days.”
In these two pieces of levity, 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 healthcare 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.
Humor, however, 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.
How, exactly, do psychotherapists take their minds off their professional burdens 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 prove 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. Or taking a family vacation may be relaxing for most, but not if you are the person responsible for coordinating everyone else and 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. This generic advice is fine and well-intentioned but results in little permanent change unless combined with some candid assessment of what purposes overwork has for you (Grosch & Olsen, 1994). If you exchange a few hours of compulsive overwork for a few hours of competitive exercising or obligatory hobbies, little has been accomplished. So, bear in mind that the advice must be combined with your own dynamics and vulnerabilities.
In this course, we offer 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 is not learning what works for you. The greatest challenge is building those escapist practices into your daily life with regularity – both in and away from the office. As Henry James astutely observed at the beginning of this section of the course, “The point is not only to get out – you’ve got to stay out; and to stay out you must have some absorbing errand.”
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