Psychotherapeutic Fatigue – Burnout
Very often my friends and acquaintances, laypeople in the psychotherapy subject, ask me if I bring my patients’ problems home along with me. Somehow, they seem to believe that psychotherapists leave their offices carrying the weight of other peoples’ problems and can hardly sleep at night.
I have always calmly answered that that is not exactly so, as therapists are required to take rigorous professional training, which enables them to distinguish their own contents from those of their patients.
That may be a good answer for laypeople ¾ that will remain so, and also deeply amazed at our absolute skill ¾ although a very unsatisfactory one if we really wish to reach the deep nature of this subject. Even Freud (1910: 1565), who defined the countertransference phenomenon as “an emotional answer from the therapist to his client”, was somewhat superficial in this analysis.
More recently, however, due to studies conducted on professional stress and violence and its traumatic sequelae, an increasing number of authors have described a kind of bio-psycho-social disease that affects those who take care of traumatized people. This “disease” is referred to in the literature by various names (Figley, 1995: 9): “Secondary Post-traumatic Stress Disorder”; “Secondary Victimization”; “Co-victimization”; “Vicarious Traumatization”; “Emotional Contagion”; “Generational Effects of Trauma”; “Savior Syndrome”; “Compassion Fatigue”; “Burnout Therapist Syndrome”, etc.
These authors’ studies do not focus on the patient or on how he may be harmed by the therapist; on the contrary, they focus on how the psychotherapist profession may be unhealthy and have a personal cost to the therapist him/herself.
There are some similarities among the different symptoms of professional stress, mainly when stress is related to excess work and bad working conditions. However, there are specific characteristics of unhealthiness occurring in the helping professions, which is the focus of this article. Being in contact with another’s trauma and trying to help traumatized people causes deep stress to the helper; ironically, the more sensitive and devoted the helper is, the more vulnerable he/she will be to the mirror-effect of another’s pain.
In this sense, I chose the terms – Secondary Post-traumatic Stress Disorder -, as in my opinion it best describes what occurs in the various psychotherapy areas, and Psychotherapist Fatigue.
WHAT IS SECONDARY POST-TRAUMATIC STRESS DISORDER?
In 1980, the Diagnostic and Statistical Manual – DSM III of the American Psychiatric Association (1989, 264-267) included, for the first time, the diagnosis of Post-traumatic Stress Disorder (PTSD), to describe symptoms affecting people who go through a psychologically painful experience.
Included in this category are unusual events of human experience that represent serious threats to one’s own life or one’s children and close relatives’ life, such as natural disasters (earthquakes, accidents) or intentional disasters (torture, power abuse).
According to this manual, the trauma may be directly or indirectly experienced through learning about threats and damages to the physical integrity of friends, relatives or close people.
Thus, PTSD – Secondary Post-traumatic Stress Disorder – may be defined as natural behaviors and emotions that arise from knowing about traumatic events experienced by a significant other.
It is a process of gradual emotional exhaustion related to excessive work, and going on vacation only is not the solution; a gradual erosion of the therapist’s spirit, which involves a loss of confidence in his/her own capacity to help. Ayala Pines (1993: 386-402) believes that only professionals with high ideals and motivations experience this syndrome, as if it were a strain between the professional’s need to help and the real problems involved in treating people.
Reviewing the empirical research about this syndrome, Kahill (1988) identifies five categories of symptoms:
- Physical Symptoms (physical exhaustion and fatigue, sleep difficulties, somatic problems like headaches, gastrointestinal disorders, influenza, etc.)
- Emotional Symptoms (irritability, anxiety, depression, guilt, sense of helplessness)
- Behavioral symptoms (aggressive behavior, callousness, pessimism, cynicism, drug abuse)
- Professional symptoms (quitting the job, poor work performance, absenteeism, tardiness, excessive work without breaks, etc.)
- Interpersonal Symptoms (inability to concentrate, avoidance of contact with clients and colleagues, difficulties in personal life, etc.)
Duton and Rubinstein (1995: 85) think that the indicators of this status reproduce in the therapist some of the symptoms of the post-traumatic stress syndrome:
- Stress Emotions including: sadness, mourning, depression, anxiety, fear and horror, rage, hatred, shame.Intrusive images of the client’s traumatic material in nightmares, for example, or in awake fantasies with visual flashes.
- Difficulty in dealing with the client’s dissociation.
- Somatic complaints such as: sleep difficulties, headaches, gastrointestinal problems and palpitation.
- Addictive and compulsive behavior including substance abuse, eating disorders and compulsive working.
- Difficulties at daily social activities and at private life roles, such as: canceling appointments, decreased use of therapy and supervision, chronic tardiness, decreased self-care and self-esteem and a sense of isolation and alienation.
- Physiological excitement.
WHO IS MOST VULNERABLE TO PTSD?
Shortly speaking, all professionals whose fundamental working tool is empathy and all people who are regularly in contact with traumatized people are potentially vulnerable to this contagious traumatization. The so called “helping” professions such as, firemen, policemen and military, emergency and rescue teams, and all professions related to health, such as nursing, medicine, especially psychology and psychiatry.
For many reasons, the last two professional categories are the most affected, from factors related to the choice of the profession to those related to peculiar working conditions.
BEING A THERAPIST: CHOICE OR FATE?
Alice Miller (1997: 30-35) thinks that choosing a helping profession, especially that of psychotherapist, has more to do with fate than with choice itself. She refers to the fact that most therapists come from dysfunctional families where, from childhood, they were demanded to help, directly or indirectly, some less capable adult for that function. Ingeniously trained from childhood to be at someone’s disposal, these people have developed their empathetic ability and sensitiveness which will be their favorite working tool in the future.
Empathy, an essential tool to access the client and to plan a strategy action, makes professionals exchange places with the victims, but doing so they indirectly experience the same events that traumatized their clients. Moreover, the professional’s unresolved trauma will be revived by the report of a similar experience by the client, especially if this experience is a childhood trauma, probably due to the higher vulnerability of the child and to the remembrance of his/her own childhood.
Many authors develop studies on the characteristics of people who choose these professions. High ideals and generous hearts are some traits pointed out by Grosch and Olsen (1994: IX). They have concluded that psychology and psychiatry students constitute a group of optimistic and all-powerful young people willing not only to make money but to change the world; that after hard training along with compassion and care they will be able to transform the life of the people they are taking care of.
Freudenberg, H. (1980) describes the “Type-A” personality, which comprises different traits such as high idealism and performance and low self-esteem; this kind of individuals work harder and harder in order to feel more acceptable. They are excessively devoted professionals who tend to demand too much from themselves and very often substitute social life for work. Some psychoanalysts (Allen, 1979.42,171-175)  believe that being successful in their careers will compensate childhood disappointments, like, for instance, unresolved fraternal rivalries or that it will represent a late Oedipal victory.
Victor C. Dias (1987: 187-195) points out to the solitude of psychotherapists, who accustomed to an open and sincere communication, devoid of the usual social dissimulations and hypocrisies, end up by restricting his/her relationships to people who also communicate like him, i.e., to people who have also taken psychological therapy. This trap leads the therapist to be more and more solitary, tending to arrogance, inadequacy and social aggressiveness.
WHAT CAUSES STRESS TO THE PROFESSIONAL?
The systemic theory seeks to understand the individual through the impact that involving systems have on his/her life. The circular causality concept may be applied to the therapist’s fatigue issue (see figure 1).
FIGURE 1: MULTI-SYSTEM PRESSURES ON THE PROFESSIONAL
This figure indicates pressures arising from various relationship systems involving the health care professional:
1-PRESENT FAMILY AND PERSONAL LIFE PRESSURE: some authors associate career success with the professional’s middle age, showing that, generally the professional attains his/her top effectiveness between 40 and 50 years of age. Also at this age, life events usually bring dissatisfaction such as: marriage crisis, aging, women’s menopause, children’s marriage, etc. Experiencing these existential crises and, at the same time, taking care of people sorely in need may be exhausting and stressing.
Grosh and Olsen (1994) conveniently describe another frequent situation to us psychotherapists: while we spend hours and hours on end listening to and being empathetic to others, we neglect our own families and ourselves. After long hours listening to patients, how many of us really feel eager to handle our children’s and companions’ routine complaints; how many of us feel like doing physical exercises or having a balanced meal? A study conducted by Michael Mahoney, showed that problems like overweight , sleep difficulties , a generalized exhaustion, were some of the most frequent complaints among the interviewed psychotherapists.
Sensitive heroes to our clients, we suddenly transform ourselves in careless participants of our family systems and neglectful of our own bodies.
2- FAMILY OF ORIGIN ISSUES: According to Bowen and his self-differentiation theory, people handle their family of origin difficulties with a large variety of ongoing responses from cutting their families off to completely joining them. There is no self-differentiation in any of these radical solutions. Total fusion or cutoff leaves a work to be done, which will be replied in the individual’s contemporary relationships.
The professional environment is extremely propitious to become a second family, where people play or try to play roles similar to those of their families of origin and where they expect to put an end to the former emotional drama, although they just keep repeating it.
3- CLIENT PRESSURE- In this item, in addition to the constant concern for the evolution and seriousness of the cases of which we take care, I would like to point out another professional fatigue factor.
Berkowitz (1987) describes the “non-reciprocal attention” phenomenon. The author says that psychotherapists seem to be prepared to deal with others’ pain and stress, but they do not seem prepared to the patient’s lack of reciprocity. Constant giving in a one-way relationship with no feedbacks or perceivable success is hard to anyone, especially to someone who has become a therapist to understand his/her own dysfunctional roots.
The therapist’s work implies a constant “affective turn on and turn off” with the other person. Many times, at the top of a therapy process we suppose to be successful, the patient quits therapy or is abruptly withdrawn from therapy by paying parents, with no explanations; this hampers the loss and mourning process demanded by any detachment. Young therapists, mainly, feel deeply upset at these solitary losses, at the sudden divestiture of a relationship they supposed to be strong and productive.
4- WORK PRESSURE, SOCIOMETRIC PROBLEMAS, PRESSURE ARISING FROM WORKING CONDITIONS- The psychotherapy profession has some unrealistic expectations in terms of healing people in a profitable and elegant way. Unfortunately, working conditions, our consultation fees as well as our sociometry are often unsatisfactory.
Our colleagues who perform community services experience various kinds of frustration, from location and attendance to their services to the lack of remuneration. “The institution care client is the one who does not pay, often does not show up and never improves”, says a humorous quotation about the reasons to stress.
Even those who have a private office very often embitter the lack of paying clients, a low remuneration from healthcare insurers, and the self-instability of a self-employed career consequently lacking gratification from the professional life.
PROFESSIONAL ABUSE AND THERAPIST FATIGUE
The therapist’s stress may lead to a careless and abusive service to patients. Some colleagues compensate their low consultation fee by seeing many patients on the same day, or organizing excessive large groups of people, in disadvantage of work quality and of their own personal health.
The therapist’s unrealistic expectations may also affect the client’s development. The urgency to be regarded as useful and to be reassured of his/her professional ability may transform the therapist’s compassion into a pressure on the patient to perform changes in his/her life.
On the other hand, a patient’s worsening may lead the therapist to feel inefficient and frustrated. Taking Kohut’s ideas about the narcissistic issue as a starting point, William Groch and David Olsen (1994: 57) describe some psychotherapists’ arrogance and “God complex”. They believe that psychotherapists who did not experience enough mirroring and empathy in their first childhood years may compensate their desire to be appreciated and esteemed using the patient for this complementary role.
In this sense, the objective of the helping careers is paradoxical: in one aspect they represent a way to transcend oneself; in another they may well serve as a means to gain others’ consideration.
Dealing with people who tend to idealize us leads to two kinds of common mistakes:
- We may assume that they are dead right, that we are really special and so we keep on doing things to maintain their opinion about us;
- We may become so anxious with this load of idealization that we’ll do anything to disappoint them – acting wrong, making stupid mistakes, or being too symmetric towards the patient.
Actually, the therapist’s role implies a certain power, which we must be prepared to assume, without excesses and for a while only. I always remember a supervisor who told me to be absent once in a while and not always replace sessions. Therapists’ faults help to adjust patients’ excessive idealization.
CONCLUSION: PREVENTION AND TREATMENT
There are many ways therapists may use to take care of their own health. All of them invariably imply a change of work and life routine. Determining the number of patients, having reasonable mealtime breaks, doing physical exercises, etc. are some of these ways, which although apparently simple, they are extremely hard to be put in practice.
It is not just a matter of working less, you must substitute a portion of the financial, professional and narcissistic assumption, which comes from a booked up agenda, for the growing awareness that we are as vulnerable as our patients and that there’s no possible way to support others’ needs if we don’t take care of our own needs.
Another desirable way is to balance clients’ attendance activities with didactic activities like giving classes, lectures or institutional work. That makes the therapist mover around, talk to other people; get into more symmetrical relationships than those he/she has with the patient.
Therapy and supervision groups are also very important, as long as they represent a safe place where the professional can expose himself without fearing reproaches and personal critics. In my point of view, a proper supervision group does not exceed 6 or 7 colleagues and implies an intimate work of constructing the professional’s role. Large groups favor idealizations and defenses that end up destroying the information originality.
Organizing small study groups on an issue jointly selected is another kind of group support that reduces professional isolation. These “groups of equals”, in addition to being productive – recycling professionals and producing written work – provide a symmetrical relationship less formal than the supervision. Almost naturally, colleagues share their working difficulties in the clinic and offer emotional control to delicate issues such as: lack of clients, sessions seemingly ill-conducted, “therapist’s love and hatred towards clients”, tips about a service that’s been worrying us, etc. Personally, I am strongly in favor of this resource.
Participating in congresses, experiences and researches on the working area also help the therapist to keep a healthy interest in his/her own personal practice.
I think it extremely important that we recognize these issues related to our professional performance and would very much appreciate it to have them discussed more often in our congresses. I believe that shame is associated to this matter, as we see each other as semi-gods, and admitting our needs might be taken for some kind of personal fault or failure.
The Greek myth of Asklepius, god of healing and father of medicine, gives me support to close this text:
Asklepius, son of god Apollo and mortal Coronis, was wounded before being born; his father Apollo, in a jealousy crisis upon knowing that Coronis had betrayed him, ordered her to be burnt alive. However, when he knew she was pregnant, he pulled the child from Coronis’s womb and gave it to Chiron, the Centaur, to teach him the art of healing.
Chiron, half human and half god, could never be healed from a wound caused by Hercules. Thus, Chiron, the healer, who needed to heal himself, taught Asklepius the art of healing, the ability to find seeds of light and to feel comfortable in the darkness of distress.
The paradox of the helping professions lies in the fact that the healer heals and remains wounded at the same time. All human beings have wounds and despite the excellence of our psychotherapies, they do not exclude us from our own humanity.
- Allen, (1979) Hidden stresses in success. Psychiatry, 42,171-175.
- Berkowitz (1987) Therapist survival: maximizing generativity and minimizing burnout. Psychotherapy in Private practice 5 (1) , 85-89.
- Dias, Victor R.C.S (1987) – Psicodrama- Teoria e Prática- Edtora Ágora -S.Paulo.
- Duton,M.A. and Rubinstein, F.(1985) – Working with People with PTSD: research implications In Figley, R.C. (1995) – Compassion Fatigue, Brunner/Mazsel, Inc, New York, U.S.A.
- Figley, R.C. (1995) – Compassion Fatigue, Brunner/Mazsel, Inc, New York, U.S.A
- Freud ,S. (1910) – El Porvenir de la Terapia Psicoanalitica- in Obras Completas , Biblioteca Nueva, 1973 ,Madrid.
- Freudenberguer, H. (1980)- Burnout: the high cost of high achievement, Doubleday Publisher, New York.
- Grosch, N. W. and Olsen, C. D. (1994) – When Helping Starts to Hurt , W. W .Norton & Company, New York, U.S.A.
- Kahill, S. (1988)- Interventions for Burnout in the helping professions: A review of empirical evidence. Canadian Journal for Counseling Review, 22 (3), 310-342
- Manual de Diagnóstico e Estatística de Distúrbios Mentais (1989) 3ª Edição -Revista DSMIII – R, Editora Manole Ltda .
- Miller, A. (1997)- The Drama of the Gifted Child, Editorial Summus, S.Paulo.
- Pines, Ayala (1993)- Burnout: Handbook of Stress. Free press.. Psychotherapy in Private practice 5 (1) , 85-89 , New York:
- A. (1999)- Aesculapius: A Modern Tale- MSJAMA online: http://www.ama-assn.org/sci-pubs/msjama/articles/vol_281/no_5/jms90003.htm
 Freud ,S (1910) – El Porvenir de la Terapia Psicoanalitica”
 Figley,R.C.(1995) – Compassion Fatigue
 Manual de Diagnóstico e Estatística de Distúrbios Mentais , 3ª Edição -Revista DSMIII -R, Editora Manole Ltda 1989 pp . 264- 267
 Pines, Ayala- Burnout-Handbook Of Stress
 Kahill, S. (1988)- Interventions for Burnout in the helping professions : A review of empirical evidence. Canadian Journal for Counseling Review, 22 (3)3310-342
 Duton,M.A. and Rubinstein, F.- Working with People with PTSD: research implications
 Miller, A. (1997)- O Drama da Criança bem dotada
 Freudenberguer,H. (1980)- Burnout: the high cost of high achievement
 Allen,1979. Hidden stresses in success. Psychiatry ,42,171-175
 Dias,Victor, R.C.S. ( 1987) Psicodrama-Teoria ePrática
 Circular causality: everyone is related in the system, therefore any change affects all individuals and the system as a whole
 Mahoney, Michael – Personal Communication in a workshop on “”The personal life of the psychotherapist”. He is a MD, PhD – from Stanford University, author of various books on the Cognitive and Constructivism approach.
 Berkowitz(1987)-Therapist survival: maximizing generativity and minimizing burnout. Psychotherapy in Private practice %(1) , 85-89
 Willian Groch e David Olsen (1994)- When Helping starts to hurt
 Stanton, J.ª ( 1999) – Aesculapius: A modern Tale