Psychotherapist Burnout: Causes & Cures
ISSUES IN PSYCHOANALYTIC PSYCHOLOGY, Volume 40, 2018
Psychotherapists are bombarded with feelings from their patients. Every day in their office, they listen to traumatic memories or stories of abuse and neglect; at times, they become the object of negative transference, projections, displacements, or may struggle with their own negative countertransference.
Navigating such burdensome feeling states can exhaust a psychotherapist’s psychic resources and lead to professional burnout.
Understanding the mechanisms of human psychology isn’t enough. The emotional demands of a psychotherapy practice require a strategy for self-care that goes beyond intellectual understanding.
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Psychotherapy Burnout
Burnout in psychotherapy is identified as a condition of emotional exhaustion, depersonalization, and decreased personal accomplishment. (Hammond, et al., 2018) An extensive study of burnout among psychotherapists, published in The Journal of Clinical Psychology, that examined outcomes from 30 years of research and surveyed over 9000 psychotherapists, found that over half of the psychotherapists reported moderate to high levels burnout, citing exhaustion and physical and emotional fatigue in work. (Gabrielle & Simpson, 2018)
Additional studies have also identified a higher degree of burnout for psychotherapists new to the field, psychotherapists who work with personality disorders, or psychotherapists who work with trauma victims. (Morse et al., 2012)
Conditions that fuel professional burnout include lack of professional support, excessive work hours, and high caseloads (Maslach & Lieter, 1997). One study notes a higher level of burnout among psychotherapists who became over-involved with patients, a possible result of transference/countertransference complications. (Rupert & Morgan, (2005). Another study speculated that one significant cause of burnout among mental health professionals could be the perceived stigma of psychotherapists seeking psychotherapy. (Barnett, et al., 2007)
Miller (Miller, 1979/1990) suggests that, as children, a great many individuals in the field of psychotherapy experienced emotional neglect from their caretakers, which resulted in parentification and the development of self-sacrificing tendencies. As adults, these early experiences fuel them with a sense of duty to help others while ignoring their own needs.
For this paper, the term “psychotherapist” describes mental health professionals who provide talk therapy to patients, such as social workers, psychologists, and psychiatrists.
Precurses and Causes of Professional Burnout
Based on personal experience and collected research, I have identified three primary causes of psychotherapist burnout:
- Self-Neglect
Self-neglect can take many forms, such as poor diet, insufficient sleep, a lack
of exercise, a disregard for personal relationships or finances. Such unhealthy habits breed emotional and psychic deterioration. As personal care decreases, the likelihood of burnout increases.
Psychotherapists spend hours a day in intimate settings with their patients, on the receiving end of intense feelings, such as traumatic reports, verbal and non-verbal communications, and transference/countertransference reactions. They listen attentively, analyze session content, and attune themselves to the emotional life of their patients. This requires much energy and focus on exhausting a psychotherapist’s own psychic resources and fuel professional burnout.
Studies suggest that self-neglect and professional burnout go hand in hand (Skovholt, 2000). Additionally, psychotherapists, like their patients, experience life stressors outside of the office, such as relationship conflicts, health crises, traumatic events, or financial challenges. Without a self-care plan to replenish their energy and restore balance, psychotherapists can fall into patterns of self-neglect.
- Isolation
When psychotherapists fail to continue their studies, develop creative or physical outlets, or nurture positive personal and professional relationships, their work with patients grows stagnant. As Anna Freud noted:
“…a psychoanalyst should have… interests… beyond the limits of the…field… [otherwise] his outlook on… his patient will remain too narrow.” (Kohut, 1968)
- A Sedentary Lifestyle
According to The National Library of Medicine (2018), an inactive lifestyle, also known as “sitting disease,” increases the likelihood of chronic illness and disease, including obesity, heart disease, osteoporosis, high blood pressure, high cholesterol, and type 2 diabetes. Additionally, a sedentary lifestyle has been linked to some forms of cancer, such as colon, breast, and uterine cancer.
The report notes that more hours spent sitting without physical exertion may lead to a weaker immune system, bones and muscles more vulnerable to injury, poor circulation, loss of energy, hormone imbalances, and inflammation.
The practice of psychotherapy rarely invites physical exertion; it is simply not built into the profession, making psychotherapists prime candidates for “sitting disease.”
Burnout Prevention
The beating heart of burnout prevention is self-care. Self-care is defined as activities that refresh the body and mind, inducing greater energy and vitality while discharging tension.
In the book The Resilient Practitioner: Burnout prevention and Self-care Strategies for Counselors, Therapists, Teachers, and Health professionals (Skovholt’s book (2000), the author asserts that every mental health professional needs a self-care action.
To guard against burnout, I am suggesting the following five guidelines for psychotherapists:
- Personal Therapy
Master therapists spend years in their own personal therapy, often two or three times a week, in addition to group therapy, supervision, and post-masters training programs. They scrutinize their personal history, analyze and dissect life events, and pour over the intricacies of their own relationships. In the process, they become skilled at experiencing, investigating, and analyzing their own feelings. Personal therapy fosters self-mastery and emotional insights that enhance professional skills and insulate psychotherapists from the dangers of burnout.
In a study of self-care patterns among psychotherapists by Mahoney (1997), 90 percent of the psychotherapists noted many positive benefits, personal and professional, resulting from participating in their own therapy. A commitment to personal therapy also provides therapists with the ability to navigate the challenges of countertransference and emotional reactions.
For example, therapists are frequently exposed to trauma indirectly through hearing traumatic stories from their patients. In the process, trauma from their own life may be a trigger, or they may experience vicarious trauma. (Jenkins, et al., 1999).
- Supervision
Quality clinical supervision is one of the best weapons against burnout. Regular individual or group supervision sessions with a seasoned psychotherapist provide therapists with the tools they need to manage caseloads, assess progress, and learn how to navigate negative transference and countertransference reactions. Such clinical frameworks are essential to developing professional mastery.
In a study of countertransference and burnout, Kim and Sweeny (2015) assert that the therapist’s emotional reaction to the patient needs the greatest attention. According to Gabbard and Wilkinson (1994):
“What makes us so uncomfortable in the face of the patients’ pressures
on us is not what is in the patient but what is in ourselves…”
- Physical Tension Outlets
To combat the negative effects of a sedentary profession, exercise and physical activities are essential. According to the Center for Disease Control and Prevention (2018) study, regular cardio activities lower the risk of cardiovascular disease, type 2 diabetes, metabolic syndrome, and many forms of cancer. In fact, the study concludes that people who are physically active for seven hours a week have a 40% lower risk of premature death due to disease and illness.
Studies in the effect of exercise on major depression disorder (Babyak, M. 2000) also discovered that regular cardio exercise produces the same positive effects as antidepressants by raising metabolism, boosting endorphins, and strengthening the body’s immune system. Other studies have proven that exercise is also effective in lowering anxiety and reducing panic attacks (Weir, 2011).
In addition to the obvious health dangers, sitting and listening to patients day after day without physical outlets to reduce tension and stress may increase psychosomatic illnesses.
- Creativity
Creativity is a renewable resource for ongoing energy and vitality. My mentor, Dr. Louis Ormont, a pioneering clinician in American group therapy, insisted that therapists cultivate a wide variety of creative outlets, regarding creativity as an integral part of the professional training profession.
Dr. Ormont demonstrated his commitment to creativity in his own active lifestyle, which included writing books and articles, lecturing extensively, a rigorous exercise regiment, attending plays, musicals, concerts, dance performances, and art galleries. Anyone who worked with Dr. Ormont was astonished by his positive energy, youthful spirit, and playful sense of humor. Characteristics that improved his work with patients and the quality of his life, as he continued with large group practice until his death at ninety years old, despite being legally blind for the final ten years.
An extensive analysis of research conducted on creativity and its effect on mental health was performed by The American Public Health Association (Stuckney & Nobel, 2010). By referencing 104 studies on creativity with measurable outcomes, the report found that creative activities decreased stress, anxiety, and mood disorders while also demonstrating improved psychological and physical well-being. The report concludes that creativity opens a reservoir of healing with the power to rehabilitate and rejuvenate.
- Community
Community is defined as positive relationships that offer empathy, understanding, and support. Community, as defined here, includes family and extended family members, friends, peers, colleagues, therapy groups, religious gatherings, professional organizations, and neighborhood associations.
Due to the nature of their work, psychotherapists are more likely to become isolated and overworked. This tendency, combined with a lack of community, can have negative long-term psychological and physical effects.
The American Society on Aging (Qualls, 2014) notes that social isolation impacts physical health as much as blood pressure, smoking, physical activity, and obesity. The report cites a meta-analysis of 148 longitudinal studies that reveal that individuals with healthy social relationships have a 50% increase in survival rates compared to socially isolated individuals, regardless of gender, age, or ethnicity.
Burnout Recovery
How do psychotherapists recover from burnout? By realizing that they, like their patients, need a self-care plan. When self-care replaces self-neglect, the defenses against burnout strengthen, and a deeper, healthier sense of humanity emerges. They develop into better psychotherapists and, ultimately, more rounded and happier human beings.
References:
Barnett, J.E., Baker, E.K., Elman, N.S., Schoener, G.R., Elman, N. S., & Schoener, G. R. (2007). In pursuit of wellness: The self-care imperative. Professional Psychology: Research and Practice, 38(6).
Center for Disease Control and Prevention (2018) The Benefits of Physical Activity. www.cdc.gov
Gabbard, G. O., Wilkinson, S. M. (1994). Management of countertransference with borderline patients. Arlington, VA, US: American Psychiatric Association.
Simionato, G., Simpson, S. (2018) “Personal risk factors associated with burnout among psychotherapists: A systematic review of the literature.” Journal of Clinical Psychology, Volume 74, Issue 9.
Hammond, T., Crowther, A., Drummonds, S. (2018) A Thematic Inquiry into the Burnout Experience of Australian Solo-Practicing Clinical Psychologists. Frontiers in. Psychology, 19 January 2018.
Kim. J., Sweeny. J. (2015) Countertransference and Burnout issues for Therapists who provide Dialectical Behavioral Therapy (DST) and Formative Evaluation of the DBT Consultation Group. University of Minnesota – Duluth.
Kohut, Heinz (1968) “The Evaluation of Applicants for Psychoanalytic Training.” The International Journal of Psycho-Analysis And Bulletin of the International Psycho-Analytical Association.
Jenkins SR, Baird S. Secondary traumatic stress and vicarious trauma: A validation study. Journal of Traumatic Stress. 2002;15 (5).
National Library of Medicine (2018) Health Risks of an Inactive Lifestyle. Medline Plus.
Mahoney (1997) Psychotherapists’ personal problem and self-care patterns. Journal of Professional Psychology: Research and Practice, (28).
Maslach, C., and Leiter, M. P. (1997). The Truth about Burnout. New York, NY: Jossey-Bass.
Miller, A. (1990). The drama of the gifted child. (Rev. Ed.) (R. Ward, Trans.). New York: Basic Books. (Original work was published 1979).
Morse, G., Salyers, M., Rollins, A., Monroe-DeVita, M., Pfahler, C. (2012) Burnout in Mental Health Services: A Review of the Problem and Its Remediation. Administration and Policy in Mental Health and Mental Health Services Research, Volume 39, Issue 5.
Babyak, M., Blumenthal, J., Herman, S., Khatri, P., Doraiswamy, M., Moore, K.Edward, Craighead, W., Baldewicz, T., and; Ranga Krishnan, K. (2000) Exercise Treatment for Major Depression: Maintenance of Therapeutic Benefit at 10 Months. Psychosomatic Medicine: September-October 2000 – Volume 62 – Issue 5.
Qualls, S. (2014) What Social Relationships Can Do For Us, American Society on Aging.
Skovholt, T. (2000) The Resilient Practitioner: Burnout prevention and Self-care Strategies for Counselors, Therapists, Teachers, and Health Professionals. Allyn and Bacon, 1st Edition.
Weir. K. (2011) The exercise effect. American Psychological Society, Vol 42, No. 11
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Sean Grover, LCSW, is a psychotherapist, speaker, and author with nearly 25 years of experience working with adults and teenagers. He maintains one of the largest group therapy practices in the U.S. He leads over 300 groups a year in his practice, in addition to monthly workshops in clinics, medical centers, youth organizations, and schools. He has also served as a Program Coordinator for Brooklyn Psychiatric Centers, Clinical Supervisor at the Harlem Education Arts Fund, a member of the Brooklyn District Attorney’s task force on youth violence, and presenter at national conferences for the American Group Psychotherapy Association Eastern Group Psychotherapy Society. Sean has also been interviewed and quoted in The Economist, The Wall Street Journal, Newsweek, and New York Magazine. When Kids Call the Shots, his parenting book was Publishers Weekly editor’s pick for best new nonfiction and has been translated into four different languages. Sean’s Psychology Today blog has surpassed 5 million readers and counting. For additional information, visit www.SeanGrover.com.
