In Therapy

A user's guide to psychotherapy

Therapist Burnout

Preventing therapist burnout
Hara Estroff Marano
This post is a response to For Therapists - Survey Results by Hara Estroff Marano
This blog is the user's guide to psychotherapy, but after reading the results of PT's therapist survey I feel a need to address my fellow therapists. Several respondents requested information on preventing and treating therapist burnout. I'll take a crack at this professional conundrum and include some tips for clients of burnt out therapists.

Therapists burn out? Don't we have a bottomless reservoir of empathy and patience? Aren't we masters of healthy relationships, exquisite self-care and self-actualized career fulfillment? We counsel on these ideals and personally strive for them as much as the next guy. But alas, we aren't immune to burnout; defined as "an imbalance between the psychological resources of an individual and the demands being made on those resources." When we give more than we get, we burn out; a common pitfall in our work. We provide a service based on our thoughts, feelings and energy to an often challenging clientele. Yes, we do burn out.

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How do you know you're burning out? You may have an inkling when you:

  • drag yourself into work most days
  • find yourself repeating the same interpretations over and over
  • give advice as a shortcut rather than helping clients learn and grow
  • begin sessions late and/or end early
  • doze off or space out during sessions
  • experience a noticeable decline in empathy
  • do things that would make your former ethics professor cringe
  • push your theory, technique or agenda rather than listening and adjusting
  • feel relieved when clients cancel
  • haven't read anything psychology related for a while
  • self disclose in ways that don't help the client
  • fantasize about that high school job at the food court in the mall where you were appreciated, got tips and left work at work

Burnout intensity varies from temporary career ennui to full-blown meltdown. The symptoms range from empathic lapses to grouchiness to resentment to snapping at clients to indulgent self disclosure to a complete disregard for professional boundaries and ethics. Consequences include job dissatisfaction, poor job performance, frantic job searches and/or calls to lawyers.

Why do we burn out? It depends who you ask. A psychodynamic shrink might promote Alice Miller's idea that we select this profession because we're perpetuating a caregiver role adopted in childhood and must confront the hopelessness of never being able to help all the people all the time. A CBT provider might explore irrational beliefs held regarding our worth, self-esteem and career success. Humanistic therapists might look at how we're inhibited from realizing our potential. And there are many other valid opinions. Let the debates begin.

Theorists can reach across the aisle(s) and agree on a few things: psychotherapy can be socially isolating, the progress of the work slow and the emotional toll extreme. The limits of confidentiality make venting frustrations and celebrating success difficult. Many people drawn to therapy are "helpers" who give until depleted; masters at caregiving but novices at self-care. Graduate schools don't do a great job of teaching healthy career longevity. If therapists don't have good boundaries in place, this healing profession can harm them. The list goes on.

When supervising graduate student therapists I regularly witness the good intentions that pave the road to burnout. Spawned from a desire to help, new therapists often feel compelled to go overtime in session, emotionally invest beyond healthy limits and take their work home by ruminating about clients in their free time. They want to serve their clients and validate their career choice so they work extra hard and become hypervigilant to any signs of clinical success or failure. Their self-esteem becomes dependent on their client's progress. That's far too much stress on their emerging therapy skills and too much pressure on the client. Much of my work as supervisor entails teaching (and modeling) patience, lifelong perspective on the client's process and self-care for the clinician. We must meet our own needs first: if we're emotionally spent we're no help to the client.

Onward to the treatment phase. The list below may seem like common sense, but if you're burning out I'll bet you're neglecting one of these areas.

How therapists regain and maintain passion for their work:

  1. Hold the frame -The frame is the environment of therapy, consisting of the physical, professional and ethical boundaries of our work. Therapists who are clear about boundaries of self, client and therapy from the beginning sleep better at night. Check out Glen Gabbard's excellent book for elaboration.
  2. Get therapy - I'll occasionally meet a therapist who has never been a client. I tend to judge him: either he's on the fast track to burnout or he isn't doing meaningful work with his clients. That's my bias. Personal therapy for therapists relieves stress, assists coping with a stressful career and distinguishes the therapist's issues from their clients. This objective view is invaluable, and it's also a tax write-off.
  3. Fees, office hours, vacation - We don't want to feel significant disparity between what we give and what we take. If you're working nights and weekends 51 weeks a year for a wage you feel is substandard, you will burn out. Charge a fair wage, work reasonable hours and get out of town once in a while.
  4. Don't take work home - In my experience, the first therapists to burn out are those who carry a 24 hour pager, return phone calls and emails all weekend and are generally on the clock all the time. Find coverage for your emergencies, finish your paperwork at your office and let home be your sanctuary.
  5. Join groups - From Rotary Clubs to Toastmasters to your local psych association or a consultation group, opportunities for professional connection do exist. When the only people you speak with all day are clients, you become socially isolated.
  6. Find a niche - Some of the most successful, driven therapists have found creative ways to pursue a focus within their careers. Love theatre? How about providing group therapy to acting students? Sports? How about marketing to coaches and athletes? Whether it's within a specific population or a target area of treatment, you can find vitality while increasing your expertise.
  7. Diversify - Many shrinks I know have several irons in the fire. They augment therapy with research, teaching, supervising, writing, consultation, assessment or volunteering. Spreading your talents allows you to feed parts of self not tapped in therapy.
  8. Continue education - Ten years ago I had to obtain my 36 CE's by finding weekend classes, attending and taking notes, eating lunch with classmates and actually continuing my education for 36 hours. Now, most licensing boards allow most, if not all our CE's to be acquired over the Internet. It's cheaper, faster, and there's less hassle. But there's also less collegiality, no Q & A and probably not as much learned. Take the time to attend some workshops, learn theory, interact with colleagues and get back in touch with the internal student who wanted to grow and make a difference.
  9. Get a life - I've always maintained that therapy cannot be both my career and my hobby. It's crucial to create and maintain a life outside therapy that includes hobbies, friendships, loved ones, creativity, physical activity - anything that feeds you emotionally and spiritually. Your identity needs to extend beyond "therapist." It's a valuable role, but shouldn't be your entire life.
  10. Quit - You might not want to hear this, but someone needs to say it. If you've tried the above-mentioned strategies and still feel your passion lacking, perhaps it's time to look for another line of work. We're in the business of growth and change - it shouldn't come as a surprise that some people simply grow out of their desire to provide therapy. There's no shame in that. Research shows that Americans typically have between two and five careers in their lifetime (depending where you look). Rather than force yourself to work joylessly and potentially subject your clients to subpar treatment, maybe it's time to give yourself permission to hit Monster.com.

The bottom line: in a career where your heart and brain are your most valuable resources, nurturing those commodities should be top priority. Don't just practice what you preach, model healthy boundaries and self-care for your clients. Your actions speak louder than words. Therapy can be an incredibly fulfilling career if you take proper precautions.

For Clients: Do you suspect your therapist is burning out? Are you leaving your sessions feeling like your therapist doesn't care, isn't listening or lacks enthusiasm for her work? I suggest you mention what you're observing to your therapist. Tell her what you've experienced and talk about how it makes you feel. Your feedback is valuable, and may provide a wake up call to the therapist or highlight some other barrier within the therapy. But it's not your job to take care of your therapist, so if you don't feel the issues are being addressed, you might want to consider terminating. Your time, money and effort merit a clinician who is invested in your work.

Ryan Howes, Ph.D., is a clinical psychologist, writer, musician and professor at Fuller Graduate School of Psychology in Pasadena, California.

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