Which Therapists Are More Likely to Burn Out?

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We have long believed within the psychotherapy professions that many of us come into the field as a result of our own developmental wounds. Carl Jung popularized the concept of the “wounded healer,” a person who’s own experiences of pain, rejection, and trauma have cultivated a unique ability to be insightful and empathic healers. As the priest Henri Nouwen wrote, “a deep understanding of our own pain makes it possible for us to convert our weaknesses into strength and to offer our own experiences as a source of healing to those who are often lost in the darkness of their own misunderstood sufferings.” A therapist who has processed their own pain can draw on the experience as a significant source of clinical wisdom. Yet, wounds that have not been healed make us more vulnerable to various risk factors in their work, not the least being burnout and secondary traumatic stress.

Burnout, as most popularly defined by Maslach, consists of three experiences: 1) emotional exhaustion, 2) depersonalization (negative and detached response to others), and 3) a reduced sense of accomplishment. Secondary traumatic stress is defined as suffering from symptoms such as avoidance, hypervigilance, and flashbacks as a result of working closely with trauma survivors. Reasons for burnout and secondary traumatic stress are many, some resulting from structures and policies and others more specific to the therapist.

Yang and Hayes point to a number of institutional factors that make burnout much more likely such as high caseloads and lacking supervisor or collegial support. Warren and colleagues found that having many clients with complex cases or patients who are extremely negative, aggressive, and who blame others without taking responsibility for their actions may also increase the chance of burnout. Quinn and colleagues found that social workers with lower pay were more likely to suffer from secondary traumatic stress than their peers with higher salaries. Craig & Sprang, in a study involving 532 trauma treatment therapists, found that those who used evidence based practices such as exposure therapy, cognitive-behavioral modalities, and EMDR were less likely to suffer from burnout and more likely to experience compassion satisfaction. This may speak to therapist training, which can be greatly enhanced by institutions, as a potential protector from burnout. Researchers have pointed to all of the above as significant contributors to burnout, but until recently we have had little research on how the therapist’s personal history may also be a determining factor.

McKim and Smith found, in a sample size of 98 trauma counselors, that many had their own significant personal histories of trauma. Thomas found that in a sample of 79 masters social work students, they were 3.3 times more likely to suffer from four or more adverse childhood experiences as compared to the general population. In two studies, collectively involving 380 mental health and school counselors, we found that 43% of mental health counselors and 50.42% of school counselors had four or more ACEs. This places them in a demographic with high ACEs scores who are at enormous risk of having physical and mental health illnesses such as heart disease, strokes, pulmonary problems, addiction, depression, clinical anxiety, and PTSD as well as many other health concerns. Having suffered significant levels of childhood adversities not only place these counselors at higher risk of various illnesses that can lead to death, our research found it also correlates with higher levels of burnout.

It is not surprising that many therapists may come into the field with a desire to heal the same wounds in others that they themselves have suffered. Yet, having a significant trauma history may interact with the aforementioned institutional and systemic factors (e.g. high and complex caseloads, lack of supervisor and colleague support, low pay, etc.) in complex ways and make the work of therapy unsustainable over the long haul. We tend to gravitate toward simple narratives to explain the causes of suffering, but doing so often obscures the complexity behind many of the most tenacious problems we face in our personal lives and in our society.

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Despite feeling a strong sense of calling to work with persons who have suffered most from trauma, a counselor needs to consider their own capacity for such work and choose work environments that are conducive to their ability to practice therapy for the long haul. A person with a high ACEs score may need to do their work in an institution or private practice where they can have a more balanced caseload and that offers more supervisory and collegial support. In my experience as a professor of mental health counseling over the past 16 years, burdened institutions tend to cluster around the degree to which they have a combination of high caseloads, complex cases, low pay, and unsupportive colleagues. Newer clinicians often find themselves working in such organizations, whereas some more experienced and at times better trained therapists work in private practices where they make more money and have greater control of their workloads.

If the system in which a clinician works is either over burdened or toxic enough, burnout may be inevitable regardless of a person’s personal history. Therefore therapists may have to leave an institution, program, or practice to sustain their wellbeing and professional callings. Yet, for those who want to continue where they currently practice there are a couple of things clinicians can do to help protect from burnout that I'll explore in the second part of this series entitled How Can a Therapist Prevent Burnout.

To find a therapist, visit the Psychology Today Therapy Directory.