Difficult Clients are Not the Cause of Burnout
Chronic job strain can make therapists want to ditch the couch forever. This strain can lead to burnout, a feeling of emotional exhaustion, cynicism and ineffectiveness, or what is commonly called burnout.
It is common wisdom that seeing difficult patients is at the heart of therapist burnout. Many studies have found that challenging clients do contribute to burnout but there is also a much more fundamental cause.. In a classic study on the causes of burnout, Barry Farber and Louis Heifetz interviewed 60 psychotherapists about their work experiences. The most commonly reported cause of burnout wasn’t money concerns or workload but a lack of effectiveness in the therapy room.
As they explain:
Professional satisfaction derives from the ability to promote a helpful therapeutic relationship; dissatisfaction stems primarily from a lack of therapeutic success; and burnout is primarily a consequence of the non-reciprocated attentiveness, giving, and responsibility demanded by the therapeutic relationship.”
In other words, the feeling that we aren’t creating a helping and healing relationship with our client is the main reason therapists felt burnt out.
Interestingly, the severity of mental health problems in clients wasn’t a major cause of burnout. That’s not so surprising if you think about it. Whether we are treating mild or severe mental health problems, what makes our work as therapists frustrating or fulfilling is our ability to help clients change.
In fact, I feel at my best when I can throw a rope to clients in crisis by convincing them to stop self-destructive patterns, escape abusive environments or confront long-avoided traumas.
We need these challenging clients to put our relational and conceptual skills to the test. Through this work, we discover passion for our work and we become more effective with all our clients.
Self-Efficacy and Burnout
Therapists are not alone when it comes to the impact of feeling ineffective. Many studies find that self-efficacy, the feeling that one can exert control over challenges and bring out desire results, is a consistent predictor of burnout across numerous professions, including teaching, nurses, physicians, and various office jobs. A recent meta-analysis of 57 studies found that having lower levels of self-efficacy was related to higher levels of burnout.
To apply the latter findings to mental health workers, therapists who don’t feel that they can deal with clients’ challenges in session effectively or help their clients improve their depression, anxiety or other maladies are less likely to feel a sense of accomplishment, have negative attitudes about the meaning of their work, and feel emotionally exhausted, in other words – burnt out.
This suggests a solution that at first seems paradoxical but hear me out before you hit the back button on your browser.
If you are feeling burnt out, one strategy is to put an additional task on your plate – seek training (in interventions) as well as supervision) and engage in self-reflection to improve your practice and improve your skills.
This advice even applies if you’re chronically overloaded with work. For example, you may need to guidance in time management skills, getting over the guilt of ending sessions at 45 instead of 65 minutes, or assertiveness in turning away work that might rightly belongs to others.
Really, the solution isn’t much different than what we ask of clients. Think about it from this perspective: when depressed clients seeks our services, we ask them to do additional tasks to pull themselves out it such as finding enjoyable activities, learning assertiveness training, engaging in self-reflection and completing other homework assignments.
The remedy for our own problems isn’t different from that of our clients.
The Stages of Change Model
Addressing burnout may also require us to think about effectiveness from a more flexible perspective. As a supervisor of doctoral interns, I often address the issue of effectiveness with trainees. They feel ineffective because patients are not responding with enthusiasm to their interventions, following through on homewor, or attending session as regularly as they want.
Many expect a level of compliance that is typical of highly motivated persons, those in the action stage of change.
However, many clients enter therapy in a contemplative state of mind, often torn between the desire to change and maintaining the status quo that has caused their problems.
Expecting quick and easy successes with these clients can actually lead to frustration, client dislike, or feelings of ineffectiveness.
But thinking about these patients from a stages of change model, we may begin to understand that some clients aren’t ready for action. Effective therapy for many clients involves raising awareness of the consequences of their problem, increasing personal responsibility or just helping them get over the stigma of being in therapy.
If we adopt this flexible approach to defining success, change is not just limited to reducing depression or anxiety scores on standardized measures but encompass the many ways we help our clients take essential steps that set the stage for later change.
Change is difficult and therapy is a tough venture for many. If it was easy to change, we’d never have become a profession in the first place.
To evaluate the challenges of doing PTSD therapy, Lisa Najavits, the creator of the trauma therapy seeking safety, reviewed studies of evidence-based PTSD therapies in actual clinical (as opposed to research) settings. These therapies demand a high degree of commitment from clients, including hours of homework every week and a willingness to talk about the most upsetting parts of the trauma.
Najavits found that dropout from evidence-based therapies was often high (much higher than in the typical research study) and that many patients attended only a few sessions before calling it quits.
What Can Therapists Do About Burnout?
When it comes to burnout, feeling effective is and often overlooked buffer. But how can you feel more effective? Here are several suggestions:
- Attend trainings. The more you help clients, the less you feel burnout. Regular training is one way to accomplish this goal. There are so many techniques now available to treat nearly every mental health problem conceivable. Training can expand your perceptiveness, teach you new techniques and get you thinking about your clients’ problems in new ways.
- Get supervision. Getting consultation and advice from a more experienced colleague is, well, much like what happens in therapy. Getting outside feedback allows you to see patterns in your work that you are unaware of and to learn how they affect you. Outside feedback can also open your mind to new ways of working with clients. You probably have your favorite one of two techniques but supervision can open your eyes to other valid interventions.
- Take a more complicated view of change. Give an honest and accurate assessment of what your clients have to overcome to start changing and appreciate all the steps that are necessary. Many patients are not in the action stage of change, that is, ready to start changing their problems now. For example, you may not be able to get someone to leave an abusive relationship, but if you get him or her to see how destructive it is and break down his or her denial, you have accomplished something quite significant.
- Success is your clients’ goals not yours. Sometimes, we as therapists want to get the maximum results for our clients. We expect them to change in the most ideal way possible, especially symptom reduction or even disorder remission.
For example, in working with trauma survivors, we may expect them to confront their traumas. However, our clients may be struggling just to achieve something much simpler, like sharing a trauma for the first time. Of course we should encourage as much change as possible, but our clients may be thrilled with something as basic as just committing to come to therapy. Given that the modal number of therapy sessions is one, we should really try to attune to our clients’ goals from our first meeting.
Whether you’re a new therapist or a seasoned veteran, burnout is an ever-present concern. You can combat burnout by appreciating all the subtle ways you help clients. Set realistic expectations of what you can accomplish with your clients. Additionally, adopt a continual model of learning and growth as a therapist. Don’t become complacent or think you’ve mastered it all.
The bottom line is that if you want a long and healthy career as a therapist, you not only have to see yourself as effective you have to be effective as well. If you do, not only will you appreciate it, but also your clients will too.