Dr. Skovholt: One of the great challenges of being a therapist is that we have to form attachments to many clients, and then eventually those relationships often end for various reasons, perhaps because the patient no longer needs treatment or just drops out of treatment. We don’t want to become overly attached to all our clients, because that can be draining. But on the other hand, we don’t want to distance ourselves, because the essence of healing occurs within the caring relationship.
TCPR: You talk about the “cycle of caring.” Can you describe what you mean by that?
Dr. Skovholt: In all the relationship-intense professions, there often follows, for the practitioner, a 4-phase cycle. It starts with an empathic attachment phase, where each of us begins to form a bond with the client. We see our patients, we listen to their stories, and hopefully we empathize. Once that’s established, there’s an active involvement phase. This lasts for many sessions, and it is the main work of treatment—understanding problems, helping with solutions, prescribing medications if you are a prescriber. So far it is all plowed ground for practitioners; these phases are well worn and understood.
TCPR: Yes, these are the phases that probably constitute most of our psychiatric treatment.
Dr. Skovholt: That’s right, but many practitioners don’t pay enough attention to the next 2 phases. The whole goal here is to fiercely protect our capacity to professionally attach with our patients over and over again. So there’s a felt separation phase, in which the therapeutic relationship is ending. When that happens, you have to acknowledge that an important relationship is ending, and you don’t want this to be a negative experience. You might grieve a little if you are very close to the client, and that’s appropriate, but you don’t want to feel depleted. It’s important to reaffirm your own identity as a helper, because you’ll soon be coming up to the next phase, which I call the re-creation phase. You’ve said goodbye to a client, and now you move on to your next client. If you’re very busy, this can lead to a kind of burnout in which you just can’t face beginning the process of forming another intense attachment with a troubled soul. To avoid that kind of exhaustion, you need to consciously re-energize yourself. The felt separation phase and re-creation phase can be expressed in many ways symbolically, and their time duration may vary.
TCPR: It’s true that we often just take ended relationships for granted. What you’re saying is that we should be perhaps more conscious of the fact that when a patient stops coming, that may actually affect the degree to which we are willing to re-engage with a new patient?
Dr. Skovholt: Right, and it’s just really that kind of slow erosion process that can make it challenging over time to re-engage with new patients. As an analogy, consider the simple example of dating: One day you are in a personal relationship with someone, and abruptly that person breaks up with you and essentially disappears from your life. What impact does that have the next time you try to get involved and trust somebody? So what’s the impact on the doctor of the losses, the disappearances? When a client goes away or doesn’t come back, it’s natural to think, “What happened?” “What did I do wrong?” “Did they learn anything?” And, of course, you can’t just go hunt down your former patients to answer these questions. So it’s important to have a thoughtful approach, a strategy if you will, about your investment of time and energy with each new patient.
TCPR: How would you recommend thinking about that?
Dr. Skovholt: For starters, and this is for myself, in a first meeting I would work really hard at not getting ahead of myself in terms of attachment. Because if I get too involved and the patient doesn’t return, then I might start questioning if maybe I came on too strong and scared them away, and then I’m in kind of a depleting mindset.
TCPR: Interesting. Can you give me an example?
Dr. Skovholt: Sure. Say you are doing a first session with a couple. You are trying to ascertain why they are there. One person might be threatening divorce, saying to the other, “You have to go to counseling or I’m not going to stay with you.” The other partner doesn’t want to be in the therapy at all. So you judge what you are hearing and observing, and maybe say at the beginning, “I’m thinking this is one meeting, and then when we’re done at the end we can talk a little bit and you can go home and decide whether you want to come back.”
TCPR: So my involvement is just at that initial level and no more?
Dr. Skovholt: Right; there is the ambivalence of their wanting help and not wanting it, so I am trying to create engagement and not resistance. Also, I’m focusing on not just them, but also on myself having an ending. Of course, it’s always for the sake of the patient, but it’s also for the sake of me as the practitioner. But if they do come back, then I open up a little bit more and I’m more engaged with them. So during that first meeting, you might want to decide how involved in your patient’s story, in your patient’s life, you want to be while feeling out if this is a patient who would likely benefit from seeing you.
TCPR: I can see the benefit, yet on the other hand, we don’t want to hold back to the extent that we are providing substandard care. Is there a way to incorporate this strategy and still feel like you’re providing something helpful to patients?
Dr. Skovholt: You are making a very important point. There is such a tension to being able to be totally present in the healing process while not becoming unnecessarily depleted or professionally disappointed. One way you could do this at a first meeting, especially if you get a feeling that this is a patient that may not come back, you could say something like, “Well, if we are just going to meet one time, let’s see what we can get done in this one session.” And of course the work is going faster, and certainly not in as much depth, but you are both working on what you can and it’s out in the open that you may not see each other again. In psychiatry, you also have the challenge that you mentioned earlier: that you have so many patients.
TCPR: Right. So the question becomes, how do we stay interested in our clients over the long haul without becoming disengaged or feeling like we need to distance ourselves?
Dr. Skovholt: Sometimes it helps to use an example of another helping profession. Think about elementary school teachers: In the fall, they often have up to 25 young children in a class. All of them want to be attached to the teacher; they want their teacher to know everything about them and care about them deeply. So there is this empathic attachment pull, and this active involvement throughout the winter and spring. But at the end of the year, teachers have these rituals of saying goodbye: assemblies, parties, picnics, etc. Then the school doors close and the teachers spend, in theory, 3 months in their renewal process because at the end of the summer there are going to be 25 new kids saying, “Miss Jones! Miss Jones! It’s me!” So I think that even though it’s a different kind of cycle, it’s thinking about it the same way. I suggest that psychiatrists need to create the same kind of internal renewal rituals.
TCPR: You just brought up teaching and a new school term starting in the fall, which reminds me that there is a certain spark, an energy that goes along with starting something new.
Dr. Skovholt: I was working at the University of Florida Counseling Center for 4 years part time, and I said after a while, “I know everything about 18-year-olds; could I learn something perhaps about 19-year-olds? Could I please have some different people?” Part of that, of course, is the boredom that comes with doing the same thing. In my practitioner resiliency workshops, I call this the hazard of cognitive deprivation. It can be experienced by the practitioner as boredom and perceived by patients as apathy. And as we all know if we’ve ever been patients, students, supervisees, and mentees, feeling the other person is apathetic about our need for them is not a good feeling. Our self-healing properties are not engaged in such a situation. On a different note, I recall talking to a psychiatrist some years ago, and she was really bitter about her work. She was saying things like: “How did I ever get this job with these 15-minute med checks?” She was going to group homes and doing the work, but she just felt like, “I lost my profession.”
TCPR: How do you respond to something like that?
Dr. Skovholt: First, as psychiatrists know so well, even short medication checks can reveal important information regarding patient health and well-being. You have to keep in mind that the work is important. Second, the key for practitioner resiliency is vitality. We can increase our sense of vitality in many ways, including walking away from money. For me personally as a researcher, this means saying no to research topics that may produce plenty of funding, praise, and merit pay but that diminish my soul. Overall, I have been careful to diversify so I do not get to the point of being dragged down by one segment of my work. Third, it’s important to be mindful of the lasting impact we have on our patients and that they have on us. In a book I co-edited titled Voices From the Field, 75 different practitioners write of such “defining moments” in their careers. Often these have been single encounters with patients (Trotter-Mathison M, Koch J, Sanger S, Skovholt T, eds. Voices From the Field: Defining Moments in Counselor and Therapist Development. London, England: Taylor and Francis Group; 2010). Lastly, I am a firm believer in finding people who excel at something and inquiring, “How do you do that?” That means finding psychiatrists who thrive while doing a lot of 15-minute med checks and asking them, “What are your secrets?’ We have used a peer nomination technique to study master therapists and highly resilient therapists. One can do this informally.
TCPR: Moving on specifically to burnout, what are some of the more common signs of impending burnout?
Dr. Skovholt: If you find yourself withdrawing more and more, and maintaining fewer professional and personal contacts, that can get you into trouble. If you don’t talk to your peers very much, and don’t have a personal life with active, vibrant connections with other people and energy-producing activities, that can be problematic. Also, when people aren’t doing well, they don’t use feedback from their patients or clients very well to help themselves become better clinicians.
TCPR: Much of your research has been about resilience and vitality.
Dr. Skovholt: I like to use the term vitality a lot; we need vitality because our patients need it so much from us. As practitioners, your work is so valuable, but by its very nature it is depleting, and so you really have to focus on maintaining energy. It’s easier to say than do, but people’s personal live —the vitality of their personal lives—is really important to maintaining their work in the long term.
TCPR: Where does this vitality come from?
Dr. Skovholt: Part of my research is looking at where people get their energy, and I hear people talk about specific activities that they are just thrilled by. For example, a nursing professor who gets on her loom and starts weaving, and she goes into kind of a trance. A Jungian analyst I know who has gone to Zurich a lot ended up kind of stumbling into a wine importing business. It doesn’t take away from his patients, but gives him a lot of energy. There’s a Norwegian study that came out about therapists that are doing good work with good outcomes. It found that those that felt loved in their personal lives and were able to nurture themselves in positive ways had the energy to care for their patients. At the same time, they had a sense of humility about their abilities, which is important for being open to constructive feedback (Nissen-Lie HA et al, Clinical Psychology and Psychother 2015;doi:10.1002/cpp.1977. [Epub ahead of print]).
It’s easier to say than do, but people’s personal lives—the vitality of their personal lives—is really important to maintaining their work in the long term.
~ Thomas Skovholt, PhD
TCPR: Interesting. Let’s say I’m halfway through an 8-hour day of seeing patients, 2 or 3 per hour. Here comes another new patient to evaluate. Can I change the way I look at this new patient that will kind of give me some more vitality or enthusiasm?
Dr. Skovholt: First, you have to believe that the work you are doing is valuable. Second, look at life through the lens of that new patient. You are an extremely important person in their lives; they are under so much distress. They will never forget this first meeting with you, and so you need to remember how important you are to them. Sometimes people have little rituals: They go down the hall and get a drink of water and come back for the next person. They turn something over, close their files from the patient before, etc.
TCPR: Good advice. In addition to our outside relationships and interests, you mentioned peer relationships. If we have a private individual practice, then most of the time we’re practicing in isolation. And this plays a role in burnout as well, correct?
Dr. Skovholt: Yes. One of the things about our field that is challenging is the confidentiality provisions. Who wants to go home, or go to a party, and not talk about what they’ve accomplished, whether it’s a scientific discovery or a new financial client you’ve secured? But in mental health, we can’t talk about the specifics of our work in most social settings. So setting up some kind of peer consultation is critical. If you’re not in a group practice, find some other way of having regular weekly or monthly meetings with other therapists or psychiatrists to talk about the work that you are doing. As your readers know, sometimes being the consultant-supervisor-teacher-mentor meets some of these needs.
TCPR: Thank you for your time, Dr. Skovholt.