As clinicians who sit in offices with clients who are experiencing emotional pain and turmoil, we are called on to offer solace and support, guidance and ideas for making positive change.
They look to us for answers that they have not been able to bring forth on their own.
There are times when the expectation is that we glue together what they perceive as the shattered fragments of their lives. Choices made unconsciously or by habit have led to addiction, relationship fragmentation, job loss, as well as estrangement from family and friends.
Combined with multiple mental health diagnoses that may be at the core of their chaos, they frequent inpatient and outpatient services at growing rates.
“According to SAMHSA’s 2014 National Survey on Drug Use and Health (NSDUH) (PDF | 3.4 MB) an estimated 43.6 million (18.1%) Americans ages 18 and up experienced some form of mental illness. In the past year, 20.2 million adults (8.4%) had a substance use disorder. Of these, 7.9 million people had both a mental disorder and substance use disorder, also known as co-occurring mental and substance use disorders.”
Wisdom Gained in the Trenches
When this now seasoned therapist dipped her toes in the waters of inpatient acute care psychiatric treatment, her supervisor reminded her that she was just naïve and caring enough to be ‘sucked in’ by the needs of the patients who were admitted in crises; some by choice, others by involuntary commitment.
When he saw that she was crossing the line into enabling, he would walk past her with an imaginary straw and slurping as if sucking in liquid. Laughing, she would roll her eyes and recognize her pattern.
In yet another psychiatric setting, a long time nurse cautioned, “If you are doing more for them than they are doing for themselves, there is something wrong with this mix.”
Although this guidance is sound, it sometimes slips from the mind like so much water from between clenched fingers. A few years after leaving the hospital setting for an outpatient substance abuse practice, she was facilitating a support group for women in recovery that met each Wednesday evening. One year, it fell on New Years’ Day. She offered to the participants that she would hold the meeting, rather than forgo it since it was a holiday, telling them that if they were committed enough to be there, she would as well.
Out of the 10 women who regularly attended, five showed up. Since it was a fee for service group, she was understandably frustrated with that outcome. The next year, she made the choice to cancel the group on the holiday, rather than engage in the all too common in this field inclination to go above and beyond the call of duty.
Vicarious Traumatization Hits Home
An occupational hazard is known as vicarious traumatization or secondary trauma and reflects the dynamic of taking on the pain and suffering of others such that it actually feels as if the therapist is experiencing the same symptomology.
Listening for hours at a time each day, to stories of trauma and loss, while holding space for the client to safely express their feelings, can take its toll on the clinician.
In the lives of clients, Post -Traumatic Stress Disorder (PTSD) can emerge as a result of a number of excessively distressing incidents, from being in a war zone to sexual assault. According to the Diagnostic and Statistical Manual, 5th edition (DSM-5), to be diagnosed with PTSD, a person must have experienced or witnessed a traumatic, physically threatening event or have learned that a traumatic event happened to a close friend or family member, and display specific symptoms for at least one month. Four types of symptoms are listed in the DSM-5:
- Avoidance Symptoms:
Avoiding specific locations, sights, situations, and sounds that serve as reminders of the event
Anxiety, depression, numbness, or guilt
- Re-experiencing Symptoms:
Intrusive thoughts, nightmares, or flashbacks
- Hyperarousal Symptoms:
Anger, irritability, and hypervigilance
Aggressive, reckless behavior, including self-harm
- Negative Mood and Cognition Symptoms:
Loss of interest in activities that were once considered enjoyable
Difficulty remembering details of the distressing event
Change in habits or behavior since the trauma
Once the session is over, the therapist’s work continues in the form of documentation, scheduling, billing and utilization review. Often, there is no time to regroup before the next person walks in the door. Shifting gears mentally and emotionally to greet the new client may need to happen in the blink of an eye.
It is not uncommon for the professional to work in excess of 12 hour days and when they head for home, sometimes find their clients ‘accompanying’ them in their minds.
Despite being consciously aware that she was not responsible for the choices her clients made, a therapist who had worked in the mental health field for several decades, would find herself persistently thinking about interventions she could offer to prevent them from making destructive decisions. It, among other factors, was a contributing factor to serious health problems that she encountered.
What Is a Responsible Therapist to Do?
- Recognize that self -preservation is not selfish. You can’t fill someone else’s cup when yours is empty.
- Take an inventory of the stressors in your life.
- Note the signs of compassion fatigue which include:
Physical and emotional exhaustion
Feeling a lack of job satisfaction and an ongoing desire to avoid work
Becoming socially isolated
Depersonalization (symptoms disconnected from real causes)
Anger and frustration toward clients
- Theory and book knowledge only go so far. Practical application of all you have learned is as useful for you as for your clients.
- If you have a spiritual practice, incorporate it to maintain equilibrium.
- Engage in scrupulous self-care which could include: adequate sleep, healthy nutritional choices, exercise, massage, meditation, yoga and down time; in whatever way you define it.
- Invest in yourself by time with those who nurture your wellbeing.
- Listen to music.
- Make music.
- Attend fun activities.
- Journal about your feelings.
- Avoid ‘playing therapist’ when you are off duty, as the tendency is to maintain that role with people in your personal life.
- Steer clear of substances that are self- medicating, to prevent feeling the effects of time with clients.
- Seek support from colleagues or supervisors.
- Take vacations to locales that refill your tank.
- Get up from your desk and take stretch breaks in between clients.
- Acknowledge the losses and trauma in your own life that may be reflected in the stories told by your clients.
- Read books that focus on therapist’s needs for support, including Help for the Helper: The Psychophysiology of Compassion Fatigue and Vicarious Trauma by Babette Rothschild, Transforming the Pain: A Workbook on Vicarious Traumatization and Trauma and the Therapist: Countertransference and Vicarious Traumatization in Psychotherapy with Incest Survivors by Karen W. Saakvitneand Laurie Anne Pearlman.
- Take Continuing Education classes that offer skills to assist you in providing the best care for yourself, so you can better care for those you serve.
- See a therapist yourself if need be.
- Ask yourself about the suggestions you would offer a client who was facing work related stressors.
- Know that even as a professional, you are not immune to the challenges that befall clients. You are human, after all.
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