Una Maguire in conversation with Mary Montaut

You ask, what is the hard work of psychotherapy that makes therapists burnout? I know that in my own experience I haven’t been somebody who has taken work home; my thoughts haven’t been preoccupied with clients and their distresses and so on. Very, very rarely have I dreamt about clients or found myself caught in a groove, as it were, with thoughts about them. So I used to say to myself that I didn’t find it hard, I didn’t find it stressful. And yet there were times when I would realize that my energy was getting depleted, or my body would show me that it wasn’t dealing with the onslaught of microbes as well as it normally would.

One of the things I came to realize that was demanding, that was hard, that was stressful, was the constant need to change gear from one client to another. I would be calling up one aspect of myself to meet one client and calling up another aspect of myself to meet another – and that was some­thing that I identified as perhaps particularly demanding in this work.

Clients’ Distresses

Then of course there is the dimension that everybody anticipates will be stressful about working in the in-depth way that you do in psychotherapy, and that’s when the client’s distresses match your own. That is one of the two main purposes for the attention to your own therapy, so that you are not being restimulated into your own pain by clients’ distresses. But even with your own therapy done and ongoing to the best of your ability, you’re going to hear people telling you about the most appalling circumstances, and showing you the distress and the damage that has been done to them, and your own humanity, your own human heart, is impacted upon by that. You’re going to feel outrage or grief for the person, though that I wouldn’t really count as stress, it’s simply a human reaction. At the same time you are likely to hear more of that than you would in ordinary life; professionally that is what you are available for and so you’re likely to hear more of it. A bit like the family therapist who says that her work puts her off families – the painful side of life can loom very large. Maybe there is the accumulative effect of that.

Low-grade Stress

I remember some years ago reading a book about looking after yourself – not particularly addressed to counsellors and psychotherapists – but it described a low-grade type of stress, that the book called “low-grade burnout”. That is something to watch out for. Full-blown burnout is very recognizable: you don’t sleep well, you haven’t got the same kind of ability to relax, to entertain yourself. You can be so stressed that you don’t remember from one day to the next what somebody says to you – and I don’t mean clients, but friends and family members. It’s like you are at the point where it feels as if you’re just getting through each day, or even each half day. You barely have enough energy and attention for that day, much less that week; and that’s pretty obvious to you yourself at that stage. But with the low-grade burnout, where you’re dutifully plodding along, it’s as if the resilience has gone out of your system and the weightiness of the material that you’re dealing with is more constantly present to you. You may not even be saying to yourself that this is a weighty job, but the experience of that weightiness is there and the sparkle has gone, the excitement has gone, the buzz has gone.

Another indicator of low-grade burnout is when you find yourself avoid­ing going to plays or films that would be more like being at work – I find that’s a good indicator that you need to give attention to yourself. Or when you find yourself maybe visiting less frequently, maybe keeping a certain distance from friends or family members who are in distress, because it would feel like being at work again. Not that you are going to be there as a therapist with them, but even to be around them makes you feel that you have had enough of that in your daily work.

Normalization of the Work

So there’s a difference between the dramatic burnout, which is very clear, and the low-grade burnout that I’m talking about, and I think the second one in particular is different, from a kind of change that takes place in the work of a psychotherapist. I think it’s probably true to say that at least 95% of us would have started off in psychotherapy with a tremendous sense of enthus­iasm and excitement and, in the humanistic field anyway, with a real desire to share with others the benefits we’ve experienced ourselves as clients. While it might it not be like a mission that you’re on, it has aspects of that kind of enjoyment at the prospect of working. And I think it may be true to say that if you stay with this work for ten or fifteen years, then there is a change that I don’t think is related to burnout or stress. I think it’s simply a normalization of the work that you’re doing and of you, yourself, doing this kind of work. You started off with excited motivation and it changes into something more ordinary in your own life, and other areas perhaps arise which then become the expressions of your excitement about living. I think then that there are three experiences there that it would be helpful to distinguish: the change or normalization of yourself in your work: the low-grade stress: and the more dramatic burnout.

What Can Contribute to Burnout?

The kind of things that can contribute to a full-blown burnout are firstly a combination of circumstances that come together. One of these can be that you find yourself working with a larger proportion than usual of clients who are very deeply distressed. That on its own can do it. But that can coincide with other things like new distresses in your own life – your own physical illness or that of family members, or some sort of collapse of your usual support system and what contributes to your sense of well-being.

I think events that can tip the balance into burnout can also be on a wider scale than just your own state of health or the crises in your family or friends around you. Here in Ireland, for example, there has been the constant report­ing of atrocities of one kind and another over the last twenty-five years, and even now there is an increase in punishment beatings. Perhaps this is some­what special to psychotherapists, but I sometimes notice people listening to the News with a sense of “Oh no!”, which is not only an “Oh no!” for those concerned, but also for the level of stress that it raises in ourselves … At times it feels as if the world is making no headway against the kind of things that continue to harm and distress and damage people.

A possible indicator, maybe not a red alert but an orange one, is if you find your attitude to your clients changing; not in the way I was describing earlier which is simply a normalization of your work, but a change that’s almost like pushing the person away. You may find yourself staying away from emotional areas, or moving too quickly towards solving problems. You find yourself watching the clock, or waking up and feeling, thank heaven this is the last day of the week – it’s anything that may indicate that the work is becoming distasteful to you.

What Can Help

Let me look now at what can help. The obvious one must be your own therapy. Another obvious one is the support of your regular supervision, and that is of inestimable value. I know that, for example, I have wanted to have a supervisor all to myself, that I haven’t wanted to be in group super­vision, I’ve wanted the attention for myself. And I’m really pleased that I recognized that and gave it to myself. There is also attending to your own physical health. A long time ago I was talking to somebody who was trained in Chinese medicine, and she told me that in China it is simply taken for granted that you are going to need time out every five or six years – a sabbatical – and that this is part and parcel of the way that you structure your life. I believe that in Canada, teachers have a similar inbuilt provision, whereby a seventh of their salary is kept for the seventh year, when they will be on sabbatical. I think that it would be really helpful for the profession as a whole to recognize this, and for individuals and agencies to take it into account, and simply structure it into your life.

In a more day-to-day way, that same person also told me, anybody who is doing this kind of work should be taking vitamin B supplements, and vitamin C as well, I think. I would recommend people to look into their own requirements, because it is our nervous system that takes the toll. If you find your mind continuously working on your clients’ issues, when you should be just dropping off into a good sleep, there is plenty of help available in the way of relaxation tapes and heartbeat tapes and things like that to have at your bedside. I find that a certain amount of physical exercise is really, really useful, and fairly vigorous exercise, where you can be not only exercising the muscles but also letting off steam. So if you are playing squash, you can have a good roar at the ball as you whack it to the far end of the court. That is very helpful. A lot of our day is spent just sitting, and we need to oxygenate our systems, quite literally.

The next point would probably apply mainly to single people – really make sure that your job is not the whole of your life. So you’re into line dancing, or yoga, or photography or art classes or whatever it may be – but make sure that your work is not the only thing in your life. It might be a course of studies, that is unrelated to psychotherapy. It might be falling in love – what a wonderful distraction! Of course they can also be additional stresses, but on balance I think it is better to have them because they are different stresses from those you experience at work.

The Work of a Psychotherapist

I think that psychotherapists experience the stresses and strains of their work differently from psychiatric nurses or social workers or doctors, teachers, surgeons etc. To me, the profession of psychotherapy requires a person to use their personhood much more than would be the case in those other professions I mentioned. This links up with the point I made earlier about having to draw on different aspects of yourself for different clients. The totality of your presence to a client is something which distinguishes the work of a psychotherapist. If you are a surgeon, you can switch into the technicality of the job. If you’re a social worker, you may have empathy with the person, but your job, as I understand it, is to help the person to solve their practical problems, and there is therefore a third element in the work which is lacking in most forms of psychotherapy. It is you as a person that is the main tool of the work, and it is the relationship between you and the client that is of the essence. In a sense, you are making yourself available to the client, and when I say “yourself” I really mean the fullness of yourself, the totality. You can’t leave out your mind, obviously, you can’t leave out your heart, nor your body which is present in your whole body language – all of you is there.

Some Toll is Inevitable

I hope when people get some experience, on an introductory course for example, that they realize that this stress is part and parcel of a psycho­therapist’s work, so that this realization will inform a person’s choice as to whether to go ahead and train in this profession, or which type of approach they might choose. They should ask themselves whether this is something they want in their lives? Because after the first years of enthusiastic practice, then you begin to notice the toll that it will take anyway – there is no avoiding it, I think. If you are going to take on this profession, you must take on board the fact that you are going to experience varying levels of stress or burnout, and you should take that into account in choosing. You will have to make sure that it doesn’t render you unfit to practise – and if it does (and it may well do so) then STOP. And I know that can be easier said than done – but you must take it into account. You must, I would say, put some of your earnings aside and build them up for the day when you are going to take your year or six months off, or when circumstances beyond your control might bring you into a state of burnout, and your supervisor, if you are not doing it yourself, will challenge you to cease practise for the time being.

Una Maguire is a psychotherapist. She is currently Director of Training at Creative Counselling Centre, telephone 01-280 2523.