by Ursula Somerville

Introduction
In the words of Jung “Only the wounded heal” (Jung 1995). Psychotherapists enter professional training as somewhat wounded people. In some cases the primary care they received did not take place to “good enough” standards (Winnicott 1990). Trainee psychotherapists come with unsure feelings of how things should be. Their emotional growth can have been stunted at the age of their early trauma. In training they learn about theorists and their theories, case histories, presentations etc. From the training the psychotherapist has integrated they know, at some level, the sights and signs of trauma while working with clients. But how do we recognise these signs in ourselves and more importantly how do we become aware of them before they cause illness?

This article alerts the psychotherapist to the issues relating to self-care necessitated by being with clients, our work environment, the degree of therapeutic committee involvement, the role of our accrediting association in maintaining standards that complement our self care, and, not least, the personal world of the psychotherapist.

We will be introduced to Skovholt’s (2001) understanding of the Resilient Practitioner. By using the analogy of The Turtle’s underbelly we will learn how to take care of the “Self” which, he states, is our tool in our work much like the ballerina has to look after her tools – her legs, feet and ankles.

The psychotherapist in a session
In my past life as a medical secretary in a surgical practice I became aware of psychotherapists who become ill with cancer. Most particularly, I noticed that when these psychotherapists come out the far side of their illness or experience remission they set about changing their work pattern. Some of them look for a lighter client base, give up working as psychotherapists or diversify their skills into something else. They can also attempt to work less hours and they no longer want to spend their time travelling long distances to work. A further exploration of this phenomenon with colleagues tells me that it is not necessarily only the client content of the work that we need to protect ourselves from but additionally how we are supported in this work. Of course, the client content can have its effects on us. Whether the content is trauma or euphoric in nature the psychotherapist will have experienced what Wosket (1999) described as, “(compassion) being a higher order form of empathy and sympathy” feelings of “a sudden lump in throat, lurch in stomach, tears welling up, sensation of coldness, hotness, a heaviness or lightness, a sense of nausea or pain” With this mix of energies in the air, while the trauma of the client is being revealed, we find ourselves in the presence of secondary trauma – the psychotherapist’s. If we follow Jung’s thinking that “the doctor is effective only when he is affected” (Sedgewick 2000) we should be mindful that for a one hour session experiencing these levels of feelings we should give ourselves enough time to recover before beginning the next one hour session. ‘Trauma is part of a natural physiological process that simply has not been allowed to be completed’ (Levine 1997).

In this work the psychotherapist gets to hold the client in a hyperarousal state with transference of the client’s feeling. According to Herman (2001), “their (the client’s) life depends on keeping the psychotherapist under control”. At the same time the psychotherapist can feel de-skilled in the face of such trauma. Clients can displace their rage at the event on the psychotherapist in an “effort to reduce the therapist to the same unbearable condition of terror, helplessness and shame that they themselves have suffered” (Herman 2001). They can do this by becoming vulnerable in the session and then “act out” by missing the next session, at which time the psychotherapist can wonder what has happened. The psychotherapist can suffer feelings of lack of confidence in psychotherapy and ultimately herself. The psychotherapist may feel “guilty for causing the client to re-experience the trauma in the course of treatment” (Herman). Psychotherapists can also feel abandoned. This description of a session helps us understand, the impact this work can have on psychotherapists. The psychotherapist works with the clients at such a deep and connecting level that ‘we must make professional attachments with our ‘underside of the turtle’, the vulnerable, sensitive, feeling side… (Skovholt 2005).

The cost of caring
There is a risk that the more psychotherapists care about their clients the more they will work and as they become recognised the more work will come their way. This leads on to being respected in the work environment and will result in being asked to do more in the cause of psychotherapy in situations such as committees and positions of responsibility. The cost of caring for the psychotherapist in institutional settings is somewhat different from those working in private practice.

In institutional settings
While most psychotherapists working in an institutional setting are well taken care of there is the potential for psychotherapists to experience burnout. A psychotherapist taking on a new client worries, “Will I have enough time to complete all the paperwork and calls, let alone be of help to her?” In some cases the director of the institution will have come through the ranks of therapy training and perhaps have held a totally different position before their training. Now this psychotherapist is in the role of business organiser with all the constraints attached to this role. In the event of the “director” having no experience of therapy training psychotherapists have to contend with a business model while their way of working may be intuitively. When Winnicott (1990) talks about “The Facilitating Environment” we are looking for the outer layers of this meeting of the psychotherapist and the client to be supported by the institutions (i.e. work and accrediting body) otherwise there is fallout and illness. Take, for example, the leader of the HSE, Professor Brendan Drumm, who was recently interviewed on local radio. During the course of this “interview” Professor Drumm asked and answered the questions (27 in all) he wanted to deal with. Neither the interviewer nor her producer (in her ear) could access the Professor to answer their questions. It could be interpreted that they were de-skilled and indeed, if we understand the effects of a traumatised person, perhaps Prof. Drumm was feeling beleaguered by the recent events in his world. However, if the leader of this organisation is behaving like this then it must be asked how the workers within this environment are managed? As Rosenberg (2008) stated “psychotherapists working in an institute environment are far more likely to suffer burnout than those working privately”. Psychotherapists experience less autonomy while working within an institutional environment. I am reminded of some time ago when I was responding to a job advertisement for a psychotherapist within a crisis organisation. The job description stated that everything that happened had to be run by the “director” of the organisation. Immediately I got a stifling body experience as if someone had started to wrap a rope around me with my arms held down.

While working in an institutional environment the number of clients psychotherapists are expected to work with is decided for them. They may be asked to work within a certain number of sessions because of budget constraints. The work with the client can be terminated without a sense of completion experienced because of these constraints. Within these institutions psychotherapists will have a hierarchical structure in place with team leaders and head of departments. Will it be safe for the psychotherapist to express concerns for herself in this work?  If she states she has difficulties then will “they” think she cannot cope and is in some way unfit to do this work?  Additionally, what will they do for her if she speaks out?  When in burnout, we may get less done but take more time to do it. The talking we do about our feelings may become obsessive and pointless rather than helpful in working through to a solution.

In private practice
The psychotherapist working in private practice must guard against feeling isolated. The financial aspect of being self employed must be addressed i.e. suddenly becoming ill or the capacity to be able to take the much needed holiday. However, being self employed does give the psychotherapist autonomy in the work. She gets to choose her client base and the number of clients she will work with. And, to a greater extent, the hours she will work.

Let us now look at identifying the need to care for Self whether working in an institutional setting or in private practice.

Recognising the need to self-care
There are new “buzz words” around to describe when a psychotherapist is in trouble with the hazards of the profession of psychotherapy. I highlight three of these hazards below – Burnout: Compassion Fatigue: and Vicarious Trauma / Post Traumatic Stress Disorder (PTSD)

Burnout: This is “a subtle process, in which somebody is gradually caught in a state of mental fatigue, completely empty and drained of all energy”,(Volkskrant 1989 cited in Focus Ireland 2007) “… It can manifest itself as the “…chronic condition of perceived demands outweighing perceived resources” (Gentry & Baranowsky 1998 cited in Focus Ireland 2007). This phenomenon “…occurs when energy, involvement and effectivity erode into fatigue, cynicism and an inability to function productively” ((Maaslach & Leiter 1998 cited in Focus Ireland 2007)

Burnout can also come from various external sources, including the workplace and personal relationships. In conversation with a psychotherapist who suffered two episodes of “burnout” revealed that she had been in training and also devising training requirements, together with client work. This workload became too much for her and on a somatic level she suffered illness.

Compassion fatigue: This is described as “a state of physical, emotional and mental exhaustion caused by long term involvement in emotionally demanding situations” (Figley 1995 cited in Focus Ireland 2007). The phenomenon is caused by “a personal isolation, ambiguous successes and the emotional pain of remaining empathic” (Gentry et al 2004 cited in Focus Ireland 2007). For example, Ms A (personal communication, July 21, 2008) reported as traumatic the experience of working with a fellow psychotherapist who was training and also seeing an excessive amount of clients per week (30 in number). Ms A felt she had nowhere to go with her concerns and her stress while working within that environment. She took a career break as a way of self caring.

Vicarious traumatisation/PTSD:
This phenomenon is manifest when “…inner experience is negatively transformed through the empathic engagement with client’s trauma material” (Pearlman & Saakvitne 1995 cited in Focus Ireland 2007) In this instance the  “… person experiences PTSD symptoms as a direct result of exposure to traumatic material”. (cited in Focus Ireland 2007).

During 2001 I was very busy with a full time job in a surgical setting with a catchment of approx 3,000 patients, seeing clients, completing training and assignments when 9/11 struck in New York I remember I was due to meet with a friend that evening but had to telephone to cancel as “I had no words to say”. I felt that the impact of 9/11 was, for me, the vicarious traumatisation too much for me to cope with in the company of my friend.

Whatever labels the hazards of professional therapy are given, the psychotherapist needs to be watchful for any or all of the above phenomena. Symptoms of suffering from any of these conditions are subtle and indeed I wonder how the psychotherapist would know they are suffering. With the demands of managed care and other financial considerations, one’s values may conflict with the values of the work environment in the form of seeing the most clients possible in the least time and spending less time in training, supervision, and peer consultation. Due to time pressures in some settings, there can be a breakdown of the multi-disciplinary team-oriented approach.

Indicators for burn out or any of the previously mentioned conditions are described as withdrawing from friends and intimate relationships and withdrawing from intimacy. Family and friends report the psychotherapist as “distanced” in the emotional dealing within the family and this can be inferred as disinterest which can create difficulties within relationships.

While I was in training a statistic which was brandished about was that 33 per cent of those on the course would be separated by the end of training. This statistic was confirmed by some members of my training course.

The core of the helping professions, and the power of these career fields to reduce human suffering and increase human competence, is the one-way helping relationship, one person to another. Similar to a magnificent tree, the therapist takes in the carbon dioxide of the other and gives off oxygen. It is a life-giving event. And great work”.

Skovholt 2008

The care of self
It is difficult to implement self care strategies because during our training there is no module dealing with self care – indeed, we usually seek to implement the strategies after an experience of burnout. Of course, there is peer support and supervision but for the novice psychotherapist who is full of enthusiasm within the “one-way helping relationship” (Skovholt 2008), there is a need to maintain this contact following graduation. Finding the balance between client care and self care is probably the most important work the psychotherapist can do. Skovholt (2001) tells us about finding the balance between “other-care” and “self-care” in all our worlds’ i.e. our professional and personal life. He also reminds us that our “tool” in our work is the self much like the tennis player is his/her arm and the ballerina is her feet and legs. He nominates eleven Essential Resilient Practitioner Tasks together with a final imagery exercise which I will include in this article.

Essential resilient practitioner tasks
These tasks are:

1. Losing one’s innocence for the need to assertively develop resiliency and self-care skills
2. Developing ‘a gushing well’ of positive energy.
3. Relishing the Joy and meaning of the work as a positive energy source.
4. Searching for empathy balance.
5. Developing sustaining measures of success and satisfaction.
6. Creating a ‘greenhouse’ at work.
7. Finding your way with God or…
8. Knowing the danger of excessive one-way caring relationships in personal life.
9. Maxing out the body for energy/healthy living
10. Maintaining a long-term continual focus on the development of both the professional and personal self
11. Having fun and being playful.

For the consideration of the length of this article I will concentrate only on tasks 4, 6 and, my personal favorite, number 11.

Task 4. Searching for empathy balance
As we have seen above (The psychotherapist in a session), as psychotherapists we give our all in the session. One way of finding an empathy balance is to use a variety of different theorists while working with clients – different clients have different needs. Be well versed in other disciplines such as mythology, philosophy and religion, to name but a few. Seek support by peer consultations and supervision, this may seem like stating the obvious but in a situation like burnout we may close down our need for extra support. If we isolate ourselves then it may be difficult to reach out. Inform our family of the potential for burnout as they can often see this in us before we do.

Task 6. Creating a ‘greenhouse’ at work
Skovholt (2001) uses the analogy of a greenhouse where plants grow and thrive under ideal conditions. Sometimes great managers and directors can create a good “greenhouse” for the psychotherapist to work in. Unfortunately, this is not always so and we must create our own greenhouse. We do this by having good peer and supervisor support. Work should be a place where the psychotherapist can develop professionally and have a good balance in client base, report writing and other administrative duties required of them. There should be a sense of community in a job where people are caring for others to an extent. The need to have fun and work in a supportive atmosphere is, in my opinion, of paramount importance. This work is not manual so the constant use of the Self would need to be honoured. No less than the tools of any trade need to be taken care of in order to get longevity from them so too does the Self of the psychotherapist.

Task 11. Having fun and being playful
When we join our clients in their world, for the most part, it can be a painful and serious exercise. We all have a shadow side of ourselves and in this work the shadow side is play. For most of us we fear our Shadow side, it is after all the so called “not nice side of us”. But not in this work, to support us in this work I believe we must tap into our playful side. We do this by going to the theatre, taking up a hobby. Making sense of a detective programme on the television is also fun. I love to watch comedy programmes that reveal dysfunction in relationships and more and more I find myself watching Everybody loves Raymond and Frasier (American sitcoms). While watching these I am able to analyse another without having to be invested in them. Laughing out loud is such a basic but rewarding exercise which I do when I read Ferret and Mole in this journal! The list of play is endless – what would be on your list?

Our accrediting association also has a crucial part to play in maintaining the “health and safety” (buzzwords) of the psychotherapist. Here we will look briefly at the role of our accrediting association.

Care of the psychotherapist by the accrediting association
Our association was established with responsibility towards our clients and the public in general in mind. However, I believe that the association also has a duty of care to the psychotherapist. In order for Winnicott’s (1990) “facilitating environment” to function safely and effectively it must have the support of the association. While recognising that we have a code of Ethics and Practice in relation to our clients and the public at large perhaps the time has come for our associations to have a code of Ethics and Practice in relation to its members. If we had such a code it should take the form of “safe practices” in this work. In conversation with some of my colleagues and indeed if we look at the letter from Paddy Logan (2008) in the last issue of Inside Out regarding continued professional development (CPD) his questions are most timely and urgently need to be addressed. We need to approach our CPD requirements in a collective and consultative fashion drawing experience from other associations. A typical requirement of the psychotherapist who is a long time in this profession is that they will be in the role of psychotherapist, trainer, supervisor, client, supervisee, parent, partner, friend, son/daughter, neighbor to name but a few. To work in these first five roles we are constantly learning, as Casement (1999) described in his books of Learning from…. Fulfilling unrealistic criteria in a small country as Ireland where the busy psychotherapist must find extra weekends (outside of their training weekends) to do mandatory workshops at which time they risk meeting their clients/supervisees, there must be a facility where we can meet and learn from each other without it: (a) costing: (b) risking meeting clients etc. Learning can even be a time of fun!

The Ballerina gets time to “put up their feet” The psychotherapist must have time to play – anyone for tennis?

I know I promised you the Thomas Skovholt’s (2001) Resilient Practitioner Imagery Exercise here it is:

Imagine looking ahead and seeing your favorite tree. I suggest you visualize it as vibrant, very healthy, strong and beautiful. The health of the tree permits it to take in enormous amounts of carbon dioxide and give off reams of life giving oxygen. Just like you and others in the helping professions. To give its gift of oxygen, the tree must be nurtured. Just like you. The tree must have lots of sunlight, plenty of rain and rich soil. Just like you. The tree must ward off big pests that may suddenly appear and eat its leaves. It must also defend itself against stealth pests, those little ones that are very difficult to see. Imagine what happens to the tree without sun, without rain, without rich soil. It is not a pretty picture. Without nurturance, the tree shrivels up and, in time, can no longer take in toxic carbon dioxide and give off oxygen. Its valuable place in our world is lost. No longer can it nurture human life by taking in carbon dioxide.

Conclusion
The psychotherapist is a unique individual who uses him/her self to do their work. S/he does not need to carry any tools with them as they go about their profession. The psychotherapist in training has never been taught the skill of self care but usually ends up having to learn it when it is almost too late. I believe there is a real need for a self care module to be implemented in the training of the psychotherapist.

The psychotherapist should make use of peer support as an extra mechanism in this work. While researching for this article I came upon Skovholt’s (2001) book which I ordered it online.  However, it took quite a time for me to receive it and in the end I emailed Dr Skovholt for help in the form of perhaps a paper on his work.  Instead, he stepped up and forwarded me an entire chapter from the book, together with work not yet published. Now, that is what I call peer support.

Another element of self care is the necessity for Playfulness in the psychotherapist. This play can come in many guises but however it comes, play is essential for the psychotherapist to stay vital in the work.  Play can take place even in the most difficult of circumstances i.e. at stressful committee meetings it really is possible to do strict work and get a balance of play.  Self care in forms of alternative therapeutic supports is very necessary for the wellbeing of the psychotherapist.  Also necessary for a healthy balance, the psychotherapist needs to broaden his/her social contacts outside of the therapeutic world.

We must remember the role of the associations, most particularly, as we move towards statutory regulation. It is timely that we address the area of self care in the profession with, what we do best, i.e. a humanistic and common sense approach. I believe we have a unique opportunity to fix this in place as we go forward as a service provider. As Shakespeare advised in Hamlet: “To thine own self be true”

Ursula Somerville is a psychotherapist and clinical supervisor.

References
Casement, P. (1999) On Learning from the Patient. London: Tavistock/Routledge.

Focus Ireland (2007) Occupational Health Training Manual. Retrieved from http://www.agpa.org/feeling%20burned%20out.htm.

Jung, C. G. (1995) Memories, Dreams, Reflections. London: Fontana Press

Levine, P. (1997) Waking the Tiger: Healing Trauma. Berkeley, CA: North Atlantic Books.

Logan, P. (2008) Letter to the Editors Inside Out, 56.

Rosenberg, T. (2008) Burnout among mental health professionals: special considerations for marriage and family therapist / hppt://findarticles.com/p/articles/mi_qa3658/is_200601/ai_n17180779/print?tag=artB 6.7.2008

Sedgewick, D. (2000) The Wounded Healer Countertransference from a Jungian Perspective. Sussex: Brunner Routledge

Skovholt, T.M. (2001) The Resilient Practitioner: Burnout prevention and self-care strategies. Boston: Allyn & Bacon

Skovholt, T.M. (2005). The cycle of caring: A model of expertise in the helping professions. Journal of Mental Health Counseling, 27, 82-93

Skovholt, T.M. (2008) Becoming a therapist: On the Path to Mastery New York: John Wiley & Sons.

Skovholt T.M. (2008) Two Versions of Erosion in the Helping Professions: Meaning Burnout and Caring Burnout. Personal communication received 9^th December 2008.

Winnicott D.W. (1990) The Maturational Processes and the Facilitating Environment. London: Karnac.

Wosket, V. (1999) The Therapeutic Use of Self Counselling Practice Research and supervision. New York: Routledge