by Sonya Murray
Recently I had a long conversation with a counsellor friend who is burnt out, and persuaded them to do the Beck Depression Inventory (Beck et al., 1996) for themselves prior to going to their GP. I was concerned that they did not recognise just how low they really were and hoped that completing the questionnaire, and getting a score, might help this person recognise their need for help. Their score indicated depression – in the moderate to severe range. I decided out of interest to do it myself. My score was zero! Five years ago I scored 28. The inventory contains 21 questions, each answer being scored on a scale value of zero to three. Higher total scores indicate more severe depressive symptoms; a score of 20-28 indicates moderate depression, while 29 and above is indicative of severe depression. So how did I get to that point?
It all started with a mild tummy bug. I hadn’t been sleeping well. I woke early and decided to phone in sick. I remember deliberately phoning before the office opened so that I wouldn’t have to actually speak to anyone. I knew I was physically fit to go into work but I simply couldn’t face another day. I spent the following two days lying under the duvet contemplating methods of suicide that would cause my family and friends the least inconvenience (such a polite word). It’s a tricky conundrum. As an experienced psychotherapist, I was pretty familiar with the most, and least, successful means to complete suicide. I worked with adult survivors of childhood abuse and many of my clients over the years would have contemplated or attempted suicide prior to – and occasionally during – their therapy. I became obsessed with the story of Petruska Clarkson, a well-known Gestalt therapist and author, who in 2006 was found in a hotel room in Amsterdam having left a lengthy letter of explanation before taking her own life. I only came across the letter she had written on the internet fairly recently. She clearly laid out her reasons and appeared not to be in deep personal pain. She was well known for her writings on the importance of the therapeutic relationship, positing the concept of ‘the good enough other’ (Clarkson, 1995). I thought about the impact my suicide would have on my family, clients and my colleagues, and felt enormous guilt. I definitely did not see myself as a ‘good enough other’ at that point. I lay in this bizarre reverie; I even contemplated going to Amsterdam as Petruska Clarkson had done. Eventually I realised I had to go to the GP because my work required a medical certificate after three days off, and I still hadn’t figured out a satisfactory method by which to complete suicide. Having made an appointment that day, I sat up in bed and thought, ‘I should do the Beck Depression inventory on my laptop’.
I went to the GP and there in front of me was a young trainee about the same age as my daughter. I thought to myself: ‘How could I possibly talk about this to someone so young and inexperienced?’ But strangely, it was somehow easier than talking to my own GP who was nearer my age. I felt she was unlikely to question me too closely or try to look after me in any way. She gave me two weeks off and tried to prescribe antidepressants. I refused the prescription, but I gladly took the medical certificate. I have never taken antidepressants and deep down I believe part of me was actually only buying time; I hadn’t completely let go of the possibility of completing suicide. I then had to pluck up the courage to ring the office and have them cancel my clients.
It’s hard to describe the mixture of shame, guilt and relief I felt in that moment. I was overwhelmed with relief that someone, even if she was only a youngster, had affirmed that I was ill and not fit for work. However, I dreaded telling my line manager; dreading the judgement, the questioning, the need to give an explanation when I couldn’t find words inside my own head. I felt intense shame. I thought: ‘Why has this happened to me? I’m an experienced psychotherapist. I should have seen the signs coming. It feels so unethical to let my clients down in such a sudden fashion’. The stigma felt unbearable.
Nobody heard him, the dead man,
But still he lay moaning:
I was much further out than you thought
And not waving but drowning.
Looking back, I can see that I had been showing signs of burnout for some months. I remember feeling the suffocating weight of some of my clients, and the immense relief when these clients cancelled. Childhood abuse requires lengthy and deep therapy. Often clients are not sufficiently resourced in their present lives to address the past. For some clients the one hour a week they spent with me was the only support or intimate human contact they had. The image that comes to mind is of the lifesaver who jumps into the water to rescue a swimmer in trouble, only to find themselves pulled down and in danger of drowning. Previously I had found no difficulty in leaving my clients at work and had adopted little rituals to separate work from home time. I didn’t feel able to do more than hint at my struggle to anyone because of my intense guilt and shame at failing my clients.
In supervision, we talked about how heavy my current caseload was; however I could never admit I was drowning under that weight. I dreaded Monday mornings, unless I was attending a team meeting where I could fake it because I was just so relieved not to be alone in a room with my clients. The frequency of team meetings had been cut because of economic restrictions on travel. I would ‘forget’ team conference calls – I hated the disembodied voices. I took TOIL (time off in lieu) mornings off, ‘forgetting’ I had a client. I became increasingly isolated and felt alienated from my colleagues. It seemed to me they were coping with the same demands and I judged myself as less able in comparison. Obviously, my cognitions were seriously distorted but we psychotherapists are tricky; we know too much and can fake ‘wellness’.
At weekends, when I was alone and not with family, I was self-medicating with alcohol. I would tell myself that if I didn’t drink the nights before I had clients, I was still able to function.
I remember sitting with a female client who was struggling with her own self-medication to cope with her childhood abuse, having the thought ‘Jesus, I’m drinking more units than her!’ I wasn’t sleeping properly and had to have the radio on all the time to drown out my thoughts and intrusive images at night. I was intensely lonely and was isolating myself from friends as the effort of pretence became harder.
In the end, it all came crashing down rather suddenly, as is often the case with the onset of vicarious trauma. Listening to the pain of the worst things that human beings can do to other small vulnerable human beings on a daily basis for over 10 years finally overwhelmed me. Just as my clients felt overwhelmed by their experience at times, I too couldn’t bear the pain any longer. I shut down, numbed out, dissociated, self-medicated and did all the other things clients sometimes do to cope. The thing is, I knew about vicarious trauma. I had come across Christine Courtois talking about it being a case of ‘not if, but when’ for those working exclusively in the field of complex trauma (Courtois & Ford, 2009).
Others in my team and in the service had worked for a longer time with this client group. I remember in my postgraduate psychotherapy training, a trainer talked about how our psyches are like sheer rock with tiny fissures that absorb moisture. When the water freezes, those fissures get larger with the passing of each winter. Somehow this imagery really stayed with me over the years. Like many in our profession, I was drawn to this work as a ‘wounded healer’; a phrase coined originally by C.G. Jung but now commonly used. Jung stated that:
…a good half of every treatment that probes at all deeply consists in the doctor’s examining himself…it is his own hurt that gives a measure of his power to heal. This and nothing else, is the meaning of the Greek myth of the wounded physician.
(Stevens, 1994: 110)
One study found that 73% of counsellors and psychotherapists had experienced one or more wounding experience, leading to their career choice (Barr, 2006). I had had a number of years in private practice with a more generic caseload. I felt confident that I had done plenty of personal therapy and periodically re-engaged with therapy over the years. I participated in regular exercise and had a mindfulness practice for self-care. I had personal stresses and losses in the years leading up to my becoming ill, but so had others. The most recent event was my mother dying in the middle of the previous year. She had suffered from Parkinson’s for many years, and most winters we were surprised when she survived. However, her death came unexpectedly in the summer. My mother and I were not close, but we had healed what had been a distant and difficult relationship in the years leading to her death. I was coming to terms with the fact that her death meant she would never magically be the mother I had longed for.
I rested and slept and eventually had to go back to the GP to get another medical certificate. I went back to my old therapist who knew me and who was very experienced. I was honest with her about my suicidal ideation. I asked for a referral to an occupational health physician. and that was when my recovery really began. I was referred to a very experienced occupational health GP nearer in age to me. I was aware that if I was to get the support I needed, I had to be honest with her about my suicidal ideation. This was very hard as I was worried about confidentiality and whether this would be on my employee records, which was worrying especially given my profession. I felt held and validated for the first time. She named it: vicarious trauma. She talked in terms of my needing months not weeks to recover and suddenly I could relax a little. I felt I had space and holding.
I spent my days doing very little. Some days a walk on the beach was as much as I could achieve. I spent lots of time with my little grandson. I couldn’t think about work without feeling anxious and nauseous. My employers have a policy whereby managers are supposed to ‘check in’ with employees on sick leave. I used to tremble and feel nauseous when I would see the telephone number coming up and never picked up the phone. I would eventually compose myself a day or two later and call. I did a couple of weeks on the Camino de Santiago which was enormously healing. After four months, I still couldn’t bear to think about work and couldn’t visualise ever being able to work as a psychotherapist again. I had lost all confidence in my skills and trust in my ability. I knew my sick pay was running out, but still couldn’t bear to return. Luckily, I had some savings which were the result of a small inheritance from my mother. I appreciated the symbolism of her looking after me from beyond the grave in a way she hadn’t always been able to when I was younger.
During this time the occupational health physician was a rock of practical support. It was she who said that I couldn’t possibly consider returning full time to my previous role. She stated bluntly that she felt I would be ill again very quickly. However, she helped me see that it wasn’t an all-or-nothing scenario. We explored – and we pursued – other possible options whereby I could use my skills in a different role.
Eventually, through luck and some persistent fighting on my part, I was able to negotiate a part-time change of role. I returned to work on a phased basis after about nine months, with a much-reduced caseload in my main job and a new part-time role in employee support.
I am now back at work a few years and love my job again. I enjoy going to work and can envisage myself doing this job long past retirement age. I was lucky that I had the opportunity to re-engage with most of my long-term clients, and work on the task of healing the ruptured relationships. I was able to sit with their concerns, disappointments and sometimes anger, working carefully towards a planned ending.
In my new role, most of the work is short term with a much more resilient and resourced client group. There is huge variety in the issues presented. One of the biggest differences is that most clients recover fairly quickly, so that most weeks at least one person is saying ‘Thanks. I’m finished now. I no longer need the service’. Consequently, there is a greater sense of satisfaction in seeing ‘results’. I still work with trauma but most arises from a single incident (for example, an assault) and is not complex PTSD. However, from time to time I encounter staff when they are burnt out or possibly experiencing vicarious trauma and I am now the one who ‘names it’ for them, giving them permission to acknowledge just how awful they are feeling.
This is not intended to be an academic piece about vicarious trauma and others are more qualified than I to write such a piece; I am an expert by experience. My motive is to open up some discussion on this issue by being prepared to be vulnerable myself. I have, however, done a bit of reading on the subject and find it surprising how relatively little has been written about the psychotherapist’s own experience. What I would like to see is more honesty and openness amongst our profession, perhaps creating a culture which removes the sense of shame and failure that I (and others) have felt.
Unlike burnout, countertransference, or work-related stress, vicarious trauma is specific to trauma workers. This means that the helper will experience trauma-specific difficulties – such as intrusive imagery – that are not part of burnout or countertransference (Courtois & Ford, 2009). It seems we cannot accurately predict who amongst us is more likely than others to experience it given a similar caseload (Bride, 2004). There is some evidence that helpers who have experienced early childhood trauma themselves may be more vulnerable but as I understand it, this is not conclusive: “Being traumatised by another’s trauma may well be a universal propensity, having its origin in infancy” (Halasz, 2018).
Let us consider Allan Schore’s important work on right brain to right brain communication in affect regulation theory. Here he describes the therapeutic exchange:
This dialogue of ultrarapid bodily based affective communications in patient-therapist (and infant-mother) attachment transactions occurs beneath levels of conscious awareness in both members of the dyad
I have a keen amateur interest in the field of neuroscience and in particular the research around compassion versus empathy. The work of Singer and Klimecki (2014) demonstrates that empathy activates a different part of the brain than compassion. They posit that holding a compassionate stance leads to less burnout and that we should talk about ‘empathy fatigue’ rather than ‘compassion fatigue’ (Singer & Klimecki, 2014).
Empathy is defined as the capacity to understand or feel what another person is experiencing from within their frame of reference
Neuroscientific studies demonstrate that mirror neurons in our brain explain the basic processes of empathy (Keysers, 2012). My own little theory is that those of us who have experienced early childhood trauma have our mirror neurons more activated when engaged in a therapeutic relationship with clients who have had a similar background to us. An interesting angle of research might be to look at the ACE (Adverse Childhood Experiences) scores of psychotherapists and compare this to rates of burnout and vicarious traumatisation.
Innoculation or prevention
So, if vicarious traumatisation is a known risk factor for psychotherapists working with clients with complex Post Traumatic Stress Disorder (PTSD) then how do we inoculate and prepare people? I am not familiar these days with the content of counselling/therapy training courses but I would suggest that psychoeducation about this issue should be included if it isn’t already. I believe there should be much less emphasis on empathy and more on compassion training.
I realise that I was fortunate in working for an organisation where I had paid sick leave, and there was a structure in place for holding my clients. The majority of counsellors are in private practice and I believe that this places a huge onus on clinical supervisors to support and monitor for signs of burnout and/or vicarious traumatisation in their supervisees. Just as our clients may have no idea when they come into therapy that their symptoms might be connected to PTSD, it is often very difficult for supervisees to be aware of their own traumatisation.
I believe that organisations need to pay greater attention to the types and range of cases being handled at any one time. A caseload exclusively dealing with complex trauma will inevitably increase the risk to therapists. Managers and supervisors need to pay attention to simple issues like reducing caseloads during times of personal stress. As well as individual clinical supervision, I believe that facilitated group supervision should also be included as peer support can be very important in helping therapists feel less isolated in the work.
In preparing for this article, I searched for guidelines around the prevention and management of vicarious traumatisation. I found relatively little for psychotherapists. The best and most comprehensive were written for researchers in the field of sexual violence in Australia and South Africa. I couldn’t find anything from the NHS or the HSE. I believe that organisations like the HSE, which is the largest single employer of workers in the field of mental health in all categories, need to develop policies and guidelines for managers on identifying and supporting staff who have – or may be at risk of – vicarious traumatisation and/or burnout. I believe it is an occupational health and safety issue.
Working exclusively with people who have experienced trauma in their lives requires us to be constantly operating at the edge of our capacity as psychotherapists. We need to be like top flight athletes delivering our optimum performance with no injuries to impede us and yet we are ordinary humans with cracks and fissures in our psyches.
There was a multiplicity of factors at play in my own experience, both individual and organisational. Living in a rural area, I had a very long commute to work which was draining. I had asked for some change in working arrangements to alleviate this but was refused. Due to cutbacks our team meetings were reduced from fortnightly to monthly, which meant that if you happened to be sick or on holiday, it could be two months between meetings. Waiting lists were ridiculously long with no prospect of change, and because I dealt with most referrals directly, often by phone, I felt a personal connection to those people. Furthermore, all travel to meetings and outside trainings was cut. I operated in a setting where I was a lone worker. So although I theoretically worked in a team, I was disconnected from my colleagues. In researching this article and re-reading the work of Allan Schore, I have come to understand a little more about my own process. Schore theorises that a reaction to early trauma in the infant is dissociation, which can become a lifetime response in the face of pain and overwhelm. I was separated from my mother at birth for a period of two months and no doubt experienced this as traumatic; so perhaps the death of my mother had activated a very old deeply buried traumatic wound from which I dissociated and which disabled normal attachment-seeking behaviours such as asking for help.
Today things are very different. One of the first things I did on my return to work was to refuse to deal with the waiting list and I no longer take referrals directly. I am extremely rigid about the number of trauma clients I see. In the past because I felt the pressure of the waiting list, I would squeeze extra people in, sometimes taking a new person on while finishing with another. My workload is very varied. I now work mostly using a Sensorimotor approach to trauma which ensures I hear less of the story, among other things. In my personal life I’ve undertaken more body-oriented trauma therapy and I’ve made a number of changes to ensure I’m less isolated, such as taking up singing and cold water swimming – all of which do wonders for my mental health! Of course, the year-round sea swimming does cause people to question my sanity!
Your doctor must have a broken leg to doctor.
Your defects are the ways that glory gets manifested
Whoever sees clearly what is diseased in himself
Begins to gallop on the way.
There is nothing worse than thinking you are well enough.
More than anything, self complacency
Blocks the workmanship…….
Don’t turn your head. Keep looking at
the bandaged place.
That’s where the light enters you.
(Rumi & Barks, 1995)
Sonya Murray is a mother, grandmother, trauma survivor, good enough psychotherapist and wild swimmer, currently living and practising in the west of Ireland. She can be contacted by email: firstname.lastname@example.org
Barr, A. (2006). An investigation into the extent to which psychological wounds inspire counselors and psychotherapists to become healers, the significance of these wounds on their career choices, the causes of these wounds and the overall significance of demographic factors. Retrieved 22 January 2018 from: http://www.thegreenrooms.net/ wounded-healer/
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