If you are a mental health professional (e.g. social worker, MFT, counselor, intern), please read my article in the September/October 2016 edition of Family Therapy Magazine about the importance of establishing self-care practices early on in your career. It is never too late to begin!
"The Resilient Therapist: A Form of Best Practice"
By Ariella Cook-Shonkoff, LMFT, ATR
To be in the "helping" profession is not for the faint-of-heart. It requires compassion, patience, presence, flexibility, intuitive trust, and resilience from the practitioner. It is true that we, as therapists, have the potential to impact our clients, but let us not forget that our clients significantly impact us. As therapists, we are in positions of authority, but at the end of the day, we are all human beings and we touch each other in unexpected ways. To be a therapist is both a challenging and a humbling job and it teaches volumes about life.
As one who has served on the front lines of the public mental health field, I feel protective of interns and believe that as committed as we are to other aspects of our work, it is just as important for us to commit to taking care of ourselves.
The Potential for Burnout
If we do not adequately take care of and monitor ourselves, we put ourselves at greater risk for burnout and other consequences (poor health, vicarious trauma). Burnout can be defined as experiencing any or all of the following: 1) emotional exhaustion, 2) cynicism towards clients and/or work, and 3) negative self-evaluation (Morse, Salyers, Rollins, Monroe-DeVita, & Pfahler, 2014). When we, or our colleagues, experience symptoms of burnout, it is time to refrain from judgment and offer support.
Burnout likely occurs at a higher rate than we are even aware of; it is underreported due to ignorance, denial, shame, and stigma. There are various reasons for burnout in this profession, as well as plenty of ways to re-establish our sense of equilibrium. Just consider the many difficult emotions that we field from our clients over the course of a day: anger, despair, loneliness, self-hatred, anxiety, and grief, to name a few. Even with the best effort to maintain good boundaries and good self-care practices, these emotions can be unconsciously metabolized by our systems.
The prominent trauma researcher Bessel van der Kolk (2014) describes
how humans and other mammals are innately wired to respond to others.
He writes: “Our mirror neurons . . .make us vulnerable to others’ negativity,
so that we respond to their anger with fury or are dragged down by
their depression...Treatment needs to reactivate the capacity to safely mirror, and be mirrored, by others, but also to resist being hijacked by others’ negative emotions” (p. 59). Therapists are not immune to the dynamics of human social interactions. We possess tools for managing our work, but we still have the potential to be deeply impacted by our clients. Our profession asks us to walk a fine line by responding to clients with empathy, while not over-empathizing, as this can undermine our objectivity and effectiveness. For many of us, this is a growth edge, which requires careful monitoring over the course of a career.
The Challenge of Working in this Field
Interns and trainees are particularly vulnerable because they enter this field leading with their hearts and with so much to give, but also with so much to learn. The learning curve is steep and sometimes deeply personal and there is continual on-the-job-training. In order to remain effective and balanced as therapists, it is critical to manage stress and explore the impact that the work has on us.
The following are three examples of stressful scenarios that I encountered as an intern. I am sure that many of you have experienced similarly stressful situations. I share these to help illustrate the intense nature of the work that we do, why the potential for burnout exists, and why self-care practices are critical to establish early on in our careers.
Scenario A: While dealing with a stressful situation in my personal life, I receive a “goodbye” text from a client thanking me for my help, but acknowledging that
her pain is too great to bear any longer. I take some deep breaths, put my personal drama on hold and contact my client to ensure her safety.
Scenario B: After arriving at my agency one morning, I receive the following message via email: “The campus is on lockdown because there is an unidentified man with a gun walking around. The police have been contacted. Please do not leave your building.” I later discover that the man was looking for my client, who was shaken up, to say the least.
Scenario C: “I am sorry to be the one to tell you this,” the social worker says, “but your client broke into a woman’s house during the night and viciously attacked her. The woman will be disfigured for life and your client is in jail.”
These scenarios represent a small sampling of some of the more intense situations that I encountered during my five years working as an intern. The truth is that, although classified as “interns” and paid meagerly for their services, interns often bear the brunt of working with some of the most challenging populations with the fewest resources, highest rates of trauma, and greatest psychological needs. Some of their clients face incredible odds as they are mired in multi-systemic issues such as: poverty, racism, violence, abuse, homelessness, immigration, and addiction. At times, it can feel as though they are troops deployed in community battlefields—working in the front lines and bumping up against societal forces that are larger than they are.
The community mental health sector has notoriously high caseloads, high billing expectations, and extensive documentation procedures, so self-care does not always seem realistic. Agencies and graduate programs have an ethical responsibility to promote the importance of good self-care measures, but there is high variability and no guarantees. At the end of the day, we therapists must assume responsibility for how we incorporate it into our work.
The Challenge of Self-Care
Part of the intern’s task is to establish and maintain a self-care practice as early on as possible. The “airplane metaphor” that is often used suggests that you
have to put on your own oxygen mask before you can help somebody else. If we view self-care through this lens, we can understand its function as not only self- protective, but as protective of others,
as well. By exercising good self-care, we can be more present with clients and
be our best “therapist selves”—which is something that our clients deserve.
Self-care is not always as easy as it sounds. At the start of the day, you might envision doing something nice for yourself after work—like meet with a friend or exercise or take a bubble bath. By the end of the day, however, you may feel as though the only thing that you can do is vegetate on the couch with Netflix and a bowl of ice cream. So much for your lofty self-care goals! Providing space to “unpack” the day can help your mind sort and let go of any unfinished business, which supports a good night’s sleep and bolsters emotional resilience.
Self-care practices take time to establish and, like a garden, must be continually watered and maintained. Inevitably, you will be tested in some way, much like I was during the difficult scenarios described earlier. Here are 5 ways that you can practice self-care and increase your resilience as an intern:
1. Seek out quality individual and group supervision
As with therapy, which acknowledges that not all therapists are suitable for
all clients, so it is also true with the supervisor/supervisee relationship. There are many different styles of supervision and it is possible that you just do not resonate with a supervisor for some reason. What suits a process- minded, client-centered therapist might not suit a directive, cognitive-behavioral therapist.
It is also possible for you to be matched with a supervisor who has not yet developed the skillset to be effective in her or his role, does not particularly relish the role, or is distracted by workplace politics or other duties. I encourage you to seek out the best possible supervision, to value it highly during your job search, and to advocate for yourself as needed, because supervision is truly the bedrock of learning. It is not always possible to change supervisors, but it is always worth a try!
2. Establish healthy professional boundaries for yourself
Our profession is only one aspect of our lives. At times, work stress can feel overwhelming and threaten our work- life balance. It can be useful to establish healthy boundaries for yourself outside of work so that you do not have to feel like you are constantly “on” when you are, in fact, off-duty. Boundaries will help you separate from your clients’ problems. You might consider devising some guidelines for yourself, such as: turning off your phone at a certain time each day, designating one room at home for work, setting boundaries around the type of work that you do at home (such as, only email or emergency phone calls), or perhaps not working from home at all.
Inevitably, you will work with clients who tug at your heartstrings or trigger strong countertransference or who appeal to you directly for more help. You may feel compelled to help in any way you can. Be wary of getting “pulled in” and overextending yourself (whether it be your services, time, or emotional involvement). This is a natural reaction, but it is not usually in your best interest. Maintaining awareness of your different responses to clients and attending good quality supervision will support healthy boundaries.
3. Develop and maintain strong self-care practices
I often found that it was the small, but intentional rituals that made the biggest difference. Here are some examples you can try:
· Meditate in the car for 5-10 minutes every morning before entering the office
· Listen to music that complements your mood (be intentional rather than going on auto-pilot)
· Use a hand-washing ritual after sessions and imagine washing away all of the emotional “muck” to help you let it go
· Place a special object on the dashboard of your car as a psychological anchor; something that makes you laugh or smile
· Color in mandalas or write in a journal after intense client sessions to help process countertransference
· Create a cozy space for yourself and drink a cup of tea while making a difficult phone call
· Practice self-care during group supervision whenever possible— drawing, stretching, knitting
These types of practices may feel contrived at the beginning, but will gradually become part of your routine.
4. Help foster a self-care culture at your workplace
Agencies approach self-care in different ways. Some have developed agency-wide events to promote self-care, while others rely on program managers to integrate it. If you notice that you or your colleagues are showing signs of burnout, it could be a good idea to talk to your supervisor. A good supervisor will not reprimand you for it, but will help support you and your team by finding ways to address it.
Similarly, if you are concerned about the self-care culture in your program, you can speak with HR and express your concerns. You may be able to share such information anonymously (although different agencies have different policies, so it is helpful to clarify this beforehand). At one of my programs, I advocated for our staff to move into a different room in our office because the room in which we worked was dark, windowless, and overcrowded. My program manager brought this to the administration and we were able to move into a more spacious room with windows. This had a positive impact on workplace morale. When we, as interns, do not feel safe or welcome to discuss self-care or burnout, it is a missed opportunity to seek support and to positively impact our workplace cultures.
5. Stay positive and trust that other options do exist
It may feel as though the easiest thing to do is to stay “stuck” in a job, but if your needs are not being met, rest assured that there are other jobs out there! At times, you may feel so hopeless, confused, or overwhelmed that it clouds your perspective and your optimism. The truth is that if your workplace does not feel like a good fit, you can move on and try to find a program that is more aligned with your needs and interests or offers the support that you are seeking. While “agency-hopping” is not a cure for burnout and is problematic on many levels, it is fine to explore your options and make an informed decision. When I was feeling “stuck” at one job and began interviewing at other agencies, it was a tremendous confidence boost to suddenly have other offers on the table. It helped me recognize my own self- worth and feel valued at a time when I was approaching burnout. When you are so engrossed with accruing hours or busy with work details, you can forget that you do have agency as an intern.
As many of us can attest, working in this field can feel rewarding, inspiring, productive, and transformative. On the other hand, life as an MFT intern is not always easy. We may be financially strapped, working with high-needs clients, or caught in the web of workplace politics. At times, we may experience stress, burnout, vicarious trauma, or compassion fatigue. It is important to de-stigmatize these responses so that it feels safe to discuss them with our colleagues.
Another therapist once told me, “Burnout is the soul crying out for help.” I appreciated hearing this because what it meant to me was that my inner flame—my passion for the work—had not been extinguished. Like a fire, it just needed some tending to, as well as some compassion and intention. Burnout does not have to be viewed as the end of your career or as failure. It can and it should be reframed as an invitation, a wake-up call, an exercise in resilience, a time to reorient, and an opportunity to reinvigorate your passion for the work. Establishing self-care practices as soon as possible only helps to sustain the work that we do. It is never too late to begin.
Ariella Cook- Shonkoff, MA, LMFT, ATR, Pre-Clinical Fellow of AAMFT, is a licensed staff therapist at Child Therapy Institute and recently launched her private practice in Oakland, CA. She meets with adults, teens, and children in her practice, and provides support and guidance to interns and trainees. In 2017, she plans to facilitate focused art therapy groups, some of which will be geared towards mothers, young adults, and teens. Info+Blog: www. ariellacookshonkoff.com
Morse, G., Salyers, M. P., Rollins, A., Monroe-DeVita, M., Pfahler, C. (2012). Burnout in mental health services: A review of the problem and its remediation. Administration and Policy in Mental Health and Mental Health Services Research, 39(5), 341–352. doi:10.1007/s10488-011-0352-1
van der Kolk, B. (2014). The body keeps the score. New York: Penguin Books.