Cover Story

Michael Mahoney, PhD, is well-known for his workshops that encourage fellow psychotherapists to learn techniques for relaxation and self-care. Yet three years ago, the veteran psychotherapy researcher and clinician found himself in a hospital room being treated for fatigue and pneumonia--the result of a harrowing schedule of travel, lectures and clinical work.

Sneaking in a phone call despite hospital protocol, "I remember retrieving a message from friends who heard where I was," Mahoney recalls. "They said, 'You can't die! We need you to remind us to take care of ourselves!'"

It's an irony many practicing psychologists are all too familiar with: They promote self-care to their clients, but put their own needs on the shelf.

"We all know we need to sleep well at night, eat nutritious foods, get plenty of exercise and do something joyful and fun," says Anne Pratt, PhD, of the Traumatic Stress Institute in South Windsor, Conn., and a member of the APA Board of Professional Affairs' Advisory Committee on Colleague Assistance, or ACCA. "But we're some of the worst at actually following through on it."

Fortunately, ACCA members and others are discussing ways to normalize the experience of stress by making self-care a regular part of one's life. And while there's no national study on how many clinical training programs are addressing these issues in their coursework, self-care has become a more important topic on campuses.

"The bottom line is, we need to be in optimal functioning form because our self is the instrument we draw on to do our work," says Ellen Baker, PhD, a Washington, D.C.-based private practitioner and author of the upcoming APA book, "Caring for Ourselves: A Therapist's Guide to Personal and Professional Well-Being." "Unless we take care of ourselves, we won't be able to take good care of our clients, our families or our loved ones."

Psychologists' occupational hazards

The well-known risk factor for practicing psychologists' work is their natural tendency to absorb clients' pain and carry it with them--a concept variously referred to as "vicarious traumatization," "compassion fatigue" and "secondary post-traumatic stress disorder (PTSD)."

"The result of empathically connecting with someone who's experiencing an emotional roller-coaster is, to some extent, to experience those emotions oneself," says Pratt, who counsels survivors of child abuse, war veterans and others who have experienced severe trauma. "This isn't something clients inflict on us or that happens to us because we're bad therapists. It's a normal, inevitable result of doing this work."

The danger lies in not acknowledging how the work can affect you, Pratt adds. Psychologists who work with trauma survivors commonly experience PTSD-like symptoms themselves, including:

  • Withdrawal from family and friends.

  • Emotional numbing orhyperalertness.

  • A loss of interest in everyday pleasures.

  • A preoccupation with clients' problems.

  • Physical symptoms, such as headaches, muscle tension and back problems.

  • Insomnia.

  • Disruptions in sexual function, particularly if one is working with rape victims or child-abuse survivors.

Other factors that can escalate psychologists' occupational stress levels include the time pressures of managed care, having young children, working in isolation, juggling many high-level roles, and being part of a professionally competitive field, says ACCA Chair Michael O'Connor, PhD, a clinical assistant professor in Stanford University's School of Medicine and a private practitioner in Palo Alto, Calif. "There's quite a bit of pressure on psychologists to walk the walk, to be a competent person who doesn't have problems and who has the answers," he says.

Intersecting with these factors, O'Connor adds, are personal psychological variables that can impact how psychologists react to job stress. A 1981 study by Gary R. Racusin, PhD, and colleagues, for example, found that half of the psychotherapists studied came from alcoholic or physically abusive homes, while a 1993 study by Diana Elliot, PhD, and James Guy, PhD, found higher rates of childhood trauma in female mental health professionals than in controls, O'Connor notes in a summary article on professional distress in the August 2001 Professional Psychology: Research and Practice (Vol. 32, No. 4). Evidence also suggests that as children, psychologists often assumed overly responsible parenting roles. "All of this suggests that psychologists may learn in childhood to take on roles that make us more amenable to the role of psychologist," comments O'Connor. "And if you're from an alcoholic or abusive background, you learn to tolerate, you learn to cope. So, instead of noticing that we're stressed or distressed, many psychologists just take it as part of our jobs and go forward."

Some solutions

Fortunately, there are many ways psychologists can learn to take better care of themselves and to get help if their problem becomes serious. Here are some suggestions:

Assess yourself subjectively and objectively. Learn to notice what you do when you get stressed out, then take steps to rebalance your life, advises Judith Kovach, PhD, an ACCA member who is also director of professional affairs for the Michigan Psychological Association and a private practitioner in Detroit. "When I'm stressed, the first clue is that I stop returning phone calls," Kovach says. Others she knows stop attending to their spiritual practices, eat compulsively or flock to the movies. "Each one of us needs to know what we do, and what we should be watching for," she says.

Psychologists can also test their level of professional stress via a self-test developed by Charles Figley, PhD, one of the originators of the concept of PTSD and author of "Treating Compassion Fatigue" (Brunner/Rutledge, 2002). The test--which gauges work satisfaction, the likelihood of developing compassion fatigue and problematic aspects of the job--can be accessed for free at www.mhsa.fsu.edu/cf/test_instructions.htm.

Determine which clients you obsess over. This exercise can help you assess whether your personal history is playing into your reaction, or whether you simply need to take better measures to cope with your client's pain, says Figley. For instance, psychologists who have young children may be especially vulnerable to hearing about child-abuse cases, Figley notes. Others may have clients whose psychological histories remind them of their own. Specialists who treat mainly one type of troubled client are also vulnerable, and should balance their caseloads if they start feeling burned out, he says.

Celebrate your successes. Because of the nature of their work, psychologists often see only their failures, notes Figley. Balance that equation by looking at your successes: "Keep track of signs, symbols, letters and notes that indicate you're doing a good job and that your work is useful," he advises.

Separate yourself from your work. In the office, that means learning strategies for remaining connected and empathic, but also protecting yourself emotionally, says Figley. At home, it means leaving your work at work. Make pacts with yourself about doing this, such as deciding to stop thinking about clients once you've stepped into your car and turned on the radio.

Consult with peers. Meeting regularly with colleagues in an informal but in-depth way is essential to countering some of the profession's pitfalls, ACCA members believe. "I share an office space with four other psychologists, and we frequently joke that we can be here all day and not see each other," says Kovach. "Many of us work in real isolation, and that can be a problem."

Kovach meets twice a month with three close colleagues to talk about any issues that come up, including personal, ethical, clinical and financial ones. "We all trust each other enormously and we can be very honest with each other," she says. "You can't do that with a drop-in group."

Use self-care strategies. There are self-care basics--eating right, getting enough sleep and exercising regularly--and more luxurious ones. Use them all. Mahoney, for instance, recommends that his therapist clients get regular massages. Likewise, he maintains an attractive office with a minifountain and comfortable chairs--not just for his clients, but for himself. He also advises psychologists to view relaxation as part of daily life, not as something to put off until you get your work or project done. "If self-care is experienced as just one more thing you have to do, it's not the same thing as having little reminders to yourself to take a deep breath and just let go," he says.

Get psychotherapy if you need or want it. Psychotherapy isn't just good for your clients, it's good for you, says Pratt. It can help you keep intact the essential ingredient of being a good therapist: yourself.

For psychologists who find themselves drinking too much, using drugs or acting out sexually, psychotherapy or a colleague-assistance program is essential, Kovach adds (see Further Resources). And if you know a colleague who's embroiled in some of these activities, first use informal means to try to address this problem, per the requirements of APA's Ethics Code.

Contact your state psychological association. While not all state associations provide colleague-assistance programs, many do offer materials and services for psychologists concerned about their own well-being or that of their colleagues.

Training needs

While some clinical training programs emphasize self-care, others don't. No national study has been done to assess the state of the field, ACCA members say.

Until more systemic efforts get under way, however, supervisors can do much to model healthy behavior.

"We've found that graduate students are eager to learn and talk about this," says O'Connor. "But instead of modeling for them that it's important to lead a balanced life, we model late nights, hard work and heavy course loads. We could do a much better job of helping them understand that a balanced life is an antidote to this kind of problem."

Faculty can do this, he suggests, by openly calling colleagues for advice; getting peer consultation themselves; and showing students that their own family and personal life don't receive short shrift.

In the final analysis, such modeling is important because it's what the field professes to stand for, adds Pratt.

"We know that making a policy of denying emotions is a bad plan," she says. "When I try to hide my vulnerability, that's when I'm most vulnerable. We can only carry out our responsibilities from a position of knowing ourselves and acknowledging the truth."

Tori DeAngelis is a writer in Syracuse, N.Y.

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