munnelly mp 2010 - adler graduate school mp 2010.pdf · and emotional needs during a particularly...

Running Head: THE HIDDEN TREASURES OF SELF CARE 1

THE HIDDEN TREASURES OF SELF CARE

A Paper

Presented to the faculty of the Adler Graduate School

In Partial fulfillment of the Requirements For

The degree of Master of Arts in

Adlerian counseling and Psychotherapy

By:

Gina Munnelly

May, 2010

THE HIDDEN TREASURES OF SELF CARE 2

Acknowledgments

There are several people that have made this thesis project possible.

First, a special thanks to my advisor Dr. Herb Laube. Thank you for your dedication, hard work

and flexibility in helping me to develop my thesis. It has been a long project but we have stuck

with it together and I am grateful.

Trish Anderson has been a dedicated and caring reader. Thank you for working hard on my

behalf. You too are helping me to graduate.

A special thanks to Herb’s advanced counseling class of 2010 for your participation in the

discussion of self care. Each of you brought a unique and insightful perspective to the discussion.

The openness and honesty shared was inspiring.

Thank you to family and friends who have been supportive throughout this process. I have

needed all the support I can get. Your words, care, and prayers have been incredible. It really

does take a village to write a large paper like this.


TABLE OF CONTENTS

Abstract……………………………………………………………………………………………4

The Hidden Treasures of Self Care………………………………………………………………..5

Consequences of Unhealthy Self Care…………..………………………..……………………….5

Compassion Fatigue……………………………………………………………………….....12

Secondary and Vicarious Traumatization…………………………………………………....17

Burnout……………………………………………………………………………..………..28

Strategies and Solutions for Healthy Self Care…………………………………………….…….37

Appendix…………………………………………………………………………………………49

My Personal Journey of Self Care……………………………………………………………49

References………………………………………………………………………………………..60


Abstract

Self care in the human services field is an emerging issue. The author asserts that it is a hidden

treasure that every professional needs to discover about themselves. It is crucial to the emotional

health and psychological well being of the helping professional. This subject is underdeveloped

and misunderstood among the practitioners themselves. In one study (Mahoney, 1997) authors

found that therapist’s attitudes toward their own self care were indifferent. The aim of this thesis

will be to explore the various aspects that hinder healthy self care. The article will look at

consequences of therapists chronic lack of integrated self care such as: compassion fatigue,

secondary traumatization, vicarious traumatization and burnout. This paper will define and

explore what healthy self care actually is. Finally, we will move to the discussion of how

students from the Adler Graduate School perceive their own self care and the issues that

surround it. Questions about self care and strategies to improve it will be discussed.


The Hidden Treasures of Self Care

The personal and professional self care of mental health practitioners is an issue that

needs to be addressed. If the practitioner does not care for themselves harm can come to both the

counselor and their client.

A therapist has a difficult job. Often they hear stories of tragedy, loss and incredible pain.

This pain can extend to the counselor themselves which can result in syndromes like compassion

fatigue, vicarious traumatization and burnout.

This thesis will highlight the various aspects of self care. Included are the importance of

caring for oneself, what studies have shown about self care, the harmful effects of the three

syndromes listed above, and an experiential section taken from a presentation and discussion

given to a class of students at Adler Graduate School. Finally, an appendix will be added to this

thesis by the author as requested by students and teachers. It features the author’s personal

journey and thoughts on the issues of self care.

Consequences of Unhealthy Self Care

Therapists are often called the wounded healer. The story behind this seems to be

accurate for some who have chosen this as their profession. In the book Caring for ourselves: A

therapist's guide to personal and professional well-being (Sapienza & Treadway, 2003), the

authors tell the story of Chiron. Chiron was a mythical character who was incurably wounded.

As a result, he was given the great gift of empathy and understanding of the pain of others. For

the rest of his life he was commissioned to help others and walk with them on their journey of

pain. This is just a legend but its importance is evident.


In one qualitative study (Grafanaki et al., 2005), ten experienced therapists were

interviewed about the issues that make them feel incompetent. Every one of them talked about

feeling or being triggered by their own past when clients opened up to them. All of them reported

feeling depressed in their careers at one time or another. If the depression is untreated, the

effectiveness of a therapist is diminished. This issue of self care is slowly being researched and

understood. It has become important because of the chronic lack of self care therapists have

shown. If we don't care for ourselves great harm can come to the professional and the client. The

consequences of harming oneself and others can be life changing and long lasting. This point

cannot be emphasized enough.

However, one of the main problems is that the issue appears to be undervalued and not

understood by counselors and scholars alike. One therapist said "I have never learned how to

care and how to nourish myself, for I had been trained to believe that this would be selfish or that

there is no time for this when there is so much else to handle" (Sapienza, 1997, p. 5).

One could make the observation that when a person travels by airplane they are advised

to place the oxygen mask on themselves before helping another. For the compassionate and hard

working therapist, it seems they do just the opposite. Mahoney (1997) found that therapists are

ambivalent about their own self care. They often don't engage in healthy self care behaviors.

This analogy of the oxygen mask serves as an important one. Healthy self care is defined as the

integration of emotional, spiritual, physical and leisure in one’s personal life. It is having that

balance of a personal and professional existence. It focuses on maintaining those relationships

that are most important. It emphasizes connections to self and loved ones. It is basically the care

and nurturing of our souls physically, emotionally, spiritually, relationally and psychologically.


Hadler (1996) succinctly expressed this point by saying that self care is a healthy self respecting

mature process. Some might question if we are indulging ourselves or being responsible by

taking care of ourselves. We require both physical and emotional rest and nurture so we can give

to our clients and loved ones life. Self care is different than selfishness or self absorption or self

indulgence. Self preoccupation comes if there is a lack of self care. Taking care of yourself

shows you respect yourself.

Hadler (1996, p. 18) said: "I need to feed myself and nurture myself and value and honor

myself….. That's what self care is…. Remembering that I have a self…. That I'm alive, I'm

well…. I can help another person,… Listen to him or her…. In a way that they can then… hear."

Authors have presented this information in different ways. This section of the paper will review

the different theories and observations of many of the leading academic scholars studying the

issue of self care.

Figley (2002) asks the direct question of why it is so hard for a therapist to take care of

themselves and cite three components. First is self awareness which is defined as a counselor

being aware of their own issues and past. It is being aware enough to see our own psychological

and emotional needs during a particularly difficult experience with a client. If one is not self

aware, clients may not get their needs met. They may be exploited unintentionally for the

therapist’s personal benefit. A therapist may act out indirectly and actions could lead to further

harm of the patient.

The second component is self regulation. Regulation is a term associated with the

behavioral and dynamic theoretical orientations of psychology. Mental health professionals must

manage their own emotions, impulses, anxieties and drives in this field. Managing our own


emotions and moods can decrease therapist’s chances of becoming more easily overwhelmed. If

a worker cannot manage, it is poor modeling for our client and can result in harm to them.

The third component is balance which is being able to juggle our own psychological needs while

listening to our clients. It is existing both personally and professionally. It is trying to maintain

some sort of equilibrium that works for the professional. The key concept is Balance. Balance

focuses on day to day living. Balancing time, money, stress levels and personal life with the

professional life is essential.

Balance could be described as being in the middle rather than on the extreme ends of the

spectrum. Mahoney (1997) describes that personal sense of balance as:

“Slowly, slowly over the years, I’ve begun to realize that you can’t be working at the boundaries

without a sense of the center. To me, that’s what life is . . . always in movement and often off-

balance a little bit. You never quite attain the static equilibrium which, of course, would be the

end of life. If you did . . . but learning to catch myself at earlier and earlier moments of leaving

center, and coming back to that.” This encompasses all three components of self awareness, self

regulation and balance. As Mahoney pointed out, no component is easy to master but it is

essential.

In the book Caring for ourselves, Sapienza & Treadway (2003) describe self care in more

detail. There are several factors explored regarding the lack of self care of therapists.

Starting at the beginning, authors look at a therapist's family of origin. As noted above, many

come into this profession because of the difficulties in their own lives. Despite what some might

say, therapists do not have the "perfect" or "normal" family either. Their role in the family could

have been to take care of everyone else. They could have been the peacemaker or the rescuer or


the scapegoat. If a counselor has not worked through their own family issues, they may over

identify with a particular client in a family. For instance, if they were the scapegoat growing up

and another client comes in who is the scapegoat, it could create problems. The professional

might over identify with that client. They may become less objective or look more favorably on

that client.

A counselor may have never been taught to care for themselves. In the article Self Care

for Women Psychotherapists this is explained. If a little girl sees her mother come home from a

long day at work and do all the housework and never enjoy herself the future counselor might

learn that life is not to be enjoyed. She could learn perfectionist traits or observe that life is

always about work and her mom never has time for herself. For women psychotherapists, authors

observe that they have so many roles. They have to balance being a wife, mother therapist friend

and colleague. Unless they have a supportive spouse, after a long day of listening to others; they

may come home and do the entire household work.

Even birth order can have an effect. In a study done by Guy, Poelstra, and Stark (1987)

results showed that half the therapists were either only children or first born children. Adlerian

psychology would describe an only child or a first born as having to be responsible, hard

working and the caretaking over achiever. Naturally, with those qualities one can see how

personal self care might not be given the attention it deserves.

Generational factors play a huge role in therapist’s lack of self care. For instance,

currently the world is in a recession. Non-profit Agencies are cutting budgets. Those in private

practice may have to take more cases just to make a living.


People view work and its' value in different ways. Sociocultural factors such as work,

money, religion and ethnicity, all may play into a therapist's cognitive schemas about how to care

for themselves.

Family obligations both extended and immediate can influence self care. Again that

female psychotherapist for example, might not have enough time. Even a man having to have

dual roles might find caring for himself difficult.

Regardless of gender, one's personality can be an influential factor. Authors describe

therapist’s personality traits in some general ways. As a group counselors tend to be

compassionate, caring, empathetic, reflective, tolerant, accepting, warm open and hardworking.

These are all exceptional qualities to have. However, these therapists can also be, hard working,

perfectionist, self judging, self critical and driven. The need to get things right can be strong.

In addition to the factors above significant life events can play a role in the lack of self care.

Events could include: pregnancy, loss, death of a parent or illness.

The final factor explored was the mundane day to day life each therapist lives. The pace

can be grueling. A therapist may have to take care of children and get them off to school. They

might have a large caseload. A helper might get less sleep; they might not feel they have time for

breaks or a regular lunch hour. All of this can lead to stress on the body. Not only emotional but

physical stress can occur.

In Adlerian psychology the factors above can be defined as a person's style of life. Adler

defines lifestyle as everything you are and more. The lifestyle is like taking a snapshot and

seeing the big picture of the whole person.


The deep seeded values and goals one has can contribute not only to their lifestyle but to

their private logic as well. Private logic focuses on the goals and drives of a person realized or

unrealized. For instance, a supervisor's private logic may cause their perfectionistic and

workaholic like traits to come out.

One of the therapist groups that can experience a lack of self care are supervisors of other

mental health practitioners. These are more seasoned therapists who move from directly seeing

clients to seeing the client's therapist. Often, this person has many cases to contend with. In an

article taken from BASPR (British Association for Supervision Research and Practice) these

experienced individuals related how they don't have time for themselves. They tend to work long

hours, skip meals or eat on the run and not take breaks. A supervisor can still be triggered by

what a supervisee says about their client. If they are not in their best emotional and physical self

the consequences for all involved can be drastic. Taking care of and being attentive to the needs

of others is commendable. However, it can become narcissistic in nature. Perhaps, a therapist or

even their supervisor would really like to be taken care of and that need might result in extreme

care taking of others.

One of the damaging effects a lack of self care can have on a therapist has to do with

boundaries. If a counselor is feeling stressed, is isolated, or is not emotionally and physically as

stable as necessary, boundary violations can occur. This could lead to exploitation of the client,

an unhealthy duel relationship or abuse of power. It can lead to the helper feeling shame and the

client feeling extreme discomfort. Often, if violations continue the therapist may start to feel

violated or trapped.


In this field there is a chronic lack of self care among therapists. Boundary violations are

serious but even more serious is the concept known as compassion fatigue.

Compassion Fatigue

Compassion Fatigue is a concept being studied in the field of psychology and mental

health. Some of the main authors who have done large amounts of research on this subject

include Charles R. Figley and Brian Bride. There are three common terms that this author has

found in every piece of compassion fatigue literature. They are: secondary traumatization stress

disorder, Vicarious Traumatization and burn out. These concepts will be defined in this review.

The author will discuss them in greater detail in further sections of this thesis.

The terms of secondary traumatization stress and vicarious traumatization are similar in

nature. They are so alike that authors worked to come up with a more user friendly umbrella term

that would encompass these concepts. This is how compassion fatigue came to be. In this review,

the three terms will be defined and discussed and will also be used interchangeably. The fourth

term of burnout is more distinct but will still be noted.

When looking at compassion fatigue C. Kraus (2005) notes that the price a therapist pays

can be quite high. Compassion fatigue can occur when a therapist treats a client who has

experienced a trauma. The presenting issue could be broadly defined as sexual, physical or

emotional trauma. The client or a member of their family might be chronically ill or could have

gone through a disaster. Naturally, they come to therapy seeking help to deal with their issue. A

therapist is then indirectly exposed to this issue. Their response is empathic and understanding.

Fatigue comes in when the therapist over identifies with the client and their trauma. The

issue may trigger something from a therapist's past. The empathy that would have been basic


understanding can then become traumatic. A therapist may become mentally, emotionally or

physically exhausted. It is almost as if they experience the trauma and take on the feelings of

their patients. The counselor may experience feelings of isolation, intrusive thoughts or avoidant

behaviors notes Figley & Radey in their article, "The Social Psychology of Compassion" (2007).

The key word when discussing and defining compassion fatigue is to note the therapist's

empathic response.

Secondary Traumatization stress disorder is defined as bearing the sufferings of another.

As a result of bearing those burdens, the clinician themselves becomes traumatized. This could

be due to counselors past and their inability to separate their past from the client's present. For

instance, Figley presents a case study of a young female graduate student with the sudonymn of

Jane. She is seeing a client who has a chronically ill family member. Jane's mother has been ill

for a long time as well. Jane has come in experiencing these symptoms and seeking help from

her supervisor. It is clear that Jane is triggered by her client's struggle to deal with their family

member's chronic illness. Jane can identify empathically with them. She is still having issues

dealing with her own mother's sickness. Thus secondary traumatization stress disorder and

compassion fatigue occur.

Vicarious traumatization is a similar term. Again Jane is exposed to her client's issues.

Jane over identifies and becomes traumatized. Vicarious traumatization takes this one step

further. Jane feels a sense of responsibility for her client's well-being outside of their sessions.

This concept is more cognitive in nature. This would affect her life relationally, socially and

cognitively. It is not just over identifying with a client but one might say over engagement with

them as well in thought and possibly in action as well.


The final term that needs to be discussed when addressing compassion fatigue is burn

out. This is more clearly defined. It results from a therapist feeling overloaded by the amount of

cases they have. Burn out is when a therapist might become emotionally and physically

exhausted. They may become disengaged with cliental which can cause less progress with their

cases.

Regardless of what term one uses to describe the phenomenon of a therapist suffering

with clients trauma each term can result in serious consequences for that mental health worker.

All of these terms are very similar and fall under the umbrella of Compassion fatigue. Several

researchers have worked to study compassion fatigue and its effects.

This issue does not only affect mental health workers but medical professionals too.

Lamson and Meadors (2008) conducted a study of 125 nurses who worked in a critical care unit

at a children's hospital. They were asked to complete a voluntary questionnaire and an

educational seminar on this topic. The aim of their research was to look at how this fatigue

affects professionals working with critically ill children. Results found that those nurses who had

more stressful personal lives were more susceptible. It was also noted that education before

fatigue set in would be key to reducing it.

Another study assessed compassion fatigue and therapists who work with torture

survivors. Working with this type of trauma over a longer period of time can increase a

counselor's fatigue. This was an international study taking 100 therapists from Switzerland,

Austria and Germany; who worked at trauma centers specifically with this type of client. Results

showed that those therapists who advocated for their client's but had not been able to have a


sense of working through the trauma with their clients had a higher rate of compassion fatigue,

secondary traumatization, and the possibility of burnout of the professional.

In one final study Stam (1997) looked at social workers who had clients facing various

types of traumas. The authors found that social workers experiencing this fatigue were more

likely to make poor professional judgments in areas such as misdiagnosing, treatment planning

and possibly engaging in abuse of clients.

As the reader can see, Compassion Fatigue is a very serious issue for a helping

professional to suffer from. It can have life altering consequences both personally and

professionally. If this goes untreated it only gets worse.

Authors like Figley and Bride have worked to develop several scales and compassion

fatigue self tests for a therapist to complete or a supervisor to give if it is necessary. The first step

in dealing with the issue is to assess its severity and intensity. These forty point scales and self

report questionnaires help do that.

There are many schools of thought about how to help the helper who is suffering.

Prevention and awareness are two keys. In the study of critical care nurses participants were

asked to attend a four hour workshop that made them aware of the symptoms, consequences and

help to deal with Compassion fatigue. Nurses reported that after going to the workshop they felt

more equipped to recognize the symptoms of Fatigue. They also reported feeling that they had

more professional support and resources to deal with this issue.

Figley and Radey (2007) discuss four factors that contribute to a social worker's suffering

from compassion fatigue. Those factors include: lack of self care, past trauma in professionals


own life, inability to control workplace stress and less satisfaction with the work they do over

time.

Authors introduce a conceptual model for the helping professional. It all surrounds

positive psychology and finding fulfillment in both their personal and professional lives. Social

workers often hear the same kinds of stories again and again. If they are emotionally exhausted

or stressed they might become cynical or disconnected from their clients. Figley and Radey

(2007) make the case that positivity can increase the professional's inner resources and help treat

the client with dignity. This is a very strengths based model in the sense that professionals are

asked to take care of themselves and find new ways to approach the same problems. They are

asked to find things they appreciate about clients and be creative in the resources they give.

Authors assert that the more positive fulfillment a professional has in their life the less fatigued

they will become.

In a study of therapists who work with adolescent sex offenders in the state of Oregon (V.

I. Kraus, 2005) the argument for self care is compelling. Participants were given a list of forty

activities and asked to rate how often they had engaged in them over the last six months. They

were also asked to rate their satisfaction in their field. V. I. Kraus (2005) found that a

professional who took care of themselves had higher levels of compassion satisfaction.

In the Alabama Nurse, C. Kraus (2005) gives some very practical tips for self care.

Activities like exercise, listening to uplifting music and reading are considered ways for a

professional to take care of themselves. Engaging in a hobby can also allow the helper to take

their mind off their work when out of the office. Engaging in activities with family and friends is

also helpful. Even the professional needs the support of their family and friends. C. Kraus


(2005) notes physically and medically caring for oneself is equally important. Finally, writing in

a journal can aid the therapist in letting go of the day's work.

This next section will focus entirely on the concepts of vicarious traumatization and

secondary traumatization. Although the terms of compassion fatigue and the types of

traumatization are similar; there are bodies of literature that focus solely on vicarious and

secondary trauma.

Secondary and Vicarious Traumatization

In secondary traumatization the helper bears the burdens of his or her patient. They may

have difficulty separating their past from their client's present. As a result, they may become

traumatized themselves.

Vicarious traumatization takes that one step further. With this type of trauma a therapist

feels an overwhelming responsibility for the client's well being. This terminology is more

specifically defined in that a therapist is exposed to a client’s traumatic material and as a result

could end up traumatized themselves.

However, there is one overarching disorder that can affect a therapist who is traumatized

either vicariously or secondarily by a client's story. It is commonly known as PTSD. This stands

for Post Traumatic Stress Disorder. One may think of PTSD as something only a soldier or a

rape victim might experience after a trauma. However, therapists can be just as susceptible as

any of their clients.

The Diagnostic and Statistical Manual of Mental Disorders IV-TR in section 309.81

(American Psychiatric Association, 2000) presents detailed criteria for diagnosing PTSD, the list

of that criteria includes:


A. The person has been exposed to a traumatic event in which both of the following were

present:

(1) The person experienced, witnessed, or was confronted with an event or events that involved

actual or threatened death or serious injury, or a threat to the physical integrity of self or others

(2) The person's response involved intense fear, helplessness, or horror. Note: In children, this

may be expressed instead by disorganized or agitated behavior

B. The traumatic event is persistently experienced in one (or more) of the following ways:

(1) Recurrent and intrusive distressing recollections of the event, including images, thoughts, or

perceptions. Note: In young children, repetitive play may occur in which themes or aspects of the

trauma are expressed.

(2) Recurrent distressing dreams of the event. Note: In children, there may be frightening dreams

without recognizable content.

(3) Acting or feeling as if the traumatic event were recurring (includes a sense of reliving the

experience, illusions, hallucinations, and dissociative flashback episodes, including those that

occur on awakening or when intoxicated). Note: In young children, trauma-specific reenactment

may occur.

(4) Intense psychological distress at exposure to internal or external cues that symbolize or

resemble an aspect of the traumatic event

(5) Physiological reactivity on exposure to internal or external cues that symbolize or resemble

an aspect of the traumatic event


C. Persistent avoidance of stimuli associated with the trauma and numbing of general

responsiveness (not present before the trauma), as indicated by three (or more) of the following:

(1) Efforts to avoid thoughts, feelings, or conversations associated with the trauma

(2) Efforts to avoid activities, places, or people that arouse recollections of the trauma

(3) Inability to recall an important aspect of the trauma

(4) Markedly diminished interest or participation in significant activities

(5) Feeling of detachment or estrangement from others

(6) Restricted range of affect (e.g., unable to have loving feelings)

(7) Sense of a foreshortened future (e.g., does not expect to have a career, marriage, children, or

a normal life span)

D. Persistent symptoms of increased arousal (not present before the trauma), as indicated by two

(or more) of the following:

(1) Difficulty falling or staying asleep

(2) Irritability or outbursts of anger

(3) Difficulty concentrating

(4) Hyper vigilance

(5) Exaggerated startle response

E. Duration of the disturbance (symptoms in Criteria B, C, and D) is more than 1 month.


F. The disturbance causes clinically significant distress or impairment in social, occupational, or

other important areas of functioning.

PTSD can occur in a helper because they can become traumatized and it is as if they have

gone through the event themselves. Even though in reality, they are experiencing it vicariously

or secondarily through their client. It is as if the helper experiences the horrors with the client or

they may feel like the trauma’s happened to them too. In looking at Compassion fatigue, one can

see that the emotional and physical fatigue can be present.

In Vicarious and secondary trauma the effects of traumatization or possibly PTSD like

symptoms can extend into their personal lives as well.

Danielli (1984) first studied sixty one therapists (and their children) who worked with

survivors of the Holocaust. The author found themes of counter transference. Participants

reported feeling emotions of guilt and shame that they could not help their client's as much as

they wanted to. Danieli (1984) concluded that therapists were having reactions to their client's

stories. In turn, that affected them outside of the office. For instance, the children of these

therapists were affected by the work of their parents. The children noted noticeable changes in

their parent.

The field of studying trauma was just being developed at that time. Many of the terms

found today were not directly said in that article. However, the emotions and intensity of

therapists and the effects on their families stood out.

The terms to describe trauma were introduced and more clearly defined starting with

Perlman and McKinnen (1995). Vicarious traumatization happens as a result of a therapist being


exposed to shocking or violent images and horrors that their client has endured. This is known

as Traumatic material.

Once a counselor is exposed to this kind of material they can become traumatized

themselves. Research has shown that a therapist’s cognition and emotions are impacted

negatively. (Perlman 1990) These clients might be the more extreme cases that come across a

therapist’s desk. For instance, this includes those who have experienced senseless random acts of

violence such as sexual assault, domestic violence or torture or tragedy of any kind.

During sessions therapist will be exposed to their shocking images and the horrors that

the client has been through. The counselor experiences the story as if it were happening to them.

It does not mean they over identify with the client like in compassion fatigue. It is more as if they

feel like the trauma happened to them. They almost take that experience into their own cognitive

schema and emotions.

One theory that can better explain this idea of vicarious trauma and how a therapist lives

that through their client is the theory of intersubjectivity. This is more of a Meta theory. It

emphasizes the conscious and the unconscious. Authors say that we live in two worlds. That of

the observer and the observed. Both of these worlds are subjective based on the uniqueness of

each person. Each experience we have is organized into one of three subconscious levels.

The pre reflective looks at our experiences but emphasizes that we are not as aware of

them as we think. These might be the more inconsequential experiences of life such as our every

day routines.

The dynamic unconscious holds all our bad or threatening memories. This theory says

those memories are too painful for a person and so they are locked away in this part of the


unknown. This could be why certain traumatic childhood events are blocked out and cannot be

accessed by a person’s conscious memory.

Then there is the invalidated level of unconscious. This is the place where memories,

events, emotions and experiences go that were not properly acknowledged in our lives. Thus,

these types of experiences are usually those from childhood where the person needed their

caregivers to acknowledge them and that did not happen.

The experiences therapists have in hearing their clients trauma goes in the invalidated

category. Often when working with survivors therapists do have to work hard to maintain

professionalism. At times, that means not validating their own emotions, feelings and

experiences around what the clients have said. The account a client gives could trigger a

therapist’s own past invalidated experiences as well.

The main point of the theory of intersubjectivity is that therapist’s lives and sense of self

can be impacted based on the trauma of their clients. This is similar to the widely acclaimed

theory of cognitive self development theory. This is a concept that was developed by Pearlman

and McKinnen in 1990.

Not unlike the three basic needs of Adlerian therapy; these authors say that each person

has five basic cognitive and psychological needs. Everyone has needs for trust, intimacy, safety,

power and control. When trauma happens one or several of these needs can be disrupted. This

might not just happen with one client.

However, if a therapist is seeing several people with traumatic histories over time their

sense of others, self and the world can be jarred and turned upside-down during tragedy, loss or

disaster.


Therapists who are exposed to client’s stories then experience the trauma as stated above.

Therefore, a counselor’s own cognitive schemas can be disrupted or disturbed in the same or

different ways as their clients.

For instance, Illife found that after working with domestic violence victims female

therapists reported feeling less safe in their own environments. For instance, they might be more

aware of their physical surroundings after a difficult session with a client. Their lack of feeling

safe might cause them to notice more gender and power and control issues. This author also

found that female therapist working with this client population reported having more trouble

establishing new romantic relationships. This taps into the cognitive needs of intimacy and trust.

Hunter also found support for CDST. Therapists working with sexual assault survivors

were given a values and beliefs questionnaire. Respondents indicated that their values and beliefs

were negatively affected by the work they did. They reported having trouble with intimacy issues

outside of work. Therapists also reported having a heightened awareness of power and control

within their personal relationships especially when it comes to the opposite gender. In both of

these examples the reader can see that the different needs of safety, intimacy, trust, power and

control can be negatively impacted by the trauma of their clients.

It is as if they take on the memories of their client as their own. One therapist in Illife's

study said that the visual images they had from some clients would stick with them forever.

One study took fifty three therapists and asked them to pick their most difficult and least

difficult cases. Therapist's asked client's from these cases if they would like to participate as well.

All one hundred-six respondents filled out anonymous symptom checklist (SCL90) and the

impacts of events scale when a traumatic case was chosen. The Impact of events scale


instructions were amended for therapists. Counselor's thought they were answering questions

about their client's when in reality they were actually answering the questions based on how their

client's trauma personally affected them.

Results showed that twenty percent of therapists were in the clinical range for vicarious

traumatization regarding their most difficult cases. Fifteen percent of therapist's fell in that

clinical range for their least difficult cases. In other words, results showed that vicarious trauma

can negatively impact many therapists who work on diverse cases.

It is important to understand how a therapist can become this traumatized by a client's

experiences.

Some of the most impacted counselor's are those working with clients who are sex

offenders. Farrenkopf (1992) developed the four phases of traumatization that this type of mental

health professional can go through.

Phase one looks at the initial shock a therapist experiences when hearing about a sexual

offender's crimes. They may feel emotions of fear, vulnerability or weakness. Their own sense of

safety could be or even feel threatened. Their sense of safety for their loved ones might feel

threatened.

Phase two is the mission. Counselor's as a group are usually caring compassionate

people. Everyone wants to help their clients in the best ways they can. Since we are helpers our

natural inclination is to keep working with someone so that progress can be made.

Phase three focuses on anger. If several attempts to help a client don't work a counselor

may start to become angry or frustrated. A therapist might become overly confrontational with

this type of client thus resulting in the erosion stage. The professional has tried to help, has tried


to be compassionate with little to no success. After the feelings of anger are gone the one thing

left to feel is just being drained. A counselor can become worn out, depressed or feel like their

efforts are futile after working with a client over a significant period of time.

Again, therapists working with this client population have a much higher rate of burnout

and are at higher risk for vicarious trauma then are their colleagues. Steed and Bicknell (2001)

conducted a study that bore this out. 67 male and female therapists working with ex offenders

took the Impacts of events scale (revised version.) Results showed that 46% of participants

suffered from compassion fatigue and 38% were at high risk for burnout. In this same study

results found that 15% of therapists reported having intrusive thoughts about clients while 12%

reported engaging in avoidant behaviors. 8% were found to have symptoms of hyper arousal.

Rich (1997) conducted a more descriptive study of therapist working with the same client

population. Authors asked 135 therapists open ended and true false questions. Participants listed

having common feelings of mistrust, depression, isolation, vulnerability and anxiety. Many said

they reported feeling ill-equipped to handle some of their more difficult cases. Some reported

experiencing flashbacks in and outside of work.

A therapist’s level of experience plays a role in their susceptibility to vicarious Trauma.

Several studies including Adams, Matto, and Harrington (2001); Crothers (1995); and Perlman

(1995) indicate this fact. The newly trained therapists are more likely to become traumatized by

the materials they are exposed to.

The experience of sharing someone's trauma with them can make even a seasoned

professional feel and experience being vulnerable. This is the key feeling that will be addressed.

In the article shared trauma therapist and increased vulnerability this concept is further explored.


Authors discuss the levels of vulnerability that come when heartbreaking information is

shared. First there is the direct level of trauma; for instance, if a therapist has had a past history

of crime in their own family. Then there is the secondary level. This is when a client tells their

counselor about a violent crime that has happened in their own family.

The theories and supporting articles above show that this can be interconnected for the

therapist. For example, if this therapist with the history of violent crime then hears about another

case of it at work; they are more likely to identify with this patient. They are being transformed

by the trauma they hear and see. This could increase feelings of responsibility and obligation for

the therapist. In this case, that over identification with a client and empathy can become harmful

rather than helpful.

As a therapist it is important to have a genuine connection with a client. Rapport building

is key when working with traumatized individuals. However, some key questions to ask are:

When does that go too far? How can it be managed? Can there be a healthy balance of

genuineness and emotional distance?

Many in this body of literature point to supervision and consultation as a helpful tool. The

job of supervision is more difficult than it looks. In the article what to do with wounded Healers

dilemma this is explored. The difficulty for a supervisor is to balance supervision with support.

In other words, authors stress that helpful feedback is different than one therapist giving

counseling to another. The amount and level of supervision will often vary based on the

experience and skill level of the therapist. If the counselor is newer say just out of graduate

school more supervision is helpful. This type of therapist might need more encouragement,

support, feedback and confrontation then their more experienced colleague.


Authors stress the importance of knowing the supervisee. It may be helpful to know if

your supervisee's have personal trauma histories. This way if that is triggered a supervisor can be

prepared. There may also be times where a supervisor might need to recommend that their

supervisee get personal therapy.

The other important factor stressed is the idea of the inner transformation and its effect on

the therapist. The question supervisor's need to ask their clients is: How does hearing that client's

stories affect you? Vicarious trauma happens over a period of time. It can take several cases for

this type of trauma to stick and severely impact the practitioner.

It is suggested that good regular supervision can be helpful to prevent vicarious trauma.

Good supervision is defined as feedback and encouragement and attention to detail in the

therapist's life which can positively impact their experiences working with traumatized clients.

As demonstrated above, the syndromes of compassion fatigue, secondary, and vicarious

traumatization can be very serious for the mental health practitioner. However, there is one more

concept that needs to be discussed. It is commonly called burnout.

Burnout

First, it is important to note that burnout is possible. It is not some foreign term we hear

that could never really happen. It is very real and clearly defined. Compassion fatigue and

vicarious trauma can be root causes for burnout. However, the actual definition can be simply

defined as frustration and fatigue with the work one does or is devoted to doing (Maslach, 1982).

It can also be described as "excessive demand and constant expenditure of energy on behalf of

clients" (Renjilian & Stites, 2002, p. 8).


Unlike the syndromes above, it could be argued that burnout may have more of an

overarching effect on all of a professional's active cases. It is also a more broad term in that other

helping professionals, such as those in medical and human services professions, may also

describe their practitioners as experiencing burnout. This wider reach has allowed academic

scholars to study several different groups of professionals to know how this affects them.

Burnout can occur when a helper experiences lasting effects from clients and a high amount of

job related stress. In more severe and untreated cases this may cause them to leave the field

altogether.

Dr. Kristina Maslach is one of the leading scholars on this topic. She characterized the

three main dimensions of burnout. The first dimension is depersonalization. This occurs when a

counselor starts to display a distant attitude and cynicism toward his or her clients. After hearing

so many stories therapists may become detached from clients. They may start to experience

feelings of resentment and less compassion towards them.

The second dimension is emotional exhaustion. Listening to clients and providing their

basic care can be draining. Helpers suffer from pure exhaustion. This could be displayed both in

physical tiredness and emotional fatigue.

Finally, the last dimension involves a professional's personal level of accomplishment at

work. Maslach (1982) explained that the levels of personal accomplishment decrease as job

related stress and significant life events of the professional increase. They may be so preoccupied

by their stress that they find they cannot concentrate. They may have trouble getting things done

at the office. It may be the environment itself or its dynamics that cause them to get less work

done.


Job related stress is noted in the literature as a large contributing factor to a professional's

burnout. This type of stress can be characterized in several ways. Heavy workloads, inadequate

supervision, and lack of resources on the job play a role. In addition, stress can be caused by

confusion of job roles, lack of positive feedback, loss of control, and pressure at work.

Unrealistic expectations perceived or set by the professional or management can be seen as job

related stress.

One could have unrealistic expectations personally or professionally. Significant life

events, lack of a supportive work environment, loss of meaning, purpose to work, and lack of

commitment to the profession can also contribute to a practitioner’s burnout. The consequences

can be very serious and have long lasting effects such as, somatic complaints, absenteeism from

work, decreased attention to self, and increased family conflicts. If untreated, one may leave the

field.

The signs and symptoms of burnout may be easier to spot than the professional realizes.

In one study, college students were asked to evaluate three segments of actual video of three

therapy sessions. The purpose was to see if they could spot burnout among therapists. The first

video segment showed a normal client and therapist session. The second showed a similar

session. Only this time, the therapist showed symptoms of burnout. The third video went back to

showing a portion of a normal therapy session. One hundred forty-seven graduate students were

asked to evaluate video portions on the following dimensions. Effectiveness of therapist,

likability of the helper, competence, skill level, and dedication to the patient.

College students reported seeing signs and symptoms of burnout among therapists.

Students in the study noted that in the second vignette therapists appeared to be more hostile,


fatigued, and displayed more obvious behaviors such as clock watching. Students gave lower

ratings to the therapist from the second video segment than from the other two. It was noted that

those graduate students who had experienced personal therapy saw the signs even more clearly

than their peers.

It is not only college students who are concerned about burnout. This is an international

issue that has caught the attention of several professional groups. In Hong Kong, 132

professionals were surveyed. The range of professionals varied from five different disciplines,

including psychiatrists, psychiatric nurses, social workers, counselors, and licensed

psychologists. Instruments used were the Maslach Burnout Inventory (BMI), the Purpose in Life

test, and the Seeking of Noetic Goals test by Crumbaugh.

Results indicated that having that purpose and meaning in their work was associated with

one feeling personal accomplishment at work. If a professional felt unmotivated to seek that

purpose, or had lost it, he or she may be experiencing higher levels of emotional exhaustion.

Psychiatric nurses experienced the highest levels of exhaustion. Authors note that this may be

due to the fact that nurses spend so much time with each patient. Psychiatrists were found to be

the least likely to be motivated to seek purpose and meaning in their job. This may be linked to

their higher pay scale and less time spent with their clients.

Another Hong Kong study (Chan, Kwok, Li, & Yiu, 1988) had similar findings. Again a

very large group of mental health practitioners were asked to participate. In this study, results

showed that 60% of participants reported feeling frustrated with job-related factors, including

heavy case loads and lack of resources for clients. Two hundred five of the participants reported


feeling dissatisfied with job performance, which points to low levels of personal

accomplishment.

A professional's performance can be impacted by the stress they are under. In their

article, Elman and Dowd (1997) discuss Selye's stages of stress model. When one encounters

stress, the first reaction might be a feeling of alarm. The helper may have physical reactions or

just start to feel disturbed by what they are hearing from a client.

After the initial alarm, the helper may start to become resistant to clients. This could be

experienced by the client as the therapist being angrier, less warm, or less caring. Finally after

the resistance comes exhaustion. This can be emotional, physical, or a mental combination of the

two.

This may sound as if it were vicarious trauma or compassion fatigue. Again they are

similar in some of the symptoms that a helper experiences. However, the main difference is that

the resistance and exhaustion may be caused by more than just a client's harrowing story of

tragedy or extreme trauma. In burnout, one’s level of personal accomplishment is key.

For instance, for chemical dependency counselors this proved to be true. Elman and

Dowd (1997) studied 79 chemical dependency counselors who worked at various inpatient

treatment centers. Out of the total, 29 were identified as recovering. Participants were asked to

fill out three different instruments: the Maslach Burnout Inventory, the Social Readjustment

Scale and the Occupational Stress Inventory. Social readjustment looks at significant life events

and a person's adaptability. The Occupational Stress Inventory measures job-related stress and

coping resources.


Results showed that the counselor who identified as recovering scored higher on having a

sense of personal accomplishment in their work. Job-related stress was also a major factor in

burnout. Social support was positively correlated with decreased burnout. A combination of

social support and a sense of personal accomplishment proved an even greater buffer against

burnout.

Having a buffer, and a way to cope with the challenges of helping, proved to be

significant in the literature on this topic. The ways in which a professional copes with his or her

stress can significantly reduce burnout (Thornton, 1991). This author reviews the stress and

coping model. It was developed by Richard Lazerous in 1966.

Authors explain that two processes occur when a helper encounters a stressful situation or

environment. One is cognitive coping. The other is cognitive appraisal. The appraisal occurs

when a helper is evaluating if an encounter in their environment is relevant for their well being.

This is done in two ways. Primary appraisal is when one evaluates their stressful environment as

being positive, negative, or neutral. Once the evaluation that this is a stressful place or event is

made, secondary appraisal takes over. The helper evaluates the situation in light of the resources

and coping strategies they can bring to the conversation.

Coping itself is defined as a person constantly changing cognitive or behavioral

approaches in order to adapt to a stressful situation or environment. There are two types of

coping. Emotionally focused and problem focused. The study by Thornton (1991) used this

model as its guide. 237 full-time psychiatric workers were asked to participate. The group

consisted of 31 psychiatrists, 30 psychologists, 83 social workers, 47 psychiatric nurses, 17

rehabilitation counselors, 17 recreation therapists, 5 occupational therapists, and 4 home care


workers. Participants were given questionnaires based on job-related stress and feelings of

satisfaction surrounding their work.

Results showed that regardless of the level of burnout, counselors used problem-focused

coping to work through difficult obstacles. However, those who were more burned out tended to

use escapism and avoidance with clients as a means of coping. Secondary appraisal did not play

a huge role in this study. Authors interpreted this to mean that if a practitioner is burning out they

do not necessarily feel hopeful about the situation ever changing or getting better.

If a therapist feels hopeless or helpless in the face of burnout do their colleagues have a

duty to help them if they see the signs? This question was explored in the article Signs and

Symptoms of the Impaired Counselor (Emerson & Markos, 1996). In one study Wood, Klein,

Cross, Lammers and Elliott (1985) found that 64% of clinicians saw signs of burnout among

colleagues. 32 of the respondents identified themselves as experiencing burnout. When they were

asked what should be done the results were surprising. The majority reported they would say

nothing for fear of retaliation at work.

However, if burnout is seen but avoided, the ones who suffer the most are the clients who

cross paths with the burned out therapist. Authors note that therapists who suffer from burnout

may cancel more appointments or feel a sense of relief when a client needs to reschedule.

Significant changes in behavior can occur. Such as, the therapist may show up late or be more

hostile to the clients. If this goes undetected, the public is not protected. Sadly, the therapist only

hurts him or herself more.

It can be difficult for a therapist who has a particularly demanding or frustrating case; for

instance, a client who is diagnosed with borderline personality disorder. Patients with borderline


personality disorder can be less responsive to therapy, may engage in para suicidal behavior or in

other self harming behaviors. Perseius, Kåver, Ekdahl, Åsberg, and Samuelsson (2007) noted

that the demands patients put on helping professionals increased burnout. These authors decided

to use the treatment of dialectical behavioral therapy (DBT) on the helping professionals

themselves. Ironically, this is the very same treatment the practitioners often use on their

patients. 22 psychiatric professionals (two physicians, three psychologists, eight registered

nurses, eight mental care assistants and one occupational therapist) were asked to be in this

longitudinal study/intervention.

The first six months consisted of education in the basics of DBT. The skill set of

mindfulness was intentionally taught. The next 18 months consisted of the participants treating

patients while being supervised weekly in a group setting. Two open-ended questionnaires were

given at the beginning of the study. The Maslach Burnout Inventory was given at the beginning

of the study, six months later and eighteen months following. Results indicated that mindfulness

training and group supervision were viewed as supportive for the professional. DBT proved to be

a helpful intervention for even the professional in order to prevent burnout when working with

borderline personality patients.

The literature notes that intervening against the symptoms of burnout is key. Many

interventions have been studied to see which ones prove to be the most effective in decreasing

burnout. In a meta-analysis, Awa, Plaumann, and Walter (2009) looked at 25 prevention and

intervention studies on the topic of burnout from 1997-2007. 68% of the interventions were

known as personal interventions. This might be considered personal therapy, expanding one’s

social support network or relaxation exercises. They are more cognitive behavioral in nature. 6%


were organizational changes made to decrease burnout. These might be increased supervision at

work, evaluation of skills and appraisal of job related stressors. 24% were a combination of the

two types of interventions. The three types decreased burnout to varying degrees. The

combination of the personal and organizational interventions decreased burnout for a longer

period of time. Some more practical interventions that might be helpful for a therapist

experiencing burnout could include, taking the time for breaks during the day or taking

vacations. Edwards et al. (2003) found that some of the most common coping strategies included

enlarging a social support network and having adequate and frequent supervision. Other

important interventions, notes Edwards, are for a therapist to recognize their own limitations.

This could be linked back to the important concept of having unrealistic expectations. A therapist

needs to know themselves and be aware of their own personal and professional limits. At times,

the professional may be so busy helping a client that they forget to ask for what they need. It is

also important for the professional to be assertive when feeling stressed and giving voiced to

those unheard needs. Finally, it is important for the therapist to have and set realistic

expectations for them regarding the time they spend at work and the amount of cases they choose

to take on. This is where the importance of good self care comes in for every helping

professional.

Strategies and Solutions for Healthy Self Care

The consequences of not taking care of oneself as a helping professional can be life

altering and impacting. For a suffering therapist, it might seem hopeless to find ways to get back

to that center or equilibrium. However, just as there are many factors about what causes a lack of

self care the solutions are just as diverse.


Authors discussed three components to self care; self awareness, self regulation and

balance. These are easy topics to discuss.

Authors hope that being self aware can improve self care. Being aware can decrease

reactivity to client’s issues. It may lessen the triggers therapists may feel after hearing a

traumatic story.

Regulating one's own emotions also can make a difference. For instance, if a therapist

feels depressed exercising before going to work or after might help them.

The concept of balance can be one of those very difficult ideas to apply. Juggling

personal and professional obligations can be taxing.

In the book "Caring for Ourselves" (Baker, 2003) several factors are listed that can

positively affect therapists self care. Authors emphasize knowing the structure of yourself. Being

self aware is a part of that. However, it is more holistic then that. It involves understanding ones

limitations and personality traits. It takes into account contextual ideas of a helper's day to day

moods and emotions.

As professionals, it is necessary to practice the skill of self and other differentiation. At

times, a therapist can over identify with a client and their story. The word compassion means to

bear the burdens of another. Sometimes a therapist does this in a more literal way then necessary.

Differentiation helps the professional to separate themselves from their clients. Authors describe

it in this way. If we fail to maintain appropriate differentiation from our clients, we run the risk

of counter transference, or projective identification onto the patient. That is, we may project our

needs onto a patient and then, in turn, base treatment on our own covert needs rather than the

patient's actual needs" (p. 47).


Trying to meet one’s own needs through a client can be dangerous. Authors talk about the

different selves each person presents to the world. First, there is your true self. This is the real

and authentic person inside. This is where likes, dislikes, opinions and preferences are stored. It

is the self that may be more difficult to show our clients.

We also have the false self. This is less genuine, real and authentic. This is the self that

strives to please others. This could be the self that always puts the needs of everyone ahead of

their own. It may be the part of ourselves we feel most comfortable displaying.

The final self we have is our public self. Every person wears a mask to some degree. In

some ways, it is protective. A person does not want to let just anyone see all of their true self.

Keeping that mask on at all times can prove to be difficult. As mentioned above, therapists are

often driven and perfectionistic in nature. If one always wears that mask they may put pressure

on themselves to never mess up. When a person tries they are often stuck between hiding their

true self and presenting a lack of sincerity and genuineness that can be evident. In a sense this

stuck person can be out of sync with themselves. If a therapist is unsure of whom they are and

have vulnerabilities, they are more likely to be shown. Being out of touch with oneself can result

in being more easily triggered.

Healthy self care for some may involve learning how to have a balance of the three levels

of self. Learning how to become a more whole and integrated person. If a helper stays out of

touch they are less likely to truly be present to their client.

In a therapeutic relationship that presence can be life changing. When client's come in

they often are sharing some of the most intimate and painful details of their life. As therapists,

being present and empathetic is crucial for continuing that relationship.


However, being present can be difficult. One author observed that "Most of us lead lives

that are increasingly busy. But can we say that they are truly full? How often do we feel guilty if

we're not doing something with our time? And that is just the point. We have forgotten how to

simply be. . . . We ensure life as human beings, not human doings, (Treadway, p. 61)

In other words, our daily obligations and the grueling pace of life can hinder a helper being truly

present to a client.

Another interesting factor that can improve self care is wisdom. This can be defined as

that little voice everyone has that is a guiding force in our life. It might be still and small and feel

more like intuition. However that feels for a person it is important to pay attention. Often it can

tell us things like when we are stressed out or give us an answer when we have none.

The trick to hearing that voice is learning just to be. Surprisingly, this can be a form of

leisure. When a person thinks of leisure often the first words that come to mind are hobbies or

activities. Those things are only a smaller part under this larger umbrella like term. Leisure is

more of an attitude then an activity. Being able to nourish oneself is necessary in a field like this.

It's even more than just being able to nourish oneself. It is the therapist having the attitude that

they deserve that. As Hadler pointed out, taking care of oneself shows a respect for the self.

This concept has been studied. Coleman (1993) found that a therapist who practices leisure is

positively impacted. Leisure promotes things like, fulfillment of personal needs, expression and

creativity and a way of being. Wright (1984) found that leisure decreases burnout in therapists.

Leisure also can be defined as having and maintaining connections. This includes

connections to family and friends. Being connected to a community and having a social support


network. In Adlerian terms it could be seen as striving on the useful side of life. It may also be

seen as having a healthy balance of the three tasks of life; love, friendship and work.

The word leisure has the root word of pleasure. One part of leisure is engaging in

hobbies, interests and activities. Things like exercise, reading for pleasure, relaxation, watching

movies, listening to music or spending time with loved ones can all go under this category. This

term can define any activity that a mental health professional finds relaxing, stimulating or even

calming. It's about finding what brings each individual pleasure.

Authors ----- conducted a qualitative study on the specifics of leisure. Ten therapists five

male and five female were given a chance to write a narrative and semi structured interviews

were conducted about this topic. Results were broken into themes.

The first had to do with leisure as a mindset. Participants reported engaging in activities

like prayer, mindfulness or meditation. It was relaxing for them and calming. It helped to let the

stresses of work go at the end of the day.

Another theme explored was leisure in space. This has to do with a counselor

experiencing the natural elements of life. For instance, activities like taking a nature walk or

watching a thunderstorm. These kinds of activities helped therapists feel connected to the world

around them. Some reported feeling more peaceful in nature or in seeing the natural climate

changes of life.

A popular theme already discussed was that of leisure in the form of connectedness. For

some it meant being involved in church, for others being connected meant feeling like a part of

their community or social group.


The final theme focused on leisure as a reward. It can be either intrinsic or extrinsic. For

a therapist it might be taking a family vacation or going on a trip with friends. Rewards could be

understood as finding validation and encouragement from colleagues or family and friends.

That idea of admiration and self respect were themes that kept cropping up in the research.

Authors asserted that one can be motivated to maintain a healthy self by our desire to have the

respect and admiration of those around us. To be recognized for our individual skill sets and

talents can make even the most seasoned therapist feel a sense of pride. Authors advise that each

person needs a few people in their life in a consistent ongoing way to validate and encourage us.

If one has that, their personal needs are more easily met. This allows them to not seek that from

their clients. Being interdependent on a few can help a person find positive outlets for concepts

like mirroring and feeling fulfilled. Authors observe that a little validation, admiration and

encouragement can go a long way.

If a therapist needs more than a supportive network of loved ones; personal therapy is

another helpful self care strategy. There are times in a therapist’s life where they may need

therapy. The stories and problems heard day in and day out can be draining.

In a study of 155 therapists 90% reported seeking personal therapy at one time or another

in their career. Over half the sample reported experiencing fatigue and personal problems in their

professional life. All participants reported experiencing depression at various times in their

careers. Seeking personal therapy helped to alleviate those types of feelings.

In many professional settings consultation occurs. This gives colleagues the chance to

discuss their most difficult or heartbreaking cases. It is important to take advantage of the


opportunity if given. Many of the authors noted in this thesis advise seeking supervision if

struggling. Again it is important to note that every therapists struggles.

A therapist cannot know everything about every issue. In looking at feelings of

incompetence among experienced therapists authors found that a therapist cannot be all things to

all people. One thing that increased competence in a therapist is to increase one's own knowledge

about particular topics.

This is where the concept of seeking continuing education as a professional comes in.

several authors have asserted that the important skill and mindset of self care do not seem to be

taught in graduate programs. As noted above, some counselors have not learned how to care for

themselves or that it is as necessary as it actually is. Seminars, workshops or graduate school

classes can help to educate all practitioners in the field.

It is important for each therapist to look at their personal motivations as to why they got

into this field. Know thyself is a popular phrase. For helpers it needs to be a reality.

The idea that self care is lacking is more than just a concept. It is a reality for many.

The experiential portion of this thesis centered on education and discussion of students and their

own self care at Adler Graduate School. The author worked to take some of the lessons from the

discussions on self care into a useful summary.

Self care is an important issue. The night of the presentation was surprising. It had been

planned that the presenter would speak in an academic way about the topic for twenty minutes.

Then, the class would engage in discussion for the next forty minutes.

However, those plans quickly changed. People appeared to be interested, attentive and

even fascinated with the topic. The academic portion went smoothly. The concepts of self care,


compassion fatigue, vicarious traumatization and burnout were taught in a basic fashion. There

was so much material to present that it needed to be edited. Thus, the basics of each concept

were only able to be taught.

It seemed that the presenter was privileged enough to not only speak about self care but

educate students on the real meaning of caring for oneself. It was pointed out to students that self

care is not self absorption, selfish or self indulgent. For that is a common misconception. That

misunderstanding can often turn people off to taking care of themselves.

Then we moved into the discussion portion. Many points were brought up. One important

statement was that self care is not taught in schools. Therapists are trained to be empathetic,

compassionate and caring toward their patients. However, they are not taught to care for

themselves. They are not taught that if that self care does not happen, serious consequences can

occur.

Unfortunately, it seems that counselors find themselves experiencing symptoms and then

wondering what’s wrong with them. Instead of prevention of burnout, traumatization or fatigue

the field only sees an increase in these sad phenomena. Rather than practicing prevention we

practice cleanup after the damage has been done.

Another interesting topic that was discussed was the physical body and self care. This is

an important topic. If a professional does not take care of themselves; serious physical

consequences can happen. It may be wise to conduct a qualitative study on the effects a lack of

self care has on the physical body. For instance, people grind their teeth at night. This can have

long term effects on ones mouth. Another professional could have high blood pressure. The


stress could cause them to skip meals or eat unhealthily. This could lead to a messed up

metabolism or obesity depending on one’s personal habits and maybe even heart trouble.

The emotional effects of depression and anxiety were noted. How could one not become

depressed if they are constantly fatigued or suffering with PTSD like symptoms? In other words,

the mental issues seemed more obvious then the physical ones. But, both are very important to

the overall health and self care of the therapist.

Another point that was discussed in detail dealt with a helper’s personality. A student

pointed out that therapists tend to have more of the co-dependent personality. They often have

difficulty saying no and end up taking on more and more. They also worry and want to “fix the

problem for the client. These are all traits that could lead to burnout or traumatization. The

author discusses personality and self care; but, not in such specific detail. There could be

something to the theory that therapists with a more co-dependent personality may have more

difficulty taking care of themselves.

The discussion ended up lasting about two hours. Students were able to personally apply

the concepts to their own lives and work. It was realized by many how important self care truly

is. Many discovered they were experiencing slight symptoms of burnout and stress. They were

able to talk through that. Sometimes, it is hard to see that you are under stress until the symptoms

are pointed out. It was impressive that students were so aware of their stress. Their eagerness to

change it was inspiring. Everyone discussed personal habits of healthy self care. Each came up

with good habits they could practice to reduce their stress.

Finally one other factor that was unable to be covered in the thesis was the added

component of graduate school in a professional’s life. A student goes to work. They may have a


family. They may also have an internship. Then, they have to come to school. Graduate work

involves thinking, reading, writing and discussing. After a long day, it is hard to engage in those

activities. Self care becomes much more necessary yet much more difficult if you are a student.

There are times when the struggling professional needs practical advice on how to take

care of themselves. These concepts discussed are more broad and theoretical. However, having a

list of strategies to present could be useful in developing healthy self care.

The author went out and found a list of 30 strategies to promote healthy self care. These

are all things that are practical, simple and yet meaningful. The list of strategies is as follows.

1. Take a long walk.

2. Check out a yoga video or DVD from your local library, and make time to do it twice

a week.

3. Read a fiction book or short story that you can totally lose yourself in.

4. Write your life story.

5. Daydream.

6. Try a new recipe.

7. Get a babysitter and go to a movie alone.

8. Write a letter to a friend.

9. Smile.

10. Set the timer, close your eyes, and breathe deeply for five minutes.

11. Read a magazine.

12. Clean your house - it's a great stress reliever!

13. Sit outside and breathe fresh air.


14. Get up fifteen minutes early so you can linger over a cup of coffee.

15. Swap play dates with a neighbor so you can each enjoy a few minutes of solitude.

16. Bake a scrumptious dessert just for you.

17. Re-read something that has been especially encouraging to you.

18. Write in a journal.

19. Go to a park and sit on the swings with your kids.

20. Go to bed an hour early.

21. Watch the sunset.

22. Listen to soothing music.

23. Grow something, such as a house plant or fresh herbs.

24. Sit with a cup of hot chocolate or some hot tea.

25. Surround yourself with pictures of the people you love and things you care about.

26. Give yourself permission to say "No" to something you really don't have time for or

are not interested in.

27. Say "Yes" to something you'd really like to do!

28. Express your creativity.

29. Lend a hand to someone in need.

30. Hug your kids!

Finally, it is important to highlight the rewards a person experiences by being in this type

of work. Mahony and Radiky (2000) found that therapists experienced positive benefits in their

jobs such as, increased psychological growth and benefits to themselves and their clients and the

ability to enjoy life more fully. These authors point out that one of the most rewarding aspects is


the relationship a therapist and client can form. It is a unique relationship that most professionals

are not privileged to have with their clients. The amount of trust, care, time and energy that goes

into a therapeutic relationship can be life changing for all involved. It is a rapport that starts off

small yet may have lasting effects. For instance, for the abused woman, the relationship with her

therapist could be the first real example of caring she has had in her life. Again, this is not an

opportunity everyone is privileged to have. It is all the more reason for each therapist to take care

of themselves, so that they can be the best helper to their client as possible.

In conclusion, if a therapist does not actively engage in caring for themselves the results

can be devastating. However, if one has a healthy sense of what self care personally means to

them; they can experience the joys and rewards of being a therapist.


Appendix

My Personal Journey of Self Care

Being a therapist is an awesome responsibility. It carries with it so much weight. People

are coming to me seeking my help, advice, council and support. It is my job to do the best I can

for each and every client who walks through the door.

I stumbled upon this thesis topic purely by accident.

In one class at Adler graduate school there was a video clip that had an impact on me. It

was about a well loved and respected psychiatrist. He had been in practice for several years.

One day he took his own life. It was so sad. Everyone on the video seemed not only devastated

but shocked. I wondered how a therapist could kill themselves. Shouldn't they of all people know

when they are that depressed? I realize how judgmental this might sound. That is not my

intention. It was just that I would hope that as educated professionals, we would see when we

need help and be able to ask for it. It made me wonder why he was not able to. For awhile I sat

with that thought.

A few months later I listened to classmates discuss how burned out they felt at their

internships. It seemed to always be an issue in my internship classes at Adler for several

students. Thoughts of the video came back to me. Maybe I thought it's a lack of self care. But

what was self care? I didn't even know. And so my journey to discover the topic of self care and

its impact on the professional began.

The title of this paper is the hidden treasure of self care. Discovering this treasure took

time and reflection. I honestly didn’t know what a gem I held in my hands regarding this topic.


At first, it seemed like a contemporary and interesting topic to study. However, little did I know

how life changing it would be.

I started out by looking at the concept of compassion fatigue. It was a term I had heard in

passing but again I didn't have a sense of what it meant. I soon learned that the effects of

Compassion fatigue on a therapist were very serious. Interestingly, this type of fatigue is very

common for those who work with the chronically ill. The very sick patient adds a whole new

dimension to self care that I did not have the time to delve into.

Scholars kept emphasizing that there was a lack of self care on the part of the counselor and as a

result this or other serious syndromes developed.

I wondered how effective a therapist could be for a client if they were so worn down. I

wondered how they have a family life if they don't take care of themselves professionally. I had

heard that therapists have a high divorce rate. I wondered if that was true. If so did it have to do

with a lack of self care?

Next, I looked at the topic of vicarious and secondary trauma. I quickly learned how

similar and how confusing these two terms were. Authors would use them interchangeably and

synonymously with one another. However, the terms are different as you have already read.

PTSD was a concept that was continually mentioned and noted in the research on

traumatized professionals. I had only thought PTSD effected soldiers coming back from war or

victims of violent crime. I was unaware that professionals just like me could develop PTSD like

symptoms as well.

It almost breaks my heart to think that a therapist can be so empathetic to the point that

they become fragile or traumatized themselves. In some ways, it shows the care and


understanding that professional tries to bring to each client. It makes sense in that if one chooses

this profession; they are kind and warm and do want to help others.

However, someone once said that the road to hell is paved with good intentions. In this

case, they may have been right. Sometimes what might appear as a "good or admired quality

might just be someone's downfall if taken to the extreme.

PTSD sounds like it can be a debilitating and devastating syndrome to fight through. If a

person has trouble sleeping how do they come to work ready to take on another's problems? If

they are jumpy and exhibit that startled response they may be on guard most of the time. If I

were in that counselor's office receiving therapy I may not feel so welcomed or understood. It

may feel like the therapist is not truly present to me. This could cost the professional business

and that is self defeating.

PTSD can also cause irritability, depression or even flashbacks. If one client's story is

embedded in my mind then it may be difficult to focus on the next patient when appropriate.

A therapist may be more sensitive to a client’s needs because of their own past. When

traumatized it is certainly understandable that the professional may have trouble separating their

past from the clients present. After all, where do they have the energy or time to do that? One

might not have time for personal self reflection or therapy if needed.

The story of the mythical character Chiron seems apt to mention here. Many therapists

truly are the wounded healer. It almost seems as though the professional triggered by a client

could be more vulnerable to being traumatized. In these cases self care is even more important.

Yet, sadly it is barely even taught or studied.


I was surprised to learn that my classmates like the leading scholars in the field predicted

would have misconceptions of what self care is and what it is not. Self care is not selfishness,

self indulgence or self absorption. During the discussion some voiced their feeling of almost

guilt. It was almost as if they too felt like it was selfish to care for themselves. Some said they

just did not have time to care for themselves as they know they should.

Time really is a huge factor. It seems that the days just fly by. 24 hours sounds like a long

time but in reality it is not.

In fact, the time just flies by as a graduate student. Students at Adler often have several

commitments these might include: work, an internship, school one night a week and on some

weekend days and maybe a family. There are many requirements to complete a master's degree.

Balance is key and very difficult as a student. I am inspired by those who have children and still

manage to get their degree. In those cases, students have to care for others before themselves.

Yet, self care is still important, maybe even more so, so they do not burn out.

Currently the world is in an economic recession. Many find themselves struggling to

make ends meet. One might feel pressure to work harder and increase their case load. While this

might work for their pocket book, it may be harmful to their personal lives and self care habits.

Cultural, economic and self pressures can cause one to feel they need to increase their

case load. This is known as a job related stressor when talking about burnout. Having more cases

then one can handle adequately can cause burnout.

In crisis management work or nonprofit organizations burnout may be more likely. For

instance, I did an internship at a short-term youth shelter. As one might imagine, the intensity in

a place like that is high. There is always a client in crisis. The turnover of clients happened very


quickly. As a result, workers needed to stay late or come in early to supervise the teens or to

complete or start paperwork with a new or existing client.

At times, I found it hard to say no when asked to stay late. There were nights when I

would work up to 12 hours on an 8 hour shift. Then I would come back the next day at 7 am to

start all over again. Looking back, at the time I would have reasoned that I was just working hard

for the kids and doing my best.

However, one might guess there could have been some very slight co-dependent type

tendencies in me. I dislike admitting that. However, when that was discussed in the class it made

some sense.

For instance, I always wanted to help the teenagers. I wanted to make sure I did the best

job I could. Again, all of this sounds good and it seems my motives were right. However, after

awhile, it all began to catch up to me.

I found myself worrying about the kids on my off time. I started coming in on my off

days. I felt like I was more tired when I came and went to my internship. I noticed that the zest

and passion I felt for this cause was dwindling.

I ended up leaving that internship not specifically for reasons of burnout but I wonder

how much that actually played a role in my subconscious. This was a good reason for me. It was

truly a learning moment. If I could feel slightly burned out then it could happen to anyone.

As I processed that internship and moved onto my next one, thoughts for my thesis

started coming together. I also felt some regret as to my lack of self care and boundaries. I

wondered how many students or faculty had been in a similar situation as me. I wondered how

many knew the importance of self care and setting good and healthy boundaries. I hope that the


teenagers I worked with at the shelter never felt like I didn’t care. I hope they never saw that

fatigue I tried so hard to mask.

Let me stress how much I cared about this particular population. I think it was my care

for them that made me want to give more when I had nothing left to give. So as the reader can

see my heart was in the right place.

However, the problem with this was when one is burned out, helping someone else or

truly being present to them is not really possible or fair to them. This is something that most

professionals don’t realize. Maybe its denial or maybe it is just the professional wanting to get it

right and help others as much as possible. Whatever the cause, the effects are still damaging to

the client.

For instance, a client may be at risk of being exploited. The power imbalance between

therapist and client might reach a new and harmful level. It is interesting to note that the

decision making abilities of the therapist may decrease if they are not taking care of themselves.

This in turn can effect a client’s treatment and the outcome of their therapy.

After my internship at the shelter I realized I needed to take better care of myself. I

transitioned to an internship where I would go into families’ homes and teach parenting skills. If

I thought I didn’t need self care working with teens, I certainly needed it for this job. To go in to

someone’s home and conduct therapy and teach skills requires a different skill set. It is expected

that I have good boundaries. There are even more policies and procedures to follow. Ethics and

doing things well becomes more important. So, I decided I wanted to “practice” what I would

soon preach.


The first thing I did was decide that I would only take on a certain amount of in-home

cases at a time. This way I could keep up with the paperwork and the various skills I was

teaching each family. Since I was new to teaching these skills I needed to be thorough and

detailed. In order to do that, I needed to have fewer cases and devote more time to each one.

It was important for me to make a schedule that was organized and not so chaotic. My

main theme was balance. I wanted to have balance in time and in case load. I also needed to take

time to be reflective about myself and the issues that would hinder me from properly taking care

of myself.

One issue as I noted above is my personality. I do think that there is a little codependence

in it. It’s not my personality style or type in an extreme way. Most would describe me as strong,

independent and capable. In truth, a little of everything is good. But the key is moderation.

I have found that I am more willing to sacrifice myself for my clients at times. My

teachers have always said never work harder than your client. I’m afraid I have probably done

that at least once.

At times, I would stay late at my internship because I had so much to do. That is ok to

stay late sometimes. However, doing it every day with the kind of intense work I was doing is

self defeating. Knowing that tendency about myself, when it was time to go home or stop

working I usually stopped. I prepared myself for that and just left my internship even if I had

stuff to do. There was always tomorrow.

There is a bible verse that says ‘do not worry about tomorrow for it will take care of

itself.’ It’s a principle I needed to eat, sleep and breathe. I also learned that I needed to develop

my own self care. I looked at what hobbies I had. What could I do that I could get lost in? I


needed a list. A list might sound silly. But for me, it was concrete and I could look back at it and

see ways to care for myself each day.

Some of the items on my self care list include:

Watch either a favorite TV show or sports game to take my mind off of a long day.

I actually was not a sports fan before this year. However, I decided that I wanted to get

into watching baseball to make connections with my clients. Sometimes the work I do is intense

and it’s good to have something easy to talk with them about to build rapport. I found that

worked quite well.

I was pleasantly surprised at how much I ended up liking not only baseball but football

and basketball. Now, when I have had a long day I find myself watching all or part of a game

and it provides a nice escape for me.

Call a friend.

When I call a friend I don’t typically talk with them about anything client related.

Sometimes, it is just good to talk with someone about life. It is good for me to relate to someone

not on a therapy level but on a friend level.

Cooking.

I love to cook. I make up my own recipes. If I can slowly cook a meal it is relaxing for

me. It’s a way for me to be by myself and work on something at a slower pace. In life I rush

around from one thing to the next. With cooking it’s my chance to stop and smell the roses.

Pray.

I am a practicing Catholic/Christian. I gain strength from my faith in God. Every day I

take 20 to 60 minutes to pray. I pray for my intentions and for others. I sometimes pray for


guidance in difficult situations at my internship. Then, there are those times I just sit in silence.

It’s almost like meditating. I sit and allow God to come into my being. It’s in that calmness

where I find my strength. I think that praying for my day and for at times for my clients well

being allows me to let it go. It takes it out of my hands and that is crucial for balance.

Other activities like exercising, socializing singing and reading also help me to care for

myself. Activities like these allow me to lose myself and it changes my focus, so that, after a

long day I can separate myself from the day’s events.

One thing I am learning when working with clients is that therapy is not just something I

do but it is an experience. I am walking for a time on a journey with someone else. In order to do

that, I have to be present. I need to come ready to serve, give, advice and support each client. The

only way I can truly do this is by taking care of myself. This has been a huge discovery for me.

As I conducted this seminar for the class at Adler I found a passion I didn’t know I had. I

saw this passion and eagerness about my topic. I saw that people were hungry for self care. That

they wanted to change what they did and some had already started on that journey. I realized that

not only did they want that for themselves but I wanted that for them too.

I began that night to realize in some ways what a revolutionary topic this could be.

How do I make it revolutionary to people? I spread the message.

I would like to conduct self care workshops. In educating and then leading a fruitful

discussion I saw how impactful that was for others. Could you imagine if one therapist came

away from a workshop with the strong conviction to take better care of themselves? The entire

way they conduct themselves would change. This would have an impact on not only their clients

but on their families and loved ones too.


I asked for thoughts and feedback at the end of the discussion. I did not mention my idea

or passion about these workshops. So you can imagine my surprise when it was brought up.

People didn’t just give me feedback but they were passionate and excited for me to conduct these

workshops. Everyone saw my dream as clearly as I did. It was an amazing half hour of

connectedness and like minded brainstorming. It was like we all saw the importance in them. It

was a very affirming half hour of the discussion for me. It told me I was on the right track with

my passion.

I came to Adler a couple of years ago. I didn’t know why I was supposed to go to

graduate school for marriage and family therapy. I had originally wanted and planned to go to

law school until I was called in a different direction. So when I got here I didn’t understand why

I was here but vowed to do my best and just trust God and obey.

Now I sit here, my journey almost complete. I think I now after much contemplation,

frustration and questioning know why I came to school and why I studied counseling. I am

excited to develop, market, and start these self care workshops. The idea of taking care of myself

is revolutionary and life changing to me. My hope is that it will be the same for others.


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