The Importance of Self Care for Therapists

I have worked as a psychotherapist for several decades in many different professional settings. While there have been great advances in our therapeutic interventions, up to recently there was not much attention paid more to the issue of self-care for mental health professionals. This in some ways still is a somewhat neglected topic and denial or failure to acknowledge these issues can have implications and costs to us as individuals and, as a consequence, to our clients and the delivery of therapy.

There is considerable research showing that mental health practitioners can experience many psychological problems running on a continuum from transient distress to burnout and more serious psychological issues, sometimes requiring professional intervention. Research reveals that;

• at least 3 out of 4 therapists have experienced major distress within the past three years.
• over 60% have experienced depression at some time
• one in four have experienced suicidal thoughts
• one in 16 have made suicide attempts

This is a serious problem which until relatively recently has been neglected in the literature and more importantly in training, research and practice.

I can still recall how shocked I was several years ago when I heard that two Cognitive Behavior Therapists, in my home country of Ireland, had committed suicide. They no doubt had colleagues, family and friends, not to mention professional services, to provide support. So, I couldn’t help but wonder did they ever talk about their issues with anyone, did anyone notice their distress and so on. We will never know but it raises the question, how can we better look after ourselves and others in this demanding field we work in.

More traditional Behavior Therapists and Cognitive Behavior Therapists have tended to ridicule the psychoanalytic tradition of personal analysis, as evidence of the follies of this approach. However, we non-psychodynamic therapists, may have been guilty of going too far in the other direction and, maybe, subscribing to an irrational belief that we, as therapists, should never have any personal issues/problems and should be emotionally stable at all times.  

Given this high prevalence of stress\distress, how many therapists seek help or even acknowledge they are struggling emotionally. I would suspect that the number is very few, based on my own and my colleagues’ experiences. An issue here may be that therapists and counselors have difficulty reaching out for help for various reasons . When I needed some short-term therapeutic help at an earlier stage in my life, I know I had trouble in initiating this process. Why? An analysis (Cognitive Behavioral) of my own anxiety and shame reactions uncovered some dysfunctional beliefs such as “I should be in control of my emotions, since I know all this stuff”, a belief I would have used CBT to question and/or challenge in any of my clients. I would guess that dysfunctional beliefs about seeking help or admitting that there are problems, probably, exist in many mental health providers. But herein lies the beauty of CBT. It is reflexive. It will work just as well to combat our own dysfunctional thinking and behavior, as it does to help our clients. So, maybe it would be good to practice what we preach!

The key question is how do we all become more adept at recognizing and intervening in cases of therapist or caregiver distress, our own or others. It may be helpful to consider working at number of different levels depending on the nature and severity of the issues.

1. Self-therapy.   A Cognitive Behavioral conceptualization can greatly aid in understanding distress in the professional caregiver and CBT and related interventions can help in alleviating such distress. It is patently obvious that we are not immune to the same emotional changes that we help our clients to process and manage. We may be responding in a maladaptive way behaviorally, cognitively and emotionally to both work-related and non-work related situations. In a similar way to how we present and help demonstrate the cognitive behavioral model to our clients we might think about this relates to ourselves following the model outlined below.

A therapist or mental health provider experiencing distress might find it very helpful to apply this cognitive behavioral analysis to professional and\ or personal distress. Readers will, of                 course, recognize in the above the strategies they may use frequently with clients. Am I alone,             however, in my conjecture that we don’t do such a good job in applying these CBT tools, of               known effectiveness, to ourselves?

• Supervision This .can be very helpful in these situations. Supervisors should be sensitive to the more personal reactions of their supervisees to this work we do. Supervision isn’t just about how the supervisee’s clients are doing or how techniques are applied, it should crucially involve looking at the supervisee’s anxieties and other issues, related to working with certain clients or the stress of being a therapist in general.
• Organizational support. This can facilitate at-risk individuals (not based necessarily on their personal characteristics but on the kind of work they do) getting peer support or professional help and can be extremely helpful. I was very moved recently when observing a therapist colleague in our weekly staff meeting for clinicians feel safe enough to, with great courage, speak emotionally about the impact a client’s suicide had had on her and to receive many very supportive and compassionate responses. This was a sign of changing times and greater openness about these issues.
• Training programs. Trainings offered either in graduate school or through Continuing Education providers could do more to highlight these issues and ways to cope with them. Only once, in the course of many years of post-graduate clinical training, did I receive a seminar on therapist stress and how to manage it. This neglect fosters the dysfunctional beliefs that we are miraculously immune to the same issues which affect our clients. Similarly, national conferences and trainings rarely offer workshops on these topics. In a related vein, there are few CBT books and articles on this topic but thankfully this situation is improving.      

There now are a range of CBT techniques which can be mutually beneficial for both therapists and their clients (Bamber, 2006; Kennerley et al 2010: Ludgate2012). In the broader field of psychotherapy in general, John Norcross and Gary Vanden Bos have an excellent book Leaving it at the Office, now in a second edition (2018) which is a great resource for self-care strategies. I would also highly recommend Kelly Wilson’s Mindfulness for Two; An Acceptance and Commitment Therapy Approach to Mindfulness in Psychotherapy (New Harbinger, 2008) which demonstrates the use of mindfulness and allied strategies for the therapist while he\she is simultaneously engaged in instructing clients in the use of these techniques.

Further reading:

Bamber, M. R. (2006) CBT for occupational stress in health professionals; Introducing a schema focused approach. Routledge.

Kennerley, H., Mueller, M., & Fennell, M. (2010) Looking after yourself. In M. Mueller, H. Kennerley, F. Mc Manus & D. Westbrook (Eds) Oxford Guide to Surviving as a CBT Therapist. New York: Oxford University Press.

Kottler, J. (1999) The Therapist’s Workbook: Self-assessment, Self-Care and Self-improvement Exercises for Mental Health Professionals. San Francisco: Jossey-Bass.

Ludgate (2012) Heal Yourself; A CBT Approach to Reducing Therapist Distress and Increasing Therapist Effectiveness.   Professional Resources Press.

Norcross, J.C. & Vanden Bos, G. (2nd Edition) (2018) Leaving It At the Office: A Guide to

Psychotherapists Self-care. New York: Guilford.

Wilson, K. (2009) Mindfulness for Two. An Acceptance and Commitment Therapy Approach to Mindfulness in Psychotherapy. New Harbinger.

John Ludgate, Ph.D. works at the CBT Center in Asheville, NC and is author of the book “Heal Yourself: A CBT Approach to Reducing Therapist Distress and Increasing Therapeutic Effectiveness” published by Professional Resources Press in 2012.