During this bizarre and painful epoch, which is plagued by pandemic, racial trauma and social injustice, more and more emphasis is rightly placed on the well-being and self-care of doctors.
Countless articles and blogs have been written about self-care by counseling clinicians, and here is one more. Why write another one? Because as a consultant, educator and supervisor, I want to sell you a different goal than being okay to work. Because avoiding burnout is not enough. We have to raise the bar to make care competent. Make no mistake, this is an ethical question.
Like many perhaps I have always worshiped Latin in a way that emphasizes the meaning of a phrase or idea. Whether carved in corner pillars or encircled by university seals, Gravitas has a tradition. One idea that I find so awe-inspiring, as it relates to psychotherapy and behavioral health, is that clinicians must "do their own work." Therapists need to heal.
Whether through traditional talk therapy or other means, therapists must deal with their own trauma, developmental journeys, and growth. While the Hippocrates often quoted phrase "primum non nocere" (first, do no harm) is a vital doctrine for mental health, I suggest that an overlooked and sequentially more important step in relation to primacy is required to avoid harm: that Therapists deal with and treat their own problems.
Although therapists are often told that they have to take care of themselves and "do their own job", I don't think there is enough understanding why this is so important. Yes, it benefits the therapist, it can alleviate burnout and increase the longevity of on-site professionals. In my view, however, not enough emphasis was placed on the idea that people who are not doing well are not competent therapists
This does not mean that people who have suffered trauma or who previously met criteria for a behavioral health diagnosis should not work as therapists. Far from it. Many of the best therapists I know are as good as in large part because of the difficult roads they had to walk.
There are many ways to describe how therapists who do their own work can influence them professionally, but I will focus on three ideas:
1) Your nervous system is a tool for bonding and relationship and it depends on how much work you have done.
2) As you get your job done, you can project less and become more aware of your projections.
3) When you get the job done, you need to be able to really relate to what your patients are going through, rather than just understanding. (Note: Although I say "patient," feel free to replace "client." The reason I prefer the patient is because I think that this better emphasizes the connection between the physical and the psychological realms, and that current understanding of the field for the connection between the patient In both cases I intentionally use a language that fits into both lexicons.)
The nervous system
In a typical stress reaction, a perceived threat can activate the amygdala, which leads to the release of adrenaline and coordinates a sympathetic reaction to the stressor. Typically, this type of sympathetic activation means that you no longer use the circuitry associated with optimal social engagement (is it harder to tell how other people feel when you are angry?).
The system of social engagement is characterized by the feeling of social connection, the ability to read social cues, eye contact, voice modulation and comfort. All of these things are turned off when we go into sympathetic activation as part of a stress response.
Imagine, a therapist who has not “done his own job” and is sitting in his office and listening to his patient describes a traumatic event. Even if an activated therapist doesn't make an obvious facial expression or gesture, how do you think the person sitting across from you is affected by the therapist's nervous system as it switches from social engagement to fight or flight?
Imagine for a moment a scared child running to a parent or caregiver and confronted with warm eyes, a soft smile and a soothing voice. Now imagine that the same child is faced with frightened eyes, decreased facial muscle tone, and a flat voice. In what situation will the child be better?
A similar dynamic takes place in therapy. This means that the therapists 'ability to stay in their social engagement system affects the patients' likelihood of being okay while doing things like trauma work. Part of a therapist's job is to use their nervous system to support a patient's nervous system. For some, it will take significant and ongoing work to do this well.
Consciousness
Awareness and projection share a simple relationship: the more aware you are of your projections, the less likely it is that you inadvertently allow those projections to affect your relationships with others.
Regardless of the theoretical basis, modality or clinical philosophy, practically all types of psychotherapeutic work consider the relationship between therapist and patient to be instrumental. So if the therapeutic relationship itself is one of the main means by which therapists practice their profession, and a lack of awareness can lead to one's own projections affecting relationships with others, it must be argued that therapists are on ethical grounds when practicing without having cultivated enough awareness and done enough work to overcome this potential danger.
You miss your patient when you can only see your projection. You will not realize that it is a projection unless you have cultivated enough awareness.
Based on
There is a difference between understanding what someone is going through and being able to really relate to it. While psychotherapists are undoubtedly a sensitive bunch, helping someone get involved in the process of developmental growth that goes beyond growth is not an easy task.
Imagine for a moment a 40 year old in the midst of an existential crisis. Now imagine a sensitive and well meaning 14 year old trying to help this 40 year old. Unfortunately, a stage of development is not always as clear as chronological age, and this can create blind spots for doctors that can adversely affect the quality of care. It is important to be able to really relate to what your patients are going through and the 14 year old will have a hell of a lot of time to help the 40 year old.
Continue with your work
The thing to which all of the above ideas are limited is the relationship. It is your job to ensure a helpful clinical relationship, and the relationship itself is the greatest clinical tool you have. Ensuring that this primary tool is functional or even optimal can take time, effort, and a willingness to endure the ailments necessary for growth.
Of course, more basic daily self-care is still important to combat burnout and take care of yourself, especially when your job is to look after others, and especially at times when nobody seems to be okay. The invitation, the challenge, the mandate is not to stop at “resources”.
Aim higher. Embrace catalysts for growth and development. Familiarize yourself with discomfort if it means a potential breakthrough. Do it for you. Do it for her. Do it like it's your job.
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Samuel Kohlenberg is a clinical psychophysiologist, licensed professional counselor, and behavioral counselor who specializes in the treatment of stress. He holds a Master of Education in Health Professions from Johns Hopkins University and a postdoctoral fellow at Saybrook University and works in a private practice in Denver. Contact him through his Facebook page or through his website at denverstressclinic.com.
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It should not be assumed that opinions or statements in articles appearing on CT Online represent the opinions of the editors or guidelines of the American Counseling Association.
