Riding Out the Storm

This article first appeared in the January/February 1998 issue.

Marianne, a gifted, dedicated clinician I’ve known for 15 years, was sitting in front of me with tears streaming down her face. I’d been her supervisor, colleague and, in recent years, good friend. Now, we were meeting to go over a messy case we were sharing. I’d never seen her cry before.

“I just can’t do it anymore,” she said, “I don’t know why. It isn’t just my crazy borderline clients. It’s all of them. I’m just all dried up. I feel like I’m becoming a wizened old crone. At the end of the day, all I want to do is sit in front of the tube, sip some chardonnay and never answer the phone again. And every therapist I know is saying the same stuff. They complain about managed care and all the competition, but I don’t think that’s it. All I know is that I used to love being a therapist; sometimes even more than being a mother. It was certainly easier. But now I just feel spent. I’m ashamed to say this, but I just don’t care in the same way anymore.”

She paused and then flashed a wry smile at me and said, “Well, you’re the burnout guru. How do you keep the spark alive?”

I chuckled ruefully. She knows I’ve been traveling around the country giving workshops called “Keeping the Spark Alive.” I was tempted to give her my standard pep talk about self-care, but I just couldn’t. The truth slipped out.

“I don’t know, Marianne. Sometimes, I feel the same way you do. If I wasn’t giving those workshops, I’d have to be going to them.” We both laughed and I said, “Burnout is like an offshore gale that just won’t quit. Usually, what gets you into the worst trouble in a storm is getting worn down so much by the fear and the lack of sleep that your judgment goes. That’s when you take dumb chances.”

“Well, I hope you don’t think it’s dumb to quit my group practice,” Marianne interrupted. “All we ever do is sit around talking about marketing and money. If I wanted to be a businesswoman I’d have gotten an M.B.A.” I understood all too well what Marianne was describing. Our profession is undergoing enormous, stressful change, and I’ve been confronting my own burnout for a while now. A few months ago, I dragged out of my office at 8 p.m. feeling like a used tissue after 10 hours of seeing clients. My 12-year-old son greeted me with a smile and said, “Hey, Dad, how about some Dungeons and Dragons?”

“Look, Sam, I just got out of my goddamn office,” I snarled, “I can’t play D&D. I’m beat. I’ve had it.” His face whitened and his eyes filled with tears. He whispered, “I’m sorry, Dad. Did you have a bad day with your clients?” His words slapped me. I felt like ripping my face off.

That’s when I fully acknowledged the obvious: I was in the abyss of the burnout that I’ve been cheerfully teaching others how to manage. I felt like such a fraud. Okay, teacher, let’s see you practice what you preach.

Throughout our careers, we all have times when we become so reactive to the stress of our clinical work that we become exhausted, anxious and agitated. Burnout is an occupational hazard. In the 26 years I’ve been practicing, there have been plenty of times that I’ve hit the proverbial wall the way Marianne had, but what I’ve experienced recently seems harsher to me. And as I travel across the country, the frustration and vulnerability that I see among other therapists seems qualitatively different as well. More and more people are talking about cutting back, taking sabbaticals or opening a bed and breakfast in Vermont. Our profession seems to have hit some serious heavy weather.

Go to any national conference and take a look around. Or simply take a closer look in the mirror. Many of us have been practicing for 20-plus years. We are sagging boomers with falling arches, graying hair, sore backs and, most important, tired hearts. Some of us are experiencing profound compassion fatigue. We’ve discovered that the wellspring of empathy isn’t infinite.

Part of getting older and, perhaps, wiser is becoming more aware of the limits of possibility in our lives and in the lives of our clients. Many of us were drawn to the work because our sense of self-worth was defined by our ability to care for others. At the beginning of our careers, most of us would have qualified for that much-maligned diagnosis of codependency. Taking care of others was our own pathway to healing.

Now, after years of practice, we have seen plenty of glorious new therapeutic miracle techniques come and go. We’ve dutifully learned them, tried them on ourselves, practiced them on our clients. Too often, we’ve seen the appearance of dramatic change fade. Does anyone do paradoxical injunctions anymore?

Once I fancied myself as skillful as a heart surgeon. Now, as the seasons pass in my own life and in the lives of my clients, I see that I’m more of an old-fashioned general practitioner. I make my rounds, dispense my limited repertoire of medicines and sage advice, assist at births and sit by the bedside of the dying. It’s good work. But as I now occasionally treat a third generation of clients from the same family, I no longer see myself as a rescuer, miracle worker or surgeon.

Another shock of reality that therapists undergo as the years pass is a more acute awareness of life’s arc. Confronting our mortality and diminishing physical capacity is as important developmentally as going through puberty. We feel the gravity of time as women go through menopause and men lose hair and, occasionally, their erections. As we help our parents die and our children leave, we all face the challenge of how to embrace a dwindling future. Sometimes I sound a little like Prufrock: “Shall I part my hair behind? Do I dare to eat a peach?” Should I roll my Keogh over into a SEP IRA? Some of us tremble before the dark unknown, while others are seizing the moment, planning new careers, reprioritizing their lives. But whether we’re dealing with it or not, there’s a subtle chill in the air. You can feel fall coming.

And, of course, any discussion of therapists’ struggles can’t ignore managed care. Whether we’re fresh out of graduate school or old hands at the trade, we are all confronted with the profoundly destabilizing effect that managed care has had on our profession. We are feeling a loss of autonomy, economic    security and therapeutic integrity. Our society has decided to reduce health care costs by cutting back on the care of the mentally ill and the walking wounded. More than ever before, we are competing against one another in a shrinking marketplace. Like the auto industry in the 1980s, we are being downsized. Our sense of common mission and mutual support as a professional community has been shredded by our growing fear that many of us will be driven from the field. The whispered words in conference corridors aren’t about difficult cases anymore, but about managed care panels; not about treatment plans, but referral sources.

And as the profession’s economic base has eroded, most of us are working much harder with virtually no institutional support for our supervision or continuing education. As a new clinician 24 years ago at the Philadelphia Child Guidance Clinic, each week I had an hour of individual supervision, two hours of peer supervision, a two-hour family therapy seminar, an intake worker who scheduled all of my new cases and a caseload of only 22 clinical hours. That kind of professional nurturance is unthinkable today. More than ever before, we are isolated individuals operating behind closed doors. And while resources and support dwindle, clinicians are hearing different kinds of stories in the treatment room than they did 20 years ago. The veils that covered the ugly secrets of American family life have been swept aside, and we are forced to look repeatedly at the cruel truth that serious abuse is not an uncommon event in children’s lives. Gone are Ozzie and Harriet, as we are increasingly confronted with episodes of little girls and boys having their bodies violated by parents, uncles, teachers, priests and babysitters. Over and over again, therapists working with these clients find themselves experiencing vicarious traumatization. We are constantly faced with our own helplessness and inadequacy as we recognize the limits of what we can do to help shattered adults bear the unbearable.

The plethora of today’s theoretical and clinical approaches can also leave many of us bewildered and confused about the very nature of therapy. How do we sort out what is truly therapeutically important on any given case? For example, one of my supervision groups was discussing a tangled case involving an acting-out adolescent. During the heated discussion, we suggested individual therapy, family therapy, Ritalin, Prozac, group treatment, an Interven-tion, residential care, EMDR, tutoring, boarding school, AA and even Outward Bound. By the end of the conversation, the poor treating therapist put up her hands in mock surrender and said, “How about if we just wait and see if the kid grows out of it?”

We all laughed. Our group had exhausted itself with the wealth of our ideas. In the family therapy world of old, we started with the simplistic, assured models of treatment that gave us a sense of mastery and competence. Now we are so sophisticated that we find ourselves wading through an endless variety of possible ways of conceptualizing a case and designing a treatment plan. How do we choose between family, individual and psychopharmocological approaches? How do we achieve differential diagnosis and treatment, matching the right methodology to each case? Many of us feel both wiser and less self-confident because we are so much more acutely aware of how much we don’t know.

Each of us experiences burnout in his or her own way. It is as individual as a fingerprint. Sometimes we don’t even recognize the danger signs of burnout. Until the moment I exploded at my son for wanting to play a game, I was unaware of my exhaustion and agitation. Conscious burnout drains us; unconscious burnout is often taken out on the people we love. Our challenge isn’t to avoid burnout, but to handle it well when it comes. When the large, rolling swell and the greasy sky warn of heavy weather and you are far from port, the best thing you can do is get ready to ride it out. You reef your sails, lash down everything on deck, heat up some soup and try to rest.

We all have to develop our own survival strategies. As I’ve begun to confront my own alienation from my work, I’ve been listening carefully to my clients, students, colleagues and friends. Here are some of the suggestions I’ve gleaned from them that I’m trying to practice myself.

Don’t go it alone. When I asked a workshop audience in New Hampshire for their ideas about how to handle burnout, one man said, “Well, everybody knows you don’t climb Mount Washington alone. It’s no different in this business.” He’s right. Many of us practice in too much isolation. When burnout hits, we often feel ashamed of feeling inadequate and overwhelmed, and so we retreat further. None of us should be flying solo. We all need to be in a peer group, maintain supervision and attend conferences in order to have a sense of community and belonging. We need to reach out to one another as we do this work, just like climbers are tethered together as they make their way up the rock face.

I violated this principle last year while treating three severely suicidal clients, until I became totally exhausted. I finally surrendered my idiotic pride and went into weekly supervision. As I tried to maintain a grip on these people at the edge of the crevasse, my supervisor held onto me. Why did I wait so long? Well, why does it take a million sperm to fertilize just one egg? Because none of them will stop and ask for directions. Don’t climb Mount Washington alone.

Maintain beginner’s mind. My colleague Sandy is an expert in treating borderlines and clients with eating disorders. It’s thoroughly depleting work, yet she seems vibrant and energized. When I asked her secret, she said, “I’m always passionately involved in learning something new: one year it was quilting, last year it was EMDR and–you’re not going to believe this–now I’m taking flying lessons. And I love it. All of my difficult cases just disappear from my mind when I’m learning something new. All of a sudden I don’t have to be an expert anymore. It’s just like being in first grade again. You work hard, follow the directions and then one day you know how to read! Each step of progress gives you a new sense of accomplishment. It doesn’t matter whether you’re being a student in your clinical work or in a hobby. It’s about the freedom not to know the answers and to take in rather than give out. Last Sunday morning, I went out to the airport, sat in the cockpit of my instructor’s Piper Cub and went over the manual before my lesson. I looked at the schematic of the control panel on the page and the dials and switches in front of me. I closed my eyes and found each instrument by feel. Then I sat there and visualized the runway, the takeoff and being airborne. My clients were as far away as the tiny cars on the road when you look down at them from 3,000 feet.”

Too often, as therapists, we’re expected to know what we don’t know, be decisive when we are unsure, be helpful when we feel helpless. The best antidote is to be a student again. No matter how old or established you are, always have a teacher. Being in the student position is a way of being nurtured and staying open.

Maintaining a beginner’s mind is not only an antidote for surviving your practice, it’s also the basic stance from which to do the best therapy. When I am not lost in my own sense of self-importance and over-responsibility, I remember to let my clients teach me. I remember that they are the experts and I am the student. Holding on to beginner’s mind is not just a hobby, it’s a way of life.

Prioritize. One of the consequences of our increased economic fear is that we are working harder. Very few of us feel comfortable turning down a referral, and many of us are reducing fees, so our hourly return has dropped. We add more hours at the expense of our spouse, children and friends. How often have I challenged my clients with the comment, “No one has ever said on their deathbed, ‘Gee, I wish I had spent more time at the office.’ ” But my glib wisdom wasn’t reflected in my own life. I remember all the times I glanced out the window past my clients and saw my older son when he was little, sitting by himself on the swing set. Now he’s 20 and gone. My clients are still in my office. The swings are empty.

My friend Marianne has made another tough decision that challenges me to think about my priorities. She said, “One of the things I’m going to do is give up some of my expensive trips and take a morning off every week instead. I love those trips, but I just can’t keep working so hard to pay for them. I’ve got to give myself some time in my own home. I’m killing myself most of the year to escape for a few weeks. That’s nuts.”

She’s right. The consumer culture  drives us all insidiously. We never know what is enough success, money or happiness. All of us need to address realistically what we need materially as opposed to what we want. Could I have spared a client hour in the afternoon to play a game of catch with my older son while he was growing up? Fortunately, Sam’s only 12: I still have time with him.

Stop for a refill. It isn’t just the exhaustion of working too hard that leads to burnout. When I was most fried, I retreated into clicking through TV channels, watching sports endlessly. I did it “to relax,” but at the end of several hours, I would feel more jagged and edgy than before. You know you’re in trouble when your relaxation techniques leave you more stressed. Whether it’s vegging out in front of the TV, overeating or overdrinking, playing solitaire or losing yourself on the Internet, we need to watch out for numbing-out activities that don’t provide either genuine escape or comfort. We all need downtime, but we have to be wary of the kind that makes us feel worse. We know exercise, meditation, eating well and hobbies wake us up and are restorative, but we often think we’re too tired for energizing activities.

Many of you are much more disciplined and skillful than I am in maintaining good self-care practices. But my work with addictions has taught me that past failure is no excuse to avoid renewed efforts. “One day at a time” really does work. Lately, I’ve been dragging myself out of bed half an hour early to meditate and write in my journal, and after dinner I force myself out into the cold, dark winter to drive to the pool and swim laps. Is this fun? Most of the time, I grumble about it. Yet, I know that starting the day centering myself prepares me for the onslaught of my clients, and that plowing through the water releases the day’s toxins. And lest you think that good self-care is all work and no play, I also indulge in a full-body massage once a week. The paradox of all this extra time I’m devoting to myself is that I have more energy for my clients and more enthusiasm for playing D&D with Sam.

We wouldn’t try to drive across the country without regularly stopping for gas and checking the oil. Treat yourself as well as you do your car. Stop for a refill.

Therapist, heal thyself. One of the most acute manifestations of burnout is loss of confidence in our own work. Yet, it’s the nature of our profession that a sense of mastery will be elusive and inconsistent. During burnout, our loss of self-confidence can activate our old, unresolved issues that we have carried from childhood and have dealt with many times before. Many of us resist recognizing when it is time to go back to our own therapist for a tune-up or even a major overhaul–“Been there, done that.” We don’t want to face how many unresolved issues we still carry around, especially if we’ve completed our therapy and have been treating others for a long time.

My colleague Eric wasn’t happy to see me when he came back to therapy last fall. “Don’t take it personally, but I really didn’t want to be here. I’m so bored with my issues. But I feel like everything is kicking me now that I’m taking care of my parents, who are still the same old drunks they always were. I’m the same old me: still fighting with my father and protecting my mother. The house is so empty without the kids that suddenly I feel like all the old demons have just moved back in again. And lately, I’ve been looking at my clients and wondering if people really change anyway. Maybe I should just skip talking about it and head directly for Prozac, but I hate the idea of taking drugs.” I felt the same way when I went back into therapy in my mid-forties to deal, once again, with my mother’s suicide and the rest of my family-of-origin mess. How discouraging to discover that the cure didn’t last. But as they say in AA, we’re never recovered; we’re always recovering. And therapy isn’t the only answer. Some of us need to confront our ambivalence about taking medication. Many therapists who are quite skillful at persuading their clients to try antidepressants are ashamed of their own use of Prozac. But if it’s good enough for them, it should be good enough for us, too. Eric benefited enormously from a combination of therapy and six months of Zoloft.

In addition to therapy and/or medication, therapists in the midst of burnout have available to them the full range of alternative healing possibilities: daily affirmations, meditation, acupuncture, spiritual direction, massage, journaling, support groups. But we say we don’t have the time. For example, we know that regular meditation is beneficial, and yet when I ask my audiences of therapists what percentage of folks meditate regularly, invariably only a few hands go up. Six months ago, I began a bare-bones meditation technique that only takes three minutes. I call it the soft-boiled-egg meditation. I’ve been using it for releasing the self-doubts, insecurities and frustration that I’ve been experiencing. No matter how busy and harried I am, I can always devote three minutes a day. No excuses. Here’s how it’s done:

Minute 1: Breathe slowly and deeply while focusing on the physical experience of breathing. Just notice the breath going in out of your nose and lungs. Let your thoughts float through your mind like soft, puffy clouds across a summer sky, like wind ruffling the leaves in the trees, like waves rolling up a beach. In other words, do the standard meditation for a minute. When your thoughts distract you, gently refocus on your breathing.

Minute 2: Continue to deep-breathe and, for one minute, focus on whatever negative thoughts are bothering you. “I’m a fraud. I’m too old. I’m tired of my clients. I’m not that good a therapist. I’m frightened. I failed as a parent. The readers are going to think this exercise is so gimmicky and superficial.” Whatever. If you run out of angry, anxious, insecure thoughts, then just start your list over again.

Minute 3: Continue to deep-breathe. Now imagine yourself in a place that is a soothing, comforting sanctuary. It may be sitting by a rushing brook, walking along the beach or hiking in the mountains; any place where you feel calm, relaxed and accepting of who you are, with all of your flaws and strengths. Notice all the details of the place, the sights and the sounds.

That’s it. Do it at the same time every day, just like brushing your teeth. Don’t expect it to have the same effect as traditional meditation; it’s too short. Sometimes it will feel good, sometimes your negative thoughts will stick, sometimes it will be ho-hum. Just let it be.

The reason why such a short exercise is helpful is quite simple: Always trying to block out our insecurities, fears and frustrations is exhausting. By setting aside a time to give free rein to your negative thoughts while combining them with deep breathing, you release them rather than fight with them. Slowly, over time, you learn how not to run from your own shadows.

Sit still. Breathe. It’s only three minutes a day.

You’re not it. Ultimately, the root cause of burnout is losing touch with our spirtual center. We have to find a way to connect our small, insignificant lives to a pattern of purpose and meaning in the universe in whatever way we understand it. This sense of belonging allows us to soldier forth every day, knowing that being responsive to our clients’ suffering can make a difference, and that we are not responsible for their lives.

Many of us struggle to reconcile our rational minds with our yearnings for spiritual beliefs. Years ago, a friend of mine presented a lowest-common-denominator description of the Higher Power that bypasses tangled questions about God and gets to the heart of the matter. We were presenting to a group of freshly minted social work students on the subject of spirituality and A.A. My friend, a talented social worker and a longtime member of A.A., has a tough, blunt speaking style that sometimes belies the twinkle in her eye.

She said to the audience, “When I was an active drunk, I was an atheist and I didn’t believe in any of this God crap.”

The audience gasped and stared at her expectantly.

She went on, “Now, I’ve been sober in A.A. for 15 years, and I’m still an atheist and I still don’t believe in any of this God crap!”

The startled audience froze as if she had spoken blasphemy.

She glared at them for a long while and then said, “There’s only one thing you need to believe to have the healing presence of the Higher Power in your life. The only thing you need to know about the Higher Power is you’re not it!”

Time and again, I’ve walked into my office with my suicidal clients repeating the mantra, “Remember, David, you’re not it.” And then I ask for help. I don’t know if God is on the other end of the line when I pray, but I do know that prayer is good for me. It puts me in a right relationship to the universe. It puts me in touch with how little I am and breaks through my presumption of grandiose self-importance and sense of responsibility. It frees me to do my best and turn over the rest.

What’s the nature of your spiritual life? Does it nurture you or burden you? When in doubt, remind yourself that you’re not it. In the end, beneath the theory, rhetoric and technique, being a therapist challenges us to learn how to let our clients touch our souls as we touch theirs. If we do, then, sometimes, grace happens.

Working through burnout is like riding out a gale at sea. You can’t just bash into the wind and waves. You have to shorten sail, slow the boat down and run before the oncoming seas. You have to accept being driven way off course. Although your tactics will vary depending on the boat you’re sailing, the crew needs careful preparation, good teamwork and, most of all, steadfast patience. You have to surrender to the power of the storm.

During my recent period of burnout, there were many days when I was just trying to bull my way through each clinical hour. Finally, I surrendered. I reduced my caseload, went for supervision, asked my friends for support and began to practice better self-care. I fantasized about career changes and prayed for help. And I just plain waited.

At sea, when you’re miserably cold and wet, tired and scared, you forget that the storm will pass. You have to learn to go with it rather than try to fight through it. You have to wait. However, slowly but surely, the moan in the rigging will diminish, fewer waves will break on deck, the rain will slacken and patches of sunlight will appear in the western sky.

Illustration by James Endicott