When Burnout Threatens Therapy with Survivors

Imagine you’re putting a puzzle together, but everything is upside-down. You know the pieces fit, but you don’t know how. Making it whole feels like an impossible task. You start to wonder, How long will this take? What’s the big picture? Am I skilled enough to do this?

This is what it’s like working with survivors of coercive control. We aim to empathize, support, and validate them, but when the work is undermined by the long-term effects of covert manipulation and devaluation, it can cause us to doubt our clinical skills and avoid important topics in session. Often, it leaves us feeling clinically lost and depleted. And if we’re not careful, we start to distance ourselves from these clients in subtle ways.

Over time, a layer of dread can creep into our work. We experience frustration at their lack of progress. We begin focusing on their ambivalence about their relationship instead of what’s really at play. We struggle with a sense of inadequacy and shame, as the client struggles to process their experience as abuse. Even seasoned clinicians may start to second-guess themselves and wonder, Is this abuse, or am I overreacting? The upside-down puzzle shifts around before our eyes, and we can lose important pieces if we don’t understand what’s happening and how to stick with it.

The Impact on Clinicians

Beth first came to me for help because she was experiencing chronic anxiety and intermittent depression. She admitted feeling overwhelmed by the constant tension in her relationship, but she was quick to add that the relationship problems were often her fault. “I’m emotionally unstable,” she said with a self-deprecating laugh.

I looked at her with curiosity. “What makes you think that?” I asked.

She smiled and shrugged. “Paul’s always pointing out how sensitive I am.”

“Did you always feel this way?” I asked.

“Actually,” she said, “I always thought of myself as a fairly easygoing person. I was voted most laid-back in high school.”

“What changed?” I asked.

She shrugged again. “I don’t know. I just feel so reactive. Paul makes all these jokes and wants me to laugh at them, but I can’t. I just always feel criticized, like I can’t get anything right.”

As the session went on, it sounded to me like he criticized her often—about everything from how she interacted with people to where she shopped for groceries—then when she defended her choices, he criticized her reaction. He liked to talk about his interests in voting rights and climate adaptation, but when she suggested it might be nice for him to inquire about her interests once in a while, he said there was nothing much to discuss since they weren’t, in his words, “substantive.”

Beth often felt exhausted, and she’d cut back on seeing her friends because she just didn’t have the energy to interact with other people. The whole thing made her feel angry and resentful. Over time, she’d developed a pervasive pattern of self-blame, and lived in a constant state of hypervigilance. She told me she was seeking therapy because she felt that if she could manage her emotions better, and if Paul saw she was working on herself, maybe the tension between them would ease.

As I learned more about Beth’s relationship, I began hearing other things that alerted me to the subtle signs of emotional manipulation, gaslighting, and isolation. She made sure to tell me about Paul’s positive qualities—he was smart, a great cook, and endlessly resourceful—but she also mentioned that he monitored her credit card statements, arguing he was trying to help her save money, and that he often asked to read her texts, arguing that it shouldn’t be a problem unless she was writing bad things about him. She’d never felt right about either of these things, but she’d gone along with them.

Because I’ve been working with abuse survivors for over a decade, I was putting the pieces of the upside-down puzzle together, but I was hesitant to tell Beth what I saw. After all, it’s hard to predict how a client will react when you inject certain words like emotional abuse and coercive control into the conversation. Will they respond with anger, accusing you of misjudging their relationship? Will they feel misunderstood or ashamed? Will they deny the reality of the situation and get defensive? Will they run out the door? Will they plummet into a depressive cycle of feeling trapped and hopeless? Thinking about all these possible reactions can cause even experienced clinicians to backpedal. I’ve spent many moments outside of sessions wondering, What if I’m wrong? Am I reading too much into these behaviors? How should I approach the client? Will I damage the therapeutic alliance by confronting the abuse?

After a few sessions with Beth, I felt I’d built enough trust with to her to ask plainly, “Beth, do you think that what you’re experiencing might be abuse?”

My question hung in the air, and for a few moments, neither of us said anything. I allowed the silence to just be, giving her the time and space to process my words. After several minutes, she took a deep breath and replied, “I’ve never thought about it like that.”

I wish I could say it was just that easy: bring the abuse and mechanisms of coercive control to the client’s awareness, jump into setting boundaries, and help them reclaim their autonomy. But as clinicians, we know the reality is far more complicated. When a client’s autonomy has been eroded in a coercively controlling relationship, it takes patience and persistence to rebuild it. There are many setbacks. It’s a journey filled with ups and downs, hope and despair—not just for the client, but the clinician as well.

A Tidal Wave of Exhaustion

The door was open, but as with many survivors I’ve worked with, Beth wasn’t ready to step through it fully. There were weeks when she was able to identify and process the impact of the abuse and weeks when she couldn’t. She vacillated between the painful realization of what was truly happening in her relationship and holding on to her love for Paul and the life she’d imagined for them.

For me, there were days when it was hard to remain present with her ambivalence, uncertainty, and indecision. Sometimes I wanted to grab her by the shoulders and tell her she deserved to be valued and respected—period. Unfortunately, this experience is common when working with survivors: clinicians often find themselves feeling tired, frustrated, and helpless. Trying to identify signs of abuse while also validating our clients can be exhausting, particularly when progress appears negligible. If we’re not careful, it can become hard to access and cultivate empathy. We may genuinely believe that we’re containing our frustration and emotional exhaustion, but our highly attuned clients will sense we’ve retreated.

With Beth, I was overcome by a tidal wave of emotional exhaustion about six months into our work. I didn’t see it coming, though the signs had been there. I’d been showing up to our sessions less engaged, less present, and less hopeful than with my other clients. I’d also become more rigid in my posture and more focused on our outcomes. Although I aimed to allow her healing to unfold organically, I struggled to respect her timing and pace.

I’m sure Beth could feel this shift in our work, too. She’d begun expressing more and more doubt about her situation. We both felt stuck but couldn’t quite put our finger on why. One day, instead of trying to get Beth to see the various aspects of the abuse, I decided to have her focus on her internal experiences. “Beth, what are you feeling right now as we talk about your relationship?” I asked.

“I feel trapped but also scared to leave. What if I regret it? What if my anxiety gets even worse?”

Tamping down my desire to tell her that she deserved a healthy, non-abusive relationship, I simply acknowledged her fears and reminded her that her feelings and thoughts were valid. I let her know that it’s a big step to decide whether or not to leave, and that it wasn’t a step she had to take right now unless she felt ready. Staying grounded in my empathy and focusing on her emotional experiences, rather than putting pressure on myself (and her) to “fix” things or rush her process, became a regular practice for me.

Before our sessions, I’d take a few moments to ground myself by focusing on my breath, reminding myself to be present and attuned to Beth’s needs while being aware of my emotional reactions during our sessions. This mindful approach enabled me to create a supportive and nonjudgmental space where Beth could move through her healing journey at her own pace. I checked in with myself regularly, using my breath as an anchoring tool to recognize, manage, and release any emotional reactions or biases that may have arisen. By meeting her where she was, without any preconceived notions or therapeutic agenda about how things should progress, I was better able to support her, stay attuned to her subtle emotional shifts, and respond with empathy, patience, and compassion.

After each session, I made a point of practicing a brief body scan, noticing any tension and residual emotions or reactions. This practice helped me maintain clarity and stamina as her clinician, practice self-compassion by reminding myself of the emotional toll this work can take, and release any unrealistic expectations I’d placed on myself so that I could hold space not just for Beth, but for all my clients.

When I radically accepted that Beth’s journey would be longer than I wanted it to be, I could begin to trust that shifts were occurring, however slowly. Over time, rather than doubting her gut reactions to the emotional manipulation she was experiencing, she began trusting her feelings and slowly rebuilding confidence in her own judgment. Rather than blaming herself for the difficulties in her relationship, she began seeing that she’s not responsible for her partner’s actions or emotions. She understood that the emotional abuse and manipulation she has endured are not a reflection of her worth and actions.

Beth hasn’t left Paul yet, but she’s working on securing her finances and support network for when the time comes. Although there are still difficult moments on our therapeutic journey, there are now many more successes, marked by Beth’s increased ability to trust herself, set boundaries, and reclaim her autonomy.

It’s easy to forget that working with survivors is long-term therapy. So when the work stalls, we need to reframe our self-doubt and frustration as part of the process. After all, we wouldn’t feel frustrated if we didn’t genuinely care about them. In the end, putting that upside-down puzzle together is complicated, and it’s hard to see where you’re going at times, but it isn’t impossible—and it’s entirely worthwhile.