Therapists in the Patient’s Chair

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As we endure the third summer of COVID-19 and a wave of divisive social and geopolitical conflicts, many Americans are feeling the need for mental health support. As the younger generations move beyond the stigma previously surrounding mental health treatment and seek it out, pediatric therapists are at the forefront of efforts to help shoulder the burden during these “unprecedented times.” Unfortunately, new crises continue to emerge, and the need for compassionate and competent therapists continues to grow. In fact, 30% of therapists report seeing an increased patient load amid the pandemic,¹ and many clinicians feel pressure to take on extra patients.

One question that remains is: What happens when therapists themselves start to feel stress and anxiety about the state of the world? Who cares for these caregivers? Unfortunately, many therapists today are experiencing “compassion fatigue”: a condition that describes the physical, emotional, and psychological impact of taking on patients’ suffering while also managing their own.² This condition may drain therapists of empathy to give, which can threaten both the care they can provide to patients as well as their own health and longevity in the profession.

As a clinical psychologist and a clinical senior manager at a pediatric behavioral health platform, I am always looking to be proactive about how to best support my team of therapists to combat compassion fatigue. Addressing this topic head-on protects both the individuals involved and our collective ability to continue to provide great care through challenging times. In this article, I have summarized some of the coping skills and mindsets that I use and encourage therapists to try in order to prevent compassion fatigue.

Caring for Others Means Caring for Yourself

First and foremost, therapists must practice what we preach in setting ourselves up for success, starting with the basics: eating well, moving our bodies, and getting enough sleep. Beyond individual habits, managers of therapists should also support their staff’s self-care after hours, put a healthy work-life balance at the heart of their culture, and model a healthy lifestyle to staff members.

I feel strongly that every therapist should also seek out peer groups and therapist consultation groups. Having a professional support system with individuals who can understand and relate to the struggles of compassion fatigue in the field can be especially validating, providing new and helpful insights. Even for therapists who work independently, it is absolutely worthwhile to create a professional network that can relate. In private practice or in more structured group practice settings, therapist consultation groups are a must, providing a safe space for therapists not only to discuss cases, but also to share one another’s feelings of burnout while offering suggestions for coping.

Finally, in terms of preventing burnout, I think every therapist should think critically about the workload they can realistically handle without sacrificing the quality of care they can provide. I encourage therapists to recognize that finding ways to provide good care to a few individuals in a sustainable way is ultimately more helpful than trying to provide care to all and risking the need to leave the profession altogether.

Allow Your Feelings In

In addition, there are psychological tools and mindsets that may be necessary for therapists to engage when it comes to providing care over the past couple of years. At this point in history, it is absolutely justified to be experiencing feelings of defeat, numbness, and exhaustion. However, just as we do with patients, therapists may consider practicing mindfulness of these thoughts and feelings to get some distance. As most therapists know, mindfulness in this case means becoming aware of the thought or feeling and allowing it to be there without either rejecting it or holding on too tightly.

Much of my advice on this topic comes from my training in dialectical behavioral therapy (DBT). As is acknowledged in DBT—which in turn draws on centuries of Buddhist philosophy—pain (or discomfort that we cannot control) is an essential and inevitable part of the human experience. However, rejecting this pain—or attempting to justify, argue, or fight it—leads to a different state: suffering, which is defined as pain plus resistance. DBT teaches that suffering can be avoided through careful practice and utilization of acceptance and mindfulness skills.

For therapists trained in DBT, I believe applying these skills to their own feelings is 1 way to do this. In fact, a 2017 exploratory study among DBT therapists found that when therapists reported regular DBT skills use, this was a predictor of decreased burnout.³ Therefore, I think it is important that therapists in today’s environment are aware and accepting of the pain that comes with our jobs, while remaining wary of the temptation to spiral into suffering as we fight against what we view “should” be the state of the world and our patients.

Balance Acceptance of Today with Action for a Better Tomorrow

Finally, amid a persistent pandemic, social reckonings, and relentless economic insecurity, I think a second driver of compassion fatigue is that it can feel challenging for therapists to maintain a sense of agency.

DBT also provides a framework for how to think about this issue. As therapists, we have to balance acknowledging and accepting our feelings (including pain) with looking for ways to encourage incremental change. This is what is known as the “core dialectic” in DBT: We can honor both acceptance and change at once.

Therefore, just as much as I value accepting the tough feelings and avoiding wallowing in what the world “should” look like (eg, suffering), I also think it is important for therapists to resolve to change what they can by focusing on what is within their locus of control. In the global sense, that might mean attending a demonstration, getting vaccinated against COVID-19, or sending letters to politicians to advocate for policies and budgets that increase mental health care access.

Relatedly, I think it is also important to weigh acceptance and change concerning the fact that there are entrenched systemic issues within our health care system that make it difficult for therapists to find balance. While it is not therapists’ responsibility to shoulder this burden alone (acceptance), it can help to focus on what we can directly affect (change). For example, some therapists may choose not to accept insurance and to provide care on a sliding-scale basis, but to spend some of their free time advocating at the state level for better reimbursement rates so that these sliding scales are not necessary.

To give a related example: Throughout my clinical career, I have worked with teens with significant nonsuicidal self-injury and active suicidal ideation. In these cases, it is well-known that it is very difficult to provide appropriate care in the setting that is accessible to most families (in-network, weekly outpatient therapy), but it is even more difficult to find referrals for more appropriate intensive options for therapy such as full-program DBT—which is unfortunately often only accessible via a year-long waitlist or extremely expensive out-of-pocket payments. This work in particular helps to illustrate the importance of the balance between acceptance and change.

When working in standard outpatient care settings, I have had to accept that while the care I can offer these teens is not exactly what I would like them to receive, it may be the closest thing that they can access at the present moment. At the same time, I have resolved to focus on change by taking time to advocate at all levels for more access to intensive, evidence-based programs like DBT to be readily available to teens who need them at record rates.

I am glad to see that there has recently been more acknowledgment of the mental health care system’s gaping holes and that we are beginning to see innovation—like the model we have at Brightline—to address them. Although it is unfortunate that an extraordinary situation like the pandemic was needed to bring mental health to the forefront, I am hopeful that as a result, we will see longer-term policy changes that accurately reflect the value of therapists’ time and expertise.

Concluding Thoughts

Overall, the pandemic has laid bare the important role that mental health clinicians serve in society. However, even the most highly trained and skilled mental health professionals are not immune from compassion fatigue and burnout. Therapists need to take care of themselves in all the ways we advise our patients, allow space for pain (but avoid suffering), balance acceptance and change, and—to the extent that it is within our control—advocate to close the demand and access gaps in the mental health system today.

Dr Loren is clinical senior manager at Brightline.

References

1. Patients with depression and anxiety surge as psychologists respond to the coronavirus pandemic. American Psychological Association. November 2020. Accessed July 18, 2022. https://www.apa.org/news/press/releases/2020/11/telehealth-survey-summary.pdf

2. Cocker F, Joss N. Compassion fatigue among healthcare, emergency and community service workers: a systematic review. Int J Environ Res Public Health. 2016;13(6):618.

3. Jergensen K. Practice what you preach: an exploration of DBT therapists personal skill utilization in burnout prevention. Clin Soc Work J. 2018;46(3):187-199.