Embodied Self-Care for Therapists
This post focuses on the importance of self-care for therapists who work with trauma. Without a commitment to self-care, maintaining a practice focused on the treatment of PTSD can have a significant impact on the mental, emotional, and physical health of the therapist. You can think of this impact as existing on a Burnout Continuum that begins with relatively mild caregiver stress that builds over time progressing into compassion fatigue, vicarious trauma, secondary trauma symptoms, and, in the worst case, into complete burnout. Trauma counselors, such as those who practice EMDR therapy or Somatic therapy, need to have sufficient support to process the mental, emotional, and physical weight of the traumatic material that they are exposed to. Otherwise, it is common to begin to feel weighed down by the heaviness of this work and, as a result feel tension in the body, fatigue, and emotions of anger or resentment.
Clients with trauma often come in with extreme states of high or low arousal. They might be trembling with anxiety and panic, flattened by depression and despair, or numbed by dissociation. The psychophysiology of these states can be induced in therapists. When therapists recognize that they have joined with the physiology of the client they are better able to engage their boundaries or explore valuable self-care strategies. In addition, we must remember that therapists are people first. We come into the field of trauma work with our own historical wounds and injuries. This work tends to flush to the surface personal unfinished business such as unprocessed traumatic memories or attachment related material.
“We must take a preventative approach to mitigate therapist burnout by addressing risk factors and responding to early symptoms of caregiver stress. Too much empathy can have negative repercussions. A therapist must first start by resourcing and re-energizing the self. A therapist who focuses on self-regulation during a session can serve as an important model for the client. This process also allows the physiology of the therapist to be an available, present-centered resource for the client.”
-Dr. Arielle Schwartz
The Burnout Continuum
It is common for therapists to arrive in the field of trauma treatment with enthusiasm which dampens over time through experiences that are both frustrating and painful. This process might be useful to refine unrealistic expectations and help clients develop stronger boundaries if they are over-identified with their clients. However, in situations where there on ongoing stressors without sufficient support therapists are at risk for feeling overwhelmed and incompetent. Let’s take a closer look at the Burnout Continuum as related to therapists working with traumatized clients:
- Caregiver Stress: Caregiver stress refers to the normal mental, emotional, and physiological challenges that therapists experience when working with traumatized clients. Such stress can build up in the course of a single session, after a day of multiple sessions, or the stress can build up slowly and over time. This might be felt as tension in the shoulders, a headache after a long day, the feeling of frustration after sitting with a client who is resistant to change, or tiredness at the end of the day. Ideally, this kind of stress is addressed within daily self-care practices that help to release tension or within supervision that attends to countertransference.
- Compassion Fatigue: If unaddressed caregiver stress accumulates then a therapist is at greater risk of developing compassion fatigue. Compassion fatigue impacts the therapist’s emotional, physical and spiritual sense of self. The therapist may struggle to stay present with clients, or have limited capacity for an empathic response toward clients’ pain. The therapist may begin to resent clients for having needs. It becomes harder to refuel or regenerate at the end of the day. Therapists may lose their capacity for empathy with people in personal life such as friends and family. Compassion fatigue is often felt as a physical experience of being tired or drained and if left untreated can develop into physical symptoms of tension, pain, or illness.
- Vicarious Trauma: Therapists working in trauma treatment face the stress of hearing descriptions of horrific events faced by clients. This kind of caregiver stress can develop into vicarious trauma in which the therapist’s own world view begins to change. As a result of the cumulative exposure to traumatic stories, therapists might experience feelings of helplessness, powerlessness, ineffectiveness, despair, or depression. These feelings may be the result of an induced set of emotions that are direct reflections of the types of emotions expressed by clients with PTSD. Such feelings might also be amplified by the therapist’s own unresolved traumatic material or attachment wounds.
- Secondary Trauma: If vicarious trauma goes untreated, the therapist might develop symptoms of PTSD known as secondary trauma. In such as case, the therapist might have intrusive re-experiencing symptoms such as thoughts or images that are drawn from client’s traumatic experiences. The therapist might resist going to work or turn toward unhealthy coping strategies such as eating or substance use to avoid dealing with unwanted sensations or emotions. Overtime, secondary trauma becomes a deterrent that significantly impacts the therapist’s ability to continue in the therapy field.
- Burnout: Burnout is defined as the point at which a previously committed therapist disengages from the profession in response to the accumulation of stress, compassion fatigue, and/or secondary trauma. Burnout is typically experienced as mental, emotional, and physical, exhaustion that results in apathy and indifference toward the healing profession. Therapists often feel depleted, helpless and hopeless about their ability to help their clients. They might feel plagued by self-critical thoughts or believe that they have failed.
Self-Care for Embodied EMDR Therapists
Embodied self-care emphasizes developing nervous system flexibility. Initially, this process is fostered as therapists learn their own vulnerabilities to get stuck in high or low arousal states. For example, the therapist who has his or her own anxiety might have difficult down regulating with a client who is experiencing panic in the office or may feel a residue of anxiety after the session. Self-awareness of arousal patterns can help therapists stay regulated during sessions by recognizing the need for self-care strategies such as grounding or breath awareness. A therapist who focuses on self-regulation during a session can serve as an important model for the client. This process also allows the physiology of the therapist to be an available, present-centered resource for the client.
The realities of working with trauma is that therapists sit with extreme and often debilitating experiences with our clients such as helplessness, hopelessness, despair, isolation, loneliness, injustice, unfairness, suffering, rage, and evil. Often clients have lost faith, and the meaning or purpose of life is put into question. Self-care during a session might involve connecting to your own meaning making or spiritual perspectives that helps you orient to trauma, loss, and suffering without getting stuck with your client. However, it is also common to “shut down” with the client as the natural impulse to empathize and understand the client evokes within the therapist the fogginess of dissociation or the hopelessness of despair.
As discussed in Babette Rothschild‘s book Help for the Helper, when therapists join strongly with client’s stuck or shut-down emotion and arousal states it is important to have strategies to disengage from the client’s somatic process. Here, the therapist compassionately differentiates from the client in order to access personal self-care resources. This helps to prevent the session and client from remaining stuck. Differentiation asks the therapist to consciously uncouple their somatic resonance and arousal state from that of the client. Otherwise, too much empathy can have negative repercussions. In order to disengage from a client’s “shut down” or dissociative states, the therapist must first start by resourcing and re-energizing the self. You can think of this process as similar to putting your own oxygen mask on during a hazardous flight. Once you have yourself resourced you can better attend to the need of another.
During a session, the differentiation process involves recognizing when you are mirroring a client’s posture or facial expressions and consciously choosing to change how you are sitting or allowing your face to relax. This process, in turn, can inform the client about how to support their own psychophysiology. In short, the therapist can attune to the client’s dysregulated arousal states; however, this process can also work in the opposite direction where the therapist invites the client to attune to the therapist’s regulated and resourced body and mind.
Looking for a mind-body approach to healing C-PTSD?
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About Dr. Arielle Schwartz
Dr. Arielle Schwartz is a licensed clinical psychologist, wife, and mother in Boulder, CO. She offers trainings for therapists, maintains a private practice, and has passions for the outdoors, yoga, and writing. Dr. Schwartz is the author of The Complex PTSD Workbook: A Mind-Body Approach to Regaining Emotional Control and Becoming Whole. She is the developer of Resilience-Informed Therapy which applies research on trauma recovery to form a strength-based, trauma treatment model that includes Eye Movement Desensitization and Reprocessing (EMDR), somatic (body-centered) psychology and time-tested relational psychotherapy. Like Dr. Arielle Schwartz on Facebook, follow her on Linkedin and sign up for email updates to stay up to date with all her posts.