How Do Therapists Manage the Stress of the Job?

When I chose my majors in college and grad school, at least one person warned me of the negativity I was getting myself into. I learned each day about the darkness people fight through and recognize pain. But I love this. Compassion is the ability to see a person's hurt and a willingness to help (even if it does not always mean the ability to change another person's circumstances). By definition, psychotherapy and related careers focus on engaging with another person in pain in an attempt to help. It is a career of compassion, as well as respect for the individual resilience of humans and their right to their own choices.

Landing my first job after undergrad, I felt invigorated. Meeting individuals experiencing a mental health crisis gave wings to my dreams. The agency I worked with had an admirable mission and provided essential services to the community in a way I felt good about. My colleagues were kind and effective clinicians. Still, we were all working within a world and system with gaps. The challenges that bring a person to need crisis services run deep. The people I met showed genuine pain often presenting with thoughts of suicide, psychosis, or other serious emotional pain leaping out of an array of difficult life situations.

I often found myself wishing for resources that didn't exist. I worried for the people I met. I hoped with all my heart for good things in their future as our single crisis intervention session would end and the baton would be passed to others in the helping circles.

Compassion, Meaning, and the Witness of Human Suffering

Mental health providers usually enter this field because they want to help others. We want to help others because we care for their well-being. We are honored to walk with people in some of their darkest times and sometimes we get to help people. Yet, the people we seek to help are capable and living their own lives. What we wish for them might be different from what they are moving toward.

For example, a person may decide to remain in an abusive relationship or not access support available to them. If it is their choice, it is their right and we must respect that except in cases of grave danger where we have a degree of duty and resources for emergency services such as a call to child protective services or involuntary hospitalization. Even in these cases, there can be a sense of moral injury in that we are going against a person's self-determination (in favor of their safety and obedience to the law/ethical requirements of our profession).

Research has shown that psychotherapists who are young, early in their careers, and overinvolved in client's problems are at particular risk of early burnout (Simionato and Simpson, 2018). Mental health professionals must find a balance between the desire/responsibility to help and respect for individuals' self-determination. Striking this middle ground is not easy making supervision and consultation critical particularly for early career professionals.

Moral Injury in an Imperfect System

In my early days in the mental health field, I quickly discovered that hospital emergency rooms are chaotic places for anyone, let alone someone in a mental health crisis. It's hard for someone to focus on managing a mental illness when experiencing homelessness yet shelters often have very specific criteria and there are not enough beds for everyone in need. Accessing housing resources is a process. I would often assist with the process of admission to an inpatient psychiatric unit. Still, even here, the closest available "bed" would sometimes be hours away, and medical systems which often focus on safety above all else, can be experienced as coercive.

The truth is, that these gaps in services are not contained to crisis resources. Within the caring professions, gaps in available resources and the ability to access these due to distance, funding, transportation, and other constraints run rampant. As mental health professionals, many of us advocate to fill these gaps.

We do our best. Clients are often doing their best too. In time, however, this can cause moral injury, the tax of acting in ways that feel go outside one's values. Ethical dilemmas and the inability to intervene effectively in all situations add up. Over time, these moral injuries wear on the well-being of the provider. Compassion fatigue and burnout are examples of this. Lack of supervisory support, lessened control over other job factors, and a high need caseload are factors that have been found the link with burnout among mental health professionals (Yang and Hayes, 2020). Terms like burnout and compassion fatigue are buzzwords, but the real impact of these realities on the well-being of providers and client care is not always acknowledged.

Moral Injury Essential Reads

A New Writing Therapy is Helping to Heal Moral Injury

Moral Courage as the Antidote to Moral Injury

Research shows that most mental health professionals are unfamiliar with the term moral injury (Levi-Belz and Zerach, 2022) and that examining this experience among mental health professionals is non-existent. Still, research suggests that moral injury runs rampant in the healthcare field as a whole (Mantri et al., 2021). Moral injury, compassion fatigue, and burnout are issues that go deep and require more intervention than simple self-care.

A Sacred Profession

Since working in this field, I've always seen myself as getting two paychecks. The first is money. The second is the meaning I derive from this work, the privilege of witnessing others' stories, and the opportunity I sometimes get to help. Other therapists I meet seem to share this experience. Finding where we find meaning in our work and drawing upon that can assist with getting the difficult moments.

Mental health professionals choose to take a step into the darkness. Most of us did not enter this field with expectations of butterflies and rainbows. We can not always create the changes we'd like to see. Still, we marvel when others walk through fire and keep walking and create changes for themselves. Sometimes we get to be a part of this. Like many other providers I know, I thrive on this compassion even when the sparks fly back.

The following are things that can help.

1. Remembering Our Reasons

Remembering our reasons for entering the mental health field gives us grounding. Many of us started with a vague wish to "help others." Maybe someone helped us, or maybe we just became aware of what a need there is. As we've worked in the field, there are likely to be moments when this mission feels so real. Remember those times.

2. Rituals of Letting Go

No one can carry all the pain of others, nor would it be healthy or helpful for us to do so. Create a ritual of letting go after leaving your workspace. For me, this is loving-kindness meditation. I imagine the people I saw in the day and send well wishes. On my way home, I switch on my music and sing. I go swimming. I breathe. These are all rituals of letting go.

3. Reaching Out to Support When Needed

Therapists need therapy and there is nothing wrong with that. Just like we might hope a master chef gets to eat a nice meal at the end of the day, therapists deserve and require everything necessary for their growth. Those of us who have been privileged to have our own psychotherapy are often very grateful for it. Both we and our clients benefit when we are at our best.

4. Find Mentors

In every step of my career, there have been several senior colleagues whose work I have looked up to. Consultations when needed, and choosing to take the time to learn from them are steps I am grateful to have taken both for my well-being and the quality of services I can provide. You don't have to be a student or provisional therapist to seek mentorship. We all can learn from each other. A study of psychotherapists found that interacting with these professional mentors has served as a source of professional development for the majority (Rønnestad and Skovalt, 2003).